Every finding on record at Somerset Ridge Center

Based on observations, interviews, and records reviewed, the facility failed to provide services that met professional standards of practice for one Resident (#124,) out of 24 sampled residents and one of two closed records. Specifically, the facility failed to ensure medication recommendations, after a hospitalization and an office visit, were implemented as recommended. Findings include:Review of the facility's policy titled Reconciliation of Medication on Admission, dated as revised 7/2017, indicated but was not limited to:-Medication reconciliation is the process of comparing pre-discharge medication to post-discharge medication by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route and indication for use for the purpose of preventing unintended changes or omissions at transition points in care.-If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy-Document findings and actions-Document the medication discrepancy on the medication reconciliation form.-Document what actions were taken by the nurse to resolve the discrepancy-If the discrepancy was resolved, document how the discrepancy was resolved. Resident #124 was admitted to the facility in July 2021 with diagnoses which included esophageal obstruction and gastroesophageal reflux disease (GERD). Further review of the medical record indicated he/she was hospitalized and returned to the facility on 9/28/25. Review of Resident #124's Hospital Discharge summary, dated [DATE], indicated but was not limited to:-Change how you take these medications: pantoprazole (used to decrease the amount of acid produced in the stomach) 40 milligrams (mg), take one tablet (40mg) by mouth two times a day. What changed: medication strength, how much to take, when to take this-Expected medication list at discharge: pantoprazole 40mg by mouth two times per day (before breakfast and dinner) Review of Resident #124's Medication Reconciliation Form, dated 9/28/25, indicated but was not limited to:-Home medication list: pantoprazole 40mg by mouth twice daily, marked as continued on discharge Review of Resident #124's Physician's Progress Note, dated 10/3/25, indicated but was not limited to:-Medications: pantoprazole 40mg Review of Resident #124's Progress Note, dated 9/28/25, indicated he/she was readmitted to the facility and new orders for medications were sent to and reviewed by the physician. Further review of his/her progress notes failed to indicate the pantoprazole dose had been clarified or changed. Review of Resident #124's Consultation Report, dated 10/14/25, indicated he/she should continue present meds. Review of Resident #124's Consulting Physician's documentation titled After Visit Summary, dated 10/14/25, indicated but was not limited to:-Continue taking these medications: pantoprazole 40 mg by mouth two times per day before breakfast and dinner Review of Resident #124's Progress Notes, dated 10/14/25, indicated he/she saw a consulting physician and was to continue his/her present meds. Further review of his/her progress notes failed to indicate the pantoprazole dose had been clarified. Review of Resident #124's Physician's Orders indicated but was not limited to:-pantoprazole 20mg by mouth two times per day Review of Resident #124's September, October, November, and December 2025 Medication Administration Record (MAR) indicated he/she received pantoprazole 20mg by mouth twice per day as ordered. During an interview on 12/3/25 at 9:40 A.M., Nurse #2 said Resident #124 had GERD and was receiving pantoprazole 20mg twice per day. Nurse #2 said when a resident returned from the hospital or an appointment, recommendations were reviewed and reported to the provider for approval or declination. Nurse #2 said if the provider declined a recommendation the nurse should document the refusal in the medical record. During an interview on 12/3/25 at 9:49 A.M., Unit Manager #2 said when a resident returned from a hospital or a consultation/appointment a nurse would review the orders and recommendations. Unit Manager #2 said medication reconciliations are completed on admission and/or readmission. Unit Manager #2 reviewed Resident #124's Discharge Summary Medication Reconciliation Form, dated 9/28/25, and the Consultant Physician's documentation, dated 10/14/25, and said the Resident should have been receiving pantoprazole 40mg twice per day as ordered. Unit Manager #2 reviewed the medical record and said there was no documented evidence that the recommendations for pantoprazole dose of 40mg had been declined. During an interview on 12/3/25 at 11:02 A.M., the Director of Nurses (DON) said she was not sure how the inaccurate dose was missed. The DON said Resident #124 should have been receiving pantoprazole 40mg twice daily.

Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one of three nurses observed during the medication pass made two errors out of 35 opportunities, resulting in a medication error rate of 5.71%. Those errors impacted two Residents (#134 and #136). Findings Include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated and revised April 11, 2018, indicated but was not limited to the following: Nurses Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers.Review of the facility's policy titled Administering Medications, dated as last revised April 2019, indicated but was not limited to the following:-The medications are administered in a safe and timely manner, and as prescribed.-Medications are administered in accordance with prescriber orders.-The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.-Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable.a. Resident #134 was admitted to the facility in October 2025 with diagnoses which include moderate protein-calorie malnutrition (moderate protein-calorie malnutrition is an insufficient intake of protein/calories, causing weight loss, fatigue, poor appetite, and muscle loss) and hypertensive heart disease (medical condition with high blood pressure that affects the heart).On 12/1/25 at 9:25 A.M., the surveyor observed Nurse #4 prepare and administer medication for Resident #134. Nurse #4 poured a magnesium oxide 400 milligram (mg) tablet (white, round pill) into the medication cup with Resident #134's other morning medications and administered the medications to Resident #134.Review of the Physician's Orders indicated but were not limited to following:-Magnesium Oral Tablet 250mg (Magnesium), give 250mg by mouth one time a day. (10/23/25)Review of the Medication Administration Record (MAR) indicated but was not limited to the following:-Magnesium Oral Tablet 250mg was signed off as administered on 12/1/25.During an interview on 12/2/25 at 8:30 A.M., Nurse #4 said he administered the wrong medication and dose to Resident #134.b. Resident #136 was admitted to the facility in October 2025 with diagnoses which include multiple fractures of ribs left side, wedge compression fractures of T5-T6 and T7-T8 vertebra (when the front part of the vertebra collapses resulting in a partial or complete break in the bone).On 12/1/25 at 9:00 A.M., the surveyor observed Nurse #4 prepare and administer Resident #136's medication. Nurse #4 prepared one Lidocaine patch 4% for topical application and applied one Lidocaine patch 4% to Resident #136's middle upper back.Review of Physician's Orders indicated but were not limited to the following:-Lidocaine External Patch 4% (Lidocaine)- Apply to bilateral rib cage topically one time a day for pain management. Apply one patch to each side of ribs for total of two patches in am and remove in pm. Removal after 12 hours and remove per schedule (10/29/25).Review of the MAR indicated but was not limited to the following:-Lidocaine External Patch 4% - Apply to bilateral rib cage topically one time a day for pain management. Apply one patch to each side of ribs for total of two patches in am and remove in pm was signed off as administered on 12/1/25.During an interview on 12/2/25 at 8:32 A.M., Nurse #4 said he administered the Lidocaine patch 4% to the wrong location on Resident #136 and failed to apply two (2) patches as ordered.During an interview on 12/2/25 at 9:28 A.M., Unit Manager #1 said Magnesium oxide 400mg and Magnesium 250mg are not the same medication and said the nurse should be administering the correct medication per physician's orders.During an interview on 12/3/25 at 3:55 P.M., the Director of Nurses said the nurse should administer the correct dose of medication and follow the medication orders as prescribed.

Based on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for three Residents (#3, #134, #136), out of a total of seven residents. Specifically, the facility failed:1. For Resident #3, to implement personal protective equipment (PPE) for Transmission-Based Precautions when entering the Resident's room;2. For Resident #134, to follow hand hygiene procedures prior to handling medication(s) and after administering medication(s); and3. For Resident #136, to implement PPE, safe injection practices, and hand hygiene procedures prior to handling medication(s) and after administering medication(s).Findings include:Review of the facility's policy titled Standard Precautions, last revised 1/25, indicated but was not limited to:-Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases.-Hand hygiene is performed with alcohol-based hand rub (ABHR) or soap and water: Before and after contact with the resident Before performing an aseptic task After contact with items in the resident's room; and after removing gloves.-Safe Injection practices, always use aseptic technique when handling injection equipment.-Transmission-Based Precautions, Contact precautions; potential exposure to microorganisms through direct contact with the resident, or indirect contact with belongings/environment to include: Use standard precautions (SP) with transmission-based isolation precautions.Review of the facility's policy titled Administering Medications, last revised 4/19, indicated but was not limited to: Medications are administered in a safe and timely manner, and as prescribed. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.Review of the facility's Inservice education for all staff provided by the facility's Infection Control Nurse, dated 9/2/25, indicated but was not limited to: Contact precautions apply to entire room regardless of who is infected or not. Hand hygiene is to be performed prior to entering room and upon exiting. Personal protective equipment (PPE) must be worn in the room-no exceptions. Centers for Disease Control and Prevention (CDC) Contact precaution isolation sign. Contact precautions everyone must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: put on gloves and gown before entering the room (DON), discard gown and gloves before room exit (DOFF), do not wear the same gown and gloves for the care of more than one person, use dedicated or disposable equipment, clean and disinfect reusable equipment before use on another person. Seventy-two (72) staff members signed the education, including Nurse #4 and Activities Director #1. 1. Resident #3 was admitted to the facility in August 2025 and had diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA- a type of bacteria that is resistant to several antibiotics) infection, atherosclerosis with gangrene (plaque buildup of ones arteries which blocks blood flow causing tissue death), osteomyelitis (serious infection of the bone), lower leg, other specified bacterial agents as the cause of diseases.Review of Resident #3's December 2025 Medication Administration Record (MAR) indicated but was not limited to:-Infection precautions, contact r/t MRSA and cellulitis of wound, current active order with a start date of 10/06/25.On 12/2/25 at 11:58 A.M., the surveyor observed Activities Director #1 enter Resident #3's room without performing hand hygiene or donning gloves and gown. Activities Director #1 exited Resident #3's room with a food tray, the food tray was placed in the food delivery truck. She did not perform hand hygiene. Resident #3 had a sign posted outside the entrance of the room which identified Transmission-Based Precautions, specifically Contact Precautions, were required.During an interview on 12/2/25 at 3:56 P.M., Activities Director #1 said Resident #3 was on precautions for something with his/her wound. Activities Director #1 said she did not perform hand hygiene when entering or exiting the room or wear PPE. During an interview on 12/2/25 at 12:28 P.M., Nurse #6 said Resident #3 was on contact precautions for MRSA of the wound and she observed Activities Director #1 enter Resident #3's room without performing hand hygiene or donning/doffing PPE and remove Resident's meal tray. Nurse #6 said there is a sign posted, and her expectation is all staff follow the sign posted by performing hand hygiene and wearing PPE.2. Resident #136 was admitted to the facility in October 2025 with diagnoses which included multiple fractures of ribs left side, wedge compression fractures (when the front part of the vertebra collapses resulting in a partial or complete break in the bone) of T5-T6 and T7-T8 vertebra.Review of Resident #136's December 2025 MAR indicated but was not limited to:-Lidocaine External Patch 4% - Apply to bilateral rib cage topically one time a day for pain management. Apply one patch to each side of ribs for total of two patches in am and remove in pm [10/29/25] (Lidocaine patch is an adhesive, medicated patch which contains the local anesthetic lidocaine, which is used for targeted pain relief by numbing the nerves in specific areas of the skin were applied).-Heparin Sodium (Porcine) injection solution 5000 unit/ML. Inject 1mL subcutaneously (under the skin) every 12 hours for blood clot [10/21/25] (Heparin is a medication that acts as a blood thinner).On 12/1/25 at 9:00 A.M., the surveyor observed Nurse #4 prepare Resident #136's medications without performing hand hygiene prior to or after administration of medications to include a topical application of one Lidocaine patch 4% and Heparin Sodium injection solution. Nurse #4 was observed applying one Lidocaine patch 4% to Resident #136's middle upper back with his ungloved left hand. Nurse #4 administered Heparin Sodium injection solution with glove donned to right hand only with ungloved left hand having contact with Resident #136's abdomen during injection administration. Nurse #4 then disposed of the used injection into the sharps container that was located on his medication cart. Nurse #4 did not perform hand hygiene. Nurse #4 then went to his keypad on the computer that was located on top of the medication cart and began typing.During an interview on 12/2/25 at 8:32 A.M., Nurse #4 said he administered the Lidocaine 4% patch and Heparin injection to Resident #136 without wearing a glove to his left hand or performing hand hygiene prior to or after medication administration. 3. Resident #134 was admitted to the facility in October 2025 with diagnoses which include moderate protein-calorie malnutrition (Moderate protein-calorie malnutrition is an insufficient intake of protein/calories, causing weight loss, fatigue, poor appetite, and muscle loss) and hypertensive heart disease (medical condition with high blood pressure that affects the heart).On 12/1/25 at 9:25 A.M., the surveyor observed Nurse #4 prepare medications for Resident #134 without performing hand hygiene prior to administration. Nurse #4 did not perform hand hygiene post medication administration. Nurse #4 was observed going to his computer that was located on top of the medication cart and began typing.During an interview on 12/2/25 at 8:30 A.M., Nurse #4 said he did not perform hand hygiene before and after each medication administration for Resident #134.During an interview on 12/3/25 at 2:53 P.M., Unit Manager #1 said her expectation was all staff must follow the precautions signs to hand sanitize before entering and when exiting the resident's room and follow appropriate PPE steps required. Unit Manager #1 said nurses should follow proper hand hygiene steps with medication administration.During an interview on 12/3/25 at 3:55 P.M., the Director of Nurses said nurses should follow hand hygiene procedures for medication administration. She said all staff should follow standard precautions and follow appropriate signs indicated for precautions to include hand hygiene and PPE as required by the signs posted.

Based on record reviews and interviews, the facility failed to identify a significant change in condition and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment for two Residents (#11 and #25), out of a total sample of 24 residents. Specifically, the facility failed:1. For Resident #11, to identify a significant change in his/her condition and complete a SCSA; and2. For Resident #35, to complete a SCSA when he/she was discharged from Hospice A and admitted to Hospice B. Findings include:Review of the facility's policy titled Change in a Resident's Condition or Status, last revised February 2021, indicated but was not limited to:-If a change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA (Omnibus Budget Reconciliation Act of 1987) regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2025, indicated but was not limited to the following:-An SCSA comprehensive assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred.-An SCSA is appropriate when: -There is a determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and -The resident's condition is not expected to return to baseline within two weeks. -An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than)-Decline in two or more of the following: -Resident's decision-making ability has changed; -Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment; -Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; -Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days) 1. Resident #11 was admitted to the facility in October 2024 with diagnoses including dementia.During an interview on 12/1/25 at 11:44 A.M., Certified Nursing Assistant (CNA) #1 said Resident #11 had a change in his/her transfer ability to transfer from one surface to another.Further review of the medical record indicated Resident #11 had a significant weight loss of 12.20% from 4/1/25 (weight 108.2 pounds (lbs.)) to 10/17/25 (95 lbs.).Review of Resident #11's MDS assessment, dated 10/23/25, indicated but was not limited to:-He/she had a severe cognitive deficit as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 3 out of 15.-He/she was dependent on staff for eating.- Walking 10 feet: Not attempted due to medical condition or safety concerns.-He/she was dependent on staff for toileting transfers-He/she had a Health Care Proxy (HCP- health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) and it was activated.Review of Resident #11's MDS assessment, dated 7/24/25, indicated but was not limited to:-He/she had a moderate cognitive deficit as evidenced by a BIMS assessment score of 12 out of 15.-He/she was able to eat independently with assistance for set-up and clean-up.-He/she was able to walk 10 feet, 50 feet, and 150 feet with moderate assistance.-He/she required moderate assistance for toileting transfers.-He/she had an HCP, which was not activated.During an interview on 12/2/25 at 5:09 P.M., CNA #2 said Resident #11 was on a regular texture diet before and now was on a puree diet, and used to be able to stand and walk, but now required a wheelchair when out of bed. CNA #2 said Resident #11 had a decline over the last four or five months.During an interview on 12/3/25 at 10:20 A.M., Activity Assistant #1 said Resident #11 used to actively participate in activities but now participates passively.During an interview on 12/2/25 at 5:02 P.M., MDS Nurse #2 said an SCSA is indicated when a resident had a significant change in weight, a decline in activities of daily living (ADLs), and change in behavior. MDS Nurse #2 reviewed Resident #11's medical record and said Resident #11 should have had a SCSA completed because he/she had a significant weight loss, change in ADL status, change in mental status, and he/she was no longer able to make his/her own medical decisions; a SCSA was not done. 2. Resident #35 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease.Review of the medical record indicated Resident #35 was discharged from Hospice A and admitted to Hospice B on 11/11/25.Further review of Resident #35's medical record indicated the facility failed to conduct a SCSA when his/her hospice status changed.During an interview on 12/2/25 at 10:52 A.M., the Director of Social Work said Resident #35 was admitted to Hospice A in April 2024, but per their Health Care Proxy's request he/she was discharged from Hospice A and admitted to Hospice B on 11/11/25.During an interview on 12/2/25 at 11:00 A.M., MDS Nurse #2 said when a resident switched from one hospice to another hospice a SCSA should be completed. MDS Nurse #2 said a SCSA should have been completed for Resident #35 when he/she switched hospice providers but one had not been completed.

Based on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for one Resident (#61), out of a total sample of 23 residents. Specifically, the facility failed to ensure a schedule II-controlled substance (hydrocodone-acetaminophen, high potential for abuse) medication to treat pain was administered to the Resident within parameters as ordered by the physician. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised 4/11/18, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Administering Medications, revised April 2019, indicated but was not limited to the following: - Medications are administered in accordance with prescriber orders, including any required timeframe. -The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #61 was admitted to the facility in December 2023 and had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, osteomyelitis, and post procedural pain. Review of the Minimum Data Set (MDS) assessment, dated 6/26/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and was on a scheduled and as needed pain medication regimen. Review of current Physician's Orders indicated the following: -hydrocodone-acetaminophen (Norco) oral tablet 5-325 milligrams (mg), give 1 tablet by mouth every 8 hours as needed for pain 7-10, 7/1/24 Review of the September 2024 Medication Administration Record (MAR) indicated the Norco was administered outside of physician prescribed parameters (pain scale documented as less than 7-10) (the pain scale is a tool that helps people measure their pain so that doctors can plan how to treat it with 0 indicating no pain and 10 the worst) on the following days: -9/2/24, 5:05 A.M., pain level 6 -9/3/24, 12:05 P.M., pain level 6 -9/3/24, 8:07 P.M., pain level 6 -9/4/24, 11:20 P.M., pain level 6 -9/6/24, 5:16 A.M., pain level 6 -9/11/24, 4:41 A.M., pain level 5 -9/13/24, 5:02 A.M., pain level 6 -9/13/24, 10:38 P.M., pain level 6 -9/15/24, 10:26 P.M., pain level 6 -9/16/24, 5:24 A.M., pain level 6 -9/17/24, 9:01 P.M., pain level 5 -9/24/24, 8:30 A.M., pain level 2 -9/25/24, 5:04 A.M., pain level 6 -9/27/24, 5:20 A.M., pain level 5 -9/29/24, 8:45 A.M., pain level 6 Review of the October 2024 MAR indicated the Norco was administered outside of physician prescribed parameters on the following days: -10/1/24, 8:25 A.M., pain level 5 During an interview on 10/1/24 at 11:30 A.M., Resident #61 said he/she had frequent pain in his/her mouth, upper back, neck, and right middle finger status post a partial amputation about a month ago and took Tylenol and Norco for it. During an interview on 10/1/24 at 11:52 A.M., the surveyor reviewed the medical record with Nurse #5 who said the physician's order indicated to give the Norco as needed for a pain scale rating of 7-10. She said she gave it this morning for a pain scale rating of 5; it was not given per physician's orders as it was below the parameter. During an interview on 10/1/24 at 3:44 P.M., the surveyor reviewed the medical record with the Director of Nursing (DON). The DON said the Norco should be given per physician's orders due to the risk of dependence, respiratory depression, lethargy, and constipation if not given as indicated.

Based on record review and interview, the facility failed to monitor for signs and symptoms of adverse consequences (i.e., side effects) of medications for one Resident (#61), out of 23 sampled residents. Specifically, the facility failed to monitor for signs and symptoms of hypoglycemia and hyperglycemia (low and high blood sugars) with the administration of insulin (anti-diabetic injectable medication). Findings include: Review of the facility's policy titled Diabetes-Clinical Protocol, revised December 2020, indicated but was not limited to the following: - Risk of hypoglycemia should be considered in any treatment plan, as it is a significant and high-risk complication of treatment. - The physician will follow up on any acute episodes associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. - The physician will order desired parameters for monitoring and reporting information related to blood sugar management. - The staff will incorporate such parameters into the Medication Administration Record and care plan. - An example of appropriate treatment of hypoglycemia for a responsive individual would be 15 grams (g) to 20 g of carbohydrates in the form of glucose, sucrose tablets, or juice, combined with a sandwich, crackers, or other light snack containing protein. Resident #61 was admitted to the facility in December 2023 and had diagnoses including type 2 diabetes mellitus (DM) with diabetic neuropathy, end stage renal disease, and dependence on renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 6/26/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and received insulin injections. Review of current Physician's Orders indicated the following: - Insulin glargine subcutaneous solution 100 units/milliliter (ml), inject 10 units subcutaneously at bedtime for DM, 8/29/24 - Novalog FlexPen subcutaneous solution pen-injector 100 units/ml (insulin aspart), inject 5 units subcutaneously with meal for diabetes, hold for CBG (capillary blood glucose) less than 120, 5/11/24 - Novolog injection solution 100 units/ml (insulin aspart), inject per sliding scale: if 0-250=0 units; 251-300=2 units; 301-350=4 units; 351-400=6 units; 401-450=6 units, subcutaneously with meals for diabetes. If blood sugar is less than 70 or greater than 400 notify MD, 4/3/24 Review of Resident #61's Blood Sugar Vitals Record indicated the following values documented as being less than 70: 9/3/24 - 9:17 A.M., 60.0 mg/deciliter (dL) 9/4/24 - 10:21 A.M., 64.0 mg/dL 9/5/24 - 8:01 A.M., 69.0 mg/dL 9/11/24 - 11:36 A.M. and 11:39 A.M., 69.0 mg/dL 9/13/24 - 10:39 A.M., 68.0 mg/dL 9/14/24 - 9:09 A.M., 68.0 mg/dL 9/15/24 - 8:27 A.M., 68.0 mg/dL 9/18/24 - 10:25 A.M., 63.0 mg/dL Review of the September 2024 Medication Administration Record (MAR) indicated the insulin was held for the above below range blood sugar readings as ordered per sliding scale parameters. Further review of the September 2024 MAR and review of the September 2024 Treatment Administration Record (TAR) did not indicate documentation of monitoring of adverse consequences related to insulin medications. Further review of the medical record failed to indicate documentation that the above below range CBGs were reported to the physician to obtain potential treatment orders, if the Resident was experiencing signs and symptoms of hypoglycemia such as sweating, chills, confusion, anxiety, shakiness dizziness, or blurred vision, or follow up monitoring of the Resident's blood glucose level. During an interview on 10/1/24 at 11:30 A.M., Resident #61 said he/she was on insulin and his/her blood sugars could run low. The Resident said he/she was on dialysis so they could not have orange juice for it, but had food brought in by the family that he/she would eat. During an interview on 10/1/24 at 11:41 A.M., the surveyor reviewed the medical record with Nurse #5 who said there should be an order for hypo/hyperglycemia monitoring and treatment but there wasn't. She said there was no sign off on the MAR or TAR for it. Nurse #5 said the order is to call the physician if the blood sugar is less than 70 or greater than 400 and, if out of range, the nurse should document in a progress note. She said she could not locate documentation that this was done. She said the Resident should be monitored, but she has not had to personally treat him/her for low blood sugars. During an interview on 10/1/24 at 4:07 P.M., the Director of Nursing (DON) said the batch orders for diabetes management for Resident #61 were not entered which would have included: may obtain blood glucose as needed for symptoms of hypo/hyperglycemia, offer diabetic snack at bedtime, glucose gel (treats severe low blood sugar), Glucagon (treats severe low blood sugar) emergency medication, and diabetic hypo/hyperglycemia monitoring. She said the batch order is prepopulated and would have included everything. The DON said the orders should have been placed but weren't. She said if the blood sugar is less than 70 then the nurse should be notifying the physician even if the resident isn't symptomatic to let them know what the blood sugar was and to get a recommendation or order for treatment. She said the nurse would then document this in the medical record and go through the protocol. She said she couldn't determine if the Resident was symptomatic or not if it was not documented and would continue to look for the documentation and get back to the surveyor. During an interview on 10/2/24 at 7:16 A.M., the DON said she could not locate any documentation to support whether or not the Resident had signs and symptoms of hypoglycemia, if the physician was notified, or if recommendations or treatment orders were obtained for the below range blood sugar readings. During a telephone interview on 10/2/24 at 10:39 A.M., Physician #2 said he was covering for the attending physician but was familiar with the Resident. He said the Resident's blood sugars seemed to be stable with the highest recent daily reading being 155 and the lowest 74 with an order to notify the physician if the blood sugars were less than 70 or greater than 400. He said he would follow up with those readings and tell staff to hold the insulin if below range and said maybe the Resident just hadn't eaten. He said nurses would call and he would give a verbal telephone order for treatment. The surveyor reviewed the September 2024 blood sugar readings with Physician #2 that were below 70. Physician #2 said yes, he saw them in the electronic record and was somewhat familiar with them but said he couldn't locate any documentation about them or if the Resident had experienced any symptoms. He said typically he does not document in the record when on call but said the Resident usually did not have symptoms of hypoglycemia. He said typically there is an order for monitoring for hypo/hyperglycemia and treatment orders.

Based on observation, interview, and document review, 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 when the facility was currently experiencing an outbreak of COVID-19 infection. Specifically, the facility failed to ensure staff rapid antigen COVID-19 testing (CorDx) was conducted in a manner that is consistent with current standards of practice and manufacturer's instructions for use for two of three staff members observed. Findings include: During an interview upon entrance to the facility on [DATE] at 7:57 A.M., the Director of Nursing (DON) said the facility was experiencing a COVID-19 outbreak with 13 current positive residents residing on the Pottersville Unit (long-term care). During an interview on 9/30/24 at 3:42 P.M., the Infection Preventionist (IP) said staff were currently testing daily prior to their shift in the main lobby and that the facility followed Centers for Disease Control and Prevention (CDC), Massachusetts Department of Public Health (DPH), and Centers for Medicare and Medicaid Services (CMS) guidance for testing, whichever was the more stringent. Review of the 2024 staff and resident COVID-19 Positive Logs provided by the IP indicated there were currently 13 residents residing on the Pottersville Unit and three staff members who were positive for COVID-19. The [NAME] Unit (short-term rehab) became an affected unit on 9/4/24 and cleared on 9/28/24. The Pottersville Unit was affected on 9/12/24 to current. Review of the Massachusetts Department of Public Health (DPH) Memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, Including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 10, 2023, indicated but was not limited to the following: - Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. - Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless the DPH epidemiologist directs otherwise. - Residents and staff who are recovered from COVID-19 in the last 30 days can be excluded from this testing. Review of the CorDX rapid COVID-19 Ag Test manufacturer's product insert, revised September 2023, indicated but was not limited to the following: - A false result may occur if all the test steps are not followed as indicated below. If you skipped or incorrectly performed one or more steps, repeat the test with a new sample and cassette. Step 1: Collect Sample - Carefully insert the swab tip into one nostril about 1/2 to 3/4 inch. Firmly and slowly rotate the swab 5 times, brushing against the inside walls of the nostril to ensure both mucous and cells are collected. - Using the same swab, repeat this process for the other nostril to ensure an adequate sample is collected from both nostrils. Failure to swab properly may cause incorrect results. Step 2: Process Sample - Insert the swab in tube to the bottom. - Rotate the swab at least 10 times while pressing the swab head against the bottom and side of the tube. Step 4: Read Result - Wait 10 minutes. Read the result at 10 minutes. - The result is valid when read at 10-30 minutes. If a positive result is obtained within 10 minutes, it should also be considered valid. On 10/1/24 at 6:35 A.M., the surveyor observed Rehabilitation Services Staff (RSS) #1 perform COVID-19 outbreak testing prior to his shift at the testing station in the main lobby of the facility. RSS #1 inserted the swab into each nostril rotating the swab only three times, not five. RSS #1 then inserted the swab into the tube to the bottom rotating the swab only four times, not 10, per manufacturer's instructions for use. During an interview on 10/1/24 at 1:05 P.M., RSS #1 said he should have swabbed each nostril five times and swirled the swab in the solution 10 times. On 10/1/24 at 6:38 A.M., the surveyor observed Nurse #4 perform COVID-19 outbreak testing prior to her shift at the testing station in the main lobby of the facility. Nurse #4 inserted the swab into each nostril rotating the swab only three times, not five. Nurse #4 inserted the swab into the tube to the bottom rotating the swab only four times, not 10. At 6:39 A.M., Nurse #4 applied three drops of the solution into the sample well. At 6:47 A.M., eight minutes later, Nurse #4 returned to the testing station to interpret her results then disposed of the testing cassette. Nurse #4 did not wait 10 minutes to read the result. During an interview on 10/1/24 at 10:34 A.M., Nurse #4 said the expectation was to swab each nostril five times, swirl the swab in the testing solution only four times, then wait 10 minutes for the result. Nurse #4 said she did not know she was supposed to swirl the swab in the solution 10 times. During an interview on 10/1/24 at 2:58 P.M., the surveyor reviewed the staff testing observations with the IP who said staff should have swabbed each nostril five times then put the swab in the vial of solution twisting it 10 times while pinching it to try and get the most sample out of there. She said staff are to wait 10 minutes for their test results and are expected to follow manufacturer's recommendations. The IP said if the sample is not collected properly it could lead to false results and staff are to retest.

Based on observation, interview and record review, the facility failed to provide the necessary respiratory care and services for two Residents (#86 and #11), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #86, to ensure nasal cannula (device that delivers extra oxygen (O2) through a tube into the nose) tubing and nebulizer mask/tubing (device that delivers aerosolized medication through tubing into the mouth and nose) was maintained to ensure sanitary conditions and decrease the risk of potential contamination by germs; and 2. For Resident #11, to maintain sanitary conditions of nasal cannula tubing and O2 equipment to help decrease the risk of potential contamination and exposure of infection to the Resident. Findings include: Review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, indicated but was not limited to the following: - The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. - Infection Control Considerations Related to Oxygen Administration: 7. Change the oxygen cannula and tubing every seven (7) days, or as needed, 8. Keep the oxygen cannula and tubing used as needed (PRN) in a plastic bag when not in use. - Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses, 9. Discard the administration set-up every seven (7) days. Review of the facility's policy titled Nebulizer/Care and Use Of, dated 3/1/24, indicated but was not limited to the following: - Nursing will replace tubing, mask/mouthpiece weekly. - Tubing will be dated and replacement documented in resident record. - Equipment will be stored in a loosely covered plastic bag. 1. Resident #86 was admitted to the facility in October 2023 with diagnoses including Post-Polio Syndrome, disorders of diaphragm, and asthma. Review of the Minimum Data Set (MDS) assessment, dated 7/16/24, indicated Resident #86 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS assessment also indicated Resident #86 did not use continuous oxygen and required substantial or maximal assistance with activities of daily living. Furthermore, the MDS assessment indicated Resident #86 had shortness of breath (SOB) with exertion, SOB sitting at rest, and SOB lying flat. Review of Resident #86's current Physician's Orders indicated but was not limited to: - 11/15/23: Oxygen at two liters per minute (LPM) via nasal cannula (NC) PRN. - 11/23/23: Albuterol Sulfate Inhalation Nebulization Solution (25 milligrams (MG)/3 milliliters (mL)) 0.083%, one vial inhale orally via nebulizer every four hours as needed for SOB/wheeze. - 6/18/24: Change and date nebulizer tubing and storage bag once weekly, every night shift every Sunday. On 9/26/24 at 9:35 A.M., the surveyor observed the following: - Nebulizer mask/tubing was attached to the concentrator on a nightstand next to the Resident's bed. - The nebulizer mask/tubing was dated 9/30/24 and not covered or contained within a bag. During an observation with interview on 9/26/24 at 2:50 P.M., the surveyor observed Resident #86 resting in bed. The nebulizer mask/tubing was attached to the concentrator on a nightstand next to his/her bed and not covered or contained in a bag. Resident #86 said he/she uses the nebulizer as needed when he/she is SOB. Resident #86 said the nursing staff administers the treatment to him/her and when the treatment has ended takes the nebulizer mask/tubing back to store it. On 9/30/24 at 9:58 A.M., the surveyor observed the following: - An oxygen concentrator (a piece of equipment used to deliver oxygen to a resident through tubing or mask) was noted next to the Resident's bed by the window. - The NC tubing, dated 9/30/24, was wrapped around the top of the oxygen concentrator not stored in a bag. On 9/30/24 at 2:53 P.M., the surveyor observed the following: - Resident #86 sleeping in bed with the NC tubing donned (on). - The NC tubing was dated 9/30/24. - The oxygen concentrator was set to 2-LPM of Oxygen. On 10/1/24 at 7:56 A.M., the surveyor observed Resident #86 eating breakfast while positioned upright. Resident #86 had oxygen donned via his/her NC tubing dated 9/30/24. Resident #86 said he/she was feeling SOB and nursing staff helped him/her put the oxygen tubing on yesterday. On 10/1/24 at 10:21 A.M., the surveyor observed the following: - The oxygen concentrator was positioned by the window, not running. - The NC tubing, dated 9/30/24, was wrapped around the top of the oxygen concentrator not stored in a bag. During an interview on 10/1/24 at 1:08 P.M., Nurse #4 said nebulizer mask/tubing along with NC tubing is changed weekly and dated by the nursing staff. Nurse #4 said at that time a bag is supplied to store the mask and/or tubing when not in use. Nurse #4 and the surveyor made an observation of Resident #86's oxygen concentrator and NC tubing. Nurse #4 said the NC tubing should not be wrapped around the concentrator when not in use. Nurse #4 said it should be stored in the bag attached to the concentrator. Nurse #4 and the surveyor also reviewed the observations made regarding the nebulizer mask/tubing. Nurse #4 said the nebulizer mask/tubing is cleaned after use and then should be stored in a bag. During an interview on 10/2/24 at 8:34 A.M., Unit Manager (UM) #3 said tubing for nebulizers and oxygen is changed weekly on Sunday nights. UM #3 said NC tubing and nebulizer masks/tubing should be stored in bags when not in use. 42742 2. Resident #11 was admitted to the facility in May 2021 and had diagnoses including bronchiectasis (condition in which the lungs' airways become damaged, making it hard to clear mucous), asthma, and dementia. Review of the MDS assessment, dated 7/18/24, indicated Resident #11 was cognitively intact as evidenced by a BIMS score of 14 out of 15 and had a pulmonary condition. Review of current Physician's Orders indicated the following: -Oxygen via NC 1-3 Liters (L) as needed for shortness of breath/keep sats >92%, 6/20/23 -Oxygen equipment maintenance as needed for equipment maintenance. Change oxygen tubing (mask, nasal cannula) and storage bags as needed, 10/13/22 -Oxygen equipment maintenance as needed for equipment maintenance. Cleanse oxygen concentrator filter, 10/13/22 -Oxygen equipment maintenance every night shift, every 1 month starting on the 8th for 1 day for equipment maintenance. Wipe down oxygen concentrator with clean damp cloth once monthly, 11/8/22 -Oxygen equipment maintenance every night shift, every Monday for equipment maintenance. Change oxygen tubing mask, nasal cannula, humidifier bottle, and storage bags once weekly, 10/13/22 During an observation with interview on 9/26/24 at 9:36 A.M., the surveyor observed Resident #11 sitting in a chair in their room. His/her NC tubing was observed attached to an O2 concentrator (takes air from your surroundings, extracts and filters it into purified oxygen for you to breathe) which was in the off position. The exterior of the concentrator was laden with a white powdery substance and dust. Resident #11 said, Yeah, it needs to be cleaned and that he/she used the oxygen at night for his/her breathing and for asthma. On 9/30/24 at 12:00 P.M., the surveyor observed Resident #11 sitting in a chair in their room eating lunch. His/her NC tubing was observed inserted into the Resident's nostrils with the other end attached to an O2 concentrator which was delivering 2 L of Oxygen. The exterior of the concentrator was laden with a white powdery substance and dust. On 10/1/24 at 8:17 A.M., the surveyor observed Resident #11 sitting in a chair in their room eating breakfast. His/her NC tubing was observed attached to an O2 concentrator which was delivering 2 L of Oxygen. The other end of the tubing was observed resting on top of the Resident's mattress, partially underneath a pillow, and potentially exposed to environmental contaminants. The tubing was not stored in the protective bag when not in use which was observed hanging from the concentrator. The tubing was dated 9/23/24 indicating it had not been changed. The exterior of the concentrator was laden with a white powdery substance and dust. On 10/1/24 at 8:21 A.M., Unit Manager (UM) #2 said she was the Resident's assigned nurse that morning and entered the room with the surveyor to observe the oxygen equipment. UM #2 said the oxygen tubing should have been changed and dated weekly on Sundays, but it was not, and should be stored in a plastic bag when not in use. UM #2 removed the concentrator's internal filter and said it needed to be changed and was not clean. She said the oxygen concentrator should be sanitized every week and as needed and the Resident needed a whole new concentrator. During an interview on 10/1/24 at 8:24 A.M., the surveyor reviewed the medical record with UM #2 who said, per physician's orders, the concentrator should be wiped down monthly and as needed, the tubing changed weekly on Mondays during the night shift, and the filter cleansed as needed but this was not done as ordered. During an interview on 10/1/24 at 3:37 P.M., the Director of Nursing (DON) said O2 concentrators should be wiped down as needed and the tubing should be changed weekly on the overnight shift on Monday. She said oxygen tubing should be labeled with the date when changed and initials of the nurse. She said this verifies how old the tubing is. The DON said maintenance oversees the external components, filters, and cleaning of the external parts and was frustrated this was missed. She said the oxygen tubing should be stored in a plastic bag when not in use and if it's a prn (as needed) thing, then it should be stored in a bag when not in use.

Based on observation, document review, and interview, the facility failed to store drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to store drugs and biologicals in accordance with accepted professional standards of practice until time of disposal, on one of three units. Findings include: Review of the facility's policy titled Administering Medications, dated as last revised April 2019, indicated but was not limited to the following: - Medications are administered in a safe and timely manner, and as prescribed Review of the facility's policy titled Storage of Medications, dated as last revised January 2018, indicated but was not limited to the following: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner - Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. On 10/1/24, the surveyor observed the following during the morning medication pass at 8:18 A.M.: - Nurse #3 poured the scheduled 8:00 A.M. medications for Resident #370 into one small, clear plastic medication cup which included: a. Loratadine (antihistamine) 10 milligrams (mg) one tablet for allergies b. Oxycodone (opioid for pain) 5 mg one tablet for pain management c. Zofran (antiemetic) 4 mg one tablet for nausea/vomiting - Resident #370 was sitting upright in his/her bed, with a pink basin on his/her lap. Resident #370 told the nurse he/she was nauseous and only wanted his/her medication for nausea and would take the rest of his/her medications, when he/she felt better. Nurse #1 administered only the Zofran 4 mg to Resident #370. - Nurse #3 returned to the medication cart in the hallway, opened the narcotic drawer, and put the clear, plastic medication cup including the Loratadine and Oxycodone (unlabeled) in the bottom of the narcotic drawer, surrounded by other resident medications, and locked the top of the narcotic drawer. - Nurse #3 then proceeded to medicate one other resident with their scheduled morning medications (the clear plastic medication cup unlabeled remained in the narcotic drawer of the medication cart). - At 8:40 A.M., Nurse #3 returned to the mediation cart with Unit Manager (UM) #1 and unlocked it and then unlocked the narcotic drawer, retrieved the clear plastic cup of pills, and handed the clear plastic cup of pills to the UM. The UM placed the two tablets into a clear pouch and placed the clear plastic pouch into the pill crushing machine crushed and disposed of the pills. During an interview on 10/1/24 at 8:43 A.M., Nurse #3 said she did not know what to do with the medications after she poured them for Resident #370, and was unable to administer them, so she locked them in the narcotic box. She said she went to ask her UM what to do with the medications. During an interview on 10/1/24 at 8:45 A.M., UM #1 said no medications should be stored in the medication cart, unlabeled, they should have been destroyed, and that is why she was destroying and disposing of the medications with Nurse #1. During an interview on 10/1/24 at 4:01 P.M., the Director of Nursing (DON) said the cup of pills should not have been put back in the medication cart without the proper packaging. She said they should have been disposed of when Resident #370 refused them.

Based on document review and interview, the facility failed to maintain complete medical records to accurately reflect the care of one Resident (#111), out of a total sample of 23 residents. Specifically, the facility failed to: 1. Document an administered dose of intravenous antibiotics (IV ANTBX) on the medication administration record (MAR) to reflect the date and time it was received; and 2. Ensure the medical record reflected physician notification of an acute change in potential medication side effects and the physicians follow up assessment to the presence of the condition. Findings include: Review of the facility's policy titled Charting and Documentation, dated as revised July 2017, indicated but was not limited to the following: - all services provided to the resident, progress towards goals or any changes in the resident's condition shall be documented in the medical record - the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care - the following information must be documented in the medical record: objective observations, treatments and services, medications administered - documentation of procedures and treatments will include: date and time the treatment/procedure was provided, notification of physician or other staff, and assessment data Review of the facility's policy titled Acute Condition Changes, revised March 2018, indicated but was not limited to the following: - the attending physician or nurse practitioner will respond in a timely manner to notification of problems or changes in condition and status Resident #111 was admitted to the facility in June 2024 with diagnoses including: malignant neoplasm of the bone (cancer), obsessive compulsive disorder and agoraphobia (intense fear of being in places or situations in which it may be difficult to escape or help is not available) with panic disorder. Review of the Brief Interview for Mental Status, dated 9/8/24, indicated Resident #111 was cognitively intact with a score of 15 out of 15. 1. During an observation with interviews on 9/26/24 at 9:40 A.M., the surveyor observed Resident #111 with a Contact precautions sign posted outside of his/her bedroom door and a dual lumen peripherally inserted central line (PICC) in their right arm. There was an intravenous (IV) pump and pole in the room, but no tubing or bag of medication was observed. Resident #111 said he/she is receiving medicine through he PICC for an infection on their leg. Nurse #2 said the Resident had methicillin resistant staph aureus (MRSA) as their infection germ and reason for IV antibiotics. Review of the current Physician's Orders as of 9/26/24 indicated but were not limited to the following: - Vancomycin IV solution 750 milligrams (mgs) in 150 milliliters of solution two times a day for infection until 10/3/24 at 8:00 A.M., and 8:00 P.M. Review of the progress notes for Resident #111 indicated but was not limited to the following: 9/25/24 at 10:46 P.M., PICC line blocked, MD notified and gave orders to contact IV support to have line unblocked or changed; Vancomycin on hold Review of the September MAR on 9/26/24 for Resident #111 indicated the IV Vancomycin was on hold for the 8:00 P.M. dose on 9/25/24 and 9/26/24 and the 8:00 A.M. dose on 9/26/24. During an observation with interview on 9/27/24 at 8:41 A.M., Resident #111 was lying in bed, beside the bed on the IV pole the surveyor observed a bag of IV Vancomycin not infusing. The Resident said he/she believes he/she received the IV medication the night prior at around 10:00 P.M. but was unsure of the exact time. During an interview on 9/27/24 at 9:25 A.M., Nurse #6 said she was the nurse for Resident #111 this morning and had just hung the IV ANTBX a few moments ago and took down the previous bag and replaced all the tubing. She said the bag that was hanging on the IV pole this morning was from the evening shift the night prior and was in place when she arrived at 11:00 P.M. the previous night and the medication must have been administered on 9/26/24 on the evening shift. During an interview on 9/27/24 at 9:31 A.M., Nurse #1 reviewed the MAR for 9/26/24 and said the MAR was documented as having the IV ANTBX on hold, as indicated by the H, for the evening shift on 9/26/24 and she could not explain how or why the IV medication was in the room this morning and not signed off as administered last evening if it was. During an interview on 9/27/24 at 9:32 A.M., Unit Manager #1 said she was having the Director of Nurses (DON) look into what may have occurred with the IV ANTBX last evening since the medication was documented on the MAR as being on hold and not signed off as administered on the 9/26/24 evening shift. Unit Manager #1 said she was in the room numerous times yesterday and never saw an IV bag or tubing in the room so the medication must have been administered in the evening after she had left for the day. Review of the progress notes for Resident #111 from 9/26/24 and 9/27/24 indicated but were not limited to the following: 9/26/24 at 10:29 A.M., Infectious disease called and said rash is not related to IV ANTBX and medication may continue 9/27/24 at 1:30 A.M., IV team fixed occluded line, MD aware of missed doses and gave order to resume Vancomycin at current dose; IV patent and flushing; Vanco running at scheduled time During an interview on 9/27/24 at 9:53 A.M., the DON said she reviewed the medical record and spoke to the Nurse who worked on 9/26/24 in the evening and the Nurse informed her she did administer the IV ANTBX but did not sign the administration off on the MAR and therefore the medical record is inaccurate and it appears the Resident had missed three doses of the IV ANTBX when they would have only missed two doses. During an interview on 9/27/24 at 10:43 A.M., Nurse #2 said she worked on the evening shift on 9/26/24 and the IV team attended to Resident #111 and unblocked the IV line. She said once the line was clear, she contacted the MD and received orders to resume the IV ANTBX administration. She said she thought she clicked the electronic medical record correctly to unhold the medication and administer the dose but she did not. She said she administered the IV ANTBX at approximately 10:00 P.M. but could not recall the exact time on 9/26/24. She said she did not document the administration of the medication on the MAR as she should have and she did not document the date and time of the IV ANTBX being administered in her progress note as she should have and that was an error on her part. During an interview on 9/27/24 at 11:55 A.M., the DON said the MAR does not accurately reflect the administration of the IV ANTBX on 9/26/24 as it should and the expectation is that medications are administered and documented at the time they are administered on the MAR to ensure the medical record is accurate and complete. She said the inaccurate record, if unnoticed, could result in inaccurate information being communicated to providers who make medical decisions on the Resident's care and accuracy of the MAR was important for these situations. 2. During an interview on 9/26/24 at 9:40 A.M., Resident #111 said he/she is on medications to manage his/her psychiatric conditions and has his/her own psychiatric provider in the community that they continue to have virtual therapy sessions with. He/She said it is important that they stay on their medications. Review of the current Physician's Orders for Resident #111 indicated but were not limited to the following: - Aripiprazole (antipsychotic) 5 mg oral tablet give one tablet by mouth at bedtime for mood stability - obsessive compulsive disorder (6/20/24) - Monitor for side effects of antipsychotic use: dry mouth, constipation, blurred vision, changes in urination, jerky movements in face tongue and jaw, swelling in hands ankles or feet, drooling, disturbed gait, or restlessness; every shift for surveillance. If side effect observed, document in progress note and notify practitioner. (6/18/24) Review of the MAR for Resident #111 for September 2024 indicated but was not limited to the following: - Aripiprazole was administered as ordered throughout the month daily at bedtime - Yes, side effects of the antipsychotic medication were identified on: 9/13, 9/14, 9/15, 9/17, and 9/18 Review of the progress notes for Resident #111 for 9/12/24 through 10/2/24 indicated but were not limited to the following: 9/13/24 at 7:15 P.M., Resident noted with increased movement of tongue, medicated as ordered, will continue to monitor 9/14/24 at 9:22 P.M., Resident noted with increased movement of tongue, medicated as ordered, will continue to monitor Further review of the notes failed to indicate what side effects of the antipsychotic were identified on 9/15, 9/17 and 9/18/24 or that the MD or Nurse Practitioner (NP) were ever notified of the new onset of symptoms. During an interview on 10/2/24 at 8:45 A.M., Nurse #1 reviewed the medical record of Resident #111 and said she could not find any evidence that the MD was aware of the new onset of symptoms from the antipsychotic or that the MD or NP evaluated the Resident's new symptoms once they were identified. She did however say the Nurse who documented the symptoms was currently in the facility. During an interview on 10/2/24 at 8:59 A.M., Nurse #3 said residents are monitored for signs and symptoms (s/s) of side effects for antipsychotic medications and the information is then documented on the medication administration record (MAR). She said she would also write a progress note indicating what s/s were observed and notify the Unit Manager (UM). She said she may or may not notify the physician, but if she did, she would document it in the progress notes. She said she does not know why she did not document that the physician was notified for Resident #111 or why there were no documented symptoms in the progress notes on 9/15, 9/17, and 9/18 as there should be. During an interview on 10/2/24 at 9:03 A.M., UM #1 said she was aware of the situation with Resident #111 intermittently being observed to have new symptoms of side effects from his/her antipsychotic and said she believes she notified the physician and he came and evaluated the Resident himself. She said she cannot be sure what exact date she notified the physician, since there is no documentation of that, and she is also unsure of the exact date the physician saw the Resident or what the outcome was since there was no progress note available from the MD that addresses the situation. She said the physician would typically write a note after seeing the Resident and then fax it to the facility so it could be placed in the medical record but there is no documentation available from the physician at this time. During an interview on 10/2/24 at 9:14 A.M., Physician #1 said he was made aware that Resident #111 was having an increase in mouth and tongue movements but couldn't recall the exact date of that indicating it was a few weeks ago. He said he examined the Resident himself and did not observe any of the reported s/s and since the Resident is on the lowest dose, he felt the medication remained appropriate. He said he had not provided a note of that visit to the facility as of this time and that is his error. He said he had not yet sent his notes for the visit to the facility and that is why the medical record is incomplete and does not reflect his evaluation of the Resident and follow up to the new identified change. During an interview on 10/2/24 at 9:27 A.M., the DON said the expectation is that the medical record is complete and accurate and the nurses document the s/s they observe in the progress notes along with notification to the MD as the order directs to ensure the record is complete and tells a story. She said the MD should have documented his follow-up visit to the Resident and that note should be available to the facility within a day or so to ensure the medical record reflects the follow up and resolution of a situation and is accurate and complete. She said at this time the medical record lacks the information that the MD was notified or visited the Resident to assess him/her and what was done.

Based on record review and interview, the facility failed to complete a discharge assessment to ensure timely coding and transmitting of a Minimum Data Set (MDS) assessment for one Resident (#80), out of one resident assessment reviewed, resulting in a 137-day delay in the encoding and transmission of a MDS post-discharge from the facility. Findings include: Review of the facility's policy titled Electronic Transmission of the MDS, revised November 2019, indicated but was not limited to the following: -All MDS assessments (e.g. admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. Review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, Version 3.0, indicated assessments must be completed no later than 14 calendar days after the assessment reference date (ARD) and transmitted and encoded within 7 days of assessment completion. Resident #80 was admitted to the facility in January 2024 and had diagnoses including mild cognitive impairment, Alzheimer's disease, cerebral infarction, syncope (loss of consciousness) and collapse, left femur fracture, muscle wasting and atrophy, and generalized anxiety. The Resident was discharged to the community in May 2024. Review of the medical record on 10/1/24 at 8:57 A.M. indicated a discharge MDS had not been encoded and transmitted to CMS and was 137 days overdue. During an interview on 10/1/24 at 12:43 P.M., the MDS Coordinator said the discharge assessment was not completed and electronically coded into the facility's MDS information system and transmitted to CMS in accordance with current OBRA regulations but should have been.

Based on observation, interview, record review, and policy review, the facility failed to develop and implement comprehensive person-centered care plans for three Residents (#84, #107, and #77), out of a sample of 24 residents. Specifically, the facility failed to: 1. For Resident #84, to develop and implement a care plan for resident safety with smoking; 2. For Resident #107, to develop and implement a person-centered care plan to address the use of antidepressant medication and behaviors; and 3. For Resident #77, to implement the plan of care for supervision while eating. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated but was not limited to the following: - a comprehensive person-centered care plan is developed and implemented to meet the resident's physical, psychosocial and functional needs - care plan interventions are derived from a thorough analysis of the information gathered as part of the assessment - the comprehensive person-centered care plan includes measurable objectives, describes services to be furnished and reflects current standards of practice - assessments of residents are ongoing and care plans are revised as information about the residents and their condition changes 1. Review of the facility's policy titled Smoking Policy - Residents, dated as revised July 2022, indicated but was not limited to the following: - a resident will be evaluated upon admission to determine if they are a smoker and their ability to safely smoke - a resident's ability to smoke safely will be re-evaluated quarterly, upon significant change and as determined by staff - any smoking related privileges, restrictions, and concerns shall be noted on the care plan and all personnel caring for the resident will be alerted Resident #84 was admitted to the facility in December 2023 with diagnoses including: cerebral palsy and muscle weakness. The most recent Brief Interview for Mental Status (BIMS), dated 3/20/24, indicated the Resident was cognitively intact with a score of 15 out of 15. Review of the medical record indicated Resident #84 had a smoking assessment completed upon admission and again on 3/21/24. The 3/21/24 smoking assessment indicated but was not limited to the following: - Yes, the Resident is a smoker and smokes cigarettes - There are no cognitive loss, visual deficit, or dexterity problems - Smoking occurs 1-2 times a day and the Resident can light their own cigarette and use an ashtray properly - the Resident does not express a desire to quit smoking - Resident is independent and does not require assistance to smoke - The care plan has been updated to assure the Resident is safe with smoking Review of the current active care plans for Resident #84 as of 5/31/24 failed to indicate a care plan had been developed for smoking. Review of the Resident's care Kardex (nursing reference with resident-specific care information), dated 5/31/24, failed to indicate Resident #84 was a smoker. During an interview on 5/31/24 at 9:11 A.M., Activity Assistant #1 said Resident #84 is an active smoker and joins the smoking group daily at approximately 9:00 A.M. and 3:30 P.M. She said the Resident does not require any safety devices and is handed his/her cigarette and lighter and can independently light their cigarette, manage the ashes and extinguish the cigarette. She said cigarettes and lighting materials are kept locked up in the staff's possession and all smoking residents come to the smoking area at the designated times and a staff member is present. During an interview on 5/31/24 at 9:24 A.M., Nurse #1 said Resident #84 is an active smoker and is assessed quarterly. She said the process is to assess residents who smoke upon admission and quarterly and then an individualized care plan is developed for the Resident. She reviewed the medical record and care plans for Resident #84 and said there was not a care plan in place for smoking. During an interview on 5/31/24 at 9:34 A.M., Unit Manager #1 said Resident #84 was a smoker and should have a care plan for smoking safety. She reviewed the medical record and care plans for Resident #84 and said there was no care plan in place and it must have been missed in error. During an interview on 5/31/24 at 10:54 A.M., the Director of Nurses (DON) said all residents who smoke are required to have a care plan for smoking as part of the smoking assessment and care planning process. She reviewed the care plans for Resident #84 and said a care plan was not in place for smoking. 2. Resident #107 was admitted to the facility in April 2024 with diagnoses including dislocation of left hip prosthesis and metabolic encephalopathy. Review of the BIMS for Resident #107, dated 5/22/24, indicated the Resident was cognitively intact with a score of 14 out of 15. Review of the active orders for Resident #107, as of 5/31/24, indicated but were not limited to the following: - Trazodone (an antidepressant) 0.5 milligrams every eight hours as needed for agitation to be re-evaluated in 14 days (5/22/24) Review of the current care plans for Resident #107 failed to indicate a care plan had been developed for management of the perceived agitation or use of the antidepressant medication. Review of the current care Kardex, dated 5/31/24, failed to indicate the Resident had any agitation behaviors. During an interview on 6/4/24 at 9:51 A.M., Unit Manager #1 said the Resident does exhibit some minor agitated behaviors at times, but it is infrequent. She reviewed the care plans for Resident #107 and said the Resident does not have a care plan developed for the agitated behavior or the trialing of an antidepressant at this time. She said there should be care plans in place for the use of the antidepressant and the management of the Resident's agitation and there are not. During an interview on 6/4/24 at 10:02 A.M., the DON said the process is for residents on antidepressant medications or who demonstrate behaviors is to have specific care plans to address the need for those medications and to assist staff in managing any potential behaviors. She reviewed the medical record and care plans for Resident #107 and said there were no care plans in place to address the Resident's behavior of agitation or the antidepressant use as there should be in accordance with the care plan policy. 36542 3. Resident #77 was admitted to the facility in September 2020 with a diagnosis of dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 4/11/24, indicated Resident #77 needed supervision (helper provides verbal cues or touching/steadying as resident completes activity) with eating. Review of the care plans indicated Resident #77 required assistance with activities of daily living including continual supervision while eating. Review of the Physician's Orders indicated that effective 6/9/23 Resident #77 had a mechanical soft diet, nectar thick liquids, one to one (1:1) supervision and aspiration precautions for aspiration pneumonia. Review of the Speech Therapy Discharge Summary, dated 3/27/23, indicated Resident #77 needed 1:1 supervision and to be cued to cough to clear penetration and minimize aspiration. During an interview on 5/30/24 at 8:55 A.M., the family member of Resident #77 said he visits Resident #77 twice per day, for breakfast and dinner. He said Resident #77 does not get out of bed and eats all meals in bed. On 5/30/24 at 12:00 P.M., the surveyor observed Resident #77 in his/her room alone, self-feeding. At 12:02 P.M., the surveyor observed a nurse enter the room and leave at 12:04 P.M. No staff were observed to be with the Resident during lunch. On 5/31/24 at 11:43 A.M., the surveyor observed Certified Nurses Assistant (CNA) #2 bring the lunch tray to Resident #77, thicken the Resident's juice and attempt to wake the Resident up to eat, then leave the room. On 5/31/24 at 11:54 A.M. and 12:05 P.M., the surveyor observed Resident #77 in bed with his/her eyes closed and the lunch tray in front of them. During an interview on 5/31/24 at 12:19 P.M., CNA #2 said she occasionally works on this unit and was told when she was passing trays that Resident #77 needed to be set up for meals and that the Resident can feed him/herself and did not need any assistance after set-up. On 5/31/24 at 12:32 P.M., the surveyor observed Resident #77 to be awake and attempting to eat a piece of cauliflower (with two heads) from a spoon. The Resident was not able to open his/her mouth wide enough for the piece of cauliflower. During an interview with observation on 5/31/24 at 12:33 P.M., Nurse #2 said she was helping on the unit and could not speak to the Resident's supervision level. She said the cauliflower should have been cut up for the Resident when the meal tray was set-up. During an interview on 5/31/24 at 12:38 P.M., CNA #3 said she was familiar with Resident #77. She said the Resident did not like to get out of bed and that the Resident did not like to be fed and did well feeding his/herself once they woke up. She said the staff set up the meals and then leave the Resident to self-feed. During an interview on 5/31/24 at 12:45 P.M., the DON said she was not sure of the supervision status of Resident #77 and thought the Resident's family member was at the facility for every meal. During an interview on 5/31/24 at 1:25 P.M., the DON said Resident #77 should be supervised for all meals and staff should be assisting in cutting up food as needed.

Based on observation, interview, and policy review, the facility failed to ensure staff stored drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to ensure medications were administered under direct supervision and not left at the bedside for one Resident (#6), out of a total sample of 24 residents. Findings include: Review of the facility's policy titled Administering Oral Medications, dated as revised October 2010, indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for the safe administration of oral medications. -Remain with the resident until all medications have been taken. Review of the facility's policy titled Storage of Medications dated as revised November 2020, indicated but was not limited to the following: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. -The nursing staff is responsible for maintaining medication storage. Resident #6 was admitted to the facility in November 2021 with diagnoses including hyperlipidemia (high cholesterol). Review of the Minimum Data Set (MDS) assessment, dated 5/7/24, indicated the Resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the June 2024 Medication Administration Record (MAR) indicated the following medication was scheduled for 8:00 A.M. and signed off as administered by the nurse: -Cholestyramine Light Oral Powder (used to treat high cholesterol) 4 grams (gm) On 6/3/24 at 8:41 A.M., the surveyor observed Nurse #3 prepare Resident #6's 8:00 A.M. medications. The following was observed: -Nurse #3 took one scoop of Cholestyramine Light Powder and mixed it with 4 ounces of water and placed it on top of the medication cart. -Nurse #3 placed the Cholestyramine mixed with water on Resident #6 bedside table -Nurse #3 instructed Resident #6 to drink the medication and exited the room -Nurse #3 left the Cholestyramine on the bedside table, unattended, and unlocked Review of the Care Plan failed to indicate Resident #6 self-administered medications. Review of the Physician's Orders failed to indicate an order to self-administer medications. During an interview on 6/3/24 at 8:52 A.M., Nurse #3 said Resident #6 does not have an order to self-administer medications. During an observation with interview on 6/3/24 at 9:02 A.M., Resident #6 said the nursing staff leaves the medication with him/her alone every day. The Resident said he/she usually doesn't drink it all because he/she does not like the taste. The surveyor observed the Cholestyramine mixed with water on Resident #6's bedside table. During an interview on 6/3/24 at 4:44 P.M., the Director of Nursing (DON) said medications should not be left at the bedside unattended, and the nurse should remain with the resident until all medications have been administered. She said Resident #6 does not have an order to self-administer medications and the medication should not have been left unattended and unsecured at the bedside.

Based on observation, interview, and policy review, the facility failed to follow professional standards of nursing practice for one Resident (#6), out of a total sample of 24 residents. Specifically, the facility failed to allow adequate time for absorption of eye medication, when administering two eye medications. Findings include: Review of the facility's policy titled Instillation of Eye Drops, dated as revised January 2014, indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. -When administering two or more different eye drops allow three to five minutes between each application. Resident #6 was admitted to the facility in November 2021 with diagnoses including dry eyes and insomnia. Review of the Minimum Data Set (MDS) assessment, dated 5/7/24, indicated Resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the current Physician's Orders indicated the following: -Restasis Ophthalmic Emulsion 0.05% (eye drop to increase tear production) instill one drop in both eyes two times a day for prevention -Artificial Tear Solution Instill one drop in both eyes two times a day for dry eyes During an observation on 6/3/24 at 8:41 A.M., Nurse #3 instilled one drop of Restasis into Resident #6's left eye, and one drop into his/her right eye. Nurse #3 then immediately picked up the container of Artificial tears and instilled one drop into Resident #6's left eye, and one drop into his/her right eye. During an interview on 6/3/24 at 2:45 P.M., Nurse #3 said she is not sure of the time frame needed to wait in between eye drops. She said she just administers them together. During an interview on 6/3/24 at 4:44 P.M., the Director of Nursing (DON) said when administering more than one eye drop, the nurse must wait a minimum of three to five minutes before administering another eye drop. She said if eye drops are given to close together, they do not have time to absorb, and are ineffective.

Based on interviews and record reviews, the facility failed to ensure a monthly medication regimen review was completed once per month for one Resident (#52), out of a total of five residents selected for unnecessary medication review. Findings include: Resident #52 was admitted to the facility in December 2023. Review of the medical record for Resident #52 included monthly medication regimen reviews for February 2024, April 2024 and May 2024. The record failed to indicate a medication regimen review was completed in March 2024. During an interview on 5/31/24 at 10:30 A.M., the Director of Nurses said she reviewed the March 2024 pharmacy reports and Resident #52 did not have a recommendation and was also not on the list of residents reviewed who did not have recommendations. During an interview on 5/31/24 at 10:57 A.M., the consultant Pharmacist said he had reviewed the information and found that Resident #52 had switched units on the day the Pharmacist was at the facility doing monthly reviews and the Resident had not been reviewed in March 2024.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had severe cognitive impairment, but could make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 01/19/24, Certified Nurse Aide (CNA) #1 spoke to Resident #1 in a loud, tough, degrading and inappropriate manner during care. Findings include: Review of the Facility's Resident Rights Policy, dated as revised February 2021, indicated federal and state laws guarantee certain basic rights to all residents of this facility. The Policy indicated these rights include the resident's right to a dignified existence, and to be treated with respect, kindness, and dignity. Resident #1 was admitted to the Facility in April 2015, diagnoses included: vascular dementia, myocardial infarction, major depressive disorder and anxiety disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 11/09/23, indicated he/she had severe cognitive impairment and had verbal and physical behaviors directed at others. Review of the Facility's Internal Investigation Summary, dated 1/19/24, indicated that at 12:45 P.M. on 1/19/24, a staff CNA (later identified as CNA #2) and an agency CNA (later identified as CNA #1) were providing care to Resident #1, when Resident #1 became combative towards CNA #1. The Summary indicated that CNA #1 verbally threatened Resident #1 and spoke abusively towards Resident #1. The Summary indicated that CNA #1 stated to Resident #1, If you're going to be mean, I'll be mean right back, I'll f*** you up, you got the wrong girl. The Summary indicated that CNA #1 was asked to provide a statement, refused to provide a statement and was asked to leave the facility immediately. Review of CNA #2's Written Witness Statement, undated, indicated that she was helping CNA #1 provide care to Resident #1 when CNA #1 said to Resident #1, If you touch me, I'll F--- you up, today you have the wrong girl. During an interview on 01/30/24 at 3:30 P.M., CNA #2 said that she was helping CNA #1 provide care to Resident #1 and said Resident #1 began throwing food at her (CNA #2) and became feisty with CNA #1 and said he/she verbally told CNA #1 to get out of his/her room. CNA #2 said that CNA #1 stated to Resident #1, If you touch me, I'm going to F--- you up and beat the crap out of you. CNA #2 said she immediately called out for a nurse and Nurse #1 came into the room immediately. Review of Nurse #1's Written Witness Statement, dated 1/19/24, indicated that a CNA (later identified as CNA #2) called her into Resident #1's room and an agency CNA (later identified as CNA #1) was being verbally abusive to Resident #1. The Statement indicated that CNA #1 said, If you're going to be mean to me, I will be mean to you. During an interview on 01/30/24 at 1:02 P.M., Nurse #1 said that she was at her medication cart when she heard CNA #2 yell out for a nurse. Nurse #1 said that when she entered Resident #1's room, CNA #1 was in the room and she heard CNA #1 state to Resident #1, If you're going to do that to me, I'm going to do that to you. Nurse #1 said that Resident #1 was going to scratch CNA #1 when she said that to Resident #1. Nurse #1 said that CNA #1 was sent home after the incident. During a telephone interview on 01/31/24 at 8:12 A.M., CNA #1 said she and CNA #2 were providing care to Resident #1 when he/she became combative and threw food at CNA #2. CNA #1 said that she told Resident #1 in a loud and tough voice that he/she needed to stop throwing food and stop doing that. CNA #1 said she was tough and loud with Resident #1 but denied swearing at him/her, denied that she said she was going to be mean to Resident #1 and denied that she said she was going to scratch Resident #1. During a telephone interview on 01/31/24 at 8:57 A.M., the Director of Nurses (DON) said that CNA #1 should not have talked to Resident #1 in the manner that she did. The DON said that it was her expectation that staff treat all residents with dignity and respect and not speak to residents in a loud and tough voice. The DON said that CNA #1 is not allowed back in the facility to provide care to any of the residents. On 01/30/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction that addressed the area(s) of concern as evidenced by: A) On 01/19/24, Resident #1 was immediately assessed by Nursing for any injuries. B) On 01/19/24, CNA #1 was sent home during the Facility's internal investigation, the Agency was notified of the incident and CNA #1 was not allowed to return to the Facility. C) On 01/19/24, the Director of Social Services provided a supportive visit and interviewed Resident #1. D) On 01/19/24, other residents on CNA #1's assignment were interviewed by the Director of Social Services, to identify any additional issues. E) On 01/19/24, the Local Police were notified of the incident and investigated the incident. F) On 01/19/24, Resident #1's Care Plan was updated by the Unit Manager to indicate that he/she was at increased risk for abuse related to aggressive behaviors. G) On 01/19/24, Abuse Prohibition and Resident Rights education was initiated for all staff, by the Staff Development Coordinator. H) On 01/29/24, Resident #1 was assessed by Behavioral Health Services. I) On 01/29/24, random Resident Interviews/Audits were completed by the Director of Social Services. The Director of Social Services will conduct weekly random resident interviews/audits twice a week for two weeks, then weekly for one month, then monthly for three months. J) The Director of Social Services/designee will meet with Resident #1 weekly for three months. K) Results of the random Resident Interviews/Audits will be discussed and reviewed monthly at the Quality Assurance and Performance Improvement (QAPI) Committee meeting for three months or until substantial compliance is met. L) The Director of Nurses/designee is responsible for overall compliance.

Based on interviews, policy review, and record review, the facility failed to ensure one Resident (#5), out of a total sample of 26 residents, received care and treatment to prevent and promote the healing of a pressure injury. Specifically, for four days after returning from the hospital, the facility failed for Resident #5, to inspect/assess skin and obtain a physician's order for wound care, to assess and monitor a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), and to provide wound care per physician's orders, resulting in a scab/abrasion progressing to an infected Stage 3 pressure ulcer (full-thickness skin loss as a result of intense and/or prolonged pressure or pressure in combination with shear). Findings include: Review of the facility's policy titled Admission Assessment and Follow up: Role of Nurse, dated as last revised September 2012, indicated but was not limited to the following: -Conduct a physical assessment, including the following systems: Skin. -Documentation: The following information should be recorded in the resident's medical record: All relevant assessment data obtained during the procedure and orders obtained from the physician. Review of the facility's policy titled Non-Pressure Area-Abrasions, Skin Tears, and Minor Breaks, Care of, dated as last revised September 2022, indicated but was not limited to the following: -Obtain a physician's order as needed and document physician notification in the medical record. -Generate a non-pressure incident report and complete. -An abrasion is an area on the skin that has been damaged by friction, scraping, rubbing, or trauma. -Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. -Documentation: Document physician and family notification, and resident education (if completed). -Interventions implemented or modified to prevent additional abrasions (e.g., clothes that cover arms and legs). Review of the facility's policy titled Prevention of Pressure Injuries, dated as last revised April 2022, indicated but was not limited to the following: -Conduct a comprehensive skin assessment upon admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. -Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADLs). -Identify any signs of developing pressure injuries (i.e., non-blanchable erythema (discoloration that does not turn white when pressed) -Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) -Evaluate, report and document potential changes in the skin. Resident #5 was admitted to the facility in November 2020 and readmitted after a brief hospitalization in December 2023 with diagnoses which included: pneumonia, hemiplegia and hemiparesis following a cerebral infarction (partial paralysis and weakness after a stroke) affecting right dominant side, difficulty walking, muscle wasting and atrophy and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 10/24/23, indicated Resident #5 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and needed assistance with activities of daily living (ADLs). During an interview on 1/4/24 at 7:52 A.M., Resident #5 said there was a wound on his/her foot and he/she was unsure how it got there. Review of the December 2023 hospitalization paperwork indicated Resident #5 was transferred to the hospital on 12/17/23 with fever, change in mental status, and confusion. Resident #5 was treated for pneumonia and discharged back to facility on 12/23/23. Further review of the hospital paperwork indicated Resident #5 had a wound on his/her right outer ankle which was present on admission. The assessment dated [DATE], indicated the area was painful and scabbed, with blanchable erythema surrounding the scab, and a foam dressing was applied to the area. Further review of the discharge paperwork failed to indicate any new treatment orders for the right ankle. Review of Resident #5's recent skin checks indicated but were not limited to the following: -11/30/23, no open areas or marks on the skin were documented. -12/7/23, Right ankle (outer), dried scab noted. -12/14/23, Right ankle (outer), dried scab noted. -Re-Admission 12/23/23, failed to indicate a wound on the right ankle. -12/28/23, Right ankle (outer), treatment in place, followed by the wound doctor. -12/30/23, Other (specify)-Right outer ankle stage 3 previously noted and followed by the wound doctor. Review of the Physician's and Nurse's Notes for Resident #5 failed to indicate the scab noted on the 12/7/23 and 12/14/23 skin checks had been measured or communicated to the physician and/or supervisor, per facility policy. Review of the Incident Reports for Resident #5 failed to indicate an Incident Report had been completed when the scab was noted on 12/7/23 or on 12/14/23, per facility policy. During an interview on 1/9/24 at 4:05 P.M., Nurse #6 said she was interrupted when doing the re-admission skin check and never looked at the Resident's ankle. She said she did not know if the wound was covered with a dressing or not, or what the area looked like as she did not assess the right ankle and should have. Review of the Treatment Administration Record (TAR) for December 2023 indicated but was not limited to the following: -Sure Prep (protective barrier film) was signed off, as administered to right outer ankle from 12/23/23 evening shift through 12/26/23 morning shift. -Sure Prep was not administered to right outer ankle as ordered on 12/26/23 evening shift. Review of the Nurse's Note, dated 12/26/23, indicated the treatment to the right ankle was held because there was a dry, protective dressing over the area. Further review of the Physician's and Nurse's Notes for Resident #5 failed to indicate: -An assessment of the right ankle wound had been completed and communicated to the physician from 12/23/23 through 12/27/23 when the wound doctor saw the Resident. -The dressing on the ankle observed on 12/26/23 had been communicated to the physician. During an interview on 1/9/24 at 4:05 P.M., Nurse #6 was unable to tell the surveyor if she did the treatment as ordered or if there was a dressing on the area on 12/23/23 and 12/25/23. (Nurse #6 had signed off the treatment order for Sure Prep to the right outer ankle on 12/23/23 and 12/25/23). However, Nurse #6 said she had not looked at the right ankle on 12/23/23 when doing the re-admission skin assessment and the first time she had observed the right ankle was on 12/26/23 when she noted the dressing on the area. She said she did not report the dressing observed on the right ankle to the physician or remove the dressing to assess the skin. During an interview on 1/9/24 at 11:55 A.M., Nurse #1 was unable to tell the surveyor if she did the treatment as ordered or if there was a dressing on the area on 12/25/23 and 12/26/23. (Nurse #1 had signed off the treatment order for Sure Prep to the right outer ankle on 12/25/23 and 12/26/23). Further review of the December 2023 Physician's Orders failed to indicate an order for a dressing to the right outer ankle. Review of the Nurse's Note, dated 12/27/23, indicated Resident #5 was seen by the wound doctor for an initial visit related to the lateral ankle open area, previously intact and red prior to medical leave of absence; dry, protective dressing in place upon return for protection of area. Further review of the Nurse's Notes failed to indicate when the dry, protective dressing was applied to the right outer ankle, if it was the same dressing applied while Resident #5 was at the hospital, or that the area to the right outer ankle had been assessed and reported to the Physician. Review of the Physician's Progress Note, dated 12/27/23, indicated Resident #5 had a pressure area and was currently followed by the in-house wound doctor. Review of the Wound Doctor Evaluation Summary, dated 12/27/23, indicated but was not limited to the following: Patient presents with an infected, full thickness wound on his/her right ankle measuring 0.5 x 1 x 0.1 centimeters (cm). The skin surrounding tissue had erythema (redness usually resulting from injury or irritation), wound had light serous drainage and 100% granulation tissue (pink/red tissue that fills an open wound when it starts to heal) noted. The treatment plan was to start Mupirocin 2% topical ointment (antibiotic ointment) and cover with a gauze island dressing twice daily and to off-load the wound. Review of Resident #5's Physician's Orders indicated but was not limited to the following: -Apply Sure Prep two times per day to right outer ankle for red bony prominence (12/21/22) -Wound care: Right lateral ankle: cleanse site with normal saline, pat dry, apply Mupirocin ointment (antibiotic ointment) to wound bed, apply skin prep to peri wound, cover with bordered island gauze every day and evening shift (12/27/23) Resident #5 had a preventative measure order for Sure Prep in place for the bony prominence on the right outer ankle for greater than one year. The new order for the Mupirocin 2% Ointment treatment was obtained on 12/27/23, four days after returning from the hospital when the wound was assessed as a full thickness wound and determined to be infected. During an interview on 1/9/24 at 11:23 A.M., Resident #5 said the ankle wound still hurts but it has a dressing on it now so it's a little better. During an interview on 1/9/24 at 11:30 A.M., Nurse #8 said the area was a callous before, but she had not seen it right before the hospitalization or since Resident #5's return from the hospital. During an interview on 1/9/24 at 11:55 A.M., Nurse #1 said the wound doctor was already here today and she had not done the rounds with the wound doctor, so she had not seen the wound today. She said yesterday the area was still inflamed and was a Stage 3 with yellow drainage and granulation tissue in the center. Additionally, she said Resident #5 had a skin prep order to the right outer ankle area for a long time, for protection. She said she thought the area opened at the hospital, but she did not know the details, as she was off for a few days when the Resident returned. She said she was unsure if a dressing was in place prior to the wound doctor seeing the Resident on 12/27/23. During an interview on 1/9/24 at 12:16 P.M., Unit Manager #1 said she did not know why the area was not documented on the skin check, dated 12/23/23, as it should have been assessed and documented. She said there should have been an order for a dressing written that day and putting skin prep on an open wound would not be an appropriate treatment. She said the wound doctor saw Resident #5 on 12/27/23, the wound was infected, and a new treatment order was not written until then. During an interview on 1/9/24 at 1:00 P.M., the Infection Control Nurse said she was not aware of the wound until 12/27/23, when she and the wound doctor saw the area. She said, as for her progress note dated 12/27/23, the dry protective dressing on the wound was there when they did rounds, but she was unable to recall what type of dressing it was, if it was dated, and did not know who put the dressing on or how long it had been there. Additionally, she said there should have been an order for the dressing and to check it every shift and there was not. During an interview on 1/9/24 at 4:05 P.M., Nurse #6 said before Resident #5 went to the hospital, the right ankle was red and blanchable (skin becomes pale or white when pressure applied), and that it had looked like that for a long time. She said after Resident #5 came back from the hospital on 12/23/23, the first time she observed the area was on 12/26/23 and it had a dressing on it. She said she did not take the dressing down or look at the wound because it was covered and there was not an order to change the dressing. She said there should have been an order for the dressing and to check it, but she thought someone just forgot to put it in, so she passed it on in report to the next shift. Additionally, she said she did not know what type of dressing was on it or if it was dated. During an interview on 1/10/24 at 1:00 P.M., Physician #1 said before the hospitalization it was a Stage 1 (non-blanchable erythema of intact skin)- it was red and non-blanchable, and the area had not improved since his/her return and is at least a Stage 2 (partial-thickness skin loss with exposed dermis) now, but the wound doctor is involved. He said he had not seen the wound since Resident #5 had returned from the hospital until the facility asked him to look at it on 1/8/24. During an interview on 1/10/24 at 4:12 P.M., the Director of Nurses (DON) said the area was closed when he/she went to the hospital, at the hospital they said it was an open abrasion and put a foam dressing on it. She said she did not know why the nurse didn't look at it on admission because she should have and then gotten an order for an appropriate treatment. Additionally, she said the nurses were signing the Sure Prep order so they must have been looking at it, but perhaps not, if Nurse #6 is saying she never saw it from the time of re-admission on 12/23/23 until she saw the dressing on it on 12/26/23. The DON said she herself never looked at the wound and did not know what type of dressing was on it on 12/26/23. Additionally, she said the length of time a dressing would be okay to stay on would depend on the order and Resident #5 did not have any orders for a dressing to the open area from 12/23/23 through 12/27/23 when the wound doctor saw him/her and said the wound was infected. The DON said a foam dressing would be good for a few days, but an island or gauze dressing would usually be changed at least daily. She did not know what type of dressing was on it, when it was put on, or if it was the same foam dressing the hospital had put on the area on 12/18/23. She also said there should have been orders for a dressing and to check it every shift and there were not. She said a skin incident report should be done with all new areas and she had never received any incident report related to Resident #5's right ankle. She said when it was red and then scabbed the nurses should have completed one and they did not. During an interview on 1/10/24 at 4:12 P.M., the Infection Control Nurse said Resident #5 did not have any orders for a dressing to the open area from 12/23/23 through 12/27/23 when the wound doctor saw him/her and said the wound was infected. She said she was not made aware of the wound until 12/27/23 and was told it had a dressing on it. Additionally, she said a foam dressing is usually only good for a few days, but an island or gauze dressing would be changed at least daily. She did not know what type of dressing was on it, when it was put on, or if it was the same foam dressing the hospital had put on the area on 12/18/23. She also said there should have been orders for a dressing and to check it and there were not.

Based on interview, policy review, and document review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that had a systematic analysis and action plan to rectify identified issues. Specifically, after implementing actions to improve call light response time the facility failed to measure the success and track the performance to ensure improvements were sustained. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated as revised in February 2020, indicated the QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: -tracking and measuring performance; -establishing goals and thresholds for performance measurements; -identifying and prioritizing quality deficiencies; -systematically analyzing underlying causes of systemic quality deficiencies; -developing and implementing corrective action or performance improvement activities; and -monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. Review of the Resident Council Meeting Minutes indicated concerns with call light response times in the months of September 2023, October 2023, and November 2023. The Resident Council Minutes indicated the facility had initiated a QAPI project to improve call light response time. On 1/4/24 at 10:30 A.M., the surveyor held a group meeting with 10 residents in attendance. The residents said every month they bring up the concerns of the call lights and discuss waiting anywhere from 30 to 60 minutes for their call lights to be answered. Eight out of 10 residents said they have waited over a half hour for a call light to be answered. They said a facility representative at Resident Council discusses every month that the call light concern will be looked in to, but the Resident Council was never told what the facility was going to do to fix the concern. During an interview on 1/4/24 at 11:40 A.M., the Ombudsman said he attends Resident Council every month. He said there were consistent and constant concerns with call lights not being answered and has brought this to the attention of management with no improvement. During an interview on 1/5/24 at 11:40 A.M., the Activity Director said the residents voice concerns about long call light wait times every month at Resident Council. She said the residents voice waiting 30 minutes to an hour for call lights to be answered and this usually occurs in the evening hours. She said she reports the concerns to the Director of Nurses who also attended one of the Resident Council meetings and there was a QAPI in place. During an interview on 1/9/24 at 9:20 A.M., Unit Manager #3 said she conducts call light audits sporadically during the month, during the weekdays. She said when doing the audits, she waits about 10-15 minutes and then gets the staff to remind them to answer call lights. Review of the QAPI minutes provided by the facility indicated the facility had been conducting call light audits since March 2023. Review of the July 2023 QAPI projects indicated the facility identified a concern through Resident Council for call light response time. Review of an ad hoc QAPI project, dated 10/12/23, indicated a topic of Customer Service/Fall Prevention, with a Goal of Safety/Fall Prevention and an Objective of Staff education on customer service related to answering call lights/fall prevention for every resident. The project indicated the following: -Problems: staff indicating it's not my resident, increase risk of falls -Action: education provided to staff on expectation of answering call lights, rounding, and random call light audits -When: immediate education initiated as a result of a resident falling when a nurse asked for assistance, education monthly at each meeting -Follow-up: Administrator will continue to follow up with staff to ensure understanding of responsibilities to respond to call lights to decrease risk of falls and ensure resident needs are met timely. Review of the Quarterly QAPI Agenda, dated 10/26/23, indicated the following projects: Administrator: Answering call lights Nursing: Fall prevention During an interview on 1/9/24 at 3:17 P.M., the Director of Nurses said the call light audits were conducted by management staff discreetly going to a unit and pulling a call light. She said the audits are conducted between 8:00 A.M. and 5:00 P.M. and the management staff wait 10-15 minutes and will notify staff if the call light has not been answered. She said the management staff are not waiting to see the full response time. The Director of Nurses said the residents had concerns regarding evening call light wait times but no audits had been conducted during that time. She said there was a QAPI plan for call light response time which included conducting audits and the QAPI plan had not been re-evaluated for the effectiveness of doing audits. During an interview on 1/10/24 at 4:00 P.M., the Administrator said the most recent QAPI meeting was held on 10/26/23. He said there was no project in the QAPI binder for October 2023 that was specifically for call light response time, as there had been at the previous quarterly meeting in July 2023. He said there had been a customer service QAPI that included call light response time related to falls. He said the Resident Council continued to identify concerns with call light response time. He said the QAPI project for call lights had not been evaluated for the effectiveness of the program. He said the call light audits provided information but he was not sure what the facility was doing with the information. He said the staff have been educated on answering call lights but this had not changed the concern with call light response time. He said the facility was able to identify the concerns but had not taken the projects further to ensure improvement.

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#5), out of a total sample of 26 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed to obtain a physician's order for Ankle Foot Orthotics (AFO) and to monitor skin surrounding/under the braces daily. Findings include: Review of the [NAME] Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Orthotic and Assistive Devices, dated as last revised February 2022, indicated but was not limited to the following: -An assistive device is any piece of equipment that assists a resident in coping with the effects of his/her disability/limited range of motion due to medical condition. -Determining the best type of device stabilization for the resident includes assessment of skin integrity, rehab screen and recommendation. -Assistive devices are assessed during activities of daily living (ADL), prior to application and after removal. -Skin is assessed during ADL, prior to application and after removal. Report abnormalities to the provider. -Update care plan as needed. -The device is removed regularly, and the resident is assessed for circulation, skin integrity and range of motion. -The reason for the use of the joint stabilization device is documented in the medical record. Resident #5 was admitted to the facility in November 2020 and readmitted after a brief hospitalization in December 2023 with diagnoses that included: hemiplegia and hemiparesis following a cerebral infarction (partial paralysis and weakness after a stroke) affecting right dominant side, difficulty walking, muscle wasting and atrophy and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 10/24/23, indicated Resident #5 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and needed assistance with activities of daily living (ADLs). The surveyor made the following observations: -1/3/24 at 10:06 A.M., Resident #5 was sitting in his/her wheelchair in his/her room with bilateral AFO braces on. -1/4/24 at 7:52 A.M., Resident #5 was sitting in his/her wheelchair in his/her room with bilateral AFO braces on. -1/5/24 at 11:06 A.M., Resident #5 was sitting in his/her wheelchair in the day room with bilateral AFO braces on. -1/8/24 at 9:40 A.M., Resident #5 was sitting in his/her wheelchair in his/her room with bilateral AFO braces on. -1/9/24 at 11:23 A.M., Resident #5 was sitting in his/her wheelchair in day room with bilateral AFO braces on. Review of the current Physician's Orders for Resident #5 failed to indicate an order for bilateral AFO braces or an order to check the skin surrounding/under the braces daily. Review of the Care Plan failed to indicate Resident #5 wore AFO braces daily. During an interview on 1/4/24 at 7:52 A.M., Resident #5 said he/she wears the AFO braces every day. During an interview on 1/4/24 at 9:36 A.M, Nurse #1 said Resident #5 wears the AFOs every day. During an interview on 1/8/24 at 2:34 P.M., the Director of Nurses (DON) said Resident #5 has bilateral AFO braces and wears them daily. Additionally, she said there is no order for them and there should be. She said there should be an order to put them on and take them off and an order to monitor the Resident's skin daily. She said a care plan for the use of the AFO's should be in place and there is not one. During an interview on 1/9/24 at 11:30 A.M., Nurse #8 said Resident #5 wears the AFOs every day. During an interview on 1/9/24 at 12:16 P.M., Unit Manager #1 said Resident #5 has had the AFO braces for years and there should have been orders in place for them, specifically to put them on, take them off, and for skin checks daily. During an interview on 1/9/24 at 4:05 P.M., Nurse #6 said Resident #5 has had the AFO braces forever, and she did not realize there were no orders for them but there should have been orders in place for them.

Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding long call light wait times were acted upon to resolve the issue. Findings include: Review of the facility's policy titled Resident/Family Council, dated 12/19/22, indicated residents may voice grievances to the Resident Service Coordinator, Performance Improvement Coordinator, Social Services designee or Charge Nurse. The management team shall investigate any grievance. Review of the Resident Council Minutes, dated 9/7/23, indicated call light response time continued to be an issue, there was a QAPI (Quality Assurance and Performance Improvement) plan in place for call lights, nursing would continue to monitor, and the Resident Council requested the Director of Nurses attend the next meeting. Review of the follow up provided by the facility indicated a call light audit was conducted in September 2023 with call light wait times ranging from 4 minutes to 15 minutes. No other information was provided in response to the September Resident Council concern of long call light wait times. Review of the Resident Council Minutes, dated 10/5/23, indicated call lights continued to be an issue. The Director of Nurses was in attendance and addressed call light concerns stating the unit managers would conduct audits and there was an ongoing QAPI plan in place. Review of the follow up provided by the facility indicated a call light audit was conducted in October 2023 with call light wait times ranging from 2 minutes to 15 minutes and staff education to answer call lights was conducted on 10/23/23. Review of the Resident Council Minutes, dated 11/2/23, indicated call lights continued to be an issue, that Unit Managers had completed call light audits, and there was a QAPI plan in place for call lights and nursing would continue to monitor. Review of the follow up provided by the facility indicated a call light audit was conducted in November 2023 with call light wait times ranging from 4 minutes to 13 minutes. No other information was provided in response to the November Resident Council concern of long call light wait times. On 1/4/24 at 10:30 A.M., the surveyor held a group meeting with 10 residents in attendance. The residents said every month they bring up the concerns of the call lights and discuss waiting anywhere from 30 to 60 minutes for their call lights to be answered. Eight out of 10 residents said they have waited over a half hour for a call light to be answered. They said a facility representative at Resident Council discusses every month that the call light concern will be looked into, but the Resident Council was never told what the facility was going to do to fix the concern. During an interview on 1/4/24 at 11:40 A.M., the Ombudsman said he attends Resident Council every month. He said there were consistent and constant concerns with call lights not being answered and has brought this to the attention of management with no improvement. The Ombudsman said he has observed call lights on and multiple staff members sitting at a nurses' station and not responding to the call lights. During an interview on 1/5/24 at 11:40 A.M., the Activity Director said the residents voice concerns about long call light wait times every month at Resident Council. She said the residents voice waiting 30 minutes to an hour for call lights to be answered and this usually occurs in the evening hours. She said she reports the concerns to the Director of Nurses who also attended one of the Resident Council meetings. During an interview on 1/5/24 at 12:04 P.M., the Director of Nurses said she and other management staff have been conducting call light audits and if any call light is on for 10 to 15 minutes they will intervene and pull the staff together for an ad hoc education on answering call lights timely. During an interview on 1/9/24 at 9:20 A.M., Unit Manager #3 said she conducts call light audits sporadically during the month, during the weekdays. She said when doing the audits, she waits about 10-15 minutes and then gets the staff to remind them to answer call lights. During an interview on 1/9/24 at 3:17 P.M., the Director of Nurses said the call light audits were conducted by management staff discreetly going to a unit and pulling a call light. She said the audits are conducted between 8:00 A.M. and 5:00 P.M. and the management staff wait 10-15 minutes and will notify staff if the call light has not been answered. She said the management staff are not waiting to see the full response time. The Director of Nurses said the residents had concerns regarding evening call light wait times but no audits had been conducted during that time. She said there was a QAPI plan for call light response time which included conducting audits and the QAPI plan had not been re-evaluated for the effectiveness of doing audits.

Based on records reviewed and interviews for one of three sampled Residents (Resident #1), who was severely cognitively impaired and required physical assistance of one staff person to meet his/her care needs, the Facility failed to ensure he/she was free from physical abuse by staff, when on 03/29/23 at approximately 5:50 A.M., Certified Nurse Aide (CNA) #2 witnessed CNA #1 grab Resident #1's face and push his/her head backward onto the bed, hold his/her arms down, and squeeze/pinch his/her arms. Although Resident#1's impaired cognition minimized his/her understanding of the incident, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner. Findings include: Review of the Facility's Policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated as revised April 2021, indicated the following: -residents have the right to be free from abuse, -the resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment to protect residents from abuse by anyone, including staff, and -the facility will establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, and emotional problems. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/29/23, indicated that on 3/29/23 at approximately 6:00 A.M., a Certified Nurse Aide (later identified as CNA #2), witnessed another CNA (later identified as CNA #1) grab a resident (later identified as Resident #1). The Report indicated CNA #2 reported the abuse to a nurse (later identified as Nurse #1). Review of the Facility's Investigation Report, undated, indicated that on 03/29/23 at 6:24 A.M., Nurse #1 called the Administrator and said CNA #2 reported to her that she had witnessed CNA #1 grab a resident. The Report indicated that CNA #2 reported to Nurse #1 that CNA #1 pushed Resident #1's face backward then pinched his/her arms as she was forcefully holding down Resident #1's arms. The Report indicated that CNA #2 said Resident #1 was combative and CNA #1 grabbed Resident #1's face really hard and slapped his/her arms. The Report indicated that CNA #2 said when she saw the situation, she told CNA #1 No, no. no! to intervene, and CNA #1 stopped. Resident #1 was admitted to the Facility in July 2020, diagnoses included Alzheimer's Disease, depression, and anxiety disorder. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 02/02/23, indicated that Resident #1 had severe cognitive impairment and required physical assistance of one staff to meet his/her care needs. Review of Nurse #1's Written Witness Statement, dated 03/29/23 at 6:15 A.M., indicated that Nurse #1 said that on 03/29/23, CNA #2 came to her visibly upset, shaking, and crying, and told her that CNA #1 assaulted one of the residents (later identified as Resident #1) during care. The Statement indicated Nurse #1 said CNA #2 told her that CNA #1 pushed Resident #1's face backward, pinched his/her arms and forcefully held his/her arms down. The Statement indicated that Nurse #1 said she immediately assessed Resident #1 and said Resident #1 told her, You have [NAME] working here, and she did this to me .as Resident #1 motioned with his/her hand pushing his/her own face and head backward. The Surveyor was unable to interview Nurse #1, as she did not respond to the Department of Public Health's telephone or letter requests for an interview. During an interview on 05/16/23 at 11:02 A.M., and review of CNA #2's Written Witness Statement, dated 03/29/23, CNA #2 said on 03/29/23, at approximately 5:50 A.M., CNA #1 asked her to help with Resident #1 because Resident #1 was being combative. CNA #2 said when she entered Resident #1's room, she saw Resident #1 in bed and he/she was pushing and kicking CNA #1. CNA #2 said CNA #1 grabbed Resident #1's face and pushed his/her head back onto his/her bed. CNA #2 said Resident #1 screamed when CNA #1 pushed his/her face. CNA #2 said CNA #1 also squeezed/pinched and held Resident #1's arms really hard. CNA #2 said she yelled, No, no, no!, and then CNA #1 stopped and left Resident #1's room. CNA #2 said she was so upset and nervous after she saw CNA #1 physically abuse Resident #1 and said she ran out to tell Nurse #1. Review of a Written Interview Report conducted by the Director of Nurses (DON) and the Chief Nursing Officer, dated 03/30/23, indicated that the nurse on duty (Nurse #1) said that CNA #2 reported an alleged incident to her, and said she identified the alleged victim to be Resident #1. The Report indicated that Nurse #1 said CNA #2 approached her, that CNA #2 was very upset and reported to her that she witnessed CNA #1 physically assault Resident #1 during care. The Report indicated that Nurse #1 said CNA #2 told her that CNA #1 pushed Resident #1's face backward and squeezed/pinched his/her arms as she forcefully held Resident #1's arms down. The Report indicated that CNA #2 said Resident #1 was being combative when CNA #1 grabbed Resident #1's face really hard and slapped his/her arms. The Report indicated that CNA #2 said when she saw this, she told CNA #1 No, no, no! as a way to intervene in the situation and then CNA #1 stopped. Review of a Written Interview Report conducted by the DON and the Chief Nursing Officer, dated 03/30/23, indicated that CNA #1 said on the morning of 03/29/23, she was trying to change Resident #1's brief when he/she started fighting back, and was grabbing at her (CNA #1's) hands. The Report indicated that CNA #1 said she went to get CNA #2 to help her get Resident #1 out of bed, and that he/she continued to fight her, so she told the nurse, and they left Resident #1 in bed. During an interview on 05/22/23 at 11:04 A.M., and review of CNA #1's Written Witness Statement, dated 03/29/23, CNA #1 said Resident #1 tried to scratch her up all over the place and grabbed the skin on her arms. CNA #1 said she tried to get her own skin out of Resident #1's grip, so she held Resident #1's hands. CNA #1 said Resident #1 was fighting her so she had asked CNA #2 for help. CNA #1 said she was not familiar with Resident #1 or CNA #2. During an interview on 05/17/23 at 9:46 A.M., and review of a Written Witness Statement, dated 03/29/23, Social Worker (SW) #1 said she was Resident #1's primary SW, she knew him/her well, and spoke with Resident #1 at least four times per week. SW #1 said she asked Resident #1 what happened and said Resident #1 told her he/she had been in a fight, and said the other person was heavy set and dressed like that as he/she pointed to someone in scrubs. SW #1 said as Resident #1 pointed to another staff member wearing scrubs, and told her, hers had flowers on them. SW #1 said Resident #1 also told her that the person was pulling at his/her clothes. SW #1 said Resident #1 did not typically talk about fights and/or anything related to complaints about staff, even though he/she was frequently combative with care. SW #1 said Resident #1's complaint about being in a fight was out of the ordinary for him/her. During an interview on 05/16/23 at 2:01 P.M., Unit Manager #1 said Resident #1 was disoriented and had uncontrolled anxiety. Unit Manager #1 said when she arrived to the facility on [DATE], the Administrator had already interviewed Resident #1. Unit Manager #1 said the Administrator told her CNA #2 said that CNA #1 pushed Resident #1's head back, held his/her arm and possible pinched his/her arm, while providing care. During an interview on 05/17/23 at 12:45 P.M., the Director of Nurses (DON) said she was notified on 03/29/23 at 6:30 A.M. that CNA #2 saw CNA #1 push Resident #1's head backward, and said both CNA #1 and CNA #2 had said that Resident #1 was agitated. The DON said CNA #1 had left the Facility by the time she got there. The DON said she interviewed CNA #2 via phone on the 03/29/23, and said she re-interviewed CNA #1 and CNA #2 on 03/30/23 because she needed to clarify what they had written in their statements. During an interview on 05/17/23 at 1:14 P.M., the Administrator said on 03/29/23, early in the morning (exact time unknown), Nurse #1 reported to him that CNA #2 told her that CNA #1 pushed Resident #1, and said later he read that Nurse #1's statement indicated CNA #1 pushed Resident #1's face. The Administrator said he suspended CNA #1 immediately during their investigation. However, the facility was unable to provide any documenation to support that all staff were in-serviced or re-educated related to resident abuse, or that any other additional corrective actions were implemented

Based on observation, interview, and schedule review, the facility 1. Failed to ensure there was sufficient staff available to provide nursing services and care required to meet the residents needs; and 2. Failed to ensure there was sufficient clinical staff to assure resident safety for one Resident (#93). Findings include: 1. During an interview on 4/12/22 at 3:30 P.M., the Ombudsman said the family members of residents had been complaining about the facility not having enough staffing and not replacing staff when there was a call-out, especially in the evenings. On 4/14/22 at 11:00 A.M., the surveyor held a group meeting with 10 residents in attendance. During the meeting, residents said there were not enough staff working on the units and sometimes on the 3:00 P.M. to 11:00 P.M. shift there are only two Certified Nursing Assistants (CNAs) on the long-term care units (each having approximately 40 residents). Six out of 10 residents said in the previous two weeks, they had waited over a half hour for their call light to be answered. A. On 4/14/22 at 4:40 P.M., the surveyor observed the Slades [NAME] unit to have three call lights ringing. Resident #69 was sitting in his/her doorway and said he/she needed to go to the bathroom. At 5:02 P.M., Nurse #10 told Resident #69 that she will get someone to help him/her. The Resident responded that he/she had been waiting a half hour. A CNA arrived at 5:04 P.M. to assist the Resident, 24 minutes after the surveyor observed the call light to be on. During an interview on 4/14/22 at 5:10 P.M., CNA #9 said there were currently three CNAs working on the unit, with 42 residents (14 residents per CNA). She said it was difficult to get to all of the residents when there were only three CNAs and that was why the call lights were going off. She said there were times when there were only 2 CNAs working the 3:00 P.M. to 11:00 P.M. shift and they were not able to provide care to all of the residents. During an interview on 4/14/22 at 5:15 P.M., Nurse #11 said the unit often only had three CNAs and the staff could not get to all the residents' care timely. B. During an interview on 4/13/22 at 1:51 P.M., Resident #26 said he/she was told they could not have a shower on the previous night because there were only two CNAs working the 3:00 P.M. to 11:00 P.M. shift. Resident #26 said the facility frequently did not have the staff for showers, especially on the 3:00 P.M. to 11:00 P.M. shift and weekends. During an interview on 4/13/22 at 1:37 P.M., Resident #38 said there were only two CNAs on duty the previous night, so he/she did not get the alternate meal he/she requested. During an interview on 4/13/22 at 3:20 P.M., the family member of Resident #77 said she had concerns with the lack of staffing. She said the Resident gets out of bed in the morning and prefers to go back to bed for a nap around 1:30 P.M. She said when the Resident goes back to bed, the staff do not get the Resident out of bed for dinner. She said she had concerns regarding the Resident being in bed from 1:30 P.M. until 9:00 A.M. She said the staff had told her there were not enough staff to get the Resident out of bed on the 3:00 P.M. to 11:00 P.M. shift. During an interview on 4/14/22 at 11:00 A.M., Resident #61 said he/she did not get out of bed on some weekends because there was not enough staff and had missed Bingo. During an interview on 4/14/22 at 4:30 P.M., Resident #35 said he/she had previously waited for 40 minutes on a commode for help and there was not enough staff. During an interview on 4/19/22 at 8:45 A.M., Resident #4 said there was not enough staff over the weekend and he/she had not gotten washed up over the weekend. During interviews on 4/19/22 at 11:30 A.M., Resident #35 said he/she was experiencing respiratory difficulty over the weekend and waited 50 minutes for the call light to be answered. On 4/21/22 at 8:10 A.M., Resident #35 said he/she did not receive showers because they did not have enough staff. C. During an interview on 4/13/22 at 11:30 A.M., CNA #8 told the surveyor that it was not uncommon to have anywhere from 16 to 19 residents to care for on one shift. CNA #8 said it occurred the middle of March and that it was the day shift (7:00 A.M. to 3:00 P.M.). CNA #8 said the nurses do not help out. CNA #8 said that one CNA should be not be providing care to that number of residents alone. During an interview on 4/14/22 at 4:20 P.M., Nurse #2 said the facility had been very short staffed. He said the staff wanted to provide care to the residents, but they were not able to because there were not enough staff. He said sometimes on the 3:00 P.M. to 11:00 P.M. shift there were only two CNAs on the long-term care units, and it was not enough. During an interview on 4/15/22 at 2:00 P.M., Certified Nursing Assistant (CNA) #12 said Resident #4 was due for a shower today. She said for the Resident to take a shower they need to have enough staff. Review of the shower schedule log along with CNA #12 indicated Resident was scheduled to receive a shower on 4/15/22 on the 7:00 A.M.- 3:30 P.M. shift. CNA #12 said she does not want to give him/her a shower today because it is only the three of us here for the 7:00 A.M. to 3:30 P.M. shift. The CNA said it is supposed to be five of us and we only have three on the schedule for today. During an interview on 4/20/22 at 4:00 P.M., CNA #1 said it is very difficult working the 3:00 P.M. to 11:00 P.M. on the short-term rehabilitation unit with 16 to 18 residents and one CNA. She said the nurse helps the best she could, but residents did not always get to bed on time. She said the facility previously used agency staff who would come to help, but they had not had that in a while. D. During an interview on 4/20/22 at 4:45 P.M., the Scheduler said the facility had contracts with staffing agencies but tend to use them regularly (scheduled blocks) for nurses and that she had been told not to use too many agency CNAs by the Administrator. She said the staffing schedule should be the following for CNAs: [NAME]: 3 CNAs for 7:00 A.M. to 3:00 P.M. and 2 CNAs for 3:00 P.M. to 11:00 P.M. Slades [NAME] and Pottersville: 5 CNAs for each unit for 7:00 A.M. to 3:00 P.M. and 4 CNAs for each unit for 3:00 P.M. to 11:00 P.M. She said sometimes the long-term care units (Slades [NAME] and Pottersville) will have 4 CNAs on the day shift or 3 CNAs on the evening shift. Review of the schedule of staff from 4/1/22 through 4/15/22, provided by the facility (as worked) indicated the following days when this ratio was not met: 4/1/22: Pottersville: from 10:00 A.M. until 3:00 P.M. had 2 CNAs with 46 residents [NAME] Point: from 3:00 P.M. to 10:00 P.M. had 1 CNA with 18 residents Slades [NAME]: from 6:30 P.M. to 10:00 P.M. had 2 CNAs with 42 residents 4/2/22: Pottersville: from 7:30 P.M. to 11:30 P.M. had 2 CNAs with 46 residents Slades [NAME]: from 2:30 P.M. until 5:00 P.M. had 2 CNAs with 42 residents 4/3/22: Pottersville: from 3:30 P.M. to 6:00 P.M. had 2 CNAs with 46 residents 4/4/22: [NAME]: from 6:30 A.M. until 2:30 P.M. had 1 CNA with 18 residents Pottersville: from 12:00 P.M. until 2:00 P.M. had 2 CNAs and from 3:00 P.M. to 10: 00 P.M. had 2 CNAs for 46 residents Slades [NAME]: from 7:00 A.M. to 2:00 P.M. had 3 CNAs for 42 residents 4/6/22: Pottersville: from 2:30 P.M. to 7:00 P.M. had 2 CNAs for 46 residents 4/8/22: Pottersville: from 2:30 P.M. to 7:00 P.M. had 2 CNAs for 46 residents Slades [NAME]: from 7:00 P.M. to 10:00 P.M. had 2 CNAs for 42 residents 4/9/22: Slades [NAME]: from 2:30 P.M. until 6:00 P.M. had 1 CNA for 42 residents 4/10/22: Slades [NAME]: from 6:00 P.M. to 10 P.M. had 2 CNAs for 42 residents 4/15/22: [NAME]: from 3:30 P.M. to 5:00 P.M. had 1 CNA for 20 residents During an interview on 4/20/22 at 05:30 P.M., the Administrator said the facility utilized agency nurses on a regularly scheduled basis and was looking to start using a scheduled CNA on the 11:00 P.M. to 7:00 A.M. shift. She said there were no regularly scheduled agency CNAs at this time and the facility tried to get staff if there were call outs, but they were not always able to get the staff. 2. For Resident #93 the facility failed to provide adequate staffing to maintain supervision of the resident. Resident #93 was admitted to the facility in February 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #93 indicated the Resident had 17 falls in the two months between admission to the facility through 4/20/22. The following eight falls were reviewed for staffing ratios: -3/20/22 at 7:00 P.M. fall in day room. Two staff statements which indicated there was one CNA and one nurse working, with 17 residents. Review of the schedule indicated there was one nurse and one CNA for 17 residents. -3/21/22 at unknown times; nursing progress notes indicated Resident #93 fell four times during the day shift. Review of the schedule indicated there was one nurse and one CNA for 17 residents. -4/1/22 at an unknown time; Resident was found on the left side of his/her bed on the floor. Review of the documentation indicated the nursing progress note was written at 6:32 P.M. Review of the schedule indicated there was one nurse and one CNA for 18 residents. -4/16/22 at 5:55 P.M. Resident had a fall with a suspected head strike, showing signs of pain, while waiting for the ambulance resident began to fall asleep and not easily aroused. Review of the schedule indicated there was one nurse and one CNA for 20 residents. -4/18/22 at 6:30 P.M. Resident fell at the nurses' station. Review of the documentation indicated the Resident said he/she smacked his/her face. Review of the schedule indicated there was one nurse and 3 CNAs for 42 residents. During an interview on 4/20/22 at 4:00 P.M., CNA #1 said on the 3:00 P.M. to 11:00 P.M. shift if there were two CNAs, then one would sit with the Resident in the day room, while the other provided care to residents and the staff would take turns offering the Resident supervision. She said when there was only one CNA it was difficult to provide supervision to prevent falls and occasionally Resident #93 would sit with the nurse in the hall, while the nurse provided medications to other residents. Review of the Nursing Progress notes indicated on the following days the staff referenced Resident #93 needing one to one (1:1) supervision: 2/22/22, 2/23/22, 3/1/22, 3/5/22, 3/6/22, 4/12/22, 4/14/22, and 4/15/22. During an interview on 4/20/22 at 5:24 P.M., the Director of Nurses said she was not aware that staff needed to provide 1:1 supervision to Resident #93, she had not scheduled a staff member to provide 1:1 supervision and she said the nurse on the medication cart should not be providing that supervision while distributing medications to other residents.

Based on interview and record review, the facility failed to immediately notify and consult with the physician that significant medications were not administered to 34 of 39 residents and treatments were not administered for 7 of 39 residents on the [NAME] Unit on 7/10/22 to potentially alter or commence a new course of treatment resulting in the likelihood of serious outcomes and specifically, for one Resident (#1 A) requiring an extended duration of intravenous (IV) antibiotic therapy and an extended stay at the facility. It was determined the Immediate Jeopardy began on 7/10/22 and was identified on 7/15/22. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 7/15/22, including the Immediate Jeopardy Templates. The Immediate Jeopardy which began on 7/10/22 was found to be removed on 7/21/22 following an onsite visit on 7/22/22. In addition to the residents in Immediate Jeopardy, non-compliance at F580 continued at a lower scope and severity of actual harm that is not immediate jeopardy because the facility also failed 2. For Resident #38, to notify the physician of a pressure injury on the Resident's coccyx, and of treatment recommendations made by the wound consultant; and 3. For Resident #95, to notify the Nurse Practioner and/or physician that 18 doses of a chemotherapeutic medication had not been administered. Findings include: 1. On 7/12/22 at 10:00 A.M., during a tour of the [NAME] Unit, the surveyor identified through resident interviews and review of the medication administration records (MAR) that significant medications and treatments had not been administered to residents during the 7:00 A.M. to 3:00 P.M. and the 3:00 P.M. to 11:00 P.M. shifts on 7/10/22 and only one nurse was assigned to care for 39 residents. Review of the MAR, dated 7/10/22, for 39 out of 39 residents on the [NAME] Unit indicated every resident had a missed scheduled medication on 7/10/22 from 7:00 A.M. through 11:00 P.M. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Insulin (injection to treat high blood sugar in diabetics), 11 residents missed doses -Diuretics (to help rid the body of salt and water), 6 residents missed doses -Cardiac Medications (relating to the heart), 25 residents missed doses -IV Antibiotics, 3 residents missed doses -Antibiotics (oral), 6 residents missed doses -Anticoagulants (prevent or reduce coagulation of blood), 11 residents missed doses -Pain Medications, 6 residents missed doses -Oral Hypoglycemic Agents (to treat diabetes), 9 residents missed doses -Respiratory treatments (Duonebs), 2 residents missed doses Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for 39 residents on the [NAME] unit indicated 7 residents did not receive treatments to their wounds on 7/10/22. Review of 39 of 39 medical records failed to indicate the physician was notified of the missed medications and the missed treatments. During an interview on 7/13/22 at 3:00 P.M., Nurse Practitioner #1 said she and Physician #1 had not been notified of which residents did not receive medications on 7/10/22 and which medications were missed, so she was unsure if an alteration in treatment was needed. During an interview on 7/13/22 at 3:30 P.M., Unit Manager #1 said she had just called the Medical Director, two days after the missed medications, and said, I told him about all the medications that had not been given. During an interview on 7/14/22, the Medical Director said he was not notified that the residents did not receive their significant medications or treatments on 7/10/22 until after the fact requiring him to have to extend IV antibiotics for one Resident (#1 A). The Medical Director said, They need more people; that's the problem and that there was a shortage of nurses. Review of a Social Service progress note, dated 7/19/22, indicated Resident #1A's discharge date scheduled for 7/20/22 would need to be extended to 7/24/22 to continue with IV antibiotic therapy. See F725, F760, and F835 The non-compliance continued at a lower scope and severity of actual harm that is not immediate jeopardy as follows: 2. Resident #38 was readmitted to the facility in June 2022 with a pressure injury wound to the right buttock. Review of the Initial Wound Evaluation and Management Summary, dated 6/30/22, indicated a wound to the right buttock. The consultant form did not indicate there were any additional pressure areas. Review of the Wound Evaluation and Management Summary, dated 7/5/22, indicated the wound to the right buttock had resolved. The wound consultant form further indicated a new stage 2 pressure area to the coccyx measuring 6 centimeters (cm) (length) by 2 cm (width) by 0.1 cm (depth), a surface area of 12.0 cm squared; with [CONDITION(S)] (redness), excoriation (damage to the surface) and surrounding deep tissue injury. The recommendations included to off-load the wounds, add Vitamin C, add [MEDICATION(S)], add a multivitamin, and add a protein supplement. In addition, the recommended wound treatment was for [MEDICATION(S)], followed by a gauze island with border, twice daily. A review of the July 2022 Treatment Administration Record (TAR) failed to include any treatments to the coccyx area. Review of the Wound Evaluation and Management Summary, dated 7/12/22, indicated the pressure injury to the coccyx had deteriorated, was now a stage 3 pressure injury measuring 15 cm (length) by 2 cm (width) by 0.1 cm (depth), now 30 cm squared; with surrounding deep tissue injury, maceration (softening, breaking down) and an odor with 30% necrotic tissue, 20% granulation tissue and 50% other viable tissue. The recommended treatment was for Alginate Calcium, [MEDICATION(S)] followed by a gauze island with border, once daily. Review of the medical record on 7/13/22 failed to include any documentation regarding the stage 3 pressure injury and failed to include any treatments to the area. During an interview on 7/14/22 at 7:25 A.M., the Medical Director (the primary physician for Resident #38) said there's not much of a pressure there for Resident #38. When the surveyor informed the physician of the stage 3 pressure injury to the coccyx, which had increased in size from 7/5/22 to 7/12/22, the Physician said he was not aware of the pressure area to the coccyx and had not been notified of any of the recommendations for treatment to the area. 3. Resident #95 was admitted to the facility in March 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record included an oncology visit summary from 5/10/22 which indicated to take [MEDICATION(S)] (a [CONDITION(S)] medication) for 21 days, with a 7-day break. Review of an oncology report of consultation, dated 6/14/22, indicated to continue [MEDICATION(S)] with the next start date of 7/1/22. During an interview on 7/13/22 at 3:00 P.M., Nurse Practitioner (NP) #1 said she was concerned Resident #95 had missed one treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #95's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/14/22 at 8:50 A.M., Nurse #6 said on 7/6/22 she had contacted the facility contracted pharmacy to inquire about the medication and was informed it would need to be filled by the oncology pharmacy, it was ordered at that time, and would take about a week to fill the prescription. During an interview on 7/14/22 at 12:25 P.M., NP #1 said Resident #95 was in remission for a period of time and was no longer in remission and the physicians were attempting to get a handle on the treatment. She said herself and the primary physician were not informed Resident #95 had missed 13 doses of the [CONDITION(S)] medication and she should have been notified.

Based on observation, record review, policy review, and interview the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for 10 Residents (#12, #20, #52, #82, #107, #258, #94, #259, #108, and #109), out of a total sample of 30 residents. Specifically, the facility failed 1. For Resident #12, to obtain a physician's order for the administration of eye drops. 2. For Resident #20, to ensure that a treatment recommendation from a consultant was addressed by facility staff or the Physician, and a follow up appointment was made. 3. For Resident #52, to: a. Ensure the physician's order for the Resident being-1:1 (one to one) feed (order dated [DATE]) was implemented. b. Accurately document the Resident's ability to self-release a seatbelt. c. Transcribe a verbal physician's order at the time it was obtained (three times that the Resident had been sent to the hospital). 4. For Resident #82, to ensure that Resident #82's pacemaker was monitored. 5. For Resident #107, to inform the physician about the change in time on the Resident's cardiac medication, as per the physician's orders. 6. For Resident #258, the facility failed to ensure the physician was notified for a blood sugar over 200. 7. For Resident #94, to a. Ensure that when medications were unavailable for administration, the physician was notified. b. Ensure that medications were administered per the physician's orders. 8. For Resident #259, to ensure the Residents pacemaker was monitored and evaluated as per the facility policy and standards of practice. 9. For Resident #108, to ensure that staff followed professional standards for the following: a.) the facility staff failed to implement a physician's order for a advanced directives b.) the facility staff failed to obtain a physician's order to transfer Resident #108 to hospital for acute care; and c.) the facility staff failed to obtain a physician's order for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 10. For Resident #109, to ensure staff followed professional standards, to ensure recommendations made by the Hospice service were communicated to the Resident's physician, transcribed properly and his/her medication were administered per the physician's order. Findings include: 1. Resident #12 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] Minimum Data Set assessment indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. During an interview on [DATE] at 8:38 A.M., Resident #12 said that he/she experiences dry eyes and uses [MEDICATION(S)] eye drops that he/she keeps in the top drawer of the bureau. The Resident said that whenever he/she wants to use them, the Certified Nursing Assistants (CNA) will put them in his/her eyes. The Resident gave the surveyor permission to open the top drawer of the bureau and two opened boxes of [MEDICATION(S)] lubricant eye drops were observed. During an interview with Resident #12 on [DATE] at 10:11 A.M., Nurse #4 entered the Resident's room to administer medications. Resident #12 told Nurse #4 that he/she keeps [MEDICATION(S)] eye drops in the bureau, and the CNAs administer them whenever he/she requests. Nurse #4 examined the two boxes of eye drops and said that there was no Physician's order for the eye drops, that CNA staff should not administer the eye drops, and the drops should not be kept in the Resident's bureau. During an interview on [DATE] at 10:23 A.M., CNA #2 said that she places [MEDICATION(S)] eye drops into Resident #12's eyes whenever he/she asks her to. 2. Resident #20 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the [DATE] Minimum Data Set assessment indicated Resident #20 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of the medical record indicated a [DATE] Report of Consultation completed by a community Dermatology consultant. The report indicated Resident #20 had [NAME] surgery (surgical technique used to treat skin cancer) done to a lesion on the left side of the nose, and a biopsy to the lesion on the right side of the nose. A follow up appointment was scheduled for [DATE]. On [DATE] at 12:34 P.M., the surveyor observed an opened envelope with a [DATE] Report of Consultation completed by a community Dermatology group at the nursing station. The report indicated: sutures removed, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the report failed to indicate any notation to indicate the consultant's note was reviewed by facility staff, or the Resident's Physician was notified of the recommendation. Review of the medical record failed to indicate that Vaseline was applied, and a follow up appointment scheduled as indicated by the Dermatology consultant in the [DATE] consultant note. During an interview on [DATE] at 12:55 P.M., Resident #20 said that he/she went to the Dermatologist to have sutures removed in [DATE] and has not returned for another visit. The Resident pointed to a lesion on his/her left cheek and said that the area needs to be checked out. The Resident said he/she was concerned about the area and was dry and itchy. The surveyor asked if staff had applied Vaseline to any areas on his/her face since the sutures were removed, and the Resident said, No. During an interview on [DATE] at 1:15 P.M., the surveyor and Nurse #1 reviewed the Dermatologist's Report of Consultation and the medical record. She said that there was no documentation to indicate the treatment recommendation was addressed by facility staff or the Physician, and a follow up appointment was not made. 3. Resident #52 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] Minimum Data Set indicated Resident #52 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15 and required extensive assistance/was dependent on staff for activities of daily living. a. Review of [DATE] Physician's Orders indicated the following dietary order including: -Regular/Liberalized diet, 1:1 (one to one) feed (initiated [DATE]) On [DATE] from 8:35 A.M. to 10:15 A.M., the surveyor observed Resident #52 seated in a wheelchair at the bedside sleeping. An overbed table with a breakfast tray (uncovered) on it was in front of the Resident. During the continuous observation, no staff entered the room to supervise, cue, encourage or feed the Resident. During an interview on [DATE] at 10:18 A.M., Nurse #12 said Resident #52 is dependent of staff to feed him/her, and the Resident should have been brought to the dining room and fed, not left alone in his/her room. b. Review of [DATE] Physician's orders indicated a [DATE] Physician's Order for a self-release alarming seatbelt to be on while up in a chair, check placement, function, and if resident is able to self-release every shift for safety. On [DATE] at 12:29 P.M., the surveyor observed Resident #52 seated at a table in the unit dining room being fed by Nurse #1. Resident #52 had a seat belt on. On [DATE] at 8:43 A.M., the surveyor observed Resident #52 seated in a wheelchair in his/her room sleeping. Resident #52 had a seat belt on. During an interview with Nurse #12 on [DATE] at 10:18 A.M., the surveyor observed Resident #52 seated in a wheelchair near the nursing station with a seat belt on. Nurse #12 said that the seat belt was not a restraint and was in place to prevent the Resident from falling out of the wheelchair. The surveyor requested Nurse #12 to ask the Resident to release the seat belt. The Nurse asked the Resident several times to release the seat belt, and Resident #52 was unable to release the seat belt on command. Nurse #12 said that she has never asked the Resident to release the seat belt, and he/she does not have the cognitive ability to understand a command to release it. On [DATE] at 11:53 A.M., the surveyor observed Resident #52 seated at a table in the unit dining room with a seat belt on. The surveyor requested that Nurse #5 ask the Resident to demonstrate releasing the seat belt. Nurse #5 asked the Resident multiple times to release the seat belt, and he/she was unable to do so. Nurse #5 said that he has never observed the Resident release the seat belt on command. Review of the [DATE] Treatment Administration Record (TAR), indicated although Nurse #12 and Nurse #5 said they had never observed Resident #52 release the alarmed seat belt on command, they documented they observed the Resident self release it on 30 occasions in [DATE] occasions in February 2022, 29 occasions in [DATE], and 18 occasions in [DATE]. During an interview on [DATE] at 12:45 P.M., the surveyor reviewed the medical record, observations, and staff interviews with the Director of Nursing (DON). She said the alarmed seat belt is a restraint because the Resident cannot release it when asked, and she found it disturbing that staff were inaccurately documenting the TAR to indicate the Resident was able to release it. c. Review of the medical record indicated that Resident #52 was transferred to the hospital on [DATE], [DATE], and [DATE], for evaluation after sustaining unwitnessed falls. Further review of the medical record failed to indicate that a Physician's order was obtained for the Resident to be transferred to the hospital for evaluation. During interviews on [DATE] at 1:15 P.M. with Nurse #1, and at 2:20 P.M. with Nursing Supervisor #1, the surveyor reviewed Resident #52's medical record. They said they were unable for find Physician's orders for transfers to the hospital on [DATE], [DATE], and [DATE]. 4. Review of the facility's policy titled Pacemaker-ICD Management, revised ,d+[DATE], included but was not limited to: It is the policy of this facility that residents with a pacemaker be managed for safe operation and equipment functionality. Any resident with a pacemaker will have their pacemaker checked in accordance with standards of practice as outlined below or sooner if symptoms develop. Upon admission residents should be observed for the presence of a pacemaker This can be obtained through resident history interview, family interview or hospital referral paperwork. If a pacemaker is present, it should be documented in the medical record. A photocopy of the ID card or obtain information regarding the pacemaker such as model, make, and date of insertion and special precautions should be placed in residents record and subsequent physician orders. Obtain orders for pacemaker management and telephonic/office monitoring as applicable. Orders may include, but are not limited to: -Contact number Frequency of telephonic checks -Instructions on how to use the transmitter -Schedule of planned phone checks -Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] -Based on the physician's order, an ongoing schedule will be established for each resident with the appropriate company -Monitor the resident for pacemaker failure by monitoring for signs and symptoms of [NAME] arrhythmias. Symptoms associated with bradyarrhythmia may include: [CONDITION(S)] ([CONDITION(S)], shortness of breath, dizziness, fatigue and/or confusion. Resident #82 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] Minimum Data Set assessment indicated that Resident #82 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 7 out of 15 and was dependent on staff for activities of daily living. On [DATE] at 12:17 P.M., the surveyor observed Resident #82 sitting upright in bed watching television. A white box was noted on the bedside table. The Resident said that he/she did not know what it was. Review of Comprehensive Care Plans includes, but is not limited to: -Focus: Resident is at risk for complications related to internal defibrillator: Biotronic ICD single chamber implanted date: [DATE] (last revised [DATE]) -Interventions: Internal defibrillator checks per cardiology-Dr. Nasser; box at bedside for remote monitoring (last revised [DATE]); Notify Physician as needed ([DATE]) -Goal: Resident will not develop any internal defibrillator related complications over the next 90 days (last revised [DATE]) Review of hospital documentation indicated that Resident #82 had an ICD Generator change (pacemaker battery change) on [DATE] and had a scheduled post procedure follow up appointment with his/her cardiologist on [DATE] for device integration with potential reprogramming. During an interview on [DATE] at 12:03 P.M., Nurse #5 said he is aware Resident #82 has a pacemaker and had a box at the bedside but does not know anything about it. He said in the four years he has worked at the facility; he has never heard anything about testing or monitoring of the Resident's pacemaker. The surveyor reviewed Resident #82's medical record with Nurse #5, and he was unable to find any information about monitoring of the pacemaker. Nurse #5 called the Resident's cardiologist in the presence of the surveyor and learned that Resident #82 had a pacemaker battery change on [DATE], and had a follow up appointment scheduled on [DATE], but refused to go. Another appointment was made for [DATE], but the Resident again refused to go, and no further attempts were made for the Resident to go to the cardiologist. The cardiologist's office told Nurse #5 that the pacemaker's function has not been checked since it was implanted on [DATE]. During an interview on [DATE] at 12:45 P.M., the Director of Nursing said that she did not know anything about monitoring for Resident #82's pacemaker. 5. Review of the facility's policy titled, Medication Administration, dated [DATE], indicated medications shall be administered in a safe and timely manner, and as prescribed. It also included the following procedure: - Medications should be administered in accordance with the physician orders, including any required time frame. Resident #107 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 08:50 A.M., the surveyor observed Nurse #13 passing medications, and omit a dose of [MEDICATION(S)] (used to treat high blood pressure) 25 milligrams (MG) that was due to be administered at 8:00 A.M. During an interview on [DATE] at 9:20 A.M., Nurse #13 said the medication was not available on the medication cart. She said there is an Omnicell on the first floor; the surveyor accompanied Nurse #13 to the first floor to obtain the [MEDICATION(S)] 25 MG tablet. On [DATE] at 09:24 A.M., as Nurse #13 and the surveyor were returning to the Slades Unit on the second floor with the Metopropol tablet, the surveyor observed Nurse #13 pick up an alcohol pad that was on the floor. Nurse #13 did not sanitize her hands and went to the med cart opened the Metopropol tablet put it in a medication cup and proceeded to the Resident's room to administer it. The surveyor stopped the Nurse at the door and asked her about hand hygiene. The Nurse said she should have performed hand hygiene after touching the floor and will get another pill later. During an interview on [DATE] at 03:30 P.M., Nurse #13 said she administered the [MEDICATION(S)] at 11:30 A.M. to the Resident. The Nurse said she did not notify the physician. Nurse #13 had changed the time that she administered the medication ([MEDICATION(S)]) and did not notify the physician to receive further instructions. Review of the Physician's orders dated [DATE] indicated [MEDICATION(S)] [MEDICATION(S)] Extended Release 25 MG tablets, give one tablet by mouth two times a day for hypertension. Review of the Medication Administration Record (MAR), dated [DATE], indicated to administer [MEDICATION(S)] 25 MG at 08:00 A.M. and at 08:00 P.M., further review of the MAR indicated Nurse #13 administered the pill to the Resident at 11:30 A.M., on [DATE]. During an interview on [DATE] at 04:28 P.M., the Director of Nursing (DON) said Nurse #13 should have notified the physician that the medication was not administered as per the physician's orders. The DON said, whenever such an incident happens, the physician must be notified. 6. Resident #258 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Physician's Order for [DATE] indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Call the physician if CBG is >200 every morning and at bedtime (7:00 A.M. and 8:00 P.M.) Review of the Medication Administration Record for [DATE] indicated that on: [DATE] at 7:00 A.M., the CBG was 249 [DATE] at 8:00 P.M., the CBG was 222 [DATE] at 8:00 P.M., the CBG was 217 [DATE] at 8:00 P.M., the CBG was 273 [DATE] at 8:00 P.M., the CBG was 280 Further record review indicated that on the above dates, the physician had not been notified of the CBG above/greater than 200. During an interview on [DATE] at 2:20 P.M., the DON confirmed that there was no information documented in the record that the physician had been notified as ordered for the CBG's that were over 200. Review of the facility's policy titled Unavailable Medications dated 2017 included but was not limited to: Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. The facility must make every effort to ensure that medications are available to meet the needs of each resident. The Nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy (ies) that are available. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the facility Medical Director for orders and/or direction. 7. Resident #94 was admitted to the facility [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was admitted to the facility on a 2000 cubic centimeter (cc) fluid restriction. Review of the Medication Administration Record (MAR) dated ,d+[DATE] indicated the following medications were not administered to the medications being unavailable: [MEDICATION(S)] (muscle relaxant) Tablet 4 miligrams (mg) one tablet on [DATE] at 9:00 P.M. [MEDICATION(S)] (urinary analgesic)100 mg one tablet on [DATE] at 9:00 P.M. [MEDICATION(S)] (used primarily to treat nerve pain medication, anti-convulsant) capsule 75 mg on [DATE] at 9:00 P.M. [MEDICATION(S)] (used to prevent asthma attacks) Tablet 10 mg one tablet on [DATE], [DATE] and [DATE] at 9:00 P.M. [MEDICATION(S)] (antibiotic),d+[DATE] mg one tablet on [DATE] at 9:00 P.M. Record review indicated that the medications were documented as not available and on order. Further record review indicated that the physician was never notified that the Resident did not receive the above medications on the dates indicated. In reviewing the MAR and nurses notes on the above dates, it was indicated that Nurse # 14 frequently documented the medications as not being available for administration and on order. (This was brought to the attention of the Director of Nursing and the Administrator during review of the above information on [DATE] at 4:09 P.M.). During an interview on [DATE] at 4:09 P.M., the Director of Nursing and the Administrator said that if a medication is out of stock and the Resident does not receive the medication, the physician should be notified. b. Record review of the hospital discharge summary included but was not limited to: Medication List- Start taking these medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 5 mg tablet (commonly known as [MEDICATION(S)] which is an anti-coagulant) take 2 tablets (10 mg total) two times a day then; [MEDICATION(S)] 5 mg (5 mg total) by mouth two times a day. Start taking on [DATE]. Review of the MAR indicated Resident #94 was started on [MEDICATION(S)] 10 mg on [DATE] at 9:00 P.M. Review of the nurses note dated [DATE] at 5:05 P.M. included but was not limited to: Resident arrived at 4:30 P.M. from hospital. New order for [MEDICATION(S)] 10 mg BID (twice a day) and then titrate on the 11th down to 5 mg BID. Further review of the MAR indicated that the Resident received the last dose of the [MEDICATION(S)] 10mg at 9:00 P.M. on ,d+[DATE], and according to the physician's orders, hospital discharge summary and nurses note, was to begin [MEDICATION(S)] 5 mg at 9:00 A.M. on [DATE]. The MAR indicated that the 5mg of [MEDICATION(S)] was not started until 9:00 P.M. on [DATE] resulting in the Resident not receiving the [MEDICATION(S)] 5 mg dose at 9:00 A.M. (missed dose). There was no notification to the physician of the missed dose documented in the record. During an interview on [DATE] at 4:09 P.M., the DON reviewed the MAR with the surveyor and confirmed that the [MEDICATION(S)] had not been administered as ordered resulting in the Resident missing a dose of the medication. 8. Resident #259 was admitted to the facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge summary in which an x-Ray of the right shoulder was performed, indicated the presence of a right sided pacemaker. Review of the Interagency Referral Form (page 2) indicated that the Resident had a Pacemaker, ventricular paced-Premature Ventricular Contractions (PVC's) occasional. Record review of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Admission Minimum Data Set indicated the presence of a cardiac pacemaker. Further record review indicated there was no documentation by the facility staff or by the Residents physician as to the type of pacemaker that had been implanted and when. No physician's orders for pacemaker checks, frequency of checks, how the checks will be performed, cardiologist follow-up (if any) and no care plan for the Residents pacemaker. During an interview on [DATE] at 2:20 P.M., the DON confirmed that there was no information documented for the pacemaker, by the staff or by the physician addressing care of the Resident's pacemaker. 9. Resident #108 was admitted to the facility in February 2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a.) Record review, on [DATE], indicated on [DATE], the Resident's Physician signed and dated a Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) order. Although the MOLST form was incomplete, the Resident's physician said, during an interview on [DATE] at 7:00 A.M., he had met with the Resident and had reviewed end of life care and signed a MOLST form. He said the Resident did not want to be resuscitated, hospitalized , or intubated. He said he reviewed the Resident's decisions with the staff nurse and directed the staff nurse to complete the MOLST form. He said the facility staff should have called him if there was a question about the Resident's care. The Physician said he was unaware the Resident was admitted with end-of-life physician's orders. In addition, during interviews on [DATE] at 1:17 P.M. with Social Worker #1 and with Hospice Nurse #1, on [DATE] at 10:45 A.M., said that prior to [DATE], the facility had copies of the Resident's advance directives and it included a signed and completed MOLST, dated [DATE]. The physician orders for end-of-life care included do not resuscitate (DNR), do not intubate (DNI) and do not hospitalize (DNH). The document was provided to the facility prior to the Resident's admission to the facility and on admission by the Hospice agency. The document had been available in attachments in an email and in a binder provided by the Hospice agency. The Resident's advance directives had not been incorporated into the record. On [DATE], the nurses note indicated the Resident had a significant change in condition, and she initiated Cardiopulmonary Resuscitation (CPR), called 911, intubated and transferred the Resident to the hospital. The orders for end-of-life care had not been acted upon by the facility staff. During an interview on [DATE] at 12:48 P.M., the Director of Nurses (DON) said she was aware that the clinical records were not complete. The DON said she did not know what to say except the staff do not follow up when they need to. b.) Review of the nurse's note, dated [DATE], indicated that Resident #108 was unresponsive. The nurse documented she initiated Cardiopulmonary Resuscitation (CPR), called 911, and transferred Resident #108 to the hospital. Review of the Physician's order indicated there was no order to transfer Resident #108 to the hospital. c.) Resident #108 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A fistula or stoma is an opening in your abdomen that allows waste to exit your body, rather than through your digestive system into a secured protective bag. The secured bag is applied to hold the waste in a waterproof, odorless protective appliance and attached to seal waste and protect the skin from output from the stoma. Review of the Physician's Orders indicated there was no order to check or care for the stoma. Review of Resident #108's medical record indicated there was no documentation indicating the facility staff provided stoma care and/ or monitoring, with the exception of one nurse's note. On [DATE], the nurse's note indicated she observed brown liquid associated with the stoma. During multiple interviews on [DATE] at 12:48 P.M., 2:00 P.M. and 2:45 P.M., the Director of Nurses (DON) said she did not know the Resident had a stoma. She said she would investigate, but during interviews had not been able to describe the stoma and what the care needs should have been. She said the facility staff should have obtained physician's orders for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 10. Resident #109 was admitted in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on [DATE], indicated the Resident was admitted from home for Hospice care and services. The Hospice transfer documents indicated the Resident had been receiving the antipsychotic medication [MEDICATION(S)] daily. On [DATE], the nurses' note indicated she sat with Resident #109's Health Care Agent, reviewed and confirmed his/her medications. The nurse indicated all medications and doses were reviewed with no discrepancies. In addition, the nurse documented on the medication list (provided by his/her Hospice service), that medications were reviewed with the Health Care Agent. She documented next to the antipsychotic medication that the medication was given at hour of sleep. Review of Resident #109's Physician's Orders failed to include the antipsychotic medication, and therefore was nnot administered. There was no Physician note or correlating information to indicate why the medication was not transcribed onto the Medication Administration Record (MAR) and subsequently administered. Furthermore, the facility failed to communicate to the Resident's Physician the Hospice recommendations. - On [DATE], Hospice recommended to discontinue skilled services which included, speech, occupational and physical therapy, to discontinue laboratory / diagnostic tests and weights. Review of the Hospice communication form indicated the Resident's physician agreed to the recommendations. However, record review failed to indicate the staff transcribed the orders into the plan of care. - On [DATE], Hospice indicated the Resident had decreased responsiveness and increased secretions. Resident #109's Physician's orders from [DATE] through [DATE], included [MEDICATION(S)] (narcotic) 20 milligram (mg) / 5 milliliters (ml) - give .0.25 by mouth every three hours for pain; and [MEDICATION(S)] ([MEDICATION(S)] mediation used to treat excessive secretions at end of life) 0.125 mg by mouth every four hours, as needed (PRN) for excessive secretions. Hospice recommended changing the [MEDICATION(S)] to a [MEDICATION(S)] concentrate 5 mg, sublingual (applied under the tough), twice daily for pain and shortness of breath; and to change the medication [MEDICATION(S)] from PRN to twice daily and to administer the medication sublingual. Record review failed to indicate the recommendations were reviewed with Resident #109's physician. The nurses' notes dated [DATE] and [DATE], indicated the Resident was not arousable and was unable to swallow at times. -On [DATE], Hospice indicated the Resident's condition was transitioning to end of life treatment, that included mottling to the Resident's bilateral extremities. The Hospice requested to please consider the Resident's comfort and recommended [MEDICATION(S)] concentrate 5 mg, sublingual every four hours. Review of the medical record indicated on [DATE], the Hospice recommendations were approved by the Resident's physician and ordered [MEDICATION(S)], however the note indicated he increased the [MEDICATION(S)] to every hour. Review of the MAR indicated the [MEDICATION(S)] was transcribed as a PRN / as needed not as a scheduled medication as recommended by the Hospice provider. Review of the medical record failed to clarify the discrepancy. - On [DATE], Hospice indicated the Resident was unresponsive to verbal and tactile stimulation. The recommendations included discontinuing all non-comfort medications due to the Resident's inability to swallow; and to administer the [MEDICATION(S)] at 5 mg, sublingual, every four hours. Review of the physician orders indicated the PRN [MEDICATION(S)]; every hour was discontinued, and orders included [MEDICATION(S)] 0.25 mg every 2 hours as needed and [MEDICATION(S)] every four as needed. Record review failed to indicate the orders, as recommended were not communicated to the Resident's Physician. During an interview on [DATE] at 12:48 P.M. and 2:45 P.M., the Director of Nurses (DON) said she was aware that the clinical records lacked documentation. She said she was not surprised that Hospice recommendations were not followed and said she did not know what else to say.

Based on record review and interview, the facility failed to: 1.) Ensure that 34 of 39 residents on the [NAME] unit were administered significant medications as ordered on 7/10/22 resulting in the likelihood of significant adverse outcomes to the residents, including 2.) Resident #1G for which the facility failed to administer pain medication as prescribed resulting in the Resident experiencing pain at an 8 on a 0-10 pain scale (with zero being none and 10 being the worst pain ever felt in their life) without relief or intervention until 10:00 P.M.; 3.) Provide ordered intravenous antibiotics to Resident #1A, resulting in an extension of both the duration of the antibiotic and the Resident's stay in the facility; and 4.) In addition, the facility failed to ensure Resident #95 was administered a [CONDITION(S)] medication as prescribed by oncology. It was determined the Immediate Jeopardy began on 7/10/22 and was identified on 7/15/22. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 7/15/22, including the Immediate Jeopardy Templates. The Immediate Jeopardy which began on 7/10/22 was found to be removed on 7/21/22 following an onsite visit on 7/22/22. In addition to the residents in Immediate Jeopardy, non-compliance at F760 continued at a lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility also failed 5. For Resident #95, to administer a chemotherapeutic medication as ordered by the physician; and 6. For Resident #1C, to administer a diuretic as ordered by the physician, resulting in the Resident receiving the incorrect dose of [MEDICATION(S)] (a diuretic) and subsequently requiring a potassium supplement due to a low potassium blood level. Findings include: 1.) Review of the facility nursing schedule for 7/10/22 indicated there was one nurse (Nurse #11) scheduled for both the day and evening shifts on the short-term rehabilitation unit ([NAME] Unit). The resident census was 39 on that day. Review of the Medication Administration Records (MARs) for the residents residing on the [NAME] Unit on 7/10/22 indicated 34 out of the 39 residents had significant medications omitted between 7:00 A.M. and 11:00 P.M. resulting in significant medication errors that had the likelihood to result in serious adverse outcomes. The following significant medications were omitted for the residents: - [MEDICATION(S)] Respiratory Treatments = 2 residents - Cardiac medications (for the treatment and prevention of high blood pressure and arrhythmia) = 25 residents - Pain medications = 6 residents - Diuretic medications (to remove access fluid from the body) = 6 residents - Anticoagulant medications (to prevent the formation of blood clots) = 11 residents - Antidiabetic oral medications (to control blood sugar in people whose pancreas produces insulin) = 9 residents - Insulin (to treat high blood sugars in diabetic residents whose bodies do not produce their own insulin) = 11 residents - Oral antibiotics (to treat or prevent infection) = 6 residents - Intravenous (IV) antibiotics (to treat infections throughout the body through an infusion) = 3 residents During an interview on 7/13/22 at 3:00 P.M., Nurse Practitioner #1 said she and Physician #1 had not been notified of which residents did not receive medications on 7/10/22 and which medications were missed, so she was unsure if an alteration in treatment was needed for any of the residents on the [NAME] unit on 7/10/22. During an interview on 7/14/22 at 9:45 A.M., the Director of Nursing (DON) and the Administrator said they were made aware on 7/11/22 of the medications not being administered as ordered to the residents on the [NAME] unit on 7/10/22 as they had received some grievances. They said they do not know if the physicians were notified of missed medications or how many residents were affected or how many medications were missed and neither of them spoke with Nurse #11 about the situation or received grievances. During an interview on 7/14/22 at 9:55 A.M., Nurse #11 said she was the only nurse scheduled on 7/10/22 for both the day and evening shifts (7:00 A.M. to 11:00 P.M.) on the [NAME] Unit. She said when she arrived on 7/10/22 the DON was still passing medications for the 11:00 P.M. to 7:00 A.M. shift and she did not receive the keys to the medication carts for the unit until between 10:30 A.M. and 11:00 A.M. She said she was not trained to hang IV medications at the facility and therefore did not do so on 7/10/22 as ordered and requested the nurse from upstairs to come down to assist her and the nurse did not. She said there were also two admissions on 7/10/22 that she needed to complete as the only nurse for the whole unit. She said there were about 40 residents on the unit. She said she was told by the Director of Clinical Operations (DCO) on the phone to give pertinent medications. She said she did not administer all medications for all residents for both shifts but she does not know what was missed or for whom. She said she felt the situation was very unsafe. During an interview on 7/15/22 at 10:27 A.M., the DCO and the Administrator said the DCO was aware that medications were not being given on 7/10/22 and the DCO had spoken with Nurse #11 and directed her to check for significant medications and notify the physicians to administer the most significant medications and get orders to hold the others or some alteration to each residents' treatment plan. She said they did not follow up on the omitted medications for all the residents on the unit but did receive grievances from some residents and are working through the grievance process for those individual situations. The DCO said her belief was Nurse #11 did not provide medications as ordered on the day shift on 7/10/22 in the morning but did provide all other medications while on duty that day. The DCO said she was not aware of what medications were omitted, for which residents, or at what times on 7/10/22. Upon leaving the facility on 7/15/22, the Administrator was unable to produce any medication error reports or follow up for the numerous omitted doses of significant medications for residents on the [NAME] Unit from 7/10/22. 2.) Resident #1G was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident's active orders for pain management included the following: - order started on 6/10/22: [MEDICATION(S)] 4% apply to the skin 1 patch daily for back pain - order started on 6/10/22: [MEDICATION(S)] 100 mg two times a day for pain - order started on 6/23/22: [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]- a narcotic pain medication) tablet 5-325 mg three times a day for pain management - order started on 6/23/22: Acetaminophen 325mg by mouth three times a day for pain along with [MEDICATION(S)] - order started on 6/23/22: [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) tablet 5-325 mg, 1 tablet every 24 hours as needed for pain During an interview on 7/13/22 at 8:10 A.M., Resident #1G said he/she was in pain and had not received his/her pain medications over the last few days as prescribed. Review of the 7/10/22 Nurse's Notes for Resident #1G indicated the nurse did not have the capability of administering the scheduled [MEDICATION(S)] at 10:00 P.M., as it was stored in the facility medication storage machine and required two nurses to remove it from the system and only Nurse #11 was available. Review of the MARs for July 2022 for Resident #1G indicated the Resident did not receive his/her scheduled 9:00 A.M., [MEDICATION(S)], scheduled 2:00 P.M. Acetaminophen, scheduled 2:00P.M. [MEDICATION(S)], or scheduled 2:00P.M. or 10:00 P.M. [MEDICATION(S)], as prescribed on 7/10/22. It further indicated a pain rating of 8 on a 0-10 scale at 10:00 P.M., following the missed scheduled pain medications, with no other evidence of a pain scale being ascertained after the start of the 7:00 A.M. shift. 3.) Resident #1A was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #1A indicated the treatment plan and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - order started on 6/30/22: [MEDICATION(S)]-Sodium Chloride reconstituted (an antibiotic mixed in solution for administration) 1 Gram/50 milliliters (ml) IV three times a day for abdominal wall abscess for 48 administrations a total of 21 days - order started on 7/11/22: [MEDICATION(S)]-Sodium Chloride reconstituted 1 Gram/50 ml IV three times a day for abdominal wall abscess until 7/17/22 (previous order discontinued) - order started on 7/13/22: [MEDICATION(S)]-Sodium Chloride reconstituted 1 Gram/50 ml IV three times a day for abdominal wall abscess until 7/19/22 (previous order discontinued and antibiotic extended) - order started on 7/15/22: [MEDICATION(S)]-Sodium Chloride reconstituted 1 Gram/50 ml IV three times a day for abdominal wall abscess until 7/23/33 (previous order discontinued and antibiotic extended) Review of the Social Service notes indicated Resident #1A would require an extension in his/her in-patient stay with a previous discharge date of [DATE] on hold until 7/24/22 related to the extension of the antibiotic administration. The Immediate Jeopardy which began on 7/10/22 was found to be removed on 7/21/22 following an onsite visit on 7/22/22. See F835 The non-compliance remained at a lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy as follows: 4.) Resident #95 was admitted to the facility in March 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record included an oncology visit summary from 5/10/22 which indicated to take [MEDICATION(S)] (a [CONDITION(S)] medication) for 21 days, with a 7-day break. Review of an oncology report of consultation, dated 6/14/22, indicated to continue [MEDICATION(S)] with the next start date of 7/1/22. During an interview on 7/13/22 at 3:00 P.M., Nurse Practitioner (NP) #1 said she was concerned Resident #95 had missed one treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #95's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/14/22 at 8:50 A.M., Nurse #6 said the [CONDITION(S)] medication was scheduled to be administered at 6:00 A.M. and the overnight staff had not notified the day shift until 7/6/22 that the medication had not been received. She said the overnight staff had never contacted the pharmacy about the medication and did not know who to contact. Nurse #6 said on 7/6/22 she had contacted the facility contracted pharmacy to inquire about the medication and was informed it would need to be filled by the oncology pharmacy, was ordered at that time, and would take about a week to fill the prescription. During an interview on 7/14/22 at 12:25 P.M., NP #1 said Resident #95 was in remission for a period of time, but was no longer in remission and the physicians were attempting to get a handle on the treatment. She said she was not informed that Resident #95 had missed 13 doses of the [CONDITION(S)] medication and she should have been notified. 5. Resident #1C was admitted to the facility in July 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/19/22 at 8:30 A.M., Resident #1C told the surveyor that he was being sent out to the emergency room (ER), because of swelling in the Resident's lower legs, feet, and hands. Record review indicated a Physician's Interim/Telephone order for the following: Dated 7/19/22, noted/verified by Unit Manager #1 at 8:00 A.M. -[MEDICATION(S)] 40 mg by mouth daily -Doppler lower ext. R/L -Send to ER for evaluation (the last two words were illegible) -ER today Review of the Nurse's Note, dated 7/19/22 at 10:09 A.M. indicated - Sent out via 911 at approx. 10:00 A.M. for evaluation Review of a Nurse's Note, dated 7/19/22 at 1:20 P.M. included but was not limited to the following: Resident was found having increased [CONDITION(S)] in upper/lower extremities. TBD (To be Determined) MD continued to give order to send to ER. Resident was sent to the Hospital for evaluation and treatment. ID (Infectious Disease) was contacted at the hospital and felt that the [CONDITION(S)] could be from the [MEDICATION(S)] (antibiotic) the Resident is receiving. The Resident returned to the facility with rec.(recommendations) to start [MEDICATION(S)] and a one-liter fluid restriction, MD in and reviewed paperwork and saw Resident. N.O. (New Order) start [MEDICATION(S)] 40 mg by mouth x three days and repeat CBC (Complete Blood Count/BMP (Basic metabolic Panel)/LFT (liver function tests) on 7/25/22. Review of a Nurse's Note, dated 7/22/22 at 8:37 A.M., indicated MD in and changed -[MEDICATION(S)] to 40 mg by mouth daily. Review of a Nurse's Note -eMar Medication Administration Note, dated 7/22/22 at 11:12 A.M., indicated -[MEDICATION(S)] Tablet 40 mg Give 40 mg by mouth one time a day for CHF ([CONDITION(S)]) Review of a Nurse's Note-eMar Medication Administration Note, dated 7/23/22 at 10:05 A.M., indicated -[MEDICATION(S)] Tablet 40 mg Give 60 mg by mouth one time a day for CHF Review of a Nurse's Note-eMar Medication Administration Note, dated 7/23/22 at 1:50 P.M., indicated -[MEDICATION(S)] Tablet 40 mg Give 40 mg by mouth one time a day for CHF Review of the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet 40 mg Give 40 mg one time a day for 3 days. Start 7/21/22 at 9:00 A.M. -[MEDICATION(S)] tablet 40 mg on 7/21/22 and 7/22/22 documented as given at 9:00 A.M. The order was discontinued on 7/22/22 at 11:12 A.M. The above order was for 3 days. Review of the physician's interim/telephone, dated 7/22/22, indicated to -Continue [MEDICATION(S)] 40 mg daily (the order was noted/verified by Unit Manager #1 on 7/22/22 at 8:40 A.M). -[MEDICATION(S)] Tablet 40 mg Give 40mg by mouth one time a day for CHF. Start date 7/22/22 at 2:00 P.M. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and received a dose at 2:00 P.M. for a total dose of 80 mg for 7/22/22. -[MEDICATION(S)] Tablet 40mg Give 60 mg by mouth one time a day for CHF. Start 7/23/22 at 9:00 A.M. The Resident received a total dose of 80mg on 7/22/22 when the order written by the physician was to continue [MEDICATION(S)] 40mg and on 7/23/22, the [MEDICATION(S)] was now a total dose daily of 100 mg (60mg at 9:00 A.M. and 40 mg at 2:00 P.M.) daily. Review of the documentation in the nurse's notes did not indicate that a new order had been obtained from the physician for the Resident to receive the [MEDICATION(S)] twice a day. Review of a Nurse's Note, dated 7/25/22 at 2:21 P.M., indicated -Resident had labs today, K+(potassium) at 3.3 milliequivalents (meq) (normal blood potassium level is ranges from 3.6 to 5.2). -N.O. give 1 x dose of Potassium 40 meq now. During an interview on 7/26/22 at 11:45 A.M., Unit Manager #1 was made aware of the concern with the [MEDICATION(S)]. Unit Manager #1 could not locate any documentation (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor also made her aware that the increase in the [MEDICATION(S)] dose was indicative of the Residents potassium level becoming low and the Resident required a potassium replacement medication and she agreed.

Based on observation, interview, record review and policy review, the facility failed to utilize resources effectively and failed to ensure resident care attained or maintained the highest practicable physical, mental, and psychosocial well-being for each resident. Findings include: The facility failed to: a. Adequately address concerns brought to their attention from the Resident Council: On 4/14/22 at 11:00 A.M., the surveyor held a group meeting with 10 residents in attendance. The residents said the concerns they have brought forward in Resident Council have not been resolved: -Four out of 10 residents said they continue to have missing clothing, which has not been resolved; and -Two out of 10 residents said their clothes have been stained through the laundry without resolution; and -The residents said they have continued to complain about the food temperature and texture every month without any changes and they had not received any follow up to their concerns. During an interview on 4/14/22 at 8:56 A.M., the Activity Director said she did not have any supporting documentation to indicate the concerns brought forward during Resident Council had been addressed by the facility. She said she did not have a list of residents who attended the Resident Council meetings and was unable to determine which residents had which concerns She said the Food Service Director attended some of the Resident Council meetings (one out of four reviewed by the surveyor) and was therefore aware of the food concerns; she said there was no documentation to indicate the facility had addressed the continued food complaints brought forward by the residents. b. Promote and facilitate resident self-determination through support of resident choice. During an interview on 4/21/22 at 8:58 A.M., Resident #34 said that he/she declined the Pfizer COVID-19 vaccine in November, and told the Director of Nursing (DON) that he/she would accept the Moderna vaccine. The Resident said the DON told him/her she would order the Moderna vaccine. Resident #34 said that he/she has not received the vaccine yet, has not heard anything about it, and still wants to receive it. During an interview on 4/21/22 at 12:45 P.M., the Director of Nursing (DON) said the previous DON no longer works at the facility, and she was not aware Resident #34 requested the Moderna vaccine and never received it. c. Ensure that staffing was adequate to prevent resident falls specifically for Residents #93 and #52. -Review of the medical record for Resident #93 indicated the Resident had 17 falls in the two months between admission to the facility through 4/20/22. Review of the 17 falls failed to include information of time of falls, locations of falls, interventions in place at the time of the fall, or interventions implemented to reduce the risk of falls. During an interview on 4/20/22 at 4:00 P.M., CNA #1 said on the 3:00 P.M. to 11:00 P.M. shift if there were two CNAs, then one would sit with the Resident in the day room, while the other provided care to residents and the staff would take turns offering the Resident supervision. She said when there was only one CNA it was difficult to provide supervision to prevent falls and occasionally Resident #93 would sit with the nurse in the hall, while the nurse provided medications to other residents. Review of the Nursing Progress notes indicated on the following days the staff referenced Resident #93 needing one to one (1:1) supervision: 2/22/22, 2/23/22, 3/1/22, 3/5/22, 3/6/22, 4/12/22, 4/14/22, and 4/15/22. During an interview on 4/20/22 at 5:24 P.M., the Director of Nurses said she was not aware that staff needed to provide 1:1 supervision to Resident #93, she had not scheduled a staff member to provide 1:1 supervision and she said the nurse on the medication cart should not be providing that supervision while distributing medications to other residents. -For Resident #52, the facility failed to ensure the Resident was provided adequate supervision and assistive devised to prevent 11 falls, three of which required transfer to the hospital for evaluation and treatment. During an interview on 4/14/22 at 12:25 P.M., Resident #52's Responsible Person (RP) said that he/she has had several falls while at the facility, and the Resident must have close supervision by staff. The RP said the Resident fell out of his/her wheelchair in the day room three weeks ago and still has a bruise on his/her head. d. Ensure there was sufficient staff available to provide nursing services and the care required to meet the resident's needs. Review of nursing schedules provided (4/1/22 through 4/15/22) indicated that there was insufficient staff available to provide required nursing services to meet the resident's needs. The Ombudsman said the family members of residents had been complaining about the facility not having enough staffing and not replacing staff when there was a call-out, especially in the evenings. On 4/14/22 at 11:00 A.M., the surveyor held a group meeting with 10 residents in attendance. During the meeting, residents said there were not enough staff working on the units and sometimes on the 3:00 P.M. to 11:00 P.M. shift there are only two Certified Nursing Assistants (CNAs) on the long-term care units (each having approximately 40 residents). Six out of 10 residents said in the previous two weeks, they had waited over a half hour for their call light to be answered. At 5:02 P.M., Nurse #10 told the Resident of room [ROOM NUMBER] that she will get someone to help him/her. The Resident responded that he/she had been waiting a half hour. A CNA arrived at 5:04 P.M. to assist the Resident, 24 minutes after the surveyor observed the call light to be on. During an interview on 4/14/22 at 5:10 P.M., CNA #9 said there were currently three CNAs working on the unit, with 42 residents (14 residents per CNA). She said it was difficult to get to all of the residents when there were only three CNAs and that was why the call lights were going off. She said there were times when there were only 2 CNAs working the 3:00 P.M. to 11:00 P.M. shift and they were not able to provide care to all of the residents. During an interview on 4/14/22 at 5:15 P.M., Nurse #11 said the unit often only had three CNAs and the staff could not get to all the residents' care timely. During an interview on 4/13/22 at 1:51 P.M., Resident #26 said he/she was told they could not have a shower on the previous night because there were only two CNAs working the 3:00 P.M. to 11:00 P.M. shift. Resident #26 said the facility frequently did not have the staff for showers, especially on the 3:00 P.M. to 11:00 P.M. shift and weekends. During an interview on 4/13/22 at 3:20 P.M., the family member of Resident #77 said she had concerns with the lack of staffing. She said the Resident gets out of bed in the morning and prefers to go back to bed for a nap around 1:30 P.M. She said when the Resident goes back to bed, the staff do not get the Resident out of bed for dinner. She said she had concerns regarding the Resident being in bed from 1:30 P.M. until 9:00 A.M. She said the staff had told her there were not enough staff to get the Resident out of bed on the 3:00 P.M. to 11:00 P.M. shift. During interviews on 4/19/22 at 11:30 A.M., Resident #35 said he/she was experiencing respiratory difficulty over the weekend and waited 50 minutes for the call light to be answered. On 4/21/22 at 8:10 A.M., Resident #35 said he/she did not receive showers because they did not have enough staff During an interview on 4/20/22 at 4:45 P.M., the Scheduler said the facility had contracts with staffing agencies but tend to use them regularly (scheduled blocks) for nurses and that she had been told not to use too many agency CNAs by the Administrator. She said the staffing schedule should be the following for CNAs: [NAME]: 3 CNAs for 7:00 A.M. to 3:00 P.M. and 2 CNAs for 3:00 P.M. to 11:00 P.M. Slades [NAME] and Pottersville: 5 CNAs for each unit for 7:00 A.M. to 3:00 P.M. and 4 CNAs for each unit for 3:00 P.M. to 11:00 P.M. She said sometimes the long-term care units (Slades [NAME] and Pottersville) will have 4 CNAs on the day shift or 3 CNAs on the evening shift. Review of the schedule of staff from 4/1/22 through 4/15/22, provided by the facility (as worked) indicated this ratio was not met. During an interview on 4/20/22 at 05:30 P.M., the Administrator said the facility utilized agency nurses on a regularly scheduled basis and was looking to start using a scheduled CNA on the 11:00 P.M. to 7:00 A.M. shift. She said there were no regularly scheduled agency CNAs at this time and the facility tried to get staff if there were call outs, but they were not always able to get the staff. For Resident #93 the facility failed to provide adequate staffing to maintain supervision of the resident. Review of the medical record for Resident #93 indicated the Resident had 17 falls in the two months between admission to the facility through 4/20/22. Eight falls were due to the staffing ratios. Review of the Nursing Progress notes indicated the staff referenced Resident #93 needing one to one (1:1) supervision: 2/22/22, 2/23/22, 3/1/22, 3/5/22, 3/6/22, 4/12/22, 4/14/22, and 4/15/22. During an interview on 4/20/22 at 5:24 P.M., the Director of Nurses said she was not aware that staff needed to provide 1:1 supervision to Resident #93, she had not scheduled a staff member to provide 1:1 supervision. e. Ensure that [CONDITION(S)] medications were administered in a safe manner and monitored for potential adverse outcomes. [CONDITION(S)] medications were extended beyond 14 days without a documented rationale and specific duration by the physician or nurse practitioner and 72 of 72 residents receiving psychoactive were not monitored for effectiveness and potential signs and symptoms of side effects. During an interview on 4/21/22 at 9:15 A.M., the Pharmacy consultant said he has left several recommendations for [CONDITION(S)] PRN medications to have a stop date or reevaluation date with clinical rationale for continued use after an initial 14-day period and they have gone without response. Review of the Census and Condition included but was not limited to the following: Residents receiving any psychoactive medications were 72 and then broken down into the categories below: antipsychotics- 16 antianxiety- 18 antidepressants- 63 hypnotics- 1 During an interview on 4/21/22 at 8:55 A.M., the DON said the nursing staff do not document signs and symptoms of side effects of the [CONDITION(S)] medications as there is no process/system in place to ensure that potential side effects of the [CONDITION(S)] medications were being monitored as required. f. Ensure that the nutritional status of residents was monitored for significant unplanned weight changes and that nutritional interventions were implemented to prevent further significant weight loss. The facility did not address and monitored significant weight loss for two Residents with unplanned, significant weight loss by failing to monitor food intake consistently and implement nutritional interventions to prevent further significant weight loss. From 12/29/21 to 4/3/22, a Resident experienced a 12.1% significant weight loss. The Dietitian and/or Physician was not notified of weight loss identified on 2/2/22 and 4/3/22, so that interventions could be implemented. From 12/8/21 to 4/11/22, a Resident experienced a 15.2% significant weight loss. The facility did not address the continuation of weight loss and the lack of dietitian availability, interventions, and family involvement to prevent further weight loss. During an interview on 4/19/22 at 1:18 P.M., the Administrator and Director of Nurses (DON) said there should be more interventions attempted and a better monitoring of interventions. The Administrator said the policy and expectations for nutritional and weight management were not being met. None of the concerns had been identified by the QAPI committee and there has not been a meeting since 9/2021. The facility's administrative team and governing body did not provide the services and staffing that is necessary to provide for the needs of residents. Concerns were reviewed with the Administrator and the Director of Nursing on 4/20/22 at 5:00 P.M. and on 4/21/22 at 6:00 P.M. with the Administrator and Director of Nursing.

Based on interview and document review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that had a systematic analysis and action plan to rectify identified issues and failed to meet at least quarterly as required. Findings include: Review of the facility's QAPI documentation indicated the QAA Committee consisted of the Administrator, Director of Nursing (DON), Medical Director, Pharmacy Consultant, Laboratory, X-Ray Consultants, and Interdisciplinary team members. Review of the facility's policy titled Quality Assurance (revised 3/2020) included but was not limited to the following: The center implements and maintains an effective, ongoing and data driven quality assurance and performance improvement (QAPI) program that reflects the organization and services provided. The QAPI program includes processes for measuring, tracking, and analyzing quality indicators, including re-hospitalization , and other aspects of performance that enable the center to assess processes of care, services, and operations. The center's leadership, Administrator, and Director of Nursing Services, ensures that the QAPI program is developed, implemented, and maintained and delegates leadership and management of the program to appropriate staff. Through regularly scheduled meetings, the QAPI committee directs and assists in the ongoing quality assessment and performance activities. The centers leadership, Administrator, and DON, ensures the implementation of the program. The Centers leadership assumes full responsibility for the QAPI program. During an interview on 4/20/22 at 4:49 P.M., with the DON, and Administrator, the Administrator said there was no QAPI or Performance Improvement Project (PIP) documentation that she could locate that occurred prior to her starting at the facility in September 2021, so she was starting from the beginning. Since January 2022 a new PIP had been put into place based on issues identified during a focused infection control survey. However, it was never formally brought to the QAPI committee as there have not been any meetings since she started. During an interview on 4/20/22 at 7:00 A.M., the Medical Director said the facility had not had any QAPI meetings for a while nor has he attended/participated in any QAPI/PIP meetings. During an interview on 4/21/22 at 9:15 A.M., the Pharmacist Consultant said that he sends in the information required for the quarterly meetings, however, has not attended a meeting. The Administrator said that as of today (4/20/22) there have been no QAPI meetings held monthly or quarterly as required with the consultants. The Administrator said that there have been no QAPI meetings since she began at the facility in September 2021.

Based on record review, interview, and policy review, the facility failed to ensure the 39 residents on the [NAME] unit were free from neglect on 7/10/22 from 7:00 A.M. to 11:00 P.M. Specifically, the facility failed to ensure 1) Residents received medications & wound treatments as ordered; 2) Intravenous antibiotics were administered per Resident #1A's plan of care for resolution of infection and discharge from the facility; and 3) Pain medication for Resident #1G was administered and available to prevent pain at an 8 out of 10 (with zero being no pain and 10 being the worst pain ever felt in their life) pain scale. Findings include: Review of the facility's policy titled Abuse, dated as revised February 2019, indicated but was not limited to the following: The facility prohibits the mistreatment, neglect, and abuse of residents by anyone including staff, family, friends, etc. Notify charge nurse, shift supervisor, or manager immediately of suspected abuse, neglect, or misappropriation. Upon receiving an incident or suspected incident of abuse, neglect, or misappropriation the administrator, director of nurses (DON), or designee will conduct an investigation. Neglect is defined as: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility ensures prevention techniques are implemented in the facility, not limited to: - ongoing supervision of employees through visual observation of care delivery and recognition of signs of burn out, frustration, or stress - identify, correct, and intervene in situations where abuse, neglect, and/or mistreatment are more likely to occur - sufficient staffing on each shift to meet the needs of the residents - assigned staff demonstrating knowledge of individual resident needs 1) On 7/12/22 at 10:00 A.M., during a tour of the [NAME] Unit, the surveyor identified through resident interviews and review of the medication administration records (MAR) that significant medications and treatments had not been administered to residents during the 7:00 A.M. to 3:00 P.M. and the 3:00 P.M. to 11:00 P.M. shifts on 7/10/22 and only one nurse was assigned to care for 39 residents. Review of the MARs, dated 7/10/22, for 39 out of 39 residents on the [NAME] Unit indicated every resident had a missed scheduled medication on 7/10/22 from 7:00 A.M. through 11:00 P.M. Review of the Treatment Administration Records (TAR) for 39 residents on the [NAME] unit indicated seven residents did not receive treatments to their wounds on 7/10/22. During an interview on 7/15/22 at 8:30 A.M., Nurse #16 (the former Director of Nurses (DON), until 7/11/22) said she worked on the [NAME] unit on 7/9/22 during the 11:00 P.M. to 7:00 A.M. shift. She said at 6:00 A.M. on 7/10/22 she was trying to administer all of the 6:00 A.M. scheduled medications to the residents. She said when Nurse #11 arrived at 7:00 A.M., Nurse #11 sat at the nurses' station and would not help with the 6:00 A.M. medications. She said at approximately 10:15 A.M., she was able to do report and medication count with Nurse #11. Nurse #16 left the facility at 11:00 A.M., having not given any medications scheduled for the 7:00 A.M. to 3:00 P.M. shift. During an interview on 7/14/22 at 9:45 A.M., the DON and Administrator said they had received grievances on 7/11/22 and were aware that residents and their families had complaints about not receiving medications, treatments and care, and Nurse #16 had filled them (DON and Administrator) in on the situation. The DON and Administrator said they did not initiate an investigation for neglect and were working through the grievances and provided customer service education to the staff. During an interview on 7/14/22 at 9:55 A.M., Nurse #11 said she arrived to work at the facility on 7/10/22 at 7:00 A.M. and Nurse #16 was not done with the 6:00 A.M. medication pass. Nurse #11 said she waited for Nurse #16 to provide report and count medications prior to taking the medication keys. Nurse #11 said she was told by the Director of Clinical Operations (DCO) on the phone to give pertinent medications. Nurse #11 said she was not trained to hang IV medications at the facility and therefore did not do so on 7/10/22 as ordered. Nurse #11 said she did not administer all medications for all residents for both shifts but she does not know what was missed or for whom. During an interview on 7/15/22 at 10:27 A.M., the DCO and the Administrator said the DCO was aware that medications were not being given on 7/10/22 and the DCO had spoken with Nurse #11 and directed her to check for significant medications and notify the physicians to administer the most significant medications and get orders to hold the others or some alteration to each residents' treatment plan. The DCO said they did not follow up on the omitted medications for all the residents on the unit but did receive grievances from some residents and are working through the grievance process for those individual situations. The DCO said her belief was Nurse #11 did not provide medications as ordered on the day shift on 7/10/22 in the morning but did provide all other medications while on duty that day. The Administrator said Nurse #11 did work again following the incident while they were still investigating and working on the grievances of missed care. The DCO said she did report Nurse #11 to her staffing agency on 7/13/22 for not providing medications, treatments, and assessments as required on 7/10/22 and also for leaving medications unsecured. The DCO said although she felt the lack of care and services provided was unsafe, the facility did not investigate or report the incident as neglect or implement their abuse policy and procedures. The DCO said she did not consider Nurse #11 not providing the care and treatments to be negligent although it was clear the Nurse did not intend to provide assistance to Nurse #16 prior to receiving a report, did not follow instruction and determine what medications were significant and notify the physicians, and did not intend to provide the prescribed IV medications or notify anyone that they were not provided. 2) Resident #1A was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current July 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - order started on 6/30/22: [MEDICATION(S)]-Sodium Chloride reconstituted (an antibiotic mixed in solution for administration) 1 Gram/50 milliliters (ml) IV three times a day for abdominal wall abscess for 48 administrations a total of 21 days - order started on 7/11/22: [MEDICATION(S)]-Sodium Chloride reconstituted 1 Gram/50 ml IV three times a day for abdominal wall abscess until 7/17/22 (previous order discontinued) - order started on 7/13/22: [MEDICATION(S)]-Sodium Chloride reconstituted 1 Gram/50 ml IV three times a day for abdominal wall abscess until 7/19/22 (previous order discontinued and antibiotic extended) - order started on 7/15/22: [MEDICATION(S)]-Sodium Chloride reconstituted 1 Gram/50 ml IV three times a day for abdominal wall abscess until 7/23/22 (previous order discontinued and antibiotic extended) Review of the MARs for Resident #1A indicated he/she did not receive his/her IV antibiotic of [MEDICATION(S)]-Sodium Chloride as ordered on 7/10/22 for any of the three scheduled administration times. Review of the Social Service notes indicated Resident #1A would require an extension in his/her in-patient stay with a previous discharge date of [DATE] on hold until 7/24/22 related to the extension of the antibiotic administration. 3) Resident #1G was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident's active orders for pain management included the following: - order started on 6/10/22: [MEDICATION(S)] 4% apply to the skin 1 patch daily for back pain - order started on 6/10/22: [MEDICATION(S)] 100 mg two times a day for pain - order started on 6/23/22: [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]- a narcotic pain medication) tablet 5-325 mg three times a day for pain management - order started on 6/23/22: Acetaminophen 325mg by mouth three times a day for pain along with [MEDICATION(S)] - order started on 6/23/22: [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) tablet 5-325 mg, 1 tablet every 24 hours as needed for pain Review of the Physician's Progress Note, dated 7/5/22, indicated there is less pain over the leg, Resident #1G has been ambulating (walking) with physical therapy and pain medications are helping. During an interview on 7/13/22 at 8:10 A.M., Resident #1G said he/she was in pain and had not received his/her pain medications over the last few days as prescribed. Review of the MARs for July 2022 for Resident #1G indicated the Resident did not receive his/her scheduled 9:00 A.M., [MEDICATION(S)], scheduled 2:00 P.M. Acetaminophen, scheduled 2:00 P.M. [MEDICATION(S)], or scheduled 2:00P.M. or 10:00 P.M. [MEDICATION(S)], as prescribed on 7/10/22. The MARs further indicated a pain rating of 8 on a 0-10 scale at 10:00 P.M., following the missed scheduled pain medications, with no other evidence of a pain scale being ascertained after the start of the 7:00 A.M. shift.

Based on observations, interviews, record review, and policy review, the facility failed to ensure five Residents (#93, #23, #52, #48 and #259), out of a total sample of 30 residents, were provided adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to follow their falls management and prevention policy of investigating falls and initiating fall prevention interventions for: 1.) Resident #93, 17 falls with one resulting in a concussion; 2.) Resident #23, 9 falls, with one resulting in an abrasion; 3.) Resident #52, 11 falls, with one resulting in an ER visit for evaluation and treatment; 4.) Resident #48, failing to monitor and apply a wander guard device; and 5.) Resident #259, failed to follow documentation protocols as per the facility's falls management policy. Findings include: Review of the Falls Management and Prevention policy, dated as revised in January 2021, indicated the interdisciplinary team identified and implemented appropriate interventions to reduce the risk of falls or injuries. The policy indicated the following procedures: -staff will evaluate and document falls that occur (when and where) -if the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the falls and will re-evaluate the continued relevance of current interventions -the nurse will complete an incident report -Resident fall will be evaluated for 72 hours post fall, including full vital signs every shift. -The Director of Nursing will be notified immediately for falls resulting in injury and/or transfer. The DON will notify State agency per state specific requirements. -staff will attempt to define possible causes within 24 hours -interdisciplinary team should monitor and document resident's response/success with fall reduction interventions 1. Resident #93 was admitted to the facility in February 2022 with a diagnosis of dementia and a history of a craniotomy. On 4/13/22 at 4:19 P.M., the surveyor observed Resident #93 seated in a wheelchair, in the unit day room, making multiple attempts to stand and causing an alarm to sound. Each time the alarm sounded, a visitor intervened to get the Resident to sit back down, after the alarm sounded five times a staff member came and intervened. Review of the Minimum Data Set assessment for Resident #93, dated 2/27/22, indicated the Resident had multiple falls since admission, was not steady, and was only able to stabilize with human assistance for moving from seated to standing, walking, and turning around and facing the opposite direction while walking. Review of the Care Plans for Resident #93 indicated the Resident was a fall risk and the following interventions were implemented: 2/20/22: verbal cues for safety and sequencing, call light within reach, clutter free environment in Resident's room, medication evaluation as needed 3/28/22: therapy to evaluate for chair and positioning 4/20/22: common areas/supervised while awake related to poor safety awareness, monitor and assist with toileting needs Review of the medical record for Resident #93 indicated the Resident had 17 falls in the two months between admission to the facility through 4/20/22. Review of the 17 falls failed to include information of time of falls, locations of falls, interventions in place at the time of the fall, or interventions implemented to reduce the risk of falls: -2/20/22 at 7:00 P.M., Resident found on knees next to bed. Review of documentation indicated a motion sensor alarm was implemented and the Resident's bed was put in the lowest position. There were no staff statements to indicate how the fall occurred. -2/21/22 at an unknown time; Resident found sitting on the floor next to bed. Review of the documentation indicated interventions were for a chair alarm, frequent checks, and a motion sensor. There was no incident report for the fall and no staff statements to indicate how or when the fall occurred. A nurses note on 2/22/22 indicated the Resident was moved closer to the nurses' station, the Resident continued to attempt to get out of bed and a CNA (certified nursing assistant) was placed outside the Resident's door. -2/23/22 at an unknown time, Resident stood up from chair and fell to the ground. Review of the documentation failed to include an incident report or any staff statements to indicate when or where the fall occurred. -3/10/22 at an unknown time, Resident found on the floor in the day room on his/her back. Review of the documentation failed to include any information regarding which interventions were in place or which interventions would be initiated. There were no staff statements to indicate how or when the fall occurred. -3/15/22 at 11:00 A.M. fall in dining room. Review of the documentation failed to include an incident report, which interventions were in place, or which interventions would be initiated. There were no staff statements to indicate how the fall occurred. -3/16/22 at an unknown time; nursing note indicated Resident had a fall in the morning. Review of documentation failed to include an incident report or staff statements to indicate how, when, or where the fall occurred. -3/20/22 at 7:00 P.M., fall in day room. Review of the documentation failed to include an incident report. There were two staff statements which indicated there was one CNA and one Nurse working, with 17 residents on this shift. -3/21/22 at unknown times; nursing progress notes indicated Resident #93 fell four times during the day shift. There were no incident reports for any of the falls, there was no indication of when, where, or how any of the falls occurred. -3/28/22 at 12:23 P.M., the Resident slid out of the wheelchair in the day room. Review of the care plan indicated an intervention to evaluate the chair and positioning. -4/1/22 at an unknown time; Resident was found on the left side of his/her bed on the floor. Review of the documentation failed to include an incident report and failed to include staff statements to indicate when and how the fall occurred. -4/7/22 at an unknown time; Resident found on the floor in the day room. Review of documentation failed to include an incident report and failed to include staff statements to indicate when and how the fall occurred. -4/16/22 at 5:55 P.M., Resident had a fall with a suspected head strike, showing signs of pain, while waiting for the ambulance Resident began to fall asleep and not easily aroused. Review of the documentation failed to include staff statements to indicate where and how the fall occurred. -4/18/22 at 7:55 A.M. Resident had an unwitnessed fall in the dining room. Review of the incident report failed to include any other information regarding the fall. A Social Service note indicated Resident #93 was moved to another unit due to needing more supervision and was placed in a private room. The surveyor observed the room to be the furthest room from the nurses' station, approximately 100 feet away. -4/18/22 at 6:30 P.M., Resident fell at the nurses' station. Review of the documentation indicated the Resident said he/she smacked his/her face. All three staff statements forms indicated n/a on all questions regarding how the Resident fell , how the Resident was found, when the last time the Resident was seen. Review of the Hospital Discharge Summary, dated 4/20/22, indicated Resident #93 had a fall and was found between the bed and the wall on 4/18/22. The documentation indicated the Resident had falls almost daily and was sent to the emergency room almost daily. The assessment and plan indicated the Resident had a change in mental status with a suspected concussion. During an interview on 4/21/22 at 9:50 A.M., Physician #2 said he agreed with the hospital discharge summary that Resident #93 had a concussion resulting in a change in mental status. He said Resident #93 was at an increased risk for injury related to the multiple falls. During an interview on 4/20/22 at 4:00 P.M., CNA #1 said Resident #93 had multiple falls and it was difficult to provide supervision to this Resident when there were two CNAs working on the 3:00 P.M. to 11:00 P.M. shift. She said if there was only one CNA during the shift, then the staff would have Resident #93 stay with the nurse on the medication cart to try to provide supervision. She said Resident #93 often needed one to one (1:1) supervision and the staff were unable to provide this. During an interview on 4/20/22 at 5:24 P.M., the Director of Nurses said the documentation provided for the falls was the only documentation available and staff had not consistently been completing fall incident reports. She said if there were no interventions listed on the care plan or incident reports, then no interventions were implemented. She said the interdisciplinary team had not met to review the multiple falls of Resident #93 to reduce the risk of falls or injuries, per their facility policy and was unable to determine any trends or root cause because staff had not documented how or when the falls occurred. She said she was not involved in Resident #93 transferring units and was not sure why the Resident was placed in the room furthest from the nurses' station or who made this decision. 2. Resident #23 was admitted to the facility in February 2021 and had nine falls from 11/15/21 through 4/15/22. Review of the MDS assessment for Resident #23, dated 1/19/22, indicated the Resident had multiple falls, was not steady, and was only able to stabilize with human assistance for moving from seated to standing, walking, and turning around and facing the opposite direction while walking. Review of the Care Plans for Resident #23 indicated the Resident was a fall risk and the following interventions were implemented: 5/21/21: ensure Resident has shoes on when out of bed 12/6/21: assist Resident when transferring to and from recliner in front of nurses' station 3/7/22: encourage proper footwear to be worn at all times including non-skid socks; medication evaluation as needed; verbal cues for safety and sequencing 4/8/22: when sleeping in recliner, assess often for positioning On 4/13/22 at 12:00 P.M., the surveyor observed Resident #23 seated in a straight sofa chair at the end of the hallway, wearing plain white socks (not non-skid socks) without shoes. Resident #23 was observed to be ambulating the halls of the unit at 2:00 P.M. wearing the same socks, no shoes. Review of the medical record and incident reports for Resident #23 included the following falls from 11/15/21 through survey review on 4/15/22: -11/19/21 at 5:15 P.M., Resident was attempting to sit on recliner and slid to the floor. Review of the documentation failed to include any information regarding which interventions were in place or which interventions would be initiated. There were no staff statements to indicate how the fall occurred. -12/5/21 at an unknown time; CNA saw Resident get up from chair and fall to the ground. Review of the documentation failed to indicate which interventions were in place at the time of the fall; the documentation indicated the new intervention to be implemented was to assist the Resident with transfers to and from the recliner. There were no staff statements to indicate how or when the fall occurred. -12/31/21 at an unknown time; Resident was found sitting on the floor against the medication cart. Review of the documentation failed to include any information regarding which interventions were in place or which interventions would be initiated. There were no staff statements to indicate how or when the fall occurred. -1/3/22 at 10:15 P.M., Resident lying on floor in another resident's room. Review of documentation failed to include any information regarding which interventions were in place or which interventions would be initiated. There were no staff statements to indicate how the fall occurred. -1/30/22 at unknown time; Resident sitting in recliner in hallway, attempted to get up and tripped over a side table. Review of the documentation indicated the immediate intervention was to remove the side table. There was no further documentation to indicate interventions in place or which were implemented following the fall. There were no staff statements to indicate how or when the fall occurred. -3/1/22 at 6:45 P.M., Resident was found on the floor in the hallway and had tripped over legs of Hoyer lift device. Review of the documentation failed to include any information regarding which interventions were in place or which interventions would be initiated. -3/3/22 at 7:20 P.M., Resident attempted to sit in chair, missed chair and fell to floor. Review of the documentation indicated predisposing factors which included a cluttered environment and improper footwear. The care plan was updated with the same intervention as previously initiated in May 2021 of proper footwear. There was no indication of how the previous intervention of staff assisting in and out of recliner was implemented. -3/11/22 at 12:30 P.M., Resident tripped over side table and hit his/her head, as noted in the nursing progress note. There was no incident report or change in condition assessment. There were three staff statements which all indicated they did not find the Resident and had not seen the Resident since lunch. There was no indication of how the Resident tripped over the side table twice in a month and half. -4/8/22 at 5:45 A.M., Resident sleeping in chair, then was on the floor with an abrasion to the forehead. Review of the documentation indicated an intervention to assess for repositioning when Resident was sleeping in recliner. During an interview on 4/15/22 at 2:00 P.M., the Director of Nurses said the documentation provided to the surveyor regarding each fall was all the documentation the facility had. She said if interventions were not listed on the care plan or on the incident reports/change of condition assessments, then interventions were not implemented. She said she could not speak to why individualized interventions had not been implemented for Resident #23 who had multiple falls. 3. During an interview on 4/14/22 at 12:25 P.M., Resident #52's Responsible Person (RP) said that he/she has had several falls while at the facility, and the Resident must have close supervision by staff. The RP said the Resident fell out of his/her wheelchair in the day room three weeks ago and still has a bruise on his/her head. Review of the 2/2/22 Minimum Data Set assessment indicated Resident #52 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required extensive assistance/dependent on staff for activities of daily living. Review of interdisciplinary care plans includes, but is not limited to: -Problem: Resident at risk for falls: [CONDITION(S)] and recent fall (4/30/21) -Interventions: Place call light within reach while in bed or close proximity to the bed (4/30/21); monitor for and assist toileting needs (4/30/21) -Goal: Resident will have no falls with injury X 90 days (4/30/21) Review of the medical record indicated Resident #52 sustained the following falls: - 5/10/21, unwitnessed fall out of bed. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall in an effort to evaluate their effectiveness. On 5/12/21, the care plan was updated to include: Resident's preference/usual routine is to stay up and go to bed around 8:30-9:00 P.M., non-skid socks at all times. - 5/22/21, unwitnessed fall out of a wheelchair into the hallway while seated in the doorway of his/her room. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall in an effort to evaluate their effectiveness. On 5/24/21, the care plan was updated to include supervision of meals/snacks by staff or family due to poor safety awareness. - 6/5/21, unwitnessed fall out of a wheelchair while in his/her room. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall in an effort to evaluate their effectiveness. The care plan was not updated with new interventions in an attempt to reduce the risk of further falls. A 6/6/21 Nursing Documentation Note indicated Resident #52 continues to attempt to get out of his/her wheelchair, 1:1 with staff when family not available. This intervention was not carried over the care plan for falls. - 6/7/21, unwitnessed fall in the Resident's room. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall in an effort to evaluate their effectiveness. On 6/7/21, the care plan was updated to include the Resident is to be in common areas/supervised while awake related to anxiety and poor safety awareness, and medication evaluation as needed. On 6/9/21, the care plan was updated to include family/visitors to notify staff when they are leaving related to the Resident's anxiety when visits end. - 6/23/21, witnessed fall in the day room. A 6/23/21 Clinical Progress Note indicated that Resident #52 was seated in a wheelchair in the day room and was observed by a Nurse to stand up and fall onto his/her buttocks. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall in an effort to evaluate their effectiveness. The care plan was updated to include foot pedals to wheelchair and assist the Resident with ambulation providing contact guard with gait belt and wheelchair for safety with Resident utilizing a rolling walker. - 6/26/21, witnessed fall out of a wheelchair in the hallway. Review of witness statements indicated that Resident #52 was supposed to have one to one staff supervision, but it was not in place at the time of the fall. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall in an effort to evaluate their effectiveness. The Resident was sent to the hospital for evaluation on 6/27/21 and found to have a 2 centimeter laceration to his/her left eye. On 6/28/21 the care plan was updated to include a self-release seatbelt and bed alarm. - 10/29/21, unwitnessed fall. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall to evaluate their effectiveness. The care plan was not updated with new interventions in an attempt to reduce the risk of further falls. - 12/15/2, unwitnessed fall. A 12/15/21 Change in Condition Note indicated that a Nurse heard a loud sound and found Resident #52 lying on the floor in his/her room, with a lump on the side of his/her head. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall in an effort to evaluate their effectiveness. The Resident was sent to the hospital for evaluation. On 12/17/21, the care plan was updated to include bed in low position, offer routine toileting (toilet and bedpan) upon waking, before/after meals and before bed. - 1/9/22, unwitnessed fall. A 1/9/22 Change in Condition note indicated that a Certified Nursing Assistant (CNA) found Resident #52 on the floor next to his/her bed in the fetal position with a blanket covering him/her. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall in an effort to evaluate their effectiveness. The care plan was not updated with new interventions in an attempt to reduce the risk of further falls. - 3/15/22, unwitnessed fall. A 3/15/22 Change in Condition note indicated that a CNA found the Resident sitting on the floor in the Resident's room. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall to evaluate their effectiveness. The care plan was not updated with new interventions in an attempt to reduce the risk of further falls - 3/30/22, unwitnessed fall. A 3/30/22 Shift Level Progress Note indicated that staff notified the Nurse that Resident #52 was found on the floor in front of his/her wheelchair in the day room. A 3/31/22 Change In Condition Follow Up Note indicated that the Resident had a bump and bruise to the left side of his/her head, and a bruise on the left hip. On 4/1/22, Resident #52 was sent to the hospital for evaluation. There was no documentation in the medical record, and no fall investigation was conducted to ascertain what, if any, interventions were in place at the time of the fall to evaluate their effectiveness. No investigations were conducted for any of Resident #52's 11 falls, and there was no documentation in the medical record to ascertain what, if any, interventions were in place at the time of each fall to evaluate their effectiveness. During an interview on 4/19/22 at 1:15 P.M., the surveyor reviewed Resident #52's medical record and falls with Nurse #1. Nurse #1 said that staff is so busy because of low staffing, and they don't have time to update care plans. During an interview on 4/21/22 at 12:45 P.M., the Director of Nursing (DON) said that she was aware that no investigations and reporting had been done for the Resident's falls, and that they need to be completed. 4. Review of the facility's policy titled Elopement Prevention, dated as revised 2/2020, indicated but was not limited to the following: -facility maintains a process to assess all residents for risk for elopement and implement strategies for those identified as an elopement risk -interventions that may be used for residents identified at risk includes implementation of a wander bracelet -place wander bracelet on the resident's wrist or ankle -check wander bracelet placement every shift, reapply as needed, document on the medication administration record (MAR) -check wander bracelet function daily and document on the MAR -document use or discontinuation of the wander bracelet in the medical record Resident #48 was admitted to the facility in December 2021 with a diagnosis of Alzheimer's disease. Review of the most recent Elopement evaluation for Resident #48 completed on 2/10/22 indicated the Resident was at risk for elopement. Review of the April 2022 Physician's Orders indicated Resident #48 had a wander device due to poor safety awareness and placement should be checked every shift; the start date on the order was 2/10/22. Review of the current Care Plans for Resident #48 indicated he/she wore a wander bracelet on the left ankle. On 4/13/22 at 11:42 A.M., the surveyor observed the Resident in his/her room sitting in a chair without a wander bracelet to either wrist or ankle. On 4/15/22 at 10:25 A.M., the surveyor observed the Resident self-propelling in his/her wheelchair without a wander bracelet to either wrist or ankle. Review of the April 2022 Treatment Administration Record (TAR) indicated placement of the wander bracelet was being monitored but lacked evidence of function of the wander bracelet being monitored or documented. During an interview on 4/15/22 at 10:29 A.M., Unit Manager (UM) #1 said the staff should be documenting the placement and function of the wander bracelet every shift. UM #1 reviewed both the MAR and TAR and said the nurses are not documenting the function of the wander bracelet anywhere and there is no order for them to do so. He said the function of the bracelet must be monitored according to the policy and it is not being completed for this Resident. On 4/15/22 at 10:39 A.M., the surveyor observed UM #1 attempt to verify placement and function of the wander bracelet for Resident #48 using a handheld testing device. UM #1 looked at both of the Resident's wrists and ankles and searched the Resident's wheelchair and could not find a wander bracelet in place on the Resident. During an observation with interview on 4/15/22 at 10:49 A.M., the surveyor observed UM #1 place a new wander bracelet on Resident #48's left ankle and check the function of the bracelet. He said the bracelet must have been removed when the Resident went out to the hospital and was not replaced, but the expectation is it should be replaced promptly upon returning to the facility. 5. For Resident #259, the facility failed to complete an incident report/investigation according to the facility policy and document 72-hour post fall shift notes and define possible causes within 24 hours, after the Resident sustained a fall which required a transfer to the hospital for evaluation and treatment as per the facility policy. Resident #259 was admitted to the facility March 2022 with diagnoses including traumatic subdural hemorrhage requiring surgical intervention, (craniotomy) [CONDITION(S)] with left sided weakness and frequent falls. Review of Resident # 259 Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was not steady, and was only able to stabilize with human assistance for ambulation, moving from seated to standing, walking, and turning around and facing the opposite direction while walking, and for moving on and off the toilet. Requires extensive assistance of one person for ambulation (with assistive device/walker) and toileting. Review of the care plan for falls included but was not limited to: -Problem: Resident at risk for falls: Impaired Mobility -Interventions: Medication evaluation as needed, provide verbal cues for safety and sequencing when needed, provide verbal cues for proper pacing and energy conservation techniques, Maintain a clutter-free environment in the resident's room and consistent furniture arrangement, Place call light within reach while in bed or close proximity to the bed; -Goal: Resident will have no falls with injury X 30 days. Review of a nurses note dated 3/22/22 included but was not limited to the following: At 1:30 P.M., resident was found by Certified Nursing Assistant (CNA) lying on floor between wall and toilet in his/her bathroom. When asked what had occurred, Resident stated that he/she fell when ambulating, unassisted to the toilet with walker. The Resident stated that while attempting to close the bathroom door for privacy, became dizzy, fell backward onto the floor and reported striking the back of his/her head on the floor. A three-centimeter (cm) round, red, contusion noted on the back of the Residents head with no open areas noted. Resident was then assisted to stand and reported feeling dizzy immediately upon standing. Given the Residents status and post-surgery for subdural hematoma, the Resident was sent to the emergency room for evaluation. There was no documentation as to physician notification, the Resident returned to the facility and neurological signs were initiated. Record review indicated no fall investigation/incident report and no evaluation for 72 hours every shift, post fall. Other to the above nurse's note dated 3/22/22, there was no further documentation as to the fall occurrence. Review of the falls care plan did not indicate any update to the care plan was completed. During interview on 4/21/22 at 10:45 A.M., the DON said that an incident report had not been completed and that there was no documentation that the 72 hour post fall shifts notes had been completed as per the facility policy. She further said that the fall was not reported/entered into HCFRS, and it should have been.

Based on interview, observation, and policy review, the facility failed to ensure recommendations to prevent skin breakdown were followed for one Resident (#8), out of a total sample of 30 residents. Findings include: Review of the facility's policy titled Pressure Wound Prevention, dated as revised 10/2021, indicated but was not limited to: -purpose of the policy is to provide information regarding identification of pressure ulcer factors and interventions for specific risk factors -review the Resident's plan of care and identify the risk factors, as well as, the interventions designed to reduce or eliminate those considered modifiable -determine if a special mattress is needed -protect bony prominences as needed 1) Resident #8 was admitted to the facility in May 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record indicated Resident #8 has been receiving hospice services since May 2021 and has a chronic deep tissue injury to his/her left heel. Further review indicated the Resident is followed for wound management by a facility contracted nurse practitioner. Review of the most recent Norton Skin Assessment, completed on 3/30/22, indicated the Resident was at high risk for skin breakdown. Review of the Hospice Recommendations on 4/8/22 indicated recommendations for a soft boot to the left foot/heel to be worn daily while out of bed, put on in the AM and remove in the PM. It further indicated the soft boot was ordered by Hospice on the same day, 4/8/22. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Practitioner's Notes indicated the Wound Nurse Practitioner assessed the Resident on 4/11/22 and indicated Resident #8 had a chronic left heel deep tissue injury and a recommendation to off-load [distribute the load to other areas which are not susceptible to pressure] heels with boot. On 4/13/22 at 12:34 P.M., the surveyor observed Resident #8 sitting in a wheelchair in the dayroom with slipper socks on his/her feet and no soft boot on the left foot. On 4/19/22 at 1:38 P.M., the surveyor observed Resident #8 self-propelling in his/her wheelchair in slipper socks without a soft boot to the left foot. On 4/20/22 at 11:09 A.M., the surveyor observed Resident #8 sitting in a wheelchair in the dayroom with slipper socks on his/her feet and no soft boot on the left foot. Review of the April 2022 Treatment Administration Record (TAR) indicated the soft boot to the left foot was in place each day shift and removed each evening. During an interview on 4/20/22 at 11:21 A.M., Hospice Staff #2 said she provides care for Resident #8 daily Monday thru Friday. She said she is aware that a boot for the left foot was ordered, but it hadn't come in yet, and therefore she hasn't been placing it on the Resident in the mornings following morning care. During an interview on 4/20/22 at 12:27 P.M., Unit Manager (UM) #1 said to the best of his knowledge the left foot boot was ordered by Hospice but has not come in yet. UM #1 reviewed the April 2022 TAR and said the staff are signing off that the boot has been in place since the initiation of the order on 4/9/22, but they should not be. He visually confirmed Resident #8 did not have the boot in place, and then searched the Resident's room for the boot and confirmed it had not yet arrived. During an interview on 4/20/22 at 12:30 P.M., Nurse #3 said she must have signed the placement of the left boot off in error, but she thought she had seen one. She said the Resident is not wearing one at this time but is wearing soft fluffy slipper socks. Nurse #3 searched the Resident's room for the equipment and said she couldn't locate the soft boot for the Resident but would find one in house stock to use until the ordered boot is delivered. During an interview on 4/20/22 at 1:22 P.M., Hospice staff #1 said he ordered the soft boot on 4/8/22 and it had not yet been delivered to the facility for the Resident.

Based on observation, interviews, record review, and policy review, the facility failed to ensure staff identified, addressed, and monitored significant weight changes for three Residents (#34, #48, and #94) with unplanned, significant weight changes, out of a total sample of 30 Residents. Specifically, the facility failed to re-check weights timely, monitor food intake consistently, and implement nutritional interventions to prevent further significant weight loss and gains. Findings include: Review of the facility's policy titled Weight Assessment and Interventions, dated as revised 5/2019, indicated but was not limited to: - the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight changes -weights will be recorded in the medical record for each resident -any weight change of 5 pounds (lbs.) in a month and 3 lbs. in a week will be retaken within 48 hours, confirmed, reviewed, and verified by nursing -licensed nurse will notify dietician of identified weight changes once reviewed -dietitian notification should be documented in the medical record -dietitian or diet technician will respond within 72 hours of receipt of notification -dietitian/diet technician will review the resident weights for trends to evaluate whether or not significant weight change has been met -significant unplanned or undesired weight change is based on the following criteria a. 1 month - 5% weight change is significant; greater than 5% is severe b. 3 months - 7.5% weight change is significant; greater than 7.5% is severe c. 6 months - 10% weight change is significant; greater than 10% is severe -care planning for weight change or impaired nutrition should be a multidisciplinary effort -individualized care plans shall address to the extent possible the cause of weight change, goals and benchmarks for improvement, time frames and parameters for monitoring and reassessment -interventions for undesirable weight change shall be based on careful consideration of the following: a. resident choice and preference b. nutrition and hydration needs c. functional factors that may exhibit independent eating d. environmental factors that may inhibit appetite or desire to participate in meals e. chewing and swallowing abnormalities f. medications that may interfere with appetite, chewing, swallowing, or digestion g. use of supplements and/or feeding tubes h. end of life decisions and advanced directives i. regularly scheduled lab work 1. Resident #34 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 1/25/22 Minimum Data Set assessment indicated Resident #34 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15, had weight loss of 5% or greater in the last month, and was not on a physician prescribed weight loss plan. Review of the medical record indicated the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Weigh daily (12/29/21) Review of Resident #34's weight record indicated: -12/29/21=201.4 lbs. -12/30/21=no weight -12/31/21=no weight -1/1/22=no weight -1/2/22=199.0 lbs. -1/3/22=201.0 lbs. -1/4/22=199.9 lbs. -1/5/22=202.6 lbs. -1/6/22=204.6 lbs. -1/7/22=no weight -1/8/22=201.2 lbs. (-3.4 lb. loss) -1/9/22=no weight -1/10/22=202.3 lbs. -1/11/22=no weight -1/12/22=202.3 lbs. -1/13/22=204.1 lbs. -1/14/22 through 1/18/22=no weights -1/19/22=194.0 lbs. (-9.9 lb. loss) -1/20/22 through 1/23/22=no weights -1/24/22=194.6 lbs. -1/25/22=194.0 lbs. -1/26/22 through 2/1/22=no weights -2/2/22=184.4 lbs. (-9.6 lb. loss) -2/3/22=no weight -2/4/22= 185.0 lbs. -2/5/22 through 4/2/22=no weights -4/3/22=177.0 lbs. (-8 lb. loss); 12.1% significant weight loss in 4 months -4/4/22 through 4/18/22=no weights -4/19/22=179.8 lbs. Review of the medical record indicated that Resident #34 was not weighed daily according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence in the medical record that the Dietitian and/or Physician were notified of and responded within 72 hours to a 9.6 lb. weight loss identified on 2/2/22, and an 8 lb. weight loss identified on 4/3/22. From 12/29/21 to 4/3/22, the Resident experienced a 12.1% significant weight loss. During an interview on 4/19/22 at 1:15 P.M., Nurse #1 could not explain why Resident #34 was not weighed daily according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #48 was admitted to the facility in December 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weight Summary for Resident #48 indicated a weight of 127.6 pounds (lbs.) on 12/8/21 and a weight of 108.2 lbs. on 4/11/22, representing a significant weight loss of 15.2% in 4 months. Review of two Nutritional Assessments in the medical record indicated the following: 1. assessment dated [DATE], dated as signed 3/11/22 -ideal body weight 125 lbs. -height 65 inches as of 1/2/22 standing -weight 124.6 lbs. as of 1/11/22 -regular diet with regular texture and fluid consistency -independent with meals -additional comments indicated: new fracture status post [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. assessment dated [DATE], dated as signed 3/11/22 -ideal body weight 125 lbs. -height 65 inches as of 1/2/22 standing -weight 116.4 lbs. as of 2/21/22 -regular diet with regular texture and fluid consistency -dependent for meals -weight loss noted; meal intakes goal greater than 50%; continue regular diet -additional comments indicated: regular diet with variable intakes of 25%-75%, needs more assistance depending on mood and level of fatigue, down 11 lbs. from 2 months ago, below ideal range at 93%, [MEDICATION(S)] added at 7.5mg daily to help enhance appetite, will provide high caloric drinks at meals for added nutrition, continue to monitor closely for any further changes. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Dietitian's Progress Notes, dated 4/13/22, failed to indicate the Dietitian consulted on the Resident's weight loss following the 3/22/22 order. Review of the Nurse Practitioner's Visit Notes, dated 1/25/22 and 2/22/22, indicated awareness of the Resident's weight loss and a plan for the Resident to be supervised or assisted with meals. On 4/14/22 at 8:21 A.M., the surveyor observed the Resident in bed with breakfast in front of him/her not eating, no staff were supervising or assisting the Resident. On 4/19/22 at 8:19 A.M., the surveyor observed the Resident in bed eating breakfast independently, no staff were supervising or assisting the Resident. Review of the Minimum Data Set (MDS) assessment, dated 2/19/22, indicated the following: -Section G, functional status - independent eating one person set up only -Section K, swallowing and nutritional status, indicated a weight loss of 5% or more in the last month or 10% or more in the last 6 months, not on a physician prescribed weight loss plan. Review of the Activity of Daily Living (ADL) Record for Resident #48 indicated the following: -February 2022: Independent with meals 71 out of 84 possible meals documented and 65 out of 75 documented meal intakes at 50% or less out of the possible 84 meals documented. -March 2022: Independent with meals for 83 out of 93 possible meals documented and 10 out of 77 documented meal intakes at 50% or less out of the possible 93 meals documented. During an interview on 4/19/22 at 11:03 A.M., Certified Nurse Assistant (CNA) #4 reviewed the ADL records for February, March, and April of 2022 and said the documentation indicated the Resident eats independently. She said the Resident is not supervised, although Resident #48 does eat lunch and dinner in the common room on the unit and a staff member is available in the room, but this Resident is independent with his/her meals. During an interview on 4/19/22 at 11:29 A.M., Nurse #3 said Resident #48 has orders for a house supplement twice a day. She reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the Resident is independent with his/her meals. The surveyor reviewed the care plan with Nurse #3 and the Nurse said she was unaware the Resident was supposed to be supervised or assisted with meals. The Nurse said that is not happening and the care plan is not being followed. During an interview on 4/19/22 at 12:33 P.M., the Dietitian said she was unaware of the order for a dietitian consult on 3/22/22 and did not review the Resident or write a note until 4/13/22. The Dietitian said the timeframe between the order in March and the note in April is a delay, but she is only in the facility about 8 to 10 hours a week. The Dietitian reviewed the nutritional assessments and said the date of the assessment is the date the evaluation is initiated, and the date locked and signed is the date she completed the evaluation. She said the Resident is on supplement drinks twice a day and she reviews the MAR for percentage consumed and would adjust her supplement intervention based on the consumption of the supplement. The Dietitian reviewed the MAR for April 2022 and said she was unaware the staff were not documenting supplement intake. The Dietitian reviewed the medical record of Resident #48 and said she is unsure why she updated the care plan with an intervention for the Resident to have supervision or assistance with meals; she said the staff must have informed her the Resident required assistance. She said all residents with weight loss have an update monthly note by a Dietitian with new interventions but could only locate a note for February (2/8/22) and April (4/13/22) of 2022 and said monthly notes were best practice and that was not followed for this Resident. The Dietitian reviewed the care plans and said she revised the care plan goal on 4/13/22 but added no new care plan interventions even though the Resident continues to lose weight and that she doesn't have a plan for the Resident's ongoing weight loss at this time and feels the information needs to be re-evaluated. She said she does not typically participate in care plan meetings and has not discussed weight loss or interventions in a care plan meeting for this Resident or had any conversations with the Resident or his/her responsible party regarding the significant weight loss, dietary preferences, or concerns around the Resident's nutritional status. She said the Resident had a 13% weight loss in a 3-month time frame, but she feels the weight loss is slowing down since the Resident has only lost an additional 4 lbs. between February and April. She said although the Resident continues to lose weight she has no addition interventions for the Resident at this time, but if the Resident should demonstrate a significant loss again during the next month, he/she would be re-evaluated. During an interview on 4/19/22 at 1:18 P.M., the Administrator and Director of Nurses (DON) was made aware of concerns regarding the significant weight loss for Resident #48 and the continuation of weight loss and the lack of dietitian availability, interventions, and family involvement to prevent further weight loss. The Administrator said her expectation is that the Resident and family would be involved and provide assistance and insight into food preferences. She said she believes other interventions should have been and could be attempted such as fortified foods. The DON said there should be more interventions attempted and a better monitoring of supplement consumption for a Resident with a significant weight loss. The Administrator said the policy and expectations for nutritional and weight management were not being met. 3. Resident #94 was admitted to the facility in March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was admitted to the facility on a 2000 cubic centimeter (cc) fluid restriction. Review of the Comprehensive Nutrition Assessment completed by the facility Registered Dietitian (RD), dated 4/1/22, included but was not limited to: -Most recent weight 202.7 lbs. Weight has increased over the past week 27.1 lbs. -Recommendation to obtain a re-weight to ensure accuracy. -Will continue to monitor resident closely. Record review indicated that no re-weigh had been obtained and the RD did not have any further monitoring of the Resident's weight gain. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Weigh every day for CHF monitoring. Review of the record indicated the Resident had not been weighed daily as ordered by the physician on 4/8/22 and 4/11/22. Further record review indicated the physician had not been notified of the 27.1 lb. weight gain. During an interview on 4/19/22 at 12:58 P.M., the Registered Dietitian (RD) said she could not remember exactly about this Resident's need for a re-weigh. The RD further said that the process for obtaining a resident's re-weigh is by word of mouth and that there is no communication book for dietary recommendations/concerns. There was no documentation to indicate, if anyone, was told or that a reweigh was requested. On 4/20/22 the DON and Administrator were made aware of the concerns with the weight gain, no daily weights as ordered by the physician, not closely monitored as the Dietician indicated that she was going to do, no notification of the physician of the weight gain, and no re weigh. During an interview on 04/21/22 at 8:25 A.M., the DON said that after reviewing the Resident's record, the facility failed to ensure daily weights were completed as ordered by the physician, that the physician was notified of the weight gain and that a re-weigh was obtained.

Based on observations, interviews, record review, and policy review, the facility failed to ensure for three Residents (#93, #110, and #65), out of 4 residents with indwelling catheters, that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The total resident sample was 30 residents. Specifically, for 1. Resident #93, the facility failed to attempt a voiding trial to remove a catheter and failed to have the Resident seen by a urologist; 2. Resident #110, the facility failed to assess for the removal of the catheter as ordered by his/her Physician; and 3. Resident #65, the facility failed to follow standards of practice of infection control practice for continuous drainage (CD) bags. Findings include: Review of the Bladder Incontinence- Assessment and Management policy, last revised in May 2019, indicated if a resident was admitted from the hospital with a newly placed indwelling catheter, the physician and staff would evaluate the potential for removing it, depending on the current condition and the rationale for its original placement. Review of the facility's policy titled Catheter Guidelines, dated 8/2019, included but was not limited to: Policy: -The purpose of this procedure is to prevent catheter-associated urinary tract infections Infection Control: -Be sure the catheter tubing and drainage bag are kept off the floor. 1. Resident #93 was admitted to the facility in February 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospital Discharge Summary for Resident #93, dated February 2022, indicated the Resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation indicated a voiding trial should be attempted at the facility. A review of the Nursing Progress notes, dated 2/20/22, indicated a voiding trial would be attempted on 2/25/22. Review of the Physician's Progress Note, dated 2/21/22, indicated Resident #93 had a Foley catheter and needed a voiding trial. Review of the February Treatment Administration Record (TAR) indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was not signed off as completed. Review of the Nursing Progress Note, dated 2/25/22, indicated the Resident had the catheter changed the night prior, with trauma noted related to Resident pulling at it, with no urinary output and Resident was sent to the emergency room where the catheter was changed. Review of the hospital documentation, dated 2/25/22, indicated Resident #93 had pulled out the catheter the previous night; a new Foley catheter was inserted and to follow up with Urology. Review of the Nursing Progress notes indicated on 3/1/22 and 3/2/22, Resident #93 was tugging at the catheter. Review of a Social Service Progress note, dated 3/4/22, indicated Resident #93 was to see Urology in March 2022. Review of the March 2022 TAR indicated an order to attempt a voiding trial on 3/4/22, obtain post-void residual check every shift for 72 hours. The TAR was signed off by the nurses as hold- see nurse's note or other-see nurse's note. A review of the nursing documentation failed to include any information regarding an attempted voiding trial or a reason the voiding trial was not attempted. A nursing progress note on 3/5/22 acknowledges the order for a voiding trial and notes the catheter remained in place. Review of Nursing Progress notes on 3/5/22 and 3/6/22, indicated the Resident continued to tug on the catheter. Review of the Physician's Progress note, dated 3/5/22, indicated Resident #93 continued to have a catheter in place with gross hematuria (blood in the urine), possible Foley catheter trauma, and to see a Urologist. A review of the hospital visit information, dated 3/15/22, indicated Resident #93 had a urinary tract infection ([CONDITION(S)]) and to follow up with Urology. The Hospital Discharge Summary indicated the hospital scheduled a Urology follow-up appointment for 3/22/22, four weeks after admission to the facility. Review of a Nursing Progress Note, dated 3/21/22, indicated Resident #93 continued to tug on the catheter and the nurse observed dark blood in the bag. The Resident was sent to the hospital on 3/21/22. A review of the Hospital Discharge Summary, dated March 2022, indicated Resident #93 was supposed to have the Foley catheter removed, but it never was, and the Resident had a few traumas due to pulling the catheter and as a consequence was having increased agitation and confusion. The hospital removed the catheter at this time and the Resident was able to void successfully. Review of the Unit Appointment Book indicated Resident #93 had a scheduled follow-up with Urology on 4/8/22. The medical record failed to include any information regarding the Urology appointment During an interview on 4/20/22 at 5:15 P.M., the Director of Nurses said there was no documentation a voiding trial was ever attempted for Resident #93, as ordered and she was not sure why. She said she was unable to locate any documentation to indicate Resident #93 had seen a Urologist while at the facility, except while as in-patient at the hospital. During an interview on 4/21/22 at 9:25 A.M., Physician #2 said Resident #93 had not seen a Urologist, except as an out-patient at the hospital. He said Resident #93 was doing better without the catheter and he suspected the catheter was one of the contributing factors for the agitation of Resident #93. 2. Resident #110 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospital discharge summary, dated January 2022, indicated Resident #110 had difficulty urinating and an indwelling urinary catheter was inserted during the hospital stay. The Hospital discharge record indicated the facility should remove the catheter and attempt a voiding trial and have the Resident follow-up with a urologist as indicated. Review of Resident #110's Physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Discharge Summary, dated January 2022, indicated a Foley catheter had been inserted on 1/2/22 for urinary retention and would require care and re-evaluation of use/need. Review of Resident #110's medical record failed to indicate that a voiding trial was conducted on 1/10/22. Review of a Nurse's Note, dated 1/11/22, questioned if the voiding trial had been conducted and if the Resident needs a follow-up consultation with the urologist. Further review of the medical record failed to indicate the facility staff re-evaluated the indwelling urinary catheter and failed to indicate the reason the voiding trial was not conducted. In addition, there was no documentation that an appointment with a Urologist was made. During an interview on 4/20/22 at 12:48 P.M. and 2:45 P.M., the Director of Nurses (DON) said she was aware that the clinical records lacked documentation and said the staff do not follow-up when they needed to. The DON said she was unable to locate anything in the medical record, and that the voiding trial should have been done as ordered and did not know why it had not been done. 3. Resident #65 was admitted in August 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review on 4/20/22, indicated the Resident had an indwelling urinary catheter due to urine retention. The surveyor observed the Resident's catheter drainage (CD) bag resting on the floor on multiple occasions as follows: - On 4/20/22 at 10:06 A.M., the Resident was lying in bed and resting quietly; the Resident's CD bag was resting on the floor. The urine in the tubing appeared cloudy with a significant amount of pale, yellow sediment. - On 4/20/22 at 10:16 A.M., the Resident's urinary CD bag remained resting on the floor. - On 4/20/22 at 11:04 A.M., the Resident's urinary CD bag remained resting on the floor. A significant amount of off-white colored sediment was observed in the tubing. - On 4/20/22 at 11:52 A.M., the Resident's urinary CD bag remained resting on the floor. Review of the Care Plan for the Resident's indwelling catheter indicated the CD bag was to be kept off the floor. During an interview on 4/20/22 at 4:00 P.M. with the Administrator and the Director of Nursing (DON), both said the facility policy is to ensure that the CD bag is positioned so it is not resting on the floor. They acknowledged the risk of the Resident contracting a urinary tract infection if the CD bag is positioned on the floor.

Based on record review and interview, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice for care of patients on oxygen therapy, for one Resident (#73) out of a total sample of 36 residents. Specifically, the facility failed to implement appropriate monitoring of interventions and initiate a process to ensure portable oxygen tanks were filled and ready for use which resulted in the Resident experiencing an acute episode of shortness of breath with his/her oxygen saturation level dropping to 89% and causing the Resident undue physical and emotional distress. Findings include: LIPPINCOTT NURSING PROCEDURES, 8th edition oxygen .all oxygen delivery systems should be checked at least once each day -verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed -monitor the patient's oxygen (O2) saturation level by pulse oximetry to assess response to O2 therapy -assess the patient frequently for signs and symptoms of [CONDITION(S)], such as restlessness, decreased level consciousness, increased heart rate, arrhythmias, perspiration, dyspnea, use of accessory muscles, yawning or flared nostrils, cyanosis, and cool, clammy skin, obtain vital signs, as needed. DOCUMENTATION record the date and time of oxygen administration, the type of delivery device, the oxygen flow rate, the patient's vital signs, skin color, respiratory effort and breath sounds. Review of the facility's policies, Oxygen-concentrators (last revised 1/2020), Oxygen-cylinders (created 1/2020), Oxygen Administration (last revised 10/2019) and Oxygen Therapy (last revised 1/2020) included, but was not limited to: -Oxygen orders should specify the liter flow or concentration required as routine or as needed (PRN), delivery mode (nasal cannula, mask, etc.), oxygen saturation level checks, frequency, equipment -Oxygen use will be documented on the Medication/Treatment Administration Record -Oxygen equipment will be checked daily for correct liter flow and concentration, properly filled humidification system if in use -Oxygen tubing will be changed at least weekly, date initial tubing when changed -Oxygen therapy should be used carefully in residents with [CONDITION(S)] ([CONDITION(S)]) due to the possibility of hypercarbia (presence of higher-than-normal level of carbon [MEDICATION(S)] in the blood) -Portable oxygen cylinders are the mode of choice for mobile residents who require oxygen therapy -Oxygen tanks should be changed out at 1/4 tank (i.e., 500 psi) Resident #73 was admitted to the facility in March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 6/12/22 Minimum Data Set assessment indicated Resident #73 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 9 out of 15, required extensive physical assistance of staff for toileting and had an activated health care proxy. Review of the medical record indicated the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Continuous humidified oxygen via nasal cannula (small, flexible tube with two open prongs intended to sit just inside the nostrils to deliver oxygen) at 2 liters/minute for [CONDITION(S)], as needed (5/10/22) The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/14/22 at 9:29 A.M., Resident #73's Responsible Person (RP) said yesterday afternoon she was on the telephone with the Resident while he/she was left in the bathroom by facility staff for a long time. The RP said she could hear the Resident wheezing and struggling to breathe, and it sounded like the Resident was having an asthma attack or panic attack and was scared and upset. She said she kept telling the Resident to call the nurse for help. She said she remained on the telephone when a nurse finally came to the bathroom to assist the Resident. She heard the nurse say that the oxygen tank was empty, and the Resident's oxygen saturation was measured in the 80's. Review of the medical record indicated a 7/13/22 Clinical Nurse's Note written by Nurse #4: Patient was complaining of shortness of breath, Nurse Practitioner assessed, nebulizer treatment given per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/14/22 at 9:50 A.M., Nurse #4 said Resident #73 was in activities all day off the unit and did not know if anyone checked the portable oxygen tank. She said the Resident was brought back up to the unit at the end of the day and taken directly into the dining room to socialize with friends. She said no one on the unit checked the tank to see if it still had oxygen. Nurse #4 said she heard the Resident calling and when she arrived at the Resident's bathroom, she noted the portable oxygen tank was empty and the Resident was short of breath. She measured the Resident's oxygen saturation, and it was down to 89%. Nurse #4 said there is no process in place to ensure portable oxygen tanks are filled, checked during the day, and available for residents' use. During an interview on 7/14/22 at 9:55 A.M., Activity Assistant #1 said Resident #73 was off the unit all day in activities on 7/13/22. Activity Assistant #1 said that no one checked the Resident's portable oxygen tank all day, and she brought the Resident back to the unit dining room and left the unit without alerting staff the Resident had returned. During an interview on 7/14/22 at 12:00 P.M., the Nurse Practitioner said she was at the nursing station on 7/13/22 when Resident #73 was in respiratory distress while in the bathroom in his/her room. She said she could hear the Resident struggling to breathe all the way down the hallway. She said she accompanied Nurse #4 to the Resident's room and noted the portable oxygen tank was empty.

Based on observation, record review, policy review and interview, the facility failed to ensure that care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy titled PICC line dressing change dated 10/2021 included but was not limited to: -PICC dressings are changed 24 hours after the initial placement of the line -Transparent dressings are changed every 7 days of sooner if the integrity of the dressing is compromised -Only sterile tapes, sterile wound closure strips or manufactured catheter securement devices (preferred) will be used to stabilize and maintain the position of the catheter. Equipment: 1 Central line Dressing Kit 1 pair clean gloves Securement device Procedure: -Remove old dressing and securement device -Dispose of old dressing and gloves appropriately -Don Sterile gloves -Apply securement device, maintaining sterile technique -Apply Sterile dressing -Document date and time of procedure, site assessment, measurement of external catheter length, patient response to procedure. Review of the procedure titled PICC or Midline Dressing Changes from Infusion Nursing, revised, 7/2020, indicated but was not limited to the following: The PICC dressing change is a sterile procedure which requires the use of sterile gloves. It is strongly recommended that the nurse and the patient wear a mask during the procedure. If the patient is unable to do so, they should be instructed to turn their head away from the catheter exit site. For Resident #258, the facility failed to provide care and services for the Residents PICC, specifically the facility failed to ensure that sterility could be maintained during the dressing and failed to secure the PICC to prevent catheter migration. Resident # 258 was admitted to the facility April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #258 returned to the facility with the PICC in place for the administration of daily IV antibiotics ([MEDICATION(S)] One Gram daily). Review of the physician's orders indicated the following: -Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference every Thursday for maintenance. (Start 4/14/22-Day shift 7:00 A.M. to 3:00 P.M.). -Change Catheter Securement Device upon admission and weekly every Thursday for maintenance. (Start 4/14/22-Day shift 7:00 A.M. to 3:00 P.M.) On 4/14/22 at 8A.M , the surveyor asked Nurse # 7 if Resident # 248 was due to have the PICC dressing changed today. Nurse # 7 said the dressing is due to be changed today, the surveyor informed Nurse # 7 that she will observe the procedure. On 4/14/22 at 12:00 P.M., the surveyor was alerted that Nurse #7 was ready to change Resident #248 PICC dressing. Upon entering the [NAME] Unit, Nurse #7 verbally reviewed the process/procedure (at Nurse #7 request). The verbal review by Nurse #7 indicated that she was aware of the process/procedure, and the Surveyor and Nurse #7 proceeded to Resident #248's room. The Infection Control Preventionist (ICP)joined to provide assistance as needed for Nurse #7. With the Residents permission, the surveyor observation was as follows: Nurse #7 maintained sterility opening the sterile field, donned a pair of clean gloves, removed the old dressing and securement device without an issue. Nurse #7 attempted to don the sterile gloves and was unable to put the first glove on due to the cuff of the glove sticking together, and in the process of trying to get the glove apart, contaminated the glove breaking sterility. Nurse#7 then opened another dressing change kit (back-up) to obtain a second pair of gloves. While attempting to don the first glove, and her fingernail punctured the glove, and it had to be discarded. The ICP left the room to obtain extra sets of sterile gloves. Upon return, Nurse #7 began to don the sterile gloves. She donned the first glove and maintained sterility, however while attempting to don the second glove, Nurse #7 touched the wrong area (the glove was picked up from the outside of the second glove and not from under the cuff) of the second glove, causing contamination of the glove when Nurse #7 attempted to don the glove, and was stopped by the surveyor and indicated to Nurse #7 that she had contaminated the glove, and she agreed with the surveyors' observations of contamination. Nurse #7 attempted one more time to don a pair of sterile gloves without contaminating, (Nurse #7, touch the outside of the first glove to the inside of the second glove and touched her wrist, while attempting to don) and she was unable to do so. At this time, the surveyor intervened and indicated to the ICP that it might be reasonable to have her finish the dressing change, and she agreed, The ICP finished the dressing change with any breaches in sterility. Upon completion of the dressing change, the surveyor inquired about the securement device, as one had been removed and not replaced. The ICP said that the facility dressing change kits supplied by the facility do not have the securement device and the kit does not contain a securement device. She further stated that the staff who changed the previous dressing probably did not remove the device and kept it in place when the previous dressing charge had been performed (dressing had been dated 4/9/22, measurements and change documented in the nurse's notes, but did not address the securement device as being changed). During interview on 4/19/22 at 2:00 P.M. the Director of Nursing (DON) said that the ICP was correct about the kits not containing the device, however the facility does have them available, separate from the kit. She further said that she should have used a device or secured it with tape. The DON was also made aware of Nurse #7 inability to don the sterile gloves during a dressing change and said that sterility should have been maintained as the PICC dressing change is a sterile dressing change/procedure. 2. For Resident #160 the facility failed to: a. Change the Peripherally inserted central-line catheter (PICC) dressing, measure the external catheter length and securement device on admission as ordered by the physician. b. Change the Administration set and reconcile the set as ordered by the physician. 2. Resident #160 was admitted to the facility in 4/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was admitted to the facility with a left upper extremity PICC, for the administration of Intravenous (IV) antibiotics ([MEDICATION(S)] 2 gm (grams) IV every 8 hours). Record review indicated the following physician's orders (4/2022) for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Change administration (tubing set) set every 24 hours for maintenance, label with date/time/initials, change sterile end cap on intermittent administration with each use. -Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference. Change on admission. -Change Catheter securement device upon admission and weekly as needed (if not integral to the dressing) and with dressing change. -Administration Set Reconciliation: (intravenous infusion set tubing -Reconcile upon admission, shift change, new infusion, or device, any IV related procedure or when order changes, every shift for maintenance. Review of the Treatment Administration Record (TAR) dated 4/2022 indicated the following: -There was no documentation/evidence to support the administration set was changed on 4/14/2022 and 4/15/2022. -There was not documentation/evidence to support that the transparent dressing to the PICC and the securement device had been changed on admission as per the physician's order. There was no documentation of the upper arm circumference and external catheter length as per the physician's order. -There was no documentation to support that on 4/15/2022 (3:00 P.M. to 11:00 P.M.-evening shift), that the administration set was reconciled. During interview on 4/20/2022 at 5:00 P.M., the Director of Nursing (DON) said that she understood the concerns regarding nursing's failure to provide care and treatment to the Resident's PICC line. During interview on 4/21/22 at 8:15 A.M., the DON said that the facility staff failed to change the dressing and securement device, measure the external catheter length, measure the upper arm circumference, change the administration set and reconcile the administration set according to the facility policy/protocol and the physician's order for care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and interview, the facility failed for one Resident (#1G), to provide pain medications as prescribed resulting in the Resident experiencing pain at an 8 on a 0-10 pain scale (with zero being none and 10 being the worst pain ever felt in their life). The total sample was 36 residents. Findings include: Resident #1G was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1G's care plan indicated the Resident exhibits or is at risk for alterations in comfort related to chronic pain from spinal stenosis and right lower extremity (RLE) [CONDITION(S)], with a goal of Resident achieving an acceptable level of pain control for the next 90 days. Interventions included, but were not limited to: medicate Resident as ordered for pain and monitor for effectiveness and potential side effects. Review of the Pain evaluation assessment dated : 6/22/22 indicated Resident 1G had a deep sharp persistent pain in his/her lower sacral back and a personal pain goal of a 1 out of 10 (with zero being none and 10 being the worst pain ever felt in their life), which they felt was not being reached, and their scheduled [MEDICATION(S)] was increased from twice a day to three times a day related to this assessment. Review of the Resident's active orders for pain management as of 7/15/22 included the following: - order started on 6/10/22: [MEDICATION(S)] 4% apply to the skin 1 patch daily for back pain - order started on 6/10/22: [MEDICATION(S)] 100 mg two times a day for pain - order started on 6/23/22: [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]- a narcotic pain medication) tablet 5-325 mg three times a day for pain management - order started on 6/23/22: Acetaminophen 325mg by mouth three times a day for pain along with [MEDICATION(S)] - order started on 6/23/22: [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) tablet 5-325 mg, 1 tablet every 24 hours as needed for pain During an interview on 7/13/22 at 8:10 A.M., Resident #1G said he/she was in pain and had not received his/her pain medications over the last few days as prescribed. Review of the July 2022 medication administration record (MARs) for Resident #1G indicated the following missed pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - 7/8/22: [MEDICATION(S)], Scheduled [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]), Acetaminophen all at 6:00 A.M. - 7/9/22: scheduled [MEDICATION(S)] at 10:00 P.M. - 7/10/22: scheduled [MEDICATION(S)] at 6:00 A.M., 2:00 P.M., and 10:00 P.M., 8:00 A.M. [MEDICATION(S)], 2:00 P.M. [MEDICATION(S)] and Acetaminophen - 7/11/22: scheduled [MEDICATION(S)] at 6:00 A.M., and 10:00 P.M. - 7/12/22: scheduled [MEDICATION(S)] at 6:00 A.M. - 7/13/22: Acetaminophen at 6:00 A.M. Further review of the July 2022 MAR indicated the Resident experienced pain at the following rates as documented per pain monitoring and pain scales: - 7/8/22: Pain at a 5 out of 10 at 2:00 P.M., after missing 6:00 A.M., scheduled medications - 7/9/22: Pain at 5 out of 10 at 2:00 P.M., and 8 out of 10 on the night shift (11:00 P.M. - 7:00 A.M.) - 7/10/22: 6:00 A.M. pain at 8 out of 10, after missing 10:00 P.M. [MEDICATION(S)] on 7/9/22; 10:00 P.M. pain of 8 out of 10 - 7/11/22: Pain at a 5 out of 10 on day shift (7:00 A.M. - 3:00 P.M.), after missing 6:00 A.M., scheduled [MEDICATION(S)] - 7/12/22: Pain at an 8 out of 10 at 2:00 P.M., after missing a 6:00 A.M., dose of [MEDICATION(S)] - 7/13/22: Pain at a 2 out of 10 at 2:00 P.M., after missing a 6:00 A.M., dose of acetaminophen Review of the Medication and Progress notes for Resident #1G indicated a problem with the Resident receiving his/her prescribed narcotic pain medication: - 7/9/22 at 9:54 P.M. it was identified that a new prescription was needed for [MEDICATION(S)] - 7/10/22 a prescription was called into the pharmacy and an access code received to remove the [MEDICATION(S)] pain medication from the emergency kit, but no second nurse to witness the removal of the medication from the emergency kit - 7/11/22 at 7:36 A.M., a note indicating [MEDICATION(S)] was not available and could not be obtained from emergency stock and again at 11:13 P.M., a note indicating medication was not available and a note was faxed to the physician - 7/12/22 at 7:45 A.M., [MEDICATION(S)] not available with call placed to pharmacy and nurse practitioner and again at 11:56 A.M., [MEDICATION(S)] not available awaiting delivery from pharmacy During an interview on 7/15/22 at 1:18 P.M., Unit Manager #1 was made aware of surveyor findings and that Resident #1G did not receive prescribed pain medication for more than 48 hours resulting in pain. Unit Manager #1 reviewed the notes and the MAR and said the medication should have been available and the Resident should not have had to be in pain, and that was not acceptable.

Based on record review, observation and interview with staff, the Facility failed for 1 Resident (#31) to address an unplanned weight changes and ensure nutritional and clinical conditions affecting intake were maintained/implemented. Finding include: 1. For Resident #31, the facility failed to ensure the Resident received adequate nutritional interventions that prevented significant weight loss and addressed his/her clinical condition (tooth abscess and broken dentures) which may have affected the Resident's ability to eat foods and accounted for some weight loss. Record review indicated the Resident had a significant weight loss of 9.57 % of his/her body weight or 13.8 lbs in 1 month and had a total weight loss of 17 pounds in less than 3 months following his/her admission. On 3/7/18 at 10:30 A.M., the Director of Nurses was asked for the Facility's policy and procedure for weight loss. The Director provided the Surveyor with the Facility's Weight and Height Policy (dated as revised on 11/30/15). The Director said this was the policy the Facility followed for weight loss. Review of the policy indicated weights were obtained on admission, then weekly for 4 weeks and monthly thereafter. Additional weights may be obtained at the discretion of the Facility staff and the purpose of weights were to obtain a baseline weight and identify significant weight changes and to determine possible causes of significant weight changes. The policy did not include a procedure for when weight loss was identified. Resident #31 was admitted in 12/2017 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had memory loss, exhibited some symptoms of depression and required a set up with meals. The Resident's Health Care Proxy was not invoked. The medical record indicated the Resident's admission height and weight on 12/18/17 was 62 inches tall and 145.8 lbs. The dietician completed the Resident's admission assessment on 12/20/17. The assessment indicated that the Resident's weight was up (higher) from his/her previous admission (and discharge home ) in 12/2016. The dietician noted the Resident weight had been 124.8 lbs. and had increased to 21 lbs on his/her readmission. She noted it was possible reflective of fluid from the Resident's hip surgery and she would monitor trends and liberalize the Resident's diet from heart healthy to regular. The dietician's assessment indicated she observed Resident #31 eating lunch in bed. She said the Resident ate poorly and was told by staff the Resident ate better with his/her family. The dietician recommended that staff get the Resident out of bed and provide supervision for meals. Although, the dietician did not initiate a formal plan of care, she had outlined a plan for the Resident in her assessment. Review of the Resident's weight record indicated the Resident's weight were as follows: *12/18/17 - 145.8 lbs *12/20/17 - 146.2 lbs *01/10/18 - 141.0 lbs - the record did not indicate if the staff identified a 5 lb weight loss and there was no explanation for the missing weights that were to be recorded following an admission. On 1/12/18, the Facility staff identified the Resident with a change in condition for a dental infection. The electronic record identifies changes when the staff order a new medication or a concern is identified. The eInteract Change in Condition then automatically triggers Change of Condition Follow-up Notes for 72 hours (following the initial change). Although, the 1/12/18 eInteract note, the nurse notified the Nurse Practitioner of a dental infection and an antibiotic was order ([MEDICATION NAME] 500 mg, every 8 hours for 10 days. However, on 1/12/18, the Resident was transferred to a dentist office for a consult. According to the 1/12/18, dental consult, the Resident had a broken tooth, caused by gingivitis, the tooth had necrotic pulp and an abscess was present. The dentist order's included the antibiotic ([MEDICATION NAME]) and requested the Resident be sent to an oral surgeon for extraction. The record did not indicate when the staff originally identified the tooth ache. A care plan was initiated for the tooth infection on 1/15/18. The goals were to resolve the infection. The interventions did not include referring the Resident to an oral surgeon, but indicated that staff would monitor for changes in nutrition (including intake, ability to feed self and unplanned weight loss). On 1/17/18, the weight record indicated the the Resident weighed 132.0 lbs - a 13.8 lb weight loss/-9.57 % total body weight in 1 month. Review of the medical record found no documented consult from the dietician and no documentation indicating that the staff were aware of the significant weight loss. On 1/19/18, a house supplement was ordered three times per day. The order did not include the amount of the supplement provided. On 1/24/18, the Resident weight was 130.2 lbs, a 15 lb weight loss since 12/18/17. Record review failed to indicate staff were addressing the weight loss. The nursing notes indicated the Resident was receiving an antibiotic and there had been 4 notes indicating the Resident had some [MEDICAL CONDITION] of the left lower leg, but had not documented [MEDICAL CONDITION] since 12/21/17 and had documented that the leg had minimal [MEDICAL CONDITION]. On 1/28/18, the electronic record indicated a weight warning note. The weight of 130.2 lbs was identified as significant. The nurse indicates that the Resident was awaiting a dental appointment and was on house supplements. The nurse indicated the Resident eats 50 to 75 % of his/her meals and that the Family brings in snacks. There was no indication the nurse notified the dietician and/or physician. The weight records indicated the Resident's weights were 131.2 lbs on 1/31/18 and on 2/07/18 - 132.0 lbs. On 2/7/18, the electronic record identified an additional Weight Warning after the staff entered the Resident's weight on 2/7/18. The nurses note indicated that she addressed the weight loss with the Nurse Practitioner and indicated the Resident was not eating well. The note did not indicate that the dietician was notified or that additional interventions were started. The Nurse Practitioner did not address the weight loss. On 2/13/17, (a week later and month and half after the Resident had initially loss significant weight loss) the dietician completed a nutrition assessment. The dietician indicated she saw the Resident for unplanned weight loss. She attributes some of the weight loss to [MEDICAL CONDITION] and indicates the nursing flow sheets indicated the Resident was eating 100%. The dietician , however, indicates that the flow sheets are inaccurate and that the staff reported the Resident's intake varies, sometimes sits in his/her room with tray and does not eat much. The dietician reiterates what was already in place and indicates the Resident's weight had been stable since 1/17/18. She initiates a care plan for weight loss on 2/13/18 and uses the Resident's current weight to be maintained (130 lbs, even though the Resident had a significant weight loss of almost 16 lbs since his/her admission) as the goal. The interventions were not changed and remained supplements, monitor intake supervise and assist with meals and encourage the Resident to go to the dining room. The Resident subsequent weights were as follows : 2/14/18 - 130.4 lbs and 2/21/18 - 130.4 lbs, - a -10.7 % total body weight loss since 12/18/17. In addition, there was no documentation that the Resident had been treated by an oral surgeon and/or the status of his/her oral condition (pain etc.). Observations and interviews of Resident #31 is as follows: On 2/27/18 at approximately 8:00 A.M., the Resident was observed in room and in bed. During an observation period of 1 hour it was noted the Resident ate his/her breakfast in room and did not receive assistance from staff. On 3/1/18 at 8:18 A.M. and at lunch time, the Resident was observed in room and eating meals in room. During the breakfast meal it was noted the Resident did not have teeth/dentures in his/her mouth. The Resident said he she was having problems with his/her dentures. The Resident did not complete either meal with a consumption that looked like less than 50%. On 3/2/1/8, Resident #31 was observing eating both breakfast and lunch in room and was unassisted during the meal consumption. On 3/2/18 at 11:115 A.M. Nurse #3 said that Resident #31 ate meals in room and was a set up. When asked about a care card or the plan of care the Nurse did not know where they were or how to access them. Review of the book that contained Kardex card (a brief description of a Resident's care) there was no Kardex for Resident #31. On 3/05/18, the weight record indicated the Resident's weight was 128.8 lbs - a 17 lb weight loss/-11.7 % total body weight loss since 12/18/17. During observation of the Resident on 3/6/18 during the breakfast meal, the Resident was observed taking his/her dentures in and out of his/her mouth. The Resident said that his/her mouth was a little sore, but that the dentures were broken and were not currently fitting right. The Resident said it affected his/her eating and that was why she was removing them during the meal. During interview on 3/7/18 at 9:30 A.M., Unit Manager #2 said that Resident #31 was a transfer from another unit. She was not aware of the full plan that had been initiated in 12/2017, that included encouraging the Resident to go to the dining room and for the staff to provide support and encouragement (because of poor intake) during meals. She said she was aware of the weight loss, but did not know why there was a delay in addressing it. She said that the supplement was most likely started based on the weight warning that are automatically trigger into the electronic record after staff put in a weight that is significantly lower than the prior weight. Unit Manager #2 said she did not know why it had not consistently triggered, as this system was available (in the electronic record) to avoid missing significant changes. The Unit Manager was asked about Resident #31's dentures and infection She said the Resident had not gone to the oral surgeon because the Resident was on a blood thinner and although was aware of the ill fitting and broken dentures, had not done anything about it. The Unit Manager said that she had not documented this information. The Dietician was not available to interview during the days of survey and there was not additional documentation that indicated the staff implemented effective nutritional and clinical services to ensure optimal nutrition and prevent unplanned weight loss.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that a self releasing seat belt, used to remind Resident #1 not to stand without assistance, was in place while Resident #1 was in the wheelchair, per plan of care. On 1/20/13 at approximately 5:00 P.M., Resident #1 reached forward over the wheelchair to retrieve an item from the floor and he/she fell out of the wheelchair and sustained a fractured right 5th metacarpal. Resident #1 said he/she fell out of the chair because someone forgot to clip the seat belt and he/she felt more comfortable with the seat belt in place. Findings include: Resident #1 was admitted to the Facility October of 2006, and [DIAGNOSES REDACTED]. The care plan, dated 9/11/08, indicated that Resident #1 was at risk for falls due to impaired mobility and care plan interventions included self releasing seat belt to remind Resident #1 not to stand without assistance. The quarterly Minimum Data Set (MDS) assessment, dated 10/23/12, indicated that Resident # 1 required: extensive assistance of two staff persons for bed mobility and transfers; did not ambulate in the room or corridor; was totally dependent on staff for dressing, bathing and grooming, and Resident #1 was not steady when moving from a seated to standing position. The nurse's note, dated 1/20/13, indicated that at 5:00 P.M., Resident #1 fell out of the wheelchair, he/she had bruising to bilateral knees, right upper chest and an abrasion to the right thumb. The nurse's note indicated that the Physician and family were notified of the fall and Resident #1 received the pain medication, Tylenol 650 milligrams (mg) at 5:30 P.M. with little relief of pain. The nurse's note indicated that at 6:00 P.M. Resident #1 was unable to bear weight with the right wrist, the Physician was notified, and the Physician ordered Resident #1 transferred to the Hospital for evaluation. The nurse's note indicated that the Hospital evaluation revealed a fractured right hand. The Surveyor interviewed Nurse #1 on 3/14/13 at 8:45 A.M. Nurse #1 said she worked on 1/20/13 on the 3:00 P.M. to 11:00 P.M. shift, and provided care to Resident #1. Nurse #1 said she assisted Resident #1 from the bed to the wheelchair at approximately 5:00 P.M.. Nurse #1 said she did not remember attaching the self releasing seat belt to the wheelchair. Nurse #1 said in a few minutes, she heard yelling from Resident #1's room, she went into the room and observed Resident #1 on the floor. Nurse #1 said she provided first aid to Resident #1, and had staff ask Resident #1, who spoke only Portuguese, what happened. Nurse #1 said Resident #1 said he/she reached over the wheelchair to retrieve an item off the floor and he/she fell . Nurse #1 said Resident #1 told staff that someone forgot to clip the seat belt on his/her wheelchair. The Surveyor interviewed Resident #1 on 3/14/13, with the Unit Manager as the interpreter, at 9:30 A.M. Resident #1 said through the Interpreter that he/she fell out of the chair because someone forgot to clip the seat belt. Resident #1 said through the Interpreter that he/she felt more comfortable with the seat belt in place. The Surveyor interviewed the Unit Manager in person on 3/14/13 at 9:30 A.M. The Unit Manager said she was asked to interview Resident #1 through the course of the investigation. The Unit Manager said Resident #1 was alert and oriented, had the self releasing seat belt for a reminder to ask for assistance, and Resident #1 said staff forgot to clip the seat belt on 1/20/13.

Based on record review, observation and staff interview, the facility failed for 1 (#11) of 24 sampled residents to provide sufficient amount of fluids, based on the individual needs of the resident to prevent dehydration. For resident #11, the facility failed to utilize the assessed fluid needs to ensure that the resident was receiving a sufficient amount of fluids to prevent dehydration. Following a hospitalization for a urinary tract infection and dehydration, the facility failed to consistently monitor and assess the adequacy of the resident's fluid intake based on the estimated fluid needs. The resident became dehydrated requiring a second hospitalization . Findings include: Resident #11 was admitted for a short term rehabilitation following hospitalization for surgical repair of a right proximal tibial fracture. Additional [DIAGNOSES REDACTED]. Review of the initial minimum data set (MDS) assessment with a completion date of 1/23/12, indicated that the resident was cognitively impaired and was dependent on staff for all activities of daily living including eating and drinking. The resident was coded as having a urinary catheter. Review of a nutritional care plan dated 1/10/12 indicated that the resident was at nutritional risk due to refusal to eat or drink. The goal was to maintain the resident's weight at greater than or equal to 109 pounds. The interventions included: - Encourage 100% consumption of all fluids provided - Encourage resident to chew and swallow each bite - Weigh as ordered and alert dietician and physician of any significant weight loss - Monitor for changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs and report to dietician/ physician as indicated - Monitor intake at all meals, offer alternate choices as needed, alert dietician and physician to any decline in intake - Provide diet as ordered - Supervise/cue/assist as needed with meals Per record review, the resident visited with the orthopedic doctor on 1/9/12 and had his/her right knee brace adjusted with orders to continue with non weight bearing status. On 1/9/12 the 3-11 nurse documented that the resident's 4:00 P.M. blood sugar was elevated to 424. The Nurse Practitioner was contacted and gave a one time order for Humalog insulin administration. The nurse documented that the resident had only consumed 25 % of his/her dinner and was sleepy during feeding. Review of scheduled blood work completed on 1/9/12 revealed that the resident's Sodium level was high at 150 (range 135-145); Chloride high at 112 (range 96-107); Glucose high at 343 (70-100); Blood/Urea/Nitrogen high at 40 (range 6-26). Previous blood work completed at the hospital on [DATE] reflected that all of the values listed above were within normal range. On 1/10/12 at 2:24 P.M., the nurse's note indicated that the results were called to the Nurse Practitioner who ordered to recheck the blood work in one week. Review of the Dietician's initial assessment completed on 1/10/12 at 3:31 P.M. recommended that the physician be notified of a significant weight loss. The Dietician noted the resident was 118 pounds in the hospital and 102 pounds on 1/9/12. The Dietician assessed the resident's estimated fluid needs as 1745 cc's per 24 hour period. This figure represents the amount of fluid that the resident should receive in order to prevent dehydration. The amount of fluid would fluctuate if the resident's condition fluctuated. For example, increased fluid may be needed if the resident had a fever. The Dietician documented that the resident had poor to fair by mouth intake, had high blood sugars and had developed a temperature of 102 degrees and a blister to the left heel - stage II indicating increased fluid needs. The Dietician referenced the 1/9/12 lab values and questioned if the resident was in need of intravenous (IV) hydration. Review of the 1/10/12, 6:47 P.M. nurse's note indicated the facility contacted the physician at 4:00 P.M. to report the resident's fever of 102.7 and elevated blood sugar of 401. The nurse documented that fluids were encouraged, but at dinner the resident only took sips of water and started coughing. The resident's mucous membranes were documented as dry and skin turgor poor. The Nurse Practitioner gave new orders to send the resident to the hospital. At 10:27 P.M. the nurse documented that the resident was admitted with [DIAGNOSES REDACTED]. On 1/17/12, the resident was readmitted to the facility following improved hydration status and blood sugars and resolution of the urinary tract infection. Review of the nurse's notes for 1/18/12 and 1/19/12 indicated that the resident was refusing to eat, drink much or be fed. However, there was no monitoring of the resident's I & O to ensure adequate hydration. The care team and responsible family member made a decision to transfer the resident on 1/19/12 to the facility's sub acute unit for management of medical needs. On 1/20/12 the Dietician completed an assessment of the resident's nutritional status. Review of the assessment reveled that the resident had a varied intake, and that family frequently assists with meals. The Dietician recommended a more liberal diet versus a consistent carbohydrate diet due to poor to fair oral intake and dementia. The resident was assessed with [REDACTED]. The resident's fluid needs were estimated at 2090 cc's per day. Review of a hydration protocol monitor dated 1/21/12, 1/22/12 and 1/23/12 was incomplete and inconclusive regarding the resident's status. For example, on 1/22/12 the nursing staff documented that the resident's 24 hour intake was 1260 cc's (800 cc's less than the dietician's targeted amount). The urine output was recorded as 900 cc's. There was no assessment to indicate if the recorded I & O amount met or did not meet the target range; no completion of the clinical assessment for dehydration section - i.e., if there were signs and symptoms of dehydration noted or no signs and symptoms of dehydration noted. The daily assessments contained no nurse's signature(s). The evaluation section, which determined if the resident meets hydration needs with the current plan or, if continued evaluation was needed was left blank. There were no interdisciplinary team signatures listed. On 1/30/12, the 11-7 shift nurse reported that at 12:45 A.M. the resident temperature was 102.4, blood sugar was 269 with 160 cc's of fluids spoon fed to the resident. The resident was assessed with [REDACTED]. The resident was transferred to the hospital and admitted with aspiration pneumonia and dehydration which required IV therapy to correct. Review of the 1/31/12 hospital lab values were as follows: Sodium high at 151; Chloride high at 120; Blood/Urea/Nitrogen high at 46; and Glucose high at 180. According to the primary physician on 2/9/12 the lab values did improve following IV supplementation. The resident was readmitted to the facility on [DATE] and was placed on a hydration protocol to monitor the resident's hydration status. Review of the 3 day protocol initiated on 2/9/12 revealed the following: Day 1: 2/9/12 oral intake was 240 cc's; Output: catheter 800 cc's; Day 2: 2/10/12 oral intake 840 cc's; Output: catheter 1200 cc's Day 3: 2/11/12 oral intake 360 cc's: Output: catheter none listed The facility failed to complete a comprehensive clinical assessment for dehydration on all 3 days reviewed for this resident with a history of dehydration requiring repeated hospitalization s. In addition, the protocol incorrectly identified the resident's estimated fluid needs as 1527 cc for a 24 hour period not 2090 cc's as was previously assessed by the Dietician. No further monitoring of the resident's I & O was completed following completion of the 3 day protocol. On 2/13/12 at 4:42 P.M., the nurse documented that the resident was lethargic and disoriented, "skin is hot" and the resident had a temperature of 100.9 with decreased fluid and food intake since breakfast. The physician was contacted and gave orders to initiate continuous IV fluids at 85 cc's per hour. No comprehensive monitoring of the resident's I&O was initiated following initiation of intravenous therapy. On 2/14/12 a care plan for dehydration was initiated. Interventions included: Monitor signs and symptoms of dehydration; dry mucous membranes, increased temperature, mental status changes, orthostatic [MEDICAL CONDITION] and [MEDICAL CONDITION] Staff was to monitor I&O per protocol. Review of the 2/15/12 Dietician's assessment documented that the resident was refusing to eat or drink which required initiation of IV fluids. The Dietician noted that the family has chosen to proceed with placement of a feeding tube which was scheduled for 2/17/12. The dietician determined that the resident continued to require increased protein and fluid needs of 1981 cc's per day. Despite the initiation of intravenous fluids there was still no monitoring of the resident's I&O status from 2/11/12 through 2/18/12. Review of completed I&O sheets from 2/19/12 through record review on 2/28/12 failed to account for IV fluid intake. Medication Nurse #1 was interviewed on 2/28/12 at 3:30 P.M. Medication Nurse #1 said that the daily I&O's were missing and incomplete. Interview and record review was completed with Unit Manager #1 on 2/29/12 at 1:00 P.M.. Unit Manager #1 said that the family member had decided against insertion of a feeding tube for Resident #11, but that the resident was doing better over the past few days. Unit Manager #1 said that the resident was at high risk for dehydration. Unit Manager #1 was not aware of the residents's multiple episodes of dehydration saying the resident had recently been transferred to the sub acute unit. The Unit Manager said that hydration protocol(s) failed to provide a comprehensive picture of the adequacy of the resident's fluid intake based on the utilization of targeted fluid needs for Resident #11. Unit Manager #1 said that the I & O sheets were missing and incomplete and failed to ensure that the resident had received a sufficient amount of fluids to prevent dehydration

Based on record review, interview, and observation for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was given hot tea in a sippy cup, per plan of care for hot beverages, when on 6/30/11 at about 6:00 PM after the supper meal, Resident #1 was given a hot cup of tea in a regular plastic coffee/tea cup by a person not identified, and Resident #1 spilled the hot tea onto self, resulting in burns with blisters. Findings included: The nurse's note, dated 2/3/11, indicated that at about 12:30 PM, Resident #1 spilled hot coffee on the chest and top of left thigh. The nurse's note indicated the areas were immediately reddened, and ice packs were applied with no redness or blistering noted. The nurse's note indicated one hour later the areas were clear. The nurse's note, dated 2/4/11, indicated Resident #1 was to use a "sippy" cup with all hot liquids. Resident #1's plan of care, dated 2/4/11, indicated all hot liquids would be placed in a covered sippy cup at all times. On 7/21/11 at 9:40 AM, the Surveyor interviewed the Director of Nurses (DON). The DON said the Facility did not have a specific policy in regards to sippy cups but the DON would provide the Surveyor with the manufacturer's description of a sippy cup. The manufacturer print out indicated a sippy cup was a two handled cup, made of a clear material which allowed monitoring of hot and cold liquid intake. The Facility's Investigation Report, dated 6/30/11, indicated at 6:00 PM, Resident #1 was in the day room, and spilled hot tea on self during dinner. The Investigation Report indicated Resident #1's left thigh was assessed with [REDACTED]. The Investigation Report indicated the first stage of blistering was the left inner thigh, the skin was intact, and fluid was starting to pool. The Investigation Report indicated cool compresses with ice packs over the compresses, were placed on Resident #1's burn areas, and the physician was notified. The Investigation Report indicated Resident #1's mental status prior to the incident was alert and disoriented. The Investigation Report indicated Resident #1 had poor coordination and confusion due to Resident #1's dementia diagnosis, and the spill was caused accidentally by Resident #1. The Facility's Investigation Report had not indicated what type of cup Resident #1 was using at the time of the incident. Nurse #1's written statement, dated 6/30/11, indicated Nurse #1 heard Resident #1 yell out "it burns, it's hot, I need help." Nurse #1's written statement indicated Nurse #1 approached Resident #1 and observed a cup of hot tea was spilled over Resident #1's left hand and wrist, onto Resident #1's lap covering both thighs. Nurse #1's written statement indicated Nurse #1 called for assistance, Resident #1 was transported to Resident #1's room, Resident #1's clothes were removed, and assessment indicated Resident #1's left wrist was pink, left inner thigh had a fluid filled blistered area, and right inner thigh was red with no blistering. On 7/21/11 at 3:15 PM, the Surveyor interviewed certified nurse aide (CNA) #3. CNA #3 said CNA #3 worked 6/30/11, on the 3:00 PM - 11:00 PM shift. CNA #3 said CNA #3 did not know who gave Resident #1 a regular coffee/tea cup with no lid and hot tea on the evening of 6/30/11. CNA #3 said CNA #3 observed Resident #1's tray at suppertime and Resident #1 had the appropriate sippy cup with Resident #1's supper. CNA #3 said Resident #1's supper tray had been removed prior to Resident #1's incident with hot tea. CNA #3 said Resident #1's family member who was a resident at the Facility, was seated with Resident #1 at the table. CNA #3 said CNA #3 observed the other resident with a cup of coffee on the table and Resident #1 with a pink plastic cup, no lid, which had held tea. CNA #3 said CNA #3 was not in the dining room at the time Resident #1 spilled the hot tea however, CNA #3 heard Resident #1 screaming "hot, hot." On 7/21/11 at 2:55 PM, the Surveyor interviewed Nurse #2. Nurse #2 said Nurse #2 worked 6/30/11, on the 7:00 AM - 7:00 PM shift. Nurse #2 said Nurse #2 was returning to Resident #1's unit the evening of 6/30/11 after assisting downstairs in the main dining room, when upon entering the unit, Nurse #2 heard Resident #1 yelling from the dining area. Nurse #2 said Nurse #2 assisted Nurse #1 and a CNA with removing Resident #1's clothing and assessment of the burn areas. Nurse #2 said Nurse #2 did not know what type of cup Resident #1 used the night of 6/30/11 because Nurse #2 was not on the unit during supper. Nurse #2 said Nurse #2 had never observed Resident #2 attempting to remove the cover from the sippy cup when it was provided to Resident #1. On 7/21/11, the Surveyor interviewed CNA #4 at 2:00 PM, CNA #5 at 2:50 PM, and CNA #6 at 5:15 PM. CNA #4, CNA #5, and CNA #6 said they worked on 6/30/11 on the 3:00 PM - 11:00 PM shift but were not present in the dining room, when Resident #1 spilled hot tea. CNA #4, CNA #5, and CNA #6 said they did not know who gave Resident #1 hot tea in a plastic coffee/tea cup, not the sippy cup. The nurse's note, dated 7/1/11 at 4:43 AM, indicated Resident #1 had a fluid filled blister measuring 5 centimeter (cm) by 2 cm, on the left inner thigh, and on the right thigh an intact blister measuring 2 cm by 1 cm. Resident #1's plan of care, updated 7/1/11, indicated Resident #1 would wear a smoker's apron at all times when having meals, and Resident #1 would have all hot liquids in a covered sippy cup at all times. On 7/21/11 at 10:05 AM, the Surveyor interviewed Nurse Manager #1. Nurse Manager #1 said when Resident #1 wore a smoking apron, Resident # was also provided with a long cloth clothing protector which covered the apron in Resident #1's lap for dignity. On 7/21/11 at 12:20 PM, the Surveyor observed Resident #1 in the dining room seated in a wheelchair, at a table with one other resident. The Surveyor observed Resident #1 wearing the smoking apron which was covered with the clothing protector. The Surveyor observed CNA #2 setting up Resident #1's meal tray. The Surveyor observed Resident #1's dietary slip on Resident #1's tray which indicated a sippy cup for all liquids, no straws. The Surveyor observed CNA #2 preparing hot tea for Resident #1 in a plastic pink tea/coffee cup and then placing a disposable plastic lid with an opening onto the cup. The Surveyor asked CNA #2 if this cup with the throw away lid was a sippy cup. On 7/21/11 at 12:20 PM, the Surveyor interviewed CNA #2. CNA #2 said Resident #1's tray arrived on the unit without the sippy cup. CNA #2 said it took too long for the kitchen to send up a sippy cup, so staff used the throw away snap on plastic lids with the opening on the pink coffee/tea cups for Resident #1. On 7/21/11 at 12:21 PM, the Surveyor interviewed CNA #1. CNA #1 said a coffee/tea cup with a snap on lid with an opening was an acceptable sippy cup. When the Surveyor asked a CNA to show the Surveyor where the disposable plastic lids were stored on the unit, the CNA was not able to locate any disposable lids. CNA #2 provided the Surveyor with the plastic disposable lid which was taken from another resident's room who used a covered cup. On 7/21/11 at 12:40 PM, the Surveyor interviewed the Food Service Director. The Food Service Director said a sippy cup was a two handled plastic cup with a cover. The Food Service Director gave a sippy cup to the Surveyor for inspection. The Food Service Director said Resident #1 utilized a sippy cup which was provided on Resident #1's tray at meals. The Surveyor informed the Food Service Director that on that day, 7/21/11, no sippy cup came up on Resident #1's lunch tray. The Surveyor asked the Food Service Director if the disposable plastic lids were stored in the kitchen and the Food Service Director stated yes however, the Food Service Director was unable to locate any plastic disposable lids in the kitchen area. The Food Service Director said the Food Service Director was not sure if a regular plastic coffee/tea cup with a disposable lid with an opening would be considered a sippy cup. The Surveyor showed Nurse #2 a plastic disposable lid with an opening, given to the Surveyor by CNA #2. Nurse #2 said Nurse #2 never observed that type of cover in the Facility before being shown by the Surveyor. Nurse #2 suggested that maybe Resident #1's family members provided Resident #1 with the disposable lids however, the Surveyor told Nurse #2 that the lids were provided by the Facility. On the day of survey, 7/21/11, there appeared to be confusion among the nursing staff on the definition of a sippy cup and what was acceptable for Resident #1's use, given Resident #1's two burn incidents because of spillage of hot beverages, and no staff person was able to say how Resident #1 got the cup of hot tea on the evening of 6/30/11. On 7/21/11 at 12:50 PM, the Surveyor interviewed the Speech Pathologist. The Speech Pathologist said a sippy cup was a specific type of cup which had two handles, a cover, and a slow flow valve so liquids flowed out at a slower rate. On 7/21/11 at 3:50 PM, the Surveyor interviewed Resident #1. Resident #1 was unable to tell the Surveyor what happened the evening Resident #1 spilled hot tea on self.