Every finding on record at South Hadley Rehabilitation and Nursing Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #2) who resided in the facility with a service/emotional support dog, the facility failed to ensure they developed and implemented an individualized comprehensive person-centered care plan that included interventions, goals and outcomes related to the safety, psychosocial wellbeing and associated care needs. Findings include:Review of the facility policy titled, Comprehensive Person-Centered Care Planning, dated no month indicated, 2026, indicated the Facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights set forth under the law that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs. The care plan shall be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly assessments.The facility was unable to provide a policy related to Service/Emotional Support Animals.Resident #2 was admitted to the facility April 2026, diagnoses included acute respiratory failure, chronic obstructive pulmonary disease, and generalized anxiety disorder.Review of Resident #2's Minimum Data Set (MDS) Assessment, dated 06/29/26, indicated he/she was cognitively intact, exhibited verbal behavior symptoms directed toward others, wandered, was independent for eating, hygiene, toileting and dressing.Review of Resident #2's quarterly Social Service note, dated 06/29/26, indicated he/she had a service dog that stays (resides) with him/her wherever he/she goes.Review of Resident #2's Nurses Note, dated 07/02/26, indicated the Director of Nursing and the regional [NAME] President met with the resident regarding an event related to his/her service animal. The Note indicated Resident #2 had been instructed by the local Board of Health that his/her dog was under a 10-day quarantine, must remain muzzled at all times unless eating or drinking, must remain on a leash and not be separated from him/her.Review of Resident #2's care plans, reviewed and revised with the 06/29/26 MDS indicated the facility had developed a mood care plan related to his/her admission, disease process and insomnia. Review of the interventions for his/her mood problem indicated there was no documentation to support that the Resident utilized a service/emotional support dog.Further review of the care plan indicated there was no documentation to support that an individualized plan of care was developed or implemented specific to the need for a service/emotional support dog or that interventions, goals and outcomes were in place to help maintain Resident #2's safety, the safety of other residents, and to ensure care needs were met. During a telephone interview on 07/29/26, at 8:35 A.M., the Director of Nursing (DON) said the use of a service/emotional support dog should have been documented on Resident #2's care plan but that it was not.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3) the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice when nursing staff failed to: 1) provide on-going wound assessment and treatment to Resident #1 who had sustained an injury from a dog, and 2) provide wound treatment to Resident #3 as recommended by the Wound Care Consultant.Findings include:1.Resident #1 was admitted to the facility February 2026 with diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke resulting in weakness and paralysis of the right side), congestive heart failure, diabetes mellitus, acquired absence of left leg below the knee, hypertension and respiratory failure.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 05/18/26, indicated he/she had moderate cognitive impairment, was dependent on staff assistance for all activities of daily living (bathing, dressing, toileting, transfer), independent for mobility in his/her wheelchair and was administered anticoagulant (slows blood clotting) and antiplatelet (prevents the formation of blood clots) medications.Review of the facility Skin Alteration Report dated 07/01/26, indicated that while Resident #1 was attending a smoke break, he/she reported that he/she was rough housing with a dog when he/she was scratched on his/her right hand, by the mouth of the dog, causing a laceration and bleeding. The Report indicated the Physician had been notified, and the Resident's right hand had been cleansed and a dressing applied.Review of Resident #1's Physician Assistant (PA) Note, dated 07/02/26 indicated the Resident sustained a small open superficial laceration from a dog bite. The Note indicated Resident #1 was prescribed prophylactic antibiotics, and a tetanus vaccine.Review of Resident #1's Physician Orders for July 2026 indicated the following:-start date 7/02/26: right hand open area and bruise: cleanse with normal saline or wound cleanser; apply thin layer of bacitracin and cover with dry clean dressing change daily and notify MD for concerns, complete treatment every (7:00 A.M. - 3:00 P.M.) day shiftReview of Resident #1's Treatment Administration Record (TAR) for the month of July 2026, indicated there was no documentation to support that ongoing wound assessment or dressing changes had been ordered or provided by nursing. Review of Resident #1's late entry Nurse's Note, dated 07/05/26, indicated that on 07/01/26 at approximately 6:30 P.M., the Resident had been bleeding from a spot at his/her right dorsal hand between the thumb and index finger. The Note indicated the wound was 6.2 millimeters (mm) by 5.1mm and had been cleansed and a dry clean dressing applied.Review of Resident #1's Nurse's Notes dated 07/01/26 through 07/05/26, indicated there was no documentation to support that his/her right hand had been assessed by nursing or treatment administered after the initial injury was identified on 07/01/26.During an interview on 07/22/26 at 8:30 A.M., Resident #1 said he/she had sustained a puncture wound from a dog to his/her right hand. Resident #1 said the wound had bled through the bandage for about two days.During an interview on 07/22/26 at 2:00 P.M., the Director of Nursing (DON) said that Resident #1's initial wound treatment order to his/her right hand had been entered into the electronic medical record incorrectly as a one-time order and had not displayed on the TAR as daily wound care as it should have. The DON said nursing staff should have assessed Resident #1's right hand wound every shift until it resolved, however she said there was no documentation to support that nursing staff had provided ongoing wound assessment or treatment.2.Resident #3 was admitted to the facility June 2025 with diagnoses including cirrhosis of liver (scarring and injury to the liver), diabetes mellitus, and pressure ulcer of the sacral area (bottom of the spine) stage 4.Review of Resident #3's Minimum Data Set (MDS) dated [DATE], indicated he/she was cognitively intact, was dependent on staff assistance for activities of daily living (eating, hygiene, dressing, toilet, transfer, and had one stage 4 pressure ulcer and was provided with pressure ulcer care.Review of Resident #3's Wound Consultant Progress Report, dated 07/08/26, indicated it included the following wound care recommendation for his/her coccyx wound:1. Cleanse wound with NaCl (saline), Sterile water, or Wound cleanser2. Apply Skin prep to the peri wound, Collagen particles to base of the wound.3. Dry clean dressing.4. Change Monday, Wednesday, Friday and PRN soiling, saturation, or accidental removal.Review of Resident #3's Treatment Administration Record (TAR) for July 2026, which included current Physician's orders indicated the following:-to coccyx: cleanse with normal saline, apply skin prep to peri wound, apply powder collagen and pack into wound bed, cover with dry clean dressing daily and as needed, every day shift for monitoring, start date 07/09/26.Review of Resident #3's TAR, dated 07/09/26 through 07/22/26 indicated his/her coccyx dressing had been changed daily (7 days a week) and not three times a week on Monday, Wednesday and Friday as recommended by the Wound Care Consultant. eDuring an interview on 07/22/26 at 4:15 P.M., The Unit Manager said that she is responsible for making rounds with the Wound Consultant and for obtaining new orders based on the consultant's recommendations. The Unit Manager said that she had made a mistake and entered Resident #3's treatment orders into the electronic medical record to be changed daily, when she should have entered the orders as (three times a week) every Monday, Wednesday and Friday. The Unit Manager said Resident #3's dressing should not have been changed every day.

Based on interview, and record review, the facility failed to ensure resident beds were routinely inspected to identify areas of possible entrapment on three of three units. Specifically, the facility failed to ensure that resident bed frames, mattresses, and bed rails, were inspected annually as part of a routine maintenance program. Findings include: During the initial entrance conference on 5/20/25 at 8:01 A.M., with the Administrator and the acting Director of Nursing (DON), the Administrator said the facility's capacity was 132 resident beds and the current census was 117 residents. During an interview on 5/23/25 at 2:58 P.M., the Director of Maintenance (DOM) said resident beds were to be inspected for entrapment risk yearly. The DOM said he had a kit that was utilized to measure the zones applicable for entrapment risk and included the mattress, side rails, head and foot boards. The DOM said the facility did not have a current policy relative to routine bed assessments, but that all resident beds should be inspected annually. The DOM provided the surveyor with the Bed Assessment book for review at the time. Review of the Bed Assessment book indicated the following: -25 resident beds were inspected for entrapment from 12/13/23 through 12/14/23 -59 resident beds were inspected for entrapment from 4/1/24 through 11/15/24 -4 resident beds were inspected for entrapment from 11/16/24 through 11/23/24 Further review of the Bed Assessment book failed to indicate documented evidence that resident beds were inspected annually for entrapment. During an interview on 5/23/25 at 3:48 P.M., the Administrator said the facility did not currently have a policy relative to bed assessments. The Administrator said all resident beds should be inspected yearly for entrapment risk by the maintenance department who utilize an entrapment risk tool. During a follow-up interview on 5/23/25 at 4:21 P.M., the DOM said resident bed inspections for entrapment needed to be completed yearly. The DOM said there was currently no process/system in place to ensure the bed inspections were completed routinely and timely.

Based on interviews, and record reviews, the facility failed to maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility staff failed to: 1. Review the facility's IPCP standards, policies and procedures annually, placing residents and staff at risk for outdated standards of practice for preventing and controlling infections. 2. Develop, monitor, and implement the resident vaccination process within the facility relative to Influenza, Pneumococcal and Covid, placing residents at risk for infection. Findings include: Review of the Facility Assessment, dated November 2024 and reviewed by QAA/QAPI committee in November 2024, indicated but was not limited to: -Services provided: a. Infection prevention and control: >Identification and containment of infections > .use of standard infection prevention and control practices >prevention of infections Review of the facility's policy titled Immunizations and Vaccines-Residents, dated December 2022 included but was not limited to: -It is the policy of this facility that all residents receive immunizations and vaccinations that assist in preventing infectious disease unless .refused by the resident or resident's activated Health Care Proxy (HCP- a person who can make decisions for another person when they are unable to do so themselves). 1. Vaccine information statements and consent for Pneumococcal, Influenza and Covid will be part of the resident's admission packet. Consent for these vaccinations will be obtained .at the time of admission. 2. Orders for administration of vaccines will be obtained from the resident's Physician or Nurse Practitioner (NP). 3. Influenza Vaccination: >Each resident is offered the Influenza vaccination as soon as the vaccine is available through March 31st annually. 4. Pneumococcal Vaccination: >Recommendations are based on a person's previous Pneumococcal vaccine history. -No evidence specific to Covid Vaccination procedure or process was included in this policy. Review of the facility policy titled Infection Prevention and Control Program (IPCP), dated December 2022, without revision date, included but was not limited to: -Healthcare Associated Infections (HAI). Can cause significant pain and discomfort for residents in nursing homes and can have significant adverse consequences .IPCP must follow national standards and guidelines. -Program development and oversight focus on the prevention and management of infections. >identify staff roles and responsibilities for the routine implementation of the program. >define and manage appropriate resident health initiatives such as immunization programs for influenza, pneumococcal, etc . -The Infection Preventionist (IP) has been appointed to be responsible for the IPCP, and responsibilities shall include . >Implementing evidenced-based infection control practices, including those mandated by regulatory and licensing agencies, and guidelines from the CDC. >Program oversight including planning .monitoring and maintaining all the elements of the program and ensuring that the facility's interdisciplinary team is involved in infection prevention and control. >Implementing measure to prevent the transmission of infectious agents .and procedure-related infections. -Influenza and Pneumococcal immunizations: >Each resident is offered the influenza vaccination between October 1st and March 31st annually. >Each resident is offered a Pneumococcal vaccination unless contraindicated or refused. -No evidence specific to Covid vaccination procedure was included in this policy. -Annual Review: >The facility's IPCP and its standards, policies and procedures will be reviewed at least annually to ensure effectiveness and that they are in accordance with current standards of practice for preventing and controlling infection. 1. During an interview on 5/27/25 at 9:10 A.M., the IP said she has been employed at the facility since March 2024. The IP said that the facility IPCP Manual policies and procedures should be reviewed and updated annually then signed by the Medical Director, Director of Nursing (DON) and IP. The surveyor and the IP reviewed the facility's current IPCP manual and the IP said that the IPCP Manual provided and reviewed was the Master IPCP Manual and was the most current one that she was following. The IP said that the most recent annual review and update to the facility's IPCP Manual, policies and procedures had occurred back on 2/2/24 as evidenced by the signature sheet at the front of the manual signed by the Medical Director, DON, and IP. The IP said that the IPCP should have been reviewed and updated by 2/2/25 to ensure IPCP practices were within current guidelines for the facility's residents and staff, but the IPCP had not been reviewed and updated. 2. During a follow-up interview on 5/27/25 at 3:26 P.M., the IP said that the facility followed current guidance from CDC for immunization of the residents. The IP said that all residents should be offered the Influenza, Pneumococcal and Covid vaccines on admission. The IP said that the admitting Nurses were responsible to obtain consent or refusal at the time of admission for all residents. The IP said that once a resident had provided consent for vaccine the admitting Nurse should obtain an order from the resident's Provider. The IP said that the admitting Nurse should then inform the IP that the resident had requested vaccination though an email, phone call, or nursing report. The IP also said that once the vaccine was available it should be administered by the IP or the Nurse that was on duty. The IP said that the process from consent to administration should take about five to seven days. The IP said that she did not have a monitoring system in place prior to today, for resident vaccinations but should have. The IP further said that according to her audit, which had been initiated after the survey team entered the facility, she had identified the following: >Four residents out of 115 residents audited, consented to an Influenza Vaccine for the 2024-2025 season but did not receive the Influenza Vaccine as requested. Five residents had not yet been audited. The IP said that the window for Flu vaccination had ended on March 31st. >Nine residents out of 115 residents audited, had consented to the Pneumococcal Vaccine but did not receive Pneumococcal vaccination timely or as requested. Nine residents had not yet been audited. >11 residents out of 115 residents audited, had consented to the Covid Vaccine but did not receive Covid vaccination timely or as requested. Nine residents had not yet been audited. The IP said several of the residents that had provided vaccine consent had been in the facility for over a year and were not up to date on vaccinations. The IP said that all resident's should have been administered vaccinations timely and as requested. The IP that there was no current Covid immunization policy in place for residents in the facility but there should be. The IP said that failure to develop policy, monitor and administer vaccinations could place the residents at risk for infections.

Based on interview, and record review, the facility failed to assess for continued use of a prophylactic antibiotic, for one Resident (#63), of two applicable residents reviewed for antibiotic use, out of a total sample of 28 residents. Specifically, for Resident #63, the facility failed to: -ensure the Physician orders for the Infectious Disease (ID) and Endocrinology Consults were implemented as required. -coordinate ID and Endocrinology appointments to assess for the need/rationale for continued use of a prophylactic antibiotic (Ciprofloxacin) prescribed for chronic osteomyelitis, when the Resident requested to discontinue the medication. Findings include: Resident #63 was admitted to the facility in April 2021, with diagnoses including chronic osteomyelitis (infection of the bone), Diabetes and constipation. Review of the Minimum Data Set (MDS) Assessment, dated 3/11/24, indicated Resident #63: -was cognitively intact as evidenced by Brief Interview of Mental Status (BIMS) score of 13 out of possible 15 points. -received an antibiotic during the assessment period. Review of the Provider Note, dated 4/7/25, indicated the following: -Resident #63 reported he/she did not want to take Ciprofloxacin (antibiotic) any longer and that the Resident has been on the antibiotic for a couple years. -The Provider indicated to continue the Ciprofloxacin 250 mg twice daily with no stop date, for [suppression] and an order was placed for the Resident to follow up with ID. Review of the May 2025 Physician's orders indicated the following: -Ciprofloxacin HCl Oral Tablet 250 milligrams (mg), Give 250 mg by mouth two times a day for chronic osteomyelitis, initiated 6/4/24 with no stop date . Review of the May 2025 Medication Administration Record (MAR) indicated Resident #63: -was administered the Ciprofloxacin 250 mg on seven out of 53 occurrences. -On the remaining dates/times, for 46 occurrences, Resident #63 refused the medication. Review of the completed Physician's orders indicated the following: -Please schedule ID follow-up for a chronic suppressive therapy - Resident wishes to stop (the medication), initiated on 4/17/25 and end date 4/18/25. -Refer to Endocrinology for evaluation on necessity to continue long term antibiotics, initiated on 4/29/25 and end date 4/30/25. Review of Resident #63's clinical record failed to indicate documented evidence that an ID consult or Endocrinology evaluation was scheduled to assess the need for continued use of antibiotic therapy. During an interview on 5/27/25 at 9:40 A.M., during a review of the facility Antibiotic Stewardship Program, the Director of Nursing (DON), who also was the Infection Preventionist (IP), said she did not track residents who were on prophylactic antibiotics. The DON said she was not aware that Resident #63 requested to discontinue the antibiotic treatment. The DON/IP said she would follow up to see if the ID consult was initiated to assess for the continued need for Resident #63's antibiotic. During an interview on 5/27/25 at 2:32 P.M., Unit Manager (UM) #2 said the Provider gave a verbal order for the ID consult (on 4/7/25) which did not get put into the Resident's electronic health record (EHR) as a Physician's order. UM #2 said the Provider asked about the ID consult again on 4/29/25, but the appointment had not yet been made. UM #2 said the facility used to have medical records book resident appointments, but this task was now delegated to the Unit Managers. UM #2 said because she was frequently working as the floor Nurse, scheduling the Resident's appointment was missed. During a follow-up interview on 5/27/25 at 3:33 P.M., the DON/IP said there was no evidence that the requested appointments (ID and Endocrinology) were set up for Resident #63.

Based on observations, interviews, and record reviews, the facility failed to ensure one Resident (#2), of four applicable residents reviewed with feeding tubes, in a total sample of 28 residents, had care and services in place for enteral feedings and gastrostomy site care. Specifically, for Resident #2, the facility failed to ensure Physician's orders were implemented and/or that orders were in place relative to enteral feeding (refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories) care including: -Gastrostomy (G-tube: surgical procedure for inserting a tube through the abdomen wall and into the stomach to administer medications, fluids and nutrition) site care. -Monitoring and recording residuals (amount of fluid or other contents remaining in the stomach after a feeding and a crucial indicator of gastric emptying and assist with assessing tolerance to the feeding). -Administration of the prescribed feedings when tube feeds and water boluses were not administered by staff due to the Resident being asleep. -Physician orders relative to the accurate route medication should be administered when the Resident was ordered nothing by mouth (NPO) and the medications were prescribed to be administered by mouth. Findings include: Review of the facility policy titled Enteral Nutrition, dated March 2023, indicated adequate nutritional support through enteral nutrition is provided to residents as ordered, and included the following: -The nurse confirms that orders for enteral nutrition are complete. Complete orders include: >the enteral nutrition product >delivery site (tip placement) >the specific enteral access device (nasogastric [nose and to the stomach], gastric [stomach], jejunostomy [tube inserted into the small intestine] tube, etc.) >administration method (continuous, bolus [large doses of formula several times a day poured slowly into a syringe attached to a feeding tube], intermittent) >volume and rate of administration >the volume/rate goals and recommendations for advancement towards these >instructions for flushing (solution, volume, frequency, timing, and 24-hour volume) -The provider will consider the need for supplemental orders, including: >confirmation of tube placement >oral care >checks for gastric residual volume Resident #2 was admitted to the facility in November 2024 with diagnoses including gastrostomy status, underweight, severe protein-calorie malnutrition, adult failure to thrive and dysphagia (difficulty swallowing). Review of the Nutrition Care Plan, initiated 11/25/24, indicated Resident #2 had malnutrition and evidence of muscle wasting and included a goal for the Resident to accept the tube feeding as ordered by the Physician in order to promote gradual weight gain. The plan of care included the following interventions: -enteral protocols in place, initiated 11/25/24 -TwoCal HN (type of enteral feeding solution) via G-tube . revised 3/16/25 Review of the Tube Feed Care Plan, initiated 11/19/24, indicated the following interventions: -Resident was dependent with tube feedings and water flushes. See Physician's orders for current feeding orders, initiated 11/19/24 -Check tube placement and gastric contents/residual volume per facility protocol and record, revised 11/20/24 Review of the Potential for Skin Impairment Care Plan, initiated 11/20/24, indicated Resident #2: -was at risk due to weakness, impaired mobility and G-tube use -G-tube care as ordered -Monitor insertion site for skin breakdown, initiated 11/20/24 Review of the Minimum Data Set (MDS) Assessment, dated 2/26/25, indicated Resident #2: -had no speech. -was rarely or never understood or understands other. -has severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 0 out of 15. -was on a feeding tube and received greater than 51 percent (%) of calorie needs and more than 501 cubic centimeters (cc: unit of measure equivalent to milliliters) daily. Review of Resident #2's May 2025 Physician's orders included the following: -weekly skin checks, initiated 11/19/24 -NPO (nil per os, or nothing by mouth) diet ., initiated 11/22/24 -Monitor for abdominal distention and pain every shift, initiated 12/30/24 -Enteral Feed Order, six times a day, give via gravity (method of delivering formula using the force of gravity which would be positioned above the patient and without the need for a pump) 150 milliliters (ml) of TwoCal HN, initiated 3/20/25 -Water bolus prior to G-tube feed, administer a total of 200 ml, 100 ml pre and 100 ml post feed, six times a day, free flush of 100 ml prior to TwoCal HN admin and post TwoCal HN administration, initiated 3/20/25 -the following medications were ordered to be administered by mouth: >Benztropine (medication to treat movement disorders) 0.5 milligrams (mg), give 3 tablets by mouth daily >Celexa (antidepressant medication) 10 mg, give 0.5 tablet by mouth daily >Miralax (laxative medication) 17 grams (gm) per scoop, give 1 scoop by mouth daily >Acetaminophen (analgesic medication used for pain and/or fever) 325 mg, give 2 tablets by mouth as needed every 6 hours Further review of Resident #2's Physician's orders failed to indicate evidence of: -orders/frequency of mouth care to be provided -instructions relative to G-tube site care, including cleaning of the area, monitoring of the site, as referenced on the Resident's Skin Impairment Care Plan. -instructions relative to residual checks referenced on the Resident's Tube Feed Care Plan and parameters (specific instructions) in which to hold the tube feeding. Review of the April 2025 and May 2025 Medication Administration Records (MARs) indicated the Resident's scheduled G-tube feedings and water boluses were held due to the Resident sleeping on the following dates/times: -4/13/25 at 1:00 A.M. and 5:00 A.M. -5/20/25 at 5:00 A.M. -5/21/25 at 5:00 A.M. Further review of the April 2025 and May 2025 MARs failed to indicate documented evidence of: -G-tube site care -documentation of residual amounts -mouth care provided On 5/21/25 at 12:40 P.M., the surveyor observed Resident #2 seated in a specialized wheelchair near the nurses station. Resident #2 had his/her eyes closed and was observed to be very thin. On 5/27/25 at 2:41 P.M., the surveyor and Unit Manager (UM) #2, who was the Nurse assigned to Resident #2's care for that shift reviewed Resident #2's clinical record. UM #2 said the Resident received scheduled G-tube feedings six times daily and did not take food/fluids/medications by mouth. UM #2 said the Resident's G-tube site should be monitored every shift and that there should be Physician's orders for monitoring the site for signs of infection and treatment orders for scheduled dressing changes to clean and provide care to the Resident's G-tube site, but there were currently no orders to do this. UM #2 further said the Resident should also have an order to assess for the placement of the G-tube prior to the scheduled feedings and currently there were no Physician's orders do to this for Resident #2. UM #2 said Resident #2 received scheduled bolus feedings via the G-tube using a piston syringe (medical device used to inject or withdraw fluids), and the Physician's orders should include instructions to change the piston syringe daily and to check and document residuals prior to the G-tube feedings with parameters (specific amounts) on when to hold the G-tube feedings, but there were currently no Physician's orders for this. At this time, the surveyor and UM #2 observed Resident #2's room and observed a piston syringe dated 5/23 on the Resident's bedside table, and UM #2 said the piston syringe should have been changed daily. The surveyor and UM #2 reviewed the April 2025 and May 2025 MARs which indicated the scheduled G-tube feedings and water boluses were not administered due to the Resident sleeping, and UM #2 said the Resident's enteral feeding and water should be administered even if he/she were sleeping. UM #2 said that because the Resident was NPO, the Resident's medications should be received through the G-tube and that the medications ordered and documented as administered by mouth were not accurate. Please refer to F842.

Based on observations, interviews, and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice relative to podiatry services and skin assessment for one Resident (#110), out of a total sample of 28 residents. Specifically, for Resident #110, the facility failed to: -implement podiatry recommendations when the Resident received podiatry care and services and was recommended to have continued wound treatment to the right great toe. -perform a weekly skin assessment as ordered, putting the Resident at risk for infection and delayed wound healing. Findings include: Resident #110 was admitted to the facility in November 2024, with diagnoses including chronic viral Hepatitis C, and Adjustment Disorder with Depressed Mood. Review of the Minimum Data Set (MDS) Assessment, dated 2/24/25, indicated Resident #110 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15. During an interview on 5/20/25 at 11:15 A.M., Resident #110 said that he/she was concerned about his/her right great toe because the Podiatrist came in last week, removed his/her toenail, and placed a band aid on the right great toe. Resident #110 further said that staff had not removed and looked at the toe since the Podiatrist had placed the band aid. Resident #110 then showed the surveyor his/her right foot and a band aid was securely applied to the right great toe. Review of the active Physician orders for Resident #110, dated 5/22/25, indicated the following: -Consults: Podiatry, Dental, Audiology, Optometry or Behavioral Health, initiated 1/26/25. -Weekly skin check: complete weekly skin check documentation .on weekly skin evaluation assessment every day shift, every Saturday, initiated 11/23/24. Further review of the Physician orders failed to indicate any treatment orders in place for Resident #110's right great toe. Review of the Consultant Podiatry documentation, dated 5/15/25, indicated the following: -Resident #110 was examined by the Podiatrist on 5/15/25. -A Podiatry Progress Note indicated the right great toe with mild erythema (redness) and swelling, ½ loosening or separation of the toenail. -Recommend new orders: Right great toe contusion with loss of nail. >Please cleanse area with sterile saline solution, >Please apply topical antibiotic i.e. bacitracin once daily with sterile dressing for two weeks, >monitor for signs and symptoms of infection, >Please contact PCP (Primary Care Provider) in case this [infection] occurs and consider oral antibiotics. Review of Resident #110's clinical record failed to indicate that a weekly skin assessment had been performed as ordered for the Resident on: -Saturday 5/10/25 -Saturday 5/17/25 During an interview on 5/21/25 at 9:29 A.M., Nurse #6 said she was aware that Resident #110 was seen by the Podiatrist last week but was unaware that Resident #110 had a bandaid on his/her right great toe. Nurse #6 said that the Podiatrist writes recommendations on the Consultant Podiatry Documentation Sheet and gives the sheet to the Unit Manager (UM). Nurse #6 further said that there were no treatment orders in place for the care of Resident #110's right great toe. During an interview on 5/21/25 at 10:09 A.M., UM #2 said Resident #110 had a Physician's order in place for weekly skin assessments to be performed every Saturday but no weekly skin assessment had been performed for Resident #110 on 5/17/25 as ordered. UM #2 further said that if the weekly skin assessment had been completed 5/17/25, staff would have seen the band aid on the Resident's toe and followed up with the Provider. UM #2 said the Consultant Podiatry Group sends an email to the facility that includes a summary report of podiatry recommendations for residents that were provided services. UM #2 said that she was unsure if she received the summary report from the Podiatrist visit on 5/15/25. UM #2 said that the podiatry recommendations for Resident #110 should have been printed out and placed into the Physician Assistant's (PA)'s book for the PA to review and prescribe a treatment. UM #2 said she was unsure if the recommendations for Resident #110 had been communicated to the PA. During an interview on 5/21/25 at 10:22 A.M., the PA said that she was never notified of the podiatry recommendations for Resident #110's right great toe, but she should have been notified of the recommendations made by the Podiatrist.

3. Resident #68 was admitted to the facility in April 2025 with diagnoses including Stage 4 Pressure Ulcer of the sacral region, open wound of the front wall of the thorax, open wound of left lower leg, open wound of the left thigh, Unstagable Pressure Ulcer of the left heel, Diabetes and Peripheral Vascular Disease (PVD). Review of the Skin Assessment, dated 4/28/25, indicated Resident #68 had the following skin concern areas: -chest surgical incision -pressure ulcer to the coccyx (tail bone) -cluster of blisters to the right rear thigh -vascular area to the outer left ankle -two vascular areas to the left heel -vascular area to the left lateral (outer side) lower extremity -vascular scabs to the left toes -vascular area to left lateral lower extremity below the knee Review of the May 2025 Physician's orders indicated Resident #68 had treatment orders for the following areas initiated on 4/29/25: -coccyx -left Achilles (tendon that connects calf muscles to the heel bone) and left toes -left medial (towards the middle) foot -left lower extremity -left lateral malleolus (outer side of the ankle) -left Achilles -left lateral foot -sternoclavicular area (area between collar bone and breast bone) Review of the MDS Assessment, dated 5/4/25, indicated Resident #68: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. -has two Stage 3 Pressure Ulcers and one Stage 4 Pressure Ulcer which was present on admission. -had no other wound or skin problems including surgical wounds or arterial and vascular wounds noted under Section M (Skin Conditions). Review of the Skin Care Plan, initiated 4/29/25, indicated Resident #68: -has Stage 4 Pressure Ulcer on his/her sacrum (a triangular bone in the lower back) -has a left heel wound -has left lower extremity wounds -has a front wall chest wound On 5/21/25 at 8:32 A.M., the surveyor observed Resident #68 dressed, seated at the edge of the bed and eating breakfast, with a dressing observed on the Resident's upper chest. During an interview at the time, Resident #68 said he/she had a chest wound. During an interview on 5/23/25 at 8:34 A.M., Unit Manager (UM) #1 said Resident #68 had a Pressure Ulcer, diabetic ulcers, vascular ulcers, and a surgical area which had been present since admission. During an interview on 5/23/25 at 8:35 A.M., MDS Nurse #2 said the MDS assessment dated [DATE], was not accurate and did not include the Resident's surgical wound, diabetic wound, or vascular wounds. 4. Resident #90 was admitted to the facility in October 2022 with diagnoses including chronic pain, abnormal posture, and low back pain. Review of the MDS Assessment, dated 4/10/25, indicted Resident #90: -had clear speech, was understood and understands others. -was cognitively intact as evidenced by a BIMS score of 13 out of 15. -was on scheduled and as needed (PRN) pain medication. Review of Section J of the MDS Assessment indicated Resident #90 should be assessed for pain. Further review of Section J indicated the pain assessment was not completed (not assessed or dashed) and that the staff assessment was also not completed (not assessed or dashed). During an interview on 5/27/25 at 12:59 P.M., MDS Nurse #1 said the Pain assessment was not completed for the MDS assessment dated [DATE] because the assessment was not completed within the required timeframe. MDS Nurse #1 said the MDS Nurse would complete the pain assessment under Section J of the MDS Assessment and that this information was important to obtain so that the Resident's MDS assessment was accurate. MDS Nurse #1 further said the information in Section J should be obtained five days up until the assessment reference date of 4/10/25, for Resident #90's MDS Assessment 5. Resident #91 was admitted to the facility in April 2025 with diagnoses including malignant neoplasm of the tongue, other lesions of the oral mucosa, and pain related to neoplasm (acute on chronic). Review of the Nursing Assessment, dated 4/23/25, indicated Resident #91: -had an alteration in his/her oral status. -had broken or chipped teeth. -had mouth/facial pain. Review of the MDS Assessment, dated 4/29/25, indicated Resident #91: -was cognitively intact as evidenced by a BIMS score of 15 out of 15. -had no abnormal mouth tissue (ulcers, masses or oral lesions). -had no mouth or facial pain, discomfort or difficulty with chewing. -had no obvious or likely cavity or broken natural teeth. -had difficulty swallowing. Review of the April 2025 Physician's orders indicated the following: -Lidocaine Viscous HCL Mouth/Throat Solution (local anesthetic/numbing medication used for mouth and throat pain), 2%, give 1 application orally every six hours as needed for mouth pain, initiated 4/23/25 -Morphine Sulfate Oral Solution (opioid medication used to treat moderate to severe pain) 20 mg/milliliter (ml), give 5 mg as needed orally every four hours for moderate pain, initiated 4/23/25 -Oxycodone (opioid medication used to treat moderate to severe pain) HCL 5 mg every four hours for severe pain, initiated 4/23/25 Review of the April 2025 Medication Administration Record indicated the following medications were administered from 4/23/25 to 4/29/25: -Lidocaine Viscous -Morphine Sulfate -Oxycodone HCL Review of the Provider Note, dated 4/26/25, indicated the following: -Resident #91 was evaluated -Continues management with Oxycodone and Morphine for tongue cancer related to pain -Resident has oral pain, cancer of the tongue, dental cavities/cancer related pain On 5/21/25 at 8:22 A.M., the surveyor observed Resident #91 dressed and eating breakfast in his/her room. During an interview at the time, Resident #91 said he/she has oral pain, has medication for his/her oral pain, but was looking to talk to his/her Provider about his/her continued pain. Resident #91 said he/she had numerous infected/broken teeth that needed to be extracted and was working with the facility to make an appointment. During an interview on 5/23/25 at 9:58 A.M., Nurse #1 said Resident #91 had regular complaints of mouth pain and had oral sores due to mouth cancer. During an interview on 5/23/25 at 11:27 A.M., MDS Nurse #2 said she reviewed Resident #91's medical record which indicated he/she did have mouth pain during the assessment period for the MDS assessment dated [DATE]. MDS Nurse #2 further said that the Resident's abnormal mouth tissue, and presence of broken teeth should also have been coded on the 4/29/25 MDS Assessment but were not. 2. Resident #33 was admitted to the facility in September 2021, with diagnoses including Fibromyalgia and chronic pain. Review of Resident #33 most recent Quarterly MDS Assessment, dated 4/16/25, indicated Resident #33: -had clear speech, -was able to make him/herself understood, and was able to understand others. Further review of the Quarterly MDS Assessment failed to indicate documentation that Resident #33 had been interviewed about his/her chronic pain. Review of Resident #33's May 2025 Physician's orders indicated the following: -Pain assessment 0-10 every shift, for pain monitoring, start date of 9/16/21. -Acetaminophen Tablet (analgesic medication) give 500 milligrams (mg) by mouth every six hours as needed for pain .start date of 3/12/24 -Pregabalin (medication used to treat nerve and muscle pain ) Oral Capsule 100 mg, give one capsule by mouth two times a day related to Fibromyalgia, start date of 1/16/25. Review of Resident #33's April 2025 Medication Administration Record (MAR) indicated the following: -Resident #33 was administered Pregabalin daily as ordered. Review of Resident #33's Care Plan titled Resident #33 is on pain medication therapy, initiated 9/26/24, indicated the following intervention: -Administer Analgesic medications as ordered by Physician. Monitoring/document side effects and effectiveness every shift (Q-Shift), initiated 10/17/24. During an interview on 5/27/25 at 1:09 P.M., MDS Nurse #1 said a Resident interview was not completed for Resident #33's 4/16/25 Quarterly MDS Assessment. MDS Nurse #1 further said Resident #33 was able to be interviewed and a Resident pain assessment should have been completed with Resident #33 within five days of 4/16/25 and this was not done. MDS Nurse #1 said not completing the Resident pain assessment with Resident #33 did not give an accurate picture of Resident #33's current pain level for the assessment. Based on record reviews, and interviews, the facility failed to accurately complete Minimum Data Set (MDS) Assessments that reflected the residents status as of the Assessment Reference Date for five Resident's (#80, #33, #68, #90 and #91), out of a total sample of 28 residents. Specifically, 1. For Resident #80, the facility staff failed to code the MDS assessment accurately relative to a pressure ulcer under Section M. 2. For Resident #33, the facility failed to complete the Pain Assessment under Section J with the Resident involvement, when the Resident had clear speech, was able to make him/herself understood, and understood others. 3. For Resident #68, the facility failed to accurately code skin conditions under Section M on the comprehensive MDS Assessment relative to surgical, diabetic and vascular wounds that were present. 4. For Resident #90, the facility failed to complete the Pain Assessment under Section J on an MDS Assessment when the Resident had clear speech and was able to make him/herself understood. 5. For Resident #91, the facility failed to accurate code oral/dental status under Section L of the MDS assessment relative to abnormal mouth tissue, broken dentition and presence of mouth pain. Findings include: 1. Resident #80 was admitted to the facility in May 2024 with diagnoses including pressure ulcer of sacral region. Review of Resident #80's May 2025 Physician orders included but was not limited to: -Coccyx wound: cleanse with Normal Saline, apply zinc to the peri-wound, pack with Puracol (a collagen based wound product), cover with dry clean dressing daily, effective 4/3/25. Review of Resident #80's admission Skin Assessment from May 2024 included but was not limited to: -The Resident had an unstageable (deep pressure injury where the base of the ulcer is covered by nonviable tissue making it impossible to accurately assess the depth to stage) pressure ulcer that measured nine centimeters (cm) by five cm by one-half cm (9 cm x 5 cm x 1/2 cm) on the sacral/coccyx area. Review of Resident #80's Person-Centered Care Plan included but was not limited to: >Focus - Resident has a Stage Three (full thickness skin loss exposing fat but not reaching muscle, tendon or bone) pressure ulcer to the sacral/coccyx area, initiated on 6/5/24. >Goal - Resident's pressure ulcer will show signs of healing and remain free from infection, initiated 6/5/24, revision date 12/29/24, and target date on 8/25/25. Review of Resident #80's most recent Skin Assessment, dated 5/15/25, included but was not limited to: -Resident has a stage three pressure ulcer that measured 3 cm x 1 cm x 3/4 cm to the sacral/coccyx area. Review of Resident #80's most current and completed MDS assessment dated [DATE], included but was not limited to: -Resident has one, Stage Three pressure ulcer. -Resident did not have the pressure ulcer present on admission to the facility. During an interview on 5/27/25 at 1:00 P.M., MDS Nurse #1 said that the facility did not have a policy related to coding of resident MDS's, and that the facility followed the Resident Assessment Instrument (RAI) Manual to code all MDS assessments. The surveyor and MDS Nurse #1 reviewed the electronic medical record (EMR) for Resident #80 and MDS Nurse #1 said Resident #80 had been admitted with the pressure ulcer to the sacral/coccyx area and the pressure ulcer had not yet healed or closed since the Resident had been admitted . MDS Nurse #1 said Resident #80's MDS Assessment (dated 3/4/25) had been coded incorrectly because the pressure ulcer was present on admission, had not yet healed or closed and should have been coded as being present on admission. MDS Nurse #1 said accurate MDS coding was important for care planning to ensure proper care and services were in place for Resident #80.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice to prevent and treat a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one Resident (#40), of six applicable residents reviewed for pressure, out of a total sample of 28 residents. Specifically, the facility staff failed to evaluate and monitor a pressure ulcer located on Resident #40's left ischium (left lower back of the hip bone) to help identify any wound changes, promote healing and prevent deterioration of the wound, infection, and new ulcers from developing. Findings include: Review of the facility policy titled Pressure Ulcer Prevention effective May 2023, indicated the following documentation to be recorded in the resident's medical record: -Any change in the resident's condition -All assessment data (i.e. wound bed color, size, drainage etc.) obtained when inspecting the wound -The type of wound care provided -The date and time the wound care was given Resident #40 was admitted to the facility in March 2024, with diagnoses including Paraplegia, Diabetes Mellitus II (DM II), and pressure ulcer of the sacral region and left ischium. Review of the Minimum Data Set (MDS) Assessment, dated 3/23/25, indicated Resident #40 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. Review of Resident 40's Physician orders dated 5/27/25, indicated the following: -Santyl external ointment 250 mg/GM (gram) topically every day shift for wound care to left ischium. On 5/20/25 at 12:18 P.M., the surveyor observed Resident #40 lying in bed, with the head of the bed elevated and a Negative Pressure Wound Therapy device (NPWT: a medical treatment device connected by tubing to a wound dressing that uses suction to assist in wound healing) set to 125 mm (millimeters) of Hg (mercury). During an interview at the time, Resident #40 said he/she had a large sacral wound and a smaller ischial wound on his/her back side and that the NPWT device was applied to the sacral wound and not on the ischial wound. Resident #40 also said he/she is followed by a wound doctor and goes out to the wound clinic every week. Review of the Treatment Administration Record (TAR), dated 5/1/25 through 5/31/25, indicated the following: -Cleanse left ischium with normal saline, pat dry. - .apply a nickel size layer of Santyl to wound bed. - .cover with dry clean dressing. Further review of the TAR indicated a wound documentation ledger and corresponding spaces for the documentation of wound characteristics observed during the provision of wound care: >Progress- I = Improved, N=No >Change- W= Worsened >Wound Base- C=Clean, Slough=S, Eschar=E >Drainage Amount- None=0, Small=S, Moderate=M, Large=L >Drainage Type- Serous=S, Serosanguinous=SS, Purulent=P Review of the TAR for 5/22/25 through 5/28/25, failed to indicate: -any wound characteristic documentation on the TAR in the spaces corresponding to Resident #40's left ischial wound on these dates. -any indication that the left ischium wound status was evaluated and monitored on these dates. Review of the facility Skin Assessments, dated 5/12/25 and 5/26/25, failed to indicate any evaluation and monitoring were completed relative to the characteristics of Resident #40's left ischial wound. During an interview on 5/27/25 at 3:36 P.M., the Director of Nursing (DON) said that facility staff were expected to document wound descriptions on the TAR in the spaces provided so that any wound changes could be identified. The DON said that it was important to document descriptions of the wound bed, drainage characteristics, and signs of infection with every dressing change performed. During a follow-up interview on 5/27/25 at 4:59 P.M., the DON said that there was no wound documentation entered on the TAR from 5/22/25 through 5/27/25, relative to the description of Resident #40's left ischial wound but there should have been documentation on the TAR.

Based on interview, and record review, the facility failed to ensure two Residents (#90 and #181), out of a total of 28 sampled Residents, received laboratory services as ordered by the Physician. Specifically, the facility failed to: 1. For Resident #90, obtain weekly Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) labwork as ordered by the Physician. 2. For Resident #181, obtained Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) labwork as ordered by the Physician. Findings include: 1. Resident #90 was admitted to the facility in October 2022 with diagnoses including Severe Protein-Calorie Malnutrition and Cerebral Infarction (stroke). Review of the May 2025 Physician orders indicated the following: -Complete Blood Count (CBC: measures the number and characteristics of different types of blood cells) and Comprehensive Metabolic Panel (CMP: blood test that provides broad overview of the body's metabolic health including kidney function, liver function, electrolyte balance, blood sugar and protein levels) every Monday, initiated 1/6/25 Review of the Resident #90's clinical record failed to indicate documented evidence that CBC and CMP labwork was obtained as ordered during the month of May 2025. During an interview on 5/27/25 at 4:37 P.M., Unit Manager (UM) #1 said Resident #90's weekly labs were not obtained in May 2025 as ordered by the Physician. 2. Resident #181 was admitted to the facility in May 2025 with diagnoses including Neuromuscular Dysfunction of the Bladder and Hypertension. Review of the May 2025 Physician orders indicated the following: -CBC, CMP on 5/17/25 (Saturday), then on every Monday, initiated on 5/16/25 Review of Resident #181's clinical record failed to indicate documented evidence that the CBC and CMP ordered on 5/17/25 and on 5/19/25 (Monday) were obtained as ordered by the Physician. During an interview on 5/21/25 at 10:50 A.M., UM #1 said because Resident #181's labwork was scheduled for a weekend (Saturday 5/17/25), the facility staff would need to notify the contracted laboratory service to notify them that labwork needed to be drawn on a non-scheduled day. UM #1 further said the ordered labwork for 5/19/25 was not completed. During a follow-up interview on 5/22/25 at 10:58 A.M., UM #1 said Resident #181's labwork was not obtained as ordered by the Physician on 5/17/25 and on 5/19/25. UM #1 said this was a systems issue and that education on the process for how to request resident labwork needed to be completed with the nursing staff. UM #1 said if resident labwork was ordered for a weekend or holiday, the facility staff would need to contact the contract laboratory service company to notify them that the labwork needed to be drawn, but this was not done for Resident #181. UM #1 further said that routine labwork needed to be put on a separate requisition lab slip from the non-routine labwork, and this also did not occur for Resident #181.

2. Resident #91 was admitted to the facility in April 2025 with diagnoses including Severe Protein-Calorie Malnutrition, Adult Failure to Thrive and Acidosis. Review of the May 2025 Physician's orders included the following: -Sodium Chloride (medication used to replenish water and salt in the body), give one tablet daily, initiated 5/8/25 Review of the May 2025 MAR indicated the Sodium Chloride was administered to Resident #91 in the month of May 2025. On 5/27/25 at 3:13 P.M., the surveyor and Nurse #1 observed the Sodium Chloride medication prescribed to Resident #91. Nurse #1 said Resident #91 was receiving 1 gram (gm) of Sodium Chloride daily and that the Physician's order should include the medication dosage but it currently did not. During an interview on 5/27/25 at 3:15 P.M., Unit Manager (UM) #1 said Resident #91's order for Sodium Chloride should indicate the dosage of the medication to be administered. UM #1 said the Resident's current order for Sodium Chloride was an incomplete order and would need to be clarified with the Physician. 3. Resident #2 was admitted to the facility in November 2024 with diagnoses including gastrostomy status, underweight, severe protein-calorie malnutrition, adult failure to thrive and dysphagia (difficulty swallowing). Review of the Tube Feed Care Plan, initiated 11/19/24, indicated the following interventions: -Resident was dependent with tube feedings and water flushes. See Physician's orders for current feeding orders, initiated 11/19/24 Review of the May 2025 Physician's orders included the following: -NPO (nil per os, or nothing by mouth) diet ., initiated 11/22/24 -the following medications were ordered to be administered by mouth: >Benztropine (medication to treat movement disorders) 0.5 milligrams (mg) give 3 tablets by mouth daily >Celexa (antidepressant medication) 10 mg, give 0.5 tablet by mouth daily >Miralax (laxative medication) 17 grams (gm) per scoop, give 1 scoop by mouth daily >Acetaminophen (analgesic medication used for pain and/or fever) 325 mg, give 2 tablets by mouth as needed every 6 hours On 5/27/25 at 2:41 P.M., the surveyor and Unit Manager (UM) #2, who was the Nurse assigned to Resident #2's care for that shift reviewed Resident #2's clinical record. UM #2 said the Resident received scheduled G-tube feedings six times daily and did not take food/fluids/medications by mouth. UM #2 said because the Resident was not to receive anything by mouth, the Resident's medications should be received through the G-tube and that the medications ordered and documented as administered by mouth was not accurate. Based on interview, and record review, the facility failed to ensure completed and accurate medical records were maintained for three Residents (#15, #91 and #2), out of a total sample of 28 residents. Specifically, 1. For Resident #15, the facility failed to ensure that staff documented daily fluid intakes when Resident #15 was on a fluid restriction. 2. For Resident #91, the facility failed to ensure a dosage for Sodium Bicarbonate was included in the Physician's orders to ensure accurate administration of the medication when the Resident was being administered the medication without an ordered dosage. 3. For Resident #2, the facility failed to ensure accurate routes for medication administration were documented when the Resident was unsafe to receive medication/food/fluid by mouth. Findings include: 1. Review of the facility policy titled Encouraging and Restricting Fluids, revised 10/2010, indicated the following: -Follow specific instruction concerning fluid intake or restrictions. -Be accurate when recording fluid intake. -Record fluid intake on the intake side of the intake and output record. Record fluid intake in milliliters (mls). Resident #15 was admitted to the facility in October 2024 with diagnoses including Lymphedema and Generalized Edema. Review of Resident #15's most recent Minimum Data Set (MDS) Assessment, dated 2/11/25, indicated Resident #15 scored a 15 out of 15 on the Brief Interview of Mental Status (BIMS) Assessment indicating he/she was cognitively intact. During an interview on 5/20/25 at 8:27 A.M., Resident #15 said he/she was on a fluid restriction relative to his/her diagnosis of Lymphedema. Resident #15 said nursing staff managed his/her fluid restriction. Review of Resident #15's May 2025 Physician's orders indicated the following order with a start date of 4/4/25: -Fluid restriction as directed 1500 cubic centimeter (cc) per day: *Nursing: 720 cc: 7:00 A.M.-3:00 P.M.: 360 cc (in own container 16 ounces (oz) ice and 4 oz water) 3:00 P.M.-11:00 P.M.: 360 cc (in own container 16 ounces (oz) ice and 4 oz water) 11:00 P.M.-7:00 A.M.: 0 cc (medications are in apple sauce) *Dietary: 780 cc: *Breakfast: 300 cc *Lunch: 240 cc *Supper: 240 cc . Review of Resident #15's Care Plan titled Resident #15 has fluid overload or potential fluid volume overload due to disease process: Lymphedema, initiated 11/2/24, indicated the following intervention: -Monitor and document intake and output as per facility policy, initiated 11/2/24. Review of Resident #15's May 2025 Medication Administration Record (MAR), indicated the following: -On 16 out of 20 days, Resident #33 received 360 cc during the 7:00 A.M.-3:00 P.M. shift. -On one out of 20 days, Resident #33 received 700 cc during the 7:00 A.M.-3:00 P.M. shift. -On one out of 20 days, Resident #33 received 540 cc during the 7:00 A.M.-3:00 P.M. shift. -On one out of 20 days, Resident #33 received 380 cc during the 7:00 A.M.-3:00 P.M. shift. -One day out of 20 days, was marked yes with no total cc during the 7:00 A.M.-3:00 P.M. shift. -On 17 out of 20 days, Resident #33 received 360 cc during the 3:00 P.M-11:00 P.M. shift. -On one day out of 20 days, Resident #33 received 340 cc during the 3:00 P.M-11:00 P.M shift. -On one day out of 20 days, Resident #33 received 240 cc during the 3:00 P.M.-11:00 P.M. shift. -On one day out of 20 days, was marked yes with no total cc on the 3:00 P.M.-11:00 P.M. shift. -On 16 days out of 20 days, Resident #33 received 60 cc during the 11:00 P.M.-7:00 A.M. shift. -On four days out of 20 days, Resident #33 received 0 cc during the 11:00 PM.-7:00 A.M. shift. Further review of Resident #15's May 2025 MAR failed to indicate: -documentation of the total daily fluid intake. -documentation of how much fluid the Resident consumed during his/her meals. During an interview on 5/21/25 at 11:23 A.M., Nurse #3 said Resident #15 was on a fluid restriction because he/she had a diagnosis of Lymphedema. Nurse #3 said it was important to monitor the Resident's daily fluid intake to make sure he/she was not at risk for fluid overload. During a follow-up interview on 5/21/25 at 12:37 P.M., Nurse #3 said fluid intake should be documented on a Resident's MAR by the Nurses each shift. Nurse #3 said the Nurses only document what they provide to the Resident during the medication pass and when they gave him/her 16 ounces (oz) of ice. Nurse #3 said that nursing did not document what was provided on the Resident's meal trays for fluid. The surveyor and Nurse #3 reviewed Resident #15's May 2025 MAR, and Nurse #3 said with the documentation that was available she was unable to tell how much fluid Resident #15 consumed each day as there was no 24-hour totals. Nurse #3 also said there was no documentation indicating how much fluid Resident #15 consumed during his/her meals as the documentation recorded on the MAR appeared to only be what was provided at medication pass and the allotted ice Resident #15 received. During an interview on 5/21/25 at 12:44 P.M., Certified Nurses Aide (CNA) #1 said Resident #15 got one cup of coffee in the morning and one cup of juice or ginger ale in the afternoon. The surveyor and CNA #1 observed Resident #15's meal tray which had vanilla ice cream and peach in fruit juice. CNA #1 said she was unsure if the ice cream or the juice in the peaches counted as additional fluid for Resident #15. CNA #1 said the CNAs were not responsible for keeping track of how much fluid Resident #15 took in at each meal. During an interview on 5/22/25 at 8:43 A.M., the Food Service Director (FSD) said the dietary department only ensures that the total amount of fluid Resident #15 could have was written on the Resident's meal ticket. The FSD said the dietary department did not measure out any fluids for the Resident at meals and that nursing should be checking Resident #15's tray at each meal and adjusting what was on the tray to accommodate Resident #15's fluid restriction. The FSD said items such as ice cream cups, soups, Jello cups, and fruit in juice cups should all be counted as fluid and staff on the units should know which items on a Resident's tray count towards total fluid intake. During an interview on 5/22/5 at 9:37 A.M., the Dietician said nursing should be adding all fluid intake Resident #15 consumes daily so the total fluid intake can be monitored and adjusted if needed. The Dietician said nursing staff should be counting not only the water and ice they give Resident #15, but they should also be recording how much fluid Resident #15 consumes at each meal from his/her meal tray. The surveyor and the Dietician reviewed Resident #15's May 2025 MAR and the Dietician said it did not appear nursing was recording all of Resident #15's daily fluid intake and they were not calculating a total daily fluid intake. The Dietician said while it was not the only tool she utilized to monitor a Resident for changes, it would be beneficial for her to be able to review how much fluid Resident #15 was taking in daily so the fluid restriction could be adjusted if needed especially if Resident #15 was to experience an episode of fluid overload and changes in his/her edema.

3. Resident #2 was admitted to the facility in November 2024 with diagnoses including Severe Protein-Malnutrition, Adult Failure to Thrive and Cerebral Infarction (Stroke). Review of the Immunization Consent form, undated, indicated the following: -Resident #2 had not received the Pneumococcal vaccine. -the Resident's Representative provided consent for Resident #2 to be administered the Pneumococcal Vaccine. Review of the Massachusetts Immunization Information System (MIIS) indicated no history of Pneumococcal vaccination for Resident #2. Review of the MDS Assessment, dated 2/26/25, indicated the following relative to Resident #2: -he/she had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 0 out of a possible 15 points. -the Pneumococcal Vaccine was not up-to-date and the vaccine was not offered. During an interview on 5/27/25 at 8:49 A.M., the DON/IP said Resident #2 had not received the Pneumococcal Vaccine and should have received it because there was a consent for it to be administered. The DON/IP said residents vaccination statuses were reviewed during admission to the facility and if Resident #2's Responsible Party had consented to the Pneumococcal Vaccine, it should have been administered. Based on interview, and record review, the facility failed to ensure Pneumococcal vaccination history was maintained and/or that the Pneumococcal Vaccine was administered after consent was obtained to administer the vaccinations for three Residents (#15, #114, and #2), out of six applicable residents for immunizations. Specifically, the facility failed to ensure: 1. For Resident #15, the Pneumococcal Vaccine was administered after the Resident consented to receive the updated Pneumococcal vaccinations as needed. 2. For Resident #114, the Pneumococcal Vaccine was administered after the Resident's Representative consented for the Resident to receive the updated Pneumococcal vaccinations as needed. 3. For Resident #2, the Pneumococcal Vaccine was administered when the Resident's Representative consented for the administration of the vaccine and the Resident had no history of previously receiving the Pneumococcal Vaccine. Findings include: Review of the facility policy titled Immunizations and Vaccines-Residents, effective 12/2022, indicated the following: -The resident's medical record includes documentation that indicates, at a minimum the following: >The resident or resident's legal representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization; and >That the resident either received the Pneumococcal immunization or did not receive the immunization due to medical contraindications or refusal. -All residents without documentation of adequate immunization, including those with uncertain histories, should be considered not immunized and should be vaccinated accordingly. Review of the Centers for Disease Control and Prevention's (CDC) website, titled Pneumococcal Vaccine Timing for Adults, www.cdc.gov/pneumococcal/index.html, dated 10/2024 indicated the following: -Adults over the age of 50 who have not received any prior Pneumococcal vaccination should receive a Pneumococcal Conjugate Vaccine 20 (PCV20) or PCV21. 1. Resident #15 was admitted to the facility in October 2024 and was over the age of 50. Review of Resident #15's Immunization Consent Form, signed by the Resident on 10/31/24, indicated Resident #15 had not received any Pneumococcal vaccination in the past. Further review of the Immunization Consent Form indicated Resident #15 had consented to receiving an updated Pneumococcal vaccination including Pneumococcal Polysaccharide Vaccine 23 (PPSV23), PCV13, or PCV20 as needed. 2. Resident #114 was admitted to the facility in March 2025 and was over the age of 50. Review of Resident #114's Immunization Consent Form, signed by the Resident's Representative, undated, indicated no documentation was obtained by the facility of previous Pneumococcal vaccinations Resident #114 had received. Further review of the Immunization Consent Form indicated Resident #114's Resident Representative had consented for the Resident to receive an updated Pneumococcal vaccination including PPSV23, PCV13, or PCV20 as needed. During an interview on 5/21/25 at 9:59 A.M., the Staff Development Coordinator (SDC) said when a resident was admitted to the facility, staff were expected to obtain a vaccination history from the resident or the resident's representative, indicating which vaccines the resident had received prior to admission or a Massachusetts Immunization Information Systems (MIIS-system that maintains vaccination history) report should be obtained. The SDC said this information should then be documented in the resident's medical record. The SDC further said if a resident was not up-to-date on his/her vaccinations, the facility should then acquire a vaccination consent from the resident or the resident's representative, a doctor's order to provide the vaccine, and then provide the vaccination shortly after the consent was obtained. During an interview on 5/27/25 at 12:46 P.M., the Director of Nursing (DON) who was also the facility Infection Preventionist (IP), said Resident #15 and the Resident Representative for Resident #114 had consented to both Residents being administered Pneumococcal vaccinations to ensure that the Residents were up-to-date with their Pneumococcal vaccinations, but the vaccinations had been administered to Resident #15 or Resident #114. The DON/IP further said the Pneumococcal vaccines should have been administered to Resident #15 and Resident #114 shortly after they were admitted to the facility. During a follow-up interview on 5/27/25 at 3:26 P.M., the DON/IP said that the facility followed current guidance from CDC for immunization of the residents in the facility.

3. Resident #2 was admitted to the facility in November 2024 with diagnoses including Severe Protein-Malnutrition, Adult Failure to Thrive and Cerebral Infarction (Stroke). Review of the Immunization Consent form, undated, indicated the following: -Resident #2 has not received the COVID-19 vaccine. -the Resident's Representative provided consent for Resident #2 to receive the COVID-19 vaccine. Review of the Massachusetts Immunization Information System (MIIS) failed to indicate any history that Resident #2 received the COVID-19 vaccination. Review of the MDS Assessment, dated 2/26/25, indicated the following relative to Resident #2: -he/she had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 0 out of a possible 15 points. -COVID-19 vaccine was not up-to-date. During an interview on 5/27/25 at 8:49 A.M., the DON/IP said Resident #2 had not received the COVID-19 Vaccine and should have received it because there was a consent for it to be administered. The DON/IP said residents vaccination statuses were reviewed during admission to the facility and if Resident #2's Responsible Party had consented to the COVID-19 Vaccine, it should have been administered. Based on interview and record review, the facility failed to develop and implement a COVID-19 vaccination policy for three Residents (#15, #114, and #2), out of a total of six applicable residents for immunization review. Specifically the facility failed to ensure: 1. For Resident #15, that documentation was maintained relative to COVID-19 vaccination history, and that the most up-to-date COVID-19 Vaccine was administered when the Resident consented to receive it. 2. For Resident #114, that documentation was maintained relative COVID-19 vaccination history, and that the most up-to-date COVID-19 vaccine was provided when the Resident's Representative consented for the Resident to receive the most up-to-date COVID-19 Vaccines as recommended by the Centers for Disease Control and Prevention (CDC). 3. For Resident #2, that the COVID-19 Vaccine was administered when the Resident Representative consented for Resident #2 to receive the vaccine. Findings include: 1. Resident #15 was admitted to the facility in October 2025. Review of Resident #15's Immunization Consent Form, signed by the Resident on 10/31/24, failed to indicate documentation was obtained by the facility relative to Resident #15's COVID-19 vaccination history. Further review of the Immunization Consent Form indicated that Resident #15 had consented to receiving an updated COVID-19 vaccination as needed. 2. Resident #114 was admitted to the facility in March 2025. Review of Resident #114's Immunization Consent Form, signed by the Resident's Representative, undated, failed to indicate that documentation was obtained by the facility relative to Resident #15's COVID-19 vaccination history. Further review of the Immunization Consent Form indicated Resident #114's Resident Representative consented for the Resident to receive an updated COVID-19 vaccination as needed. During an interview on 5/21/25 at 9:59 A.M., the Staff Development Coordinator (SDC) said when a resident was admitted to the facility, staff were expected to obtain a vaccination history from the resident or the resident's representative, indicating which vaccines the resident had received prior to admission or a Massachusetts Immunization Information Systems (MIIS-system that maintains vaccination history) report should be obtained. The SDC said this information should then be documented in the resident's medical record. The SDC further said if a resident was not up-to-date on his/her vaccinations, the facility should then acquire a vaccination consent from the resident or the resident's representative, a doctor's order to provide the vaccine, and then provide the vaccination shortly after consent was obtained. During a follow-up interview on 5/21/25 at 10:46 A.M., the SDC said there were no available COVID-19 vaccinations in the facility and the facility was awaiting a new batch of vaccines. When the surveyor requested the pharmacy request for the newly ordered COVID-19 vaccinations, the SDC said she would speak with the Administrator. During an interview on 5/27/25 at 12:46 P.M., the Director of Nursing (DON), who was also the Infection Preventionist (IP), said the facility had not developed a written COVID-19 vaccination policy. During a follow-up interview on 5/27/25 at 12:46 P.M., the DON/IP said the facility has not maintained documentation of Resident #15's or Resident #114's COVID-19 vaccination history. The DON/IP said Resident #15 and the Resident Representative for Resident #114 had consented to the Residents being given vaccination to ensure they were up-to-date with their COVID-19 vaccinations. The DON/IP said no COVID-19 vaccinations had been administered to Resident #15 and Resident #114 and this should have been done shortly after they were admitted to the facility. The facility failed to provide any documentation to the survey team relative to the facility being in the process of ordering COVID-19 vaccinations from the pharmacy by the end of the survey on 5/27/25.

Based on observations, interview, and policy review, the facility failed to ensure staff stored all drugs, and biologicals used in the facility in a secure manner, on three Units (East One, [NAME] Two, and East Two) of three units observed. Specifically, the facility failed to ensure 1. on East One, one medication cart was locked when not in direct supervision of a licensed nurse, 2. on [NAME] Two, one medication cart and one treatment cart were locked when not in direct supervision of a licensed nurse, and 3. on East Two one medication cart was locked when not in direct supervision of a licensed nurse. Findings include: Review of the facility policy titled Medication Storage in the Facility, effective date 1/2023, indicated the following: It is the policy of the facility that medications, treatments, and biological are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 1. On 8/4/24 at 10:32 A.M., on the East One Unit the surveyor observed an unlocked medication cart stocked with medication and medical supplies. No authorized nursing staff were observed to be in direct supervision of the unlocked medication cart. During an interview on 8/4/24 at 10:35 A.M., Nurse #1 said medications carts should be locked when a nurse is not in direct supervision of the cart, and she had left the medication cart unlocked. 2. On 8/4/24 at 10:42 A.M., on the [NAME] Two Unit the surveyor observed an unlocked treatment cart stocked with treatment supplies in the hallway leading to the activities room. Topical medication products observed in the treatment cart included but was not limited to antifungal powder, bacitracin ointment, povidone iodine swab sticks, and vitamin a & d ointment. No authorized nursing staff were observed to be in direct supervision of the unlocked treatment cart. Four Residents were seated in the vicinity of the treatment cart. During an interview on 8/4/24 at 10:43 A.M., Nurse #2 said it was the responsibility of all the nurses on the unit to ensure the treatment cart was locked up when not in use, so that it could not be accessed by residents, and the treatment cart in question had not been locked up after it had been used. On 8/4/24 at 10:45 A.M., on the [NAME] Two Unit the surveyor observed an unlocked medication cart stocked with medication and medical supplies. No authorized nursing staff was observed to be in direct supervision of the unlocked medication cart. One Resident was observed seated directly next to the unlocked medication cart. During an interview on 8/4/24 at 10:47 A.M., Nurse #3 said she should not have left her unlocked medication cart unattended, and she should have locked the cart when she walked away from it. 3. On 8/4/24 from 10:50 A.M. to 10:55 A.M., on the East Two Unit the surveyor observed an unlocked medication cart stocked with medication and medical supplies. No authorized nursing staff was observed to be in direct supervision of the unlocked medication cart. Five Residents were observed in the vicinity of the unlocked medication cart. During an interview on 8/4/24 at 10:55 A.M., Nurse #4 said she should not have left her medication cart unlocked and that she should have locked the cart when she walked away from it.

Based on records reviewed and interviews, the Facility, (who had an in-house census of 118 residents) failed to ensure the Director of Nurses (DON) did not serve as a charge nurse on a unit, when their daily occupancy rate was greater than 60 residents. Findings include: Review of the Facility's Job Description for the Director of Nurses, dated 12/2022, indicated the purpose of this position is to plan, organize, develop, and direct the overall operations of the Nursing Service Department in accordance with federal, state, and local standards, guidelines and regulations that govern our facility, and may be directed by the administrator, the Medical Director, and/or the Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times. Review of the Census Daily Report, dated 07/11/24, indicated the Facility Census was 118 and the total capacity was 132. Review of the Nursing Daily Schedule, dated 07/10/24, indicated the DON worked as a charge nurse on a unit, for the 7:00 A.M. through 3:00 P.M. shift. Review of the Nursing Daily Schedule, dated 07/11/24, indicated the DON worked as a charge nurse on a unit, from 7:00 A.M. through 11:00 A.M. During an interview on 07/11/24 at 7:25 A.M., the Director of Nurses (DON) said that she had to work as a charge nurse on a unit on 07/10/24 and 07/11/24 because of everything that happened since Monday (07/08/24). The DON said they had lost a lot of nursing staff in a short period of time, and she had to help where she was needed.

Based on observations, interviews, and policies reviewed, the facility failed to adhere to professional standards and the facility's policies for: 1. Food storage, preparation and service, and cleanliness of food preparation equipment in the facility's main kitchen, placing residents at risk for foodborne illness; and 2. Food storage, food equipment cleanliness, and reheating of resident food items in one Unit (West 2) Kitchenette out of three-unit kitchenettes observed. Specifically, the facility failed to: - Serve thoroughly cooked eggs at one breakfast meal when the eggs were not pasteurized. - Maintain cold food storage according to professional standards in the walk-in refrigerator. - Maintain food preparation equipment in a sanitary manner. - Maintain unit nourishment kitchens in a sanitary manner. - Provide equipment and proper instructions for staff to reheat resident food items according to food safety requirements. Findings include: 1. Review of the facility's policy titled Dietary-Proper Food Preparation, dated December 2022, indicated all foods would be prepared following established procedures for sanitation, handling, and protection from cross-contamination. Review of the facility's policy titled Dietary-Food Purchasing, dated December 2022, indicated only Grade A pasteurized shell eggs and egg products were allowed. Review of the facility's policy, titled Sanitizing Equipment and Dietary Space, dated December 2022, indicated all equipment and dietary areas would be maintained in a sanitary manner to prevent contamination and infections. Review of the facility's policy titled Dietary-Food Storage, dated December 2022, indicated it is the policy of the facility that prepared foods shall be kept labeled with contents and dated, raw meats should be placed on sheet pans, and that refrigerator units will be kept clean at all times and placed on a routine and as needed cleaning schedule. On 3/20/24 at 7:19 A.M., the surveyor observed the following during the initial kitchen walk-through: - A puddle of wet pink liquid on the floor of the refrigerator, dripping from a box of raw chicken stored on the bottom rack of the refrigerator. Some of the pink liquid at the edge of the puddle on the floor was dry. The pink liquid was also dripping from the box of chicken onto an adjoining tray of meat. - One torn yellow piece of paper laying on the floor of the refrigerator in the pink liquid that indicated: made 3/14 egg salad. - One plate containing a wet, white, lumpy substance that was covered in plastic wrap and labeled with black marker, but unable to be read. - Two boxes of 15 dozen each, Grade A Cage Free eggs. One box was open and half empty. There was no indication on either box that the eggs were pasteurized. Cooking instructions located on the box indicated to cook thoroughly. - One juice cart located in the food preparation area with dry, crusty, brown and white debris on the bottom shelf of the cart and atop the juice pump. - Pots and pans stored on a shelving unit with dry, white spattered debris on the shelves. - The blender base was stored on a counter in the food preparation area with dry, spattered white and brown debris on the top and front of the unit. - One soup tureen, bolted to the floor in the food preparation area, covered with a black plastic bag, coated in dust and dried white spattered substance. - One black metal fan coated with dust on the blades and the outer cage on top of the counter next to the three-compartment sink in the dish room, on and blowing toward the dish machine. There was a three-tiered plastic cart that contained three plates, a mini spatula, one soup bowl, and a beverage pitcher next to the dish machine. The cart was soiled with dried and spattered white debris. During an interview on 3/20/24 at 8:12 A.M., Food Service Director (FSD) #1 said he had been working at the facility for approximately six weeks and that he was just starting to be able to put in for food orders himself. He said that the facility was supposed to order pasteurized shelled eggs if they were to be served runny. FSD #1 said kitchen staff served runny, fried, and sunny side up eggs to residents that requested them for breakfast. At this time, FSD #1 removed the open box of Grade A Cage Free eggs from the refrigerator, reviewed the labels on the box, and said the eggs were not pasteurized, so they should only be served after being cooked thoroughly. At this time, the surveyor observed the refrigerator, food preparation area, and dish room with FSD #1. FSD #1 said the dripping box of raw chicken should have been stored on a pan to prevent leaking and surface contamination. FSD #1 said the plated wet, white, lumpy substance was unidentifiable and he did not know if it belonged to a staff member or was facility food. FSD #1 said that the shelved pots and pans in the food preparation area were clean and should not have been stored on shelves that were not clean. FSD #1 said the juice cart, blender base, and soup tureen cover were not clean, but should have been. FSD #1 said that the fan in the dish room should be clean but it was not. FSD #1 further said that he could not produce any evidence that kitchen equipment had been cleaned or sanitized since he started working at the facility. During an interview on 3/20/24 at 8:25 A.M., Cook #1 said she thought the facility only ordered shelled eggs that were pasteurized. Cook #1 said that she had cooked runny eggs for three residents for breakfast that day because they requested them. She said that she usually cooks runny eggs to about 135 degrees F because if they were cooked to a higher temperature, they would not be runny. When asked what temperature the shelled eggs were cooked to that morning for the three residents who requested them Cook #1 said she did not check the final cooked temperature. She further said the eggs were served without having their temperatures checked. Cook #1 then said that cooking unpasteurized eggs thoroughly was important to prevent residents from getting sick. 2. Review of the facility's policy titled Food Brought in for the Residents from the Outside, dated February 2022, indicated: - Any unlabeled food containers/items would be removed from the refrigerator and will be disposed of accordingly. - Any perishable foods that require refrigeration would be placed in the unit's nourishment/kitchen refrigerator and needed to be consumed within 72 hours of the date brought in. - Unit refrigerators would be checked daily by . staff. - Any foods stored in the refrigerator would be discarded after the 72-hour time frame. - Any foods not stored or labeled properly would be discarded. Review of the facility's policy titled Food and Liquid Re-heating, undated, indicated: - The facility would provide foods and liquids to residents in the allowable temperature range by State and Federal regulations, both at initial delivery as well as when re-heated. - Necessary equipment and supplies included a food thermometer and approved sanitizing solution for the thermometer (alcohol swabs or equivalent). - Re-heat leftover or cooled food/liquid items to 165 degrees F for 15 seconds . On 3/22/24 at 8:23 A.M., the surveyor observed the following in the [NAME] Two Unit Kitchenette: - The inside of the microwave and the refrigerator were soiled with dried debris and crusted matter. - Two keep frozen breakfast bowls were dated 3/14 and stored on the bottom shelf of the refrigerator, not in the freezer. - One open apple sauce container, dated 3/20 located on the top shelf in the refrigerator. - One sign, posted to the wall of the Kitchenette, that indicated: when heating food please ensure the temperature is not above Food: 120 degrees, Liquid 110 degrees. - There was no thermometer present in the kitchenette at the time of observation. During an interview on 3/22/24 at 10:05 A.M., FSD #2 said that any food items in the refrigerator that were outdated should have been discarded and the room should be stocked and cleaned twice a day. FSD #2 said the breakfast bowls that were stored in the refrigerator should have been kept frozen, but they were not, so they should have been discarded. FSD #2 said she thought food requiring reheating in the microwave would need to be reheated to 125 degrees F, but needed to confirm that once she had time to check. She said she had removed the posted sign for reheating from another kitchenette area in the building and did not realize the same sign was posted in the [NAME] Two Unit Kitchenette. FSD #2 also said microwaved food needed to sit for a minute after heating because pockets of high temperatures could be present in the heated food and cause burns to a resident. During an interview on 3/22/24 at 10:20 A.M., CNA #3 said she reheated resident foods and water for tea or coffee using the microwave in the Kitchenette. CNA #3 said she would reheat food items for a minute or so just to make sure they were lukewarm and not too hot. CNA #3 said that she had never seen or used a thermometer to check the temperature for reheated food items and that she was unaware of any specified reheating protocol. During an interview on 3/22/24 at 10:20 A.M., CNA #4 said she had never seen a thermometer in the kitchenette to be used for reheating resident food items and she did not know if there was a specific protocol for reheating resident food items.

Based on observations, interviews, and records and policies reviewed, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and choices for one Resident (#17), out of 25 total sampled residents. Specifically, the facility failed to: a. Provide seating, adequate for the Resident's condition, when the Resident was non-ambulatory (unable to walk) and required assistance from staff to get out of bed, increasing the Resident's for further physical debility and social isolation. b. Maintain an accurate record of the Resident's fluid intake and urinary output when the Resident's Physician ordered fluid intake and output monitoring and the Resident had a history of fluid overload (too much fluid in one's body that can cause swelling, high blood pressure, and impact organ function). c. Provide timely incontinent (loss of bladder control) care when the Resident had been incontinent of urine, was dependent on staff for incontinent care, and requested incontinent care be provided which increased the Resident's risk for a deterioration in skin condition. Findings include: Resident #17 was admitted to the facility in October 2022 with diagnoses including End Stage Renal Disease (ESRD: condition where the kidney reaches advanced state of loss of function which can result in changes in urination, fatigue, swelling .), dependence on renal dialysis (blood purifying treatment given when kidney function is not optimum), obesity, and muscle weakness. a. Review of the facility's policy titled Seating System and Positioning Devices, dated December 2023, indicated: - The guideline was to establish appropriate seating systems for residents . to maintain comfort and good . body alignment. - Seating systems . assist with . maintaining independence so residents remain engaged in functional activities of choice. Review of Resident #17's Activities of Daily Living (ADL) Care Plan, initiated 10/10/22 and revised 1/18/24, indicated: - The Resident required assistance of two staff for all positioning. - The Resident did not walk. - The Resident required assistance when out of bed with the use of a wheelchair. Review of Resident #17's Activities Care Plan, initiated 1/20/23 and revised 1/18/24, indicated: - Needs a variety of activity types and locations to maintain interests. Review of Resident #17's Physical Therapy Evaluation, dated 6/15/23, indicated: - The Resident was dependent on staff for transfers to and from a chair/wheelchair. - The Resident did not walk. - The Resident's Mobility Function Score was 0 (using a 0 to 12 scale where 12 is the highest function). Review of Resident #17's Physical Therapy Discharge Summary, dated 6/20/23, indicated: - The Resident's Mobility Function Score was 0. - The Resident was discharged to the hospital. Review of Resident #17's Activity Care Plan, initiated 7/20/23 and revised 1/18/24, indicated: - Explain the importance of social interaction . Review of Resident #17's Minimum Data Set (MDS) assessment, dated 1/4/24, indicated: - The Resident had impaired range of motion in both lower extremities. - Transfers to and from the bed and chair/wheelchair had not been attempted. - The Resident did not use a wheelchair. On 3/20/24 at 11:01 A.M., the surveyor observed Resident #17 positioned in bed, on his/her back, with the head of the bed elevated. The Resident's legs were covered with bed linens and the surveyor observed the Resident's upper body dressed in a hospital gown. During an interview at this time, Resident #17 said he/she was unable to walk, was unable to get up without the use of a mechanical lift operated by two staff members, and did not have a chair to sit in, so he/she just stayed in bed. At this time, the surveyor observed the Resident's room and bathroom. There was a standard straight back chair next to the Resident's bed, but the surveyor observed no wheelchair. During a follow-up interview on 3/26/24 at 10:12 A.M., Resident #17 said he/she used to have a wheelchair, but that he/she had not seen it for months and did not know where it was at that time. Resident #17 said she did not ask staff to help him/her out of bed because he/she refused often a while back and no one offered for him/her to get out of bed anymore. Resident #17 said the straight back chair in the room next to the bed had been there since the Resident had been in that room, but that he/she had never tried sitting in it because he/she needed a different width chair. Resident #17 further said he/she would like to get out of bed. During an interview on 3/26/24 at 10:53 A.M., Certified Nurse Aide (CNA) #3 said Resident #17 used to have a wheelchair in his/her room, about four to five months prior, but that the Resident had a history of refusing to get out of bed when this was offered by staff. CNA #3 further said Resident #17 no longer had a wheelchair available to get into if he/she did want to get up. During an interview on 3/26/24 at 12:00 P.M., Therapist #2 said Resident #17's most recent therapy episode occurred in June 2023. Therapist #2 said Resident #17 was dependent upon staff with the use of a mechanical lift for transfers, the Resident could not walk, and that the Resident was discharged from therapy services with a wheelchair to sit in if he/she got out of bed. At this time, the Regional Rehab Director said all residents who required a wheelchair should have one. During an interview on 3/26/24 at 1:13 P.M., the Director of Nursing (DON) said she thought Resident #17 had a wheelchair available to sit in if the Resident chose to get out of bed. The DON further said the facility provided all residents with a wheelchair if they needed one. On 3/27/24 at 8:00 A.M., the surveyor observed Resident #17 lying in his/her bed with the head of the bed elevated. The surveyor also observed a wheelchair with a seat cushion and bilateral leg rests in Resident #17's room, beside the Resident's bed. During an interview at this time, Resident #17 said a staff member brought the wheelchair into the room that morning and left it beside the Resident's bed. During an interview on 3/27/24 at 12:35 P.M., the Regional Rehab Director said Resident #17 was evaluated by one of the Therapists on 3/26/24 and it was identified that the Resident did not have a wheelchair available to him/her to get out of bed, so one was provided for the Resident in the morning on 3/27/24. The Regional Rehab Director then said that every resident who needs a wheelchair should have one as an option to get out of bed. b. Review of the facility's policy, titled Intake and Output (I and O) Measuring, dated January 2023, indicated: - The purpose was to accurately determine the amount of liquid a resident consumed and put out in a 24-hour period. - At the end of the shift, total the amounts of all liquids the resident consumed in cubic centimeters (milliliters: mls). - If a resident is continent, record output in mls . - If a resident is incontinent, record the number of episodes of incontinence. - The amount of fluid consumed, and number of urinary incontinence episodes were to be documented in the resident's medical record. Review of Resident #17's Nutrition Care Plan, initiated 1/9/23 and revised 2/4/24, indicated: - The Resident was at risk for fluid imbalance relative to ESRD and Dialysis. - A 1500 ml fluid restriction was in place. - Fluid intake monitoring was required for each meal. Review of Resident #17's Nutrition Assessment, dated 2/4/24, indicated the following: - The Resident had fluid gains between dialysis treatments, occasionally as much as nine kilograms (equivalent to 19.8 pounds). - A 1500 milliliter (ml) fluid restriction was recommended. Review of Resident #17's March 2024 Physician's Orders indicated the following: - 1500 ml daily fluid restriction, initiated 2/5/24. - Intake and output monitoring every shift with total intake and output on 11-7 shift . every night shift, 1.5 Liter (1500 ml) fluid restriction, initiated 2/5/24. Review of Resident #17's March 2024 Treatment Administration Record (TAR) indicated the following relative to fluid intake: - Total fluid intake was recorded in mls on 21 out of 25 days reviewed (three days were indicated as unknown and one day was indicated as + for total fluid intake). - One day (7:00 A.M. through 3:00 P.M.) shift and four evening (3:00 P.M. through 11:00 P.M.) shifts were not completed. Further review of Resident #17's March 2024 TAR indicated the following relative to urine output: - Measurable total urine output was recorded in mls on 16 out of 25 days reviewed. - Total urine output was indicated as not applicable on two days, unknown on one day, x on one day, and x 1 on five days out of 25 days reviewed. During an interview on 3/26/24 at 10:12 A.M., Resident #17 said that he/she was incontinent of urine and used incontinent briefs. Resident #17 said he/she used to have a urinary catheter, but did not have one anymore, and he/she did not use a bed pan, so he/she was unsure how staff monitored his/her urinary output. During an interview on 3/26/24 at 1:33 P.M., Nurse #6 said staff were required to monitor fluid intake (I) and urine output (O) for residents on I and O monitoring and that the monitoring for I and O was recorded on residents' TARs. Nurse #6 said Resident #17 was on a fluid intake restriction and that the Resident had a physician's Order for I and O monitoring. Nurse #6 said the Resident's fluid intake was supposed to be recorded on the MAR in mls, but that the urine output had to be recorded as number of incontinent episodes as the Resident did not have any devices in use to measure urine output in mls and was incontinent of urine. At this time, the surveyor reviewed Resident #17's March 2024 TAR with Nurse #6. While reviewing the Resident's TAR, Nurse #6 said staff had not been accurately recording Resident #17's I and O. Nurse #6 further said all the boxes on the TAR should have been completed to indicate how many mls of fluid the Resident took in each shift and daily, and how many urinary incontinent episodes the Resident had each shift and daily. Nurse #6 then said recording the Resident's I and O on the TAR was the only place where fluid intake and urine output were documented. During an interview on 3/27/24 at 12:30 P.M., the Registered Dietitian (RD) said Resident #17's fluid restriction was implemented due to having weight gain between dialysis treatments. The RD said staff should record the Resident's I and O accurately for monitoring purposes. c. Review of the facility's policy, titled Answering the Call Light, dated June 2022 indicated it was the policy of the facility that quick response was given to a resident's call light to respond to the resident's request and needs in a timely fashion. Review of Resident #17's Incontinence Care Plan, initiated 4/21/23 and revised 1/18/24, indicated: - The Resident was at risk for skin breakdown due to incontinence and impaired mobility. - The Resident was incontinent of bowel and bladder. - The Resident used disposable incontinence briefs. - Staff were to clean the Resident's peri area with each incontinent episode. Review of Resident #17's MDS assessment, dated 1/4/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. Further review of the MDS assessment indicated: - The Resident required substantial/maximal assistance to roll in bed. - The Resident required substantial/maximal assistance for toilet hygiene. - The Resident was always incontinent of urine. On 3/20/24 at 11:01 A.M., the surveyor observed Resident #17 positioned in bed, on his/her back, with the head of the bed elevated. The Resident's legs were covered with bed linens and the surveyor observed the Resident's upper body dressed in a hospital gown. During an interview at this time, Resident #17 said he/she was incontinent of urine and that he/she wore incontinence briefs. Resident #17 said he/she used the call bell to request assistance from staff for incontinent care when needed, but that staff did not assist him/her with incontinent care in a timely manner. When asked how the Resident determined timely assistance, the Resident #17 said wait times for staff to provide assistance ranged anywhere from 30 minutes to a few hours after he/she rang the call bell. Resident #17 then said staff had provided incontinent care to him/her around 5:00 A.M. that day and that he/she used the call light around 8:30 A.M. to request incontinent care be provided again. Resident #17 said staff responded to the call light but told the Resident they were still assisting other residents with breakfast, so he/she would need to wait. Resident #17 further said no staff had returned to provide him/her with the incontinent care he/she requested around 8:30 A.M., and that he/she was still waiting. On 3/26/24, between 9:30 A.M. and 10:10 A.M., the surveyor observed the following outside of Resident #17's room: - The Resident's call light was observed to be on at 9:30 A.M. - Nurse #10 entered the Resident's room at 9:31 A.M., turned off the call light, and exited the room. - At 9:32 A.M., Nurse #10 told CNA #3 Resident #17 requested incontinent care and CNA #3 said okay. - At this time, CNA #3 entered another resident's room and closed the door. - Nurse #6 entered Resident #17's room at 9:33 A.M. and said, Did I leave my thermometer in here?, then exited the Resident's room and closed the door. - At 9:52 A.M. the surveyor observed an activities staff member place a rolled piece of paper behind Resident #17's door handle. At this time, the Activities staff member said she was delivering the Daily Chronicle to residents on the Unit and that if a resident's door was closed, she would leave it behind the door handle and nursing staff would bring it into the room when they went in. - At 9:54 A.M., the surveyor observed CNA #3 exit the Resident's room she was observed to enter at 9:32 A.M. - The surveyor observed CNA #3 enter Resident #17's room at 10:02 A.M. with one other CNA. and close the door. - Both CNAs exited Resident #17's room at 10:10 A.M. Throughout this observation, the surveyor observed two nurses at the nurses' station. During an interview on 3/26/24 at 10:12 A.M., Resident #17 said he/she had put the call light on that morning to request incontinent care because he/she had urinated in his/her incontinence brief. Resident #17 further said it took staff about a half-hour before they came into his/her room to provide the incontinent care he/she requested. During an interview on 3/26/24 at 10:53 A.M., Certified Nurse Aide (CNA) #3 said the unit was staffed with four CNAs and three Nurses on the day shift. CNA #3 said from the start of the shift through lunchtime it was difficult to answer call lights and provide incontinent care to residents because the CNAs were busy providing morning personal care to residents. CNA #3 said that residents would sometimes have to wait a half-hour or more after calling for assistance if the CNAs were busy assisting other residents with morning personal care. CNA #3 also said residents would have to wait until after mealtimes if they required incontinent care during mealtimes. CNA #3 said Nurse #10 told her that Resident #17 requested incontinent care that morning, but she needed to assist another resident with morning personal care first, so she was unable to provide incontinent care to Resident #17 until about a half-hour later. CNA #3 then said Resident #17 required assistance of two staff for incontinent care, so CNA #3 had to wait until another CNA was available to help her provide incontinent care to Resident #17. During an interview on 3/26/24 at 5:30 P.M., the Director of Nursing (DON) said the census capacity on the East One Unit was 39 residents and there were currently several empty beds. The DON said the Unit was adequately staffed, with four CNAs and three Nurses, on the day shift. The DON also said any Nurse or CNA could assist residents with incontinent care and it was not required that a resident's assigned CNA be the only CNA responsible to provide care to the resident. The DON further said staff on the Unit just needed to communicate with each other to request help if a resident needed care and their assigned CNA was caring for another resident. The DON further said Resident #17 should not have had to wait for a half-hour after his/her call light was answered to be provided with incontinent care.

Based on observation, interviews, and records and policies reviewed, the facility failed to support the right for one Resident (#17), to participate in his/her care planning process, in a total sample of 25 residents. Specifically, the facility failed to include Resident #17 in the interdisciplinary team (IDT) care plan review process when the Resident was his/her own responsible person, had a preference to be in bed, and the IDT met in a location not in the Resident's room to review Resident #17's plan of care, which impacted the Resident's ability to make choices about his/her plan of care and treatment interventions. Findings include: Review of the facility's Care Planning Policy, dated February 2023, indicated the following: - It was the policy of the facility that each resident . participate in the development of the resident's . care plans. - Residents . were invited to attend and participate in care planning conferences (admission, quarterly, annual, and significant change in status). - All care plans would be reviewed and revised by the clinical team and the resident . Resident #17 was admitted to the facility in October 2022 with diagnoses including End Stage Renal Disease (ESRD: condition where the kidney reaches advanced state of loss of function which can result in changes in urination, fatigue, swelling .), dependence on renal dialysis (blood purifying treatment given when kidney function is not optimum), obesity, and muscle weakness. Review of Resident #17's clinical record indicated the following: - A Minimum Data Set (MDS) assessment, dated 10/5/23, was completed due to the Resident having had a significant change in status. - The Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. - There was no evidence that the Resident's Health Care Proxy (HCP: a representative to make healthcare decisions on one's behalf if they become unable to make those decisions themselves) had been invoked. Review of a Social Services Progress Note, dated 10/20/23, indicated Resident #17 had a care plan meeting scheduled for 10/19/23 which was rescheduled to 11/6/23. Review of a Social Services Progress Note, dated 11/6/23, indicated an IDT meeting was held to discuss the Resident's current level of care, including refusals of care, . diet restrictions, dialysis, medications, and treatments. Further review of the Note indicated: - No evidence the Resident was in attendance at the meeting. - A family member of the Resident was in attendance at the meeting. - The Resident's HCP had not been invoked. On 3/20/24 at 11:01 A.M., the surveyor observed Resident #17 positioned in bed, on his/her back, with the head of the bed elevated. The surveyor observed no wheelchair in the Resident's room. During an interview at this time, Resident #17 said staff at the facility held care plan meetings, but he/she could not go because meetings were held in a certain room in the facility and he/she was unable to get out of bed on his/her own or walk and that he/she did not have a wheelchair. Resident #17 also said a care plan meeting had been held in his/her room before, but that no one had offered that to him/her for a long time. During an interview on 3/27/24 at 11:02 A.M., the Social Worker (SW) said Resident #17 never attended his/her care plan meetings because the Resident didn't get out of bed and preferred to stay in his/her room. The SW said some residents at the facility chose to have care plan meetings in their rooms, but she did not think that Resident #17 would want care plan meetings held in his/her room, so this had not been offered. The SW also said having Resident #17's IDT meeting in the Resident's room on 11/6/23 had not been offered to the Resident. The SW further said Resident #17's family member attended the meeting and was involved in IDT discussions regarding the Resident's care, but the Resident's HCP was not invoked.

Based on observations, interviews, and records reviewed, the facility failed to provide reasonable accommodation of resident needs for three Residents (#174, #30, and #67), out of 25 total residents sampled. Specifically, the facility failed to provide: 1. Resident #174 with a working call light or an alternative means to call for assistance; 2. Resident #30 with a wheelchair that accommodated the Resident's needs; and 3. Resident #67 with a seat cushion and leg rests for his/her wheelchair. Findings include: 1. Review of the facility's policy titled Answering the Call Light, dated 6/2022, indicated the following: -Some residents may not be able to use their call light. Be sure to check these residents frequently: and if applicable give the resident an alternative device . -Report all defective call lights to the nurse supervisor promptly. Resident #174 was admitted to the facility in March 2024 with the following diagnoses: anxiety disorder (a mental illness that can cause constant fear and worry), bipolar disorder (a mental illness that causes extreme mood swings, from high to low, that affect your energy, thinking, and behavior), dysphagia (difficulty in swallowing food or liquid), major depressive disorder (a persistent feeling of sadness and loss of interest), and schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, symptoms of a mood disorder, such as mania and depression), and morbid obesity. Review of the Advanced Directives care plan, initiated on 3/8/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15. Review of the Activities of Daily Living care plan, initiated on 3/20/24, indicated to encourage the Resident to use the call light to call for assistance. During an interview and observation on 3/20/24 at 1:41 P.M., Resident #174 said that he/she had not been cleaned up since yesterday and was soiled. Additionally, the Resident said he/she was unable to see his/her call light button because he/she was blind. The surveyor observed the call light button to be wrapped around the bed rail on the right side of the bed, hanging downward, just out of reach of the Resident. The surveyor requested Nurse #1 to enter the room and observe the location of the call light button. As the call light button was lifted to be given the Resident, he/she said it did not matter because the call light did not work and began to cry. Nurse #1 and the surveyor pressed the button and observed the light outside of the Resident's room to not light up. Nurse #1 indicated he would notify someone. During an observation and interview on 3/21/24 at 12:27 P.M., Nurse #1 and the surveyor checked the functioning of the call light for Resident #174. Resident #174 was asked to press the call light button while Nurse #1 stepped out into the hallway to observe the light above the Resident's door. Nurse #1 said the light was not activated. He said that he notified the supervisor yesterday and the maintenance department verbally this morning. The surveyor asked the Resident if he/she was provided an alternative call bell to use while waiting for the call light to be fixed. He/she began to cry and said, No, I have nothing to call them. Nurse #1 said that the Resident did not have anything to use to call for assistance if he/she needed it but would reach out to the Unit Manager to see if they could find something to use until the call light was fixed. From 12:35 P.M. until 12:41 P.M., the surveyor observed Nurse #1 attempt to call maintenance and supervisors to remind them of the broken call light. He said that he had been trying to reach people, but no one had responded to him. He said that the standard protocol is to place equipment concerns into the maintenance log, unless it was something emergent, then he would place a phone call to maintenance. He further said that he felt the non-working call light was something that was urgent and that it should have been resolved yesterday. 44222 2. Resident #30 was admitted to the facility in July 2013 with diagnoses of morbid (severe) obesity due to excess calories, abnormal posture, hereditary lymphedema (a genetic condition affecting the lymphatic system and is characterized by chronic swelling (edema) of certain parts of the body), and muscle weakness. Review of the Physical Therapy (PT) Evaluation and Plan of Treatment, dated 8/25/23, included: -wheelchair management and training -New Goal - A letter of medical necessity will be written in order to obtain the manual wheelchair in order to decrease the risk of pressure injuries and improve comfort/Quality of Life (QOL). (Target 9/5/23) -patient goals - said I want a new wheelchair -reason for referral for assessment/ordering of a new bariatric wheelchair .due to discomfort in (his/her) current wheelchair, as well as management of severe hereditary lymphedema Review of the PT Discharge Summary, dated 9/14/23, included: -looking into getting a chair donated, therefore, this goal has been discontinued. Review of the Resident's Physician's Orders included an order for PT Evaluation for WC (wheelchair) assessment and recommendations. (initiated 2/17/24) Review of the PT Evaluation and Treatment, dated 2/17/24 indicated: -wheelchair management and training -goal to be able to sit upright in (his/her) wheelchair more -morbidly obese with hereditary lymphedema and weakness -Physician orders received to evaluate for recommendations for customized wheelchair . will require a custom bariatric wheelchair with an off-loading cushion to provide pressure relief when sitting and elevating foot (boxes) to allow for lymph drainage. Review of the Manual Tilt Wheelchair Functional Mobility Evaluation, dated 2/18/24, indicated that the Resident was currently in a manual wheelchair loaned to them by the facility. The form indicated that the Resident was unable to propel the chair due to the wheels being back so far. The evaluation indicated that a vendor had assessed the Resident for a custom wheelchair. The sections of the form requiring justifications for each piece of equipment for the wheelchair were left blank. The physician did approve and sign for the recommended wheelchair on 2/21/24. Review of the Resident's Minimum Data Set (MDS) assessment, dated 3/5/24, indicated the Resident was cognitively intact as evidenced by a BIMS score of 15 out of 15. On 3/20/24 at 11:20 A.M., the surveyor observed the Resident sitting forward in a wheelchair with personal belongings stored on the seat behind the Resident's back. The Resident told the surveyor that the wheelchair was uncomfortable and was not fitted for him/her, and the seat was too deep preventing him/her from sitting all the way back in the chair. During an interview on 3/27/24 at 9:36 A.M., Physical Therapist Manager #1 said that she was not aware that a script or written letter of necessity was obtained in August 2023. She said that she was not aware of any new or donated wheelchair being obtained at that time for the Resident in response to the referral and treatment in August 2023. Physical Therapist Manager #1 said she was aware that a Manual Tilt Wheelchair Functional Mobility Evaluation was completed by facility staff on 2/18/24, and then signed by the Physician on 2/21/24, but could not find any evidence that the facility staff ever finished completing the form or ever submitted the evaluation, order, and justification to the Wheelchair company in order to acquire the wheelchair. Physical Therapist #1 said that the Resident had not received the recommended wheelchair. She said that she was not aware of any reason why this evaluation and wheelchair request was not followed through with and said that it just wasn't done. 3. Resident #88 was admitted to the facility in May 2021 with diagnoses of adult failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment), unspecified dementia (a cognitive impairment that has yet to be diagnosed as a specific type), and muscle weakness. Review of the Resident's MDS assessment, dated 1/10/24, indicated that he/she was severely cognitively impaired as evidenced by a BIMS score of 2 out of 15, and it indicated a pressure relieving device for the Resident's chair was in use. On 3/20/24 at 10:18 A.M., the surveyor observed the Resident sitting in a wheelchair in the unit day room. There were no seat cushion or leg rests on the wheelchair. On the following dates the surveyor observed the Resident resting in bed. The wheelchair was adjacent to the bed with no seat cushion or leg rests visible on or near the wheelchair. -3/21/24 at 11:55 A.M. -3/26/24 at 2:00 P.M. During an interview on 3/27/24 at 10:02 A.M., Physical Therapist Manager #1 said that she looked at the Resident's wheelchair and it should have had a seat cushion and leg rests but it did not. She further said that the Resident had leg rests to use, but she had found them in the Resident's closet and was unsure how long the leg rests had been in the closet.

Based on record review, policy review, and interview, the facility failed to execute Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) for one Resident (#115), out of a total sample of 25 residents. Specifically, for Resident #115, the facility failed to ensure that Advanced Directives on a completed (prior to facility admission) Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form were honored per the Resident's wishes. Findings include: Review of the facility's policy titled MOLST Form, dated 5/1/15, indicated the following: -The MOLST form is a medical order form that converts an individual's wishes regarding life-sustaining treatment into Medical Orders. -A legally recognized health care agent (HCA) or guardian may execute, revise, or revoke the MOLST form for a resident only if the resident lacks decision-making capacity. -For a resident admitted with a MOLST form already completed check to make sure all sections of the form, front and back, are filled out completely and that the form is signed by the resident or their Health Care Proxy (HCP) and a physician/NP/PA (NP-Nurse Practitioner, PA-Physician Assistant). On admission orders, write FOLLOW MOLST INSTRUCTIONS. Resident #115 was admitted to the facility in February 2024 with diagnoses including unstageable pressure ulcer (a wound with an obscured wound bed, that occurs because of prolonged pressure on a specific area of the skin). Review of the Minimum Data Set (MDS) assessment, dated 3/7/24, indicated the Resident scored 15 out of a possible 15 points on the Brief Interview for Mental Status (BIMS) assessment, indicating the Resident was cognitively intact. Review of the March 2024 Physician's Orders indicated the following: -Honor MOLST found in chart FULL CODE, date initiated 2/28/24. Further review of the Physician's orders showed no evidence that the Resident's HCP had been activated. Review of the medical record indicated a MOLST form, completed and signed by the Resident and a Physician, dated 8/24/18 (prior to facility admission), indicated a Do Not Resuscitate (DNR) and Do Not Intubate and Ventilate status. Review of the medical record indicated a second MOLST form, completed and signed by the Resident's HCP and the facility Nurse Practitioner, dated 2/29/24, indicating attempt resuscitation, intubate, and ventilate. During an interview on 3/26/24 at 8:43 A.M., Nurse #4 and the surveyor reviewed both MOLST forms. Nurse #4 said that if she were to find the resident not breathing, she would use the MOLST form that said full code and start resuscitation. She said that she would use the form that was done at the facility instead of the form the Resident had signed prior to admission because he/she had an HCP. Nurse #4 and the surveyor reviewed the HCP activation form and she said that it was incomplete, and not signed by the physician. Nurse #4 said she believed that the process for invoking the HCP was to get a doctor's order, but she did not see an order, and she was not sure if the Resident should be a full code or a DNR at this time. During an interview on 3/26/24 at 9:04 A.M., the Social Worker said that the facility should honor a MOLST that was completed prior to admission unless the HCP was activated. She said when the HCP is activated, the doctor should do an evaluation, fill out the activation form and then a nurse will get the order to invoke the HCP. Once the process is completed, a new MOLST could be signed by the health care agent. She said a new MOLST was completed when Resident #115 was admitted to the facility because he/she was confused at that time. The Social Worker and the surveyor reviewed the HCP activation form and the Physician's orders, and she said a new MOLST should not have been signed unless the Resident had been invoked by the Physician but since her BIMS was 15 now, she could sign a new MOLST.

Based on observations, interviews and record reviews, the facility failed to ensure necessary treatment and services were provided to promote healing and/or prevent decline in pressure ulcers for four sampled Residents ( #12, #64, #98 and #216), out of a total sample of 43 residents. Review of the facility policy titled Wound Care, dated 2017, indicated the purpose of the guidelines for the care of wounds was to promote healing. The policy also included the following: -verify that there is a physician's order for the procedure -review the resident's care plan to assess for any special needs of the resident -the following should be recorded in the resident's medical record: --type of wound care given --date and time the wound care was given --any changes in the resident's condition --all assessment data (for example: wound bed color, size, drainage .) obtained when inspecting the wound --any problems or complaints made by the resident related to the procedure --if the resident refused the treatment and the reason(s) why, if resident refused wound care- notify the supervisor --the signature and title of the person recording the data Review of the facility policy titled Charting and Documentation, dated 2017, indicated all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record. The policy also included that all observations, medications administered, services performed etc. must be documented in the resident's clinical record. Findings include: 1. For Resident #216, the facility failed to A.) provide physician ordered treatment and services for pressure areas resulting in the areas worsening, B.) failed to ensure weekly ordered skin assessments were completed as ordered by the physician, and C.) that a pressure reducing mattress was set at the appropriate setting to promote healing. Resident #216 was admitted to the facility in September 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital records, undated, indicated Resident #216 had the following areas requiring treatments prior to discharge: -Stage 2 Pressure Area (skin breaks open/wears away and forms a ulcer, which extends to the deeper layers of the skin) area on the coccyx (small triangular bone at the base of the spinal column)/buttock -Stage 2 Pressure Area on the right ankle Review of the 9/2021 Physician's Orders, included the following: -right ankle Stage 2, cleanse with normal saline, pat dry, apply barrier cream to the affected area followed by a small gauze and foam dressing daily (initiated 9/16/21) -coccyx/buttocks Stage 2, cleanse with normal saline, pat dry, apply barrier cream to affected area followed by a small gauze and foam dressing every shift for wound care (initiated 9/16/21) -weekly skin checks, complete weekly skin check documentation on the facility evaluation form located in the electronic medical record (initiated 9/16/21) Review of the Skin assessment dated [DATE] did not indicate the pressure areas on the Resident's right ankle or coccyx/buttocks. Review of the Weekly Skin Check, dated 9/28/21, included the following: -Pressure Area on the coccyx measuring 4.0 centimeters (cm) in length, 2.0 cm width and less then 0.1 cm depth with a congested wound bed Further review of the Skin Check did not indicate any area of concern involving the Resident's right ankle. Further review of the clinical record did not indicate documented evidence that the weekly skin assessments were completed, as ordered by the Physician after 9/28/21. Review of the 9/2021 Treatment Administration Record (TAR) did not indicate documented evidence that treatments were administered as ordered on the following days/shifts to the Resident's coccyx/buttocks Stage 2 wound: -9/16/21 night (11:00 P.M. to 7:00 A.M.) shift -9/17/21 evening (3:00 P.M. to 11:00 P.M.) shift -9/19/21 evening shift -9/20/21 day (7:00 A.M. to 3:00 P.M.) shift Further review of the 9/2021 TAR did not indicate evidence that treatment was administered to the Resident's right ankle Stage 2 wound, as ordered on the 9/20/21 day shift. Review of a Nurse Practitioner (NP) Progress Note, dated 9/20/21, indicated Resident #216 had Stage 2 areas to his/her coccyx/buttocks and right ankle which were treated with Triad (cream that absorbs moderate levels of wound drainage while maintaining a moist wound healing environment) to the wound bed and were to be covered with small gauze and a foam dressing, which were to be changed and monitored for infection daily. Review of the clinical record indicated Resident #216 was transferred to the hospital on 9/21/21 from an Orthopedic appointment and returned to the facility on [DATE]. The hospital notes indicated the Resident had a pressure ulcer, Stage 2/3 on his/her coccyx/buttocks and a Stage 2 pressure ulcer on his/her right ankle, which were to be treated with Triad cream, frequent repositioning, and an air loss bed. Review of the Physician's Orders, dated 9/27/21, indicated the following treatment orders: -coccyx/buttock: cleanse with soap and warm water, pat dry. Apply barrier cream to the peri-wound followed by Silver Alginate (type of medicated cream to assist with preventing bacterial growth to treat wounds) to the wound bed. Cover with a large foam dressing every day for wound care and as needed (PRN) -Anterior (front) right ankle: cleanse with soap and warm water, pat dry. Apply barrier cream to the affected area, cover with foam dressing daily and PRN -Lateral (outside) right ankle: cleanse with soap and warm water, pat dry. Apply [MEDICATION(S)] Ag+ (type of medicated cream to treat wounds) to the wound bed and barrier cream to the peri-wound. Cover with foam dressing every shift and PRN Review of the Physician's Progress Note, dated 9/28/21, indicated the Resident was readmitted from the hospital after treatment. The Physician indicated in the note that the Resident had an area to the right ankle which was to be treated with [MEDICATION(S)] Ag+, a scab on the top of the ankle, and a Stage 2 area to his/her coccyx/buttocks and indicated the treatment to be Triad cream applied to the wound bed and the area was to be covered with gauze and a foam dressing, which were to be changed daily. Review of the Physician's orders, dated 9/28/21, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 9/2021 TAR did not indicate verification of the air mattress, nor did the TAR indicate the Triad cream treatment to the Resident's coccyx/buttocks as per the 9/28/21 Physician's note, but that the Silver Alginate treatment was applied to the Resident's coccyx/buttocks wound on 9/28/21 and 9/29/21. Further review of the TAR indicated no documented evidence that treatments were completed to the Resident's coccyx/buttocks wound nor right ankle wounds on 9/30/21, as ordered. Review of the Physician Assistant's (PA) Note, dated 9/30/21, indicated Resident #216 continued with a Stage 2 area to his/her coccyx/buttock and a Stage 2 to the ankle. The practitioner indicated Triad cream was applied to the wound beds and was covered with gauze, foam dressing, and was to be changed daily. Review of the PA Note, dated 10/4/21, indicated Resident #216 continued with a Stage 2 areas to his/her coccyx/buttocks and right ankle, and that an air mattress was requested (was previously ordered 8 days earlier) and a wound consult were ordered. The Practitioner indicated that the treatment to the wounds were changed to Hydrogel and foam dressings that they were to be changed daily. Review of the TAR did not indicate this order was implemented until 10/6/21 for the coccyx/buttock wound and was not implemented for the Resident's right ankle. Review of a Nurses' Note, dated 10/5/21 (was a late entry for 10/4/21), indicated the Resident's coccyx/buttocks was presenting as a Stage 3 (worsened from a Stage 2), and had a foul odor when the dressing was changed on 10/2/21. The physician was updated and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse indicated in the note that the practitioner confirmed that the area was now a Stage 3. Review of a PA Note, dated 10/6/21, indicated Resident #216 was seen and examined and the coccyx/buttock pressure area was worse, was now a Stage 3, and had presence of slough (yellow/white material in the wound bed consisting of dead cells) present. The Practitioner indicated the requested air mattress was not in place yet and that the wound consult was still pending. The PA indicated in the note that the treatment to the coccyx/buttocks was going to be changed to Santyl (which breaks up and removes dead skin and tissue to promote healing). The Practitioner also indicated in the note that the right ankle treatment had not been changed for four days (was ordered to be changed daily), had some slough and drainage present and the treatment was changed to Calcium Alginate (highly absorbent dressing that maintains moist environment and promotes healing and minimizes bleeding of a wound), and that nursing leadership was notified of the treatments not being completed as ordered. Review of the Physician's Orders indicated the PA's recommended treatment change dated 10/6/21 for the Resident's coccyx/buttocks did not occur until 10/8/21, and that the recommended treatment change for the Resident's right ankle was not implemented. Review of the PA Note, dated 10/8/21, indicated the Resident was evaluated and the right ankle dressing was dated 2 days prior indicating the treatment was not completed as ordered. The right ankle area had drainage and nursing was instructed to change the Resident's dressing. The Practitioner indicated that coccyx/buttock was a Stage 3 with presence of slough, that a wound consult was still pending, and that the air mattress was now in place. The PA indicated to continue with Santyl to the Resident's coccyx/buttocks and to implement [MEDICATION(S)] Ag+ to the Resident's right ankle wound bed with barrier cream to the area surrounding the wound. Review of the 10/2021 TAR indicated multiple changed treatment orders for the Resident's coccyx/buttocks pressure area: - apply silver alginate to the wound bed from 10/1/21 until 10/8/21; the record indicated no documented evidence that this treatment was administered on six of the eight days it was ordered - Hydrogel to the wound bed from 10/6/21 until 10/8/21; the record indicated no documented evidence that this treatment was administered on three of three days it was ordered - apply Santyl to the wound bed from 10/8/21 until 10/22/21; the record indicated no documented evidence that this treatment was administered on nine of the 15 days it was ordered Further review of the 10/2021 TAR indicated no documented evidence that treatments were administered as ordered as follows: -Anterior right ankle on 19 out of the 31 scheduled days -Lateral right ankle on 19 out of 30 scheduled days Review of the Wound Evaluation Note, dated 10/14/21, indicated Resident #216 was evaluated for multiple wounds and had the following: -Stage 3 pressure wound of the right lateral ankle -Stage 3 pressure wound to the coccyx -unstageable area (due to necrosis; dead tissue) of the right posterior (backside) ankle The Evaluation Note indicated that the right lateral ankle was chemically debrided, and the coccyx wound was surgically debrided to remove the presence of slough. The treatments to the areas were changed to the following: -right lateral ankle: [MEDICATION(S)] sterile gauze, daily, with a gauze island with border dressing daily -coccyx wound: calcium alginate with a foam silicone border dressing and skin prep to the surrounding skin daily -unstageable area to the right posterior ankle: apply skin prep daily Review of the Wound Evaluation Note, dated 10/21/21, indicated the Stage 3 pressure wound on the Resident's right lateral ankle and Stage 3 pressure wound to the coccyx/buttocks had dressings that were dated 10/19/21 (indicating the last time the treatment was completed was 10/19/21). The Wound Physician indicated that the coccyx wound had deteriorated (worsened), did not have the treatment administered (Calcium Alginate), the wound was larger, and the concerns were discussed with the Resident's Responsible Party and the Director of Nurses (DON). The Wound Physician did not change the previous treatment recommendations from 10/14/21 but indicated in the note that the dressings were to be changed daily, as ordered. Review of the 10/2021 TAR indicated the recommendations from the Wound Physician dated 10/14/21 were not implemented until 10/23/21, nine days later, and further review of the TAR indicated no documented evidence that the treatment was administered for the coccyx/ buttocks wound on four out of the nine scheduled days, and for the right lateral ankle wound five out of the nine scheduled days. During an interview on 10/20/21 at 10:55 A.M., DON #1 said that the care levels at the facility have declined. He said that medications and treatments had not been administered as ordered. During an interview, on 10/21/21 at 1:49 P.M., the Resident's Responsible Party said the Resident had dementia and had multiple open areas. He said Resident #216 was being seen by the Wound Physician and was told that treatments for the areas had not been completed for two days. He said Resident #216 had periods of incontinence and he/she would not receive staff assistance, when needed, to be changed for hours. He further said that if the wound dressings were soiled, they needed to be changed, but were not changed for a long time. He said that the Resident's dressings were still filthy and dirty and were supposed to be changed as needed given the amount of drainage from the areas. He said he was concerned for Resident #216 and did not want him/her to have to go back to the hospital. On 11/02/21 at 1:44 P.M., the surveyor observed Resident #216 lying in bed on an air mattress which was set at 280 lbs. Review of the Resident #216's clinical record indicated a weight obtained on 10/8/21 of 144.8 lbs. During an interview and review of Resident #216's clinical record, on 11/03/21 at 11:09 A.M., the PA said he spoke with DON #1 about the wound dressings not being completed as well as the nurse who was taking care of the Resident, and also spoke at the regular meetings with the facility staff about treatments not being completed as ordered. PA further said that he requested the air mattress and communicated with the facility staff about the need for the Resident to have one. He further said he did not determine the air mattress settings as it was usually based on the Resident's weight, but a setting of 280 lbs. was not appropriate based on Resident#216's weight. The PA said that he completed some of the treatments for Resident #216, and the dressings that were in place were the previous ones that he had applied, so he knew staff did not change the dressings, as ordered. The PA said that the Resident was followed by the Wound Physician beginning 10/14/21, that he was not receiving the Wound Physician/s recommendations, and that prior to the Wound Physician's evaluations, there was no documentation of the measurements for Resident #216's pressure wounds. During an interview, on 11/03/21 at 11:54 A.M., DON #2 said all treatments should be administered as ordered by the Physician and if there was a change or a treatment was not completed as ordered, then the Physician should be notified. DON #2 said that comprehensive wound assessments would be completed weekly, which included wound measurements, drainage present, and any status changes to the areas. DON #2 said that the weekly skin assessments were key to identifying concerns and that there needed to be a person to oversee that this was done. DON #2 further said that the nurses determined the setting of an air mattress based on the Resident's weight. She said to determine the setting, they would look at the resident's weight and set the air mattress to meet the level. She said that once the setting was determined, the order would be clarified in the record to indicate the proper air mattress setting. DON #2 further said that the Unit Secretary was responsible fo rtracking when air mattresses. During an interview on 11/4/21 at 8:11 A.M. and 10:25 A.M., the Unit Secretary said when a PA orders an air mattress, there should be an order in the resident's clincal record. She further said that Resident #216's roommate had an air mattress that was not in use, so she thought it would have been transferred onto Resident #216's bed. When the surveyor inquired about the date the air mattress was applied, the Unit Secretary said she was unsure but that she thought it was 10/8/21 or 10/9/21, and that she determined this by reviewing the PA's progress notes. 2. For Resident #12, the facility failed to ensure that wound specialist consultation reports were included in the medical record to facilitate coordination of care, skin assessments were completed as ordered, wound dressings were changed per facility protocol and the air mattress was at the appropriate setting to promote the healing of an existing pressure wound. Resident #12 was admitted to the facility in July 2021 with a pressure wound (an opening in the skin caused by pressure over a bony prominence). Review of the Minimum Data Set (MDS) Assessment, dated 7/7/21 indicated that Resident #12 scored 15 out of 15 on the Brief Interview of Mental Status (BIMS) assessment which indicated he/she was cognitively intact, was at-risk for pressure wounds and had one Stage 2 Pressure Wound (is an open wound that involves all layers of the skin but does not involve the underlying tissue) present on admission. Review of a Physician's Assistant (PA) Progress Note dated 7/15/21, indicated that the unstageable sacral (on the sacrum, the triangular bone at the base of the spine) ulcer present on admission to the facility was worsening and a wound consult was requested. Review of a Physician's Progress Note dated 7/22/21 indicated: -The resident was seen for sacral wound debridement. -Wound clinic appointment for 8/5/21 Further review of the Physician or delegate Progress Notes indicated the following: -Note dated 8/4/21indicated the Resident was seen yesterday at Wound Clinic and has follow-up appointment in 2 weeks -Note dated 8/9/21 indicated wound clinic follow-up appointment next week -Note dated 9/2/21 indicated Resident was seen at Wound Clinic yesterday and there were no new orders. -Note dated 9/10/21 indicated the Nurse Practitioner was unsure of the date of the next wound clinic follow-up appointment and would check with the unit secretary -Note dated 10/5/21 indicated it was unclear when the next wound clinic appointment was and that it would be clarified with the Unit Secretary. Review of a Nurse Practitioner's Progress Note, dated 7/23/2021, indicated the Resident was sent to Emergency Department for an acute change in condition related to wound worsening and positive blood cultures (bacteria identified in the blood indicative of systemic infection). Review of an in-hospital Wound Consultation Note, dated 7/25/21, indicated the sacral wound was grossly infected with exposed bone at the base, measured 10 centimeters (cm) x 14 cm x 2 cm, was necrotic (containing dead tissue) with surrounding [CONDITION(S)] (reddened/inflamed at the edges) and would need surgical debridement (the use of a sharp instrument to remove dead, damaged and/or infected tissue to improve healing). Review of the hospital records, dated 7/28/21, indicated Resident#12 was hospitalized for a change in his/her medical condition and while there, the wound was surgically debrided, the Resident received antibiotics for an infection in the sacral wound and was discharged back to the facility with recommendations to continue with antibiotic therapy, application of a wound vacuum to the area, and to follow-up with the wound clinic. Review of the Progress Note, dated 8/3/21, indicated the Resident went out to the wound clinic appointment via stretcher. Review of Weights and Vitals Summary in the clinical record indicated Resident #12 weighed 222.2 pounds (lbs.) on 8/24/21. Review of the clinical record indicated: -Inpatient Wound Clinic Consultation notes dated 7/26/21 and 10/25/21 -In-facility Wound Consultation Notes from the facility Wound Physician dated 10/14/21 and 10/21/21. -There was one outpatient wound clinic consultation note dated 8/31/21, but further review of the record did not indicate documented evidence of additional outpatient wound clinic consultation notes. Review of the Weekly Skin Check Assessment, dated 8/26/21, indicated Resident #12 had a Stage 4 Pressure Wound on the Sacrum. Further review of the clinical record indicated no documented evidence that the Weekly Skin Check Assessments were completed, as ordered by the Physician. Review of the Skin Integrity Care Plan, initiated 9/20/21, indicated Resident #12 had a Stage 4 Pressure Ulcer which was present on admission. The plan of care including the following interventions: - to assess and document the wound characteristics per the facility protocol, - maintain the wound vacuum, and - provide treatments as ordered by the Physician Review of the October 2021 Physician's Orders indicated the following orders: -weekly skin checks, and document in the electronic medical record, ordered 7/16/21 Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - that weekly skin checks assessments were completed on four out of the four weeks it was ordered by the Physician. Further review of the Physician's Orders and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/20/21 at 10:22 A.M., the surveyor observed Resident #12 in his/her room, in bed, lying on top of an air mattress. During an interview on 10/20/21 at 10:23 A.M., Resident #12 said he/she went to the wound clinic the other day and was scheduled to go to the Wound Clinic every two weeks but there were occasions when he/she was unable to go because the transportation set up was not appropriate for him/her. The Resident said the Wound Physician came to the facility last Friday and showed the nurse how to change the dressing to the wound. The Resident said he/she was concerned about whether the facility had enough staff who were trained in wound care because of experiences he/she has had relative to a nurse leaving his/her room without providing wound care. The Resident further said that he/she had concerns about the staffing levels on the weekends as there may only be one nurse on duty which he/she felt affected the wound care. On 10/21/21 at 10:12 A.M., the surveyor observed Resident #12 lying in bed on an air mattress on the right side positioned off his/her back. On 11/01/21 at 3:44 P.M., the surveyor observed Resident #12 resting in bed on an air mattress which was set at 280 lbs. On 11/03/21 at 10:19 A.M., the surveyor observed the Resident lying in bed on an air mattress set at 280 lbs. Resident #12 said occasionally his/her back was sore from staying in the same position. On 11/03/21 at 10:23 A.M., during an observation of the Resident's sacral wound care and interview with the in-facility Wound Physician, the Wound Physician said Resident #12's old dressing had large amounts of drainage and contained a foul odor. She further said the old dressing was not signed, dated, and initialed indicating the last time it had been changed, as required. During an interview on 10/27/21 at 6:19 P.M., Director of Nursing (DON) #2 said the most recent Weekly Skin Check Assessment for Resident #12 was dated 8/26/21. DON #2 further said the Weekly Skin Check Assessments were not completed as ordered by the Physician. During an interview on 11/01/21 at 9:48 A.M., DON #2 said that the Resident's air mattress should be set according to the his/her weight, and that the setting of the air mattress should be documented within the clinical record. 3. For Resident #64, the facility failed to ensure recommendations and treatment orders relative to wound care and services were implemented timely and failed to ensure the air mattress was at the appropriate setting to promote wound healing. Resident #64 was admitted to the facility in May 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record indicated Resident #64 weighed 165.0 pounds (lbs.) on 5/16/21. Review of the Physician's Orders, dated 5/18/21, indicated to conduct Weekly Skin Check Assessments. Review of a Physician or delegate Progress Note, dated 5/17/21, indicated the Resident had multiple non-healing wounds to his/her sacrum (large triangular bone at the base of the spine), bilateral hips and ischium (the lower and back part of the hip). The Provider indicated that daily dressings changes would be implemented, the wound clinic would be consulted, nutritional supplementation would be added, and an air mattress was ordered. Review of a Physician or delegate Progress Note, dated 5/18/21, indicated the following wound measurements were obtained: -Stage Three Right buttock (hip) Pressure Wound: 2.6 centimeters (cm) in length (L) x 2.6 cm in width (W) x 3.4 cm depth (D), -Sacrum Pressure Wound: 10.4 cm x 6.7 cm x 1.8 cm, -Left hip Pressure Wound: 4.3 cm x 3.2 cm x 1.2 cm Review of the MDS Assessment, dated 5/23/21, indicated the Resident scored 15 out of 15 in the BIMS assessment which indicated he/she was cognitively intact, required extensive assistance with bed mobility, dressing, toileting, personal hygiene, had range of motion impairment of the lower extremities on both sides, was at risk for pressure wound, had one Stage 3 (a wound that involves all layers of the skin and extend into the underlying tissue) Pressure Wound, and two Stage 4 (wounds that involve all layers of skin, and tissue and can extend as far as the bone in the most serious cases) Pressure Wound that were present on admission. Review of the Physician or delegate Progress Note, dated 6/8/21, indicated Resident #64 had an appointment at the Wound Clinic but the wounds could not assessed due to poor positioning as the Resident was transported to the clinic in a wheelchair (not a stretcher). Review of a Physician or delegate Progress Note, dated 7/20/21, indicated the following wound measurements were obtained: -Right hip Pressure Wound: 1.5 cm x 1.0 cm x 1.0 cm, - Sacrum Pressure Wound: 7.0 cm x 7.0 cm x 6.0 cm, had pronounced tunneling (indicating that the wound had progressed and formed passageways underneath the surface of the skin) and was deeper than the 5/18/21 measurement -Left hip Pressure Wound: 4.0 cm x 7.0 cm x 2.0 cm., had large amounts of purulent (containing pus) drainage and had an odor present, the area was longer in length and deeper than the 5/18/21 measurement Review of the Physician or delegate Progress Note, dated 7/27/21, indicated the Resident's wounds continued to deteriorate, had increased drainage and an odor. Review of the Physician's Orders, initiated 8/3/21, indicated to apply an air mattress to the Resident's bed set at 165 lbs. (Resident's weight as of 5/16/21)., and for nursing staff to check the setting and function of the air mattress every shift. Review of the Skin Care Plan, initiated 9/1/21, indicated Resident #64 was admitted to the facility with wounds located on his/her sacrum (the large triangular bone at the base of the spine), right hip and left hip. The Care Plan also included the following: - the Resident was at risk for skin breakdown - an air mattress should be set at 165 pounds (lbs.) - the Resident's skin should be kept clean and dry - conduct weekly skin checks per facility Review of the Nurse Practitioner (NP) Progress Note, dated 9/1/21 indicated the Resident's wounds were visualized and the sacral wound had tunneling and green odorous purulent (pus-like) drainage. The right hip wound had some blood-tinged drainage and undermining (erosion underneath the skin surface) at the wound edges. The left hip wound had continued undermining with large amounts of purulent drainage. In addition, there was a new open area identified on the side of the existing left hip wound. The NP indicated that the wounds appeared to be worse and that there was a concern that the Resident was developing an abscess (a swollen area in the body containing pus), and the wound clinic would be consulted. Review of a Nurse's Note, dated 9/2/21, indicated the Resident's pressure wounds were declining, his/her lab work (white blood cells) were elevated (indicating possible infection) and the Resident was transferred to the emergency room (ER) for evaluation. Review of the Physician or delegate Progress Note, dated 9/14/21, indicated Resident #64 was readmitted from the hospital after being transferred to the ER for evaluation on 9/2/21 for worsening pressure wounds. The Resident was diagnosed with [CONDITION(S)] (infection of the bone) and was started on two intravenous (IV) antibiotics while hospitalized . Upon return the facility (on 9/13/21) the Resident was prescribed one IV antibiotic for a six-weeks course. Review of the Physician's Orders indicated the following initiated on 9/27/21: -Stage 4 Pressure Wound on the sacrum: wash with normal saline (a salt water solution similar to body fluid), pat dry, apply [MEDICATION(S)] Ag (a wound dressing that contains fibers that absorb wound drainage and decrease infection to assist in healing) to the wound bed, and apply barrier cream (skin protectant) to the area surrounding the wound (peri-wound) and cover with dry sterile dressing (DSD) -Left hip Pressure Wound: wash wounds with NS, pat dry, apply [MEDICATION(S)] to the wound bed, apply barrier cream to the peri wound, and cover with DSD daily on day shift Further review of the 10/2021 Physician's Orders did not indicate treatment orders for the pressure wounds on the Resident's right trochanter (the top portion of the bone in the upper leg where the leg and the hip connect) and right ischium (the lower and back part of the hip). Review of a Nurse Practitioner (NP) Progress Note, dated 10/1/21, indicated the Resident had a wound clinic appointment and recommended to apply a wound vacuum (a machine that when applied to a pressure wound provides negative pressure to promote wound healing) to the Resident's pressure wound. The note indicated the Practitioner requested to review the wound clinic documentation/recommendations as the wound clinic consultation note was not present in the clinical record. Review of a NP Progress Note, dated 10/6/21, indicated she contacted the wound clinic relative to the Resident's appointment on 10/1/21 because the information requested 10/1/21 had still not been obtained by the facility. The NP indicated she spoke with the Wound Nurse at the Wound Clinic who verified that a wound vacuum was recommended on 10/1/21 to the Resident's left trochanter and recommended to continue ordered treatments to the Resident's sacrum. The NP indicated in the note that she had ordered lab work twice on specific dates in addition to scheduled weekly lab work but none of the orders had been implemented by the facility. The NP ordered the previously requested lab work again on 10/6/21. Review of a Physician/delegate Progress Note, dated 10/12/21, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, interviews, and record reviews the facility failed to ensure behavioral health care and services were provided to attain or maintain the highest practicable mental and psychosocial well-being for five sampled Residents (#15, #16, #97, #62 and #86), out of a total sample of 43 residents. Findings include: 1. For Resident #16 the facility failed to obtain a psychiatric consult as ordered by the Physician/Practitioner. Resident #16 was admitted to the facility in June 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician's Assistant (PA) Progress Note, dated 7/1/21, indicated Resident #16 had a recent hospitalization for mental status changes, infection was ruled out, and Psychiatric services was consulted to assess his/her psychoactive medications (medication that affects mood and behavior). The PA indicated in the note that the changes in the Resident's mental status were likely related to worsening [CONDITION(S)], and the PA requested a psychiatric consult. Review of the 7/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (antidepressant used to treat [CONDITION(S)]) 15 milligrams (mg) at bedtime, initiated 7/1/21 -[MEDICATION(S)] (antipsychotic medication) 50 mg three times daily, initiated 7/1/21 -[MEDICATION(S)] 25 mg as needed (PRN) every 6 hours for increased agitation, initiated 7/1/21 Review of the Nurses' Notes, from 7/1/21 through 7/31/21, indicated Resident #16 received PRN doses of [MEDICATION(S)] for confusion, attempting to self-transfer, restlessness, weeping, anxiety, calling out, crying, screaming, being inconsolable and having increased agitation. Review of the 7/2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses' Notes, from 8/1/21 through 8/31/21, indicated the Resident received PRN doses of [MEDICATION(S)] for anxiety, agitation, calling/screaming/yelling out, unassisted transferring, tearfulness and being disruptive. Review of the 8/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses' Notes, from 9/1/21 through 9/30/21, indicated Resident #16 received PRN doses of [MEDICATION(S)] on 16 out of 30 days for increased agitation, crying out and being very upset. Review of the 9/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses' Notes, from 10/1/21 through 10/25/21, indicated the Resident received PRN doses of [MEDICATION(S)] for increased agitation, screaming and anxiety. Review of the 10/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Social Service Note, dated 10/8/21, indicated a referral was sent to the consultant Psychiatric services for review due to the Resident's increased behaviors. Review of the Resident's Care Plan, initiated 10/8/21, indicated Resident #16 had the potential to be disruptive to others by yelling out due to his/her Dementia. The plan included the following intervention: -please avoid over-stimulated areas, loud noises, crowds and other verbally aggressive residents may trigger my behaviors. Remove Resident to a quiet place with a calming activity -provide Psychiatric services as needed Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/21/21 from 9:19 A.M. to 9:24 A.M., the surveyor observed Resident #16 self-propelling in the wheelchair in the hallway near the nursing station. The Resident was weeping, had a furrowed brow, and stated to the surveyor that he/she was shaky and needed to use the bathroom. The surveyor alerted Nurse #7 who was caring for Resident #16 on that day, and the Resident was assisted to the bathroom by a Certified Nurse Aide (CNA). After being toileted, the Resident was observed in the hallway, weeping, and visibly upset, while propelling him/herself up/down hallway. During an interview with Nurse #7, she said Resident #16 was always like that and was confused. Nurse #7 said Resident #16 experienced paranoia and hallucinations and needed to have his/her medications reviewed. She further said that there was a request to have the Resident seen by Psychiatric services over a month ago, but it had not occurred. During an interview on 10/21/21 at 12:51 P.M., the Psychiatric Nurse Practitioner (NP) said that Resident #16 was not evaluated until this date. She said there was a facility breakdown in communication relative to Psychiatric services, and that she had concerns about the communication numerous times since consulting with the facility. The Psychiatric NP said that any resident who had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She further said that she had explained this process to facility administration numerous times previously, and that the process for referrals was reviewed with the facility staff in morning meetings. The Psychiatric NP said there was inconsistent staff and management in the facility which made this process difficult. She further said that was an issue with the Psychiatric evaluation notes and recommendations being reviewed by the Physicians/Practitioners because the evaluations/recommendations were not immediately given to the Physicians to review. Relative to Resident #16, the Psychiatric NP said she was very concerned about him/her and that she though the Resident was in a [CONDITION(S)] (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings) and needed to have some medication adjustments. She further said that she attempted to evaluate Resident #16 the week prior but was unable to because the required consent for Psychiatric services was not obtained by the facility, as required. Review of the Psychiatric Evaluation, dated 10/21/21, indicated Resident #16 was evaluated due to cognitive decline, crying, paranoid and delusional behaviors. The NP indicated in the note that the behaviors exhibited by Resident #16 were severe and he/she presented with [CONDITION(S)] (abnormal condition of the mind that resulted in difficulties determining what is real and what is not real); that nursing staff reported the Resident had daily delusional thoughts and paranoia, felt people were trying to kill him/her, and was often inconsolable and difficult to redirect away from those thoughts. The NP indicated that she was concerned about [CONDITION(S)] which may have been induced by the high [MEDICATION(S)] doses that he/she was receiving, including the scheduled dose of [MEDICATION(S)] (150 mg daily) and the additional PRN [MEDICATION(S)] (25 mg) which he/she was receiving often. The recommendation by the NP was to taper off the [MEDICATION(S)] and discontinue the PRN [MEDICATION(S)], obtain lab work and urine results, and to reassess the Resident the following week. On 10/22/21 from 8:05 A.M. through 9:57 A.M., the surveyor observed Resident #16 seated in a wheelchair and was self-propelling up/down the hallway and in/out of rooms. The Resident at was yelling loudly, asking for shoes. Occasional bouts of weepiness were observed. During an interview on 10/26/21 at 11:22 A.M., CNA #6 said Resident #16 had behaviors which made it difficult to take care of other residents. She said that Resident #16 needed one to one (1:1) assistance from staff relative to his/her behaviors because no other interventions worked. CNA #6 said that when the Resident had behaviors, she would let the nurse know so that he/she could get medication. On 10/26/21 at 12:17 P.M., the surveyor observed Resident #16 seated in a wheelchair in the hallway, weeping and calling out for family. On 10/28/21 from 1:40 P.M. through 1:45 P.M., the surveyor observed Resident #16 seated in a wheelchair and wandering around the hallway on the unit and into other resident rooms. The Resident was weeping, looked distressed as evidenced by his/her furrowed brow, and was observed to go in/out of resident rooms and the unit bathroom. Review of a Psychiatric Evaluation, dated 10/28/21, indicated Resident #16 continued with behaviors including crying, agitation, and was paranoid and could not be consoled at times. The Practitioner recommended in the note to start [MEDICATION(S)] (a medication used to stabilize mood/behavior) 125 mg at 2:00 P.M., and to notify the Psychiatric team with any changes in mood/behavior. During an interview on 11/03/21 at 11:07 A.M., the PA said that he first assessed Resident #16 on 7/1/21, that he spoke with the nurses about the Resident, and that he gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/04/21 at 11:20 A.M., the PA said that he was not made aware of the Psychiatric NP recommendations from 10/21/21 nor 10/28/21 for Resident #16 until this date. He further said that this information was supposed to be put in the Physician/Practitioners communication book so that they could review the recommendations and address them. The PA said that there was practitioner coverage in the facility six days a week, so there was no reason why these recommendations should not have been provided to the Physician/Practitioner to be reviewed and addressed prior to this date. On 11/04/21 at 1:12 P.M., the surveyor observed Resident #16 seated in a wheelchair in the hallway, weeping. During an interview on 11/04/21 at 1:30 P.M., Nurse #7 said that the Psychiatric NP recommendations made on 10/21/21 and 10/28/21 were not provided to the Physician/Practitioner, as required, until this date. 2. For Resident #97 the facility failed to ensure behavioral health services were obtained timely. Resident #97 was admitted to the facility in December 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Psychiatric Evaluation, dated 8/5/21, indicated Resident #97 was assessed and had some episodes of refusal of care. The practitioner indicated in the note that Psychiatric services would reassess the Resident in 30 days. Review of the clinical record indicated no documented evidence that Resident #97 had been seen by Psychiatric services since 8/5/21. On 10/19/21 at 11:05 A.M., the surveyor observed the Resident lying in bed. He/she looked disheveled, had thick hair on his/her face and chin, and a strong body odor was detected around him/her. He/she spoke but was difficult to understand. The Resident's tone of voice was sharp and aggressive when he/she spoke of his/her roommate. During an interview on 11/03/21 at 5:37 P.M., the Social Worker said that Resident #97 had not been evaluated by Psychiatric services since 8/5/21. She said that when the transition occurred from the previous Psychiatric service to the new one, the facility did not complete an updated consent for Resident #97, as required, therefore he/she had not been seen. 3. For Resident #15 the facility failed to provide the necessary behavioral health care and services. Resident #15 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment, dated 7/1/21 indicated a Brief Interview for Mental Status (BIMS) score of 14/15 indicating Resident #15 was cognitively intact. Review of a Psychiatric Evaluation, dated 9/21/21, indicated the following: -Resident #15 was being seen for depression -Resident had a flat affect and stated he/she continued to feel depressed -A referral was previously made however Resident #15 stated he/she had not met with a psychotherapist -Resident continued to have nightmares -Resident was currently prescribed an antidepressant with no apparent effect -Refer to psychotherapy for depressed mood -Follow up in 14 days -Start [MEDICATION(S)] 15 milligrams (mg) every night for depressed mood; monitor for effect and tolerance Review of the Resident's clinical record indicated no documented evidence that he/she was seen for psychotherapy after the 9/21/21 Psychiatric Evaluation, or that the recommendations for [MEDICATION(S)] were addressed. During an interview on 11/01/21 at 11:37 A.M., Social Worker (SW) #1 said that the current process to communicate a resident's need for a psych referral did not work because there was no communication between the provider and the facility when and if a referral had been made or followed through with. Additionally, she said that when a recommendation was made, it would go to medical records. She said that no one was aware that any recommendations had been made during the 9/21/21 encounter with behavioral health and should have been addressed by the facility but were not. 4. For Resident #86, the facility failed to obtain a psychiatric consult as ordered by the Physician/Practitioner. Resident #86 was admitted to the facility in August 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the clinical record indicated a Physician Assistant (PA) Progress Note, dated 8/20/21, Nurse Practitioner (NP) Progress Notes, dated 9/7/21, 9/13/21, 9/15/21 9/17/21, and 10/5/21, and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician Order, dated 9/17/21, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/18/21 at 12:35 P.M., the surveyor observed Resident #86, seated in the hallway, across from the nurse's station, and repeatedly called out, help me, where do I go? loudly while pulling him/herself forward in the wheelchair. On 10/19/21 at 1:49 P.M., the surveyor observed Resident #86 in the unit dining area, calling for help. On 10/20/21, from 2:06 through 2:20 P.M., the surveyor observed Resident #86, seated in the hallway across from the nurse's station. Resident #86 groaned loudly, pulled him/herself forward in the wheelchair frequently, and screamed repetitively. On 10/26/21, between 8:00 A.M. and 8:05 A.M., the surveyor observed Resident #86 seated in the hallway, screaming repetitively for help, and said he/she was afraid and felt like he/she was falling off a cliff. Review of the Resident's clinical record indicated no documented evidence that a psychiatric consultation was obtained fo Rersident #86, as ordered by the Physician. During an interview on 10/26/21 at 9:30 A.M., Nurse #9 said that she was not aware whether psychiatric services were involved in the Resident's care. During an interview on 10/26/21 at 12:21 P.M., Director of Nursing (DON) #2 said that the Resident should have been seen by Psychiatric Services, as ordered by the Physician on 9/17/21, but he/she was not. During an interview on 10/26/21 at 1:00 P.M. the NP said that the facility should have obtained a psychiatric consultation for Resident #86, as ordered, but they did not. Please refer to F744 5. For Resident #62, the facility failed to obtain psychiatric services as ordered by the Physician/Practitioner. Resident #62 was admitted to the facility in August 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident's active Psychiatric Care Plans included the following: - Please refer me for a psychiatric consult to target recent hallucinations and delusions (initiated 9/8/21 and revised 9/15/21) Review of the a Physician Order, dated 9/17/21 indicated the following: - Obtain psychiatric consult, initiated 9/17/21 Review of a Nurse Progress Note, dated 9/17/21 included that the Resident had experienced an increase in [CONDITION(S)] and hallucinations, was reaching for items that did not exist, and that a Psychiatric consult was on order. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record indicated no documented evidence that a psychiatric consult was obtained for Resident #62 as ordered by the Physician/Practitioner. During an interview on 11/03/21 10:45 A.M., the Physician Assistant (PA) said he was not aware that Resident #62 was not being followed by psychiatric services as ordered.

Based on observations, interviews, and record reviews, the facility failed to ensure that seven sampled Residents ( #15, #33, #35, #58, #72, #216, and #268), out of 43 total sampled residents, received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, relative to non-pressure related skin conditions and medication administration. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing practice, revised April 2018, included the following: - Licensed nurses accept, verify, transcribe, and implement orders received by various methods, including verbal and written orders, in emergent and non-emergent situations. Review of the facility policy titled Verbal Orders, dated 2017, included the following: - Verbal orders shall only be given in an emergency. - Verbal orders will always be based on verbal exchange with the prescribing practitioner or on approved written protocols. - Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. Review of the facility policy titled Change in a Resident's Condition or Status and Notification, dated 2017, included that the nurse supervisor/charge nurse was required to record information relative to changes in the resident's medical condition or status in the resident's medical record. 1. For Resident #33, the facility failed to provide treatment and care in accordance with professional standards of practice relative to a.) following a verbal physician order, b.) adhering to the person-centered comprehensive care plan, and c.) comprehensively assessing a non-pressure related change in skin condition. Resident #33 was admitted to the facility in May 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/18/21 at 10:00 A.M., the surveyor observed Resident #33 seated in his/her room, in a wheelchair at the bedside. Both of the Resident's lower legs were visible from mid-calf to the ankles; the left foot and ankle were wrapped and the Resident wore a slipper sock over his/her toes, to the mid-foot. The right leg had a loosely fitting stockinette (non-sterile cotton bandage wrap used on legs for gentle pressure) that was bunched up and rested around the ankle. Review of a Physician Order, dated 5/12/21, indicated that Resident #33 required weekly skin checks and included instructions to complete a weekly skin evaluation in the electronic medical record (EMR). Review of the Resident's Skin Integrity Care Plan, dated 7/6/21, indicated that the Resident was at risk for skin impairment related to fragile skin, history of skin impairment concerns, and PVD. The goal indicated was to maintain or develop clean and intact skin, and interventions included weekly skin checks. Review of the clinical record indicated no documented evidence that weekly skin evaluations were completed on 8/3/21, 8/24/21, 8/31/21, or between 9/26/21 and 10/18/21, as ordered by the physician. Review of the Podiatry Consult, dated 9/3/21, included that Resident #33's dorsal pedis (top of the foot) pulse was 1/4 bilaterally, that his/her posterior tibial (behind the inner ankle bone) pulse was absent bilaterally (indicating reduced blood flow), and that the Resident had a non-pressure related ulcer to his/her left mid-foot with malodor (foul smell), [CONDITION(S)] (swelling), and [CONDITION(S)] (reddening of the skin), that measured 30 millimeters (mm) by 20 mm by 0 mm. No drainage was indicated. Further review of the consult included that the Resident's left foot ulcer had signs of infection and that wound attention and intravenous (IV; method of medication administration directly into a vein) antibiotics would be required. Review of the Physician Assistant (PA) Progress Note, dated 9/3/21, included that the Resident was seen by the PA due to a newly identified left foot ulceration with necrotic (dead) tissue, a surrounding yellow tint, [CONDITION(S)], warmth when touched, pain with mild exam, and high suspicion for deep tissue infection. Review of the note also indicated a concern for [CONDITION(S)] (bone infection) with likely need for an infectious disease consultation, a vascular consultation due to PVD, surgical debridement (removal of dead or infected tissue), IV antibiotics, and that the PA gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident's clinical record indicated no documented evidence that the Resident had been transferred to the ED, as ordered, on 9/3/21. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound was described as a large vascular wound on the left foot that extended from the forefoot (top of the foot including the toes), down through and behind the ankle, with an area of very dysvascular (lack of blood flow) dark eschar (dead skin) that was warm and tender to touch, with significant serosanguineous (body fluid with blood) drainage. The area surrounding the wound bed was described as macerated (lighter in color, wrinkly, and occurs when skin is in contact with moisture for too long, often associated with improper wound care). Further review of the note indicated that the Physician became aware on that date that the Resident had not been transferred to the ED, as ordered, on 9/3/21, that the Physician provided another order for the Resident to be transferred urgently to the ED on 9/9/21, and that the Resident was at very high risk for amputation (removal of a limb). Review of the hospital Emergency Medicine Note, dated 9/9/21, indicated that the Resident had left lower extremity purulent (discharge of pus) [CONDITION(S)] (bacterial skin infection involving the inner layers of the skin), a left foot ulcer, and required admission to the hospital. Review of the hospital Admission Note, dated 9/9/21, included that the Resident had a left foot wound that extended toward his/her ankle with serosanguineous drainage, and that poor foot hygiene with breaks in skin between the toes were identified bilaterally. The Resident was diagnosed with purulent cellultis, was placed on IV antibiotics, and a wound care consultation was recommended. Review of a Minimum Data Set (MDS) Assessment, dated 9/9/21, indicated that Resident #33 exhibited no behaviors related to rejection of care and that he/she required total dependence on staff at the facility for bathing and hygiene. Review of the hospital Wound Care Consultation Note, dated 9/10/21, indicated that the Resident was placed on IV [MEDICATION(S)] (antibiotic) 1000 mg relative to purulent [CONDITION(S)] and that the wound required debridement (mechanical or chemical removal of dead, damaged, or infected tissue). Review of the Nurse Practitioner (NP) Progress Note, dated 9/15/21, indicated that the Resident was seen for a follow-up visit at the facility since his/her return from the hospital, and that the Resident was to follow up with the hospital Vascular Services. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PA Progress Note, dated 10/5/21, indicated that the Resident was seen for a 30-day follow-up visit for his/her left foot wound, that the Resident was to follow-up with the hospital Vascular Services, and that a wound consultation was requested. Review of the clinical record included no documented evidence that the Resident had followed up with the hospital Vascular Services, as required. During interviews on 10/27/21 at 12:18 P.M. and 10/28/21 at 11:18 A.M., the PA said that he assessed Resident #33 on 9/3/21, relative to a wound of unknown etiology (origin) to his/her left foot, after it was identified by the Consultant Podiatrist. The PA said that when he assessed the wound, he was concerned that it may have been infected, and he gave a verbal order to the nurse on the unit for an emergent transfer to the ED. During an interview on 10/28/21 at 12:06 P.M., Nurse #9 said that she was not aware that a follow-up visit was recommended with Vascular Services for Resident #33 after he/she was discharged from the hospital, and that she was not aware that the PA had requested a wound consult for the Resident on 10/5/21. Nurse #5 said that if an appointment needed to be scheduled, the nurse was responsible to alert the Secretary, and the Secretary would make the appointment. During an interview on 10/28/21 at 1:00 P.M., the Secretary said that she scheduled appointments for residents throughout the facility. She said that if an appointment needed to be scheduled, a nurse would place a request in the schedule book on the unit, and the Secretary would call to make the appointment. The Secretary said that she was never instructed to schedule a follow-up appointment with Vascular Services or to schedule a wound consultation for Resident #33 after he/she returned from the hospital on 9/15/21, but that if she had known it needed to be done, she would have scheduled it. During an interview on 11/1/21 at 10:54 A.M., Director of Nursing (DON) #2 reviewed Resident #33's clinical record with the surveyor and said that the Resident should have been transferred to the ED on 9/3/21, when the PA gave the verbal order for the transfer, but he/she was not. She also said that there was no evidence that a follow-up appointment had been scheduled with the hospital's Vascular Services for the Resident when he/she returned from the hospital on 9/15/21, but it should have been done. During an interview on 11/2/21 at 12:49 P.M., the Physician said that she was asked to evaluate Resident #33 on 9/9/21 because the Resident's left foot wound that was identified on 9/3/21 had worsened. The Physician said that she was concerned with the Resident's wound, that it had deteriorated significantly since 9/3/21, and described it as full thickness (damage that extends below all layers of the skin), incredibly macerated, with significant serosanguineous drainage and [CONDITION(S)], and said that the Resident presented with pain. The Physician said that, in comparison to the Resident's presentation on 9/3/21, the wound was larger, deeper, and had more drainage and [CONDITION(S)]. She said that when she evaluated the Resident on 9/9/21, she was under the impression that the Resident had gone to the ED on 9/3/21, as ordered by the PA under her direction, but that when she reviewed the Resident's record, she identified that the Resident had not been sent to the ED, as ordered. She said that she was concerned that the wound was infected, that the Resident was at high risk for amputation, and that she instructed the facility to send the Resident emergently to the ED. 2. For Resident #58, the facility failed to provide treatment and care in accordance with professional standards of practice relative to a.) skin care related to diabetes and [CONDITION(S)] (when blood pools in the veins, affecting blood return from the lower extremities), b.) weekly weights, as ordered, and c.) addressing hospice care with the Resident/Resident Representative, as indicated by the Physician. Review of the facility policy titled Nursing Care of the Resident with Diabetes Mellitus, dated 2017, included the following: - That complications associated with diabetes included, but was not limited to, skin problems and foot complications, such as dry skin and ulcers. - Skin assessment, including color, moisture, temperature, redness, ulcers, irritation, or abrasions was to be documented. - Assessment of the feet included hygiene, temperature, color, circulation, and any abrasions, sores, or injuries. Review of the American Academy of Dermatology Association's web page titled Dermatologist - Recommended Skin Care for People with Diabetes, dated 2021, included the following: - Well-moisturized skin can help to avoid skin complications due to diabetes. - Moisturize every day to keep skin flexible and prevent cracks that can lead to infection. - Use a cream or ointment rather than a lotion. - Apply cream after bathing. - Check your feet daily, including between toes and on the bottoms of feet for skin wearing away, sores, . Resident #58 was admitted to the facility in November 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/18/21 at 2:19 P.M., the surveyor observed Resident #58 seated in a wheelchair in his/her room. Both of the Resident's legs were visible from his/her knees to ankles, and looked dry and flaky. There was a Band-Aid on the Resident's left shin. On 10/20/21 at 8:54 A.M., the surveyor observed Resident #58 positioned in bed on an air mattress. The Resident appeared very thin, and the air mattress was set at 120 pounds, normal pressure. Review of a Physician Order, dated 5/12/21, indicated that Resident #58 required weekly skin checks and that a weekly skin evaluation was to be completed in the electronic medical record. Review of the PA Progress Note, dated 7/14/21, indicated that Resident #58 had an overall decline in health with weight loss, and that he recommended the facility discuss hospice services with the Resident/Resident Representative. Review of the Resident's Skin Integrity Care Plan, dated 7/19/21, indicated that Resident #58 was at risk for impaired skin integrity due to fragile skin, decreased mobility, diabetes, and PVD, and that the goal was for the Resident's skin to remain clean and intact. Further review indicated that the air mattress was to be set to static at five bars, to be checked for its function and settings every shift, and that weekly skin checks were to be completed. Review of the Resident's Diabetes Care Plan, dated 7/19/21, indicated no intervention related to diabetic skin care. Review of a Physician Order, dated 8/3/21, indicated to encourage and assist Resident #58 to reposition minimally every two hours, as tolerated, to assist with skin protection. Review of a Physician Order, dated 8/4/21, indicated that Resident #58's air mattress was to be set to static, and that the setting and function was to be checked every shift and documented in the clinical record. Review of the Podiatry Note, dated 9/3/21, included that Resident #58's dorsal pedal pulse and posterior tibial pulse were absent bilaterally, that the Resident was diabetic, and that he/she had a circulation disorder and a history of hyperkeratotic [CONDITION(S)] (bumps or patches of thickened skin). Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician Order, dated 9/29/21, indicated that the Resident was to be weighed weekly. Review of the October 2021 Treatment Administration Record (TAR) included no documented evidence that: -the air mattress settings and functions were checked every shift, as ordered, for 11 out of 60 shifts reviewed, -the Resident was encouraged or assisted to reposition every two hours, as tolerated, as ordered, for nine out of 60 shifts reviewed, -the Weekly Skin Check Assessments were completed on 10/1/21, 10/8/21, or 10/15/21, and -the Resident had been weighed weekly after 9/29/21, as ordered by the Physician. Review of the Resident's clinical record on 10/20/21 indicated no documented evidence that hospice care was discussed with the Resident/Resident Representative, as recommended by the PA on 7/14/21 and by the Physician on 9/14/21. On 10/20/21 at 11:02 A.M., the surveyor observed Nurse #5 assess the Resident's legs and feet while the Resident was in bed. She said that the skin on the Resident's legs was dry, that both legs had multiple round, yellow, flaky, raised areas, and that both legs were discolored and cold to the touch. The balls of the Resident's feet were pressed against the foot board of the bed, and Nurse #5 said that he/she needed to be repositioned to take pressure off of his/her feet from the foot board. There was a Band-Aid on the Resident's left shin that was dated 10/17/21, and when Nurse #5 attempted to remove it, one of the flaky areas began to lift from the Resident's leg. Nurse #5 said that the Band-Aid should not have been left on the Resident's skin that long, that it was stuck, and that it would need to be saturated in order to be removed without lifting the Resident's skin. The surveyor then observed Nurse #5 inspect the Resident's heels; Nurse #5 said that both heels were boggy (abnormal texture of tissue characterized by sponginess). Nurse #5 said that the Certified Nurse Aides (CNAs) were required to provide basic skin care with lotion when they provided bathing care, but that it was clear that this had not been done for quite some time. She also said that skin care and repositioning were very important for Resident #58 because he/she was at risk for impaired skin. Nurse #5 also said that Resident #58 required weekly skin assessments, and that the nurse was required to record the results of the skin assessments on the Weekly Skin Check assessments in the clinical record. Nurse #5 said that she was unsure what the Resident's air mattress was supposed to be set at and that she was unsure how a setting of five bars related to the dial set on the air mattress control panel to 120 pounds, but that she would find out. During an interview on 10/20/21 at 1:35 P.M., Nurse #5 said that she checked with the Maintenance Director regarding the setting for Resident #58's air mattress and that the setting of five bars was equivalent to the number of lines on the dial. She said that the dial needed to be on the fifth line and that the air mattress was now set at 220 pounds. Nurse #5 said that although the dial indicated numbers in pounds, the setting was not determined by the Resident's weight. During an interview on 10/20/21 at 3:00 P.M., Director of Nursing (DON) #2 said that she was unable to locate the manufacturer instructions for use of Resident #58's air mattress, but that after observing the mattress, it should have been set according to the Resident's weight. She further said that the care plan intervention to set the mattress at five bars was inaccurate and was not compatible with the Resident's air mattress. DON #2 said that the Resident was weighed on 10/20/21 after the surveyor inquired about the Resident's weights, that he/she was 91 pounds, and that the mattress should have been set to 100 pounds. During an interview on 10/21/21 at 4:37 P.M., DON #2 said that she reviewed the Resident's Record and observed the Resident's air mattress. She said that the settings at 120, then 220 pounds were too high and that it should have been set to the Resident's weight, at 100 pounds. DON #2 said that resident air mattress settings were to be determined by the clinical team, and not by the maintenance department. DON #2 also said that the Resident had not been weighed weekly, as ordered, since 9/29/21, but he/she should have been, and that his/her weights should have been documented in the Resident's clinical record. DON #2 further said that the option for hospice palliative care had not been addressed with the Resident/Resident Representative, as requested by the physician, but it should have been. During an interview on 10/28/21 at 1:29 P.M., CNA #5 said that CNAs only knew which residents were diabetic if they saw the nurses check resident blood sugar levels. She said that CNAs were supposed to apply moisturizer to all residents' arms, hands, and legs, but that they did not apply moisturizer to any residents' feet, and that they did not provide any specialized skin care for residents who were diabetic or had circulatory problems. During a follow-up interview on 11/1/21 at 10:58 A.M., DON #2 said that all residents should receive basic skin care when staff provided bathing care, and that this included washing, drying, and applying lotion to extremities, including the legs and feet. She said said that it was important to pay special attention to diabetic residents' feet, especially their heels, as residents with diabetes were at very high risk for problems with healing if ulcers developed. DON #2 said that Resident #58 should have had weekly skin checks and been repositioned, as ordered, and that he/she should have had skin care provided during bathing since he/she was diabetic and at very high risk for problems with his/her skin. 3. For Resident #216, the facility failed to A.) administer care and services for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .) implement weekly skin checks, as ordered by the Physician. Resident #216 was admitted to the facility in September 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital records, undated, indicated that Resident #216 had a right hip surgical wound that required a treatment prior to discharge from the hospital. Review of the 9/2021 Physician's Orders, included the following: -Right hip- keep wound vac (a device that is connected to the wound that assists with holding the wound edges together and removes fluid from the area to promote healing and protect from infection) dressing clean, dry, and intact, every shift (initiated 9/16/21) -keep sterile gauze dry sterile dressing to the Resident's right hip incision in place, change as needed for soiling every shift (initiated 9/18/21) -weekly skin assessments (initiated 9/16/21) Review of the Skin Assessment, dated 9/18/21, indicated the following: - a surgical wound on the Resident's right hip - the surgical incision had moderate serosanguineous (thin watery, pale, red/pink) drainage, normal skin around the surgical site, and did not have any odor. Review of the clinical record indicated a Weekly Skin Assessment was completed on 9/28/21, but no evidence that ordered weekly skin assessments were completed after this date. Review of a Nurse's Note, dated 9/18/21, indicated the Resident's dressing to the right hip incision was attached, but the foam had lifted, and the wound vac indicated the canister was full. The on-call Physician was updated, and a new order was given to place gauze and a [MEDICATION(S)] (a type of transparent dressing) to the Resident's right hip incision line, to keep the area clean, dry, and intact, and to have the Resident follow up with the Orthopedic office. Review of the 9/2021 TAR indicated no documented evidence that treatments to the Resident's surgical wound were administered, as ordered, on the following days/shifts: -9/16/21 night (11:00 P.M. to 7:00 A.M.) shift -9/17/21 evening (3:00 P.M. to 11:00 P.M.) shift -9/19/21 all three shifts (day; 7:00 A.M. to 3:00 P.M., evening, and night) -9/20/21 day shift Review of a Nurse's Note, dated 9/19/21, indicated a dressing was to be in place until the Resident received an Orthopedic evaluation. Review of a Nurse Practitioner (NP) Progress Note, dated 9/20/21, indicated Resident #216 had large amounts of drainage that contained an odor from his/her right hip surgical site. The note indicated that the Resident's dressing to his/her right hip had not been changed since 9/18/21, that recent lab work indicated elevated White Blood Cells (WBCs-cells of the immune system which can be elevated in a response to infection), and indicated the Resident was to have a follow up with the Orthopedic surgeon. Review of a Nurse's Note, dated 9/21/21, indicated the Resident was out of the facility for a scheduled Orthopedic appointment. Review of the Nurses' Notes, dated 9/22/21 through 9/27/21, indicated Resident #216 was hospitalized . Review of the Hospital Notes, dated 9/26/21, indicated Resident #216 was sent to the hospital for evaluation from the Orthopedic office due to a concern of right hip instability. The note indicated the Resident's right hip had purulent drainage (white, yellow, or brown discharge, thick in texture and was a sign of infection), that the right hip hardware had to be removed, and that the Resident required a blood transfusion and antibiotics. Review of a Nurse's Note, dated 9/27/21, indicated Resident #216 was readmitted to the facility with a massive dressing to his/her right hip. Review of the Physician's Progress Note, dated 9/28/21, indicated the Resident was readmitted from the hospital after treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician indicated that the Resident's hip was externally rotated during her exam and that an X-Ray and lab work was ordered for 9/29/21. Review of the TAR, dated 9/28/21 through 9/30/21, indicated the following order: -Cleanse the right hip incision line with normal saline, pat dry and cover with [MEDICATION(S)] to the incision, followed by an ABD pad (type of dressing), cover with large [MEDICATION(S)] dressing three times daily and as needed for soiling. Review of the 9/2021 Physician's Orders, indicated a new order initiated on 9/28/21, to apply an air mattress, set to (blank) pounds (lbs), check inflation and function every shift. Review of the clinical record did not indicate an X-Ray of the Resident's right hip was obtained, as ordered by the Physician. Review of a Physician Assistant's (PA) Progress Note, dated 10/1/21, indicated the Resident continued antibiotics for a right surgical hip infection, lab work was ordered and daily treatments to the right hip were to continue. Review of the PA Progress Note, dated 10/4/21, indicated that an air mattress was requested (original order for the air mattress was 9/28/21- 8 days earlier) and lab work was scheduled to be drawn on this date due to recent infection and blood loss which required transfusion at the hospital. Review of the PA Progress Note, dated 10/6/21, indicated Resident #216 was evaluated and that his/her right hip incision had increased drainage and mild warmth to the incision site. The Practitioner indicated the Resident still did not have the air mattress applied to the bed and the blood work scheduled for 10/4/21 was not drawn, as ordered. The Resident was to have the lab work checked, was to follow up with the Orthopedic office, and continue daily wound care dressings. Review of the 10/2021 TAR did not indicate evidence that treatments were administered, as ordered, three times daily to the Resident's right hip on the following days/shifts: -10/1/21 day and night shift -10/2/21 night shift -10/3/21 evening shift -10/4/21 through 10/8/21 day shifts -10/8/21 evening shift -10/10/21- 10/15/21 day shifts -10/18/21 evening and night shift -10/19/21 day shift -10/22/21 day and evening shifts -10/24/21 day and night shifts Review of the Physician's Orders, dated 10/25/21, indicated a clarification order to the Resident's right hip treatment which instructed the nursing staff to provide details about the status of the dressing (whether it was changed or reinforced), the status of the wound bed (clean, slough or eschar (dead tissue) present), drainage amount (none, small, moderate or large), type of drainage (serous, serosanguineous or purulent), and condition of the skin surrounding the wound (healthy, macerated, pale or reddened). Review of the TAR dated 10/25/21 through 10/31/21 indicated no documented evidence that the treatments to the Resident's right hip were administered as ordered on the following days/shifts: -10/25/21 all three shifts -10/26/21 day and night shifts -10/27/21 evening shift -10/28/21 day and night shifts During an interview on 10/20/21 at 10:55 A.M., Director of Nurses (DON) #1 said that the care levels at the facility had declined and that medications and treatments were not completed, as ordered. During an interview, on 10/21/21 at 1:49 P.M., the Resident's Responsible Party said the Resident had dementia and had multiple open areas including one on his/her right hip after a surgery. He said Resident #216 had periods of incontinence and he/she would not receive staff assistance, when needed, to be changed for hours. He further said that if the wound dressings were soiled, they needed to be changed, but were not changed for a long time. He said that the Resident's dressings were still filthy and dirty and were supposed to be changed, given the amount of drainage from the areas. He said he was concerned for Resident #216 and did not want him/her to have to go back to the hospital. On 11/02/21 at 1:44 P.M., the surveyor observed Resident #216 lying in bed on an air mattress set at 280 lbs. Review of the Resident #216's clinical record indicated a weight obtained on 10/8/21 of 144.8 lbs. During an interview and review of Resident #216's clinical record, on 11/03/21 at 11:09 A.M., the PA said that there was no evidence that the X-Ray was completed for Resident #216 as ordered by the Physician. He said the X-Ray should have been completed the day it was ordered or the next day. The PA said he spoke with DON #1 about the wound dressings not being completed as well as the nurse who was taking care of the Resident and spoke at the regular meetings with the facility staff about treatments not being completed as ordered. The PA said that he requested the air mattress and communicated with facility staff about the need for the Resident to have one. He further said he did not determine the air mattress setting, that it was usually based on the Resident's weight, and that a setting of 280 pounds was not appropriate based on the Resident's weight. The PA said that lab work was not completed for Resident #216 as ordered, and that prior to 10/14/21, there was no documentation on the measurement or status of the Resident's wounds. The PA said that he completed some of the treatments ordered for Resident #216's wounds, and the dressings that were in place were the previous ones that he had applied, so he knew staff did not change them as ordered. During an interview, on 11/03/21 at 11:54 A.M., DON #2 said all treatments should be administered as ordered by the Physician and if there was a change, or if a treatment was not completed as ordered, then the Physician should be notified. DON #2 said that a comprehensive wound assessment would be completed weekly and that this included wound measurements, drainage present, and any status changes to the area. DON #2 said that the weekly skin assessments were key to identifying concerns and that there needed to be a person to oversee that this was done. DON #2 further said that the nurses determined the setting of an air mattress based on the Resident's weight. She said to determine the setting, they would look at the resident's weight and set the air mattress to meet the level. She said that once the setting was determined, the order needed to be clarified in the record to indicate the proper air mattress setting. 4. For Resident #35, the facility failed to provide documented evidence that weekly skin checks were completed in accordance with the Resident's plan of care. Resident #35 was admitted to the facility in July 2021. Review of the Minimum Data Set (MDS) Assessment, dated 5/12/21, indicated the following: -a score of zero out of 15 on the Brief Interview of Mental Status (BIMS), which indicated Resident #35 was severely cognitively impaired -the Resident required extensive assist of two staff for transfers, bed mobility, and toileting Review of the Skin Integrity Care Plan, dated 9/1/21, indicated the resident was at risk for impairment in skin integrity and included an intervention for weekly skin checks, per facility protocol. Further review of Resident #35's Care Plan indicated no interventions related to the use of an a[TRUNCATED]

Based on interviews and record reviews, the facility failed to ensure that four sampled Residents (#34, #61, #64, and #69) were free from significant medication errors, out of a total sample of 43 residents. Findings include: Review of the facility policy titled Administering Medications, dated 2017, indicated that medications were required to be administered according to physician orders. Review of the facility policy titled Adverse Consequences and Medication Errors, dated 2017, indicated the following: -Any medication that has a potential for adverse consequences will be monitored to ensure that any such consequences are promptly identified and reported. -An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication and may include side effects. -An adverse drug reaction (ADR) is defined as a secondary and undesirable effect of a drug and is different from the therapeutic effects of the drug. An ADR is any noxious and unintended response to a drug and occurs in doses for prophylaxis, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -An omission, a drug is ordered but not administered, is a medication error. -In the event of a significant medication related error or adverse consequence, immediate action is taken to protect the resident's safety and welfare. Significant is defined as requiring treatment with a prescription medication. -The attending physician is promptly notified of any significant error or adverse consequence. -The following information is documented in the medical record: factual description of the error or adverse consequence, name of physician and time notified, physician's subsequent orders, resident's condition for 24-72 hours as directed. Review of the facility's policy titled, Administering Medications, dated 2017 indicated the following: - The individual administering medications must verify the resident's identity before giving the resident his/her medications by checking the identification band, checking photograph attached to the medical record, if necessary verify resident information with other facility personnel. - The individual administering the medication must check the label three times to verify the right resident, the right medication , right dosage, right time and right route of administration before giving the medication. Review of the Nursing 2022 Drug Handbook, 42nd edition, dated 2022, included the following: The eight rights of medication administration: 1. The right drug: Check the drug label and verify that the drug and form to be given is the drug that was prescribed. 2. The right patient: Confirm the patient's identity by checking two patient identifiers. 3. The right dose: Verify that the dose and dosage form to be given are appropriate for the patient, and check the drug label with the prescriber's order. 4. The right time: Ensure that the drug is administered at the correct time and frequency. 5. The right route: Verify that the route by which the drug is to be given is specified by the prescriber and is appropriate for the patient. 6. The right reason: Verify that the drug prescribed is appropriate to treat the patient's condition. 7. The right response: Monitor the patient's response to the drug administered. 8. The right documentation: Completely and accurately document in the patient's medical record the drug administered; the monitoring of the patient, including the patient's response; and other nursing interventions. 1. For Resident #34, the facility failed to ensure the Resident received the correct medications which resulted in an emergency transfer to the hospital. Resident #34 was admitted to the facility in August, 2021. Review the clinical record indicated a Physician's Progress Note, dated 9/21/21, that Resident #34 was accidentally given 75 milligrams (mg.) of [MEDICATION(S)] (a medication that affects the heart and circulation, used to treat chest pain, high blood pressure and slows down heart rate) and 10 mg. of [MEDICATION(S)] (a medication used to treat high blood pressure and heart failure after heart attacks). The note further indicated that the Resident's heart rate was down to 52 and there was concern for [CONDITION(S)] (slower than normal heart rate) and he/she would need cardiac monitoring and will send him/her to the emergency department for further evaluation. Review of Physician's Orders did not indicate any order for [MEDICATION(S)] or [MEDICATION(S)]. Review of the clinical record did not indicate the Resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/03/21 at 2:21 P.M., Unit Manager #2 said the said the error occurred when she was working for a nursing agency and she was not familiar with the residents at this facility. She said after she pulled out medications for a resident, she became distracted by something happening in the hallway, then subsequently walked into Resident #34's room and administered the medication. She then went on to say when she went back to her computer to sign off on the medication administration, she realized she went into the wrong room and gave Resident #34 medication that belonged to another resident. In addition, she said she should have verified the identity of the resident before administering the medication. 2 .For Resident #69, the facility failed to ensure that the Resident was free of significant medication errors relative to the administration of a medication that was not ordered by the Physician and caused an allergic reaction. Resident #69 was admitted to the facility in August 2021 with [MEDICATION(S)] [CONDITION(S)] (an inflammation in a section of the spinal cord which results in pain, muscle weakness, paralysis and sensory problems). During an interview on 10/21/21 at 8:52 A.M., Resident #69 said he/she was sent to the emergency room due to a medication error. He/she said he/she had nasal congestion on the night shift and asked the nurse for [MEDICATION(S)] (a name brand topical ointment, containing [MEDICATION(S)], used on the back or chest for cough suppression), but the nurse applied a white muscle rub. Resident #69 informed Director of Nurses (DON) #1 but said he/she wasn't taken seriously until he/she became symptomatic. DON #1 identified the cream that was used and discovered it was a muscle rub that contained aspirin, a drug that Resident #69 was allergic to. Resident #69 said he/she was sent to the emergency room for evaluation and treatment and returned to the facility that evening. Review of the clinical record indicated Resident #69 had an allergy to Non-Steroidal Anti-[CONDITION(S)] Drugs (NSAIDs: a class of drugs used to treat pain, fever, and inflammation such as aspirin and [MEDICATION(S)]). Review of 10/2021 Physician Order's did not indicate orders for the application of muscle rub to Resident #69. Review of Physician's Progress Note, dated 10/19/21, indicated the Resident was seen at the request of nursing as he/she was being sent to the hospital for an allergic reaction. Review of the hospital records, dated 10/19/21, indicated the Resident was evaluated and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with DON #2 and Administrator #2, on 11/04/21 at 1:13 P.M., Administrator #2 said that a medication was given to the Resident that was not ordered; a muscle rub containing salicylates, and the Resident went to the hospital to be evaluated. DON #2 said there was [MEDICATION(S)] in the muscle rub which could cause a reaction in those who have an aspirin allergy. 3. For Resident #61, the facility failed to ensure the Resident was free from significant medication errors relative to the administration of anticoagulants (blood thinners; a class of medications used to prolong clotting time for patients prone to blood clots). Resident #61 was admitted to the facility in May 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Anticoagulation-Clinical Protocol, dated 2012, indicated the following: -The staff should follow trends in anticoagulant dosage and response. -The staff and physician will monitor for potential complications in individuals who are being anticoagulated Review of an article titled International Normalized Ratio (INR: a calculation based on the results of a prothrombin time and used to assess clotting factor in the blood. blood test), dated 5/10/21, (Shikdar S, Vashisht R., [NAME] PT) ©2021 StatPearls Publishing, LLC, and accessed on-line at ncbi.nlm.nih.gov, indicated the following: -INR monitoring is, most commonly, required for patients who are on [MEDICATION(S)] (also known as [MEDICATION(S)], an anticoagulant used to prevent the blood from clotting) -the dose of [MEDICATION(S)] is adapted based on the INR scores so that it remains in the therapeutic range to prevent [CONDITION(S)] (blood clot formation) from subtherapeutic (a level of the medication in the person's system that is below the level determined to be therapeutic) INR or hemorrhagic (rapid blood loss) complications from supratherapeutic INR -For patients on anticoagulant therapy, the therapeutic INR ranges between 2.0-3.0. -INR levels above 4.9 are considered critical values and increase the risk of bleeding Review of the 10/2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the INR results ranged from 2.12-2.86 in early October, which was within the therapeutic range. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurse's Progress Note dated 10/14/21 indicated the [MEDICATION(S)] 2.5 mg tablet was not available. There was no evidence that the provider was notified of the missed dose. Review of the Physician Orders and the corresponding MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the INR results, dated 10/22/21, indicated the INR had dropped from 2.12 on 10/11/21 (therapeutic level) down to 1.36 on 10/22/21 (subtherapeutic level). There were no lab results provided by the facility from 10/23/21 through 10/25/21. Review of Nurse's Progress Note, dated 10/25/21, indicated that Nurse #5 was asked by Unit Manager #2 to place a call to the on-call Practitioner regarding the Resident's missed [MEDICATION(S)] doses, and an order was given to administer [MEDICATION(S)] 7.5 mg and to redraw the labs (PT/INR) in the A.M. Review of the Resident's medical record indicated Physician's Orders for PT/INR labs and [MEDICATION(S)] dosing with dates from 5/15/21 through 8/18/21. Further review of the medical record indicated next order after 8/18/21 was dated 10/26/21. During an interview on 10/26/21 at 10:59 A.M., the Nurse Practitioner (NP) said there were issues with orders not being followed or addressed by the facility and said she wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #61 on 10/22/21. She further said the Physician's Order page which included the orders written from 10/22/21 were missing in the Resident's medical record, the [MEDICATION(S)] doses prescribed were not administered, and the bloodwork ordered was not completed. During an interview on 10/27/21 at 5:17 P.M., Nurse #5 said she worked the evening (3:00 P.M.-11:00 P.M.) shift on 10/25/21, and Unit Manager #2 had asked her to call the Nurse Practitioner (NP) about [MEDICATION(S)] not being administered to Resident #61 for those three days (10/22/21-10/24/21). Nurse #5 said she called the NP for [MEDICATION(S)] and laboratory testing orders and that the Resident did not have his/her [MEDICATION(S)] administered as ordered for three days. During an interview on 10/28/21 at 1:45 P.M., the NP said that the Resident's PT/INR had been stable, and she was able to reduce blood work to once a week. However, more recently, the lab results were very inconsistent, and resulted in more frequent blood work and [MEDICATION(S)] dosage changes to keep Resident #61's INR within the therapeutic range. The NP said she was unsure if the Resident was receiving the [MEDICATION(S)] as ordered. She said she was concerned that if the Resident got too much [MEDICATION(S)], the PT/INR would go up, it would take too long for the blood to clot, and the Resident could hemorrhage. She further said that if the resident didn't get the [MEDICATION(S)], the blood could clot too quickly, and the resident could develop a blood clot. Further review of the 10/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a lab result, dated 10/29/21, indicated an INR result of 2.31 (within the therapeutic level). Review of the 10/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #61 on 10/29/21, 10/30/21, and 10/31/21. Review of the November 2021 lab results, dated 11/1/21, indicated the INR increased to 5.28 (critical level value), the scheduled dose of [MEDICATION(S)] was held, and labs were ordered to be repeated in the morning. During an interview and review of the Resident's clinical record, on 11/01/21 at 11:09 A.M., the Director of Nurses (DON) #2 said that the Resident missing three doses of [MEDICATION(S)] was a medication error. She said she found out about the error and directed the staff to consult with the provider to obtain a new order for the [MEDICATION(S)]. On 11/02/21 at 11:02 A.M., the surveyor observed Nurse #7 receive a call from the lab indicating that Resident# 61's INR results were 5.41 and were at critical level. Nurse #7 notified the Physician's Assistant of the lab result, and an order was given to hold the [MEDICATION(S)], and to administer a dose of Vitamin K (a group of Vitamins that the body needs for blood clotting: used to treat low levels of blood clotting factors that can result in hemorrhage: escape of blood from a ruptured blood vessel, especially when profuse) intramuscularly (injection into the muscle). During an interview on 11/2/21 at 11:10 A.M., the NP said she received a call from the Nurse who said the INR lab draw was not obtained as ordered on 11/1/21. The NP said that she ordered a STAT (to be completed immediately) INR lab to be drawn the afternoon of 11/1/21, the results were reported to the on-call provider, the [MEDICATION(S)] was held, and repeat lab work was ordered for 11/2/21. The NP said that Resident #61's INR goal was 2.0-2.5. 4. For Resident #64 the facility failed to administer [MEDICATION(S)] (a blood pressure support medication) as ordered by the Physician. Review of the facility policy titled Administering Medications, dated 2017, indicated that medications were to be administered in a safe and timely manner, as prescribed, and in accordance with the orders which included any required time frames. Resident #64 was admitted to the facility in May 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders indicated an order, initiated on 5/16/21, to administer [MEDICATION(S)] 15 milligrams (mg) three times daily for orthostatic [CONDITION(S)] (decrease in blood pressure with change in position). The medication orders indicated to hold the medication if the systolic blood pressure (SBP; the top blood pressure number which measures the force exerted by the heart on the walls of the arteries with each beat) was greater than 100. Review of the 9/2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - twice on 9/1/21, 9/18/21, 9/19/21, 9/20/21, 9/25/21, and 9/29/21 - once on 9/3/21, 9/13/21, 9/17/21, 9/24/21, and 9/27/21 - three times on 9/15/21, 9/22/21, 9/23/21, and 9/30/21 Review of the 10/2021 MAR, indicated the [MEDICATION(S)] was administered when the Resident's SBP was greater than 100 as follows: -three times on 10/1/21, 10/2/21, 10/3/21, 10/4/21, 10/6/21, 10/7/21, 10/8/21, 10/10/21, 10/11/21, 10/14/21, 10/16/21, 10/17/21, 10/18/21, 10/20/21, 10/22/21, 10/23/21, 10/24/21, 10/30/21, and 10/31/21 -one time on 10/5/21 and 10/12 21, 10/26/21, 10/27/21, and 10/28/21 - twice on 10/9/21, 10/19/21, and 10/25/21 During an interview and review of Resident #64's MARs on 11/04/21 at 4:05 P.M., the Senior Regional Director of Clinical Operations (SRDCO) said the check marks observed on the MARs indicated that a medication was administered. She said that the 9/2021 and 10/2021 MARs indicated [MEDICATION(S)] was administered to Resident #64 outside of the parameter that the Physician had ordered, but that it should not have been. The SRDCO said that this was considered a medication error and that the Physician needed to be notified.

Based on observations, interviews, and record review, the facility failed to ensure A.) one sampled Resident (#35) who was receiving assisted nutrition and hydration via a gastrostomy tube (a tube placed directly through the skin and into the stomach and used to administer feedings, fluids and medications) was provided adequate nutrition to prevent unplanned significant weight loss, and B.) one sampled Resident (#16) was provided a fluid restriction as ordered by the Physician, out of a total sample of 43 sampled residents. Findings include: 1.For Resident #35, the facility failed to ensure an enteral feeding was administered as ordered by the Physician and the Resident experienced unplanned significant weight loss. Review of the facility's policy titled Enteral (artificial opening or natural opening that allows nutrition through the mouth, esophagus or intestines) Nutrition, dated 2017, indicated that nursing staff are responsible for monitoring the resident for signs and symptoms of inadequate nutrition. Review of the facility policy titled Weight Assessment and Intervention, revised 2019, indicated the facility would strive to prevent, monitor, and intervene for undesirable weight loss for the residents. The policy also included the following: -weights will be monitored as recommended or as ordered -weights will be recorded -the threshold for unplanned or undesired weight loss will be based on the following criteria: one month 5% weight loss is significant, greater than 5% weight in one month is severe, three months 7.5% weight loss is significant, greater than 7.5% in three months is severe; and in 6 months 10% weight loss is significant, greater than 10% weight loss in six months is severe) -any three-pound (lb.) weight change will result in a re-weigh within a 24-hour period -once the three-pound weight change is confirmed, nursing will immediately notify the Physician and Dietician of the weight change Review of the facility policy titled Administering Medications, dated 2017, indicated the following: -Medications must be administered in accordance with the (Physician's) orders Review of the facility policy titled Charting and Documentation, dated 2017, indicated the following: -All observations, medications administered, and services performed must be documented in the resident's clinical record -All incidents, accidents, or changes in the resident's clinical condition must be recorded Resident #35 was admitted to the facility in July of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment, dated 5/12/21 indicated the Resident did not speak but was able to hear, had the ability to sometimes understand, and had a score of 0 out of 15 on the Brief Interview of Mental Status Assessment which indicated the Resident had severe cognitive impairment. The Assessment also indicated the Resident required extensive assist with transfers, bed mobility and toileting, did not ambulate and required assistance with personal hygiene and bathing. The Resident has a gastrostomy tube (g-tube: a tube placed into the stomach to provide nutrition/hydration), weighed 159 pounds and received his/her daily nutritional needs via the g-tube during the assessment reference period. Review of the care plan, initiated 5/12/21, indicated Resident #35 was at nutritional risk related to requiring total enteral nutrition to meet nutritional needs through g- tube and included the following interventions: -administer tube feedings, fluid flushes and medications as ordered, -obtain weights and labs as ordered Review of the Physician's Orders, dated October 2021, indicated the following: -NPO status (Latin for nothing by mouth), initiated 4/26/21 -Enteral Feed Order: [MEDICATION(S)] 1.2 (brand of formula that has concentrated calories and protein to help tube-fed residents gain and or maintain weight) at 70 cubic centimeters (cc) /hour (hr.) continuous, initiated 8/3/21 -Give free water 200 milliliters (ml) every four hours for hydration, initiated 6/22/21 -provide mouth care every four hours for g-tube maintenance, initiated 4/26/21 -obtain weekly weights every Friday on the day shift, initiated 6/10/21 Review of the 8/2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -seven out of 93 shifts that the [MEDICATION(S)] 1.2 feeding was not documented as administered. -four occurrences that free water was documented as administered -no documented evidence that three of the four weekly weights were obtained, as ordered by the Physician -17 out of 186 occurrences where mouth care was not documented as ordered by the Physician. Review of the 9/2021 MAR, indicated the following: -five out of 90 shifts that the [MEDICATION(S)] 1.2 feeding was not documented as administered -no documented evidence that three of the four weekly weights were obtained, as ordered by the Physician. -30 out of 90 occurrences mouth care was not documented as ordered by the Physician Review of the 10/2021 MAR, indicated the following: -ten out of 93 shifts that the [MEDICATION(S)] 1.2 feeding was not documented as administered. -five out of 186 occurrences where the free water was not documented as administered. - no documented evidence that one of the four weekly weights were obtained, as ordered by the Physician -In addition, there were 30 out of 186 occurrences where mouth care was not documented as ordered by the Physician. Review of the clinical record indicated Resident #35 weighed the following: -158.0 pounds (lbs.) on 4/26/2021, -163 lbs. on 8/6/21 -143.8 on 9/29/21 -142.2 lbs. on 10/08/2021, indicating 10.13% weight loss (severe) in a six-month period Review of the progress notes dated 9/29/21 indicated no evidence that the resident's weight loss had been reported to the physician or dietician. Review of the Dietician's Progress Note, dated 10/13/21, indicated there was a weight decline from 163 lbs. to 142 lbs., had not had a change in his/her tube feeding formula, rate or volume delivered. The Dietician indicated that Resident #35's prescribed formula was calculated to meet his/her needs for weight stability for 160 lbs., and that she notified the Nurse Practitioner (NP) of the Resident's significant weight loss. Review of the Physician's Progress Note dated 10/19/21 indicated that the resident had some weight loss and that the Dietician was following the Resident's weights and questioned whether there was a discrepancy in the documented weights. Review of the Dietician's Progress Note, dated 10/20/21, indicated Resident #35 was reweighed at 145 lbs., which was an 11% weight loss, indicating severe weight loss. The Dietitian recommended that the tube feeding formula be changed from [MEDICATION(S)] 1.2 to Vital 1.5 at 59 cc/hr. to promote increased calories/protein and absorption. Review of the 10/2021 Physician's Orders on 10/27/21 indicated there were no orders for Vital 1.5 formula. On 10/25/21 at 8:52 A.M., the surveyor observed Resident #35 in bed, with his/her eyes were open. The Resident made eye contact but did not respond verbally when the surveyor attempted to converse. The feeding pump was set to deliver [MEDICATION(S)] 1.2 at 70 cc/hr., however the surveyor observed that there was no date, time or initials on the enteral feeding bottle indicating when it was started. Upon further observation, the surveyor observed the tubing from the enteral feeding of [MEDICATION(S)] 1.2 was not connected to Resident #35 to deliver the nutrition and was draining into a bottle which was positioned on the floor. The surveyor observed that the bottle on the floor contained over 400 cc of tube feeding formula. During an interview on 10/25/21 at 9:02 A.M., Unit Manager (UM) #2 said the Resident's g- tube feeding [MEDICATION(S)] 1.2 was supposed to be connected and because it was not, the Resident was not administered the enteral feeding as ordered by the Physician. During an interview on 10/25/21 at 11:49 A.M., Director of Nurses (DON) #2 said that she was notified about the issue with the Resident's enteral feeding draining into a container on the floor and had reported the incident to the Dietician and the NP. During an interview on 10/25/21 at 1:42 P.M., the Dietician said she was notified about the incident with the Resident's g-tube feeding draining into a container on the floor, but she was not aware of how much formula Resident #35 did not receive. The Dietician said Resident #35 was NPO and received all his/her nutrition through the g-tube. The Dietician further said she was watching the Resident's weights because he/she was losing weight and was unsure why because the enteral feeding prescription was set for him/her to gain weight, so the weight loss did not make sense. The Dietician said that a recommendation to change the enteral feeding formula from [MEDICATION(S)] 1.2 to Vital 1.5 was given to the nurse, but the order was never changed in the Resident's clinical record, therefore the change in enteral feeding order was not implemented. She further said that she always had problems with getting her recommendations followed through with when she recommends a change and that she was now concerned that Resident #34 was not receiving the full enteral feedings as ordered. On 10/27/21 at 10:09 A.M., the surveyor observed that Resident #35 was not in his/her room and staff indicated he/she was transferred to the hospital for an issue with his/her g- tube. Review of the progress note dated 10/27/21 and entered at 6:28 A.M., indicated the adaptor for the feeding tube was broken and there was no way to repair it, a bolus feeding was administered, and that the issue would be reported to the nurse on the next shift. Further review of the Progress Notes dated 10/27/21 indicated no documented evidence that the physician was notified about the Resident's change in condition. Review of the Physician's Orders for 10/21 indicated no order for a bolus feeding for Resident #35's g-tube. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/27/21 at 12:24 P.M., the NP said that she had a conversation with the Dietician on Friday (10/22/21) about the Resident's weight loss but she was never notified by nursing that the Resident had significant weight loss on 9/29/21. During an interview on 10/27/21 at 3:03 P.M., the Dietician said that when she went in to see Resident #34 this morning, the Resident was not connected to the enteral feeding and there was not enteral feeding bottle in his/her room, as ordered by the Physician. The Dietician said that she and Nurse #7 together assessed Resident #35 and observed that he/she was missing the port (connector) to the g-tube. The Dietician said that a nurse on the previous shift had indicated that Resident #35 had an issue with the g-tube, that a bolus feeding (a way to deliver enteral feeding without the use of a feeding pump, typically involves a higher amount of fluid over a short period of time), even though there was no order in place for the Resident to receive a bolus feeding, and the Resident had never been given a bolus feeding before. The Dietician said that the nurse's note did not indicate the amount of the bolus feeding administered to Resident #35. The Dietician said that a bolus feeding, if given too great a volume over a short period of time, could result in gastro-intestinal complications such as cramping, bloating, abdominal distention, diarrhea and dumping syndrome (define dumping syndrome). The Dietician further said that this was the second time that week that Resident #35 was not administered the tube feeding as ordered, and he/she had experienced a significant unplanned weight loss. She said if no enteral feeding or free water was administered to a resident who has a g-tube, he/she could become dehydrated and lose weight. On 11/03/21 at 11:21 A.M., the surveyor observed Resident #35 lying in bed. Nurse #15 and Unit Manager (UM) #2 were preparing to hang a new enteral feeding for Resident #35. The surveyor observed the Resident's lips had dried secretions and peeling skin on them (a sign of not receiving mouth care or adequate fluids) The enteral feeding pump was off, and the bottle hanging was empty. During an interview at the time of the observation, UM#2 said that a new bottle of [MEDICATION(S)] 1.2 was hung every 24 hours, and that the tubing connecting the feeding to the Resident and all other equipment were to be initialed, dated and timed by the nurse upon the feeding bottle change. 2. For Resident #16, the facility failed to ensure a fluid restriction was provided, as ordered by the Physician. Review of the facility policy titled Encouraging and Restricting Fluids, dated 2017, indicated the procedure was to provide residents with the amount of fluids necessary to maintain optimum health, and included the following: -verify that there is a physician's order -follow specific instructions concerning fluid intake or restrictions -be accurate when recording fluid intake -record fluid intake on the intake side of the intake and output record. Record the fluid intake in milliliters (mls) Resident #16 was admitted to the facility in June 2021. Review of a Physician's Assistant (PA) Note, dated 7/27/21, indicated Resident #16 had [CONDITION(S)] (low sodium level) and a fluid restriction was implemented. Review of an active Physician Order, initiated 7/28/21, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Records (MARs), dated 10/2021 through 11/2021, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the active Care Card, dated 11/4/21, indicated Resident #16 was on a 1500 ml fluid restriction daily. Review of the clinical record indicated no documented evidence of Resident #16's fluid intake or output. During an interview on 10/26/21 at 11:22 A.M., Certified Nurse Aide (CNA) #6 said that Resident #16 was independent with meals, was not on any special diet and was not on intake and output monitoring. On 10/26/21 at 12:39 P.M., the surveyor observed Resident #16, seated in the day room while he/she ate lunch. The surveyor observed the Resident's meal ticket on his/her lunch tray which did not indicate Resident #16 required a 1500 ml fluid restriction. During an interview and review of the Resident's clinical record, on 10/28/21 at 12:16 P.M., Nurse #7 said that Resident #16 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #7 said Resident #16 was not on input and output monitoring and that there should have been a place in the Resident's clinical record where the amount of fluid taken was monitored, but there was not. She further said that she was able to account for the amount of fluids Resident #16 received on her shift but could not account for what fluids he/she received on previous days/shifts.

Based on observations, interviews, and record reviews, the facility failed to ensure three sampled Residents (#64, #98, and #267) were provided with effective pain management consistent with their plans of care, out of a total sample of 43 residents. 1. For Resident #98, the facility failed to effectively assess and manage the Resident's pain during wound care treatments. Resident #98 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/20/21 at 9:03 A.M., the surveyor observed Resident #98 in bed wearing a hospital gown. The resident's eyes were open, and he/she responded to the surveyor's question about having pain with a shrug. He/she did not respond verbally. During an interview on 10/20/21 at 9:08 A.M., at the time of the observation, Certified Nursing Assistant #8 said that the Resident had several wounds and didn't usually speak using words but shrugged and nodded to communicate. She asked the Resident if he/she had pain and the Resident nodded yes, but, when she tried to get him/her to rate the pain using a number scale, he/she shook his head. CNA #8 said that when the Resident was in pain, he/she would become restless and would rub his/her arms. On 10/21/21 at 12:57 P.M., the surveyor observed the Wound Physician examine the Resident and perform debridement (the removal of dead or damaged tissue from a wound to improve healing) of the wound using a scalpel (a small and extremely sharp bladed instrument used for wound debridement).The resident winced frequently and stared at the Wound Doctor. The Wound Physician said I know, it will just be a little bit longer to the Resident during the procedure. On 11/02/21 from 3:30 to 4:30 P.M., the surveyor observed Nurse #7 provide wound care which included removing the old dressing, cleaning the wound bed, placing measured to fit foam into the wound bed, and applying a transparent dressing over the foam and attempt to attach the Wound Vacuum (a negative pressure vacuum that promotes healing in wounds). Nurse #7 attempted to complete the procedure three times, and at no time during the observation did she assess the Resident's pain or offer any pain medication. The Resident was positioned on his/her right side for the duration of the procedure, was observed grimacing, appeared uncomfortable, and swatted at the nurse and the two other staff members who were maintaining the Resident's position. Nurse #7 was not observed to stop the treatment or conduct a pain assessment during the procedure. Review of the record indicated that the Resident had the following care plans in place: -a Pain Care Plan in place that indicated the Resident had chronic pain, initiated 6/14/21 that included to administer analgesics (pain medications) as ordered and monitor for side effects or any significant changes from the Resident's past experiences of pain. -a Communication Care Plan, revised 6/14/21 that included staff should anticipate and meet the Resident's needs, request clarification from the Resident, and use alternative communication tools as needed. Review of the October 2021 Physician Orders included the following: -Pain Assessment 0-10 every shift for pain monitoring, dated 3/11/21 -Acetaminophen (Tylenol: a mild pain reliever) 325mg give 2 tablets by mouth every four hours as needed, dated 3/11/21 -Acetaminophen Give 500mg po every 6 hours as needed for pain, dated 5/13/21 -[MEDICATION(S)] ([MEDICATION(S)]: a narcotic pain reliever) tablet 5mg give 5mg by mouth every six hours as needed for pain, dated 5/13/21 Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - no documented evidence that pain assessments were completed 15 out of 93 occurrences - of the pain assessments completed, six occurrences indicated the Resident had pain ranging from the level of three to eight on a one to 10 scale. There was no documented evidence that the Resident received any of the as needed pain medications ordered. During an interview on 11/02/21 at 5:03 P.M., Nurse #7 said that Resident #98 was uncomfortable during wound care and that she did not medicate him/her prior to the procedure and should have. 2. For Resident #267, the facility failed to ensure continuity of his/her pain medication regimen. Resident #267 was admitted to the facility in October 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment, dated 10/14/21, indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status Assessment (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated Resident #267 received both scheduled and as needed (PRN) pain medication, that pain assessments should be conducted, and his/her pain was rated as moderate. Review of Resident #267's Care Plan indicated no individualized care plan relative to the Resident's pain. Review of the Physician Orders included the following: - Pain Assessment to be done every shift, reactivated on 10/6/21 - 10/6/21 [MEDICATION(S)] (a narcotic used to treat moderate to severe pain), 50 milligrams (mg.), give one tablet by mouth every 12 hours as needed (PRN) for pain. - 10/6/21-10/9/21 [MEDICATION(S)]-APAP-[MEDICATION(S)] tablet (a medication used for migraine headaches), 50-325-40 mg., give two tablets by mouth every 12 hours PRN for migraines. - 10/9/21 Acetaminophen (a medication used to treat minor aches and pains) tablet 325 mg., give two tablets by mouth every 4 hours PRN for pain. - 10/9/21 [MEDICATION(S)] capsule (brand name for [MEDICATION(S)]) 50-300-40 mg., give two capsules by mouth every 6 hours PRN migraines. During an interview on 10/21/21 at 11:45 A.M., Resident #267 said the facility ran out of his/her migraine medication three times since he/she was admitted . Review of the Controlled Substance Register (a book where the facility records inventory of controlled medications for each resident), page 99, indicated the following: - No [MEDICATION(S)] on hand until 10/9/21 at 11:00 P.M., with no evidence any on hand prior to this time. - No [MEDICATION(S)] was on hand after the Resident received a dose on 10/19/20 at 10:00 P.M. until a delivery from the pharmacy was logged 10/20/21 at 10:02 P.M., indicating the Resident did not have access to the medication for 24 hours. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the October, 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 10/26/21 at 1:01 P.M., Resident #267 said he/she had been waiting since 11:45 A.M. for her PRN [MEDICATION(S)] (a medication to relieve nausea) and [MEDICATION(S)] because he/she had nausea and a migraine. The surveyor noted the Nurse on duty (Unit Manager; UM #1), was not visible on the Unit from 11:45 A.M. until 1:05 P.M., and facility staff did not know her whereabouts. Resident #267 requested the surveyor stay with him/her until Unit Manager #1 came back to ensure he/she got his/her medication. When UM #1 arrived back on the Unit at 1:05 P.M., the Resident requested his/her [MEDICATION(S)] and [MEDICATION(S)]. Unit Manager #1 said she would be right back, wheeled the medication cart which was parked in front of the Resident's room down the hall to the nursing station, removed the medications from the cart, and walked them back down the hall to the Resident. During an interview on 10/21/21 at 12:18 P.M., the Physician Assistant (PA) said he was aware that resident #267 had run out of pain medication. The PA said he was once told on a Monday morning by Resident #267 that facility ran out of his/her pain medication and asked him to write a prescription. He said the nurse on duty should have called the on-call physician to provide a prescription and it should not have waited until he came in on Monday morning. He then said it was his practice to coordinate narcotic prescriptions with the nursing staff during the week, however the communication had been lacking. During an interview on 10/26/21 at 12:01 P.M., while reviewing medications with the surveyor, Resident #267 said he/she always took a medication called [MEDICATION(S)] for migraine headaches but he/she has never received it at the facility. Review of the clinical record did not indicate that [MEDICATION(S)] had ever been ordered. Review of the Patient Care Referral Form discharge orders dated 10/6/21 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . tablet, take one tablet by mouth as needed. During an interview on 10/26/21 at 3:43 P.M., UM #1 said there had been a problem getting medications from the Pharmacy, that this happened regularly, and she was not sure what the problem was. During an interview on 10/28/21 at 2:05 P.M., upon reviewing the Patient Care Referral Form, Nurse #13 said [MEDICATION(S)] must not have been transcribed (put data into a written form), therefore was never ordered for the Resident. During an interview on 11/02/21 at 1:25 P.M., Physician #1 said that obtaining medications for newly admitted residents had been on ongoing issue. During an interview on 11/4/21 at 2:20 P.M., Nurse #13 said she can remember two times for sure where the overnight nurse gave Resident #267 the last pain medication, leaving her with none to administer in the morning when the Resident requested it. She also said the Pharmacy had delays in sending medications to the facility. 3. For Resident #64, the facility failed to ensure pain medication was available and provided, as ordered by the Physician. Review of the facility policy titled Pain Assessment and Management, dated 2017, indicated the procedure was to help staff identify a resident's pain, to develop interventions consistent with the resident's goals and needs, and to address the underlying causes of pain. The policy also indicated that pain management was defined as the process of alleviating a resident's pain to a level acceptable to the resident, and was based on his/her clinical condition and established treatment goals, and included the following: -assess the potential for pain -effectively recognize the presence of pain -identify the characteristics of pain -address the underlying causes of pain -develop and implement approaches to pain management -identify and use specific strategies for different levels and sources of pain -monitor for the effectiveness of interventions -modify approaches as necessary Review of Healthline's Numeric Rating Scale for Pain, undated, indicated the following assessment on a scale of 0-10: - 1 to 3 indicated mild pain - 4 to 6 indicated moderate pain - 7 to 10 indicated severe pain Resident #64 was admitted to the facility in May 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician Assistant (PA) Progress Note, dated 5/17/21, indicated the Resident was admitted to the facility after a hospital stay for worsening pain to his/her chronic buttock wound and [CONDITION(S)] (infection) of the wound. The Practitioner indicated in the note that the Resident had acute on chronic pain due to the nonhealing sacral (bony structure at the base of the spine) ulcer, bilateral hip ulcers which were recently debrided (dead tissue surgically removed) and diverting [CONDITION(S)] (a fecal diversion by creating an opening /stoma from the colon to eliminate stool). The Practitioner indicated in his note that the plan for pain management included Oxycodone (a narcotic) 5-10 milligrams (mg) every 4 hours as needed (PRN) for five days, then re-evaluate. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician indicated to continue the pain medication Oxycodone 5-10 mg as needed every 4 hours indefinitely. Review of the Minimum Data Set (MDS) Assessment, dated 5/23/21, indicated Resident #64 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15, received scheduled pain medications, did not receive as needed (PRN) pain medication, and had frequent pain, that was 8 out of 10 per interview, during the assessment reference period. Review of a Physician's Progress Note, dated 6/8/21, indicated Resident #64 had an appointment with the wound clinic and that the Resident stated he/she had a lot of pain and that sitting in a wheelchair for a long period was excruciating. New orders for pain management were written and included Oxycodone ER (Extended Release or long acting) 15 mg every 12 hours and Oxycodone 5 mg every 4 hours PRN. Review of the 6/2021 Physician's Orders included the following: -[MEDICATION(S)] ER 15 mg every 12 hours, initiated 6/8/21 -Oxycodone 5 mg every 4 hours PRN for mild to moderate pain, initiated 5/18/21 -Oxycodone 10 mg every 4 hours PRN for severe pain, initiated 5/18/21 Review of a PA Progress Note, dated 6/10/21, indicated the Resident had a delay in receiving his/her pain medications from the pharmacy but currently had them available. Review of the clinical record indicated no evidence relative to when the Resident experienced a delay in receiving PRN pain medication. Review of a Nurse Practitioner Progress Note, dated 7/27/21, indicated Resident #64 continued to report increased sacral pain, decreased appetite due to pain, nausea and overall increased fatigue which was no longer managed by current pain regimen. The Practitioner indicated in the note that the long-acting pain medication [MEDICATION(S)] was increased to 30 mg twice daily. Review of the 7/2021 Physician's Orders included the following: -[MEDICATION(S)] 30 mg every 12 hours (initiated 7/27/21) -Oxycodone 5 mg every 4 hours PRN for mild to moderate pain, initiated 5/18/21 -Oxycodone 10 mg every 4 hours PRN for severe pain, initiated 5/18/21 Review of the Pain Care Plan, dated 9/1/21, indicated Resident #64 was at risk for pain related to multiple wounds and included the following interventions: -administer pain medications as ordered -monitor/record/report to the nurse Resident's complaints of pain or requests for pain treatment -notify the Physician if interventions are unsuccessful or if current complaint is a significant change from the Resident's past experiences of pain Review of a Nurse Practitioner Progress Note, dated 9/1/21, indicated Resident #64 had worsening wounds and a new left hip wound. The Resident's PRN Oxycodone was increased to 10-15 mg every 4 hours along with the continued scheduled dose of [MEDICATION(S)] 30 mg twice daily. Review of the Nurse's Note, dated 9/2/21, indicated Resident #64 had worsening wounds, elevated White Blood Cells (WBC- indicate signs of infection) and was transferred to the hospital for evaluation. Review of a Nurse's Note, dated 9/13/21, indicated the Resident was readmitted from the hospital with an intravenous (IV) access site in place. Review of Physician's Orders, dated 9/13/21, included the following: -[MEDICATION(S)] 40 mg every 12 hours -Oxycodone 15 mg every 4 hours PRN Review of the Nurse Practitioner Progress Note, dated 9/14/21, indicated the Resident was transferred to the hospital and was diagnosed with multiple wounds with [CONDITION(S)] and returned on IV antibiotic treatments. The Practitioner indicated in the note that the Resident's pain regimen was adjusted at the hospital and included [MEDICATION(S)] 40 mg twice daily (increased from 30 mg) and Oxycodone 15 mg every 4 hours as needed. The Practitioner indicated in the note that the Resident said he/she was receiving [MEDICATION(S)] (narcotic used to treat moderate to severe pain) prior to wound treatments but was not readmitted with orders for that medication. Review of a Nurse Practitioner Progress Note, dated 9/22/21, indicated that the Resident continued to report sacral and bilateral hip pain and was not receiving the pain medication in a timely fashion. The Practitioner indicated that nursing was made aware of the Resident's concern. Review of a Nurse's Note, dated 10/8/21 at 8:44 P.M., indicated the on-call Practitioner was contacted and gave a one time order for Oxycodone 5 mg from the emergency medication supply while the facility was waiting delivery of additional medications to arrive. The Nurse indicated in the note that the order was obtained for 5 mg as this was the only dose available in the emergency medications. Review of the 10/2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. On 10/21/21 at 12:33 P.M., the surveyor observed the Resident speaking to Nurse #8 stating that it had been four days since he/she had the PRN pain medication and his/her pain was a 15 out of 1-10 scale, and that the fast acting (PRN) medication was more effective in relieving his/her pain than the long-acting medication. Nurse #8 said she obtained a prescription for the medication from the Nurse Practitioner, and it was faxed to the pharmacy on 10/20/21. Nurse #5 said that she would check with the pharmacy about the status of the medication. Review of the 10/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Oxycodone 15 mg PRN doses were not administered on 10/7/21, 10/8/21, 10/17/21, 10/18/21, 10/19/21, 10/20/21 and 10/24/21. During an interview on 10/29/21 at 9:22 A.M., Resident #64 was observed lying in bed on his/her right side. The Resident said he/she was always in pain and that sometimes the pain was astronomical. The Resident said that he/she did not get the PRN Oxycodone medication on time and that when he/she asked for the medication it would be administered two to three hours later. Resident #64 also said that there were times when scheduled medications were administered late as well. The Resident said he/she went numerous days during the prior week without his/her PRN pain medication and was told by the staff that the facility had not received the mediation from the pharmacy. The Resident said that when he/she asked if the facility had access to another pharmacy, he/she was told that the facility utilized one pharmacy. Resident #64 further said that he/she did not think his/her needs were being met. On 11/02/21 at 4:38 P.M., the surveyor observed Resident #64 lying in bed. During an interview at that time, the Resident said that he/she was out of the PRN Oxycodone and the last time he/she had received it was the previous day around 2:00 P.M. During an interview on 11/02/21 at 4:57 P.M., Unit Manager (UM) #2 said that she called in the Resident's PRN Oxycodone order stat to the pharmacy yesterday and that the Resident received the PRN dose from the emergency kit yesterday on the 3:00 P.M. to 11:00 P.M. shift. She further said that the PRN Oxycodone doses had still not been received from the pharmacy. Review of the Emergency Medication Supply Log for Resident #64 indicated 15 mg of Oxycodone were dispensed on 11/1/21 at 4:30 P.M. only. There was no documented evidence to indicate the facility obtained Oxycodone from the Emergency Medication Supply on 10/7/21, 10/17/21-10/20/21 nor on 10/24/21. During an interview on 11/03/21 at 10:41 A.M., the PA said that he was not aware that Resident #64 was out of the PRN Oxycodone on 11/1/21, and was just made aware, and filled out a prescription for the medication. He said that Resident #64 requested the PRN Oxycodone regularly every 4 hours. During an interview on 11/04/21 at 3:55 P.M., the Senior Regional Director of Clinical Operations (SRDCO) said that she reviewed Resident #64's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She further said that the Emergency Medication Log would indicate if the medication was obtained for Resident #64. The SRDCO said that if the Resident requested the PRN Oxycodone regularly every 4 hours, then his/her pain medication regimen was not effective and it should have been reviewed for improved pain management.

Based on records reviewed and interviews, for three of three nursing units, East One, East Two and West Two, during May 1, 2021 through June 1, 2021, the Facility failed to ensure sufficient staffing levels were maintained to meet resident's needs safely and adequately, per their plans of care. The Facility failed to ensure that there was sufficient staffing levels to provide the level of assistance needed for residents with physical limitations, failed to ensure call lights were responded to timely, failed to provide adequate supervision to prevent falls, failed to ensure residents received assistance with feeding for meals, that requests for, as needed, medications where addressed timely and incontinence care needs were met, which resulted in residents becoming upset, feeling uncomfortable while left in soiled briefs, and frustrated due to being unable to obtain assistance from staff for extended periods of time. Findings include: The Facility Policy, titled Staffing, dated 4/2017, indicated that the Facility will: - Provide adequate staffing to meet the care needed and services for our residents. - Maintain adequate staffing on each shift to ensure that our resident's needs and services are met. Nurses are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants (CNAs) are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. - Information will be furnished for the average numbers and types of personnel on each shift to the appropriate state agencies. Review of Resident Council Minutes, date 05/04/21, indicated that the Residents want help from nurses and Certified Nursing Aides (CNAs) on the second floor. Review of the Resident Council Minutes, dated 06/01/21, indicated for old business, that the staffing issue was not resolved and that recruitment of nursing staff was still going on. During an interview on 06/08/21 at 2:30 P.M., The Director of Activities said that the Residents at the 05/04/21 meeting had complaints that there was not enough nursing staff to address their care needs on both the East Two Unit and West Two Unit, and said that the issue had not been resolved at the 06/01/21 meeting. During an interview on 06/08/21 at 1:10 P.M. and at 2:00 P.M., Resident #3 and Resident #4 said that frequently the call bells are not answered and they are left in a dirty (soiled) brief for one to two hours. Resident #3 said being left in a dirty brief is uncomfortable and it smells. Resident #4 said he/she is frequently left in a dirty brief for one to two hours, and when this occurs, he/she feels like a slob. Resident #4 said that during the 11:00 P.M. to 7:00 A.M. shift, when there was not enough nursing staff, he/she has been left in a urine soaked bed for 9 to 11 hours. The Surveyor requested the Facility Assessment, a tool for determining and allocating the needed resources for the delivery of resident care, from the Director of Nurses and Administrator multiple times during the survey on 6/08/21, 6/09/21 and 6/10/21, however this information was not provided. During an interview on 06/09/21 at 11:30 A.M., the Scheduler said that the Facility has been short staffed since 12/2020, that it's been terrible, and it's been a rough road. The Scheduler said there is a shortage of CNAs and weekends are the worse for staffing the units. The Scheduler reviewed staffing schedules from 05/1/21 through 06/01/21 with the Surveyor and said the staffing was based on resident care needs and according to the full-time equivalents (FTEs). The Minimum Data Sheet, Summary of Residents Care Needs, dated 5/21/21, indicated for the 32 residents identified as residing on the East One Unit: - 30 residents required 1 to 2 staff members for assistance with bathing - 30 residents required 1 to 2 staff members for assistance with dressing - 29 residents required 1 to 2 staff members for assistance with transferring - 30 residents required 1 to 2 staff members for assistance with toilet use - 16 residents required staff assistance with ambulation or an assistive device - 14 residents were incontinent of bladder - 17 residents were incontinent of bowel - 5 residents had indwelling catheters Unit East One, to meet resident care needs, per Scheduler, staffing should be as follows: -7:00 A.M. to 3:00 P.M. shift - 2 Nurses and 2 CNAs -3:00 P.M. to 11:00 P.M. shift - 2 Nurses and 2 CNAs -11:00 P.M. to 7:00 A.M. shift - 1 Nurse and 2 CNAs However, review of the East One actual Staffing Schedules (as worked) indicated staffing consisted of: On 05/01/21, to care for 24 residents, - 7:00 A.M. to 3:00 P.M. shift, 2 Nurses and 1 CNA - 3:00 P.M. to 11:00 P.M. shift, 1 Nurse entire shift, 1 Nurse 1/4 of the shift, 1 CNA entire shift, 1 CNA for a 1/4 of the shift - 11:00 P.M. to 7:00 A.M. shift, 1 nurse and 1 CNA On 05/02/21, to care for 25 residents, - 7:00 A.M. to 3:00 P.M. shift, 2 Nurses and 1 CNA - 3:00 P.M. to 11:00 P.M. shift, 1 Nurse entire shift, 1 Nurse for 1/4 of the shift and 2 CNAs On 05/05/21, to care for 28 residents, - 3:00 P.M. to 11:00 P.M. shift, 1 Nurse and 2 CNAs On 05/06/21, to care for 28 residents, - 3:00 P.M. to 11:00 P.M. shift, 1 Nurse and 2 CNAs On 05/14/21, to care for 31 residents, - 7:00 A.M. to 3:00 P.M. shift, 1 Nurse and 2 CNAs On 05/15/21, to care for 33 residents, - 7:00 A.M. to 3:00 P.M. shift, 1 Nurse as 2 CNAs On 05/18/21, to care for 30 residents, - 7:00 A.M. to 3:00 P.M. shift, 2 Nurses and 1 CNA On 05/21/21, to care for 33 residents, - 7:00 A.M. to 3:00 P.M. shift, 1 Nurse and 2 CNAs - 3:00 P.M. to 11:00 P.M. shift, 1 Nurse and 2 CNAs. On 05/24/21, to care for 33 residents, - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA. On 05/29/21, to care for 35 residents, - 7:00 A.M. to 3:00 P.M. shift, 2 Nurses and 1 CNA. During an observation on 06/09/21 at 3:15 P.M. on Unit East One, the Surveyor observed that Resident #5's call bell was sounding, and when the surveyor returned to Resident #5's hallway at 4:10 P.M. (55 minutes later), Resident #5's call bell was still sounding. Review of Resident #5's Admission Minimum Data (MDS), dated [DATE], indicated he/she was cognitively intact. During an interview on 06/09/21 at 4:10 P.M., Resident #5 said that his/her call bell had been sounding for approximately 60 minutes to request muscle spasm medication for leg cramps, but said no-one responded to it. Resident #5 said there is not enough staff to meet his/her needs, and the call bell wait time is usually 45 minutes to 90 minutes. During an interview on 06/08/21 at 3:10 P.M., Unit Manager #1 said on One East during the 7:00 A.M. to 3:00 P.M. shift there are usually two Nurses and two CNAs, with each CNA being assigned to care for 18 residents. Unit Manager #1 said this is a huge workload. During an interview on 06/08/21 at 12:15 P.M., Nurse #1 said on the East One Unit, because of the inadequate staffing, said she cannot pass medications within the required one hour window of the time they are scheduled, which results in the delay of many scheduled medications. Nurse #1 said staffing is poor on weekends, and said this past weekend during the 7:00 A.M. to 3:00 P.M. shift, a Nurse had to work as a CNA, so there was only staff person (a Nurse working as a CNA) to meet the care needs for 37 residents. During an interview on 06/10/21 at 3:00 P.M., Nurse #4 said that on East One when Resident #1 was COVID positive (on 11/17/20), he/she needed to be fed meals, but said they did not have the staff to feed Resident #1 or to monitor his/her intake. Nurse #4 said that there is not enough staff to supervise the residents who are at risk for falls and consequently the number of residents falling have significantly increased. The Minimum Data Sheet, Summary of Residents Care Needs, dated 05/21/21, indicated for the 46 residents identified as residing on the East Two Unit: - 38 residents required 1 to 2 staff members for assistance with bathing - 35 residents required 1 to 2 staff members for assistance with dressing - 34 residents required 1 to 2 staff members for assistance with transferring - 31 residents required 1 to 2 staff members for assistance with toilet use - 19 residents required staff assistance with ambulation or an assistive device - 24 residents were incontinent of bladder - 20 residents were incontinent of bowel - 6 residents had indwelling catheter - 3 with pressure injuries Unit East Two, to meet resident care needs, per Scheduler, staffing should be as follows: - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 3.5 CNAs - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 3.5 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 2 CNAs However, review of the East Two actual Staffing Schedules (as worked) indicated staffing consisted of: On 05/01/21, to care for 43 residents, - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/03/21, to care for 42 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 1.5 CNAs On 05/08/21, to care for 43 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs. - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/09/21, to care for 43 residents, - 7:00 A.M. to 3:00 P.M. shift, 2 CNA and 1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/10/21, to care for 44 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs On 05/15/21, to care for 42 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs On 05/16/21, to care for 41 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 2 CNAs - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs On 05/18/21, to care for 46 residents, - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/21/21, to care for 46 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 1 CNA On 05/24/21, to care for 46 residents, - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/28/21, to care for 44 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 1.5 CNAs On 05/29/21, to care for 44 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 1 CNA - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 1 CNA -11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/31/21, to care for 38 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs On 06/01/21, to care for 40 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs The Minimum Data Sheet, Summary of Residents Care Needs, dated 05/21/21, indicated for the 34 residents identified as residing on the West Two Unit: - 26 residents required 1 to 2 staff members for assistance with bathing - 23 residents required 1 to 2 staff members for assistance with dressing - 22 residents required 1 to 2 staff members for assistance with transferring - 26 residents required 1 to 2 staff members for assistance with toilet use - 8 residents required staff assistance with ambulation or an assistive device - 29 residents were incontinent of bladder - 17 residents were incontinent of bowel - 1 residents had indwelling catheters - 3 residents were identified with pressure injuries Unit West Two, to meet resident care needs, per Scheduler, staffing should be as follows: - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 3 CNAs - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 3 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 2 CNAs However, review of the West Two actual Staffing Schedules (as worked) indicated staffing consisted of: On 05/01/21, to care for 33 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 2 CNAs - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 nurse and 1 CNA On 05/02/21, to care for 33 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/05/21, to care for 32 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 2 CNAs On 05/06/21, to care for 34 residents, - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/07/21, to care for 34 residents, - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/08/21, to care for 34 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 0 (zero) CNAs On 05/09/21, to care for 34 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 2 CNAs - 3:00 P.M. to 11:00 P.M. shift,1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/10/21, to care for 34 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/13/21, to care for 34 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 2 CNAs On 05/14/21, to care for 34 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs On 05/15/21, to care for 34 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 2 CNAs - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/16/21, to care for 34 residents, - 7:00 A.M. to 3:00 P.M. shift, 1.5 Nurses and 2 CNAs - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/24/21, to care for 35 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 05/28/21, to care for 34 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs - 11:00 P.M. to 7:00 A.M. shift, 1 nurse and 1 CNA On 05/31/21, to care for 34 residents, - 11:00 P.M. to 7:00 A.M. shift, 1 Nurse and 1 CNA On 06/01/21, to care for 34 residents, - 3:00 P.M. to 11:00 P.M. shift, 1.5 Nurses and 2 CNAs During an interview on 06/08/21 at 1:30 P.M., Nurse #2 said on the West Two Unit during the 11:00 P.M. to 7:00 A.M. shift, there have been several occasions when there were no CNAs to staff the Unit and only one Nurse. Nurse #2 said most of the residents are incontinent and there are approximately 7 residents that use a mechanical lift to get in/out of bed, which requires two staff members to safely complete the transfer. Nurse #2 said we have a lot of temporary staff who are listed on the schedule, but said they do not show up for work. During an interview on 06/08/21 at 1:30 P.M., Nurse #2 said that on the West Two Unit due to the inadequate staffing, residents needs for assistance with eating did not get met all the time, and said residents needing assistance had to wait longer than the other residents to get their meal. During an interview on 06/09/21 at 7:00 A.M., Nurse #3 said that the West Two Unit is horribly under staffed, and said over the past year the facility has lost so many staff members. Nurse #3 said the bed capacity on West Two is approximately 39 residents and said during the 11:00 P.M. to 7:00 A.M. shift, the unit should be staffed with one Nurse and two Certified Nurse Aides (CNAs), but said there are not enough nursing staff. Nurse #3 said during one of the 11:00 P.M. to 7:00 A.M. shifts, there were no CNAs on West Two and the Facility did not provide any more staff, even after the administrative team was informed that the staffing was inadequate. Nurse #3 said it was not right. Nurse #3 said she could not change everyone, so some of the incontinent residents did not have their soiled briefs changed on the 11:00 P.M. to 7:00 A.M. shift, and remained in soiled briefs for greater than 8 hours. Nurse #3 said the resident care requirements are heavy and the Unit is only adequately staffed with two CNAs only 1/3 of the time. During an interview on 6/10/21 at 4:30 P.M, CNA #2 said that she had been the only CNA that worked the 3:00 P.M. to 11:00 P.M. shift, (which is inconsistent with the Facility staffing Schedule as worked report which indicated 1.5 CNAs were assigned). During an interview on 06/09/21 at 3:00 P.M., Witness #1 said that staffing was horrible, they did not have enough staff to provide supervision to prevent some of the resident falls nor to feed the residents. Witness #1 said residents are frequently found in urine-soaked beds at the start of the shift because there was inadequate staffing on the previous shift to change them. Witness #1 said some of the residents are going hours without needed care, that there is not enough staff to pass extra fluids, and staffing is so short at times they cannot insert the resident's hearing aids or dentures.

Based on records reviewed and interviews for one of five sampled residents (Resident #2), who was assessed as being at increased risk for falls, was a one-person physical assist for ambulation and transfers, the Facility failed to maintain his/her safety to prevent incident/accident. On 09/28/20, Resident #2 had an unwitnessed fall in his/her room and sustained a large arm skin tear, requiring 12 steri-strips to close. On 10/27/20, Resident #2 was left unattended in the bathroom and hit his/her head, no injury occurred. On 01/07/21, Resident #1 had an unwitnessed fall in his/her room and sustained a laceration to his/her finger which required treated with a dressing. On 02/08/21, Resident #2, an another unwitnessed fall, was found on the floor in his/her room, with a laceration to his/her forehead, he/she was transferred to the Hospital Emergency Department for further evaluation and required 6 sutures to close the wound. Findings include: The Facility's Policy titled, Managing Falls and Fall Risk, dated 2017, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes, to try to prevent the resident from falling and to try to minimize complications from falling. The Facility's Policy titled, Accidents and Incidents, Investigating and Reporting, dated 2017, indicated that all accidents or incidents involving residents occurring on the Facility's premises shall be investigated. The Nurse Supervisor or Charge Nurse shall promptly initiate and document the investigation of the accident or incident and submit the original report of the Incident & Accident form to the Director of Nursing (DON) Services within 24 hours of the incident or accident. Resident #2 was admitted to the Facility in September 2020, medical history included a previous fracture of the right humerus from a fall, abnormal gait and mobility with generalized muscle weakness and unsteadiness on his/her feet and [CONDITION(S)]. The Falls Care Plan, dated 09/25/20, indicated Resident #2 was at risk for falls, resident to have a personal alarm at all times, he/she was not to be left alone in the bathroom, and required staff assistance with transfers and ambulation. Review of the Nurse Progress Note, dated 09/28/20, indicated that Resident #2 had an unwitnessed fall, he/she was found on the floor near his/her bed, Resident #2 was attempting to transfer self into a wheelchair and although the call bell was within reach, he/she did not attempt to sound it. The Note indicated Resident #2 had a large skin tear to his/her left arm with a small amount of bleeding. The Note indicated the skin tear measured 10 by 8.5 (the note did not specify if the measurement was in inches or centimeters), and greater than 12 steri-strips (for wound closure) were applied with a dressing. During an interview on 06/10/21 at 9:30 A.M., the Director of Nurses (DON) said there was no documentation to support or indicated if Resident #2's personal alarm was turned on, functioning or sounded at the time of the fall on 09/28/20. Review of Resident #2 Falls Care Plan, updated 09/29/20, indicated additional interventions included to anticipate Resident #2's needs, to keep the call bell within reach at all times and to assist him/her to the bathroom at the first and last rounds during the 11:00 P.M. to 7:00 A.M. shift. Resident #2's Admission Minimum Data Set (MDS), dated [DATE], indicated that he/she was moderately cognitively impaired, was at increased risk for falls, was an extensive assist of one-person for ambulation and transfers, was an extensive assist of two persons with toilet use. The MDS indicated he/she had a history of falls on admission, with a fall in the last two to six months and since his/her admission, had a fall with injury. Review of the Nurse Progress Note, dated 10/27/20, indicated that at 5:00 A.M. Resident #2 stood up unassisted in the bathroom, after a staff member left him/her in the bathroom to retrieve a disposable brief. The Note indicated Resident #2 said he/she hit his/her head on the wall, neurological checks were performed, and the Physician was notified. Review of Resident #2's Falls Care Plan indicated there were no changes or updates to his/her goals or interventions, to help maintain his/her safety. During an interview on 06/10/21 at 3:00 P.M., Nurse #4 said Resident #2 was high fall risk and said the CNA should not have left him/her alone in then bathroom on the toilet. The Physician Progress Note, dated 11/10/20, indicated that Resident #2 had an unsteady gait, was de-conditioned and had a recent fall in his/her room when he/she ambulated without assistance. The Note indicated Resident #2 was ambulatory although unsteady and unsafe, and had a tab alarm in bed and chair. Review of Nurse Progress Note, dated 01/07/21, indicated that at 5:00 A.M. Resident #2's personal alarm was sounding, Resident #2 was found sitting on the floor in his/her room, and his/her 4th finger (left or right hand, not indicated) had a laceration, which was cleansed, and a dressing was applied. Review of Resident #2's Falls Care Plan indicated there were no changes or updates to his/her goals or interventions, to help maintain his/her safety. During an interview on 06/09/21 at 2:10 P.M., the Director of Nursing (DON) said she could not find the Facility's Internal Investigations related to Resident #2's falls for 09/28/20, 10/27/20, or 01/07/21. The DON said there were no changes or new interventions for safety added to Resident #2's falls care plan after he/she sustained falls on 10/27/20 and 01/07/21. Review of Nurse Progress Note, dated 02/08/21, indicated that at 2:30 A.M., a large bang sound was heard from Resident #2's room, Resident #2 was found on the floor in his/her room with the personal alarm sounding. The Note indicated he/she had laceration to the right side of his/her forehead, which was bleeding, pressure was applied to stop the bleeding, a dressing was applied, and Resident #2 was sent to the Hospital. Review of the Fall Investigation dated 02/08/21, at 2:23 A.M. indicated Resident #2 had an unwitnessed fall, his/her personal alarm was heard sounding from his/her room, Resident #2 was found sitting on the floor with a laceration to the right side of his/her forehead. The Investigation indicated prior to the fall Resident #2 was in bed, the call bell was within his/her reach, it was unknown what he/she was doing at the time of the fall and that his/her mobility status was an assist of one person. The CNA's Witness Statement, dated 02/08/21, indicated that Resident #2 was found on the floor around 2:30 A.M., the Nurse and the CNA then helped him/her up off the floor. The Hospital Emergency Department (ED) Note, dated 02/09/21, indicated Resident #2 had a fall when he/she tried to get up from bed and use the bathroom. The ED Note indicated Resident #2 had a forehead scalp laceration, and that six sutures were applied for wound closure.

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to ensure he/she was provided with adequate monitoring of fluid intake, assistance with fluid intake in order to maintain adequate hydration, which resulted in Resident #1 becoming dehydrated and requiring intravenous hydration. Findings include: The Facility Policy titled, Nutritional Assessment, dated 2017, indicated that a nutritional assessment will occur to determine whether the resident's current intake is adequate to meet his or her nutritional needs. Nursing will monitor and have a description of the resident's intake. The Facility's Policy titled, Hydration, dated 2017, indicated that residents will be monitored for significant fluid and electrolyte imbalances appropriately in a timely manner. Review of the Facility's Dietary Intake Record directions indicated that: - For each meal, record the total fluids (in milliliters - ml) the resident consumed in the bottom portion of the box, the fluid intake. - If the resident was offered snacks, indicated refusal or document percentage consumed. Resident #1 was admitted to the Facility in September 2020, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Care Plan, dated 09/17/20, indicated Resident #1's nutrition and fluid intake would be greater than 75% with the intervention to encourage fluids. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated for meals he/she required set up or physical help from the staff, had a mechanically altered diet and had a urinary tract infection. The Care Areas Assessment Summary dated 10/06/20 indicated he/she triggered for being at risk for dehydration and fluid maintenance. The Dietician's Nutritional Assessment, dated 10/19/20, indicated that the Admission Assessment for Resident #1's fluid intake by mouth was greater than 50%, estimated fluid needs were 2,250 milliliters (ml) a day, that he/she was at nutritional risk, to monitor intake of meals, and provide ensure 237 ml twice a day. Review of Resident #1's Nutrition care plan, dated 10/19/20, indicated that he/she required an altered texture diet, complicated by a poor intake. The Care Plan indicated goals included that Resident #1 would have stable weights and would accept 50% of his/her meals. The Care Plan indicated interventions included to monitor and document Resident #1's consumption of meals. Resident #1's laboratory work, dated 10/19/20, indicated a (baseline) blood urea [MEDICATION(S)] (BUN) of 12 milligrams per deciliter (mg/dl) (normal range is 5 to 25 mg/dl) and creatinine 0.85 mg/dl (normal 0.5 to 1.1 mg/dl) - both laboratory tests evaluate for dehydration. Review of Resident #1's Dietary Intake Records, dated 10/2020, for fluid intake in milliliters from 10/15/20 through 10/20/20, indicated that: There were no documented intake values for breakfast. There were no documented intake values for lunch. There were only 3 of 6 documented intake values for dinner. For 6 days (3 meals per day), only 3 of 18 values were documented. For 6 days (3 snacks per day), only 2 of 18 values for snacks were documented. Review of Resident #1's Dietary Intake Records dated 10/2020, for his/her fluid intake for 10/30/20 and 10/31/20, indicated that: There were no documented fluid intake values for breakfast, flow sheet was left blank. There were no documented fluid intake values for lunch, flow sheet was left blank. There were no documented fluid intake values for dinner, flow sheet was left blank. There were no documented values for snacks in the morning, at lunch or at bedtime Review of Resident #1's Physician Order, dated 10/29/20, indicated if he/she required hydration, then intravenous fluids would be an acceptable treatment. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's laboratory work, dated 10/31/20, indicated a BUN of 25 mg/dl (normal range is 5 to 25 mg/dl) and creatinine of 1.15 mg/dl, elevated, (normal 0.5 to 1.1 mg/dl). During an interview on 6/09/21 at 2:20 P.M., the Dietitian said that Resident #1's minimum daily fluid intake need was 1,850 to 2,200. The Dietician said in October 2020, the staff were not monitoring his/her fluid intake for early identification of dehydration and his/her BUN and creatinine levels had increased, which were indicators of insufficient fluid intake and dehydration. Review of Resident #1's Dietary Intake Records dated 11/2020, indicated the fluid intake from 11/01/20 through 11/30/20, indicated that: Review of Resident #1's Dietary Intake Records, for 11/2020, for the fluid intake from 11/01/20 through 11/30/20, indicated that: - 28 out of of 30 days, there were no documented fluid intake values, flow sheet was left blank. - 28 out of 30 days had no documented values for lunch. - 24 out of 30 days had no documented values for dinner. - 6 days, (3 meals per day), only 5 of 18 values were documented. - There were no documented values for snacks in the morning, at lunch or at bedtime. Review of the Dietician's Nutritional Assessment, dated 11/02/20, indicated that on Resident #1's admission assessment his/her food and fluid intake by mouth conflicted and both were indicated as less than 50% and greater than 50%. The Nurse Practitioner's Note, dated 11/06/20, indicated that Resident #1 had limited oral intake today but was drinking well. The Nurse Practitioner's Note, dated 11/09/20, indicated that Resident #1's fluid intake was fair. Review of Resident #1's blood laboratory work, dated 11/20/20, indicated a blood urea [MEDICATION(S)] (BUN) of 38 mg/dl, elevated (normal range is 5 to 25 mg/dl) and creatinine 1.40 mg/dl elevated, (normal 0.5 to 1.1 mg/dl), which were elevated compared to his/her 10/31/20 values. The Nurse Practitioner's Note, dated 11/22/20, indicated that Resident #1's appetite had decreased, and he/she was diagnosed with as being positive for COVID 19. The Nurse Practitioner's Note, dated 11/23/20, indicated that Resident #1 had increased confusion and he/she would not eat or drink. Laboratory work was remarkable for mild dehydration. During an interview on 06/08/21 at 10:47 A.M., Complainant #2 said that Resident #1's ability to eat independently had declined and he/she needed assistance with eating while a resident on The East One Unit and the West Two Unit. Complainant #2 said she observed multiple meals on the East One Unit during which the staff would just deliver the meal tray to Resident #1's room and leave the room without assisting him/her with eating. Complainant #2 said when she asked the staff why Resident #1 was not being fed, said she was told they were working on it, but Resident #1 was still not being fed by staff, even after she complained. During an interview on 06/08/21 at 1:30 P.M., Nurse #2 said that on West Two, due to inadequate staffing levels, residents needs for assistance with eating did not get met all the time. During an interview on 06/10/21 at 3:00 P.M., Nurse #4 said that on East One when Resident #1 was COVID positive (on 11/17/21), he/she needed to be fed meals, but said the Facility did not have the staff to feed Resident #1 or to monitor his/her intake. Review of the Certified Nurse Aide (CNA) flow sheet, dated November 2020, indicated Resident #1 status changed from being independent with eating meals to requiring limited assistance with eating (an assistance of one staff member with eating). However, there was no documentation on the CNA flow sheets to indicate if assistance was provided by staff to Resident #1 with eating on the following dates: - 11/12/20 and 11/13/20 - breakfast, lunch, and supper (6 meals), flow sheet was blank - 11/20/20 - lunch and supper (2 meals), flow sheet left blank - 11/21/20 - breakfast, lunch, and supper (3 meals), flow sheet left blank - 11/24/20 through 11/30/20 - breakfast, lunch, and supper (18 meals), flow sheet left blank For a total of 29 meals in 10 days with no supporting documentation. During an interview on 06/10/21 at 9:00 A.M., the MDS Nurse said that on the CNA flow sheets, limited assistance means staying with the resident with meals as a one person assist with meals. The MDS Nurse said that Resident #1's CNA flow sheets for November 2020 and December 2020 had multiple blanks, where the eating assistance should have been documented. The Nurse Practitioner's Note, dated 12/02/20, indicated he/she was being cared for on the COVID positive unit, and for nursing to monitor his/her fluid intake due to the adverse effect of a COVID infection. Review of Resident #1's Dietary Intake Records, dated 12/2020, for the fluid intake from 12/01/20 through 12/08/20, indicated that: - 2 out of 8 days documented, as refused breakfast. - 2 out of 8 days documented, as refused lunch. - 8 out of 8 days with no documented values (for all meals, fluid intake, snacks) all were left blank. - 8 days, (3 meals per day) only 4 of 24 fluid intake values were recorded. The Nurse Practitioner's Note, dated 12/08/20, indicated he/she had very poor fluid intake and she had a discussion with Health Care Agent to start intravenous fluids for dehydration. Resident #1's blood laboratory work, dated 12/10/20, indicated a blood urea [MEDICATION(S)] (BUN) of 48 mg/dl, elevated (normal range is 5 to 25 mg/dl) and creatinine 1.27 mg/dl elevated, (normal 0.5 to 1.1 mg/dl), which was indicative of dehydration. During an interview on 06/08/21 at 10:47 A.M., Complainant #2 said that by the time the Facility finally decided to give Resident #1 intravenous fluids, because staff had not been assisting him/her with drinking fluids on his/her meal trays, she believed the lack of fluids had gone on too long, for him/her to recover. During an interview on 06/09/21 at 2:20 P.M., the Dietitian said, that based on review of Resident #1's Dietary Intake Records, dated 10/2020, 11/2020 and 12/2020, that staff did not fill them out well, and that this documentation is needed to monitor and identify dehydration and early fluid needs, as care planned.

Based on observation, record review, and staff interviews, the facility failed to follow the plan of care for 2 residents, (#6 and #24) out of a total sample of 24 residents. Findings include: 1. For Resident #24, the facility failed to provide working pressure alarms, as care planned. The facility failed to provide the correct alarm, as care planned. The resident fell and experienced two fractures. Resident #24 was admitted to the facility in August of 2014, with [DIAGNOSES REDACTED]. The falls care plan of 8/14/14 identified the resident as having a history of falling. The care plan interventions included: Resident to wear eye glasses. Encourage rising slowly and using a platform walker when ambulating. Utilize a pressure pad alarm to bed and chair. Remind not to ambulate/transfer without assistance, keep call light within reach and remind resident to use. Keep personal items within reach, proper footwear to be worn, clutter free environment and toilet with every request. Remind to use call bell. Review of the nurse's note of 8/30/14 indicated the resident fell on [DATE] at 8:50 P.M.. Review of the investigation into this fall indicated the resident fell in his/her room. There was no indication that the alarm sounded, as planned. Review of the nurse's note and falls investigation of 10/15/14 indicated the resident fell out of bed at 5:00 A.M., and fractured his/her right hip, requiring hospitalization and surgery. The falls investigation indicated a Tabs alarm was in place, and not the bed pressure alarm, as care planned. Review of the nurse's note of 11/14/14 indicated the resident was found on the floor in the resident's bathroom at 6:00 A.M. The note indicated the bed pressure alarm was not sounding, as planned. Review of the nurse's note of 12/10/14 indicated that the resident was found on the floor at 2:45 P.M. The investigation into the fall indicated the pressure alarm did not sound, as planned. The resident sustained [REDACTED]. During interview on 4/6/15 at 12:50 P.M., the Corporate Nurse said that the facility staff was educated on falls in 10/2014. During interview on 4/6/15 at 12:50 P.M., the Corporate Nurse did not have a response to inquiries concerning malfunctioning alarms. Please refer to F323. 2. For Resident #6, the facility failed to ensure the resident wore slipper socks, as planned. Resident #6 was admitted to the facility in 1/2013 with [DIAGNOSES REDACTED]. Review of a current plan of care originally dated 1/22/13, and updated on 1/2/15, indicated that the resident had a history of [REDACTED]. - Encourage to call for assistance if feeling weak, - Resident may also self toilet as needed, - Encourage out of room activities, - Encourage to use environmental devices such as hand grips, hand rails, etc., - Slipper socks at night (1/22/15), - Offer toileting before and after meals, on rounds, and as needed (1/22/15). Review of a nursing note dated 3/8/15 indicated that at 11:15 P.M., the resident was found sitting on the floor next to the wheelchair in his/her room. The resident was attempting to self transfer to the toilet and slipped, had regular socks on, instead of non skid socks as care planned. The resident sustained [REDACTED]. The staff were re-educated regarding the application of non skid socks at bedtime. During interview on 4/2/15 at 4:50 P.M., with the Director of Nursing, she said that the resident did not have slipper socks on as care planned when he/she fell on [DATE].

Based on record review and staff interviews, the facility failed to provide adequate supervision and effective interventions/devices to prevent accidents for 1 of 9 applicable residents (# 24), out of a total sample of 24 residents. Resident #24, experienced 7 unwitnessed falls in six months. Two of the falls resulted in fractures. Resident #24 was admitted to the facility in August of 2014, with [DIAGNOSES REDACTED]. Review of the Admission Assessment of 8/5/14 indicated the resident had experienced 1 or 2 falls in the three months, prior to admission. Review of the admission nurse's note of 8/5/14, indicated the resident had decreased safety awareness. A tabs alarm was placed on the resident. This note indicated the resident was attempting to cut the tabs alarm with a nail clipper and attempted to climb out of bed, requiring redirection. Review of the nurse's note of 8/6/14 indicated the resident was found on the floor and that the tabs alarm was not attached. This note indicated the resident removed the tabs alarm. Review of the investigation of this fall indicated the fall occurred at 11:00 P.M., in the resident's room. The cause of the fall was determined to be the resident's non-compliance, as the resident removed the tabs alarm and did not ring his/her call bell, before attempting transfer to the bathroom. The investigation also indicated the room was dark. The investigation did not indicate any new interventions were put in place to prevent further falls. Review of the nurse's note of 8/7/14 indicated the resident "takes alarm off to self transfer, was unable to re-direct secondary to dementia". The nurses' notes of 8/8/14 and 8/11/14 indicated the resident continued to remove the alarm and attempted to self transfer. Review of the Minimum Data Set (MDS) assessment of 8/12/14 identified the resident as utilizing eye glasses; requiring extensive assistance during transfers, ambulation, and toileting. The resident was coded as being moderately impaired in cognition with a BIMS (Brief Interview of Mental Status) score of 9 of 15. The resident was coded as having falls since admission. The falls care plan of 8/14/14 identified the resident as having a history of falling. The care plan interventions included: Ensure resident wears eye glasses. Encourage rising slowly and use of a platform walker when ambulating. Utilize a pressure pad alarm to bed and chair. Remind not to ambulate/transfer without assistance, keep call light within reach and remind resident to use. Keep personal items within reach, proper footwear to be worn, clutter free environment and toilet with every request. Remind to use call bell. The care plan did not include a tabs alarm as an intervention. Review of the nurse's note of 8/30/14 indicated the resident fell (on 8/29/14 at 8:50 P.M.). There was no nurse's note on 8/29/14 when the resident fell . Review of the investigation into this fall indicated the resident fell in his/her room. This investigation indicated the staff heard someone calling for help and found the resident sitting on the floor in the bedroom. There was no indication that the alarm sounded. The cause of the fall was determined to be the resident's non-compliance. The investigation indicated the resident is confused, with an unsteady gait and was unaware of need to call for assistance. Safeguards to prevent the reoccurrence of falls included "Pressure pad tested and functioning. Non skid socks on". The interventions of reminding the resident to use the call bell before getting out of bed continued in the care plan despite the resident's persistent demonstration of attempting to get up without utilizing the call bell. Review of the nurses' notes of 9/2/14 to 10/9/14 indicated the resident continued to attempt self transfer and had an unsteady gait. No new interventions were added to the care plan in an attempt to prevent accidents. Review of the nurse's note of 10/15/14 indicated the resident fell at 5:00 A.M., and was complaining of right hip and knee pain. The physician was notified and the resident was transferred to the hospital. This note indicated the resident was admitted to the hospital with [REDACTED]. Review of the investigation into the fall of 10/15/14 indicated the resident was found on the floor in the resident's room, after staff heard a noise ("boom"). This investigation indicated the resident removed the tabs alarm and self transferred. This investigation indicated no pressure alarm was in place, as care planned. This review did not indicate if proper footwear and eyeglasses were in place, at the time of the fall. Additionally, the investigation concluded, inaccurately, that this was the first fall the resident had in the facility and reported to the Department of Public Health that this was the resident's first fall. The resident returned to the facility on [DATE] following surgical repair of the right hip. Review of the 10/27/14 Significant Change MDS indicated the resident was now coded to be severely impaired in cognition with a BIMS score of 3 out of 15. The resident now used a wheelchair for locomotion and was coded as having had a fall with major injury. No other changes were made to the MDS. The Care Plan to prevent falls of 8/14/15 was continued without change, except that the resident was now receiving physical and occupational therapy. Review of the nurse's note of 11/9/14 indicated the resident removed the alarms and transferred self back to bed. The resident was reminded not to transfer self (despite a BIMS of 3 out of a possible 15, indicating severe cognitive impairment). Review of the nurse's note of 11/14/14 indicated the resident was found on the floor in the resident's bathroom. This note indicated the bed pressure alarm was not sounding. Review of the investigation into this fall indicated the resident fell at 6:00 A.M., in the bathroom. This investigation indicated the resident moved his/her over the bed table into the bathroom, and fell . The investigation indicated that the resident did not use the call bell before transferring out of bed and slipped in water, on the bathroom floor. The alarm did not sound. The causal factor was determined to be the resident's non-compliance. The investigation did not indicate if the resident's glasses were on and if proper footwear was worn, at the time of the fall. Review of the nurse's note of 12/5/14 indicated the resident was found of the floor in his/her room at 6:45 A.M. The alarm was sounding No injuries were noted but the resident indicated he/she had hit his/her head. Review of the investigation indicated the resident transferred self to go to the bathroom. There is no mention of whether or not the resident had glasses on and if proper footwear was worn, as planned, at the time of the fall. Review of the nurse's note of 12/10/14 indicated the resident "was confused per baseline". The note indicated that the resident's roommate was heard yelling that the resident was on the floor. The resident was noted to have a bruise on the upper left leg, a hematoma on the right side of the head, and the top of the left hand had a purple bruise. Review of the investigation into the fall indicated the fall occurred at 2:45 P.M., and the pressure alarm did not sound. No new interventions were added to the care plan despite the demonstrated ineffectiveness of the resident's alarm. The investigation did not indicate if the resident had eye glasses on and if proper footwear was worn, at the time of the fall. Review of the nurse's note of 12/10/14 indicated that after the fall the resident continued to attempt to transfer out of bed without assistance. Review of the nurse's note of 12/11/14 indicated the resident's right hand was bruised with swelling and the resident was complaining of discomfort. The physician was notified and ordered an X-Ray of the right wrist. The results indicated an "acute wrist fracture" of the right wrist. The resident was transferred to the hospital for treatment. A splint was placed on the resident's right wrist/arm and a referral to a surgeon was provided to the resident. The resident was transferred back to the facility on [DATE]. Review of the investigation (into the fall of 12/10/14) did not indicate if the resident's glasses were on and proper footwear was worn, at the time of the fall. Review of the Incident Report Form, provided by the facility, as part of the investigation into the fall of 12/10/14, indicated that corrective measures would include adding a bed pad alarm to the care plan. However, the pad/pressure alarm had already been part of the care plan (since 8/14/14). Review of the nurse's note of 12/31/14 indicated the resident was found on the floor, at 6:20 A.M. The alarm was sounding. The investigation into this fall indicated the resident attempted to transfer out of bed, without assistance. During interview on 4/6/15 at 12:50 P.M., with the Assistant DON, the DON, and the Corporate Nurse, the ADON said that the facility could have put other interventions in place to prevent the falls such as getting the resident out of bed earlier, keeping the resident in a more supervised area, removing items that create a hazard from the resident's room. The ADON said the Tabs alarms did not work for this resident. The Corporate Nurse said that the fall of 10/15/14 was inaccurately assessed to be the first fall the resident experienced, while in the facility, and said the pressure alarm was already care planned to be on the bed when the resident fell on [DATE]. The Corporate Nurse said the facility staff were educated regarding falls in 10/2014.

Based on observation, record review and interview, the Facility failed to ensure that 2 of 12 Residents with falls (#2 and 19) received adequate supervision and assistance devices to prevent accidents, in a total sample of 24. Findings included: 1. For Resident #2 (who was exhibiting signs of delirium, delusions and hallucinations), the facility failed to provide adequate assistance devices and supervision to prevent a fall with new femoral fracture and displacement of hardware. Resident #2 was admitted to the Facility 2/12, discharged to the Hospital one day later due to a fall and new fracture, and then readmitted to the Facility in 2/12, 5 days later. Resident #2 had the following admission Diagnoses: [REDACTED]. The Hospital Transfer Summary of 2/13/12 indicated that the resident had multiple medical problems, newly diagnosed diabetes mellitus and dementia. Minimize narcotics. The Admission Nursing Assessment of 2/17/12 indicated that the Resident was alert and confused, and was weight bearing as tolerated. The Fall Risk Assessment of 2/17/12 indicated a score of 15 (total score of 10 or above represents High Risk). The High Risk For Falls/Admission Checklist of 2/17/12 included: Resident oriented to call light use. Remind Resident to ask for assist with transfers and toilet use. Educate family not to leave Resident alone and tell staff when leaving. No personal alarm. Ensure Resident has proper footwear. Star on door by Resident name plate. Educate resident regarding use of walker. Provide commode or bedpan if needed. The Medication Record of 2/12 indicated the Resident received Oxycodone 5 milligrams (opioid/narcotic) by mouth at 4:00 P.M. for right hip pain. Nurse's Notes of 2/17/12 at 11:15 P.M. indicated that the Resident was confused and found digging at the right hip incision. The Resident had bloody drainage on the right hand and under fingernails. The Resident was transferred to the emergency room for dehiscence of the right leg incision. Nurse's Notes of 2/18/12 at 1:20 A.M. indicated that the Resident returned to the Facility extremely confused. The Resident attempted to pull out the indwelling Foley catheter and "was stripping in bed." The Resident stated: "he/she going to the garage, and please don't break my bicycle." The Resident complained of hip pain, and received Oxycodone 5 milligrams by mouth at 1:30 A.M. The Medication Record of 2/12 indicated the Resident received Oxycodone 5 milligrams by mouth on 2/18/12 at 8:00 A.M. for right hip pain. The Occupational Therapy Evaluation of 2/18/12 included the following Precautions/Complications: fall risk, very confused, right hip status [REDACTED]." Patient hallucinating dog in room throughout evaluation." The Physician's Progress Note of 2/18/12 included: Alert and oriented times one only, mental status change, check urinalysis and culture and sensitivity, monitor laboratory work, and avoid opioids due to dementia. The Physician Communication and Progress Note of 2/18/12 indicated that at 1:35 P.M., the Resident was found lying on the floor on right side. The Resident complained of severe pain to the right hip and upper leg. The Resident had increased confusion and was delusional. The Resident stated: he/she was climbing a ladder and fell off. The Resident was transferred to the emergency room and admitted to the hospital. The Event/Incident Report and Falls Investigation/Post Fall assessment of 2/18/12 indicated that the Resident was found lying on the floor on right side next to the wheelchair. The Location was listed as Resident room. The Cause was listed as Resident health/mental status. Root cause: self transfer out of wheelchair due to increased confusion - delusions. The Hospital Discharge Summary of 2/23/12 indicated that the Resident was admitted to the Hospital after sustaining a fall at the Facility. Imaging showed a right femoral neck fracture with displacement of hardware in the recently repaired hip. The Resident under went a second surgery to repair the right hip. Nurse's Notes of 2/23/12 indicated that the Resident was readmitted to the Facility. The admission Minimum Data Set assessment of 3/1/12 indicated that the Resident had short term memory loss, had moderately impaired cognitive skills for daily decision making, required assist of 2 for transfers, did not ambulate, required supervision with meals and had a fracture related to a fall in the 6 months prior to current admission. Observation, on 4/24/12 from 12:20 P.M. to 12:40 P.M., found the Resident sitting in a wheelchair in the bedroom. There was a bedside table placed in front of the Resident, and the Resident was eating lunch. There was a personal alarm on the back of the wheelchair, and the cord was clipped to the Resident's shirt. On 4/24/12 at 3:50 P.M., the Assistant Director of Nurses (ADON) indicated that he/she was off the weekend Resident #2 fell . The ADON said that if staff had called her to report the Resident's increased confusion and delirium (digging at incision, delusions, hallucinations), he/she would have advised staff to implement new fall risk interventions. 2. For Resident #19, the facility failed to provide effective interventions and adequate supervision to prevent falls in order to provide an effective falls intervention program for this resident who was easily distracted and had severely impaired cognition. Findings included: Resident #19, with [DIAGNOSES REDACTED]. Review of an Annual MDS (Minimum Data Set) Assessment completed on 10/3/11 identified the resident as having severe cognitive impairment; adequate vision with glasses; difficulty focusing attention/easily distracted; little interest or pleasure in doing things; required extensive assistive assist of two for transfers, utilized a wheelchair, (required limited assistance of one person/physical assist for locomotion in the wheelchair on and off the unit); was totally dependent for hygiene and bathing; continent of bowel and bladder; and had no falls. The plan of care for falls (originally dated 11/19/10 and updated on 10/2/11 to discontinue bed and chair alarms), indicated the resident was at risk for falls related to: right BKA and left AKA; the necessity for extensive assistance from staff for mobility and transfers; and risk of declining vision due to diabetic retinopathy. Interventions included: - Assure resident is wearing eyeglasses. Keep eyeglasses clean and in good repair. FYI (for your information) does not always wear eyeglasses. - Continue to remind resident not to transfer without staff assistance. - Keep call light in reach at all times. Keep personal items and frequently used items within reach. -PT (Physical Therapy) and OT (Occupational Therapy) screen PRN (as needed). - Report any eye pain or vision changes to MD (Medical Doctor). - Vision exam as needed Review of the 11/1/11 Nurse's Note revealed that the resident experienced an unwitnessed fall (in hallway), at 12:00 P.M. The resident sustained [REDACTED]. Review of the investigation indicated that Dycem would be added to the wheelchair to prevent reoccurrence and that it was added to the fall care plan. Review of a Quarterly MDS Assessment completed on 10/3/11 remained basically the same, the resident continued to have difficulty focusing attention/was easily distracted and was identified as having one fall with no injury since the last assessment. Review of the 2/19/12 Nurse's Note indicated that a member of the rehabilitation staff called the resident's unit and indicated the resident was sitting in the lobby in the wheelchair and fell asleep and almost tipped out of the wheelchair, "...but therapist was able to prevent it." Resident was assessed for injury and no injury noted. Review of the 3/3/12 Nurse's Note indicated that at 9:25 A.M. the resident was found sitting on the floor next to the bed. The resident stated that he/she was trying to stand up to transfer from the bed to ambulate to the bathroom and he/she forgot that he/she had no feet. No injuries were sustained from the fall. The resident was reminded to use the call bell, despite the resident's severe cognitive impairment. The care plan was updated to include to offer toileting before breakfast. Review of an Investigation dated 3/3/12 indicated the resident experienced a second fall at 4:35 P.M. The fall was unwitnessed, in the resident's room, and the resident was found sitting on the floor by the bed indicating he/she wanted to get up out of bed. The resident's wheelchair was in the hallway. The plan of care was updated to get the resident up out of bed at the change of shift 7-3 (7:00 A.M. -3:00 P.M.) and 3-11 (3:00 P.M. - 11:00 P.M.). The resident sustained [REDACTED]. Review of the 3/19/12 Nursing Note indicated the resident was found on the floor in the resident's bathroom with no injuries identified. The resident stated he/she crawled to the bathroom (7:00 A.M. - 3:00 P.M. shift). During discussion with the DON (Director of Nursing) on 4/26/12 at 5:00 P.M., she said that the resident had been in the wheelchair prior to finding him/her on the floor in the bathroom. The DON also said an investigation/event report had not been completed because this was not considered a fall. Review of a Quarterly MDS Assessment completed on 3/19/12 remained basically the same, the resident continued to have difficulty focusing attention/was easily distracted and was identified as having two or more falls (2) falls with no injury since the last assessment. Review of a Nursing Note of 4/3/12 indicated that the nurse was paged "STAT" (urgent/rush) to the first floor recreation hallway, to find the resident lying on the floor on his/her right side. The resident stated he/she fell asleep and fell out of the wheelchair and was complaining of discomfort to the right buttock/hip. The resident was moving the right leg with no complaints of pain. The fall was unwitnessed, and the resident denied hitting his/her head. The plan of care was updated to have staff encourage the resident to return to the unit after supper. The surveyor observed the resident on 4/26/12 at 3:30 P.M. The resident was sitting upright in the wheelchair in his/her room watching television. During discussion with the DON on 4/26/12 at 5:00 P.M., she acknowledged that the resident had four falls between 11/1/11 and 4/3/12. The DON also said that the resident used to have bed and chair alarms; however, they were discontinued on 10/2/11, and no other interventions were put into place. The resident fell again on 11/1/11. The surveyor also discussed with the DON how on 2/19/12, the Therapist had to intervene after the resident fell asleep in the wheelchair in the lobby (to keep the resident from tipping onto the floor), and how on 4/3/12, the resident had an unwitnessed fall in the first floor recreation hallway when falling asleep in the wheelchair and falling to the floor. The DON said that PT (Physical Therapy) looked at the cushion and a different chair following the fall of 4/3/12; however, no other appropriate chair was available for the resident.

Based on record review and interview, for 1 of 3 sample residents (Resident #1), the Facility failed to provide sufficient fluid intake to Resident #1, to maintain proper hydration when: - Resident #1, who was being treated with antibiotics for a urinary tract infection when admitted , was not placed on intake and output measurement (I&O) for 72 hours per Facility policy; - 5 days after admission, Resident #1 was placed on I&O for 4 days, off for 4 days and back on for 6 days and had an oral fluid intake that did not on any day meet the assessed dietary fluid requirements; and - the Physician was not notified when the intake was below 1500 cubic centimeters (cc) per day, per the Facility policy. Resident #1 sent to the Hospital for scheduled hip surgery on 3/28/11 and a decline in condition was noted. Resident #1 presented with unresponsiveness, lethargy, dry mucous membranes, and poor skin turgor. The surgery was cancelled and Resident #1 was admitted to the Hospital for treatment of [REDACTED]. The findings included: The face sheet indicated that Resident #1 was admitted to the facility on [DATE]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The physician progress notes [REDACTED]. The admission dietary assessment, dated 3/14/11, indicated that Resident #1's daily fluid requirement was 1575 cc to 1890 cc. The physician progress notes [REDACTED].#1 was "taking po (oral intake)". The intake record for Resident #1, initiated on 3/16/11 (5 days after admission), indicated that Resident #1's intake on 3/16/11 was 1260 cc. The intake record for Resident #1 dated 3/17/11 through 3/19/11 (when it was discontinued) indicated Resident #1's intake was as follows: 3/17/11 - 1260 cc 3/18/11 - 1140 cc 3/19/11 - 960 cc Resident #1 did not meet the minimum fluid requirement of 1575 cc on any day from 3/16/11 through 3/19/11. The physician progress notes [REDACTED].#1 was confused. There was no documentation relative to Resident #1's fluid intake. The intake record for Resident #,1 initiated on 3/23/11, indicated the following intake for Resident #1: 3/23/11 - 960 cc 3/24/11 - 940 cc 3/25/11 - 960 cc 3/26/11 - 540 cc 3/27/11 - 590 cc 3/28/11 - 240 cc Resident #1 did not meet the minimum fluid requirement of 1575 cc on any day from 3/23/11 through 3/28/11. The care plan, dated 3/24/11, developed to address Resident #1's risk for dehydration related to diuretic use and urinary tract infection indicated that fluids should be encouraged up to 1890 cc per day, Resident #1 should be monitored for a decline in mental status or decline in intake and the decline should be reported to the Physician. A nurse's note, dated 3/26/11, indicated that Resident #1 ate 10% of dinner and drank sips of fluid. Nurse's notes, dated 3/11/11 through 3/26/11, did not indicate that the physician was notified of Resident #1's declining intake. A nurse's note, dated 3/27/11, indicated that Resident #1 was lethargic, refused lunch and drank 120 cc of fluid. The note indicated that the physician was notified of Resident #1's condition. A nurse's note, dated 3/28/11, and written as a late entry for 3/27/11 at 10:00 AM, indicated that certified nurse aide staff reported that Resident #1 had a decreased fluid intake. The note indicated that Resident #1 refused morning medications. The note indicated that Resident #1 drank 60 cc of fluid. The note indicated that the Physician was notified of the medication refusal and Resident #1's scheduled surgery on 3/28/11. . A nurse's note, dated 3/28/11, indicated Resident #1 was transferred to the Hospital for a scheduled surgery and documentation of Resident #1's increased weakness, poor oral intake and change in mental status was sent with Resident #1. The Hospital history and physical note, dated 3/28/11, indicated that when Resident #1 arrived at the Hospital for a scheduled surgery, Resident #1 was unresponsive with a rapid heartbeat and rapid respirations. The history and physical indicted that Resident #1's skin turgor was diminished, the mucous membranes were very dry and a significantly elevated the BUN (blood urea nitrogen - blood test to measure kidney function). The note indicated that the change in mental status was most likely due to underlying urosepsis and dehydration. Nurse #1 was interviewed on 4/20/11 at 12:20 PM. Nurse #1 said that Resident #1's appetite and fluid intake were always poor. Nurse #1 said that Nurse #1 was not sure if residents were automatically placed on intake and output measurement when admitted to the Facility. Nurse #2 was interviewed on 4/20/11 at 2:15 PM. Nurse #2 said that Resident #1 had a poor appetite and poor fluid intake. Nurse #2 said that Nurse #2 did not notify the Physician because Nurse #2 thought the Physician was aware. Nurse #2 said that Nurse #2 did not think that residents were automatically placed on intake and output measurement on admission to the Facility. Nurse #3 was interviewed on 4/20/11 at 2:40 PM. Nurse #3 said that Nurse #3 did not recall Resident #1. Nurse #3 said that if a residents intake is poor, the physician should be notified and was not sure if residents were put on intake and output measurement when admitted to the Facility. The Physician was interviewed on 4/20/11 at 2:25 PM. The Physician said that the Physician was not made aware of Resident #1's poor intake. The Director of Nursing (DON) was interviewed on 4/20/11 at 7:30 AM. The DON said that Resident #1 had been lethargic most of the time at the Facility and that during the last few days at the Facility, Resident #1's intake was poor. The DON said that new admissions to the Facility are automatically placed on intake and output measurement for 72 hours. The Facility policy relative to Hydration indicated that each resident will be placed on intake and output measurement when admitted to the Facility, for a period of 72 hours. The policy indicted that if the intake and output are appropriate, the measurement will be discontinued. The policy indicated that the 24 hour intake and output totals would be reviewed every morning and reported to the Physician if intake is less than 1500 cubic centimeters (cc) on 3 consecutive days.

Based on record review and interview, for 1 of 3 sample residents (Resident #1), the Facility failed to provide services which met the professional standards of quality when Resident #1 was not placed on intake and output (I&O) measurement for 72 hours after admission per Facility policy; and 5 days after admission, Resident #1 was placed on I&O measurement and although Resident #1's fluid intake on every day documented was less than the assessed daily dietary fluid requirements, the Physician was not notified of Resident #1's poor intake per the Facility policy. The findings included: The Facility policy relative to Hydration indicated that each resident will be placed on intake and output measurement when admitted to the Facility, for a period of 72 hours. The policy indicted that if the intake and output are appropriate, the measurement will be discontinued. The policy indicated that the 24 hour intake and output totals would be reviewed every morning and reported to the Physician if intake is less than 1500 cubic centimeters (cc) on 3 consecutive days. The face sheet indicated that Resident #1 was admitted to the facility on [DATE]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The admission dietary assessment, dated 3/14/11, indicated that Resident #1's daily fluid requirement was 1575 cc to 1890 cc. The physician progress notes [REDACTED].#1 was "taking po (oral intake)". The intake record for Resident #1, initiated on 3/16/11 (5 days after admission), indicated that Resident #1's intake on 3/16/11 was 1260 cc. The intake record for Resident #1 dated 3/17/11 through 3/19/11 (when it was discontinued) indicated Resident #1's intake was as follows: 3/17/11 - 1260 cc 3/18/11 - 1140 cc 3/19/11 - 960 cc Resident #1 did not meet the minimum fluid requirement of 1575 cc from 3/16/11 through 3/19/11. The physician progress notes [REDACTED].#1's fluid intake. The intake record for Resident #1, initiated on 3/23/11, indicated the following intake for Resident #1: 3/23/11 - 960 cc 3/24/11 - 940 cc 3/25/11 - 960 cc 3/26/11 - 540 cc 3/27/11 - 590 cc 3/28/11 - 240 cc Resident #1 did not meet the minimum fluid requirement of 1575 cc from 3/23/11 through 3/28/11. Nurse's notes, dated 3/11/11 through 3/26/11, did not indicate that the physician was notified of Resident #1's intake. Nurse #1 was interviewed on 4/20/11 at 12:20 PM. Nurse #1 said that Resident #1's appetite and fluid intake were always poor. Nurse #1 said Nurse #1 was not sure if residents were automatically placed on intake and output measurement when admitted to the Facility. Nurse #2 was interviewed on 4/20/11 at 2:15 PM. Nurse #2 said that Resident #1 had a poor appetite and poor fluid intake. Nurse #2 said that Nurse #2 did not notify the Physician because Nurse #2 thought the Physician was aware. Nurse #3 was interviewed on 4/20/11 at 2:40 PM. Nurse #3 said that Nurse #3 did not recall Resident #1. Nurse #3 said that if a residents intake is poor, the physician should be notified and was not sure if residents were put on intake and output measurement when admitted to the Facility. The Physician was interviewed on 4/20/11 at 2:25 PM. The Physician said that the Physician was not made aware of Resident #1's poor intake. The Director of Nursing (DON) was interviewed on 4/20/11 at 7:30 AM. The DON said that Resident #1 had been lethargic most of the time at the Facility and that during the last few days at the Facility, Resident #1's intake was poor. The DON said that new admissions to the Facility are automatically placed on intake and output measurement for 72 hours. Please refer to F 327.