Every finding on record at St Joseph Rehab & Nursing Care Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively impaired, required staff assistance to meet his/her daily care needs, and was known to be resistant during care, the Facility failed to ensure that Resident #1 was treated in a dignified and respectful manner. On 6/08/26, Certified Nurse Aide (CNA) #1 reported that while assisting CNA #2 to provide care to Resident #1, that in response to the residents' resistant behavior, who was combative and yelling at them to stop, that CNA #2 responded in an aggressive, rough and disrespectful manner, did not stop as requested and continued until completing his/her care.Findings Include: Review of the Facility's Residents' Rights Policy, revised 08/06/24, indicated that each resident has the right to a dignified existence, self-determination, communication with and access to persons and services inside and outside the Facility. The policy further indicated that Facility staff are responsible for protecting and promoting the rights of each resident. Resident #1 was admitted to the Facility in February 2024 with diagnoses that included metastatic prostate cancer, malignant neoplasm of the prostate, thoracic spinal stenosis, hypertension, weakness, osteoporosis, and cognitive communication deficit. Review of Resident #1's most recent Minimum Data Set (MDS) assessment, dated 06/02/26, indicated Resident #1 was cognitively impaired and required staff assistance to meet his/her care needs. Review of the Facility's Internal Investigation, dated 06/08/26, indicated CNA #1 reported that while assisting CNA #2 with incontinent care, Resident #1 swatted at CNA #2. The Investigation indicated CNA #1 reported that CNA #2 then grabbed Resident #1's arm and struck him/her near the right wrist. The Investigation further indicated that after care was completed, CNA #1 immediately reported the incident to the Nurse Supervisor and Nurse #1, and CNA #2 was immediately removed from resident care. The Internal Investigation indicated that the Nurse Supervisor and Nurse #1 immediately assessed Resident #1. Resident #1 had no visible bruising, discoloration, or swelling. The Internal Investigation further indicated that on 06/09/26, around 8:30 A.M., the Director of Nursing (DON) and the Administrator interviewed Resident #1. Resident #1 identified the male CNA (identified as CNA #1) as gentle and stated that the female CNA (identified as CNA #2) was mean, mean, mean, was rough, moved too fast, grabbed his/her right arm, and twisted it. Review of CNA #1's Written Witness Statement, dated 06/08/26, indicated CNA #2 requested assistance with providing incontinent care to Resident #1. The Statement indicated CNA #1 lowered the head of the bed, removed the positioning pillows, removed Resident #1's pants, and observed that Resident #1 was soiled. CNA #1's statement indicated that CNA #2 was wiping Resident #1 roughly and that he (CNA #1) told her to slow down and be gentle; however, she (CNA #2) continued providing care. CNA #1's Statement also indicated that when CNA #2 turned Resident #1 onto his/her side, she was extremely rough while grabbing Resident #1's arm and the bed sheets. CNA #1 Statement indicated that Resident #1 raised his/her hand and that CNA #2 grabbed Resident #1's arm and that he thought CNA #2 struck Resident #1 on the hands several times. During a telephone interview on 07/23/26 at 3:05 P.M., CNA #1 declined to discuss the incident and said he was leaving for vacation and would not be returning until 07/30/26. The Surveyor was unable to interview CNA #1 as he did not respond to the Surveyors multiple follow-up telephone calls or voices messages left for him to arrange for an interview. During an interview on 07/21/26 at 12:50 P.M., the Social Worker (SW) said that on 06/09/26, she interviewed Resident #1 regarding the incident. The SW said Resident #1 was able to recall some of the incident and reported that the CNA (Identified as CNA #2) was mean and rude. The SW said Resident #1 also reported feeling safe at the Facility. During an interview on 07/21/26 at 1:20 P.M., the Surveyor attempted to interview Resident #1 regarding the 06/08/26 incident. Resident #1 was unable to recall the incident and was unable to provide additional information. During a telephone interview on 07/27/26 at 11:58 A.M., the Nurse Supervisor said CNA #1 reported that CNA #2 was rough and aggressive with Resident #1 while providing incontinent care. The Nurse Supervisor said she immediately removed CNA #2 from resident care pending an investigation. The Nurse Supervisor said she assessed Resident #1 immediately after the incident and found no visible injuries or bruising. The Nurse Supervisor said Resident #1 denied having any pain. During a telephone interview conducted through a Haitian Creole interpreter on 07/27/26 at 12:27 P.M., Certified Nurse Aide (CNA) #2 said she asked Certified Nurse Aide (CNA) #1 to assist with providing incontinent care to Resident #1. CNA #2 said that while providing care, Resident #1 punched her in the breast and swatted at her. CNA #2 said she stepped back, that she attempted to redirect Resident #1 and explained to him/her that care was being provided. CNA #2 said Resident #1 was being resistant to care, was raising and moving his/her hands all around and was difficult to reposition. CNA #2 said she had provided care to Resident #1 many times before without any issues and that when Resident #1 resisted care, she (CNA #2) normally stopped, and reapproached later when Resident #1 was calmer, and provided care with the assistance of another staff member. CNA #2 said she was not aware it was CNA #1's first day working with Resident # and was not familiar with his/her behaviors. CNA #2 absolutely denied hitting or striking Resident #1 and said the only mistake she made was failing to respect Resident #1's refusal of care by continuing to provide care. During an interview on 07/21/26 at 2:15 P.M., the Director of Nursing (DON) said that on 06/08/26, CNA #1 reported that while assisting CNA #2 with providing incontinent care to Resident #1, he observed CNA #2 handling Resident #1 roughly and aggressively. The DON said CNA #1 reported that Resident #1 was resisting care; however, CNA #2 continued providing incontinent care. The DON said CNA #1 reported that CNA #2 grabbed Resident #1's arms, handled Resident #1 roughly during care, and struck Resident #1 on the hands. On 07/21/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a Plan of Correction with an effective date of 6/16/26, which addressed the identified area(s) of concern, as evidenced by: A. On 06/08/26, Resident #1 was immediately assessed for signs of injury or emotional distress, upon interview by Social Worker he/she said he/she felt [NAME] at the Facility. B. Resident #1 will continue to be monitored by staff and will be provided emotional support as needed. C. On 06/09/26, all residents assigned to Certified Nurse Aide (CNA) #2 were immediately assessed to determine potential adverse effects related to the identified area of concern. None of the residents voiced any concerns related to CNA #2, or how she provided or met their care needs. D. On 06/09/26, clinical and management staff conducted resident interviews to ensure resident safety and identify any additional concerns. No additional concerns were identified. E. From 06/09/26 through 06/16/26, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and Nursing Supervisor provided re-education to all nursing staff on the following: - The definition of Abuse Prohibition, Resident Rights. - What is rough care, what to do when a resident hits you. - Proper approach during resident care. F. During the June 2026 monthly Quality Assurance and Performance Improvement (QAPI) meeting, the committee reviewed discussed the incident and identified an area of concern, and their correction action plan. G. The QAPI committee will continue to monitor this issue for a period of two months to ensure continued substantial compliance. H. The Director of Nursing and/or designee are responsible for ongoing compliance.

Based on record review and interviews, the facility failed to ensure one Resident #6 was free from signifigant medication error, out of a total sample of 27 residents. Specifically, for Resident #6 the facility failed to ensure nursing scheduled intravenous (IV) cefazolin (antibiotic) every eight hours as recommended by Infectious Disease (ID) placing Resident #6 at risk for not having a consistent level of antibiotic in his/her blood stream. Findings include:Resident #6 was admitted to the facility in January 2026 with diagnosis including periprosthetic fracture around internal prosthetic left hip joint and an infection and inflammatory reaction due to internal left hip prosthesis. Review of the most recent Minimum Data Set assessment, dated 2/4/26, indicated Resident #6: C: Brief Interview of Mental Status score 11/15, indicating a moderate cognitive impairment. N: antibiotic use, coded as yes. O: IV medications, coded as yes. Review of Resident #120's hospital Discharge summary, dated [DATE], indicated Infectious Disease recommended long term antibiotics:- Cefazolin 2 grams (gm) every 8 hours, end date 3/6/26. Last dose administered on 1/28/26 at 6:14 A.M. Review of Resident #6's physician's orders, 1/28/26, indicated:-Cefazolin Sodium-Dextrose Intravenous Solution 2-4 gm/100 milliliter, use 2 gram intravenously three times a day for infection. Scheduled at 10:00 A.M., 2:00 P.M., and 8:00 P.M., not evenly spaced out every 8 hours as recommended. Review of Resident #6's Nurse Practitioner note, dated 2/9/26, indicated:- Continue IV Cefazolin 2 gr every 8 hours until 3/6/26.- Patient will require lifelong antibiotic suppression after IV antibiotics. Review of Resident #6's Infectious Disease (ID) consultant form, dated 2/11/26, indicated:-Continue cefazolin 2 gram IV every 8 hours through next ID follow up. Review of Resident #6's nursing note, dated 2/11/26, indicated:-Patient returned from appointment Recommendation is to continue on Cefazolin 2g IV Q8h through next ID f/u on 3/4 1:00P.M. During an interview on 2/18/26 at 11:11 A.M., Unit Manager #1 reviewed Resident #6's physician's order for cefazolin, and she said the order was for three times daily, additionally she said if the hospital discharge summary says 'every 8 hours' they would space it every 8 hours. During an interview on 2/18/26 at 1:00 P.M., Nurse #1 said that Resident #6 is on cefazolin for an infection. Nurse #1 said that she thought that Resident #6's cefazolin was originally scheduled at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and she said that 'someone changed the times at some point'. Nurse #1 said that she has been administering Resident #6's cefazolin since his/her admission at 10:00 A.M., and at 2:00 P.M., and Nurse #1 said she was aware that the recommendations were for every 8 hours as she reviewed the ID recommendations on 2/11/26. Nurse #1 said that 'she made a mistake'. Review of Resident #6's Medication Administration Record, indicated between 2/1/26 through 2/16/26, Nurse #1 administered Resident #6 cefazolin at 10:00 A.M., and 2:00 P.M., 13 days out of 16 applicable days reviewed. During an interview on 2/18/26 at 12:19 P.M., the Nurse Practitioner (NP) said that Resident #6 is on IV cefazolin for a recurrent hip infection based on the ID recommendations. The NP said that the cefazolin should be scheduled every 8 hours since the cefazolin is most effective to be spaced apart every 8 hours to ensure there is a steady level of medication in the blood stream, the NP said she was not aware that nursing transcribed the cefazolin doses to be administered so closely together but that was in error. During an interview on 2/18/26 at 3:31 P.M., the Assistant Director of Nursing said that nursing should have transcribed the cefazolin to be administered at 6:00 A.M., 2:00 P.M., and 10:00 P.M., or evenly spaced out, to prevent the medication error.

Based on observation and interview, the facility failed to ensure that the proper dish machine wash and final rinse temperatures were maintained at the appropriate temperatures to effectively clean and sanitize dishware and cutlery to prevent foodborne illness. Findings include: During the kitchen revisit on 2/18/26 at 11:20A.M., the Foodservice Director (FSD) told the surveyor that there was currently no broken equipment in the kitchen. At 11:34 A.M., the surveyor and the Foodservice Director (FSD) operated the dish machine to observe its functionality. The FSD informed the surveyor that the dish machine is a high temperature conveyor dish machine, and it needs to reach a minimum of 160 degrees Fahrenheit for the wash temperature and a minimum of 180 degrees Fahrenheit for a final rinse temperature. The FSD said the dish machine water was just changed, the FSD proceeded to run the dish machine multiple times and the temperature gauge for the wash temperature did not go above 140 degrees Fahrenheit. The FSD said she was not aware that there was an issue with the dish machine and she was going to contact the contracted dish machine vendor. As the surveyor was leaving the dish machine room, the surveyor observed the Dish Machine Temperature Log for February 2026 hanging on the wall which documents the dish machine wash and rinse temperatures three times daily every day. Review of the log indicated that there were 17 occurrences where the wash temperature was below 160 degrees Fahrenheit and 25 occurrences where the final rinse temperature was below 180 degrees Fahrenheit. On the bottom of the temperature log sheet the following was written High Temperature Machines wash 160 > degrees Fahrenheit, Rinse temperature > 180 degrees Fahrenheit. ***Notify supervisor when temps not adequate. The FSD said she was not aware of the low temperatures and staff have never told her about it and she said her expectations are that staff should have notified her of the inadequate temperatures. During a follow up interview on 02/18/2026 1:40 PM, the FSD said she interviewed all of the kitchen staff, and she said none of them contacted herself of the cook despite knowing about the low dish machine temperatures. During an interview on 02/19/26 at 7:05 A.M., the FSD said the dish machine is still not reaching the proper wash temperature, so food is being served using disposable plates and cutlery and they are still waiting for the contracted dish machine vendor to come into the facility.

Based on observations, record review, and interviews, the facility failed to ensure that services met professional standards of practice for one Resident (#120), out of 27 sampled Residents. Specifically, for Resident #120 the facility failed to ensure nursing dated and labelled tube feeding formula as required, nursing failed to stop a tube feeding as ordered, and nursing failed to ensure free water flushes were scheduled in accordance with the physician's order. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.Review of the facility policy titled Enteral Feeding Guidelines, dated as effective 2/21/22, indicated the ensure the safe administration of enteral nutrition. *Preventing errors in administration6. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order. *Flushes 1.Provide flushes as ordered to maintain gastric tube patency. Flush the tube according to physician orders prior to administering medications. 3.The physician may order free water infusion via g-tube to maintain resident's hydration status in the even the resident cannot tolerate oral intake of fluids. Resident #120 was admitted to the facility in October 2025 with diagnosis including diabetes, moderate protein malnutrition, dysphagia, and a mild cognitive impairment. Review of Resident #120's Minimum Data Set assessment, dated 2/4/26, indicated he/she had a memory problem and required supervision with eating. This MDS indicated Resident #120 experienced no weight loss, he/she required a feeding tube, and he/she received greater than 51% of meals via feeding tube. Review of Resident #120's risk for malnutrition care plan related to g-tube, dated as revised 12/4/25, indicated: - Administer tube feed and flushes as ordered. Review of Resident #120's physician's orders, dated 2/2/26, indicated:- two times a day Enteral Feed Order, via G-Tube Nepro 1.8 at 70 ml/hr (start at 2000 and end at 0600) Free water Flush 30 ml pre/post regimen for patency. Elevate Head of Bed. Further review of the order indicated for nursing to start at 8:00 P.M., and end at 6:00 A.M.,- four times a day bolus via g-tube, free water flush 200 milliliters (ml) Q6 (every six hours). Further review of the order indicated for nursing to administer at 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M., not every six hours according to the order. Review of Resident #120's nutrition note, dated 1/7/26, indicated: - Free water flush 30 milliliter (ml) pre/post regimen for patency.- Free water flush 220 ml Q6.- Total Regimen Provides 1800 kcal, 81g protein, 1667ml total fluid (60ml FWF pre/post + free water flush 880, free water TF 727ml) On 2/17/26 at 7:40 A.M., the surveyor observed Resident #120 in bed, he/she was connected to a tube feeding pump. The pump was set at 70 ml an hour for the tube feeding rate and water flushes were set to 200 ml every 3 hours. The pump indicated 849 ml of feeding had been administered (greater than the estimates per the Dietitian). The tube feeding bag did not have a label or date of the contents inside the bag and therefore contents and the expiratory date could not be verified. Additionally, the feeding was still infusing one hour and 41 minutes after the feeding should have been completed. During an interview on 2/19/26 at 6:55 A.M., Nurse #4 said that he worked the overnight shift on Monday into Tuesday, and he said that the tube feeding should have been stopped at 6:00 A.M. Nurse #4 said that during the night shift that Resident #120's tube feeding pump is auto set to have water flushes of 200 ml every 3 hours. Nurse #4 said that tube feeding bags should be dated and labelled with the contents of the type of tube feed should be written on the bag and Nurse #4 said that sometimes the facility has bottles of tube feeding and sometimes the facility has bags that need to be filled from cartons of tube feeding. During an interview on 2/18/26 at 2:15 P.M., the Registered Dietitian (RD) said that Resident #120 receives nocturnal feedings and Resident #120 receives free water flushes every 6 hours. The RD reviewed the physician's orders, and she said that the free water flushes were not scheduled every 6 hours but should be. During an interview on 2/18/26 at 2:25 P.M., Nurse #3 said that Resident #120 has tube feeding free water flushes based on the physician's order. Nurse #3 said that he only had to flush Resident #120's g-tube once this morning and he did it around 9:00 A.M. Review of the Medication Administration Record, dated 2/18/26, indicated that Nurse #3 administered the free water flush at 9:00 A.M. and again at 1:00 P.M., conflicting with his interview on 2/18/25 at 2:25 P.M., which was 1 hour and 25 minutes after he documented he administered a free water flush at 1:00 P.M. During an interview on 2/18/26 at 3:34 P.M., the Assistant Director of Nursing said that nursing should label and date the tube feeding bags. The ADON said that nursing should have stopped the tube feeding at 6:00 A.M. on 2/17/26, as ordered. The ADON reviewed the flush orders, and she said that orders indicate every 6 hours, and she said that the flushes are not scheduled according to the physician's orders, and she said nursing should have updated the order to reflect every 6 hours as ordered.

Based on observations, record review, and interview for two Residents (#78 and #85) out of four residents observed the facility failed to ensure it was free from a medication error rate of greater than 5%. When two out of four nurses observed made two errors out of 27 opportunities resulting in a medication error rate of 7.41%. Specifically, 1. For Resident #78 the facility failed to ensure Nurse #1 administered the correct vitamin B complex with C and folic acid. 2. For Resident #85 the facility failed to ensure Nurse #2 administer the correct dose of MiraLAX. Findings include: Review of the facility policy titled, General Dose Preparation and Medication Administration, dated as revised 11/15/24, indicated:2.2 Only prepare medications for one resident at a time, using a 3-way-check (i.e, comparing the medication to the Medication Administration Record). 1. On 2/18/26 at 8:11 A.M., the surveyor observed Nurse #1 prepare and administer Resident #78 one tablet of B-complex plus vitamin C. Review of Resident #78's physician's order, dated 12/31/25, indicated:- B-Complex-C (with Folic Acid) Oral Tablet, give 1 mg by mouth one time a day for MULTIVITAMINS. During an interview on 2/18/26 11:10 A.M., Nurse #1 said she did not give the correct vitamin B complex with folic acid, but she should have. Nurse #1 said she administered the vitamin B complex with C which she always has on hand. Review of Resident #78's Medication Administration Record (MAR), dated 2/1/26 through 2/18/26, indicated Nurse #1 administered the vitamin B complex with C on 14 occasions. During an interview on 2/18/26 at 3:41 P.M., the Assistant Director of Nursing (ADON) said that Nurse #1 should have administered the correct vitamin B complex with folic acid. 2. On 2/18/26 at 8:52 A.M., the surveyor observed Nurse #2 prepare and administer Resident #85 Polyethylene Glycol Powder (MiraLAX) 17 grams mixed in 8 ounces of water. Review of Resident #85's physician's order, dated 1/21/25, indicated:-Polyethylene Glycol Powder (MiraLAX), give 8.5 gram by mouth one time a day for constipation mix with 8 ounces of liquid of resident choice. During an interview on 2/18/26 at 11:14 A.M., Nurse #2 said she administered Resident 17 grams of MiraLAX, and she filled the cap full of the medication to ensure she gave the full dose. Nurse #2 and the surveyor reviewed the order that indicated to administer 8.5 grams of MiraLAX, and she said she didn't realize the order was for 8.5 grams. Nurse #2 said that she always administers Resident #78 a full cap of MiraLAX. Review of Resident #85's MAR, dated 2/1/26 through 2/18/26, indicated Nurse #2 administered Resident #85's MiraLAX on 8 occasions. During an interview on 2/18/26 at 3:43 P.M., the ADON said Nurse #2 should have administered the correct dose of MiraLAX.

Based on observations, record review and interview, the facility failed to maintain a dignified existence for residents during mealtimes on two out of three units. Specifically, 1. Staff stood over residents while assisting with meals on two out of three units. 2. Staff referred to residents as feeders on one out of three units. Findings include: Review of facility policy titled Quality of Life- Dignity, dated September 20, 2018, indicated the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. -Residents shall always be treated with dignity and respect. -Resident who require staff assistance for feeding shall be fed by the staff member who is seated in a chair next to the resident. Staff shall not feed residents while in a standing position. -Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 1. On 2/3/25 during the breakfast meal, staff were observed standing while assisting two residents on the fourth floor with their breakfast. On 2/3/25 during the breakfast meal, staff were observed standing while assisting one resident on the third floor with their breakfast On 2/3/25 during the lunch meal, staff were observed standing while assisting two residents on the fourth floor with their lunch. On 2/4/25 during the breakfast meal, staff were observed standing while assisting four residents on the fourth floor with their breakfast. On 2/4/25 during the lunch meal, staff were observed standing while assisting two residents on the fourth floor with their breakfast. On 2/4/25 during the lunch meal, staff were observed standing while assisting one resident on the third floor unit with their breakfast. During an interview and observation on 2/04/25 at 12:03 P.M., Nurse #3 observed staff standing while assisting two residents with their meals and said that staff should be sitting down to assist with meals. During an interview on 2/4/25 at 12:07 P.M. Unit Manager #2 said that staff should be sitting next to residents at eye level when assisting with meals and standing over them would be a dignity concern. During an interview on 2/4/25 at 2:05 P.M., the Director of Nursing said that staff should be sitting when assisting residents with meals and not standing over them. 2. On 2/4/25 at 8:17 A.M., on the third-floor unit, the Minimum Data Set (MDS) Nurse was heard asking if a resident was a feeder outside of patient rooms, in a tone audible to several residents. During an interview on 2/4/25 at 12:03 P.M., Nurse #3 said that staff should not refer to residents as feeders because it is not dignified. During an interview on 2/4/25 at 12:07 P.M., Unit Manager #2 said that it is undignified to refer to a resident as a feeder. During an interview on 2/4/25 at 2:05 P.M., the Director of Nursing said that staff should not be using the term feeders to refer to residents and that it would be a dignity concern.

Based on observation, record review and interview the facility failed to ensure medications were stored in accordance with professional standards of practice. Specifically, 1 Medication used for Residents #15 and #18 were left unsecured in the resident's room, 2 Medication carts were left unattended and opened 3. Keys to the medication cart were left on top of the cart and unattended, and 4. Medication was administered and left by the bedside of a resident. Findings include: Review of the Manual title: LTC Facility's Pharmacy Services and Procedure Manual indicated the following: The Policy 5.3 sets for the procedures relating to the storage and expiration date of medications, biologicals, syringes and needles. Procedure 1 Facility should ensure that only authorized Facility staff, as defined by Facility, should have procession of the keys, access cards, electronic code, or combinations which open medication storage areas. 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that in inaccessible to by residents or visitors. 1a. Resident #15 was admitted to the facility in July 2022 with diagnoses that include chronic obstructive pulmonary disease and colostomy status. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #15 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having intact cognition. During an observation and interview on 2/3/25 at 8:32 A.M., Resident #15 was sitting on the side of his/her bed. A tube of ointment labeled clotrimazole betamethasone was on his/her tray table. Resident #15 said the staff use it for his/her stoma. Review of Resident #15's medical record failed to indicate an assessment for self-administration of medications Review of Resident #15's current physician's orders failed to indicate an order to self-administer medications. Further review of Resident #15's physician's order indicated the following: -Lotrisone Cream 1-0.05% (clotrimazole Betamethasone) apply to stoma area topically two times a day for skin condition. On 2/3/25 at 12:19 P.M., Resident #15 was observed in his/her room eating lunch, the tube of clotrimazole Betamethasone ointment was on his/her tray table next to his/her meal tray. On 2/04/25 at 6:58 A.M., Resident #15 was resting in bed. A tube of clotrimazole betamethasone ointment was observed on the tray table. During an observation and interview on 2/4/25 at 9:57 A.M., Nurse #2 said she did not know of any residents who are assessed for self-administration of medication. Nurse #2 said all treatments are stored in the treatment cart and should not be left in a resident's room. On 2/4/25 at approximately 10:30 A.M., Nurse #2 and the surveyor observed two tubes of ointment on Resident #15's bedside table. 1b. For Resident #18 the facility failed to ensure topical medication used to treat a rash was stored safely. Resident #18 was admitted to the facility in November 2021 and has diagnoses that include acute and chronic respiratory failure. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #18 scored 15 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having intact cognition and is dependent on staff for bathing and toileting. Review of Resident #18's medical record indicated an administration informed consent assessment dated [DATE] that indicated I wish to have the Med nurse administer my medications Review of the physician's orders indicated the following: Hydrocortisone External Cream 1% (topical) Apply to left posterior shoulder topically two times day for left posterior shoulder rash. Active 11/13/24. During an interview and observation on 2/3/25 at 8:16 A.M., Resident #18 was observed in bed with oxygen being administered via a nasal cannula. On the windowsill next to the Resident was a tube of hydrocortisone cream and a box with a tube of hydrocortisone. Resident #18 said he/she could not apply the ointment him/herself. On 2/3/25 at 12:32 P.M., one tube and one box of hydrocortisone was observed on the windowsill next to Resident #18's bed. On 2/3/25 at 3:52 P.M., one tube and one box of hydrocortisone was observed on the windowsill next to Resident #18's bed. During an interview on 2/4/25 at 9:57 A.M., Nurse #2 said all treatments are to be stored in the treatment cart. Nurse #2 and the surveyor observed the hydrocortisone ointment and box of hydrocortisone on Resident #18's windowsill. Nurse #2 said Resident #18 could not apply the treatment him/herself, had an order for the hydrocortisone topical cream and it should be stored in the treatment cart and not in the Resident's room. 46339 2. On 2/3/25 at 7:15 A.M., the surveyor observed a medication cart left open and unattended the nurse was off the unit. During an interview on 2/3/25 at 7:15 A.M., Nurse #7 said he locked the medication cart before he left the unit and did not know why it was still unlocked. He said medications carts are to be locked at all times if nurse On 2/3/25 at 9:15 A.M., the surveyor observed a nurse walk away from her medication cart and briefly go into a resident room, the nurse left the top drawer wide open. 3 During a medication pass on the second-floor unit, the surveyor observed the following: On 2/4/25 at 8:44 A.M., the surveyor observed Nurse #5 leave his medication cart open at the nurse's station and went to administer medication into a resident room. 3. On 2/4/25 at 8:45 A.M., as Nurse #7 was administering medications to the resident, the surveyor observed a medicine cup with one capsule (yellow/green). The Resident said that was his/her medication from last night that the nurse had left, and he/she was too sleepy to take. The pill was identified as Flomax (a medication used to treat benign prostatic hyperplasia). 4. On 2/4/25 at 9:32 A.M., Nurse #7 left his medication cart keys on top of the medication cart and went into a resident room to administer medications, the medication cart was not in the direct view of the nurse. During an interview on 2/4/25 at 9:35 A.M., Nurse #7 said medication carts should be locked while unattended, medication keys always kept with the nurse and nurses are to ensure residents take all their medications before leaving the room. He said not unless the residents are assessed for self-administration. During an interview on 2/5/25 at 7:20 A.M., the Director of Nursing said medications carts are to be locked while unattended, medication cart keys are to be on the person at all times and nurses should ensure all medications are taken by the residents before they leave or unless the residents have been assessed for self-administration.

Based on observation, record review and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed 1. Ensure food items were properly dated and stored in the main kitchen. 2. Ensure food items and food preparation equipment were not stored with chemicals. Findings include: Review of the facility's Food Storage Guideline, effective date January 3, 2022, indicated: Policy Statement Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. 4. Chemical must be clearly labeled, kept in original containers, when possible, kept in a locked areas and stored away from food. 8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or open packages. All containers or storage bags must be legible and accurately labeled and dated. 11. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. 12 Refrigerated food storage: f. All food should be covered, labeled, and dated and routinely monitored to assure that foods parentheses (including leftovers) will be consumed by their safe use by dates, or frozen where applicable, or discarded. 13. Frozen foods: c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. During an interview and observation of the main kitchen on 2/3/25 at 7:16 A.M., the following was observed: At 7:19 A.M., the walk-in refrigerator was left open with no staff present going in or out. At 7:20 A.M., kitchen staff closed the door. At 7:20 A.M., the Food Service Director observed the kitchen with the surveyor and the following observations were made: The gasket around the milk chest cover, used to seal the chest had an area that was pulled away and not secured around the cover. The chest contained individual milk cartons. The FSD said it has been that way for a few weeks and has not impacted the internal temperature at this time. The FSD said he did email to company to have it fixed. A box of bananas and box of potatoes stored on the floor, next to a container that the FSD said contained used cleaning rags. The FSD said the banana and potatoes should not be on the floor. Observation of the walk-in freezer revealed the following: The floor had debris on it. A plastic bag tied in a knot of meatballs not labeled or dated. An open box of pie shells not labeled or dated. A plastic wrapped meat product not labeled or dated, the FSD said it was boloney. A box with an internal bag that was opened and not secured, of frozen omelets did not have an open date. The top of a frozen omelet had a buildup of ice particles. The FSD said food items should be sealed and have the date they were opened. Observation of the walk-in refrigerator indicated the following: An open bag tied in a knot of coleslaw mix was not labeled or dated. A container with muffins was not labeled or dated. Observation of the dry food storage area revealed the following: A packet of taco seasoning was opened and not dated. A large, opened bag tied in a knot of toasted oat cereal was not labeled or dated. An open bag tied in a knot of dry past was not labeled or dated. The FSD said food that is opened should be labeled, dated and secured in a sealed bag or container. On 2/5/25 at 9:42 A.M., the surveyor with the FSD and Regional FSD conducted a tour of the kitchen resulting in the following observations: A storage cabinet in the food preparation area had the following: - parts to food preparation equipment, including a large whisk, -a can of stainless-steel cleaner and polish, -a bottle of Liquid Cream Cleanser that was covered with brown debris and dented, -a bag of dry beef stew mix, -a box of food that the Regional FSD said was ethnic food, -1 can of oven cleaner, -a box of food scrubbers, -boxes of gloves. The FSD said it is not policy to store chemicals with food or appliances for food preparation. Observation of the walk-in freezer revealed a box containing an open bag of omelets. An omelet had a thin layer of ice. The FSD said he expects the staff to follow the policy of securing the bag and dating the food when opened. The Regional FSD said food should not have ice crystals on it. During an observation of the dry storage room the following was observed: 1 open bag, tied in a knot of toasted oat cereal not labeled or dated. 1 open bag, tied in a knot of pasta, not labeled or dated. The FSD said food items should be labeled, dated with the date it was opened.

Based on observation, record review and interview the facility failed to ensure garbage and trash were disposed of properly. Specifically, the area around the two dumpsters had a large volume of various debris, garbage and trash. Findings include: Review of the facility Guideline: Waste Policy, revision date 1-2025 indicated Garbage will be disposed of as needed throughout the day and the end of each day. Guideline: 1. Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers that are kept covered when not in use. 2. Containers will be emptied as often as necessary throughout the day and at the end of each day. Trash bags will be sealed prior to removing then from the facility. Trash will be deposited into a sealed container outside the premises. 5. Dumpsters will be emptied and maintained on a schedule determined by vendor. Dumpster lid will be closed to contain trash when not in use. During an observation and interview on 2/5/25 at 10:16 A.M., the Food Service Director (FSD) and Surveyor observed the area where two dumpsters were located outside the facility. Upon reaching the area the FSD said often there is no room in the dumpster so staff leave trashed bags outside of the dumpster. With the FSD present the surveyor made the following observation: -The ground in front of the left dumpster was covered with various debris. - The area between the two dumpsters had an accumulation of trash on the ground including gloves, unidentified debris, a decomposing flat box, many plastic lids, wet/decomposing papers, condiment containers, small milk cartons, plastic forks, stacked cardboard, a box of oatmeal pies, yogurt containers, 2 chairs, a broken tray table. -The back of the dumpster on the left had at least three full trash bags piled next to the dumpster. One bag was open with the contents spilling out. The area surrounding the trash bags had an abundance of accumulated trash which not all could be identified. There was an accumulation of food container debris including multiple milks cartons, plastic covers, juice containers, plastic utensils, a large unlabeled crushed can covered in dirt, plastic lids, condiment containers, plastic bowls, deterioated paper plates. The FSD said the trash should be contained and staff are leaving the bags outside of the dumpster. The FSD said he did not know how the trash bag became opened and said that by having all the trash around the dumpsters it creates a risk for mice and rats. During an interview on 2/05/25 at 12:37 P.M., the Maintenance Director said all trash should be contained. The Regional Maintenance Director said having trash not contained increases the risk for having mice and rats.

Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment that prevents the development and transmission of communicable diseases and infections for five Residents (#89, #33, #84 , #15 and #217) out of a total sample of 31 Residents. The facility also failed to implement and follow Enhanced Barrier Precautions (EBP) and droplet precautions for residents who were positive for influenza. Specifically, 1. For Resident #89 and Resident #33, the facility failed to maintain infection control practices during a wound dressing change 2. For Resident #84 and Resident #15, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented in accordance with the infection prevention control program. 3. For Resident #217, the facility failed to ensure isolation/droplet precaution signage was applied on the Resident's door. 4. The facility failed to follow Enhanced Barrier Precautions on one out of three units 5. The facility failed to follow Droplet Precautions for residents who have influenza on two out of three outs. Findings include: Review of Facility policy titled Infection Prevention and Control dated as revised January 16, 2024 indicated the following: -An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -Prevention of infection: Important facets of infection prevention include: -Educating staff and ensuring that they adhere to proper techniques and procedures. -Implementing appropriate isolation precautions when necessary. Review of facility policy titled Policy Glove use, dated as 1/24/25 indicated the following: -Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. -Wash hands after removing gloves. May use alcohol gel. Review of facility policy titled Dressing Change, dated as revised on 1/2025, indicated the following: Steps in the Procedure: 3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below the clean field. 5. Wash and dry your hands thoroughly. May use alcohol gel. 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. May use alcohol gel. 9. Open dry clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 12. Wash and dry your hands thoroughly, May use alcohol gel. 13. Put on clean gloves. 15. Cleanse the wound with ordered cleanser 17. Apply the ordered dressing. 19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. 1a. Resident #89 was admitted to the facility in April 2024 with diagnoses that include pressure ulcer of the sacral region, stage 4, pressure ulcer of the left heel stage 4 and pressure ulcer of the right heel stage 4. Review of Resident #89 most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/25/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating that the Resident is cognitively intact. The MDS further indicated that the resident has one or more unhealed pressure ulcers, indicating three stage 4 pressure ulcers that were present on admission to the facility. Review of the Consulting Wound Physician's note dated 1/30/25 indicated that Resident #89 had a stage 4 pressure ulcer to their sacrum, a stage 4 pressure ulcer to the left heel and a stage 4 pressure ulcer to the right heel. A stage 4 pressure ulcer extends below the subcutaneous fat into deep tissues, including muscle, tendons and ligaments. In severe cases, they can even reach the cartilage or bone posing a high risk of infection. Review of Resident #89's physician's orders indicated the following: - Left heel cleanse area with wound cleanser, gently pat dry. Calcium Algenate, foam silicone boarder. Wrap with kerlix. Off- loading boot when out of bed and as needed, dated 2/4/25. - Right heel cleanse area with wound cleanser, gently pat dry. Calcium Alginate, foam silicone boarder. Wrap with kerlix. Offloading boot when out of bed and as needed, dated 2/4/25. - Sacral wound: NSW [normal saline wash], pat dry, apply Skin prep to peri wound, apply alginate calcium pack into wound bed, cover with Foam silicone boarder daily, dated 11/13/24. Review of Resident #89's active plan of care indicated the following care plan, dated June 2024: -Resident has osteomyelitis (an infection in the bone) of sacrum related to stage 4 pressure injury. On 2/4/25 at 11:13 A.M., the surveyor observed Nurse #4 perform wound care and dressing changes to Resident #89's sacral wound as well as the left and right heel wounds. The following observations were made: -Nurse #4 set up a trash bag on the Resident's bag, at the level of the wounds and utilized it to dispose of soiled dressings and other soiled materials used during the dressing change. -After cleansing the sacral wound, Nurse #4 removed her gloves, and applied new gloves without sanitizing her hands between glove use. -After completing the sacral wound dressing, Nurse #4 removed her gloves, sanitized her hands and applied new gloves. She then removed the right heel dressing, and without changing gloves or sanitizing her hands, she removed the left heel dressing as well. - After removing both heel dressings, she sanitized her hands, applied new gloves and continued to provide the treatment to both the left and right heel at the same time, moving back and forth between the two wounds. During an interview on 2/4/25 at 2:02 P.M., the Director of Nurses, who is also the Infection Preventionist for the facility said that she would expect hand hygiene in between all glove changes, and she would expect that one wound treatment is being completed at a time. She also said that the trash bag should not have been on the Resident's bed. During an interview on 2/5/25 at 10:26 A.M., Nurse #4 said that she should have sanitized her hands between all glove changes and should have only changed the dressing for one wound at a time. During an interview on 2/5/25 at 10:48 A.M., Unit Manager #2 said that she would expect hand hygiene between all glove changes, and that only one wound should be dressed at a time to prevent the spread of any potential infections. 1b. Resident #33 was admitted to the facility in October 2022 with diagnoses that include nontraumatic intracerebral hemorrhage in cerebellum and abnormal weight loss. Review of Resident #33's most recent Minimum Data Set (MDS) Assessment, dated 1/13/25, indicated that the Resident was unable to complete a Brief Interview for Mental Status and was assessed by staff as having moderate cognitive impairment. Review of Resident #33's physician's orders indicated the following: Cleanse wound right buttock with Normal Saline Spray pat dry apply house barrier cream every day shift on even days for right buttock wound, dated 2/2/25. -House Barrier Cream - apply to coccyx, buttocks, and groin every shift for preventative skin care every shift for prevention, dated 11/7/24. On 2/4/25 at 12:53 P.M., the surveyor observed Nurse #2 perform wound to Resident #33's right buttock. The following observations were made: -Nurse #2 performed hand hygiene, then opened the treatment cart draw to take out supplied and place them on top of the treatment cart. Nurse #2 then rolled multiple gloves and the treatment supplied in a paper towel, entered Resident #33's room and rolled out the paper towel with the gloves and supplied on the Resident's bedside table. -Nurse #2 then sanitized her hands and applied gloves. With her gloved hands, she was utilizing the bed controller to raise the height of the Resident's bed, and then assisted the resident in removing a brief to access his/her right buttock. Without changing her soiled gloves, she cleansed the Resident's buttock. While cleaning the Resident's buttock, she cleaned between the resident's buttock, wiping stool from the buttock, and then patting the same gauze over the superficial area on the Resident's buttock twice. - Nurse #2 then removed her gloves and applied clean gloves without performing hand hygiene and applied barrier cream, as ordered, to the Resident's buttock. -Nurse #2 then removed her gloves and without performing hand hygiene, applied clean gloves, and assisted the resident in changing his/her brief. During an interview on 2/4/25 at 1:59 P.M., the Director of Nurses, who is also the Infection Preventionist for the facility said that hand hygiene should be performed between all glove changes. She also said that when cleaning the wound, Nurse #2 should not have patted the open area with a gauze that had stool on it from cleaning up the resident. 36431 2. For Resident #84 and Resident #15 the facility failed to ensure enhanced barrier (EHB) precautions were implemented in accordance with the infection prevention control program. Review of the facility's Guideline: Enhanced Barrier Precautions, effective date April 1, 2024, indicated the following: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with and MDRO as well as those residents at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). High-Contact Resident Care Activities requiring a gown and glove use for enhanced barrier are defined as: dressing, bathing/showering, transferring, providing hygiene care, changing linens, changing briefs, or assisting with toileting, and devise care that includes Central Venous Access Devices, Urinary Catheters, Gastrostomy Tubes, and wound care that requires a dressing Guidelines: 3. Post clear signage outside of resident rooms indicating the type of PPE (personal protection equipment) required defining high risk resident care activities. For Resident #84 the facility failed to ensure enhanced precautions were implemented in accordance with the infection control program. 2a. Resident #84 was admitted to the facility in September 2021 and has diagnoses that include aphasia and cerebral infarction. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #84 scored an 11 out of 15 on the Brief Interview for Mental Status, is dependent on staff for care including toileting and bathing and has the nutritional approach of a feeding tube. Review of Resident #84's Physician's orders indicated the following: -An enteral feed order at bedtime flush tube with 250 cc water then hang overnight continuous feed of jevity 1.5 at 60 ml/hour x 12 hours, active 11/25/24. -Enhanced Barrier Precautions secondary to: gastric tube, every shift. Ensure signage is in place, active 10/31/24 Review of Resident #84's care plans indicated: -Resident requires Enhanced Barrier Precautions during high contact care activities that include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, d/t (due to) gastric tube, dated 10/31/24. During an observation on 2/3/25 at 10:20 A.M., Resident #84 was in bed with his/her eyes closed and did not respond to the surveyors greeting. A pole with a pump was near the head of Resident #84's bed. There was no Enhanced Barrier Precaution signage on the door or the vicinity of the room. The following observations made on 2/3/25 at 1:00 P.M., 2/3/25 and at 4:00 P.M., failed to reveal a sign was posted alerting staff that Resident #84 required enhanced barrier precautions. On 2/4/25 at 6:59 A.M., Resident was observed with his/her enteral feeding running through the pump. There was no enhanced barrier precaution signage on the outside of Resident #84's room alerting staff to use enhanced barrier precautions. On 2/4/25 at approximately 8:22 A.M., Nurse #2 was observed going into Resident #84's room. Nurse #2 said she was flushing the Resident's g-tube. Nurse #2 did not don a gown for the flushing of the g tube which requires high contact care. During an interview on 2/4/25 at 10:30 A.M. Nurse #2 said a resident with a g-tube should be on enhanced barrier precautions. 2b. For Resident #15 the facility failed to implement enhanced barrier precautions in accordance with the facility infection prevention program. Resident #15 was admitted to the facility in July 2022 with diagnoses that include chronic obstructive pulmonary disease and colostomy status. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #15 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition and requires partial/moderate assistance with bathing and had an ostomy. During an observation and interview on 2/3/25 at 8:32 A.M., Resident #15 said he/she has a colostomy, and that staff provide a cream to his/her stoma (A stoma is an opening in your belly's wall that a surgeon makes for waste to leave your body if you can't have a bowel movement through your rectum). Resident #15's ostomy bag was visible as he/she sat on the side of his/her bed. Resident #15's room did not have an enhance barrier precaution sign outside his/her room on the door or near the door. The following observations on 2/3/25 at 12:19 P.M., 2/03/25 at 4:00 P.M., and on 2/4/25 at 6:57 A.M., failed to reveal an enhanced barrier precaution sign was posted to inform staff of the need for PPE. During an interview on 2/4/25 at 10:19 A.M. Nurse #2 said any resident who has an open area, g-tube (gastrostomy), catheter or colostomy requires enhanced barrier precautions. Nurse #2 said a sign is used outside the resident's room to identify a resident who needs enhanced barrier precautions. Nurse #2 went to Resident #15's room and said he/she has a stoma and said staff providing care are to use gowns and gloves. 46339 3. For Resident #217, the facility failed to ensure isolation/droplet precaution signage was applied on the Resident's door. Review of facility policy titled 'Transmission Based Precautions' dated December 2019, indicated the following but not limited to: -When transmission-based precautions are implemented, the infection preventionist (or designee): - Clearly identify the type of precautions, the anticipated durations, and the personal protective equipment (PPE) that must be used. -Determines the appropriate notification on the room entrance door so that personnel and visitors are aware of the need for and type of precautions. -The signage informs the staff of the type of Centers for Disease Control (CDC) precaution(s), instructions for use of PPE, and /or instructions to see a nurse before entering the room. Resident #217 was admitted to the facility in January 2025 with diagnoses including maxilla (facial) fractures. Review of Resident #217's Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. On 2/3/25 at 8:58 A.M., Resident #217 doorway had an Enhanced Barrier Precaution (EBP) signage at the door. The surveyor observed Resident #217 lying in his/her bed. On 2/3/25 at 9:00 A.M., the surveyor observed staff going in and out of the Resident's room wearing surgical masks only. On 2/3/25 at 12:44 P.M., a Certified Nursing Assistant was observed delivering a lunch tray to the Resident and only wearing a surgical mask. The CNA assisted the Resident with the tray set up in the room. On 2/4/25 at 8:10 A.M., the surveyor observed Resident #217's doorway with an EBP signage. On 2/4/25 at 8:10 A.M., the surveyor observed CNA #3 enter the Residents room wearing only a surgical mask. CNA #3 said most rooms on the unit have the EBP sign on the door and staff only need to wear full PPE (personal protective equipment) when giving direct care to the residents. Review of Resident #217's medical record indicated the following: -On 1/31/25 Resident #217 tested positive for influenza A -A physician order dated 1/31/25: isolation precaution (droplet/contact). All nursing care and therapy to be done in room every shift. -A physician order dated 1/31/24: Tamiflu oral capsule 30 mg (milligram) give one capsule by mouth two times a day for influenza treatment for 5 days. During an interview on 2/4/25 at 8:09 A.M., Charge Nurse #3 said the Resident had tested positive for the influenza and should have been on droplet precaution, she said the signage on the door should say isolation/droplet precaution for staff to be aware what PPE to wear. 4. During an observation on 2/4/25 at 10:46 A.M., the surveyor observed a Certified Nurses Aide (CNA) changing linen while the resident was in bed, without the use of PPE (Personal Protective Equipment). A sign on the resident ' s door indicated that the resident was on Enhanced Barrier Precautions. The CNA said that she was changing the bed because the resident felt hot, but said she should not have handled the linen and changed the bed without appropriate PPE (personal protective equipment). During an interview on 2/4/25 at 1:37 P.M., the Director of Nursing who is also the Infection Preventionist for the facility said that she would expect that Enhanced Barrier Precautions would be implemented for all high contact care, including changing and handling linens. 5. Review of facility policy titled Transmission Based Precautions, dated as revised May 5, 2023, indicated the following: -Droplet Precautions: used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: respiratory MRSA [Methicillin-resistant Staphylococcus aureus] pneumonia, influenza, whooping cough, bacterial meningitis, RSV [Respiratory syncytial virus], Covid-19). Droplet precaution signs throughout the facility indicated the following: Staff and providers must: -Clean hands: when entering and exiting. -Gown- change between each resident. -N95 Respirator (face mask is acceptable if N95 not available). -Eye Protection (goggles or face shield). -Gloves- change between each resident. During an observation on 2/3/25 at 7:11 A.M., on the second-floor unit the surveyor observed two staff members enter a resident room wearing only a surgical mask. A sign on the doorway indicated that the resident was on droplet precautions. The staff member did not perform hand hygiene when entering or exiting the room. There was a precaution cart outside of the resident ' s room, with no PPE (personal protective equipment, including gloves, gowns, masks) inside the cart. During an observation on 2/3/25 at 7:33 A.M., on the second- floor unit, the surveyor observed three precaution carts outside of resident rooms that indicated the residents were on droplet precautions without any PPE in them. During an observation on 2/3/25 at 8:16 A.M., the surveyor observed an Activities Assistant entering and hanging calendars in a resident room wearing only a surgical mask. A sign on the doorway indicated that the resident in that room was on droplet precautions. The Activities Assistant said she is new here and sanitizes her hands between resident rooms. She said she was not sure why this resident was on precautions. During an observation on 2/3/25 at 9:03 A.M., the surveyor observed a staff entering a resident room on the second- floor unit with no PPE. The sign on the resident ' s door indicated that the resident was on isolation/ droplet precautions. During an observation on 02/3/25 at 8:39 A.M., on the third- floor unit, a Certified Nursing Assistant (CNA) was feeding a resident wearing a mask and no other PPE. The sign next to the entrance of the resident room, indicated droplet precautions. The CNA exited the resident's room carrying the meal tray, went to the food cart in the hall, touched the cart, placed the tray in the cart and continued down the hall. The CNA did not perform hand hygiene. During an observation on 2/3/25 at 12:22 P.M., the surveyor observed a staff member on the third-floor unit assisting a resident with their lunch meal. The staff member was wearing only a surgical mask. The sign on the resident ' s door indicated that the resident was on droplet precautions. During an observation on 2/3/25 at 12:36 P.M., the surveyor observed a staff member exit a room on the third floor of a resident on droplet precautions with a dirty lunch tray, placed it in the meal truck, then proceeded to another resident room without performing hand hygiene and removing the dirty lunch tray to put into the meal cart, again no hand hygiene was performed. The staff member then entered another resident room, without performing hand hygiene, touched the tray table, raised up the bed and said to the resident, time to eat. During an observation on 2/4/25 at 6:43 A.M., a CNA was observed providing care to a resident on the third-floor unit. The CNA was wearing only a surgical mask. A sign on the resident ' s door indicated that the resident was on droplet precautions. During an observation on 2/4/25 at 8:19 A.M., a staff member entered a resident room on the third-floor unit wearing only a surgical mask. The sign on the resident ' s door indicated that the resident was on droplet precautions. There was a precaution cart outside of the resident ' s door with PPE in the cart for use. During an observation on 2/4/25 at 9:48 A.M., a nurse on the second floor entered a resident ' s room wearing only a surgical mask and stood next to the resident conversing. A sign on the resident ' s door indicated that they were on droplet precautions. During an observation on 2/4/25 at 10:18 A.M., a nurse entered a resident room on the third-floor unit wearing only a surgical mask. A sign on the resident ' s door indicated that the resident was on droplet precautions. During an interview on 2/5/25 at 11:30 A.M., CNA #5 said that when a resident is sick there will be a sign on the door to let staff know what PPE to use in the room. CNA #5 said the PPE should be worn at all times and be worn for both residents in the room. During an interview on 2/4/25 at 1:37 P.M., the Director of Nursing who is also the Infection Preventionist for the facility, said that she would expect full PPE to be worn for any resident on droplet precautions, including both residents in the room. She said PPE should be changed, however, between caring for each resident. She said she would expect the staff to refill precautions carts that are empty and utilize PPE for all resident interactions. She said there is a flu outbreak right now in the facility and this is why residents are on droplet precautions.

Based on observation, record review and interview the facility failed for 2 Residents (#15 and #44 ) out of a total sample of 31 residents, to ensure: 1. Resident #15 was equipped with a call bell that functioned for him/her and, 2. That Resident #44 had a Broda chair available for when he/she chose to get out of bed. Findings include: Review of the facility's policy entitled, Call light policy, revision date 1/2025 indicated the following: Resident will have a functioning call light at their bedside for use to alert staff that they need assistance. Resident #15 was admitted to the facility in July 2022 with diagnoses that include chronic obstructive pulmonary disease and colostomy status. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #15 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having intact cognition and requires partial/moderate assistance with bathing and has an ostomy. During an observation and interview on 2/3/25 at 8:32 A.M., Resident #15 said he/she was concerned that his/her call bell did not work and that he/she told staff about one month ago. Resident #15 said he/she had terminal cancer, and it would be nice to have a call bell that worked. Resident #15 had a call bell with a bulb. Resident #15 squeezed the bulb, and the call light did not illuminate. The surveyor pressed the bulb, and the light illuminated outside of Resident #15's room. Resident #15 said he/she wanted a call bell that worked for him/her. During an interview and observation on 2/4/25 at 10:20 A.M., Resident #15 squeezed the bulb of the call bell. The call light did not illuminate outside of his/her room, thus not alerting staff if he/she required assistance. During an observation on 2/4/25 10:31 A.M., Nurse #2 and the surveyor observed Resident #15 squeeze the bulb of the call light. The call light did not illuminate outside of the room to alert staff. Resident #15 said he/she wants it to work so he/she can get the help he/she needs for his/her colostomy bag. Nurse #2 said it would be addressed. During an interview and observation on 2/5/25 at 10:55 A.M., Resident #15 was resting in bed. He/she squeezed the call light bulb, which did not illuminate in the hall to alert staff. Resident #15 said he/she thought they took care of it yesterday. On 2/5/25 at approximately 11:00 A.M., the Administrator in Training (AIT) went to Resident #15's room with the surveyor. Resident #15 squeezed the call light bulb which did not illuminate in the hall. Resident #15 said he/she wanted a call bell that worked and that last night he/she had to walk down the hall to let staff know he/she had a full colostomy bag. 2. For Resident #44 the facility failed to have his/her Broda Chair available for when he/she chose to get out of bed. Review of the facility's Guideline: Assistive Equipment and Devices effective date 1/24/2025 indicated, Policy Statement: Our facility provides and maintains the use of assistive devices and equipment for residents. 1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include, but are not limited to a. Wheelchairs (manual and powered). 2. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. Resident #44 was admitted to the facility in December 2023 and has diagnoses that include hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting right dominant side. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #44 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having intact cognition and is dependent on staff for bed to chair transfers and uses a wheelchair. Further review of the MDS, indicated Resident #44 did not display any behaviors including rejection of care. During an interview on 2/3/25 at 8:16 A.M., Resident #44 said he/she retired from work, had a stroke and requires care. Resident #44 said he/she recently moved from a room down the hall and has a wheelchair that he/she used when he/she got out of bed. Resident #44 said he/she has not seen the wheelchair and has not got out of bed. Observation of Resident #44's area including the bathroom and adjacent hallway failed to reveal a chair was present. On 2/3/25 at 3:52 P.M., Resident #44 was observed in bed. There was no chair available in his/her vicinity. Review of Resident #44's medical record indicated the following: -A physician's order OOB (out of bed) to Broda chair (a type of wheelchair that supports mobility, and safe, comfortable positioning) active 2/14/23. -A care plan focus Resident has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Alzheimer's, confusion due to dementia, dated 5/24/2021 with the Intervention/Task TRANSFER: Resident #44 is dependent of 2 staff via mechanical lift for transfers to BRODA. Resident often refuses out of bed bound by preference. On 2/4/25 at 7:56 A.M., Resident #44 was in bed. There was no Broda chair in his/her vicinity. During an interview on 2/4/25 at 11:10 A.M., Resident #44 said he/she used to get up in a high (back) chair but has not got up and said his/her chair may have been left behind in his/her previous room when he/she moved last week. On 2/4/25 at 12:28 P.M., Resident #44 was observed in bed eating his/her lunch. No chair was in his/her vicinity. During an interview on 2/4/25 at 1:02 P.M., Certified Nursing Assistant (CNA) #1 said Resident #44 is dependent on staff for transfers out of bed using a Hoyer lift (a mechanical lift). CNA #1 said Resident #44 recently moved rooms. CNA #1 said Resident #44 will get out of bed 2 to 3 times a week when he/she wants. CNA #1 said the Resident has a wheelchair which is usually in his/her room. CNA #1 looked in both Resident #44's old room and new room with the surveyor present and could not locate the Resident's Broda chair. At this time CNA #1 stopped an Occupational Therapist (OT) in the hallway and asked about Resident #44's chair. The OT said the Resident uses a Broda chair and at times refuses to get out of bed. The OT said she took the Broda chair at the end of last week to trial it for another resident. The OT said it had not been returned yet. Review of documentation provided by the OT indicated the the trial of the Broda chair for another resident as dated 1/31/24, indicating Resident #44 was without his/her Broda Chair for five days. During an interview and observation on 2/5/25 at approximately 10:50 A.M., Resident #44 said he/she had his/her chair back and wanted to get out of bed. Resident #44 said his/her left leg was hurting and getting out of bed helps. During an interview on 2/05/25 at 11:10 A.M., the Director of Nursing said they have enough equipment for mobility and Resident #44 should have had his/her chair available.

Based on record review and interviews, the facility failed to develop a skin impairment care plan for one Resident (#33) out of a total sample of 31 residents. Findings include: Resident #33 was admitted to the facility in October 2022 with diagnoses including cerebral hemorrhage and hemiplegia. Review of Resident #33's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) exam and staff had assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #33 is dependent on staff for self-care and mobility tasks. Review of the wound physician note dated 1/30/25 indicated Resident #33 had a non-pressure wound on his/her sacrum for over 11 days measuring 1.4 x 1.3 x 0.1 cm (centimeters). Review of Resident #33's care plans failed to indicate a care plan for actual skin impairment was developed when the Resident's wound began. During an interview on 2/5/25 at 6:55 A.M., the Director of Nursing said Resident #33 developed a new wound on his/her buttocks with a self-inflicted scratch. The Director of Nursing said any resident with a newly developed wound should have a care plan for skin impairment developed.

Based on observations, interviews, and record review the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#69) out of a total sample of 31 residents. Specifically for Resident #69 the facility failed to review and revise the care plan related to the use of an air mattress. Findings include: Review of facility policy titled Care Plan- Nursing, dated October 7, 2021, indicated the following: -The care plan is to be reviewed and revised by all staff providing care or services for the resident at least 92 days following the completion of every MDS. The Care plan includes a statement of problem; reasonable, measurable and time limited goals; and specific interventions, along with the discipline responsible. -When there are changes in resident's condition, the comprehensive care plan is updated as needed to change goals, time frames or interventions. Resident #69 was admitted to the facility in October 2020 with diagnoses that include major depressive disorder and weakness. Review of Resident #69's most recent Minimum Data Set (MDS) Assessment, dated 12/4/24, indicated the Resident was unable to participate in a Brief Interview for Mental Status and was assessed by staff as having severe cognitive impairment. The MDS further indicated that the Resident is at risk for developing pressure ulcers. Review of Resident #69's Norton Assessment (an assessment to determine the risk of pressure ulcer development), dated 10/5/24 indicated a score of 7, indicating high risk for skin breakdown. Review of Resident #69's physician's orders indicated the following order dated as 2/9/24: -Air mattress setting at 100 lbs. (pounds). Monitor setting and functioning every shift for prevention of skin breakdown. -On 2/3/25 at 8:18 A.M. and 12:28 P.M., the surveyor observed Resident #69 lying in bed on an air mattress. The air mattress was set at 400 lbs. -On 2/4/25 at 8:02 A.M., the surveyor observed Resident #69 lying in bed on an air mattress. The air mattress was set at 100 lbs. Review of Resident #69's active care plan indicated the following care plan, initiated on 10/22/20: -[Resident] has Potential for Pressure ulcer r/t [related to] cognitive impairment, advanced age, end of life care, decreased mobility, incontinent of bowel and bladder. Interventions in the care plan included the following: Peri-care after incontinent episodes, apply barrier cream, wears disposable adult Brief size: medium Pressure redistribution mattress on bed Reposition as [resident] allows with a draw sheet. The care plan failed to indicate the use of an air mattress and the required settings. During an interview on 2/5/25 at 10:30 A.M., Nurse #4 said that the use of an air mattress should be included in the care plan with settings so that all staff caring for the resident know the plan of care. She said the Resident is unable to change the settings on the air mattress independently. During an interview on 2/5/25 at 10:38 A.M., Unit Manager #2 said that yesterday afternoon she found the Resident's air mattress set to 400 and changed it to the correct setting. She said the air mattress was in place for prevention of skin breakdown. Unit Manager reviewed Resident #69's care plan and said that the air mattress was not addressed in the care plan, and it should have been. Unit Manager #2 updated the care plan at this time. She said that it should be in the care plan so that the Certified Nurse's Aides (CNA) know the settings for the air mattress because they do not have access to physician's orders but can pull up the care card for the Resident in their documentation portal to see the settings, if it is in the care plan. During an interview on 2/5/25 at 11:44 A.M., the Director of Nurses (DON) said that she would expect the use of the air mattress to be indicated the Resident's care plan so that the CNAs and other care staff are aware of the appropriate settings.

Based on record review, observations and interviews, the facility failed to ensure a physician's order was implemented for three Residents (#28, #101 and #69) out of a total sample of 31 residents. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #28 was admitted to the facility in January 2024 with diagnoses including diabetes, chronic diabetic ulcer of the left foot, and tachycardia. Review of Resident #28's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #28 requires substantial assistance from staff for functional daily tasks. Review of Resident #28's physician orders indicated the following orders: -Bi-lat (bilateral) LE (lower extremity) ACE wraps, initiated 11/28/24. -Abdominal binder daily for orthostasis hypotension, every day and evening shift for Orthostatic Hypotension Wear when OOB (out of bed). May remove for ADLs, initiated 11/27/24 On 2/3/25 at 9:19 A.M., Resident #28 was observed in his/her room. The Resident was not wearing an abdominal binder and did not have an ace wrap to his/her right leg. On 2/4/25 at 8:51 A.M., 10:05 A.M., and 11:00 A.M., Resident #28 was observed in his/her room. The Resident was not wearing an abdominal binder and did not have an ace wrap to his/her right leg. During an interview on 2/4/25 at 10:10 A.M., Resident #28 said he/she never has an ace wrap to his/her right leg and has not worn his/her abdominal binder in a few weeks. During an interview on 2/5/25 at 7:48 A.M., Nurse #1 said all physician orders should be followed as written. Nurse #1 said she was unaware of Resident #28's order for bilateral ace wraps, and she did not complete the order as written. Nurse #1 said Resident #28 did not wear his/her abdominal binder on 2/4/25 as ordered. During an interview on 2/5/25 at 11:45 A.M., the Director of Nursing said all physician orders should be followed as written. 2. Resident #101 was admitted to the facility in May 2024 with diagnoses including diabetes, adult failure to thrive and depression. Review of Resident #101's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #101 is dependent on staff for all functional tasks. Review of Resident #101's physician orders indicated the following orders: -Prevelon boots to bilateral feel on as tolerated, every shift, initiated on 7/22/24 -Monitor RUE (right upper extremity) edema elevate on pillow, every shift for edema notify MD (physician) if increased edema is noted or if pt (patient) c/o (complain of)pain, initiated on 11/22/24 On 2/3/25 at 8:21 A.M., Resident #101 was observed lying in bed. The Resident was wearing a prevalon boot on his/her left foot only and his/her right upper extremity was not elevated. There was no prevalon boot observed in the room and there was no pillow observed that could be used to elevate the Resident's arm. On 2/3/25 at 10:58 A.M., Resident #101 was observed lying in bed. The Resident was wearing a prevalon boot on his/her left foot only and his/her right upper extremity was not elevated. There was no prevalon boot observed in the room and there was no pillow observed that could be used to elevate the Resident's arm. On 2/3/25 at 4:06 P.M., Resident # 101 was observed sitting in broda chair with his/her arms resting on his/her lap, not elevated. The Resident was wearing a prevalon boot on his/her left foot only. On 2/4/25 at 6:40 A.M., 9:43 A.M., and 11:00 A.M., Resident #101 was observed lying in bed. The Resident was wearing a prevalon boot on his/her left foot only and his/her right upper extremity was not elevated. There was no prevalon boot observed in the room and there was no pillow observed that could be used to elevate the Resident's arm. During an interview on 2/5/25 at 7:48 A.M., Nurse #1 said all physician orders should be followed as written. Nurse #1 said she was unaware of Resident #101's physician orders for bilateral prevalon boots and elevation of the right upper extremity and that these orders were not followed. During an interview on 2/5/25 at 11:45 A.M., the Director of Nursing said all physician orders should be followed as written. 49880 3. Review of facility policy titled Skin Management Guideline, dated as revised August 17, 2022, indicated the following: -Assess the resident's skin on admission (within eight hours) for existing pressure ulcer/ injury risk factors or other skin conditions such as skin tears, bruising, surgical wounds, etc. Repeat the risk assessment weekly and upon any changes in condition. -Evaluate, report and document potential changes in the skin on the weekly skin check in the [electronic medical record] or in a daily progress note. -Document licensed nurse weekly skin assessment on the Treatment Administration Record (TAR) and UDA (user defined assessment) [in the electronic medical record]. Resident #69 was admitted to the facility in October 2020 with diagnoses that include major depressive disorder and weakness. Review of Resident #69's most recent Minimum Data Set (MDS) Assessment, dated 12/4/24, indicated the Resident was unable to participate in a Brief Interview for Mental Status and was assessed by staff as having severe cognitive impairment. The MDS further indicated that the Resident is at risk for for developing pressure ulcers. Review of Resident #69's Norton Assessment (an assessment to determine the risk of pressure ulcer development), dated 10/5/24 indicated a score of 7, indicating high risk for skin breakdown. Review of Resident #69's active care plan indicated the following care plan, initiated on 10/22/20: -[Resident] has Potential for Pressure ulcer r/t [related to] cognitive impairment, advanced age, end of life care, decreased mobility, incontinent of bowel and bladder. Review of Resident #69's physician's orders indicated the following order, dated 4/17/24: -Complete weekly Skin check, every Wednesday 3-11 shift. Review of Resident #69's Weekly Skin Assessments indicated that from August 2024 to February 2025 weekly assessments were completed on the following dates: -8/21/24, 8/28/24, 12/25/24, 1/15/25, and 1/29/25. Review of the medical record indicated that out of 26 opportunities, from 8/1/24 to 2/1/25 the weekly skin assessment was completed five times. Review of Resident #69's nursing progress notes failed to indicate that weekly skin checks had been completed as indicated in the physician's orders. Review of Resident #69's September, October and November 2024 Treatment Administration Record (TAR) was signed off indicating that skin checks were completed, when they were not. During an interview on 2/5/25 at 10:30 A.M., Nurse #4 said that skin checks are done weekly, and nurses should complete them based on physician's orders. Nurse #4 said that it should be signed off on the TAR, and then entered into the weekly assessment. During an interview on 2/5/25 at 10:38 A.N., Unit Manager #2 said that Resident #69 is at risk for skin breakdown. Unit Manager #2 said that skin checks are completed weekly, and the weekly skin assessment should be completed in the assessments tab in the electronic medical record. The Unit Manager reviewed completed assessments and said that they have not been completed as indicated in the physician's orders. She said that nurses should not sign off on physician's orders that they are not completing. During an interview on 2/5/25 at 11:44 A.M., the Director of Nursing said that she would expect orders to be followed as written. The process in the facility is weekly skin checks and they should be completed as indicated in the physician's orders. She further said that nurses should not sign off on physician's orders that they are not completing.

Based on observations, record review and interviews, the facility failed to: 1) provide assistance with incontinence care for two Residents (#60 and #33) and 2) provide assistance with meals for two Residents (#25 and #55) out of a total sample of 31 residents. Findings include: Review of the facility policy titled, ADL (Activities of Daily Living) Policy, dated 1/2025, indicated the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent if the resident and in accordance with the plan of care, including appropriate support and assistance with: c. elimination (toileting) and d. toileting (meals and snacks). Review of the facility policy titled, Incontinence Policy, dated 1/2025, indicated the following: -The staff and practitioner will appropriately screen for, and manage, individuals with urinary and bowel incontinence. -If the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment, staff will use the check and change strategy. -A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goal is to maintain dignity and comfort and to protect the skin. 1a. Resident #60 was admitted to the facility in November 2018 with diagnoses including chronic obstructive pulmonary disease. Review of Resident #60's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 9 out of a possible 10 on the Brief Interview for Mental Status (BIMS) exam, indicating he/she had moderate cognitive impairment. The MDS also indicated Resident #60 is frequently incontinent and is dependent on staff for toileting needs. Review of the Bowel and Bladder assessment dated [DATE], indicated Resident #60 is incontinent all the time, is never aware of need to toilet, and never voids appropriately without incontinence. The assessment also included a care plan intervention to check the Resident every two hours and assist with toileting as needed. Review of Resident #60's bladder incontinence care plan initiated on 5/27/23 indicated the following intervention: -Clean peri-area with each incontinence episode. Review of Resident #60's potential for skin impairment care plan initiated on 5/26/23 indicated the following interventions: -Clean peri-area with each incontinence episode -Provide peri-care after incontinence episodes, apply barrier cream, wears adult brief Review of Resident #60's activities of daily living care plan initiated on 5/26/23 indicated the following intervention: -(the Resident) requires total assist of 1 staff for toileting and incontinent care Review of the Documentation Survey Report for January and February 2025 indicated Resident #60 is incontinent of bowel and bladder daily. Review of Resident #60's Kardex (a form indicating the level of care required for a resident) indicated the following: -Clean peri-area with each incontinence episode. -(the Resident) requires total assist on 1 staff for toileting and incontinent care On 2/4/25 at 8:14 A.M., Resident #60's morning care had been completed by the Certified Nursing Assistant (CNA). From 8:00 A.M. until 11:15 A.M., the surveyor observed the hallway outside of Resident #60's room and did not see any staff enter his/her room to provide care or check for incontinence. During an interview on 2/4/25 at 12:46 P.M., CNA #1 said she often takes care of Resident #60 and that he/she is not always continent. CNA #1 said the Resident will use the call light for care however he/she often has already been incontinent. CNA #1 said she had provided morning care for Resident #60 but had not yet gone back in to check for or provide incontinence care. CNA #1 said she usually waits until after lunch to provide care again. During an interview on 2/04/25 at 1:01 P.M., CNA #1 said the Resident was still eating lunch so she was going on her break and would check on the Resident after she returned to the floor. On 2/4/25 at 1:43 P.M., CNA #1 entered Resident #60's room to provide incontinence care. The surveyor observed Resident #60's brief after care was provided. The brief was filled with a significant amount of stool and urine. During an interview on 2/4/25 at 1:00 P.M., Nurse #1 said residents who are incontinent should be changed every two hours or as needed. During an interview on 2/5/25 at 6:55 A.M., the Director of Nursing said rounds should be completed every couple of hours and any resident with known incontinence should be checked. The Director of Nursing said incontinent care should be provided during rounding and as needed. 1b. Resident #33 was admitted to the facility in October 2022 with diagnoses including cerebral hemorrhage and hemiplegia. Review of Resident #33's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) exam and staff had assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #33 is always incontinent and is dependent on staff for toileting tasks. On 2/4/25 at 7:59 A.M., Resident #33's morning care was completed by the Certified Nursing Assistant (CNA). From 8:00 A.M. until 11:15 A.M., the surveyor observed the hallway outside of Resident #33's room and did not see any staff enter his/her room to provide care or check for incontinence. Review of the Bowel and Bladder assessment dated [DATE], indicated Resident #33 is incontinent all the time, is never aware of need to toilet, and never avoids appropriately without incontinence. Review of Resident #33's bladder incontinence care plan initiated on 10/21/22 indicated the following intervention: -BRIEF USE: The resident uses disposable briefs. Check and change q2 (every 2) hours and prn (as needed). Review of Resident #33's potential for skin impairment care plan initiated on 10/21/22 indicated the following interventions: --BRIEF USE: The resident uses disposable briefs. Check and change q2 hours and prn -Clean peri-area with each incontinence episode apply barrier cream, wears adult brief Review of Resident #33's activities of daily living care plan initiated on 10/21/22 indicated the following intervention: -Toileting hygiene: (the Resident) is dependent, and the helper provides all the effort to complete activity. Review of the Documentation Survey Report for January and February 2025 indicated Resident #33 is incontinent of bowel and bladder daily. Review of Resident #33's Kardex (a form indicating the level of care required for a resident) indicated the following: -Check resident every two hours and assist with toileting as needed -Clean peri-area with each incontinence episode. -Provide pericare after each incontinent episode -Toileting Hygiene: (the Resident is dependent, and the helper provides all the effort to complete the activity. During an interview on 2/4/25 at 1:00 P.M., Nurse #1 said residents who are incontinent should be changed every two hours or as needed. During an interview on 2/4/25 at 12:40 P.M., CNA #2 said she had provided morning care for Resident #33 this morning and had not gone in again to check for possible incontinence or to check the Resident. During an interview on 2/5/25 at 6:55 A.M., the Director of Nursing said rounds should be completed every couple of hours and any resident with known incontinence should be checked. The Director of Nursing said incontinent care should be provided during rounding and as needed. 36431 2a. For Resident #25 the facility failed to ensure the Resident was provided the necessary assistance and supervision during his/her meals. Resident #25 was admitted to the facility in January 2013 and has diagnoses that include unspecified dementia, anemia, major depressive disorder, osteoarthritis, and dysphagia, oropharyngeal phase (a disruption or delay in swallowing). Review of Resident #25's Minimum Data Set assessment, dated 11/20/24 indicated Resident #25 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderately impaired cognition and required supervision/touching assistance for eating. During an observation on 2/3/25 at 8:28 A.M., Resident #25 was sitting up in bed approximately 60 degrees, using a fork and eating a cut up banana from his/her plate. The tray ticket indicated minced moist. There was no staff in the room at the time of the observation. Further observations on 2/3/24 included: -At 8:46 A.M., Resident #25 was slowly eating, with some of the food on his/her plate partially eaten. No staff were in his/her room providing supervision or touching assistance. -At 9:08 A.M., Resident #25 was touching his/her milk carton, was not actively eating, staring, with no staff were present. The plate of food was partially consumed. Review of Resident #25's medical record indicated the following: -A physician's order House diet Dysphasia Mechanical (minced and Moist-MM5) texture, thin (thin-TNO) consistency, Lip plate with meals. Add extra sauce/gravy with meals, active 9/12/24. -The Kardex dated as of 2/5/24 indicated Eating/Nutrition, allow ample time to complete meals with max 1:1 assist to increase endurance, encourage Resident to utilize safe swallow strategies-Allow whole banana, SOFT COOKIES, CAKE, MUFFINS and graham/saltine/peanut butter crackers at this time. NO SOLID DRY BREADS/TOAST. NO STRAWS. Review of the care plan with the focus: Resident presents to skilled ST (speech therapy) for cognitive and swallowing treatment dated 5/22/24. Interventions included: allow ample time to complete meals with max assist 1:1 assist to increase endurance, Position: (staff identified to provide the intervention) (C.N.A. (certified nursing assistant)). Encourage Resident to utilize safe swallow strategies, Position N (nurse) dated 6/5/2024. Review of the Activities of Daliy Living care plan printed and provided to the surveyor did not indicate the level of assistance Resident #25 required for eating. On 2/3/25 at 12:17 P.M., Resident #25 was observed up in a chair in his/her room. A lunch tray was in front of him/her. Resident #25 was not actively eating, nor was there any staff present in his/her room. Further observations on 2/3/25 included: At 12:27 P.M., Resident #25 using a fork in his/her right hand and was slowly eating, then he/she slowly picked up a glass, there was no staff present providing supervision or touching assistance. At 12:34 P.M., Resident remained in his/her room alone and eating slowly. At 12:46 P.M., Resident #25 had his/her head leaning on his/her right hand, and his/her left hand was resting inside of his/her soup bowl. Resident #25's plate was minimally consumed. There was no staff observed in Resident #25's room. On 2/4/25 at 8:09 A.M., 2 staff members were observed boosting Resident #25 in bed. One of the staff exited the room. Further observations on 2/4/25 included: At 8:11 A.M., staff set up the tray, exited the room returned with a towel, placed the towel on the Resident, assisted the resident to pick up a spoon, then the staff exited the Resident's room. From 8:15 A.M., till 8:21 A.M., Resident was using a spoon to eat his/her banana, and no staff was present to provide supervision or touching assistance. On 2/4/25 at 12:15 P.M., Resident #25 was observed sitting up in a chair in his/her room. Resident #25's lunch was on the tray in front of him/her. Resident #25 was holding Glucerna (a nutritional supplement drink). Further observations on 2/4/25 included: At 12:22 P.M., Resident #25 lunch tray was in front of him/her and some food was partially consumed. Resident #25 was staring and not actively eating. There was no staff present. At 12:27 P.M., Resident #25 was staring at the lunch tray, there was no staff present. At 12:30 P.M., a staff member entered the room and started to feed Resident #25. At 12:31 P.M., the staff member exited Resident #25's room. At 12:35 P.M., staff entered Resident #25's room and began feeding him/her. During an interview on 2/5/25 at 11:54 A.M., CNA #6 said Resident #25 requires staff to feed him/her, and there are times the Resident will use a spoon and try to feed him/herself but needs staff to supervise his/her during meals. During an interview on 2/05/25 at 12:07 P.M., the Director of Nursing said a resident who requires supervision for eating should have staff present. 2b. For Resident #55 the facility failed to ensure the Resident was assisted during meals in accordance with his/her plan of care. Resident #55 was readmitted to the facility in April 2024 and has diagnoses that include cognitive communication deficit, heart failure and dysphagia (a swallowing disorder). Review of Resident #55's Minimum Data Set assessment, dated 12/18/24 indicated Resident #55 scored a 5 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having severely impaired cognition and requires supervision/touching assistance with eating. During an observation on 2/3/25 at 8:50 A.M., Resident #55 was siting up in bed and had a partially consumed breakfast tray in front of him/her. Resident #55 was using adaptive utensils and his/hands were shaking. Resident #55 had some food particles on the front of him/her. There was no staff in Resident #55's room. Review of Resident #55's medical record indicated the following: -A physician's order, House Diet, regular (regular-RG7) texture, thin (thin-TNO) consistency, fortified foods BID (twice a day) -A Kardex dated as of 2/5/25 indicated: Oral/Nutrition follow safe swallow strategies, monitor coughing episodes and report increased wet productive cough during meals. Eating/Nutrition: Eating: Resident requires supervision for eating with use of weighted utensils at all meals. A care plan with focus: Resident presents to ST (speech therapy) due to increased coughing episodes during meals. Dated 7/27/24. Care Plan interventions included: Follow for safe swallow strategies, monitor coughing episodes and report increased wet productive cough during meals dated 7/27/24. An Activities of Daily Living care plan indicated: Resident has an ADL self-care performance deficit related to Activity Intolerance, Fatigue, Impaired Balance, Limited Mobility dated 11/2/2020. Interventions included: Eating: Resident requires supervision for eating with use of weighted utensils at all meals. On 2/3/24 the following observations were made during Resident #55's lunch meal: At 12:20 P.M., Resident #55 was sitting up in bed, with his/her meal in front of him/her. Resident #55 was drinking from a cup. No staff present. At 12:29 P.M., Resident #55 was sitting up in bed, he/she was chewing on pie and was heard coughing. Resident #55 continued to eat his/her pie, and no staff was present to support safe swallow strategies. At 12:39 P.M., Resident #55's hand had a bowl raised. Resident #55's hand had a tremor. Resident #55 coughed. No staff were present to provide supervision, safe swallow strategies or hear his/her coughing. At 12:45 P.M., Resident #55 pushed his/her partially consumed lunch away. No staff were present. On 2/04/25 the following observations were made during Resident #55's breakfast meal: At 8:07 A.M., Resident #55's breakfast tray was delivered, he/she was assisted by staff to sit up in bed. After staff set up the breakfast tray they exited the room. Resident #55 was not actively eating his/her meal and was heard clearing his/her throat. At 8:12 A.M., Resident #55 was not actively eating, his/her mouth was gaped open, and his/her eyes were closed. No staff were present. At 8:17 A.M., a staff member entered the room, woke him/her up and said they would come back and exited the room. At 8:22 A.M., Resident #55 was heard coughing. Staff then entered and began to assist Resident #55 with breakfast. Fifteen minutes had passed. On 2/4/25 at the following observation were made during Resident #55's lunch meal: At 12:11 A.M., Resident #55 was in bed with his/her lunch tray in front of him/her. There was no staff present. Resident #55 eyes were closed. At 12:26 P.M., After fifteen minutes where staff were not present to supervise, provide touching assistance, provide safe swallow strategies or monitor for wet coughing, staff entered the room and began feeding Resident #55. During an interview on 2/5/25 at 11:30 A.M., Certified Nursing Assistant (CNA) #5 said Resident #55 used to just need a set up for his/her meals but more recently Resident #55 needs someone to supervise and be with him/her during meals. CNA #5 said staff tried to go back and forth to the rooms of residents who requires supervision, but supervision means someone needs to be with the Resident. During an interview on 2/05/25 at 12:07 P.M., the Director of Nursing said a resident who requires supervision for eating should have staff present.

Based on record review and interview the facility failed to ensure services consistent with professional standards were provided for one Resident (#75) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 31 residents. Specifically, the facility failed to follow physician's orders to ensure that blood pressure readings were not taken on the arm where the dialysis shunt (an access point from the dialysis machine to a blood artery) is located. Findings include: Review of facility policy titled Home Dialysis Program: Hemodialysis Access Site Care, dated November 1,2023, indicated the following: -Care of AVFs (arteriovenous fistula): -h. Do not use the access arm to take blood pressure. Resident #75 was admitted to the facility in October 2022 with diagnoses that include end stage renal disease, dementia and diabetes. Review of the most recent Minimum Data Set (MDS) Assessment, dated 1/1/25, indicated that the Resident was unable to complete the Brief Interview for Mental Status and was assessed by staff as having moderately impaired cognition. The MDS further indicated that the Resident received dialysis. On 2/05/25 at 10:24 A.M., the surveyor observed Resident #75 in bed with a bracelet to the left wrist indicating no blood pressures on that arm. The Resident was unable to say why he/she had the bracelet on his/her wrist. Review of Resident #75's physician's orders indicated the following: -No B/P (blood pressure) On left arm every shift for AV (arteriovenous) Fistula Placement, dated 1/10/24. -Monitor left AV Fistula for Bruits and Trills every shift for HD (hemodialysis), dated 1/10/24. Review of Resident #75's active care plan indicated the following: -A care plan that indicated the Resident is at risk for complications and requires on-going dialysis due to end stage renal disease with interventions that included do not draw blood or take B/P in left arm with fistula. Review of Resident #75's blood pressure readings in the electronic medical record (EMR) indicated the following: -34 times in January 2025 blood pressure was documented as taken on left arm. -Four times in February 2025 between 2/1/25 and 2/4/25 blood pressure was documented as taken on the left arm. During an interview on 2/5/25 at 10:30 A.M., Nurse #4 said that Resident #75 has a fistula to his/her left arm, and you cannot draw blood or take blood pressures on that arm. She said staff should not be documenting blood pressures taken on the left arm. During an interview on 2/5/25 at 10:51 A.M., Unit Manager #2 said that staff should not be obtaining blood pressures on the left arm and documenting it in the medical record. She further said that Resident #75 is not able to tell staff not to use his/her left arm for blood pressures. During an interview on 2/5/25 at 11:54 A.M. the Director of Nursing said that when a resident has a fistula, no blood draws or blood pressures should be taken on that arm. She would expect that staff are not taking blood pressures on Resident #75's left arm and are documenting accurately in the medical record.

Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 2 out of 2 eligible sampled CNAs. Findings include: During review of 3 CNA employee records, the Surveyor was unable to locate annual performance reviews for 2 out of 2 eligible CNAs. The third CNA had not yet been at the facility for a year. During an interview on 2/05/25 at 11:33 A.M., the Human Resource Director said the annual reviews were not completed and he was unsure why. During an interview on 2/5/25 at 11:45 A.M., the Director of Nursing was unable to say why the annual reviews had not been completed.

Based on record review, observations and interviews, the facility failed to ensure accurate medical records were completed for three Residents (#28, #101 and #33) out of a total sample of 31 residents. Specifically, 1) for Residents #28 and #101 the facility failed to ensure physician orders were documented accurately and 2) for Resident #33 skin assessments were completed accurately. Findings include: 1a. Resident #28 was admitted to the facility in January 2024 with diagnoses including diabetes, chronic diabetic ulcer of the left foot, and tachycardia. Review of Resident #28's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #28 requires substantial assistance from staff for functional daily tasks. Review of Resident #28's physician orders indicated the following orders: -Bi-lat (bilateral) LE (lower extremity) ACE wraps, initiated 11/28/24. -Abdominal binder daily for orthostasis hypotension, every day and evening shift for Orthostatic Hyptotension Wear when OOB (out of bed). May remove for ADLs, initiated 11/27/24 On 2/4/25 at 8:51 A.M., 10:05 A.M., and 11:00 A.M., Resident #28 was observed in his/her room. The Resident was not wearing an abdominal binder and did not have an ace wrap to his/her right leg. During an interview on 2/4/25 at 10:10 A.M., Resident #28 said he/she never has an ace wrap to his/her right leg and has not worn his/her abdominal binder in a few weeks. Review of the February 2025 Treatment Administration Record indicated the nurse documented the physician orders for abdominal binder and bilateral ace wraps were completed on 2/4/25. During an interview on 2/5/25 at 7:48 A.M., Nurse #1 said all physician orders should be followed as written and should never be marked as completed if not actually done. Nurse #1 said she was unaware of Resident #28's order for bilateral ace wraps, did not complete the order as written, and should not have marked the order as completed. Nurse #1 said Resident #28 did not wear his/her abdominal binder on 2/4/25 as ordered because it was in the laundry, and she should not have marked the order as completed. During an interview on 2/5/25 at 11:45 A.M., the Director of Nursing said physician orders should only be documented as completed if the order was done. 1b. Resident #101 was admitted to the facility in May 2024 with diagnoses including diabetes, adult failure to thrive and depression. Review of Resident #101's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #101 is dependent on staff for all functional tasks. Review of Resident #101's physician orders indicated the following orders: -Prevelon boots to bilateral feel on as tolerated, every shift, initiated on 7/22/24 -Monitor RUE (right upper extremity) edema elevate on pillow, every shift for edema notify MD (physician) if increased edema is noted or if pt (patient) c/o (complain of)pain, initiated on 11/22/24 On 2/3/25 at 8:21 A.M., Resident #101 was observed lying in bed. The Resident was wearing a prevalon boot on his/her left foot only and his/her right upper extremity was not elevated. There was no prevalon boot observed in the room and there was no pillow observed that could be used to elevate the Resident's arm. On 2/3/25 at 10:58 A.M., Resident #101 was observed lying in bed. The Resident was wearing a prevalon boot on his/her left foot only and his/her right upper extremity was not elevated. There was no prevalon boot observed in the room and there was no pillow observed that could be used to elevate the Resident's arm. On 2/3/25 at 4:06 P.M., Resident # 101 was observed sitting in broda chair with his/her arms resting on his/her lap, not elevated. The Resident was wearing a prevalon boot on his/her left foot only. On 2/4/25 at 6:40 A.M., 9:43 A.M., and 11:00 A.M., Resident #101 was observed lying in bed. The Resident was wearing a prevalon boot on his/her left foot only and his/her right upper extremity was not elevated. There was no prevalon boot observed in the room and there was no pillow observed that could be used to elevate the Resident's arm. Review of the February 2025 Treatment Administration Record indicated the nurse documented the physician orders for elevation of the right arm and bilateral prevalon boots were completed on 2/3/25 and 2/4/25. During an interview on 2/5/25 at 7:48 A.M., Nurse #1 said all physician orders should be followed as written. Nurse #1 said she was unaware of Resident #101's physician orders for bilateral prevalon boots and elevation of the right upper extremity and that these orders were not followed. Nurse #1 said she should not have marked these orders as completed. During an interview on 2/5/25 at 11:45 A.M., the Director of Nursing said physician orders should only be documented as completed if the order was done. 2. Resident #33 was admitted to the facility in October 2022 with diagnoses including cerebral hemorrhage and hemiplegia. Review of Resident #33's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) exam and staff had assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #33 is dependent on staff for self-care and mobility tasks. Review of the wound physician note dated 1/22/25 indicated Resident #33 had a non-pressure wound on his/her sacrum for 3 days measuring 1.4 x 1.7 x 0.1 cm (centimeters). Review of Resident #33's weekly skin assessment completed 1/29/25 failed to indicate Resident #33's sacral wound. Review of the wound physician note dated 1/30/25 indicated Resident #33 had a non-pressure wound on his/her sacrum for over 11 days measuring 1.4 x 1.3 x 0.1 cm (centimeters). During an interview on 2/4/25 at 8:43 A.M., Nurse #2 said weekly skin assessments are completed on all residents and any skin impairment should be included on the assessment. During an interview on 2/5/25 at 6:55 A.M., the Director of Nursing said any skin impairment observed should be documented on the weekly skin assessment to ensure accurate documentation.

Based records reviewed and interviews for one of three sampled residents (Resident #1), whose admission physician's orders included the administration of Eliquis (anticoagulant ), the Facility failed to ensure that upon completion of his/her Admission Medication Regimen Review (MRR) by the Consultant Pharmacist that nursing reviewed and addressed the pharmacy recommendation related to his/her dosage of Eliquis timely, as a result for more than a month, Resident #1 was overmedicated with Eliquis, he/she experienced an acute change in medical status due to being administered excess Eliquis, and required hospital transfer with admission, where he/she received blood transfusions and additional treatments to stabilize his/her condition. Findings Include: Review of the Facility's Policy titled Admission Medication Regimen Review (MRR), dated as last revised 06/01/24, indicated that an admission MRR will be performed within 72 hours of admission or an agreed upon timeframe of admission by a licensed pharmacist per authorization of the facility. Significant medication issues, considered to be time sensitive, identified by the consultant pharmacist during the admission MMR, must be communicated to the physician/prescriber or designees and resolved by 11:59 P.M. of the following day, per the IMPACT Act. The Policy further indicated the following: -Upon completion of the Admission MMR, the pharmacy consultant recommendations may be made electronically or by printed copy and are submitted to the DON or designee who will notify the prescriber for review; -When a time sensitive medication issue is identified that requires immediate attention of the prescriber, the pharmacist will call the facility. Resident #1 was admitted to the Facility in April 2024, diagnoses include septic shock due to a stage IV (wound tunnels through all layers of the skin and expose bone) decubitus ulcer, sickle-cell anemia (inherited group disorder that causes blood cells to become misshapen and break down), diabetes mellitus, a deep vein thrombosis (blood clot) to both lower extremities, and a pulmonary embolism (blood clot in the lung) to his/her left lower lung. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/10/24, indicated (per the hospital discharge summary) Resident #1 was supposed to be transitioned to Eliquis 5 milligrams (mg) by mouth two times a day (for a total of 10 mg a day) upon admission to the facility, and that the Hospital discharge medication list had Eliquis 10 mg by mouth twice daily that had been reconciled (by nursing) with the physician with no stop date or clarification. Review of Resident #1's Hospital Discharge Summary, dated 04/11/24, indicated that he/she was started on Eliquis 10 mg twice daily (total of 20 mg a day), last dose to be administered on the evening of 04/11/24, and then transition resident to Eliquis 5 mg twice daily thereafter. Review of Resident #1's Facility Medication Reconciliation Form, dated 04/11/24, indicated he/she was to be administered Eliquis 5 mg, 2 tablets, (total of 10 mg) by mouth daily. However, Resident #1's order for Eliquis, as written and indicated on the Medication Reconciliation Form, was still incorrect, since the Hospital Discharge Summary indicated he/she was to be administered Eliquis 5 mg, two times a day (for a total of 10 mg a day), and not 10 mg, as a one time dose daily. Review of Resident #1's admission Physician's Orders, dated 04/11/24, indicated to administer Eliquis 5 mg, give two tablets (10 mg) by mouth two times a day for blood clots (which totaled 20 mg a day). Review of Resident #1's Pharmacy Consultation Report, dated 04/15/24, indicated it contained a time sensitive recommendation requiring a prescriber response and facility action by 11:59 P.M. on 04/16/24 per federal impact act requirements. The Consult indicated the following: Resident #1 is ordered Eliquis 10 mg twice a day for blood clots without a stop date for use (typically for 7 days acutely). The Consult further indicated to reevaluate continued use at this dose and document stop date. During a telephone interview on 7/17/24 at 10:11 A.M., and a follow-up telephone interview at 2:46 P.M., the Consultant Pharmacy Manager said the Consultant that completed Resident #1's MMR on 4/15/24, had emailed the recommendations to the Director of Nurses and 4 other designated staff members at the facility that same day. The Manager said the body of the email indicated it contained a recommendation that was time sensitive and that when they flag an email in the PCC system on their end, it is also flagged in the email on the facility end. The Manager could not explain why the Pharmacy had not conducted a follow-up to see if the recommendation had been completed. Review of Resident #1's electronic and hard copy Medical Record, indicated there was no documentation to support nursing staff addressed this time sensitive pharmacy recommendation by the Consultant with the MD or the NP. Review of Resident #1's Medication Administration Record (MAR) dated 04/15/24 to 05/28/24, indicated that despite the pharmacy recommendation to address the dosage of Eliquis, he/she was still administered 10 mg two times a day (for a total of 20 mg a day) during the above referenced time frame. On 5/29/24 Resident #1 was transferred to the Hospital Emergency Department with shortness of breath, weakness, nausea, vomiting, and critically a low Hemoglobin (Hgb, protein in red blood cells that carries oxygen) 6.4 (normal range is between 12.3 and 15.3) and critically low Hematocrit (Hct, measures the volume of red blood cells compared to the total blood volume) 19.2 (normal range is between 36-48) ) requiring blood transfusions and a spinal Arteriovenous (AV) fistula (an abnormal connection between an artery and a vein). Review of Resident #1's Hospital Discharge Summary, dated 06/07/24, indicated he/she had been admitted for anemia in setting of an excessive anticoagulation dose, was found to have a spinal AV fistula, requiring blood transfusion and embolization (procedure used to block a blood vessel, used to stop bleeding). Review of Resident #1's Medication Error Report, dated 06/11/24, indicated the Unit Manager had been sent a pharmacy recommendation for his/her Eliquis on 04/15/24, that had not been completed. During an interview on 07/08/24 at 1:19 P.M., Unit Manager #1 said that on 06/11/24, the Director of Nurses (DON) informed her that the Admission Medication Regimen Review (MRR) by their Pharmacy Consult which had included a recommendation regarding the dosage of Eliquis, had been completed for Resident #1 on 04/15/24, and that the recommendations had not been addressed or followed up on by nursing. The Unit Manager said that she had not remembered seeing any pharmacy recommendations for Resident #1 and said typically the pharmacy will electronically mail (e-mail) a copy of the recommendations to both the unit manager and the DON. Unit Manager #1 said that it was her responsibility to follow through with pharmacy recommendations, and said that prior to this incident there had not been a good system in place and that was why the recommendation had been missed. During an interview on 07/08/24 at 12:15 P.M., the Nurse Practitioner (NP) said typically nursing staff will leave a whole bunch of pharmacy recommendations for them to review and sign for the providers. The NP said she was unaware of Resident #1's pharmacy recommendation from 4/15/24. During a telephone interview on 07/11/24 at 10:20 A.M., the Former Director of Nurses (DON) said that she was made aware of Resident #1's 04/15/24 pharmacy recommendations that had been missed by nursing, while he/she was in the hospital after being sent out acutely for critically low blood laboratory work. The DON said typically all pharmacy recommendations are sent to the unit manager and herself for review and said that recommendations are expected to be completed in a timely manner. The DON said she was unaware of the missed recommendation until 06/10/24 when the Pharmacy sent a message stating that the 4/15/24 recommendation had not been completed. During an interview on 07/08/24 at 3:34 P.M., the Interim DON said that he had only now became aware of the missed pharmacy recommendation for Resident #1. The Interim DON said that is the Facility's expectation that all pharmacy recommendations be reviewed by nursing and completed according to the Facility policy and procedures and completed in a timely manner.

Based on records reviewed and interviews, for one of three sample residents (Resident #1), whose Hospital Discharge Summary indicated that the daily dosage of his/her Eliquis (anticoagulant) was to be decreased from 10 milligrams (mg) two times a day, to 5 mg two times a day, the facility failed to ensure Resident #1 was free from a significant medication error when due to a medication reconciliation error upon admission by nursing, he/she continued to be administered Eliquis 10 mg two times a day for more than a month after his/her admission. Resident #1 experienced an acute change in medical status which include shortness of breath, weakness and critically low blood laboratory work related to being overmedicated with Eliquis, he/she was transferred and admitted to the Hospital where he/she required blood transfusions and additional treatment in order to stabilize his/her condition. Findings include: Review of the Facility Policy titled, Reconciliation of Medication on Admission Guideline, dated 01/26/23, indicated medication reconciliation is to ensure medication safety by accurately for the resident's medications, routes and dosages upon admission or readmission to the facility. The Policy indicated the following guidelines; -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission process; -Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and their condition; and -Medication reconciliation helps to ensure the medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/10/24, indicated (per the hospital discharge summary) Resident #1 was supposed to be transitioned to Eliquis 5 milligrams (mg) by mouth two times a day upon admission to the facility, and that the Hospital discharge medication list had Eliquis 10 mg by mouth twice daily that had been reconciled with the physician with no stop date or any additional clarification. The Report indicated that, on 05/29/24, Resident #1 was transferred to the Hospital Emergency Department secondary to weakness, nausea, vomiting, and a critically low Hemoglobin (Hgb, protein in red blood cells that carries oxygen) 6.4 (normal range is between 12.3 and 15.3) requiring transfusion of two units of blood. Resident #1 was admitted to the Facility in April 2024, diagnoses include septic shock due to a stage IV (wound tunnels through all layers of the skin and expose bone) decubitus ulcer, sickle-cell (inherited group disorders that causes blood cells to become misshapen and break down) anemia, diabetes mellitus, a deep vein thrombosis (blood clot) to both lower extremities, and a pulmonary embolism (blood clot in the lung) to his/her left lower lung. Review of Resident #1's Hospital Discharge Summary, dated 04/11/24, indicated that he/she was started on Eliquis 10 mg twice daily (total of 20 mg a day), last dose to be administered on the evening of 04/11/24, and then transition resident to Eliquis 5 mg twice daily (for a total of 10 mg a day) thereafter. Review of Resident #1's Facility Medication Reconciliation Form, dated 04/11/24, indicated he/she was to be administered Eliquis 5 mg 2 tablets by mouth daily (for a total of 10 mg a day). However, Resident #1's order for Eliquis, as written and indicated on the Medication Reconciliation Form, was still incorrect, since the Hospital Discharge Summary indicated he/she was to be administered Eliquis 5 mg, two times a day (for a total of 10 mg a day), not 10 mg as a one time dose daily. Review of Resident #1's admission Physician's Orders, dated 04/11/24, indicated to administer Eliquis 5 mg, give two tablets (10 mg) by mouth two times a day for blood clots (for a total of 20 mg a day). However, the facility's Medication Reconciliation and physicians orders, were not consistent with the Hospital Discharge Summary that indicated Resident #1 was to be transitioned to and administered Eliquis 5 mg, two times a day (for a total of 10 mg a day) after the 4/11/24 evening dose. Review of Resident #1's auto-populated Alert Order Progress Note, (generated by Point Click Care, PCC, the Facility's electronic medical record) which is auto-generated by PCC once an alert is identified regarding a physician's order, dated 04/12/24, indicated his/her Eliquis order was outside of the recommended dose or frequency; The auto-populated Alert Order Progress Note further indicated: Eliquis oral tablet 5 mg (2 tablets) by mouth two times a day for blood clots. -The daily dose of 4 tablets exceeds the usual dose of 1 to 2 tablets; and -The single dose of 2 tablets exceeds the maximum single dose of 1 tablet. The usual dose is 1 to 2 tablets. Review of Resident #1's electronic and hard copy Medical Record, indicated there was no documentation to support that nursing staff had addressed the Alert Order related to the dosage of his/her Eliquis with his/her physician or nurse practitioner. Review of Resident #1's Nurse Practitioner (NP) Progress Note, dated 04/12/24, indicated his/her current medication included Eliquis 5 mg tablet, take 2 tablets (10 mg) by mouth 2 times a day (for a total of 20 mg a day). However, this was inconsistent with the Hospital Discharge Summary that indicated Resident #1 was to be transitioned to Eliquis 5 mg, two times a day (total of 10 mg day), after receiving his/her 4/11/24 evening dose. Review of Resident #1's Physician's (MD) Progress Note, dated 04/15/24, indicated his/her current medication included Eliquis 5 mg tablet, take 2 tablets (10 mg total) by mouth 2 times a day (for a total of 20 mg a day). However, this was inconsistent with the Hospital Discharge Summary that indicated Resident #1 was to be transitioned to Eliquis 5 mg, two times a day (total of 10 mg day), after receiving his/her 4/11/24 evening dose. Review of Resident #1's Medication Administration Record (MAR), date 04/12/24 through 5/29//24, indicated he/she received Eliquis 5 mg, two tablets (10 mg) by mouth two times a day, for a total of 20 mg a day (instead of total of 10 mg a day as indicated in the Hospital Discharge Summary). Review of Resident #1's Complete Blood Counts (CBC) laboratory work, for the month of May 2024, indicated he/she had abnormal lab values that were steadily declining, which included the following: (HGB - Hemaglobin, protein in red blood cells that carry oxygen, normal range is between 12.3 and 15.3) (HCT - Hematocrit, percentage by volume of red blood cells in the blood, normal range is between 36-48) 05/01/24-HGB 9.6 and HCT 28.8 05/08/24-HGB 9.5 and HCT 28.6 05/15/24-HGB 9.0 and HCT 27.7 05/22/24-HGB 8.0 and HCT 24.1 05/29/24-HGB 6.4 and HCT 19.2 Review of Resident #1's Nurse Progress Note, dated 05/21/24, indicated he/she had a very large and bloody wound to his/her buttocks. Review of Resident #1's Nurse Progress Note, dated 05/22/24, indicated his/her buttocks wound had bloody drainage and required an abdominal pad dressing for the excessive drainage. Review of Resident #1's Nurse Progress Note, dated 05/29/24, indicated he/she complained of nausea and vomiting times three, weakness, and shortness of breath. Resident #1 was transferred to the Hospital Emergency Department on 5/29/24 for evaluation and was admitted for treatment. Review of Resident #1's Hospital Discharge Summary, dated 06/07/24, indicated he/she had been admitted for anemia in setting of an excessive anticoagulation dose, was found to have a spinal AV fistula, requiring blood transfusion and embolization (procedure used to block a blood vessel, used to stop bleeding). Review of Resident #1's Medication Error Report, dated 06/11/24, indicated that the Assistant Director of Nurses (ADON), neglected to note the recommendations from the Hospital Discharge Summary to decrease his/her Eliquis dose to 5 mg after the last 10 mg dose due to be given in the evening on 04/11/24. During an interview on 07/08/24 at 2:17 P.M., the Assistant Director of Nurses (ADON) said at the time of the incident she had been working as the evening nursing supervisor, that she recalled assisting with the admission process for Resident #1 and said she had completed his/her medication reconciliation form. The ADON said that she was unaware there was medication reconciliation error for Resident #1, until the DON informed her on 06/11/24. The ADON said Resident #1's Eliquis dose should have been changed to 5 mg by mouth twice a day (for a total of 10 mg a day) upon admission, but had not and that it was an error. The ADON said that once the auto-generated Alert Order Progress Note (for Resident #1's Eliquis order), had been generated by PCC, the physician should have been made aware and clarification of his/her Eliquis should have been completed at that time. During an interview on 07/08/24 at 12:46 P.M., the Charge Nurse said that once an Alert Order Progress Note from PCC appears in the resident's electronic medical record, the nurse is then responsible for informing the practitioner of the alert and obtaining a clarification order. During an interview on 07/08/24 at 1:19 P.M., Unit Manager #1 said she was unaware of the medication reconciliation error regarding Resident #1 until 06/11/24 when the former DON informed her. Unit Manager #1 said nurses should be reading the resident entire hospital discharge summary prior to reconciling the medications, that there are a lot of admissions, and some things get lost in translation. Unit Manager #1 said that either herself or the Charge Nurse should be reviewing all new admission and readmission medication reconciliation forms for accuracy. Unit Manager #1 said she had missed the change in Resident #1's Eliquis order and never saw the Alert Order Progress Note in PCC to address the Eliquis dose with a prescriber. During an interview on 07/08/24, the Interim Director of Nurses (DON) said that the former DON had made him aware of Resident #1's medication error in relation to medication administration sometime in June 2024. The Interim DON said that is the Facility's expectation for nurses to follow all policies and procedures for medication reconciliation, including having two licensed nurses sign the Medication Reconciliation Form to ensure accuracy and that the Management Staff double check all new admission as soon as possible.

Based on observations, record review, policy review and interviews, the facility failed to prevent a decline in range of motion causing the development of a contracture for one Resident (#78) out of a total sample of 33 residents. Findings include: Review of the facility policy titled Range of Motion and Mobility Guideline, dated September 25, 2019, indicated the following: *Residents will not experience an avoidable reduction in range of motion (ROM) *Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. *Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. *As part of the resident's comprehensive assessment, the nurse will identify the resident's: *Current range of motion of his or her joints *Limitations in movement or mobility *As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: *Contractures *The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. *The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. *The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Resident #78 was admitted to the facility in April 2023 with diagnoses including neuroleptic induced parkinsonism, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle weakness and schizoaffective disorder. Review of Resident #78's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15 indicating that he/she has moderate cognitive impairment. Section GG of the MDS failed to indicate an impairment in range of motion of Resident #78's left hand/fingers. During an observation on 2/6/24 at 8:22 A.M., Resident #78 was observed sitting in his/her wheelchair eating breakfast. His/her left hand was closed into a half-closed fist with his/her fourth and fifth fingers bent at the first and second knuckles. Resident #78 was unable to straighten his/her fourth and fifth fingers. Resident #78 was observed holding a drink cup only using his/her thumb and index finger. During an interview on 2/7/24 at 10:32 A.M., Resident #78 said he/she can only move his/her thumb, first and second fingers on his/her left hand and could not move his/her fourth or fifth fingers. When observing the Resident's left palm, an indentation mark was observed where the fourth finger was pressing into the palm. Resident #78 said his/her left hand has been like this for about two months. During an interview on 2/8/24 at 7:51 A.M., Resident #78 said his/her left hand hurt and is painful. Review of Resident #78's physician's orders do not indicate an orthotic or any intervention for the Resident's left hand. Review of Resident #78's care plan dated 4/4/23 indicated the following: *Focus: The resident has limited physical mobility *Goal: The resident will remain free of complications related to immobility, including contractures. Resident #78's care plans did indicate a care plan for a contracture of his/her left hand. However, during an interview on 2/7/24 at 2:03 P.M., the Assistant Director of Rehab stated that the care plan inaccurately documented Resident #78's contracted hand as his/her left hand when it was meant for his/her right hand. During an interview on 2/7/24 at 11:10 A.M., Certified Nursing Assistant (CNA) #2 attempted to move the Resident #78's fingers on his/her left hand with the surveyor present. CNA #2 said she was unable to straighten the Resident's fourth and fifth fingers, saying the fingers were too tight. Resident #78 said it was painful when CNA #2 attempted to move his/her fingers. CNA #2 said she does a quick range of motion when she provides routine care for the residents. During an interview on 2/7/24 at 11:11 A.M., Nurse #3 observed Resident #78's left hand with the surveyor present. She said the Resident's left hand feels stiff and this was a new contracture. She continued to say that CNAs do not do range of motion and if they see something new they should tell a nurse. Nurse #3 said if a change in range of motion is observed by the nursing staff they would make a referral to the therapy department for an evaluation. Review of Resident #78's Occupational Therapy Evaluation and Plan of Treatment document, dated 12/12/23 indicated the following: *Musculoskeletal System Assessment: LUE (left upper extremity) = WFL (within functional limits) During an interview on 2/7/24 at 2:03 P.M., the Assistant Director of Rehab (ADOR) said long term care residents are screened by therapy during rounds every Monday. The ADOR said the therapy department receives referrals from nursing if a change in status is identified and if such referral was made a therapist would evaluate the resident. The ADOR said a change in range of motion would be a reason for a nursing referral. The ADOR continued to say if a staff member noticed a deficit, then therapy should have been notified so it can be treated. When asked about Resident #78, the ADOR said his/her left hand is within functional limits and if there was any deficit in range of motion then it would have been documented on the previous occupational therapy evaluation. The ADOR reviewed the evaluation and confirmed the Resident did not have a previous impairment in range of motion of his/her left hand. The ADOR continued to say that a contracture can form within 2 months, which is the time since Resident #78 was last seen by therapy. The ADOR said therapy has not received a referral for Resident #78's left hand and she would expect staff to document any deficit in range of motion in the medical record. During an interview on 2/7/24 at 2:27 P.M., the Occupational Therapist (OT) said she completed the occupational therapy evaluation on 12/12/23. The OT said the Resident has always kept his/her hand in a slight fist formation, but staff were always able to straighten all fingers on the left hand prior. The OT said she observed Resident #78's left hand and there is a possible new contracture since his/her last evaluation, and she would be completing a full evaluation to determine this. During an interview on 2/8/24 at 10:05 A.M., the Director of Nursing (DON) said CNAs should be doing range of motion during routine care and if staff observed a decline in range of motion it should be reported to the nurse or unit manager so therapy can be made aware. The DON continued to say that even though Nurse #3 said CNAs do not do range of motion during daily care, it is the expectation that they do. Review of Resident #78's Occupational Therapy Evaluation and Plan of Treatment dated 2/8/24 indicated the following: *Musculoskeletal System Assessment: LUE ROM (left upper extremity range of motion) = impaired. Ring finger = impaired, little finger = impaired. *Assessment Summary - Clinical Impressions: *Pt. (patient) referred to OT services due to nursing concerns for decreased functional use and concern for contracture of L (left) hand. Noted decreased use of 5th digit during self-feeding but able to extend when grasping cup. Approached after meal and pt presenting with L digits in flexed fisted position. When prompted to extend digits pt able to extend digits 2 and 3 WFL, digits 4 and 5 with decreased ROM at PIP (lower joint) and DIP (upper joint) as well as pt endorsing pain. Pt would benefit from OT services 2-3x/week to address bilateral contracture. During an interview on 2/8/24 at 1:04 P.M., the OT said she completed an evaluation of Resident #78's left hand and the Resident has a new contracture to the fifth finger, and he/she will be going back on therapy services.

Based on record reviews, policy reviews and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for two Residents (#36 and #96) out of a total sample of 33 residents. Specifically, 1) the facility failed to provide non-pharmacological interventions or behavioral health services for Resident #36 as he/she had increasing behaviors and psychological distress leading to two involuntary hospitalization s for psychiatric concerns and 2) the facility failed to provide behavioral health services for Resident #96 after he/she displayed increased depressive symptoms. Findings include: Review of the facility policy titled, Behavior Assessment Guideline, dated June 2017, indicated the following: *The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. *Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. *Behavioral health services will be provided by qualified staff who have competencies and skills necessary to provide appropriate services to the residents. *Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. *The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address and modifiable factors that may have contributed to the resident's change in condition, including: physical or medical changes; emotional, psychiatric, and or psychological stressors; and functional, social or environmental factors. *Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. *Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational environmental reasons for behavior. The care plan will include, as a minimum: in description of the behavioral symptoms and precipitating factors or situations. *Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. 1. Resident #36 was admitted to the facility in December 2021 with diagnoses including major depression and dementia. Review of Resident #36's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated he/she had moderate cognitive impairment. Section E of the MDS indicated Resident #36 has had physically and verbally aggressive behaviors toward others for at least 1 out of 3 days assessed. During an interview on 2/9/24 at 8:51 A.M., Resident #36 said he/she has been feeling frustrated for a long time and is sad that he/she cannot leave the facility. Resident #36 said he/she would be willing to talk to someone about his/her problems if it would help. Review of Resident #36's medical record indicated that throughout his/her stay at the facility, he/she has been seen by a nurse practitioner for psychotropic medication management, however has never been seen by other behavioral services for counseling or non-pharmacological behavioral or emotional interventions. Resident #36 was sent out to the hospital with involuntary section 12 hospitalization s for psychiatric concerns on 9/20/23 and 10/3/23. Review of Resident #36's medical record indicated the following: Review of the clinical record indicated that between 8/20/23 and 8/23/23, Resident #36 showed increased behaviors such as being combative, verbally and physically abusive towards staff. On 8/24/23, Resident #36 was seen by the psychiatric nurse practitioner. The treatment encounter note indicated the Resident was seen for depression and failure to thrive and did not mention the Resident's increased behaviors or refusal of care. The note indicated 20 time was spent discussing patient's issues with staff, discussing patients issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing support and the recommendations were to continue medications as ordered. Review of the clinical record indicated that between 8/25/23 to 9/11/23, Resident #36 continued to display behaviors of irritability, aggression, verbal and physical abuse toward staff, and refusing care. The nursing note dated 9/3/23 indicated: Alert, verbal, to baseline. Refused to go bed on 3-11 shift in (his/her) wheelchair in-front of the nurses station. (He/she) was tried several times to be assisted to (his/her) bed but being verbally abusive with ' I will kill you' remark on the staff. After 2 AM (he/she) was falling asleep on (his/her) chair, & was physically wheeled to (his/her) room in order for to be changed & to go bed. (He/she) continues (his/her) verbal assault on the staff, was very soiled both (his/her) perineal in being red in which we can't put some barrier Creme this time secondary to (his/her) belligerent behavior. Went there several time for safety check, then about 3:30 AM found (him/her) sitting on (his/her) bedside with only (his/her) brief, offered to dressed but refused, also throw all (his/her) bedding onto the floor. This morning several attempt to give (his/her) med but continue to refused & verbally abusive, At one point ' you go home to china & you to Africa'. Safety maintained, no S/S of pain on assessment, continue plan of care. On 9/12/23, Resident #36 was seen by the psychiatric nurse practitioner, 9 days after he/she threatened to kill a staff member. The treatment encounter note indicated the Resident was irritable at times. The note indicated 20 time was spent discussing patient's issues with staff, discussing patients issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing support and the recommendations was to increase the Resident's antidepressant medication. Review of the clinical record indicated that between 9/13/23 to 9/20/23, Resident #36 continued to have aggressive behaviors toward staff, including sexual, physical and verbal abuse, refusing medications, and paranoia. Medication changes during this time frame were as follows: *On 9/12/23, Resident #36's Zoloft (antidepressant) was increased from 25 mg (milligrams) once a day to 50mg once a day. *On 9/15/23, Resident #36's Zoloft was decreased back down to 25mg. *On 9/14/23, Resident #36 was prescribed Seroquel (an antipsychotic) as follows: give 12.5 mg by mouth at bedtime. *On 9/16/23, Resident #36's Seroquel was changed to 12.5mg every 24 hours as needed. Review of the record from 8/20/23 until 9/20/23, did not indicate the social workers at the facility assessed or spent time with the resident during the August 2023 to September 2023 frame when he/she was demonstrating increased behaviors or prior to either hospitalization . The medical record also failed to indicate any social service notes after Resident #36's increased behaviors in August and September 2023 that showed social services involvement with monitoring or assisting with the Resident's behavior management and coordination of behavioral/psychiatric care services or providing the intervention as listed in his/her behavior care plan. Further, the medical record failed to indicate Resident #36 had ever been seen by a therapist for non-pharmacological interventions. Resident #36 was sent out on an involuntary basis on 9/20/23. Review of the discharge paperwork from the hospital dated 9/26/23 indicated (The Resident) was increasingly combative with staff at the nursing home, yelling, cursing, physically aggressive, and reports HI (homicidal ideation), SI (suicidal ideation). Refusing medications. (he/she) was sent to the ED on sec 12 (involuntary hospitalization ) due to inability to manage (his/her) behaviors. In ED (he/she) was agitated and aggressive, not allowing care, exam, or labs. The hospital discharged the Resident back to this facility as stable. Review of Resident #36's care plans failed to indicate a care plan for Resident #36's SI/HI had been developed upon return from the hospital. Review of the nursing notes after readmission to the facility indicated the following: *9/28/23: Resident was resistive and combative tonight refusing to go to bed. Stayed by the elevator trying to put a code in. Supervisor came up to help and convinced (him/her) to get ADL (self care) care and go to bed. Asleep at this time. *9/28/23: Continue to be non cooperative with care, aggressive when trying to help with ADLs. Patient verbally abusive to staff. Refused all meds, attempted multiple times. RNP (Registered Nurse Practitioner) covering for Dr made aware of patient behavior, episodes of delusion. Family was contacted by NP (Nurse Practitioner) and came to visit. Seroquel 50mg given Per HCP agreement and per NP order. 15 min safety check initiated, monitored closely during the shift. Review of the nurse practitioner note dated 9/28/23 indicated the following: Today, pt is delusional, thinking my pen is a knife. When auscultating (his/her) heart I briefly touched (his/her) necklace which (he/she) informed me was voo doo and made a cutthroat gesture. (He/she) is holding on to a metal fork, refusing to let it go and threatening staff. The psychiatric nurse practitioner saw the Resident on 9/29/23 and the encounter note indicated the following: Pt has had severe psychotic break. He/she mistook a pen as a knife. (He/she) is at risk to him/herself and others. Staff placed (him/her) on 15 minute checks. Mood: depressed, psychotic, anxiety. Severity: severe. 20 time was spent discussing patient's issues with staff, discussing patient's issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing emotional or behavioral support. After this visit, Resident #36's Zoloft dose was increased from 25mg once daily to 25mg twice daily. The psychiatric nurse practitioner saw the Resident again on 10/2/23 and the encounter note indicated the following: Send to acute psych. (His/her) condition has worsened and not improved by Zyprexa. Review of the clinical record indicated that Resident #36 was not sent out to the hospital on 10/2/23 and continued to have aggressive behaviors, including physical and verbal abuse. On 10/3/23, a nursing progress note indicated the following: 10/3/23: Situation: patient exhibiting aggressive behavior towards staff, verbally abusive, threatening (sic) nurse I will kill you anyway b ., I will strangle you My son is coming with his gun to kill you. Patient has been non cooperative with with meds, food, ADL care since yesterday. (He/she) is at risk for (him/herself) and other. 15 minutes safety check was initiated since last week due to safety concern and exit seeking. Assessment/Appearance: Verbally and physical aggressive to staff and at time to other residents, very delusional. Refused to eat or drink properly, appears weaker. Recommendations: (His/her) behavioral disturbance, increased agitation, cannot be managed at the nursing home, sent to your facility for further evaluation and care. Resident #36 was sent out on an involuntary basis on 10/3/23, 5 days after the psychiatric nurse practitioner documented that Resident #36 was experiencing a severe psychotic break and he/she was unsafe to self and others. Resident #36 was readmitted to the facility on [DATE]. Upon readmission the facility did not develop a care plan for SI/HI and no new interventions were added to his/her behavioral care plans. Review of the Resident's care plan also failed to indicate a care plan was in place for the use of psychotropic/antipsychotic medications. The psychiatric nurse practitioner saw the Resident on 10/24/23; two weeks after his/her readmission for a psychiatric hospitalization , and the encounter note indicated the following: Staff report (he/she) has periods of irritability. Delusions or hallucinations: has reported hallucinations of pen looking like a knife. Suicidal or homicidal: (his/her) thought process is nonsensical. 30 time was spent discussing patient's issues with staff, discussing patient's issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing emotional or behavioral support. The psychiatric nurse practitioner saw Resident #36 on 11/14/23 and the encounter note indicated the following: Delusions or hallucinations: has reported hallucinations of pen looking like a knife. Suicidal or homicidal: (his/her) thought process is nonsensical. 30 time was spent discussing patient's issues with staff, discussing patient's issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing emotional or behavioral support. Final review of Resident #36's medical record indicated the following: *Social service notes dated 10/13/23 and 10/20/23 that indicated Resident #36 would be followed by psychiatric services closely. *A physician note dated 10/12/23 that indicated the medical team would like the Resident to be continued to be seen by psychiatric services. *A nurse practitioner note dated 1/16/24 that indicated the medical team would like the Resident to be continued to be seen by psychiatric services. *Behavior sheets from October 2023 to February 2024 indicated the Resident continued to have behaviors of being sexually inappropriate, abusive language, yelling/screaming, pinching/scratching/spitting, refusal of care and wandering. *The Resident has not been by any psychiatric nurse practitioner or behavioral health counselor since November 2023. The psychiatric nurse practitioner no longer works at the facility and was not able to be interviewed. During an interview on 2/08/24 at 12:54 P.M., Nurse #3 said Resident #36 wants to return to his/her home and leaving the facility is a trigger for his/her increased behaviors. Nurse #3 said she noticed a change in the Resident's behaviors started when his/her family took him/her off the unit and he/she did not want to return to the unit. Nurse #3 said when the Resident was triggered and became more agitated and aggressive, the staff would just leave him/her alone. Nurse #3 said she never had a conversation with the social worker on providing Resident #36 with any services beyond the psychiatric nurse practitioner. During an interview on 2/8/24 at 11:13 A.M., Social Worker (SW) #1 said she is a full time social worker in the facility, however does not work on the floor Resident #36 resides on. SW #1 said the responsibility of the social workers in the facility is to jump in to situations that are concerning for residents, including increased behaviors or change in mood, and try to refer these residents to behavioral services. SW #1 said the facility has the use of a psychiatric nurse practitioner but has never had behavioral health services for counseling/talk therapy and said there are definitely residents in the facility who would benefit from that type of service. SW#1 said she talks to residents, but it is not a counseling session. SW #1 said that when behavioral services in not available, social services and the nursing department fill that need. SW #1 said some interventions available when behavioral services are not available would be talking to the resident, distracting/redirecting the resident, and addressing any concerns the resident may have. SW#1 said SW#2 would have been responsible for intervening with Resident #36's care and she is not aware if Resident #36 is currently receiving behavioral health services. SW #1 said the facility recently made a change with behavioral health service providers and the facility was without a provider for about a month. During an interview on 2/9/24 at 9:49 A.M., SW #2 said she has been supporting the building on and off for the last couple of years and she is the main social worker for the floor Resident #36 resides on. SW #2 says she works 16 hours a week and all her work is completed remotely. SW #2 said she primarily assists the building with MDS interviews and care plan meetings and however else she can help. SW #2 said she would meet with residents as needed if brought to her attention but does not recall any staff telling her about a specific resident concern. SW #2 said she does not remember being involved with Resident #36 in the months of August and September 2023 and was unable to recall specifics about Resident #36's care during the interview. SW #2 said there was a change in psychiatric providers in the facility and the facility she expected the facility to ensure all residents who were being treated prior would also be seen by the new provider. SW #2 was unaware if Resident #36 has continued to be seen by psychiatric services. On 2/9/24 at 8:18 A.M., SW #3 and SW#1 were interviewed. SW #3 said she is a social service assistant and is responsible for scheduling appointments for residents on the unit Resident #36 resides. SW #3 said she was unsure if Resident #36 has continued to be seen for psychiatric services since November of 2023. SW #1 said she didn't believe any behavioral health services, such as talk therapy, would have been beneficial to Resident #36, however, when asked if the facility had ever attempted this, she said they had not. SW #1 said she would expect any individual with increased behaviors or threats of harm would be continually seen by the psychiatric nurse practitioner. SW #1 was unaware if Resident #36 was still being followed by the psychiatric nurse practitioner. During an interview on 2/9/24 at 10:10 A.M., the Administrator and Director of Nursing (DON) said the facility has had a psychiatric nurse practitioner in the building, however there was a lapse in coverage from mid November 2023 to January 2024 when the facility changed providers. The Administrator said the facility has never had a counselor available to the residents of the facility and both the Administrator and DON said they felt there were residents in the facility who would benefit from that service. The DON said that when the behavioral service providers changed, she went through all residents to ensure anyone that was on services prior would have services with the new provider. Both the Administrator and Director of Nursing said there were weekly at risk meetings to discuss residents' behaviors and Resident #36 was discussed in an attempt to provide non-pharmacological behavioral interventions. Review of the risk meeting notes from August 2023 to February 2024 noted the Resident's increased behaviors, however failed to indicate any new behavioral interventions were discussed. During an interview on 2/9/23 at approximately 11:00 A.M., the Administrator confirmed Resident #36 has not been seen by any psychiatric services since November of 2023. 36876 2. Resident #96 was admitted to the facility in April 2023 with diagnoses including end stage renal disease and cognitive communication disorder, delusional disorder, adjustment disorder, and major depressive disorder. Review of Resident #96's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is severely cognitively impaired and requires assistance with bathing, dressing and transfers. Additional Review of the MDS indicated he/she triggered for moderate depression on section D: Mood Interview; which indicated that he/she felt down/depressed or hopeless, feeling tired or little energy and changes in appetite nearly every day over the previous 14 days. During an interview on 2/9/24 at 8:51 A.M., Resident #96 presented with flat affect and depressed mood. Resident #96 said my family comes and visits and we laugh, they leave and I get depressed. Resident #96 said he/she did not believe he/she had been offered counseling services. Review of Resident #96's care plans, indicated: Focus: Resident at risk for potential decline in mood state related to dx (diagnosis) of mood disorder, major depressive disorder, 4/3/23 Interventions: Allow resident the opportunity to express feelings, needs, and concerns to staff provide reassurance as needed. Attempt to determine potential triggers of alteration in mood and adjust as able. Encourage active participation in and out of room, therapeutic and leisure programs of choice. Refer to alternate support systems as appropriate. Focus: Psychotropic [medications], 4/1/23 Interventions: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness. Referral to psych services. Review of Resident #96's clinical progress notes indicated the following: Behavioral Health Nurse Practitioner 11/21/23: Pt (patient) seen for depression and anxiety. he/she is receiving Staff MD reporting today that pt refused dialysis (harm to self) and has higher level of persistent self absorption, anger, paranoia. Pt was strongly preoccupied about his/her family and why they are not coming to his/her aid. More depressed today, no si/hi (suicidal ideation and homicidal ideation). Patient was seen in today in his/her room space. He/she was strongly perseverating about his/her family. With his/her recent disabling medical issues, he/she is upset they are not helping him/her more. he/she is presenting with anxiety to staff. Nurse Practitioner note 12/26/23: Seen in his/her room. He/she appears disheveled in bed. He/she complains of body ache and pains, malaise and fatigue. His/her words shabby. With respect to his/her mood, he/she states, I am afraid of going to the ED (emergency department) [because] I cant control myself. I yell at people. He/she recently decided to stop Prozac, (an antidepressant medication) and abilify (an anti-psychotic medication). Monitor mood closely. Social Services note 12/30/23: This writer met with resident on this date to complete BIMS and PHQ 9. He/she repeated the 3 words then refused the rest of the evaluation stating this is the year for dying and I'm gonna die. Asked for clarification and asked if he/she was having thoughts, plans means to harm himself/herself and to kill himself/herself which he/she denied. Resident stated he/she was very angry and that he/she was sick. Attempted again to finish evaluations and he/she closed his/her eyes. Nursing outside of door notified and both nurse and aid stated this is Resident behavior since his/her return from hospital (11/29/23), and that he/she had been on psych meds and refused them. Discussed referral for psych services and nurse stated he/she would put in for consult. Nurse progress note 12/30/23: Pt very agitated this morning. Stated, I'm going to die, but I'm not ready. Pt did not finish his/her evaluation. Social Services note 1/2/24: Social Worker and Social Service Assistant attempted to check in multiple times with Resident. Daughter had been visiting and asked for SS (social service) team to come back at a later time. Nurse practitioner note 1/4/24: Current moderate episode of major depression disorder. Per my discussion with daughter, he/she had no h/o (history of) depression for many years, no [in patient] psych admission. While in rehab, has expressed some sadness over current health situation and loss of functional independence. Used to be on Prozac and abilify but [patient] wanted them stopped. He/she has expressed statements about not wanting to die to staff. He/she denies SI/HI (suicidal and homicidal ideation) Contracted for safety today. He/she will consider restarting on Prozac. Appreciate psych input. Physician progress note 1/11/24: Resident told me he's/she's sad about the state of his/her health, doesn't want to die and has no plans of hurting himself/herself or other people. Current moderate episode of major depressive disorder. H/O depression for many years, sadness over loss of function and state of health. Today, wiling to restart fluoxetine (Prozac). Appreciate psych input. Nurse Progress note 1/24/24: Resident alert and oriented with baseline screaming, yelling, calling nursing names nonstop during the shift. Pain med was offered x 3, refused all three times stated his/her daughter told him/her not to take pain pill from us. The clinical record failed to indicate Resident #96 had been seen by behavioral health services since 11/21/23 despite a documented increase in depressive symptoms. During an interview on 2/9/24 at 8:54 A.M., Unit Manager #1 said that Resident #96 has become more depressed and sad about his/her current health status. Unit Manager #1 said that the facility has a psychiatrist that comes in, but does not currently have any providers for therapy services. During an interview on 2/9/24 at 9:35 A.M., Social Worker #1 said that Resident #96's mood has been variable and with his/her decline in health, has had some depression. Social Worker #1 said that Resident #96 would benefit from counseling services. During an interview on 2/9/24 at 10:10 A.M., the Administrator and Director of Nursing (DON) said that there had been a change in behavioral health services for the facility and the new service provider had just started. The Administrator said that the new behavioral health services is able to offer counseling services. The Administrator and DON said that in the event that a resident was in need of supportive counseling, outside vendors could be contacted. The Administrator and DON were not aware that Resident #96 had not been seen by behavioral health services since 11/21/24. During a follow up interview on 2/9/24 at 11:39 A.M., the Administrator confirmed Resident #96 had not been seen by behavioral health services since 11/21/24.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the administration of an anticonvulsant for management and treatment of seizures, the facility failed to ensure services provided by nursing met professional standards of practice, when upon admission to the facility the Hospital Discharge Summary and medication list were not thoroughly reviewed by nursing and his/her medications were not accurately reconciled. Upon admission, the need for Resident #1 to be continued on an anticonvulsant medication was not communicated to the physician, and therefore not ordered or administered. As a result, Resident #1 went nine days without being administered his/her anticonvulsant medication, he/she experienced seizure activity, and required emergent transfer to the Hospital Emergency Department for evaluation and treatment. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the facility in January 2023, diagnoses included confusion, end stage renal failure requiring hemodialysis (a machine that filters your blood), dislodged dialysis catheter, bipolar disease, hypertension and a history of repeated falls. Review of the Hospital Discharge Summary, Medication Administration Record, Transfer Report, dated 1/12/23, indicated that Resident #1's Active Medication Orders included that he/she was being administered Lacosamide (Vimpat, anticonvulsant used to treat seizures) 100 milligrams (mg) by mouth two times a day, (for seizures). Further review of the Discharge Summary indicated Resident #1 was to continue to be administered Lacosamide at his/her facility. However, review of Resident #1's Physician Orders, dated January 2023, indicated there were no physician orders for the medication Lacosamide for treatment of his/her seizures. Review of Resident #1's Medication Administration Record, dated January 2023, also indicated there were no physician orders related to the administration of Lacosamide. Review of WebMD, Uses, Side Effects, and More related to Vimpat (Lacosamide an anticonvulsant or antiepileptic drug), indicated it is used to prevent and control seizures. It works by reducing the spread of seizure activity in the brain. This medication works best when the amount of drug in the body is kept at a constant level. Patients should not stop taking this medication without first consulting with their physician. Seizures can become worse when the drug is suddenly stopped. Review of Resident #1's Nursing Progress Note, dated 1/23/23, indicated that Resident #1 required hospitalization following possible seizure activity at 6:45 A.M. Review of Resident #1's medical record indicated there was no documentation to support that an admission chart audit (checklist) had been completed by nursing. Per the Facility, an admission chart audit includes nursing review of the referring facility discharge summary and medication reconciliation. During interview on 2/07/23 at 2:19 P.M., the Second Floor Unit Manager said the weekend Nursing Supervisor on duty would have completed the admission chart audit for Resident #1. The Unit Manager said a checklist is used for the audits and when completed, the audit checklist is filed in the front of the residents chart. The Unit Manager said she had not noticed that Resident #1's admission chart audit had not been completed. During interview on 2/07/23 at 3:20 P.M., the Admission Nurse said that she was not working when Resident #1 was admitted , but said when she came to work on Monday 1/16/23, she reviewed the records for the new admissions that had come in over the previous few days to check for the completion of admission chart audits. The Admission Nurse said she did not recall seeing a chart audit completed for Resident #1. During interview on 2/07/23 at 3:45 P.M., the Minimum Data Set (MDS) Nurse said that she reviews all the hospital paperwork for each new admission. The MDS Nurse said she completed a medication review but, can only use medications that have been administered in the facility. The MDS Nurse said when something is out of the ordinary, the nursing staff is notified. The MDS Nurse said she did not recall seeing the medication Lacosamide in Resident #1's discharge summary. During interview on 2/7/23 at 10:35 A.M., the Assistant Director of Nursing (ADON) said the facility admission process is to complete a post admission chart audit that begins as soon as the admission is complete. The ADON said a facility audit tool (checklist) is utilized for all admissions. The ADON said the Nursing Supervisors, the Admission Nurse, and the Unit Managers all participate in completing admission audits. The ADON said, although Resident #1 was being administered seizure medication while in the Hospital, when nursing first reviewed the Hospital Discharge medication list, they did not see any orders for seizure medication. The ADON said the order for the seizure medication was discovered deeper in Resident #1's Hospital Discharge Summary, after he/she required hospitalization for seizure activity, and they reviewed his/her Discharge Summary again. The facility was unable to provide the surveyor with Resident #1's admission chart audit tool, or any other documentation to support a chart audit had been completed by nursing.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who required the administration of anticonvulsant medication for the treatment of seizures, the facility failed to ensure his/her medications were accurately reconciled by nursing, in an effort to ensure he/she was free from a significant medication error. As a result of a medication reconciliation error, Resident #1 went nine days without being administered his/her anticonvulsant mediation, and required emergent transfer to the Hospital Emergency Department due to the onset of seizure activity. Findings include: The Facility Policy titled Reconciliation of Medications on Admission Guideline, dated as revised 1/26/23, indicated the medication reconciliation form, the discharge summary from the referring facility, the most recent medication administration record, and a medication history from the resident/family were to be used to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission for accurate communication to the attending physician. The Policy further indicated that medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking will continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. Use an approved medication reconciliation form to list all medications from the medical history, the discharge summary and the medication administration record and the admitting orders. Resident #1 was admitted to the facility in January 2023, with diagnoses that included confusion, end stage renal failure requiring hemodialysis (a machine that filters your blood), dislodged dialysis catheter, bipolar disorder, hypertension, and a history of repeated falls. Review of the Hospital Discharge Summary, Medication Administration Record, Transfer Report, dated 1/12/23, indicated that Resident #1's Active Medication Orders included that he/she was being administered Lacosamide (Vimpat, anticonvulsant used to treat seizures) 100 milligrams (mg) by mouth two times a day, (for seizures). Further review of the Discharge Summary indicated Resident #1 was to continue to be administered Lacosamide at his/her facility. However, review of the current Physician Orders, dated January 2023, indicated there were no physician orders for the medication Lacosamide for seizures. Review of Resident #1's Medication Administration Record (MAR), dated January 2023, indicated there was no physician orders related to the administration of Lacosamide. Further review of Resident #1's medical record and documentation related to his/her admission indicated there was no documentation to support that a medication reconciliation was performed by nursing, and the facility was unable to provide the surveyor with a copy of Resident #1's medication reconciliation form that should have been completed by nursing upon admission. Furthermore the omission of Resident #1's Lacosomide was not identified by the facility until nine days after Resident #1's admission, when he/she required transfer and re-admission to the Hospital, after experiencing seizure activity. Review of WebMD, Uses, Side Effects, and More related to Vimpat (Lacosamide an anticonvulsant or antiepileptic drug), indicated it is used to prevent and control seizures. It works by reducing the spread of seizure activity in the brain. This medication works best when the amount of drug in the body is kept at a constant level. Patients should not stop taking this medication without first consulting with their physician. Seizures can become worse when the drug is suddenly stopped. Review of Resident #1's Nursing Progress Note, dated 1/23/23, indicated that Resident #1 required hospitalization following possible seizure activity at 6:45 A.M. During interview on 2/7/23 at 2:19 P.M., the Second Floor Unit Manager said that nurses should reconcile all admission medications from the Hospital Discharge Summary medication list. The Unit Manager said nurses must look through all the documentation that comes with the resident. The Unit Manager said when the documentation differs when she is completing an admission or an audit, she would check with the resident and or family for clarification. During interview on 3/02/23 at 4:10 P.M., the Nursing Supervisor said he worked the second shift and primarily assisted with the 3:00 P.M.-11:00 P.M. admissions, reviewed the medications and the medication lists. The Nursing Supervisor said he would then call the attending physician and they would review the medications together, and the physician would confirm the medication orders. The Nursing Supervisor said he would then enter the medications into the computer and the nurse on duty would complete the resident admission assessment. The Nursing Supervisor said the Hospital Discharge Summary, upon the resident's admission must be read word by word and any concerns should be brought to the physician's attention. The Nursing Supervisor said he can only assume the physician reviews the entire record and the Hospital Discharge Summary, but he does not witness that process. The Nursing Supervisor said he did not recall any incident with Resident #1 and was not aware of the need to use a medication reconciliation form for admissions at that time. The Nursing Supervisor then said he no longer works at the facility. During interview on 2/07/23 at 10:35 A.M., the ADON said, although Resident #1 was being administered seizure medication while in the Hospital, when nursing first reviewed the Hospital Discharge medication list, they did not see any orders for seizure medication. The ADON said the order for the seizure medication was discovered deeper in Resident #1's Hospital Discharge Summary, after he/she required hospitalization for seizure activity, and they reviewed his/her Discharge Summary again.

Based on observation, record review and interview, the facility failed to develop and implement care plans for 4 residents (#92, #11, #30, #18 ) out of a total of 23 sampled residents. Specifically: (1) interventions recommended by the wound physician for an arterial calf wound were not implemented resulting in one Resident's (#92) wound worsening; (2) necessary adaptive equipment was not applied as ordered for two Residents (#11 and #30); (3) required supervision was not provided for one Resident (#18) while eating. Findings include: 1.) Review of the facility's policy titled Skin Management and Pressure Ulcer Prevention, dated 8/10/17, indicated the following: Preparations: Review the resident's care plan to identify the risk factors that are related to skin integrity concerns as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 4. Inspect the skin daily when performing or assisting with personal care or Activities of Daily Living (ADL's). Reposition resident as indicated on the care plan. Monitoring: Evaluate, report and document potential changes in the skin on the weekly skin check in [the electronic record] or in a daily progress note. Changes in skin integrity are reviewed weekly at the Clinical At Risk Meeting. Notify the Physician/Nurse Practitioner and responsible person when there is an alteration in skin integrity that warrants ongoing monitoring, evaluation and treatment. Provide periodic progress updates as indicated. Review the interventions and strategies for effectiveness on an ongoing basis. Resident #92 was admitted to the facility in 2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #92's most recent Minimum Data Set, dated dated [DATE], indicated that he/she was totally dependent for bathing, dressing and eating. Although Resident #92 also scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating that he/she is cognitively intact, his/her health care proxy had been activated by the probate court. Review of Resident #92's care plans indicated the following: Review of the consulting Wound Physicians note dated 5/17/21 indicated that Resident #92 had developed a new wound and indicated the following: *Arterial wound of the left calf *Etiology: arterial *Duration > 1 day *Wound Size: 10 x 2 x Not measurable CM (centimeters) *Surface area: 20 cm *Exudate: none *Other viable tissues: 100% dermis (skin) Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Wound Physician's note dated 5/24/21 indicated that Resident #92's calf wound had worsened: *Arterial wound of the left calf *Etiology: arterial *Duration > 8 days *Wound Size: 6 x 2 x .02 *Surface area: 12 cm *Exudate: none *Necrotic tissue: 100% *The wound was debrided. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] Primary dressing: Xeroform sterile gauze apply once daily for 30 days Secondary dressing: ABD add sterile apply once daily for 30 days; gauze roll sterile bulkee apply once daily for 30 days. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Wound Physician's note dated 6/1/21 indicated the following: *Arterial wound of the left calf *Etiology: arterial *Duration > 17 days *Wound Size: 8 x 3 x .2 CM *Surface area: 24 cm *Exudate: Light Serous *Necrotic tissue: 100% *The wound was debrided. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] Primary dressing: Xeroform sterile gauze apply once daily for 21 days Secondary dressing: ABD add sterile apply once daily for 30 days; gauze roll sterile bulkee apply once daily for 30 days Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During multiple observations of Resident #92 on 6/2/21 and 6/4/21, the surveyor observed him/her in bed with his/her legs flat on the bed and not off-loaded to relieve pressure to his/her wound. During multiple observations of Resident #92 on 6/7/21, the surveyor observed Resident #92 resting in bed with his/her left leg lying flat on a pillow, not off-loaded to relieve pressure to his/her wound. There was no evidence in the clinical record that Resident #92 was non-compliant with offloading or repositioning. Resident #92's care plans failed to indicate he/she had a wound on his/her calf. Resident #92's care plans were not updated after his/her wound had worsened. The care plans failed to include any interventions that included off-loading Resident#92's wound or that he/she had behaviors of being non-compliant with wound care or prevention. Review of Resident #92's clinical record failed to indicate any clinical note indicating that Resident #92's physician would decline to sign off on the Wound physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident #92's Physician on 6/4/21 at 10:52 A.M., he said that he has only disagreed with the Wound physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Wound Physician on 6/4/21 at 12:47 P.M., he said that the nursing staff transcribes his orders into the computer and the attending physician signs off on them. He said that Resident #92's Physician has agreed with his orders and has been signing off on them. The Wound Physician said that Resident #92's wound had gotten worse and he was not aware that his recommendations had not been implemented. The Wound Physician said he was not aware that there was no current treatment in place for Resident #92's left calf despite the recommendations he had made for treatment. During an interview with Unit Manager #1 on 6/4/21 at 1:15 P.M., she said she that the Wound Physician's treatments should be in Resident #92's orders and could not say why there were not transcribed per the Wound Physician's treatment plan. 2). Resident #11 was admitted to the facility in May 2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had severe cognitive impairment and indicated Resident #11 was dependent on staff for hygiene, bathing, dressing, transfers, and bed mobility. On 6/2/21 at 8:29 A.M., the surveyor observed Resident #11 in bed with a contracted right hand; the Resident was not wearing any device for it. The surveyor also observed a pair of blue booties (device used to offload heels) on the chair across the bed. Review of Resident #11's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 2/15/19, for palm guard splint on the right hand in the morning. Please check skin integrity before and after application for contracture. - An order, dated 2/15/21, for heel protector boots while in bed. Review of Resident #11's Norton Scale Assessment (a scale used to predict the likelihood a patient will develop a pressure ulcer) dated 5/27/21 indicated a score of 8 and he/she was at high risk for developing a pressure ulcer. On 6/2/21 at 10:50 A.M., the surveyor observed Resident #11 in bed not wearing a palm guard splint on his/her right hand nor the heel protector boots as ordered. On 6/2/21 at 2:03 P.M., the surveyor observed Resident #11 in a reclining geri-chair not wearing a palm guard splint on his/her right hand as ordered. On 6/3/21 at 8:20 A.M., the surveyor observed Resident #11 in bed not wearing a palm guard splint on his/her right hand nor the heel protector boots as ordered. On 6/3/21 at 8:40 A.M., the surveyor observed a staff member assisting Resident #11 with breakfast. Resident # 11 was not wearing a palm guard splint to his/her right hand nor heel protectors as ordered. On 6/3/21 at 11:51 A.M., the surveyor observed Resident # 11 in a reclining geri-chair not wearing a palm guard splint on his/her right hand as ordered. During an interview with Nurse #2 on 6/3/21 at 1:24 P.M., she acknowledged that Resident #11 was not wearing a palm guard splint on his/her right hand. She told the surveyor Resident #11 should be wearing booties to protect his/her heels when in bed. 3). Resident #30 was admitted to the facility in 1/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #30 had severe cognitive impairment and indicated Resident #30 was dependent on staff for hygiene, bathing, dressing, transfers, and bed mobility. On 6/2/21 at 8:35 A.M., the surveyor observed Resident #30 on an air mattress in bed with a contracted right hand; the Resident was not wearing any device on his/her right hand. The surveyor also observed a pair of blue booties (device used to offload heels) on the geri chair (used for patients with mobility issue) in the Resident's room. Review of Resident #30's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 1/17/18, for heel protectors when in bed - An order, dated 12/14/18, for right resting hand splint on in the morning when out of bed. Review of Resident #30's Norton Scale Assessment (a scale used to predict the likelihood a patient will develop a pressure ulcer) dated 5/18/21 indicated a score of 8 and he/she was at high risk of developing a pressure ulcer. On 6/2/21 at 10:21 A.M., the surveyor observed Resident #30 in bed not wearing heel protectors as ordered. On 6/2/21 at 11:50 A.M., the surveyor observed Resident #30 in his/her geri chair not wearing a right resting hand splint as ordered. On 6/2/21 at 1:02 P.M., the surveyor observed Resident #30 in bed, not wearing heel protectors nor his/her resting hand splint as ordered. The surveyor observed pair of blue booties in top of the bin below Resident #30's bed. On 6/3/21 at 8:20 A.M., the surveyor observed Resident #30 in bed, not wearing heel protectors as ordered. The surveyor observed a pair of blue booties on top of Resident #30's geri chair. On 6/3/21 at 10:09 A.M., the surveyor observed Resident #30 in bed, not wearing his/her heel protectors as ordered. During an interview with Nurse #2 on 6/3/21 at 1:24 P.M., she told the surveyor that Resident #30 should be wearing the booties to both heels when in bed and right resting hand splint. 4). Resident #18 was admitted to the facility in December 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment dated [DATE]indicated Resident #18 scored a 6 out of a possible 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment and indicated the Resident required staff supervision with eating and was dependent on staff for bed mobility, transfers, locomotion, dressing, hygiene, bathing, and toileting. Review of Resident #18's Activity of Daily Living (ADL) care plan, dated 9/12/18, indicated an intervention, initiated on 9/12/18, for continuous supervision for eating for the Resident. Review of Resident #18's Nutrition care plan, dated 8/30/18, indicated an intervention, initiated on 4/14/20, for supervision with meals. Review of Resident #18's Visual/Bedside Kardex Report as of 6/3/21 indicated the Resident required supervision with meals and continuous supervision for eating. On 6/2/21 at 8:55 A.M., the surveyor observed Resident #18 eating in bed alone in his/her room. On 6/3/21 at 8:40 A.M., the surveyor observed a Certified Nursing Assistant (CNA) set up a breakfast tray for Resident #18 while he/she was in bed in his/her room. The CNA then left the room and Resident #18 was eating his/her breakfast in bed. On 6/3/21 at 9:10 A.M., the surveyor observed Resident #18 sleeping in his/her bed in his/her room; the Resident's breakfast tray was sitting on a tray table in front of him/her with less than half of his/her breakfast eaten. There were no staff in Resident #18's room nor in the hallway outside his/her room. During an interview 6/3/21 at 12:54 P.M. CNA #3 named two other residents that need supervision with eating to prevent choking or aspiration, but did not name Resident #18 as a resident requiring supervision with meals when asked which residents on the unit required supervision with eating. During an interview on 6/3/21 at 12:56 P.M., Nurse #3, did not name Resident #18 as a resident needing supervision with eating when asked which residents on the unit required supervision with eating.

Based on record review, and staff interview, the Facility failed to ensure that staff were aware of the criteria used to determine when cardiopulmonary resuscitation (CPR) was warranted and nursing staff did not perform CPR for one of three sampled residents after Resident #1 had no pulse or respiration, per Facility policy in the event of a [MEDICAL CONDITION] for residents that had a full code status. Findings included: A review of the Facility's Advance Directives Policy indicated that the licensed nurse ensures that the residents' advance directives were honored and executed per the clinical record and the physician orders. The policy indicated that CPR (cardiopulmonary resuscitation) would be administered to a resident in the event of cardiac or [MEDICAL CONDITION] arrest unless the resident had a DNR (do not resusitate) order. The advance directive acknowledgement, dated [DATE], signed by the Health Care Proxy (HCP) Agent, indicated the HCP Agent understood the right to formulate an advance directive, and indicated that Resident #1 determined not to execute an advance directive (for a do not resuscitate status). The Annual Minimum Data Set (MDS) assessment, completed on [DATE], indicated that Resident #1 had no advance directives. The social worker's plan of care note, dated [DATE], indicated Resident #1 remained a full code status. The plan of care, dated [DATE], indicated Resident #1 remained a full code status. The physician's orders [REDACTED]. The Accused Nurse was interviewed at 11:30 A.M. on [DATE]. The Accused Nurse said, at 4:15 A.M. on [DATE], during the roommate's scheduled safety check, this Accused Nurse observed that Resident #1 was not breathing and had no pulse. The Accused Nurse said this Accused Nurse left the subacute unit to notify Week End Nursing Supervisor #1 that Resident #1 had expired and left a telephone message for the on call Nurse Practitioner that an order for [REDACTED].#1 was "long gone," assumed this Resident had a do not resuscitate status but failed to check the advanced directives or physician orders [REDACTED]. The Accused Nurse said, and this nurse's night shift nurse's note, dated [DATE] with no time provided, indicated Resident #1 had no pulse or respiration, a telephone message was left for the on call NP and Week End Nursing Supervisor #1 was notified. Week End Nursing Supervisor #1 was interviewed at 10:45 A.M. on [DATE]. Week End Nursing Supervisor #1 said the Accused Nurse telephoned the on call Nurse Practitioner (NP) to obtain an order for [REDACTED].M. treatments and medications. Week End Nursing Supervisor #2 was interviewed at 2:00 P.M. on [DATE]. Week End Nursing Supervisor #2 said during 7:00 A.M. shift report on [DATE] this Week End Nursing Supervisor #2 was notified that Resident #1 had expired during the night shift, had been transferred to the funeral home, and asked if 911 had been called because Resident #1 had a full code status. Week End Nursing Supervisor #2 said this nurse was told by Week End Nursing Supervisor #1 that the Accused Nurse had not notified Week End Nursing Supervisor #1 who was in a busy assignment on a subacute unit that Resident #1 was a full code status. Week End Nursing Supervisor #1 and Week End Nursing Supervisor #2 said the licensed nurses on the units were educated to check the advance directives that were in the clinical record and in the physician orders [REDACTED]. The Director of Nurses was interviewed at 8:45 A.M. on [DATE] and at 12:30 P.M. on [DATE]. The DON said staff were educated on the Facility's Advance Directives Policy during orientation. The policy indicated that the licensed nurse ensures the residents' advanced directives were honored and executed per the clinical record and the physician orders. The policy indicated that CPR would be administered to a resident in the event of cardiac or [MEDICAL CONDITION] arrest unless the resident had a DNR order. The DON said all staff were educated during orientation that CPR would be administered to a resident in the event of cardiac or [MEDICAL CONDITION] arrest unless the resident had a DNR order. The Accused Nurse said this nurse was aware that CPR would be done in the event of cardiac or [MEDICAL CONDITION] arrest unless the resident had a DNR order. The Accused Nurse said this nurse had not checked Resident #1's code status because this nurse determined CPR was not appropriate in this situation because Resident #1 "was too far gone" even though this Resident's body remained warm to touch. The DON said staff were educated on CPR requirements, as part of the Advance Directives Policy, during orientation and re-educated on [DATE] including criteria for not initiating CPR when a resident did not have a do not resuscitate status. The DON said the Accused Nurse was terminated for not initiating CPR when Resident #1 was found not breathing, with no pulse, and remained warmed to touch. The DON said staff were re-educated, on [DATE], in response to the incident, following the residents advanced directives, physician orders, and CPR requirements including criteria (DNR order, rigor mortis (major joints are immovable), dependent lividity (a clear demarcation that blood has pooled within the body), decapitation (separation of the skull from the spinal cord), and decomposition (breaking down of the body, usually occurs after a long period of time)) for not starting CPR.