Every finding on record at The Gardens at Cedarwood

Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2 2025 (January 1 -March 31) in accordance with the schedule specified by CMS. Findings include: Review of the facility's policy titled Payroll Based Journal, dated as revised January 2025, indicated but was not limited to: -It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS -The facility will submit direct care staffing information in the uniform format specified by CMS -The facility will submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly Review of the PBJ Staffing Report, CASPER Report 1705D, FY Quarter 2 2025 (January 1 - March 31), indicated the facility triggered for: -Failed to Submit Data for the Quarter (No Data Submitted for Quarter) -One Star Staffing Rating (Staff Staffing Rating Equals 1) -Excessively Low Weekend Staffing (Submitted Weekend Staffing data is excessively low) -No RN (Registered Nurse) Hours (Four or More Days Within the Quarter with no RN Hours) -Failed to have LN (Licensed Nurse) coverage 24 hours per day (Four or More Days Within the Quarter with <24 hours/day Licenses Nursing Coverage) During an interview on 6/16/25 at 8:35 A.M., the Administrator said PBJ Data was reported and he would find evidence of submission for the surveyor. During an interview on 6/16/25 at 11:03 A.M., the Director of Operations said the facility does submit the PBJ staffing data but there was an issue in all their buildings, and he had a call out to CMS. During an interview on 6/16/25 at 2:55 P.M., the Regional Clinical Nurse said the Director of Operations was still working on it, but the person responsible for submitting PBJ data was let go about a month ago and the company was under the impression the PBJ data had been submitted, and they were working with CMS to submit it now. During an interview on 6/17/25 at 11:29 A.M., the Administrator said corporate was responsible for submitting the PBJ data, but he did not think it happened for FY Quarter 2 2025 and could not provide evidence of submission.

Based on record review and interview, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for one Resident (#10), out of a total sample of 14 residents. Findings include: Review of the facility's policy titled Psychoactive Medication Policy, dated [DATE], indicated but was not limited to the following: -Residents who have guardians need to have a [NAME] in order for the facility to administer antipsychotic medication Resident #10 was admitted to the facility in [DATE] with diagnoses which included schizophrenia and dementia. Review of the medical record indicated Resident #10 was found to be incapable of taking care of himself/herself by reason of mental illness and Guardianship was appointed on [DATE] by the Commonwealth of Massachusetts Probate and Family Court. Subsequent review of the medical record indicated the court issued an expansion of the Guardianship on [DATE] and authorized administration of antipsychotic medication via a [NAME] Treatment Plan, which expired on [DATE] at 4:00 P.M. Review of the Physician's Orders, dated [DATE], indicated: -Clozapine (antipsychotic) 100 milligrams (mg) by mouth twice a day, start date, [DATE], discontinued [DATE]. -Clozapine 50 mg by mouth at bedtime, start date [DATE], discontinued [DATE]. -Clozapine 100 mg by mouth twice a day, start date, [DATE] Review of the Medication Administration Records (MAR), dated [DATE] through [DATE], indicated Resident #10 was administered Clozapine 100 mg by mouth twice a day as ordered by the physician without an active [NAME] Treatment Plan in place. During an interview on [DATE] at 10:22 A.M., the Administrator said the facility does not have a social worker at this time and he will need to go through documents left in the prior social worker's office to see if the active treatment plan can be located. During a subsequent interview on [DATE] at 11:13 A.M., the Administrator said Resident #10 has a permanent legal guardian in place and there is no updated court approved [NAME] Treatment plan. He said he contacted the facility's attorney used for guardianship and they do not have anything that is up to date. The Administrator said the most recent treatment plan is expired, and the facility will need to submit a new request to the court.

Based on observations, document review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for one Resident (#207), of 14 sampled residents. Specifically, the facility failed to ensure his/her indwelling Foley catheter (tube inserted into the bladder to drain urine into a collection bag outside the body) was maintained in a sanitary manner. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Summary of Recommendations, Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated March 2024, indicated but was not limited to: -Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Review of the facility's policy titled Urinary Catheter Care, undated, indicated but was not limited to: -Infection Control: be sure the catheter tubing and drainage bag are kept off the floor. Resident #207 was admitted to the facility in June 2025 with diagnoses which included retention of urine and neuromuscular dysfunction of bladder (a urinary dysfunction in which the bladder does not empty properly, depending on the type of neurological disorder causing the problem, the bladder may empty spontaneously or may not empty at all). Review of Resident #207's Minimum Data Set assessment, dated 6/11/25, indicated he/she had an indwelling urinary catheter. Review of Resident #207's Physician's Orders indicated but was not limited to: -Foley catheter to drainage bag for urinary retention, dated 6/5/25 -Provide catheter care every shift and as needed, dated 6/5/25 Review of Resident #207's care plans indicated but was not limited to: -Resident #207 has an indwelling Foley catheter for diagnosis of urine retention and neurogenic bladder, dated 6/5/2025 On the following dates of the survey, the surveyor observed Resident #207 lying in bed with his/her indwelling Foley catheter not attached to the bed and lying directly on the floor with no protective barrier: -6/12/25 at 9:15 A.M., and -6/16/25 at 7:36 A.M. During an interview on 6/16/25 at 12:44 P.M., Certified Nursing Assistant (CNA) #1 said urinary (Foley) catheter bags should be hanging from the bed and should not be touching the floor. During an interview on 6/17/25 at 1:47 P.M., CNA #6 said indwelling urinary (Foley) catheters should never be sitting directly on the floor and should be hanging from the bed. During an interview on 6/17/25 at 1:35 P.M., Nurse #2 said urinary (Foley) catheters should be hanging from the bed and should not be touching the ground to prevent contamination. During an interview on 6/17/25 at 3:25 P.M., the Director of Nurses said urinary (Foley) catheter bags should be hanging from the bed or wheelchair and should not be resting on the floor.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR- Preadmission screening for residents with a mental disorder or intellectual disability) was accurately completed prior to the admission of one Resident (#4), in a total sample of 14 residents. Findings include: Review of the Nursing Facility Bulletin 169: Updates to Nursing Facility Regulations: PASRR for Intellectual Disability (ID), Developmental Disability (DD), and Serious Mental Illness (SMI), dated October 2021, indicated the following: A Level I Screening identifies whether an applicant for admission to a nursing facility has, or may have, ID, DD, and/or SMI (i.e. a positive Level I Screening). Effective October 29, 2021, a Level I Screening must be conducted using the revised Preadmission Screening and Resident Review (PASRR) Level I Screening Form, PASRR-L1 (10/21). If the individual has a positive Level I Screening, the screener must refer the individual to the appropriate PASRR authority for a Level II Evaluation or Abbreviated Level II Evaluation, as applicable, unless the individual satisfies all of the criteria for an Exempted Hospital Discharge. Resident #4 was admitted to the facility in December 2023 with a diagnosis of schizoaffective disorder following a seven-week hospitalization on a psychiatric unit. Review of the medical record included a PASRR, dated 12/1/23, with the following information: -current location: psychiatric hospital -Section B: -Question 4A: does the applicant have any of the following documented diagnoses of mental illness or disorder; answer: no (the box to indicate a diagnosis of schizoaffective disorder was not checked) -Question 5A: within the past two years has the applicant required one of the treatments listed below; answer: no (the box to indicate an inpatient psychiatric hospitalization was not checked) -SMI Screening Results: If you answered YES to questions 5A, 5B, or 6 check positive SMI screen; answer: negative SMI screen (Level II PASRR Evaluation not indicated). -Section E: -Question 14: Has the application screened positive for SMI only, and does the applicant possibly qualify for a categorical determination: No responses were checked in this section. During an interview on 6/17/25 at 11:50 A.M., the Administrator said there was no additional information in the PASRR electronic portal system or with the PASRR office regarding if they received the Level I screen for Resident #4 and there was no indication Resident #4 had a Level II PASRR evaluation. He said the facility Social Workers were responsible for the oversight of the PASRR process but there currently was not a Social Worker.

Based on document review and interview, the facility failed to ensure that monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for one Resident (#1), out of a total sample of 14 residents. Specifically, the facility failed to ensure recommendations from August and September 2024 by the pharmacy consultant to evaluate continued use of as needed Geri-tussin (cough syrup) and menthol lozenge was reviewed and responded to by the provider in a timely manner. Findings include: Review of the facility's policy titled Medication Reconciliation Policy, revised January 2025, indicated but was not limited to the following: -This facility reconciles medication to ensure that the resident is free of any significant medication errors -Monthly Processes: Provide pharmacy consultant access to all medication areas and records for completion of pharmacy services activities -Respond to any medication irregularities reported by pharmacy consultant within relevant time frames. Review of the facility's policy titled Consultant Pharmacist Services Provider Requirements, dated 8-2020, indicated but was not limited to the following: -The facility will ensure regular and reliable consultant pharmacist services are provided to residents. -Reviewing the medication regimen (medication regimen review) of each resident at least monthly. -Documenting the review and findings in the resident's medical record or a readily retrievable format. -A written or electronic report of findings and recommendations resulting from the activities described above is given to the Attending Physician, Director of Nursing at least monthly. -The facility has a process to ensure the findings are acted upon. Resident #1 was admitted to the facility in April 2019 with diagnoses which included hypotension and dysphagia (difficulty swallowing). Review of the Physician's Orders indicated Resident #1 was prescribed the following medications: -Geri-tussin syrup 100 milligrams (mg) / 5 milliliters (ml), give 10 ml as needed (PRN), discontinued 11/4/2024. -Menthol lozenge 1 lozenge PRN, discontinued 11/4/24. Review of the progress notes indicated the following: -Pharmacy Consultant made recommendations on 8/16/24 to review the unused PRN menthol lozenge and geri-tussin. -Pharmacy Consultant made recommendations on 9/11/24 to review the unused PRN menthol lozenge and geri-tussin. Review of the medical record failed to include the pharmacy consultant recommendation report made in August and September 2024. Further review failed to indicate the physician was made aware of the recommendations until 11/4/24, 80 days after the initial recommendation was made. During an interview on 6/17/25 at 1:20 P.M., the Director of Nursing (DON) said the pharmacy consultant reviews all resident medical records monthly. She said they submit a report to the physician to review and sign, and it is placed in the resident's medical record. The DON said all recommendations should be completed prior to the next monthly review. She said she is unable to locate Resident #1's August and September 2024 pharmacy recommendation report; the reports are not in Resident #1's medical record. The DON said the physician did not address the recommendations timely as they should have been.

Based on observation, document review, policy review, and interviews, the facility failed to: 1. Maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections within the facility; 2. For Resident #36, ensure staff wore personal protective equipment (PPE) as required for Enhanced Barrier Precautions (EBP); 3. For Resident #160, ensure EBP were implemented, and PPE was utilized when providing high contact resident care; and 4. Ensure policy and procedures for EBP were developed and implemented, effective 4/1/24 as required. Findings include: Review of the facility's policy titled Infection Prevention and Control Program, undated, indicated but was not limited to the following: - The facility maintains an organized, effective facility-wide program to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, volunteers and healthcare workers. The program is interdisciplinary in design and works in collaboration with other programs and services within the facility. - Ongoing surveillance is recognized as a fundamental component of a strong effective infection control and prevention program. The Infection Preventionist will perform ongoing surveillance to identify opportunities to prevent and/or reduce the rate of infections within residents, employees, and visitors. - The McGeer criteria will be used to standardize the definition and criteria for infection. - Standardized logs will be used for line listing infections throughout the month. These will be reviewed regularly by the facility Infection Control Preventionist for any trends that need to be addressed before the monthly infection control report. - Surveillance activities will be ongoing and documented for the purpose of tracking, trending and identifying needs. - Surveillance will include information collected by either concurrent or retrospective review of resident records, review of microbial reports, reports from resident care providers, families, and review of other documents as appropriate. - Surveillance activities will include employee, visitor, and resident practices as they relate to unprotected exposure to communicable diseases including but not limited to Influenza, gastrointestinal virus, and COVID-19. Review of the facility's policy titled Enhanced Barrier precautions, dated 5/3/24, indicated but was not limited to the following: - It is the policy of this facility to implement enhanced barrier precautions - Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs gown and gloves use during high contact resident care activities. - An order for EBP will be obtained for residents with any of the following: Wounds, and/or indwelling medical device, even if the resident is not known to be infected or colonized with a Multidrug-resistant organism - PPE for EBP is only necessary when performing high-contact care activities - Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. - High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, wound care (any skin opening requiring a dressing) - EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 1. Review of the facility's surveillance sheets titled Antibiotic Use Tracking Sheet for the months of February 2024, March 2024, and April 2024 indicated the following: -The February 2024 tracking sheet 3 out of 6 residents met McGeer criteria for infection and 6 out of 6 residents were started on antibiotics -The March 2024 tracking sheet 4 out of 5 residents met McGeer criteria for infection and 5 out of 5 residents were started on antibiotics -The April 2024 tracking sheet 6 out of 6 residents met McGeer criteria for infection and all were started on antibiotics The surveillance data sheets failed to indicate any tracking or trending of illness, not prescribed antibiotics, for surveillance of the potential spread of illnesses. During an interview on 5/7/24 at 12:17 P.M., the Infection Preventionist (IP) said she completes surveillance for COVID-19 and Influenza outbreaks but does not keep a line listing of illness on a day-to-day basis that do not require the use of antibiotics. During an interview on 5/7/24 at 3:10 P.M., the IP said she reviews the resident progress notes every day for signs or symptoms of an infection, but she does not document the information anywhere. She said there is no system of surveillance to identify any potential spread of illnesses. 2. Resident #36 was admitted to the facility in December 2021 with diagnoses including Type 2 diabetes and chronic osteomyelitis (infection of bone tissue). Review of the active Physician's Orders, dated 5/4/24, indicated: - Enhanced Barrier Precautions, please use enhanced barrier precautions (gloves, gown) during all close contact resident care every shift for infection control. On 5/6/24 at 8:02 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 don (put on) gloves and enter Resident #36's room; the CNA was not observed to don a gown. A sign posted outside of the door indicated but was not limited to the following: Stop; Enhanced Barrier Precautions; Providers and staff must wear a gown and gloves for high contact care activities. Outside of the door was a clear plastic bin containing PPE (gloves and gowns). On 5/6/24 at 8:17 A.M., the surveyor observed CNA #1, open Resident #36's room door, doff his gloves in the trash located inside the Residents' room at the doorway, and exit the room. The surveyor then observed the trash in Resident #36's room by the doorway, inside the trash only used gloves were observed. During an interview on 5/6/24 at 8:22 A.M., CNA #1 said he just gave Resident #36 a bed bath and set him/her up for breakfast. He said he did not wear a gown only gloves to provide care because he/she is not on precautions. CNA #1 and the surveyor then reviewed the sign posted outside of the room together that indicated Enhanced Barrier Precautions; Providers and staff must wear a gown and gloves for high contact care activities. CNA #1 said no one told him Resident #36 was on precautions, and he did not notice the sign upon entering the room. During an interview on 5/6/24 at 10:32 A.M., Nurse #4 said Resident #36 is on EBP precautions for open wounds on his/her abdomen and requires a gown and gloves for all high contact care activities. During an interview on 5/6/24 at 10:48 A.M., Consulting Staff #3 said when residents are on precautions it is communicated to the CNAs in shift to shift report and written on the CNA care cards. She said precautions signs and PPE bins are placed outside of the rooms to alert staff of the precautions needed for that specific resident. Review of the CNA care card failed to indicate Resident #36 was on precautions. During an interview on 5/7/24 at 2:03 P.M., the Director of Nursing (DON) said CNA #1 did not wear the required PPE while providing care for Resident #36. She said assisting a resident with bathing is considered a high contact care activity and requires the use of a gown with gloves when Enhanced Barrier Precautions are in place. She said they just began utilizing EBP a couple of days ago and the staff development coordinator has not completed the education with all of the staff yet. 48084 3. Resident #160 was admitted to the facility in April 2024 with diagnoses including retention of urine and gastrostomy status. Review of the Minimum Data Set (MDS) assessment, dated 4/23/24, indicated Resident #160 had a gastrostomy tube (feeding tube), and failed to indicate the Resident had a urinary catheter. The surveyor made the following observations: - 5/3/24 at 9:20 A.M., a therapist and CNA transferred Resident #160 from his/her bed into the wheelchair. Neither staff member had a gown on during the transfer. There was no EBP sign, nor any PPE aside from gloves available in the direct proximity of the Resident's room. After the transfer, the therapist wheeled the Resident off the unit. Review of the Physician's Orders failed to indicate an order for EBP. Review of the comprehensive care plan failed to indicate Resident #160 was on EBP. During an interview on 5/3/24 at 8:45 A.M., Nurse #2 said no one on this unit (Unit 1) is on EBP. During an interview on 5/3/24 at 9:10 A.M., Nurse #3 said EBP has something to do with residents having a catheter or feeding tube but said we don't do anything differently for them. She said she did not really understand it and requested Consulting Staff #2 speak with the surveyor. During an interview on 5/3/24 at 9:12 A.M., Consulting Staff #2 said the facility had not implemented EBP yet. During an interview on 5/3/24 at 12:31 P.M., the DON said they have not rolled out EBP yet. 4. Review of the Centers for Medicare and Medicaid Services (CMS), Quality, Safety, and Oversight (QSO) Reference #QSO-24-08-NH memo dated 3/20/24, indicated but was not limited to the following: -SUBJECT: EBP in Nursing Homes to prevent spread of multi-drug resistant organisms (MDROs). -In July 2022, the Centers for Disease Control (CDC) released recommendations for implementation of PPE use in nursing homes to prevent spread of MDROs, and therefore CMS is updating its infection prevention and control guidance accordingly. The recommendations now include the use of EBP during high contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status. -EBP are indicated for residents with wounds and/or indwelling medical devices. -Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. -EBP should be used for any resident who meets the above criteria, wherever they reside in the facility. -EBP is employed when performing the following high contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. -Effective Date: 4/1/2024 The surveyor made the following observations on Unit 1: -No EBP signs or PPE carts/set ups were on the unit, except for one set, for a resident on Contact Precautions for an active infection. -During initial screening on the unit on 5/2/24, several residents were observed to have wounds and/or indwelling medical devices (pressure ulcer, Foley catheters and feeding tubes specifically). During an interview on 5/3/24 at 8:45 A.M., Nurse #2 said no one on this unit is on EBP. During an interview on 5/3/24 at 9:12 A.M., Consulting Staff #2 said the facility had not implemented EBP yet. During an interview on 5/3/24 at 12:31 P.M., the DON said they have not rolled out EBP yet. She said they got the memo, and it was supposed to be effective April 1, 2024. She said they have ordered more supplies, are getting the signs ready, and then they will do education. She said she did not have a policy at this time and Consulting Staff #1 was working on it. The facility policy titled Enhanced Barrier Precautions, dated 5/3/24, was provided by Consulting Staff #1 at the end of the business day on 5/3/24.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 1 2024 (October 1 - December 31) in accordance with the schedule specified by CMS. Findings include: Review of the CMS Payroll Based Journal (PBJ) Staffing Data Report, CASPER Report 1705D, indicated the facility failed to submit data for the quarter. During an interview on 5/8/24 at 7:44 A.M., the Nursing Staff Scheduler said she did not know who did the PBJ reporting. During an interview on 5/8/24 at 12:38 P.M., Consulting Staff #5 said in reviewing the data sent to him from the facility it appears the data from October 1-15 was missing. He said the first 15 days of data were missing from the previous owners and that is probably why it got kicked back. Additionally, he said he was going to look into it further. During an interview on 5/8/24 at 1:18 P.M, Consulting Staff #5 said the previous owners did not file the data for October 1-15 as they should have and therefore that data submission was incomplete. During an interview on 5/8/24 at 3:00 P.M., the Administrator said he was unaware of the reporting status prior to his employment start date and deferred questions to Consulting Staff #4. During an interview on 5/8/24 at 3:00 P.M., Consulting Staff #4 said the previous owners should have submitted the data and he was unsure why it was not done.

Based on observations, interviews, record review, and policy review, the facility failed for four Residents (#53, #54, #34, and #1), out of a sample of 15 residents, to ensure staff provided respiratory care and services consistent with professional standards of practice. Specifically, the facility failed: 1. For Resident #53, to ensure orders were in place for Oxygen and the equipment/tubing was changed per policy; 2. For Resident #54, to ensure a Respiratory care plan was developed and the nebulizer equipment/tubing/mask were stored and changed per policy; 3. For Resident #34, to ensure nebulizer equipment was clean and mask/tubing were stored per policy; and 4. For Resident #1, to ensure the oxygen equipment/tubing was changed per policy. Findings include: Review of the facility's policy titled Oxygen Administration Policy and Procedure, dated as last reviewed 12/6/22, indicated but was not limited to the following: -Oxygen is administered by Licensed Nurses with a physician's order. Orders should specify the oxygen equipment and flow rate, or concentration required as routine or as needed. -Oxygen equipment will be checked daily for correct flow and concentration, properly filled humidification system if in use, and correct set up of equipment. -Check the physician's order. If it is unclear, clarification must be obtained. -All tubing will be changed at least weekly, more often if soiling with secretions occurs. Review of the facility's policy titled Nebulizer Therapy, dated as last revised 3/4/24, indicated but was not limited to the following: -Verify practitioner's order. -Correctly assemble the tubing, nebulizer cup, and mouthpiece or mask per manufacturer's specifications and ensure connections are secured tightly. -Clean after each use. -Store nebulizer cup and the mouthpiece in a zip lock bag. -Change nebulizer tubing weekly or as needed. -Periodically disinfect unit per manufacturer recommendations. 1. Resident #53 was admitted to the facility in March 2024 with diagnoses including acute respiratory failure, acute on chronic heart failure, obesity, and cerebral infarction (stroke). Review of the Minimum Data Set (MDS) assessment, dated 4/2/24, indicated Resident #53 was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) and was not receiving oxygen therapy. Review of the Physician's Orders failed to indicate an order for oxygen therapy or equipment care/management. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: At risk for and has impaired gas exchange and shortness of breath related to diagnosis of respiratory failure and use of oxygen. GOAL: Will have no complications related to shortness of breath; Will maintain normal breathing pattern. INTERVENTIONS: -Oxygen as needed per order. Review of the progress notes indicated Resident #53 was receiving oxygen therapy. The surveyor made the following observations: -5/2/24 at 11:06 A.M., Resident lying in bed with Oxygen via nasal cannula on at 2 liters per minute (LPM); tubing dated 4/21/24. -5/3/24 at 11:15 A.M., Resident lying in bed with Oxygen via nasal cannula on; tubing dated 4/21/24. -5/7/24 at 8:41 A.M., Resident lying in bed with Oxygen via nasal cannula off; tubing dated 5/2/24. The facility failed to ensure orders were in place for Oxygen and the equipment was changed per policy. During an interview on 5/2/24 at 11:06 A.M., Resident #53 said they had been on Oxygen since admission to the facility. During an interview on 5/3/24 at 11:20 A.M., Nurse #3 said there should be an order for Oxygen and there is not. During an interview on 5/3/24 at 11:31 A.M., Consulting Staff #2 said there should be an order for the Oxygen and there was not. During an interview on 5/7/24 at 12:04 P.M., the Director of Nurses (DON) said there should be a physician's order for the use of Oxygen. 2. Resident #54 was admitted to the facility in April 2024 with diagnoses including diseases of the circulatory system, encounter for surgical aftercare following surgery on the circulatory system, and dissection of ascending aorta (tear in the body's main artery). Review of the MDS assessment, dated 4/9/24, indicated Resident #54 was cognitively intact as evidenced by a score of 13 out of 15 on the BIMS. Review of the Physician's Orders indicated but were not limited to the following: -Albuterol Sulfate Inhalation Nebulizer Solution 0.083% one vial inhale orally via nebulizer every four hours as needed for wheezing (4/3/24). (medication to open airway) -Ipratropium Bromide Inhalation Solution 0.02% one vial inhale orally via nebulizer every four hours as needed for wheezing (4/3/24). (medication to open airway) The physician's orders failed to indicate an order for nebulizer equipment care/management. Review of the Medication Administration Record (MAR) indicated Resident #54 received the medication via nebulizer three times in April 2024. Review of the Comprehensive Care Plans for Resident #54 failed to indicate a Respiratory Care Plan had been developed. The surveyor made the following observations: -5/2/24 at 11:06 A.M., Resident sitting on edge of bed, nebulizer face mask hanging off the nightstand onto the floor, unbagged (to protect from germs/debris), tubing dated 4/4/24. -5/7/24 at 8:41 A.M., Resident sitting on edge of bed, nebulizer face mask in nightstand drawer attached to nebulizer, mask unbagged, (to protect from germs/debris), lying in drawer full of personal belongings including unfolded gray non-skid slipper socks, tubing dated 4/4/24. The facility failed to ensure a Respiratory care plan was developed and the nebulizer equipment was stored and changed per policy. During an interview on 5/7/24 at 8:41 A.M., Resident #54 said they use the breathing treatment frequently and it helps. Resident #54 demonstrated how the nurse fills the machine and placed the mask on his/her face to show the surveyor how it worked. Additionally, he/she said they were unsure how often the tubing was changed because they had only been here (at facility) for about a month and didn't think it had been changed since admission. 3. Resident #34 was admitted to the facility in March 2024 with diagnoses which included chronic obstructive pulmonary disease (COPD-lung disease that blocks airflow), respiratory failure, and dependence on supplemental Oxygen. Review of the MDS assessment, dated 3/8/24, indicated Resident #34 was cognitively intact as evidenced by a score of 14 out of 15 on the BIMS and received Oxygen therapy. Review of the Physician's Orders indicated but were not limited to the following: -Oxygen at 4 LPM via nasal cannula for diagnosis of respiratory failure and COPD every shift (3/2/24). -Clean oxygen filter weekly on Thursdays 11 P.M. - 7 A.M. shift (3/1/24). -Change oxygen tubing weekly on Thursday 11 P.M. - 7 A.M. shift (3/4/24). -Albuterol Sulfate Inhalation Nebulizer Solution inhale orally via nebulizer every four hours as needed for shortness of breath (3/1/24). -Change nebulizer tubing weekly on Thursday 11 P.M. - 7 A.M. shift (3/4/24). Review of the April and May 2024 MAR and Treatment Administration Records (TAR) indicated the Resident received Oxygen and Albuterol medication via nebulizer daily and the tubing was signed off as changed last on 5/2/24. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Diagnosis of COPD and obstructive sleep apnea and requires oxygen, inhaler, nebulizer treatments and BiPAP. GOAL: Will display optimal breathing pattern daily. INTERVENTIONS: -Oxygen therapy as ordered by the physician. -Give aerosol or bronchodilators as ordered (Albuterol Nebulizer) The surveyor made the following observations: -5/2/24 at 9:07 A.M., Resident wearing nebulizer mask actively receiving a breathing treatment, Nebulizer machine in use laden with dust, crumbs/debris of orange color, small pieces of hair, and three twist off caps to from unit dose packaging. -5/3/24 at 7:20 A.M., Resident in bed with Oxygen in place, nebulizer mask and tubing on top of nebulizer machine, unbagged (to protect from germs/debris), an empty bag under the machine. The facility failed to ensure nebulizer equipment was clean and mask/tubing were stored per policy. During an interview on 5/3/24 at 7:24 A.M., Nurse #1 said the nebulizer mask and tubing should be cleaned and stored in the storage bag after use and it was not currently stored the way it should be. 4. Resident #1 was admitted to the facility in June 2019 with diagnoses including dementia, cerebrovascular disease, and palliative care. Review of the MDS assessment, dated 2/7/24, indicated Resident #1 had severe cognitive impairment as evidenced by a score of 2 out of 15 on the BIMS. Review of the Physician's Orders indicated but were not limited to the following: -Continue Oxygen for comfort only every shift for comfort (4/8/24). -Oxygen at 2 LPM for oxygen saturation less than 90% for comfort (10/26/23) -Change oxygen tubing every seven days on night shift and as needed (10/27/23). Review of the May 2024 MAR and TAR indicated the Resident received Oxygen daily and the tubing was signed off as changed last on 5/1/24. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Potential for altered respiratory status/difficulty breathing and needs oxygen therapy. GOAL: Will have no signs and symptoms of poor oxygen absorption; Will maintain normal breathing pattern. INTERVENTIONS: -Provide oxygen as ordered. The surveyor made the following observations: -5/2/24 at 9:25 A.M., Resident sitting in dining room in wheelchair with Oxygen in place. Tubing appeared old, was yellow from area below the chin up around both ears and up to the prongs that enter the Resident's nose. The tubing was yellow and opaque (cloudy-not clear and see through) and dated 4/10/24, the humidifier bottle attached to the concentrator was unlabeled/undated and the bottle was empty, and the concentrator was set to 2 LPM. -5/2/24 at 9:27 A.M., Nurse #1 entered the dining room, he opened a new disposable humidifier bottle and re-attached the Oxygen tubing dated 4/10/24. -5/3/24 at 7:06 A.M., Resident sitting in the dining room with no Oxygen in place or available in the room, appeared comfortable and not in distress. 5/3/24 at 9:48 A.M., Resident in the dining room, Oxygen in place via nasal canula at 2 LPM, tubing and humidifier bottle dated 5/2/24. The facility failed to ensure the oxygen equipment was changed per policy. During an interview on 5/2/24 at 9:27 A.M., the surveyor asked Nurse #1 about the tubing, and he said it was old and dirty looking and was supposed to be changed weekly. Nurse #1 checked the label and said the tubing was from 4/10/24 and should not be in use, and it was an infection control risk for germs. Additionally, he said the tubing needed to be changed and the procedure for changing it weekly was not completed as it should have been. During an interview on 5/3/24 at 11:31 A.M., Consulting Staff #2 said there should be physician's orders in place for Oxygen and the tubing for all nebulizers and oxygen should be changed weekly on Sundays and should populate on the TAR. During an interview on 5/7/24 at 12:04 P.M., the DON said there should be orders in place for Oxygen which include rate and delivery method. She said the tubing should be changed weekly on Sundays and dated accordingly, and the nebulizer equipment/mask should be cleaned and stored in a bag when not in use. She said they don't have orders that populate. Her expectation is that it is nursing practice, and the nurse should get in report who is on nebulizers or oxygen and this facility changes the equipment on Sunday nights. Additionally, she said an individualized respiratory care plan should be in place. The DON said herself or the Staff Development Coordinator/Infection Control Nurse (SDC/IP) walk the units on Mondays to ensure tubing was changed. When asked how she knows who is on Oxygen, she said she uses her clinical squares (personal worksheet of clinical information specific for each resident which she creates/updates), but not all of these residents are on her squares so she will need to look at the process to ensure things are not missed.

Based on observation, interview, and policy review, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the residents' rooms and environment were maintained in good repair and homelike on 2 of 2 resident care units. Findings include: Review of the facility's policy titled Safe and Homelike Environment, dated as last revised 10/10/24 (sic) indicated but was not limited to the following: -The facility will provide a safe, clean, comfortable, and homelike environment. -Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. -Orderly is defined as an uncluttered physical environment that is neat and well-kept. -Sanitary includes, but is not limited to, preventing the spread of disease causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. -Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. -General Considerations: Report any furniture in disrepair to Maintenance promptly. -Report any unresolved environmental concerns to the Administrator. The facility failed to provide a preventative maintenance policy. Between 5/2/24-5/3/24, the surveyor observed the following: -room [ROOM NUMBER]: Baseboard heater broken/separated; window curtain dirty with rust color stains; nightstand door broken/hanging off; bathroom sink with rust around faucet and hot water knob; ceiling above/in the closet was stained a rust color which looked like water damage and the wallpaper border was falling off the wall. -room [ROOM NUMBER]: Window blinds broken, missing multiple slats leaving large gap of uncovered window. room [ROOM NUMBER]A wheelchair filthy with caked on food/debris. -room [ROOM NUMBER]: Window cracked/broken and taped with bright red tape; baseboard/wall with scuffed up paint. -room [ROOM NUMBER]: Entry wall scuffed up with paint chipped off the wall; window curtain filthy with rust-colored stains; Bathroom wall and ceiling in disrepair with what looked like water damage to plaster/sheet rock with staining and old patch work repairs. -room [ROOM NUMBER]: Window curtain filthy with rusty colored stains; multiple holes in the wall next to the window; Bathroom sink with rust stains around faucet into sink and around hot water handle. -room [ROOM NUMBER]: Window curtain with yellow/rust-colored stains. -Unit One Day Room: Multiple window blinds broken with missing and/or broken slats, some windows with no blinds at all; Baseboard heater panels broken/hanging off the wall. -Second Floor Kitchenette: Wall grate dented and in disrepair, not fully secured to the wall. -room [ROOM NUMBER]: Window in disrepair, frame appeared to be missing parts and was taped with silver tape. -room [ROOM NUMBER]: Window blinds broken with multiple missing slats and exposed window. room [ROOM NUMBER]A left side bed rail covered with dried dirt/debris on grab handle. -room [ROOM NUMBER]: Large crack down the corner of the wall. room [ROOM NUMBER]B wheelchair armrest torn with rough material to grasp and exposed foam. -room [ROOM NUMBER]: Window broken with multiple cracks taped together with duct tape. -room [ROOM NUMBER]: Window falling off the rail/track and no screen on the window. -Unit Two Day Room: Window blinds with broken slats, baseboard heater panels broken/hanging off the wall. During an interview on 5/7/24 at 11:50 A.M., the Administrator and Consulting Staff #1 said they did not believe there was a policy for routine facility maintenance. During an interview on 5/8/24 at 9:38 A.M., the Maintenance Director said they do rounds on the units, but he did not have a schedule for rounding the floors. He said each floor has a maintenance book and he checks that twice a day but was unaware of the damage to the rooms when shown by the surveyor. During a follow-up interview on 5/8/24 at 1:18 P.M., the Maintenance Director said before a new admission comes in, they check the beds, but he does not walk around the room or look up at the ceiling. He said these concerns would be his responsibility to repair but he was unaware of them. Additionally, he said it is not very homelike with broken blinds and baseboard heaters and the broken windows that are taped are a safety concern. He said several of the rooms were in disrepair and he would have to walk around the entire building to see what else needed to be repaired. During an interview on 5/8/24 at 1:32 P.M., the Administrator said his expectation is that rounds are completed to identify issues and expect that the residents have a homelike environment and these concerns with stains on curtains, holes in the walls, and broken windows etc. should have been identified and a solution in process but they were not. During a follow-up interview on 5/8/24 at 4:16 P.M., the Administrator said they have a rounding process in place, but it needs improvement. He said the Maintenance Director is not part of it and he should be. Additionally, he said each department head is assigned a room/area and they are supposed to complete a checklist to identify concerns, however he said there is no tracking process for the forms, and he only had one returned to him with no concerns identified. He said he was unaware of the concerns the surveyor showed him and those areas would need to be addressed. The Administrator said those rooms are not very homelike with the damage and the broken windows are dangerous and should not be duct taped together.

Based on interviews, record review, and policy review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for three Residents (#21, #9, and #19), out of 5 residents selected for an unnecessary medication review. Specifically, the facility failed: 1. To ensure facility wide recommendations were addressed timely and maintained as part of the medical record; 2. For Resident #21, to ensure the January, February, and March 2024 consultant pharmacist recommendations were acted upon timely and to ensure the January, February, March, and April 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record; 3. For Resident #9, to ensure the April 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely for Abnormal Involuntary Movement Scale (AIMS) testing to be completed; and 4. For Resident #19, to ensure January 2024, February 2024, March 2024, and April 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely to decrease dosage of Escitaloram (an antidepressant) medication. To ensure March 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely to re-evaluate need for Benadryl (anti-itch), Cepacol (throat lozenge), and Mucinex (an expectorant) medications. Findings include: Review of the facility's policy titled Medication Regimen Review, dated as effective January 2024, indicated but was not limited to the following: -The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. -The findings for the offsite MRR are phoned, faxed, or emailed timely to the Director Nursing (DON) or designee and are documented and stored with the other Consultant Pharmacist recommendations in the resident's active record. -The prescriber is notified of the consultant findings applicable to the prescriber by the facility in a timely manner to allow the prescriber sufficient time to respond prior to the next monthly consultant visit. -Recommendations are acted upon and documented by the facility staff and/or the prescriber. a. Prescriber accepts and acts upon suggestion or rejects and provides an explanation including medical rationale for disagreeing. 1. During an interview on 5/7/24 at 12:04 P.M., the Director of Nurses (DON) said she did not have copies of previous monthly MRRs (December 2023-March 2024). She said she did not know where they were and said they were not kept as part of the resident's medical record once addressed. Additionally, she said only the admission review is scanned into the record. The DON said she had to call the pharmacy to get copies of the previous MRR reviews to make a binder for 2024 even though many of them were not done. Review of the MRR binder provided indicated but was not limited to the following: -January and February 2024 review reports were all unsigned. -March 2024 reviews were signed 5/3/24. -April 2024 reviews were signed 5/3/24. Review of the Executive Summary of the Consultant Pharmacists Monthly Visits indicated but were not limited to the following: -12/21/23: Residents Reviewed 43; Recommendations forwarded to the Physician were 23 and Nursing 4; The three most prevalent areas of focus were Psychotropic Management, Deprescribing Initiative, and Unused as needed (PRN) medication. The care center's follow up of last visit's recommendations was determined to be 44.4%. -1/19/24: Residents Reviewed 48; Recommendations forwarded to the Physician were 33 and Nursing 4; The three most prevalent areas of focus were Psychotropic Management, Deprescribing Initiative, and Risk/benefit documentation. The care center's follow up of last visit's recommendations was determined to be 11.5%. -2/14/24: Residents Reviewed 52; Recommendations forwarded to the Physician were 24 and Nursing 3; The three most prevalent areas of focus were Psychotropic Management, Unused as needed (PRN) Medications, and Risk/benefit documentation. The care center's follow up of last visit's recommendations was determined to be 53.3%. -3/20/24: Residents Reviewed 50; Recommendations forwarded to the Physician were 34 and Nursing 2; The three most prevalent areas of focus were Psychotropic Management, Unused PRN Medications, and Deprescribing Initiative. The care center's follow up of last visit's recommendations was determined to be 12.5%. -4/16/24: Residents Reviewed 55; Recommendations forwarded to the Physician were 37 and Nursing 6; The three most prevalent areas of focus were Psychotropic Management, Deprescribing Initiative, and Unused PRN Medications. The care center's follow up of last visit's recommendations was determined to be 32.3%. In summary 11.5% - 53.3% of recommendations were addressed by the facility in the five monthly summaries reviewed. During an interview on 5/7/24 at 12:04 P.M., the DON said the MRR recommendations should be given to the provider and addressed timely, scanned into medical record after they have been completed, and a progress note should be written. She said her expectation for all recommendations to be addressed within a week or so but certainly before the next review. Additionally, she said right now there is no tracking method in place to ensure all the recommendations have been addressed. 2. Resident #21 was admitted to the facility in January 2024 with diagnoses including unspecified dementia with agitation, adjustment disorder with mixed anxiety and depressed mood, and insomnia. Review of the Minimum Data Set (MDS) assessment, dated 4/10/24, indicated Resident #21 had severe cognitive impairment as evidenced by a score of 6 out 15 on the Brief Interview for Mental Status (BIMS) and took antipsychotic and antidepressant medications. Review of the Pharmacist's progress notes indicated recommendations were made 1/19/24, 2/13/24, 3/20/24, and 4/16/24. Review of the medical record (paper chart and electronic medical record) failed to indicate any of the recommendations had been completed and failed to indicate copies of signed/completed recommendations were filed or scanned into the record. The surveyor requested copies of the MRR from the DON for 1/19/24, 2/13/24, 3/20/24, and 4/16/24 for Resident #21 on 5/7/24 at 3:53 P.M. During an interview on 5/7/24 at 3:53 P.M., the DON said she had the March and April recommendations as she just had those addressed. She said she did not have the ones previous and would call the pharmacy to have them sent over. The MRRs provided by the DON indicated but were not limited to the following: -1/19/24- This Resident is receiving an antipsychotic agent Seroquel. Please update the diagnosis for this medication in PCC (the electronic medical record). A list of appropriate diagnosis/conditions was part of the recommendation including Dementia with behavioral symptoms. The document was unsigned by the Physician. -2/13/24- This Resident is receiving an antipsychotic agent Seroquel. Please update the diagnosis for this medication in PCC. A list of appropriate diagnosis/conditions was part of the recommendation including Dementia with behavioral symptoms. The document was unsigned by the Physician. (SAME RECOMMENDATION FROM JANUARY 2024) -2/13/24- This Resident has an order for a psychoactive PRN Trazodone which has been in place without a stop date recorded. After 14 days, the use of this psychoactive PRN may be continued if it is determined that the benefit of treatment outweighs the potential/actual risk of the continued PRN therapy. Please consider discontinuing this medication or scheduling this medication if necessary. If this medication is continued as a PRN, a stop date or evaluation date must be added to the PRN order. The document was unsigned by the Physician. -3/20/24- This Resident is receiving an antipsychotic agent Seroquel. Please update the diagnosis for this medication in PCC. A list of appropriate diagnosis/conditions was part of the recommendation including Dementia with behavioral symptoms. (SAME RECOMMENDATION FROM JANUARY and FEBRUARY 2024). The document was signed by the Physician and dated 5/3/24 indicating a diagnosis of Dementia with Behavioral Symptoms. -3/20/24-This Resident has an order for a psychoactive PRN Trazodone which has been in place without a stop date recorded. After 14 days, the use of this psychoactive PRN may be continued if it is determined that the benefit of treatment outweighs the potential/actual risk of the continued PRN therapy. Please consider discontinuing this medication or scheduling this medication if necessary. If this medication is continued as a PRN, a stop date or evaluation date must be added to the PRN order. The document was signed by the Physician and dated 5/3/24 indicating the Resident was no longer on the PRN Trazodone. -4/16/24- Recommendation to discontinue an unused PRN and or lab work was addressed and signed by the Physician 4/17/24. In summary, the Consultant Pharmacist recommended adding an appropriate diagnosis for the use of an antipsychotic (Seroquel) in January, February, and March which was not addressed until 5/3/24 to add a diagnosis of Dementia with Behavioral Symptoms. During an interview on 5/7/24 at 12:04 P.M., the DON said the MRR recommendations should be given to the provider and addressed timely, scanned into medical record after they have been completed, and a progress note should be written. She said her expectation for all recommendations to be addressed within a week or so but certainly before the next review. Additionally, she said this diagnosis was not added to the Resident profile in PCC until 5/3/24 and it should have been addressed sooner. 49425 3. Resident #9 was admitted to the facility in April 2024 with diagnoses which included personality disorder and chronic pain syndrome. Review of the medical record indicated Resident #9 was prescribed the following: -Olanzapine 5 milligrams (mg) give 2.5 mg by mouth in the evening for mood disorder Review of the progress notes indicated the Pharmacy Consultant made recommendations on 4/16/24 for an AIMS assessment to be completed. Review of the electronic and paper medical records failed to include the Consultant Pharmacist Recommendation from April 2024. At 8:45 A.M., the surveyor requested the Pharmacy Consultant Recommendation from the DON. During an interview on 5/8/24 at 10:01 A.M., the DON provided the surveyor with a Summary of Recommendations for DNS/Medical Director. The DON said she was unable to locate the Consultant Pharmacist Recommendation for April 2024. Review of the Summary of Recommendations for DNS/Medical Director dated for recommendations created between 4/1/24 and 4/16/24 indicated Resident #9 was taking an antipsychotic, and AIMS testing was to be performed now and every 6 months to monitor for tardive dyskinesia (involuntary movement disorder). Review of the electronic and paper medical record failed to indicate the Pharmacy Consultant recommendation was reviewed or addressed by the facility. During an interview on 5/8/24 at 10:53 A.M., Social Worker (SW) #1 said AIMS assessments are completed by their psychology consultant services. SW #1 reviewed Resident #9's medical record with the surveyor and said Resident #9 has not been seen by their psychology services yet, and an AIMS assessment had not been completed. 4. Resident #19 was admitted to the facility in December 2019 with diagnoses which included major depressive and bipolar disorders. Review of the medical record indicated Resident #19 was prescribed the following medications: -Escitalopram 30 mg by mouth every morning -Benadryl 25 mg by mouth as needed -Cepacol Sore throat lozenge one lozenge by mouth as needed -Mucinex extended release 400 mg by mouth as needed Review of the progress notes indicated the following: -Pharmacy Consultant made recommendations on 1/19/24 to review the Escitalopram dosage. -Pharmacy Consultant made recommendations on 2/14/24 to review the Escitalopram dosage. -Pharmacy Consultant made recommendations on 3/20/24 to review the Escitalopram dosage and unused as needed medications; Benadryl, Cepacol, and Mucinex. -Pharmacy Consultant made recommendations on 4/16/24 to review the Escitalopram dosage and unused as needed medication, Benadryl. During an interview on 5/8/24 at 8:45 A.M., the surveyor requested the pharmacy recommendations from the DON for Resident #19. She said she is only able to provide March 2024 Note to Attending Physician/Prescriber, and the Summary of Recommendations for DNS/Medical Director for the month of April 2024. She said she is unable to locate any pharmacy recommendations for the months of January and February 2024 for Resident #19. She said the pharmacy recommendations were not kept in the Resident's permanent medical record as they should have been. Review of the Note to Attending physician/Prescriber, dated 3/20/24, indicated Resident #19 was receiving Escitalopram 30 mg daily, and the recommended dose should not exceed 10 mg per day in residents over [AGE] years old. Physician/Prescriber response was blank and incomplete. Review of the Note to Attending Physician/Prescriber, dated 3/20/24, indicated Resident #19 was prescribed as needed Benadryl, Cepacol, and Mucinex that have not been used in over 90 days and can lead to medication errors and potentially using expired medications. Physician/Prescriber response was blank and incomplete. Review of the Summary of Recommendations for DNS/Medical Director, dated for recommendations created between 4/1/24 and 4/16/24, indicated Resident #19 was taking Escitalopram 30 mg daily, and the recommended dosage should not exceed 10 mg per day in residents over [AGE] years of age. Further review indicated Resident #19 was prescribed as needed Benadryl that has not been used in over 90 days and can lead to medication errors potentially using expired medication. Review of the electronic and paper medical record failed to indicate the Pharmacy Consultant recommendation was reviewed or addressed by the facility.

Based on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed: 1. For Resident #50, to ensure the medications were administered under direct supervision and not left at the bedside; 2. To ensure medication and treatment carts on Unit One were locked when not in direct supervision of the licensed nurse; and 3. Ensure safe storage of medications and biologicals according to current standards of practice in 2 of 2 observed medication carts. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines, dated as effective January 2024, indicated but was not limited to the following: -Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. -Medications are administered in accordance with written/electronic orders of the prescriber. -When medications are administered by mobile cart taken to the resident's location, medications are administered at the time they are prepared. -Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. -The resident is always observed after administration to ensure that the dose was completely ingested. -Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. -No medications are kept on top of the cart. Review of the facility's policy titled Storage of Medications, dated as effective January 2024, indicated but was not limited to the following: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Medication rooms, carts, and medication supplies are locked when not attended to by persons with authorized access. 1. Resident #50 was admitted to the facility in December 2023 with diagnoses including depression, alcohol dependence in remission, and alcoholic cirrhosis of the liver (severe liver disease causing the inability for the liver to function properly). Review of the Minimum Data Set (MDS) assessment for Resident #50 indicated he/she had moderate cognitive impairment as evidenced by a score of 12 out 15 on the Brief Interview for Mental Status (BIMS). The surveyor made the following observations: -5/2/24 at 11:44 A.M., Resident in his/her room, two plastic medication cups containing a slightly pale-yellow thick liquid. Each cup had approximately 30 milliliters (ml) in it. -5/2/24 at 1:58 P.M., Resident in his/her room, two plastic medication cups containing a slightly pale-yellow thick liquid. Each cup had approximately 30ml in it. -5/2/24 at 4:05 P.M., Resident in his/her room, two plastic medication cups containing a slightly pale-yellow thick liquid. Each cup had approximately 30ml in it. Review of the Physician's Orders for Resident #50 indicated but were not limited to the following: -Lactulose Oral Solution 10 grams/15 ml, give 60 ml by mouth three times a day related to Hepatic Failure, unspecified without coma (liver failure). Nursing to Monitor Resident taking medication. (1/22/24) Review of the Medication Administration Record (MAR) indicated but was not limited to the following: -Lactulose Oral Solution 10 grams/15 ml, give 60 ml by mouth three times a day related to Hepatic Failure, unspecified without coma (liver failure). -Nursing to Monitor Resident taking medication, had been signed off as administered 5/2/24 at 9:00 A.M. and 1:00 P.M. Review of the comprehensive care plan failed to indicate Resident #50 self-administered medications. Review of the medical record failed to indicate a Self-Administration Assessment Form had been completed. Further review of the physician's orders failed to indicate Resident #50 had an order to self-administer medications. Further review of the medical record indicated Resident #50 had recently (April 2024) been hospitalized for an elevated ammonia level resulting from hepatic encephalopathy (loss of brain function when a damaged liver does not remove the toxins from the blood). The lactulose helps to reduce ammonia levels in the body. The discharge summary indicated to ensure he/she is receiving the lactulose as prescribed. During an interview on 5/3/24 at 11:40 A.M., Nurse #3 said Resident #50 can self-administer and has an order. Additionally, she said she left the lactulose at the bedside yesterday. During an interview on 5/3/24 at 11:44 A.M., Nurse #2 said no residents on this unit self-administers medications. She said if they did, they would have an assessment and an order to self-administer. During an interview on 5/7/24 at 12:04 P.M., the Director of Nurses (DON) said Resident #50 should not have medication left at the bedside. Additionally, she said if a resident were to self-administer medications, they would need an assessment and an order to do so, and Resident #50 does not have those things. She said the nurses should be staying and observing him/her take the medication and if they refuse the medication the nurse should be documenting accordingly. 2. The surveyor made the following observations: -5/2/24 at 10:47 A.M., Unit One, Treatment Cart observed in the hallway, with drawers facing outward, unlocked, staff not in the vicinity of the cart, residents roaming the halls. -5/2/24 at 10:47 A.M., Unit One-High Side, Medication Cart observed in the hallway near room [ROOM NUMBER], with drawers facing outward, unlocked, staff not in the vicinity of the cart, residents roaming the halls. Additionally, Resident from room [ROOM NUMBER] was standing next to the medication cart, agitated, and pacing around the cart. -5/2/24 at 12:00 P.M., Unit One, Treatment Cart observed in the hallway, with drawers facing outward, unlocked, staff not in the vicinity of the cart, residents roaming the halls. -5/3/24 at 8:30 A.M., Unit One, Treatment Cart observed in the resident day room, with drawers facing outward, unlocked, staff not in the vicinity of the cart, residents roaming the halls with access to the day room. At 8:36 A.M. and 9:00 A.M., the treatment cart remained unlocked in the resident day room. -5/3/24 at 11:00 A.M., Unit One-Low Side, Medication Cart observed in the hallway near nurses' station, with drawers facing outward, unlocked, nurse was sitting behind the desk unable to see the drawers of the medication cart, residents were roaming the halls. The nurse got up several times and failed to lock the medication cart until it was moved down the hallway at 11:33 A.M. During an interview on 5/3/24 at 11:40 A.M., Nurse #3 said the medication and treatment carts should be locked when the nurse is not with the cart. During an interview on 5/7/24 at 12:04 P.M., the DON said the medication and treatment carts should be locked when not in use and never left unattended where residents have access to them. 49425 3. On 5/6/24 at 10:20 A.M., the surveyor observed Nurse #4 place a package of SalonPas patches (medication used to treat pain) on top of Unit Two high side medication cart along with a clear plastic container, uncovered, unlabeled with two loose pills inside. Nurse #4 then locked her cart, and walked down the hallway, leaving the medication on top of the cart, out of view, unsecured and unattended. During an observation with interview on 5/6/24 at 10:21 A.M., Nurse #4 returned to the medication cart. Nurse #4 said the two loose pills were blood pressure medications for a resident that she could not administer because the resident's blood pressure was too low, and she needed to destroy them. She said the SalonPas patches were placed on top of the cart, because she needs to apply them to a resident. Nurse #4 said she is not supposed to leave medications unlocked and unattended and should have placed them inside the medication cart before she walked away. During an observation and interview on 5/6/24 at 3:14 P.M., the surveyor observed the medication cart on Unit two high side with Nurse #9 and made the following observations: -In the fourth drawer on the left-hand side: a small, clear plastic medication cup, uncovered and not labeled, which included: four loose pills. Nurse #9 said she does not know what medications are in the clear plastic cup, and medications are not supposed to be stored unlabeled and uncovered in the medication cart. During an interview on 5/6/24 at 3:19 P.M., Nurse #4 said she put the pills in the cup and stored them in the medication cart. She said the resident was not in their room when she attempted to administer them and forgot to destroy them prior to giving report to Nurse #9. During an observation and interview on 5/7/24 at 8:12 A.M., the surveyor observed the medication cart on Unit one high side with Nurse #3 and made the following observations: -In the top drawer: a small, clear plastic medication cup, uncovered, and not labeled which included: 5 loose pills. Nurse #3 said she does not know what the medication is, she just took count and report from the 11:00 P.M.-7:00 A.M. nurse and has not opened the top drawer yet. During an interview on 5/7/24 at 8:18 A.M., Nurse #8 said she had worked the 11:00 P.M.-7:00 A.M. shift and prepared a resident's medication, got called into another resident's room, and placed the container with the pills in the top drawer. She said she was going to administer the medications before she went home for the day. During an interview on 5/7/24 at 8:33 A.M., the DON said medications should be administered once prepared. She said her expectation is for the nurse to destroy the medications, document in the resident's record the medications were not given, notify the physician, and document the physician's response in a progress note. During an interview on 5/7/24 at 12:04 P.M., the DON said the medication and treatment carts should be locked when not in use, never left unattended, and medications should not be left on top of the medication cart.

Based on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer pneumococcal vaccinations per facility policy and the Centers for Disease Control and Prevention (CDC) recommendations for three Residents (#9, #13, and #34), out of a total sample of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, updated May 2023, indicated but was not limited to the following: -It is the policy of this facility to offer and administer pneumococcal Vaccine to eligible individuals who consent for vaccination. -Vaccination for adults ages 19 through [AGE] years old with certain chronic medical conditions or risk factors. The CDC [Centers for Disease Control and Prevention] recommends vaccination for those with any of these conditions and risk factors: -Chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma. -Residents will be screened for needing vaccine, and if deemed appropriate will be offered the vaccine. -Vaccine information sheets will be provided to those who accept or decline vaccination. -Resident/Responsible party must sign or give verbal consent for vaccine prior to administration. -MD order for vaccine administration will be obtained. Review of the CDC website titled Pneumococcal Vaccine Timing for Adults (cdc.gov), dated 3/15/23, indicated but was not limited to the following: -For adults 65 and over who have not had any prior pneumococcal vaccines, then the patient and provider may choose Pneumococcal conjugate vaccine (PCV) 20 or PCV15 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later. -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20). 1. Resident #9 was admitted to the facility in April 2024 and was [AGE] years old. Review of the immunization record failed to indicate Resident #9 had previously received any pneumococcal vaccinations. Review of the medical record indicated a consent form for the Pneumococcal Vaccine, that was blank and incomplete. Further review of the record failed to indicate documentation of screening, assessment for eligibility to receive the pneumococcal vaccine, the provision of education related to the vaccine, and administration of the vaccine in accordance with facility policy and CDC recommendations. 2. Resident #13 was admitted to the facility in August 2022 and was [AGE] years old. Review of the immunization record indicated Resident #13 received the Pneumococcal Vaccine 23 in May 2012, and was eligible to receive the Pneumococcal Conjugate Vaccine PCV20 per CDC recommendations. Review of the medical record indicated a consent form for the Pneumococcal Vaccine, that was blank and incomplete. Further review of the record failed to indicate any documentation of screening, assessment for eligibility to receive the pneumococcal vaccine, the provision of education related to the vaccine, and administration of the vaccine in accordance with facility policy and CDC recommendations. 3. Resident #34 was admitted to the facility in March 2024 and was [AGE] years old with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the immunization record failed to indicate Resident #34 had previously received any pneumococcal vaccinations. Review of the medical record indicated a consent form for the Pneumococcal Vaccine, that was blank and incomplete. Further review of the record failed to indicate any documentation of screening, assessment for eligibility to receive the pneumococcal vaccine, the provision of education related to the vaccine, and administration of the vaccine in accordance with facility policy and CDC recommendations. During an interview on 5/7/24 at 2:50 P.M, the Infection Preventionist Nurse (IPN) said the admitting nurse has the residents sign the consent for vaccination upon admission, once signed they are placed in the medical record. She said she follows up with the residents within one to two days after admission, enters the order for the vaccine, and completes a progress note. The surveyor and IPN reviewed Residents #9, #13, and #34's medical records together. IPN said Residents #9, #13, and #34 consents for vaccination were blank and incomplete. She said all three residents were missing documentation of screening, assessment for eligibility, and education on the risks versus the benefits of receiving the vaccination. She said all three residents are not up to date with their Pneumococcal vaccine as they should be per facility policy.

Based on observation, record review, policy review and interview, the facility failed to provide adequate supervision and an environment free from accidents and/or hazards for three Residents (#4, #19, and #26), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #4, to follow their fall Reduction policy for investigating falls and initiating fall prevention interventions; 2. For Resident #19, to follow their fall Reduction policy for investigating falls and initiating fall prevention interventions; and 3. For Resident #26, to follow their Elopements and wandering residents policy for assessing risk factors and implementing interventions to prevent further elopements. Findings Include: 1. Review of the facility's policy titled Fall Reduction, dated as last revised [DATE], indicated but was not limited to the following: - Goal: To identify residents at risk for falls and to decrease the incidence of resident falls. - The facility will identify residents at risk for falls through use of a Fall Assessment Tool. - The facility will implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual resident's needs. - The facility will provide education on fall prevention to caregivers, residents, and family. - In the event that a fall occurs, the facility will investigate the factors contributing to the fall and develop a plan of action to minimize further falls. - Upon admission, readmission, quarterly, annually and with change in condition and/or after a fall has occurred, residents will be evaluated for risk of potential falls by completing a Fall Risk Assessment. - Residents at risk, in addition to the Universal Safety Standards; will be reviewed for resident specific intervention(s) as deemed appropriate. - In the event a resident falls, the following measures will be instituted: e. Evaluate why the resident may have fallen, clarify the details of the fall. f. Implement intervention(s) as appropriate to prevent recurrence. g. Document in the medical record. h. Complete an Incident Report. - Resident falls will be reviewed in the Standard of Care Meeting and may include, but not be limited to, the following: identification of trends, evaluation of effectiveness of interventions and development of additional measures as indicated. Resident #4 was admitted to the facility in [DATE] with diagnoses including schizoaffective disorder, history of falling, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #4 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS assessment indicated Resident #4 required assistance of one staff member for transfers, ambulation, toileting, and dressing activities. Review of the medical record indicated Resident #4 had a total four falls between [DATE] and [DATE]. Review of Resident #4's Incident Report, dated [DATE], indicated: - On [DATE] at 5:30 A.M., the nurse heard Resident #4 calling for help from their room and responded. The nurse found Resident #4 on the floor, unclothed, just beside his/her bed with his/her body facing the door. - Resident #4 stated they had slipped and fallen on the floor landing on his/her right hip. Resident #4 had complaints of right hip and neck pain. Review of the medical record failed to indicate a Fall Risk Assessment was completed for the incident on [DATE]. Review of the medical record failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's Incident Report, dated [DATE], indicated: - On [DATE] at 3:50 P.M., another resident reported to the nurse that Resident #4 was on the floor. The nurse and two other nurses went into Resident #4's room and observed him/her to be seated on the floor next to his/her bed with both feet slightly bent. Resident #4 was observed to have one foot slightly stuck underneath his/her buttock. - Resident #4 said he/she was trying to get out of bed. Review of the medical record failed to indicate a Fall Risk Assessment was completed for the incident on [DATE]. Review of the medical record failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's Incident Report, dated [DATE], indicated: - On [DATE] at 3:30 P.M., the nurse was called into Resident #4's room by the Certified Nursing Assistant (CNA). The nurse discovered Resident #4 on the ground lying on their back at the foot of the bed. No visible injury was noted. - Resident #4 said he/she went to the bathroom in the wheelchair and it moved from them causing him/her to fall. - The incident report indicated Resident #4 had a numerical pain scale rating of 3 out of 10 related to the head/neck and he/she was ambulatory with assistance. - The incident report indicated Resident #4 had removed gripper socks and donned their own socks prior to the incident occurring. The facility's Fall Risk Assessment completed on [DATE] indicated Resident #4's last known fall was during the current stay/within the last month, he/she had dizziness/generalized weakness related to mobility, he/she was oriented to person and place, he/she had no communication/sensory deficits, he/she was behavioral/non-compliant with instructions and takes medication for the cardiovascular or central nervous system. The Fall Risk Assessment failed to indicate a fall risk score for Resident #4. Review of Resident #4's interdisciplinary care plan for falls indicated an intervention of Physical Therapy (PT) referral for screen and treatment as needed. Review of the PT therapy documentation indicates Resident #4 had been receiving skilled services since [DATE] after returning to the facility from a hospitalization for a previous fall. Review of Resident #4's Incident Report, dated [DATE], indicated: - On [DATE] at 10:30 A.M., the nurse was told by a Certified Nursing Assistant (CNA) that the Resident was on the floor in the dining room. The nurse and another nurse on the unit responded to Resident #4 in the dining room. Resident #4 was observed to be lying on his/her back with his/her head between a chair and the piano in the dining room. - Resident #4 said he/she was trying to transfer from the wheelchair to a standard chair when they lost their balance and fell to the floor hitting their head on the chair. The facility's Fall Risk Assessment completed on [DATE] indicated Resident #4's last known fall was within the last three months, he/she requires assist of one person for mobility, he/she is oriented to person and place, he/she has no communication/sensory deficits, Resident #4 exhibits impulsive behavior, he/she takes medication for cardiovascular or central nervous system, and he/she has no problem with volume/electrolyte status. The Fall Risk Assessment failed to indicate a fall risk score for Resident #4 indicating level of fall risk. Review of the medical record failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented post fall. During an interview on [DATE] at 2:32 P.M., Resident #4's Health Care Proxy (HCP) said he was concerned regarding Resident #4's falls which have increased over the last year. The HCP said he is notified by the facility after Resident #4 has a fall. The HCP said Resident #4 has had no major injuries from the falls. The HCP said he did not feel like the facility informed him of what they were doing to prevent further falls or incidents for Resident #4. The HCP said he was not informed if the facility determined the cause of the fall or any plans to prevent future falls. The HCP said he was unaware of any interventions put in place after a fall occurs. The HCP said there was no communication on how the facility plans to prevent futures issues and it would be a great improvement to ensure quality care is being provided. During an interview on [DATE] at 12:04 P.M., the Director of Nursing (DON) said when a fall occurs in the facility the nursing staff would complete an incident report. The DON said the interdisciplinary team would update the resident's care plan with interventions within a day or so. The DON said all falls are reviewed weekly on Friday at the facility's Risk Meeting. The DON said interdisciplinary care plan interventions should be followed. During an interview on [DATE] at 8:36 A.M., Nurse #5 said after a resident sustains a fall in the facility, the nurse would complete a fall risk assessment and fall incident report. Nurse #5 said any orders would be updated. Nurse #5 said the interdisciplinary care plan would be updated to reflect any fall interventions implemented. During an interview on [DATE] at 11:55 A.M., the Director of Rehabilitation (DOR) said they are notified of a resident's fall through a screen form. The DOR said the screen is either given to her directly or left in her office depending on when a resident falls. The DOR said the form is reviewed and additional information is gathered the following morning in the clinical meeting. The DOR said the rehabilitation department would complete a screen and/or an evaluation to determine the need for skilled therapy services after a fall occurs. During an interview on [DATE] at 1:35 P.M., the DON said the interdisciplinary care plan should be updated after each fall that occurs in the facility. The surveyor and the DON reviewed the medical record for Resident #4. The DON said interventions should be updated on the fall care plan after each incident and were not. 49425 2. Resident #19 was admitted to the facility in [DATE] with diagnoses including neuropathy (group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet), repeated falls, and muscle weakness. Review of the most recent MDS assessment, dated [DATE], indicated Resident #19 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of the medical record indicated Resident #19 had a total of two falls between [DATE] and [DATE]. Review of Resident #19's Incident Report, dated [DATE], indicated but was not limited to the following: - On [DATE] at 3:30 P.M., the nurse heard a loud noise coming from the dining room and noted Resident #19 lying on his/her back. Resident #19 said he/she was trying to pick up lucky coins, fell and hit his/her head. Review of the medical record and interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented after the fall to prevent recurrence. Review of Resident #19's Incident Report, dated [DATE], indicated but was not limited to the following: - On [DATE] at 4:10 A.M., Certified Nursing Assistant (CNA) heard the resident calling out for help, entered the room and called for the nurse to come into the room. The nurse observed Resident #19 sitting up on the floor. Resident #19 said he/she was going to the bathroom, slipped and fell . - Resident #19 complained of soreness in their right side of his/her face and right knee. Review of the medical record indicated a Fall Risk Assessment was started but incomplete with errors after the fall on [DATE]. Further review of the medical record and review of the interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented after the fall to prevent recurrence. During an interview on [DATE] at 12:44 P.M., Nurse #1 said when a resident has a fall, he completes an incident report in the computer and obtains witness statements. He said the fall is reviewed and the resident's care plan is updated with interventions to decrease the resident's risk of falling again. During an interview on [DATE] at 12:48 P.M, the DON said her expectation is for Resident #19's care plan to be updated with a new intervention that is relevant to how the fall occurred to reduce the risk of falling again. She said all falls are supposed to be reviewed with the risk management team to ensure new interventions, and care plans are put into place for the resident's safety. She said Resident #19's medical record and care plan has not been updated with any new interventions as it should have been after his/her falls, per facility policy. 49424 3. Review of the facility's policy titled Elopements and Wandering Residents, dated [DATE], indicated but was not limited to: -Elopement is defined as when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. -The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. -Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Resident #26 was admitted to the facility in [DATE] with diagnoses including unspecified intellectual disabilities, dementia with behavioral disturbances, and unspecified psychosis. Review of the MDS assessment, dated [DATE], indicated Resident #26 scored a 13 out of 15 on the BIMS assessment. Resident's Healthcare Proxy (HCP) was activated due to impaired judgement and intellectual disabilities. During an interview on [DATE] at 12:39 P.M., Resident #26 said they had walked to the grocery store about one year ago and when they came back, the staff put the wanderguard (device to sound an alarm to prevent elopement/wandering) on him/her and then he/she kept it in their pocket. Resident #26 said he/she did not have the wanderguard device anymore and did not know when he/she stopped needing it. Review of the medical record indicated the facility failed to complete an elopement risk screen upon Resident #26's return to the facility on [DATE]. Additionally, the nursing progress notes indicated staff applied a wanderguard to right wrist on [DATE]. The medical record indicated a physician's order was received for a wanderguard to be placed on [DATE]. Review of the Care plans for Resident #26 failed to indicate a comprehensive care plan with interventions to prevent or identify risks for elopement/wandering was developed or implemented. Review of the nursing progress notes indicated on [DATE] the hand/arm of Resident #26 was swollen, the wanderguard was removed and the Resident was told to always keep the wanderguard in his/her pocket. Review of the current and active task progress notes indicated the following: -Resident has a wanderguard and carries it in his/her pocket (with serial number and expiration of [DATE]) -Elopement risk identification sheet completed and placed in elopement book -Monitor resident when going towards the elevator, for tailgating of other residents or family members Review of the Physician's Orders indicated the order for the wanderguard was updated on [DATE] to include in the description: - Wanderguard in place, check function every shift; with serial number and an expiration date of [DATE] (the device expiration date had already occured when this ordered was updated.) Review of the Physician's Orders indicated the order for wanderguard was discontinued on [DATE]. Review of the assessments for Resident #26 indicated an Elopement Risk Screen was created on [DATE] and was not completed, no additional Elopement Risk Screens were completed for Resident #26. Review of the Quarterly Care Plan review, dated [DATE], indicated Resident #26 was an elopement risk and had a wanderguard. During an interview on [DATE] at 2:40 P.M., the MDS Coordinator said she opened an elopement focused care plan for Resident #26 but did not create any interventions. She also said the risk assessment should have been completed to determine if Resident #26 continued to be an elopement risk, but it was not completed. She said in the intervention section of the care plan is where the wanderguard information should be such as placement and expiration date. She said that the wanderguard device should have been replaced when the order was updated in January since the wanderguard device had expired. During an interview on [DATE] at 7:45 A.M., the DON said she would expect to find the location of the wanderguard placed on the body, the serial number of the device, and an expiration date that had not passed to be in the care plan and orders for Resident #26 after his/her elopement. She said that she would expect that an elopement assessment was completed. She said there was a nursing note that indicated the Resident kept the wander guard device in his/her pocket, but she said she feels this does not prevent elopement since the device was not secure on the Resident's body. She said she would expect that there were personalized interventions in place to identify and reduce risks of the Resident having another elopement, but there were not. She said Resident #26 should still have the wanderguard device in place unless an assessment was completed and the assessment determined the Resident was not a risk for elopement. She said there was no assessment indicating the Resident was no longer at risk for elopement.

Based on the Beneficiary Protection Notification Review, interview, and policy review the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055 and the Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123, were provided timely and explained to the resident/resident representative for two Residents (#19 and #49), out of three sampled residents. Specifically, the facility failed to issue the SNF ABN and failed to issue and explain the NOMNC timely ensuring the Resident/Resident representative understood the appeal process. Findings include: Review of the facility's policy titled Advance Beneficiary Notices, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. -The current Center for Medicare and Medicaid Services (CMS) approved version of the forms shall be used. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055. b. For Part B items and services, the facility shall use the Advanced Beneficiary Notice of Non-Coverage (ABN), Form CMS-R131. c. A Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123, shall be issued to the resident/resident representative when Medicare covered service(s) are ending, no matter if a resident is leaving the facility or remaining at the facility. This informs the resident on how to request an appeal to expedite determination from their Quality Improvement Organization (QIO). -Delivery requirements: a. The notice shall be written legibly in a language and/or format that the resident/representative understands. Verbal explanations detailing the reasons for the determination of possible non-coverage shall be provided. b. The notice shall be hand delivered, if possible, to obtain beneficiary or resident representative signature. c. The notice shall be prepared with an original and at least two copies. The facility shall retain the original and give a copy to the resident/representative. d. If the notice cannot be hand delivered, a telephone call shall be made, followed up immediately with a mailed, emailed, faxed, or hand delivered notice. Documentation shall comply with form instructions regarding telephone notices. e. Mail, secure fax machine and internet email may also be utilized for delivery of the notice if in-person issuance is not able to be performed. -The original notice shall be placed into the resident's financial file. The notice shall be retained at least five years. -A notice must be completed before delivery, and a copy must be provided to the resident/representative immediately after signing it. Review of the NOMNC, Form CMS 10123, indicated but was not limited to the following: -Request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated. A. Resident #21 received Medicare Part A skilled services. Review of the medical record indicated Resident #21 was a long-term care (LTC) Resident and his/her Health Care Proxy (HCP) had been invoked. The facility failed to provide the surveyor with a copy of the SNF ABN, Form CMS-10055. The facility provided the surveyor with the ABN, Form CMS-R131. Review of the ABN failed to indicate a physical copy was provided to the HCP, a discussion took place with the HCP, the HCP signed any document or was aware of the services expected to not be covered or options available regarding services and billing options. The Resident was receiving Medicare Part A services and the SNF ABN (Form CMS-10055) should have been issued, not the ABN (Form CMS-R131). Review of the NOMNC indicated the notice was provided to Resident #21's HCP via a telephone call on 2/7/24 at 1:30 P.M., with a voicemail message left for effective date for last covered day (LCD) of 2/9/24. The NOMNC failed to indicate the document was mailed to the HCP. Further review of the NOMNC failed to indicate a physical copy was provided to the HCP, a discussion took place beyond a voicemail message or that the HCP signed any document or was aware of the appeal rights related to ending of the skilled benefit. Review of the progress notes from January and February 2024 failed to indicate a conversation took place or the documents were mailed. During an interview on 5/3/24 at 12:39 P.M., Resident #21's HCP said she was notified and told she needed to sign the form to show Resident #21 would not be getting therapy because he/she reached their max level, but she was not provided with any other information on her right to appeal the decision. She said she would have liked to appeal against the decision as the Resident was previously walking and eating a regular diet and feels he/she would benefit from more rehab services. She said she was not provided with the information on the appeal process and wished she was. During an interview on 5/3/24 at 1:53 P.M., Minimum Data Set (MDS) Nurse #1 said she found proof that Resident #21's HCP received the forms via certified mail on 2/23/24. Review of the secondary documents provided indicated the HCP signed for a certified mail letter delivery on 2/23/24 (16 days after the initial notice date and after the appeal window had closed). The documents were signed/dated 2/24/24. B. Resident #49 received Medicare Part A skilled services. Review of the medical record indicated Resident #49 was a LTC resident and his/her HCP had been invoked. The facility failed to provide the surveyor with a copy of the SNF ABN, Form CMS-10055. The facility provided the surveyor with the ABN, Form CMS-R131. Review of the ABN failed to indicate a physical copy was provided to the HCP, a discussion took place with the HCP, the HCP signed any document or was aware of the services expected to not be covered or options available regarding services and billing options. The resident was receiving Medicare Part A services and the SNF ABN (Form CMS-10055) should have been issued, not the ABN (Form CMS-R131). Review of the NOMNC indicated the notice was provided to Resident #49's HCP via a telephone call on 4/15/24 at 1:00 P.M., for effective date for last covered (LCD) of 4/17/24. The NOMNC failed to indicate the document was mailed to the HCP. During an interview on 5/3/24 at 12:27 P.M., Resident #49's HCP said she was not notified that the Resident was coming off skilled services or that she had any options to appeal. She said she had not received any paperwork in the mail that provided this information to her. She said the Resident may benefit from more therapy and asked if she could still appeal and was informed, she was outside of the window and would need to alert the facility of her desire and initiate a screening process, from there she said she will likely not bother. During an interview on 5/3/24 at 12:42 P.M., MDS Nurse #1 said the forms are sent via mail to the HCP and although they are not in the medical record, they are probably in the financial files. Additionally, she said the documents are not mailed in a way that can be tracked. During an interview on 5/3/24 at 12:53 P.M., MDS Nurse #1 said there was no further information available for Resident #49 and she did not have signed copies of the forms. She said there was no documentation in the medical record that the HCP was aware of the information or appeal rights. She said she didn't have the second page of Resident #49's NOMNC and thinks the original was mailed without a copy being made. Additionally, she said it appears from the documentation for both Residents #21 and #49 the process was not followed. During an interview on 5/3/24 at 1:53 P.M., MDS Nurse #1 said for Resident #49 she found evidence the second page was completed on the NOMNC but could not find evidence the documents were mailed or returned. She said they did not follow up and was unaware of the HCP's desire or awareness of the appeal rights.

Based on observation, interview, record review, and policy review, the facility failed to implement interventions on the Falls Care Plan for one Resident (#21), out of a total sample of 15 residents to meet the resident's physical, psychosocial and functional needs. Findings include: Review of the facility's policy titled Comprehensive Care Plans, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. -The comprehensive care plan will describe, at minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Qualified staff responsible for carrying out interventions specified in the care plan. Review of the facility's policy titled Fall Reduction, dated as last revised 6/22/22, indicated but was not limited to the following: -The facility will implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based in the individual resident's needs. -Implement intervention(s) as appropriate to prevent reoccurrence. Resident #21 was admitted to the facility in January 2024 with diagnoses including dementia, muscle weakness, unsteadiness on feet, and history of right hip traumatic fracture. Review of the Minimum Data Set (MDS) assessment, dated 4/10/24, indicated Resident #21 had severe cognitive impairment as evidenced by a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with activities of daily living (ADLs), and had a history of recent falls. Review of the Physician's Orders indicated but were not limited to the following: -Place Dycem on top of the cushion prior to seating patient in the wheelchair (4/23/24). Review of the Comprehensive Care Plans indicated but was not limited to the following: FOCUS: Risk for injury related to falls as evidenced by/related to history of falls, impaired mobility. GOAL: Free from fall related injury through next review. INTERVENTIONS: -Non-skid strips to side of bed and in front of the closet (1/25/24) -Place Dycem (non-slip pad) on top of cushion prior to seating patient in wheelchair (4/24/24) The surveyor made the following observations: -5/2/24 at 10:18 A.M., no non-skid strips on floor next to bed or in front of closet and no Dycem on wheelchair cushion. -5/3/24 at 8:30 A.M., no non-skid strips on floor next to bed or in front of closet; Resident was sitting in wheelchair with no Dycem on the wheelchair cushion. -5/3/24 at 9:56 A.M., no non-skid strips on floor next to bed or in front of closet and no Dycem on wheelchair cushion. (Dycem was under wheelchair cushion). -5/7/24 at 8:41 A.M., no non-skid strips on floor next to bed or in front of closet and no Dycem on wheelchair cushion. During an interview on 5/7/24 at 11:20 A.M., Nurse #3 said there were not any non-skid floor strips in Resident #21's room and the wheelchair cushion did not have a Dycem on top of it per the care plan. During an interview on 5/7/24 at 12:04 P.M., the Director of Nurses (DON) said there were no non-skid strips next to bed or closet and there was no Dycem on top of the cushion. She said she would expect the staff to be following the care plan and Resident #21 likely had a room change after the intervention was initially added for the floor strips, but she would expect the interventions to follow the Resident with a room change. During an interview on 5/7/24 at 12:04 P.M, Consulting Staff #1 said she did not realize the order/care plan said the Dycem should be on top of the cushion, and it was only beneath the cushion. Additionally, she said the floor strips were not there and they should have been placed in this room when he/she had a room change. She said she would expect the interventions to go with them when they move rooms.

Based on observations, interviews, record review, and policy review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#46), out of a total sample of 15 residents. Specifically, the facility failed to ensure nail care was performed for Resident #46. Findings include: Review of the facility's policy titled Nail Care, last revised 3/4/24, indicated but not limited to: - The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. - Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. - Routine nail care, to include trimming and filing, will be provided/offered on a regular schedule and as needed based on resident need and preference. - Principles of nail care: nails should be kept smooth to avoid skin injury; each resident will have his/her own nail care equipment (e.g., clippers, emery boards, files, etc.); equipment will not be shared between residents. - Procedure: document completion of task, any complications, or if resident refuses. Resident #46 was admitted to the facility in May 2021 with diagnoses including need for assistance with personal care and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/21/24, indicated the Resident was dependent on staff for ADLs and personal hygiene. The MDS assessment also indicated Resident #46 was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS). During an observation with interview on 5/2/24 at 9:05 A.M., the surveyor observed Resident #46 to have long fingernails. Resident #46 said he/she had long fingernails because staff do not cut them routinely. Resident #46 said he/she had a shower three days prior and no one attempted to cut his/her nails. Resident #46 said he/she was embarrassed by how long and dirty their fingernails were and he/she would not typically like them to be long but could not manage them on his/her own. On 5/3/24 at 7:19 A.M., the surveyor observed the Resident in bed and noted his/her fingernails to be long, yellowed and have a brown substance underneath some of the nails. During an observation with interview on 5/6/24 at 8:43 A.M., the surveyor observed the Resident to be resting in bed and noted his/her fingernails to be long, yellowed and have a brown substance underneath four fingers on the right hand. Resident #46 said he/she had a shower three days prior but his/her nails were not cut or trimmed by staff. Resident #46 said he/she was embarrassed by their nails being so long and untrimmed. Review of the Certified Nurse Assistant (CNA) flow sheets indicated Resident #46 was dependent for grooming and personal care. Review of the documentation in the medical record failed to indicate the last time Resident #46 had their fingernails cut, filed, or cleaned. Furthermore, the documentation in the medical record failed to indicate Resident #46 had refused fingernail care. During an interview on 5/3/24 at 8:13 A.M., CNA #2 said Resident #46 usually gets showered once a week and nail care would typically be done at that time. CNA #2 said while nail care is typically completed after a shower, it can be done any day during any shift if the Resident needs or wants their nails trimmed. CNA #2 said residents are accommodated for nail care when they ask. During an interview on 5/3/24 at 9:03 A.M., CNA #3 said Resident #46 should have his/her nails trimmed and filed on shower days but it can be done at any time nail care is needed. CNA #3 said if a resident refuses or is reluctant to nail care they would notify the nurse to document attempts that were made and resident response. CNA #3 said at times Resident #46 can be resistive to nail care but if you talk to him/her and re-approach he/she is reasonable. CNA #3 said if Resident #46 continued to refuse care, staff could have the nurse or Director of Nursing (DON) talk with him/her about why nail care was necessary. CNA #3 said he thought Resident #46 last had nail care about two to three weeks ago, but the Resident was not currently on their assignment. During an interview on 5/7/24 at 9:58 A.M., Nurse #6 said CNA staff would be noting the length of nails when completing morning care daily. Nurse #6 said if fingernails were assessed to be long or dirty during morning care, CNAs would complete nail care. Nurse #6 said there was no specific day or time when nail care was performed, but rather to be completed when fingernails were noted to be long or dirty. Nurse #6 said CNAs would report to the nurse if a resident refused nail care. Nurse #6 said they would re-approach the resident and educate them on the importance of nail care. Nurse #6 said if a resident continued to refuse nail care it should be documented in a nursing note. During an interview on 5/7/24 at 11:53 A.M., the DON said staff are expected to assess fingernails for cleanliness and length during daily care. The DON said she would also expect staff to assess fingernail length on shower days. The DON said if a resident needed nail care, she would expect staff to be trimming, filing and cleaning fingernails. The DON said nursing documentation should reflect refusal of nail care. The DON and the surveyor reviewed the observations and interviews with Resident #46 related to nail care. The DON said Resident #46 often refuses care, but refusal of nail care should be documented in the record as well as any re-approach and education provided.

Based on record review, policy review, and interview, the facility failed to ensure for one Resident (#15), out of a sample of 15 residents, that their as needed (PRN) psychotropic medication, Lorazepam (antianxiety), was re-evaluated 14 days after the medication was prescribed to ensure it was beneficial and necessary for the Resident in accordance with the standard of practice. Findings include: Review of the facility's policy titled Psychotropic Medication Treatment in Long Term Care (LTC), dated January 2021, indicated but was not limited to the following: -It is the policy to abide by state and federal regulations when requesting consent and administering medications. -Pharmacy Consultant will perform monthly medication regimen reviews. These reviews will identify existing irregularities regarding indications for use, dose, duration, and the potential for, or existence of adverse consequences or other irregularities. Any identified concerns must be reported to the attending physician and the Director of Nurses (DON). Resident #1 was admitted to the facility in June 2019 with diagnoses including dementia, mood disorder, anxiety, and epilepsy (seizure disorder). Review of the Minimum Data Set (MDS) assessment, dated 2/7/24, indicated Resident #1 had severe cognitive impairment as evidenced by a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS) and had anxiety. Review of the Physician's Orders indicated but was not limited to the following: -Lorazepam Oral Concentrate milligrams/milliliter (ml) give 0.5 ml by mouth every four hours as needed for anxiety/agitation. (4/14/24) Further review of the Lorazepam order failed to indicate a stop date or re-evaluation date as required. Review of the Consultant Pharmacist's Note, dated 4/16/24, indicated to evaluate PRN Lorazepam. The facility failed to provide the surveyor with a copy of the full pharmacist recommendation. During an interview on 5/7/24 at 12:04 P.M., the DON said all psychotropic PRN medications, including Lorazepam, should be written for 14 days only and then re-evaluated. She said the order should not be written with no stop date and would have to be clarified as it had been over 14 days since the order was written. During an interview on 5/7/24 at 12:04 P.M., Consulting Staff #1 confirmed that all psychotropic PRN orders should be written for 14 days and then re-evaluated and extended if needed. She said they should not be left open ended unless being used for seizures and this is not the case as the order is written for anxiety/agitation.

Based on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident and provide the resident and/or their representative with a summary of the baseline care plan for two Residents (#52 and #109), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #52, to provide him/her a written summary of the baseline care plan by completion of the comprehensive care plan and document receipt of the information within the Resident's clinical record; and 2. For Resident #109, to develop a baseline care plan for Post-Traumatic Stress Disorder (PTSD- mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Findings include: Review of the facility's policy titled The Baseline Care Plan, last reviewed December 2022, indicated but was not limited to the following: -The facility will develop and implement a Baseline Care Plan for each resident within 48 hours of admission. -The resident and representative, if applicable, will be informed of the initial plan for delivery of care and services by receiving a written summary of the Baseline Care Plan. 1. Resident #52 was admitted to the facility in January 2024 and had diagnoses including respiratory failure with dependence on supplemental Oxygen. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/17/24, indicated Resident #52 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. During an interview on 5/6/24 at 10:50 A.M., Resident #52 said he/she did not have a meeting within 48 hours of their admission and did not receive any written summary of the baseline care plan since admission. The Resident said he/she keeps all records the facility provides including meal tickets and he/she would have kept a copy of the baseline care plan so he/she would know what his/her care needs were. During an interview on 5/7/24 at 2:01 P.M., the Social Worker (SW) said the MDS Coordinator is responsible for coordination of the baseline care plan meetings and ensuring completion. During an interview on 5/8/24 at 8:25 A.M., the MDS Coordinator said she begins the baseline care plan and provides the copy to the rest of the interdisciplinary team to complete, and it is signed at the clinical morning meeting and uploaded into the resident's chart. She said she didn't know why this Resident's baseline care plan was not completed and she said that the interdisciplinary team should have signed the care plan. She said that she does not provide a copy to the resident or resident representative and was unaware she should be providing a copy of the baseline care plan. During an interview on 5/8/24 at 8:36 A.M., the Director of Nursing (DON) said the MDS Coordinator oversees the care plan process including the paper process for baseline care plans. She said the baseline care plan for Resident #52 was incomplete and failed to indicate clinical information, contributing staff signatures, and failed to indicate if the resident was offered or received a written summary of the baseline care plan. She said the expectation is that the resident or resident representative receive a copy of the baseline care plan since their care is collaborative and person-centered. 48084 2. Review of the facility's policy titled Trauma Informed Care, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to provide care and services which address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -DEFINITIONS: Trauma results from an event or series of events, or circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. -The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals to develop and implement individualized care plan interventions. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. Resident #109 was admitted to the facility in April 2024 with diagnoses including PTSD and depression. Review of the Nursing Admission Assessment failed to indicate a diagnosis of PTSD. Review of the MDS assessment, dated 4/30/24, Section I6100 indicated Resident #109 had a diagnosis of PTSD. Review of the Social Services Assessment, dated 5/3/24, indicated the assessment was incomplete. Review of the medical record failed to indicate a PTSD Assessment had been completed. Review of the paper Baseline Care Plan in the Resident Record/Chart with Nurse #1 failed to indicate the care plan had been developed. The document was blank. During an interview on 5/3/24 at 1:35 P.M., Nurse #1 said the facility no longer uses paper forms and the Baseline Care Plan would be in the computer and initiated within 48 hours of admission. Additionally, he said Resident #109 did not have a current care plan for PTSD. Review of the Care Plan failed to indicate a care plan had been developed for PTSD. Review of the Care Kardex (summary of resident's care and preferences) failed to indicate any trauma associated triggers to guide resident care. During an interview on 5/3/24 at 1:39 P.M., Resident #109 said he/she does have a diagnosis of PTSD, and no one had asked about it, how the trauma occurred, or what things may re-trigger the trauma. Resident #109 shared with the surveyor the physical and emotional trauma they had endured and said they have been incapable of being in a closed space with a male and could never think of having a male being nearby during care or providing personal care and speaking of it now is causing anxiety. Additionally, Resident #109 said no one at the facility had discussed this or said they could put barriers in place to ensure events like this would not come up. The surveyor encouraged Resident #109 to speak with the SW and share the triggers to ensure comfort and safety at the facility. During an interview on 5/3/24 at 11:12 A.M., SW #1 said she had not completed a PTSD Assessment on Resident #109 and had not seen one at this facility. Additionally, she said there was no Baseline Care Plan for PTSD and there should be one to identify the resident's triggers and therefore ensure the staff can do their best to avoid them or work around the process for the Resident as best as possible. SW #1 said she was unsure of the facility policy but said the regulatory guidelines in this instance were not followed.

Based on observation, interview, record review and policy review, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for three Residents (#34, #160, and #16), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #34, to ensure the Foley catheter was assessed for removal as soon as possible or determine a clinical condition related to Foley catheter placement on admission to the facility; 2. For Resident #160, to ensure orders were in place for the Foley catheter and Foley catheter care, and to ensure the Foley catheter bag was hung at an appropriate level, below the bladder to discourage backflow of urine which helps prevent urinary tract infections (UTIs); and 3. For Resident #15, to ensure the catheter bag was hung at an appropriate level, below the bladder, to discourage backflow of urine which helps to prevent UTIs. Findings include: Review of the facility's policy titled Appropriate Use Indwelling Catheters, last revised 3/4/24, indicated but was not limited to the following: - It is the policy of this facility to ensure that a resident who is continent of bladder on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain. - An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary. - It is the policy of this facility to ensure each resident with urinary incontinence: b. Who is admitted with an indwelling urinary catheter, or each resident who subsequently receives an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. - Any decision regarding the use of an indwelling urinary catheter will be based on the resident's condition and goals for treatment. - The resident and/or representative will be included in discussions about the indications, use, potential benefits and risks of urinary catheters, and alternatives to help support the resident's rights to make an informed decision. - The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of catheter necessary, size of the catheter, frequency of change (if applicable). - Documentation to support decision making will be included in the medical record, including but not limited to: a. Clinical or medical conditions demonstrating the need for an indwelling urinary catheter. b. Assessment of incontinence, including the type, frequency, duration, and complicating factors associated with the incontinence. c. Assessment of psychosocial and functional factors affecting urinary continence status. d. Services provided to restore normal bladder function to the extent possible. e. Response to interventions prior to the decision to use an indwelling catheter. f. Resident's wishes and prognosis. - Indwelling urinary catheters will be used on a short-term basis, unless the resident's clinical condition warrants otherwise. - The interdisciplinary team, with the support and guidance form the physician, will assure the ongoing review, evaluation, and decision-making regarding the insertion, continuation, or removal of an indwelling catheter. - The plan of care will address the use of an indwelling catheter, including strategies to prevent complications. Review of the facility's policy titled Catheter Care, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. -Catheter care will be performed every shift and as needed. -Privacy bags will be available and catheter drainage bags will be covered at all times while in use. -Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. 1. Resident #34 was admitted to the facility in March 2024 with diagnoses including retention of urine, history of UTI, benign prostatic hyperplasia (BPH - a condition in which the flow of urine is blocked due to the enlargement of the prostate gland). Review of the Minimum Data Set (MDS) assessment, dated 3/8/24, indicated Resident #34 was cognitively intact with a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) evaluation. The MDS assessment further indicated Resident #34 had an indwelling catheter placed and was dependent for activities of daily living (ADL), bed mobility and transfers. The MDS assessment indicated Resident #34 had a Genitourinary (reproductive/urinary system) diagnosis of BPH only. On 5/6/24 at 8:53 A.M., the surveyor observed Resident #34 resting in bed with his/her Foley catheter hanging from the side of the bed. Resident #34 said he/she does not need the Foley catheter. Resident #34 said it was put in during a hospitalization and has not been removed. Resident #34 said he/she has asked the nursing staff in the facility to remove the Foley catheter and has been given no explanation as to why he/she has it. On 5/7/24 at 12:24 P.M., the surveyor observed Resident #34 resting in bed with his/her Foley catheter hanging from the side of the bed. Resident #34 said he/she has never been given the opportunity of having the Foley catheter removed. Resident #34 said he/she would like to try to have the Foley catheter removed. Review of Resident #34's active Physician's Orders indicated but were not limited to: - 3/1/24: Provide Foley catheter care every shift and as needed - 3/2/24: Foley catheter order - Size 16 French (Fr) with 10 cubic centimeter (cc) balloon Review of Resident #34's Admission/Re-Admission Nursing Assessment, dated 3/1/24, indicated the following under Section 34 - Bladder: - Resident #34 had been incontinent or had a catheter for an unknown period. - Resident #34 was incontinent 1-2 times a week. - Resident #34 was taking diuretic (medication that help reduce fluid buildup in the body) medications. - Resident #34's catheter size and type were not indicated on the assessment. Further review of the electronic record indicated the Admission/Re-Admission Nursing Assessment, dated 3/1/24, was noted to be in progress and incomplete. Review of Resident #34's medical record failed to indicate a voiding trial had been attempted upon admission to the facility. Further review of the medical record failed to indicate the facility had contacted Resident #34's Urologist in the community to gather information related to the Foley catheter placement. Additionally, the medical record failed to indicate Resident #34 had been seen by a Urologist since admission to the facility. Review of the Hospital Summary documentation indicated Resident #34 had a chronic Foley catheter and diagnoses including BPH and history of UTIs. The documentation failed to indicate how long the Foley catheter had been inserted and if/when a voiding trial for removal had been attempted. Review of the Physician (MD) and Nurse Practitioner (NP) progress notes indicated Resident #34 had a chronic indwelling Foley catheter. MD/NP progress notes failed to indicate medical reasoning for current placement of Foley catheter, voiding trial and/or follow up with Urology regarding Foley catheter placement. During an interview on 5/7/24 at 2:18 P.M., Nurse #1 said when a resident with a Foley catheter is admitted to the facility, we check to make sure there is a reasoning or clinical diagnosis. Nurse #1 said staff would reach out to the MD to discuss the continued use or discontinuation of use related to the Foley catheter. Nurse #1 said if it was appropriate orders would be obtained from the MD to start a voiding trial. Nurse #1 said if a resident was seeing a Urologist in the community, they would contact them to gather more information regarding the Foley catheter placement. Nurse #1 said he was uncertain if Resident #34 had any voiding trials since admission or his diagnosis related to the Foley catheter placement. During an interview on 5/7/24 at 2:40 P.M., the Director of Nursing (DON) said she believed the hospital documentation indicated Resident #34 had a voiding trial during his/her stay which he/she failed. The DON said she would have to review the clinical hospital documentation to verify the information related to the voiding trial. During an interview on 5/8/24 at 11:41 A.M., Consulting Staff #1 said she would expect documentation in the record related to diagnoses and reasoning for Foley catheter placement. Consulting Staff #1 said she would expect documentation related to rationale for follow up with urology and/or voiding trials. On 5/7/24 at 2:40 P.M., the surveyor requested any additional information related to Resident #34 and a voiding trial or other clinical reasoning related to Foley catheter placement. No additional information was provided to the surveyor by the facility prior to exit. 48084 2. Resident #160 was admitted to the facility in April 2024 with diagnoses including UTI, kidney transplant, and retention of urine. Review of the MDS assessment, dated 4/23/24, indicated Resident #160 had moderate cognitive impairment as evidenced by a score of 12 out of 15 on the BIMS and failed to indicate the Resident had an indwelling catheter. Review of the Admission/Re-Admission Nursing Assessment, dated 4/17/24, Section J indicated Resident #160 had a catheter. Review of the Physician's Orders failed to indicate orders for the catheter or catheter care. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Alteration/Risk for alteration in Bowel/Bladder continence as evidenced by/related to indwelling catheter and diagnosis of urinary retention. GOAL: Free from complications of catheter. INTERVENTIONS: -Dependent on staff for Foley care. -Foley catheter care every shift and as needed. -Ensure anchoring bag to promote adequate drainage/prevent backflow. -Change catheter and drainage bag per facility protocol/orders. -Ensure drainage bag is covered for dignity at all times. -Empty and record urine from foley every shift and as needed. Review of the Care Card/Kardex indicated but was not limited to the following: -Foley catheter care every shift and as needed. -Ensure anchoring bag to promote adequate drainage/prevent backflow. -Change catheter and drainage bag per facility protocol/orders. -Ensure drainage bag is covered for dignity at all times. The surveyor made the following observations: -5/2/24 at 10:45 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/3/24 at 8:30 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/3/24 at 8:33 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). Nurse #3 stopped and spoke to Resident and failed to move the drainage bag below the bladder. -5/3/24 at 8:45 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). Nurse #3 stopped and gave Resident a drink, failed to move the drainage bag below the bladder and then assisted to put Resident back to bed. During an interview on 5/7/24 at 11:20 A.M., Nurse #3 said there should be orders for the catheter and catheter care and there were not any. During an interview on 5/7/24 at 12:04 P.M., the DON said Resident #160 should have a physician's order for the catheter and catheter care. She said there is a batch set of orders that should have been implemented and they were not. Additionally, she said the catheter drainage bag should not be hung on the armrest, it should be below the bladder on the wheelchair frame. 3. Resident #16 was admitted to the facility in December 2023 with diagnoses including urinary retention and history of urogenital implants. Review of the MDS assessment, dated 2/29/24, indicated Resident #16 was cognitively intact as evidenced by a score of 14 out of 15 on the BIMS and he/she had an indwelling catheter. Review of the Physician's Orders indicated but was not limited to the following: -Foley catheter care every shift and as needed (5/3/24). Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Indwelling Foley catheter: neurogenic bladder/urine retention. GOAL: Will be/remain free from catheter-related trauma through review date INTERVENTIONS: -Has a chronic Foley. Position catheter bag and tubing below the level of the bladder. -Change catheter once a month per doctor orders. -Catheter privacy bag is covered every shift when out of bed. Review of the Care Card/Kardex indicated but was not limited to the following: -Has a chronic Foley. Position catheter bag and tubing below the level of the bladder. -Monitor/Document for pain/discomfort due to catheter. The surveyor made the following observations: -5/2/24 at 10:45 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/2/24 at 1:15 P.M., Resident in hallway returned from appointment with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/6/24 at 12:48 P.M., Resident in hallway with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/6/24 at 4:23 P.M., Resident in hallway with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/7/24 at 8:40 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). Multiple staff members stopped and spoke to Resident between 8:40 A.M. and 9:00 A.M., none of the staff members moved the catheter drainage bag from the armrest of the wheelchair. -5/8/24 at 7:37 A.M., Resident self-propelling from dining room in wheelchair with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/8/24 at 7:41 A.M., Resident sitting in front of nurses' station with the DON and Nurse #7. -5/8/24 at 8:19 A.M., Staff Development Coordinator/Infection Control Nurse (SDC/IP) was interacting with Resident (cleaning the white board), Foley catheter drainage bag was attached to armrest of wheelchair (above the bladder), SDC/IP did not adjust catheter bag. Resident self-propelled down hallway in wheelchair past the SDC/IP after the above interaction and again the SDC/IP did not adjust the Foley catheter bag. -5/8/24 at 8:28 A.M., Resident sitting in front of nurses' station, SDC/IP sitting at nurses' station, acknowledged Resident, however, did not adjust catheter bag. Nurse #3 observed walking by Resident and did not adjust catheter bag. -5/8/24 at 11:08 A.M., Resident sitting in front of nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). SDC/IP and Nurse #3 sitting at desk, neither adjusted catheter bag. During an interview on 5/8/24 at 7:39 A.M., Certified Nursing Assistant #4 said Resident #16 transfers him/herself into wheelchair and puts the catheter bag there (pointing to armrest). During an interview on 5/8/24 at 7:42 A.M., Resident #16 shook his/her head and said they do not get up independently to get into the wheelchair and staff put the catheter bag on the armrest of the wheelchair. During an interview on 5/7/24 at 12:04 P.M., the DON said the catheter drainage bag should not be hung on the armrest, it should be below the bladder on the wheelchair frame. During an interview on 5/8/24 at 11:36 A.M., Consulting Staff #1 said she was just on the unit and saw Resident #16's catheter drainage bag hanging on the arm rest of the wheelchair. She said she tried to move it and the Resident declined. Additionally, she said if he/she likes it up there and wants it there it should have been care planned that way and it was not. She said the care plan would need to be updated for Resident preference if that was the case.

Based on record review, interview, and policy review, the facility failed to ensure one Resident (#109), out of a sample of 15 residents, received culturally competent, trauma-informed care accounting for resident experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to assess Resident #109 and identify triggers of trauma to prevent potential re-traumatization. Findings include: Review of the facility's policy titled Trauma Informed Care, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to provide care and services which address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -DEFINITIONS: Trauma results from an event or series of events, or circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. -The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals to develop and implement individualized care plan interventions. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. Review of the facility's policy titled Behavioral Health Services, dated as last revised 12/6/21, indicated but was not limited to the following: -The facility will ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services. -The resident will receive, and the facility will provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #109 was admitted to the facility in April 2024 with diagnoses including post-traumatic stress disorder (PTSD- mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) and depression. Review of the Nursing Admission Assessment failed to indicate a diagnosis of PTSD. Review of the Minimum Data Set (MDS) assessment, dated 4/30/24, Section I6100 indicated Resident #109 had a diagnosis of PTSD. Review of the Social Services Assessment, dated 5/3/24, indicated the assessment was incomplete. The medical record failed to indicate a PTSD Assessment had been completed. Review of the care plans failed to indicate a baseline or comprehensive care plan for PTSD had been developed to note any potential triggers to try and mitigate the effects and decrease the likelihood of re-traumatization. Review of the care kardex (summary of resident's care and preferences) failed to indicate any trauma associated triggers to guide resident care. During an interview on 5/3/24 at 1:39 P.M., Resident #109 said he/she does have a diagnosis of PTSD, and no one had asked about it, how the trauma occurred, or what things may re-trigger the trauma. Resident #109 shared with the surveyor the physical and emotional trauma they had endured and said they have been incapable of being in a closed space with a male and could never think of having a male being nearby or providing personal care and speaking of it now is causing anxiety. Additionally, Resident #109 said no one at the facility had discussed this or said they could put barriers in place to ensure events like this would not come up. The surveyor encouraged Resident #109 to speak with the SW and share the triggers to ensure comfort and safety at the facility. During an interview on 5/3/24 at 11:12 A.M., Social Worker (SW) #1 said she had not completed a PTSD assessment on Resident #109 and had not seen one at this facility. Additionally, she said there was no care plan for PTSD and there should be one to identify the Resident's triggers and therefore ensure the staff can do their best to avoid them or work around the process for the Resident as best as possible. SW #1 said she was unsure of the facility policy but said the regulatory guidelines in this instance were not followed. During an interview on 5/3/24 at 1:35 P.M., Nurse #1 said there was not a care plan for PTSD in the Resident's medical record.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility staff failed to follow Resident #1's plan of care that indicated he/she required the assistance of two staff persons for bed mobility, when Certified Nurse Aide (CNA) #1 rolled Resident #1 over in bed, unassisted by an additional staff person, and Resident #1 fell out of bed, onto the floor and sustained lacerations to his/her forehead and nose, which required sutures to close. Findings include: The Facility Policy titled Care Planning, dated 11/2017, indicated all resident care and interventions must be carried out per the Care Plan. Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. An ADL Care Plan, date initiated 9/27/17, indicated Resident #1 was totally dependent and required two staff participation to reposition and turn in bed. The Quarterly Minimum Data Set (MDS), dated [DATE] indicated Resident #1 had upper and lower extremity impairment on one side and required two staff persons for bed mobility. A Maintenance Activities of Daily Living (ADL) and Safety Care Plan & Communication Tool, undated, indicated Resident #1 was dependent on two staff persons for turning and repositioning. A Nurse Progress Note, dated 2/22/18, indicated while receiving ADL care Resident #1 slid off the edge of the bed on his/her right side and landed on the floor striking his/her head on the floor. The Note indicated 911 was called and Resident #1 was transferred to the Hospital Emergency Department for evaluation. A Fall Report, dated 2/22/18, indicated during ADL care, Resident #1 fell from a lowered bed position, off the edge of the bed. Although CNA #1 did not respond to Surveyors request for an interview, The Facility Investigation contained a Written Witness Statement, dated 2/22/18, written by CNA #1,that indicated while performing ADL care to Resident #1, CNA #1 turned Resident #1 onto his/her side to remove the brief, went to grab a towel on the table and Resident #1 rolled off the bed head first. A Hospital Report, dated 2/22/18, indicated Resident #1 had a fall when staff at the nursing home rolled Resident #1 in bed to change him/her and he/she slipped out of bed landing on the floor. The Report indicated Resident #1 sustained a laceration to his/her forehead that required five sutures and a laceration to his/her bridge of nose that required three sutures. The Surveyor interviewed Unit Manager #1 at 2:25 P.M. on 5/31/18. Unit Manager #1 said CNA #1 would often turn and reposition Resident #1 by himself during care. Unit Manager #1 said that on 2/22/18 while CNA #1 was providing care, CNA #1 turned Resident #1 to his/her right side and he/she rolled off the bed to the floor landing on his/her right side. Unit Manager #1 said he saw blood on Resident #1's head and face. Unit Manager #1 said he instructed CNA #1 to call 911 and Resident #1 was transferred to the Hospital for evaluation. Unit Manager #1 said Resident #1's plan of care indicated Resident #1 was to have two staff persons providing assistance for bed mobility. The Surveyor interviewed the Director of Nurses (DON) at 2:50 P.M. on 5/31/18. The DON said CNA #1 rolled Resident #1 in bed on to his/her right side by himself, CNA #1 went to reach for a towel and Resident #1 fell off the bed onto the floor sustaining a forehead and nose laceration. The DON said Resident #1's plan of care indicated he/she required two staff persons for assistance with bed mobility.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility staff failed to maintain Resident #1's safety to prevent an accident when Certified Nurse Aide (CNA) #1 rolled Resident #1 (who required two staff persons for assistance with bed mobility) over in bed, unassisted by another staff person, resulting in Resident #1 to fall out of bed onto the floor. Resident #1 sustained a laceration to his/her forehead and nose, which required sutures to close. Findings include: The Facility Policy titled, Fall Management, dated 3/1/16, indicated the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The Facility Policy titled Care Planning, dated 11/2017, indicated all resident care and interventions must be carried out per the Care Plan. Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. An Activities of Daily Living (ADL) Care Plan, date initiated 9/27/17, indicated Resident #1 was totally dependent and required two staff participation to reposition and turn in bed. The Quarterly Minimum Data Set (MDS), dated [DATE] indicated Resident #1 had upper and lower extremity impairment on one side and required two staff persons for bed mobility. A Maintenance ADL and Safety Care Plan & Communication Tool, undated, indicated Resident #1 was dependent on two staff persons for turning and repositioning. A Nurse Progress Note, dated 2/22/18, indicated while receiving ADL care Resident #1 slid off the edge of the bed on his/her right side and landed on the floor striking his/her head on the floor. The Note indicated 911 was called and Resident #1 was transferred to the Hospital Emergency Department for evaluation. A Fall Report, dated 2/22/18, indicated during ADL care, Resident #1 fell from a lowered bed position, off the edge of the bed. Although CNA #1 did not respond to Surveyors request for an interview, The Facility Investigation contained a Written Witness Statement, dated 2/22/18, written by CNA #1, that indicated while performing ADL care to Resident #1, CNA #1 turned Resident #1 onto his/her side to remove the brief, went to grab a towel on the table and Resident #1 rolled off the bed head first. A Hospital Report, dated 2/22/18, indicated Resident #1 had a fall when staff at the nursing home rolled Resident #1 in bed to change him/her and he/she slipped out of bed landing on the floor. The Report indicated Resident #1 sustained a laceration to his/her forehead that required five sutures and a laceration to his/her bridge of nose that required three sutures. The Surveyor interviewed Unit Manager #1 at 2:25 P.M. on 5/31/18. Unit Manager #1 said CNA #1 would often turn and reposition Resident #1 by himself during care. Unit Manager #1 said that on 2/22/18 while CNA #1 was providing care, CNA #1 turned Resident #1 to his/her right side and he/she rolled off the bed to the floor landing on his/her right side. Unit Manager #1 said he saw blood on Resident #1's head and face. Unit Manager #1 said he instructed CNA #1 to call 911 and Resident #1 was transferred to the Hospital for evaluation. Unit Manager #1 said Resident #1's plan of care indicated Resident #1 was to have two staff persons providing assistance for bed mobility. The Surveyor interviewed the Director of Nurses (DON) at 2:50 P.M. on 5/31/18. The DON said CNA #1 rolled Resident #1 in bed on to his/her right side by himself. The DON said Resident #1's plan of care indicated he/she required two staff persons for assistance with bed mobility.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1), the facility failed to prevent Resident #1 from a fall, when Resident #1 went outside of the facility to smoke and wheeled his/her wheelchair off a curb and fell from the wheelchair. Resident #1 was transferred to the hospital for evaluation and diagnosed with [REDACTED]. Findings include: The Admission Record, dated 5/12/17, indicated Resident #1's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score was 15 (score 13-15 cognitively intact), indicated Resident #1 was cognitively intact. An Admission/Readmission Data Collection & Initial Plan of Care (with Norton Plus), dated 2/28/17, indicated Resident #1 was a fall risk due to [DIAGNOSES REDACTED]. A Fall Risk Care Plan, dated 3/3/17, indicated Resident #1 was a fall risk related to his/her ETOH (alcohol use). The Activities of Daily Living (ADL) Flowsheet, dated April 2017, indicated Resident #1 was independent with ambulation. The Facility Investigation, dated 4/8/17, indicated Resident #1 was outside of the facility on the facility's grounds when a passerby saw Resident #1 fall from his/her wheelchair, called 911, and Resident #1 was transferred to the hospital for evaluation. A Clinical Nurses Note, dated 4/9/17, indicated Resident #1 was observed outside the building by a passerby falling down with his/her wheelchair. The passerby called 911. Resident #1 was transferred to the hospital for evaluation. The Hospital Discharge Summary, dated 4/11/17, indicated Resident #1 was intoxicated at the time of the fall with a blood alcohol level of 413 and sustained a mandibular condyle sublaxationon (dislocated jaw). The Surveyor interviewed Resident #1 at 10:25 A.M. on 6/1/17. Resident #1 said on 4/8/17, he/she had gone to the package store and bought and then drank a pint ((16 fluid ounces) of brandy. Resident #1 said upon returned to the facility he/she avoided the staff because he/she had been drinking. Resident #1 said he/she ambulated independently but knew he/she was unsteady and decided to take his/her wheelchair outside to have a cigarette. Resident #1 said while outside, his/her wheelchair went off the curb, he/she fell to the ground, someone found him/her, and he/she was transferred to the hospital. Resident #1 said he/she dislocated his/her jaw as a result from the fall. The Surveyor interviewed Nurse #2 at 4:32 P.M. on 6/5/17. Nurse #2 said she did not see Resident #1 prior to him/her going outside. Nurse #2 said she was not aware that Resident #1 had fallen outside on the facility grounds until the fire trucks were outside. Nurse #2 said Resident #1 was transferred to the hospital for evaluation. Nurse #2 said she called the hospital later that shift and was informed that Resident #2 had a high blood alcohol level and was intoxicated. The Surveyor interviewed the Director of Nurses (DON) at 11:32 A.M. on 6/2/17. The DON said Resident #1 was transferred to the hospital for evaluation and was found to have a blood alcohol level about 400.

Based on records reviewed and interviews for 2 of 4 sampled residents (Resident #1 and Resident #4), the facility failed to ensure that a comprehensive assessment was completed so that Resident #1 and Resident #4 received appropriate treatment and services for substance use issues/disorders. Findings include: 1. The Admission Record, dated 5/12/17, indicated Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Hospital History and Physical, dated 2/17/17, indicated Resident #1 had reported drinking a pint (16 fluid ounces) of vodka every day and that his/her last drink was the morning of 2/17/17. The Admission/Readmission Data Collection & Initial Plan of Care (with Norton Plus), dated 2/28/17, indicated Resident #1 had a history of [REDACTED]. A Social Services Note, dated 3/3/17, indicated Resident #1 reported drinking a pint of vodka daily prior to hospitalization and wished to go to an inpatient program and the plan was to discharge to alcohol rehab when safe. A Psychosocial Well Being Care Plan, dated 3/3/17, indicated Resident #1 had a history of [REDACTED]. An Initial Physician Comprehensive Assessment, dated 3/13/17, indicated Resident #1 had a high level of ETOH (alcohol use) and history of [MEDICAL CONDITION]. A Behavioral Health Consultation, dated 3/20/17, indicated Resident #1 was challenged with prevention of his/her need for immediate gratification of ETOH. The Facility Investigation, dated 4/8/17, indicated Resident #1 was outside of the facility on the facility's grounds when a passerby saw Resident #1 fall from his/her wheelchair, called 911, and Resident #1 was transferred to the hospital for evaluation. A Clinical Nurses Note, dated 4/9/17, indicated Resident #1 was observed outside the building by a passerby falling down with his/her wheelchair. The passerby called 911. Resident #1 was transferred to the hospital for evaluation. The Hospital Discharge Summary, dated 4/11/17, indicated Resident #1 was intoxicated at the time of the fall with a blood alcohol level of 413 (signs of impairment begin at a blood alcohol level of 30-80) and sustained a mandibular condyle sublaxationon (dislocated jaw). The Surveyor interviewed Resident #1 at 10:25 A.M. on 6/1/17. Resident #1 said on 4/8/17, he/she had gone to the package store and bought and then drank a pint of brandy. Resident #1 said upon returned to the facility he/she avoided the staff because he/she had been drinking. Resident #1 said he/she ambulated independently but knew he/she was unsteady and decided to take his/her wheelchair outside to have a cigarette. Resident #1 said while outside, his/her wheelchair went off the curb, he/she fell to the ground, someone found him/her, and he/she was transferred to the hospital. Resident #1 said he/she dislocated his/her jaw as a result from the fall. The Surveyor interviewed the Director of Nurses (DON) at 11:50 A.M. on 6/1/17. The DON said that there were no interventions or care plans in place for Resident #1 to help him/her with the desire to remain sober. #2. The Admission Record, dated 1/8/17, indicated Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Behavioral Health Consultation, dated 11/7/16, indicated Resident #4 had no ETOH use and had been sober for several months. A Patient Care Referral Form, dated 3/12/17, indicated Resident #4 was transferred to the hospital for evaluation for increased agitation and aggression. The Hospital Discharge Summary, dated 3/12/17, indicated Resident #4 had an ethyl alcohol level of 201 and was slightly agitated related to having imbibed (to consume by drinking) alcohol. A Hospital Triage Note, dated 4/1/17, indicated Resident #4 was found to have a half pint (8 fluid ounces) of vodka in his/her room, admitted to drinking alcohol last night, and was at the hospital for medical clearance. There is no documentation in Resident #4's clinical record in regards to the hospital transfer for 4/1/17. There is no assessment, interventions, or care plan in Resident #4's clinical record in regards to his/her alcohol use. The Surveyor interviewed the Director of Nurses (DON) at 4:27 P.M. on 6/9/17. The DON said that the facility does not have a policy and procedure related to substance abuse and that there are no formal assessments, interventions, or care plans for substance abuse.

Based on interview and record review, for one of four sampled Residents (Resident #1), the Facility interfered with Resident #1 access to the community and discharged him/her when he/she left the Facility unescorted. Findings include: Resident #1's most recent Minimum Data Set (MDS) Assessment Form, completed 2/14/16, indicated that his/her cognitive patterns were intact. Resident #1's clinical record contained no documentation to indicate Resident #1 was not his/her own decision maker. Psychiatric Consultation Notes, dated 2/3/16, 2/4/16 and 3/2/16, indicated that he/she was alert and oriented to person, place and time with normal or adequate memory skills, language skills and attention and an adequate fund of knowledge. The Psychiatric Consolation Note, dated 2/4/16, identified that Resident #1 was not an apparent risk to him/herself or others. The Surveyor interviewed Resident #1 at 11:00 A.M. and 4:00 P.M. on 6/20/16 and at 9:00 A.M. on 7/1/16. Resident #1 said that when he/she was first admitted the Facility, he/she left the Facility when the weather was nice and walked to a nearby shopping center. Resident #1 said that he/she liked to get outside and walk, which was his/her customary routine prior to his/her admission to the Facility and he/she often purchased a sandwich or snack on these outings. Resident #1's clincal record contained documentation from the referring hospital when he/she was admitted to the Facility, which indicated that Resident #1's prior level of function and customary routine included walking in the community up to two miles per day with his/her rolling walker. The Surveyor interviewed the Director of Nurses at 12:40 P.M. on 6/20/16. Although the Director of Nurses was unable to locate documentation of Resident #1's social leaves of absence, the Director of Nurses recalled that Resident #1 occasionally left the Facility for walks in the community during his/her stay at the Facility. Resident #1 said that at some point during his/her stay at the Facility, the Administrator caught him/her smoking marijuana outside of the Facility and on the Facility premises and, after that, the Administrator tried to restrict his/her access to the community and issued him/her a Notice of Intent to Discharge if he/she did not comply with the restrictions. Resident #1 said that the Administrator also told him/her that he/she could not go outside of the Facility unescorted because his/her marijuana use posed a risk to him/herself and other residents. Resident #1 provided the Surveyor with a copy of Transfer/Discharge Notice Form, which indicated the Notice was hand delivered to Resident #1 on 3/22/16. The Notice indicated Resident #1 was to be discharged on [DATE] because smoking marijuana was not permitted in the Facility and Resident #1 disregarded warnings, smoked marijuana and endangered the safety of other individuals. Resident #1 said he/she never smoked marijuana in the Facility. Resident #1 said that he/she kept a small amount of marijuana buried on the Facility property and occasionally was visited by friends who smoked marijuana outside of the Facility and off of the property with him/her. Review of Resident #1's nurses notes from 3/22/16 to 4/13/16 did not reveal any documentation that he/she was found smoking any substances inside of the Facility. Review of the nurses did not indicate any instances of suspected intoxication. The Surveyor interviewed Resident #4 at 6:00 P.M. on 6/21/16. Resident #4 said that he/she shared a room with Resident #1. Resident #4 said that he/she was a police officer. Resident #4 said that he/she never saw Resident #1 smoke in the room and never smelled marijuana on Resident #4. The Nurse Manager was interviewed at 3:00 P.M. on 7/1/16. The Nurse Manager said that staff members complained to her occasionally that Resident #1 smelled like marijuana, but no one ever saw him/her smoking inside the Facility. The Nurse Manager said that the Administrator told her that she saw Resident #1 smoking outside of the Facility on one occasion. The Nurse Manager said that after Resident #1 was observed smoking marijuana, the Administrator told Resident #1 that he/she could not leave the Facility without a responsible person. The Nurse Manager said that because most of the Facility residents chose not to leave the Facility without a responsible person, Resident #1 was told that it was a rule that residents could only leave the Facility escorted by a responsible person even though he/she previously accessed the community unescorted. The Nurse Manager said and Resident #1's clinical record indicated that Physician #1 wrote an order dated 4/4/16 which indicated Resident #1 could only leave the Facility for three hours with a family member and required drug testing when he/she returned. A second order from Physician #1 dated 4/4/16 indicated that, if Resident #1 did not return within the allotted three hours he/she was discharged from the Facility. The Administrator was interviewed at 9:30 A.M. on 6/20/16. The Administrator said that during Resident #1's stay, he/she was leaving the Facility for social leaves of absence and because staff members were concerned that Resident #1 used drugs, Physician #1 ordered that Resident #1 could not leave the Facility for social leaves of absence unescorted. The Administrator said that at one point she issued a Notice of Intent to Discharge Resident #1 because he/she smoked marijuana while on leaves of absence outside of the Facility, but the Ombudsman told her that she could not do that and the Notice was rescinded. The Administrator said that Resident #1 subsequently violated Physician #1's orders by leaving without an escort and the police were called when he/she returned. Resident #1's nurses' note indicated that Resident #1 left the Facility at 10:00 A.M., his/her belongings were packed in boxes by 10:40 A.M. and at 2:20 P.M. the police were called when Resident #1 returned the Facility. The Administrator said that Resident #1 was instructed that he/she needed to comply with the Facility rule that he/she could not leave the Facility unescorted and Resident #1 refused. The Administrator said that staff members packed Resident #1's belongings and the police carried the items to the side walk. This action rendered Resident #1 homeless. Physician #1 was interviewed at 1:10 P.M. on 6/20/16. Physician #1 said Resident #1 was competent but would not be compliant with the Facility rules. Physician #1 said Resident #1 had an addictive personality and staff members were concerned that Resident #1 used drugs when he/she left the Facility unescorted. Physician #1 said that based on the staff members concerns he wrote orders which indicated that Resident #1 could not leave the Facility unescorted for non-medical reasons. Physician #1 said the rules were placed on Resident #1 for his/her own safety. The Nurse Manager said Resident #1 was given ample opportunity to prove him/herself and to follow the rules, but he/she would not and continued to leave the Facility unescorted and was discharged . Resident #1 said that he/she camped behind a nearby store for the night and lit a fire to keep warm. Resident #1 said that the police spoke with him/her around 11:00 P.M. and transported him/her to the hospital. The Hospital Record Resident #1 was admitted to the hospital.

Based on interview and record review, for one of one sampled Residents (Resident #1), on 4/13/16, the Facility refused to allow Resident #1 to return to the Facility to following a trip in the community and instead told Resident #1 that he/she discharged from the Facility against medical advice when he/she refused to adhere to Physician #1's order that he/she not leave the Facility unescorted. Resident #1 slept in the woods nearby until he/she was picked up by the police and transported to the hospital. Findings include: Resident #1's most recent Minimum Data Set (MDS) Assessment Form, completed 2/14/16, indicated that his/her cognitive patterns were intact. Resident #1's clinical record contained no documentation to indicate Resident #1 was not his/her own decision maker. Psychiatric Consultation Notes, dated 2/3/16, 2/4/16 and 3/2/16, indicated that he/she was alert and oriented to person, place and time with normal or adequate memory skills, language skills and attention and an adequate fund of knowledge. The Psychiatric Consolation Note, dated 2/4/16, identified that Resident #1 was not an apparent risk to him/herself or others. The Surveyor interviewed Resident #1 at 11:00 A.M. and 4:00 P.M. on 6/20/16 and at 9:00 A.M. on 7/1/16. Resident #1 said that when he/she was first admitted the Facility, he/she left the Facility when the weather was nice and walked to a nearby shopping center. Resident #1 said that he/she liked to get outside and walk, which was his/her customary routine prior to his/her admission to the Facility and he/she often purchased a sandwich or snack on these outings. Resident #1's clincal record contained documentation from the referring hospital which indicated that Resident #1's prior level of function and customary routine included walking in the community up to two miles per day with his/her rolling walker. The Surveyor interviewed the Director of Nurses at 12:40 P.M. on 6/20/16. The Director of Nurses said that the Facility used a sign out book for each resident who left the Facility for non-medical leaves of absences. The Director of Nurses showed the Surveyor that this book contained pages for residents or their responsible persons to document the date, time, anticipated location and anticipated time of return. Although the Director of Nurses said that he was unable to locate Resident #1's leave of absence paperwork, the Director of Nurses recalled that Resident #1 occasionally left the Facility for walks in the community during his/her stay at the Facility. Resident #1 said that at some point during his/her stay at the Facility, the Administrator caught him/her smoking marijuana outside of the Facility, but on the Facility premises and, after that, the Administrator tried to discharge him/her. Resident #1 said that the Administrator also told him/her that he/she could not go outside of the Facility unescorted because his/her marijuana use posed a risk to him/herself and other residents. Resident #1 provided the Surveyor with a copy of Transfer/Discharge Notice Form, which indicated the Notice was hand delivered to Resident #1 on 3/22/16. The Notice indicated Resident #1 was to be discharged on [DATE] because smoking marijuana was not permitted in the Facility and Resident #1 disregarded warnings, smoked marijuana and endangered the safety of other individuals. Resident #1 said he/she never smoked marijuana in the Facility. Resident #1 said that he/she kept a small amount of marijuana buried on the Facility property and occasionally was visited by friends who smoked marijuana outside of the Facility and off of the property with him/her. Review of Resident #1's nurses notes did not reveal any documentation that he/she was found smoking any substances inside of the Facility. Review of the nurses did not indicate any instances of suspected intoxication. The Surveyor interviewed Resident #4 at 6:00 P.M. on 6/21/16. Resident #4 said that he/she shared a room with Resident #1. Resident #4 said that he/she was a police officer. Resident #4 said that he/she never saw Resident #1 smoke in the room or smelled marijuana on Resident #4. The Nurse Manager was interviewed at 3:00 P.M. on 7/1/16. The Nurse Manager said that staff members complained to her occasionally that Resident #1 smelled like marijuana, but no one ever saw him/her smoking inside the Facility. The Nurse Manager said that the Administrator told her that she saw Resident #1 smoking outside of the Facility on one occasion. The Nurse Manager said that after Resident #1 was observed smoking marijuana, the Administrator told Resident #1 that he/she could not leave the Facility without a responsible person. The Nurse Manager said that because most of the Facility residents chose not to leave the Facility without a responsible person, Resident #1 was told that it was a rule that residents could only leave the Facility escorted by a responsible person even though he/she previously accessed the community unescorted. The Nurse Manager said and Resident #1's clinical record indicated that Physician #1 wrote an order on 4/4/16 which indicated Resident could only leave the Facility for three hours with a family member and required drug testing when he/she returned. A second order from Physician #1 on 4/4/16 indicated that, if Resident #1 did not return within the allotted three hours he/she was discharged from the Facility. The Administrator was interviewed at 9:30 A.M. on 6/20/16. The Administrator said that Resident #1 was admitted to the Facility after hospitalization for rehabilitation but left the Facility against medical advice. The Administrator said that during Resident #1's stay, he/she was leaving the Facility for social leaves of absence and because staff members were concerned that Resident #1 used drugs, Physician #1 ordered that Resident #1 could not leave the Facility for social leaves of absence unescorted. The Administrator said that at one point she issued a notice of intent to discharge Resident #1 because he/she smoked marijuana while on leaves of absence outside of the Facility, but the Ombudsman told her that she could not do that and the Notice was rescinded. The Administrator said that Resident #1 subsequently violated Physician #1's orders by leaving without an escort and the police were called when he/she returned. The Administrator said that Resident #1 was instructed that he/she needed to comply with the Facility rule that he/she could not leave the Facility unescorted and Resident #1 refused. The Administrator said that staff members packed Resident #1's belongings and the police carried the items to the side walk. Physician #1 was interviewed at 1:10 P.M. on 6/20/16. Physician #1 said Resident #1 was competent but would not be compliant with the Facility rules. Physician #1 said Resident #1 had an addictive personality and staff members were concerned that Resident #1 used drugs when he/she left the Facility unescorted. Physician #1 said that based on the staff members concerns he wrote orders which indicated that Resident #1 could not leave the Facility unescorted for non-medical reasons. Physician #1 said the rules were placed on Resident #1 for his/her own safety. The Nurse Manager said Resident #1 was given ample opportunity to prove him/herself and to follow the rules, but he/she would not and continued to leave the Facility unescorted. A nurses note, dated 4/4/16, indicated Resident #1 became belligerent and yelled when told by the nurse that he/she could not leave the Facility unescorted and, if he/she did, he/she would be discharged from the Facility. A nurses note, incorrectly dated 4/12/16 and reflecting care for 4/13/16, indicated Resident #1 left the Facility unescorted and was told that he/she did not have an order from Physician #1 to leave the Facility. The note indicated Resident #1 said that he/she was not a prisoner and would go out as he/she pleased. The note indicated that Resident #1 left the Facility against medical advice. A nurses note, dated 4/13/16, indicated Resident #1's belongings were packed in boxes. The note indicated Physician #1 was contacted and Physician #1 said that, during his last visit he told Resident #1 that he/she could not leave the Facility except for medical reasons. The note indicated Physician #1 instructed the nurse that if Resident #1 returned to the Facility, he/she should not be accepted in as a patient. A second note on 4/13/16 indicated Resident #1 returned to the Facility and was told that he/she was discharged for leaving the Facility against medical advice. The note indicated that Resident #1's family members were called an agreed to take Resident #1 but he/she refused to go there. The note indicated that the police were contacted and the police offered to take Resident #1 to a shelter and he/she refused to go to a shelter with the police. The note indicated that Resident #1 was informed that his/her discharge would be reconsidered if he/she agreed to follow the Facility rule and to remain inside the Facility except for authorized medical absences and Resident #1 refused. The note indicated Resident #1 asked the police to help him/her move his/her personal items off of the Facility property and they did. The Police Report, dated 4/13/16, indicated that the police department was contacted at 11:50 A.M. about an unwanted party. The Police Report indicated that when officers arrived Resident #1 told them that he/she left the Facility for a short period of time and when he/she returned, his/her property had been placed in boxes and was waiting by the Facility door. The Police Report indicated Resident #1 told the police that it was unfair because he/she was not a prisoner and he/she was homeless and had no where else to go. The Police Report indicated officers spoke to the Administrator. The Police Report indicated that the Administrator told them that it had been made clear to Resident #1 on numerous occasions that he/she was only allowed to leave the Facility with staff member's permission and a physician order [REDACTED]. The Police Report indicated that before leaving for his/her walk that morning, Resident #1 was explicitly told that he/she did not have permission to leave and if he/she left, he/she would forfeit his/her ability to remain in the Facility under his/her insurance. The Police Report indicated that the Administrator said that Resident #1 chose to leave and his/her personal property was placed outside. The Police Report indicated that the officer asked the Administrator what arrangements were made for Resident #1 since he/she was homeless and now removed from the Facility, and the Administrator told the officer that once Resident #1 knowingly violated the conditions for remaining in the Facility, she was no longer obligated to provide care to him/her. The Police Report indicated the officer explained that it seemed inappropriate to evict Resident #1 without making arrangements for suitable housing and the Administrator agreed to make some telephone calls. The Police Report indicated that the Administrator subsequently told the officer she arranged for Resident #1's family member to take him/her or for him/her to return to the Facility if he/she agreed that any further violations of the rule that he/she could not leave the Facility except for medical appointments but Resident #1 flatly refused. The Police Report indicated that Resident #1 asked the officers to carry his/her belongings to the street, which they did. Resident #1 said that he/she moved his/her belongings to a wooded area behind a nearby store where he/she intended to spend the night. Resident #1 said that he/she started a campfire which was noticed by someone and the police came and transported him/her to a hospital.

Based on record review and interviews, for 1 of 19 sampled residents (Resident #10), the Facility failed to ensure Resident #10 received effective pain management. 1. Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #10's plan of care included the use of [MEDICATION NAME] 650 milligrams by mouth twice daily at 9:00 A.M. and 9:00 P.M. During the evening shift on 3/31/15, at 9:00 P.M., the nurse gave Resident #10 her scheduled pain medication. On 3/31/2015, at 9:40 P.M., Resident #10 was found on floor beside her bed. The physician and the Director of Nursing were notified. The physician ordered the staff to monitor the Resident. The Resident was reoriented to use of the call bell and instructed to use call bell for her needs. During the night shift , at 3:30 A.M., the Resident began to complain of pain in the right leg, right knee area . The Resident was medicated at that time with [MEDICATION NAME] 650 milligrams with little effect. The Resident continued to complain of pain. The Resident complained of increased pain in her right leg during and after the pain medication administration The physician was called twice again after the medication was administered at 3:30 A.M., and failed to return the phone call. At 7:30 A.M., the Resident was medicated again with [MEDICATION NAME] 650 milligrams for pain in the range of 8/10 in intensity. The physician still had not returned either of the phone calls that had been sent. The Unit manager had arrived at the floor at this time. The Unit Manager called the ambulance and the Resident was sent out to the Emergency Department . The Emergency Department notified the Nursing Facility later that morning that the Resident was admitted to the hospital with [REDACTED]. 2. The Pain Management Policy, dated January 2006, indicated the staff were to assure the resident that his/her pain can be managed effectively. The Pain Management Policy indicated the staff were to reevaluate a resident's pain status frequently and review and revise the Plan of Care as needed to relieve/control pain. The Medication Administration General Guidelines Policy, dated 2007, indicated that when PRN( as needed) medications were given, the following was to be documented: date and time of administration, complaints or symptoms for which the medication was given, results achieved from giving the dose, the time results were noted, and signature or initials of person recording administration and effects. Although the nurses progress note written during the night shift on 4/1/2015, indicated that the Resident received little effect from the PRN dose of [MEDICATION NAME], the medication sheets were not utilized to either document the dose or the effect of the pain medication. The Resident complained of increased pain in her right leg during and after the pain medication administration The physician was called twice again after the medication was administered at 3:30 A.M., and failed to return the phone call. The Resident was not sent out to the Emergency Department until 7:30 the following morning after the fall occurred at the nursing facility, the Hospital staff diagnosed the Resident with a Fracture of her right femur.

Based on interview and record review, for one of three sampled residents (Resident #1) the Facility failed to ensure that Resident #1 was not left alone and unsupervised in the kitchenette behind a closed door with a hot beverage. On 3/13/12 at 6:00 P.M., Resident #1 said he/she heated coffee in the kitchenette microwave, the kitchenette door was closed and Resident #1 struggled to open the door with one hand while holding the hot coffee in the the other hand. Resident #1 said that hot coffee splashed on his/her abdomen, burning him/her. Findings include: The Admission Minimum Data Set (MDS), assessment, with an assessment reference date of 1/27/12, indicated that Resident #1 was admitted to the Facility January, 2012. The MDS indicated that Resident #1's [DIAGNOSES REDACTED]. The MDS indicated that Resident #1's cognitive patterns were intact and he/she ambulated with supervision. The Surveyor interviewed Resident #1, on 3/27/12 at 10:30 A.M.. Resident #1 said, on 3/13/12 after dinner, Certified Nursing Assistant (CNA) #1 let him/her into the unit kitchenette to warm up his/her coffee. Resident #1 said he/she had used the microwave in the kitchenette before, but this was the first time a staff member left him/her alone in the kitchenette. Resident #1 said that the kitchenette door closed behind CNA #1 when he left, and Resident #1 struggled to open the door with one hand while holding the hot coffee in the the other hand. Resident #1 said that hot coffee splashed on his/her abdomen, burning him/her. Resident #1 said once he/she was able to open the door, he/she went to the nurses' station and reported the burn. The Surveyor interviewed Nurse Manager #1, on 3/27/12 at 3:30 P.M.. Nurse Manager #1 said she worked on 3/13/12 and was at the nurses' station when Resident #1 reported he/she was burned when hot coffee spilled. Nurse Manager #1 said she assessed Resident #1's upper abdomen which was red and not blistered. Nurse Manager #1 said that she contacted the physician who ordered cold compresses and Silvadene cream (a topical antibiotic ointment). The Pain Assessment, dated 3/13/12, indicated that Resident #1's verbal pain score was a seven (moderate significant pain) in a severity pain scale of zero through ten. The Nurse Practitioner's note, dated 3/15/12, indicated she assessed Resident #1's abdomen which was still red. The Nurse Practitioner's note indicated that she noted a large broken blister on Resident #1's abdomen. Taber's Cyclopedic Medical Dictionary defines a second degree burn as a burn that damages epidermal and some dermal tissues but does not damage the lower - lying hair follicles, sweat or sebaceous glands. The burn is painful and red; blisters form, and wounds may heal with a scar. A Rehab (rehabilitation) Addendum Note, dated 3/16/12, indicated that Resident #1 put the cup of coffee in the microwave for 90 seconds, but realized he/she should have started with 30 or 60 seconds. The Rehab Addendum Note indicated that Resident #1 said when leaving the kitchenette, the door was closed (at other times someone had been holding the door for him/her). The Rehab Addendum Note indicated that Resident #1 said the door felt heavy to him/her and was difficult to open. The Rehab Addendum Note indicated that Resident #1 had limited range of motion in both shoulders. The Rehab Addendum Note indicated that Resident #1 was educated to make sure someone either carried coffee for him/her or held the kitchenette door open for him/her. Nurse Manager #1 said Resident #1 should have been supervised in the kitchenette. Nurse Manager #1 said that the door to the kitchenette should be closed and locked, and staff members carried keys to unlock the kitchenette door. Nurse Manager #1 said staff members sometimes allowed residents to use the kitchenette under supervision in order to provide opportunities for increased independence because many residents on the unit were there for rehabilitation in anticipation of their discharge home. Nurse Manager #1 said Resident #1 should have been supervised when using the kitchenette. Nurse Manager #1 said she was not sure how Resident #1 got into the locked kitchenette, but she said the kitchenette door was sometimes left open during meals. The Surveyor interviewed the Director of Nurses on 3/27/12 at 2:00 P.M.. The Director of Nurses said that the kitchenette door should have been locked, but she thought that some residents, such as Resident #1, Resident #2 and Resident #3, were allowed to use the kitchenette independently. The Director of Nurses said the Facility did not have a protocol to ensure the safety of residents who used the kitchenette microwave. The Director of Nurses said she thought staff members of the rehabilitation department evaluated Resident #1 for using the kitchenette independently. The Surveyor interviewed Physical Therapist #1 and Occupational Therapist #1 together, on 3/27/12 at 11:15 A.M. The Surveyor interviewed Occupational Therapist #2, on 3/27/12 at 11:45 A.M. The Surveyor interviewed the Rehabilitation Program Manager on 3/27/12 at 12:05 P.M.. Physical Therapist #1, Occupational Therapist #1, Occupational Therapist #2 and the Rehabilitation Program Manager said they worked with Resident #1 and they did not tell staff members that Resident #1 could use the kitchenette unsupervised. The Surveyor interviewed CNA #1, on 3/27/12 at 2:15 P.M.. The Surveyor interviewed CNA #2, on 3/27/12 at 2:30 P.M.. The Surveyor interviewed CNA #3, on 3/27/12 at 2:50 P.M.. CNA #1 said he used his discretion regarding which residents could access the kitchenette unsupervised. CNA #1 said he gave his kitchenette key regularly to Resident #3. CNA #2 said she was not aware that any residents were allowed to use the kitchenette, although CNA #2 said that sometimes the door was left open allowing residents access. CNA #3 said he thought residents could use the kitchenette, but only with staff supervision. CNA #1 said that he did not recall letting Resident #1 into the kitchenette on 3/13/12 and only learned of her burn a few days later. The Surveyor interviewed Resident #2 on 3/30/12 at 11:00 A.M.. Resident #2 said that before 3/13/12, the door to the kitchenette was often left open and he/she accessed the kitchenette regularly. Resident #2 said that since Resident #1 burned himself/herself, the kitchenette was kept locked. The Surveyor interviewed Resident #3 on 3/30/12 at 11:20 A.M.. Resident #3 said that before 3/13/12, the door to the kitchenette was often left open and he/she accessed the kitchenette regularly. Resident #2 said that, in recent weeks, the kitchenette was always kept locked.