Every finding on record at Timberlyn Heights Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to ensure one Resident (#62) out of a total sample of 17 residents was provided assistance with personal hygiene. Specifically, the facility failed to ensure Resident #62 was offered and/or provided with grooming assistance when the Resident required the assistance of staff for grooming activities. Findings include: Resident #62 was admitted to the facility in April 2024, with diagnoses including Cerebral Infarction (Stroke: damage to the tissues in the brain due to a loss of oxygen to the area) and Diabetes Mellitus with Diabetic Neuropathy (metabolic disease involving inappropriately elevated blood glucose [sugar] levels with nerve damage). Review of the Activities of Daily Living (ADL: refers to an individual's daily self-care activities and includes bathing, dressing and grooming) Care Plan, initiated 4/26/24, indicated Resident #62 required moderate assistance with ADLs due to stroke with left sided deficits (impairment on the left side) and included the following intervention: -Assistance of one staff for grooming . (initiated 4/26/24) Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #62: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -had no behaviors -had upper and lower range of motion deficits on one side -required partial/moderate assistance with personal hygiene including grooming needs On 9/5/24 at 9:58 A.M., the surveyor observed Resident #62 dressed in a hospital gown and seated in a wheelchair which was positioned next to his/her bed. The Resident had facial hair on his/her chin, upper lip and bilateral cheeks. During an interview at the time, Resident #62 said he/she needed assistance from staff with personal care and liked to have the hair removed from his/her face. The Resident said he/she received showers on Monday and Thursdays and should be assisted with facial shaving during showers but has not been. The Resident further said that he/she was currently waiting for staff to assist him/her in the shower this morning. On 9/6/24 at 8:41 A.M., the surveyor observed Resident #62 seated in a wheelchair positioned next to his/her bed. The Resident was dressed in a hospital gown and remained with facial hair on his/her chin, upper lip, and bilateral cheeks. During an interview at this time, the Resident said that he/she did receive a shower yesterday (9/5/24), but staff did not offer or assist him/her with facial shaving. The Resident said he/she did have an electric shaver, while motioning to a bedside table, but no one has offered to assist him/her with using it. Resident #62 said he/she would like to have no facial hair. During a subsequent observation at 11:18 A.M., the surveyor observed that the Resident was dressed and seated in a wheelchair in his/her room and remained with facial hair that was unchanged from the previous observations. During an interview at the time, the Resident said again that he/she needed to have the hair removed from his/her face. On 9/10/24 at 8:59 A.M., the surveyor observed Resident #62 seated in a wheelchair in his/her room. The surveyor observed the Resident remained with facial hair. During an interview at the time, the Resident said he/she received a shower yesterday (9/9/24) and told the staff that he/she wanted to have the facial hair removed but it was not done. The Resident was observed touching the facial hair on his/her cheeks during the interview. During an interview on 9/10/24 at 3:05 P.M., Certified Nurses Aide (CNA) #1 said she was familiar with Resident #62 and has assisted with his/her care. CNA #1 said Resident #62 required the assistance of one staff with bathing, dressing and personal hygiene which includes grooming/shaving due to a previous stroke. CNA #1 said that grooming/shaving assistance would be offered and provided during showers and when the Resident requested. CNA #1 said Resident #62 received showers twice weekly, that he/she received a shower yesterday (9/9/24), and should have been offered/provided grooming/shaving. CNA #1 said if a resident refused care, they would notify the Nurse, and it would be documented in the resident's record. On 9/10/24 at 3:16 P.M., the surveyor and Unit Manager (UM) #1 reviewed the September 2024 CNA documentation for Resident #62. UM #1 said the documentation indicated Resident #62 required assistance from staff with personal hygiene which includes grooming/shaving. UM #1 said if the Resident refused care, the Nurse would be notified, and it would be documented in the nursing notes. Review of Resident #62's clinical record indicated no documented evidence that the Resident refused care relative to grooming/personal hygiene. During an interview on 9/11/24 at 8:25 A.M., CNA #2 said she has provided care assistance to Resident #62. CNA #2 said she usually provided grooming/shaving assistance during showers but had not offered this to Resident #62. CNA #2 said that it was her understanding that the Resident would ask for grooming/shaving assistance. CNA #2 said she assisted Resident #62 with a shower on Thursday (9/5/24), the Resident had not asked to be groomed/shaved, and she did not offer to groom/shave him/her. CNA #2 further said Resident #62 had been moved to the second floor for a few months and she has never offered to assist him/her with grooming/shaving. CNA #2 further said she was unaware if the Resident had an electric razor to use.

Based on interview, record and policy review, the facility failed to ensure ordered lab work was obtained and reviewed timely for one Resident (#65), out of 5 applicable residents reviewed for unnecessary medications, out of a total sample of 17 residents. Specifically, the facility failed to obtain lab work ordered by the Physician for Resident #65, so that lab results would be available for timely review and any needed intervention. Findings include: Review of the facility policy titled Diagnostic Testing Services, revised 12/6/21, indicated the facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents . and included the following: -Facility will maintain a schedule of diagnostic tests in accordance with the physician's orders. -Qualified nursing personnel will receive and review the diagnostic test reports and communicate the results to the ordering Physician within 24 hours of receipt unless the report falls outside of the clinical reference ranges and require immediate attention at which time the Physician will be notified within receipt. -Documentation of diagnostic tests, the results, and date/time of the Physician notification will be maintained in the resident's clinical record. Resident #65 was admitted to the facility in August 2024, with diagnoses including Diabetes Mellitus (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood), Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), Hypertension (HTN: high blood pressure, when the blood pressure measures consistently above 130/80 millimeters of mercury [mm Hg]), and Schizophrenia (a mood disorder that affects a person's ability to think, feel and behave clearly). Review of Resident #65's September 2024 Physician's orders included the following laboratory tests, initiated 8/12/24: -Vitamin D level, yearly -Thyroxine level (Free T4: indication of thyroid disease) yearly -Thyroid Stimulating Hormone (TSH: measures amount of hormone in blood to determine if the thyroid is working properly) yearly -Lipids (blood test that measures levels of cholesterol and other fats in the blood) yearly -Prostate-Specific Antigen (PSA: blood test: screens for prostate cancer) yearly -Hemoglobin A1C (measures the average blood sugar levels over the last three months), every 6 months -Complete Blood Count (CBC: measures levels of different types of blood cells including red blood cells, white blood cells, and platelets), every 6 months -Complete Metabolic Panel (CMP: blood test that measures 14 substances in the blood to provide overall picture of the body's chemical balance and metabolism), every 6 months Review of the facility Lab Book indicated the Resident's lab work was drawn on 8/15/24, and included the following: -CMP, Lipids, Free T4, TSH, and Vitamin D level. Review of Resident #65's clinical record indicated no documented evidence of the results of the lab work obtained on 8/15/24. During an interview on 9/10/24 at 10:33 A.M., Unit Manager (UM) #1 provided the surveyor with the requested lab work for Resident #65 that she had requested to be faxed over from the laboratory. UM #1 said the results from the lab work drawn on 8/15/24 for Resident #65 were not obtained until requested by the surveyor. UM #1said she did not believe the lab results had been reported to the Physician. During a follow-up interview on 9/10/24 at 2:06 P.M., UM #1 said after resident labs are drawn, the facility would receive the results and will report any abnormal labs to the Physician on the same day. If the labs are within normal range, the Nurses would put the lab results in the Provider Binder for review when the Provider come to the facility. UM #1 said this process was not followed for Resident #65, which could have altered his/her plan of care if reported timely. During an interview on 9/10/24 at 12:53 P.M., the Director of Nursing (DON) said Resident #65's lab work dated 8/15/24, was reviewed with the Physician on 9/10/24 and new orders were obtained to recheck the Resident's Vitamin D level on the next scheduled lab day (Thursday 9/12/24).

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Order indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation (CPR), in the event of cardiac or respiratory arrest) and Do Not Intubate (DNI, medical order written by a physician, which instructs healthcare providers not to place a tube down the patient's throat or connect to a breathing machine that pumps air into and out of lungs), the Facility failed to ensure services provided by nursing met professional standards of practice, when nursing initiated life saving measures including performing chest compressions on a resident who was a DNR/DNI. On [DATE], at approximately 12:30 P.M., Resident #1, who had been eating lunch, was found to have blue face and lips, was thought to be choking by staff, and Nursing immediately started to perform the Heimlich Maneuver (abdominal thrusts lift diaphragm and expel air from lungs, causes foreign object to be expelled from airway), without success. Resident #1 had become unresponsive, was noted to not be breathing and assessed by nursing to be without a pulse. Nursing staff were unable to locate Resident #1's Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) Form, in his/her medical record to verify his/her Code Status, and could not find his/her Physician's orders, and subsequently initiated life saving measures including starting Cardiopulmonary Resuscitation (CPR) by administering chest compressions, calling a Code Blue, and initiating 911. Emergency Medical Services (EMS) arrived, Resident #1 was noted to be breathing, had a pulse and was transported to the Hospital Emergency Department (ED). EMS personnel were not provided with Resident #1's Advanced Directives, so he/she was intubated upon arrival to the ED. Resident #1's Health Care Agent (HCA) arrived and provided the Hospital with a copy of Resident #1's Advanced Directives which indicated he/she was a DNR/DNI, and Resident #1 was extubated in the ED, but continued to breathe. Resident #1 was admitted to the Hospital for terminal comfort care, was found to have respiratory distress that was difficult to abate and required progressively more vigorous morphine (narcotic, used to treat moderate to severe pain) therapy to achieve comfort, he/she died in the hospital four days later. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Titled Nursing Practice and Cardiopulmonary Resuscitation, dated as revised ,d+[DATE], indicated that as a Standard of Nursing Practice, the nurse licensed by the Board is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board's position that these standards, in the context of practice in all settings where health care is delivered require initiating cardiopulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L. c. 46, S 9, except when the patient has a current, valid Do Not Resuscitate order/status. It further indicated, that for the purpose of this Advisory Ruling, the licensed nurse must, at a minimum, attain and maintain the following competencies through successful completion of entry-level nursing education programs or continuing education experiences, the nurse's role in obtaining accurate information about the DNR status of all assigned patients. The Facility Policy, titled Massachusetts Advance Directives, revised [DATE], indicated it is policy for staff to recognize and support the use of Advance Directives. The Policy indicated it is Resident's Rights for self-determination and will be recognized by the Facility by aiding with Advance Directive identification. The Policy indicated to maximize the rights of each resident, ensuring that their wishes regarding medical decision making are upheld and the safety of each individual is met and defined the following: -Advance Directive was defined as a written instruction, recognized under State law, relating to the provision of health care when the individual is incapacitated. -Health Care Proxy HCP was defined as a legal document that a competent adult may complete to identify agent(s) who would make their health care decisions for an incapacitated person. The Facility's Policy, titled Emergency Procedure-Cardiopulmonary Resuscitation (CPR), reviewed [DATE], indicated personnel have completed training on the initiation of CPR and Basic Life Support (BLS), including defibrillation for victims of Sudden Cardiac Arrest (SCA). The Policy indicated if a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that resident. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, Chronic Kidney Disease (CKD-Stage 3), depression, anxiety, COVID-19 and Multisystem Inflammatory Syndrome (MIS). Review of Resident #1's New York Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1's HCA on [DATE], indicated Resident #1 was a Do Not Resuscitate (DNR) and Do Not Intubate (DNI). Review of Resident #1's Massachusetts Health Care Proxy (HCP), dated [DATE] and signed by a Physician, indicated Resident #1 lacked the capacity to make, or to communicate, health care decisions permanently. Review of Resident #1's Advanced Directive Care Plan, revised [DATE], indicated Resident #1 was a DNR, DNI, a transfer to the hospital, no feeding tubes, no intravenous (IV) fluids and his/her Health Care Proxy had been invoked Review of Resident #1's Physician Orders, for [DATE], indicated Resident #1 was a DNR, DNI and had an invoked HCP. Review of the Ambulance Run Report, dated [DATE], indicated Paramedics arrived at the scene to the nurse (later identified as Nurse #1) stating she started chest compressions on Resident #1 after attempting the Heimlich Maneuver when Resident #1 was found apparently choking, the nurse said Resident #1 had immediately began breathing again. The Report indicated the Paramedic performed an immediate video laryngoscopy (a device used to visualize vocal cords and related airway structures without a direct line of sight) on Resident #1 and found no foreign bodies (food or objects), that he/she had a copious amount of saliva that required suctioning, and apparently had inflamed or swollen tissue round the glottic opening (primary valve between the lungs and the mouth). The Report indicated the Paramedic visualized a tube placement would not work due to swelling, considered surgical intervention, but Resident #1 was able to still get breaths in, so the Paramedics began assisting respirations with Bag-Valve-Mask (BVM, a basic airway management technique to allow oxygenation and ventilation until a more definitive airway can be established). The Report indicated Resident #1 was then transported to the Hospital. Review of the Hospital Discharge Summary, dated [DATE], indicated that on [DATE] Resident #1 arrived at the ED in respiratory distress after a choking episode at his/her Nursing Home. The Summary indicated Resident #1 became unresponsive at the Nursing Home and the Heimlich Maneuver and CPR were initiated. The Summary indicated Resident #1 arrived at the ED with an empty (blank) MOLST form and that the ED Physician proceeded with Resident #1's placement of an endotracheal intubation (tube placed into the trachea to maintain an open airway). The Summary, indicated Resident #1's HCA arrived, presented a filled out MOLST form indicating Resident #1's Code Status was DNR/DNI and reported that due to Resident #1 severe dementia, he/she had not wanted any invasive or noninvasive ventilation and non resuscitation under any circumstances. The Summary indicate at that point any question of life extending care whatsoever was abated due to his/her unresponsive state, resident was extubated, but continued to breathe. The Summary indicated Resident #1 was found to have respiratory distress that was difficult to abate and required progressively more vigorous morphine therapy to achieve comfort. The Summary indicated Resident #1 died in the Hospital, four days later. During an interview on [DATE] at 10:48 A.M., Nurse #1 said that on [DATE] at lunch time, Certified Nurse Aide (CNA) #1 called her to come to Resident #1's room. Nurse #1 said upon entering Resident #1's room, Resident #1 was unresponsive and his/her eyes were rolling in an upward direction. Nurse #1 said since Resident #1 had been eating lunch, she thought he/she was choking, so she performed a finger sweep of his/her mouth did not find any food, and then initiated the Heimlich Maneuver on Resident #1 without any results. Nurse #1 said upon further assessment, Resident #1 did not have a apical pulse and was not breathing. Nurse #1 said a Code Blue was called and 911 was initiated. Nurse #1 said she was unable to find Resident #1's MOLST or his/her Physician Orders in the medical record to verify his/her Code Status, so she and Nurse #2 started CPR by administering chest compression. Nurse #1 said Resident #1 started to breath just prior to the Emergency Medical Services (EMS) arrival. Nurse #1 said she did not report to Nurse #2, the EMS or the Hospital Nurse that she was unable to identify Resident #1's Code Status. Nurse #1 could not explain how she missed Resident #1's Physician's Orders for a DNR and DNI in his/her medical record. During an interview on [DATE] at 9:00 A.M., Nurse #2 said on [DATE] during lunch time, he heard a Code Blue announcement and upon arrival to Resident #1's room Nurse #1 was performing chest compressions on him/her. Nurse #2 said he asked what happened and said Nurse #1 told him Resident #1 had choked, she performed the Heimlich Maneuver and it did not work, so she started chest compressions. Nurse #2 said he took over doing chest compressions and performed only four to five chest compressions, when Resident #1 began to make quick deep breath and blowing sounds, he/she blew out saliva with tiny food particles and then opened his/her eyes. Nurse #2 said he stopped chest compressions at that time. Nurse #2 said he did not have a discussion with Nurse #1 regarding Resident #1's Code Status, since she had already initiated CPR, and said Nurse #1 should have already checked and verified Resident #1's Code Status prior to his arrival. During an interview on [DATE] at 2:56 P.M., the Director of Nursing (DON) said on [DATE] Resident #1 was choking, staff performed the Heimlich Maneuver, was unable to remove the item, said Resident #1 stopped breathing and nursing began chest compressions. The DON said the expectation of nursing staff during an emergency situation is for nursing to obtain the residents chart, read the residents MOLST, and the residents Physician Orders related to Advanced Directives and for nursing staff to follow the elected Code Status. During an interview on [DATE] at 2:56 P.M., the Administrator said on [DATE], she spoke with Nurse #1 and Nurse #1 told her she had been unable to find #1's Resident #1's Code Status in his/her medical record. The Administrator said on [DATE] during her investigation she reviewed Resident #1's medical record, and noted that his/her Physician's orders indicated Resident #1 Code Status was a DNR/DNI. The Administrator said Resident #1's Massachusetts MOLST form, (bright pink form) in the medical record, was blank without any information provided on it. The Administrator said Resident #1's New York MOLST, which was provided to the facility upon his/her admission, had been removed from his/her medical record and put into his/her overflow chart in medical records. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyors with a plan of correction which addressed the areas of concern as evidence by: A) [DATE], Resident #1 was transferred to the Hospital ED for further treatment and did not return to the facility. B) [DATE], The Administrative Staff completed a house audit of all residents Advanced Directives including MOLST forms, Physician's Orders, and Care Plans to ensure all were in place, accessible and up to date. C) [DATE], The Facility instituted a new process of adding resident Advance Directives to resident's face sheet so that in the event of the need to transfer the resident out of the facility, it is very clearly documented what the resident and/or representatives wishes are. D) [DATE] & [DATE], The Staff Development Coordinator (SDC) and/or Designee completed reeducation with the Licensed Staff on MOLST completion, and the necessary components of the MOLST to be completed. E) [DATE] & [DATE], The SDC and/or Designee reeducated all Licensed Staff on the Facility's Advanced Directive Policy. F) [DATE], [DATE] & [DATE], the SDC and/or Designee educated nursing on new process of location of the MOLST form in resident's paper medical record on the unit. The new process included that all MOLST forms and Physician's order (related to Advanced Directives) will be placed in a plastic sleeve in the front of the resident's medical record. The new process included education of location of resident's code status on the resident's facility's face sheet. G) [DATE], [DATE] & [DATE], The SDC and/or Designee reeducated staff regarding Code Blue response, which included responding in the event of a chocking resident, performing the Heimlich Maneuver and verifying a residents code status. H) Starting effective [DATE], The SDC and/or Designee completed Advanced Directive audits weekly to ensure the residents MOLST form, Physician's Orders, and the Care Plan all match each other. The Audits were continued for 4 weeks, and continued for two additional months to ensure compliance. Any discrepancies identified, were to be clarified immediately and discussed in AM meeting. I) Starting effective [DATE], The SDC and/or Designee completed resident chart audits for location of the MOLST in the resident's medical record on the unit. The audits were continued for 4 weeks, and then continued for an additional two months to ensure compliance based on the new Facility procedure. J) Effective with [DATE] QAPI Meeting, The DON and/or Designee reported on Advanced Directives, MOLST, Physician Orders, and Plan of Care chart audits and the new Facility procedure during their monthly QAPI meeting, and continued to present findings at QAPI monthly for 3 months for discussion and analysis to ensure substantial compliance was achieved. K) The Administrator, Director of Nursing and/or their Designee were responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) whose Comprehensive Person Centered Plan of Care indicated he/she was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation, in the event of cardiac or respiratory arrest) and Do Not Intubate (DNI, medical order written by a physician, which instructs healthcare providers not to place a tube down the patient's throat or connect to a breathing machine that pumps air into and out of lungs) and that staff were to honor his/her wishes, the Facility failed to ensure nursing implemented and followed interventions identified in Resident #1's plan of care related to his/her Advanced Directives. On [DATE], at approximately 12:30 P.M., Resident #1 who had been eating lunch, was noted to have a blue face and lips, was thought to be choking on food, and nursing staff performed the Heimlich Maneuver (abdominal thrusts lift diaphragm and expel air from lungs, causes foreign object to be expelled from airway) without success. Resident #1 who had become unresponsive, was then assessed by nursing to be without a pulse or respirations, and when they were unable to verify his/her elected code status, nurses began life saving measures including administering chest compressions, calling a Code Blue and initiating 911. Resident #1 was resuscitated by nursing just prior to Emergency Medical Services (EMS) arrival, and he/she was transported to the Hospital Emergency Department (ED). EMS personnel were not provided with Resident #1's Advanced Directives, so he/she was intubated upon arrival to the ED. Resident #1's Health Care Agent (HCA) arrived and provided the Hospital with a copy of Resident #1's Advanced Directives which indicated he/she was a DNR/DNI, and Resident #1 was extubated in the ED, but continued to breathe. Resident #1 was admitted to the Hospital for terminal comfort care, was found to have respiratory distress that was difficult to abate and required progressively more vigorous morphine (narcotic, used to treat moderate to severe pain) therapy to achieve comfort, he/she died in the hospital four days later. Findings include: The Facility policy, titled Comprehensive Care Plan, reviewed [DATE], indicated the Facility would develop an individualized care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs are developed for each resident. The Policy indicated the Facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, Chronic Kidney Disease (CKD-Stage 3), depression, anxiety, COVID-19 and Multisystem Inflammatory Syndrome (MIS). Review of Resident #1's New York Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1's HCA on [DATE], indicated Resident #1 was a Do Not Resuscitate (DNR) and Do Not Intubate (DNI). Review of Resident #1's Massachusetts Health Care Proxy (HCP), dated [DATE] and signed by a Physician, indicated Resident #1 lacked the capacity to make, or to communicate, health care decisions permanently. Review of Resident #1's Advanced Directive Care Plan, dated as revised [DATE], indicated Resident #1's code status was DNR and DNI. The Care Plan indicated Resident #1 wanted to be transferred to the hospital, but that no feeding tubes and no intravenous (IV) fluids were to be used. The Care Plan indicated his/her Health Care Proxy had been invoked. Review of Resident #1's Physician Orders, for [DATE], indicated Resident #1 was a DNR, DNI and his/her Health Care Proxy had been invoked. Review of the Hospital Discharge Summary, dated [DATE], indicated that on [DATE] Resident #1 arrived at the ED in respiratory distress after a choking episode at his/her Nursing Home. The Summary indicated Resident #1 became unresponsive at the Nursing Home and the Heimlich Maneuver and CPR were initiated. The Summary indicated Resident #1 arrived at the ED with an empty (blank) MOLST form and that the ED Physician proceeded with Resident #1's placement of an endotracheal intubation (tube placed into the trachea to maintain an open airway). The Summary, indicated Resident #1's HCA arrived, presented a filled out MOLST form indicating Resident #1's Code Status was DNR/DNI and reported that due to Resident #1 severe dementia, he/she had not wanted any invasive or noninvasive ventilation and non resuscitation under any circumstances. The Summary indicate at that point any question of life extending care whatsoever was abated due to his/her unresponsive state, resident was extubated, but continued to breathe. The Summary indicated Resident #1 was found to have respiratory distress that was difficult to abate and required progressively more vigorous morphine therapy to achieve comfort. The Summary indicated Resident #1 died in the Hospital, four days later. During an interview on [DATE] at 10:48 A.M., Nurse #1 said that on [DATE] at lunch time, Certified Nurse Aide (CNA) #1 called her to come to Resident #1's room. Nurse #1 said upon entering Resident #1's room, Resident #1 was unresponsive and his/her eyes were rolling in an upward direction. Nurse #1 said since Resident #1 had been eating lunch, she thought he/she was choking, so she performed a finger sweep of his/her mouth did not find any food, and then initiated the Heimlich Maneuver on Resident #1 without any results. Nurse #1 said upon further assessment, Resident #1 did not have a apical pulse and was not breathing. Nurse #1 said a Code Blue was called and 911 was initiated. Nurse #1 said she was unable to find Resident #1's MOLST or his/her Physician Orders in the medical record to verify his/her Code Status, so she and Nurse #2 started CPR by administering chest compressions. Nurse #1 said Resident #1 started to breath just prior to the Emergency Medical Services (EMS) arrival. Nurse #1 said she did not report to Nurse #2, the EMS or the Hospital Nurse that she was unable to identify Resident #1's Code Status. Nurse #1 could not explain how she missed Resident #1's Physician's Orders for a DNR and DNI in his/her medical record. During an interview on [DATE] at 9:00 A.M., Nurse #2 said on [DATE] during lunch time, he heard a Code Blue announcement and upon arrival to Resident #1's room Nurse #1 was performing chest compressions on him/her. Nurse #2 said he asked what happened and said Nurse #1 told him that Resident #1 choked, she performed the Heimlich Maneuver and it did not work, so she started chest compressions. Nurse #2 said he took over doing chest compressions and had performed only four to five chest compressions, when Resident #1 began to make quick deep breath and blowing sounds, he/she blew out saliva with tiny food particles and then opened his/her eyes. Nurse #2 said he stopped chest compressions at that time. During an interview on [DATE] at 2:56 P.M., the Director of Nursing (DON) said the expectation of nursing staff during an emergency situation is for nursing to obtain the residents chart, read the residents MOLST, and the residents Physician Orders related to Advanced Directives and for nursing staff to follow the elected Code Status. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyors with a plan of correction which addressed the areas of concern as evidence by: A) [DATE], Resident #1 was transferred to the Hospital ED for further treatment and did not return to the facility. B) [DATE], The Administrative Staff completed a house audit of all residents Advanced Directives including MOLST forms, Physician's Orders, and Care Plans to ensure all were in place, accessible and up to date. C) [DATE], The Facility instituted a new process of adding resident Advance Directives to resident's face sheet so that in the event of the need to transfer the resident out of the facility, it is very clearly documented what the resident and/or representatives wishes are. D) [DATE] & [DATE], The Staff Development Coordinator (SDC) and/or Designee completed reeducation with the Licensed Staff on MOLST completion, and the necessary components of the MOLST to be completed. E) [DATE] & [DATE], The SDC and/or Designee reeducated all Licensed Staff on the Facility's Advanced Directive Policy. F) [DATE], [DATE] & [DATE], the SDC and/or Designee educated nursing on new process of location of the MOLST form in resident's paper medical record on the unit. The new process included that all MOLST forms and Physician's order (related to Advanced Directives) will be placed in a plastic sleeve in the front of the resident's medical record. The new process included education of location of resident's code status on the resident's facility's face sheet. G) [DATE], [DATE] & [DATE], The SDC and/or Designee reeducated staff regarding Code Blue response, which included responding in the event of a chocking resident, performing the Heimlich Maneuver and verifying a residents code status. H) Starting effective [DATE], The SDC and/or Designee completed Advanced Directive audits weekly to ensure the residents MOLST form, Physician's Orders, and the Care Plan all match each other. The Audits were continued for 4 weeks, and continued for two additional months to ensure compliance. Any discrepancies identified, were to be clarified immediately and discussed in AM meeting. I) Starting effective [DATE], The SDC and/or Designee completed resident chart audits for location of the MOLST in the resident's medical record on the unit. The audits were continued for 4 weeks, and then continued for an additional two months to ensure compliance based on the new Facility procedure. J) Effective with [DATE] QAPI Meeting, The DON and/or Designee reported on Advanced Directives, MOLST, Physician Orders, and Plan of Care chart audits and the new Facility procedure during their monthly QAPI meeting, and continued to present findings at QAPI monthly for 3 months for discussion and analysis to ensure substantial compliance was achieved. K) The Administrator, Director of Nursing and/or their Designee were responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Orders indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation, in the event of cardiac or respiratory arrest) and Do Not Intubate (DNI, medical order written by a physician, which instructs healthcare providers not to place a tube down the patient's throat or connect to a breathing machine that pumps air into and out of lungs), the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of Advanced Directives. On [DATE], at approximately 12:30 P.M., Resident #1 who had been eating lunch, was found to have a blue face and lips and thought to be choking by staff. Nursing immediately started to perform the Heimlich Maneuver (abdominal thrusts lift diaphragm and expel air from lungs, causes foreign object to be expelled from airway), without success. Resident #1 was then noted to not be breathing and assessed by nursing to be without a pulse. Nursing staff were unable to locate Resident #1's Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) Form, in his/her medical record to verify his/her code status, and could not find his/her Physician's orders, and nursing initiated life saving measures which included starting chest compressions, calling a Code Blue, and initiating 911. Emergency Medical Services (EMS) arrived, Resident #1 was noted to be breathing, had a pulse and was transported to the Hospital Emergency Department (ED). EMS personnel were not provided with Resident #1's Advanced Directives, and he/she was intubated upon arrival to ED. Resident #1's Health Care Agent (HCA) arrived and provided the Hospital with a copy of Resident #1's Advanced Directives which indicated he/she was a DNR/DNI, and Resident #1 was extubated in the ED, but continued to breathe. Resident #1 was admitted to the Hospital for terminal comfort care, was found to have respiratory distress that was difficult to abate and required progressively more vigorous morphine (narcotic, used to treat moderate to severe pain) therapy to achieve comfort, he/she died in the hospital four days later. Findings include: The Facility's Policy titled Resident Rights, reviewed ,d+[DATE], indicated the Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Policy indicated the Facility must protect and promote the rights of each of the residents. The Facility Policy, titled Massachusetts Advance Directives, revised [DATE], indicated it is policy for staff to recognize and support the use of Advance Directives. The Policy indicated it is Resident's Rights for self-determination and will be recognized by the Facility by aiding with Advance Directive identification. The Policy indicated to maximize the rights of each resident, ensuring that their wishes regarding medical decision making are upheld and the safety of each individual is met and defined the following: -Advance Directive was defined as a written instruction, recognized under State law, relating to the provision of health care when the individual is incapacitated. -Health Care Proxy HCP was defined as a legal document that a competent adult may complete to identify agent(s) who would make their health care decisions for an incapacitated person. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, Chronic Kidney Disease (CKD-Stage 3), depression, anxiety, COVID-19 and Multisystem Inflammatory Syndrome (MIS). Review of Resident #1's New York Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1's HCA on [DATE], indicated Resident #1 was a Do Not Resuscitate (DNR) and Do Not Intubate (DNI). Review of Resident #1's Massachusetts Health Care Proxy (HCP), dated [DATE] and signed by a Physician, indicated Resident #1 lacked the capacity to make, or to communicate, health care decisions permanently. Review of Resident #1's Physician Orders, dated [DATE], indicated Resident #1 was a DNR, DNI and his/her Health Care Proxy had been invoked. Review of the Nurse Progress Note, dated [DATE], indicated on [DATE], at approximately 12:30 P.M., Resident #1 was eating in his/her room and was found to have a blue face and lips. The Note indicated Nurse #1 performed a finger sweep, no particles of food were found in Resident #1's mouth or throat and she performed the Heimlich Maneuver without food particles being expelled. The Note indicated Resident #1 did not have a radial pulse detected and he/she was not breathing. The Note indicated Resident #1's Code Status was checked, the Massachusetts MOLST Form was not signed, and a few chest compressions were performed by the nurses. The Note indicated the Automated External Defibrillator (AED) was obtained and 911 was called. The Note indicated Resident #1 was breathing and had a radial pulse prior to being transferred to the hospital. Review of the Ambulance Run Report, dated [DATE], indicated Paramedics arrived at the scene to the nurse (later identified as Nurse #1) stating she had started chest compressions on Resident #1 after attempting the Heimlich Maneuver when Resident #1 was found to be apparently choking, the nurse said Resident #1 had immediately began breathing again. The Report indicated the Paramedic performed an immediate video laryngoscopy (a device used to visualize vocal cords and related airway structures without a direct line of sight) on Resident #1 and found no foreign bodies (food or objects), that he/she had a copious amount of saliva that required suctioning, and apparently had inflamed or swollen tissue round the glottic opening (primary valve between the lungs and the mouth). The Report indicated the Paramedic visualized a tube placement would not work due to swelling, considered surgical intervention, but Resident #1 was able to still get breaths in, so the Paramedics began assisting respirations with Bag-Valve-Mask (BVM, a basic airway management technique to allow oxygenation and ventilation until a more definitive airway can be established). The Report indicated Resident #1 was then transported to the Hospital. Review of the Hospital Discharge Summary, dated [DATE], indicated that on [DATE] Resident #1 arrived at the ED in respiratory distress after a choking episode at his/her Nursing Home. The Summary indicated Resident #1 became unresponsive at the Nursing Home and the Heimlich Maneuver and CPR were initiated. The Summary indicated Resident #1 arrived at the ED with an empty (blank) MOLST form and that the ED Physician proceeded with Resident #1's placement of an endotracheal intubation (tube placed into the trachea to maintain an open airway). The Summary, indicated Resident #1's HCA arrived, presented a filled out MOLST form indicating Resident #1's Code Status was DNR/DNI and reported that due to Resident #1 severe dementia, he/she had not wanted any invasive or noninvasive ventilation and non resuscitation under any circumstances. The Summary indicate at that point any question of life extending care whatsoever was abated due to his/her unresponsive state, resident was extubated, but continued to breathe. The Summary indicated Resident #1 was found to have respiratory distress that was difficult to abate and required progressively more vigorous morphine therapy to achieve comfort. The Summary indicated Resident #1 died in the Hospital, four days later. During an interview on [DATE] at 10:48 A.M., Nurse #1 said that on [DATE] at lunch time, Certified Nurse Aide (CNA) #1 called her to come to Resident #1's room. Nurse #1 said upon entering Resident #1's room, Resident #1 was unresponsive and his/her eyes were rolling in an upward direction. Nurse #1 said since Resident #1 had been eating lunch, she thought he/she was choking, so she performed a finger sweep of his/her mouth did not find any food, and then initiated the Heimlich Maneuver on Resident #1 without any results. Nurse #1 said upon further assessment, Resident #1 did not have a apical pulse and was not breathing. Nurse #1 said a Code Blue was called and 911 was initiated. Nurse #1 said she was unable to find Resident #1's MOLST or his/her Physician Orders in the medical record to verify his/her Code Status, so she and Nurse #2 started CPR by administering chest compressions. Nurse #1 said Resident #1 started to breath just prior to the Emergency Medical Services (EMS) arrival. Nurse #1 said she did not report to Nurse #2, the EMS or the Hospital Nurse that she was unable to identify Resident #1's Code Status. Nurse #1 reviewed Resident #1's MOLST and Resident #1's Physician Orders with the Surveyors on [DATE], during her interview, she said Resident #1 elected Code Status was identified as a DNR, DNI, HCP was invoked, No feeding tube and no intravenous (IV) fluids. Nurse #1 said a MOLST is a Resident Right, it is their choice and as a Nurse she cannot deviate from the MOLST since it is not her wishes, and was what the resident wanted. Nurse #1 could not explain how she missed Resident #1's Physician's Orders for a DNR and DNI in his/her medical record. During an interview on [DATE] at 9:00 A.M., Nurse #2 said on [DATE] during lunch time, he heard a Code Blue announcement and upon arrival to Resident #1's room Nurse #1 was performing chest compressions on him/her. Nurse #2 said he asked what happened and that Nurse #1 told him Resident #1 had choked, that she had performed the Heimlich Maneuver and it did not work, so she started chest compressions. Nurse #2 said he took over doing Resident #1's chest compressions and performed only four or five chest compressions when Resident #1 began to make quick deep breath and blowing sounds, he/she blew out saliva with tiny food particles and then opened his/her eyes. Nurse #2 said he stopped doing chest compressions at that time and that EMS had arrived. Nurse #2 said he did not have a discussion with Nurse #1 regarding Resident #1's Code Status, since she had already initiated CPR, and said Nurse #1 should have already checked and verified Resident #1's Code Status prior to his arrival. During an interview on [DATE] 2:56 P.M., the Administrator said during her investigation into the events of [DATE], Nurse #1 said she had been unable to find Resident #1's Code Status in the medical record. The Administrator said she reviewed Resident #1's medical record and was able to find and review Resident #1's Physician's orders which indicated he/she was a DNR/DNI. The Administrator said that his/her Massachusetts MOLST form (bright pink form) had no information indicated on it and was blank. The Administrator said Resident #1's New York MOLST, that had been provided by his/her HCA upon admission to the facility was not in Resident #1's Medical Record on the Unit. The Administrator said Resident #1's New York MOLST form had been removed and filed in his/her overflow chart in the Medical Records room, because his/her medical record on the Unit had been thinned by staff. The Administrator said the New York MOLST should have been left in Resident #1's Medical Record on the Unit. The Facility was unable to explain why a Massachusetts MOLST form had not been completed for and maintained in Resident #1's medical record, or why the New York MOLST form was not left in the medical record for staff review, in the event of a medical emergency. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyors with a plan of correction which addressed the areas of concern as evidence by: A) [DATE], Resident #1 was transferred to the Hospital ED for further treatment and did not return to the facility. B) [DATE], The Administrative Staff completed a house audit of all residents Advanced Directives including MOLST forms, Physician's Orders, and Care Plans to ensure all were in place, accessible and up to date. C) [DATE], The Facility instituted a new process of adding resident Advance Directives to resident's face sheet so that in the event of the need to transfer the resident out of the facility, it is very clearly documented what the resident and/or representatives wishes are. D) [DATE] & [DATE], The Staff Development Coordinator (SDC) and/or Designee completed reeducation with the Licensed Staff on MOLST completion, and the necessary components of the MOLST to be completed. E) [DATE] & [DATE], The SDC and/or Designee reeducated all Licensed Staff on the Facility's Advanced Directive Policy. F) [DATE], [DATE] & [DATE], the SDC and/or Designee educated nursing on new process of location of the MOLST form in resident's paper medical record on the unit. The new process included that all MOLST forms and Physician's order (related to Advanced Directives) will be placed in a plastic sleeve in the front of the resident's medical record. The new process included education of location of resident's code status on the resident's facility's face sheet. G) [DATE], [DATE] & [DATE], The SDC and/or Designee reeducated staff regarding Code Blue response, which included responding in the event of a chocking resident, performing the Heimlich Maneuver and verifying a residents code status. H) Starting effective [DATE], The SDC and/or Designee completed Advanced Directive audits weekly to ensure the residents MOLST form, Physician's Orders, and the Care Plan all match each other. The Audits were continued for 4 weeks, and continued for two additional months to ensure compliance. Any discrepancies identified, were to be clarified immediately and discussed in AM meeting. I) Starting effective [DATE], The SDC and/or Designee completed resident chart audits for location of the MOLST in the resident's medical record on the unit. The audits were continued for 4 weeks, and then continued for an additional two months to ensure compliance based on the new Facility procedure. J) Effective with [DATE] QAPI Meeting, The Director of Nurses (DON) and/or Designee reported on Advanced Directives, MOLST, Physician Orders, and Plan of Care chart audits and the new Facility procedure during their monthly QAPI meeting, and continued to present findings at QAPI monthly for 3 months for discussion and analysis to ensure substantial compliance was achieved. K) The Administrator, Director of Nursing and/or their Designee were responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), whose Health Care Agent (HCA) upon admission, provided the facility with a copy of his/her New York MOLST (medical order for life-sustaining treatment) which indicated, along with his/her facility Physician's Orders that he/she was a Do Not Resuscitate (DNR) and a Do Not Intubate (DNI), the Facility failed to ensure they maintained a complete and accurate medical record, when on [DATE] after Resident #1 became unresponsive and assessed by nursing to be without a pulse or respirations, nursing was unable find a completed MOLST in his/her medical record and initiated life saving measures which included the administration of chest compression for cardiopulmonary resuscitation. It was later determined that the Massachusetts MOLST form in Resident #1's medical record was completely blank, and his/her New York MOLST form had been removed from his/her Medical Record on the Unit and filed in his/her overflow chart in the medical records room. Findings include: The Facility Policy, titled Charting and Documentation, reviewed [DATE], indicated the Facility must include services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical records. Review of Resident #1's New York Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1's HCA on [DATE], indicated Resident #1 was a Do Not Resuscitate (DNR) and Do Not Intubate (DNI). However, review of the Massachusetts MOLST form (a bright pink colored form) that was in Resident #1's medical record, was not filled out and noted to be completely blank. Review of Resident #1's Massachusetts Health Care Proxy (HCP), dated [DATE] and signed by a Physician, indicated Resident #1 lacked the capacity to make, or to communicate, health care decisions permanently. Review of Resident #1's Physician Orders, dated [DATE], indicated Resident #1 was a DNR, DNI and his/her HCP had been invoked. During an interview on [DATE] at 10:48 A.M., Nurse #1 said that on [DATE], around lunch time she went to Resident #1's room after Certified Nurse Aide called for help, she gave Resident #1 the Heimlich Maneuver (abdominal thrusts lift diaphragm and expel air from lungs, causes foreign object to be expelled from airway) because she thought he/she had been choking on food, but it did nothing. Nurse #1 said upon further assessment, Resident #1 did not have a apical pulse and was not breathing. Nurse #1 said a Code Blue was called and 911 was initiated. Nurse #1 said she was unable to find Resident #1's MOLST or his/her Physician Orders in the medical record to verify his/her Code Status, so she and Nurse #2 started CPR by administering chest compressions. Nurse #1 could not explain how she missed Resident #1's Physician's Orders for a DNR and DNI in his/her medical record. During an interview on [DATE] at 9:00 A.M., Nurse #2 said on [DATE] during lunch time, he heard a Code Blue announcement and upon arrival to Resident #1's room Nurse #1 was performing chest compressions on him/her. Nurse #2 said he asked what happened and said Nurse #1 told him Resident #1 had choked, she performed the Heimlich Maneuver, and it did not work, so she started chest compressions. Nurse #2 said he did not have a discussion with Nurse #1 regarding Resident #1's Code Status, since she had already initiated CPR, and said Nurse #1 should have already checked and verified Resident #1's Code Status prior to his arrival. During an interview on [DATE] 2:56 P.M., the Administrator said during her investigation into the events of [DATE], Nurse #1 said she had been unable to find Resident #1's Code Status in the medical record. The Administrator said she reviewed Resident #1's medical record and was able to find and review Resident #1's Physician's orders which indicated he/she was a DNR/DNI. The Administrator said that his/her Massachusetts MOLST form (bright pink form) had no information indicated on it and was blank. The Administrator said Resident #1's New York MOLST, that had been provided by his/her HCA upon admission to the facility was not in Resident #1's Medical Record on the Unit. The Administrator said Resident #1's New York MOLST form had been removed and filed in his/her overflow chart in the Medical Records room, because his/her medical record on the Unit had been thinned by staff. The Administrator said the New York MOLST should have been left in Resident #1's Medical Record on the Unit. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyors with a plan of correction which addressed the areas of concern as evidence by: A) [DATE], Resident #1 was transferred to the Hospital ED for further treatment and did not return to the facility. B) [DATE], The Administrative Staff completed a house audit of all residents Advanced Directives including MOLST forms, Physician's Orders, and Care Plans to ensure all were in place, accessible and up to date. C) [DATE], The Facility instituted a new process of adding resident Advance Directives to resident's face sheet so that in the event of the need to transfer the resident out of the facility, it is very clearly documented what the resident and/or representatives wishes are. D) [DATE] & [DATE], The Staff Development Coordinator (SDC) and/or Designee completed reeducation with the Licensed Staff on MOLST completion, and the necessary components of the MOLST to be completed. E) [DATE] & [DATE], The SDC and/or Designee reeducated all Licensed Staff on the Facility's Advanced Directive Policy. F) [DATE], [DATE] & [DATE], the SDC and/or Designee educated nursing on new process of location of the MOLST form in resident's paper medical record on the unit. The new process included that all MOLST forms and Physician's order (related to Advanced Directives) will be placed in a plastic sleeve in the front of the resident's medical record. The new process included education of location of resident's code status on the resident's facility's face sheet. G) [DATE], [DATE] & [DATE], The SDC and/or Designee reeducated staff regarding Code Blue response, which included responding in the event of a chocking resident, performing the Heimlich Maneuver and verifying a residents code status. H) Starting effective [DATE], The SDC and/or Designee completed Advanced Directive audits weekly to ensure the residents MOLST form, Physician's Orders, and the Care Plan all match each other. The Audits were continued for 4 weeks, and continued for two additional months to ensure compliance. Any discrepancies identified, were to be clarified immediately and discussed in AM meeting. I) Starting effective [DATE], The SDC and/or Designee completed resident chart audits for location of the MOLST in the resident's medical record on the unit. The audits were continued for 4 weeks, and then continued for an additional two months to ensure compliance based on the new Facility procedure. J) Effective with [DATE] QAPI Meeting, The DON and/or Designee reported on Advanced Directives, MOLST, Physician Orders, and Plan of Care chart audits and the new Facility procedure during their monthly QAPI meeting, and continued to present findings at QAPI monthly for 3 months for discussion and analysis to ensure substantial compliance was achieved. K) The Administrator, Director of Nursing and/or their Designee were responsible for overall compliance.

Based on policy review, observation and interview, the facility failed to ensure an opened Insulin Emergency Kit (E-Kit) was replaced on one of two units observed. Findings include: Review of the facility Emergency Pharmacy Service and Emergency Kits Policy, dated 9/1/13, included: -The nurse records the medication use from the emergency kit on the medication order/use form and calls the pharmacy for replacement of the kit/dose or flags the kit with a color-coded lock to indicate their need for replacement of kit/dose as soon as possible after the medication has been administered. -If exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening. If replacing used medications, the replacement doses are added to the kit within 72 hours of opening. On 8/5/21 at 10:58 A.M., the surveyor observed the Second Floor Medication Refrigerator with Nurse #2. The surveyor observed 1 opened Insulin E-Kit with a Lantus (long-acting) Insulin vial had been removed. The Refrigerated Kit Usage Report form indicated the Lantus Insulin had been removed on 8/1/21. During an interview on 8/5/21 at 11:00 A.M., Nurse #2 said the completed Refrigerated Kit Usage Form should be faxed to the pharmacy and then the pharmacy replaces the E-Kit. He further said there was no documentation found to indicate the completed Usage Form had been faxed to the pharmacy, as required.

Based on policy review, observations and interviews, the facility failed to A.) Label and/or date food items used for resident meal service, and B.) Failed to ensure food preparation equipment was clean and free of debris. Findings include: Review of facility policy titled Dietary Services, dated [DATE], indicated: -Foods will be properly labeled with name of product and date of production. -Foods will be date marked with the name of the product and the date of the production or opening . On [DATE] at 7:24 A.M., the surveyor, along with Cook #1, observed the following: - Refrigerator #1 included the following items that were opened but not labeled and/or dated: *Ginger ale *Prune juice *Chocolate milk *Package of waffles Also included in Refrigerator #1 was a bottle of Mountain Dew soda which Cook #1 said most likely belonged to the night shift dietary staff and did not belong in the refrigerator. There were 3 bowls of hot cereal covered in plastic wrap with the date of ,d+[DATE] written in marker on the plastic, however Cook #1 said she did not know if that date was the prepared date or use by date, which she said was an ongoing problem as staff are not consistent with their labeling practices. - Refrigerator #2 included the following items that were opened but not labeled and/or dated: *Jar of jelly *Jar of capers *Large jar of sliced pickles *Unlabeled plastic bag tied in a knot containing unidentified chopped white meat *Deli meat roll labeled pork/beef *Bottle duck sauce with an expiration date of [DATE] *Bottle of cooking wine with a use by date of [DATE] *Deli turkey with a use by date of [DATE] *Container of garlic cloves dated [DATE] The floor/bottom shelf of Refrigerator #2 contained a cardboard box containing a bag of thawed, raw chicken dated ,d+[DATE]. Cook #1 said she was unsure of what the date ,d+[DATE] indicated on the bag. Cook #1 said that everything that has been opened in the refrigerator should be labeled and dated. - Refrigerator #2's freezer included: *Frozen beef patties exposed in an opened plastic bag inside a box with date of ,d+[DATE]. Cook #1 said she did not know whether ,d+[DATE] was the open date or the use by date. *3 bags of unidentified frozen patties inside a plastic bag which appeared to have a date; however the date was not legible. Cook #1 stated she thought two of the packages of frozen patties were chicken and one package was fish. Cook #1 said she could not read the date which had been written in marker on the plastic bags because the writing had worn off. *A bag of frozen chicken indicating a use by date of ,d+[DATE] *Frozen peanut butter cookies exposed in an open bag inside a box with no date *3 packages of frozen seafood with no date *A bag of frozen liver with a use by date of [DATE] *A large, frozen, undated turkey breast with no expiration date - The dry storage room included 2 large open bags of pasta which were undated and 1 bag of opened, undated sugar sitting on a cart. - The shelving unit next to the dry storage room included a bottle of celery salt dated [DATE] and nutmeg dated [DATE]. Cook #1 said that items such as spices should be tossed out within a year of opening. There were several other spices that were opened but not dated. - The microwave oven had food particles throughout the interior. - Gray residue was observed on the inside walls of the ice machine. - Food debris was observed on a baking pan that was located on a rack of clean pans. - The deli slicer had residue and food particles on the slicer blade and surrounding parts. The slicer was covered with a plastic bag and was not in use at the time of the observation. During an interview on [DATE] at 8:00 A.M., the Food Service Director (FSD) said he knew that there are items not labeled and/or dated, as required and expired food items that should be discarded. On [DATE] at 1:00 P.M., the surveyor, along with the FSD, observed the following: - A container with a pinkish-orange liquid with no label or date. The FSD said it belonged to a resident who wanted their smoothie frozen like an ice pop. -The deli slicer had food residue on the machine as well as the catch tray. During an interview on [DATE] at 2:05 P.M., the surveyor asked the FSD what procedure is in place when food items are opened and put away, and the FSD said food items should be immediately covered, labeled and dated. The surveyor asked the FSD what the process was in relation to cleaning the deli slicer, and the FSD said that after use, the deli slicer should be cleaned and sanitized, then covered with a plastic bag indicating it is ready for use.

Based on policy review, observation and interview, the facility failed to ensure infection control guidelines were maintained during the preparation of a medication for an administration pass. Findings include: Review of the facility Administering Medications Policy, revised April 2019, included that staff follow established infection control procedures (such as handwashing, antiseptic technique, gloves, isolation precautions, cetera) for the administration of medications, as applicable. On 8/5/21 at 8:05 A.M., the surveyor observed the medication preparation for administration. The surveyor observed Nurse #2 pop a capsule from a medication blister pack card into a medication cup. He then removed the capsule from the medication cup with his ungloved fingers, opened the capsule and poured the contents of the capsule into a medication cup. During an interview on 8/5/21 at 10:20 A.M., Nurse #2 said he should not have handled the capsule with his bare fingers. He further said he should have worn gloves, as required.

Based on record review, policy review and interview, the facility failed to ensure accurate documentation of a fluid restriction for one sampled Resident (#54), out of a total sample of 15 residents. Findings include: Resident #54 was admitted to the facility in July 2021 with diagnoses including schizophrenia and End-Stage Renal Disease (ESRD). Review of the Minimum Data Set (MDS) Assessment, dated 7/13/21, indicated the Resident was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of a Physician Order, dated 7/9/21, indicated for a fluid restriction of 1200 milliliters (ml) daily. The order was transcribed onto the Medication Administration Record (MAR) and listed as For Your Information (FYI). There was no information on the MAR to indicate each shift breakdown as to what amount of fluids the Resident could be given to consume. Review of the facility Intake and Output Policy, revised 7/26/21, included using an intake and output record to track Resident's fluid consumption and output (include reason for tracking and write each resident's daily fluid recommendation). Review of the August 2021 MAR indicated only an FYI for the 1200 ml fluid restriction daily. During an interview on 8/6/21 at 11:40 A.M., Unit Manager (UM) #1 said the fluid restriction entries on the July and August MARs were incomplete and did not indicate a breakdown of how much fluid the resident could receive each shift from the kitchen and from the nursing staff. During an interview on 8/6/21 at 2:28 P.M., the Assistant Director of Nurses (ADON) said when a resident is placed on a fluid restriction then the amount of fluids the resident can receive from the kitchen and from the nursing staff for each shift should be listed on the MAR.

Based on policy review, observation and interview, the facility failed to ensure a proper medication refrigerator temperature on one of two units. Findings include: Review of the facility Storage of Medications Policy, revised April 2019, included that drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. On 8/5/21 at 7:35 A.M., the surveyor observed the Third Floor medication refrigerator with Nurse #3. The surveyor observed the refrigerator temperature reading to be 32 degrees Fahrenheit (F). The refrigerator contained a box of Risperdal (an antipsychotic) injections. The documentation on the Risperdal package indicated that the Risperdal needed to be stored at a temperature of 36-46 degrees F. During an interview on 8/5/21 at 7:40 A.M., Nurse #3 said the refrigerator temperature was at 32 degrees F and not at the required temperature of 36-46 degrees for the storage of Risperdal.

Based on policy review, record review and interviews, the facility failed to have a pharmacy recommendation reviewed and addressed by the Attending Physician for one sampled Resident (#43), out of a total sampled of 15 residents. Findings include: Review of the facility policy titled, Medication Monitoring, dated 2017, indicated: Section III A1: Medication Regimen Review - Resident-specific irregularities, and/or clinically significant risks resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nursing, and/or prescriber as appropriate. - Recommendations are acted upon and documented by the facility staff and/or the prescriber. - The physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing Section III A2: Documentation and Communication of Consultant Pharmacist Recommendations Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. - If the prescriber that does not respond is also the Medical Director, the Director of Nursing and the Administrator will address the requirements with the Medical Director and/or pursue more formal actions if necessary to facilitate compliance. Review of a progress note, dated 5/19/21, indicated a Medical Record Review (MRR) had been completed by the consultant Pharmacist and a recommendation was made. Review of the clinical record did not indicate documentation of the consultant Pharmacist's recommendation as indicated on the MRR dated 5/19/21. During an interview on 8/06/21 at 11:42 A.M., Unit Manager (UM) #2 stated the MRR documentation was usually located in the paper chart or in a binder organized by month on the unit. UM #2 checked both the paper chart and the binder and stated there were no recommendations for May 2021 for Resident #43. UM #2 said that she was unable to locate the MRR recommendation for 5/19/21, and that she would contact the consultant pharmacy for the information. During a follow up interview on 8/06/21 at 12:47 P.M., UM #2 said she obtained the MRR recommendation dated 5/19/21 from the pharmacy, and that the Attending Physician never addressed the recommendation, as required.

Based on record review, observation and interview, the facility failed to ensure medications were administered, as ordered, by the Physician for one sampled Resident (#54), who attends dialysis treatments, out of two applicable residents, in a total sample of 15 residents. Findings include: Resident #54 was admitted to the facility in July 2021 with diagnoses including schizophrenia and End-Stage Renal Disease (ESRD). On 8/4/21 at 10:29 A.M., the surveyor observed Resident #54 ambulating in the hallway with a visible shunt (the connection from a dialysis access point to a major artery) in the left arm. The Resident refused to converse with the surveyor. Review of the medical record indicated the Resident attended dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments every Tuesday, Thursday and Saturday. During an interview on 8/5/21 at 7:50 A.M., Nurse #4 said Resident #54 leaves the facility at approximately 9:00 A.M. and returns between 4:00 P.M.-5:00 P.M. from the dialysis treatments every Tuesday, Thursday and Saturday. Review of the July 2021 Physician Orders indicated an order for Calcium Carbonate (dietary supplement used when the amount of calcium taken in the diet is not enough) 500 milligram (mg), give 3 tablets (1500 mg) three times a day (TID) at 8:00 A.M.-12:00 P.M.- 8:00 P.M Review of the July 2021 Medication Administration Record (MAR) indicated Resident #54 did not receive 9 doses of the Calcium Carbonate due at 12:00 P.M. Review of the August 2021 MAR indicated the Resident did not receive 2 doses of the Calcium Carbonate due at 12:00 P.M. Review of the July 2021 Physician Orders indicated an order for Calcium Acetate (used to control high levels of phosphorous) 667 mg, take 2 tablets (1334 mg), by mouth TID. Review of the July 2021 MAR indicated Resident #54 did not receive 7 doses of the Calcium Acetate due at 12:00 P.M. The Calcium Acetate order was changed on 7/28/21 to administer 667 mg by mouth TID. Further review of the July 2021 MAR indicated the Resident did not receive 2 doses due at 12:00 P.M. Review of the August 2021 MAR indicated the Resident did not receive one dose of the Calcium Acetate due at 12:00 P.M. During an interview on 8/6/21 at 9:20 A.M., Unit Manager (UM) #1 said the administration of the medications should have been scheduled so that Resident #54 would not miss any of the Calcium Acetate and Calcium Carbonate doses when he/she attended dialysis treatments and the medications were not scheduled accordingly.

Based on document review, record review, observation and interview, the facility failed to follow Professional Standards of Quality during 1.) An administration of a medication and 2.) A preparation of medication, for one sampled Resident (#19), out of a total sample of 15 residents. Findings include: Review of Lippincott Nursing Center, 8 Rights of Medication Administration article, dated 5/27/11, indicated there are 8 Rights for Medication Administration. They include: - Right patient - Right medication - Right dose - Right route - Right time - Right documentation - Right reason - Right response-be sure to document your monitoring of patient and any other nursing interventions that are applicable. Review of the facility Administering Medications Policy, revised April 2019, included that the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #19 was admitted to the facility in February 2021 with diagnoses including thyroid disorder and schizophrenia. Review of a Minimum Data Set (MDS) Assessment, dated 5/19/21, indicated the Resident was severely cognitively impaired as evidenced by a score of 1 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. 1.) On 8/5/21 at 8:10 A.M., the surveyor observed the medication administration pass. The surveyor observed Nurse #2 crush medications for Resident #19. Nurse #2 then removed a breakfast tray from the meal cart and poured the crushed medications into Resident #19's oatmeal and stirred the oatmeal. During the same observation, Nurse #2 poured 20 milliliters (ml) of Depakote (an anticonvulsant) into Resident #19's cup of warm water and said the Resident puts in his/her own tea bag into the cup and drinks the tea with the Depakote in it. He then placed the cup onto the Resident's breakfast tray. Nurse #2 entered Resident #19's room, placed the breakfast tray at the bedside and instructed the Resident that his/her breakfast tray was at the bedside. The Resident was laying on his/her side and did not turn to see Nurse #2. Nurse #2 exited the room and fully closed the door. Review of Resident #19 Cognitive and Communication Care Plan indicated that, effective 3/14/21, the Resident had a history of stuffing things into the toilet and causing it to overflow. During an interview on 8/5/21 at 10:20 A.M., the surveyor asked Nurse #2 how he was sure the Resident had taken the medications. Nurse #2 said he monitors the breakfast tray intake and then he knows if the Resident had taken all of the medications. When the surveyor inquired into the Resident's history of flushing things down the toilet, Nurse #2 said he could not be sure the Resident had taken all of his/her medications and could not be sure the Resident did not flush his/her meal tray. Nurse #2 said he should have stayed with the Resident during the medication administration. 2.) Review of a Physician Order, dated 7/13/21, indicated to start Depakote Sprinkles 125 milligram (mg) capsules, give 8 capsules (1000 mg) by mouth twice a day. During an interview on 8/6/21 at 4:30 P.M., Nurse #1 said Resident #19 Depakote Liquid order was discontinued and was changed to sprinkles in capsule form. He showed the surveyor the medication cart contained both the capsule and liquid forms of the Depakote. He further said he would remove the Depakote liquid form from the medication cart.

Based on record review, observation, and interview, the facility failed to follow the plan of care relative to observing for signs and symptoms of aspiration during eating for one Resident (#19), out of a total sample of 15 residents. Findings include: Resident #19 was admitted to the facility in February 2021 with diagnoses including Diabetes Mellitus (DM), schizophrenia and thyroid disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 5/19/21, indicated the Resident had severe cognitive impairment as evidenced by a score of 1 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of a Care Plan, created on 2/25/21, indicated Resident #19 was at risk for aspiration due to a history of dysphagia and dementia. The intervention indicated to observe for signs and symptoms of aspirations, a moist cough after eating and drinking, inability to clear throat after drinking, rhonchi (specific sounds generated by the movement of air through the respiratory system), rales (small clicking, bubbling or rattling sounds in the lungs), elevated temperature or shortness of breath (SOB), and to notify the Medical Doctor (MD). On 8/5/21 at 8:05 A.M., the surveyor observed Nurse # 2 place a breakfast tray at Resident #19's bedside. The Resident was turned onto his/her side and did not face Nurse #2. Nurse #2 told the Resident that he dropped off the breakfast tray; he then left the room and closed the door. During an interview on 8/5/21 at 10:20 A.M., Nurse #2 said he should not have closed the door when he left the breakfast tray at Resident #19 bedside.

Based on policy review, record review, observation and interview, the facility failed to notify the Physician of missed medication doses for one sampled Resident (#54), out of a total sample of 15 residents. Findings include: Review of the facility Change in Condition-Physician Notification Policy, revised 3/08/13, included: - If a resident is assessed by any charge nurse to have a change in condition, concern or request, it is the responsibility of the charge nurse to notify the Registered Nurse (RN) Supervisor on duty. - It is then the RN Supervisor's responsibility to do a follow-up assessment and to ensure that the assessment is documented. - All assessment findings and relevant information should be compiled prior to calling the physician to ensure accuracy of information. - The nurse will obtain new orders as warranted from the physician. - The resident and/or responsible party will be notified. - The nurse will document in the nurses notes regarding assessments, findings, changes, physician notification and resident and/or responsible party notification. Resident #54 was admitted to the facility in July 2021 with diagnoses including schizophrenia and End-Stage Renal Disease (ESRD). On 8/4/21 at 10:29 A.M., the surveyor observed Resident #54 ambulating in the hallway with a visible shunt noted in the left arm. The Resident refused to converse with the surveyor. Review of the medical record indicated the Resident attended dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments every Tuesday, Thursday and Saturday. During an interview on 8/5/21 at 7:50 A.M., Nurse #4 said Resident #54 leaves the facility at approximately 9:00 A.M. and returns between 4:00 P.M.-5:00 P.M. from the dialysis treatments every Tuesday, Thursday and Saturday. a. Review of the July 2021 Physician Orders indicated an order for Calcium Carbonate (dietary supplement used when the amount of calcium taken in the diet is not enough) 500 milligram (mg), give 3 tablets (1500 mg) three times a day (TID) at 8:00 A.M.-12:00 P.M.- 8:00 P.M Review of the July 2021 Medication Administration Record (MAR) indicated Resident #54 did not receive 9 doses of the Calcium Carbonate due at 12:00 P.M. Review of the August 2021 MAR indicated the Resident did not receive 2 doses of the Calcium Carbonate due at 12:00 P.M. b. Review of the July 2021 Physician Orders indicated an order for Calcium Acetate (used to control high levels of phosphorous) 667 mg, take 2 tablets (1334 mg), by mouth TID. Review of the July 2021 MAR indicated Resident #54 did not receive 7 doses of the Calcium Acetate due at 12:00 P.M. The Calcium Acetate order was changed on 7/28/21 to administer 667 mg by mouth TID. Further review of the July 2021 MAR indicated the Resident did not receive 2 doses due at 12:00 P.M. Review of the August 2021 MAR indicated the Resident did not receive one dose of the Calcium Acetate due at 12:00 P.M. Review of the medical record did not indicate the Physician had been notified of any missed doses of the medications. During an interview on 8/6/21 at 9:20 A.M., Unit Manager (UM) #1 said the Physician was not notified of Resident #54 missing the doses of the Calcium Carbonate and Calcium Acetate, as required.

Based on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF- ABN) form (a notice issued to Medicare recipients intended to notify the beneficiary of their potential financial liability once their Medicare coverage ends) for three out of three residents reviewed. Findings include: During review, as part of the Beneficiary Review Task conducted by the survey team, 3 of 3 residents were found to not have received the SNF-ABN form, as required. During an interview on 8/20/21 at 2:14 P.M., the Staff Development Coordinator (SDC) said that she had been in charge of providing these notices; however she was out of work for 3 months. The SDC further said that the 3 residents did not receive the SNF-ABN form, as required.

Based on observation, interviews and record review, the facility staff failed to revise the plan of care for 1 sampled Resident (#5) relative to device used to monitor wandering (wander-guard), out of 18 sampled residents. Findings include: Resident #5 was admitted to the facility in 9/2013, with [DIAGNOSES REDACTED]. Review of the current behavior plan of care, initiated on 10/6/13, indicated Resident #5 will wander into other resident's rooms and included the following intervention: apply wander-guard and check placement every shift (added 4/21/14). Review of the physician's order sheet, dated 11/16/17, indicated an order to discontinue the wander-guard. Review of the Wander Data Collection Tool, dated 12/15/18 and 3/14/19, assessed Resident #5 as a wander/elopement risk, and had a wander-guard in place. Review of the 3/2019 Physician's Orders did not indicate an order for [REDACTED]. During an observation on 3/21/19 at 9:20 [NAME]M., the surveyor and UM #1 observed Resident #5's lower leg and observed a wander-guard on his/her left lower leg. During a follow up interview on 3/21/19 at 9:47 [NAME]M., UM #1 said the wander-guard should have been discontinued for Resident #5. During an interview on 3/21/19 at 10:02 [NAME]M., the Assistant Director of Nurses said the wander-guard should have been discontinued for Resident #5. She said the resident's care plans are reviewed quarterly and the intervention for the wander-guard for Resident #5 was missed.

Based on observation, record review and interview, the facility staff failed to follow the plan of care for 2 Residents (#5 and #6), out of a total sample of 18 residents. Findings include: 1. For Resident #6, the facility staff failed to follow the plan of care relative to application of [MEDICAL CONDITION]-Deterrent (TED) stockings (used to prevent blood clots). Resident #6 was admitted to the facility in 12/2018 with a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/14/18 indicated the Resident was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of the medical record indicated a 3/20/19 Physician order for [REDACTED].) and removed at hour of sleep (HS). During an observation on 3/22/19 at 1:00 P.M., Resident #6 was self-propelling in a wheelchair. The Resident's left lower extremity was resting on a footrest. The Resident's left lower extremity was very swollen. The Resident was not wearing TED stockings. Review of the 3/2019 Treatment Administration Record (TAR) indicated no documentation of application or removal of TED stockings since the 3/20/19 order date. During an interview on 3/22/19 at 3:46 P.M., Unit Manager (UM) #2 said the Resident did not have TED stockings applied as per physician order and she further stated that the TAR did not contain documentation that the TED stockings had been applied since the 3/20/19 physician order. 2. For Resident #5, the facility staff failed to follow the physician's order to discontinue a wander-guard (a device applied to alert facility staff that a resident is leaving a specified area). Resident #5 was admitted to the facility in 9/2013 with [DIAGNOSES REDACTED]. Review of the current behavior plan of care, initiated on 10/6/13, indicated Resident #5 will wander into other resident's rooms and included the following intervention: apply wander-guard and check placement every shift (added 4/21/14). Review of the physician's order sheet, dated 11/16/17, indicated an order to discontinue the wander-guard. Review of Quarterly MDS Assessment, dated 12/14/18, indicated Resident #5 had severe cognitive impairment as evidenced by a BIMS score of 7 out of 15, did not exhibit wandering behavior and did not utilize a wander/elopement alarm during the assessment period. Review of the Wander Data Collection Tool, dated 12/15/18 and 3/14/19, assessed Resident #5 as a wander/elopement risk, and had a wander-guard in place. Review of the 3/2019 Physician's Orders did not indicate an order for [REDACTED]. During an interview and observation on 3/21/19 at 9:20 [NAME]M., UM #1 said wander-guards are assessed weekly by the nurse, and monitored on the treatment sheets. She reviewed Resident #5's current treatment sheets and said there is no monitoring of a wander-guard. At this time, the surveyor and UM #1 observed Resident #5's lower leg and observed a wander-guard on his/her left lower leg. During a follow up interview on 3/21/19 at 9:47 [NAME]M., UM #1 said the wander-guard should have been discontinued for Resident #5. She said if a resident requires a wander-guard, the facility staff obtains a physician's order to apply one and have instructions for monitoring the device. Please refer to F657

Based on observation, record review and staff interview, the facility staff failed to treat 2 Residents (#1 and #30) with respect and dignity, out of a total sample of 16 residents. Findings include: 1. For Resident #30, the facility staff failed to ensure dignity was provided relative to the Resident's care. Resident #30 was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 1/8/19 indicated Resident #30 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of the medical record indicated Resident #30 was on Contact Precautions (used for infections that are spread by touching the resident or items in the room) due to an infectious urinary infection. Review of the facility, Quality of Life-Dignity Policy, revised (8/2009) indicated in the interest of public health, posting the resident's isolation status or Transmission-Based Precautions is permissible as long as the type of infection remains confidential. During an observation on 3/22/19 at 8:30 [NAME]M., Resident #30 was awake and lying in bed. The Surveyor observed a red colored sign with large black print hanging over the Resident's bed indicating the Resident was on Contact Precautions. During an interview on 3/22/19 at 11:15 [NAME]M., Unit Manager (UM) #2 said the Contact Precautions form should not be hanging over the Resident's bed as it is private resident information. 2. Resident #1 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15, (cognitively intact), occasionally incontinent of urine, and requires assistance with bathing. Resident #1 also has a diabetic ulcer on his/her right outer ankle. On 3/26/19 at 12:55 P.M., the surveyor observed Unit Manager (UM) #2 perform a dressing change for Resident #1. Resident #1 was in a wheelchair, and stood up to transfer to his/her bed to have the dressing change performed. The surveyor observed that Resident #1 had pants on that were visibly wet and noted an odor of urine and brought it to the attention of UM #2. UM #2 told Resident #1 that the incontinence would be taken care of later and then proceeded to perform the dressing change. On 3/26/19 at 1:15 P.M., UM #2 requested that a Certified Nursing Assistant (CNA) provide incontinence care for Resident #1. During an interview on 3/26/19 at 1:15 P.M., UM #2 said that she had not addressed the episode of incontinence prior to performing the dressing change because she did not want to embarrass Resident #1 by bringing attention to it in front of the surveyor.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to prevent Resident #1 from being verbally and physically abused when Housekeeper #1 hit Resident #1's right knee with a wet floor sign and when Resident #1 called Housekeeper #1 a [***] ing[***] or words to that effect, and Housekeeper #1 replied to Resident #1 yeah, you are or words to that effect. Findings include: The Policy titled, Abuse Prohibition, dated 11/28/16, indicated the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of residents/patient property by anyone including staff, family, friends, etc. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1's Brief Interview of Mental Status (BIMS) score was nine, which indicated moderately impaired cognition. The Admission Record, dated 5/9/17, indicated Resident #1's [DIAGNOSES REDACTED]. The Facility Investigation, dated 8/20/17, indicated Certified Nursing Assistant (CNA) #1 and CNA #2 witnessed Housekeeper #1 swing a wet floor sign at Resident #1 and hit Resident #1 on the right knee. The Investigation indicated Resident #1 called Housekeeper #1 a [***] ing[***] and Housekeeper #1 replied to Resident #1 yeah, you are. A Written Statement by Nurse #1 indicated she interviewed Resident #1 after the incident at 9:00 A.M. on 8/20/17. The Statement indicated Nurse #1 asked Resident #1 if a housekeeper hit him/her with a wet floor sign and Resident #1 responded yea she hit me. The Statement indicated Resident #1 had no injuries, pain or discomfort. The Surveyor interviewed Housekeeper #1 at 12:47 P.M. on 10/23/17. Housekeeper #1 said she did not hit Resident #1 with a wet floor sign. Although, Housekeeper #1 said Resident #1 swore at her, Housekeeper #1 said she could not recall what the swear was. Housekeeper #1 said she responded to Resident #1 by stating if I'm one then you are one too or words to that effect. The Surveyor interviewed CNA #1 at 1:02 P.M. on 10/23/17. CNA #1 said she saw Housekeeper #1 hit Resident #1 with a wet floor sign on his/her right knee. CNA #1 said she heard Resident #1 call Housekeeper #1 an[***] or words to that effect and heard Housekeeper #1 respond to Resident #1 right back at you or words to that effect. The Surveyor interviewed CNA #2 at 8:21 A.M. on 10/25/17. CNA #2 said she saw Housekeeper #1 hit Resident #1 with a wet floor sign on his/her right knee. CNA #2 said she heard Resident #1 call Housekeeper #1 a [***] ing [***] or [***] ing[***] or words to that effect and heard Housekeeper #1 respond to Resident #1 you are or words to that effect.

Based on record review, observation and interview, the facility failed to maintain/restore as much normal bladder function as possible for 1 (#7) of 8 residents with bladder incontinence, in a total sample of 15. Findings included: For Resident #7, the facility failed to provide individualized and effective treatment and services to address Resident #7's new onset of bladder incontinence. Resident #7 was admitted to the facility in 2/2011, with [DIAGNOSES REDACTED]. The Facility's Policy for "Urinary Incontinence/Indwelling Catheter" states, "Based on the patient's comprehensive assessment, care and treatment are provided to help the patient restore his/her highest level of normal bladder function as possible. . . 1. The patient is assessed for incontinence or risk factors that may lead to incontinence . . . 2. The evaluation is to include identification of individuals with reversible and irreversible . . . causes of incontinence. 3. Triggered CAAs (Care Area Assessments) for urinary incontinence . . . are used to assess causal factors for decline . . ." The Quarterly Assessment, with the Assessment Reference Date (ARD) of 7/20/11, indicated Resident #7 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #7 had intact mental status, had no behavior symptoms, was an extensive assist of 1 for toileting and was always continent of bowel and bladder. The 9/2011 Nursing Flow Sheets indicated that Resident #7 was incontinent of bladder for 2 out of 30 days on the 11:00 P.M. to 7:00 A.M. shift, and was toileted in advance of need with incontinence care for 4 out of 30 days on the 11:00 P.M. to 7:00 A.M. shift., but remained totally continent of bladder on the 7:00 A.M. to 3:00 P.M. shift and the 3:00 P.M. to 11:00 P.M. shift. The Nursing Flow Sheets from 10/1/11 to 10/12/11 indicated Resident #7 was toileted in advance of need with incontinence care for 4 out of 12 days on the 11:00 P.M. to 7:00 A.M. shift., but remained totally continent of bladder on the 7:00 A.M. to 3:00 P.M. shift and the 3:00 P.M. to 11:00 P.M. shift. The Quarterly Assessment, with the ARD of 10/12/11, indicated Resident #7 scored 11 out 15 on the BIMS, indicating Resident #7 had moderate cognitive impairment, was an extensive assist of 1 for toileting and was always continent of bowel and bladder. The Nursing Flow Sheets from 10/13/11 to 10/31/11 indicated that Resident #7 was toileted in advance of need with incontinence care daily on the 11:00 P.M. to 7:00 A.M. shift., but remained totally continent of bladder on the 7:00 A.M. to 3:00 P.M. shift and the 3:00 P.M. to 11:00 P.M. shift. The Nursing Flow Sheets for 11/2011 indicated that Resident #7 was toileted in advance of need with incontinence care for 29 out of 30 days on the 11:00 P.M. to 7:00 A.M. shift., but remained totally continent of bladder on the 7:00 A.M. to 3:00 P.M. shift and the 3:00 P.M. to 11:00 P.M. shift. The Nursing Flow Sheets for 12/2011 indicated that Resident #7 was toileted in advance of need with incontinence care daily on all 3 shifts. The Nursing Flow Sheets from 1/1/2012 to 1/4/12 indicated that Resident #7 was toileted in advance of need with incontinence care daily on all shifts. The Annual Minimum Data Set (MDS), with the ARD of 1/4/12, indicated that Resident #7 scored 14 out 15 on the BIMS, indicated intact cognitive status, had no behavioral symptoms, was an extensive assist of 1 for toileting, was frequently incontinent of bowel and was always incontinent of bladder. A Urinary Incontinence care plan developed 1/4/12 indicated Resident #7 was not a candidate for bowel and bladder retraining due to severe cognitive deficit (Resident #7 scored 14 out 15 on the BIMS indicating intact cognitive status), with the goal for Resident #7 to be kept clean, dry and comfortable. The interventions were as follows: Monitor need for / schedule appropriate diagnostic procedures. Report any changes in bladder status to nurse. Report changes in bladder status to physician. Check resident every 2 - 3 hours and PRN (as needed) for incontinent episodes. Provide incontinence / perineal care after each incontinent episode. Barrier protective cream after incontinence. The Nursing Flow Sheets from 1/5/2012 to 1/10/12 indicated that Resident #7 was toileted in advance of need with incontinence care daily on all shifts. On the Urinary Incontinence Care Area assessment dated [DATE] it was documented that there was no input from Resident #7 regarding the new onset of incontinence. There was no assessment of the causal factors, contributing factors and risk factors to the new onset of urinary incontinence. The analysis of the findings indicated that Resident #7 had several incontinent episodes, will be incontinent even with toileting in advance of need, and will not notify staff of the need to void. The goal was to keep Resident #7 clean and dry with intact skin. The Nursing Flow Sheets from 1/11/2012 to 2/09/12 indicated that Resident #7 was toileted in advance of need with incontinence care daily on all shifts. Observation and interview on 2/9/12 at 9:25 A.M., found Resident #7 lying on his/her bed, an alarm was in place and a commode was next to the bed. Resident #7 said that he/she gets up unassisted because that is what he/she does and nothing is going to change that. During an interview on 2/9/12 at 10:45 A.M., Certified Nursing Assistant (CNA) #1 said that Resident #7 will put him/herself on the commode without assistance. CNA #1 said that Resident #7 used to be continent of bladder but was having episodes of urinary incontinence daily and now wore a brief. CNA #1 said that Resident #7 was not on a toileting schedule and staff waited for Resident #7 to ask for assistance when Resident #7 wanted to be toileted. CNA #1 was asked how often Resident #7 rings the bell or asks for assistance with toileting and CNA #1 said that Resident #7 doesn't usually use the call bell. CNA #1 said that Resident #7 is sometimes wet and sometimes dry and was unaware of toileting Resident #7 in advance of need. During an interview on 2/9/12 at 11:00 A.M., Unit Manager #1 was questioned by the surveyor regarding a bladder assessment. Unit Manager #1 said that Resident #7 was always continent of bladder and said that a bladder assessment, including a bladder pattern assessment had not been completed. Unit Manager #1 said she would ask Resident #7 about the urinary incontinence. Unit Manager #1 asked Resident #7 if he/she was incontinent and Resident #7 said, "yes! Did they finally find something out?". Unit Manager #1, with the surveyor present, asked Resident #7 how long the incontinence had been a problem and Resident #7 said , "for about 2 months, I reported it". Unit Manager #1 spoke to Resident #7 about completing a bladder pattern assessment and Resident #7 was in agreement. During an interview on 2/9/12 at 1:22 P.M., the Director of Nursing said that a comprehensive bladder assessment had not been completed to identify the reason for Resident #7's new onset of urinary incontinence and that there were no interventions in place to attempt to restore as much bladder function as possible. During an interview on 2/13/12 at 11:30 A.M., the Director of Clinical Operations said that they jumped right in to complete an assessment and that the MDS nurse should be communicating changes noted when doing the MDS assessments.

Based on record review, observation and interview, the facility failed to conduct a comprehensive assessment for a new onset of bladder incontinence for 1 (#7) resident in a total sample of 15. Findings included: For Resident #7, the facility failed to assess the causal factors, risk factors, and contributing factors to provide individualized and effective treatment and services to address Resident #7's new onset of bladder incontinence. Resident #7 was admitted to the facility in 2/2011, with [DIAGNOSES REDACTED]. The Quarterly Assessment, with the Assessment Reference Date (ARD) of 7/20/11, indicated Resident #7 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #7 had intact mental status, had no behavior symptoms, was an extensive assist of 1 for toileting and was always continent of bowel and bladder. The Quarterly Assessment, with the ARD of 10/12/11, indicated Resident #7 scored 11 out 15 on the BIMS, indicating Resident #7 had moderate cognitive impairment, was an extensive assist of 1 for toileting and was always continent of bowel and bladder. The Annual Minimum Data Set (MDS), with the ARD of 1/4/12, indicated that Resident #7 scored 14 out 15 on the BIMS, indicated intact cognitive status, had no behavioral symptoms, was an extensive assist of 1 for toileting, was frequently incontinent of bowel and was always incontinent of bladder. The Urinary Incontinence Care Area assessment dated [DATE] was incomplete and it was documented on the assessment that there was no input from Resident #7 regarding the new onset of incontinence. There was no assessment of the causal factors and contributing factors to the new onset of urinary incontinence. The analysis of the findings indicated that Resident #7 had several incontinent episodes, will be incontinent even with toileting in advance of need, and will not notify staff of the need to void. The goal was to keep Resident #7 clean and dry with intact skin. Observation and interview, on 2/9/12 at 9:25 A.M., found Resident #7 lying on his/her bed, an alarm was in place and a commode was next to the bed. Resident #7 said that he/she gets up unassisted because that is what he/she does and nothing is going to change that. During an interview on 2/9/12 at 10:45 A.M., Certified Nursing Assistant (CNA) #1 said that Resident #7 will put him/herself on the commode without assistance. CNA #1 said that Resident #7 used to be continent of bladder but was having episodes of urinary incontinence daily and now wore a brief. CNA #1 said that Resident #7 was not on a toileting schedule, and staff waited for Resident #7 to ask for assistance when Resident #7 wanted to be toileted. CNA #1 was asked how often Resident #7 rings the bell or asks for assistance with toileting and CNA #1 said that Resident #7 doesn't usually use the call bell. CNA #1 said that Resident #7 is sometimes wet and sometimes dry. During an interview on 2/9/12 at 11:00 A.M., Unit Manager #1 was questioned by the surveyor regarding a bladder assessment. Unit Manager #1 said that Resident #7 was always continent of bladder and said that a bladder assessment, including a bladder pattern assessment, had not been completed. Unit Manager #1 said she would ask Resident #7 about the urinary incontinence. Unit Manager #1, with the surveyor present, asked Resident #7 if he/she was incontinent and Resident #7 said, "yes! Did they finally find something out?" Unit Manager #1 asked Resident #7 how long the incontinence had been a problem and Resident #7 said "for about 2 months, I reported it." Unit Manager #1 spoke to Resident #7 about completing a bladder pattern assessment and Resident #7 was in agreement. During an interview on 2/9/12 at 1:22 P.M., the Director of Nursing said that a comprehensive bladder assessment had not been completed to identify the reason for Resident #7's new onset of urinary incontinence, and that there were no interventions in place to attempt to restore as much bladder function as possible. Please refer to F315.

Based on record review, observation and interview, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 2 of 6 resident with falls (#9 and 12) in a total sample of 15. Findings included: 1. For Resident #12, who sustained 9 falls including a fractured nose, the facility failed to provide adequate supervision and effective assistance devices. Resident #12 was admitted to the facility in 3/10 with [DIAGNOSES REDACTED]. The Plan Of Care for fall risk included: Assist of 2 with transfers and toilet use. Toilet schedule. Low back racing wheelchair. Winged mattress. Review of nurses' notes and investigation indicated that on 5/18/10 on the 7:00 A.M. to 3:00 P.M. shift, the resident was being assisted to the bathroom by 1 CNA (Certified Nursing Assistant). The resident's knees buckled, and the resident fell to floor landing on knees. The resident's left knee cap was red. The resident's plan of care included 2 assists for transfer and toilet use, not 1 assist. Preventative measures implemented included: Staff educated on being sure that all care plans were followed to ensure safety. The Plan Of Care was updated on 6/6/10 to include: chair alarm when in wheelchair, and resident was re-educated on importance of calling for transfer assistance. Review of nurses' notes and investigation indicated that on 8/6/10 at 7:40 A.M., the resident's call bell was ringing and Neuro - Behavioral Staff #1 responded. The resident wanted to get up, and Neuro-Behavioral Staff #1 told the resident that the CNAs would be in to assist in a minute. Even though Resident #12 started to put his/her legs over the side of the bed and was advised not to, Neuro-Behavioral Staff #1 left the room. The resident had been trying to put on a pair of socks. At 7:45 A.M., the resident was heard screaming, and the nurse found the resident on the floor. The resident's head hit the floor, and the resident was bleeding from the nose. The resident was sent to the emergency room and was found to have a fractured nose. Review of nurses' notes and investigation indicated that on 8/30/10 at 2:00 P.M., the resident was sitting in a wheelchair with a seatbelt and 4 chair restraints in the facility bus. When the bus turned, the wheelchair tipped backwards and the resident fell on the floor. Two staff members, who were passengers, did not actually see the resident fall but assisted the resident back into the wheelchair. The resident complained of back pain. A referral was sent to physical therapy, and the resident was to sit in a standard wheelchair instead of a racer back wheelchair in the van. Review of nurses' notes and investigation indicated that on 10/18/10 at 7:10 A.M., the resident was found on the bedroom floor after attempting to use the bathroom. There was no injury. There was no documentation that a chair alarm was in use or sounded. Interventions included: educate resident on the importance of calling for assist with bathroom use. Nurses' notes indicated that on 11/4/10 at 9:00 A.M., the resident was sitting on a shower chair over the toilet. The CNA went to check on the resident, and the resident was found on the floor. The resident complained of severe lower left leg pain. The resident was unable to move the left leg which was bent under the right leg. The resident was transferred to the emergency room for evaluation. The resident returned to the facility with no new findings. The resident indicated that while sneezing, the resident fell off the shower chair. The Plan Of Care was updated to include: self-releasing seat belt in shower chair. The Fall Risk Assessment of 11/22/10 indicated that the resident was at high risk to fall. Review of nurses' notes and investigation indicated that on 1/2/11 at 10:50 A.M., the bed alarm sounded, and the resident was found lying with face on floor and legs in bed. There was a low bed and floor mats in place. There was no injury. The resident was placed on 5 minute safety checks. At 1:30 P.M., the resident was being transferred from a wheelchair to a shower chair via the Hoyer Lift. While the Hoyer pad was being attached to the lift, the lift hook became attached to a piece of strap on the wheelchair. As the lift was raised, the resident and wheelchair fell backwards to the floor. There was no injury. Interventions included: re-educate staff on Hoyer Lift use. Review of nurses' notes and investigation indicated that on 1/24/11 at 7:00 A.M., the resident was found lying on the bedroom floor with the wheelchair tipped over. The resident had been attempting to reach something on the floor. There was no injury. Interventions included: remind resident to call for assist. Physical therapy to evaluate for anti-tippers for wheelchair. Review of nurses' notes and investigation indicated on 2/7/11 at 3:00 A.M., the bed alarm sounded, and the resident's head and trunk were found on the floor. The resident was attempting to pick up a stuffed animal on the floor. There was no injury. There was a low bed and floor mats in place, the resident was alert and oriented times 3, with baseline confusion. Interventions included: Bonus points to be provided with call bell use. The annual MDS (Minimum Data Set) assessment of 2/16/11 (Assessment Reference Date) indicated that the resident had intact memory, required assist of 2 for transfer and toilet use, required assist with bathing and dressing, was incontinent of bowel and bladder, had verbal behavioral symptoms directed at others, and had fallen. On 3/28/11 at 1:00 P.M., the resident was observed lying in a low bed. The bed alarm was on. There was a floor mat next to the left side of the resident's bed, but the right floor mat was rolled up across the room. On 3/28/11 at 3:30 P.M., the Director of Nurses acknowledged that the resident sustained [REDACTED]. 2. For Resident #9, who sustained 6 falls, the facility failed to provide adequate supervision and effective assistance devices. Resident #9 was admitted to the facility in 3/10 with [DIAGNOSES REDACTED]. The Plan Of Care for at risk for falls included: Assist of one with transfers, ambulation, and supervision with toilet use. Assistive device: walker. Tabs alarm noncompliant, removing multiple times. Bed and chair alarms and keep out of reach Review of nurses' notes and investigation indicated that on 8/4/10 at 12:30 P.M., the resident had turned the alarm off and fell while attempting to transfer self from the wheelchair to the bed. There was no injury. Interventions included: keep alarm box out of reach. Review of nurses' notes and investigation indicated that on 10/29/10 at 1:30 P.M., the resident was found on the floor in the bathroom. The chair alarm did not sound. There was no injury. Interventions included: staff educated regarding use of chair alarm at all times in wheelchair. Review of nurses' notes and investigation indicated that on 11/6/10 at 6:00 P.M., the resident was sitting in a wheelchair, leaned forward and fell on the left hip, knee and hand. The chair alarm did not sound as the resident had turned off the alarm (the alarm box was supposed to be out of reach per care plan). There was no injury. Interventions included: resident educated about importance of proper posture in wheelchair, and rehabilitation to assess for alarming seatbelt. The Plan Of Care was updated to include: alarming self release seatbelt in wheelchair. The quarterly MDS assessment of 12/15/10 (ARD) indicated that the resident's cognitive status was intact. The resident required assist with transfers, ambulation and toilet use, was continent of bowel and bladder, and inaccurately coded for no falls. Review of nurses' notes and investigation indicated that on 12/17/10 at 3:30 P.M., the resident fell to knees while trying to stand from bed without assistance. The resident's knees were red. There was no documentation about the bed alarm. Interventions included: resident to be encouraged to use proper footwear, and encourage compliance with assistance. Review of nurses' notes and investigation indicated that on 1/23/11 at 6:00 A.M., the resident was lying in bed, attempted to reach a water bottle in the night stand, and fell out of bed. There was no documentation indicating if the bed alarm sounded or not. There was no injury. Interventions included: water bottle to be kept on top of night stand in reach of the resident. Review of nurses' notes and investigation indicated that on 2/2/11 at 8:15 A.M., the resident fell out of the low bed when attempting to reach a grabber device that was on the floor. There was no documentation indicating if the bed alarm sounded or not. There was no injury. Interventions included: staff to make sure the grabber is within reach, and educate resident to call for assistance when items are out of reach. On 3/24/11 at 2:10 P.M., the resident was observed lying in a low bed with a bed alarm in place. The resident was covered with multiple blankets. On 3/28/11 at 8:30 A.M., the resident was observed sleeping in a regular height bed. On 3/28/11 at 3:30 P.M., The Director of Nurses acknowledged that the resident had 6 falls in 8 months.