Every finding on record at Tremont Rehabilitation & Skilled Care Center

Based on observation, document review, and interview, the facility failed to ensure professional standards of practice were maintained when providing care for three Residents (#14, #75, and #10), out of a total sample of 19 residents. Specifically, the facility failed to ensure:1. For Residents #14 and #75, narcotic pain medications were administered in accordance with the prescribed parameters in the physician's order; and 2. For Resident #10, a splint/palm guard was not applied to the Resident's left hand after it was discontinued. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. 1. Review of the facility's policy titled Medication Administration - Oral, dated June 2015, indicated but was not limited to the following: -Verify medication order on medication administration record (MAR); check against physician order -Compare the medication label to the resident's MAR -Verify that the medication is being administered at the proper time, in the prescribed dose and by the correct route. A. Resident #14 was admitted to the facility in May 2024 with diagnoses including chronic pain. Review of Resident #14's medical record indicated but was not limited to the following: -Care plan for Pain/Potential for pain with intervention to administer pain medication as ordered (5/21/24) -Last pain evaluation, completed on 1/18/26 indicating use of the verbal pain scale, frequent pain that is relieved with rest and/or medications -Order: Oxycodone HCL (a narcotic pain medication) 5 milligrams (mg), give one tablet by mouth every six hours (Q6hrs) as needed (PRN) for severe pain of 6-10 on the pain scale (11/3/25) Review of Resident #14's MARs for January 2026 and February 1-10, 2026, indicated but was not limited to the following: January 2026: Oxycodone HCL 5mg one tab by mouth Q6hrs PRN for severe pain of 6-10 on pain scale (11/3/25) Oxycodone was administered 14 times outside of the ordered parameters as followed: 9 times for a pain rating of 5 out of 10 (on the 0-10 verbal-numeric pain scale), twice for a pain rating of 4 out of 10, twice for a pain rating of 3 out of 10, and once for a pain rating of 0 out of 10. February 1-10, 2026: Oxycodone HCL 5mg one tab by mouth Q6hrs PRN for severe pain of 6-10 on pain scale (11/3/25) Oxycodone was administered twice outside of the ordered parameters as followed: one time for a pain rating of 5 out of 10 and one time for a pain rating of 4 out of 10. During an interview on 2/10/26 at 11:05 A.M., Nurse #3 said she knows the Resident very well. She said the Resident's pain is usually in his/her neck, back or legs and is typically rated at about a 5 on the 0-10 pain scale. On review of the MAR, Nurse #3 was identified as one of the Nurses who was administering the Oxycodone outside of the ordered parameters. She said the Oxycodone is ordered to be administered as needed if the Resident's pain is at least a 6 out of 10, and he/she has received it multiple times for pain levels below the ordered parameter. She said the Oxycodone had been administered without following the physician's order. During an interview on 2/10/26 at 12:19 P.M., the Unit Manager said the process for administering PRN pain medications is for the nurses to assess the residents and ascertain a pain rating prior to administering a PRN to ensure the orders are followed and then re-evaluate the resident's pain to ensure effectiveness. On review of the MARs for Resident #14, she said the Resident had been administered his/her PRN Oxycodone outside of the physician ordered parameters and the expectation is for physician's orders to be followed as written and in this circumstance that had not occurred. B. Resident #75 was admitted to the facility in June 2025 with diagnoses including: hypertension, peripheral vascular angioplasty (procedure to unblock narrowed or clogged arteries), and had recently undergone a right knee arthroplasty. Review of Resident #75's medical record indicated but was not limited to the following: -Care plan for Pain with intervention to administer pain medication as ordered (6/10/25) -Last comprehensive pain evaluation, completed on 2/8/26 indicating use of the verbal pain scale, frequent pain that is relieved with rest, polar ice and/or medications -Order: Oxycodone HCL 10 mg, give one tablet by mouth every four hours (Q4hrs) PRN for severe pain of 6-10 on the pain scale (2/7/26) Review of Resident #75's MARs for January 2026 and February 1-10, 2026, indicated but was not limited to the following: January 2026: Oxycodone HCL 5mg two tabs by mouth every 8 hours (Q8hrs) PRN for moderate-severe pain, 6-10 on pain scale (12/7/25) Oxycodone was administered 20 times outside of the ordered parameters as followed: 15 times for a pain rating of 5 out of 10, three times for a pain rating of 4 out of 10, and twice for a pain rating of 0 out of 10. February 1-10, 2026: Oxycodone HCL 5mg two tabs by mouth Q8hrs PRN for moderate-severe pain, 6-10 on pain scale (12/7/25) Oxycodone was administered once outside the ordered parameters for a pain score of 3 out of 10. During an interview on 2/10/26 at 11:19 A.M., Nurse #3 said she knows the Resident very well and cares for them often. She said the Resident recently had a knee surgery and is using both his/her PRN pain medications and a polar care system to manage their pain. On review of the MAR, Nurse #3 was identified as having administered the PRN Oxycodone numerous times outside of the ordered parameters. She said the Resident received the medications outside of the ordered parameters and the orders should be followed. During an interview on 2/10/26 at 12:21 P.M., the Unit Manager reviewed the Residents' MARs for January and February 2026. She said the Nurses are administering the Oxycodone outside of the prescribed order parameters and they should be following the physician's orders as written. She said the physician's order is not being consistently followed for this Resident's pain medication administration. During an interview on 2/10/26 at 1:28 P.M., the Director of Nurses (DON) reviewed the MARs and said the Nurses didn't follow the prescribed physician's parameters in the order as required. 2. Review of the facility's policy titled Splints/Orthotics/Prosthetics, dated April 2015, indicated but was not limited to the following: -Residents will receive splint/orthotic/prosthetic devices as deemed appropriate by the physician and rehabilitation services. Staff will monitor the circulation and skin integrity of residents using these devices at least every shift as part of routine care, or more often as ordered by the physician. -Nursing staff will apply/remove the designated splint/orthotic/prosthetic device during the scheduled wearing times. Resident #10 was admitted to the facility in February 2024 with diagnoses which included hemiplegia (paralysis affecting one side) and hemiparesis (weakness or partial paralysis affecting one side) following intracerebral hemorrhage (stroke resulting in bleeding into the brain) affecting left dominant side, weakness, protein calorie malnutrition, and dementia. Review of the Minimum Data Set (MDS) Assessment, dated 10/24/25, indicated he/she was rarely/never understood and was dependent on staff for care. The surveyor made the following observations: -2/5/26 at 12:16 P.M., he/she was lying in bed with left palm guard on. -2/10/26 at 11:30 A.M., he/she was sitting in Broda recliner chair with left palm guard on. -2/10/26 at 1:40 P.M., he/she was sitting in Broda recliner chair with left palm guard on. -2/10/26 at 2:27 P.M., he/she was sitting in Broda recliner chair with left palm guard on. Review of the active Physician's Orders failed to indicate an order for a left palm guard. Review of the Comprehensive Care Plan failed to indicate a left palm guard should be in place. Review of the Physiatry (physical medicine and rehabilitation) progress note, dated 1/27/26, indicated he/she had a left-hand contracture, and therapy had been applying a hand splint. Review of the Occupational Therapy Discharge summary, dated [DATE], indicated the left palm guard was discontinued from the plan of care as not indicated at this time. Review of the discontinued Physician's Orders indicated the order for the left palm guard was discontinued on 2/5/26 at 10:00 A.M. because it was no longer needed. Review of the Comprehensive Care Plan history indicated the intervention for a left palm guard had been resolved on 2/5/26. During an interview on 2/10/26 at 2:45 P.M., Certified Nursing Assistant (CNA) #3 said Resident #10 wears the left palm guard every day. She said she was not assigned to him/her today, but typically the CNAs will put it on when they wash him/her in the morning. She said it was written on the Resident Care Card (a reference sheet for the CNAs to know how to care for each individual resident). Review of the Resident Care Card for Resident #10, last revised on 1/12/26, indicated but was not limited to the following: SPLINTS/BRACES/IMMOBILIZERS: -TYPE: palm guard -WHERE: left hand -WHEN: at all times During an interview on 2/11/26 at 12:31 P.M., Nurse #4 said splints are ultimately the nurse's responsibility. She said they will populate on the Treatment Administration Record (TAR) when to apply, remove, and to check the skin. She said therapy and the CNAs apply them as well, but the nurse must double check they are on if they should be on and off if they should be off. She said when a resident has a splint it is written in the orders, the care plan, and on the Resident Care Card so the aides know to put it on. She said Resident #10's splint should not have been applied after the order was discontinued. She said when a splint is discontinued the nurse taking the order should also discontinue it from the Resident Care Card, so everyone knows it was discontinued. During an interview on 2/11/26 at 12:37 P.M., Nurse #5 said she was unable to locate the Resident Care Card binder, but if the splint was discontinued it should no longer be on the Resident Care Card. During an interview on 2/11/26 at 12:47 P.M., Resident Care Assistant (RCA)/CNA #2 said she was in charge of updating the Resident Care Cards. She said they are updated at the quarterly care plan meetings, but she also gets a weekly order report to look for changes, and sometimes at morning meeting she would be told things that should be on the Resident Care Card to update them. She said the nurses could update them in the interim, but she was unsure if they do. During the interview she provided the surveyor with the updated Resident Care Card for Resident #10. This Resident Care Card indicated the palm guard was discontinued. She said the Staff Development Coordinator (SDC) updated it yesterday (2/10/26) afternoon after surveyor inquiry. During an interview on 2/11/26 at 1:00 P.M., the SDC said she discontinued the palm guard from the Resident Care Card and did education with the staff yesterday (2/10/26) afternoon. She said it should have been discontinued from the Resident Care Card on 2/5/26 and the palm guard should not have been applied after that date. Additionally, she said RCA/CNA #2 updates the Resident Care Cards, but she was unsure how often they were updated or how she got the information to update them. She said the nurses on the unit should be updating them with any day-to-day changes. She said the Resident Care Card was never updated and the CNAs were not educated on the change, so the CNAs probably kept applying it every day because Resident #10 had it for so long. During an interview on 2/11/26 at 1:20 P.M., the DON said the Resident Care Card should reflect the care the individual resident needs. She said the Resident Care Card is usually updated by the RCA/CNA #2, though the nurses can update them. She said the team reviews new orders in the morning to see what changes to the Resident Care Cards need to be made. She said in this case the splint was discontinued on 2/5/26 and it was not discontinued from the Resident Care Card. She said the palm guard should not have been applied after it was discontinued on 2/5/26. She said the CNAs were following the Resident Care Card, but unfortunately it was not accurate, and was not updated.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; and2. Ensure nasal cannula oxygen tubing was stored in a sanitary manner to protect it from potential contamination by germs and environmental debris for one Resident (#14), out of a total sample of 19 residents. Findings include: 1. Review of the facility's policy titled Infection Control Program, undated, indicated but was not limited to the following: -The facility has a system in place for prevention, identification, reporting and control of infections and communicable diseases of residents-Responsibility for ongoing collection and analysis of data and required follow up is assigned to the Infection Preventionist (IP)-Elements include but are not limited to monitoring and documenting infections, tracking and analyzing outbreaks of infections, managing resident health initiatives and provisions of early uniform identification and reporting of infections-Perform surveillance and investigation of infections to prevent, to the extent possible, the onset and spread of infection-Ensure compliance with all State and Federal regulations related to infection control and preventionSurveillance for Healthcare associated infections (HAI)s-Surveillance is defined as the ongoing, systematic collection, analysis, interpretation and dissemination of data-The facility will closely monitor all residents who exhibit signs/symptoms (s/s) of infection-The IP will gather additional data for infection tracking and reporting-The IP or designee will monitor the residents with infections and/or potential infections by completing the monthly infection report During an interview on 2/10/26 at 8:15 A.M., the Director of Nurses (DON) said the facility uses McGeer criteria to determine if an illness rises to the level of an infection for their surveillance program. Review of the McGeer criteria checklist in use by the facility, indicated but was not limited to the following: Category: Urinary tract infection (UTI)Criteria: Must fulfill both 1 AND 2. 1. At least one of the following signs and symptoms:- Acute dysuria (painful urination)- Fever or leukocytosis, and more than one of the following: acute costovertebral angle pain; suprapubic pain; gross hematuria; new or increase incontinence; new or increase urgency; new or increase frequency- If no fever than more than two of the above symptoms 2. At least one of the following microbiologic criteria- greater than 100,000 organism count of no more than two organisms on a voiding sample (urination in a cup/bag)- greater than 100,000 organism count of any organisms in a specimen collected by an in and out catheter (straight cath) Category: Pneumonia (PNU) (all three criteria must be present)1. A chest x-ray (CXR) positive for pneumonia or new infiltrate2. At least 1 of the following respiratory sub-criteria: new or increase cough, new or increase sputum production, Oxygen (O2) saturation less than (<) 94% on room air (RA) or a reduction in O2 saturation of greater than (>) 3% from baseline, new or changed lung examination abnormalities, pleuritic chest pain, respiratory rate of equal to or > 25 breaths per minute3. At least 1 of the constitutional criteria: fever, leukocytosis, acute change in mental status from baseline, acute functional decline Review of the Surveillance/Line listing sheets in use by the facility included the following categories: Name, Room #, Category, Date of onset (DOO), s/s (signs and symptoms), culture date, site, results, treatment, infection cleared, comments, final status (HAI/CAI), Count as infection (Y/N) Review of the facility line listings for November 2025 through January 2026 indicated but were not limited to the following: NOVEMBER 2025Resident #86, Category: UTI; DOO: 11/11; s/s: increased confusion (cf); culture (cx) date: 11/6; site: urine; results: positive (+); treatment: Ertapenem; final status: HAI; count: Y Review of the medical record for Resident #86 indicated the Resident also had signs and symptoms including a decrease in functional ability and the culture came back with E-coli as the predominant germ. The surveillance line listings did not include the results of the culture, and the signs and symptoms indicated on the line listing did not meet McGeer criteria for the illness to be counted as a UTI infection. In addition, there were three other UTIs under surveillance that did not include culture date or germ results making the surveillance both incomplete and inaccurate. DECEMBER 2025:Resident #5, Category: PNU; DOO: 12/18; s/s: temperature (T), cf; culture date, site and results are all blank; treatment: Macrobid; final status: HAI; Count: Y Review of the medical record for Resident #5 indicated signs and symptoms began on 12/15 and included swollen glands, sore throat, lethargy, dysuria, T, O2 saturation (O2 sat) of 84-86% on room air. The Resident was then hospitalized on 12/16. The facility line listing failed to include signs and symptoms that would indicate the Resident had met the criteria for a pneumonia infection and in addition did not reflect the correct date of onset for signs and symptoms. In addition, four additional residents were indicated for pneumonia on the surveillance without chest x-ray results documented on the sheets as well as one UTI without culture results making the surveillance sheets incomplete and inaccurate.Further review of the facility documents for December 2025 failed to indicate on their monthly infection analysis that any residents had any respiratory infections in December. JANUARY 2026Resident #68, Category: PNU; DOO 1/1; s/s: lethargy, T; results: CXR +; treatment: Augmentin; final status: HAI; count: Y Review of Resident #68's medical record indicated the Resident also had signs and symptoms of wheezes in the lungs (an abnormal lung sound made when air is not well exchanged). Resident #9, Category: UTI; DOO: 1/8; s/s: dysuria; culture date and site were blank; results: +; treatment: Macrobid; final status: HAI; count: Y Review of Resident #9's medical record indicated the Resident began exhibiting signs and symptoms of illness on 1/5 which included: urgency and increase frequency. Resident #41, Category: ESBL Urine; DOO 1/6; s/s: cf, lethargy; culture date and site were blank; results +; treatment: Ertapenem; final status: HAI; count: Y Review of Resident #41's medical record indicated the Resident began exhibiting signs and symptoms of an illness on 1/2 becoming unresponsive with a change in vital signs and resulting in hospitalization for sepsis (the body's extreme reaction to an infection). The facility surveillance line listings were inaccurate and did not include signs and symptoms of the category infections for Resident #68, #9 and #41. In addition, the line listings had incorrect dates of symptom onset for both Resident #9 and #41 and both UTI infections did not include the germ identified in the results column indicating the surveillance sheets were also incomplete. During an interview on 2/11/26 at 10:19 A.M., the IP confirmed the facility uses McGeer criteria to determine if an illness rises to the level of an infection. She said the surveillance sheets are line listing sheets provided by the laboratory and all sections should be completed for accuracy. She said the purpose of completing the line listings is to track all signs and symptoms of illness or infection and monitor the residents in one area that is easy for anyone to follow to identify a possible increase in illness or outbreak. The IP reviewed the line listings for December 2025 through January 2026 and said she does not use date of onset (DOO) as the date signs and symptoms were first identified and sometimes places the date a culture was done or the antibiotic was started in that section. She said she should be using the date of illness onset to better track and monitor any potential links. She said she doesn't complete the culture results section with the identified germ because the lab has the information. She said the lab results section should be completed to be able to identify if a specific germ is emerging in the facility. She said on review of the sheets, the sheets also don't have all the required signs and symptoms documented for each resident to indicate that McGeer criteria was met and therefore the illness was counted as an infection in the facility. She said looking at the sheets it appears the process needs work since the documents are both inaccurate and incomplete making the evaluation information incomplete and affecting the ability of the facility to properly evaluate their program. During an interview on 2/11/26 at 11:29 A.M., the DON reviewed the November 2025 through January 2026 line listings and monthly evaluation report documents. She said the expectation is that all the necessary information for monitoring, tracking and trending signs and symptoms and germs is documented on the line listings, so they are complete and accurate, and it does not appear that that had occurred. 2. Review of the facility's policy titled Oxygen Administration Nasal Cannula, dated as revised November 2020, indicated but was not limited to the following: -The nasal cannula will be stored in a plastic bag and maintained off the floor (when not in use) Resident #14 was admitted to the facility in May 2024 with diagnoses including: chronic obstructive pulmonary disease (COPD), acute respiratory distress syndrome, and obstructive sleep apnea. Review of the Minimum Data Set assessment, dated 1/23/26, indicated a Brief Interview for Mental Status score of 14 out of 15 indicating the Resident was cognitively intact. During an interview on 2/5/26 at 8:11 A.M., Resident #14 said he/she has two sets of oxygen tubing, one for the walker and one for the room. The Resident said they are supposed to be using the oxygen at all times but takes it on and off as needed. The Resident said he/she does not have any type of plastic bag or anything to put the oxygen tubing in when it is not in use, so he/she typically wraps it around the handlebars of their walker or puts it on the oxygen concentrator. The surveyor made the following observations of Resident #14's oxygen tubing not being stored in a sanitary way to prevent the potential contamination of the tubing by germs and environmental debris: -2/5/26 at 8:11 A.M., 4:25 P.M., and 4:44 P.M., the nasal cannula oxygen tubing was observed wrapped around and hanging off the Resident's walker's handlebars, not stored in a plastic bag and no plastic bag was observed in the area. -2/6/26 at 8:53 A.M. and 2:25 P.M., the nasal cannula oxygen tubing was observed lying across the Resident's bed directly on the bedlinens, no plastic bag was observed to be available in the area. During an interview on 2/10/26 at 9:12 A.M., the surveyor reviewed her findings with the DON of Resident #14's oxygen tubing not being stored in a plastic storage bag when not in use. The DON said the process is for the nurses to change out the tubing and plastic storage bags weekly and label them. She said this Resident should have had plastic storage bags to store their oxygen tubing when not in use in a sanitary way to protect it from potential germs and it appears that did not occur.

Based on observation, document review, and interview, the facility failed to develop and implement a smoking policy, that included a process for their independent smokers ensuring designated smoking areas, proper receptacles for safe cigarette disposal, and the storage of the lighting and smoking materials for 8 out of 16 current smokers in the facility. Findings include: Review of the Department of Health and Human Services Centers for Medicare and Medicaid Services Memorandum titled Smoking Safety in Long Term Care Facilities, dated 11/10/11, included but was not limited to:-Facilities must include assessment of smoking areas and provision of emergency equipment in the designated smoking areas. -The facility is obligated to ensure the safety of designated smoking areas which includes protection of residents from weather conditions. -The facility is also required to provide portable fire extinguishers and requires each smoking area be provided with ashtrays made of noncombustible material and safe design. Metal containers with self-closing covers into which ashtrays can be emptied must be readily available. Review of the facility's policy titled Smoking, dated as last revised November 2020, indicated but was not limited to the following: -It is the policy of the facility to provide a healthy and safe environment for residents, staff and visitors by limiting the use of tobacco smoking materials on campus.-Resident who express a desire to smoke will be asked to review and sign the Smoking policy, attesting that they will adhere to the guidelines set forth by the facility.-Residents who state they are occasional smokers will have an Occasional/Former smoker evaluation completed and signed.-Residents who smoke will be evaluated for their ability to smoke safely upon admission, quarterly and as dictated by a significant change in condition, to ensure that they continue to be capable of smoking and use smoking materials without presenting a danger to themselves or others. The need for assistive devices and/or safety devices will be identified and noted in the residents individualized care plan.-All cigarettes, igniting and smoking materials will be kept in a secure location designated at the facility. Residents will not be permitted to retain such items in their possession. Any new cigarettes, igniting or smoking materials must be turned over to staff immediately upon arrival to the facility. -Smoking will be permitted at scheduled times, which will be posted in the facility. The facility reserves the right to make changes to the designated times if or when necessary, residents will be notified of such. -A designated smoking area will be determined with fire blanket and fire extinguisher readily accessible. -Smoking or use of smoking materials by residents will not be permitted on the grounds of the facility with the exception of the designated smoking area.-Smoking will take place under the supervision of a staff member. The staff member will have the responsibility of lighting all cigarettes. During an interview on 2/5/26 at 8:11 A.M., Resident #14 said he/she is an independent smoker and goes out to smoke whenever he/she wishes to do so. The Resident said when going out to smoke they are required to sign out and leave the property. During an interview on 2/5/26 at 4:09 P.M., the facility Smoking Attendant said she is only responsible for the supervised smokers and their smoking materials and lighter. She said the residents who are independent smokers do not smoke at the facility designated smoking area and the process for them is to sign out of the facility and leave the property to smoke. On 2/5/26 at 4:44 P.M., the surveyor observed Resident #14 outside the front door of the facility. The surveyor observed the Resident pull their cigarette lighter out of their jacket pocket and use it to light their cigarette and then place the lighter back into their pocket. On 2/6/26 at 2:15 P.M., the surveyor observed Resident #11 outside in the facility visitor parking lot on the lower-level smoking independently. During an interview on 2/6/26 at 2:18 P.M., Resident #75 said he/she is an independent smoker and keeps his/her own lighter and smoking materials in their jacket. The Resident said independent smokers are supposed to leave the property to smoke. During an interview on 2/6/26 at 2:20 P.M., the surveyor observed Resident #98 to have a cigarette lighter on his/her overbed table in their room. The Resident said he/she is an independent smoker and had permission to keep their lighter and smoking materials. The Resident said he/she goes out the front door to smoke on the front walkway once a day after 4:00 P.M. On 2/6/26 at 3:08 P.M., the surveyor observed Resident #14 outside in the front visitor parking lot in between two vehicles smoking. During an interview with observation on 2/9/26 at 8:59 A.M., Resident #14 said only residents who require help or supervision smoke in the designated smoking areas. The Resident said he/she typically sits behind the trees on a bench, but the piles of snow have prevented that and therefore he/she has been standing in the facility parking lot with his/her walker. The surveyor observed that the Resident had his/her smoking materials on him/her and was ashing his/her cigarette and throwing the cigarette butts on the ground. During an interview on 2/10/26 at 11:03 A.M., Resident #11 said he/she is an independent smoker and was permitted to keep his/her own lighter and smoking materials in their jacket, which was observed by the surveyor. The Resident said he/she goes out to smoke whenever he/she wants to and usually sits in the parking lot because of all the snow, but he/she was told he/she should be leaving the property to smoke. During an interview on 2/6/26 at 9:01 A.M., Nurse #2 said the residents who are independent smokers go out the A-wing door (front door of the facility) after 4:00 P.M. until the morning and stand in the front walkway. She said the door is locked with a keypad safety code, so the staff have to let them in and out of the facility. She said prior to 4:00 P.M. those residents sign out and exit the facility out of the main entrance and are supposed to leave the property to smoke. She said independent smokers are allowed to smoke whenever they want and maintain their own lighters and smoking materials. During an interview on 2/6/26 at 10:53 A.M., the Unit Manager said she has independent smokers on her unit. She said the independent smokers are permitted to keep their own lighters and smoking materials and sign out of the facility to go smoke outside whenever they want to. She reviewed the facility provided list of smokers and identified 8 out of 16 of the smokers in the facility were independent. During an interview on 2/6/26 at 12:25 P.M., the Director of Nurses (DON) reviewed the Smoking policy with the surveyor. She said the smoking policy is really designed more for the supervised smokers at the facility and doesn't include a process for independent smokers. She said the facility's independent smokers are evaluated for safety and are allowed to keep their own smoking materials and lighters on them. She said they are supposed to leave the property to smoke. During an interview on 2/6/26 at 12:47 P.M., the Administrator and surveyor reviewed the facility smoking policy together. The Administrator said the independent smokers do not follow the smoking times or use the facility smoking location. He said the policy dictates that residents can only smoke at designated times and in the facility designated area and the policy is more for supervised smokers and doesn't include a process or information on independent smokers. He said since the policy indicated residents are not allowed to smoke anywhere on the grounds, the independent smokers are told to sign out and leave the property when they want to smoke, and they maintain all their own smoking materials. He said at the time the policy was revised the facility did not have any independent smokers and now that they do, they will need to revise the policy to include a process for the independent smokers.

Based on observation, interview, and record review, the facility failed to ensure that medications were labeled and stored in accordance with accepted professional principles in one out of two medication carts observed. Specifically, the facility failed to ensure medications were stored in the container with the pharmacy label; and ensure topical use medications were stored separate from oral medications.Findings include:Review of the facility's policy titled Medication Storage in the Facility, dated as revised December 2019, indicated but was not limited to, the following:-All medications dispensed by the pharmacy are stored in the container with the pharmacy label.-Orally administered medications are kept separate from externally used medications and treatments such as ointments and creams.-Outdated, contaminated, or deteriorated medications and those in containers that are without secure closures are immediately removed from inventory, disposed of. During an observation with interview on 2/10/26 at 9:21 A.M., the surveyor inspected a medication cart on Unit B with Nurse #1 and made the following observations:-In the top drawer, a clear plastic drinking cup, laying on its side, uncovered, with numerous brown, oval-shaped tablets inside. Handwritten in marker on the outside of the cup said Preservision. Nurse #1 said those pills are eye vitamins used for house stock. She said they should not be in use without the pharmacy container with the medication information. -In the second drawer, on the right-hand side, a clear plastic uncovered, unlabeled medication cup with 13 pills inside. The pills were different in color, shape and size.Nurse #1 said she did not prepare the medication and did not know what the pills were. She said she did not see it when she took over the cart this morning. Nurse #1 said that medications should never be left unlabeled and stored in the medication cart.-In the second drawer, adjacent to handheld respiratory inhalers, one tube of muscle rub cream, one tube of wound dressing ointment and a bottle of mineral oil. Handwritten in marker on the cap of the mineral oil bottle read mineral oil for scalps.Nurse #1 said those items are to be applied to skin or wounds and should not be stored in the medication cart. She said all skin and wound care medications should be stored in the treatment cart. During an interview on 2/11/26 at 11:47 A.M., the Director of Nursing (DON) said all medications should be stored in the packaging it was received in with the pharmacy label. She said no medications should ever be in the medication cart unlabeled and uncovered. The DON said all external use medications must be stored in the treatment cart, away from any oral medications.

Based on document review and interview, the facility failed to provide written documentation related to transfer discharge notices and bed hold upon hospitalizations and ensure this information was part of the medical record for two Residents (#1 and #8), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Reservation of beds (Massachusetts), dated as revised 11/8/2016, indicated but was not limited to the following: -This facility will reserve the bed of a hospitalized resident in accordance with facility policy, State and Federal regulations. Review of the facility's policy titled Discharge Planning Policy and Procedure, undated, indicated but was not limited to the following: -Social services will ensure systems are implemented to provide written notification to the resident/responsible party prior to transfer/discharge in accordance with Massachusetts DPH/Division of Health Care Facility Licensure-In the event of an unplanned transfer to an acute care setting, notice will be provided in writing to the resident/responsible party as soon as practicable. A. Resident #1 was admitted to the facility in September 2024 with diagnoses including: Vascular dementia, adult failure to thrive, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 12/29/25, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated the Resident was severely cognitively impaired. Review of the medical record for Resident #1 indicated he/she was transferred to the hospital for evaluation in June 2025 and November 2025. The record failed to indicate bed hold and transfer documents were provided to the Resident and/or his/her representative prior to transfer as required. During an interview on 2/10/26 at 1:52 P.M., Nurse #1 said the process for transferring a resident to the hospital includes sending a medication list, SBAR assessment form, advanced directives, and a face sheet. She said she believes they are supposed to send a transfer notice and bed hold sheet. She searched the B unit file cabinets and couldn't locate these forms on the nursing unit for resident transfers. She reviewed the medical record for Resident #1 and said there were no transfer notices or bed hold documents in the record or any evidence to indicate they were sent with the Resident at the time of the transfer to the hospital in either June or November 2025. B. Resident #8 was admitted to the facility in March 2025 with diagnoses including: Alzheimer's disease, dementia, and delusional disorder. Review of the MDS assessment, dated 12/12/25, indicated a BIMS score of 6 out of 15 indicating the Resident was severely cognitively impaired. Review of the medical record for Resident #8 indicated he/she was transferred to the hospital for evaluation in October 2025 and December 2025. The record failed to indicate bed hold and transfer documents were provided to the Resident and/or his/her representative prior to transfer as required. During a telephone interview on 2/10/26 at 12:33 P.M., the Guardian for Resident #8 said the nurses at the facility make him aware of any changes in the Resident's condition and when they are sending the Resident to the hospital. He said no one has ever discussed a bed hold with him or provided him any documents on the Resident's transfer or a bed hold at the times the Resident had been sent out to the hospital. During an interview on 2/10/26 at 12:54 P.M., Nurse #2 said when the nurses are transferring a resident to the hospital, they send an SBAR assessment, medication list and any advanced directives. She said prior to preparing the paperwork they notify the physician of the change in condition and receive an order for the transfer and notify the residents and their responsible party of the transfer occurring. She said they do not complete bed hold or transfer forms at the facility at the time a resident is transferred to the hospital for evaluation and to the best of her knowledge those documents are not used by the facility. During an interview on 2/10/26 at 2:18 P.M., the Unit Manager said she has worked at the facility for about a year and a half and has never seen any transfer or bed hold forms and as far as she knows the facility does not use them. During an interview on 2/10/26 at 2:35 P.M., the Regional Social Worker said the facility social worker is the one who completes and sends all bed hold and transfer forms to the residents' responsible parties and the ombudsman's office. She said the forms are kept in the social service office in a binder and not in the medical record as required. During an interview on 2/10/26 at 3:27 P.M., the Regional Social Worker said the process for transfer and bed hold forms to be completed in the facility is driven by the facility social worker. She said if a resident goes out to the hospital the social worker completes the forms the next day. She said she is unsure of the process for the residents/resident's responsible parties to receive copies of the forms. She said the forms should be part of the medical record and she would expect a note to be written to indicate the information was provided. She said the transfer and bed hold information is supposed to be part of the individual residents' medical records and she isn't sure why it is not. Review of the Social service progress notes for Resident #1 and Resident #8 failed to indicate any transfer or bed hold documents were reviewed with the Resident or the responsible party or provided in written format. During an interview on 2/10/26 at 3:32 P.M., the Director of Nurses said the nursing units are supposed to have a packet that they complete when a resident is transferred out to the hospital which should include the transfer and bed hold forms. She said she does not know why that process isn't in place now as it should be. During an interview on 2/11/26 at 12:02 P.M., the Social Worker said social services is exclusively responsible for completing both the transfer and bed hold documents for all residents including those that are acutely transferred to the hospital. She said nursing is not involved in the process and does not complete either form, provide them to the resident or send an accompanying copy of the bed hold to the hospital with the resident. She said when she comes in, she reviews the 24-hour report or dashboard for any transfers and completes the documents required at that time, after the residents have been sent out. She said she does communicate with the resident's responsible parties, but she does not put any documentation in the medical record to indicate those conversations have occurred, or that she has sent the notices by mail. She said the documents are not part of the medical record and are kept in a binder in the social services office. She said she is aware that the bed hold form and transfer information is supposed to be provided to the residents and the bed hold form should accompany the resident to the hospital, but that is not the process they use at the facility. She said she also knows the documents are supposed to be part of each resident's individual medical record, but that is also not a process the facility currently has in place. She said the current process does not align with the federal requirements as it should.

Based on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of Residents on one (B Unit) of two nursing units and specifically for two out of 21 sampled Residents (#6 and #48). Specifically, the facility failed: 1. For Resident #6, to ensure that staff offered and encouraged engagement in activities according to their comprehensive assessment and identified preferences; 2. For Resident #48, to ensure that staff offered and encouraged engagement in activities according to their comprehensive assessment and identified preferences; and 3. To ensure staff provided a meaningful and engaging activity program, including materials for self-directed activity, for residents residing on the B Unit (secured). Findings include: Review of the facility's policy titled Activity Programs, last revised August 2017, indicated but was not limited to: -Recreational activities are designed to contribute to the achievement of the long and short-term goals established for each resident. -The goal of this department is to assist each resident in the resumption of normal activities and maintain the optimal level of psychosocial functioning. -These leisure services encompass a versatile scope of activities that promote the cultural, spiritual, social, intellectual, and physical growth and fulfillment of each resident. -In order to achieve this, a wide and diversified leisure service program has been developed based on the needs and personal interests of each resident. -Appropriate supplies and equipment are provided to ensure the safe implementation and continuation of meaningful recreational activities. -Provisions are made by the Recreation staff in accordance with the resident's level of participation. -Maintain accurate daily attendance records on each resident's progress and use these notes as a reference point for accurately assessing each resident's Recreation Plan as per care plan policy. During the entrance conference on 1/2/25 at 8:37 A.M., the Administrator said the B Unit was a secure unit with several residents with a diagnosis of dementia. Review of the Matrix for Providers (Centers for Medicare and Medicaid Services document used to identify pertinent care categories) provided by the facility on 1/2/25 at 11:00 A.M., indicated 44 residents resided on the B Unit, 34 of which have a diagnosis of dementia. 1. Resident #6 was admitted to the facility in September 2022 and had diagnoses including Alzheimer's disease, major depression, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 10/25/24, indicated Resident #6 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. Review of the comprehensive MDS assessment, dated 7/26/24, indicated that it was very important to the Resident to: -have books, newspapers, and magazines to read -listen to music you like -do things with groups of people -do your favorite activities -to go outside to get fresh air when the weather is good Review of a Therapeutic Recreation Quarterly Progress Note, dated 10/23/24, indicated but was not limited to: -Attends activities independently; requires reminders to attend activities; is an active participant; is a passive participant. -Wellness/healing: dance/Zumba(R); light movement; massage therapy. -Mental wellness: music therapy; pet therapy -Cognitive: oriented to person; forgetful/requires reminders and cues; short attention span; requires verbal cueing; cannot comprehend instruction (Spanish speaker. Cannot comprehend English instruction). -Activity preferences: social, religious, creative crafts, music, sing a long, baking, active games, outdoor. -Notes: Resident is independent in choosing leisure pursuits; needs invitations and reminders to attend groups of interest. Resident is Spanish speaker. Enjoys small crafts, music groups and sing a long, religious groups, going outside, dancing and several others. Enjoys self-directed tasks like sorting and folding, conversing in Spanish with other Spanish-speakers. Activities staff continue to support resident as needed. Review of the Resident's Activity Care Plan, last revised 11/12/24, listed interventions including but not limited to: -Provide Resident with the Daily Activities flier and a Spanish Communication Board -Activity staff will inform, invite, and encourage him/her to participate in activities -Activity staff will introduce Resident to peers with similar interests -Offer Resident independent leisure activities per his/her request No evidence was found in the Activity Care Plan to include interventions for musical activities, religious activities, or to go outside when the weather was good. Review of the Resident's Activity Participation Log indicated the following: December 2024: -1 day of a observing a craft activity -1 day of listening to music -6 days of receiving something from the refreshment cart -1 day of engaging in 1:1 conversation -1 day of a pet visit -1 day reading materials offered -2 days of playing a balloon game -7 days of Bingo/group board game -8 days of coffee club -1 day of trivia -1 day of exercise -6 days of arts and crafts -4 days of holiday events -12 days with no activity recorded Further review of the December 2024 Activity Participation Logs showed no evidence that the Resident had been offered to go outside, attend religious groups, or more than one day of reading materials provided to the Resident for independent activity. Review of the Resident's Activity Participation Log for January 2025 failed to indicate the Resident was offered or participated in any activities. 2. Resident #48 was admitted to the facility in August 2022 and had diagnoses including Alzheimer's disease. Review of the MDS assessment, dated 12/30/24, indicated Resident #48 had severe cognitive impairment as evidenced by a BIMS score of 00 out of 15. Review of the comprehensive MDS assessment, dated 3/11/24, indicated that it was very important to the Resident to: -listen to music you like -be around animals such as pets -do things with groups of people -do your favorite activities -to go outside to get fresh air when the weather is good Review of a Therapeutic Recreation Quarterly Progress Note, dated 11/27/24, indicated but was not limited to: -Requires reminders to attend activities; is a passive participant. -Wellness/healing: light movement. -Mental wellness: music therapy; pet therapy -Cognitive: forgetful/requires reminders and cues; confused; short attention span, cannot comprehend instruction. -Activity preferences: music, sing a long, outdoor. Review of the Resident's Activity Care Plan, last revised 1/5/25, listed interventions including but not limited to: -Activity staff will visit Resident daily to inform, invite and encourage him/her to participate in activities -Offer Resident independent leisure activities as needed No evidence was found in the Activity Care Plan to include interventions for musical activities, sing along, pet therapy, or to go outside when the weather was good. Review of the Resident's Activity Participation Log indicated the following: August 2024: -2 days of listening to music -2 days of engaging conversation -1 day of refreshment cart -2 days of socializing with peers -29 days with no activity recorded Further review of the August 2024 Activity Participation Logs showed no evidence that the Resident had been offered to participate in a sing along, pet therapy, participate in light movement, or to go outside. Review of the Resident's Activity Participation Log indicated the following: September 2024: -1 day of engaging conversation -1 day of socializing with peers -29 days with no activity recorded Further review of the September 2024 Activity Participation Logs showed no evidence that the Resident had been offered to participate in music therapy, sing along, pet therapy, participate in light movement, or to go outside. Review of the Resident's Activity Participation Log indicated the following: October 2024: -1 day of listening to music -30 days with no activity recorded Further review of the October 2024 Activity Participation Logs showed no evidence that the Resident had been offered to participate in sing along, pet therapy, participate in light movement, or to go outside. Review of the Resident's Activity Participation Log indicated the following: November 2024: -1 day of basketball -2 days of Bingo/group games -1 day of Tea Club -2 days of exercise -3 days of arts & crafts -2 days of entertainment -18 days with no activity recorded Further review of the November 2024 Activity Participation Logs showed no evidence that the Resident had been offered to participate in sing along, music, pet therapy, or to go outside. Review of the Resident's Activity Participation Log indicated the following: December 2024: -1 day of reading materials offered -1 day of a holiday event -29 days with no activity recorded Further review of the December 2024 Activity Participation Logs showed no evidence that the Resident had been offered to participate in sing along, music, pet therapy, participate in light activity, or go outside. Review of the Resident's Activity Participation Log for January 2025 failed to indicate the Resident was offered or participated in any activities. During an interview on 1/3/25 at 1:00 P.M., the Activity Director (AD) said she documents all residents' participation in the activity program in the electronic medical record. She could not explain why Residents #6 and #48 did not participate in programming according to their comprehensive assessment and preferences. During an interview on 1/6/25 at 10:56 A.M., Activity Assistant #3 she said she is the program coordinator for the dementia activity program. She said the program is held off the unit and limited to 10 to 12 residents that could benefit from smaller group activities. She said Residents #6 and #48 have not participated in the dementia activity program. 3. On the following days of survey, the surveyor made the following observations of the B Unit activity/dayroom: -1/2/25 at 9:18 A.M., 18 residents were seated in the dayroom with no staff members present. Hospice Aide #1 was seated next to one resident. The television was on, but only three residents were facing the television. Two residents were sleeping and 13 residents were awake with nothing to do. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. During an interview on 1/2/25 at 9:23 A.M., Hospice Aide #1 said she comes to the facility four times a week from 8:00 A.M. to 12:00 P.M. to care for four residents. She said when she is here, she sees no staff engagement with the residents in the dayroom and wishes there were more activities for the residents to do. -1/2/25 at 9:58 A.M., 12 residents were seated in the dayroom with one staff member present who was sitting in a chair along the wall not engaging with the residents. The television was on a music station, but the sound was low and inaudible. One resident had a shape [NAME] toy, and one resident had a tube search puzzle in front of him/her. Ten residents were awake with nothing to do. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. -1/2/25 at 10:10 A.M., 11 Residents were seated in the dayroom with Activity Assistant #1 in the room with a coffee cart. Activity Assistant #1 gave a cup of coffee to one resident, then left the room. Hospice Aide #1 was seated next to one resident. One resident was engaged in manipulating puzzle pieces, five residents were sleeping in their chairs, two residents were looking at the TV (which was showing an exercise program) and three residents were awake with nothing to do. There was no staff interaction, and the residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. -1/2/25 at 10:34 A.M., 13 residents were seated in the dayroom with no staff member in the room. Hospice Aide #1 was seated next to one resident. Ten of 13 residents were awake with nothing to do and three residents were sleeping. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. The activity calendar posted outside the dayroom indicated Noodle Balloon was supposed to be occurring but was not. At 10:36 A.M., Activity Assistant #1 came into the dayroom and returned to the coffee cart. -1/3/25 at 11:44 A.M., 11 residents were seated in the dayroom with no staff member in the room. One resident was looking at magazines. Ten residents were awake and had nothing to do. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. During an interview on 1/3/25 at 11:45 A.M., Resident #144's family member said she said she comes in as often as she can to visit her loved one. She said she has seen the residents play Bingo before but otherwise has not seen any activities going on. She said there is rarely any activity staff on the unit. The family member said she is not sure if every time she is here, if staff are on a break, they call out sick, or they just don't have anyone to work. During an interview on 1/3/25 at 1:00 P.M., the Activity Director (AD) said Activity Assistant #1 works on the B Unit, and Activity Assistant #3 runs a dementia activity program on the first floor for about 10 residents. The Activity Director was unable to explain why the specialized programming was not available to all residents on the B Unit. She said Unit Manager #1 is in charge of the program and would be able to provide more detailed information. -1/3/25 at 1:41 P.M., 13 residents were seated in the Unit B dayroom awake with one staff member present who was sitting in a chair along the wall not engaging with the residents. The television was on to a music video. Three residents were watching the TV, and 10 residents were not in the line of sight to the television and had nothing to do. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. During an interview on 1/3/25 at 2:00 P.M., Unit Manager #1 said she is really not in charge of the dementia activity program. She said there is no specific eligibility criteria or assessment process for residents to participate in the program. She said they select residents that need smaller group activities, and someone that may be a fall risk or a wanderer. She said the program runs Monday through Friday after breakfast until 1:30 P.M. -1/6/25 at 9:56 A.M., 15 residents were seated in the dayroom with one staff member present who was sitting in a chair along the wall not engaging with the residents. The TV was on, but the volume was low and inaudible. All the residents were awake with nothing to do. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. -1/6/25 at 10:09 A.M., 17 residents were seated in the dayroom with one staff member present who was sitting in a chair along the wall not engaging with the residents. The TV was on, but the volume was low and inaudible. All the residents were awake with nothing to do. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. The activity calendar posted outside the activity room indicated Coffee Club was scheduled during this time, but this activity was not occurring. -1/6/25 at 10:22 A.M., 12 residents were seated in the dayroom with one staff member present and walking around the room. The residents were awake and were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. Coffee Club was not occurring as noted on the activity calendar. -1/6/25 at 10:31 A.M., 11 residents were seated in the dayroom with no staff present in the room. One resident was sleeping, eight residents were awake with nothing to do, and two residents were wandering in the dayroom. The TV was on, but no residents were watching it. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. The activity calendar posted outside the activity room indicated Seated Kickball was supposed to be occurring, but it was not. -1/6/25 at 10:43 A.M., eight residents were seated in the dayroom with no staff present in the room. All eight residents were awake with nothing to do. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. The activity calendar posted outside the activity room indicated Seated Kickball was supposed to be occurring as noted on the activity calendar but was not. -1/6/25 at 10:49 A.M., eight residents were seated in the dayroom with no staff present in the room. The TV was on with one resident watching it. Seven residents were sitting with nothing to do. The residents were not provided with materials for self-directed activity and were not otherwise engaged in meaningful activity. Seated Kickball was supposed to be occurring during this time as noted on the activity calendar but was not. -1/6/25 at 10:52 A.M., the surveyor observed Activity Assistant #1 in the hallway at the opposite end of the B Unit pushing a coffee cart in the hallway. During an interview on 1/6/25 at 10:56 A.M., Activity Assistant #3 said she is the program coordinator for the dementia activity program and tries to have 10 to 12 residents attend the program that otherwise would just sit with nothing to do. She said she can often get residents to participate when they come to the program; they come down daily or a few days a week for small group activities and to eat lunch. She said the program starts at 10:00 A.M. and ends around 1:30 P.M. every day during the week. She said after 1:30 P.M., she has her lunch, then goes upstairs to either the A or B Unit to do activities such as Bingo until 4:00 P.M. The Activity Assistant said no other activity staff do anything like this program upstairs on the B Unit for those that do not participate in the special program. She said they have regularly scheduled activities as noted on the calendar. She said she is aware that there are many periods of time that the residents on the B Unit are in the dayroom with nothing to do. She said there is a closet in the Unit B dayroom that is filled with supplies such as puzzles and sorting items for residents to use. She said the closet has a numerical lock on it, and all staff have the code and can access it at any time. She said the residents should never sit with nothing to do. -1/6/25 at 2:08 P.M., 10 residents were seated in the dayroom, four of which had Bingo cards. Activity Assistant #1 was seated at a table, positioned with her back to two of the four residents with cards as she called out Bingo numbers. There were no other staff in the room to assist in the activity. As she called out Bingo numbers, one resident fanned his/her face with the Bingo card, one resident was staring at the Bingo card, and two residents were not looking at their Bingo cards at all. Activity Assistant #1 did not assist the residents with playing the game or otherwise engage with the residents. During an interview on 1/7/25 at 9:20 A.M., Activity Assistant #1 said when she called Bingo on the B Unit on 1/6/25, she said she did not assist the residents with playing, but took turns playing their cards for them so they could win a prize. She said she did not consider playing a different game or activity that would be more appropriate for the residents' cognitive level so they could participate. She said they have low staff and she can't do it all on her own. During an interview on 1/7/25 at 11:56 A.M., the Director of Nursing (DON) said the Activity Director's last day at the facility was 1/3/25. She said she didn't get very involved with the activity program. She said they hope to hire a new Director soon and plan to work on the activity program.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections for four Residents (#294, #295, #40 and #144), out of a total sample of 21 residents. Specifically the facility failed: 1. For Resident #294, to maintain sanitary conditions of a nebulizer tubing set up and mask (parts of the nebulizer to administer aerosolized medications); 2. For Residents #295 and #40, to ensure appropriate personal protective equipment (PPE) was worn by staff while providing close contact care for a Resident on Enhanced Barrier Precautions (EBP); and 3. For Resident #144, to ensure appropriate personal protective equipment (PPE) was worn by staff while providing close contact care for a Resident on EBP and contact precautions. Findings include: 1. Review of the National Health, Blood and Lung institute document on How to use a Nebulizer, dated October 2021, indicated but was not limited to the following: How to store between uses: Store nebulizer parts in a dry clean plastic bag Resident #294 was admitted to the facility in December 2024 with diagnoses including: Chronic obstructive pulmonary disease (COPD) (a lung illness resulting in difficulty breathing). Review of the Nursing Admission Evaluation indicated the Resident was alert and oriented to person, place, and time. Review of the Self-Administration evaluations, dated 12/26/24, indicated but were not limited to the following: - Nebulizer: the Resident was capable of independently inhaling nebulizer medications by handheld device - the Resident did not express a desire to self-administer medications Review of the Resident's current interim care plans failed to indicate any information on the use of the nebulizer. On 1/2/25 at 8:01 A.M., the surveyor observed the Resident in bed with his/her eyes closed and a nebulizer machine on the floor on the right side of the bed (not on) with the tubing and mask attached, not in use by the Resident, tucked slightly behind the pillow on the right side of the bed. The face mask and tubing were not stored in a plastic bag to protect them from environmental debris or germs while not in use. No plastic storage bag was observed in the room for the storage of the nebulizer tubing. Review of the current Physician's Orders for Resident #294, dated 1/2/25, indicated but were not limited to the following: - Formoterol Fumarate (a medication used to treat COPD) nebulizer solution 20 micrograms (mcg) per 2 milliliters (ml) orally via nebulizer two times a day related to COPD - Ipratropium albuterol (a medication used to open up the airways) inhalation solution 0.5 - 2.5 (3) milligrams (mg) per 3 ml every 4 hours as needed for shortness of breath, nebulizer - Change nebulizer tubing every Sunday night shift The surveyor made the following observations throughout the survey: 1/2/25: 3:21 P.M., Resident in bed, nebulizer mask not in use, nebulizer machine in the off position, tubing and mask lying on the bed, not stored in a plastic storage bag 1/3/25: at 7:41 A.M., 12:41 P.M., and 1:05 P.M., Nebulizer mask not in use, nebulizer machine in the off position, tubing and mask lying on the bed, not stored in a plastic storage bag - no storage bag observed in the room. During an interview on 1/3/25 at 7:41 A.M., Resident #294 said he/she keeps the mask close by in case they need a nebulizer treatment. He/She said they do not self-administer and the medications are provided by the nurses. The Resident said he/she was not provided with a bag to store the mask in between uses and the staff are aware he/she is leaving it on his/her bed with the machine on the floor because there is nowhere else to put anything. During an interview on 1/3/25 at 1:05 P.M., Nurse #8 said she had not recently provided a nebulizer treatment to the Resident. She said the process is usually to set up the treatment for the residents by placing the medications in the cup securing the mask or mouthpiece to the cup, turning on the machine and handing the device to the residents or helping them put the mask on. She said once the treatments are complete the tubing and medication cup are rinsed out and dried and then the pieces are stored in a plastic bag to keep them free of germs until the next use. She observed Resident #294's nebulizer mask and tubing on the linens of the Resident's bed not stored in a plastic bag and open to potential germs and environmental debris and said the mask and tubing should not be left on the bed for infection control reasons and the machine shouldn't be on the floor. During an interview on 1/3/25 at 1:23 P.M., the Infection Preventionist said the nebulizer machine should not be left on the floor for any resident as it could become an infection control concern. She additionally said that nebulizer tubing including the mask or mouthpiece should be stored in a plastic bag to keep it clean and free of potential germs when not in use and in this circumstance that did not occur as it should have. During an interview on 1/3/25 at 1:28 P.M., the Assistant Director of Nurses said she observed Resident #294's nebulizer machine on the floor and nebulizer tubing and mask resting on the bed. She said the equipment was not being managed and stored in an appropriate manner as it should have been. 2. Review of the facility's policy titled Enhanced Barrier Precautions, undated, indicated but was not limited to the following: It is the policy to implement EBP for preventing transmission of novel or targeted multi-drug resistant organisms (organisms that are resistant to all or most antibiotics) - EBP require the use of gown and gloves for certain residents during specific high contact resident care activities in which there is an increase risk for transmission of multi-drug resistant organisms. - Orders for EBP will be obtained, signage will be posted on the door or wall outside the room, carts with appropriate PPE will be outside the room, alcohol-based hand rub (ABHR) will be available for performing hand hygiene (HH) - EBP will be continued while the qualifying condition or indwelling device is still active or in use Review of the EBP sign in use by the facility, undated, indicated but was not limited to the following: Enhanced Barrier precautions, Everyone must: Clean their hands before entering and when leaving the room Providers and staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, Device care or use of: central line, urinary catheters, feeding tubes, tracheotomies; wound care any skin opening requiring a dressing A. Resident #295 was admitted to the facility in December 2024 with diagnoses including: Open wound to right great toe. Review of the most recent Brief Interview for Mental Status (BIMS) for the Resident indicated he/she was cognitively intact with a score of 14 out of 15. On 1/2/25 at 8:36 A.M., the surveyor observed an EBP sign posted outside of Resident #295's bedroom door. During an observation with interview on 1/2/25 at 8:37 A.M., the surveyor observed Resident #295 in bed with a single lumen peripherally inserted central catheter (PICC) line in his/her right arm. The Resident said they were on antibiotics for an infection in their toe and received the medication through the PICC line three times a day. Review of the Resident record indicated but was not limited to the following: - Resident had a single lumen PICC line inserted into their right arm (in the basilic vein) on 12/17/24 - a baseline care plan was in place for use of the IV PICC line Review of the current Physician's Orders as of 1/2/25 indicated but were not limited to the following: Enhanced barrier precautions - every shift (12/20/24) During an observation with interview on 1/2/25 at 4:33 P.M., Nurse #5 said the Resident had just completed his/her dose of intravenous (IV) antibiotics and she was going to disconnect the PICC from the infusion pump. The surveyor observed Nurse #5 perform HH, don (put on) gloves, and then disconnect the IV tubing from the PICC line. Then, she flushed the PICC line with the prepared syringe of solution, doffed (took off) her gloves performed HH and left the room. At no time did the surveyor observe Nurse #5 to don a gown. Upon leaving the room, Nurse #5 confirmed that the Resident was on EBP for his/her wound and IV line. Nurse #5 said she was not aware that a gown needed to be worn when caring for the PICC line even though it is indicated on the sign posted outside of the Resident's room. During an observation with interview on 1/3/25 at 9:08 A.M., the surveyor observed Nurse #7 administer the Resident's IV antibiotic medication. Nurse #7 performed HH, donned gloves, attached the IV medication to the IV tubing, primed the line, flushed the PICC line, and then hooked the IV tubing up to the PICC line in the Resident's right arm. At no time was Nurse #7 observed to don a gown. She said the Resident is on EBP for having a wound and a central line and she should have worn a gown for that reason during the IV administration and forgot. She reviewed the EBP sign with the surveyor and said a gown should be worn during use or management of the IV line as it is a high-contact care activity and she did not wear one. During an interview on 1/3/25 at 11:18 A.M., the Director of Nurses (DON) said residents who are on EBP require staff to wear both gloves and a gown when providing high contact care. She was made aware of the surveyor's observations and said the Nurses should have put a gown on before providing any care or using the IV PICC line for Resident #295 in accordance with the guidelines and that expectation was not met. 34145 B. Resident #40 was admitted to the facility in November 2021 and has a history of Extended-Spectrum Beta-Lactamase (ESBL-a type of enzyme produced by certain bacteria that makes them resistant to a wide range of antibiotics). Review of Physician's Orders indicated but was not limited to: -Enhanced barrier precautions related to history of ESBL, every shift (12/25/24) On 1/3/25 at 8:03 A.M., the surveyor observed an EBP sign posted at Resident #40's doorway to indicate the Resident was on EBP and what PPE was to be worn for close contact care. The surveyor observed Certified Nurse Aide (CNA) #4 at Resident #40's bedside adjusting the bed linens wearing gloves and no gown. She told the Resident she was going to go get someone to assist her and left the room. On 1/3/25 at 8:09 A.M., CNA #4 returned to the Resident's room with CNA #2. Both CNAs wore gloves and no gown. CNA #4 placed shoes on the Resident's feet, then CNA #2 and CNA #4 physically assisted the Resident from a lying position to a seated position at the edge of the bed. At this time, CNA #3 entered the room, donned gloves, stood behind a wheelchair at the bedside, and assisted the other two CNAs to pivot the Resident and physically assist the Resident to sit in the wheelchair. During an interview on 1/3/25 at 8:13 A.M., CNA #3 said she didn't know Resident #40 was on EBP and only wore gloves when assisting the Resident into the wheelchair. She said if she knew the Resident was on EBP, she would have worn a gown and gloves. During an interview on 1/3/25 at 8:20 A.M., CNA #4 said when she repositioned the Resident and assisted him/her into the wheelchair, she did not wear a gown, just gloves. She said she didn't know she had to wear a gown when she repositioned the Resident. During an interview on 1/3/25 at 9:55 A.M., CNA #2 said she didn't know Resident #40 was on EBP and only wore gloves when assisting him/her into the wheelchair. During an interview on 1/6/25 at 11:30 A.M., the DON said CNAs #2, #3 and #4 should have worn gown and gloves when providing high contact care to Resident #40. 3. Review of Lippincott Nursing Procedures- 9th edition, dated 2023, section titled Contact Precautions, indicated but was not limited to: -Equipment: gowns, gloves, plastic bags, contact precaution signs; -Perform hand hygiene; -Put on a gown and gloves before entering the patient's room to comply with contact precautions; -Handle all items that have come in contact with the patient as you would for a patient on standard precautions; -Remove and discard your gown and gloves before leaving the room; -Perform hand hygiene before leaving the patient's room. Resident #144 was admitted to the facility in December 2024 and had diagnoses including ESBL in the urine and had a gastrostomy tube. Review of Physician's Orders indicated but was not limited to: -Enhanced barrier precautions related to history of ESBL, every shift (1/2/25) -Contact Precautions at all times due to ESBL Urine every shift until 1/6/25 (1/2/25) On 1/6/25 at 10:34 A.M., the surveyor observed an EBP sign and a contact precaution sign posted outside the doorway of Resident #144's room. The surveyor observed CNA #1 wearing gloves and no gown in the room physically assisting Resident #144 to get up from his/her bed. The CNA physically assisted the Resident to ambulate across the room and into the bathroom and closed the door. On 1/6/25 at 10:45 A.M., the surveyor observed CNA #1 and Resident #144, emerge from the bathroom and the CNA physically assisted the Resident to walk across the room and sit back onto the bed. The CNA adjusted the Resident's bed linen and clothing. During an interview on 1/6/25 at 10:46 A.M., CNA #1 said this was her first time working with Resident #144 and she didn't know he/she was on any type of precaution. The surveyor pointed out the contact precaution sign and EBP sign posted at the Resident's door. The CNA read the signs and said she should have worn a gown in addition to the gloves when she physically assisted the Resident with walking and when she toileted and changed the Resident. During an interview on 1/6/25 at 11:30 A.M., the DON said CNA #1 is new and she should have worn a gown and gloves when providing high contact care.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for one Resident (#40), out of a total sample of 21 residents. Specifically, the facility failed to administer medications per physician's orders. Findings include: Review of Lippincott Nursing Procedures, Eighth Edition, [Wolters Kluwer], 2019, indicated but was not limited to the following: -To promote a culture of safety and to prevent medication errors, nurses must avoid distractions and interruptions when preparing and administering medications and adhere to the five rights of medication administration: identify the right patient by using at least two specific identifiers; select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route. Recent literature identifies nine rights of medication administration, which in addition to the five rights includes the right documentation, the right action (or appropriate reason for prescribing the medication), the right form, and the right response. Verifying the Medication Order: -Follow a written or typed order, or an order entered into a computer order-entry system. Review of the facility's policy titled Medication Administration - Oral, dated June 2015, indicated but was not limited to the following: -Verify medication order on Medication Administration Record (MAR). Check against physician order. -Compare the medication label to the resident's/patient's MAR. -Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Resident #40 was admitted to the facility in November 2021 and had diagnoses including chronic venous insufficiency and chronic embolism and thrombosis of deep veins. Review of current Physician's Orders indicated the following: -Aspirin Tablet Chewable 81 milligrams (mg), give 1 tablet by mouth in the morning for pain, 3/29/24 On 1/6/25 at 8:56 A.M., the surveyor observed Nurse #8 prepare Resident #40's medications and observed the following: 8:56 A.M. - Nurse #8 opened an over-the-counter bottle of generic chewable aspirin, 81 mg, from the top drawer of the medication cart and added one whole tablet into a medication cup along with five other various whole medication tablets. Nurse #8 did not separate the chewable aspirin from the other medications. 9:03 A.M. - Nurse #8 administered the medications all together in the same medication cup to Resident #40. Nurse #8 did not separate the chewable aspirin from the rest of the medications and did not prompt Resident #40 to chew the aspirin. During an interview on 1/6/25 at 9:05 A.M., the surveyor reviewed Resident #40's medical record with Nurse #8 who said the order was for the Resident to chew the aspirin, not swallow it whole. She said the reason for a chewable aspirin is that it is absorbed faster. Nurse #8 said medications should be administered per physician's orders and the physician notified if they can't be. During an interview on 1/6/25 at 11:35 A.M., the Director of Nursing (DON) said medications should be administered per physician's orders and the chewable aspirin was probably prescribed for the Resident because of gastrointestinal reasons and easier absorption but would have to look and get back to the surveyor. She said the chewable aspirin should have been separated from the other medications and the Resident prompted to chew it. The DON said if there was any issue with the Resident not being able to chew it versus swallow it whole, then the physician would be notified to obtain a new order for a different route.

Based on observation, document review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for one Resident (#59 ), out of a total sample of 21 residents. Specifically, the facility failed to ensure medications were administered safely and not left at the Resident's bedside unsecured by the licensed staff. Findings include: Review of the facility's policy titled Medication Administration - Oral, dated June 2015, indicated but was not limited to the following: PROCEDURE: Identify resident; verify that medication is being administered at the proper time, stay with the resident until he/she has swallowed the medication Resident #59 was admitted to the facility in April 2024 and has diagnoses including: Visual disturbances, mild cognitive loss and dysphagia (difficulty swallowing). Review of the Brief Interview for Mental Status (BIMS) for Resident #59, dated 10/2/24, indicated the Resident suffered from moderate cognitive impairment with a score of 11 out of 15. During an observation with interview on 1/2/25 at 8:01 A.M., the surveyor observed Resident #59 sitting on his/her bed with two small cups on the overbed table. One cup contained two red larger oval gel caps and three small white round pills; the second cup was full to the top measurement line with a light orange liquid. The Resident said he/she does not self-administer and they do not store any medications in their room. The Resident said the cups were their morning medications but he/she was not sure what they were and that the nurses always leave them there for him/her to take while he/she is eating breakfast or prior to their smoking time. The Resident said he/she believed the medications were left so he/she could take them when he/she was ready and because the nurses are busy, they don't have to come back for him/her to take them. When asked to look in the cup and try to identify what the medications were the Resident said they take a pill for sadness and something for their eyes because they cannot see well and some type of liquid but couldn't identify them by name or say what time they were supposed to be taken except in the morning. Review of the medical record indicated but was not limited to the following: - One self-administration of medication evaluation, dated 4/1/24, and indicated the Resident did not have a desire to self-administer their medications - Current, active physician's orders, dated 1/3/25, failed to indicate an order for Resident #59 to self-administer medications - Progress notes from 11/1/24 through 1/3/25 failed to indicate the Resident expressed a desire to self-administer medications or any steps were taken in the process to identify if it were safe to leave medications at the Resident's bedside. Review of the current care plans for Resident #59 indicated but were not limited to the following: FOCUS: Resident has difficulty seeing because of decreased visual acuity - cataracts (4/1/24) GOAL: Resident will not have an accident related to impaired vision for 90 days (4/1/24) INTERVENTIONS: Announce your presence so resident will not be startled (4/1/24) FOCUS: Resident has a past medical history of dysphagia and malnutrition - placing them at increase risk for difficulty swallowing (4/2/24) INTERVENTIONS: Aspiration precautions; verbally inform resident of location of food/drink items, slow pace (4/2/24) The care plans failed to indicate medications could be left at the bedside safely or the Resident was capable of self-administering. During an interview on 1/3/25 at 8:34 A.M., Nurse #7 reviewed the medication administration record and pill cards and bottles for Resident #59's morning medications with the surveyor. She said the Resident receives two capsules of Preservision AREDS (a multivitamin formulated for eye health) [two red large oval gelcaps}, Lexapro (an antidepressant) three small white tablets of 5 milligrams (mg) each to equal the prescribed dose of 15 mg, and 30 milliliters of liquid protein (light orange colored liquid). Nurse #7 confirmed these were the Resident's prescribed morning medications, verifying the surveyor's observation the previous morning of the medications left at the bedside. She said Resident #59 is visually impaired and has some intermittent confusion and cannot self-administer medications, does not have an order to self-administer medications and that medications should not have been left at the bedside for safety reasons. She said the process is for the licensed nurses to ensure that when residents are administered medications that they observe the residents take all of their medications prior to leaving the room and that process was not followed on 1/2/25. During an interview on 1/3/25 at 12:57 P.M., Nurse #8 said medications cannot be left at the bedside unless a resident has an evaluation to determine they can safely self-administer and there is a doctor's order and care plan in place. She said Resident #59 is confused at times and is vision-impaired and would not be capable of safely self-administering their own medications or having their medications left at the bedside because he/she would be likely to forget to take them timely. She said licensed nurses should remain with the Resident while they are taking their medications to ensure the medications are swallowed. During an interview on 1/3/25 at 3:25 P.M., the Director of Nurses was made aware of the surveyor's observations and said the Resident does not want to self-administer medications and wouldn't likely be capable of doing so. The Resident's medications should not have been left at the bedside for the Resident. The process for safe medication administration was not followed.

Based on record review and interview, the facility failed to ensure residents receiving psychotropic medications receive gradual dose reductions (GDR) unless clinically contraindicated, in an effort to discontinue these drugs for one Resident (#6), out of a total sample of 21 residents. Specifically, the facility failed to ensure a GDR of the antipsychotic medication Seroquel was attempted, unless documented by the prescriber as clinically contraindicated in the medical record. Findings include: Review of the facility's policy titled Psychotropic Medication Management, dated April 2015, indicated but was not limited to: -Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Resident #6 was admitted to the facility in September 2022 and had diagnoses including Alzheimer's disease, major depression, and anxiety. Review of the Minimum Data Set assessment, dated 10/25/24, indicated Resident #6 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 3 out of 15, received antipsychotic medication on a routine basis only, a GDR has not been attempted, and has been documented by a physician as contraindicated on 10/11/24. Review of the Physician's Orders included the following medications: -Quetiapine Fumarate (Seroquel) 25 milligrams (mg) at bedtime, to be taken with 50 mg for total dosing 75 mg (10/27/22) -Quetiapine Fumarate 50 mg at bedtime to be taken with 25 mg for total dosing of 75 mg (10/27/22) Review of September 2024 through January 2025 Medication Administration Records (MAR) indicated Seroquel was administered to Resident #6 as ordered by the physician. During an interview on 1/3/25 at 2:12 P.M., consultant psychiatric Nurse Practitioner (NP) #3 said he sees Resident #6 on a routine basis for evaluation of psychotropic medications. He reviewed the Resident's medical record and said he thought he/she had had a GDR of Seroquel at some point. He reviewed the medical record and said the Resident has been treated with Seroquel since October 2022 with no GDR. Review of physician/NP notes, dated 8/30/24, 9/6/24, 10/4/24, 10/18/24, 11/7/24, 12/9/24, and 12/13/24, failed to indicate the Resident's treatment with Seroquel was evaluated for a GDR and failed to indicate a documented clinical rationale that a GDR of Seroquel was contraindicated, contrary to the 10/25/24 MDS assessment. During an interview on 1/7/25 at 11:56 A.M., the Director of Nursing (DON) reviewed Resident #6's medical record and said she has spoken to the physician in the past about her failure to document a clinical rationale for not initiating a GDR of psychotropic medication and will address it with her again. During an interview on 1/7/25 at 12:43 P.M., Physician #2 said she spoke with the DON a few minutes ago regarding documentation regarding a periodic evaluation of Seroquel for a potential GDR following surveyor inquiry. She said she had not documented a clinical rationale that a GDR was contraindicated and contacted her scribe in the office and directed her to add an addendum to her 12/10/24 progress note and forward it to the facility. During an interview on 1/7/25 at 2:30 P.M., the DON provided the surveyor with Physician #3's progress note dated 12/10/24. Review of the progress note indicated it was written and signed by Physician #3 on 1/7/25 at 2:28 P.M., following surveyor inquiry, and included a clinical rationale that a GDR of Seroquel was contraindicated.

Based on observation and interview, the facility failed to ensure all medications used in the facility were safely and securely stored in accordance with currently accepted professional principles. Specifically, the facility failed to ensure unauthorized personnel do not have unsupervised access to medications in one of two medication rooms as required. Findings include: Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated February 2018, indicated but was not limited to: -Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. -Storage for other medications will be limited to a locked medication room. On 1/3/25 at 2:15 P.M., the surveyor observed consultant psychiatric Nurse Practitioner (NP) #3 ask Nurse #2 to unlock the medication room so he could go inside and make a telephone call. Nurse #2 unlocked the medication room, and opened the door. Multiple medications, including emergency kits which contain medications including but not limited to anticoagulants, insulin, antibiotics, and antipsychotic medications, were observed on shelves inside the medication room. NP #3 went inside the medication room alone and closed the door. During an interview on 1/3/25 at 2:16 P.M., Nurse #2 confirmed that she had unlocked the medication room and allowed NP#3 to enter the room alone and remain in the room unaccompanied to make a telephone call. She said it was fine for him to be in the medication room alone. Nurse #9 was seated at the nursing station and said it was acceptable for NP#3 to enter the medication room and remain in there unaccompanied to make a telephone call. During an interview on 1/3/25 at 2:35 P.M., the Administrator said NP #3 should not have been allowed to enter and remain in the medication room alone. He said only nurses have keys and should be the only ones with access to the medication room.

Based on observation, interview, and record review, the facility failed to ensure staff provided food that accommodated the allergies, intolerances, and preferences of one Resident (#85), out of a total sample of 21 residents. Specifically, the facility failed to ensure the Resident was not served gluten (a protein found in some grains including wheat) and onions despite being listed as allergens in the Resident's medical record; and sausage despite preferences listed to not receive. Findings include: Review of the facility's policy titled Allergies, dated April 2015, indicated but was not limited to the following: Policy: -To identify and respond to all allergic reactions. Procedure: -Interview resident/family to determine if there are any allergies to food/drugs, or other substances. -Review all clinical documents to determine if there are any allergies. -Record allergies on Physician's Order Sheet and Medication and Treatment Administration Record (MAR and TAR). -Notify the Dietary Department if there are any food allergies. Review of a U.S. Foods Menu Solutions document titled Gluten Restricted Diet, dated November 2019, indicated but was not limited to the following: -Gluten-restricted diets are required for the medical management of celiac disease or gluten sensitivity. Removal of gluten from the meal plan is essential for gastrointestinal (GI) health for individuals with these conditions. -To assure a Gluten Free menu, all products purchased to be used for recipes on this diet must be reviewed for gluten content. Resident #85 was admitted to the facility in August 2024 with diagnoses including irritable bowel syndrome with diarrhea (IBS- digestive condition that causes abdominal symptoms including constipation, diarrhea, gas, and bloating). Review of the Minimum Data Set (MDS) assessment, dated 11/15/24, indicated that Resident #85 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of current Physician's Orders indicated the following: -Allergies: Celery, chicken, fish and seafood, gluten, hard cheese, onions, shellfish -Gluten free diet, regular consistency texture, thin (regular) liquids consistency, multiple food allergies and intolerances for diet order, 8/29/24 Review of Resident #85's physician's Progress Note, dated 8/23/24, January 2025 MAR and TAR, and the Certified Nursing Assistant (CNA) Resident Care Card indicated the following: -Allergies: Celery, chicken, fish and seafood, gluten, hard cheese, onions, shellfish Review of the Nutritional Evaluation, dated 11/15/24, indicated the following: -Food Allergies: Shellfish allergy, gluten, onion, celery, lactose, chicken, fish, see list Review of a physician's Progress Note, dated 11/12/24, indicated the following: Diet and Allergy Management: -Maintain gluten free diet with regular consistency and thin liquids. Educate nursing and dietary staff to avoid known allergens and prevent cross-contamination in meal preparation. During an interview on 1/2/25 at 9:07 A.M., Resident #85 said he/she had multiple food allergies, and the facility is careless with food choices. The Resident said he/she has spoken to the Dietitian and Ombudsman with limited resolution. During an interview on 1/6/25 at 12:00 P.M., Resident #85 said the lunch tray had just been delivered which consisted of beef stew with gravy, but he/she refused it because there were onions in it, and he/she can't have gluten. The Resident said these foods will wreck his/her GI track and gets very nervous about the food at the facility and is afraid to eat it. The Resident said last night sausage was on the tray which has chicken in it and isn't supposed to have that either. The Resident said if he/she eats food that he/she is allergic to or intolerant of he/she will end up puking and [expletive] my brains out. The Resident said the facility offered gluten free bread, but he/she was not able to distinguish it from other breads so was too nervous to eat it. Resident #85 said the Director of Nursing (DON) and nursing staff are aware of the concern, but nothing has changed so he/she just relies on Cheerios, apple juice, and protein powder that's stored in their room. On 1/6/25 at 12:10 P.M., the surveyor, with CNA #4 and Resident #85 present, observed Resident #85's lunch meal tray and meal ticket stored on the food truck. The lunch tray consisted of beef stew including gravy, potatoes, green beans, and carrots. The Resident said there were onions in it as well showing the surveyor. It was unclear at the time of the observation if the gravy contained gluten. Review of Resident #85's meal ticket indicated the following: -Diet Order: Regular texture, gluten free, thin fluids -Allergies: Celery, chicken, fish and seafood, gluten, hard cheese, onions, shellfish -Notes: No sausage During an interview on 1/6/25 at 12:22 P.M., with Nurse #1, CNA #5 and CNA #6, Nurse #1 said Resident #85 is allergic to hard cheeses, fish, onions, and is gluten free. She said the Resident gets irritated a lot of times because the kitchen doesn't have anything he/she can eat, just hamburgers and mashed potatoes. CNA #5 and CNA #6 said there aren't many snacks the Resident can have on the unit either. CNA #5 said the kitchen will just put a hamburger on a plate or egg salad with nothing else on the plate and did not feel that was right or presentable to the Resident. Nurse #1 said she did check the Resident's lunch tray this day and didn't see onions on it. During an interview on 1/6/25 at 3:31 P.M., the Food Service Director (FSD) said he used to have gluten free bread for Resident #85, cookies, and snacks but he/she didn't want them, so he stopped ordering them. He said he used the same toaster for the Resident's gluten free bread as other breads but toasted it first and would do a deep clean on the toaster. The FSD reviewed the gravy mix label used for the beef stew with the surveyor and said it contained gluten. The FSD said Resident #85 should not have gotten the beef stew because it had gluten and onions in the mix. On 1/7/25 at 8:15 A.M., the surveyor reviewed the Resident's breakfast meal tray with the Resident and CNA #7. The breakfast tray consisted of scrambled eggs, one hard-boiled egg, and two pieces of sausage. Resident #85 said, I can't have sausage and refused the tray. During an interview on 1/7/25 at 8:20 A.M., the surveyor reviewed the Resident's breakfast tray with Nurse #1. Nurse #1 said she checked the Resident's tray but didn't see the sausages on it. She said it was her responsibility to check the trays to ensure there were no foods on it that shouldn't be. She and CNA #7 said the Resident receives food items on his/her tray he/she shouldn't have every day. During an interview on 1/7/25 at 8:38 A.M., Resident #85 said he/she was intolerant of sausage and if ingested he/she will end up on the commode with diarrhea and would need a puke bucket at the same time. On 1/7/25 at 12:00 P.M., the surveyor reviewed the A-Unit Nourishment Kitchen with the Assistant Director of Nursing (ADON) who said the unit had no snacks to offer the Resident that he/she could have other than one frozen Lactaid ice cream in the freezer. During an interview on 1/7/25 at 12:25 P.M., the FSD said when a resident is admitted they inform staff of allergies. He said he speaks with the resident about their allergies as well as their likes and dislikes and does a menu with them. He said he used to do a menu with Resident #85, but he/she didn't want to do it anymore so dietary staff now just focuses on what he/she can have but it's very limited. The FSD said the Resident frequently sends the tray back. The FSD said the Resident should not have received the beef stew or sausages on his/her meal tray. During an interview on 1/7/25 at 12:38 P.M., the DON said nursing reviews allergies with all new admissions, and they get added to the electronic medical record. She said the pharmacy is made aware as well as the kitchen where a meal ticket gets printed out listing the allergies and intolerances. She said Resident #85 should have received the diet as prescribed by the physician.

Based on observation, interview, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for six Residents (#15, #36, #39, #47, #42 and #30), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Residents #15, #36, #39, and #47, to ensure a physician's order was in place to transfer them to the hospital; and 2. For Resident #42, to ensure a physician's order was followed to obtain a blood pressure prior to administering antihypertensive medication (used to lower blood pressure); and 3. For Resident #30, to ensure Physician's orders were in place to include PICC line catheter flushing before and after administration of intravenous antibiotic medication according to professional standards of practice and facility policy. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1A. Resident #15 was admitted to the facility in February 2023 with the following diagnoses: cirrhosis of liver and diabetes mellitus. Review of Resident #15's Minimum Data Set (MDS) assessments, dated 4/29/24 and 6/11/24, indicated he/she was discharged to the hospital with return anticipated. Review of Resident #15's Nursing Progress Note, dated 4/29/24, indicated he/she was transferred to the emergency department. Review of Resident #15's Nursing Progress Note, dated 6/11/24, indicated he/she was transferred to the hospital. Review of Resident #15's Order Listing Report for 4/28/24 through 8/1/24 failed to indicate an order to transfer him/her to the hospital on 4/29/24 or 6/11/24. During an interview on 8/5/24 at 12:55 P.M., the Director of Nurses (DON) said there was no order to transfer Resident #15 to the hospital on 4/29/24 or 6/11/24. The DON said a physician's order should be obtained when a Resident is transferred to the hospital. 50740 B. Resident #36 was admitted in June 2023 with diagnoses which included Alzheimer's disease and repeated falls. Review of Resident #36's MDS assessment, dated 6/28/24, indicated that he/she was discharged to the hospital with return anticipated. Review of Resident #36's Nursing Progress Note, dated 6/28/24, indicated Resident #36 was found on the floor, 911 was called to transfer the Resident to the hospital, and the Resident's Health Care Proxy and physician were notified. Review of Resident #36's Order Listing Report for 6/27/24-8/31/24 failed to indicate an order to transfer him/her to the hospital on 6/28/24. During an interview on 8/5/24 at 10:14 A.M., Nurse #6 said that she was the nurse on duty when Resident #36 was transferred to the hospital after a fall on 6/28/24. Nurse #6 said that when a resident is transferred to the hospital, the facility staff calls 911 and then notifies the resident's family and doctor. Nurse #6 said that she was not sure if a physician's order is needed when a resident is transferred to the hospital. During an interview on 7/31/24 at 11:17 A.M., the Assistant Director of Nurses (ADON) said a physician's order should be documented in the medical record when a resident is transferred to the hospital. C. Resident #39 was admitted in November 2022 with diagnoses which included dementia and rheumatoid arthritis. Review of Resident #39's MDS assessment, dated 6/16/24, indicated that he/she was discharged to the hospital with return anticipated. Review of Resident #39's Nursing Progress Note, dated 6/16/24, indicated Resident #39 fell on the floor in the hallway, 911 was called for transfer to the hospital, and the Resident's family and physician were notified. Review of Resident #39's Order Listing Report for 6/15/24-8/31/24 failed to indicate an order to transfer him/her to the hospital on 6/16/24. During an interview on 7/31/24 at 11:17 A.M., the Assistant Director of Nurses (ADON) said a physician's order should be documented in the medical record when a resident is transferred to the hospital. 48695 D. Resident #47 was admitted to the facility in June 2023 with diagnoses of atrial fibrillation and hypertension. Review of Resident #47's MDS assessment, dated 3/27/24, indicated he/she was discharged to the hospital with return anticipated. Review of Resident #47 Nursing Progress Note, dated 3/27/24, indicated but was limited to: -Resident c/o (complaining of) left side hip pain after fall around 4:15 while this nurse was doing neuro (neurological) assessment. Resident sent out to ER (emergency room ) for further evaluation. MD (Medical Doctor) and healthcare proxy notified. Review of Resident #47's Order Listing Report for 3/27/24 through 8/31/24 failed to indicate an order to transfer him/her to the hospital on 3/27/24. During an interview on 7/31/24 at 2:56 P.M., Nurse #1 said she thought she may have obtained an order from the Doctor to send Resident #47 to the hospital but could not remember. Nurse #1 said she should have documented the order under Physician's Orders. During an interview on 7/31/24 at 2:59 P.M., Unit Manager (UM) #1 said the expectation was that when a resident is sent to the hospital, the nurse will obtain a Physician's Order to send the resident out to the hospital and document it. UM #1 reviewed Resident #47's Order Listing Report for 3/27/24 through 8/31/24 and said he did not see an order to send Resident #47 to the hospital, but there should have been one. During an interview on 7/31/24 at 3:20 P.M., the DON said a physician's order should be obtained and documented when a resident was transferred to the hospital. 2. Review of the facility's policy titled Medication Administration- Oral, dated June 2015, indicated but was not limited to: - Procedure: - Verify Medication order on MAR. Check against physician order. - If necessary, obtain vital signs. Resident #42 was admitted to the facility in March 2022 with diagnoses of hypertension and heart failure. On 7/31/24 at 9:16 A.M., the surveyor observed Nurse #1 prepare and administer 8:00 A.M. morning medications to Resident #42 in his/her room. Nurse #1 administered the Resident's Metoprolol Tartrate (a medication that treats hypertension and heart failure) and Nurse #1 did not obtain Resident #42's vital signs including blood pressure and pulse prior to administering the medication. Review of Resident #42's current 2024 Physician's Orders indicated but was not limited to: -Metoprolol Tartrate 25 milligram (mg) tab. Give 25 mg by mouth two times daily. Hold for SBP (systolic blood pressure) < (under) 110, DBP (diastolic blood pressure) <60 and HR (Heart rate) <60 (dated 1/17/23) During an interview with record review on 7/31/24 at 9:58 A.M., Nurse #1 reviewed Resident #42's Metoprolol Tartrate order and said she did not check Resident #42's blood pressure and pulse prior to administering the medication. Nurse #1 said that Resident #42 last had his/her vital signs checked at 5:53 A.M. Nurse #1 said she had not reviewed the vital signs from 5:53 A.M. or taken Resident #42's vital signs prior to administering the medication. Nurse #1 said she should have checked Resident #42's vital signs prior to administering the medication. During an interview on 7/31/24 at 3:07 P.M., UM #1 said when administering a medication with an order to check a blood pressure and pulse the nurse should check those prior to administering the medication. UM #1 said Nurse #1 should have obtained Resident #42's blood pressure and pulse prior to administering the medication. 34145 3. Review of the facility's policy titled Central Venous Access Device Flushing, dated January 2022, indicated but was not limited to: Policy: -A prescriber order is required for vascular access device (VAD) flushing. The order will be specific with regards to flushing solution, volume, and frequency. -The VAD will be flushed before and after administration, in between multiple intravenous medication administration, and routinely at established intervals when the VAD is not in use. Procedure: -Verify prescriber's order. -Document procedure in resident's medical records, including but limited to: -Date and time -Site assessment -Flushing agent and volume flushed -Any difficulty flushing -Resident's response to procedure Review of Lippincott Nursing Procedures, eighth edition, dated 2008, indicated but was not limited to the following: Peripherally Inserted Central Catheter (PICC) Use: Flushing the PICC: -All catheters require flushing with normal saline before medication administration to clear the lumen and assess catheter function, between each medication administered to prevent drug precipitate, and after medication administration to again clear the line. Resident #30 was admitted to the facility in February 2024 with diagnoses including chronic renal failure. Review of the Minimum Data Set (MDS) assessment, dated 3/29/24, indicated Resident #30 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, received anticoagulant and antibiotic medication. Review of the medical record indicated Resident #30 was admitted to the hospital on 3/8/24 and diagnosed with severe sepsis. Review of the hospital's Inpatient Discharge Summary, dated 3/21/24, indicated a single lumen PICC line was inserted into the left basilic vein on 3/18/24 and intravenous (IV) antibiotic therapy was started in the hospital. The Resident was discharged back to the facility on [DATE] with orders to continue antibiotic therapy IV Vancomycin and IV Ertapenem 1 gram (gm) every 24 hours for two weeks. Review of March 2024 Physician's Orders indicated but was not limited to: -Flush PICC line with 10 milliliters (ml) of normal saline (NS) every shift (3/21/24) -Monitor PICC insertion site for signs/symptoms of infection every shift (3/21/24) -Ertapenem Sodium Injection Solution Reconstituted 1 gm IV one time a day (3/21/24) -Vancomycin HCI Intravenous Solution 1250 milligrams (mg)/250 ml, use 1250 mg IV one time a day (3/21/24) Further review of the medical record failed to indicate an order for PICC line flushes before and after administration of the IV antibiotic medication according to professional standards of practice and facility policy. Further review of the medical record failed to indicate a comprehensive care plan was developed and implemented for the care and treatment of the PICC device in place upon re-admission to the facility on [DATE]. Review of the March 2024 Medication Administration Record/Treatment Administration Record (MAR/TAR) indicated Ertapenem was administered at 2:00 P.M., Vancomycin was administered at 3:00 P.M. and the PICC line was flushed with 10 ml of NS as ordered by the Physician on the 7:00 A.M. to 3:00 P.M. shift by Nurse #5. Review of a documentation flow sheet (a flowsheet template provided by the consultant pharmacy and not a physician's order) titled Infusion Medication Administration Record, dated March 2024, identified the PICC line and checked off two instructions: Flush before administration 10 ml NS and Flush after administration 10 ml NS. The times for flushes were handwritten 2:00 P.M. and 3:00 P.M. The boxes corresponding to March 22 had handwritten Xs in them. The bottom of the flow sheet indicated Nurse # 5's signature and initials. Review of the medical record indicated four Nursing Progress Notes dated 3/22/24. Only one note, written at 2:24 P.M., indicated the Resident continued on IV antibiotics for sepsis; no adverse reactions noted. PICC line intact to left upper arm; no signs/symptoms of infection; flushed without difficulty. The note failed to indicate the agent and volume flushed, failed to identify if the PICC line was flushed before and after administration of antibiotic medications administered at 2:00 P.M. and 3:00 P.M. or if the flush referenced in the note was the flush ordered by the physician during the shift. Further review of the medical record indicated Resident #30 had a change of condition and was transferred to the hospital on 3/23/24 and admitted . The PICC line was removed during this hospitalization . During an interview on 8/5/24 at 10:59 P.M., Unit Manager #1 reviewed the Resident's medical record and said there should have been an order to flush the PICC line before and after each administration of the IV antibiotics and there was not. He said the Infusion Medication Administration flow sheets are redundant to the MAR/TAR, but don't represent Physician's orders. He said if Nurse #5 did the flushes before and after the medications were administered, she should have ensured an order was in place and written her initials in the corresponding box to indicate the flushes were done and not written X's. He said he doesn't know for sure if the flushes were done because there was no order to do it. Unit Manager #1 said a care plan was not developed for the PICC but should have been. He said the care plan should have identified the Resident's severe sepsis, the PICC line, and IV antibiotic treatment. During an interview on 8/5/24 at 11:31 A.M., the Director of Nursing (DON) reviewed Resident #30's medical record and said there should be orders to flush the PICC line before and after the IV medications were administered, but there is not. She said if Nurse #5 did do the flushes, there should have been an order and she should have signed off on the MAR/TAR and flowsheet with her initials, and not an X because it is confusing. During an interview on 8/5/24 at 2:14 P.M., Nurse #5 said she wrote an X on the flowsheets to indicate the IV antibiotics were administered and the flushes before and after were done. The surveyor asked Nurse #5 if she verified that there were orders prior to flushing the PICC line before and after the antibiotic administration, and she said there should have been an order, but she doesn't remember. She said if there wasn't an order, it is protocol to flush between medications and would have done it anyway.

Based on observations, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure the medication and treatment carts were locked when not in direct supervision of the licensed nurse; and 2. Ensure safe storage of medications and biologicals according to current standards of practice. Findings include: Review of the facility's policy titled Medication Administration- Oral, dated June 2015, indicated but was not limited to: - Medication carts are always locked when unattended. Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated February 2018, indicated but was not limited to: - Policy: The facility provides pharmaceutical services that are conducted in accordance with accepted ethical and professional standards of practice and that meet applicable Federal, State and Local Laws, rules and regulations. - Procedure: - Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. - The medication cart is to be kept locked at all times when not in use by the nurse. The medication cart is to be locked when stored in the medication room or some other location. 1. The surveyor observed the following medication/treatment carts to be unlocked and unattended: - 7/30/24 at 10:04 A.M., Unit A Cart 2 medication cart was unlocked in the hallway and unattended with the keys in the lock. Nurse #1 was in a Resident's room with her back to the medication cart. - 7/31/24 at 9:01 A.M., Unit A Cart 2 medication cart was unlocked in the hallway and unattended. Nurse #1 was in a Resident's room with her back to the medication cart. - 7/31/24 at 11:22 A.M., Unit A Cart 2 medication cart was unlocked in the hallway and unattended. Nurse #1 was in a Resident's room behind a privacy curtain. - 7/31/24 at 11:29 A.M., Unit A Cart 2 medication cart was unlocked in the hallway and unattended. Nurse #1 was in a Resident's room diagonally across the hall. - 7/31/24 at 12:40 P.M., Unit A Cart 2 medication cart was unlocked in the hallway and unattended. - 8/1/24 at 8:02 A.M., Unit A Cart 2 medication cart was unlocked in the hallway and unattended. Nurse #1 went into the medication room with the door closed. - 8/1/24 at 2:35 P.M., Unit A Cart 2 medication cart was unlocked and unattended in the hallway diagonally across from the nurses' station out of view of the nurse. During an interview on 8/1/24 at 12:05 P.M., Nurse #1 said a medication cart should never be left unlocked and unattended, especially with keys hanging out of the lock. Nurse #1 said the medication cart should be always locked when a nurse is next to it. During an interview on 8/1/24 at 2:28 P.M., the Director of Nursing (DON) said if a medication cart is out of the view of the nurse it should be locked. The DON said the medication cart should never be unlocked and unattended, especially with keys left in the lock of the cart. 2. Resident #48 was admitted to the facility in June 2024 with diagnoses of gastrostomy (g-tube, tube inserted through the belly that brings nutrition and medication directly to the stomach) and malignant neoplasm (cancer) of pharynx (throat). Review of the Minimum Data Set (MDS) assessment, dated 7/3/24, indicated that Resident #48 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating that he/she had moderate cognitive impairment. On the following dates and times, the surveyor observed a clear plastic medication cup with white cream in it on Resident #48's nightstand: -7/30/24 at 9:48 A.M. -7/30/24 at 2:35 P.M. -7/31/24 at 8:58 A.M. -7/31/24 at 11:23 A.M. During an interview on 7/31/24 at 8:58 A.M., Resident #48 said the cream on his/her nightstand is used by nurses to put on the area around his/her g-tube site. Review of Resident #48's current July 2024 Physician's Orders indicated but was not limited to: -Treatment: Miconazole (anti-fungal) Nitrate External Cream 2% Location g-tube site every shift for red area (dated 7/18/24) During an interview on 8/1/24 at 2:37 P.M., Nurse #1 said she was unaware there was a medicated cream on Resident #48's nightstand. Nurse #1 said Resident #48 should not have medicated cream on his/her nightstand. During an interview on 8/1/24 at 2:28 P.M., the DON said medications should not be left at any residents' bedside unless it is in a locked drawer and they have an order to self-administer the medication.

Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen was maintained in a clean and sanitary condition; 2. Ensure two of two unit kitchenettes were maintained in a clean and sanitary condition; 3. Ensure food items were properly labeled, dated, and stored in the main kitchen; and 4. Ensure food items were properly labeled and dated in two of two unit kitchenettes. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Review of the facility's policy titled Dietary Department Guidelines, undated, indicated but was not limited to: -The facility must store, prepare, and distribute food under sanitary conditions. -The Dietary Department Supervisor will be a qualified food operator and have completed certification programs as required by state regulation. She or he will oversee the entire dietary program in collaboration with the dietitian, including the purchase, storage, preparation, and serving of food to residents, employees, and visitors as indicated. She or he also will supervise the cleaning and sanitizing of dishware and utensils, as well as the cleaning of the physical dietary plant. -The Dietary Department will be maintained in a clean and sanitary manner to prevent foodborne illness. -All food items should be labeled and dated to allow for rotation of supplies. -All items stored in the refrigerator will be covered, labeled with the contents and the date. All potentially hazardous foods must be discarded within three calendar days after the date prepared. -All foods shall be prepared according to Food and Drug Administration (FDA) Food Code, with special attention paid to potentially hazardous foods . and will be handled with extreme caution throughout the preparation and storage processes. -Foods brought into the facility by family members will be kept in appropriate storage, refrigerated if indicated, must be labeled and dated and will be discarded as appropriate. For example, prepared foods that require refrigeration should be discarded after three calendar days, whereas crackers stored in an airtight container may be kept longer. Review of the facility's policy titled Personal Food Policy, dated November 2016, indicated but was not limited to: -Families and visitors of residents are permitted to bring food into the facility for the resident's use. However, nursing home residents are at risk for serious complications from foodborne illness which may occur from unsafe food handling practices. In order to ensure the safety of our residents, food may only be brought into the facility in accordance with this policy. -The staff person receiving the personal food shall label the container with the date it was brought into the facility (or the date of preparation, if known) and the name of the resident receiving it. -Dietary aides are responsible for checking nourishment refrigerator daily and discarding any unused refrigerated food after three days. Frozen foods should be discarded after three months. -Any perishable items that are found outside of the refrigerator or unlabeled shall be discarded unless it can be verified that the food has not been out for more than 2 hours. 1. On 7/30/24 at 8:15 A.M. and on 7/31/24 at 8:40 A.M., the surveyor observed the following: Main kitchen: -exposed ceiling piping covered with a noticeable layer of dust along its span, with some areas of the piping located above food prep areas; -one section of ceiling pipe with dark splotches and corrosion located above an area where meal trays are assembled; -several walls, areas of the ceiling, and bulkhead with a noticeable layer of dust; -one mini-split covered with a layer of dust, located over a food prep table; -soil and debris buildup along the perimeter of the kitchen floor and underneath kitchen equipment; -two chest refrigerators containing single-serve drinks, such as milk cartons and juices, both with condensation and black buildup along the rubber sealings. Walk-in refrigerator: -drips of condensation along the refrigerator condenser located above lidless cardboard boxes containing unopened packages of cheese and above opened and re-wrapped packages of fresh spinach and fresh broccoli florets; -light fixture with condensation running along the inside of its plastic covering and smaller amount of condensation on its exterior which was located above a rolling cart that contained several different single-serve beverages; -buildup of tan-colored, powdery substance on several areas of all shelving, easily removed by the wipe of a finger; -walls with brown spots and splashes of substances; -buildup of soil and debris around the perimeter of the floor; -debris, such as coffee creamers, plastic lids, and packaging, underneath the shelving. Walk-in freezer: -Debris, such as frozen vegetable pieces and paper and plastic packaging, on the floor and underneath the shelving. During an interview on 8/1/24 at 8:21 A.M., the Food Service Director (FSD) said he expected kitchen areas and equipment to be maintained in a clean and sanitary condition. The FSD said kitchen staff followed the following two cleaning schedules: A. Review of the cleaning schedule titled Cleaning Checklist, undated, included but was not limited to the following: -A.M. Diet Aides to sweep floors after meals. -Cook to clean all freezers and refrigerators, interior and exterior, weekly. -Diet Aide to empty and clean milk refrigerators weekly. B. Review of the cleaning schedule titled Dietary Cleaning Schedule, undated, included but was not limited to the following: -Monday, Morning Aide #3 to empty and clean milk refrigerator. -Wednesday, Night Aide #2 to empty and clean milk refrigerator. -Friday, Night Aide #2 to sweep and mop walk-in refrigerator. Underneath shelves. -Friday, Night Aide #3 to empty and clean juice refrigerator. During the same interview on 8/1/24 at 8:21 A.M., the FSD said he expected kitchen staff to clean every part of the milk and juice refrigerator chests with a multipurpose cleaner, including the rubber seals to remove any black buildup. The FSD provided cleaning schedules for the past two weeks indicating Dietary Staff had performed and signed off on their assigned cleaning tasks. During an interview on 8/1/24 at 8:40 A.M., the surveyor and FSD observed the walk-in refrigerator. The FSD said the condensation issues within the walk-in unit started within the last week and condensation should not be dripping on food or beverage items or packaging. The FSD said he expected the walk-in to be maintained clean and sanitary, including sweeping underneath the shelving. The FSD said the walk-in refrigerator could use a power wash of the walls, floors, and shelving to remove the existing soil and buildup in its interior and on the shelving. During an interview with the FSD, Maintenance Staff #1, and the Director of Housekeeping (DOH) on 8/1/24 at 10:01 A.M., the surveyor and FSD observed the walls and ceiling in the main kitchen. The FSD said he expected all kitchen walls to be clean of soil and dust collection, as well as the exposed ceiling pipes. The FSD and surveyor reviewed both cleaning checklists and observed that cleaning the walls and pipes in the main kitchen area were not on either of the cleaning checklists. The FSD said in the two years he had worked at the facility, he had never coordinated the cleaning of the walls and exposed pipe in the main kitchen with maintenance or housekeeping. Maintenance Staff #1 and the DOH confirmed there was no coordination among the departments regarding regularly scheduled cleaning of the main kitchen. On 8/5/24 at 11:00 A.M., the surveyor observed the rubber seal of the milk chest with a buildup of black substance, especially near the corners of the seals. 2. On 7/31/24 at 11:40 A.M. and on 8/1/24 at 2:57 P.M., the surveyor observed the following in the A Unit kitchenette: -soil buildup on the perimeter of the floor; -light colored grout in one corner of the kitchenette where the ice/water machine was located and the grout in the main kitchenette area black in color; -accumulation of soil, hair, food pieces, dust, a plastic bottle cap, and other debris in the gap between the refrigerator and the wall; -drips/splashes on the wall next to the refrigerator; -behind the sink, a discolored area of grout that was slimy and slick to the touch; -refrigerator interior shelving covered with sticky residue with food containers set on top; -ice and water machine with light colored residue or buildup on the interior of the ice chute where ice is dispensed. On 7/31/24 at 9:40 A.M. and on 8/1/24 at 8:13 A.M., the surveyor observed the following in the B Unit kitchenette: -the interior door of refrigerator with sticky pink and brown substances on the shelving; -the bottom of the rubber gasket was ripped and hanging off and was discolored with black/brown substance; -the exterior left side of the refrigerator, which was located next to the countertop, was discolored with a brown substance. During an interview on 8/1/24 at 8:21 A.M., the FSD said maintenance was responsible for cleaning the interior of the ice/water machines in the facility. The FSD said Dietary Aides clean the interior and exterior of Unit refrigerators and cleaning the kitchenettes occurs daily as part of the stocking rounds. The FSD said Housekeeping cleans Unit kitchenettes daily. The FSD provided Housekeeping cleaning schedules titled A Wing and B Wing Housekeeper Responsibilities. The FSD referred to the cleaning schedules and said Housekeeping cleans Unit kitchenettes when they clean the day room from 1:00-2:00 P.M. The FSD said he expected the kitchenettes and kitchenette equipment to be maintained in a clean and sanitary condition. During an interview on 8/1/24 at 10:01 A.M., Maintenance Staff #1 said the maintenance department cleans the facility's ice/water machines monthly, usually the first of each month, and as needed. Maintenance Staff #1 said maintenance staff cleans the facility's ice bins and all internal parts. Maintenance Staff #1 said Unit staff typically only requested for maintenance to clean the exterior of the ice machine between scheduled monthly cleaning, and he could not recall any requests by Unit staff to clean any internal parts or the ice chute. Maintenance Staff #1 provided a completed quarterly schedule for all ice/water machines but could not locate the monthly schedules. Maintenance Staff #1 said the Director of Maintenance (DOM) likely had the monthly ice/water machine cleaning schedule records, and the DOM would be on vacation during the survey timeframe. On 8/1/24 at 2:57 P.M., the surveyor observed Dietary Aide #2 stocking the A Unit kitchenette with snacks. The surveyor observed Dietary Aide #2 drop a package of cookies onto the floor onto the black colored grout, pick up the package, and place the cookie package into the snack bin in the kitchenette cupboard. The surveyor did not observe Dietary Aide #2 clean any part of the ice/water machine. On 8/5/24 at 9:59 A.M., the surveyor observed the following in the B Unit kitchenette refrigerator: -one slice of pie with no label or date; -at least half of the bottom rack covered with red, sticky substance and eight bottles of cranberry and orange juice located on the same shelf; -exterior left side of the refrigerator widely covered with brown substance. On 8/5/24 at 11:11 A.M., the surveyor and Assistant FSD observed the A Unit kitchenette. The Assistant FSD said the ice/water machine and the floor and wall grout needed to be cleaned. The Assistant FSD said Dietary Staff were only responsible for cleaning the exterior of the ice/water machine. On 8/5/24 at 11:23 A.M., the surveyor and Assistant FSD observed the B Unit kitchenette. The surveyor observed that the refrigerator interior had been cleaned, however, the bottoms of some juice bottles still had pink sticky residue that was observed on the shelving previously. The Assistant FSD said she expected kitchenettes to be maintained in a clean and sanitary condition, including the interior and exterior refrigerator. During an interview on 8/5/24 at 11:32 A.M., the DOH said pulling out refrigerators and cleaning that area was not part of the cleaning tasks currently. During an interview on 8/5/24 at 12:10 P.M., the surveyor and Maintenance Staff #1 observed the A Unit kitchenette ice/water machine. Maintenance Staff #1 said the ice chute where the ice dispensed needed to be cleaned of the brown substance. 3. On 7/30/24 at 8:15 A.M., the surveyor observed the following in the main kitchen walk-in refrigerator and freezer: -one opened package of hotdogs wrapped with plastic, no label or date; -one opened carton of potato salad, wrapped with plastic, no date; -one unopened package of broccoli with contents turning brown, no label or date; -one pitcher of liquid, no label or date; -one opened package of frozen green beans, rewrapped with plastic, no label or date; and -one opened package of frozen peas, no label or date; -one bag of fresh spinach, opened, no label or date, with watery brownish yellow substance inside; -one container of thickened lemon-flavored water, opened and dated 5/13; the manufacturer label states may be kept up to 7 days under refrigeration. On 7/31/24 at 8:40 A.M., the surveyor observed the following in the dry storage room: -four containers of mayonnaise, out of box, no manufacturer expiration date, undated; -one bag of flake cereal, wrapped in plastic, no label or date; -one opened 25 pound bag of panko bread crumbs, no date; the bag was loosely twisted at the top and insecurely sealed; -one package of hard taco shells, out of box, no label or date; -six bags of brownie mix, out of box, no manufacturer expiration date, undated; -four bags of white cake mix, out of box, no manufacturer expiration date, undated; -two bags of yellow cake mix, out of box, no manufacturer expiration date, undated; -four bags of corn bread and muffin mix, out of box, no manufacturer expiration date, undated. On 7/31/24 at 4:15 P.M., the surveyor observed the following in the walk-in refrigerator: -two pieces of cake, plated and wrapped in plastic, no label or date; -one tray containing plated desserts, no label or date; -one opened bag of whipped cream, wrapped in plastic, no date; -one unopened package of broccoli with contents turning brown, no label or date. On 8/1/24 at 8:21 A.M., the surveyor observed the following in the main kitchen walk-in refrigerator and freezer: -one unopened bag of broccoli with contents turning brown, no label or date. -frozen meat with no label or date; -frozen bacon, opened and wrapped with plastic, no label or date. On 8/1/24 at 8:25 A.M., the surveyor and FSD observed the walk-in refrigerator and freezer, and the dry storage room. The FSD said all food and drink items should be labeled and dated, including any opened items or items taken out of their original boxes or packaging. The FSD said the fresh bag of broccoli should have been dated and was spoiled; the frozen meat and bacon should be labeled and dated; the dry storage items that were out of their original packaging and contained no manufacturer expiration date should be labeled and dated; any opened packaging should be closed securely to prevent contamination and spoilage. On 8/5/24 at 11:00 A.M., the surveyor observed an opened carton of Lactaid milk with no date in the walk-in refrigerator. The manufacturer label stated to consume the product within 14 days of opening. During an interview on 8/5/24 at 11:10 A.M., the Assistant FSD said the Lactaid milk should be dated. 4. On 7/31/24 at 9:40 A.M., the surveyor observed the following in the B Unit kitchenette: -one open carton of Thickened Lemon-Flavored Water, undated, with a manufacturer label which indicated after opening may be kept up to seven days under refrigeration; -one open box of Cranberry Cocktail, undated, with a manufacturer label which indicated after opening may be kept up to seven days under refrigeration; -one cup of an orange substance, dated 7/27; -one cup of yellow substance, dated 7/25. On 7/31/24 at 11:40 A.M., the surveyor observed the following in the A Unit kitchenette: -four opened containers of thickened liquids, undated, with the manufacturer label stating the product can be stored up to seven days in the refrigerator after opening. On 8/1/24 at 8:13 A.M., the surveyor observed the following on the B Unit kitchenette: -one plastic food storage container containing pasta with no label or date; -one open carton of Thickened Lemon-Flavored Water, undated, with a manufacturer label which indicated after opening may be kept up to seven days under refrigeration; -one open box of Cranberry Cocktail, undated, with a manufacturer label which indicated after opening may be kept up to seven days under refrigeration; -one cup of an orange substance, dated 7/27. During an interview on 8/1/24 at 8:21 A.M., the FSD said the Dietary Staff was responsible for checking for labels and dates. The FSD said all food and drink in the Unit kitchenettes should be labeled and dated. The FSD said any food or drink item with no label and/or dated should be thrown away. The FSD said whoever opens a carton of thickened liquid should have labeled the carton with an opened date. On 8/1/24 at 1:14 P.M., the surveyor observed the following in the B Unit kitchenette: -two opened cartons of thickened liquids, undated; the manufacturer label stated to use the product within seven days of opening. On 8/1/24 at 2:57 P.M., the surveyor and Dietary Staff #2 observed the A Unit kitchenette together. Dietary Staff #2 said he made sure the items he stocked were labeled and he moved forward any opened containers and moved sealed/unopened containers toward the back of the refrigerator. The surveyor observed Dietary Staff #2 rearrange the opened containers of thickened liquid, some undated, to the front of the refrigerator and placing the sealed cartons of thickened liquid to the back of the refrigerator. Dietary Staff #2 said he was unsure if that was the right process. On 8/5/24 at 8:45 A.M., the surveyor observed the following in the A Unit kitchenette: -eight opened cartons of thickened liquid with no dates; the manufacturer label stated the product can be stored up to seven days in the refrigerator after opening; -one bowl of fresh honey dew, wrapped in plastic, no label or date; -four bowls with some type of dessert, no label or date. During an observation with interview on 8/5/24 at 10:11 A.M., the surveyor and Dietary Staff #2 observed the A Unit kitchenette together. Dietary Staff #2 said two of the eight opened thickened liquids were opened on 8/2. He selected the two cartons, labeled them 8/2 as he said that was the date he brought those cartons to the Unit and the date they were opened. The surveyor asked Dietary Staff #2 if any other cartons of thickened liquid were open and he said no. The surveyor requested Dietary Staff #2 check the remaining cartons at which point Dietary Staff #2 observed the other six cartons had broken seals. Dietary Staff #2 said he thought he should put the opened ones in the front but was not sure. Dietary Staff #2 said he did not know cartons of thickened liquids state they should only be stored in the refrigerator up to seven days after opening. The surveyor asked Dietary Staff #2 about the unlabeled and undated honeydew in the refrigerator. Dietary Staff #2 opened the refrigerator and said the honeydew should be removed since it had no label or date. During an observation with interview on 8/5/24 at 11:11 A.M., the surveyor and Assistant FSD observed the A Unit kitchenette. The Assistant FSD said cartons of thickened liquids should be labeled and dated with an opened date by the person who opens the carton. The Assistant FSD said any opened cartons with no date should be thrown away. The Assistant FSD said any food items with no label and/or date should be thrown away, and any open or prepared food or drink item that is labeled and dated has a shelf life of three days in the refrigerator. During an observation with interview on 8/5/24 at 11:32 A.M., the surveyor and Assistant FSD observed the B Unit kitchenette. The surveyor observed one slice of pie with no label or date. The Assistant FSD said the pie was from yesterday's lunch and should be thrown away as it had no date or label. The surveyor observed one Tupperware container labeled with a resident's name and dated 8/1. The Assistant FSD said the contents should be thrown away because it has been stored for greater than three days.

Based on record review, document review, observations, and interviews, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Ensure COVID-19 testing was conducted in accordance with manufacturers guidelines during a COVID-19 outbreak; 2. Ensure Personal Protective Equipment was donned/doffed (put on/ taken off) according to current professional standards; and 3. Ensure Resident #48 performed hand hygiene prior to flushing his/her gastrostomy tube (G-tube inserted through the belly that brings nutrition and medication directly to the stomach). Findings include: 1. Review of the OSang Healthcare (OHC) COVID-19 antigen self-test manufacturer's instructions for use, dated as revised 2/2023, indicated but was not limited to: - Set the timer and read the test result at 15 minutes. Do not read the result after 20 minutes. -Warning: Inaccurate test interpretations may occur if results are read before 15 minutes or after 20 minutes. Review of the [NAME] BinaxNOW COVID-19 antigen self-test manufacturer's instructions for use, dated as revised 1/2023, indicated but was not limited to: -Wait 15 minutes. Read the results at 15 minutes. Do not read the result before 15 minutes or after 30 minutes. Review of the iHealth COVID-19 antigen self-test manufacturer's instructions for use, dated as revised 12/2021, indicated but was not limited to: -Wait 15 minutes. Do not interpret your test results until after your 15-minute timer has completed, as the test result may take as long as 15 minutes to appear. -A false negative or false positive result may occur if the test result is read before 15 minutes or after 30 minutes. On 7/31/24 between 3:02 P.M. and 3:18 P.M., the surveyor observed staff conducting self-testing during a COVID-19 outbreak, as follows: -Multiple boxes of COVID-19 self-tests kits available on a table including OHC antigen self-test, BinaxNOW antigen self-test, and iHealth antigen self-test kits -Upon arrival to testing area there was one test card with the control line present, indicating the card had been utilized, sitting on a table that was unattended and completely blank, the test card remained unattended for the entire observation period. -Certified Nursing Assistant (CNA) #3 completed her swab/application of solution at 3:06 P.M. CNA #3 read her results at 3:11 P.M., disposed of the test and left the testing area. - CNA #4 completed her swab/application of solution at 3:09 P.M. CNA #4 read her results at 3:13 P.M., disposed of the test and left the testing area. - Nurse #4 completed her swab/application of solution at 3:11 P.M. Nurse #4 read her results at 3:15 P.M., disposed of the test and left the testing area. On 8/1/24, the surveyor observed staff conducting self-testing during a COVID-19 outbreak as follows: Multiple boxes of COVID-19 self-tests kits available on a table including OHC antigen self-test, BinaxNOW antigen self-test, and iHealth antigen self-test kits -CNA #5 completed her swab/application of solution at 7:08 A.M. CNA #5 read her results at 7:11 A.M., disposed of the test and left the testing area. During an interview on 8/5/24 at 11:30 A.M., the Infection Control Nurse said the facility was currently in a COVID-19 outbreak and was testing all staff members at the start of their shift. The Infection Control nurse said testing should be conducted per guidance and manufacturer's recommendations. The Infection Control Nurse said all staff should be waiting 15 minutes before leaving the testing area and reporting to their area of work. During an interview on 8/5/24 at 12:55 P.M., the Director of Nurses said staff should not be reporting to their area of work before the test has been completed as indicated in the manufacturer's instructions. 2. Review of the Centers for Disease Control (CDC) guidance titled: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 3/18/24, indicated but was not limited to the following: -Personal Protective Equipment: Healthcare providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID-19) infection should adhere to Standard Precautions and use an approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the Centers for Disease Control and Prevention (CDC) guidance titled Infection Control Guidance: SARS-CoV-2, dated 6/24/24, indicated but was not limited to: -Recommended routine infection prevention and control (IPC) practices included but was not limited to: - Source control is recommended for individuals in healthcare settings who: have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure -When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) they should be removed and discarded after the patient care encounter and a new one should be donned. Review of the sign in use by the facility and posted outside of resident rooms to indicate positive COVID status indicated but was not limited to the following: -Isolation: Droplet/Contact Precautions -In addition to standard precautions staff and providers must: Clean hands when entering and exiting and, wear gown and change in between residents, N-95 respirator, eye protection (face shield or goggles), gloves and change in between residents On 7/31/24 at 9:54 A.M., the surveyor observed Housekeeper #1 exit Resident #17's room with an Isolation: Droplet/Contact Precautions sign posted at the entrance of the room. Housekeeper #1 entered the hallway with all of his PPE in place. Housekeeper #1 removed his gloves and gown while in the hallway and disposed of them in his cart. Housekeeper #1 did not sanitize his eye protection, change his N95 or perform hand hygiene. On 7/31/24 at 10:55 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 exit Resident #36's room with an Isolation: Droplet/Contact Precautions sign posted at the entrance of the room wearing eye protection and an N95 mask. CNA #1 did not change her N95 or sanitize her eye protection after exiting the room. On 8/1/24 at 8:36 A.M., the surveyor observed Activities Assistant #1 exit Resident #17's room with an Isolation: Droplet/Contact Precautions sign posted at the entrance of the room wearing an N95 and eye protection. Activities assistant #1 was carrying a tape dispenser and papers in her hands and did not sanitize her eye protection, change her N95, or perform hand hygiene. Activities assistant #1 went directly into another resident's room. On 8/1/24 at 9:06 A.M., the surveyor observed Nurse #5 exit Resident #17's room in which an Isolation: Droplet/Contact Precautions sign was posted at the entrance of the room. Nurse #5 did not change her N95 or sanitize her eye protection after exiting the room. On 8/1/24 at 9:11 A.M., the surveyor observed Nurse #5 exit Resident #36's room in which an Isolation: Droplet/Contact Precautions sign was posted at the entrance of the room. Nurse #5 did not change her N95 or sanitize her eye protection after exiting the room. Nurse #5 went directly into Resident #9's room for whom Isolation Precautions were not indicated. During an interview on 8/1/24 at 10:03 A.M., Nurse #5 said the facility uses the CDC signs to indicate the precautions needed and notify staff and visitors of PPE required. Nurse #5 said the Isolation: Droplet/Contact Precautions sign indicated the resident was positive for COVID. Nurse #5 said when exiting a COVID room eye protection should be sanitized and a new N95 should be obtained. During an interview on 8/5/24 at 12:55 P.M., the Director of Nurses (DON) said staff should be following the CDC guidance for donning/doffing PPE. The DON said gowns and gloves should not be worn in the hallways. The DON said eye protection should be sanitized and a new N95 should be obtained after exiting a COVID room because those would be considered contaminated. 48695 Review of the Lippincott Manual of Nursing Practice, Eleventh Edition, Enteral gastrostomy and jejunostomy tube feeding and care, indicated but was not limited to: -Implementation -Perform Hand Hygiene Resident #48 was admitted to the facility in June 2024 with diagnoses of gastrostomy tube (G-tube) and malignant neoplasm (cancer) of pharynx (throat). Review of the Minimum Data Set (MDS) assessment, dated 7/3/24, indicated that Resident #48 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating that he/she had moderate cognitive impairment. During an interview on 7/30/24 at 9:48 A.M., Resident #48 said he/she had a G-tube that was not being utilized for feedings or medication. Resident #48 said he/she flushed his/her own G-tube. On the following days and times, the surveyor observed Resident #48 flush his/her G-tube without performing hand hygiene prior: -7/31/24 at 8:58 A.M. -8/1/24 at 11:58 A.M. During an interview on 7/31/24 at 9:02 A.M., Nurse #1 said Resident #48 usually flushed his/her G-tube. During an interview on 8/1/24 at 11:58 A.M., Resident #48 said he/she flushed their G-tube just like he/she did when he/she was at home. During an interview on 8/1/24 at 12:05 P.M., Unit Manager #1 said an observation and competency should have been done prior to Resident #48 flushing his/her own G-tube. During an interview on 8/1/24 at 2:28 P.M., the Director of Nursing (DON) said the Resident should have had a competency completed with observation.

Based on observations, record reviews, and interviews, the facility failed to notify the physician of a need to alter treatment significantly for two Residents (#9 and #30), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #9, to ensure the Resident's physician and Resident Representative (RR) were notified of the recommendations made by the Psychiatric Mental Health Nurse Practitioner (PMHNP) to adjust psychotropic medication because of the Resident's continued fluctuations of mood with paranoid behavior; and 2. For Resident #30, to ensure the physician was notified that STAT (urgent) labs were not obtained timely. Findings include: 1. Resident #9 was admitted in February 2024 with diagnoses including major depressive disorder, anxiety disorder, paranoid personality disorder, PTSD, and vascular dementia. Review of the Minimum Data Set (MDS) assessment, dated 5/10/24, indicated that Resident #9 scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating that he/she was severely cognitively impaired. Review of the Psychiatric Evaluation and Consultation, dated 7/23/24, indicated that Resident #9 was last seen by Nurse Practitioner (NP) #2 on 7/2/24 for a follow-up disease and medication management and that at that time, she recommended increasing Resident #9's Lamictal (a medication used for mood stabilization). Resident #9 continued to exhibit fluctuations of mood with paranoid behavior. On 7/23/24, NP #2 recommended increasing Lamictal from 75 milligrams (mg) to 100 mg, discontinuing Seroquel (an antipsychotic medication), and starting Risperdal (an antipsychotic medication) 0.5 mg by mouth in the morning. Review of the Psychiatric Evaluation and Consultation, dated 7/30/24, indicated that none of the recommendations made by NP #2 on 7/23/24 had been implemented. Review of Resident #9's Physician's Orders indicated but were not limited to the following: -Lamictal Oral Tablet 25 mg (Lamotrigine); Give 75 mg by mouth in the morning (order date 7/2/24) -Seroquel Oral Tablet 100 mg (Quetiapine Fumarate); Give 200 mg by mouth in the evening (order date 2/2/24) -Seroquel Oral Tablet 25 mg; Give 25 mg by mouth in the morning (order date 2/2/24) Review of the medical record, including Nursing Progress Notes from 7/23/24 to 7/31/24, failed to indicate the physician was notified of the Psych NP's recommendations to adjust Resident #9's medications. Review of Resident #9's Nursing Progress Notes indicated but were not limited to the following: -7/27/24 accusatory of staff and roommate. -7/28/24 noted with adverse behaviors, arguing with his/her roommate, accusatory towards staff, redirected with little to no effect. During an interview on 8/5/24 at 11:35 A.M., Unit Manager (UM) #1 said that new recommendations were made by NP #2 on 7/23/24. UM #1 said that when NP #2 makes recommendations, the recommendations are written on a log sheet and communicated to the resident's attending provider (or their designee) for approval. UM #1 said that he was unable to locate the 7/23/24 log sheet in the binder where it would typically be kept and was unable to locate any progress notes indicating that the recommendation had been reviewed by the attending physician or their designee. During an interview on 8/5/24 at 2:33 A.M., the Director of Nursing (DON) said that the PMHNP (NP #2) writes her recommendations on a log and in her progress note. The DON said that the facility nurses should review NP #2's recommendations with the resident's attending provider (or their designee) for implementation. On 8/5/24 at 8:49 A.M., the surveyor left a voicemail message left for Resident #9's RR. The RR was away and returned the surveyor's call on 8/12/24. During a telephonic interview on 8/12/24 at 1:54 P.M., the RR said that she was not aware of any recent psychotropic medication recommendations or changes. Refer to F740 34145 2. Resident #30 was admitted to the facility in February 2024 with diagnoses including chronic renal failure. The Resident had bilateral nephrostomy tubes (tubes that let urine drain from the kidney through an opening in the skin on the back) implanted on 3/9/24 during a recent hospitalization . Review of the MDS assessment, dated 3/29/24, indicated Resident #30 had moderate cognitive impairment as evidenced by a BIMS score of 11 out of 15, and received anticoagulant and antibiotic medication. Review of the medical record indicated a Nursing Progress Note, dated 3/29/24, which indicated Resident #30 had 200 milliliters (ml) of slight pink tinged yellow/gold color liquid in the left nephrostomy drain bag, and 100 ml dark gold colored liquid in the right nephrostomy drain bag. The Resident complained of pain at approximately 5:20 P.M. Review of Physician's Orders indicated a 3/29/24 STAT order for a Complete Blood Count (CBC) with differential (measure of the number of red blood cells, white blood cells, and platelets in the blood, including the different types of white blood cells (neutrophils, lymphocytes, monocytes, basophils, and eosinophils) and Comprehensive Metabolic Panel (CMP). Review of a Nursing Progress Note, dated 3/29/24, indicated the lab called to inform them that they have no staff available to come out this evening to draw labs for Resident #30, and would come to the facility on [DATE]. Further review of the medical record failed to indicate facility staff informed the Physician that STAT labs were not drawn on 3/29/24 as ordered. Review of a Nursing Progress Note, dated 3/30/24, indicated STAT labs (ordered 3/29/24) were drawn this morning, results pending, MD aware. During an interview on 8/5/24 at 11:31 A.M., the Director of Nursing (DON) and the surveyor reviewed Resident #30's medical record. She said Nursing staff should have notified the Physician the lab was unable to draw STAT labs as ordered on 3/29/24. The DON said the Physician may have wanted the Resident to be sent to the hospital to have the labs drawn.

Based on record review and staff interview, the facility failed to ensure that necessary information was communicated to the receiving health care institution to ensure a safe and effective transition of care for one Resident (#36), out of a total sample of 18 residents. Findings include: Resident #36 was admitted in June 2023 with diagnoses which included Alzheimer's Disease and repeated falls. Review of Resident #36's Minimum Data Set (MDS) assessment, dated 6/28/24, indicated that he/she was discharged to the hospital with return anticipated. Review of Resident #36's Nursing Progress Note, dated 6/28/24, indicated Resident #36 was found on the floor, 911 was called to transfer the Resident to the hospital, and the Resident's Health Care Proxy and physician were notified. Further record review indicated that there was no evidence showing that any communication was made to the receiving hospital from the facility. During an interview on 7/31/24 at 8:41 A.M., the Staff Development Coordinator said that for hospital transfers, the SBAR tool (Situation-Background-Assessment-Recommendation, a worksheet that can be used to organize information in preparation for communicating about an ill resident) is completed in the electronic medical record. During an interview on 7/31/24 at 11:17 A.M., the Assistant Director of Nursing (ADON) said a physician's order and SBAR should be documented in the medical record when a resident is transferred to the hospital. The ADON said that Resident #36 was transferred out to the hospital after a fall and no SBAR tool was completed because it was an emergency transfer. During an interview on 8/5/24 at 10:14 A.M., Nurse #6 said that she was the nurse on duty when Resident #36 was transferred to the hospital after a fall on 6/28/24. Nurse #6 said that when a resident is transferred to the hospital, the facility staff calls 911 and then notifies the resident's family and doctor. Nurse #6 said a copy of Resident #36's demographic information and advanced directive were copied from the chart and sent with the Resident to the hospital. Nurse #6 said that no additional documentation was completed and/or sent to the hospital.

Based on record review and interview, the facility failed to ensure residents were free from accident hazards for one Resident (#34), out of a total sample of 18 residents. Specifically, the facility failed to complete his/her quarterly smoking evaluation and safety screen. Findings include: Review of the facility's policy titled Smoking, dated as revised 11/2020, indicated but was not limited to: -Residents who smoke will be evaluated for their ability to smoke safely upon admission, quarterly and as dictated by any significant change in condition, to ensure that they continue to be capable of smoking and use smoking materials without presenting a danger to themselves or others. The need for assistive and/or safety devices will be identified and noted in the residents individualized care plan. Resident #34 was admitted to the facility in June 2021 with the following diagnoses: dementia and hypertension. Review of Resident #34's Minimum Data Set (MDS) assessment, dated 6/28/24, indicated he/she was cognitively intact as evidenced by a Brief Interview Mental Status (BIMS) score of 14 out of 15 and utilized tobacco products. Review of Resident #34's medical record indicated his/her last smoking evaluation and safety screen was completed on 4/23/24. During an interview on 8/1/24 at 1:32 P.M., Unit Manager (UM) #2 said smoking assessments were completed electronically and should be conducted quarterly. UM #2 said Resident #34's smoking assessment should have been completed by 7/23/24. Further review of the medical record, on 8/5/24, indicated the smoking assessment had not been completed. During an interview with record review on 8/5/24 at 12:55 P.M., the Director of Nurses (DON) said smoking assessments/evaluations should be completed quarterly. The DON reviewed Resident #34's medical record and said his/her last smoking assessment was completed on 4/23/24 and should have been completed on 7/23/24.

Based on record reviews and interviews, the facility failed to ensure that necessary behavioral health care and services were provided to create an environment to maintain the highest psychosocial well-being for two Residents (#34 and #9), out of a total sample of 18 residents. Specifically, the facility failed to review and revise the behavioral health care plan when the Residents had a change in condition. Findings include: 1. Resident #34 was admitted to the facility in June 2021 with the following diagnoses: depression, anxiety, schizoaffective disorder, post-traumatic stress disorder (PTSD), and insomnia. Review of the Minimum Data Set (MDS) assessment, dated 6/28/24, indicated Resident #34 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and received antipsychotic and antidepressant medication. Review of Resident #34's care plan indicated but was not limited to: -Focus: Resident has episodes of anxiety/history of anxiety (revised 7/12/21) Interventions: encourage participating in activities of interest as form of diversion to reduce anxiety (7/12/21), observe behaviors as/and if indicated [sic] (7/12/21), psych evaluation and follow up as needed for medication management and counseling (7/12/21) -Focus: Behavior Problem related to diagnosis: anxiety, schizoaffective disorder (revised 7/17/24) Interventions: Administer and monitor the effectiveness and side effects of medications as ordered (9/22/22), anticipate care needs and provide them before the resident becomes overly stressed (9/22/22), Investigate/monitor need for psychological/psychiatric support. Provide services as ordered by the physician (9/22/22), Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved (9/22/22), Report to MD new or change in acute behavioral status (9/22/22) -Focus: Resident is having trouble sleeping (3/13/24) Interventions: Allow resident to ventilate feelings, concerns that may be keeping resident awake (3/13/24), Offer medications as ordered and determine effectiveness of medication used to promote sleep (3/13/24) Review of Resident #34's Physician's Orders indicated but was not limited to: -Invoke Health Care Proxy (12/8/23) -Paroxetine (antidepressant medication) 30 milligrams (mg) by mouth in the morning related to anxiety, 11/17/23 -Risperdal (antipsychotic medication) 0.5 mg by mouth two times per day related to schizoaffective disorder, 6/13/24 Review of Resident #34's progress note, dated 7/22/24, indicated he/she had voiced concerns of suicidal ideation to the Certified Nursing Assistant (CNA) and had been assessed by Nurse Practitioner (NP) #1. The progress note indicated that a note was left in the psych book. Review of the Resident Log, dated 7/22/24, indicated Resident #34 had a change in condition as evidenced by increased depression, life stressor, and suicidal ideation. Further review of the log indicated NP#2 had initialed the report on 7/23/24. Review of Resident #34's progress note, dated 7/23/24, composed by Nurse #4, indicated the Resident was evaluated by NP #2 who recommended Remeron (antidepressant medication, also called Mirtazapine) 7.5 mg daily at bedtime for insomnia and depression. Further review of the progress note indicated the physician was made aware and agreed and that a message was left for the Resident Representative to obtain consent. Review of Resident #34's Psychiatric Evaluation and Consultation, dated 7/23/24, indicated but was not limited to: -The nursing staff reported that the patient was severely depressed. This provider assessed the patient and reported a lack of sleep at bedtime. He/she denied suicidal ideation/homicidal ideation. -Current Assessment/Plan: This provider assessed the patient; the patient endorsed a lack of sleep at bedtime. This provider recommended Mirtazapine 7.5 mg by mouth at bedtime. The patient will continue to take the medications as prescribed. Review of Resident #34's Physician's Orders failed to indicate an order for Remeron had been initiated. During a telephonic interview on 8/1/24 at 11:00 A.M., Resident Representative #1 said the facility had not notified her of the suicidal ideation, change in condition or NP #2's recommendation to start Remeron. Resident Representative #1 said she did not have any messages from the facility regarding a need to alter Resident #34's plan of care. Resident Representative #1 said Resident #34 had expressed to her a desire to move to another unit because there is constant yelling on the one he/she is currently on. Resident Representative #1 said she was working with the facility to decrease the medication and did not know why they would start another medication without getting to the bottom of the issue first. Resident Representative #1 said a unit change would be beneficial. During an interview on 8/5/24 at 12:33 P.M., Resident #34 said he/she had not been getting much sleep at all since he/she moved her room to the current unit. Resident #34 said he/she is not aware of any sleeping medication and could not sleep because it was too loud at night. During an interview on 8/1/24 at 1:18 P.M., Nurse # 4 said she took care of Resident #34 on 7/23/24 but did not recall the plan of care changing and did not know anything about the recommendation to initiate Remeron. Nurse #4 said she would need to follow up with Unit Manager #2. Nurse #4 and the surveyor reviewed Resident #34's medical record and Nurse #4 said the Remeron was never initiated and his/her plan of care had not changed since 7/23/24. During an interview on 8/1/24 at 1:32 P.M., Unit Manager (UM) #2 said NP #2 saw Resident #34 on 7/23/24 and there was no concern for suicidal ideation. Unit Manager #2 said she did not recall Remeron being recommended. During an interview on 8/1/24 at 2:01 P.M., the Director of Nurses (DON) and UM #2 said there was no evidence that a recommendation was made but the NP had initialed the resident log on 7/23/24 indicating the Resident had been seen. During an interview on 8/1/24 at 2:20 P.M, Social Worker #1 said she saw Resident #34 on 7/23/24 and the Resident did not recall the event and was stable. Social Worker #1 said she had not documented the visit with the Resident because everyone else had met his/her needs. During an interview on 8/1/24 at 2:17 P.M., UM #2 said the facility spoke with NP #2 who said the Resident was clear and denies suicidal ideation but if he/she continued to make comments, he/she may need to start Remeron. UM #2 said the Nurse must have misunderstood NP #2. During a telephonic interview on 8/2/24 at 11:50 A.M., NP #2 said she saw Resident #34 on 7/23/24 who voiced concerns with a lack of sleep. NP #2 said she made a recommendation to initiate Remeron 7.5 mg at bedtime and had intended for the medication to start right away. NP #2 said she discussed her recommendations with the Nurse who was providing care to the Resident on that day, the Unit Manager and the Assistant Director of Nurses (ADON) because the DON was not in the facility on that date. During an interview on 8/5/24 at 7:25 A.M., the DON said she wanted to clarify the concerns brought to her attention regarding Resident #34. The DON said she spoke with NP#2 who stated she did intend for the Resident to start Remeron and had reviewed her recommendation with the facility staff on 7/23/24. The DON said the plan of care should have been adjusted at that time. The DON provided the surveyor with a copy of a Resident Log, dated 7/23/24, which indicated a new recommendation for Remeron 7.5 mg by mouth for insomnia/depression. The DON said since this discovery a call had been made to the Resident Representative to discuss the recommended changes in the Resident's plan of care. Subsequent review of Resident #34's medical record, on 8/5/24, indicated a nursing progress note dated 8/2/24 which indicated the Resident Representative had been called and a message had been left to obtain consent for the use of Remeron. 50740 2. Resident #9 was admitted in February 2024 with diagnoses including major depressive disorder, anxiety disorder, paranoid personality disorder, PTSD, and vascular dementia. Review of the Minimum Data Set (MDS) assessment, dated 5/10/24, indicated that Resident #9 scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating that he/she was severely cognitively impaired. Review of the Psychiatric Evaluation and Consultation, dated 7/23/24, indicated that Resident #9 was last seen by Nurse Practitioner (NP) #2 on 7/2/24 for a follow-up disease and medication management and that at that time, she recommended increasing Resident #9's Lamictal (a medication used for mood stabilization). Resident #9 continued to exhibit fluctuations of mood with paranoid behavior. On 7/23/24, NP #2 recommended increasing Lamictal from 75 milligrams (mg) to 100 mg , discontinuing Seroquel (an antipsychotic medication), and starting Risperdal (an antipsychotic medication) 0.5 mg by mouth in the morning. Review of the Psychiatric Evaluation and Consultation, dated 7/30/24, indicated that none of the recommendations made by NP #2 on 7/23/24 had been implemented. Review of Resident #9's Physician's Orders indicated but were not limited to the following: -Lamictal Oral Tablet 25 mg (Lamotrigine); Give 75 mg by mouth in the morning (order date 7/2/24) -Seroquel Oral Tablet 100 mg (Quetiapine Fumarate); Give 200 mg by mouth in the evening (order date 2/2/24) -Seroquel Oral Tablet 25 mg; Give 25 mg by mouth in the morning (order date 2/2/24) Review of the medical record, including Nursing Progress Notes from 7/23/24 to 7/31/24, failed to indicate the physician was notified of the Psych NP's recommendations to adjust Resident #9's medications. Review of Resident #9's Nursing Progress Notes indicated but were not limited to the following: -7/27/24 accusatory of staff and roommate. -7/28/24 noted with adverse behaviors, arguing with his/her roommate, accusatory towards staff, redirected with little to no effect. On 7/30/24 at 9:09 A.M., the surveyor observed Resident #9 in the hallway crying and yelling at the Staff Development Coordinator. On 7/30/24 at 9:18 A.M., the surveyor observed Resident #9 in her room crying. On 7/31/24 at 9:40 A.M., the surveyor observed Resident #9 crying and yelling at a facility staff member on the unit. During an interview on 8/5/24 at 11:35 A.M., Unit Manager (UM) #1 said that new recommendations were made by NP #2 on 7/23/24. UM #1 said that he was unable to locate the 7/23/24 log sheet with NP#2's recommendations and was unable to locate any progress notes indicating that the recommendations had been implemented or declined by the attending physician or their designee. During an interview on 8/5/24 at 2:33 A.M., the Director of Nursing (DON) NP #2 writes her recommendations on a log and in her progress note. The DON said that the facility nurses should review NP #2's recommendations with the resident's attending provider (or their designee) for implementation. On 8/5/24 at 8:49 A.M., the surveyor left a voicemail message Resident #9's Resident Representative (RR). The RR was away and returned the surveyor's call on 8/12/24. During a telephonic interview on 8/12/24 at 1:54 P.M., the RR said that she was aware of Resident #9's behaviors, but was not aware of any recent psychotropic medication recommendations or changes.

Based on observation, record review, and interview, the facility failed to follow the fall and activity of daily living (ADL) plans of care and provide adequate supervision and assistance in the shower room to prevent a fall for one Resident (#51), out of a total sample of 19 residents. Subsequently, Resident #51 sustained a fall requiring hospitalization and was diagnosed with a subdural hematoma (bleeding that occurs within the skull but outside the actual brain tissue), a nasal fracture, and a laceration that required sutures. Findings include: Review of the facility's Falls Management policy, undated, included but was not limited to: - The facility will utilize all resident/patient related information made available upon admission and ongoing to determine resident/patient at-risk for fall status. This information included but was not limited to the following: - Facility to facility referrals - Hospital Admission - Discharge summary - Rehabilitation (Physical Therapy/Occupational Therapy) referral/screening/evaluation information - Resident/patient/family/prior caregiver interview - Fall Risk Evaluation - Definition: a fall is defined as any incident in which a resident/patient unintentionally has a change in elevation/plane, an occasion where the resident would have lost their balance without staff intervention, or an incidence where a resident rolls off a bed or mattress close to the floor. - A fall risk evaluation will be conducted on each resident/patient upon admission, with the quarterly Minimum Data Set (MDS) cycle, when a significant change in status occurs, annually and following a fall. - The interdisciplinary team will develop, initiate and implement an appropriate individualized care plan based on the fall risk evaluation score - Residents/patients who are identified to be at risk on the admission fall risk evaluation will have a fall risk care plan developed with the information made available at the time of admission to implement a safety related care plan. The resident/patient can be screened/evaluated by rehabilitation services. Review of the Facility's Internal Investigation Report, dated 2/24/24, indicated that on 2/24/24 around 7:45 A.M., after hearing a loud thump, a Nurse (later identified as Nurse #3) found Resident #51 on the floor in the shower bleeding from a laceration on his/her face. Resident #51 was admitted to the facility in November 2019 with diagnoses including epilepsy and a history of falls. Resident #51's native language is not English. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/26/24, indicated Resident #51 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and could bathe independently, but required partial/moderate assistance from staff for tub/shower transfers. On 2/29/24 and 3/1/24, the surveyor made multiple observations of Resident #51 ambulating on the unit with a cane and supervised by staff. Review of a Fall Risk assessment, dated 11/9/23, indicated Resident #51 scored a 9. The assessment failed to include a legend to ascertain what level of risk was associated with the score. During interviews on 3/4/24 at 1:55 P.M. and 5:09 P.M., the Director of Nursing (DON) said the facility uses their own fall risk assessment, and a score of 10 indicates a high risk for falls. Review of Resident #51's comprehensive care plans indicated but was not limited to: - Focus: Resident has an ADL deficit related to: cognitive impairment, disease process/condition (1/21/19); Interventions: Needs intervention with the following areas. Level of assistance varies related to mood, behavior and motivation: - Bathing, grooming, hygiene: Continual supervision to assist as needed - Provide the amount of staff intervention that is needed for task completion with self-performance fluctuations (11/21/19) - Focus: At risk for fall related injury disease process/condition, functional problem (decreased strength and endurance), medication usage, use of assistive device: cane (3/24/20); -Interventions: Medication for epilepsy per physician's order (2/21/23); Provide resident/family/staff teaching to include safety measures to reduce fall risk; Provide/monitor use of adaptive device: cane (3/24/20) Review of Resident #51's Kardex (a form utilized to describe care needs for residents), last revised 11/9/23, indicated Resident #51 was a high risk for falls and required continual supervision and assistance of one staff for bathing/showering and personal hygiene. Review of a Nurse Progress Note, dated 2/24/24 at 11:22 A.M., indicated Nurse #3 heard a loud thump coming from the shower room, and found Resident #51 on the floor, very lethargic with blood coming out of his/her head. The Resident was transferred to the hospital emergency department, then transferred to another hospital's trauma center and admitted . Review of a Nurse Progress Note, dated 2/24/24 at 5:57 P.M., indicated Resident #51 sustained a subdural hematoma, a nasal fracture, and an 8-centimeter (cm) laceration on his/her forehead. Review of a Hospital Emergency Department Discharge Summary, dated 2/25/24, indicated that Resident #51 had an unwitnessed fall at the facility and sustained a 6 millimeter (mm) left lateral subdural hematoma, an 8 cm laceration above the right eyebrow, and a nasal bone fracture. During an interview on 2/29/24 at 2:17 P.M., Nurse #3 said she was working the morning Resident #51 fell in the shower room. She said she was standing at the medication cart at the nursing station and saw Resident #51 walking down the hallway with his/her cane and towels. A few minutes later, she said she heard a noise down the hall and went down the hall to check on Resident #51 in the shower room. Nurse #3 said when she arrived at the shower room, she saw Resident #51 on the floor with lots of blood and said he/she smashed his/her face. Nurse #3 said the shower room floor was slippery from the soap and water. She said at the time of the fall, Resident #51 was out of it and unable to say what happened. Nurse #3 said it is her understanding that Resident #51 is independent with all of his/her care. During an interview on 3/1/24 at 8:30 A.M., Nurse #2 translated for the surveyor and Resident #51. Resident #51 said he/she went to the shower room to take a shower and dropped a bottle of shampoo onto the floor. The Resident said he/she bent over to pick it up off the floor and slipped and fell because of the water and soap on the floor. The Resident said no staff was assisting him/her with the shower and wishes someone would have been there to help. During an interview on 3/1/24 at 8:40 A.M., Nurse #2 reviewed the Kardex for Resident #51. She said according to the Kardex, a staff member should have been with Resident #51 while he/she showered on 2/24/24. During an interview on 3/1/24 at 10:00 A.M., Unit Manager #1 said continual supervision is non-stop visualization of a resident. He reviewed Resident #51's comprehensive care plan and Kardex and said for bathing/showering, the Resident is supposed to have both continual supervision and assistance of one staff. He said on the day of the fall, Resident #51 should have had a staff member with him/her to supervise and assist with a shower. During an interview on 3/1/24 at 11:10 A.M., the Director of Nursing (DON) said that the CNA staff were likely busy with breakfast distribution and assisting other residents and didn't see Resident #51 go to the shower. She said when Nurse #3 saw Resident #51 ambulating down the hallway toward the shower room, she should have ensured he/she was supervised and assisted with showering according to the Resident's care plan and Kardex.

Based on interviews and record review, the facility failed to notify the physician about changes in condition and to re-evaluate the potential need to alter the treatment plan for two Residents (#141, #67), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #141, to notify the physician of treatment and medication recommendations made by the Wound Consultant physician and to notify the physician of changes to a sacral wound resulting in a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) with osteomyelitis (infection of the bone) and sepsis (infection of the blood stream) requiring a 19-day hospital admission and intravenous (IV) antibiotics followed by oral antibiotics for four weeks; and 2. For Resident #67, to notify the physician of significant weight loss. It was determined the Immediate Jeopardy began on 9/15/23 and was identified on 10/25/23. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 10/25/23, including the Immediate Jeopardy Templates. The Immediate Jeopardy, which began on 9/15/23, was abated on 10/26/23. The non-compliance remained at a lower scope and severity of no actual harm with potential for no more than minimal harm that is not immediate jeopardy. Findings include: Review of the facility's policy titled Condition: Significant Change, dated April 2015 indicated but was not limited to the following: -staff will communicate with the physician regarding changes in condition to provide timely communication of resident status change which is essential to quality care management -the physician will be notified by the nurse in the event of a change in condition -order changes given by the physician will be carried out -this notification shall be documented in the clinical record Review of the facility's policy titled Consultant Services, dated April 2015, indicated but was not limited to the following: -a note should be recorded on the consultation form by any health care consultant who sees the resident. The consultant should document findings and recommendations on the form. -the charge nurse will then notify the attending physician of findings and he/she can then order the specific treatments as outlined by the consultant. 1. Resident #141 was admitted to the facility in February 2015 with diagnoses including diabetes, Parkinson's disease, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #141 was dependent for all care including bathing, dressing, and eating. Review of the care plans for Resident #141 included a care plan initiated on 9/6/23 for an actual alteration in skin integrity related to moisture-related dermatitis to the sacrum acquired on 9/5/23. The care plan included goals of improved skin integrity as evident by signs and symptoms of healing and remaining free from infection. The interventions included consulting with the certified wound physician, following physician orders for skin care and treatments, monitoring for signs and symptoms of infection, and reporting to physician. Review of the medical record indicated on 9/5/23 the Wound Consultant physician identified Resident #141 had a shearing (when the skin remains stationary, and the underlying tissue moves) to the right and left sacral area (lower back, bottom of the spine). Review of the Wound Evaluation and Management Summary from the Wound Consultant, dated 9/5/23, indicated the following new areas as identified by the Wound Consultant: Non-pressure wound of the right, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 9 centimeters (cm) in length by 4.2 cm in width by 0.05 cm in depth Periwound: induration (hardening of skin), maceration (the softening and breaking down of skin as a result of prolonged exposure to moisture)- mild Exudate (drainage): light serous (clear fluid) Other viable tissue: 100% Non-pressure wound of the left, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 8 cm in length by 5 cm in width by non-measurable depth Periwound: induration, maceration-mild Exudate: none Other viable tissue: 100% Additional wound details from the Wound Consultant indicated Resident #141 was spending too much time in the Broda chair (positioning wheelchair) with the following recommendations to both buttocks: normal saline wash, house barrier cream and Zinc ointment to the periwound, three times per day. Additional recommendations included Multivitamin once daily and Zinc Sulphate 220 mg (milligrams) once daily. Review of the medical record including Physician's Orders, Medication Administration Records (MAR) and Treatment Administration Records (TAR) indicated the treatment of barrier cream and Zinc ointment three times a day was implemented on 9/6/23 and the Multivitamin and Zinc Sulphate 220 mg were not ordered as recommended. Review of the Wound Evaluation and Management Summary from the Wound Consultant, dated 9/12/23, indicated the right and left medial buttock areas were merged to one area with the following information: Non-pressure wound, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 7.5 cm in length by 9 cm in width by 0.05 cm in depth Periwound: induration - mild Exudate: none Other viable tissue: 100% The recommended treatment was for a normal saline wash, followed by Xeroform gauze and to cover with a gauze island with border dressing, once daily. Additional recommendations included a Multivitamin once daily and Zinc Sulphate 220 mg once daily. During an interview on 10/23/23 at 2:27 P.M., Unit Manager #2 said the process for when the Wound Consultant physician completed visits was for the Wound Consultant to provide verbal information regarding recommendations, then send over the written recommendations. She said, as the Unit Manager, she would obtain the written recommendations the day after the visit and review them with the physician and enter the orders as recommended. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she had not seen the recommendations for the Multivitamin and Zinc Sulphate 220 mg that were made on 9/5/23 and 9/12/23. Unit Manager #2 said she did not know the Wound Consultant physician made recommendations regarding medications. She said she must have overlooked the recommendations and the Primary Physician had not been notified of the medication recommendations. Review of the TAR indicated the recommended wound treatment of normal saline wash, followed by Xeroform gauze and to cover with a gauze island with border dressing once daily was initiated on 9/12/23 with a start date of 9/13/23. Review of the TAR indicated the wound dressing was not completed on 9/13/23 or 9/18/23. Review of the TAR indicated the following nursing documentation of the sacral area: 9/13/23: not completed as ordered 9/14/23: Base: C (clean); Drainage: none; Drainage amount: none; Outcome: NC (no change); Periwound: H (healthy) 9/15/23: Base: S (slough- non-viable necrotic (dead) skin tissue that is yellow, tan, gray, green or brown; usually moist, can be soft, stringy and mucinous in texture); Drainage: SS (serosanguineous- thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells); Drainage amount: S (small); Outcome: W (worse); Periwound: M (macerated) 9/16/23: Base: clean; Drainage: none; Drainage amount: none; Outcome: no change; Periwound: healthy 9/17/23: Base: clean; Drainage: none; Drainage amount: none; Outcome: worse; Periwound: healthy 9/18/23: not completed as ordered Review of the nursing progress notes included one note between 9/12/23 and 9/19/23. The note, dated 9/14/23, indicated there was minimal improvement to the sacral wound. There was no further documentation to indicate the changes noted in the sacral wound on 9/15/23, the reasoning for the outcome of worse on 9/17/23, or that the physician had been notified of the changes. During an interview on 10/24/23 at 1:24 P.M., Nurse #3, who completed the sacral wound treatment for Resident #141 on 9/15/23 said she could not recall how the wound looked on this date, but if she documented there was slough and drainage, then there was. She said she had not notified the physician. Review of the Wound Evaluation and Management Summary from the Wound Consultant, dated 9/19/23, indicated the following: Non-pressure wound of the right, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 4.3 cm in length by 4.5 cm in width by 3.2 cm in depth Periwound: induration, maceration- mild Exudate: moderate serous Thick adherent devitalized necrotic tissue: 70% Slough: 10% Other viable tissue: 20% Surgical excision debridement procedure: removed necrotic tissue and established the margins of viable tissue. Surgically excised 13.54 cm of devitalized tissue and necrotic muscle level tissues along with slough and biofilm were removed at the depth of 3.6 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80% to 10%. The Wound Consultant physician recommended the following treatment: normal saline wash, Sodium Hypochlorite Solution (Dakins- made from bleach that has been diluted, an antiseptic that kills most forms of bacteria and viruses) apply for 15 minutes then rinse with normal saline, apply Calcium Alginate (a highly absorbent dressing that interacts with the wound fluids to form a gel that provides a moist wound environment and facilitates auto debridement; the calcium in the dressing interacts with sodium in the wound to promote healing), apply a gauze island with border dressing, once per day. During an interview on 10/23/23 at 2:27 P.M., Unit Manager #2 said when the Wound Consultant physician came in on 9/19/23 there was a nickel size necrotic area on the sacral wound of Resident #141. She said she did not remember when the necrotic area started or when the wound changed. She said the process was for the primary physician to be notified of changes to the wound. She reviewed the medical record and said she was unable to see that the primary physician was notified of the changes of the wound becoming necrotic between 9/12/23 and 9/19/23. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said he had worked with Resident #141 for many years on various arterial, venous and pressure wounds. He said Resident #141 had a history of picking at wounds on his/her legs and that was why the Resident was considered non-compliant. He said Resident #141 had never previously developed any open areas to his/her sacrum. The Wound Consultant said the sacral area started off as moisture associated skin damage. He said he had recommended a Multivitamin and Zinc Sulphate as the supplements help with collagen and wound healing. He said he had recommended bed rest on 9/5/23 as the Resident was always sitting up in a wheelchair and wanted to alleviate pressure to the area; he said the Resident did stay in bed that week. The Wound Consultant said on 9/12/23 the sacral area had looked pretty much the same as it did on 9/5/23 and he had added the Xeroform to prevent additional moisture to the area. The Wound Consultant said when he saw the sacral area on 9/19/23, It was a shock; it was necrotic and there was a drastic change from the week before. The Wound Consultant said the change in the wound did not occur in one day, adding not a chance with that degree of necrosis. He said the wound on 9/19/23 was a sacral Stage IV pressure injury and he should have updated the Wound Evaluation and Management Summary to reflect the status of pressure injury. The Wound Consultant said on 9/19/23 there was no overwhelming odor to the wound and the Dakins was recommended to prevent infection. He said the nursing staff had not notified him between 9/12/23 and 9/19/23 of changes to the wound. He said the staff were able to call, text, and send pictures if needed. Review of the TAR indicated on 9/20/23 the wound descriptions were as follows: Base: SE (slough, eschar); Drainage: P (purulent- white, yellow, or brown fluid and might be slightly thick in texture, made up of white blood cells trying to fight the infection); Drainage amount: small; Outcome: worse; Periwound: macerated. The TAR indicated the following sacral wound treatment was started on 9/21/23: Normal saline wash, pat dry, pack undermining pocket with Alginate and cover wound with large foam dressing. The order indicated the use of Alginate, instead of Calcium Alginate, as indicated in the recommendation from the Wound Consultant and failed to include the Dakins. Review of the TAR indicated the following nursing documentation of the sacral pressure injury: 9/21/23: Base: slough, eschar; Drainage: purulent; Drainage amount: small; Outcome: no change; Periwound: healthy 9/22/23: Base: slough, eschar; Drainage: purulent; Drainage amount: moderate; Outcome: worse; Periwound: healthy 9/23/23: Base: slough; Drainage: purulent; Drainage amount: large; Outcome: worse; Periwound: macerated 9/24/23: Base: clean; Drainage: serosanguineous; Drainage amount: moderate; Outcome: no change; Periwound: macerated 9/25/23: Base: clean; Drainage: serosanguineous; Drainage amount: moderate; Outcome: no change; Periwound: macerated During an interview on 10/23/23 at 12:36 P.M., Nurse #2 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/21/23 and 9/22/23. She said she could recall that there was purulent drainage and that the wound smelled. She said she had not notified anyone of the changes, but that the purulent drainage was a sign of an infection. She said if there were any changes to the wound then the Wound Consultant would be told on the following visit (one week between visits). During an interview on 10/24/23 at 1:24 P.M., Nurse #3 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/23/23. She said she remembered that the treatment was for Alginate only. She said the wound had a lot of drainage and it was purulent drainage. Review of the medical record failed to indicate the physician was notified of the purulent drainage. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she was the one who had obtained verbal recommendations from the Wound Consultant on 9/19/23 and had waited for the written recommendations to call them into the physician and obtain a new treatment order on 9/21/23, two days later. She said she must not have reviewed the written recommendations because the Wound Consultant did not tell her verbally to use Calcium Alginate (versus Alginate) or to use Dakins. She said the treatment of only Alginate followed by a large foam dressing was used from 9/21/23 through 9/25/23. Review of the nursing progress notes included one note between 9/19/23 and 9/24/23. The note, dated 9/21/23, indicated the sacrum wound was worsening. There was no indication the physician was notified. Review of a Physician's Progress Note, dated 9/20/23, failed to include any documentation related to the Stage IV pressure injury of the sacrum. Review of a nursing progress note, dated 9/26/23, indicated the sacral pressure wound for Resident #141 had been worsening over the course of treatment, the physician was notified and there was a pending wound culture to rule out infection. Review of a nursing progress note from 9/26/23 at 11:50 A.M. indicated the laboratory (lab) called with critical lab values for pre-albumin (a protein) of 9.2 (reference range 16 to 40 milligrams per deciliter; low pre-albumin can be an indication of malnutrition). Review of a nursing progress note from 9/26/23 at 2:07 P.M. indicated additional laboratory values with critical levels including elevated white blood cells (WBC) and low Hemoglobin and Hematocrit (H&H). The nursing progress notes indicated the physician was made aware of the lab values and a new order was obtained to send Resident #141 to the hospital. Review of the facility obtained wound culture, dated 9/26/23, indicated the sacrum wound of Resident #141 showed moderate growth of Staphylococcus aureus, a bacteria. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said on 9/26/23 the sacral wound had a lot of slough and when physically looking at the wound, the team (the Director of Nurses, the Infection Control Preventionist and the Unit Manager) thought the wound treatment should have included Dakins. She said at this time, she checked the Wound Consultant's recommendation from 9/19/23 and saw that Dakins had been recommended and never ordered. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said the facility had notified him when Resident #141 went to the hospital and that the Dakins had not been used as ordered. He said with this type of progression of a wound the Dakins should have been used and that Dakins works really well in difficult wounds like the sacral wound of Resident #141. He said he had not been contacted between 9/19/23 and 9/26/23 for changes to the wound. Review of the Hospital Discharge Summary for Resident #141 indicated the Resident was admitted to the hospital on 9/26/23 with an infected Stage IV pressure injury on the sacrum, which further testing revealed osteomyelitis and sepsis (when an infection affects the entire body). Review of the discharge summary indicated on 9/26/23, in the emergency room , Resident #141 was found to have a gangrenous Stage IV pressure injury. Review of the imaging results indicated the Stage IV pressure injury encompassed the sacrum and the coccyx. Resident #141 was started on an intravenous (IV) antibiotic from 9/26/23 through 10/18/23 and then would transition to two oral antibiotics (ciprofloxacin 750 mg twice per day and doxycycline 100 mg twice per day for four weeks) with weekly CBC (complete blood count) labs. During an interview on 10/24/23 at 1:44 P.M., the primary Physician of Resident #141 said that she defers the wound recommendations to the Wound Consultant physician. She said the facility staff can contact her or the Wound Consultant with any changes to the wound. She said she could not recall if she had been contacted for changes to the wound prior to 9/26/23 when the Resident was sent to the hospital. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said Resident #141's Stage IV sacral pressure injury was a failure of wound care. Refer to F600, F658, and F686 48362 2. Review of the facility's policy titled Weights, dated 8/2015, included but was not limited to: - Residents will be weighed monthly, unless clinically indicated. - If a significant weight loss/gain is identified (>5% in 30 days or >10% in 6 months), the IDT [Interdisciplinary Team], Dietitian, Physician and Family are notified. - All residents with significant weight loss are reviewed by the Interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly. Resident #67 was admitted to the facility in May 2021 with diagnoses including hypertension, hypothyroidism, and ileus (the inability of the intestine to contract leading to a buildup of food). Resident #67's Health Care Proxy (HCP) was activated on 2/10/20. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/1/23, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. Section K of the MDS, which indicated swallowing/nutritional status, triggered for weight loss of 5% or more in the last month or 10% or more in the last 6 months. Section K also indicated the Resident was not on a prescribed weight loss regimen. Review of Resident #67's weights in the electronic documentation system indicated the following weights in pounds (lbs.): - 1/12/23: 244.8 lbs. - 2/1/23: 240.6 lbs. - 3/1/23: 241.8 lbs. - 4/11/23: 242.3 lbs. - 5/1/23: 235.6 lbs. - 6/15/23: 227.0 lbs. - 7/3/23: 223.0 lbs. - 8/1/23: 213.0 lbs. - 9/1/23: 208.2 lbs. - 10/10/23: 203.4 lbs. Review of Resident #67's weights from 4/11/23 to 10/10/23 showed a 16.05% weight loss. Review of Resident #67's active Physician's orders indicated the Resident was on a regular diet with regular consistency texture and thin (regular) liquids. Resident #67's Physician's orders did not show he/she was on any dietary supplements. Review of Resident #67's nutritional care plan indicated the Resident was at risk for nutritional decline. Interventions for Resident #67's nutritional care plan, dated 5/18/21, indicated notification of Registered Dietitian, family and physician of significant weight changes. Review of Resident #67's Nurse Practitioner's documentation, dated 10/4/23, indicated the Resident was re-screened for congestive heart failure and adult malnutrition. Further review of the Nurse Practitioner's documentation indicated the Resident was seen for monthly weight monitoring and no significantly noticeable weight loss/malnutrition was noted. The Nurse Practitioner's documentation indicated the weight was the same as the previous month and to continue to monitor for changes and evaluation by nutritionist. The medical record did not indicate the Nurse Practitioner was aware of the >10% weight loss in six months. Review of Resident #67's quarterly Nutrition Therapy Assessment completed by the Dietitian, dated 8/24/23, indicated the Resident had weight loss this quarter and past 6 months. No further documentation by the dietitian was provided or indicated in the medical record. During an interview on 10/24/23 at 1:36 P.M., Certified Nursing Assistant (CNA) #2 said the Unit Manager (UM) gives the CNAs a list of residents who need to be weighed at the start of shift. CNA #2 said there is a monthly and weekly weight list. CNA #2 said once the weight is obtained it is written on the sheet and given to the nurses to document. During an interview on 10/24/23 at 1:52 P.M., Nurse #3 said weights are a part of the TAR for each resident. Nurse #3 said the weights flag in the system if there is a notable weight loss. Nurse #3 said no weights were flagged for Resident #67. During an interview on 10/24/23 at 1:58 P.M., UM #1 said the Dietitian notifies the UM if there is a concern with weights. UM #1 said residents with weight loss are monitored and reviewed at weekly risk management meeting. UM #1 said Resident #67 is not currently reviewed at the weekly risk management meeting. During an interview on 10/24/23 at 2:22 P.M., the Dietitian said she follows the quarterly MDS assessments to complete nutritional reviews for each resident in the building. The Dietitian said that she will look at weights for each resident she is reviewing and ask for re-weights as necessary. The Dietitian said that a weight report is run every Tuesday and Thursday for the entire building and if status change is noted it is addressed. The surveyor and the Dietitian reviewed the medical record for Resident #67. The Dietitian said the only assessment she completed on Resident #67 was on 8/24/23. The Dietitian reviewed the weights throughout the past six months for Resident #67. The Dietitian said there was a significant weight loss and it should have been addressed. The Dietitian said she should have followed up again with the Resident approximately one month after the 8/24/23 assessment. The Dietitian said the goal for the Resident's nutritional care plan was to be around 215 lbs. The Dietitian said a weight of 203.4 lbs. was below her expectation for Resident #67's weight. The Dietitian said when a significant weight loss is identified she would speak with the Physician regarding recommendations and notification. The Dietitian said she did not make recommendations or notify the Physician of Resident #67's significant weight loss.

Based on record review, policy review, and interview, the facility failed to protect one Resident (#141) from neglect, out of a total sample of 20 residents. Specifically, for Resident #141 the facility failed to implement recommendations from the wound consultant physician including medications and treatments, failed to provide wound care treatments as ordered to a pressure injury of the sacral area, and neglected to identify, assess, and notify the physician of changes to the sacral wound resulting in a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) with osteomyelitis (infection of the bone) and sepsis (infection of the blood stream) requiring a 19-day hospital admission and intravenous (IV) antibiotics followed by oral antibiotics for four weeks. It was determined the Immediate Jeopardy began on 9/15/23 and was identified on 10/25/23. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 10/25/23, including the Immediate Jeopardy Templates. The Immediate Jeopardy, which began on 9/15/23, was abated on 10/26/23. Findings include: Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility's policy titled Skin & Wounds, last revised March 2023, indicated but was not limited to the following: -The necessary treatment and services will be provided to promote healing, prevent infection and prevent new pressure injuries from developing. Resident #141 was admitted to the facility in February 2015 with diagnoses including diabetes, Parkinson's disease, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #141 was dependent for all care including bathing, dressing, and eating. Review of the care plans for Resident #141 included a care plan initiated on 9/6/23 for an actual alteration in skin integrity related to moisture-related dermatitis to the sacrum acquired on 9/5/23. The care plan included goals of improved skin integrity as evident by signs and symptoms of healing and remaining free from infection. The interventions included consulting with the certified wound physician, follow physician orders for skin care and treatments, monitor for signs and symptoms of infection and report to physician, rehabilitation screen for seating/positioning. Review of the medical record indicated on 9/5/23 the Wound Consultant physician identified Resident #141 had a shearing (when the skin remains stationary and the underlying tissue moves) to the right and left sacral area (lower back, bottom of the spine). The nursing progress note from 9/5/23 indicated the area was a result of moisture-related dermatitis following the Resident's more frequent times out of bed. Review of the Wound Evaluation and Management Summary from the Wound Consultant, dated 9/5/23, indicated the following new areas as identified by the Wound Consultant: Non-pressure wound of the right, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 9 centimeters (cm) in length by 4.2 cm in width by 0.05 cm in depth Periwound: induration (hardening of skin), maceration (the softening and breaking down of skin as a result of prolonged exposure to moisture)- mild Exudate (drainage): light serous (clear fluid) Other viable tissue: 100% Non-pressure wound of the left, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 8 centimeters (cm) in length by 5 cm in width by non-measurable depth Periwound: induration, maceration-mild Exudate: none Other viable tissue: 100% Additional wound details from the Wound Consultant indicated Resident #141 was spending too much time in the Broda chair (positioning wheelchair) with the following recommendations to both buttocks: normal saline wash, house barrier cream and Zinc ointment to the periwound, three times per day. Additional recommendations included Multivitamin once daily and Zinc Sulphate 220 mg (milligrams) once daily and to upgrade the off-loading chair cushion. Review of the medical record including Physician's Orders, Medication Administration Records (MAR), and Treatment Administration Records (TAR) indicated the treatment of barrier cream and Zinc ointment three times a day was implemented on 9/6/23 and the Multivitamin and Zinc Sulphate 220 mg were not ordered as recommended. Review of the medical record including nursing progress notes, rehabilitation screens, Physical Therapy notes, and Occupational Therapy notes, failed to indicate Resident #141 was re-evaluated for an upgrade to the off-loading chair cushion, per the Wound Consultant physician's recommendations. Review of the Wound Evaluation and Management Summary from the Wound Consultant, dated 9/12/23, indicated the right and left medial buttock areas were merged to one area with the following information: Non-pressure wound, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 7.5 cm in length by 9 cm in width by 0.05 cm in depth Periwound: induration - mild Exudate: none Other viable tissue: 100% The recommended treatment was for a normal saline wash, followed by Xeroform gauze and to cover with a gauze island with border dressing, once daily. Additional recommendations included a Multivitamin once daily, Zinc Sulphate 220 mg once daily, and to upgrade the off-loading chair cushion. During an interview on 10/23/23 at 2:27 P.M., Unit Manager #2 said the process for when the Wound Consultant physician completed visits was for the Wound Consultant to provide verbal information regarding recommendations, then send over the written recommendations. She said, as the Unit Manager, she would obtain the written recommendations the day after the visit and review them with the Primary Physician and enter the orders as recommended. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she had not seen the recommendations for the Multivitamin and Zinc Sulphate 220 mg and did not know the Wound Consultant physician made recommendations regarding medications. She said she must have overlooked the recommendations and the Primary Physician was not contacted regarding the newly recommended medications. During an interview on 10/24/23 at 10:56 A.M., Occupational Therapist #1 said Resident #141 had a Pommel cushion for the Broda chair in September 2023. During an interview on 10/24/23 at 11:00 A.M., the Director of Nurses said Resident #141 had an order for a Pommel cushion from July 2023 until October 2023. During an interview on 10/24/23 at 1:21 P.M., Occupational Therapist #1 said the process for a re-evaluation of a cushion was for the nursing department to send a referral to the Rehab department for review. During an interview on 10/24/23 at 2:06 P.M., the Director of Nurses said if the Wound Consultant physician wrote a recommendation to review the off-loading cushion, then nursing should have referred the Resident to Rehab for an evaluation of the cushion. She said she did not know the Wound Consultant physician had made the recommendation on 9/5/23 and 9/12/23, and Resident #141 had not been referred to the Rehab department. Review of the Resident Flow Sheets indicated Resident #141 was up in the wheelchair on 9/13/23, 9/14/23, 9/22/23, 9/23/23, 9/24/23 and 9/25/23 (six days without an evaluation of an upgrade to the cushion, as recommended by the Wound Consultant). Review of the TAR indicated the recommended wound treatment of normal saline wash, followed by Xeroform gauze and to cover with a gauze island with border dressing once daily was initiated on 9/12/23 with a start date of 9/13/23. Review of the TAR indicated the wound dressing was not completed on 9/13/23 or 9/18/23. Review of the TAR indicated the following nursing documentation of the sacral area: 9/13/23: not completed as ordered 9/14/23: Base: C (clean); Drainage: none; Drainage amount: none; Outcome: NC (no change); Periwound: H (healthy) 9/15/23: Base: S (slough- non-viable necrotic (dead) skin tissue that is yellow, tan, gray, green or brown; usually moist, can be soft, stringy and mucinous in texture); Drainage: SS (serosanguineous- thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells); Drainage amount: S (small); Outcome: W (worse); Periwound: M (macerated) 9/16/23: Base: clean; Drainage: none; Drainage amount: none; Outcome: no change; Periwound: healthy 9/17/23: Base: clean; Drainage: none; Drainage amount: none; Outcome: worse; Periwound: healthy 9/18/23: not completed as ordered During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she was working as the assigned nurse for Resident #141 on 9/13/23 and 9/18/23. She said she cannot say why the treatments were not completed as ordered. She said the treatments should have been done as ordered. She said she did not remember seeing any changes to the wound between 9/12/23 and 9/19/23. During an interview on 10/24/23 at 1:24 P.M., Nurse #3, who completed the sacral wound treatment for Resident #141 on 9/15/23 said she could not recall how the wound looked on this date, but if she documented there was slough and drainage, then there was. She said she had not contacted a physician regarding the changes to the wound. Review of the Wound Evaluation and Management Summary from the Wound Consultant, dated 9/19/23, indicated the following: Non-pressure wound of the right, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 4.3 cm in length by 4.5 cm in width by 3.2 cm in depth Periwound: induration, maceration- mild Exudate: moderate serous Thick adherent devitalized necrotic tissue: 70% Slough: 10% Other viable tissue: 20% Wound Progress: exacerbated due to general decline of patient, non-compliant with wound care, always supine. Surgical excision debridement procedure: removed necrotic tissue and established the margins of viable tissue. Surgically excised 13.54 cm of devitalized tissue and necrotic muscle level tissues along with slough and biofilm were removed at the depth of 3.6 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80% to 10%. The Wound Consultant physician recommended the following treatment: normal saline wash, Sodium Hypochlorite Solution (Dakins- made from bleach that has been diluted, it is an antiseptic that kills most forms of bacteria and viruses) apply for 15 minutes then rinse with normal saline, apply Calcium Alginate (a highly absorbent dressing that interacts with the wound fluids to form a gel that provides a moist wound environment and facilitates auto debridement; the calcium in the dressing interacts with sodium in the wound to promote healing), apply a gauze island with border dressing, once per day. During an interview on 10/23/23 at 2:27 P.M., Unit Manager #2 said when the Wound Consultant physician came in on 9/19/23 there was a nickel size necrotic area on the sacral wound of Resident #141. She said she did not remember when the necrotic area started or when the wound changed. She reviewed the medical record at this time and said the medical record did not reflect that the primary physician had been notified of the changes. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said the sacral area started off as moisture associated skin damage. He said he had recommended a multivitamin and Zinc Sulphate as the supplements help with collagen and wound healing. The Wound Consultant said on 9/12/23 the sacral area had looked pretty much the same as from 9/5/23 and he had added the Xeroform to prevent additional moisture to the area. The Wound Consultant said when he saw the sacral area on 9/19/23, It was a shock; it was necrotic and there was a drastic change from the week before. The Wound Consultant said the change in the wound did not occur in one day, adding not a chance with that degree of necrosis. He said the wound on 9/19/23 was a sacral Stage IV pressure injury. The Wound Consultant said on 9/19/23 there was no overwhelming odor to the wound and the Dakins was recommended to prevent infection. Review of the TAR indicated on 9/20/23 the previous treatment of normal saline wash, followed by Xeroform, followed by a gauze island border dressing was completed, despite the wound changing to a Stage IV pressure injury. The wound descriptions on 9/20/23 on the TAR are as follows: Base: SE (slough, eschar); Drainage: P (purulent- white, yellow, or brown fluid and might be slightly thick in texture, made up of white blood cells trying to fight the infection); Drainage amount: small; Outcome: worse; Periwound: macerated. The TAR indicated the following sacral wound treatment was started on 9/21/23: Normal saline wash, pat dry, pack undermining pocket with Alginate and cover wound with large foam dressing. The order indicated the use of Alginate, instead of Calcium Alginate, as indicated in the recommendation from the Wound Consultant and failed to include the Dakins. Review of the TAR indicated the following nursing documentation of the sacral pressure injury: 9/21/23: Base: slough, eschar; Drainage: purulent; Drainage amount: small; Outcome: no change; Periwound: healthy 9/22/23: Base: slough, eschar; Drainage: purulent; Drainage amount: moderate; Outcome: worse; Periwound: healthy 9/23/23: Base: slough; Drainage: purulent; Drainage amount: large; Outcome: worse; Periwound: macerated 9/24/23: Base: clean; Drainage: serosanguineous; Drainage amount: moderate; Outcome: no change; Periwound: macerated 9/25/23: Base: clean; Drainage: serosanguineous; Drainage amount: moderate; Outcome: no change; Periwound: macerated During an interview on 10/23/23 at 12:36 P.M., Nurse #2 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/21/23 and 9/22/23. She said she could recall that there was purulent drainage and that the wound smelled. She said she had not notified anyone of the changes, but that the purulent drainage was a sign of an infection. She said if there were changes to the wound the Wound Consultant would be notified during the next visit (scheduled weekly visits). During an interview on 10/24/23 at 1:24 P.M., Nurse #3 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/23/23. She said she remembered that the treatment was for Alginate only. She said the wound had a lot of drainage and it was purulent drainage and she had not contacted a physician regarding the changes. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/24/23 and 9/25/23. She said she didn't recall an odor, and that it smelled like a regular wound to the coccyx. She said she had not identified purulent drainage and had not identified any signs or symptoms of infection. She said she had completed the treatments on 9/24/23 and 9/25/23 as ordered for Alginate followed by a foam dressing. The Unit Manager said she was the one who had obtained verbal recommendations from the Wound Consultant on 9/19/23 and had waited for the written recommendations to call them into the physician and obtain a new treatment order on 9/21/23, two days later. She said she must not have reviewed the written recommendations because the Wound Consultant did not tell her verbally to use Calcium Alginate (versus Alginate) or to use Dakins. She said only Alginate followed by a large foam dressing was used from 9/21/23 through 9/25/23. Review of the nursing progress notes included one note between 9/19/23 and 9/24/23. The note dated 9/21/23 indicated the sacrum wound was worsening. Review of a nursing progress note, dated 9/26/23, indicated the sacral pressure wound for Resident #141 had been worsening over the course of treatment and there was a pending wound culture to rule out infection. The nursing progress notes indicated the physician was made aware of the lab values and a new order was obtained to send Resident #141 to the hospital. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said on 9/26/23 the sacral wound had a lot of slough and when physically looking at the wound, the team (the Director of Nurses, the Infection Control Preventionist, and the Unit Manager) thought the wound treatment should have included Dakins. She said at this time, she checked the Wound Consultant's recommendation from 9/19/23 and saw that Dakins had been recommended and never ordered. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said the facility had notified him when Resident #141 went to the hospital and that the Dakins had not been used as ordered. He said with this type of progression of a wound the Dakins should have been used and that Dakins works really well in difficult wounds like the sacral wound of Resident #141. Review of the Hospital Discharge Summary for Resident #141 indicated the Resident was admitted to the hospital on 9/26/23 with an infected Stage IV pressure injury on the sacrum, which further testing revealed osteomyelitis and sepsis (when an infection affects the entire body). Review of the discharge summary indicated on 9/26/23, in the emergency room , Resident #141 was found to have a gangrenous Stage IV pressure injury. Review of the imaging results indicated the Stage IV pressure injury encompassed the sacrum and the coccyx. Resident #141 was started on an intravenous (IV) antibiotic from 9/26/23 through 10/18/23 and then would transition to two oral antibiotics (ciprofloxacin 750 mg twice per day and doxycycline 100 mg twice per day for four weeks with weekly CBC (complete blood count) labs. Review of the Hospital Discharge Summary for Resident #141 indicated the following regarding the Stage IV pressure injury on the sacrum: Measurements on 10/16/23: 8.7 cm in length by 8.0 cm in width by 3.5 cm in depth Drainage: moderate amount of serosanguineous Treatment: cleanse with normal saline, vitamin A&D ointment to periwound; followed by nickel thick Santyl and packed with normal saline moistened Kerlix, followed by an ABD pad (a non-adhesive gauze pad), secured with brief. Review of the medical record indicated Resident #141 returned to the facility on [DATE]. Review of the TAR indicated the treatment to the Stage IV sacral pressure injury was not entered until 10/17/23 and not completed until 10/18/23 (missing a treatment on 10/17/23). Review of the nursing progress notes indicated on 10/18/23 Unit Manager #2 wrote a late entry admission note from 10/16/23 indicating the Resident had returned to the facility and all medications and treatments were reconciled with the physician. During an interview on 10/24/23 at 10:27 A.M., Unit Manager #2 said the nurse who had completed the re-admission for Resident #141 on 10/16/23 did not know how to enter the treatments for Resident #141, which is why the treatments were not entered to start until 10/18/23. The surveyor and the Unit Manager reviewed the current treatment order which indicated to secure the ABD pad with a brief. She said she was not aware the physician's order said to secure with a brief and she was not sure how the brief would secure an ABD pad. She said she is unable to tell in the medical record if the nurse called the physician to verify the treatment order and had assumed the nurse verified the order with the physician. On 10/24/23 at 2:00 P.M., the surveyor observed the treatment change of Resident #141's Stage IV sacral pressure injury by Nurse #4. Nurse #4 was observed to remove a soiled brief revealing a foam dressing dated 10/23/23, which was not part of the treatment order. Nurse #4 was observed to remove the foam dressing which had serosanguineous drainage and the Kerlix packing which had thick yellow drainage. The wound base was observed to be dark pink with the presence of yellow slough. Nurse #4 was observed to clean the wound with a normal saline wash, soak the Kerlix in normal saline and pack the wound with the Kerlix. The Nurse was observed to apply A&D ointment to the buttocks and apply an ABD pad over the wound, prior to applying the brief. The nurse was not observed to apply A&D ointment to the periwound and was not observed to use the Santyl as ordered. During an interview on 10/24/23 at 2:58 P.M., Nurse #4 said the bordered foam dressing should not have been in place as it was not part of the treatment order. She said she had forgotten to apply the A&D ointment to the periwound and had forgotten to apply the Santyl to the wound base, but that both should have been applied per the treatment orders. On 10/24/23 at 2:00 P.M., the surveyor observed Resident #141 to be moaning and groaning during the positioning and during wound care. Review of the physician's orders indicated on 10/19/23 an order was initiated for Oxycodone 5 mg every 8 hours as needed for pain and wound care. During an interview on 10/24/23 at 2:10 P.M., Nurse #4 said she had not pre-medicated Resident #141 prior to the wound care and did not think there were any orders for pain medication in place. She said she had not seen Resident #141 since returning from the hospital and did not know if there had been a history of pain with wound care. During an interview on 10/25/23 at 2:30 P.M., Nurse #1 said she had completed wound care for Resident #141 on this day. She said she secured the Kerlix packing with a foam dressing. She said she was not aware the order read to secure with a brief and did not understand how a brief would keep an ABD pad on. She said she had not contacted a physician to verify the order. During an interview on 10/24/23 at 1:44 P.M., the primary physician of Resident #141 said that she defers the wound recommendations to the Wound Consultant physician. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said Resident #141's Stage IV sacral pressure injury was a failure of wound care. Refer to F658 and F686

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#141), out of a total sample of 20 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed for Resident #141, to implement recommendations from the wound consultant physician including medications and treatments, to provide wound care treatments as ordered to a pressure injury of the sacral area, to implement a physician ordered setting for an air mattress, to identify and assess changes to the sacral wound, resulting in a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) with osteomyelitis (infection of the bone) and sepsis (infection of the blood stream) requiring a 19-day hospital admission and intravenous (IV) antibiotics followed by oral antibiotics for four weeks. It was determined the Immediate Jeopardy began on 9/15/23 and was identified on 10/25/23. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 10/25/23, including the Immediate Jeopardy Templates. The Immediate Jeopardy, which began on 9/15/23, was abated on 10/26/23. Findings include: Review of the [NAME] Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018 indicted: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Skin & Wounds, last revised March 2023, indicated but was not limited to the following: -The necessary treatment and services will be provided to promote healing, prevent infection and prevent new pressure injuries from developing. -Pressure injuries are assessed and documented on at least weekly and with a significant change in the wound until it is resolved. -Use minimal linen under areas prone to skin breakdown. Multiple incontinence pads may reduce the effectiveness of pressure reduction mattresses. -A wound infection should be considered if wound presents with purulent drainage. Consult with the MD (Doctor of Medicine) and if culture is ordered, follow procedure. Further review of the facility's Skin & Wounds policy included a Pressure Injury Investigation Tool for Newly Acquired Facility Wounds form which included: Risk Factors, Clinical Status, Nutritional Considerations, Clinical Symptoms, Interventions Prior to Wound Discovery, Self Determination of Resident and sections to indicate new interventions and staff investigation findings and a Summary to include if the pressure injury was avoidable or unavoidable. The form indicated an unavoidable determination can only be made if preventative measures, the resident clinical picture and individual resident needs, wishes and risk factors were managed and interventions were consistently implemented. The form included signature sections for the physician, the infection control preventionist and the Director of Nurses. Review of the facility's policy titled Consultant Services, dated April 2015, indicated but was not limited to the following: -a note should be recorded on the consultation form by any health care consultant who sees the resident. The consultant should document findings and recommendations on the form. -the charge nurse will then notify the attending physician of findings and he/she can then order the specific treatments as outlined by the consultant. Review of the facility's Air Mattress Overlay policy, dated April 2015, indicated an air mattress overlay is used to prevent skin breakdown in accordance with physician's orders. The procedure indicated to verify the physician's order and evaluate air mattress functions and proper inflation every shift. Resident #141 was admitted to the facility in February 2015 with diagnoses including diabetes, Parkinson's disease, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #141 was dependent for all care including bathing, dressing, and eating. Review of the care plans for Resident #141 included a care plan initiated on 9/6/23 for an actual alteration in skin integrity related to moisture-related dermatitis to the sacrum acquired on 9/5/23. The care plan included goals of improved skin integrity as evident by signs and symptoms of healing and remaining free from infection. The interventions included consulting with the certified wound physician, follow physician's orders for skin care and treatments, monitor for signs and symptoms of infection and report to physician, rehabilitation screen for seating/positioning, and a [NAME] Relief alternating pressure system with low air loss- set at: alternating 160. Review of the medical record indicated on 9/5/23 the Wound Consultant physician identified Resident #141 had a shearing (when the skin remains stationary and the underlying tissue moves) to the right and left sacral area (lower back, bottom of the spine). The nursing progress note from 9/5/23 indicated the area was a result of moisture-related dermatitis following the Resident's more frequent times out of bed. Review of the Wound Evaluation and Management Summary from the Wound Consultant, dated 9/5/23, indicated the following new areas as identified by the Wound Consultant: Non-pressure wound of the right, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 9 centimeters (cm) in length by 4.2 cm in width by 0.05 cm in depth Periwound: induration (hardening of skin), maceration (the softening and breaking down of skin as a result of prolonged exposure to moisture)- mild. Exudate (drainage): light serous (clear fluid) Other viable tissue: 100% Non-pressure wound of the left, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 8 cm in length by 5 cm in width by non-measurable depth Periwound: induration, maceration-mild Exudate: none Other viable tissue: 100% Additional wound details from the Wound Consultant indicated Resident #141 was spending too much time in the Broda chair (positioning wheelchair) with the following recommendations to both buttocks: normal saline wash, house barrier cream and Zinc ointment to the periwound, three times per day. Additional recommendations included Multivitamin once daily and Zinc Sulphate 220 mg (milligrams) once daily and to upgrade the off-loading chair cushion. Review of the medical record including Physician's Orders, Medication Administration Records (MAR), and Treatment Administration Records (TAR) indicated the treatment of barrier cream and Zinc ointment three times a day were implemented on 9/6/23 and the Multivitamin and Zinc Sulphate 220 mg were not ordered as recommended. Review of the medical record including nursing progress notes, rehabilitation screens, Physical Therapy notes, and Occupational Therapy notes, failed to indicate Resident #141 was re-evaluated for an upgrade to the off-loading chair cushion, per the Wound Consultant physician's recommendations. Review of the Wound Evaluation and Management Summary from the Wound Consultant dated 9/12/23 indicated the right and left medial buttock areas were merged to one area with the following information: Non-pressure wound, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 7.5 cm in length by 9 cm in width by 0.05 cm in depth Periwound: induration - mild. Exudate: none Other viable tissue: 100% The recommended treatment was for a normal saline wash, followed by Xeroform gauze and to cover with a gauze island with border dressing, once daily. Additional recommendations included a Multivitamin once daily, Zinc Sulphate 220 mg once daily, and to upgrade the off-loading chair cushion. During an interview on 10/23/23 at 2:27 P.M., Unit Manager #2 said the process for when the Wound Consultant physician completed visits was for the Wound Consultant to provide verbal information regarding recommendations, then send over the written recommendations. She said, as the Unit Manager, she would obtain the written recommendations the day after the visit and review them with the physician and enter the orders as recommended. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she had not seen the recommendations for the Multivitamin and Zinc Sulphate 220 mg that were made on 9/5/23 and 9/12/23. Unit Manager #2 said she did not know the Wound Consultant physician made recommendations regarding medications. She said she must have overlooked the recommendations. During an interview on 10/24/23 at 11:00 A.M., the Director of Nurses said Resident #141 had an order for a Pommel cushion from July 2023 until October 2023. During an interview on 10/24/23 at 1:21 P.M., Occupational Therapist #1 said the process for a re-evaluation of a cushion was for the nursing department to send a referral to the Rehab department for review. During an interview on 10/24/23 at 2:06 P.M., the Director of Nurses said if the Wound Consultant physician wrote a recommendation to review the off-loading cushion, then nursing should have referred the Resident to Rehab for an evaluation of the cushion. She said she did not know the Wound Consultant physician had made the recommendation on 9/5/23 and 9/12/23 and Resident #141 had not been referred to the Rehab department. Review of the Resident Flow Sheets indicated Resident #141 was up in the wheelchair on 9/13/23, 9/14/23, 9/22/23, 9/23/23, 9/24/23 and 9/25/23 (six days without an evaluation of an upgrade to the cushion, as recommended by the Wound Consultant). Review of the TAR indicated the recommended wound treatment of normal saline wash, followed by Xeroform gauze and to cover with a gauze island with border dressing once daily was initiated on 9/12/23 with a start date of 9/13/23. Review of the TAR indicated the wound dressing was not completed on 9/13/23 or 9/18/23. Review of the TAR indicated the following nursing documentation of the sacral area: 9/13/23: not completed as ordered 9/14/23: Base: C (clean); Drainage: none; Drainage amount: none; Outcome: NC (no change); Periwound: H (healthy) 9/15/23: Base: S (slough- non-viable (necrotic (dead) skin tissue that is yellow, tan, gray, green or brown; usually moist, can be soft, stringy and mucinous in texture); Drainage: SS (serosanguineous- thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells); Drainage amount: S (small); Outcome: W (worse); Periwound: M (macerated) 9/16/23: Base: clean; Drainage: none; Drainage amount: none; Outcome: no change; Periwound: healthy 9/17/23: Base: clean; Drainage: none; Drainage amount: none; Outcome: worse; Periwound: healthy 9/18/23: not completed as ordered Review of the nursing progress notes failed to include information regarding the changes noted in the sacral wound on 9/15/23 or the reasoning for the documented outcome of worse on 9/17/23. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she was working as the assigned nurse for Resident #141 on 9/13/23 and 9/18/23. She said she cannot say why the treatments were not completed as ordered. She said the treatments should have been done as ordered. She said she did not remember seeing any changes to the wound between 9/12/23 and 9/19/23. During an interview on 10/24/23 at 1:24 P.M., Nurse #3, who completed the sacral wound treatment for Resident #141 on 9/15/23 said she could not recall how the wound looked on this date, but if she documented there was slough and drainage, then there was. Review of the Wound Evaluation and Management Summary from the Wound Consultant dated 9/19/23 indicated the following: Non-pressure wound of the right, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 4.3 cm in length by 4.5 cm in width by 3.2 cm in depth Periwound: induration, maceration- mild Exudate: moderate serous Thick adherent devitalized necrotic tissue: 70% Slough: 10% Other viable tissue: 20% Wound Progress: exacerbated due to general decline of patient, non-compliant with wound care, always supine. Surgical excision debridement procedure: removed necrotic tissue and established the margins of viable tissue. Surgically excised 13.54 cm of devitalized tissue and necrotic muscle level tissues along with slough and biofilm were removed at the depth of 3.6 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80% to 10%. The Wound Consultant physician recommended the following treatment: normal saline wash, Sodium Hypochlorite Solution (Dakins- made from bleach that has been diluted, it is an antiseptic that kills most forms of bacteria and viruses) apply for 15 minutes then rinse with normal saline, pack with Calcium Alginate (a highly absorbent dressing that interacts with the wound fluids to form a gel that provides a moist wound environment and facilitates auto debridement; the calcium in the dressing interacts with sodium in the wound to promote healing), apply a gauze island with border dressing, once per day. During an interview on 10/23/23 at 2:27 P.M., Unit Manager #2 said when the Wound Consultant physician came in on 9/19/23 there was a nickel size necrotic area on the sacral wound of Resident #141. She said she did not remember when the necrotic area started or when the wound changed. She said the process was for the Primary Physician to be notified of changes to the wound. She reviewed the medical record and said she was unable to see that the Primary Physician was notified of the changes of the wound becoming necrotic between 9/12/23 and 9/19/23. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said the sacral area started off as moisture associated skin damage. He said he had recommended a Multivitamin and Zinc Sulphate as the supplements help with collagen and wound healing. The Wound Consultant said on 9/12/23 the sacral area had looked pretty much the same from 9/5/23 and he had added the Xeroform to prevent additional moisture to the area. The Wound Consultant said when he saw the sacral area on 9/19/23, It was a shock; it was necrotic and there was a drastic change from the week before. The Wound Consultant said the change in the wound did not occur in one day, adding not a chance with that degree of necrosis. He said the wound on 9/19/23 was a sacral Stage IV pressure injury and he should have updated the Wound Evaluation and Management Summary to reflect the status of pressure injury. The Wound Consultant said on 9/19/23 there was no overwhelming odor to the wound and the Dakins was recommended to prevent infection. Review of the TAR indicated on 9/20/23 the previous treatment of normal saline wash, followed by Xeroform, followed by a gauze island border dressing was completed, despite the wound changing to a Stage IV pressure injury. The wound descriptions on 9/20/23 on the TAR are as follows: Base: SE (slough, eschar); Drainage: P (purulent- white, yellow, or brown fluid and might be slightly thick in texture, made up of white blood cells trying to fight the infection); Drainage amount: small; Outcome: worse; Periwound: macerated. The TAR indicated the following sacral wound treatment was started on 9/21/23: Normal saline wash, pat dry, pack undermining pocket with Alginate and cover wound with large foam dressing. The order indicated the use of Alginate, instead of Calcium Alginate, as indicated in the recommendation from the Wound Consultant, and failed to include the Dakins. Review of the TAR indicated the following nursing documentation of the sacral pressure injury: 9/21/23: Base: slough, eschar; Drainage: purulent; Drainage amount: small; Outcome: no change; Periwound: healthy 9/22/23: Base: slough, eschar; Drainage: purulent; Drainage amount: moderate; Outcome: worse; Periwound: healthy 9/23/23: Base: slough; Drainage: purulent; Drainage amount: large; Outcome: worse; Periwound: macerated 9/24/23: Base: clean; Drainage: serosanguineous; Drainage amount: moderate; Outcome: no change; Periwound: macerated 9/25/23: Base: clean; Drainage: serosanguineous; Drainage amount: moderate; Outcome: no change; Periwound: macerated During an interview on 10/23/23 at 12:36 P.M., Nurse #2 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/21/23 and 9/22/23. She said she could recall that there was purulent drainage and that the wound smelled. She said she had not notified anyone of the changes, but that the purulent drainage was a sign of an infection. During an interview on 10/24/23 at 1:24 P.M., Nurse #3 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/23/23. She said she remembered that the treatment was for Alginate only. She said the wound had a lot of drainage and it was purulent drainage. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/24/23 and 9/25/23. She said she didn't recall an odor, and that it smelled like a regular wound to the coccyx. She said she had not identified purulent drainage and had not identified any signs or symptoms of infection. She said she had completed the treatments on 9/24/23 and 9/25/23 as ordered for Alginate followed by a foam dressing. The Unit Manager said she was the one who had obtained verbal recommendations from the Wound Consultant on 9/19/23 and had waited for the written recommendations to call them into the physician and obtain a new treatment order on 9/21/23, two days later. She said she must not have reviewed the written recommendations because the Wound Consultant did not tell her verbally to use Calcium Alginate (versus Alginate) or to use Dakins. She said only Alginate followed by a large foam dressing was used from 9/21/23 through 9/25/23. Review of the nursing progress notes included one note between 9/19/23 and 9/24/23. The note dated 9/21/23 indicated the sacrum wound was worsening. Review of a nursing progress note, dated 9/26/23, indicated the sacral pressure wound for Resident #141 had been worsening over the course of treatment and there was a pending wound culture to rule out infection and based on recent lab values the Primary Physician ordered for the Resident to be sent to the hospital. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said on 9/26/23 the sacral wound had a lot of slough and when physically looking at the wound, the team (the Director of Nurses, the Infection Control Preventionist, and the Unit Manager) thought the wound treatment should have included Dakins. She said at this time, she checked the Wound Consultant's recommendation from 9/19/23 and saw that Dakins had been recommended and never ordered. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said the facility had notified him when Resident #141 went to the hospital that the Dakins had not been used as ordered. He said with this type of progression of a wound the Dakins should have been used and that Dakins works really well in difficult wounds like the sacral wound of Resident #141. During an interview on 10/23/23 at 4:34 P.M., the Director of Nurses said there was no incident report (Pressure Injury Investigation Tool- as indicated in the Skin and Wound policy) for the Stage IV pressure injury of Resident #141 and there had been no root cause analysis. Review of the Hospital Discharge Summary for Resident #141 indicated the Resident was admitted to the hospital on 9/26/23 with an infected Stage IV pressure injury on the sacrum, which further testing revealed osteomyelitis and sepsis (when an infection affects the entire body). Review of the discharge summary indicated on 9/26/23, in the emergency room , Resident #141 was found to have a gangrenous Stage IV pressure injury. Review of the imaging results indicated the Stage IV pressure injury encompassed the sacrum and the coccyx. Resident #141 was started on an intravenous (IV) antibiotic from 9/26/23 through 10/18/23 and then would transition to two oral antibiotics (ciprofloxacin 750 mg twice per day and doxycycline 100 mg twice per day for four weeks with weekly CBC (complete blood count) labs. Review of the Hospital Discharge Summary for Resident #141 indicated the following regarding the Stage IV pressure injury on the sacrum: Measurements on 10/16/23: 8.7 cm in length by 8.0 cm in width by 3.5 cm in depth Drainage: moderate amount of serosanguineous Treatment: cleanse with normal saline, vitamin A&D ointment to periwound; followed by nickel thick Santyl and packed with normal saline moistened Kerlix, followed by an ABD pad (a non-adhesive gauze pad), secured with brief. Review of the medical record indicated Resident #141 returned to the facility on [DATE]. Review of the Evaluations indicated there had been no nursing evaluations completed on 10/16/23 or 10/17/23. Review of the TAR indicated the treatment to the Stage IV sacral pressure injury was not entered until 10/17/23 and not completed until 10/18/23 (missing a treatment on 10/17/23). Review of the nursing progress notes indicated on 10/18/23 Unit Manager #2 wrote a late entry admission note for 10/16/23 indicating the Resident had returned to the facility and all medications and treatments were reconciled with the physician. During an interview on 10/24/23 at 10:27 A.M., Unit Manager #2 said the nurse who had completed the re-admission for Resident #141 on 10/16/23 had not completed any nursing evaluations and that nurse had said they did not know how to enter the treatments for Resident #141, which is why the treatments were not entered until 10/18/23. The surveyor and the Unit Manager reviewed the current treatment order which indicated to secure the ABD pad with a brief. She said she was not aware the physician's order said to secure with a brief and she was not sure how the brief would secure an ABD pad. She said she is unable to tell in the medical record if the nurse called the physician to verify the treatment order and had assumed the nurse verified the order with the physician. During an interview on 10/23/23 at 10:00 A.M., Nurse #1 said she had already completed the treatment to the sacral pressure injury for Resident #141. On 10/24/23 at 2:00 P.M., the surveyor observed the wound care of Resident #141's Stage IV sacral pressure injury with Nurse #4. Nurse #4 was observed to remove a soiled brief revealing a foam dressing dated 10/23/23, which was not part of the treatment order and had been on the Resident for at least 28 hours. Nurse #4 was observed to remove the foam dressing which had serosanguineous drainage and the Kerlix packing which had thick yellow drainage. The wound base was observed to be dark pink with the presence of yellow slough. Nurse #4 was observed to clean the wound with a normal saline wash, soak the Kerlix in normal saline and pack the wound with the Kerlix. The Nurse was observed to apply A&D ointment to the buttocks and apply an ABD pad over the wound, prior to applying the brief. The nurse was not observed to apply A&D ointment to the periwound and was not observed to use the Santyl as ordered. During an interview on 10/24/23 at 2:58 P.M., Nurse #4 said the bordered foam dressing should not have been in place as it was not part of the treatment order. She said she had forgotten to apply the A&D ointment to the periwound and had forgotten to apply the Santyl to the wound base, but that both should have been applied per the treatment orders. On 10/24/23 at 2:00 P.M., the surveyor observed Resident #141 to be moaning and groaning during the positioning and during wound care. Review of the Physician's Orders indicated on 10/19/23 an order was initiated for Oxycodone 5 mg every 8 hours as needed for pain and wound care. During an interview on 10/24/23 at 2:10 P.M., Nurse #4 said she had not pre-medicated Resident #141 prior to the wound care and did not think there were any orders for pain medication in place. She said she had not seen Resident #141 since returning from the hospital and did not know if there had been a history of pain with wound care. During an interview on 10/24/23 at 3:14 P.M., Unit Manager #2 said Resident #141 should not have had a foam dressing over the sacral wound, as this was not part of the physician's order. She said Nurse #4 should have followed the treatment order and used Santyl in the base and A&D ointment on the periwound. During an interview on 10/25/23 at 2:30 P.M., Nurse #1 said she had completed wound care for Resident #141 on this day. She said she secured the Kerlix packing with a foam dressing. She said she was not aware the order read to secure with a brief and did not understand how a brief would keep an ABD pad on. During an interview on 10/26/23 at 2:00 P.M., Nurse #7 said she had worked with Resident #141 since he/she returned from the hospital and noted the Resident had a foam dressing over the sacral Stage IV pressure injury, although she had not provided the wound care. She said she did not know the order for the treatment indicated to secure the ABD with a brief and did not see how an ABD would stay in place or keep the wound free from incontinence and the treatment order should have been reviewed with a physician for clarification. Review of the Physician's Orders indicated Resident #141 had an order for a specialty air mattress to be in place at all times set at 160, alternating pressure. Review of the medical record indicated on 10/19/23 Resident #141 weighed 164.3 pounds. The following observations were made during the survey process: 10/22/23 at 9:17 A.M. Resident in bed, air mattress set to 200. 10/22/23 at 2:28 P.M. Resident in bed, air mattress set to 200. 10/23/23 at 11:08 A.M. Resident in bed, air mattress set to 200. 10/24/23 at 8:14 A.M. Resident in bed, air mattress set to 200. Resident lying on two disposable incontinent pads and a fitted sheet. 10/24/23 at 1:28 P.M. Resident in bed, air mattress set to 200. Resident lying on two disposable incontinent pads and a fitted sheet. During an interview with observation on 10/24/23 at 2:58 P.M., Nurse #4 said she had marked the order for the alternating air mattress to be set at 160, but that she did not know what that meant. In observing the air mattress to currently be set at 200, the Nurse said she was not sure what the setting should be. During an interview on 10/24/23 at 3:14 P.M., Unit Manager #2 said she thought the order for the air mattress for Resident #141 was set for comfort and reviewed the orders and confirmed the order for the air mattress to be set at 160, based on weight. She said the facility had purchased thin incontinent pads for Resident #141 and only one incontinent pad should be placed under the Resident. During an interview on 10/24/23 at 1:44 P.M., the Primary Physician of Resident #141 said that she defers the wound recommendations to the Wound Consultant physician. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said Resident #141's Stage IV sacral pressure injury was a failure of wound care. Refer to F686

Based on observations, interviews, policy review, and record review, the facility failed to ensure three Residents (#141, #87, #21), out of a total sample of 20 residents, received care and treatment to prevent and to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #141, to implement recommendations from the wound consultant physician including medications, treatments, and evaluation of an off-loading cushion, to provide wound care treatments as ordered to a pressure injury of the sacral area, to follow physician orders for settings of a pressure relieving air mattress, to identify and assess changes to the sacral wound, resulting in a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) with osteomyelitis (infection of the bone) and sepsis (infection of the blood stream) requiring a 19-day hospital admission and intravenous (IV) antibiotics followed by oral antibiotics for four weeks; 2. For Resident #21, to provide wound care per physician's orders; and to obtain orders for consultant recommended medications to promote wound healing; and 3. For Resident #87, to provide wound care per physician's orders. It was determined the Immediate Jeopardy began on 9/15/23 and was identified on 10/25/23. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 10/25/23, including the Immediate Jeopardy Templates. The Immediate Jeopardy, which began on 9/15/23, was abated on 10/26/23. The non-compliance remained at a lower scope and severity of no actual harm with potential for no more than minimal harm that is not immediate jeopardy. Findings include: Review of the facility's policy titled Skin & Wounds, last revised March 2023, indicated but was not limited to the following: -The necessary treatment and services will be provided to promote healing, prevent infection and prevent new pressure injuries from developing. -Pressure injuries are assessed and documented on at least weekly and with a significant change in the wound until it is resolved. -Avoidable means that the resident developed a pressure injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure injury risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. -Use minimal linen under areas prone to skin breakdown. Multiple incontinence pads may reduce the effectiveness of pressure reduction mattresses. -A wound infection should be considered if wound presents with purulent drainage. Consult with the MD (Doctor of Medicine) and if culture is ordered, follow procedure. Further review of the facility Skin & Wounds policy included a Pressure Injury Investigation Tool for Newly Acquired Facility Wounds form which included: Risk Factors, Clinical Status, Nutritional Considerations, Clinical Symptoms, Interventions Prior to Wound Discovery, Self Determination of Resident and sections to indicate new interventions and staff investigation findings and a Summary to include if the pressure injury was avoidable or unavoidable. The form indicated an unavoidable determination can only be made if preventative measures, the resident clinical picture and individual resident needs, wishes and risk factors were managed and interventions were consistently implemented. The form included signature sections for the physician, the infection control preventionist, and the Director of Nurses. Review of the facility's policy titled Treatments, dated April 2015, indicated but was not limited to the following: -In order for the residents to achieve an optimum in their physical state, various treatments may be necessary. -It is the responsibility of all nursing staff to constantly evaluate the health state of residents. -Once treatments are ordered, they are to be carried out as prescribed. -All treatments are to be charted on the treatment sheets. -The physician is to be notified of treatments omitted. Review of the facility's policy titled Consultant Services, dated April 2015, indicated but was not limited to the following: -a note should be recorded on the consultation form by any health care consultant who sees the resident. The consultant should document findings and recommendations on the form. -the charge nurse will then notify the attending physician of findings and he/she can then order the specific treatments as outlined by the consultant. Review of the facility's Air Mattress Overlay policy, dated April 2015, indicated an air mattress overlay is used to prevent skin breakdown in accordance with physician's orders. The procedure indicated to verify the physician's order, evaluate air mattress functions and proper inflation every shift. 1. Resident #141 was admitted to the facility in February 2015 with diagnoses including diabetes, Parkinson's disease, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #141 was dependent for all care including bathing, dressing, and eating. Review of the care plans for Resident #141 included a care plan initiated on 9/6/23 for an actual alteration in skin integrity related to moisture-related dermatitis to the sacrum acquired on 9/5/23. The care plan included goals of improved skin integrity as evident by signs and symptoms of healing and remaining free from infection. The interventions included consulting with the certified wound physician, follow physician's orders for skin care and treatments, monitor for signs and symptoms of infection and report to physician, rehabilitation screen for seating/positioning, and a [NAME] Relief alternating pressure system with low air loss- set at: alternating 160. Review of the medical record indicated on 9/5/23 the Wound Consultant physician identified Resident #141 had a shearing (when the skin remains stationary and the underlying tissue moves) to the right and left sacral area (lower back, bottom of the spine). The nursing progress note from 9/5/23 indicated the area was a result of moisture-related dermatitis following the Resident's more frequent times out of bed. Review of the Wound Evaluation and Management Summary from the Wound Consultant dated 9/5/23 indicated the following new areas as identified by the Wound Consultant: Non-pressure wound of the right, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 9 centimeters (cm) in length by 4.2 cm in width by 0.05 cm in depth Periwound: induration (hardening of skin), maceration (the softening and breaking down of skin as a result of prolonged exposure to moisture)- mild. Exudate (drainage): light serous (clear fluid) Other viable tissue: 100% Non-pressure wound of the left, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 8 cm in length by 5 cm in width by non-measurable depth Periwound: induration, maceration-mild Exudate: none Other viable tissue: 100% Additional wound details from the Wound Consultant indicated Resident #141 was spending too much time in the Broda chair (positioning wheelchair) with the following recommendations to both buttocks: normal saline wash, house barrier cream, and Zinc ointment to the periwound, three times per day. Additional recommendations included Multivitamin once daily, Zinc Sulphate 220 mg (milligrams) once daily, and to upgrade the off-loading chair cushion. Review of the nursing progress note, dated 9/5/23, indicated the Wound Consultant physician also recommended Resident #141 stay in bed for one week with frequent repositioning. Review of the medical record including Physician's Orders, Medication Administration Records (MAR), and Treatment Administration Records (TAR) indicated the treatment of barrier cream and Zinc ointment three times a day was implemented on 9/6/23 and the Multivitamin and Zinc Sulphate 220 mg were not ordered as recommended. Review of the MAR indicated Resident #141 stayed in bed from 9/6/23 through 9/12/23 as recommended. Review of the medical record including nursing progress notes, rehabilitation screens, Physical Therapy notes, and Occupational Therapy notes, failed to indicate Resident #141 was re-evaluated for an upgrade to the off-loading chair cushion, per the Wound Consultant physician's recommendations. Review of the Wound Evaluation and Management Summary from the Wound Consultant dated 9/12/23 indicated the right and left medial buttock areas were merged to one area with the following information: Non-pressure wound, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 7.5 cm in length by 9 cm in width by 0.05 cm in depth Periwound: induration - mild. Exudate: none Other viable tissue: 100% Wound Progress: exacerbated due to patient non-compliant with wound care, MASD (moisture associated skin damage). The recommended treatment was for a normal saline wash, followed by Xeroform gauze and to cover with a gauze island with border dressing, once daily. Additional recommendations included a Multivitamin once daily, Zinc Sulphate 220 mg once daily and to upgrade the off-loading chair cushion. During an interview on 10/23/23 at 2:27 P.M., Unit Manager #2 said the process for when the Wound Consultant physician completed visits was for the Wound Consultant to provide verbal information regarding recommendations, then send over the written recommendations. She said, as the Unit Manager, she would obtain the written recommendations the day after the visit and review them with the physician and enter the orders as recommended. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she had not seen the recommendations for the Multivitamin and Zinc Sulphate 220 mg that were made on 9/5/23 and 9/12/23. Unit Manager #2 said she did not know the Wound Consultant physician made recommendations regarding medications. She said she must have overlooked the recommendations. During an interview on 10/23/23 at 2:27 P.M., Unit Manager #2 said Resident #141 was not having any difficulty accepting wound treatments and had not refused any wound treatments when the wound developed in early September. During an interview on 10/23/23 at 12:45 P.M., Certified Nursing Assistant (CNA) #1 said Resident #141 accepted repositioning without any issues or difficulties. During an interview on 10/23/23 at 4:34 P.M., the Director of Nurses said Resident #141 had accepted treatments to the wound and had completed the bed rest as ordered by the physician. Review of the medical record, including MARs and TARs, failed to indicate Resident #141 had been non-compliant with interventions, as indicated on the Wound Evaluation and Management Summary. During an interview on 10/23/23 at 4:34 P.M., the Director of Nurses said she did not know anything about the type of off-loading cushion Resident #141 had, as the rehabilitation department (Rehab) was responsible for cushions. During an interview on 10/24/23 at 10:56 A.M., Occupational Therapist #1 said Resident #141 had a Pommel cushion for the Broda chair in September 2023. During an interview on 10/24/23 at 11:00 A.M., the Director of Nurses said Resident #141 had an order for a Pommel cushion from July 2023 until October 2023. During an interview on 10/24/23 at 1:21 P.M., Occupational Therapist #1 said the process for a re-evaluation of a cushion was for the nursing department to send a referral to the Rehab department for review. During an interview on 10/24/23 at 2:06 P.M., the Director of Nurses said if the Wound Consultant physician wrote a recommendation to review the off-loading cushion, then nursing should have referred the Resident to Rehab for an evaluation of the cushion. She said she did not know the Wound Consultant physician had made the recommendation on 9/5/23 and 9/12/23 and Resident #141 had not been referred to the Rehab department. Review of the Resident Flow Sheets indicated Resident #141 was up in the wheelchair on 9/13/23, 9/14/23, 9/22/23, 9/23/23, 9/24/23 and 9/25/23 (six days without an evaluation of an upgrade to the cushion, as recommended by the Wound Consultant). Review of the TAR indicated the recommended wound treatment of normal saline wash, followed by Xeroform gauze and to cover with a gauze island with border dressing once daily was initiated on 9/12/23 with a start date of 9/13/23. Review of the TAR indicated the wound dressing was not completed on 9/13/23 or 9/18/23. Review of the TAR indicated the following nursing documentation of the sacral area: 9/13/23: not completed as ordered 9/14/23: Base: C (clean); Drainage: none; Drainage amount: none; Outcome: NC (no change); Periwound: H (healthy) 9/15/23: Base: S (slough- non-viable (necrotic (dead) skin tissue that is yellow, tan, gray, green or brown; usually moist, can be soft, stringy and mucinous in texture); Drainage: SS (serosanguineous- thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells); Drainage amount: S (small); Outcome: W (worse); Periwound: M (macerated) 9/16/23: Base: clean; Drainage: none; Drainage amount: none; Outcome: no change; Periwound: healthy 9/17/23: Base: clean; Drainage: none; Drainage amount: none; Outcome: worse; Periwound: healthy 9/18/23: not completed as ordered Review of the nursing progress notes included one note between 9/12/23 and 9/19/23. The note, dated 9/14/23, indicated there was minimal improvement to the sacral wound. There was no further documentation to indicate the changes noted in the sacral wound on 9/15/23 or the reasoning for the documented outcome of worse on 9/17/23. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she was working as the assigned nurse for Resident #141 on 9/13/23 and 9/18/23. She said she cannot say why the treatments were not completed as ordered. She said the treatments should have been done as ordered. She said she did not remember seeing any changes to the wound between 9/12/23 and 9/19/23. During an interview on 10/24/23 at 1:24 P.M., Nurse #3, who completed the sacral wound treatment for Resident #141 on 9/15/23 said she could not recall how the wound looked on this date, but if she documented there was slough and drainage, then there was. Review of the Wound Evaluation and Management Summary from the Wound Consultant, dated 9/19/23, indicated the following: Non-pressure wound of the right, medial buttock, full thickness: Etiology: trauma/injury Wound Size: 4.3 cm in length by 4.5 cm in width by 3.2 cm in depth Periwound: induration, maceration- mild Exudate: moderate serous Thick adherent devitalized necrotic tissue: 70% Slough: 10% Other viable tissue: 20% Wound Progress: exacerbated due to general decline of patient, non-compliant with wound care, always supine. Surgical excision debridement procedure: removed necrotic tissue and established the margins of viable tissue. Surgically excised 13.54 cm of devitalized tissue and necrotic muscle level tissues along with slough and biofilm were removed at the depth of 3.6 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80% to10%. The Wound Consultant physician recommended the following treatment: normal saline wash, Sodium Hypochlorite Solution (Dakins- made from bleach that has been diluted, it is an antiseptic that kills most forms of bacteria and viruses) apply for 15 minutes then rinse with normal saline, pack with Calcium Alginate (a highly absorbent dressing that interacts with the wound fluids to form a gel that provides a moist wound environment and facilitates auto debridement; the calcium in the dressing interacts with sodium in the wound to promote healing), apply a gauze island with border dressing, once per day. During an interview on 10/23/23 at 2:27 P.M., Unit Manager #2 said when the Wound Consultant physician came in on 9/19/23 there was a nickel size necrotic area on the sacral wound of Resident #141. She said she did not remember when the necrotic area started or when the wound changed. During an interview on 10/23/23 at 4:34 P.M., the Director of Nurses said the moisture shearing on Resident #141's sacrum developed necrosis in a day or two. She said she did not recall hearing there was a change in the wound from the nurses. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said he had worked with Resident #141 for many years on various arterial, venous, and pressure wounds. He said Resident #141 had a history of picking at wounds on his/her legs and that was why the Resident was considered non-compliant. He said Resident #141 had never previously developed any open areas to his/her sacrum. The Wound Consultant said the sacral area started off as moisture associated skin damage. He said he had recommended a Multivitamin and Zinc Sulphate as the supplements help with collagen and wound healing. He said he had recommended bed rest on 9/5/23 as the Resident was always sitting up in the wheelchair and wanted to alleviate pressure to the area; he said the Resident did stay in bed that week. The Wound Consultant said on 9/12/23 the sacral area had looked pretty much the same from 9/5/23 and he had added the Xeroform to prevent additional moisture to the area. The Wound Consultant said when he saw the sacral area on 9/19/23, It was a shock; it was necrotic and there was a drastic change from the week before. The Wound Consultant said the change in the wound did not occur in one day, adding not a chance with that degree of necrosis. He said the wound on 9/19/23 was a sacral Stage IV pressure injury and he should have updated the Wound Evaluation and Management Summary to reflect the status of pressure injury. The Wound Consultant said on 9/19/23 there was no overwhelming odor to the wound and the Dakins was recommended to prevent infection. Review of the TAR indicated on 9/20/23 the previous treatment of normal saline wash, followed by Xeroform, followed by a gauze island border dressing was completed, despite the wound changing to a Stage IV pressure injury. The wound descriptions on 9/20/23 on the TAR are as follows: Base: SE (slough, eschar); Drainage: P (purulent- white, yellow, or brown fluid and might be slightly thick in texture, made up of white blood cells trying to fight the infection); Drainage amount: small; Outcome: worse; Periwound: macerated. The TAR indicated the following sacral wound treatment was started on 9/21/23: Normal saline wash, pat dry, pack undermining pocket with Alginate and cover wound with large foam dressing. The order indicated the use of Alginate, instead of Calcium Alginate, as indicated in the recommendation from the Wound Consultant and failed to include the Dakins. Review of the TAR indicated the following nursing documentation of the sacral pressure injury: 9/21/23: Base: slough, eschar; Drainage: purulent; Drainage amount: small; Outcome: no change; Periwound: healthy 9/22/23: Base: slough, eschar; Drainage: purulent; Drainage amount: moderate; Outcome: worse; Periwound: healthy 9/23/23: Base: slough; Drainage: purulent; Drainage amount: large; Outcome: worse; Periwound: macerated 9/24/23: Base: clean; Drainage: serosanguineous; Drainage amount: moderate; Outcome: no change; Periwound: macerated 9/25/23: Base: clean; Drainage: serosanguineous; Drainage amount: moderate; Outcome: no change; Periwound: macerated During an interview on 10/23/23 at 12:36 P.M., Nurse #2 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/21/23 and 9/22/23. She said she could recall that there was purulent drainage and that the wound smelled. She said she had not notified anyone of the changes, but that the purulent drainage was a sign of an infection. During an interview on 10/24/23 at 1:24 P.M., Nurse #3 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/23/23. She said she remembered that the treatment was for Alginate only. She said the wound had a lot of drainage and it was purulent drainage. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said she had provided the treatment to the sacral pressure injury for Resident #141 on 9/24/23 and 9/25/23. She said she didn't recall an odor, and that it smelled like a regular wound to the coccyx. She said she had not identified purulent drainage and had not identified any signs or symptoms of infection. She said she had completed the treatments on 9/24/23 and 9/25/23 as ordered for Alginate followed by a foam dressing. The Unit Manager said she was the one who had obtained verbal recommendations from the Wound Consultant on 9/19/23 and had waited for the written recommendations to call them into the physician and obtain a new treatment order on 9/21/23, two days later. She said she must not have reviewed the written recommendations because the Wound Consultant did not tell her verbally to use Calcium Alginate (versus Alginate) or to use Dakins. She said only Alginate followed by a large foam dressing was used from 9/21/23 through 9/25/23. Review of the nursing progress notes included one note between 9/19/23 and 9/24/23. The note, dated 9/21/23, indicated the sacrum wound was worsening. Review of a physician Progress Note, dated 9/20/23, failed to include any documentation related to the Stage IV pressure injury of the sacrum. Review of a nursing progress note, dated 9/26/23, indicated the sacral pressure wound for Resident #141 had been worsening over the course of treatment and there was a pending wound culture to rule out infection. Review of a nursing progress note from 9/26/23 at 11:50 A.M. indicated the laboratory (lab) called with critical lab values for pre-albumin (a protein) of 9.2 (reference range 16 to 40 milligrams per deciliter; low pre-albumin can be an indication of malnutrition). Review of a nursing progress note from 9/26/23 at 2:07 P.M. indicated additional laboratory values with critical levels including elevated white blood cells (WBC) and low Hemoglobin and Hematocrit (H&H). The nursing progress notes indicated the physician was made aware of the lab values and a new order was obtained to send Resident #141 to the hospital. Review of the facility obtained wound culture, dated 9/26/23 indicated the sacrum wound of Resident #141 showed moderate growth of Staphylococcus aureus, a bacteria. During an interview on 10/23/23 at 5:26 P.M., Unit Manager #2 said on 9/26/23 the sacral wound had a lot of slough and when physically looking at the wound, the team (the Director of Nurses, the Infection Control Preventionist, and the Unit Manager) thought the wound treatment should have included Dakins. She said at this time, she checked the Wound Consultants recommendation from 9/19/23 and saw that Dakins had been recommended and never ordered. During an interview on 10/24/23 at 9:40 A.M., the Wound Consultant physician said the facility had notified him when Resident #141 went to the hospital that the Dakins had not been used as ordered. He said with this type of progression of a wound the Dakins should have been used and that Dakins works really well in difficult wounds like the sacral wound of Resident #141. During an interview on 10/23/23 at 4:34 P.M., the Director of Nurses said there was no incident report (Pressure Injury Investigation Tool- as indicated in the Skin and Wound policy) for the Stage IV pressure injury of Resident #141 and there had been no root cause analysis. Review of the Hospital Discharge Summary for Resident #141 indicated the Resident was admitted to the hospital on 9/26/23 with an infected Stage IV pressure injury on the sacrum, which further testing revealed osteomyelitis and sepsis (when an infection affects the entire body). Review of the discharge summary indicated on 9/26/23, in the emergency room , Resident #141 was found to have a gangrenous Stage IV pressure injury. Review of the imaging results indicated the Stage IV pressure injury encompassed the sacrum and the coccyx. Resident #141 was started on an intravenous (IV) antibiotic from 9/26/23 through 10/18/23 and then would transition to two oral antibiotics (ciprofloxacin 750 mg twice per day and doxycycline 100 mg twice per day for four weeks with weekly CBC (complete blood count) labs. Review of the Hospital Discharge Summary for Resident #141 indicated the following regarding the Stage IV pressure injury on the sacrum: Measurements on 10/16/23: 8.7 cm in length by 8.0 cm in width by 3.5 cm in depth Drainage: moderate amount of serosanguineous Treatment: cleanse with normal saline, vitamin A&D ointment to periwound; followed by nickel thick Santyl and packed with normal saline moistened Kerlix, followed by an ABD pad (a non-adhesive gauze pad), secured with brief. Review of the medical record indicated Resident #141 returned to the facility on [DATE]. Review of the Evaluations indicated there had been no nursing evaluations completed on 10/16/23 or 10/17/23. Review of the TAR indicated the treatment to the Stage IV sacral pressure injury was not entered until 10/17/23 and not completed until 10/18/23 (missing a treatment on 10/17/23). Review of the nursing progress notes indicated on 10/18/23 Unit Manager #2 wrote a late entry admission note for 10/16/23 indicating the Resident had returned to the facility and all medications and treatments were reconciled with the physician. During an interview on 10/24/23 at 10:27 A.M., Unit Manager #2 said the nurse who had completed the re-admission for Resident #141 on 10/16/23 had not completed any nursing evaluations and that nurse had said they did not know how to enter the treatments for Resident #141, which is why the treatments were not entered until 10/18/23. The surveyor and the Unit Manager reviewed the current treatment order which indicated to secure the ABD pad with a brief. She said she was not aware the physician's order said to secure with a brief and she was not sure how the brief would secure an ABD pad. She said she is unable to tell in the medical record if the nurse called the physician to verify the treatment order and had assumed the nurse verified the order with the physician. During an interview on 10/23/23 at 10:00 A.M., Nurse #1 said she had already completed the treatment to the sacral pressure injury for Resident #141. On 10/24/23 at 2:00 P.M., the surveyor observed the wound care of Resident #141's Stage IV sacral pressure injury with Nurse #4. Nurse #4 was observed to remove a soiled brief revealing a foam dressing dated 10/23/23, which was not part of the treatment order and had been on the Resident for at least 28 hours. Nurse #4 was observed to remove the foam dressing which had serosanguineous drainage and the Kerlix packing which had thick yellow drainage. The wound base was observed to be dark pink with the presence of yellow slough. Nurse #4 was observed to clean the wound with a normal saline wash, soak the Kerlix in normal saline and pack the wound with the Kerlix. The Nurse was observed to apply A&D ointment to the buttocks and apply an ABD pad over the wound, prior to applying the brief. The nurse was not observed to apply A&D ointment to the periwound and was not observed to use the Santyl as ordered. During an interview on 10/24/23 at 2:58 P.M., Nurse #4 said the bordered foam dressing should not have been in place as it was not part of the treatment order. She said she had forgotten to apply the A&D ointment to the periwound and had forgotten to apply the Santyl to the wound base, but that both should have been applied per the treatment orders. On 10/24/23 at 2:00 P.M., the surveyor observed Resident #141 moaning and groaning during positioning and during wound care. Review of the Physician's Orders indicated on 10/19/23 an order was initiated for Oxycodone 5 mg every 8 hours as needed for pain and wound care. During an interview on 10/24/23 at 2:10 P.M., Nurse #4 said she had not pre-medicated Resident #141 prior to the wound care and did not think there were any orders for pain medication in place. She said she had not seen Resident #141 since returning from the hospital and did not know if there had been a history of pain with wound care. During an interview on 10/24/23 at 3:14 P.M., Unit Manager #2 said Resident #141 should not have had a foam dressing over the sacral wound, as this was not part of the physician's order. She said Nurse #4 should have followed the treatment order and used Santyl in the base and A&D ointment on the periwound. During an interview on 10/25/23 at 2:30 P.M., Nurse #1 said she had completed wound care for Resident #141 on this day. She said she secured the Kerlix packing with a foam dressing. She said she was not aware the order read to secure with a brief and did not understand how a brief would keep an ABD pad on. During an interview on 10/26/23 at 2:00 P.M., Nurse #7 said she had worked with Resident #141 since he/she returned from the hospital and noted the Resident had a foam dressing over the sacral Stage IV pressure injury, although she had not provided the wound care. She said she did not know the order for the treatment indicated to secure the ABD with a brief and did not see how an ABD would stay in place or keep the wound free from incontinence and the treatment order should have been reviewed with a physician for clarification. Review of the Physician's Orders indicated Resident #141 had an order for a specialty air mattress to be in place at all times set at 160, alternating pressure. Review of the medical record indicated on 10/19/23 Resident #141 weighed 164.3 pounds. The following observations were made during the survey process: 10/22/23 at 9:17 A.M. Resident in bed, air mattress set to 200. 10/22/23 at 2:28 P.M. Resident in bed, air mattress set to 200. 10/23/23 at 11:08 A.M. Resident in bed, air mattress set to 200. 10/24/23 at 8:14 A.M. Resident in bed, air mattress set to 200. Resident lying on two disposable incontinent pads and a fitted sheet. 10/24/23 at 1:28 P.M. Resident in bed, air mattress set to 200. Resident lying on two disposable incontinent pads and a fitted sheet. During an interview with observation on 10/24/23 at 2:58 P.M., Nurse #4 said she had marked the order for the alternating air mattress to be set at 160, but that she did not know what that meant. In observing the air mattress to currently be set at 200, the Nurse said she was not sure what the setting should be. During an interview on 10/24/23 at 3:14 P.M., Unit Manager #2 said she thought the order for the air mattress for Resident #141 was set for comfort and reviewed the orders and confirmed the order for the air mattress to be set at 160, based on weight. She said the facility had purchased thin incontinent pads for Resident #141 and only one incontinent pad should be placed under the Resident. During an interview on 10/24/23 at 2:06 P.M., the Director of Nurses said she thought all residents in the facility with air mattresses had an order to be set for comfort. She reviewed the order for Resident #141 and said the air mattress must be set for weight for this Resident and that if the order was written that way then the order should be followed. During an interview on 10/24/23 at 1:44 P.M., the Primary Physician of Resident #141 said that she defers the wound recommendations to the Wound Consultant physician. She said she has worked with the Wound Consultant physician for a while and the process was that when the Wound Consultant sees the Resident, he will verbally tell the Primary Physician of the recommendations and she will agree with his recommendations as he was the one managing and seeing t [TRUNCATED]

Based on records reviewed, review of video surveillance camera footage, and interviews, for one of three sampled residents (Resident #1) who was severely cognitively impaired and was dependent on staff for care, the Facility failed to ensure he/she was free from physical and mental abuse when he/she was restrained and taunted by staff. Review of surveillance camera footage provided by the Facility, indicated that on 11/09/22, Resident #1 was seated in a wheelchair behind the nurses' station, and was restrained by staff to prevent him/her from getting up. In the video staff members draped a blanket over the front of Resident #1 from his/her neck down to his/her waist, and then secured it (tied it in a knot and/or held it tightly in place) behind him/her. Staff can be seen taunting and adding to Resident #1's agitation while he/she was being restrained. Although several staff members can be seen walking by or sitting next to Resident #1, and looking at how the blanket is secured, no one removed or untied the blanket, and Resident #1 remained confined to his/her wheelchair for almost an hour. Findings include: Review of the Facility's Policy titled Abuse Prohibition Policy, undated, indicated that the Facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, and neglect. The Policy indicated it is the Facility's responsibility to identify, correct, and intervene in situations where abuse, mistreatment or neglect occur. The Policy indicated Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Review of the Facility's Policy titled Restraint Management, undated, defined a physical restraint as any manual, mechanical or physical device, material of equipment attached to, or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The Policy also indicated that restraints also include devices used in conjunction with a chair, such as trays, tables, bars or belts, that resident cannot remove easily, that prevent the resident from rising. Review of the Facility's Event Narrative Report and the report submitted by the Facility via Healthcare Facility Reporting System (HCFRS), dated 11/11/22, indicated that on 11/11/2022 at approximately 11:30 A.M., the 3:00 P.M. to 11:00 P.M. responsible person (later identified as Nursing Supervisor #1) and a Certified Nurse Aide (later identified as CNA #4) alerted the Unit B Manager (later identified as Unit Manager #1) of an incident on 11/09/2022 at approximately 8:42 P.M. where a resident (later identified as Resident #1) was confined to wheelchair by a sheet (blanket). Review of the Facility's Investigation Narrative Report, undated, indicated Resident #1 had been sitting at the nurses' station during the 7:00 A.M.-3:00 P.M. shift and the 3:00-11:00 PM shifts for safety related concerns. The Report indicated Resident #1 was assisted multiple times due to agitation and was placed on a 1:1 supervision. The Report indicated that while Resident #1 was on a 1:1, that CAN #1 said Nurse #1 told her (CNA #1) to hold up the blanket to keep it from falling off Resident #1, and she (CNA #1) lightly secured it in a knot to make sure it did not fall off. The Report indicated CNA #1 said Nursing Supervisor #1 came to the unit and told her (CNA #1) not to tell anyone what she did and left the unit. The Report indicated Nurse #1 did not report the incident because Nursing Supervisor #1 was the responsible person (that night) and she (Nurse #1) had not realized Resident #1 had a tied blanket on him/her. The Report indicated that on 11/10/22, Nursing Supervisor #1 told Unit Manager #1 that Resident #1 had behaviors with periods of anxiety throughout the evening shift (3:00 P.M.-7:00 P.M.) on 11/09/22. The Report indicated Unit Manager #1 called the Director of Nurses (DON) on 11/10/22 at 9:00 P.M. to request access to the surveillance camera footage on Resident #1's unit because Nursing Supervisor #1 was not giving her complete answers related to Resident #1's behaviors. The Report indicated that on 11/11/22, while viewing the surveillance camera footage, CNA #1 can be seen securing a blanket behind Resident #1's wheelchair and that there was also a question of Nurse #1 securing the blanket at one point. The Report indicated that the allegation of abuse was not substantiated. Review of a Police Report, dated, 11/11/22, indicated that on 11/09/22 at approximately 20:42 hours (8:42 P.M.), Resident #1 is seen on camera sitting in a wheelchair behind the nurses' station. The Report indicated CNA #1 and Nurse #1 are seen on camera taking a sheet (blanket), bringing it to neck height of Resident #1 and then tying a knot to restrain Resident #1 in the chair. The Report indicated an elder abuse form was filed. Resident #1 was admitted to the Facility in October 2022, and readmitted to the Facility in November 2022, diagnoses included dementia, depression, history of violent behaviors, and age-related cognitive decline. Review of Resident #1's Minimum Set Data (MDS) Admission Assessment, dated 11/19/22, indicated Resident had significant cognitive impairment and required two or more staff members to assist with transfers and ambulation, and he/she exhibited behaviors that significantly interfered with care. Review of Resident #1's Care Plan, dated 10/18/22, indicated the following: - he/she required assistance from two staff members for transfers and ambulation, -when Resident #1 exhibited agitation and aggression toward staff, they should assist the resident to identify triggers or events that may precipitate symptoms, and approach resident warmly and calmly, -when Resident #1 does not use assistive devices or ambulates or transfers unassisted, staff should accept Resident #1's right to refuse and show respect for his/her decision, -identify stressors that may contribute to inappropriate behavior, -anticipate care needs and provide them before Resident becomes overly stressed, and -provide opportunities for positive interaction or attention; stop and talk when passing by. Review of Resident #1's Restraint Evaluation, dated 10/18/22, indicated the only restraint devices in use for him/her was a bed alarm for safety. Review of Resident #1's Physician's Order, dated 10/18/22, indicated he/she should have a bed alarm in place at all times when in bed. During an interview on 11/30/22 at 3:38 P.M., the Administrator and the Surveyor reviewed the surveillance camera video footage dated 11/09/22 on the evening shift from Resident #1's unit. The Administrator said the surveillance video footage was not continuous and was broken up into clips of varying timeframe's. Review of the surveillance camera video footage clips from 11/09/22 19:59:59 to 21:59:51, provided by the Administrator, illustrated the following: 20:04:01, Resident #1 is seen seated in a wheelchair at the nurses' station with CNA #1 and CNA #2. There is no blanket on Resident #1 at this time. CNA #1 gets up from sitting on top of the nursing station desk and as she walks by Resident #1, she quickly pinches Resident #1's nose. Resident #1 flinches and pulls his/her face away. 20:05:18, Resident #1 attempts to stand up from his/her wheelchair. CNA #2 places a hand on Resident #1's left shoulder and holds him/her back in the wheelchair to prevent him/her from standing. 20:07:53, Resident #1 stands up from his/her wheelchair. CNA #2 puts her right hand on Resident #1's left arm, then moves it away. CNA #1 then comes from behind Resident #1 and places her hands on Resident #1's shoulders and forces him/her to sit back down in the wheelchair. Resident #1 reaches back with his/her right hand to remove CNA #1's hand from his/her left shoulder and tries to stand again. CNA #1 pulls on Resident #1 so his/her shoulders are back against the wheelchair seat back. Resident #1 uses his/her left hand to remove CNA #1's hand from his/her right shoulder. 20:09:15, CNA #1 is touching Resident #1's right arm and Resident #1 repeatedly keeps trying to move away from CNA #1. 20:10:13, CNA #1 wiggles her fingers on Resident #1's right arm and Resident #1 pulls his/her arm away. 20:11:22 - 20:11:36, CNA #1 and CNA #2 are sitting on either side of Resident #1. Resident #1 is leaning forward in the wheelchair trying to stand and CNA #1 places her hand on Resident #1's right shoulder to hold him/her down. Resident #1 attempts to stand repeatedly and CNA #1 holds him/her back, so he/she cannot stand. Resident #1 hits CNA #1 and appears frustrated at being held back. CNA #2 intermittently places her right hand on Resident #1's left shoulder to push him/her back in his/her wheelchair. 20:11:53 -20:12:08, CNA #1 and CNA #2 are sitting on either side of Resident #1 and can be seen taking turns poking Resident #1 on his/her torso and arms, while he/she is sitting in a wheelchair behind nurses' station. Resident #1 crosses his/her arms in front of him/herself as they continue to poke him/her. 20:13:24, CNA #1 stands up and touches Resident #1 on what appears to be his/her right hip, and Resident #1 jumps, leans forward and appears to fight back, moving his/her hand toward CNA #1 quickly. CNA #2 is sitting on Resident #1's left side and holds onto Resident #1's left arm as CNA #1 quickly pulls Resident #1's right shoulder back and upper torso back into the wheelchair. 20:14:14, Nurse #1 covers Resident #1 with blanket once he/she is seated in the wheelchair. 20:15:29, Resident #1 is seated in the wheelchair with a blanket up to his/her neck with his/her arms tucked underneath the blanket. Nurse #1 secures the blanket behind Resident #1's wheelchair, and can be seen as she tugs up and pulls forcefully on the ends of the blanket. CNA #2 then helps Nurse #1 by tugging on a secured piece of the blanket, and is seen throwing her head back laughing. Nurse #1 widens her stance for leverage and uses forceful arm movements to secure the blanket. Nurse #1 is seen holding a piece of the blanket, lifting it up high, and pulling at it as if she were tying it. 20:22:00, Nurse #1 is seen untying the blanket and Resident #1 leans forward immediately. However, Nurse #1 then grabs the right and left sides of the blanket with two hands from behind and pulls Resident #1 back in the wheelchair, preventing him/her from getting up. 20:22:11, Resident #1 leans forward in wheelchair, Nurse #1 pulls him/her back into the wheelchair with the blanket which is still covering his/her body up to his/her neck, and limits movement of Resident #1's torso and arms. 20:23:35, Resident #1 leans forward in the wheelchair, Nurse #1 pulls the blanket from behind and repositions Resident #1 back in the wheelchair, and then she (Nurse #1) holds two pieces of the blanket together behind Resident #1's wheelchair. 20:23:56, Nurse #1 stands behind Resident #1, who remains seated in the wheelchair, holds the blanket with two hands, and braces herself with a widened stance for leverage. 20:24:24, Nurse #1 twists the blanket behind Resident #1 which tightens around Resident #1 and holds Resident #1 back in the wheelchair. The blanket is covering the top half of Resident #1's body, up to his/her neck. 20:41:59, CNA #1 puts both her hands on Resident #1's shoulders and Residents #1 pushes her hands away. 20:42:50, Nurse #1 is standing behind Resident #1 holding him/her back in the wheelchair with the blanket. Nurse #1 releases the blanket from her grip, and Resident #1 pushes the blanket down off the upper part of his/her body. 20:42:59, CNA #1 is pulling the blanket up over Resident #1's body, and he/she leans forward and grabs the blanket out of CNA #1's hands. CNA #1 pulls Resident #1 back in the wheelchair with her hands as Resident #1 fights to get CNA #1's hands off him/her. Resident #1 appears frustrated. 20:43:11, CNA #1 pulls the blanket up over Resident #1's arms and torso up to his/her neck and ties the blanket behind Resident #1's wheelchair. Nurse #1 watches CNA#1 tie the blanket. CNA #1 finishes tying the blanket, and looks at Nurse #1 who gives her the okay hand gesture. 20:44:12, CNA #1 is looking at her cell phone as she sits next to Resident #1. Resident #1 attempts to move the blanket to lean forward, and CNA #1 immediately adjusts the secured blanket. 20:44:51, CNA #1 is sitting at the nurses' station with Resident #1. CNA #4 walks by and looks at Resident #1 and CNA #1. CNA #1 holds up a piece of the blanket, which appears to be tied from behind Resident #1's wheelchair and shows it to CNA #4. CNA #4 continues walking by and does not intervene. 20:49:04, CNA #1 touching (wiggling her fingers) on Resident#1's neck while Resident #1's arms and body are restrained under the blanket. 20:51:13, CNA # 2 is sitting behind Resident #1 (while he/she is restrained by the blanket). 20:51:48, Resident #1 is pushing his/her hands against the blanket from underneath while it is secured behind him/her. Resident #1's eyebrows are furrowed and his/her eyes are closed. 21:00:19, Resident #1 still restrained under blanket (arms included), CNA #1 is wiggling her fingers on Resident #1's neck. Resident #1 appears annoyed by CNA #1's touch, and repeatedly moves away from her (CNA #1). 21:00:45, Resident #1 remains restrained under blanket (arms included), CNA #1 again can be seen wiggling her fingers Resident #1's neck and Resident #1 flinches. 21:01:37, CNA #1 is touching Resident #1's face, Resident #1 appears irritated, and is unable to get his/her arms out from underneath the blanket. 21:04:30 - 21:05:06, CNA #1 pokes Resident #1's neck several times and Resident #1 jumps. 21:08:04, CNA #1 is patting Resident #1's head, Resident #1 attempts to move his/her hands but is unable because the blanket is secured and won't allow him/her to. 21:10:07, CNA #1 shows Nursing Supervisor #1 the secured blanket behind Resident #1. Nursing Supervisor #1 is behind nurses' station at med cart, which is behind and to the right of Resident #1. 21:19:46, Nurse #1 checks the secured blanket behind Resident #1's wheelchair and then walks away from the Nurses Station, leaving Resident #1 alone with his/her arms underneath the secured blanket which is up to his/her neck. 21:20:29, Resident #1 is sitting in wheelchair, looks like he/she has slid down attempting to lean forward and use his/her arms, but is restricted by the blanket. 21:20:34, Nurse #1 returns to the nurses' station with CNA #6 who sits down next to Resident #1. 21:20:39, CNA #4 returns to the B Unit and is walking with Nurse #3. They walk by and both look at Resident #1. Nurse #3 continues to look at Resident #1 as she's walking around the outside of the nurses' station. Resident #1 is sitting with his/her eyes closed, the blanket is still covering him/her and it looks to still be secured. 21:24:37, Resident #1 gets his/her left hand out from under the secured blanket but is only able to get it out at the neck level because the blanket is restricting him/her from moving his/her arms any further. 21:29:30, Resident #1 is moving his/her hands under the blanket and is struggling. CNA #6 is sitting next to Resident #1, but does not intervene or help him/her. 21:30:14, CNA #2 is sitting next to Resident #1 behind the nurses' station. 21:30:02, Resident #1 lifts bottom portion of blanket up over his/her head and is moving underneath it. Resident #1's head is covered by the blanket, he/she is moving his/her arms under the blanket, and looks like he/she is struggling to free him/herself from under the blanket. 21:32:25, The blanket is now loosely draped over Resident #1. From the video surveillance footage, it is unable to be determined who loosened the blanket, and when. Nurse #1 is playing with Resident #1's hair and CNA #2 is sitting next to Resident #1. 21:33:03, Nurse #1 reaches behind Resident #1 and boosts him/her back in the wheelchair. The blanket is loose, at chest level, and Resident #1's arms free. 21:34:59, Resident #1 stands, Nurse #1 is standing with him/her and CNA #3 puts her hands on Resident #1's hips and pulls him/her back into the wheelchair. Resident #1 pushes CNA #1 away. CNA #3 moves Resident #1's wheelchair back quickly to remove Resident #1 from the nurses' station. Resident #1 is transported away from the nurses' station, his/her is head down and in his/her left hand. Review of Nursing Supervisor #1's Written Witness Statement, dated 11/11/22, indicated that on 11/09/22 at approximately 8:45 P.M., she saw Resident #1 tied to his/her wheelchair with a blanket. The Statement indicated that she (Nursing Supervisor #1) told Nurse #1 and CNA #1 she could not believe what she was seeing, and this could be considered a restraint and told them (Nurse #1 and CNA #1) to untie the blanket. The Statement indicated that she (Nursing Supervisor #1) was under the impression that Nurse #1 and CNA #1 would untie Resident #1 so she left the nurses' station and returned to the conference room. The Statement indicated that when she (Nursing Supervisor #1) returned to Resident #1's unit later in the shift and Resident #1 was in bed. During an interview on 11/30/22 at 1:17 P.M., and review of CNA #1's written statement, CNA #1 said she sat with Resident #1 on 11/09/22 at the nurses' station because he/she had been repeatedly trying to stand up since 3:00 P.M. CNA #1 said on 11/09/22, Resident #1 sat behind the nurses' station from 3:00 P.M. until 9:00 P.M. CNA #1 said when Nurse #1 asked her to sit with Resident #1, she saw Nurse #1 holding a blanket wrapped around Resident #1 from behind, and Resident #1's arms were underneath the blanket. CNA #1 said Nurse #1 was holding the blanket tightly like she was trying to hold Resident #1 back in the wheelchair. CNA #1 said Nurse #1 told her to make sure the blanket did not come off Resident #1. CNA #1 said she tied two pieces of the blanket together, and lightly secured the blanket with a knot behind Resident #1's wheelchair. CNA #1 said Nursing Supervisor #1 came onto the B Unit at some point during the shift but had not said anything to her. CNA #1 said she felt uncomfortable after her shift, and said she was going to report that Nurse #1 was holding a blanket tightly around Resident #1, but she did not. CNA #1 said she was also going to report that Nurse #1 had her wrap a blanket around Resident #1 and secure it, but she did not. Review of CNA #2's written Witness Statement, dated 11/11/22, indicated CNA #2 had worked on B Unit from 3:00 P.M. on 11/09/22 until 7:00 A.M. on 11/10/22. The Statement indicated she (CNA #2) helped with Resident #1's 1:1 supervision on and off that night, and saw he/she had a blanket around the top part of his/her body up to his/her neck but had not realized it was tied. During an interview on 12/12/22 at 2:37 P.M, although CNA #2 said she did not see or help Nurse #1 secure a blanket around Resident #1 and behind his/her wheelchair, her statements are suspect based on what can be seen on the video camera surveillance footage. CNA #1 and CNA #2 said they did not remember poking or teasing Resident #1. CNA #1 said she did not remember pushing Resident #1 back into his/her wheelchair or holding him/her back to prevent him/her from standing up. CNA #1 said Resident #1 can stand up by him/herself and had been repeatedly trying to stand up since 3:00 P.M. (greater than five hours). CNA #2 said CNA #1 told her she was going to tie Resident #1 to the wheelchair. During an interview on 12/14/22 at 9:16 A.M., and review of CNA #6's written Witness Statement, dated 11/15/22, indicated she (CNA #6) sat with Resident #1 on 11/09/22 at the nurses' station for 1:1 supervision for a very short period of time, but she did not see a blanket tied around him/her. Although written Witness Statements submitted by CNA #3 dated 11/11/22, , CNA #4 dated 11/11/22, CNA #5 dated 11/14/22, and CNA #6 dared 11/14/22, indicated in their written Witness Statements that they did not see Resident #1 secured to his/her wheelchair with a blanket, their statements seem suspect given based on what can be seen on the video surveillance footage, which depicts them either standing around or the nurses' station or sitting next to Resident #1 behind the nurses' station during the time he/she was restrained. Review of Unit Manager #1's written Witness Statement, dated 11/14/22, indicated on 11/10/22, Nursing Supervisor #1 told her (Unit Manager #1) that Resident #1 had difficult behaviors on 11/09/22 during the 3:00 P.M. to 11:00 P.M. shift. The Statement indicated when she watched the surveillance camera video footage, she saw Resident #1's blanket secured and tied behind him/her. During an interview on 11/30/22 at 1:53 P.M., Unit Manager #1 said when she and the DON viewed the surveillance camera video footage on 11/11/22, she saw Resident #1 sitting at the nurses' station with a blanket up over his/her shoulders and said she saw CNA #1 tie the blanket around the back of Resident #1's wheelchair, which was a restraint. Unit Manager #1 said even if there had been an order for a restraint (there was not), this was not an appropriate restraint device and tying Resident #1 to his/her wheelchair was considered abuse. During an interview on 11/30/22 at 2:58 P.M., the Director of Nurses (DON) said on 11/11/22, she watched the surveillance camera video footage from 11/09/22, and said she saw CNA #1 secure the blanket behind Resident #1. The DON said Nurse #1's role was in question because (based on the video) she had to have seen CNA #1 secure the blanket. The DON said if Resident #1 was confined to his/her wheelchair, that would be considered abuse. The DON said she had not watched any further video footage other than where CNA #1 secured the blanket around Resident #1. During an interview on 11/30/22 at 3:38 P.M., the Administrator said the first time he watched the surveillance camera video footage from the 3:00 to 11:00 shift on 11/09/22 was when he viewed it with the Surveyor on 11/30/22. While viewing the video footage with the Surveyor, the Administrator said he saw CNA #1 tie a blanket around and behind Resident #1's wheelchair, and that Nurse #1 had been present. On 12/05/22 at 12:48 P.M., the Administrator identified staff in the video footage for the Surveyor. The Administrator said he still had not had time to review all the surveillance camera footage from the 11/09/22 evening shift. The Surveyor asked the Administrator to review the footage from 20:15:29 and tell the Surveyor what he saw. The Administrator said it looked like Nurse #1 was tying the blanket around and behind Resident #1's wheelchair. During an interview on 12/07/22 at 1:23 P.M., the Administrator said after he watched more surveillance camera video footage, he substantiated abuse in both instances where Resident #1 is secured to his/her wheelchair with a blanket (once by Nurse #1 and again by CNA #1).

Based on interviews and records reviewed for one of five sampled residents (Resident #1), who been admitted to the Facility with a history of physical aggression toward other residents and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of the Facility not permitting Resident #1 to return to the Facility, he/she remained in the Hospital ED for 19 days, while the Hospital searched for alternative placement for him/her. Findings include: Review of the Resident Bill of Rights Policy, dated July 2021, indicated that residents had the right to remain in the Facility and would not be discharged from the Facility except as provided by Federal law. The Policy indicated that Federal and State law permitted involuntary transfer or discharge when the resident's needs and welfare cannot be met in the Facility, when the resident's health has improved or when the health and safety of other residents is endangered. Review of Resident #1's medical indicated that he/she was admitted to the Facility during June 2022 after a stay at a Geriatric Psychiatric Hospital. Review of documents from the Geriatric Psychiatric Hospital contained in Resident #1's screening by the Facility, prior to his/her admission to the Facility, revealed the following: -The Emergency Department Document, dated 6/13/22, indicated Resident #1 presented to the emergency department from a nursing home after having punched a nursing home resident in the face. -The History and Physical, dated 6/14/22 indicated that Resident #1 had a number of admissions to the hospital for behavioral problems over the past few years and had been sent to the hospital on 6/13/22 from his/her previous nursing home for striking a resident. The History and Physical indicated that because Resident #1's behavior was so different at the hospital (happy and content), it was suspected that his/her bad behavior was situational rather than related to medications. -The Hospital Nursing Progress Note, dated 6/16/22, indicated that Resident #1 was noted to dislike other patients at times and became upset with them for being too close to him/her at times. -The Hospital Discharge Summary, dated 6/24/22, indicated Resident #1 was pleasantly confused and aphasic (a disorder which affects how a person communicates) at baseline, was able to answer yes and ok for his/her name, date of birth, and responded to questions with non-sensical speech and a few clear words. During an interview on 10/07/22 at 8:30 A.M., the Director of Nursing said that Resident #1's Health Care Proxy was activated 6/24/22. Resident #1's most recent Admission Minimum Data Set Assessment (MDS), dated as completed 6/30/22, indicated that his/her cognitive patterns were severely impaired and he/she ambulated with supervision. The MDS indicated that Resident #1 was sometimes able to understand others and could sometimes make him/herself understood by others. Review of Resident #1's Baseline Care Plan, dated 6/24/22, identified a concern regarding Behavioral Symptoms, a goal for fewer symptoms, and interventions included assessing internal and external contributors. Review of the Resident to Resident Investigation Reports for Resident #1 indicated he/she was involved in the following resident to resident incidents while at the Facility: - on 7/27/22, Resident #1 hit Resident #4 in the face with a pillow, - on 8/11/22, Resident #1 slapped Resident #5's face, and, - on 8/14/22, Resident #1 hit Resident #2 on the right shoulder. During an interview on 9/20/22 at 9:05 A.M., Family Member #1 (Resident #1's Health Care Agent), said that on 8/14/22, Facility staff members notified her that Resident #1 was being transferred to the hospital after he/she swatted at a resident standing near the nurses station. Family Member #1 said that once Resident #1 was in the Emergency Department (ED), hospital staff said that although Resident #1 had no behavioral issues in the ED and did not require hospitalization , the Facility was unwilling to allow Resident #1 return. Family Member #1 said that on 8/16/22 she went to the Facility and spoke to the Administrator, who told her that Resident #1 had been discharged to the hospital over the weekend. Family Member #1 said Resident #1 remained in the ED for 19 days while the ED searched for alternate placement. Although Resident #1's cognitive deficits and [CONDITION(S)] limited the degree to which he/she could express his/her feelings about having been in the ED for 19 days, an unimpaired individual would experience mental anguish spending that length of time in a Hospital Emergency Department, which is not intended or designed for long-term care placement of a resident who requires nursing home care. During an interview on 9/20/22 at 10:10 A.M., the Administrator said that the Facility discharged Resident #1 to the ED on 8/14/22 following his/her third resident to resident incident at the Facility. The Administrator said that because Resident #1 was a younger resident, was strong, able to ambulate independently, and had no known triggers for his/her aggressive behaviors, that they determined he/she could not be cared for at the Facility and discharged him/her to the ED. During an interview on 9/21/22 at 11:50 A.M., the Director of Nursing said she was not aware of the documentation in Resident#1's medical record from the referring hospital regarding his/her history of aggression toward other residents. The Director of Nursing said that she became aware of Resident #1's potential for aggressive behavior toward other residents after the incident on 7/27/22 in which Resident #1 hit Resident #4 with a pillow. The Director of Nurses said that there were no known triggers for Resident #1's aggression toward other residents. Although the Administrator and Director of Nurses said that the Facility discharged Resident #1 to the ED because Resident #1's aggression was without any kind of trigger, staff members said that his/her aggression toward other residents was triggered by loud sounds, noises or commotion. During interviews on: - 9/20/22 at 11:40 A.M. with CNA #1, - 9/20/22 at 12:05 P.M. with Nurse #1, - 9/20/22 at 12:51 P.M. with the Unit Manager, - 9/20/22 at 1:30 P.M. with the Scheduler, and - 9/21/22 at 9:35 A.M. with Nurse #2, CNA #1, Nurse #1, the Unit Manager, the Scheduler and Nurse #2 said Resident #1's aggression was triggered by noises, loud sounds or circumstances when there was a lot of commotion. The Director of Nurses said that following the altercations between Resident #1 and other residents on 7/27/22 and 8/11/22, the Facility implemented additional care plan interventions for Resident #1. Resident #1's medical record contained a Care Plan related to Behavior Problems and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing said that she reviewed the Care Plan related to Behavior Problems in Resident #1's electronic health record and confirmed that it was initiated 7/17/22, but said the interventions dated as initiated on 7/17/22, were actually put into place and initiated on 7/27/22. Resident #1's Care Plan related to Behavior Problems and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included the following; - administering medications - monitoring the side effects of medication - anticipating care needs before Resident #1 became overly stressed - providing for care needs before Resident #1 became overly stressed - explaining care in advance - intervening to protect the rights and safety of others - approaching in a calm manner - diverting attention - removing from situations and take to another location as needed. Resident #1's Care Plan related to Behavioral Problems indicated additional interventions were initiated 8/11/22. Additional interventions included the following: - to be sure staff were present during times Resident #1 spent in the dining room - educate Resident #1 and his/her responsible party on the causal factors of behaviors and planned interventions - discuss behaviors - reinforce why behaviors are unacceptable. Despite having admitted Resident #1 with a known history of aggression toward residents and staff having identified that his/her aggression was triggered by loud sounds, noises or commotion, the Facility refused to allow Resident #1 to return from the ED on 8/14/22 following an evaluation and he/she remained in the ED for 19 days while the hospital looked for alternate placement.

Based on observations, interviews, and record reviews, the facility failed to ensure proper care and treatment for 4 Residents (#83, #15, #68, and #25) out of 6 residents with catheters. Specifically, the facility failed to ensure: - Residents (#83 and #15) with indwelling catheters were assessed for removal of the catheter as soon as possible; - Residents (#83 and #15) were provided catheter care in accordance with standards of practice; - Residents (#25 and #68) urology consults were reviewed and reflected in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Resident #68, with a catheter, was assessed for infection per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Residents (#83, #15, #68) urinary output was monitored per the plan of care. Findings include: 1A. Resident #83 was admitted to the facility in August 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record indicated Resident #83 returned from a hospital admission on 9/15/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Progress Notes from re-admission failed to indicate Resident #83 had a catheter upon re-admission to the facility. During an interview on 10/14/21 at 3:18 P.M., the Physician said she was not aware the Hospital Discharge Summary indicated to trial the discontinuation of the catheter after 10 days and she had not ordered a voiding trial for Resident #83. She said she thought a urologist had recommended to keep the catheter in place and she had not evaluated the need for continued use. She said she did not know when the last time Resident #83 was seen by a urologist. During an interview on 10/14/21 at 3:26 P.M., Nurse #7 said Resident #83 was last seen by a urologist in 2019, two years prior to the insertion of the catheter. During an interview on 10/15/21 at 9:10 A.M., the Infection Control Preventionist (IP) said the use of catheters leads to increased infections in residents. She said the catheter for Resident #83 should have been assessed for removal, a voiding trial should have been attempted as indicated on the discharge summary. During an interview on 10/19/21 at 9:10 A.M., the Medical Director reviewed the Physician's and Nurse Practitioner's Progress Notes for Resident #83. He said the progress notes failed to indicate Resident #83 had a catheter and that it was assessed for removal. B. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the October 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) indicated catheter care included daily hygiene with soap and water of the catheter area to aid in the prevention of infections. Review of the care plans indicated a focus for the catheter was initiated on 10/7/21 with interventions of providing catheter care every shift and as needed and monitor output for odor, color, consistency, amount, blood and sediment. There was no documentation to indicate catheter care was provided for Resident #83 for three weeks. During an interview on 10/12/21 at 4:54 P.M., the Director of Nurses (DON) said catheter care should have been provided every shift for Resident #83 and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said an order had been written on 10/7/21 for catheter care, following a surveyor inquiry about catheters. She said when the order was written on 10/7/21, she was unsure if the physician was notified to determine risk for infection. During an interview on 10/14/21 at 3:18 P.M., the Physician said she had not been notified of the lack of catheter care for three weeks for Resident #83. She said she thought catheter care was emptying the catheter bag and did not feel the cleaning of the area around the catheter was necessary. During an interview on 10/15/21 at 9:10 A.M., the IP said catheters increase infections in individuals and catheter care should be provided every day. During an interview on 10/19/21 at 9:10 A.M., the Medical Director said the physician was not aware of standards of practice for catheter care and the implications for infection related to the use of a catheter. C. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plans indicated a focus for the catheter was initiated on 10/7/21 with interventions of providing catheter care every shift and as needed and monitor output for odor, color, consistency, amount, blood and sediment. Review of the Certified Nursing Assistant (CNA) documentation for bladder continence indicated documentation of urinary output was not recorded for 40 out of 81 shifts. The documentation indicated the following large urinary outputs: -9/18/21 3:00 P.M. to 11:00 P.M. 2,800; -9/19/21 3:00 P.M. to 11:00 P.M. 2,700; -9/21/21 7:00 A.M. to 3:00 P.M. 2,700; and -9/29/21 3:00 P.M. to 11:00 P.M. 2,500. During an interview on 10/12/21 at 4:10 P.M., Nurse #7 said she did not know where the input and output documentation was kept on the unit, furthermore, she said there were no residents on the unit who were being monitored for output. During an interview on 10/12/21 at 4:54 P.M., the Director of Nurses said Resident #83, with a catheter, should be monitored by a nurse for urinary output. She said the nurses do not check the CNA documentation and the nurses have not been monitoring urinary output. She said urinary output, for one shift, which is over 2000 should have been reported to a nurse. 2. Resident #15 was admitted to the facility in July 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Hospital Discharge Summary indicated the urine retention was likely due to benign prostrate [CONDITION(S)] and bladder deconditioning, to continue [MEDICATION(S)], a urinary catheter, and follow-up with outpatient urology. A. Review of the medical record for Resident #15 failed to include any documentation from a urology consult to assess the continued need for a catheter. Review of the Bladder and Bowel Assessment, dated 7/16/21, indicated the Resident had a catheter; there was no indication of the plan for the catheter. The Bladder and Bowel Assessment, dated 10/5/21, was blank and not completed as of 10/19/21. During an interview on 10/19/21 at 2:02 P.M., the Director of Nurses said Resident #15 had not seen a urologist in the three months since admission, as indicated on the Hospital Discharge Summary. B. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the October 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) indicated catheter care included daily hygiene with soap and water of the catheter area to aid in the prevention of infections. Review of the care plans indicated a focus for the catheter was initiated on 10/14/21 with interventions of providing catheter care every shift and as needed and monitor output for odor, color, consistency, amount, blood and sediment. There was no documentation to indicate catheter care was provided for Resident #15 for three months. During an interview on 10/19/21 at 12:09 P.M., the DON said an order had been written on 10/7/21 for catheter care, following a surveyor inquiry about catheters. She said when the order was written on 10/7/21, she was unsure if the physician was notified to determine risk for infection. During an interview on 10/15/21 at 9:10 A.M., the IP said catheters increase infections in individuals and catheter care should be provided every day. C. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plans indicated a focus for the catheter was initiated on 10/14/21 with interventions of providing catheter care every shift and as needed and monitor output for odor, color, consistency, amount, blood and sediment. Review of the CNA documentation for bladder continence indicated documentation of urinary output was not recorded for the following: July 2021 missing 32 out of 54 shifts August 2021 missing 44 out of 93 shifts September 2021 missing 51 out of 90 shifts October 2021 missing 24 out of 54 shifts During an interview on 10/12/21 at 4:10 P.M., Nurse #7 said she did not know where the input and output documentation was kept on the unit, furthermore, she said there were no residents on the unit who were being monitored for output. During an interview on 10/19/21 at 12:09 P.M. the DON said the nurses were not monitoring the urinary output of Resident #15 per the plan of care. 3. Resident #68 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #68's Urinary Care Plan, initiated 2/9/21, indicated the following: Focus - Resident has Foley catheter because of urinary retention. This places resident at risk for infection. Interventions - Change Foley and bag per MD orders. - Monitor output for odor, color, consistency, amount, blood and sentiment. A. Record review indicated there was a Physician's Telephone Order, received by Nurse #1 on 3/22/21, with the following orders: -Change Foley catheter 16 fr, 5 ml balloon once monthly every day shift starting on the 22nd and ending on the 22nd every month related to urinary retention, discontinue 3/22/21. Review of the Urology Consultation Report, dated 3/26/21, indicated the recommendation for a monthly catheter change was signed off by the attending physician on 3/26/21 who indicated we will do his/her monthly catheter change here now. Record review failed to indicate the order was followed through and entered into Resident #68's electronic medical record to indicate what size Foley catheter was to be inserted (Fr and balloon size) or the frequency. Review of the Urology Consultation Report, dated 9/14/21, indicated Resident #68's Foley catheter was changed to a 16 fr with 10 cc coude (bent tip) and it was okay for the facility nursing staff to change the Foley catheter every four weeks. The attending physician reviewed and signed the report on 9/16/21. Review of the 10/6/21 urology consultation report, dated 10/6/21, indicated Resident #68's Foley catheter was exchanged with the same size and the next change was due in four weeks by facility nursing staff due to safety concerns at the urologist's office. The attending physician reviewed and signed the report on 10/7/21. Record review failed to indicate the order was followed through and entered into Resident #68's electronic medical record to indicate what size Foley catheter was to be inserted (Fr and balloon size) and the frequency. Further review of Resident #68's medical record failed to indicate an order to change/re-insert the Foley catheter including what size (Fr and balloon size) and frequency from 3/22/21 through 9/14/21 and after 10/7/21. On 10/19/21 at 2:09 P.M., with permission from Resident #68, and Nurse #1 present, the surveyor observed that the Resident had an 18 fr Foley catheter with 10 cc balloon inserted, not a 16 fr as the 10/6/21 urology report indicated. During an interview on 10/19/21 at 2:16 P.M., Nurse #1 said she did not know what the current order was for the size of the catheter or if Resident #68's Foley was changed between 3/22/21 and 9/14/21. She also said she did not know why the telephone order from 3/22/21 was discontinued the same day by her when it should have been continued monthly. She further said the orders were not carried over to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/19/21 at 3:06 P.M., the DON said when there is a new order by the physician, nurses are responsible to enter the orders into the electronic record as well as the MAR/TAR. She said there were no current orders in the electronic record or MAR/TAR to change Resident #68's Foley catheter, but should have been. During an interview on 10/19/21 at 4:08 P.M., the Attending Physician said she was not aware there was no continued order from 3/22/21 to change Resident #68's Foley catheter, but said there should have been. B. Review of Nursing Progress Notes, dated 8/24/21, indicated Resident #68 was having back pain. Review of Nursing Progress Notes, dated 8/25/21, indicated Resident #68 continued to have back pain and was experiencing burning with urination. His/her daughter requested a urine culture. Review of laboratory results for urinalysis (UA), culture & sensitivity (C+S), dated 8/24/21, indicated multiple gram positive and negative bacteria (classification of species) and suggested either specimen contamination or patient colonization (multiplication of the organism without clinical expression). Further laboratory results were recommended. Nurse Practitioner #1 reviewed the results and hand wrote an order on 8/30/21 to repeat UA, C+S to assess for infection, however, the medical record failed to indicate this was done. During an interview on 10/19/21 at 4:08 P.M., the Attending Physician said the repeat UA, C&S was not done, but should have been. During an interview on 10/20/21 at 10:04 A.M., the DON said despite multiple nursing progress notes from 8/25/21 through 9/3/21 indicating a repeat UA, C&S was done, she said it was not. She also said corporate reviewed the batches of labs since 8/24/21 and it did not show that a repeat UA, C&S was done, but should have been. C. Review of the September 2021 Documentation Survey Report for bladder continence failed to consistently document Foley catheter output on each shift per Resident #68's plan of care. 13 out of 90 shifts in September were not documented. During an interview on 10/19/21 at 4:49 P.M., the DON said there was no consistent documentation for Foley catheter output for September 2021, but should have been. 4. Resident #25 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/18/21 at 12:37 P.M., with Resident #25's permission, and Nurse #1 present, the surveyor observed that the Resident had a 10 cc balloon inserted, not a 15 cc balloon per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/18/21 at 2:14 P.M., Nurse #1 said Resident #25's balloon size was different than the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Urology Consultation Report, dated 10/13/21, indicated Resident #25's catheter was changed to a 20 Fr with a 10 cc balloon at the office with the next catheter change due 11/20/21. The report was not signed by the attending physician or nursing staff as being reviewed or addressed. During an interview on 10/19/21 at 3:58 P.M., the Attending Physician said she did not see the 10/13/21 urology consultation report in the Resident's chart and was not aware the Foley catheter had been changed at the urologist's office. She said she should have reviewed and signed off on it, but did not. During an interview on 10/19/21 at 4:49 P.M., the DON said the report should have been addressed by the attending physician and new orders entered into Resident #25's electronic medical record by nursing staff, but were not.

Based on interviews and record review, the facility failed to monitor the nutritional and hydration status of two Residents (#73 and #83), out of a total sample of 23 residents. Specifically, the facility 1. Failed to monitor the weight loss of Resident #73; and 2. Failed to monitor the hydration status of Resident #83, resulting in dehydration. Findings include: 1. For Resident #73 the facility failed to follow the weight policy to monitor the weight of a resident, during which the Resident lost 11.51% within the first month of admission. Review of the facility's policy titled weights, dated August 2015 indicated the following residents would be weighed weekly for four weeks: -new admissions -readmitted residents -residents with unanticipated weight loss of more than 5% in one month -all residents with significant weight loss are reviewed by the interdisciplinary team and interventions implemented as appropriate and are monitored weekly -a weight loss/gain of 5 pounds or more on a resident weighing over 100 pounds, requires a reweigh for verification Resident #73 was admitted to the facility in June 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record indicated Resident #73 was not weighed during the first week of admission, weighed 144.2 lbs (pounds) on 6/15/21 and weighed 116.4 lbs on 9/14/21; a loss of 19.28% in three months. Review of the medical record and the Unit Weight Book indicated the following weights were obtained during the Resident's admission: - 6/15/21 144.2 lbs - 7/5/21 127.6 lbs - 7/12/21 127.8 lbs - 7/26/21 119.4 lbs (reweigh requested by Registered Dietitian) - 9/10/21 116.8 lbs - 9/14/21 116.4 lbs Review of the weights indicated Resident #73 was not weighed weekly following the admission, and was not weighed weekly following a significant weight loss, and was not reweighed following a greater than 5 pound loss. Review of the Registered Dietitian's (RD) Notes did not include documentation of any weights or monitoring of weights between 6/15/21 and 7/5/21 (20 days) in which Resident #73 lost 11.51%. At that time, the RD indicated a plan to monitor weights weekly for four weeks, start a multivitamin, Ensure Plus twice per day and Magic Cup twice per day. On 7/26/21 Resident #73 weighed 119.4 lbs, a loss of 7.04% in two weeks and had not been weighed between 7/12/21 and 7/26/21. The RD's note indicated an intervention of double protein was not added until 7/30/21. Following 7/26/21 Resident #73 was not weighed in the month of August 2021 and a weight was not obtained until 9/10/21 (46 days following significant weight loss). Review of the RD's Quarterly Nutrition Assessment, dated 9/6/21, indicated there was no weight for September 2021 at this time and the assessment was completed based on a weight from six weeks prior. On 9/10/21 Resident #73 weighed 116.8 lbs, an additional loss of 2.18% since the previous weight was taken on 7/26/21. During an interview on 10/12/21 at 10:44 A.M., the RD said Resident #73 should have been weighed weekly when he/she was admitted and then weekly while the weight continued to decrease. She said she could not be sure why the weekly weights were not obtained, why the re-weigh was not obtained on 7/26/21 or why there were no weights obtained in the month of August 2021, following a significant weight loss. 2. For Resident #83 the facility failed to monitor the hydration status of a newly admitted resident who was identified at the hospital as being at risk for dehydration. Review of the facility's policy for Hydration, dated April 2015, indicated residents identified for a potential risk for dehydration will be placed on intake and output (I & O) monitoring until adequate hydration status is achieved or I & O is no longer clinically indicated. Procedure: -Registered Dietitian/MD/nurse will determine minimum fluid needs -implement interventions to promote hydration - if the resident has consumed less than their estimated needs for three consecutive days, complete a dehydration evaluation -establish, implement, and revise as necessary, a plan of care for any resident at risk for dehydration Review of the facility's policy for Intake and Output (I &O) monitoring, dated April 2015, indicated I & O would be monitored, as indicated by the resident's hydration status, risk for dehydration and/or per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - monitor for 72 hours for new admissions or readmissions; continue to monitor based on risk factors for dehydration - document each shift, to be totaled daily by the 3:00 P.M. to 11:00 P.M. shift nurse, with 24 hour totals transcribed to the Medication Administration Record. Resident #83 was admitted to the facility in August 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Hospital Discharge Summary, dated 8/16/21, included a progress note that the hospital labs indicated some dehydration. The Discharge Summary further indicated Resident #83 was not able to reliably take enough fluids by mouth due to the advanced dementia and recommended to periodically monitor outpatient. Review of an RD's Progress Note, dated 9/3/21, indicated a significant weight loss for Resident #83 with a plan to check the Comprehensive Metabolic Panel (CMP). Review of a Nursing Progress Note, dated 9/10/21, indicated Resident #83 had critical labs and was sent to the hospital. Review of the laboratory results indicated a critically high Sodium of 169 (normal range 133-145), Potassium 5.5 (normal range 3.3 - 5.1), and Chloride of 131 (normal range 96-108). Review of the Hospital Discharge Summary, dated 9/15/21, indicated an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Summary indicated [CONDITION(S)] and acute [CONDITION(S)], superimposed on stage 3 [CONDITION(S)], due to dehydration, please encourage free water between meals. Review of the care plans for Resident #83 indicated a focus for the Resident's weight loss with a goal of consuming 75% of food/beverage. There was no plan of care to indicate a plan for the risk of dehydration and what interventions would be implemented. Review of the orders for Resident #83 included an order to monitor I & O for 72 hours following admission and re-admission. A review of the paper and electronic medical record failed to include any intake and output documentation. Review of the Nursing Progress Notes indicated fluids were offered throughout the shift on 9/16/21 (3:00 P.M. to 11:00 P.M.), 9/17/21 (3:00 P.M. through 11:00 P.M.) and 9/18/21 (3:00 P.M. through 11:00 P.M.). There was no indication in the medical record that I & O's were monitored following a hospital admission for dehydration. During an interview on 10/12/21 at 3:30 P.M., Nurse #4 said she did not know where she was supposed to document I & O. During an interview on 10/12/21 at 4:10 P.M., Nurse #7 said she did not know where the I & O documentation was kept on the unit, furthermore, she said there were no residents on the unit who were having their I & O monitored. Review of the Physician's Progress Notes from admission through 10/12/21, failed to include documentation that Resident #83 was at risk for dehydration upon admission, was then hospitalized related to dehydration and failed to include a plan of care to address hydration. During an interview on 10/12/21 at 4:54 P.M., the Director of Nurses said there was no documentation regarding the intake of fluids for Resident #83, as ordered on admission and upon re-admission with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident #83 eats and drinks during meals, and residents on the unit were provided juices or ginger ale between meals (not water) and coffee in the morning. She said there was no specific plan in place to address Resident #83's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/19/21 at 9:10 A.M., the Medical Director reviewed the Physician and Nurse Practitioner (NP) Progress Notes and said the Physician and NP had not addressed the hydration status of Resident #83, the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on policy review, medical record review, and interviews, the facility failed to ensure staff 1. Followed the facility's policy on Bowel Evacuation to prevent hospitalization and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Followed the facility's policy on Falls Management resulting in a five day delay in sending one Resident (#20) to the hospital with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. Review of the facility's policy titled Bowel Evacuation Protocol, dated 3/2016, included but is not limited to the following: -If the resident has had no bowel movement for nine consecutive shifts, begin the bowel protocol on the 3:00 P.M. - 11:00 P.M. shift. -The bowel protocol is to give Milk of Magnesia (MOM- a [MEDICATION(S)]) on the 3:00 P.M. - 11:00 P.M. shift. If the MOM is ineffective, then the resident is to receive a [MEDICATION(S)] suppository ([MEDICATION(S)]) on the 11:00 P.M. to 7:00 A.M. shift. If the [MEDICATION(S)] suppository in ineffective, then the resident is to receive a Fleets enema on the to 7:00 A.M. to 3:00 P.M. shift. -Record the results of the Bowel protocol on the reverse side of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . -Notify the physician if the Bowel Protocol is ineffective. 1. Resident #80 was admitted to the facility in December 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 6/2/21, indicated Resident #80 was incontinent of bowel and bladder, required extensive assistance of one staff for toileting needs, and had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 00 out of 15. Review of the 8/2/21 discharge MDS indicated the Resident had not had a bowel movement in the past seven days. Review of the Certified Nursing Assistant (CNA) documentation for July 2021 and August 2021 indicated Resident #80's last documented bowel movement was on 7/24/21 (incontinent of a small formed Bowel Movement-BM). Further review of the Bowel Log indicated that from 7/25/21 to 8/2/21, the Resident had no documented bowel movements for 22 consecutive shifts. Review of the July 2021 and August 2021 Medication Administration Records (MAR) indicated that from 7/25/21 through 8/2/21, Resident #80 was never administered MOM, a [MEDICATION(S)] suppository, and/or a Fleets enema per the facility's bowel protocol. Review of the Attending Physician's Progress Note, dated 8/5/21, indicated that on 8/2/21, Resident #80 was sent to the hospital for evaluation following a change in mental status. The Resident had been increasingly agitated and had more confusion. Review of the hospital documentation indicated the Resident complained of abdominal pain, and x-ray was performed showing a moderate amount of stool in the rectum. Dulcolax ([MEDICATION(S)]) and a Mineral Oil enema was given in the hospital with passing of a small amount of stool. Review of the Hospital Discharge Summary indicated further follow-up was needed at the nursing home (including outpatient providers) to address disimpaction, as needed and: -Anxiety/agitation -Slow transit constipation with fecal impaction in the rectum, for which the patient may need disimpaction -Hospice care -Do not transfer to the hospital unless for comfort care During interviews on 10/18/21 at 3:10 P.M. and 10/19/21 at 8:21 A.M., the surveyor reviewed Resident #80's medical record with the Director of Nursing (DON). The DON said the facility did not implement the bowel protocol according to the facility's policy, and subsequently, the Resident was transferred to the hospital and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident #20 was admitted to the facility in February 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Falls Management, dated 4/2015 and revised 8/2018, included but is not limited to the following: A fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. Once the resident/patient is clinically evaluated as being stable, vital signs, neurological signs, range of motion, and evaluation of cognitive status will be documented. Neurological checks, to be documented on the neurological flow sheet for 72 hours in the following circumstances, resident/patient states that he/she hit head, physical evidence resident hit head and unwitnessed fall if the resident an unreliable historian. In addition, documentation for 72 hours to assess for latent injury. Review of the facility form titled FALL A&I (Accidents and Incidents) CHECK-LIST (not dated) included but is not limited to the following: All A&I events require nine shifts post event documentation which includes vital signs and neurological assessment (when applicable). Review of Nurse's Notes, dated 7/18/21 at 1:49 P.M., indicated at 1:30 P.M. the Resident was found on the floor next to the bed lying on the left side of her/his body. There no visible injuries and no c/o of pain r/t the fall. Resident could not verbalize account of fall. Vitals were in normal range. MD aware, no new orders. Family notified. Resident was placed in wheelchair and put in the day room to be monitored and to prevent further incidents. Recommend Resident is a daily get up to avoid time unsupervised. Further review of the Nurse's Notes indicated post fall notes were written on the following dates and times: -7/19/21 at 6:59 A.M. S/P [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Neuro's at baseline. Denies any discomfort. Slept well. Safety maintained. -7/19/21 at 2:32 P.M. Resident alert to self with baseline confusion one day s/p fall, no late injury noted. Range of motion (ROM) within normal limits (WNL) no c/o [complaints of] pain, Resident cooperative with morning care, currently in day room in wheelchair participating in activities. -7/19/21 at 9:41 P.M. Alert to self s/p fall without injury denies any pain or discomfort at this time. Neuro's, VS and ROM, WNL Appetite fair, consumed 50% of dinner with good fluid intake. Participated with activities in dining room this evening. Currently sleeping in bed with call bell within reach. -7/20/21 at 10:53 P.M. s/p fall on 7/18/21 with out injury vital signs stable (VSS), compliant with all care and medication regimen. Currently sleeping in bed with call bell in reach, safety maintained -7/21/21 at 10:07 P.M. T-97.7, R-18, P (pulse)-74 Oxygen saturation 96% on Room Air (RA) Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M.-11:00 P.M. shift when the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/21/21 on the 3:00 P.M.-11:00 P.M. shift the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On these two above dates there was no documentation or assessment regarding that the Resident was now noted to be having pain (this was a change in the Resident's pain status). There were no further Nurse's Note from 7/21/21 at 10:07 P.M. through 7/23/21 until 2:36 P.M. when: On 7/23/21 at 2:36 P.M., Resident presented with discomfort to her/his left hip during AM (morning) care, signs of facial grimacing and guarding present, STAT (immediately) left hip x-ray ordered, scheduled. Tylenol 1,000 milligrams administered three times a day r/t hip pain. MD and hospice nurse aware, family has been updated, x-ray remains pending. The results of the x-ray were reported to the facility at 3:59 P.M. which indicated the Resident had a left hip fracture. The Resident was subsequently sent to the hospital at 6:30 P.M. for surgical intervention. Record review failed to indicate documentation had been completed by the staff for the first 72 hours (nine shifts) post fall to assess and identify latent injury. When the Resident began having pain on 7/20/21, there is no documentation indicating a comprehensive assessment was completed as the Resident had a fall on 7/18/21. During interviews on 10/18/21 at 3:10 P.M. and 10/19/21 at 8:21 A.M., the surveyor reviewed Resident #20's medical record with the DON. The DON said the facility did not implement the Falls Management policy and had not documented the Resident's status for 72 hours (nine shifts) post event according to facility policy to assess for/identify latent injuries and subsequently, the Resident was transferred to the hospital and had surgical intervention for a fractured left hip.

Based on observation, interviews, policy review, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing, prevent new ulcers from developing, and provide ongoing assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. For Resident #20, the facility failed to ensure staff followed their skin care program policy, failed to consistently implement effective pressure ulcer prevention interventions, failed to ensure a pressure relief mattress/air mattress was at the appropriate setting to promote healing and failed to monitor an identified pressure area/Deep Tissue Injury (DTI) on the Resident's left heel. Resident #20 was admitted to the facility in February 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/8/21 at 9:30 A.M. and at 2:25 P.M., the surveyor observed Residents #20 in bed with the dial on the air mattress/pressure relief mattress set past the 400 mark. On 10/12/21 at 10:45 A.M., the surveyor observed Resident #20 in bed with the dial on the pressure relief mattress/air mattress set past the 400 mark. During an observation with interview on 10/14/21 at 10:59 A.M., the Director of Nursing (DON) and the surveyor entered Resident #20's room and observed the dial on the pressure relief mattress/air mattress which continued to be set past the 400 mark. The DON said it was not set correctly and should be set per the Resident's weight (weight on 6/3/21 was 142.2 pounds- weights had been discontinued by Hospice). The DON further stated there should be a Physician's Order for the mattress and should include what the mattress should be set at. She also stated that it should be addressed in the Resident's care plan and the Care Card (this is the care plan that the Clinical Nursing Assistants (CNAs) refer to and indicates what care is required for the individual resident). Record review indicated no Physician's Orders for the mattress with settings, no current care plan addressing the need for the pressure mattress/air mattress, and the CNA's Care Card did not indicate that the Resident had a pressure relief/air mattress. During an interview on 10/18/21 at 3:10 P.M., the DON said the facility failed to ensure that there was a physician's order for the mattress with settings, include the pressure relief/air mattress on the Resident's Care Card and update the Resident's Care Plan to include the pressure relief/air mattress. Review of the current Physician's Order indicated: -To apply skin prep to the Resident's bilateral heels; and -To float/elevate the bilateral heels Review of the medical record failed to indicate documentation since 8/26/21 as to the condition of the Resident's heels and if the skin was intact. On 10/19/21 at 8:20 A.M., with Resident #20's permission, the DON and the surveyor observed the Resident's heels. The DON removed the right bootie first. The skin was dry but intact with no evidence of any skin concerns. The DON removed the bootie on the Resident's left heel. The surveyor and the DON observed a 4 centimeter (cm) by 4 cm dark purple area with lifting edges. Review of an initial Pressure Injury Evaluation, dated 8/19/21, indicated the Resident was noted to have a DTI of the left heel that measured 3.5 cm x 2 cm. A deep tissue injury is defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm mushy, boggy, warmer or cooler as compared to adjacent tissue. The treatment to the above area was to apply skin prep every shift, elevate heels when in bed, and order an air mattress. Review of a Pressure Injury Evaluation, dated 8/26/21, indicated the areas have resolved. Review of the Weekly Skin Assessments (which were not consistently completed weekly) and the Weekly Pressure Injury Reports for August 2021, September 2021, and October 2021, did not have the Resident listed for any pressure areas even though documentation indicated the Resident had a DTI on 8/19/21. During an interview on 10/19/21 at 11:05 A.M., the DON said Nurse #8 measured the area and the surveyor was told the area on the Resident's left heel measured 2.5 cm x 1.5 cm is now an open area. Nurse # 8 said that the large dark purple area had lifted off exposing the open area. The DON told the surveyor that the wound consultant was due into the facility today and that she would have the Resident's left heel evaluated by the wound consultant. During an interview on 10/19/21 at 1:18 P.M., the DON said that in reviewing the documentation for the above area that the previous Assistant Director of Nursing (ADON) had completed a Pressure Injury Evaluation on 8/26/21 indicating the area had resolved. The DON said the facility failed to monitor and provide ongoing assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. For Resident #80, the facility failed to ensure staff follow their skin care program policy, failed to consistently implement effective pressure ulcer prevention interventions, failed to ensure a pressure relief mattress/air mattress was at the appropriate setting to promote healing and failed to monitor an identified pressure/blister on the Resident's left calf. Resident #80 was admitted to the facility in December 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/07/21 at 9:30 A.M. and 2:36 P.M., the surveyor observed the pressure relief mattress set between 160-240. Record review indicated the Resident's weight is 79.2 pounds, and the pressure relief/air mattress was set incorrectly (the mattress is set per the Resident's weight). The Resident did have a current physician's order to monitor the functioning of the pressure relief/air mattress, however no setting was indicated so that staff would ensure the setting of the pressure relief/air mattress was correct. During an interview on 10/18/21 at 3:10 P.M., the DON said the facility failed to ensure there was a physician's order for the proper setting of the pressure relief/air mattress and there should be. Review of a Nurse's Note, dated 10/6/21, indicated that during morning care a 3 cm fluid blister was noted on the left posterior leg. Review of the Physician's Order, dated 10/6/21, indicated: -Apply skin prep to fluid filled blister on left posterior leg until resolved, two times a day. Review of the October 2021 Treatment Administration Record (TAR) indicated that from 10/6/21 at 6:00 P.M. through 10/11/21 at 6:00 A.M., the treatment had not been done as ordered by the physician. The first time the treatment was performed by the nursing staff was on 10/11/21 at 6:00 P.M. On 10/19/21 at 11:26 A.M., the DON and the surveyor observed the blister on the Resident's left calf. The DON and the surveyor observed that the area is no longer a blister and that the Resident now has an open area on her/his left calf. During an interview on 10/19/21 at 11:51 A.M., the DON said Nurse #8 measured the area and indicated the open area measures 3.0 cm x 1.5 cm. The DON was then shown the TAR where the treatment had not been done as ordered by the physician. During an interview on 10/19/21 at 1:13 P.M., the DON agreed with the surveyor that there were no assessments or documentation addressing the blister on the Resident's left calf. The DON further said that because of the location of the area, it should have been classified as a pressure area and was not. The DON said that the staff did not perform the treatment as ordered by the physician and failed to ensure that monitoring and ongoing assessments were completed for the blister on the Resident's left calf resulting in an open area. 3. For Resident #73, the facility failed to provide care and services according to the facility's policy and standards of practice for a DTI of the left heel. Resident #73 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record indicated Resident #73 returned from a hospital admission in July 2021 with a DTI to the left heel. Review of the Pressure Injury Evaluation, dated 8/30/21, indicated the area was 2 cm by 1 cm with an undeterminable depth and a plan to float heels off mattress when in bed to prevent further pressure to the area. The weekly pressure injury evaluation was completed on 9/6/21 and 9/13/21. A review of the medical record on 10/14/21 did not include any further evaluations of the area after 9/13/21, one month prior. Review of the October 2021 TAR indicated an order to apply skin prep to the left heel blister every shift. The TAR indicated the treatment was not provided on: -10/1/21 on the 3:00 P.M. to 11:00 P.M. shift, -10/5/21 on the 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. shifts, -10/6/21 on the 7:00 A.M. to 3:00 P.M. shift, and -10/9/21 on the 7:00 A.M. to 3:00 P.M. shift. Review of the October 2021 TAR indicated an order to wear bilateral booties at all times and to off-load heels while in bed. The TAR indicated these interventions were not provided on: -10/1/21 from 3:00 P.M. to 11:00 P.M. shift, -10/5/21 from 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. shifts, and -10/6/21 from 7:00 A.M. to 3:00 P.M. shift. The surveyor made the following observations of Resident #73: -10/7/21 at 8:49 A.M. lying in bed, not wearing bilateral booties, with the heels directly on the mattress; -10/8/21 at 10:39 A.M. in a wheelchair, wearing slipper socks, no booties; -10/12/21 at 10:28 A.M. in bed, no booties, with heels directly on the mattress; -10/12/21 at 11:37 A.M. in a wheelchair, not wearing booties; and -10/13/21 at 10:26 A.M. in a wheelchair, wearing slipper socks, no booties. During an interview on 10/12/21 at 2:30 P.M., Nurse #4 said Resident #73 continued to have a blister to the left heel with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/14/21 at 11:38 A.M., the DON said the nurses should be completing the weekly pressure injury evaluations and she was not sure why the area had not been evaluated with measurements or descriptions in a month.

Based on observation, interviews, record review, and policy review, the facility failed to effectively evaluate for latent injury and pain status post [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to evaluate Resident #37 for pain when it was identified and reported to the nursing staff after a rehabilitation session. Findings include: Resident #37 was admitted to the facility in April 2021 with abnormalities of gait and mobility and repeated falls. Review of the Minimum Data Set (MDS) assessment, dated 12/29/21, indicated the Resident had moderate cognitive impairment and requires cues and supervision for decisions. During an interview on 2/2/22 at 11:20 A.M., Resident #37 said he/she had a fall four days ago and hurt his/her right shoulder and the right side of the ribs. Resident #37 said the pain was terrible and rated the pain 8 out of 10, on scale from 0-10 (10 being severe). The Resident described the rib pain as being worse than the shoulder pain and thought the ribs might be broken. Resident #37 said he/she could not remember if he/she told anyone about the pain. The Resident attempted to lift his/her right arm up away from his/her side but was limited by complaints of pain pointing to the top of the shoulder and then pointing under the arm to the upper side of the rib cage. Review of the facility's policy titled Falls Management, dated August 2018, indicated but was not limited to, the following procedure: -documentation for 72 hours to assess for latent injury. Review of Nursing Progress Notes indicated the following: -1/27/22, Resident #37 was lying on the floor on his/her right side. States I was trying to walk to the bathroom, lost my balance and fell . Witnessed by co-worker. -1/28/22 at 4:32 A.M., Alert, denies pain, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . -1/28/22 at 10:25 P.M., No complaints of any discomfort, call light and alarms in place. No attempt to get up alone. 1/29/22 (late entry written 1/31/22 by Director of Nursing (DON) at 1:37 P.M.), status post [MEDICAL RECORD OR PHYSICIAN ORDER] . 1/29/22 at 2:00 P.M., Resident reminded multiple times not to get up and walk around the room without assistance. 1/30/22 (late entry written 1/31/22 by DON at 1:39 P.M.), status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Aspercreme [MEDICATION(S)] 4%, apply right knee topically one time a day for knee pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M., indicated the following: -Monitor for pain every shift using 0-10 scale -Resident #37's pain level was recorded to be zero, every shift for January and February 2022. Review of Pain Evaluation, dated 1/27/22, indicated the Resident was able to vocalize pain and was not currently experiencing any pain. Review of Physical Therapy notes, dated 1/31/22, indicated Resident #37 did have complaints of right sided upper one third rib soreness today during balance activities. When the Resident was brought back to the unit, his/her nurse was notified of the pain and the Resident reported it was from his/her fall last Thursday. Resident did have a fall and landed on the right side. During an interview on 2/2/22 at 4:30 P.M., Rehabilitation (Rehab) staff #1 said Resident's right shoulder and rib pain was new since he/she had the witnessed fall on 1/25/22. She said on 1/31/22, Resident #37 complained to her about right shoulder and rib pain that was significant and interfered with his/her rehab session. She said Resident #37 has cognitive impairments and when she asked Resident #37 if he/she told anyone about the pain, the Resident could not remember. Rehab Staff #1 said, she brought the Resident back to the unit and informed the nurse about the complaints of shoulder and rib pain. She said the nurse was going to notify the doctor and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/2/22 at 3:05 P.M., Nurse #1 said she is not aware of any complaints of pain from Resident #37 since his/her fall last week. During an interview on 2/2/22 at 3:10 P.M., Resident #37 said to Nurse #1 with the surveyor present, he/she has right shoulder and rib pain and was having trouble lifting his/her arm. Nurse #1 was observed doing a brief evaluation, in which Resident #37's right shoulder abduction (lifting arm out to the side) was limited by pain. Resident #37 had pain when Nurse #1 pushed on the top of the shoulder and right side of the upper portion of the rib cage. Following the surveyor inquiry regarding the vocalized pain of Resident #37 a pain evaluation was conducted. Review of the Pain Evaluation, dated 2/2/22, indicated the following: -Resident able to vocalize pain and is currently experiencing pain. -Pain duration is continuous -Pain has made it hard to sleep at night: Yes -Have you had to limit your day to day activities: Yes -Present pain on scale 0-10: 8 -Worst the pain gets: 8 -Acceptable level of pain: 2 -Pain quality: Ache/dull, throbbing -What relieves pain: I don't know yet During an interview on 2/2/22 at 4:05 P.M., the Director of Nurses (DON) said she read all the nursing notes and was not aware Resident #37 was having any pain related to his/her recent fall. During an interview on 2/2/22 at 5:00 P.M., the DON said she interviewed Resident #37 and he/she reported a pain level of 6 out of 10 in right ribs today.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure staff followed Resident #1's plan of care, when CNA #4 provided care, unassisted, to Resident #1, who was dependent on two staff for assist with care and as a result, Resident #1 fell , sustained a laceration to the right elbow and required sutures. Findings include: The Policy titled, Comprehensive Care Plans, dated as revised in (MONTH) (YEAR), indicated the Facility is committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life. The Policy indicated care plans are oriented toward preventing avoidable decline in clinical and functional levels, developed by the Interdisciplinary Team and include measurable objectives to accommodate medical, nursing and psychosocial needs. Resident #1's [DIAGNOSES REDACTED]. The Annual Minimum Data Sheet (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, was totally dependent and required assist of two staff for personal hygiene, dressing, transfers, bathing and bed mobility. The Care Plan, dated 9/20/17, indicated Resident #1 had impaired functional mobility and was dependent of two staff for bed mobility, positioning, bathing and dressing. A Resident Care Card, undated, indicated Resident #1 was dependent and required assist of two staff with grooming, dressing, positioning, bathing, and bed mobility. A Resident Daily Flow Sheet, dated (MONTH) (YEAR), indicated Resident #1 was totally dependent and required assist of two with grooming, dressing, positioning, bathing and bed mobility. The Health Care Facility Reporting System (HCFRS) Report, dated 11/2/17, indicated that on 10/28/17 at 11:00 A.M., Resident #1 crossed his/her left leg over his/her right leg and rolled off the side of the bed onto the floor during care. The Report indicated Certified Nurse Aide (CNA) #4 was aware Resident #1 required two assists for care and that CNA #4 did not wait for the second CNA to arrive before she provided care to Resident #1. Resident #1 sustained a laceration to his/her right elbow and was transferred to the hospital where he/she required three sutures to close the laceration An Accident/Incident Report and Investigation Form, dated 10/28/17 at 11:00 A.M., indicated during incontinence care, CNA #4 rolled Resident #1 over and Resident #1 crossed his/her legs, rolled off the bed, sustained a laceration to the right elbow and was transferred to the hospital. The Report indicated CNA #4 did not utilize two assists with care as indicated in Resident #1's plan of care. A witness statement, dated 10/28/17, indicated CNA #4 was providing care to Resident #1 when he/she crossed his/her legs and rolled off the bed. The statement indicated CNA #4 was aware that Resident #1 required two assists with care. A Nurse Progress Note, dated 10/28/17, indicated Resident #1 fell out of bed during morning care, sustained a one inch by half inch wide laceration to his/her right elbow which was unable to be closed and was transferred to the hospital for wound closure. The Physician's Telephone Order, dated 10/28/17, indicated to transfer Resident #1 to the hospital for urgent medical care. A Hospital Discharge Packet, dated 10/28/17, indicated Resident #1 was found lying on the side of his/her bed with a laceration to his/her right elbow. The Report indicated Resident #1 required three sutures to close the laceration to his/her right elbow. The Surveyor interviewed Nurse #1 at 12:54 P.M. on 6/4/18. Nurse #1 said CNA #4 was aware that Resident #1 required two CNA's with care and that CNA #4 provided morning care to Resident #1 without assist. Nurse #1 said Resident #1 crossed his/her leg over the other leg, fell on to the floor and sustained a laceration to his/her right elbow. Nurse #1 said Resident #1 was transferred to the hospital where he/she received three sutures to close the laceration. Nurse #1 said Resident #1 required two assists with care and that CNA #4 did not follow Resident #1's plan of care. The Surveyor interviewed CNA #4 at 2:20 P.M. on 6/4/18. CNA #4 said she knew Resident #1 required two assists with care and that she did not wait for another CNA to assist her with Resident #1's morning care on 10/28/17. CNA #4 said when she turned Resident #1, without assistance, Resident #1 swung his/her legs off the bed and fell on to the floor. CNA #4 said Resident #1 had a skin tear to his/her arm and needed to go to the hospital for stitches. CNA #4 said she was wrong, or words to that effect, when she provided care without assistance to Resident #1 and said she did not follow Resident #1's plan of care. The Surveyor interviewed the Regional Director of Clinical Services (RDCS) at 12:50 P.M. on 6/8/18. The RDCS said Resident #1 required two assists with care, that CNA #4 was aware Resident #1 required two assists with care and that CNA #4 did not follow Resident #1's plan of care.

Based on records reviewed and interviews, for one of four sampled residents, (Resident #1), who had [DIAGNOSES REDACTED].#1 who fell out of bed during care, sustained a laceration to the right elbow, was transferred to the hospital and required three sutures to close the right elbow laceration. Findings include: The Policy titled, Comprehensive Care Plans, dated as revised in (MONTH) (YEAR), indicated the Facility is committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life. The Policy indicated care plans are oriented toward preventing avoidable decline in clinical and functional levels, developed by the Interdisciplinary Team and include measurable objectives to accommodate medical, nursing and psychosocial needs. Resident #1's [DIAGNOSES REDACTED]. The Annual Minimum Data Sheet (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, was totally dependent and required assist of two staff for personal hygiene, dressing, transfers, bathing and bed mobility. The Care Plan, dated 9/20/17, indicated Resident #1 had impaired functional mobility and was dependent of two staff for bed mobility, positioning, bathing and dressing. A Resident Care Card, undated, indicated Resident #1 was dependent and required assist of two staff with grooming, dressing, positioning, bathing, and bed mobility. A Resident Daily Flow Sheet, dated (MONTH) (YEAR), indicated Resident #1 was totally dependent and required assist of two with grooming, dressing, positioning, bathing and bed mobility. The Health Care Facility Reporting System (HCFRS) Report, dated 11/2/17, indicated that on 10/28/17 at 11:00 A.M., Resident #1 crossed his/her left leg over his/her right leg and rolled off the side of the bed onto the floor during care. The Report indicated Certified Nurse Aide (CNA) #4 was aware Resident #1 required two assists for care and that CNA #4 did not wait for the second CNA to arrive before she provided care to Resident #1. Resident #1 sustained a laceration to his/her right elbow and was transferred to the hospital where he/she required three sutures to close the laceration An Accident/Incident Report and Investigation Form, dated 10/28/17 at 11:00 A.M., indicated during incontinence care, CNA #4 rolled Resident #1 over and Resident #1 crossed his/her legs, rolled off the bed, sustained a laceration to the right elbow and was transferred to the hospital. The Report indicated CNA #4 did not utilize two assists with care as indicated in Resident #1's plan of care. A witness statement, dated 10/28/17, indicated CNA #4 was providing care to Resident #1 when he/she crossed his/her legs and rolled off the bed. The statement indicated CNA #4 was aware that Resident #1 required two assists with care. A Nurse Progress Note, dated 10/28/17, indicated Resident #1 fell out of bed during morning care, sustained a one inch by half inch wide laceration to his/her right elbow which was unable to be closed and was transferred to the hospital for wound closure. The Physician's Telephone Order, dated 10/28/17, indicated to transfer Resident #1 to the hospital for urgent medical care. A Hospital Discharge Packet, dated 10/28/17, indicated Resident #1 was found lying on the side of his/her bed with a laceration to his/her right elbow. The Report indicated Resident #1 required three sutures to close the laceration to his/her right elbow. The Surveyor interviewed Nurse #1 at 12:54 P.M. on 6/4/18. Nurse #1 said CNA #4 was aware that Resident #1 required two CNA's with care and that CNA #4 provided morning care to Resident #1 without assist. Nurse #1 said Resident #1 crossed his/her leg over the other leg, fell on to the floor and sustained a laceration to his/her right elbow. Nurse #1 said Resident #1 was transferred to the hospital where he/she received three sutures to close the laceration. Nurse #1 said Resident #1 required two assists with care and that CNA #4 did not follow Resident #1's plan of care. The Surveyor interviewed CNA #4 at 2:20 P.M. on 6/4/18. CNA #4 said she knew Resident #1 required two assists with care and that she did not wait for another CNA to assist her with Resident #1's morning care on 10/28/17. CNA #4 said when she turned Resident #1, without assistance, Resident #1 swung his/her legs off the bed and fell on to the floor. CNA #4 said Resident #1 had a skin tear to his/her arm and needed to go to the hospital for stitches. CNA #4 said she was wrong, or words to that effect, when she provided care without assistance to Resident #1, and said she did not follow Resident #1 plan of care. The Surveyor interviewed the Regional Director of Clinical Services (RDCS) at 12:50 P.M. on 6/8/18. The RDCS said Resident #1 required two assists with care, that CNA #4 was aware Resident #1 required two assists with care and that CNA #4 did not follow Resident #1's plan of care.

Based on interview and record review, of two of fifteen sampled residents (Resident #1 and Resident #3), the Facility failed to prevent ongoing and repeated incidents of verbal abuse and taunting by Certified Nurse Aide (CNA) #1, over a period of at least a few months prior to 7/25/14. The incidents included: - CNA #2, CNA #3, and CNA #5 said they observed CNA #1 being impatient with and yelling at, Resident #1 and Resident #3 on multiple occasions (dates unknown) prior to 7/25/14. - CNA #2 said she heard CNA #1 say words to the effect, "be quiet with your nasty teeth." to Resident #1. CNA #3 and CNA #5 said they also heard CNA #1 commenting on his/her teeth, causing Resident #1 to become upset. - CNA #2 and CNA #3 said when Resident #1 asked about his/her Friend, CNA #1 told him/her loudly to stop asking because he was not coming to visit, and Resident #1 cried in response to these words. CNA #2 said Resident #1 was afraid of CNA #1 and CNA #1 teased and yelled at Resident #1 for months. - Resident #1 told the Director of Nurses (DON) CNA #1 said Resident #1 was ugly; his/her Friend thought he/she was a "[MEDICATION NAME]"; CNA #1 made him/her feel like less than a human being, and Resident #1 was afraid of her. - CNA #2, CNA #3, CNA #4, and CNA #5 said CNA #1 raised her voice to Resident #3 on an ongoing basis. The CNAs were unable to provide specific times or dates, but they indicated it was a common occurrence. - CNA #2, CNA #3 and CNA #5 said CNA #1 taunted Resident #3 by removing items from his/room in his/her presence and against his/her wishes. - CNA #5 said CNA#1 scolded Resident #3 like he/she was a five year old child. - Nurse #2 said she saw CNA #1 yell at and be rude to other cognitively impaired residents, in addition to Resident #1 and Resident #3. Findings include: The Facility's Policy and Procedure on Abuse Reporting, (undated) indicated that each resident must be protected from verbal, sexual, physical and mental abuse and that staff members should notify a Nursing Supervisor and the Administrator or Director of Nursing of any allegations. 1. The quarterly Minimum Data Set (MDS) assessment, dated 5/19/14, indicated Resident #1 had a score of nine on the Brief Interview for Mental Status (BIMS) cognitive assessment, which denoted moderate cognitive impairment. The MDS indicated Resident #1 was totally dependent on staff for transfer, ambulation, toilet use and personal hygiene. Resident #1's Care Plan for Cognitive Deficit, dated 4/12/12, indicated he/she had cognitive deficits due to a [DIAGNOSES REDACTED]. Surveyor #1 interviewed the Director of Nurses at 8:05 A.M. on 8/11/14. Surveyor #1 interviewed the Administrator at 10:30 A.M. on 8/11/14. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses at 12:45 P.M. and throughout the day on 8/27/14. The Director of Nurses and the Administrator said staff brought allegations of the mistreatment of [REDACTED].#1's conduct with staff. The Administrator and the Director of Nursing said they had no knowledge of CNA #1's conduct with residents prior to the investigation into staffing matters. The Director of Nursing said he began an internal investigation after the allegations were disclosed. Surveyor #1 and Surveyor #2 interviewed Unit Manager #2 at 8:07 A.M. on 8/26/14. Unit Manager #2 said CNA #1 was difficult to direct as an employee and her behavior bordered on insubordination, but she was unaware of CNA #1's behavior toward residents and staff. During an interview with the Director of Nurses, he said he interviewed Resident #1 twice as part of the internal investigation. The Director of Nurses said on 7/25/14, Resident #1 told him CNA #1 said Resident #1 was ugly and his/her Friend thought he/she was a "[MEDICATION NAME]." The Director of Nurses said Resident #1 told him CNA #1 made him/her feel like less than a human being and Resident #1 was afraid of her. The Director of Nurses said Resident #1 told him CNA #1 said Resident #1's teeth were ugly and they were some of the ugliest teeth she had seen. The Director of Nurses said Resident #1 identified CNA #1, when he/she was shown pictures of staff. The Director of Nurses said Resident #1 told him that he/she could not stand CNA #1 and CNA #1 was a "[***] ." The Director of Nurses said when he interviewed Resident #1 for the second time on 7/28/14, Resident #1 repeated that CNA #1 made comments on how horrible his/her teeth were. The Director of Nurses said he began an internal investigation, which included staff interviews, after the allegations were disclosed. Surveyor #1 interviewed CNA #2 at 2:15 P.M. on 8/11/14. CNA #2 said she observed CNA #1 being impatient and and yelling at Resident #1. CNA #2 said she heard CNA #1 say words to the effect, "be quiet with your nasty teeth." CNA #2 said Resident #1 spoke about his/her Friend and CNA #1 told him/her loudly to stop asking because he was not coming to visit. CNA #2 said Resident #1 cried in response to these words. CNA #2 said Resident #1 was afraid of CNA #1 and CNA #1 teased and yelled at Resident #1 for months. Surveyor #1 interviewed CNA #3 at 11:25 A.M. on 8/11/14. Surveyor #1 and Surveyor #2 interviewed CNA #3 at 9:10 A.M. on 8/27/14. CNA #3 said Resident #1 told her CNA #1 was a "[***] " and mean to him/her. CNA #3 said she observed that CNA #1 became frustrated with Resident #1 and raised her voice to him/her multiple times. CNA #3 said Resident #1 was weepy because he/she missed his/her Friend. CNA #3 said CNA #1 told Resident #1 he was not coming to see him/her, which upset Resident #1 more. Surveyor #1 interviewed CNA #4 at 1:45 P.M. on 8/11/14. Surveyor #1 and Surveyor #2 interviewed CNA #4 at 9:25 A.M. on 8/27/14. CNA #4 said she heard CNA #1 raise her voice to Resident #1 and noticed that Resident #1 got upset when CNA #1 worked. CNA #4 could not provide more specific information about these observations. 2. The quarterly Minimum Data Set (MDS) assessment, dated 6/11/14, indicated Resident #3 had problems with cognition and that he/she required supervision with ambulation and was independent with eating and personal hygiene. Resident #3's Care Plan for [MEDICAL CONDITION] Drug Use, dated 4/22/14, indicated Resident #3 wandered and rummaged through the belongings of others and that he/she hoarded items from the dining room and around the unit, which included perishable items. Interventions included redirect Resident #3 when rummaging and wandering and offer activities to decrease episodes of rummaging. CNA #2, CNA #3 and CNA #4 said normally, staff removed hoarded, perishible food items from Resident #3's room, while Resident #3 was out of the room, because removing the items while Resident #3 was present caused Resident #3 to become visibly upset. CNA #2, CNA #3, and CNA #4 said CNA #1 yelled at Resident #3, and taunted him/her by removing hoarded items and food from his/her room, in his/her presence and against his/her wishes. Surveyor #1 and Surveyor #2 interviewed CNA #5 at 10:00 A.M. on 8/27/14. CNA #5 said she thought CNA #1 was mean to Resident #3, got in his/her face and ordered him/her around. CNA #5 said CNA #1 scolded Resident #3 as if he/she was a five year old child. CNA #2, CNA #3 and CNA #1 said this treatment of [REDACTED].#3 by CNA #1 took place on an ongoing basis, but they could not provide more specific information on the incidents. 3. Surveyor #1 interviewed Nurse #2 at 3:40 P.M. on 8/11/14. Nurse #2 said she saw CNA #1 yell at and be rude to other residents, in addition to Resident #1 and Resident #3. Nurse #2 said that on 7/25/14, she observed CNA #1 yelling at unidentified cognitively impaired residents to "get outside." Nurse #2 was unable to provide more specific information including the names of residents, dates or times of the incidents. 4. Surveyor #1 interviewed the Director of Social Services at 3:20 P.M. on 8/11/14. The Director of Social Services said on one occasion, (date unknown), she saw CNA #1 feeding an unidentified cognitively impaired resident. The Director of Social Services said the resident did not want to eat and CNA #1 said words to the effect, "You are going to eat this." The Director of Social Services said she spoke to CNA #1 at the time of the incident and CNA #1 reported being tired and stressed. The Director of Social Services said she did not report her observations to administrative staff.

Based on interview and record review, of two of fifteen sampled residents (Resident #1 and Resident #3), the Facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported immediately to the administrator of the facility, so an investigation could be initiated. Although Resident #1 reported being afraid of CNA #1, and staff observed what they considered to be inappropriate treatment of [REDACTED].#3 and other residents on multiple occasions, these concerns and allegations were not reported until a separate investigation into CNA #1's conduct with staff began on 7/25/14. Findings include: The Facility's Policy and Procedure on Abuse Reporting, (undated), indicated that each resident must be protected from verbal, sexual, physical and mental abuse and that staff members should notify the Nursing Supervisor and the Administrator or Director of Nursing of any allegations. 1. The quarterly Minimum Data Set (MDS) assessment, dated 5/19/14, indicated Resident #1 had a score of nine on the Brief Interview for Mental Status (BIMS) cognitive assessment, which denoted moderate cognitive impairment. The MDS indicated Resident #1 was totally dependent on staff for transfer, ambulation, toilet use and personal hygiene. Resident #1's Care Plan for Cognitive Deficit, dated 4/12/12, indicated he/she had cognitive deficits due to a [DIAGNOSES REDACTED]. Surveyor #1 interviewed the Director of Nurses at 8:05 A.M. on 8/11/14. Surveyor #1 interviewed the Administrator at 10:30 A.M. on 8/11/14. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses at 12:45 P.M. and throughout the day on 8/27/14. The Director of Nurses and the Administrator said staff brought allegations of the mistreatment of [REDACTED].#1's conduct with staff. The Director of Nurses said he began an internal investigation, which included interviews of staff, after the allegations were disclosed. Surveyor #1 and Surveyor #2 interviewed Unit Manager #2 at 8:07 A.M. on 8/26/14. Unit Manager #2 said CNA #1 was difficult to direct as an employee and her behavior bordered on insubordination, but she was unaware of CNA #1's behavior toward residents and staff. During an interview with the Director of Nurses, he said he interviewed Resident #1 twice as part of the internal investigation. The Director of Nurses said that on 7/25/14, Resident #1 told him CNA #1 said Resident #1 was ugly and his/her Friend thought he/she was a "[MEDICATION NAME]." The Director of Nurses said Resident #1 told him CNA #1 made him/her feel like less than a human being and Resident #1 was afraid of her. The Director of Nurses said Resident #1 told him CNA #1 said Resident #1's teeth were ugly and they were some of the ugliest teeth she had seen. The Director of Nurses said Resident #1 identified CNA #1, when he/she was shown pictures of staff. The Director of Nurses said Resident #1 told him that he/she could not stand CNA #1 and that CNA #1 was a "[***] ." The Director of Nursing said he had no knowledge of CNA #1's treatment of [REDACTED]. Surveyor #1 interviewed CNA #2 at 2:15 P.M. on 8/11/14. CNA #2 said she observed CNA #1 being impatient and and yelling at Resident #1. CNA #2 said she heard CNA #1 say words to the effect, "be quiet with your nasty teeth." CNA #2 said Resident #1 spoke about his/her Friend and CNA #1 told him/her loudly to stop asking because he was not coming to visit. CNA #2 said Resident #1 cried in response to these words. CNA #2 said Resident #1 was afraid of CNA #1 and CNA #1 teased and yelled at Resident #1 for months. Surveyor #1 interviewed CNA #3 at 11:25 A.M. on 8/11/14. Surveyor #1 and Surveyor #2 interviewed CNA #3 at 9:10 A.M. on 8/27/14. CNA #3 said Resident #1 told her CNA #1 was a "[***] " and mean to him/her. CNA #3 said she observed that CNA #1 became frustrated with Resident #1 and raised her voice to him/her multiple times. CNA #3 said Resident #1 was weepy because he/she missed his/her Friend. CNA #3 said CNA #1 told Resident #1 he was not coming to see him/her, which upset Resident #1 more. Surveyor #1 interviewed CNA #4 at 1:45 P.M. on 8/11/14. Surveyor #1 and Surveyor #2 interviewed CNA #4 at 9:25 A.M. on 8/27/14. CNA #4 said she heard CNA #1 raise her voice to Resident #1 and noticed that Resident #1 got upset when CNA #1 worked. CNA #4 was unable to provide more specific information about her observations 2. The quarterly Minimum Data Set (MDS) assessment, dated 6/11/14, indicated Resident #3 had problems with cognition and that he/she required supervision with ambulation and was independent with eating and personal hygiene. Resident #3's Care Plan for [MEDICAL CONDITION] Drug Use, dated 4/22/14, indicated Resident #3 wandered and rummaged through the belongings of others and that he/she hoarded items from the dining room and around the unit, which included perishable items. Interventions included redirect Resident #3 when rummaging and wandering and offer activities to decrease episodes of rummaging. CNA #2, CNA #3 and CNA #4 said CNA #1 yelled at Resident #3 and taunted him/her by removing hoarded items and food from his/her room in his/her presence and against his/her wishes. Surveyor #1 and Surveyor #2 interviewed CNA #5 at 10:00 A.M. on 8/27/14. CNA #5 said she thought CNA #1 was mean to Resident #3, got in his/her face and ordered him/her around. CNA #5 said CNA #1 scolded Resident #3 as if he/she was a five year old child. CNA #2, CNA #3 and CNA #5 said this treatment of [REDACTED].#3 by CNA #1 took place on an ongoing basis. CNA #2 estimated it took place over a period of a few months prior to 7/25/14, but she did not have specific information about the duration. 3. Surveyor #1 interviewed Nurse #2 at 3:40 P.M. on 8/11/14. Nurse #2 said she saw CNA #1 yell at and be rude to other residents, in addition to Resident #1 and Resident #3. Nurse #2 said that on 7/25/14, she observed CNA #1 yelling at unidentified cognitively impaired residents to "get outside." 4. Surveyor #1 interviewed the Director of Social Services at 3:20 P.M. on 8/11/14. The Director of Social Services said on one occasion, (date unknown), she saw CNA #1 feeding an unidentified cognitively impaired resident. The Director of Social Services said the resident did not want to eat and CNA #1 said words to the effect, "You are going to eat this." The Director of Social Services said she spoke to CNA #1 at the time of the incident and CNA #1 reported being tired and stressed. The Director of Social Services said she did not report her observations to administrative staff. See F 223

Based on interview and record review, of two of fifteen sampled residents (Resident #1 and Resident #3), the Facility failed to ensure that its abuse preventions policies and procedures were implemented. Although Resident #1 reported being afraid of CNA #1, and staff observed what they considered to be inappropriate treatment of [REDACTED].#3 and other residents on multiple occasions, these concerns and allegations were not reported until a separate investigation into CNA #1's conduct with staff began on 7/25/14. Findings include: The Facility's Policy and Procedure, (undated), on Abuse Reporting, indicated all employees were expected to report any potential or actual occurrences of abuse immediately to their supervisor. 1. The quarterly Minimum Data Set (MDS) assessment, dated 5/19/14, indicated Resident #1 had a score of nine on the Brief Interview for Mental Status (BIMS) cognitive assessment, which denoted moderate cognitive impairment. The MDS indicated Resident #1 was totally dependent on staff for transfer, ambulation, toilet use and personal hygiene. Resident #1's Care Plan for Cognitive Deficit, dated 4/12/12, indicated he/she had cognitive deficits due to a [DIAGNOSES REDACTED]. Surveyor #1 interviewed the Director of Nurses at 8:05 A.M. on 8/11/14. Surveyor #1 interviewed the Administrator at 10:30 A.M. on 8/11/14. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses at 12:45 P.M. and throughout the day on 8/27/14. The Director of Nurses and the Administrator said staff brought allegations of the mistreatment of [REDACTED].#1's conduct with staff. The Director of Nurses said he began an internal investigation, which included staff interviews, after the allegations were disclosed. The Director of Nurses said he had no prior knowledge of the alleged abuse of residents by CNA #1. Surveyor #1 interviewed CNA #2 at 2:15 P.M. on 8/11/14. CNA #2 said she observed CNA #1 being impatient and and yelling at Resident #1. CNA #2 said she heard CNA #1 say words to the effect, "be quiet with your nasty teeth." CNA #2 said Resident #1 spoke about his/her Friend and CNA #1 told him/her loudly to stop asking because he was not coming to visit. CNA #2 said Resident #1 cried in response to these words. CNA #2 said Resident #1 was afraid of CNA #1 and CNA #1 teased and yelled at Resident #1 for months. During an interview with the Director of Nurses, he said he interviewed Resident #1 twice as part of the internal investigation. The Director of Nurses said on 7/25/14, Resident #1 told him CNA #1 said Resident #1 was ugly and his/her Friend thought he/she was a "[MEDICATION NAME]." The Director of Nurses said Resident #1 told him CNA #1 made him/her feel like less than a human being and Resident #1 was afraid of her. The Director of Nurses said Resident #1 told him CNA #1 said Resident #1's teeth were ugly and they were some of the ugliest teeth she had seen. The Director of Nurses said Resident #1 identified CNA #1, when he/she was shown pictures of staff. The Director of Nurses said Resident #1 told him that he/she could not stand CNA #1 and that CNA #1 was a "[***] ." The Director of Nurses said he was unaware of these issues prior to 7/25/14. Surveyor #1 interviewed CNA #3 at 11:25 A.M. on 8/11/14. Surveyor #1 and Surveyor #2 interviewed CNA #3 at 9:10 A.M. on 8/27/14. CNA #3 said Resident #1 told her CNA #1 was a "[***] " and mean to him/her. CNA #3 said she observed that CNA #1 became frustrated with Resident #1 and raised her voice to him/her multiple times. CNA #3 said Resident #1 was weepy because he/she missed his/her Friend. CNA #3 said CNA #1 told Resident #1 he was not coming to see him/her, which upset Resident #1 more. Surveyor #1 interviewed CNA #4 at 1:45 P.M. on 8/11/14. Surveyor #1 and Surveyor #2 interviewed CNA #4 at 9:25 A.M. on 8/27/14. CNA #4 said she heard CNA #1 raise her voice to Resident #1 and noticed that Resident #1 got upset when CNA #1 worked. 2. The quarterly Minimum Data Set (MDS) assessment, dated 6/11/14, indicated Resident #3 had problems with cognition and that he/she required supervision with ambulation and was independent with eating and personal hygiene. Resident #3's Care Plan for [MEDICAL CONDITION] Drug Use, dated 4/22/14, indicated Resident #3 wandered and rummaged through the belongings of others and that he/she hoarded items from the dining room and around the unit, which included perishable items. Interventions included redirect Resident #3 when rummaging and wandering and offer activities to decrease episodes of rummaging. CNA #2, CNA #3 and CNA #4 said CNA #1 yelled at Resident #3 and taunted him/her by removing hoarded items and food from his/her room in his/her presence and against his/her wishes. Surveyor #1 and Surveyor #2 interviewed CNA #5 at 10:00 A.M. on 8/27/14. CNA #5 said she thought CNA #1 was mean to Resident #3, got in his/her face and ordered him/her around. CNA #5 said CNA #1 scolded Resident #3 as if he/she was a five year old child. CNA #2, CNA #3 and CNA #5 said this treatment of [REDACTED].#3 by CNA #1 happened on an ongoing basis. CNA #2 estimated it took place for a few months prior to 7/25/14. 3. Surveyor #1 interviewed Nurse #2 at 3:40 P.M. on 8/11/14. Nurse #2 said she saw CNA #1 yell at and be rude to other residents, in addition to Resident #1 and Resident #3. Nurse #2 said that on 7/25/14, she observed CNA #1 yelling at unidentified cognitively impaired residents to "get outside." 4. Surveyor #1 interviewed the Director of Social Services at 3:20 P.M. on 8/11/14. The Director of Social Services said on one occasion (date unknown) she saw CNA #1 feeding an unidentified cognitively impaired resident. The Director of Social Services said the resident did not want to eat and CNA #1 said words to the effect, "You are going to eat this". The Director of Social Services said she spoke to CNA #1 at the time of the incident and CNA #1 reported being tired and stressed. The Director of Social Services said she did not report her observations to administrative staff.