Every finding on record at Vantage at Worcester LLC

Based on records reviewed and interviews, for three of six sampled residents (Residents #1, #4, and #5), whose physician's orders included wound care and dressing changes, the facility failed to ensure professional standards of practice were maintained, when after completing dressing changes nursing staff did not document specific wound characteristics, as well as effectiveness of treatment, in accordance with nursing best practice and facility policy.Findings include:Review of the National Pressure Injury Advisory Panel (NPIAP) website, included the following:-The NPIAP emphasizes that all pressure injury care, including dressing changes, must be documented in a way that supports evidenced-based practice, quality improvement, and regulatory compliance.-Core documentation elements for dressing changes (aligned with NPIAP and related clinical guidelines) include:*Date, time, and location (body area) of the dressing change*Type of dressing used*Condition of the wound- size, depth, base (granulation-healing tissue, slough-tissue consisting of dead cells and bacteria, necrosis- dead tissue), drainage type/amount, odor, and color.*Surrounding skin condition*Patient response- pain level, comfort, adverse reactions.*Signs of infection or complications- redness, warmth, purulent drainage, odor.*Provider signature and date/time- to confirm the documentation is current and accurate.Review of the facility's policy titled Non-Sterile Dressing Change, dated August 2016, indicated the following:-Designated staff members will use non-sterile dressing techniques for all dressing changes unless otherwise indicated by physician or manufacturer guidelines.-Procedure includes:*Assess wound characteristics and determine appropriate interventions.*Document the dressing change in the medical record.1. Resident #1 was admitted to the facility in March 2026 diagnoses included Type 2 Diabetes Mellitus and acute and chronic respiratory failure. Review of Resident #1's Physician's Orders for the month of March 2026 indicated he/she had orders for the following:-Left heel unstageable (wound bed is covered with slough/dead tissue) pressure wound- cleanse with Normal Saline (NS), apply Betadine to entire wound and cover with dry gauze dressing daily and as needed for soilage (ordered 03/03/26 and discontinued 03/05/26).-Left heel Deep Tissue Pressure Injury (DTPI: persistent deep red, maroon, or purple discoloration from pressure)- cleanse with NS, apply Betadine to entire wound and cover with ABD pad and wrap with kling daily and as needed for soilage (ordered 03/05/26).-Right heel unstageable pressure wound- cleanse with NS, apply Betadine (topical antiseptic) to entire wound and cover with dry gauze dressing daily and as needed for soilage (ordered 03/03/26 and discontinued 03/05/26).-Right heel DTPI- cleanse with NS, apply Betadine to entire wound and cover with ABD and wrap with kling daily and as needed for soilage (ordered 03/05/26).-Stage 4 (full-thickness skin loss where extensive tissue damage extends through the fascia, exposing underlying bone, muscle, tendons, or joints) sacral wound: Cleanse with NS, apply calcium alginate to wound bed, to peri wound apply TRIAD and cover areas with large border foam/super absorbent dressing daily and as needed for soilage (ordered 03/03/26 and discontinued 03/05/26).-Stage 4 sacral wound: Cleanse with NS, apply Santyl (used to remove dead tissue from chronic skin ulcers) followed by calcium alginate (used for moderate to heavy wound drainage) to wound bed, to peri wound apply TRIAD and cover areas with large border foam/super absorbent dressing daily and as needed for soilage (ordered 03/05/26).-Right lateral lower leg venous ulcer: Cleanse with NS, apply calcium alginate to wound bed, cover with ABD pad and wrap with kling daily and as needed for soilage (ordered 03/03/26 and discontinued 03/05/26).-Right lateral lower leg venous ulcer: Cleanse with NS, apply Bactroban and cover with xeroform, cover with ABD pad and wrap with kling daily and as needed for soilage (ordered 03/05/26).-Left top of foot DTPI- Apply skin prep daily (ordered 03/03/26).Review of Resident #1's Treatment Administration Record (TAR) for the month of March 2026 indicated that although nurses were signing off on the TAR that they were changing his/her wound dressings daily, there was no documentation to support that nursing documented the wound appearance, drainage type and amount, and/or odor, during the daily dressing changes.2. Resident #4 was admitted to the facility in March 2026, diagnoses included paraplegia and polyneuropathy.Review of Resident #4's Physician's orders for the month of May 2026 indicated he/she had orders for the following:-Sacrum unstageable pressure wound: cleanse with NS, apply calcium alginate to wound bed and cover with border foam dressing daily and as needed for soilage (ordered 04/30/26 and discontinued 05/07/26).-Sacrum unstageable pressure wound: cleanse with Vashe or wound cleanser, apply gentamycin to wound bed and they Santyl to necrotic areas followed by border foam dressing daily and as needed for soilage (ordered 05/07/26).Review of Resident #4's TAR for the month of May 2026 indicated that although nurses were signing off on the TAR that they were changing his/her wound dressing daily, there was no documentation to support that nursing documented the wound appearance, drainage type or amount, and/or odor, during the daily dressing changes.3. Resident #5 was admitted to the facility in March 2010 diagnoses included quadriplegia and history of traumatic brain injury (TBI).Review of Resident #5's Physician's orders for the month of May 2026 indicated he/she had orders for the following:-Sacrum stage 4 pressure wound: Cleanse with NS, apply calcium alginate with border foam dressing daily and as needed for soilage (ordered 4/30/26 and discontinued 05/14/26).-Sacrum stage 4 pressure wound: Cleanse with Vashe solution, apply calcium alginate to wound bed and TRIAD to peri wound, cover with border foam dressing daily and as needed for soilage (ordered 05/14/26).-Right buttock DTPI: Cleanse with NS, apply calcium alginate and cover with foam dressing daily and as needed for soilage (ordered 05/07/26 and discontinued 05/14/26).-Right buttock DTPI: Cleanse with Vashe solution, apply collagen followed by calcium alginate and cover with foam border dressing daily and as needed for soilage (ordered 05/14/26).Review of Resident #5's TAR for the month of May 2026 indicated that although nurses were signing off on the TAR that they were changing his/her wound dressing daily, there was no documentation to support that nursing documented the wound appearance, drainage type or amount, and/or odor, during the daily dressing changes.During an interview on 05/21/26 at 11:51 A.M., the Director of Nurses (DON) said it was her expectation that the nurses document the location of the wound, drainage type and amount, if the resident had any pain during the dressing change, and if there are any signs or symptoms of infection, with each dressing change on the resident's Treatment Administration Record. The DON said she was unaware the option for nurses to document the specific wound characteristics was not available on each resident's TAR. The DON said it was important because it would help the nurses quickly identify a change or deterioration in a resident's wound status.

Based on records reviewed and interviews for one of six sampled residents (Resident #3), the Facility failed to ensure they protected his/her right to privacy, when a staff member took a screenshot of his/her facility face sheet image which included his/her personal and health information, without his/her knowledge or consent, and sent a copy of the screenshot to another person (who was subsequently identified as not being a facility employee).Findings include:Review of the facility's policy titled Release of Information, revised date of November 2009, included the following:-Our facility maintains the confidentiality of each resident's personal and protected health information.-All information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his/her legal representative, consistent with state laws and regulations.Review of the Report submitted by the facility via the Health Care Facility Reporting System (HCFRS), dated 04/29/26, indicated that on 04/28/26 the facility received a report from the [NAME] County Sheriff's Department informing them that a Certified Nurse Aide (later identified as CNA #1), reportedly sent a photograph to an inmate at the [NAME] County Jail. The report indicated that the photograph contained Resident #3's protected health information including his/her name, date of birth , and additional health related details. Resident #3 was admitted to the facility in January 2026, diagnoses included Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease (COPD).Review of Resident #3's Minimum Data Set (MDS) assessment, dated 04/30/26, indicated he/she was alert and oriented and had a Brief Interview for Mental Status (BIMS) score of 15 (0-7 suggests severe cognitive impairment, 8-12 suggests moderate cognitive impairment, and 13-15 suggests no cognitive impairment).Review of the Facility's Investigation indicated that the facility received a copy of the photograph from the [NAME] County Sheriff's Department which included Resident #3's name, date of birth , room number, allergies, blood pressure, and respiratory rhythm. The Facility's name was also visible on the right-hand corner of the computer screen in the photograph.Further review of the Investigation indicated CNA #1 was blocked from accepting or working any further shifts at the facility and his/her staffing agency was notified of the allegation. The Investigation indicated that the Administrator and Social Worker notified Resident #3 of the alleged breach and he/she declined further action.The Surveyor was unable to interview CNA #1, as she did not respond to the Department of Public Health's telephone or letter requests for an interview.During an interview on 05/21/26 at 10:01 A.M., the Director of Nurses (DON) said that she expected facility staff to keep all residents' personal information private and confidential. The DON said CNA #1 should not have shared Resident #3's information with anyone.

Based on observations, interviews, and record review, the facility failed to ensure the main facility kitchen used to store, prepare and distribute resident food and beverages was maintained in a clean and sanitary manner and kept free from dust and debris increasing the risk for the potential of physical contamination. Findings include: Review of the facility policy titled Environment, revised 9/2017, indicated all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The policy also included the following: -the Dining Service Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceiling, lighting and ventilation. -the Dining Service Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. -the Dining Service Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. Review of the facility policy titled Equipment, revised 9/2017, included the following: -all food service equipment will be clean, sanitary, and in proper working order. -all equipment will be routinely cleaned and maintained . -all non-food contact equipment will be clean and free of debris. -the Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. Review of the Food Drug Administration (FDA) Food Code 2017 (www.fda.gov), indicated the following: -Food Preparation: >During preparation, unpackaged food shall be protected from environmental sources of contamination. -Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: >the objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. >Microorganisms may be transmitted from food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. >Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. >Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. >The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. -Cleaning, Frequency and Restrictions: >Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when food is in protected storage and when food is not being served or prepared. >Both intake and exhaust ducts can be a source of contamination and must be cleaned regularly. On 1/8/26 at 7:18 A.M., the surveyor conducted an initial tour of the facility's kitchen with the Food Service Director (FSD) and observed the following: -Fan located above the milk cooler and the three-compartment sink was dust laden and was tacky to the touch. During an interview at the time, the FSD said the maintenance staff were responsible for cleaning the fans in the kitchen and that the fan observed was dusty. -Shelf which contained pots/pans and clear storage containers. Three of the clear containers were stacked on top of each other and wetness observed on the inside of the interior portion of the containers. The FSD said the inside of the stacked containers were wet, should not be stored in this manner and there would be a concern for wet nesting. The FSD said stacking the food storage containers when they were still wet would be a concern for potential bacterial growth. -Two full steam pans which contained numerous clean utensils for food service. The bottoms of the pan had evidence of food debris. The FSD said the utensils in the full-size steam table pan were clean and that there was food debris noted in the storage pan which would be a concern for contamination. -Dried whitish yellow residue on a pan stored with other clean pots and pans. -Lower shelving used to store kitchen equipment was dust and debris laden and was tacky and rough to the touch. The FSD said the shelving was dirty and should be cleaned once every two weeks. -Large utility bins housing sugar and food/beverage thickener products were located on lower shelf near the convection ovens. The covers of the bins had dried red products and were covered with crumbs/food debris. The FSD said the covers of the utility bin needed to be cleaned. On a follow-up visit during lunch service on 1/13/26 at 11:43 A.M. through 12:42 P.M., with the Regional Director of Operations for Dietary Services (RDODS), the surveyor observed the following: -The cook utilizing the lower ovens to heat up plates used for meal service. The internal door of the oven had numerous dried blackish, brown drips. Above the flat-top grill, a large knife was stored against the wall between external piping (and not contained in the knife holder which was underneath). -A large area of dust was observed on the ceiling above the food preparation areas near the exhaust vent. -The walls next to the beverage preparation areas had evidence of dust and dirt. The ceiling and electrical components above the coffee maker were dust laden and the filter and coffee grounds were exposed and open underneath these areas. -The partial wall behind the juice dispenser had a large dust ball approximately two inches in diameter and dust was observed along the entire edge of the partial wall. -The wall between the dish room and food preparation area had dried splatters and was grimy to touch. -Numerous dark dried drips on the lower part of the convection oven and the flat-top range. During an interview at 12:42 P.M., the RDODS said the plate warmer in the kitchen was broken and until it is fixed, the dietary staff use the lower oven to warm the plates. The RDODS said the walls near the coffee and juice station and between the dish room and preparation areas needed to be cleaned. During an interview on 1/14/26 at 9:10 A.M., the FSD said the four-week cleaning schedule has been in place for the last couple of months, but he had not been strict on enforcing it. The FSD said he did not keep evidence of the previous cleaning schedules when the surveyor requested these because he was unaware that he should have kept the cleaning schedules. The FSD said the kitchen staff are responsible for ensuring the kitchen is clean and sanitary, but he was ultimately responsible. The FSD said he needed to do a better job ensuring the cleaning tasks were completed as scheduled. On 1/14/26 at 9:29 A.M., the surveyor conducted a final walk through of the kitchen with the FSD. The following was observed: -Dust remained on ceiling above the food preparation area near the exhaust vent and on the walls, and the pipes in the beverage preparation areas. -The coffee machine with open top exposing filter and grounds was underneath the exhaust vent and walls. -The large dust ball remained on the shelving above the juice dispenser. During an interview at the time, the FSD said dust present in a kitchen would be a concern for contamination. The FSD said that they will be working with the maintenance department to schedule detailed cleaning of these areas. The FSD further said that knives should be stored in the knife holder and that storing them against the wall using the pipes to secure them in place was not an appropriate storage place because of risk for contamination. During an interview on 1/14/26 at 10:16 A.M., with the FSD and the RDODS, the RDODS said she was aware of the kitchen sanitation concerns relayed by the surveyor and that they were actively working with the maintenance department to establish a routine cleaning schedule to maintain sanitation and cleanliness because there has not been one in place.

Based on record review, and interview, the facility failed to provide care consistent with professional standards of practice relative to the administration of prescribed medication for one Resident (#2) out of a total sample of 22 Residents.Specifically, for Resident #2, the facility failed to ensure that a Physician ordered antihypotensive medication (Midodrine) was administered in accordance with the ordered blood pressure parameters (for Systolic Blood Pressure [SBP] less than 100 mmHg), when the medication was being administered for SBP's greater than 100 mmHg, placing the Resident at risk for adverse hemodynamic side effects. Findings include: Review of the facility policy titled Medication Therapy, dated, 2017 included but was not limited to:-Medication use shall be consistent with an individual's condition, prognosis, values, wishes and response to such treatment.-All decisions related to medications shall include appropriate elements of the care process such as adequately detailed assessment; review of cause of symptoms; consideration of clinical relevance of symptoms and abnormal diagnostic test results.-upon or shortly after admission and periodically thereafter the staff and practitioners will review an individual's current medication regime to identify whether: there is a clear indication for treating the individual with the medications; the dosage is appropriate; the frequency of administration and duration of use are appropriate.-the facility shall review medication-related issues as part of its quality assurance and performance improvement committee activities. Resident #2 was admitted to the facility in July 2016 with diagnoses including orthostatic hypotension, cardiac arrest and anoxic brain damage. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Review of the January 2026 Physician's orders indicated:-Midodrine HCl (antihypotensive medication) Oral Tablet 10 mg (milligrams). Midodrine HCl - give 1 tablet by mouth two times a day for hypotension. Give for SBP (systolic blood pressure) less than 100 (mmHg - millimeters of mercury), initiated 12/26/25. Review of Resident #2's December 2025 and January 2026 Medication Administration Records (MAR's) indicated the following:*December 2025:-12/28/25 at 5:00 P.M., SBP was 107 mmHg, Midodrine administered at this time.*January 2026:-1/1/26 at 5:00 P.M., SBP was 108 mmHg, Midodrine administered at this time-1/5/26 at 9:00 A.M., SBP was 112 mmHg, Midodrine administered at this time. SBP at 5:00 P.M. was 114 mmHg, Midodrine administered at this time.-1/6/26 9:00 A.M., SBP was 118 mmHg, Midodrine was administered at this time. SBP was 122 mmHg at 5:00 P.M., Midodrine was administered at this time. During an interview on 1/12/26 at 4:08 P.M., the Director of Clinical Operations said the Midodrine medication for Resident #2 was administered outside of the parameters in the Physician's order and it should not have been administered. During an interview on 1/13/26 at 10:53 A.M., Resident #2's Physician said his expectation was that the facility should have been administering the medication as the order was written and if the staff had concerns with the parameters of the Midodrine medication they should have called him to reassess the order and see if adjustments to the Midodrine order were needed.

Based on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#8) of six applicable respiratory residents, out of a total sample of 22 residents.Specifically, for Resident #8, the facility failed to provide consistent care of an oxygen concentrator in accordance with manufacturer's instructions and recognized infection control practices. Findings include:Resident #8 was admitted to the facility in April 2025 with diagnoses including Acute Respiratory Failure with Hypoxia, Encounter for Attention to Tracheostomy, and Anoxic Brain Damage. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #8 was severely cognitively impaired, rarely understood, and had a tracheostomy in place. On 1/8/26 at 10:28 A.M., and 1/12/26 at 11:48 A.M., the surveyor observed Resident #8 lying in bed with oxygen tubing connecting the oxygen concentrator to the corrugated tracheostomy tubing. The oxygen concentrator was observed running and the corrugated tracheostomy tubing was attached to a trach mask in place on the Resident's neck. The surveyor observed the filter located on the back of the oxygen concentrator was covered with thick grey dust over the entire filter. Review of Resident #8's January 2026 Physician's orders included: -Oxygen: O2 at 2 - 8 liters via trach mask, may titrate to maintain POX (pulse oximetry) at 92% or greater every shift. Review of the Resident's Medical Record failed to indicate that staff had cleaned the filter located on the back of the oxygen concentrator. Review of the manufacturer's policy for cleaning of the concentrator filter, undated, indicated:-Oxygen concentrators: rinse and dry the external filter weekly and PRN (as needed) when visibly dusty or soiled. On 1/12/26 at 11:50 A.M., the surveyor and Nurse #1 observed the Resident's oxygen concentrator filter to be covered with thick grey dust over the entire filter. During an interview at the time, Nurse #1 said the filter looked very dirty. Nurse #1 said that she was unsure how often the oxygen concentrator filter should be cleaned or replaced, or who was responsible for cleaning the filter. During an interview on 1/12/26 at 1:28 P.M., Unit Manager (UM) #1 said that the oxygen concentrator filter should be cleaned weekly. UM #1 was unable to provide any evidence that Resident #8's oxygen concentrator filter had ever been cleaned. UM #1 said that there should have been an order in place to clean the oxygen concentrator filter weekly, but none had been put in place. UM #1 said that she was unable to provide any facility policy or procedure for the care and maintenance of an oxygen concentrator but did provide the manufacturer's instructions for the care of the oxygen concentrator which indicated to rinse and dry the external filter weekly and PRN when visibly dusty.

Based on observations, interviews, and record reviews, the facility failed to ensure professional standards to maintain adequate nutrition were implemented for one Resident (#92) of 4 applicable residents reviewed for nutrition, out of a total sample of 22 residents. Specifically, for Resident #92, the facility failed to ensure that nutritional supplements recommended by the Registered Dietician (RD) and ordered by the Physician were implemented after the Resident was re-admitted to the facility from a hospitalization, resulting in weight loss for two months. Findings include: Review of the Nutritional Assessment Policy and Procedure revised October 2017, indicated: -the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for, or with impaired nutrition. -Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the residents' prognosis and personal preferences. Review of the Weight Assessment and Intervention Policy and Procedure revised March 2022, indicated: -Resident weights are monitored for undesirable or unintended weight loss or gain. -The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/ (usual weight) x100]: >1 month - 5% weight loss is significant; greater than 5% is severe. >3 months - 7.5% weight loss is significant; greater than 7.5% is severe. > 6 months - 10% weight loss is significant; greater than 10% is severe. -Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: >the resident's calories, protein, and other nutritional needs compared with the resident's current intake. -Interventions for undesirable weight loss are based on careful consideration of the following: >Nutrition and hydration needs of the Resident. Resident #92 was admitted to the facility in December 1990 with diagnoses including Traumatic Brain Injury (TBI), dementia and cerebrovascular disease affecting the dominant right hand. Review of the Comprehensive Nutritional Care Plan initiated 12/2/25, indicated Resident #92: -was at risk for Malnutrition. -had a BMI of 23.-had a goal of remaining free from significant weight change. -has a goal of gradually gaining weight to a healthy BMI parameter [sic]. -had a goal of nutritional supplements intake over 75% [sic]-was to be provided the ordered diet.-was to have the Registered Dietician evaluate and make diet changes recommendations as needed. Review of Resident #92's January 2026 Physician orders included: -Frozen Nutritional Treat at Breakfast, initiated 6/5/23. -Frozen Nutritional Treat at Lunch, initiated 6/5/23. -Frozen Nutritional Treat at Dinner, initiated 6/5/23. -House Supplement Clear [also referred to as Ensure Supplement or Ensure Supplement Clear] one time a day for weight stability 8 ounces (oz.) at 10:00 A.M., ordered on 11/4/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #92: -has short and long-term memory problems and was severely cognitively impaired. -required set-up from staff for eating. -had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months. -required a mechanically altered diet. Review of Resident #92's Nursing Note dated 11/2/25, indicated Resident #92 was re-admitted from the hospital with diagnoses including septic shock and Urinary Tract Infection (UTI). Review of Resident #92's Nursing Note dated 11/3/25, indicated the Resident's Representative (RR) voiced concerns about the Resident's appetite and weight. The RR said that on admission to the hospital, he/she was told the Resident was mildly malnourished. The RR was informed of the supplements the Resident was ordered to receive and the RR requested for the Resident to receive Ensure Supplements which he/she had and enjoyed while at the hospital. Review of Resident #92's Medical Doctor (MD) History and Physical Medical re-admission Note dated 11/4/25, indicated: -Resident's current weight was 151.5 lbs. (11/3/25) -Protein (shakes) and nutritional supplements are ordered. Review of Resident #92's Dietary Progress Note dated 11/4/25, included the following recommendations: -Add 8 oz. House Supplement Clear every day at 10:00 A.M. -Continue current diet and other supplements as ordered. Review of Resident #92's Dietary Progress Note dated 12/2/25, indicated Resident #92: -was receiving an 8 oz. House Supplement Clear and 4 oz. House Supplement every day -was receiving a 4 oz. frozen nutritional treat with meals -had an intake of 75 -100% of meals -had a current body weight of 143.3 lbs. (12/1/25) -experienced a 5.4% weight loss (severe) in one month (since 11/3/25) -experienced a 11.0% (severe) weight loss in four months (since 8/7/25) -appeared to be meeting below his/her nutritional needs as evidenced by weight loss. Review of Resident #92's Dietary Progress Note dated 12/19/25, indicated Resident #92: -presented with mild muscle wasting to temporalis, interosseous, clavicle (assessment for malnutrition based on loss of muscle mass and strength to the temporalis muscle, interosseous muscles of the hand and prominence of clavicle). -the criteria for moderate malnutrition was met due to the Resident's significant weight loss of 5% in one month. Review of Resident #92's documented weights indicated the following: -151.5 lbs. on 11/3/25 -151.1 lbs. on 11/17/25 -148.5 lbs. on 11/24/25 -145.3 lbs. on 12/1/25 (5.4% weight loss in one month)-143.3 lbs. on 12/6/25 -142.8 lbs. on 12/15/25 -143.0 lbs. on 12/22/25 -141 lbs. on 12/29/25 -141.5 lbs. on 1/1/26 -140.3 lbs. on 1/4/26 (7.39 % weight loss in two months) Review of the Medication Administration Record (MAR) for November 2025 through 1/11/26 indicated Resident #92 was ordered to receive the following and was signed off as being administered: -Frozen Nutritional Treat at breakfast, lunch, and dinner. -8 oz. House Supplement Clear daily at 10:00 A.M. On 1/9/26 at 8:35 A.M, the surveyor observed Resident #92's breakfast tray and noted a frozen nutritional snack was not served on his/her breakfast tray and was not listed on the Resident's dietary slip as ordered by the Physician. On 1/12/26 at 12:07 P.M., the surveyor observed Resident #92's lunch tray and noted that a frozen nutritional snack was not served on his/her lunch tray and was not listed on the dietary slip as ordered by the Physician. During an interview on 1/12/26 at 12:18 P.M., Nurse # 2 said the Nurses were responsible for checking resident meal trays to make sure the residents were receiving everything listed on their dietary slip. Nurse #2 said she served Resident #92 his/her lunch tray and that all items were provided as indicated on the dietary slip, but the slip did not include the frozen nutritional snack. During an interview on 1/12/26 at 12:26 P.M., Dietary Aide (DA) #2 said when a resident received a nutritional supplement such as a shake or frozen treat with meals, these nutritional supplements were provided by the kitchen and served on meal trays. DA #2 further said when a resident receives a nutritional supplement in between meals, the dietary staff send nutritional supplements to the floor separately and they are kept in the unit refrigerators and are labeled with the resident's name. During an interview on 1/12/26 at 1:48 P.M., the Registered Dietician (RD) said the dietary department supplies all of the nutritional supplements to the units. The RD said nutritional supplements that are ordered with meals should arrive on the resident's meal tray but hadn't been. During an interview on 1/12/26 at 2:17 P.M., Clinical Consultant #1 said if any nutritional supplement was ordered to be given with a resident's meal, the kitchen should be sending the nutritional supplement up on the resident's meal tray. Clinical Consultant #2 said that Resident #92 should have received a nutritional supplement on his/her tray. On 1/13/26 at 8:18 A.M., the surveyor observed Resident #92 eating his/her breakfast tray in the dining room. No frozen nutritional treat as ordered by the Physician was observed on the breakfast tray. During an interview on 1/13/26 at 8:31 A.M., Nurse #3 said when a resident was ordered to have a nutritional supplement with a meal, the kitchen would provide the nutritional supplement on the meal tray, and the nutritional supplement should be listed on the resident's dietary slip. Nurse #3 said when a resident was ordered to receive a nutritional supplement in between meals, those nutritional supplements come labeled from the kitchen and the nursing staff administer them. Nurse #3 reviewed Resident #92's Physician orders, January 2026 MAR, and the Dietary slip from Breakfast 1/13/25, and said that he/she should have been receiving the frozen nutritional snack on his/her meal trays but had not been receiving them. Nurse #3 said the frozen nutritional snack should have been listed on the Resident's dietary slip but was not. Nurse #3 said since the frozen nutritional snack was not listed on the Resident's dietary slip, the Nurses would not have known to give the frozen nutritional snack to Resident #92. Nurse #3 said she was not sure why she and the Nurses had been signing off that Resident #92 had been receiving the frozen nutritional snack with meals on the MAR because he/she had not received it and the documentation was an error. Nurse #3 said it would have been important for Resident #92 to receive the Physician ordered nutritional supplements because he/she lost weight and needed proper nutrition. During an interview on 1/13/26 at 10:42 A.M., the Medical Doctor said that it was important for Resident #92 to have received the ordered nutritional supplements to maintain his/her overall health. The Medical Doctor said he had expected the facility to follow through and administer all of the nutritional supplements that were ordered for Resident #92. During an interview on 1/13/26 at 11:09 A.M., the Regional Director of Dietary Services (RDODS) said that she was covering as the Food Service Director in November 2025 and the dietary department mistakenly stopped giving Resident #92 frozen nutritional snacks on the meal trays and mistakenly stopped giving house supplements. The RDODS said Resident #92 had not received any supplements from the dietary department since 11/4/25. During an interview on 1/13/26 at 3:27 P.M., the Director of Nursing (DON) said Resident #92 should have received all the ordered nutritional supplements to help prevent further weight loss and medical complications. The DON said she was unsure why Nurses were signing off the MAR that nutritional supplements were administered when the Resident had not been receiving them. During an interview on 1/13/26 at 3:46 P.M., the Administrator said Resident #92 had not received the frozen nutritional shakes with meals since 11/5/25 but should have. The Administrator said Resident #92 had a full dietary evaluation on 1/12/26 and still required the supplements to meet his/her nutritional needs. The Administrator said Resident #92 had not received the ordered House Supplement Clear because the facility has not ordered any since August 2025 and something else should have been ordered in its absence but was not. The Administrator said the facility has had several Dieticians helping out in the building which she felt caused a communication breakdown resulting in Resident #92 not receiving the Physician ordered nutritional supplements. The Administrator said Nurse #3 told her that she had been signing off on the Resident's MAR that supplements were being administered but could not say for sure which supplement were given or how often. The Administrator said Nurses should not have signed the Resident's MAR that supplements were administered when they were not available in the building or not given on the meal trays per the Physician order. During an interview on 1/14/26 at 9:02 A.M., the RR said he/she had concerns about the Resident's weight loss and had asked the facility to continue giving him/her Ensure shakes upon return from the hospital in November 2025. The RR said after Resident #92 returned from the hospital, the Resident continued to lose weight, and he/she was unsure why that was occurring. During an interview on 1/14/26 at 11:57 A.M., the RD said the facility notified her this week that Resident #92 had not been receiving the ordered frozen nutritional treat with meals or the Ensure Clear supplement and he/she should have been receiving. The RD said if she had been notified that Resident #92 was not receiving those nutritional supplements, she would have completed a new dietary assessment and re-assessed the Resident, but this did not occur. The RD further said that she thought the Resident would be more clinically stable if he/she had been receiving the nutritional supplements as ordered.

Based on observation, record review, and interview, the facility failed to ensure one Resident (#2) out of a total sample of 22 residents received appropriate care and services for the use of an external urinary catheter.Specifically, for Resident #2, the facility failed to ensure that a Physician's order was obtained for the use and care of a non-invasive external urinary catheter when the Resident was observed with an External urinary catheter in use. Findings include:Resident #2 was admitted to the facility in July 2016 with diagnoses including Anoxic Brain Damage and Urinary Tract Infection (UTI), Not Specified. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. On 1/8/26 at 9:38 A.M., the surveyor observed Resident #2 sitting in a wheelchair, and tubing from a urinary catheter drainage bag with a privacy cover was suspended from the bottom of the wheelchair above the floor surface. Review of Resident #2's Care Plan indicated the following:*Incontinence of the bowel and bladder care plan related to Anoxic Brain Injury revised on 7/25/24, included interventions:-Resident #2 will not experience skin breakdown related to incontinence through the next review, revised 12/30/25-[External] catheter as tolerated, initiated 2/4/20-Apply [External] catheter as ordered, initiated 7/25/24 Review of the Medical Record indicated Resident #2 had no Physician's orders for use of an [External] urinary catheter. During an interview on 1/12/26 at 11:14 A.M., Nurse #2 said she was not sure if Resident #2 had a urinary catheter in place. Nurse #2 said she would look for an order in the Resident's medical record to see there was an order for a urinary catheter. Nurse #2 was unable to find an order for a urinary catheter. The surveyor and Nurse #2 observed Resident #2, and Nurse #2 confirmed the Resident had an [External] urinary catheter in place. Nurse #2 said the [External] catheter was not invasive but there should still be orders in place so the staff would know when and how often to change the catheter and monitor if the catheter was working correctly. Nurse #2 said she had no way of knowing when the [External] catheter was last changed or how the Physician would like the urinary catheter cared for without an order. During an interview on 1/12/26 at 11:36 A.M., the Director of Nursing (DON) said Resident #2 should have Physician's orders in place for the use of an [External] catheter. The DON said orders would need to be obtained from Resident #2's Physician and added to the Resident's treatment plan, so that staff could care for the [External] catheter properly. During an interview on 1/13/26 at 10:52 A.M., Resident #2's Physician said the facility should have obtained an order for the [External] urinary catheter and the order should have been in place prior to initiating the use of the [External] catheter.

Based on observations, interview, and record review, the facility failed to provide activities of daily living (ADL) care relative to personal hygiene and grooming for one Resident (#102), out of a total sample of 22 residents. Specifically, the facility failed to provide assistance with removal of unwanted facial hair when Resident #102 required assistance from staff for ADL care. Findings include: Review of the facility policy titled Supporting Activities of Daily Living, revised March 2018, indicated the following:-residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.-appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care) . Resident #102 was re-admitted to the facility in December 2024 with diagnoses including abnormal posture, cognitive communication deficit, and anxiety. Review of the Minimum Data Set (MDS) Assessment, dated 10/30/25, indicated Resident #102: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15 points. -was dependent on staff with ADL care including personal hygiene (grooming) tasks. Review of the ADL Care Plan, initiated 2/16/20, indicated Resident #102 had an alteration in ADL self-performance related to weakness and deconditioning and included the following interventions: -total assistance of staff with dressing and grooming tasks, revised 1/29/25-encourage grooming of facial hair and document any refusals, revised 1/29/25 Review of the Certified Nurse Aide (CNA) Care Card (printed on 1/14/26) indicated the following under Dressing, Grooming, and Bathing: -provide total assistance with grooming, dressing and bathing -encourage grooming of facial hair, and document any refusals Review of the clinical record on 1/13/26 failed to indicate that Resident #102 refused care relative to grooming/facial hair removal for the last 31 days. On 1/8/26 at 8:57 A.M., the surveyor observed Resident #102 lying upright in bed and a CNA assisting the Resident with the breakfast meal. The Resident was observed to have dark hair over his/her upper lip and several strands of hair, approximately one inch in length, on his/her chin. On 1/9/26 at 10:23 A.M., the surveyor observed Resident #102 lying in bed dressed in a hospital gown. The surveyor observed that dark hair remained on the Resident's upper lip and several long hairs on his/her chin. During an interview at the time, Resident #102 said he/she wanted to get dressed. At 10:35 A.M., the surveyor observed a CNA enter the Resident's room to provide ADL care. On 1/9/26 at 12:41 P.M., the surveyor observed Resident #102 dressed and seated in a specialized wheelchair in the common area with other residents during the lunch meal. The surveyor observed that dark hair remained on the Resident's upper lip and several long hairs remained on the Resident's chin. During an interview on 1/13/26 at 9:38 A.M., CNA #3 said Resident #102 required the assistance of one person with ADL care. CNA #3 said the Resident was washed and dressed daily after breakfast. CNA #3 said the Resident was receptive to receiving ADL care from staff and did not refuse care. On 1/14/26 at 10:44 A.M., the surveyor observed Resident #102 lying in bed dressed in a hospital gown and dark hair remained on the Resident's upper lip and several long hairs, approximately one inch in length and curled, remained on the Resident's chin. During an interview at the time, Resident #102 said he/she would like to be washed and dressed. When the surveyor asked about his/her preference for facial hair, the Resident said he/she did not want to have facial hair and would like to have it removed. On 1/14/26 at 10:48 A.M., CNA #3 was observed preparing to enter Resident #102's room. During an interview at the time, CNA #3 said she was going to assist Resident #102 with ADL care. The surveyor requested CNA #3 to observe Resident #102's upper lip and chin during care. CNA #3 said if facial hair was present, the staff should offer to remove it. On 1/14/26 at 11:51 A.M., the surveyor observed Resident #102 dressed and seated in a specialized wheelchair in the common areas with other residents. The surveyor observed that the Resident's upper lip and chin were free of facial hair. During an interview on 1/14/26 at 11:56 A.M., CNA #3 said she removed the facial hair on the Resident's upper lip and chin. CNA #3 said the hair on the Resident's chin was very long prior to removal. During an interview on 1/14/26 at 12:11 P.M., the Assistant Director of Nurses (ADON) said she was responsible for the unit at this time. The ADON said the expectation was that all residents would be offered to have their facial hair removed daily when care was being provided by staff unless the resident requested to have the facial hair present. The ADON said if a resident refused to have the facial hair removed, this would be documented and if a resident requested facial hair, it would be care-planned.

Based on interviews and records reviewed, for one of three sampled residents (Residents #1), the Facility failed to ensure that after being made aware on 6/02/25 of an allegation of verbal abuse by a staff member, that the incident was reported to the Department of Public Health (DPH), within two hours, as required. Findings include: The Facility Policy titled Administration, last reviewed 10/2022, indicated that the Administrator would report allegations to the DPH within two hours. Resident #1's medical record indicated he/she was admitted to the Facility during May of 2025. Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 5/22/25, indicated his/her cognitive patterns were moderately impaired.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 7/16/25, indicated Resident #1 reported the Social Worker screamed at him/her and called him/her a crackhead.During an interview on 9/15/25 at 2:00 P.M. the Director of Nursing said that on 7/16/25 she learned that Resident #1 had told the Nurse Practitioner on 7/15/25 that the Social Worker screamed at him/her, told him/her that he/she should go and kill him/herself and called him/her a crackhead. The Director of Nursing said during that investigation into Resident #1's allegation, she learned that another allegation had previously been reported to the Former Administrator. The Director of Nursing said that a Written Witness Statement (dated 6/02/25) from the Behavioral Department Staff Member was found on the Former Administrator's desk.Review of the Written Witness Statement from the Behavioral Staff Member, dated 6/02/25, indicated the Behavior Staff Member witnessed the Social Worker and Resident #1 having a discussion and during the discussion, the Social Worker called Resident #1 a crack addict and berated and taunted him/her.During a telephone interview on 9/16/25 at 3:20 P.M., the Behavioral Department Staff Member said that he witnessed the Social Worker argue with and yell at Resident #1 and call him/her a drug seeking crackhead. The Behavioral Department Staff Member said that he reported his observation to the immediate supervisor and the Former Administrator.The Surveyor was unable to interview the Former Administrator as he did not respond to the DPH's telephone or email requests for an interview.The Director of Nursing said that the Former Administrator told her that he handled the Behavior Department Staff Member's report as a grievance and did not report the allegation that the Social Worker verbally abused Resident #1 to the DPH, as required.The Director of Nursing said that she submitted a report via the HCFRS on 7/16/25, (regarding the 6/02/25 incident) about six weeks after the allegation had been reported to the Former Administrator.On 9/15/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 7/25/25, which addressed the area(s) of concern as evidenced by: A) On 7/16/25, the Former Administrator was suspended and subsequently terminated. B) On 7/16/25 and on-going until his/her discharge in August 2025, Resident #1 received support and counseling from the Behavioral Health Service. C) Between 7/16/25 and 7/22/25, the Director of Nursing/designee trained all Facility staff members on the Facility Abuse Policy. D) Between 7/16/25 and 7/24/25, the Director of Nursing/designee interviewed all Facility residents without identifying further allegations which had not been reported. E) On 7/25/25, the Facility held an ad hoc meeting of the Quality Assurance Committee to review the correction plan. F) On 7/16/25 and on-going, the Facility leadership (Administrator, Director of Nursing and Regional Staff) initiated daily interviews of a sample of staff members to assess their understanding of the Facility Abuse Policy. G) In July 2025 on-going Facility leadership (Administrator, Director of Nursing and Regional Staff) initiated monthly meetings with the Ombudsman and Resident Council to ensure relevant concerns had been reported timely in accordance with the Facility Abuse Policy. H) On 7/16/25 and on-going, Facility leadership (Administrator, Director of Nursing and Regional Staff) initiated a daily review of all Progress Notes to ensure relevant concerns had been reported timely in accordance with the Facility Abuse Policy. I) The Administrator/designee is responsible for overall compliance.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who reported an allegation of verbal abuse to a staff member, the Facility failed to ensure staff implemented and followed the Facility Abuse Prohibition Policy, when the staff member did not immediately report the allegations to the shift supervisor/charge nurse/manager or the Administrator/designee. Findings include: The Facility Policy titled Administration, last reviewed 10/2022, indicated that the Facility prohibited abuse, that all staff would notify the shift supervisor/charge nurse/manager immediately if suspected abuse occurred, that the incident would be reported to the Director of Nursing and the Administrator and to the DPH within two hours. Resident #1's medical record indicated he/she was admitted to the Facility during May of 2025. Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 5/22/25, indicated his/her cognitive patterns were moderately impaired.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 7/16/25, indicated Resident #1 reported that the Social Worker screamed at him/her and called him/her a crackhead.During a telephone interview on 9/23/25 at 12:51 P.M., the Nurse Practitioner (NP) said that on 7/15/25 Resident #1 told her that the Social Worker screamed at him/her and called him/her a crackhead. The Nurse Practitioner said that she did not report Resident #1's statement to the shift supervisor/charge nurse/manager immediately or to the Administrator or Director of Nursing. The Nurse Practitioner said that she documented Resident #1's comments in a Progress Note.Review of the Nurse Practitioner's Progress Note, dated 7/15/25, indicated Resident #1 told this writer (the NP) that the Social Worker screamed at him/her, told him/her that he/she should go and kill him/herself and called him/her a crackhead.During an interview on 9/15/25 at 2:00 P.M. the Director of Nursing said that on 7/16/25, she learned that on 7/15/25, the Nurse Practitioner documented in a Progress Note that Resident #1 alleged that the Social Worker screamed at him/her, told him/her that he/she should go and kill him/herself and called him/her a crackhead. The Director of Nursing said that the Nurse Practitioner had not informed her or the Administrator of the allegation on 7/15/25, in accordance with the Facility Policy.On 9/15/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 7/25/25, which addressed the area(s) of concern as evidenced by:A) On 7/16/25, the Nurse Practitioner was suspended and subsequently terminated.B) On 7/16/25 and on-going until his/her discharge in August 2025, Resident #1 received support and counseling from the Behavioral Health Service.C) Between 7/16/25 and 7/22/25, the Director of Nursing/designee trained all Facility staff members on the Facility Abuse Policy.D) Between 7/16/25 and 7/24/25, the Director of Nursing/designee interviewed all Facility residents without identifying further allegations which had not been reported.E) On 7/25/25, the Facility held an ad hoc meeting of the Quality Assurance Committee to review the correction plan.F) On 7/16/25 and on-going, the Facility leadership (Administrator, Director of Nursing and Regional Staff) initiated a process for daily interviews of a sampled of direct care staff in order to assess their understanding of the Facility Abuse Policy.G) In July 2025 and on-going, Facility leadership (Administrator, Director of Nursing and Regional) initiated monthly meetings with the Ombudsman and Resident Council to ensure relevant concerns had been reported timely in accordance with the Facility Abuse Policy.H) On 7/16/25 and on-going, Facility leadership (Administrator, Director of Nursing and Regional Staff) initiated a daily review of all Progress Notes to ensure relevant concerns had been reported timely in accordance with the Facility Abuse Policy.I) The Administrator/designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a gastrostomy tube (G tube, placed through the abdomen into the stomach, for feedings, liquids and medications) in place to meet his/her nutritional and fluid intake needs, the Facility failed to ensure nursing staff were competent related to gastrostomy tubes (G tube) and appropriate actions to take when dislodged, when after Resident #1's G Tube became dislodged, nursing inserted a new G Tube and restarted his/her tube feeding without verifying tube placement, resulting in a change in Resident #1's condition, he/she subsequently required transfer and admission to the Hospital. Findings include:Review of the Facility policy titled Enteral Feedings, undated, indicated the procedures for administering enteral feed formulas and flushes, changing administration set tubing and verification of tube placement. Review of the policy indicated there was no evidence to support that nursing staff were allowed to insert a gastrostomy tube. The Facility was also unable to provide any documentation to support the nurses had received clinical training on G tube insertion. Review of the Covidien Kangaroo Gastrostomy Feeding Tube manufacturer's instructions, dated as revised 12/2018, provided by the Facility, indicated the device should only be inserted by a trained clinician. Review of Nurse #1's Required Competency, dated [DATE] indicated there was no documentation to support that Nurse #1 had been trained or was competent to insert G Tubes. Resident #1 was admitted to the Facility in [DATE], diagnoses included but not limited to acute respiratory failure with hypoxia (low oxygen), dependence on respirator (ventilator), cerebral infarct (stroke-damage to brain from interruption in blood supply), dysphagia (difficulty swallowing) and gastrostomy.Review of Resident #1's Hospital Record indicated the following:The Emergency Department (ED) Report, dated [DATE], indicated Resident #1 was being transferred to the Hospital for PEG (gastrostomy tube) study when he/she was found to be significantly hypotensive by Emergency Medical Services (EMS). On arrival at the Emergency Department (ED) Resident #1 had no pulse and cardiopulmonary resuscitation (CPR) was initiated. Resident #1 achieved return of spontaneous circulation after one round of CPR. The Critical Care History and Physical, dated [DATE], indicated Resident #1 had his/her PEG tube replaced with a G-tube at [nursing facility], on [DATE] at around 12:00 P.M., at which time tube feeds were continued. Computed Tomography (CT) scan of the abdomen and pelvis, dated [DATE], indicated that the gastrostomy tube was malpositioned (not in the stomach) with the balloon and tip within the peritoneum (membrane that lines the abdominal cavity) with associated moderate free air and moderate free ascites (accumulation of fluid). During a telephone interview on [DATE] at 10:00 A.M., the Facility Physician said that on [DATE] at approximately 3:30 P.M., she was made aware that a Facility nurse had inserted a G-tube into Resident #1. The Physician said she assessed Resident #1, found his/her abdomen to be distended, that she was unable to withdraw gastric contents to verify placement of the G tube, ordered the feeding stopped and ordered Resident #1 to be transferred to the hospital. The Physician said that G tube placement should be checked with Gastrografin (a contrast medium injected into a tube followed by an X ray that is used to confirm proper placement of a G tube after insertion), prior to the G tube being used. Review of Nurse #1's written statement, undated, indicated that Nurse #1 had notified Unit Manager #1 that Resident #1's G tube had been dislodged. The statement indicated that Unit Manger #1 had notified the Provider, and that Nurse #1 had replaced the G tube, administered medication and restarted the tube feeding. The Surveyor was unable to interview Nurse #1, as she did not respond to the Department of Public Health's request for an interview. During an interview on [DATE] at 12:35 P.M., Unit Manager #1 said that on [DATE], she instructed Nurse #1 to insert a G tube into Resident #1. Unit Manager #1 said she did not assess Resident #1 or review the Facility policy prior to giving Nurse #1 instructions to insert a G tube into Resident #1.During an interview on [DATE] at 2:00 P.M., the Director of Nurses (DON) said Nurse #1 should not have inserted a G tube into Resident #1 and that the Facility did not have a policy or protocol to support this practice.On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of [DATE], which addressed the areas of concern as evidenced by:a) Resident #1 was transferred and admitted to the hospital on [DATE] for treatment.b) Nurse #1 and Unit Manager #1 have received disciplinary actions for not following Facility policy related to G tube insertion.c) The Facility has revised the Enteral Feedings policy (effective 05/2025) to include a statement that no licensed professionals (Nurses/Physicians, Nurse Practitioners etc.) will replace or insert any enteral tube at the facility. Any replacement/insertion of enteral tubes will be performed at the hospital to ensure confirmation of placement. d) On [DATE] Unit Managers and/or designee completed audits of current residents with G tubes for compliance with Physician's orders that indicate residents will not have enteral tubes changed at the facility and will transfer to the hospital for evaluation.e) On [DATE] the Director of Nurses and/or designee-initiated education for Nurses and Providers that residents will not have enteral tubes changed at the facility and will transfer to the hospital for evaluation.f) On [DATE] the Director of Nurses and/or designee initiated ongoing monthly audits, to be completed for three months, of Physician's orders to ensure the orders indicate that residents will not have enteral tubes changed at the facility and will transfer to the hospital for evaluation.g) The concern for G tube insertion at the Facility was discussed by the Quality Assurance Performance Improvement (QAPI) Committee on [DATE] and ongoing audit results have continued to be reviewed at the QAPI Committee meeting monthly for three months. Target compliance date for this concern is [DATE].h) The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a gastrostomy tube (G tube, placed through the abdomen into the stomach, for feedings, liquids and medications) in place to meet his/her nutritional and fluid intake needs, and whose physician's orders included formula feeds, water flushes and medication administration through the G tube, the Facility failed to ensure that Resident #1 was provided with appropriate treatment and services when his/her G tube was replaced by a Facility Nurse, and formula feeding and water flushes were administered into the incorrectly positioned G tube resulting in a change in Resident #1's condition, with subsequent need for transfer and admission to the Hospital. Findings include:Review of the Facility policy titled Enteral Feedings, undated, indicated the procedures for administering enteral feed formulas and flushes, changing administration set tubing and verification of tube placement. Review of the policy indicated there was no evidence to support that nursing staff were allowed to insert a gastrostomy tube. The Facility was also unable to provide any documentation to support the nurses had received clinical training on G tube insertion. Review of the Covidien Kangaroo Gastrostomy Feeding Tube manufacturer's instructions, dated as revised 12/2018, provided by the Facility, indicated the device should only be inserted by a trained clinician. Resident #1 was admitted to the Facility in [DATE], diagnoses included but not limited to acute respiratory failure with hypoxia (low oxygen), dependence on respirator (ventilator), cerebral infarct (stroke-damage to brain from interruption in blood supply), dysphagia (difficulty swallowing) and gastrostomy. Review of Resident #1's Nutrition Care Plan, date initiated [DATE], indicated the following:Tube feedings will provide 100% of estimated needs for nutrition/hydration. Check placement and patency of tube prior to initiating tube feeding. Review of Resident #1's Physician's orders for the month of [DATE], related to G tube feeds and water flushes indicated it included orders for, but not limited to the following:Enteral Feed Order-Vital 1.5 at 50 milliliters per hour (ml/hr) via PEG (gastrostomy) tube daily, start date [DATE].Water flushes 400 ml via PEG every six hours, start date [DATE].Document tube feed/water intake every shift, start date [DATE]. Review of Resident #1's Medication Administration Record (MAR) for the month of [DATE] indicated the following was documented as administered:[DATE]-Day Shift-Enteral Feed Order-Vital 1.5 at 50 ml/hr, documented as administeredXXX[DATE]-Day Shift-Water flushes 400 ml via PEG every six hours, documented as administeredXXX[DATE]-Day Shift-Document tube feed/water intake every shift-documented as administered: feed-400, water 400. Review of Resident #1's Nurse Progress Note, dated [DATE], indicated the following:Guardian updated on (Resident #1) removing his/her PEG tube today and that we replaced it with a G-tube. He/she now has 18 French (Fr) 20 milliliter (ml) (size of gastrostomy tube) and orders changed to support that and changing times.Review of Resident #1's Provider Progress Note, dated [DATE], indicated that the Nurse Practitioner was informed by the Unit Manager that Resident #1's PEG tube fell out this morning and that we replaced it with a G-tube, so it will need to be replaced every three months now. The Provider Progress Note indicated that at approximately 3:30 P.M., Resident #1 was examined by his/her Physician and observed to have abdominal distention after bedside G Tube replacement and that Resident #1 was to be sent to the Hosptial Emergency Department (ED).During a telephone interview on [DATE] at 10:00 A.M., the Physician said that on [DATE] at approximately 3:30 P.M., she was made aware that a facility nurse had inserted a G-tube into Resident #1. The Physician said she then assessed Resident #1, found his/her abdomen to be distended, that she was unable to withdraw gastric contents to verify placement of the G tube, ordered the feeding stopped and ordered Resident #1 to be transferred to the hospital. The Physician said that G tube placement should have been checked with Gastrografin (a contrast medium injected into a tube followed by an X ray that is used to confirm proper G tube placement after insertion), prior to the G tube being used. Review of Resident #1's Hospital Record indicated the following:The Hospital Emergency Department (ED) Report, dated [DATE], indicated Resident #1 was transferred to the ED for PEG (gastrostomy tube) study when he/she was found to be significantly hypotensive by Emergency Medical Services (EMS). On arrival at the Emergency Department (ED) Resident #1 had no pulse and cardiopulmonary resuscitation (CPR) was initiated. Resident #1 achieved return of spontaneous circulation after one round of CPR. The Critical Care History and Physical, dated [DATE], indicated Resident #1 had his/her PEG tube replaced with a G-tube at [nursing facility], on [DATE] at around 12:00 P.M., at which time tube feeds were continued. Computed Tomography (CT) scan of the abdomen and pelvis, dated [DATE], indicated that the gastrostomy tube was mal-positioned (not in the stomach) with the balloon and tip within the peritoneum (membrane that lines the abdominal cavity) with associated moderate free air and moderate free ascites (accumulation of fluid). The Surveyor was unable to interview Nurse #1, as she did not respond to the Department of Public Health's requests for an interview. Review of Nurse #1's written statement, undated, indicated that Nurse #1 had notified Unit Manager #1 that Resident #1's G tube had been dislodged. The Statement indicated that Unit Manger #1 had notified the Physician, and that she (Nurse #1) had replaced the G tube, administered medication and restarted the tube feeding. During an interview on [DATE] at 12:35 P.M., Unit Manager #1 said that on [DATE] she had instructed Nurse #1 to insert a G tube into Resident #1. Unit Manager #1 said she did not assess Resident #1 at that time or review the Facility policy prior to giving Nurse #1 instructions to insert a G tube into Resident #1.During an interview on [DATE] at 2:00 P.M., the Director of Nurses (DON) said the facility did not have a policy or protocol to support the insertion of gastrostomy tubes by nurses. The DON said Nurse #1 should not have inserted a G tube into Resident #1. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of [DATE], which addressed the areas of concern as evidenced by:a) Resident #1 was transferred and admitted to the hospital on [DATE] for treatment.b) Nurse #1 and Unit Manager #1 received disciplinary actions for not following Facility policy related to G tube insertion.c) The Facility revised the Enteral Feedings policy t(effective 05/2025) to include a statement that no licensed professionals (Nurses/Physicians, Nurse Practitioners etc.) will replace or insert any enteral tube at the facility. Any replacement/insertion of enteral tubes will be performed at the hospital to ensure confirmation of placement. d) On [DATE] Unit Managers and/or designee completed audits of current residents with G tubes for compliance with Physician's orders that indicate residents will not have enteral tubes changed at the facility and will transfer to the hospital for evaluation.e) On [DATE] the Director of Nurses and/or designee-initiated education for Nurses and Providers that residents will not have enteral tubes changed at the facility and will need to be transferred to the hospital for evaluation.f) On [DATE] the Director of Nurses and/or designee initiated ongoing monthly audits, to be completed for three months, of Physician's orders to ensure the orders indicate that residents will not have enteral tubes changed at the facility and will transfer to the hospital for evaluation.g) The concern for G tube insertion at the Facility was discussed by the Quality Assurance Performance Improvement (QAPI) Committee on [DATE] and ongoing audit results have continued to be reviewed at the QAPI Committee meeting monthly for three months. Target compliance date for this concern is [DATE].h) The Director of Nurses and/or designee are responsible for overall compliance.

Based on observations, interviews, and record reviews, for five out of ten sampled residents (Resident #3, #4, #5, #6, and #7), on one of four nursing units (Unit #2), all of whom were either on Enhanced Barrier Precautions (EBP) or Contact Precautions, both of which required staff to use Personal Protective Equipment (PPE) during the provision of care, the Facility failed to ensure they implemented and maintained an infection control program that helped prevent the development and spread of infections, when staff were observed not following infection control practices in accordance with performing hand hygiene at appropriate intervals and not adhering to posted Precaution Signs. Findings include: Review of the facility's policy, titled Handwashing/Hand Hygiene, with a revision date of October 2023 indicated the following: -The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. -Indications for Hand Hygiene: *Immediately before and after touching a resident *After touching the resident's environment Review of the facility's policy, titled Transmission Based Precautions, with a revision date of January 2024, included the following: -Transmission based precautions are designed for patients documented or suspected of being infected or colonized (a person who is colonized carries the organism in or on their body, but it is not causing symptoms) with transmissible pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission in the healthcare setting. -Enhanced Barrier Precautions will be implemented for residents with active or colonized multi drug resistant organisms (MDRO) infections, those with indwelling devices [i.e. urinary catheters (tubes to drain urine from the bladder), tracheostomy (a surgical opening to the wind pipe), gastrostomy (a surgical opening to the stomach)], or chronic wounds. -Review of the Enhanced Barrier Precaution sign, undated, indicated: -Everyone Must: Clean their hands including before and when leaving the room. -Providers and Staff Must Also: Wear a gown and gloves for the following High-Contact Resident Care Activities: *Dressing *Bathing/showering *Transferring *Changing Linens *Providing Hygiene *Changing briefs or assisting with toileting *Device Care of Use: central line, urinary catheter, feeding tube, tracheostomy and *Wound Care: any skin opening requiring a dressing -Contact Precautions will be implemented for residents with known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Review of the Contact Precaution Sign, undated, indicated: -Everyone Must: Clean their hands including before entering and when leaving the room. -Providers and Staff Must Also: *Put on gloves before room entry and discard gloves before room exit. *Put on gown before room entry and discard gown before room exit. *Do not wear the same gown and gloves for the care of more than one person. During the initial tour of Unit 2 on 06/18/25 at 7:22 A.M., Surveyor #1 observed that there were Enhanced Barrier Precautions Signs on the doorways of Residents #4, #5, #6, and #7 rooms, and a Contact Precaution Sign on the doorway of Resident #3 room. 1. Resident #5 was admitted to the facility in August 2023, diagnoses included gastrostomy and tracheostomy. Review of Resident #5's medical record indicated he/she had a current Physician's order for Enhanced Barrier Precautions due to having a tracheostomy. On 06/18/25 at 7:28 A.M., Surveyor #1 observed Certified Nurse Aide (CNA) #1 exit Resident #5's room wearing gloves and then walk down the hallway to the Nurses Station, where she then removed the gloves. During an interview on 06/18/25 at 7:30 A.M., CNA #1 said she had just changed Resident #5's bed linens and should have taken her gloves off and performed hand hygiene prior to exiting his/her room. 2. Resident #7 was admitted to the facility in February 2025, diagnoses included neuromuscular bladder, and he/she had an indwelling urinary catheter. Review of Resident #7's medical record indicated he/she had a current Physician's order for Enhanced Barrier Precautions. On 06/18/25 at 7:51 A.M., Surveyor #1 observed Certified Nurse Aide (CNA) #2 enter Resident #7's room without performing hand hygiene and then minutes later CNA #2 exited his/her room holding a plastic bag of linen, without performing hand hygiene. During an interview on 06/18/25 at 7: 54 A.M., CNA #2 said she had provided care for Resident #7 and his/her roommate, and they were both on Enhanced Barrier Precautions. CNA #2 said she should have performed hand hygiene when she entered and exited the room. 3. Resident #6 was admitted to the facility in January 2025, diagnoses included traumatic brain injury, gastrostomy, and tracheostomy. Review of Resident #6's medical record indicated he/she had a current Physician's order for Enhanced Barrier Precautions. A. On 06/18/25 at 7:32 A.M., Surveyor #1 observed Laboratory Technician #1 leaning over Resident #6's bed and obtaining a blood sample from his/her right arm, without wearing a gown. Laboratory Technician #1 exited Resident #6's room moments later without performing hand hygiene. During an interview on 06/18/25 at 7:36 A.M., Laboratory Technician #1 said she did not know, until the nurse just told her, that she was supposed to wear a gown when providing direct care to Resident #6. B. On 06/18/25 at 9:16 A.M., Surveyor #1 observed Certified Nurse Aide (CNA) #4 enter Resident #6's room without performing hand hygiene. During an interview on 06/18/25 at 9:20 AM., CNA #4 said she did not know she was supposed to perform hand hygiene before entering Resident #6's room. 4. Resident #4 was admitted to the facility in December 2024, diagnoses included tracheostomy and gastrostomy. Review of Resident #4's medical record indicated a current Physician's order for Enhanced Barrier Precautions. On 06/18/25 at 7:58 A.M., Surveyor #1 observed CNA #3 inside Resident #4's room, tidying Resident #4's bed linens, without wearing a gown. During an interview on 06/18/25 at 8:00 A.M., CNA #3 said she had just completed activities of daily living care (bathing/dressing/grooming) for Resident #4 and only needed to wear gloves during care. CNA #3 said she did not need to wear a gown because, although Resident #4 had a tracheostomy and a gastric tube,, he/she was able to feed him/herself, therefore it was her understanding that a gown was not required for high contact care. 5. Resident #3 was admitted to the facility in April 2025, diagnoses included carbapenem resistant pseudomonas colonized in his/her sputum (CRPA-can be spread through direct contact with patients or residents who are colonized or infected with CRPA or by the hands or clothing of health care personnel (HCP). CRPA can also be spread through contaminated surfaces in the patient's or residents' environment. A person who is colonized with CRPA carries the organism in or on their body, but it is not causing symptoms. People who are colonized can spread the organism to surfaces in their environment and to other people), anoxic brain injury and tracheostomy. Review of Resident #3's medical record indicated he/she had a current Physician's order for Contact Precautions every shift for CRPA in the sputum. On 06/18/25 at 7:28 A.M., Surveyor #1 observed the Certified Occupational Therapist Assistant (COTA) leaning over Resident #3's bed, wearing a gown, gloves and surgical mask. -At 7:34 A.M., Surveyor #1 observed the COTA exit Resident #3's room, wearing a surgical mask. Surveyor #1 did not observe a supply of surgical masks inside Resident #3's room, and noted the box of clean surgical masks was in a bin located outside of Resident #3's room. During an interview on 06/18/25 at 7:35 A.M., the COTA said she was doing Range of Motion exercises with Resident #3 and that she changed her mask inside Resident #3's room before leaving it. The COTA said she had a mask in the pocket of her scrubs which she applied before leaving Resident #3's room. The COTA said she knew Resident #3 was on precautions but was not sure why. The COTA said she should not have used a mask that was kept in her pocket. During a telephone interview on 06/20/25 at 10:13 A.M., the Director of Nurses (DON) said that all staff, including vendors, are expected to follow the Precaution Signs posted at the entry of residents' rooms. The DON said all staff should perform hand hygiene upon entry and exit of rooms for residents who are on precautions. The DON said clean PPE should not be stored in the pockets of staff members clothing and staff should not wear masks in general. The DON said she expected all staff to always adhere to infection control protocols.

Based on observations, interviews, and record reviews, for one of four nursing units (Unit #1) that specialized in the care and treatment of residents with a tracheostomy and/or ventilator, with an average daily census of 27 residents all of whom were on Enhanced Barrier Precautions (EBP) which required staff to use Personal Protective Equipment (PPE) during the provision of care, and had a known issue with the spread of Candida Auris (C. Auris, a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities, which can cause a range of infections from superficial (skin) infections to more severe, life-threatening infections, such as bloodstream infections), the Facility failed to ensure they implemented and maintained an infection control program that helped prevent the development and spread of infections, when staff 1) were observed not following infection control practices in accordance with posted Precaution Signs, 2) were observed not performing hand hygiene at appropriate intervals, 3) did not maintain respiratory equipment, and 4) were observed not using appropriate cleaning products in resident areas with confirmed C. Auris cases, all of which increased the potential for additional residents to be exposed and at risk for contracting C. Auris. Findings include: Review of the Facility's policy titled Candida Auris (C. Auris), dated April 2024, indicated the following: -C. Auris is highly contagious in healthcare facilities and spreads easily in healthcare settings and can cause outbreaks. -C. Auris can colonize in patients for many months, persists on surfaces, and is not killed by some commonly used healthcare facility disinfectants. -Hand hygiene, appropriate precautions, and environmental disinfection prevent and control outbreaks. -How it spreads: *Person to person contact: C. Auris can spread through direct contact with an infected person. *Contaminated surfaces: C. Auris can survive on surfaces for weeks, including bedrails, doorknobs, and medical equipment. *Shared equipment: C. Auris can spread through sharing medical equipment that has not been disinfected. -Recognizing that residents are at an increased risk of becoming colonized and developing infection, the facility will implement the use of Enhanced Barrier Precautions (EBP). -Enhanced Barrier Precautions targets the use of a gown and gloves during high contact care activities. -The Personal Protective Equipment (PPE) required when following Enhanced Barrier Precautions is a gown and gloves which are to be donned (applied) prior to the high contact care activity. -Hand hygiene is to be performed before donning PPE and after doffing (removing). -Examples of high contact care include (but not limited to): Device care or use, tracheostomy/ventilator. Review of the Facility's Policy, titled Hand Hygiene, dated 5/28/21, indicated the following: -It is the policy of the facility that staff will perform hand hygiene as a means of cleaning hands by either soap and water (hand washing), or antiseptic hand rub (alcohol based hand rub-ABHR), to decrease the risk of transmission of infection. -Gloves are not a substitute for hand hygiene. -If your task involves gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. -Perform hand hygiene before donning gloves and immediately after doffing. -Always perform hand hygiene when moving from the care of one resident to the care of another. Review of the Enhanced Barrier Precaution sign, undated, indicated: -Everyone Must: Clean their hands including before and when leaving the room. -Providers and Staff Must Also: Wear a gown and gloves for the following High-Contact Resident Care Activities: *Dressing *Bathing/showering *Transferring *Changing Linens *Providing Hygiene *Changing briefs or assisting with toileting *Device Care of Use: central line, urinary catheter, feeding tube, tracheostomy and *Wound Care: any skin opening requiring a dressing During the initial tour of Unit #1 on 01/29/25 at 8:20 A.M., the surveyors observed that there were Enhanced Barrier Precautions signs on the doorways of every resident's room. 1A. Resident #3 was admitted to the Facility in December 2024, diagnoses included acute respiratory failure with hypoxia (low oxygen level), pneumonia, tracheostomy (surgical opening in the windpipe to aid in breathing and sepsis (life threatening response to infection). Review of Resident 3's medical record indicated that he/she had tested positive for Candida Auris (C. Auris) on 12/11/24. Review of Resident #3's Physician Orders dated 1/29/25 indicated he/she required: -Enhanced Barrier Precautions -Trach (tracheostomy) care every shift and prn (as needed), -Suction (a procedure to remove secretions from the respiratory tract) every shift and prn, -Administer Ipratropium-Albuterol Inhalation Solution (a medication to make breathing easier) 0.5-2.5 3 milligrams (mg)/3 milliliters (ml) - 3 ml via trach four times daily. On 1/29/25 at 8:55 A.M., Surveyor #2 observed an Enhanced Barrier Precaution sign posted at the entrance doorway to Resident #3's room. Surveyor #2 further observed the Respiratory Therapist (RT) don (put on) gloves and enter Resident #3's room, and without donning/wearing a gown, the RT proceeded to Resident #3's bedside and started tracheal suctioning. The RT continued to suction Resident #3 for approximately three minutes. Resident #3 was observed to cough during the procedure. The RT finished the procedure, exited the room, removed his gloves and performed hand hygiene using hand sanitizer. During an interview on 1/29/25, at 9:30 A.M., the Respiratory Therapist said he knew that Resident #3 was on Enhanced Barrier Precautions and that he should have worn a gown to perform suctioning on Resident #3, but he had not. The RT said there was a risk of exposure to respiratory secretions, and said he forgot to put a gown on before the procedure. On 01/29/25 at 11:39 A.M., Surveyor #1 observed the Respiratory Therapist administer a nebulizer treatment to Resident #3. -The RT performed hand hygiene prior to entering Resident #3's room, donned a gown and gloves, and entered Resident #3's room. The RT removed the nebulizer cup (holds medication) and the nebulizer tubing out of a bag which was on the side of a respiratory equipment treatment cart in the resident's room. The treatment cart held shared supplies for Resident #3 and his/her roommate. -The RT placed the medication into the nebulizer cup and attached the nebulizer to Resident #3's tracheostomy tubing for administration of the medicine. -The RT then reached for the Yankeaur suction tip, (a rigid plastic suction catheter used to remove secretions from the airway) which was stored in its original plastic sheath package, on top of the treatment cart. The RT suctioned Resident #3's mouth with the Yankeaur and placed it back in its package when he was done. -The RT removed his gloves, and without performing hand hygiene, put on a new pair of gloves and went back to Resident #3's bedside where he disconnected the nebulizer connector including the medication cup from the tracheostomy tubing, performed tracheal suctioning, then removed his gloves, and without performing hand hygiene put on a new pair of gloves. -The RT picked up the nebulizer medication cup and tubing and brought them into Resident #3's bathroom where he rinsed the medication cup with tap water, then placed the nebulizer medication cup back in the bag on the side of the treatment cart. -The RT removed his gloves, and without performing hand hygiene, put on new gloves, reached into the shared treatment supplies cart, touched several items, did not remove anything, removed his gloves, and without performing hand hygiene, put on a new pair of gloves. -The RT picked up the pulse oximeter (a small machine used to measure the amount of oxygen in blood) from Resident #3's bed and placed it on his/her bedside table. The RT removed his gown and gloves in Resident #3's room, exited the room and then performed hand hygiene. During an interview on 01/29/25 at 2:56 P.M. with Surveyor #1, the Respiratory Therapist said that he changed his gloves several times during Resident #3's nebulizer treatment and did not need to perform hand hygiene because he had remained with the same resident. The RT said he only needed to do hand hygiene between glove changes if he was working between two different residents. B. Resident #4 was admitted to the Facility in November 2024, diagnoses included indwelling urinary catheter, tracheostomy and dependence on respiratory ventilator. Review of Resident #4's Physician's orders, dated January 2025, indicated he/she required Enhanced Barrier Precautions. On 01/29/25 at 9:15 A.M., Surveyor #1 observed an Enhanced Barrier Precaution sign posted at the entrance doorway to Resident #4's room. Surveyor #1 observed the Respiratory Therapist (RT) enter Resident #4's room without performing hand hygiene, the RT then proceeded to Resident #4's bedside where he donned a pair of gloves, not a gown, and began tracheal suctioning. The RT finished Resident #4's tracheal suctioning, removed his gloves, exited Resident #4's room and performed hand hygiene using hand sanitizer. During an interview on 01/29/25 at 9:20 A.M., the Respiratory Therapist said he had been a full time Respiratory Therapist at the Facility for the last eight years. The RT said that when a resident was on Enhanced Barrier Precautions, he only needed to wear a mask and gloves to perform tracheal suctioning. C. Resident #6 was admitted to the Facility in October 2024, diagnoses include respiratory failure, anoxic brain damage, cerebral infarction and tracheostomy. Review of Resident #6's Physician Orders dated 1/29/25 indicated he/she required Enhanced Barrier Precautions and tracheostomy care as needed. On 1/29/25 at 8:35 A.M., Surveyor #2 observed an Enhanced Barrier Precaution sign posted at the doorway entrance of Resident #6's room. Surveyor #2 further observed Resident #6 lying in bed and Nurse #2 wearing gloves and a mask, but without a gown, as she leaned over Resident #6 to change the dressing around his/her tracheostomy. Nurse #2 removed the gauze dressing from Resident #6's tracheostomy site, wiped around the tracheostomy with another piece of gauze and applied a clean piece of gauze around the tracheostomy. Nurse #2 completed the dressing change, then placed a blood pressure cuff around Resident #6's arm to obtain his/her blood pressure and placed her stethoscope on Resident #6's chest. Nurse #2 exited Resident #6's room, removed her gloves and performed hand hygiene using hand sanitizer. Nurse #2 then wiped down the blood pressure cuff and stethoscope using Oxivir (broad spectrum disinfecting) wipes. During an interview on 1/29/25 at 8:48 A.M., with Surveyor #2, Nurse #2 said she had performed tracheostomy care and obtained vital signs for Resident #6. Nurse #2 pointed to a PPE bin outside of Resident #6's room that was filled with gowns and other personal protective equipment and said she should have worn a gown when she provided tracheostomy care for Resident #6. Nurse #2 said it was a mistake that she had not worn one. 2. On 1/29/25 at 1:20 P.M., Surveyor #2 observed the following on Unit #1: -The Activity Director entered a resident's room and failed to perform hand hygiene upon entry. -The Activity Director was in the room for approximately two minutes, exited the room, and failed to perform hand hygiene. -The Activity Director walked down the corridor and entered a second resident room and failed to perform hand hygiene upon entry. The Activity Director was in that room for approximately five minutes, exited the room and failed to perform hand hygiene. -The Activity Director entered a third resident room, failed to perform hand hygiene, stayed in the room for approximately five minutes and washed her hands in the sink in the room then exited the room. During an interview on 1/29/25, at 1:33 P.M., the Activity Director said that she did not need to perform hand hygiene when entering and exiting resident rooms because she was not caring for the residents. The Activity Director said that she did not usually do hand hygiene when entering and exiting resident rooms. During the interview, the Activity Director then observed the Enhanced Barrier Precautions signs posted outside the resident rooms on the unit (Unit #1) and said that now she knew she needed to do hand hygiene when entering and exiting all resident rooms. During an interview on 01/29/25 at 3:40 P.M., with Surveyor #1 and Surveyor #2, the Unit Manager #1 said that all residents on her unit (Unit #1) required Enhanced Barrier Precautions. Unit Manager #1 said staff were not required to perform hand hygiene to enter and exit a resident room on the unit if they were not providing high-contact resident care. Unit Manager #1 said that when staff performed high-contact resident care activities they were supposed to wear a gown and gloves. During interviews on 01/29/25 at 10:18 A.M. and 2:35 P.M., with Surveyor #1 and Surveyor #2, the Infection Preventionist (IP) said the staff were required to wear a gown and gloves when they performed any high-contact activities with residents who were on EBP. The IP said that she expected all staff, and anyone who entered the residents' rooms who were on EBP, to perform hand hygiene upon entering and exiting the residents' rooms. The Infection Preventionist said that although she was aware of the on-going transmission of C.Auris in the Facility (on Unit #1), said she was new to the role of IP and had not yet been able to do much work related to the on-going transmission of C. Auris. During an interview on 1/29/25, at 4:00 P.M. with Surveyor #1 and Surveyor #2, the Director of Nursing (DON) said that all residents residing on Unit #1 required Enhanced Barrier Precautions because they had indwelling medical devices or wounds. The DON said it was her expectation that any staff member entering residents' rooms would adhere to the posted Enhanced Barrier Precautions signage and said that the Respiratory Therapist should have worn a gown when suctioning a resident due to the increased risk of exposure to infections during high-contact resident care activities. The DON said that all staff should perform hand hygiene every time they change their gloves. 3. Resident #5 was admitted to the Facility in September 2023, diagnoses included acute respiratory failure with hypoxia, tracheostomy and dependence on a ventilator. Review of Resident #5's Physician Orders for the month of January 2025 included the following: -Change all canisters (used to hold the secretions from suctioning), tubing tracheostomy strap (to secure it in place), tracheostomy mask, oxygen tubing and Yankeaur, every week on Wednesday. -Vent settings, AC (ventilator delivers a set number of breaths) 500, rr (respiratory rate) 14, Peep (positive end-expiratory pressure- maintains a certain amount of pressure in the lungs at the end of expiration) +5, Oxygen (0-8) 3 liters every evening and night shift. On 1/29/25, at 11:35 A.M., Surveyor #2 observed Resident #5 sitting in a chair near his/her bed. Resident #5's oxygen and tracheostomy tubing were in a bag attached to the bedside rail. One end of the oxygen tubing was attached to the oxygen concentrator and was labeled with a piece of tape, and was dated 12/23 [12/23/24]. One end of the tracheostomy tubing was attached to the ventilator and near the connection was dated 12/23 [12/23/24] with black marker. During an interview on 01/29/25, at 11:35 A.M., Resident #5 said he/she wore the oxygen and tracheostomy tubing only in the evening and overnight, not during the day. Resident #5 said that the nursing staff applied them both at 6:00 P.M. every evening. Review of Resident #5's Respiratory Flow Sheet documentation for the month of January 2025 indicated there was an order to; change all canisters, tubing trach strap, trach mask, oxygen tubing and Yankeaur every week on Wednesday, and that the flow sheet had been signed off by a Respiratory Therapist as having been completed on 01/01/25, 01/08/25, 01/15/25 and 01/22/25. During an interview on 01/29/25, at 2:56 P.M, the Respiratory Therapist (RT) said that the respiratory therapists changed the oxygen tubing once a week and the tracheostomy tubing monthly. The RT said that they wrote the date of the change right on the tubing. The RT said the date written on Resident #5's tubing [12/23] was the date that it had been changed. During an interview on 01/29/25, at 3:40 P.M., Unit Manager #1 said that the Respiratory Therapists change oxygen tubing weekly and label it with the date. Unit Manager #1 said the date [12/23] written on Resident #5's equipment was the date that it was last changed. Unit Manager #1 said that Resident #5 had an order to use oxygen and ventilator on the evening and overnight shifts, not during the day, Unit Manager #1 said that although Resident #5's Respiratory Flow Sheet indicated the equipment had been changed as ordered, said it had not been changed. 4. The Facility was unable to provide the surveyors with a policy or process related to the cleaning and disinfecting of resident areas where C. Auris was present. During an observation on 1/29/25, at 11:12 A.M., Surveyor #2 observed the following on Unit #1: -Housekeeper #1 cleaning a Resident's room who had an Enhanced Barrier Precaution sign posted on the door. -Housekeeper #1 wore gloves and removed two bags from two barrels in the resident's room that were filled with used Personal Protective Equipment and other waste. - Housekeeper #1 exited the resident's room with her gloves on and walked down the corridor to dispose of the bags in a utility room. -Housekeeper #1 then re-entered the resident's room and failed to remove her soiled gloves or perform hand hygiene. -Housekeeper #1 then removed a spray bottle containing a pink liquid solution (later identified as n-alkyl dimethyl benzyl ammonium chloride) from her cleaning cart and started spraying the solution on the surfaces of the resident's room including his/her over-the-bed table, windowsills and doorknobs. -Housekeeper #1 turned and saw Surveyor #2 observing the process. -Housekeeper #1 then placed the bottle of pink solution on the cleaning cart and removed the Oxivir cleanser. -Housekeeper #1 sprayed the same surfaces using Oxivir, then wiped all the surfaces using a rag. After wiping the surfaces, she mopped the floor using a floor cleaner from the bucket on the cart. -Housekeeper #1 mopped the entire floor, set up a wet floor sign, and left the room. -Housekeeper #1 then removed her gloves, did not perform hand hygiene, put on new gloves and walked down the hallway pushing the housekeeping cart. -Housekeeper #1 then entered another resident's room which also had an Enhanced Barrier Precaution sign posted on the door. Housekeeper #1 gathered her cleaning supplies and entered the resident's room wearing the same gloves. During an interview on 1/29/25 at 11:55 A.M. with Surveyor #2, Housekeeper #1 said she did not do hand hygiene after throwing the trash away or between resident rooms. Housekeeper #1 said she normally did, but said she forgot to that day. Housekeeper #1 showed Surveyor #2 the pink liquid solution she used to clean the surfaces of the resident's rooms on Unit #1, the bottle was labeled n-alkyl dimethyl benzyl ammonium chloride. Housekeeper #1 said she should not have used it on the surfaces because it was a deodorizer and not a cleaner. Housekeeper #1 said when she saw the Surveyor, she changed the cleaning product to Oxivir solution which she should have used to clean the residents' rooms. Housekeeper #1 said she used the yellow cleaner (bottle was labeled Quat 64 from Simoniz) stored in the Housekeeping Closet to clean the floors. Housekeeper #1 demonstrated that she fills the bucket on her cart with the solution and said she uses a new mop head for each room. Review of the Safety Data Sheet and Information Sheet for Quat 64 Lemon Liquid Disinfectant by Simoniz, undated, indicated a list of the pathogens including bacteria, viruses and Fungi that it is effective against. The Information Sheet did not indicate that Quat 64 was effective against Candida Auris. Review of the United States Environmental Protective Agency's list of Registered Antimicrobial Products Effective Against Candida Auris (List P), undated, did not include Quat 64 by Simoniz or n-alkyl dimethyl benzyl ammonium chloride. During an interview on 1/29/25 at 2:00 P.M., with Surveyor #2, the Housekeeping Director said that the residents' rooms were cleaned every day. The Housekeeping Director said the Housekeeping Staff should use Oxivir on the flat surfaces like tables, doorknobs and windowsills. The Housekeeping Director said that Housekeeper #1 should not have used the pink solution (n-alkyl dimethyl benzyl ammonium chloride), to clean the rooms because it was deodorizer which was used to remove foul odors. The Housekeeping Director said the facility recently started using Oxivir because it was effective against Candida Auris. The Housekeeping Director showed Surveyor #2 the system for cleaning the floors and said they were using Quat 64 to clean all floors, but added it was not effective against Candida Auris. During an interview on 1/29/25, at 4:10 P.M., the Administrator said he left the management of the Candida Auris outbreak to the Director of Nursing (DON). The Administrator said he knew that the DON was in contact with an Epidemiologist at the Department of Public Health. The Administrator said he was not aware that the Quat 64 Disinfectant used to clean all the floors in the facility was not effective against Candida Auris. The Administrator asked if it made a difference about what disinfectant was used on the floors and said he would talk with the Housekeeping Director about it. During an interview on 02/05/25 at 1:33 P.M., the Medical Director said she was aware of the on-going transmission of C. Auris in the Facility and that she expected all staff to adhere to infection control practices including proper hand hygiene and wearing the appropriate PPE for all resident interactions.

Based on records reviewed, policy reviews and interviews, the Facility which had a known area of concern related to the continued spread of Candida Auris (C. Auris, a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities, which can cause a range of infections from superficial (skin) infections to more severe, life-threatening infections) an infectious disease on Unit #1, which specializes in care and treatment of residents' requiring a tracheostomy and/or ventilator to breathe, with new cases of the infection identified in December 2024 and several more new cases identified in January 2025, the Facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' received care in accordance with their Infection Control Program, and was focused on quality of care for residents in the facility. Findings include: Review of the Facility's QAPI Policy, dated 12/06/21, indicated the following: -Purpose: To provide a means of continuous assessment of care and services provided, and to identify and investigate areas that could be improved through a multi-disciplinary approach. -Policy: QAPI encompasses all administrative, managerial, clinical, and environmental services as well as external providers and suppliers of care and services. QAPI is a comprehensive program by which the facility identifies problems or issues early on, develops a plan to address the root causes of the problems and prevent adverse events throughout the system while involving the entire team in using the data to understand and work to improve performance. -Procedure: The facility will incorporate the following five elements of a QAPI plan: *Design and Scope: Ongoing and comprehensive, all services offered, all departments. *Governance and Leadership: Led by Administration, input from staff, residents, families. *Feedback, Data Systems, and Monitoring: Systems to monitor care and services, draws data from multiple sources. *Systematic Analysis and Systematic Action: Determine when in-depth analysis is needed and understand the problem, causes, implications of change. Review of the Facility's Line List (a tracking tool used for infectious diseases) for Candida Auris, [which included documentation that the facility had cases of C. Auris as far back as 2021] indicated there were a total of 10 cases in 2024, including three new cases in December 2024 and an additional four new cases in January 2025. Review of the QAPI Meeting Minutes, dated 12/27/24, indicated there was no documentation to support that newly identified cases and on-going spread of C. Auris was identified or investigated. Review of the QAPI Meeting Minutes, dated 01/15/25, indicated that C. Auris management and planning was on-going. The Facility was unable to provide the surveyors with documentation to support that a QAPI project had been developed and maintained, related to the continual spread of C. Auris. During an interview on 02/05/25 at 3:28 P.M., the Director of Nurses (DON) said between December 2024 and January 2025, facility administration had talked about what they could do to address and prevent the spread of C. Auris. The DON said they had no documentation to support that audits had been carried out to ensure staff were performing hand hygiene or using Personal Protective Equipment appropriately, (both of which can help minimize or stop the spread of infection). The DON said they had not developed a QAPI project, initiated a Root Cause Analysis, or documented any data to analyze, related to the ongoing spread of C. Auris. During an interview on 02/05/25 at 10:42 A.M., the Administrator said the QAPI committee had reviewed the on-going spread of C. Auris at the January 2025 QAPI meeting but they were still in the talking phase of how best to mitigate its spread. The Administrator said he was aware it was a problem in December 2024 because of the three new positive cases, with an additional four new cases in January 2025. The Administrator said he had not done anything directly related to the management of the on-going spread of C. Auris.

Based on observations, records reviewed and interviews, for one of four nursing units (Unit #1), that specialized in the care and treatment of residents with a tracheostomy and/or ventilator, the facility failed to ensure it provided appropriate administrative oversight of Infection Control Practices when resident cases of Candida Auris (C. Auris- a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities, which can cause a range of infections from superficial (skin) infections to more severe, life-threatening infections, such as bloodstream infections) on Unit #1 continued to spread. Although Administration was aware of the on-going spread of this infection, the facility failed to ensure that resources available to the facility were used in an effort to prevent the spread of C. Auris and as a result the facility had a total of seven new cases of C. Auris between December 2024 and January 2025 on Unit #1, placing additional residents on the unit at risk for exposure and acquisition of C. Auris that could cause harm, including death. Findings include: Review of the Centers of Disease Control and Prevention (CDC) website, article titled Infection Control Guidance for Candida Auris, dated 04/24/24, indicated the following: -C. Auris typically affects patients with severe underlying medical conditions who may need invasive devices. These include lines and tubes, including central venous catheters, urinary catheters and tracheostomy (a surgical hole in the windpipe to aid in breathing) tubes. These devices can provide ways for C. Auris to enter the body. -The primary infection control measures for prevention of C. Auris transmission in healthcare settings are: *Hand hygiene *Setting-based precautions *Environmental disinfection with product effective against C. Auris -Ensuring that all healthcare personnel adhere to infection control recommendations is critical to preventing transmission of C. Auris, other Multiple Drug Resistant Organisms (MDRO), and communicable diseases. Consider taking the steps outlined below to enhance adherence: *Ensure that adequate supplies are available to implement and maintain appropriate infection control measures. *Monitor for adherence to appropriate infection control practices by performing audits. *Provide feedback on hand hygiene practices, donning (put on) and doffing (take off) of gowns and gloves, and environmental cleaning and disinfection. *Consider increasing the number of audits performed on units with C. Auris cases. Review of the Massachusetts Department of Public Health's Infection Prevention and Control Resource Hub website indicated the Massachusetts Department of Public Health (MDPH) partnered with the Centers for Disease Control and Prevention (CDC) to offer healthcare facilities in Massachusetts onsite infection prevention and control assessments. An Infection Control Assessment and Response (ICAR) visit consists of an on-site, collaborative, non-regulatory visit from a Public Health Nurse and an Epidemiologist to assess and strengthen current infection prevention and control practices in Massachusetts Health Care Facilities, may be needed when a facility is experiencing an outbreak or after an infection control breach has been identified. During the entrance interview on 01/29/25 at 7:45 A.M., the Director of Nurses said that the residents who resided on Unit #1 had tracheostomies and/or were ventilator dependent (relied on a machine for breathing). Review of the Facility's Line List (a tracking tool used for infectious diseases) for C. Auris indicated there were a total of 10 cases identified in 2024, including three new cases in December 2024 and an additional four new cases were identified in January 2025, all of which occurred on Unit #1. Throughout the survey, the surveyors observed breaches of infection control practices by the staff on Unit 1, including inadequate hand hygiene, lack of and/or improper use of Personal Protective Equipment (PPE), and use of cleaning supplies that were not approved to treat C. Auris. -On 01/29/25 at 8:35 A.M., Surveyor #2 observed Nurse #2 provide a tracheostomy dressing change for a resident on Unit #1, without wearing a gown as required. -On 01/29/25 at 9:15 A.M., Surveyor #1 observed the Respiratory (RT) perform tracheal suctioning for a resident on Unit #1, without wearing a gown as required. -On 01/29/25 at 1:20 P.M., Surveyor #2 observed the Activity Director enter and exit multiple resident rooms on Unit #1, without performing hand hygiene upon room entry and exit. -On 01/29/25 at 11:12 A.M., Surveyor #2 observed Housekeeper #1 using cleaning products in resident care areas on Unit #1 that were ineffective against C. Auris. During an interview on 01/29/25 at 2:35 P.M., the Infection Preventionist said she had provided staff with education on proper hand hygiene and use of PPE in December of 2024, but that she had not conducted any audits to ensure staff were adhering to proper infection control guidelines including hand hygiene and appropriate use of PPE. During an interview on 02/05/25 at 3:28 P.M. with Surveyor #1 and Surveyor #2, the Director of Nurses (DON) said that she was aware of the on-going transmission of C. Auris on Unit #1. The DON said the Facility had several ICAR visits, the most recent one was conducted at the facility in November 2024. The DON said the Facility had implemented some, but not all, of the recommendations generated by the ICAR. The DON said the Facility's Administration had talked about plans to address the on-going transmission of C. Auris. The DON was unable to provide the surveyors with any documentation to support evidence of a facility plan. During an interview on 02/05/25 at 1:33 P.M., the Medical Director said she was aware of the on-going transmission of C. Auris in the Facility and that she expected all staff to adhere to infection control practices including proper hand hygiene and wearing the appropriate PPE for all resident interactions. The Medical Director said she assumed the Facility had consulted with an Epidemiologist from the Department of Public Health (DPH) regarding the on-going transmission of C. Auris. During an interview on 02/05/25 at 2:47 P.M., with Surveyor #1 and Surveyor #2, the Administrator said he was aware of the on-going transmission of C. Auris on Unit 1 and that it had his attention. The Administrator said they were still in the talking phase of how best to mitigate the spread of the infection. The Administrator said that he had not done anything directly, related to the management of C. Auris.

Based on observations, records reviewed and interviews, on one of four nursing units (Unit #1) that specialized in the care and treatment of residents who were dependent on a tracheostomy and/or ventilator for breathing, whose residents all required Enhanced Barrier Precaution (EBP) to be utilized by nursing staff during the provision of care, and where there was on-going spread of Candida Auris (C. Auris, a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities, which can cause a range of infections from superficial (skin) infections to more severe, life-threatening infections, such as bloodstream infections), the Facility failed to ensure 1) that nursing staff on the unit were competent and had the necessary skill set to appropriately care for residents on EBP by donning the correct Personal Protective Equipment (PPE), when a nursing staff member was observed not following EBP when caring for a resident, and 2) the Unit Manager (for Unit #1) who was responsible for ensuring nursing staff on the unit followed established infection control procedures when caring for the residents on the unit, (who were all on EBP), was unable to verbalize the Facility's hand hygiene protocol for residents on EBP, both of which increased the risk of spread of infectious diseases (like C. Auris) to other residents on the unit. Findings include: Review of the Facility's policy titled Competent Nursing Staff, undated, indicated it was the practice of the Facility to employ nursing staff that have the competency and skills to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The Policy indicated nursing competencies would be performed during the orientation period to validate skills necessary to perform duties of the employees' job description and additional competencies may be conducted as indicated as standards of practice or regulation changes. Review of the Facility's policy titled Candida Auris (C.Auris), dated April 2024, indicated the following: -C. Auris is highly contagious in healthcare facilities and spreads easily in healthcare settings and can cause outbreaks. -C. Auris can colonize in patients for many months, persists on surfaces, and is not killed by some commonly used healthcare facility disinfectants. -Hand hygiene, appropriate precautions, and environmental disinfection prevent and control outbreaks. -How it spreads: *Person to person contact: C. Auris can spread through direct contact with an infected person. *Contaminated surfaces: C. Auris can survive on surfaces for weeks, including bedrails, doorknobs, and medical equipment. *Shared equipment: C. Auris can spread through sharing medical equipment that has not been disinfected. -Recognizing that residents are at an increased risk of becoming colonized and developing infection, the facility will implement the use of Enhanced Barrier Precautions (EBP). -Enhanced Barrier Precautions targets the use of a gown and gloves during high contact care activities. -The Personal Protective Equipment (PPE) required when following Enhanced Barrier Precautions is a gown and gloves which are to be donned (applied) prior to the high contact care activity. -Hand hygiene is to be performed before donning PPE and after doffing (removed). -Examples of high contact care include (but not limited to): Device care or use, tracheostomy/ventilator. Review of the Enhanced Barrier Precaution sign, undated, indicated: -Everyone Must: Clean their hands including before and when leaving the room. -Providers and Staff Must Also: Wear a gown and gloves for the following High-Contact Resident Care Activities: *Dressing *Bathing/showering *Transferring *Changing Linens *Providing Hygiene *Changing briefs or assisting with toileting *Device Care of Use: central line, urinary catheter, feeding tube, tracheostomy and *Wound Care: any skin opening requiring a dressing. Review of the Facility's Line List (a tracking tool used for infectious diseases) for Candida Auris (C. Auris- a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities, which can cause a range of infections from superficial (skin) infections to more severe, life-threatening infections, such as bloodstream infections) indicated that on Unit #1, there were three cases in identified in December 2024 and an additional four more cases were identified in January 2025. 1) Review of Nurse #2's Competency Assessment for Licensed Nurses, dated 07/19/24, indicated Nurse #2 was competent in the knowledge of infection prevention policies and applied the procedures. Review of the Licensed Practical Nurse (LPN) job description, signed by Nurse #2 and dated 12/12/24, included the following: -Ensures that safety and sanitation standards are maintained in residents' rooms. -Follows organizational policies and procedures when providing nursing care. Resident #6 was admitted to the Facility in October 2024, diagnoses include respiratory failure, anoxic brain damage, cerebral infarction and tracheostomy. Review of Resident #6's Physician Orders dated 1/29/25 indicated he/she required Enhanced Barrier Precautions and tracheostomy care as needed. On 1/29/25 at 8:35 A.M., Surveyor #2 observed an Enhanced Barrier Precaution sign hanging in the doorway outside of Resident #6's room. Surveyor #2 further observed Resident #6 lying in bed and Nurse #2 wearing gloves and a mask, and without a gown, lean over Resident #6 to change the dressing around his/her tracheostomy. Nurse #2 removed the gauze dressing from Resident #6's tracheostomy site, wiped around the tracheostomy with another piece of gauze and applied a clean piece of gauze around the tracheostomy. Nurse #2 completed the dressing change, then placed a blood pressure cuff around Resident #6's arm to obtain his/her blood pressure and placed her stethoscope on Resident #6's chest. Nurse #2 exited Resident #6's room, removed her gloves and performed hand hygiene using hand sanitizer. Nurse #2 then wiped down the blood pressure cuff and stethoscope using Oxivir (broad spectrum disinfectant) wipes. During an interview on 1/29/25 at 8:48 A.M., with Surveyor #2, Nurse #2 said she had performed tracheostomy care and obtained vital signs for Resident #6. Nurse #2 pointed to a bin outside of Resident #6's room that was filled with gowns, as well as other personal protective equipment and said she should have worn a gown when she provided care for Resident #6. Nurse #2 said it was a mistake that she had not worn one. 2) Review of the Unit Manager job description, signed by the Unit Manager and dated 05/14/24, indicated responsibilities of this position included the following: -Assist the Director of Nursing in directing the day-to-day functions of the nursing activities in accordance with current rules, regulations, and guidelines that govern the long-term care facility. -Ensure that all nursing service personnel are following their respective job description. -Ensure that personnel follow the established procedures for the use and disposal of personal protective equipment. -Ensure that nursing service personnel follow established handwashing and hand hygiene procedures. -Participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel. Review of the competency evaluations completed for Unit Manager #1 indicated the following: -Hand Hygiene Competency Validation was completed on 10/11/24, and the competency included a return demonstration. -Personal Protective Equipment Competency was completed on 10/11/24, and the competency included a return demonstration. During an interview on 01/29/25 at 3:40 P.M., with Surveyor #1 and Surveyor #2, Unit Manager #1 said that all residents on her unit (Unit #1) required Enhanced Barrier Precautions. Unit Manager #1 said staff were not required to perform hand hygiene to enter and exit a resident room on the unit if they were not providing high-contact resident care. Unit Manager #1 said that when staff performed high-contact resident care activities they were supposed to wear a gown and gloves. Although Nurse #2 and Unit Manager #1 had received education, training, and had been required to complete competencies related to infection control practices, they were unable to apply their training when Nurse #2 was observed providing high-contact care to Resident #6 without wearing a gown, and Unit Manager #1 was unaware of hand hygiene protocol unit staff were required to complete for residents on Enhanced Barrier Precautions, which included all of the residents on her unit (Unit #1). During an interview on 1/29/25, at 4:00 P.M. with Surveyor #1 and Surveyor #2, the Director of Nursing (DON) said that all residents residing on Unit #1 required Enhanced Barrier Precautions because they had indwelling medical devices or wounds. The DON said it was her expectation that any staff member entering residents' rooms would adhere to the posted Enhanced Barrier Precautions. The DON said that all staff should perform hand hygiene every time enter/exit a resident room and when they change their gloves.

Based on observation, interview, and record review, the facility failed to provide necessary care and services, relative to enteral feeding (nutrients provided directly into the stomach), for two Residents (#114 and #86) out of a total sample of 26 residents. Specifically, the facility failed to: 1. Ensure interventions were implemented in a timely manner to determine Resident #114's abilities for restoring oral eating skills, as recommended by the Ear Nose and Throat (ENT) Clinic Specialist and as requested by the Resident. 2. Adequately monitor Resident #86's gastric residual volume (amount of liquid drained from the stomach following enteral feeding), as ordered by the Physician, increasing the Resident's risk for aspiration (when food or liquid enters your airway or lungs by accident which may cause serious health problems such as Pneumonia [infection of the lungs]). Findings include: 1. Review of the facility's policy titled Enteral Feedings, undated, indicated the following: -The facility will remain current in and follow accepted best practices in enteral nutrition. -Check gastric residual volume every four hours for the first 48 hours after tube insertion and then every six to eight hours after target feeding volume and rate have been established or as ordered by the Physician. -Document all assessments, findings, and interventions in the medical record. Resident #114 was admitted to the facility in September 2023, with diagnoses including Hemiplegia (paralysis on one side of the body) and Hemiparesis (one-sided muscle weakness) following Cerebral Infarction (stroke) affecting the non-dominant left side, encounter for attention to Gastrostomy (G-tube: tube inserted through the abdominal wall into the stomach), encounter for attention to Tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow placement of a breathing tube), and Oropharyngeal Phase Dysphagia (medical condition that causes a disruption or delay in swallowing). Review of Resident #114's Hospital Specialty Inpatient Provider Progress Note, dated 8/22/23, indicated the following: -The Resident had Oropharyngeal Phase Dysphagia -The Resident did not pass his/her FEES (flexible endoscopic evaluation of swallowing: procedure used to assess how well one swallows where a thin, flexible instrument is placed through the nose to view parts of the throat as one swallows) test completed 7/5/23. -The Resident had notable swelling and left sided weakness with evidence of some aspiration. -A Modified Barium Swallow Study (MBSS: contrast-enhanced radiographic study commonly used to assess structural and functional characteristics of swallowing) was completed with the Resident on 8/16/23. -The MBSS revealed definite esophageal narrowing and little to no upper esophageal sphincter (UES: opens to allow food and liquids to pass into the esophagus) opening. -The Resident was to remain NPO (nothing by mouth) and continue on enteral feeding and free water flushes (water provided through enteral means that gets counted toward the Resident's fluid needs). -The Resident had been scheduled for an appointment with the ENT Clinic. Review of Resident #114's Hospital Specialty Inpatient Speech Therapy Treatment Record, dated 8/22/23, indicated the following long term goals: -Patient will improve swallow function . -Patient will maintain adequate hydration/nutrition via least restrictive means possible. Review of Resident #114's active Physician Order, initiated 9/5/23, with no stop date, indicated: -NPO diet texture. Review of Resident #114's active Nutrition Care Plan, initiated 9/6/23, indicated the Resident had alteration in nutrition related to Dysphagia . Review of Resident #114's active Advance Directive Care Plan, initiated 9/8/23, indicated the Resident had a healthcare proxy (HCP: individual appointed to make health care decisions for someone when they are unable to do for themself), but the Resident was currently his/her own responsible person. Further review of the Advance Directive Care Plan indicated the appointed HCP would make health care decisions for the Resident if the Resident became incapacitated (deprived of power). Review of Resident #114's Nurse Practitioner (NP) Progress Note, dated 9/29/23, indicated the Resident was awaiting an ENT visit. Review of Resident #114's clinical record indicated the following: -The Resident received Speech Therapy services, which included treatment of swallowing dysfunction, from 9/7/23 through 9/21/23. -Speech Therapy services were discontinued on 9/21/23 due to the Resident being discharged to the hospital. -The Resident returned to the facility on [DATE]. -A Speech Therapy Evaluation and Plan of Treatment was completed for the Resident on 10/2/23. Review of Resident #114's Speech Therapy Evaluation and Plan of Treatment, dated 10/2/23, indicated the following: -The Resident's level of function prior to medical decline and placement of a feeding tube included eating regular foods and managing thin liquids. -The Resident was currently NPO. -The Resident's Laryngeal (area in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration)/Pharyngeal (the part of the throat behind the mouth and nasal cavity, and above the esophagus [tube that goes to the stomach] and trachea [tube that goes to the lungs] performance was impaired. -The Resident had a history of decreased opening of the UES to allow for passage of bolus (small rounded mass of a substance, especially of chewed food at the moment of swallowing). -The Resident's dry swallow was intact. -The Resident's Functional Oral Intake Scale score was one out of seven (seven is the highest functional level). -The Resident was at high risk for Pneumonia and was NPO. -The Resident had severe Oropharyngeal Phase Dysphagia. -The Resident was awaiting ENT assessment due to lack of UES opening for PO (by mouth) intake. -The Resident's goal was to eat again. Review of Resident #114's Speech Therapy Discharge Summary, dated 10/22/23, indicated the following: -The Resident remained NPO due to lack of UES opening. Review of Resident #114's Speech Therapy Evaluation and Plan of Treatment, dated 12/5/23, indicated the Resident was being assessed in response to the Resident's request for ice chips. Review of Resident #114's Speech Therapy Discharge Summary, dated 12/11/23, indicated the Resident was discharged from Speech Therapy services due to being transferred to the hospital. Review of Resident #114's ENT Clinic Consultation Report, dated 5/28/24, indicated: -The Resident had left vocal fold (muscular band inside one's voice box that produce the sound of one's voice and help one breathe and swallow food safely) immobility. -The Resident exhibited minimal pooling (accumulation) of secretions in the pyriform sinuses (small recess on either side of the laryngeal inlet). -The Resident had possible severe stenosis (narrowing of a passage)/complete stenosis of the esophagus and left vocal fold paralysis. -The ENT Clinic Provider requested to see the MBSS performed in 2023 to see whether any contrast went through into the esophagus. -If not, an MBSS would need to be re-ordered. Further review of the ENT Clinic Consultation Report, dated 5/28/24, indicated the NP had reviewed the Consultation. Review of Resident #114's NP Progress Note, dated 5/29/24, indicated the following: -ENT visit completed one day ago. -Recommendations from Barium studies to be faxed to ENT. -Checking for dye (contrast) penetration into esophagus. Review of Resident #114's Interdisciplinary Quarterly Screen Form, dated 5/31/24, by the Speech Language Pathologist (SLP), indicated the following: -? need for MBSS. -The Resident told the SLP the MBSS would be performed through the ENT Clinic. Review of Resident #114's NP Progress Note, dated 6/5/24, indicated the following: -Discussion with SLP regarding obtaining MBSS results from another Provider. -Awaiting results . Review of Resident #114's NP Progress Note, dated 6/12/24, indicated the following: -Sourcing copies of MBSS completed outside of this facility with SLP support. -Results pending. Review of Resident #114's NP Progress Note, dated 6/28/24, indicated the following: -Request for previous MBSS studies discussion with SLP. -SLP will assist as able to get the Resident's records. Review of Resident #114's Interdisciplinary Quarterly Screen Form, dated 8/30/24, indicated the Resident had experienced no change in swallowing. Review of Resident #114's Minimum Data Set (MDS) Assessment, dated 9/4/24, indicated the following: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. -The Resident demonstrated no refusal of care. -The Resident received 51% or more total calories through . tube feeding. -The Resident received 501 cc/day or more average fluid intake per day by . tube feeding. Review of Resident #114's Physician Progress Note, dated 8/20/24, indicated: -Consider ENT evaluation for the Resident's vocal cord . Review of Resident #114's Interdisciplinary Quarterly Screen Form, dated 11/14/24, indicated: -the SLP discussed scheduling an MBSS for the following week with the Nurse Practitioner (NP), Nursing, and the Resident, pending Respiratory Therapy (RT). -the Resident's BIMS score was 15 out of 15 total possible points. During an interview on 11/13/24 at 2:10 P.M., Resident #114 said he/she had not eaten any food in a year and a half. Resident #114 said his/her swallowing had been evaluated in the past and that he/she had been told his/her esophagus could be widened, but that widening of his/her esophagus had not been done. Review of Resident #114's Mobile Dysphagia Consultation Order Form, dated 11/14/24, completed by the SLP and signed by the NP, indicated the following: -The Resident consented to having an MBSS and Esophageal Assessment to Stomach. -The MBSS was being ordered per the ENT Clinic Provider's request. -The Resident was currently NPO. -The medical necessity for the consult included breathing difficulty with PO intake and vocal fold paralysis. During an interview on 11/19/24 at 10:00 A.M., the SLP said she was responsible to schedule MBSSs for Residents at the facility and that she would schedule the MBSSs once the order was obtained from the NP. The SLP said Resident #114 had an MBSS and a FEES prior to his/her admission to the facility in September 2023 and that the facility was never able to obtain the MBSS and FEES results. The SLP said she had been notified by Nursing Staff on 11/14/24 of a Physician request for an MBSS to be completed for Resident #114. The SLP said the MBSS was requested to determine whether any barium entered the Resident's esophagus during swallowing. The SLP further said she had not been made aware of the request for an MBSS to be completed for Resident #114 prior to 11/14/24. During an interview on 11/19/24 at 10:10 A.M., Unit Manager (UM) #1 said she referred Resident #114 to the SLP on 11/14/24 because the ENT Clinic staff had called the facility that same day to inquire of the status of the previously requested MBSS results. UM #1 said she thought the Resident had gone to see the ENT Provider in August 2024, then reviewed the Resident's record and said the Resident went to the ENT clinic in May 2024. UM #1 said she could not believe it had been almost six months since the Resident's appointment with the ENT clinic. UM #1 said she had been unavailable to work for about one month around the time Resident #114 went to the ENT clinic, so she did not see the results and recommendations from the Consultation. UM #1 said that if she had been working when the recommendations were made, she would have been responsible to follow-up on the recommendations from the ENT clinic consultation. UM #1 further said she returned to work in July 2024. UM #1 said could not speak to who would have been responsible to follow-up on the ENT clinic's recommendations when she was not at work. During a follow-up interview on 11/19/24 at 10:20 A.M., the SLP said that nursing staff should alert her to any new recommendations for residents relative to swallowing and requests for MBSSs when the recommendations are received by the facility. The SLP said she would complete a screen and address the recommendations within 24 hours of being notified by staff of the recommendations. The SLP said she spoke with Resident #114 when she completed the Quarterly Screen on 5/31/24, and that the Resident said he/she thought the MBSS was going to be scheduled through the ENT Clinic. The SLP further said she had not been alerted by staff whether the MBSS had been completed and had not been notified of any changes in the Resident's swallowing status, so she had no indication to follow-up with the Resident. The SLP said she should have been notified by nursing staff when the ENT clinic recommendations were made on 5/28/24, so she could have obtained the order from the NP for an MBSS to be completed for the Resident since the MBSS results from 2023 had never been obtained by the facility for review. The SLP said that the Resident experienced a delay in treatment because she was not aware of the ENT clinic recommendations and the MBSS was not ordered timely. During an interview on 11/19/24 at 10:25 A.M., the Nurse Practitioner (NP) said that she reviewed Resident #114's ENT Clinic Consultation Report on 5/29/24, and that her initials on the Consultation indicated agreement with the ENT Clinic's recommendations. The NP said that she expected that the facility would provide the results of the MBSS completed in 2023 for the ENT Clinic Provider to review and that if the MBSS results could not be obtained, staff would have discussed the need for an MBSS to be ordered and completed for the Resident. The NP said that the need for an MBSS to be completed for Resident #114 should have been addressed when the recommendations were made for the Resident by the ENT Clinic Provider. The NP said that the Resident's need for an MBSS not yet having been addressed resulted in a delay in care for the Resident. During an interview on 11/19/24 at 12:53 P.M., the Director of Nursing (DON) said that Resident #114's ENT Clinic recommendations from 5/28/24, should have been addressed when the recommendations were made and that the recommendations not yet being addressed was a concern for delay in treatment for the Resident. 44337 2. Review of the Facility Policy titled Checking Gastric Residual Volume (GRV) indicated the following: -The purpose of this policy is to assess tolerance of enteral feeding and minimize the potential for aspiration. -If the resident is on continuous tube feedings (enteral feedings), the stomach should contain no more than the total intake from the last hour. If so, withhold feeding and notify the Physician. -If the GRV is between 250-500 ml (milliliters), take measures to prevent aspiration. Resident #86 was admitted to the facility in November 2019, with diagnoses including Acute and Chronic Respiratory Failure (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with acute symptoms of trouble breathing and fatigue), Tracheostomy, G-Tube, and persistent vegetative state (a chronic condition that occurs when someone is awake but shows no awareness of their surroundings). Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated no BIMS score entered for Resident #86. Review of the active Physician orders dated 11/18/24, indicated the following: -Enteral Feed Order every shift Glucerna 1.5 at 55 ml/hour via G-tube times 22 hours, initiated 2/21/24. -NPO Diet, initiated 9/16/21. -Check residual tube feeding (enteral feeding) every shift and record. If residual (GRV) is greater than 150 ml, hold feeding and notify MD, initiated 10/19/20. Review of Resident #86's Medication Administration Record (MAR) did not provide any evidence that gastric volume residuals had been completed and documented every shift as ordered. During an interview and record review on 11/19/24 at 9:06 A.M., the Director of Nursing (DON) said that the Physician orders for Resident #86 included to document the amount of gastric residual volume every shift. The DON said that the gastric residual volume for Resident #86 should have been documented on the MAR as ordered but was not documented. The DON said that it is important to document the gastric residual volume so that staff can assess Resident #86's tolerance to the tube feedings and be aware of any trends that can lead to complications for the Resident.

Based on observation, and interview, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles of practice. Specifically, the facility failed to: 1. Ensure that staff properly labeled all medications stored in one of four medication carts reviewed. 2. Ensure that staff removed four expired medications from one medication room refrigerator of two refrigerators reviewed. Findings include: 1. Review of the facility's Labeling of Medication Containers Policy (dated 2017) indicated but was not limited to the following: 1. Any medication packaging containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. 2. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; e. The prescription number (if applicable); f. The date the medication was dispensed; g. Appropriate accessory and cautionary statements; h. The expiration date when applicable; and i. Directions for use. 3. Only the dispensing pharmacy can label or alter the label on a medication container or package. On 11/14/24 at 1:42 P.M., the surveyor and Nurse #1 observed medication cart A on the third floor. Two Ventolin HFA (bronchodilator medication) inhalers in boxes were observed in the second drawer, with no pharmacy label affixed to the inhaler or the box. The labeling failed to indicate the resident's name, prescribing physician's name, the name, address and telephone number of the pharmacy, the prescription number, dispensing date or directions for use. The surveyor observed that a resident's name was handwritten in black marker on one of the Ventolin boxes, and the expiration date on the box was February, 2024. The other Ventolin box did not have a name written on it. During an interview at the time, Nurse #1 said he forgot to take the expired inhaler off the medication cart when the new inhaler came in. Nurse #1 said both medications should have pharmacy labels attached and that the resident was no longer receiving the Ventolin medication. During an interview on 11/15/34, at 11:00 A.M., the Director of Nursing (DON) said that all medications in medication carts and storage rooms needed to be labeled with the required information for use. 2. Review of the facility's Storage of Medications Policy (dated 2022) indicated but was not limited to the following: -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing facility or destroyed. Review of the facility's Insulin Storage Policy (dated 2022) indicated but was not limited to the following: -Insulin (medication used to manage blood sugars) has a 'use-by' date as well as an expiration date. Insulins removed from the refrigerator and/or opened shall be dated as such with the 'use-by' date not to exceed 28 days. On 11/14/24, at 3:52 P.M., the surveyor and Unit Manager (UM) #1 observed the medication room on the First Floor. In the refrigerator, medications were observed: -A bottle of Vancomycin Hydrochloride (liquid antibiotic) for Oral Solution, USP 50 mg/ml. Affixed to the bottle was a red sticker indicating Beyond Use Date including a date, 10/30/2024 (handwritten on sticker). -A bottle of Vancomycin Hydrochloride for Oral Solution, USP 25 mg/ml. Affixed to the bottle was a red sticker indicating Beyond Use Date including a date, 9/28/2024 (handwritten on sticker). -A bottle of Konvomep (A combination medication used to prevent upper gastrointestinal bleeding) [NAME] [sic] 2 mg/ml. Affixed to the bottle was a red sticker indicating Beyond Use Date including a date, 11/11/2024 (handwritten on sticker). -A vial of Humolog Insulin with the top seal removed and open. Affixed was a yellow label indicating: Date opened 9/11/24 and expiration date 10/1/24. During an interview on 11/14/24 at 3:52 P.M., UM #1 said she does not know what the Beyond Use Date means but she plans to dispose of the medication. UM #1 said that the opened bottle of Humalog Insulin should not have been in the refrigerator and it should have been disposed of when it expired on 10/1/24. During an interview on 11/14/24 at 4:25 P.M., Pharmacist #1 said that the Beyond Use Date is the date that the medication cannot be used passed. Pharmacist #1 said the Beyond Use Date is used for medications that are compounded and have short end expiration dates that is typically 14 days. Pharmacist #1 said the Pharmacist who compounds the medication places the sticker and writes the date on the sticker. Pharmacist #1 said that the three medications with the Beyond Use Date stickers were expired and they should not have been in the medication refrigerator because there is a risk that they could be used. Pharmacist #1 said the medications should have been disposed of. Pharmacist #1 also said the labeled opened Humalog Insulin that had an expiration date of 10/1/24, should have been disposed of and not in the refrigerator. Pharmacist #1 said there is no way of knowing how long the medication was out of the refrigerator and there is a risk that it could be used. During an interview on 11/15/34 at 11:00 A.M., the Director of Nursing (DON) said that all expired medications in medication carts and storage rooms should be removed or disposed of.

Based on observation, interview, and record review, the facility failed to preserve the dignity of one Resident (#55) out of a total sample size of 26 residents. Specifically, the facility failed to provide Resident #55 with a wheelchair that was properly maintained and repaired as required. Findings include: Review of facility policy titled Quality of Life-Dignity, undated indicated: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. -Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self esteem and self worth. Resident #55 was admitted to the facility in September 2020 with diagnoses including unsteadiness on feet. Review of Resident #55's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had moderate cognitive impairment as evidenced by a BIMS (Brief Interview for Mental Status) score of 10 out of a total possible score of 15. On 11/13/24 at 8:50 A.M., the surveyor observed Resident #55 sitting in a wheelchair with a broken left sided arm rest in his/her room. The surveyor further observed that the broken arm rest had a sharp uneven edge at the midway point and a screw post (area where the armrest is connected to the arm of the wheelchair) was exposed. During an interview at the time, Resident #55 said that the wheelchair he/she was sitting in belonged to him/her. Resident #55 said that he/she had told the staff about broken arm rest a few weeks ago but the staff have done nothing about it. On 11/14/24 at 1:38 P.M., the surveyor observed Resident #55 sitting in his/her wheelchair with the broken left sided arm rest in the unit hallway at the nurses station. On 11/15/24 at 8:57 A.M., the surveyor observed Resident #55 seated in day room eating breakfast with staff supervision of three Certified Nurses Aides (CNA). During an observation and interview on 11/15/24 at 9:17 A.M., the surveyor observed Resident #55 sitting in his/her wheelchair with the broken left arm rest in the unit hallway at the nurses station. Resident #55 said he/she had reported the broken wheelchair to the Nurse last week. Resident #55 said the wheelchair looks like it came from a junk yard, why wouldn't he/she tell someone about this, maybe if they gave he/she the screwdriver he/she could do it myself. During an interview on 11/15/24 at 9:26 A.M., CNA #1 said he had not noticed the broken arm rest on the wheelchair. CNA #1 said that Resident #55 required some help with care and staff were in contact with the Resident three to four times during any given shift. CNA #1 said the left sided arm rest that was broken, and the screw that was exposed, could cause some trouble. CNA #1 said he was surprised nobody had noticed the broken arm rest. During an interview on 11/15/24 at 11:10 A.M., Nurse #2 said she was a regular Nurse on the unit. Nurse #2 said that Resident #55 gets seen by a Nurse two to three times during a shift. Nurse #2 also said that Resident #55 was very social, and staff see him/her several times a day because he/she goes everywhere like activities, socializing in the hallway, eating in the dining room and was always in his/her wheelchair. Nurse #2 said Resident #55 requires assist for some care areas and it was ultimately the staff members' responsibility to identify broken equipment. Nurse #2 said the CNA providing care should have noticed the broken wheelchair and reported it to the Nurse. During an interview on 11/15/24 at 1:11 P.M., the Director of Nursing (DON) said that she would have expected a staff member would have identified the broken arm rest for Resident #55 because he/she is seen several times throughout the day. The DON said wheelchairs in disrepair could be a dignity issue. During an interview and record review on 11/19/24 at 12:19 P.M., the Director of Rehabilitation (DOR) said she did monthly audits on facility owned wheelchairs and personal wheelchairs for all residents. The surveyor reviewed the October 2024 audit log which indicated that Resident #55's wheelchair had been audited and not found to be in disrepair at the time of the October audit. The DOR said staff should report broken wheelchairs to herself or the maintenance department as broken wheelchairs could affect a Resident's safety and level of dignity.

Based on observations, record reviews and interviews, the facility failed to notify the physician 1.) for a of change in condition for one sampled Resident #132 and, 2.) a medication omission for 13 out of a total of 29 sampled residents. Findings include: Review of the facility's policy titled Change in Resident's Condition or Status Notification, dated 1/01/20, included but was not limited to: The Registered Nurse (RN) Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician, Physician extender or On-Call Physician when there has been a significant change in the resident's medical/mental conditions and/or status including but not limited to: a. An accident or incident involving the resident; b. A discovery of injuries of unknown source; c. A reaction to medication; d. A change/deterioration in the resident physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. A refusal of treatment or medications (ex. (2) or more consecutive times); g. A need to transfer the resident to a hospital/treatment center; h. A discharge without proper medical authority; and/or i. Instructions to notify the Physician of changes in the resident's condition. A significant change of condition is a deterioration in the resident's physical, mental or psychosocial status in either life threatening conditions or clinical complications. 1. For Resident #132, the facility failed to notify the physician of a change in condition. Resident #132 was hospitalized and was diagnosed to be septic, to have a bowel obstruction, and aspiration pneumonia. Resident #132 was admitted to the facility in March 2011 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #132 had severe cognitive impairment for daily decision making skills. The MDS Assessment further indicated the Resident required extensive assistance with dressing and personal hygiene. Review of a nurse note, dated 11/16/21, indicated that the 7:00 A.M.-3:00 P.M. nurse arrived on the unit and a distinct odor was detected upon entering the nursing unit. The nurse note further indicated that the previous shift nurse reported that all the residents were fine and there were no issues throughout the night. A Certified Nursing Assistant (CNA) and a Behavioral Specialist indicated the odor might be coming from Resident #132's room. The Resident was found sitting in a wheelchair, in his/her bathroom. There was black liquid observed in the toilet. There was dried black liquid on the side of the toilet, on Resident #132's johnny (hospital gown) and on his/her hands. The Resident was pale and sweating. Emergency Medical Technicians (EMTs) were notified and the Resident was transferred to the emergency room (ER) for further evaluation. Review of the hospital Discharge Summary indicated the Resident was hospitalized in November due to a severe infection. Further review of the summary indicated the Resident was diagnosed with aspiration pneumonia (a lung infection caused by inhaling mouth secretions, stomach contents or both) and was started on antibiotics. The Resident had a cystoscopy (a hollow tube with a lens inserted into the tube that carries urine out of the body to examine the lining of the bladder) done due to bladder distention and urine specimen obtained from the procedure indicated a bacterial and fungal infection. The Resident was placed on an anti-fungal medication and antibiotics. The Resident's condition worsened and a Cat Scan (a medical imaging technique used in radiology to obtain detailed internal images of the body) was done which showed a complicated fluid collection in the lower left abdomen. A drain was placed to drain the fluid. The fluid also contained bacteria and the Resident completed a course of antibiotics to target the bacterial infection. During an interview on 2/17/22 at 8:14 A.M. with Nurse #7, he said he worked the 11:00 P.M.-7:00 A.M. shift on 11/15/21. He further said he checked on the Residents before 7:00 A.M. and observed Resident #132 sitting in a wheelchair and watching television in his/her room. He could not provide any further information concerning the odor observed on the unit by the oncoming shift staff. On 2/17/22 at 8:50 A.M., the surveyor observed Resident #132 seated in a wheelchair and propel him/herself from his/her room and place him/herself on floor by the nursing station. During an interview on 2/17/22 at 9:09 A.M. with the Behavioral Specialist, she said she came onto the unit on 11/16/21 for the 7:00 A.M.-3:00 P.M. shift and there was a very strong foul smell on the unit. She said she and a CNA investigated the smell and they found Resident #132 in his/her bathroom with dark, odorous emesis all over the toilet and him/herself. She said the EMTs came quickly and the Resident was transferred to the ER. During an interview on 2/17/22 at 9:40 A.M., the Director of Nurses (DON) said during a review of the nurse note, dated 11/16/21, the physician was not notified of a change in condition regarding vomiting of a black colored liquid for Resident #132, as required. Review of the facility policy titled Medication Administration-General Guidelines, dated January 1, 2021, indicated the following: -The five rights of medication administration are applied with each medication being administered and include the right resident, right drug, right dose, right route and the right time. -Medications are administered within 60 minutes of scheduled time. 2.) Review of the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and one was an as needed medication. In addition, four of the 14 medications administered were medications that were given in two or more doses throughout the day: -[MEDICATION(S)] insulin 48 units twice a day, scheduled for 8:00 A.M. and 8:00 P.M. -[MEDICATION(S)] 25 milligrams (mg: weight measurement denoting strength of medication), three times a day scheduled for administration at 8:00 A.M., 2:00 P.M., and 8:00 P.M. -[MEDICATION(S)] 75 mg twice a day scheduled for administration at 8:00 A.M. and 8:00 P.M. -[MEDICATION(S)] 400 mg three times a day scheduled for 12:00 A.M., 8:00 A.M., and 4:00 P.M. On 2/16/22 at 10:45 A.M. the surveyor observed Nurse #3 prepare and administer 14 medications to Resident #126, during the morning medication pass on Unit One. During an interview on 2/16/22 at 10:56 A.M., following the medication administration, Nurse #3 said that the medication pass on Unit One took a long time due to the number of medications and could not be accomplished within the two-hour window, as required. During an interview on 2/23/22 at 10:02 A.M., the DON said that medications must be administered within a two-hour window, an hour before and an hour after the medication administration time, to be considered administered on time. She said that if a medication cannot be given within that two-hour window, the Nurse Practitioner should be notified as well as the Resident and the Resident's legal representative. During an interview on 2/23/22 at 10:36 A.M., the Nurse Practitioner said that she does not get called for the late administration of medications. She said she was not notified of the late administration of medications for Resident #126 on 2/16/22. She further said if a dose of a morning medication is administered beyond the two hour window, the practitioner should be called to adjust the timing of subsequent doses so the resident does not get too much medication in a short amount of time.

Based on observation, record review and interview, the facility failed to ensure physician orders were implemented for 4 Residents (#65, #96, #45 and #18) out of a total sample of 31 residents. Findings include: 1. For Resident #65, the facility failed to ensure the physician's orders were implemented for the care of a wound. Review of Resident #65's medical record indicated the resident was admitted to the facility in March, 2011 and scored a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating intact cognition. During an interview on 12/11/19 at 12:15 P.M., Resident #65 said he/she was transferred to the emergency room to have an abscess cut and drained from his/her left great toe. Resident #65 said he/she had seen the podiatrist prior to this and the podiatrist had cut his/her left great toe before the abscess had formed. The surveyor observed Resident #65's left great toe dressing to be falling off and the toe was exposed. Resident #65's left great toe was reddened and he/she said it was painful. Review of Resident #65's podiatry consult dated 11/4/19 indicated the following: -Increased risk for infection secondary to [MEDICAL CONDITION] of lower extremities. -Bilateral ingrown toenails. Treatment was nails trimmed. -Recommendation for [MEDICATION NAME] (an antibacterial medication) ointment and dry protective dressing for 7 days. Review of Resident #65's physician's orders indicated the following: -An order dated 11/4/19, to cleanse both great toes then apply [MEDICATION NAME] and a dry protective dressing daily. -An order dated 11/15/19, to continue the previous treatment orders for bilateral great toes (cleanse both great toes then apply [MEDICATION NAME] and a dry protective dressing daily) for an additional 10 days or until resolved. Add- warm foot/feet soaks every other day, may add normal saline 0.9% to warm water. Pat dry and initiate above treatment every other day. -An order dated 11/25/19, for left great toe, foot soak with Epsom (magnesium sulfate salts that can be dissolved in water to assist with wound infection and healing) salt/warm water every other day, pat dry, protective dressing, triple antibiotic ointment (a change from [MEDICATION NAME] ointment) for additional 10 days. Add Resident #65 to podiatry list. There were no orders for the right great toe. -An order dated 12/6/19, to send Resident #65 to the emergency room for evaluation and treatment of [REDACTED]. Review of Resident #65's hospital discharge summary dated 12/6/19 indicated Resident #65 had an abscess and paronychia (bacterial or fungal infection) of the left great toe and required an incision to be made in his/her toe in order to drain the abscess. Review of Resident #65's Treatment Administration Record (TAR) for November, 2019 indicated a treatment dated 11/25/19 for left great toe, foot soak with Epsom salt/warm water every other day, pat dry, protective dressing, triple antibiotic ointment for additional 10 days. This treatment was discontinued on the TAR on 11/29/19 (4 days after it was ordered - with no evidence of a corresponding physician's order to discontinue treatment). Further review of Resident #65's TAR failed to indicate that the treatment ordered for the left great toe on 11/25/19 (triple antibiotic ointment for 10 additional days and Epsom salt/warm water soaks to Resident #65's left foot) was completed. Review of Resident #65's wound physician consult dated 12/6/19 indicated the following: -Resident #65 verbalizes pain with score of 5 out of 10. -Resident #65 had a paronychia abscess of the left great toe. -Wound progress deteriorated. -Recommendations to send to the emergency room ASAP for incision and drainage. During an interview on 12/11/19 at 3:40 P.M., Unit Manager #1 said the [MEDICATION NAME] ointment order should have been continued on 11/15/19 for the 10 days as ordered by the Nurse Practitioner, but was not. Unit Manager #1 was unable to say why it had not been continued as ordered. Unit Manager #1 was not able to say why the Epsom Salts/warm soaks order had been discontinued. During an interview on 12/11/19 at 3:56 P.M., the Nurse Practitioner said she ordered to have the [MEDICATION NAME] ointment continued for 10 more days on 11/15/19. During an interview on 12/12/19 at 11:00 [NAME]M., the Director of Nursing said the order for the antibiotic treatment and Epsom salt soaks to Resident #65's great toe should have been implemented as ordered by the Nurse Practitioner. 2. For Residents #96, #45, and #18, the facility staff failed to follow physician orders to provide thickened liquids. Review of the facility policy titled, Modified Therapeutic Diets, dated 4/12/2017, indicated that each dietary staff member involved with serving must refer to and follow the appropriate therapeutic diet on the menu. The Surveyor observed a chart on the wall in the dining room, where the resident meals are prepared, that indicated the required amount of thickener needed for each consistency and the required measuring scoop to use to accurately measure the thickening agent. The measuring scoop had a tablespoon measure at one end and a teaspoon at the other end. The Chart indicated that for nectar thick liquids to be obtained the following amount of thickener needed to be added: *For coffee: 2 tablespoons *For juice: 2 ½ teaspoons *For milk: 1 tablespoon and 1 teaspoon During observation of the dining room, the surveyor observed that measuring spoons for the thickener and a chart for how to thicken all liquids appropriately according to each therapeutic diet were provided for staff during every meal. a. Resident #96 was admitted in February, 2007 with [DIAGNOSES REDACTED]. As of the most recent Minimum Data Set (MDS), dated [DATE], Resident #96 is moderately cognitively impaired with a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #96 requires extensive assistance with eating. Review of the current physician's orders indicate that Resident #96 was on a heart healthy diet with nectar thickened liquids. During an observation on 12/9/19 at 8:40 [NAME]M., a Certified Nursing Aide was thickening liquids for Resident #96 and used one scoop from the metal teaspoon on the resident's tray to put thickening powder in each liquid of coffee, juice and milk. The liquids were not of nectar thick consistency. The Certified Nursing Aide stirred the drinks and then brought the tray over to Resident #96. The Certified Nursing Aide then proceeded to walk back over to the thickening powder and pour some powder into a medication cup to further thicken Resident #96's beverages. The thickening agent was not measured using the designated measuring spoon. During an observation on 12/9/19 at 8:40 [NAME]M., a Certified Nursing Aide was thickening liquids for Resident #96 and used one scoop from the metal teaspoon on the resident's tray to put thickening powder in each liquid. The liquids were not of nectar thick consistency. The Certified Nursing Aide stirred the drinks and then brought the tray over to Resident #96. The Certified Nursing Aide then proceeded to walk back over to the thickening powder and pour some powder into a medication cup to further thicken Resident #96's beverages. The thickening agent was not measured using the designated measuring spoon. b. Resident #45 was admitted in February, (YEAR) with [DIAGNOSES REDACTED]. As of the most recent Minimum Data Set (MDS), dated [DATE], Resident #45 is severely cognitively impaired. Resident #45 requires total dependence with eating. Reviews of the current physician orders indicate that Resident #45 is on a puree diet with nectar thickened liquids. During an observation on 12/12/19 at 8:39 [NAME]M., a Certified Nursing Aide scooped thickening powder out of the can twice with a metal teaspoon from Resident #45's tray. The Certified Nursing Aide did not scoop the powder using the designated measuring spoon. The Certified Nursing Aide said that he uses the chart on the wall, which had measurements different than the measurements on the can of the thickening powder, to thicken the liquids. The Certified Nursing Aide was not aware he had to use the appropriate measuring spoons when thickening the liquids. The Certified Nursing Aide said that the chart is confusing for them and that they make a judgement on their own. The Certified Nursing Aide further said that when a resident starts to cough the staff just add more thickening powder. During an interview on 12/12/19 at 8:45 [NAME]M., Unit Manager #1 said that the thickening powder was changed to another brand the week before and that the chart on the wall had not been updated. During an interview on 12/12/19 at 1:00 P.M., the Speech Language Pathologist (SLP) said that the staff should be using the appropriate measuring spoons and that she was unaware that the staff was thickening liquids with the spoons from the resident's meal tray. c. Resident #18 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #18's most recent Minimum (MDS) data set [DATE], revealed that Resident #18 had a Brief Interview for Mental Status score of 11 out of a possible 15, which indicated that he/she had moderate cognitive impairment. The Minimum Data Set also indicated that Resident #18 required extensive assistance from staff for all activities of daily living. Review of Resident #18's current physician orders indicated an order for [REDACTED].>Review of Resident #18's nutritional care plan initiated 11/24/15 and last edited 12/8/17, indicated an intervention for nectar thick liquids for all meals. During the breakfast meal on 12/11/19 at 8:56 [NAME]M., Certified Nursing Assistant (CNA) #5 was observed preparing Resident #18's meal. CNA #5 was thickening the resident's liquids using a small plastic teaspoon from the nursing cart, not the provided measuring spoons. The surveyor observed the liquid to still be a thin consistency and stopped the CNA from serving the liquid. CNA #5 said that he was aware that Resident #18 required nectar thick liquids but was unaware that there was a chart to assist with the amount of thickener needed or measuring spoons to use. CNA #5 said that the liquid he was going to provide was not nectar consistency and CNA #5 re-thickened the liquid. During an interview on 12/11/19 at 11:21 [NAME]M., Nurse Manager #1 said that Nursing assistants are able to thicken the residents' liquids, however, are required to use the measuring scoops to ensure accuracy and the nurses in the room should be monitoring.

Based on observation, record review, and interview, the facility failed to provide 1 Resident (#8) with dental services, out of a total sample of 31 residents. Findings include: Resident #8 was admitted to the facility in (MONTH) 2010 with [DIAGNOSES REDACTED]. Review of Resident #8's most recent annual Minimum Data Set, dated dated [DATE], revealed that he/she had a Brief Interview for Mental Status score of 15 out of possible 15, which indicated he/she was cognitively intact. The Minimum Data Set also indicated Resident #8 was independent with all activities of daily living. During an interview on 12/12/19 at 9:28 [NAME]M., Resident #8 said that his/her teeth hurt all of the time and that he/she has told nursing and the doctor about it several times. Resident #8 was observed to only have approximately 4 teeth, with the right, front tooth jagged. Resident #8 had reddened gums. Resident #8 said that his/her gums are painful because the teeth that are left are digging into his/her gums. Review of Resident #8's medical record indicated the following: *A Health Drive (company that provides dental services) consent form that was signed by Resident #8 indicating he/she would like to be seen by dental services. *An oral assessment, dated 2/27/19, indicated that Resident #8 had multiple broken and missing teeth and that it was recommended that he/she be seen by the dentist for routine care and additional dental services as needed. The medical record failed to indicate Resident #8 was seen after the completion of this oral assessment. *A physician order, dated 5/6/19, to send patient to the dentist (Connecticut Medicaid) for an evaluation of painful, broken teeth on the right lower row, which was affecting the right side of the resident's tongue. The medical record failed to indicate that Resident #8 was seen by the dentist after the order was written. *A nursing progress note, dated 10/22/19, that indicated Resident #8 was seen by the nurse practitioner due to a tooth ache and started on Keflex (a medication used for treating infections) for a tooth abscess. * A physician order, dated 10/22/19, to make appointment for Resident #8 to be seen by the dentist for first available appointment. The medical record failed to indicate that Resident #8 was seen by the dentist after the order was written. *A dental care plan, last updated 12/10/18, that had a goal for Resident #8 to be free from oral pain and infection. The interventions on the care plan included assessing the condition of the oral cavity, teeth, tongue, and lips yearly and as needed. Interventions also included were to obtain a dental consult as needed, and for Resident #8 to have soft food with meals secondary to difficulty chewing due to his/her dentition. Review of the line listing of residents in the facility that have seen the dentist for the past year failed to indicate that Resident #8 had been evaluated by a dentist after the Nurse Practitioner ordered a dental consult on 5/6/19 or 10/22/19. During an interview on 12/11/19 at 11:00 [NAME]M., the Medical Records Director said that she coordinates all dental visits. The Medical Records Director said that she is told which residents need to be seen by the dentist by the nurses on the floor. The Medical Records Director said that, if a resident was not on the list to be seen, it would be because she was never told that they needed to be seen by the dentist. During an interview on 12/12/19 at 9:29 [NAME]M., Nurse #1 said that he was aware that Resident #8 has tooth/oral pain off and on and did not ever ask for a consult to the dentist for Resident #8. During an interview on 12/12/19 at 9:40 [NAME]M., Unit Manager #1 said that residents in the facility are seen by the dentist yearly and as needed. Unit Manager #1 was unsure of Resident #8's oral pain, was unaware of the two physician orders [REDACTED].#8. During an interview on 12/12/19, the Director of Nursing was unable to provide a policy for obtaining dental services for residents of the facility.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an [MEDICATION NAME] pump (pump implanted under the skin, programmed to infuse [MEDICATION NAME], a muscle relaxant and anti[DIAGNOSES REDACTED] medication, into the spinal canal), the Facility failed to ensure that Resident #1 was free from a significant medication error. On 4/8/19, Nurse #4, upon arrival at the Facility to refill Resident #1's [MEDICATION NAME] pump, observed that the pump's critical alarm, which notified staff that the [MEDICATION NAME] inside of the pump was at a critically low level and required immediate medical attention, had been sounding for five seconds every 10 minutes since 4/6/19, and there was no [MEDICATION NAME] left inside the pump. As a result, Resident #1 experienced a change in condition, was transferred to his/her Physician's office then to the Hospital Emergency Department where he/she was treated for [REDACTED]. Findings Include: Resident #1's Face Sheet indicated that Resident #1's medical [DIAGNOSES REDACTED]. Resident #1's Care Plan, initiated on 3/22/18, indicated that he/she had a [MEDICATION NAME] pump inserted on 3/16/18 and he/she was at risk for complications secondary to pump malfunction (internal pump programmed by his/her Physician to deliver the correct dosage of the medication, and refilled at the Facility by a nurse, from a contracted Company). The Care Plan included an intervention, dated 3/22/18, that directed staff to notify the outside contracted Company of the need to fill Resident #1's [MEDICATION NAME] pump. The Care Plan included an intervention, dated 3/22/19 and edited on 4/11/19 (after the medication error on 4/8/19), that directed staff to be aware of the beeping heard coming from the pump and to notify Resident #1's Physician as the pump may need refill or new batteries. The Facility Service Agreement Contract, with the Company (contracted to refill Resident #1's [MEDICATION NAME] pump), was signed by the Facility Administrator on 6/1/18, and indicated that the Facility maintains responsibility for the overall coordination of a patient's care which included revision and communication of a patient's plan of care or treatment plan. The Contract indicated that as the patient's primary provider, the Facility shall coordinate with the Company in the delivery of all services to be rendered by the Company throughout a patient's course of treatment. The Contract indicated that the Facility will direct personnel and/or caregivers to call the Company regarding all issues related to the refill of the implantable pumps. An [MEDICATION NAME] Pump Information Packet, dated 4/2017, indicated that abrupt withdrawal of [MEDICATION NAME] could result in high fever, altered mental status, exaggerated rebound [DIAGNOSES REDACTED] and muscle rigidity. The [MEDICATION NAME] Pump Information Packet indicated that prevention of abrupt discontinuation of [MEDICATION NAME] required careful attention to programming and monitoring of the refill scheduling, procedures, and pump alarms. The [MEDICATION NAME] Pump Information Packet indicated that caregivers should be advised of the importance of keeping scheduled refill visits. A Physician Consultation Note, dated 2/22/19, indicated that Resident #1's dosage on his/her [MEDICATION NAME] pump had been set for the pump to infuse 300.21 micrograms of [MEDICATION NAME] per day and due to ongoing [DIAGNOSES REDACTED], Resident #1's Physician increased his/her dosage to 349.53 micrograms of [MEDICATION NAME] per day. The Surveyor interviewed the Unit Manager at 11:18 A.M. on 7/24/19. The Unit Manager said Resident #1's went out to Physician's appointments for the dosing of his/her [MEDICATION NAME] pump and a nurse from the contracted Company comes to the Facility to refill his/her [MEDICATION NAME] pump. The Unit Manager said that the Facility did not contact Resident #1's Physician when the contracted Company rescheduled the refill date because when Resident #1's Physician increases the [MEDICATION NAME] dosage, they thought he contacted the nurse from the contracted Company to reschedule the refill dates accordingly. The Unit Manager said that the Facility did not contact the contracted Company to notify them that Resident #1's dosage was increased on 2/22/19. This was not consistent with the Facility Service Agreement Contract with the outside Company. The contracted Company Progress Note, undated, indicated that Resident #1's pump was programmed to deliver 300.21 micrograms per day (which was the [MEDICATION NAME] dosage prior to the increase at the 2/22/19 Physician's visit). The Note indicated that the low reservoir pump alarm was programmed to sound on 4/9/19 (which was based on the dosage prior to the increase) and the next refill appointment was scheduled for 4/2/19. There was no documentation in Resident #1's Medical Record that the Facility notified the contracted Company about Resident #1's [MEDICATION NAME] dosage increase on 2/22/19 or that the Facility determined if the scheduled refill date was adequate in consideration of the dosage increase. A Physician's Note, dated 4/8/19, indicated that Resident #1's Physician was notified by Nurse #3 that Resident #1's [MEDICATION NAME] pump low reservoir alarm had been sounding since 4/3/19 and the critical alarm had been sounding since 4/6/19 and that no one at the Facility heard the alarms. The Physicians Note indicated that Nurse #3 reported that Resident #1 was clinically more spastic and stiff. The Physician's Note indicated that Resident #1 was observed, by Nurse #4 who worked for the contracted Company, to be flushed, hot, and twitching. The Physician's Note indicated that Resident #1 had been off [MEDICATION NAME] since 4/6/19, he requested that the Facility transfer Resident #1 to his office for further examination, where he/she was treated for [REDACTED]. The ED Neurology Consult Note, dated 4/8/19, indicated that Resident #1 was noted to have increased [DIAGNOSES REDACTED], tachypnea (rapid breathing), [MEDICAL CONDITION](rapid heart rate), and twitching consistent with [MEDICATION NAME] withdrawal. The Hospital (ED) Report, dated 4/8/19, indicated that upon interrogation (withdrawal of data and download) of Resident #1's [MEDICATION NAME] pump, there was a low reservoir alarm that began sounding on 4/3/19, followed by an empty reservoir alarm at 6:30 A.M. on 4/6/19 (which was two days prior to when the pump was observed to be empty). The Surveyor interviewed Nurse #4, who was employed by the contracted Company, at 1:03 P.M. on 7/30/19. Nurse #4 said that, at approximately 10:30 A.M. on 4/8/19, she went into Resident #1's room to refill his/her [MEDICATION NAME] pump. Nurse #4 said that when she saw Resident #1 in his/her bed, she immediately knew he/she had signs of [MEDICATION NAME] withdrawal. Nurse #4 said Resident #1's face was flushed, he/she was warm to touch, he/she had total body spasms. Nurse #4 said she used a programmer and communicator which was held over the pump to interrogate the pump's data. Nurse #4 said the data logs indicated that the critical alarm on Resident #1's [MEDICATION NAME] pump began to sound on 4/6/10 and said that when the critical alarm sounded, it meant that the alarm needed immediate attention. Nurse #4 said once the critical alarm began to sound, it sounded for approximately five seconds every ten minutes. Nurse #4 said that there was no [MEDICATION NAME] left in Resident #1's pump and said that she heard the critical alarm sound while she stood next to Resident #1's bed. Nurse #4 said the Facility did not notify her that Resident #1's [MEDICATION NAME] dosage was increased on 2/22/19. The Surveyor interviewed Resident #1's Physician at 12:52 P.M. on 8/2/19. Resident #1's Physician said that the low reservoir alarm sounded once an hour and could be difficult to hear, but the critical alarm (which began sounding on 4/6/19) was programmed to sound every 10 minutes and the alarm was longer, louder, more likely to be heard, and not easy to miss. Resident #1's Physician said he knew that Resident #1's [MEDICATION NAME] pump critical alarm had sounded because the pump had memory that was downloaded and data showed that the alarm had been sounding. Resident #1's Physician said that when Resident #1 arrived at his/her office on 4/8/19, he/she demonstrated signs of [MEDICATION NAME] withdrawal and he/she was clearly in distress.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that nurses had competencies and skill sets to care for Resident #1 whose assessment and care plan included use of an [MEDICATION NAME] pump (pump implanted under the skin, programmed to infuse [MEDICATION NAME], a muscle relaxant and anti[DIAGNOSES REDACTED] medication, into the spinal canal). On 4/8/19, Nurse #4, from a contracted Company, observed the critical low alarm, which required immediate attention, on Resident #1's [MEDICATION NAME] pump had been sounding every 10 minutes since 4/6/19, without knowledge to staff. The pump was empty, did not infuse Resident #1's [MEDICATION NAME] to him/her, and he/she was transferred to his/her Physician's office then to the Hospital Emergency Department where he/she was treated for [REDACTED]. Findings Include: Resident #1's Face Sheet indicated that Resident #1's medical [DIAGNOSES REDACTED]. Resident #1's Care Plan, initiated on 3/22/18, indicated that he/she had a [MEDICATION NAME] pump inserted on 3/16/18 and he/she was at risk for complications secondary to pump malfunction (internal pump programmed by his/her Physician to deliver the correct dosage of the medication, and refilled at the Facility by a nurse, from a contracted Company). The Care Plan included an intervention, dated 3/22/18, that directed staff to notify the outside contracted Company of the need to fill Resident #1's [MEDICATION NAME] pump. The Care Plan included an intervention, dated 3/22/19 and edited on 4/11/19, that directed staff to be aware of the beeping heard coming from the pump and to notify Resident #1's Physician as the pump may need refill or new batteries. The intervention indicated that the pump was to be assessed every shift with a stethoscope for 30 seconds and indicated that the pump alarm sounded every ten minutes so the intervention may not identify an issue and to monitor for signs of [MEDICATION NAME] withdrawal. The Facility Service Agreement Contract, with the Company (contracted to refill Resident #1's [MEDICATION NAME] pump), was signed by the Facility Administrator on 6/1/18, and indicated that the Facility maintains responsibility for the overall coordination of a patient's care which included revision and communication of a patient's plan of care or treatment plan. The Contract indicated that as the patient's primary provider, the Facility shall coordinate with the Company in the delivery of all services to be rendered by the Company throughout a patient's course of treatment. The Contract indicated that the Facility will direct personnel and/or caregivers to call the Company regarding all issues related to the refill of the implantable pumps. An [MEDICATION NAME] Pump Information Packet, dated 4/2017, indicated that abrupt withdrawal of [MEDICATION NAME] could result in high fever, altered mental status, exaggerated rebound [DIAGNOSES REDACTED] and muscle rigidity. The [MEDICATION NAME] Pump Information Packet indicated that prevention of abrupt discontinuation of [MEDICATION NAME] required careful attention to programming and monitoring of the refill scheduling, procedures, and pump alarms. The [MEDICATION NAME] Pump Information Packet indicated that caregivers should be advised of the importance of keeping scheduled refill visits. A Physician Consultation Note, dated 2/22/19, indicated that Resident #1's dosage on his/her [MEDICATION NAME] pump had been set for the pump to infuse 300.21 micrograms of [MEDICATION NAME] per day and due to ongoing [DIAGNOSES REDACTED], Resident #1's Physician increased his/her dosage to 349.53 micrograms of [MEDICATION NAME] per day. The Surveyor interviewed the Unit Manager at 11:18 A.M. on 7/24/19. The Unit Manager said Resident #1's went out to Physician's appointments for the dosing of his/her [MEDICATION NAME] pump and a nurse from the contracted Company comes to the Facility to refill his/her [MEDICATION NAME] pump. The Unit Manager said that the Facility did not contact Resident #1's Physician when the contracted Company rescheduled the refill date because when Resident #1's Physician increases the [MEDICATION NAME] dosage, he contacts the nurse from the contracted Company to reschedule the refill dates accordingly. The Unit Manager said that the Facility did not contact the contracted Company to notify them that Resident #1's dosage was increased on 2/22/19. This was not consistent with the Facility Service Agreement Contract with the outside Company. The contracted Company Progress Note, undated, indicated that Resident #1's pump was programmed to deliver 300.21 micrograms per day (which was the [MEDICATION NAME] dosage prior to the increase at the 2/22/19 Physician's visit). The Note indicated that the low reservoir pump alarm was programmed to sound on 4/9/19 and the next refill appointment was scheduled for 4/2/19. There was no documentation in Resident #1's Medical Record that the Facility notified the contracted Company about Resident #1's [MEDICATION NAME] dosage increase on 2/22/19 or that the Facility determined if the scheduled refill date was accurate in consideration of the dosage increase. A Physician's Note, dated 4/8/19, indicated that Resident #1's Physician was notified by Nurse #3 that Resident #1's [MEDICATION NAME] pump low reservoir alarm had been sounding since 4/3/19 and the critical alarm had been sounding since 4/6/19 and that no one at the Facility heard the alarms. The Physicians Note indicated that Nurse #3 reported that Resident #1 was clinically more spastic and stiff. The Physician's Note indicated that Resident #1 was observed, by Nurse #4 who worked for the contracted Company, to be flushed, hot, and twitching. The Physician's Note indicated that Resident #1 had been off [MEDICATION NAME] since 4/6/19, he requested that the Facility transfer Resident #1 to his office for further examination, where he/she was treated for [REDACTED]. The ED Neurology Consult Note, dated 4/8/19, indicated that Resident #1 was noted to have increased [DIAGNOSES REDACTED], tachypnea (rapid breathing), [MEDICAL CONDITION](rapid heart rate), and twitching consistent with [MEDICATION NAME] withdrawal. The Hospital (ED) Report, dated 4/8/19, indicated that upon interrogation (withdrawal of data and download) of Resident #1's [MEDICATION NAME] pump, there was a low reservoir alarm that began sounding on 4/3/19, followed by an empty reservoir alarm at 6:30 A.M. on 4/6/19. Although Resident #1's [MEDICATION NAME] pump was inserted on 3/16/18, there was no indication that the Facility provided or ensured that nurses assigned to care for Resident #1 had skills and competencies to safely care for a Resident with a [MEDICATION NAME] pump, which included: communication with the contracted Company related to dosage changes to ensure refill schedules were accurate, what pump alarms (non-critical and critical) sounded like, how to adequately monitor for sounding alarms, what the alarms meant, and clinical monitoring of [MEDICATION NAME] withdrawal signs. There was no indication in Resident #1's Medical Record or Care Plan that, prior to 4/8/19, staff were regularly monitoring and documenting that Resident #1 was being regularly assessed for signs and symptoms of [MEDICATION NAME] withdrawal, that Resident #1's [MEDICATION NAME] pump refill schedules were being monitored for accuracy or that the Facility notified the contracted Company about dosage changes and the need for rescheduling pump refills accordingly. The Surveyor interviewed Nurse #1 at 2:15 P.M. on 7/24/19. Nurse #1 said that Resident #1 had been assigned to her and she had provided care to him/her in the past. Nurse #1 said she did not know what the signs or symptoms of [MEDICATION NAME] withdrawal were. The Surveyor interviewed Nurse #3 at 8:30 A.M. on 7/30/19. Nurse #3 said that he worked on the 7:00 A.M. to 3:00 P.M. shift on 4/8/19 and he went into Resident #1's room prior to Nurse #4 arriving and said he did not hear Resident #1's [MEDICATION NAME] pump alarm sounding, did not observe any signs that indicated that Resident #1 was in any distress and he/she did not observe that something was wrong. This was not consistent with what Resident #1's Physician's Note, dated 4/8/19, indicated regarding the clinical observations that Nurse #3 reported to Resident #1's Physician. The Surveyor interviewed Nurse #4, who was employed by the contracted Company, at 1:03 P.M. on 7/30/19. Nurse #4 said that, at approximately 10:30 A.M. on 4/8/19, she went into Resident #1's room to refill his/her [MEDICATION NAME] pump. Nurse #4 said that when she saw Resident #1 in his/her bed, she immediately knew he/she had signs of [MEDICATION NAME] withdrawal. Nurse #4 said Resident #1's face was flushed, he/she was warm to touch, he/she had total body spasms. Nurse #4 said she used a programmer and communicator which was held over the pump to interrogate the pump's data. Nurse #4 said the data logs indicated that the critical alarm on Resident #1's [MEDICATION NAME] pump began to sound on 4/6/10 and said that when the critical alarm sounded, it meant that the alarm needed immediate attention. Nurse #4 said once the critical alarm began to sound, it sounded for approximately five seconds every ten minutes. Nurse #4 said that she heard the critical alarm sound while she stood next to Resident #1's bed. Nurse #4 said that she had been unaware of the Resident #1's dosage increase and the Facility was supposed to notify her about dosage changes. Nurse #4 said that the Facility did not notify her about Resident #1's dosage increase on 2/22/19. The Surveyor interviewed Nurse #6 at 10:15 A.M. on 8/2/19. Nurse #6 said she has provided care for Resident #1 several times and was aware that he/she had a [MEDICATION NAME] pump. Nurse #6 said that her responsibility in relation Resident #1's [MEDICATION NAME] pump was to occasionally listen for alarms. Nurse #6 said there was no policy or protocol that she was aware of. Nurse #6 said that she thought head shaking and stiffness were signs of [MEDICATION NAME] withdrawal but said she could not think of any other signs or symptoms. Nurse #6 said she was never provided education by the Facility regarding signs and symptoms of [MEDICATION NAME] withdrawal or the pump alarms. The Surveyor interviewed Nurse #7 at 2:19 P.M. on 8/2/19. Nurse #7 said he worked on the 3:00 P.M. to 11:00 P.M. shift on 4/7/19 and said he was in Resident #1's room five or six times that evening. Nurse #7 said he did not hear Resident #1's [MEDICATION NAME] pump alarm sounding. Nurse #7 said the Facility did not provide him with any education regarding Resident #1's [MEDICATION NAME] pump or the pump alarms. The Surveyor interviewed Resident #1's Physician at 12:52 P.M. on 8/2/19. Resident #1's Physician said that Resident #1 had his/her [MEDICATION NAME] pump to help control [DIAGNOSES REDACTED] and said the Facility should monitor Resident #1 clinically while he/she is on the [MEDICATION NAME] pump. Resident #1's Physician said when Resident #1's [MEDICATION NAME] dosage was changed, he sent Notes and Pump Status Reports back to the Facility. Resident #1's Physician said the Facility should have monitored the refill dates and communicated dosage changes with the contracted Company. Resident #1's Physician said that the low reservoir alarm sounded once an hour and could be difficult to hear, but said the critical alarm (which began sounding on 4/6/19) was programmed to sound every 10 minutes and the alarm was longer, louder, more likely to be heard, and not easy to miss. Resident #1's Physician said he knew that Resident #1's [MEDICATION NAME] pump critical alarm had sounded because the pump had memory that was downloaded and data showed that the alarm had been sounding. Resident #1's Physician said that when Resident #1 arrived at his/her office on 4/8/19, he/she demonstrated signs of [MEDICATION NAME] withdrawal and he/she was clearly in distress. The Surveyor interviewed the Assistant Director of Nursing (ADON) at 1:52 P.M. on 7/25/19. The ADON said she contacted Resident #1's Physician's, in (MONTH) of 2019, after the incident with Resident #1's [MEDICATION NAME] pump and was informed that they would only be able to hear the alarm with a stethoscope. The ADON said she had not completed any in-service education with staff related to [MEDICATION NAME] pumps. The Surveyor interviewed the Director of Nursing (DON) at 3:53 P.M. on 7/24/19. The DON said that the nurse from the contracted Company was supposed to come to refill Resident #1's [MEDICATION NAME] pump on 4/2/19, called to reschedule the [MEDICATION NAME] refill for 4/5/19, but then did not come until 4/8/19. The DON said she was unsure if staff called Resident #1's Physician to notify him about the rescheduling of the [MEDICATION NAME] pump refill and staff must have assumed that the contracted Company knew when it was low. The DON said that, to her understanding, the contracted Company was totally responsible for Resident #1's [MEDICATION NAME] pump. This was not consistent to the Facility Service Agreement Contract. The DON said that up until the day of the Survey (7/24/19), she had been unaware that Resident #1 had signs and symptoms of [MEDICATION NAME] withdrawal in (MONTH) of 2019. The DON said the Facility did not provide staff with education about Resident #1's [MEDICATION NAME] pump and said that staff should know that if the alarms sound, what they mean and what they need to do.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to develop Care Plan interventions and implement Care Plan interventions to ensure that Resident #1, who had an [MEDICATION NAME] pump (pump implanted under the skin, programmed to infuse [MEDICATION NAME], a muscle relaxant and anti[DIAGNOSES REDACTED] medication into the spinal canal), was adequately monitored for signs and symptoms of [MEDICATION NAME] withdrawal, ensure that a system was in place to monitor the timeliness and accuracy of his/her [MEDICATION NAME] pump refill schedules in relation to dosage changes, ensure that the Company contracted to refill the pump was notified of dosage changes, and ensure that staff to adequately monitored the pump's alert alarms. On 4/8/19, Nurse #4, from a contracted Company, observed the critical low alarm, which required immediate attention, on Resident #1's [MEDICATION NAME] pump had been sounding every 10 minutes since 4/6/19, without knowledge to staff. The pump was empty, did not infuse Resident #1's [MEDICATION NAME] dosage to him/her, he/she experienced a change in condition, was transferred to his/her Physician's office, then to the Hospital Emergency Department where he/she was treated for [REDACTED]. Findings Include: Resident #1's Face Sheet indicated that Resident #1's medical [DIAGNOSES REDACTED]. damage, and a nervous system disorder. Resident #1's Care Plan, initiated on 3/22/18, indicated that he/she had a [MEDICATION NAME] pump inserted on 3/16/18 and he/she was at risk for complications secondary to pump malfunction (internal pump programmed by his/her Physician to deliver the correct dosage of the medication, and refilled at the Facility by a nurse, from a contracted Company). The Care Plan included an intervention, dated 3/22/18, that directed staff to notify the outside contracted Company of the need to fill Resident #1's [MEDICATION NAME] pump. The Care Plan included an intervention, dated 3/22/19 and edited on 4/11/19, that directed staff to be aware of the beeping heard coming from the pump and to notify Resident #1's Physician as the pump may need refill or new batteries. The intervention indicated that the pump was to be assessed every shift with a stethoscope for 30 seconds and indicated that the pump alarm sounded every ten minutes so the intervention may not identify an issue and to monitor for signs of [MEDICATION NAME] withdrawal. An [MEDICATION NAME] Pump Information Packet, dated 4/2017, indicated that prevention of abrupt discontinuation of [MEDICATION NAME] required careful attention to programming and monitoring of the refill scheduling, procedures, and pump alarms. The [MEDICATION NAME] Pump Information Packet indicated that the pump had two different alarms, a non-critical single tone alarm which sounded every hour to alert that prompt physician attention was needed and a critical two tone alarm that sounded every ten minutes to alert that the pump had stopped or will stop soon and immediate Physician attention was needed. The [MEDICATION NAME] Pump Information Packet indicated that caregivers should be advised of the importance of keeping scheduled refill visits and indicated that abrupt withdrawal of [MEDICATION NAME] could result in high fever, altered mental status, exaggerated rebound [DIAGNOSES REDACTED] and muscle rigidity (the Care Plan intervention that directed staff to listen to the pump every shift for 30 seconds was not an effective means of ensuring awareness of critical alarms). The Facility Service Agreement Contract, with the Company (contracted to refill Resident #1's [MEDICATION NAME] pump), was signed by the Facility Administrator on 6/1/18, and indicated that the Facility maintains responsibility for the overall coordination of a patient's care which included revision and communication of a patient's plan of care or treatment plan. The Contract indicated that as the patient's primary provider, the Facility shall coordinate with the Company in the delivery of all services to be rendered by the Company throughout a patient's course of treatment. The Contract indicated that the Facility will direct personnel and/or caregivers to call the Company regarding all issues related to the refill of the implantable pumps. A Physician Consultation Note, dated 2/22/19, indicated that Resident #1's dosage on his/her [MEDICATION NAME] pump had been set for the pump to infuse 300.21 micrograms of [MEDICATION NAME] per day and due to ongoing [DIAGNOSES REDACTED], Resident #1's Physician increased his/her dosage to 349.53 micrograms of [MEDICATION NAME] per day. The Surveyor interviewed the Unit Manager at 11:18 A.M. on 7/24/19. The Unit Manager said Resident #1's goes out to Physician's appointments for the dosing of his/her [MEDICATION NAME] pump and a nurse from the contracted Company comes to the Facility to refill his/her [MEDICATION NAME] pump. The Unit Manager said that the Facility did not contact Resident #1's Physician when the contracted Company rescheduled the refill date because when Resident #1's Physician increases the [MEDICATION NAME] dosage, they thought he contacted the nurse from the contracted Company to reschedule the refill dates accordingly. The Unit Manager said that the Facility did not contact the contracted Company to notify them that Resident #1's dosage was increased on 2/22/19. The contracted Company Progress Note, undated, indicated that Resident #1's pump was programmed to deliver 300.21 micrograms per day (which was the [MEDICATION NAME] dosage prior to the increase at the 2/22/19 Physician's visit). The Note indicated that the low reservoir pump alarm was programmed to sound on 4/9/19 and the next refill appointment was scheduled for 4/2/19. There was no documentation in Resident #1's Medical Record that the Facility notified the contracted Company about Resident #1's [MEDICATION NAME] dosage increase on 2/22/19 or that the Facility determined if the scheduled refill date was accurate in consideration of the dosage increase. A Physician's Note, dated 4/8/19, indicated that Resident #1's Physician was notified by Nurse #3 that Resident #1's [MEDICATION NAME] pump low reservoir alarm had been sounding since 4/3/19 and the critical alarm had been sounding since 4/6/19 and that no one at the Facility heard the alarms. The Physicians Note indicated that Nurse #3 reported that Resident #1 was clinically more spastic and stiff. The Physician's Note indicated that Resident #1 was observed, by Nurse #4 who worked for the contracted Company, to be flushed, hot, and twitching. The Physician's Note indicated that Resident #1 had been off [MEDICATION NAME] since 4/6/19, he requested that the Facility transfer Resident #1 to his office for further examination, where he/she was treated for [REDACTED]. The ED Neurology Consult Note, dated 4/8/19, indicated that Resident #1 was noted to have increased [DIAGNOSES REDACTED], tachypnea (rapid breathing), [MEDICAL CONDITION](rapid heart rate), and twitching consistent with [MEDICATION NAME] withdrawal. The Hospital (ED) Report, dated 4/8/19, indicated that upon interrogation (withdrawal of data) of Resident #1's [MEDICATION NAME] pump, there was a low reservoir alarm that began sounding on 4/3/19, followed by an empty reservoir alarm at 6:30 A.M. on 4/6/19. There was no indication in Resident #1's Medical Record or Care Plan that, prior to 4/8/19, staff were regularly monitoring and documenting that Resident #1 was being regularly assessed for signs and symptoms of [MEDICATION NAME] withdrawal, had a system in place to ensure refill schedules were accurate in relation to dosage changes, the Facility notified the contracted Company about dosage changes, or that the Facility had a method of ensuring that staff were adequately monitoring for critical alarms, which sounded every ten minutes (care plan indicated to listen for 30 seconds), in order to help prevent abrupt [MEDICATION NAME] discontinuation and withdrawal, as the result of an empty pump. The Surveyor interviewed Nurse #4, who was employed by the contracted Company, at 1:03 P.M. on 7/30/19. Nurse #4 said that, at approximately 10:30 A.M. on 4/8/19, she went into Resident #1's room to refill his/her [MEDICATION NAME] pump. Nurse #4 said that when she saw Resident #1 in his/her bed, she immediately knew he/she had signs of [MEDICATION NAME] withdrawal. Nurse #4 said Resident #1's face was flushed, he/she was warm to touch, he/she had total body spasms. Nurse #4 said she used a programmer and communicator which was held over the pump to interrogate the pump's data and the data logs indicated that the critical alarm on Resident #1's [MEDICATION NAME] pump, which indicated that the pump required immediate attention, began to sound on 4/6/10. Nurse #4 said once the critical alarm began to sound, it sounded for approximately five seconds every ten minutes. Nurse #4 said that she heard the critical alarm sound while she stood next to Resident #1's bed. Nurse #4 said that she had been unaware of the dosage change and the Facility was supposed to notify her about dosage changes. Nurse #4 said the Facility did not notify her about Resident #1's dosage increase on 2/22/19. The Surveyor interviewed Nurse #6 at 10:15 A.M. on 8/2/19. Nurse #6 said she has provided care for Resident #1 several times and was aware that he/she had a [MEDICATION NAME] pump. Nurse #6 said that her responsibility in relation Resident #1's [MEDICATION NAME] pump was to occasionally listen for alarms. Nurse #6 said there was no policy or protocol that she was aware of. Nurse #6 said that she thought head shaking and stiffness were signs of [MEDICATION NAME] withdrawal but said she could not think of any other signs or symptoms. The Surveyor interviewed the Director of Nursing (DON) at 3:53 P.M. on 7/24/19. The DON said that staff should know that if the alarms sound, what they mean and what they need to do. The DON said that after the incident with Resident #1's [MEDICATION NAME] pump, on 4/8/19, the Facility added a Care Plan intervention to check Resident 1's pump.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to prevent Resident #1 from being injured when he/she was not appropriately monitored while his/her left hand mitt restraint was in place, which resulted in Resident #1's left hand to become swollen, he/she also developed a blister to his/her left wrist, and was transferred to the Hospital Emergency Department for further evaluation and treatment. Findings include: Resident #1 was readmitted to the Facility in (MONTH) (YEAR). The Facility Policy, titled Physical Restraint Standard, revised 02/28/17, indicated monitoring requirements include, restraints are released every two hours for positioning, toileting, skin checks or exercise, and then reapplied and are documented on the Certified Nurse Aide (CNA) restraint flow records. The Policy indicated all restraints will have a specific physician's orders [REDACTED]. The Posey Peek-A-Boo Mitt Application Instructions, dated (YEAR), indicated Contraindications include, do not use on a patient who is or becomes highly aggressive, combative, agitated, or suicidal. The Instructions indicated to monitor per facility policy to ensure that the mitts are properly secured and if applied too tightly, circulation will be restricted. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and used limb restraints daily when in bed and less than daily when out of bed in his/her chair. The Activities of Daily Living (ADL) Care Plan, updated 10/30/18, indicated Resident #1 had a left hand mitt on at all times and to remove and reapply on care rounds and to check the skin integrity. The Antianxiety Medication Care Plan, updated 10/30/18, indicated Resident #1 had a left hand mitt on at all times, to release and reapply (R/R) with care and check skin integrity every shift (Qs) and as needed (PRN). The Physical Restraint Care Plan, updated 10/30/18, indicated Resident #1 required a left hand mitt due to pulling his/her [MEDICAL CONDITION] and gastrostomy tube. The Care Plan indicated to monitor for altercation in skin integrity, monitor for ecchymosis and impaired circulation and to release with care and per facility protocol. The Physician order [REDACTED].#1 had an order for [REDACTED]. A Nurse Progress Note, dated 12/19/18, indicated Resident #1's hand mitt was removed and was noted to have discoloration around the wrist and swelling of the left hand. The Note indicated the Nurse Practitioner was notified, assessed Resident #1, and ordered for Resident #1 to be transferred to the Hospital Emergency Department for evaluation. An Interim physician's orders [REDACTED].#1 to the Hospital Emergency Department for evaluation of left hand swelling and to rule out [DIAGNOSES REDACTED] (a painful and dangerous condition caused by pressure build up from internal bleeding or swelling of tissue that can be caused from a constricting bandage such as a hand mitt restraint). The Universal Transfer Form, dateless, indicated Resident #1 was transferred to the Hospital Emergency department for evaluation of his/her left hand swelling on 12/19/18. The Hospital Report, dated 12/19/18, indicated Resident #1 had blistering and ligature marks on his/her left wrist and hand due to a mitten restraint. A Nurse Progress Note, dated 12/19/18, indicated Resident #1 returned from the Hospital and his/her left hand and lateral wrist was blistered and other area of the wrist was discolored and bruised and that Resident #1's left hand was puffy. The Surveyor interviewed Unit Manager #1 at 12:32 P.M. on 02/07/19. Unit Manager #1 confirmed with Surveyor that Resident #1 had on the Posey Peek-A-Boo Mitt restraint on 12/19/18. Unit Manager #1 said at approximately 8:30 A.M. on 12/19/18, she went in to Resident #1 and checked his/her left hand Posey Peek-A-Boo Mitt restraint and noticed that the restraint was too tight. Unit Manager #1 said it was so tight that she was unable to place a finger or two under the restraint. Unit Manager #1 said when she removed Resident #1's hand mitt restraint she noticed his/her left wrist had an indentation and was slightly discolored purple and the left hand was completely swollen. Unit Manager #1 said she notified the Nurse Practitioner and obtained an order to send Resident #1 out to the Hospital Emergency Department for evaluation. Review of Resident #1's Decubitus Prevention Flowsheet, dateless, but confirmed by Unit Manager #1 that the flowsheets were for the month of (MONTH) (YEAR), indicated Resident #1 had a left hand mitt restraint that was released, repositioned, and reapplied on 12/19/18 at 12:00 A.M., 2:00 A.M., 4:00 A.M., and 6:00 A.M. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 3:20 P.M. on 02/07/19. CNA #1, who was responsible for Resident #1's care on 12/19/18 including releasing and reapplying Resident #1's left hand mitt restraint, said he did not remove, reapply, or reposition Resident #1's left hand mitt restraint at all during his 11:00 P.M. to 7:00 A.M. shift on 12/19/18 and said he was not aware that he needed too. CNA #1 said that the initials on the Decubitus Prevention Flowsheet were his, however he said he was not the one who completed the documentation that the left mitt restraint was released, repositioned, and reapplied the left hand mitt restraint. CNA #1 said he did not know who documented it, and said that he had left the Flowsheet blank for his shift on 12/19/18. The Surveyor interviewed Nurse #1 at 1:04 P.M. on 02/07/19. Nurse #1 said she checked Resident #1's left hand mitt restraint at approximately 12:00 A.M. and 4:00 A.M. by inserting two fingers under the restraint. Nurse #1 said she did not release or remove the left hand mitt restraint and was not sure if the CNA had checked the left hand mitt restraint during the night. The Surveyor interviewed the Director of Nurses (DON) at 4:03 P.M. on 02/07/19. The DON said the CNA's are responsible for the restraints being released and reapplied every two hours as well as with care, toileting, during meals, and with activities. The DON said the nurse should oversee the CNA's releasing and reapplying the restraints as well as checking the residents skin when the restraint is released.

Based on records reviewed and interviews for two of six sampled residents (Resident #1 and #4), the facility failed to provide adequate supervision, monitor equipment and maintain resident safety to prevent an accident with injury. - On 03/8/18, Resident #1 sustained a left hand laceration when staff tried to apply a pelvic restraint to Resident #1 while he/she was being resistive to the pelvic restraint being applied. Resident #1 was transferred to the Hospital Emergency Department for evaluation and received 13 sutures to his/her left hand laceration. - On 03/12/18, Resident #4 sustained a left sided [MEDICAL CONDITION] when he/she bit off his/her hand mitt restraint, unclipped his/her seatbelt buckle, and fell to the floor. Resident #4 sustained a laceration to the left side of his/her head from the fall and was transferred to the Hospital Emergency Department for evaluation. Findings include: The Application Instructions for the Soft Belt Pelvic Restraint, dated 2009, indicated Contraindications: DO NOT use on a patient who is or becomes highly aggressive, combative, agitated, or suicidal. The Safety Information for Use of Posey Torso and Limb Restraining Products, dated (YEAR), indicated BEFORE APPLYING ANY RESTRAINT: - Make a complete assessment of the patient to ensure restraint use is appropriate - Identify the patient's symptoms and, if possible, remove the cause. You may need to cater to individual needs and routines; increase rehabilitation and restorative nursing; modify the environment; or increase supervision. - Use a restraint only when all other options have failed. Use the least restrictive device for the shortest time, until you find a less restrictive alternative. Patients have the right to be free from restraints. - A restraint must only be used in accord with the patient's Individualized Care Plan. The Individualized Care Plan is an assessment by an interdisciplinary team. The Facility Policy, titled, Physical Restraint Standard, dated 02/2017, indicated: - The decision to apply a restraint requires the collaborative opinion of the resident's physician, the resident/Health Care Agent or responsible person, and appropriate interdisciplinary team members. - All efforts will be exhausted to ensure the least restrictive method of restraint is used. - A restraint assessment is required for all residents prior to initiating any form of restraint (except in an emergency). This assessment documents the interdisciplinary team's thoughts and discussion regarding restraint use for the individual resident. 1. Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A Physician's Telephone Order for Resident #1, dated 02/16/18, indicated for staff to apply the Posey soft belt pelvic restraint while he/she was in the wheelchair due to motor restlessness secondary to TBI ([MEDICAL CONDITION]), release and reapply per facility policy every shift. A Nurse's Progress Note, dated 03/08/18, indicated Resident #1 got out of bed and tried to ambulate in the room without help or assistive device. The Note indicated Certified Nurse Aide (CNA) #1 and CNA #3 tried to put the Posey soft belt pelvic seat belt on while Resident #1 was seated in the wheelchair. The Note indicated Resident #1 resisted the application of the belt and held it tight between the index and middle finger and pulled so tight that it inflicted a deep cut. The Note indicated the Nurse Practitioner was notified and gave an order to send Resident #1 to the Hospital Emergency Department for evaluation. The Event/Incident Report, dated 03/08/18, indicated Resident #1 was confused and agitated when CNA #1 and CNA #3 tried to apply the Posey soft belt pelvic seat belt on him/her while he/she was seated in his/her wheelchair. The Report indicated Resident #1 grabbed the belt ties and wrapped the belt around his/her left index and middle fingers and pulled the belt ties tightly sustaining a left hand laceration. The Report indicated the Physician and Guardian were notified and Resident #1 was transferred to the Hospital Emergency Department for evaluation. An Interim physician's orders [REDACTED]. The Surveyor interviewed CNA #1 at 2:36 P.M. on 06/08/18. CNA #1 said on 03/08/18 at approximately 9:30 P.M. Resident #1's bed alarm sounded, and he found Resident #1 out of bed. CNA #1 said he and CNA #3 tried to put Resident #1 in his/her wheelchair with the Posy soft belt pelvic restraint to prevent him/her from falling. CNA #1 said Resident #1 was agitated, he/she did not want the pelvic restraint on and was trying to prevent them from applying the pelvic restraint. CNA #1 said Resident #1 grabbed the ties to the pelvic restraint and wrapped them around his/her left hand fingers, put his/her foot on the ties, and started to pull and struggle. CNA #1 said Resident did not like the pelvic restraint and would request to use the bathroom (and not use the bathroom) so staff would have to remove the pelvic restraint and then would not let staff reapply it once it was removed. The Surveyor interviewed CNA #3 at 10:46 A.M. on 06/08/18. CNA #3 said on 03/08/18 she and CNA #1 tried to put Resident #1 in his/her wheelchair with the Posey soft belt pelvic restraint. CNA #3 said Resident #1 was fighting and grabbed the ties to the pelvic restraint and wrapped them around the fingers of his/her left hand, put his/her foot on the pelvic restraint, and started to pull. The Surveyor interviewed Nurse #3 at 3:10 P.M. on 06/11/18. Nurse #3 said on 3/8/18 at approximately 9:30 P.M. Resident #1 sustained a deep cut from the restraint ties on his/her left hand and between the fingers. A Hospital Report, dated 03/08/18, indicated Resident #1 had a laceration to his/her left hand between the index and middle fingers and to the palm of the left hand that required 13 sutures to close the wound. A Psychiatric Note, dated 03/09/18, indicated Resident #1 has had a few mildly aggressive episodes, which now have escalated to severe aggression. The Note Indicated Resident #1 has been upset with the pelvic restraint, although, he/she is compliant and cooperative with it at times. 2. Resident #4 was admitted to the Facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. A. Review of the Event/Incident Report, dated 03/12/18, indicated that on that date, Resident #4 was found lying on the floor with a two centimeter laceration to the left side of his/her head. The Report indicated that Resident #4 bit off his/her right-hand mitt and unclipped his/her seatbelt in an attempt to transfer out of his/her wheelchair. A Nurse's Progress Note, dated 03/12/18, indicated Resident #4 was transferred to the Hospital Emergency Department for evaluation. A Nurse's Progress Note, dated 03/13/18, indicated Resident #4 returned from the Hospital with the two centimeter laceration to his/her left side of head pink, dry and scabbed. The Note indicated there were no new orders. The Surveyors interviewed the Director of Rehabilitation Services at 1:31 P.M. on 06/12/18. The Director of Rehabilitation Services said that in (MONTH) (YEAR), Resident #4 sustained a fall after removing his/her right hand mitt and then disengaging his/her FCSB. B. Review of the Event/Incident Report, dated 05/15/18, indicated that on that date, Resident #4 slipped out of bed onto the floor mat next to his/her bed because the bed rail on the right upper side of his/her bed broke. The Report indicated that Resident #4 presented with agitated movements, including hitting and kicking the side rails and headboard. The Surveyors interviewed the Maintenance Director at 10:58 A.M. on 06/11/18. The Maintenance Director said that Resident #4's side rails were attached to the frame with two pins each to hold the rails in place. The Maintenance Director said that after the 05/15/18 incident, he received a work order to repair Resident #4's side rail. The Maintenance Director said Resident #4's right upper side rail had one broken pin, so the side rail was still partially attached to the bed. The Maintenance Director said he had repaired that same side rail before because Resident #4 was constantly banging on that rail. The Surveyor interviewed Unit Manager #2 at 3:11 P.M. on 06/12/18. Unit Manager #2 said she was not aware of documentation that Resident #4 climbed out of the bottom of his/her bed, or of him/her crawling over the side rails or slipping out of bed. Unit Manager #2 said Resident #4 was very active, and so she thought reduction or removal of the side rails might lead to increased injury but said that she was not sure if such attempts had been tried.

Based on records reviewed and interviews for one of six sampled residents (Resident #1), the facility failed to ensure his/her quality of life was maintained when Resident #1 became agitated during staff's attempt to place him/her in a pelvic physical restraint and despite Resident #1 becoming increasingly combative to avoid being put in the restraint, staff continued trying to put him/her in it. As a result, Resident #1 sustained a laceration to his/her left hand that required Resident #1 to be transferred to the Hospital Emergency Department for treatment, where he/she received 13 sutures to close the wound. Findings include: The Application Instructions for the Soft Belt Pelvic Restraint, dated 2009, indicated Contraindications: DO NOT use on a patient who is or becomes highly aggressive, combative, agitated, or suicidal. The Instructions indicated ADVERSE REACTIONS: severe emotional, psychological, or physical problems may occur. The Instructions indicated if symptoms of these problems ever appear for any reason, get help from a qualified medical authority and find a less restrictive, product or intervention. Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A Physician's Telephone Order for Resident #1, dated 02/16/18, indicated for staff to apply the Posey soft belt pelvic restraint while he/she was in the wheelchair due to motor restlessness secondary to TBI ([MEDICAL CONDITION]), release and reapply per facility policy every shift. A Nurse Progress Note, dated 03/05/18, indicated when staff tried to apply Resident #1's Posey soft belt pelvic restraint after using the bathroom, Resident #1 held on to the belt, said he/she didn't need it, and began to yell. A Nurse's Progress Note, dated 03/08/18, indicated Resident #1 got out of bed and tried to ambulate in the room without help or assistive device. The Note indicated Certified Nurse Aide (CNA) #1 and CNA #3 tried to put the Posey soft belt pelvic seat belt on while Resident #1 was seated in the wheelchair. The Note indicated Resident #1 resisted the application of the belt and held it tight between his/her index and middle finger and pulled so tight that it inflicted a deep cut. The Note indicated the Nurse Practitioner was notified and gave an order to send Resident #1 to the Hospital Emergency Department for evaluation. The Event/Incident Report, dated 03/08/18, indicated Resident #1 was confused and agitated when CNA #1 and CNA #3 tried to apply the Posey soft belt pelvic seat belt on him/her while he/she was seated in his/her wheelchair. The Report indicated Resident #1 grabbed the belt ties and wrapped the belt around his/her left index and middle fingers and pulled the belt ties tightly sustaining a left hand laceration. The Report indicated the Physician and Guardian were notified and Resident #1 was transferred to the Hospital Emergency Department for evaluation. An Interim physician's orders [REDACTED]. The Surveyor interviewed CNA #1 at 2:36 P.M. on 06/08/18. CNA #1 said on 03/08/18 at approximately 9:30 P.M. Resident #1's bed alarm sounded, and he found Resident #1 out of bed. CNA #1 said he and CNA #3 tried to put Resident #1 in his/her wheelchair with the Posy soft belt pelvic restraint to prevent him/her from falling. CNA #1 said Resident #1 was agitated, he/she did not want the pelvic restraint on and was trying to prevent them from applying the pelvic restraint. CNA #1 said Resident #1 grabbed the ties to the pelvic restraint and wrapped them around his/her left hand fingers, put his/her foot on the ties, and started to pull and struggle. CNA #1 said that is when he noticed that Resident #1 was bleeding from his/her left hand. CNA #1 said Resident did not like the pelvic restraint and would request to use the bathroom (and not use the bathroom) so staff would have to remove the pelvic restraint and then would not let staff reapply it once it was removed. The Surveyor interviewed CNA #3 at 10:46 A.M. on 6/8/18. CNA #3 said on 03/08/18 at approximately 9:30 P.M. Resident #1 had gotten out of bed and was agitated. CNA #3 said she and CNA #1 tried to put Resident #1 in his/her wheelchair with the Posey soft belt pelvic restraint to prevent him/her from falling. CNA #3 said Resident #1 was fighting and grabbed the ties to the pelvic restraint and wrapped them around the fingers of his/her left hand, put his/her foot on the pelvic restraint, and started to pull. CNA #3 said Resident #1's hand started to bleed. CNA #3 said Resident #1 does not like the pelvic restraint. The Surveyor interviewed Nurse #3 at 3:10 P.M. on 06/11/18. Nurse #3 said Resident #1 does not like the pelvic restraint, doesn't want it on, and will ask staff to remove it. Nurse #3 said on 03/08/18 at approximately 9:30 P.M. Resident #1 sustained a deep cut from the restraint ties on his/her left hand and between the fingers. Nurse #3 said he notified the Nurse Practitioner and obtained an order to send Resident #1 to the Hospital Emergency Department for evaluation. A Hospital Report, dated 03/08/18, indicated Resident #1 had a laceration to his/her left hand between the index and middle fingers and to the palm of the left hand that required 13 sutures to close the wound. A Psychiatric Note, dated 03/09/18, indicated Resident #1 has had a few mildly aggressive episodes, which now have escalated to severe aggression. The Note Indicated Resident #1 has been upset with the pelvic restraint, although, he/she is compliant and cooperative with it at times. An Event/Incident Report, dated 03/18/18, indicated Resident #1 was seated in his/her wheelchair with the Posey soft belt pelvic restraint in place. The Report indicated Resident #1 was agitated and tipped his/her wheelchair backwards landing on the floor. The Report indicated staff were to place Resident #1's wheelchair up against the wall to prevent him/her from tipping his/her wheelchair backwards. The Surveyor interviewed Behavioral Specialist #1 at 2:06 P.M. on 06/11/18. Behavioral Specialist #1 said Resident #1 was trying to remove the Posey soft belt pelvic restraint when he/she tipped his/her wheelchair backwards landing on the floor. The Surveyor interviewed Nurse #4 at 1:59 P.M. on 06/12/18. Nurse #4 said Resident #1 was agitated when he/she tipped his/her wheelchair backwards with the Posey soft belt pelvic restraint.

Based on interview and record review, the facility failed to ensure 1 resident (#16), of 10 applicable residents, received adequate supervision and assistance to prevent falls in a total sample of 27 residents. Findings include: Review of the undated facility Fall Prevention Program indicated the following: -General interventions for fall prevention and injury reduction will be implemented for all residents. -Door to hallway open unless staff person in the room. For Resident #16, the facility failed to implement appropriate interventions and provide adequate supervision to prevent multiple falls. Review of the Admission Minimum Data Set (MDS) Assessment, dated 9/11/14, indicated the resident had severe cognitive impairment as evidenced by impaired short and long term memory and moderately impaired decision making skills and required extensive assistance for transfers, ambulation and toileting. Resident #16 was admitted to the facility in 10/1999 and readmitted in 4/2014 with [DIAGNOSES REDACTED]. Review of the resident's care plan for falls included an intervention, initiated 1/13/10, for a wheelchair to be kept at the side of the bed while the resident was in bed. Review of an Event/Incident Report indicated, on 4/8/14 at 1:45 P.M., the resident was found by a Certified Nurses' Assistant (CNA) at the foot of the bed bleeding from a laceration on the forehead. The environmental factors present which may have contributed to the fall indicated the bed height was slightly elevated more than knee height, but the resident alters the height so it's easier to get up on his/her feet. The report did not indicate if the resident was seated in the wheelchair or in bed prior to the fall, or if a wheelchair was at the side of the bed. Review of a Nurses' Note, dated 4/8/14, indicated the resident went to the hospital for evaluation of the forehead laceration and returned with 4 sutures at 6:25 P.M.. Review of a Nurses' Note, dated 4/10/14, indicated that bruising with purple and yellow areas were observed on the right axilla, shoulder and upper chest area. The resident was sent to the hospital and returned on 4/11/14 with x-ray results indicating an acute fracture of the right clavicle (collar bone). Review of an Event/Incident Report, indicated the resident was found, on 6/1/14 at 9:00 P.M., on the floor in a kneeling position attempting to reach the television set. No injuries were observed. The resident was assisted back to bed. The safeguards in place at the time of the fall were floor mats, low bed and behavioral checks. The report did not indicate whether or not a wheel chair was at the side of the bed. Review of an Event/Incident Report indicated that on 11/3/14 at 11:30 P.M. the resident was found laying on his/her side by the right side of the bed. No injuries were observed. The resident said he/she was trying to get the television remote control and lost his/her balance. The report does not indicate if the resident was in bed or in a wheelchair, nor does it indicate if a wheelchair was at the side of the bed. Review of an Event/Incident Report indicated that, on 11/23/14 at 12:25 P.M., the resident was found in the hallway bathroom on the floor near the toilet. No injury was observed. He/she was seen by psychology services due to an increase in falls. A structured daily schedule was introduced. This schedule indicated that at 8:00 P.M. a CNA was to assist the resident with washing up for bed. In addition, the schedule indicated the resident should "NOT" be unsupervised while in his/her bedroom at any time prior to going to bed. Review of the Quarterly MDS Assessment, dated 12/11/14, indicated the resident had 2 or more falls without injury and 1 fall with an injury. Review of an Event/Incident Report indicated that, on 12/27/14 at 7:50 P.M., the resident was found on the floor of his/her room by his/her wheelchair with a 3.5 centimeter (cm.) laceration on the front of his/her head. The report indicated the resident was inside his/her room with the door shut, getting dressed by himself/herself. Review of a witness statement completed and signed by a CNA, dated 12/27/14, indicated that after being helped to get ready for bed, the resident was left alone sitting in the wheelchair watching television while the CNA went to look for another staff member. Review of a Nurses' Note, dated 12/27/14 on the 3:00 P.M. to 11:00 P.M. shift, indicated the resident had a shower and was left in his/her room afterwards by a CNA. The resident was found on the floor with a 3.5 cm. laceration on his/her forehead. The resident was sent to the hospital and returned on 12/28/14 at 1:30 A.M. with six staples to the forehead. On 2/24/15 at 10:00 A.M., Resident #16 was observed in a common area seated at a table with other residents looking at a puzzle book. He/she was seated in a wheelchair, dressed and groomed, wearing sneakers. During an interview with Unit Manager (UM) #4 on 2/25/14 at 9:00 A.M., the resident's fall history was reviewed. UM #4 said she was not the UM at the time of the resident's falls, but said it was unclear, based on the Event/Injury reports if the care plan had been followed with regard to a wheelchair at the bedside while the resident was in bed. She also said, based on documentation and review of the care plan, the resident should not have been alone in his/her bedroom relative to the fall of 12/27/14. During an interview with the Director of Nurses on 2/25/14 at 4:30 P.M., she could not say if a wheelchair was at the bedside, per the care plan, for the falls which occurred on 4/8/14, 6/1/14 and 11/3/14. She also said, relative to the fall of 12/27/14, the resident should not have been left unsupervised in his/her bedroom.

Based on observation, interview and record review, the facility failed to follow the plan of care relative to fall prevention, a positioning device and Bunny Boots for 3 residents (#6, #13, and #16) in a total sample of 27 residents. Findings include: 1. For Resident #16, the facility failed to follow the plan of care to prevent falls. Resident #16 was admitted to the facility in 10/1999 and readmitted in 4/2014 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 9/11/14, indicated the resident had severe cognitive impairment as evidenced by impaired short and long term memory and moderately impaired decision making skills, and required extensive assistance for transfers, ambulation and toileting. Review of the resident's care plan for falls included an intervention, initiated 1/13/10, for a wheelchair to be kept at the side of the bed while the resident was in bed. Review of an Event/Incident Report indicated, on 4/8/14 at 1:45 P.M., the resident was found by a Certified Nurses' Assistant (CNA) at the foot of the bed bleeding from a laceration on the forehead. The report does not indicate if the resident was in bed, in a wheelchair, or if a wheelchair was at the side of the bed. Review of a Nurses' Note, dated 4/8/14, indicated the resident went to the hospital for evaluation of the [MEDICAL CONDITION] and returned with 4 sutures at 6:25 P.M.. Review of an Event/Incident Report, indicated the resident was found, on 6/1/14 at 9:00 P.M., on the floor in a kneeling position attempting to reach the television set. No injuries were observed. The resident was assisted back to bed. The report did not indicate whether or not a wheelchair was at the side of the bed. Review of an Event/Incident Report indicated that on 11/3/14 at 11:30 P.M. the resident was found laying on his/her side by the right side of the bed. No injuries were observed. The report does not indicate if the resident was in bed or in a wheelchair, nor does it indicate if a wheelchair was at the side of the bed. Review of an Event/Incident Report indicated that, on 11/23/14 at 12:25 P.M., the resident was found in the hallway bathroom on the floor near the toilet. No injury was observed. A structured daily schedule was introduced. The schedule indicated the resident should "NOT" be unsupervised while in his/her bedroom at any time prior to going to bed. Review of an Event/Incident Report indicated that, on 12/27/14 at 7:50 P.M., the resident was found on the floor of his/her room by his/her wheelchair with a 3.5 centimeter (cm.) laceration on the front of his/her head. The report indicated the resident was inside his/her room with the door shut, getting dressed by himself/herself. Review of a witness statement completed and signed by a CNA, dated 12/27/14, indicated that after being helped to get ready for bed, the resident was left alone sitting in the wheelchair watching television while the CNA went to look for another staff member. Review of a Nurses' Note, dated 12/27/14 on the 3:00 P.M. to 11:00 P.M. shift, indicated the resident had a shower and was left in his/her room afterwards by a CNA. The resident was found on the floor with a 3.5 cm. laceration on his/her forehead. The resident was sent to the hospital and returned on 12/28/14 at 1:30 A.M. with six staples to the forehead. During an interview with the Director of Nurses on 2/25/14 at 4:30 P.M., she could not say if a wheelchair was at the bedside, per the care plan, for the falls which occurred on 4/8/14, 6/1/14 and 11/3/14. She also said, relative to the fall of 12/27/14, the resident should not have been left alone in his/her bedroom. Please refer to F323. 2. For Resident #13, the facility failed to follow the physician's orders [REDACTED]. Resident #13 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 1/28/15, indicated the resident was cognitively impaired and was totally dependent on staff for Activities of Daily Living (ADL). Review of the the 2/2015 physician's orders [REDACTED]. Review of the Certified Nurse's Aide (CNA) care card, dated 2/2015, indicated to support the RUE on elevated foam wedge while in the recliner. Review of the ADL Care Plan, dated 2/10/15, indicated an intervention that the RUE be supported on foam wedge while in the Geri chair. On 2/24/15 at 2:00 P.M. and 3:00 P.M., the resident was observed in a Geri chair recliner in his/her room. The resident had on a right hand/arm splint and the arm was resting on his/her lap. On 2/25/15 at 10:50 A.M. with UM #2, the resident was observed in the Geri chair recliner. The resident had the right hand/arm splint on, but it was not elevated on a foam wedge. During an interview with UM #2 on 2/25/15 at 1:30 P.M., she said the foam wedge should have been under the resident's right arm as ordered, and staff could not locate the foam wedge. 3. For Resident #6, the facility failed to follow the physician's orders [REDACTED]. Resident #6 was admitted to the facility in 9/2014 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 2/12/14, indicated the resident was cognitively intact, dependent for care and did not ambulate. Review of the physician's orders [REDACTED]. On 2/24/15 at 4:40 P.M., the surveyor observed the resident in bed. The resident was not wearing Bunny Boots. On 2/25/15 at 6:45 A.M., the surveyor observed the resident in bed. The resident was not wearing Bunny Boots. On 2/25/15 at 6:50 A.M. the surveyor, accompanied by Nurse #9, entered the resident's bedroom. Nurse #9 said the resident was not wearing the Bunny Boots. On 2/25/15 at 6:55 A.M. CNA #1, who was the resident's care giver, said she did not know the resident was suppose to wear Bunny Boots. Please refer to F514.

Based on record review, interviews and observation, for five of 14 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #14), the Facility failed to provide adequate supervision to prevent resident to residents altercations and injuries of unknown origin; and failed to immediately complete a reassessment of residents who presented with a change in behaviors, which placed themselves and others at risk. Findings include: 1.) Resident #2's quarterly Minimum Data Set (MDS) assessment, dated 8/9/13, indicated that Resident #2 had highly impaired vision, had memory impairment, and severely impaired decision making ability. The MDS indicated Resident #1 presented with physical behavioral symptoms directed at others; had verbal behavioral symptoms directed toward others; and had other behavioral symptoms not directed toward others every day. The MDS indicated Resident #2 was known to wander; and had indicators of psychosis which included hallucinations and delusions. The MDS indicated Resident #2's [DIAGNOSES REDACTED]. Resident #2's activities of daily living care plan, dated 8/20/09, was re-evaluated in August 2013. The care plan indicated Resident #2 had limited ability to maintain grooming, bathing, and personal hygiene and was known to remain in the bathroom for extended periods refusing to return to bed or dining room. The care plan indicated staff were to check on Resident #2 frequently when he/she was in the bathroom. Resident #2's behavioral care plan indicated the problem started on 8/17/09. The care plan indicated Resident #2 had a history of [REDACTED]. The care plan indicated Resident #2 was known to jump out of his/her chair and hit/attempt to hit staff when he/she had questions which were not answered right away and when Resident #2 thought others were chasing him/her. The care plan goal (with a target date of 5/21/13) indicated Resident #2 would have no more than two episodes of assaultive behaviors during the 90 day period before the goal. Hand written onto the care plan was documentation to indicate Resident #2 had three episodes of assaultive behaviors directed at others. Resident #2's care card, dated May 2013, indicated Resident #2 was alert, confused, and required assistance of one staff when using the toilet. The care card indicated Resident #2 took a "long time" in the bathroom and that, "frequent checks required." The care card indicated Resident #2's behaviors included wandering, being verbally and physically abusive, and having socially inappropriate behaviors. The socially inappropriate behaviors were not documented on the care card. The nurse's note, dated 6/18/13, indicated that Resident #2 punched another resident in the face. The Facility completed an investigation regarding Resident #2 punching a resident, Non-Sampled Resident #1 (NS #1) in the face and contained within the file were statements from two staff who witnessed the incident. The statement, dated 6/18/13, from a behavioral specialist present, indicated Resident #2 was seated in the dining area when he/she was observed to jump up from his/her chair and "sprinted quickly" toward another resident and hit the resident. The second statement, dated 6/18/13, from a CNA present indicated she was in the dining room pushing NS#1 in a wheelchair when Resident #2 "stridded(sic)" across the room and punched NS #1 on his/her cheek. The incident report, dated 6/18/13, indicated the plan was for Resident #2 to be evaluated by the consulting psychiatric services. Surveyor #2 interviewed Unit Manager #2 in person on 8/29/13. Unit Manager #2 said Resident #2 was a long-term resident who prior to June 2013, had no behaviors of punching other residents. The nurse's note, dated 6/23/13, indicated that at 11:15 A.M., Resident #2 punched a staff member in the left ear. The nurse's note, dated 7/7/13, indicated that at 2:15 P.M., Resident #2 hit a staff member in the face without warning. The nurse's note, dated 7/24/13, indicated Resident #2 ran down the hall verbalizing delusions and attempted to punch whoever came in Resident #2's way. The note indicated Resident #2 was administered injectable medication in response to the behavior and reports he/she thought someone was trying to kill him/her. The nurse's note, dated 8/12/13, indicated that on 8/12/13, Resident #2 was found in another resident's room (Resident #4) punching him/her in the face and chest. Resident #2 attempted to hit and kick staff when they redirected him/her and was given injectable medication and placed on intensive supervision. Contained within the Facility's investigation file were written statements from staff, which included one from a 3:00 to 11:00 P.M. Certified Nurse Aide (CNA) who documented she and a behavior specialist assisted Resident #2 into the bathroom at 9:00 P.M. on 8/12/13. The statement indicated Resident #2 remained in the bathroom at the time the CNA left the unit at 11:06 P.M. on 8/12/13. Surveyor #2 interviewed CNA #10 at 12:48 P.M. on 8/30/13. CNA # 10 said she last assisted Resident #2 into the bathroom at 10:00 P.M. on 8/12/13. CNA #10 said she completed rounds for other residents and did check on Resident #2 several times prior to leaving the unit at 11:06 P.M. on 8/12/13. CNA #10 said she did not specifically recall when she last observed Resident #2 in the bathroom, but said it was before she informed the 11:00 P.M. to 7:00 A.M. staff that Resident #2 remained in the bathroom. Surveyor #2 interviewed CNA #8 at 6:58 A.M. and 7:40 A.M. on 8/27/13, and at 1:55 P.M. on 8/29/13. CNA #8 said she arrived at the Facility at approximately 10:45 P.M. on 8/12/13 and her usual routine was to organize the linen carts the staff would need during the night. CNA #8 said she remembered walking past Resident #2's room and observing his/her bed was empty. CNA #8 said because the bed was empty, she assumed Resident #2 was in the bathroom, which was Resident #2's usual activity when not in bed at night. CNA #8 said she went to the linen closet and loaded the cart and began to walk past Resident #2's room again, which she estimated took a matter of a few minutes only. CNA #8 said as she walked past, she opened the bathroom door which adjoined Resident #2 and Resident #4's room, and asked Resident #2 if he/she needed assistance. CNA #8 said Resident #2 told her he/she was fine and she left Resident #2 in the bathroom. CNA #8 said she next observed Resident #2 in Resident #4's room at approximately 11:40 P.M. on 8/12/13. CNA #8 said she was at the nurses' station when she heard a voice saying words to the effect of, "ow, ow" and left the nurses' station to investigate and learned the voice was coming from Resident #4's room. CNA #8 said she entered Resident #4's room, observed Resident #4 in bed with Resident #2 standing over Resident #4 and Resident #2 was punching Resident #4 with a closed fist in the face, neck and chest. CNA #8 described the actions of Resident #2 as Resident #2 was words to the effect of, "whaling on" Resident #4's face, neck, and chest repeatedly, and in rapid succession with a closed fist. CNA #8 said she immediately intervened and removed Resident #2 from the room. CNA #8 said she did not know how long Resident #2 was in Resident #4's room, because prior to being found at 11:40 P.M., she thought Resident #2 was in the bathroom adjoining Resident #2 and Resident #4's rooms. The Surveyor interviewed Nurse #5 at 7:45 A.M. on 8/27/13. Nurse #5 said she was consistently assigned to care for Resident #2 and Resident #4 during the night (10:45 P.M. to 7:15 A.M). Nurse #5 said at approximately 11:40 P.M. on 8/12/13, she was at the nurses' station with CNA #8 when they heard a voice saying words to the effect of, "ow, ow." Nurse #5 said CNA #8 left the nurses' station first and called out to her for assistance in Resident #4's room. Nurse #5 said upon entering Resident #4's room she observed Resident #4 lying on his/her back in bed. Nurse #5 said Resident #4 had blood on his/her face and had swelling on the left side of the face and lip, and was noted to have bruising on both sides of the chest. The nurse's note, dated 8/13/13, indicated Resident #4 was transferred to the emergency department for an evaluation of his/her injuries. The skin assessment, dated 8/13/13, indicated the left side of Resident #4's lips (upper and lower) were swollen with a purple colored bruise, and Resident #4 had a bruise on the left side of the jaw line; and a small bruise on the right collar bone. 2.) Hospital #1's Discharge summary, dated, 4/29/12, indicated that Resident #1 had anoxic brain injury and was at a minimal verbal baseline. Hospital #1's Discharge summary included the psychotropic medications, Zyprexa 5 milligrams (mg) daily by oral route and Haldol 2 mg every four hours by oral or intramuscular route as needed (prn) for agitation. Surveyor #1 interviewed Program Director #1 on 4/1/13, at 3:15 P.M. Program Director #1 said he and other staff reviewed Resident #1's referral prior to his/her admission to the Facility. Program Director #1 said he told the former Executive Director that he believed Resident #1 was not a good fit for the Facility related to Resident #1's aggression and behaviors. Program Director #1 said he told the former Executive Director that there was not enough staff on Resident #1's unit to provide safe care during the night shift. The Resident Admission record indicated that the staff admitted Resident #1 to the Facility in May 2012. The plan of care, related to Resident #1's wandering and attempts to enter other residents' rooms, dated 8/15/12, included: two-to-one monitoring and staff member to walk with Resident #1. The plan of care, dated 10/3/12, included: hand mitts on at all times due to scratching self and aggressive behavior toward staff. The Nurse Practitioner (NP) progress note, dated 11/16/12, indicated that Resident #1 had increased aggression and agitation. The NP note indicated that due to the severity of Resident #1's behaviors, the Facility planned for 2 staff to supervise Resident #1 for patient and staff safety. Surveyor #1 interviewed the NP on 2/28/13, at 1:30 P.M. The NP said she spoke at length with Family Member #1 (Health Care Agent) regarding Resident #1's aggressive behaviors and discussed the use and benefit of psychotropic medication. The NP said Family Member #1 did not agree to the use of psychotropic medications for Resident #1. The behavior plan of care, dated 11/21/12, indicated that Resident #1's communication was minimal and non-purposeful and he/she was minimally interactive. The behavior plan of care indicated that Resident #1's behaviors included: aggression; kicking, and hitting staff members with his/her head, tripping staff, throwing items at staff, pushing staff into furniture, biting, and resistance to personal care. The behavior plan of care included: use short simple sentences when speaking to Resident #1 and redirect using one to two word phrases and hand gestures; Resident #1 may walk in hallway and common areas with one or two staff, and independent ambulation in room. The NP progress note, dated 11/26/12, indicated that Resident #1 continued to kick, punch, hit staff with his/her head and Resident #1 hit the wall with his/her hands and feet. The behavior plan of care was revised on 12/4/12 and included: discontinue two to one monitoring and resume one to one monitoring at all times. The Quarterly Minimum Data Set (MDS) assessment, completed on 1/6/13, indicated that Resident #1 had severely impaired cognitive skills for daily decision making; daily physical behavioral symptoms directed toward others; daily other behavioral symptoms not directed toward others, and wandered daily. The MDS assessment indicated that the staff provided extensive assist from two staff for personal care and fed Resident #1. The MDS assessment indicated that Resident #1 was incontinent of bowel function. The psychiatric evaluation, dated 1/11/13, indicated that Resident #1 did not respond to his/her current medication regime. The psychiatric evaluation indicated that Resident #1 had aggression, poor cognition, impulsivity, and poor safety awareness. The psychiatric evaluation recommendations included the initiation of the psychotropic medication, Zyprexa. The NP progress note, dated 1/17/13, indicated that Resident #1 sometimes spit out medications, hit the nurses with his/her hands, and kicked and pushed the staff during personal care. The NP note indicated that Family Member #1 refused the use of antipsychotic therapy recommended by the Facility psychiatric services and Physician. The NP progress note, dated 1/22/13, indicated that Resident #1 continued to self inflict injury, punched a hole in the wall yesterday, and walked into bed/bed rails and staff redirected Resident #1. The NP note indicated that the staff said Resident #1 hit himself/herself in the groin area. The NP note indicated that Resident #1 punched, kicked , and hit staff with his/her head, which complicated personal care, feedings, and medication administration. The NP note indicated that Resident #1 remained on one to one supervision. The Hospital Information form indicated that the staff transferred Resident #1 to the hospital on [DATE]. The NP progress note, dated 1/23/13, indicated that Administration was to consult with legal services as Family Member #1's actions caused harm to Resident #1 by not allowing him/her to be medicated appropriately to keep him/her safe from his/her behaviors. The NP note indicated that she and the Physician told the Facility staff that the acuity of Resident #1's behaviors due to the anoxic brain injury were not appropriate for the Facility and they advised Administration to find another placement for Resident #1 due to his/her ongoing physical aggression. The NP said unless Family Member #1 agreed to the use of psychotropic medications, she believed that the Facility staff were not equipped to provide appropriate care and services to Resident #1. Hospital #2's Discharge summary, dated 1/28/13, indicated that the Hospital staff treated Resident #1 for scrotal cellulitis (inflammation of the skin). Hospital #2's Discharge summary indicated that Resident #1 was agitated and required restraints when out of bed to the chair. Hospital #2's Discharge summary's medications included Zyprexa 5 to 10 mg prn. The NP progress note, dated 1/29/13, indicated that the Hospital staff treated Resident #1 with Zyprexa for continued agitation and physical aggression. The NP's note indicated that Resident #1 remained agitated, restless, and physically assaultive to self and staff. The NP note indicated that the Administrator was pursuing guardianship on Resident #1 related to Family Member #1's treatment decisions that adversely affected Resident #1's health and rehabilitation outcomes. The NP progress note, dated 2/1/13, indicated that Family Member #1 consented to initiating Zyprexa for Resident #1. Surveyor #1 interviewed Nurse #3 on 3/4/13, at 10:05 A.M. Nurse #3 said sometime after the staff readmitted Resident #1 on 1/28/13, she observed bruises on Resident #1's hips that resolved within a few weeks. Nurse #3 said Resident #1 had a steady gait when walking. Nurse #3 said Resident #1 occasionally walked into a chair and kicked the wall with his/her foot. Nurse #3 said she assumed Resident #'1's hip bruises were related to Resident #1 hitting himself/herself in the hip, hitting his/her hip against the chair when walking, or hitting his/her hips against the siderails during transfer activities and therefore, Nurse #3 did not report the bruises to Unit Manager #1 or complete an incident report. Nurse #3 said she never observed Resident #1 hit himself/herself on his/her hips or legs. The Patient Abuse Policy and Procedure indicated that all bruises or injuries of unknown etiology were to be investigated as patient abuse, neglect, or mistreatment. Surveyor #1 interviewed the Director of Nurses (DON) on 3/6/13. The DON said Nurse #3 did not complete an incident report and report the incident to her per the Facility Patient Abuse Policy and Procedure. The DON said she did not initiate an investigation regarding Resident #1's bruise on the hip. The physician order, dated 2/10/13, included Zyprexa 7.5 mg twice a day. The behavior 15 minute notes, dated 2/11/13 to 2/20/13, indicated that Resident #1 rested in bed, watched television, banged his hand on his/her bed, kicked the staff, punched the wall, walked in his/her room, and pushed/hit staff etc. The behavior 15 minute notes did not indicate that the staff observed Resident #1 injuring himself/herself, except for hitting his hand on the bed, hitting the wall and window, on 2/13/13 at 4:15 P.M., occasionally rubbing his/her groin area, and on 2/15/13, having his/her left hand between his/her legs between 1:45 P.M. and 2:00 P.M. Surveyor #1 interviewed CNA #1 on 3/4/13, at 10:40 A.M. Surveyor #1 interviewed CNA #2 on 3/4/13, at 10:25 A.M. Surveyor #1 interviewed CNA #4 on 3/4/13, at 11:45 A.M. Surveyor #1 interviewed CNA #5 on 3/4/13, at 2:50 P.M. CNA #1, CNA #2, CNA #4, and CNA #5 said Resident #1 hit, kicked, and tried to head butt the staff. CNA #1 said sometimes Resident #1 hit himself/herself on the chest with his mitts. CNA #2, CNA #4, and CNA #5 said other than sometimes banging his/her hands covered with mitts on the mattress, they never observed Resident #1 try to injure himself/herself. Behavior Specialist #10's 15 minute behavior notes, dated 2/21/13, between 3:30 A.M. and 6:45 A.M., indicated that Resident #1 slept in bed and/or walked around. Behavior Specialist #10's statement regarding the night shift between 2/20/13 and 2/21/13, indicated that when Resident #1 awoke, he/she was very agitated. Behavior Specialist #10's statement indicated that Resident #1 hit the bed harder than usual. Behavior Specialist #10's statement indicated that Resident #1's shirt was wet; he removed the shirt, and placed a clean shirt on Resident #1. Behavior Specialist #10's statement indicated that he observed a small bruise on Resident #1's sternum. Behavior Specialist #10's statement indicated that he did not notify the nurse regarding the bruise as the bruise did not appear to be new. Behavior Specialist #10's statement indicated that the bruise was purple and was surrounded by blue/green/yellow coloring. Behavior Specialist #10's statement indicated that he did not know how Resident #1 sustained the bruise. Behavior Specialist #10's statement indicated that he said he may have fallen asleep while supervising Resident #1. The DON said Behavior Specialist #10 did not report the bruise on Resident #1's chest per the Facility Policy. The DON said Behavior Specialist #10 removed Resident #1's shirt and placed a new shirt on Resident #1 without the nursing staff. The DON said behavior specialists were not allowed to provide personal care to residents without a nurse or CNA. The DON said two staff were needed to dress/undress Resident #1. The DON said Behavior Specialist #10 did not follow Resident #1's plan of care. CNA #4's written statement, dated 2/23/13, indicated that on 2/21/13, she heard a loud crashing noise coming from Resident #1's room. CNA #4's statement indicated that she did not know the time the noise occurred. CNA #4 said that on 2/21/13, during the night shift, she heard a crashing sound from Resident #1's room and could not pinpoint the time of the noise. CNA #4 said she had not heard that type of noise from Resident #1's room, prior to 2/21/13. CNA #4 said she was providing personal care or assisting another resident at the time of the noise. CNA #4 said that in error, she did not investigate the source of the noise and did not notify Nurse #2. Surveyor #1 interviewed Nurse #2 on 3/4/13 at 7:30 A.M. Nurse #2 said CNA #4 did not tell him that she heard an unusual loud noise from Resident #1's room during the night on 2/21/13. The DON said CNA #4 did not investigate the source of the noise and ensure that Resident #1 was all right per the Facility practice. Nurse #3's written statement, dated 2/23/13, indicated that on 2/21/13 at 8:30 A.M., Behavior Specialist #3 told her that Resident #1 had an unsteady gait, almost fell , and was sweaty. Nurse #3's statement indicated that she assessed Resident #1. Nurse #3's statement indicated that Resident #1's skin was cool and dry to touch. Nurse #3's statement indicated that Resident #1 stood, had a steady gait, and slightly decreased aggression from earlier that morning. Nurse #3's statement indicated that at 10:15 A.M., Resident #1 was lying in bed. Nurse #3's statement indicated that Resident #1 consumed lunch and was at his/her baseline status. Nurse #3's statement indicated that at 2:30 P.M., she completed a treatment to Resident #1's scrotum. Nurse #3's statement indicated that Resident #1's shirt was half way up his/her abdomen and there was no bruising, redness, or swelling. The behavior 15 minute note, dated 2/21/13, indicated that at 8:00 A.M., Resident #1 was dizzy, almost fell , and the behavior specialist caught Resident #1. The behavior note indicated that Resident #1 had increased aggression and tried to punch, push, and head butt. The behavior note indicated that Resident #1 shivered and he notified the nurse. The behavior note indicated that between 8:15 A.M. and 8:45 A.M., Resident #1 stood and continued to fall, while walking sideways. The behavior note indicated that Resident #1 was not stable on his/her feet and Resident #1 required staff assistance several times to prevent a fall. Surveyor #1 interviewed Behavior Specialist #3 on 3/4/13 at 8:50 A.M. Behavior Specialist #3 said he remained close to Resident #1 when he/she walked or sat and tried to direct Resident #1 not to walk. Behavior Specialist #3 said Resident #1 had an unsteady gait. Behavior Specialist #3 said he carefully leaned Resident #1 to his body or assisted Resident #1 to sit in the chair each time Resident #1 started to fall. Behavior Specialist #3 said Resident #1's chest and left hip never hit an object. Behavior Specialist #3 said Resident #1 never touched the floor or wall or any object during the day. Behavior Specialist #3 said Resident #1 sustained no injury during the incidents. The behavior 15 minute note, dated 2/21/13, indicated that during the remainder of the day shift, Resident #1 lay on the bed, watched television, slept, got out of bed and walked, and banged his/her hand on the mattress. Surveyor #1 interviewed Nurse #4 on 3/4/13 at 4:30 A.M. Nurse #4 said at 9:00 P.M., on 2/21/13, he, CNA #6, and the evening nursing supervisor provided personal care to Resident #1. Nurse #4 said he did not observe bruises on Resident #1's left hip. Nurse #4 said at 10:00 P.M., Behavior Specialist #1 told him that Resident #1 had a red area on the left side of his/her face. Nurse #4 said the day nurse had not reported to him that Resident #1 had bruises. The evening shift nurse's note, dated 2/21/12, indicated that Resident #1 continued head butting, hitting, and kicking. The nurse's note indicated that Resident #1's left face around the outer aspect of his/her eye was slightly red. The nurse's note indicated that Resident #1 had a red area on his/her chest area and pink areas around both knee areas. The Skin Tear/Bruise Investigation, dated 2/21/13, indicated that Resident #1 had pink/purple areas on both lower legs that were resolving. The Skin Tear/Bruise Investigation indicated that Resident #1 had areas on the upper chest and left facial forehead that appeared to be consistent with pressure areas. The DON said there was no incident report completed, per the Facility Policy, prior to 2/21/13, regarding the bruises on Resident #1's lower legs that were now resolving. The DON said she did not know when and how Resident #1 sustained the bruises. Behavior Specialist #10's behavior 15 minute note, dated 2/22/13, indicated that between 12:00 A.M. and 3:15 A.M., Resident #1 laid in his/her bed and slept. Behavior Specialist #10's written statement, indicated that on Thursday during the night shift (2/21/13 into 2/22/13), Resident #1 awoke and walked around the room. Behavior Specialist #10's statement indicated that Resident #1 opened the door and walked across the hallway to room 203. Behavior Specialist #10's statement indicated that as soon as Resident #1 went in room 203, Behavior Specialist #10 redirected Resident #1 and assisted him/her back to his/her room. Behavior Specialist #10's statement indicated that after Resident #1 left his/her room 3 to 4 times and after approximately 5 to 6 attempts to open his/her door, Behavior Specialist #10 opened the far left cabinet to block the door handle. The DON said Behavior Specialist #10 prevented Resident #1 from leaving his/her room, which was against the Facility Resident Abuse Policy and Procedure. The DON said if Behavior Specialist #10 believed that Resident #10 was at risk for injuring himself/herself or other residents, the Policy indicated that he was to notify the nurse. Nursing Supervisor #1's written statement, dated 2/22/13, indicated that Nurse #2 told her that Resident #1 had hematuria ( blood in the urine). Nursing Supervisor #1's statement indicated that she and Nurse #2 went to Resident #1's room. Nursing Supervisor #1's statement indicated that Resident #1 tried to head butt and kick Nurse #2. Nursing Supervisor #1's statement indicated that Resident #1's urine was tea colored. Nursing Supervisor #1's statement indicated that Nurse #2 irrigated Resident #1's indwelling catheter and the catheter drained clear urine. Nursing Supervisor #1's statement indicated that Resident #1 then walked in circles in the room and had no signs of pain or respiratory issues. Nursing Supervisor #1's statement indicated that when she and Nurse #2 left Resident #1's room, he/she walked to the bed, jumped in, and lay down on his/her back. Nurse #2 said Resident #1 wore gym shorts. Nursing Supervisor #1 and Nurse #2 said Resident #1's clothing covered his/her chest and hips and they observed no bruises. Nurse #2 said he observed an old yellow bruise on Resident #1's inner lower leg. Nurse #2 said usually Resident #1 repeated the words, da, da, da during interactions. Nursing Supervisor #1 said on 2/22/13, at 6:00 A.M., Resident #1 made no vocalizations. Nurse #2 said he observed no unusual incidents during the night regarding Resident #1 and the staff reported no unusual incidents. Surveyor #1 interviewed Nurse #1 on 3/6/13 at 3:45 P.M. Nurse #1 said on 2/22/13, she lifted Resident #1's sheet to one side and observed a new bruise on the left hip that measured 14 to 18 inches in length and 6 to 8 inches in width. The NP's progress note, dated 2/22/13, indicated that Resident #1 had an elevated temperature this morning of 101.3 degrees and a small amount of hematuria during the night. The NP note indicated that Resident #1 had a large left rib/flank area bruise. The NP note indicated that the nursing staff said Resident #1 did not sustain a fall or injury and did not know the cause of the bruise. The NP note indicated that Resident #1 was alert, calm, sick appearing due to less physical aggression and no resistance to the examination. The NP note indicated that Resident #1's left rib area had a large area of ecchymosis that extended from the mid ribs to the left hip, on the lateral side of the body. The NP note indicated that the entire area of ecchymosis had palpable crepitus (a medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints) with a concern for a fracture. The NP note indicated that the bruising did not extend to the center of the chest/abdomen and was not observed on the right side. The NP note indicated that the indwelling catheter drained clear yellow urine with no sediment or blood. Surveyor #1 interviewed the Executive Director on 2/28/13 at 1:00 P.M. The Executive Director said on 2/22/13, the NP spoke to him and the Assistant Director of Nurses (ADON) regarding Resident #1's injuries. The Executive Director said the ADON reviewed Resident #1's clinical record and they initiated an investigation. The Executive Director said Resident #1 had no falls or injuries between 2/20/13 and 2/22/13. The Executive Director said a behavior specialist monitored Resident #1 24 hours per day. The Executive Director said he and the ADON interviewed the staff, who were assigned or provided personal care or assistance to Resident #1 the week prior to 2/22/13. The Executive Director said all of the staff told him or the ADON that Resident #1 sustained no fall or injury between 2/15/13 and 2/22/13. The Executive Director said when he questioned Behavior Specialist #10, Behavior Specialist #10 told him that he may have nodded off a few minutes when supervising Resident #1, which indicated that Behavior Specialist #10 did not follow the Facility Policy. The Executive Director said Behavior Specialist #10 told him that he sometimes blocked Resident #1's door by opening the closet door, which prevented Resident #1 from leaving his/her room. The Executive Director said he suspended and later terminated Behavior Specialist #10 for not following the Intensive Supervision Policy and for secluding Resident #1 in his/her room. The Executive Director said he encouraged the staff to be truthful regarding Resident #1's injuries. The Executive Director said all of the staff who provided care and services to Resident #1 during the 72 hours prior to his/her injuries said that the behaviors exhibited by Resident #1 did not cause his/her current injuries. The Executive Director said something happened to Resident #1 at the Facility while the staff provided continuous supervision. The Executive Director said he was not able to determine the cause of Resident #1's injuries. The Hospital Physician progress record, dated 2/22/13, indicated that Resident #1 had multiple brown/purple, ecchymosis on the sternum, bilateral flanks, and bilateral lower and upper extremities. The Physician progress record indicated that Resident #1 had chest wall trauma, lung trauma with a contusion of the lung, a traumatic pneumothorax (collapsed lung), pleural effusion (abnormal finding of a collection of fluid between the layers of tissue covering the chest cavity and lungs), and bone fractures of the ribs and sternum. The Physician progress record indicated that the Physician placed bilateral chest tubes in Resident #1 and transferred Resident #1 to the intensive care unit. The Physician progress record indicated that Resident #1 had acute renal failure and hypovolemia (low volume) and intravenous therapy was initiated. The physician progress notes [REDACTED]. The computed tomography (CT) Scan of the chest, abdomen, and pelvis, dated 2/22/13, indicated that Resident #1 had multiple rib fractures, a bilateral hemopneumothorax with overlying atelectasis contusions , a right adrenal hematoma, a nondisplaced sternal fracture, and a transverse and spinous process fracture in the thoracolumbar spine. 3.) Resident #3's quarterly MDS assessment, dated 6/19/13 indicated Resident #3 had impaired orientation and recall; had inattention, and disorganized thinking. The MDS indicated Resident #3 required extensive assistance of two staff for bed mobility, transfers, and was non-ambulatory; and had limitations with range-of-motion with upper and lower extremities on one side of the body. Resident #3's care plan, dated 12/16/09, indicated Resident #3 had impaired decision making related to traumatic brain injury and impaired cognition. The nurse's note, dated 8/2/13, indicated that at 6:15 A.M., Resident #3 was noted to have swelling of the left side of the neck, Resident #3 had difficulty speaking, and was noted to have a firm area in the front of the neck. The note indicated Resident #3 reported pain in the area. Surveyor #2 interviewed CNA #2 at 9:10 A.M. on 8/27/13. CNA #2 said normally, Resident #3 liked to joke with staff when interacting with staff during the night. CNA #2 said bet

2. For Resident #14, the facility failed to promptly notify the Physician on two occasions (in 9/11 and 12/11) to clarify the administration and/or discontinuation of an ordered medication Acidophilus (an enzyme). Findings included: Resident #14 was admitted to the facility in 8/95 and readmitted ,[DATE] after a hospitalization , with [DIAGNOSES REDACTED]. Review on 12/12/11 at 8:15 A.M. of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Acidophilus 1 capsule via [DEVICE] (Gastrostomy Tube) Twice a Day Indefinitely." Review of the Physician Interim Orders of 9/22/11 and Nursing Notes of 9/22/11 revealed a new physician's orders [REDACTED]." Review of the 9/11 MAR indicated [REDACTED].M. No further ordered Acidophilus was administered. The MAR indicated [REDACTED].M. doses on 9/23/11, 9/24/11, 9/25/11, 9/26/11, 9/28/11 and 9/29/11. The MAR indicated [REDACTED]. doses on 9/23/11, 9/25/11, 9/26/11, 9/27/11, and 9/28/11. Acidophilus was also not provided on 9/24/11 at 8:00 P.M. and on 9/27/11 at 8:00 A.M., as evidenced by circled nurses' initials. An undated and unsigned written note on the MAR indicated [REDACTED]." Chart review of 9/11 Physician Orders, physician progress notes [REDACTED]. Review of the Physician Interim Orders of 12/7/11 and Nursing Notes of 12/7/11 revealed another, new physician's orders [REDACTED]." Review of the 12/11 MAR indicated [REDACTED].M., on 12/8/11 at 8:00 P.M., and on 12/9/11 at 8:00 P.M. No further ordered Acidophilus was administered. The MAR indicated [REDACTED].M. doses on 12/11/11, 12/12/11, 12/13/11, 12/14/11, 12/15/11, 12/16/11, and 12/17/11. The MAR indicated [REDACTED]. doses on 12/10/11, 12/11/11, 12/12/11, 12/13/11, 12/14/11, 12/15/11, and 12/16/11. Acidophilus was also not provided as ordered on [DATE] at 8:00 A.M., on 12/9/11 at 8:00 A.M., and on 12/10/11 at 8:00 A.M., as evidenced by circled nurses' initials. An undated and unsigned printed note on the MAR indicated [REDACTED]." Review of 12/11 Physician Orders, physician progress notes [REDACTED]. During interview with Unit Manager #2 on 12/12/11 at 11:15 A.M. stated the facility did not notify the resident's Physician to clarify or obtain a new order to discontinue Acidophilus orders of 9/11 and 12/11. During an interview with the Director of Nursing on 12/13/11 at 9:45 A.M., she stated "I know there was a problem for MD notification of Acidophilus." Based on record review, observation and staff interview, the facility failed to ensure that the Physician was notified in a timely manner for 2 residents (#8 and #14) out of a total sample of 26. Finding include: 1. For Resident #8, the facility failed to notify the Physician when the resident developed an unstageable pressure area to the right ankle. Resident #8 was readmitted to the facility in 7/10. The [DIAGNOSES REDACTED]. Review of the medical record indicated a physician's orders [REDACTED]. 0n 12/7/11 at 9:00 A.M. during the initial tour, the resident was observed by the surveyor sitting in a wheelchair in his/her room. The resident had a blue boot on the right foot and an AFO on the left ankle/foot. On 12/8/11 at 8:05 A.M. the resident was observed by the surveyor sitting in a wheelchair in his/her room. The resident had a blue boot on the right foot and an AFO on the left ankle/foot. On 12/8/11 at 9:20 A.M. during an interview with Unit Manager UM #4, the surveyor asked why the resident was not wearing the AFO on the right foot as ordered by the Physician, UM #4 said, the resident has a scab on the ankle, and the AFO was removed. On 12/8/11 at 9:45 A.M., the surveyor observed Nurse #1 remove the boot and pull back the resident's stocking and exposed an unstageable pressure area. Nurse #1 described the wound as a scabbed area, measuring 1 centimeter (cm) by 1 cm, surrounded by pink blanchable skin. She said it was most likely caused by the AFO. Nurse #1 said it was an unstageable pressure area and was not sure if the Physician was notified. On 12/8/11 at 10:45 A.M., during an interview with UM #4 she said that the area on the resident's ankle was noted on 12/5/11 by the 11:00 P.M. - 7:00 A.M. nurse during the weekly skin checks. She said that she sent a referral form to the Physical Therapy department notifying them that the resident had a scab to the right ankle and the AFO was off. The UM said the Physician was never notified about Resident #8's new pressure area. Please refer to F314.

Based on record review, observation, and staff interviews, the facility failed for 3 sampled residents (#3, #6, and #8) of 6 applicable residents with pressure sores out of a total sample of 26 residents, to provide all necessary treatment and services to keep the resident from developing a pressure sore, and to provide measures to promote healing and the prevention of new sores from developing. Findings included: 1. For Resident #8, the facility failed to prevent pressure sores from developing by not monitoring the resident's skin when he/she was wearing bilateral AFOs, and the facility failed to obtain a treatment order for an unstageable pressure area once developed. Resident #8 was readmitted to the facility in 7/10. The [DIAGNOSES REDACTED]. Review of the medical record indicated a physician's orders [REDACTED]. Review of the Quarterly MDS assessment dated [DATE], indicated the resident was an extensive assist of one for bed mobility and hygiene. The resident was dependent on staff for transfer, dressing and bathing. The MDS further indicated the resident had decreased range of motion to one side of the upper extremities, and decreased range of motion to both sides of the lower extremities. The MDS was coded "0" for pressure sores, indicated he/she did not have a pressure sore. On 12/7/11 at 9:00 A.M. during the initial tour, the resident was observed by the surveyor sitting in a wheelchair in his/her room. The resident had a blue boot on the right foot and an AFO on the left leg. On 12/8/11 at 9:20 A.M. during an interview with Unit Manager (UM) #4, the surveyor asked why the resident was not wearing the AFO on the right foot as ordered by the Physician, UM #4 said, the resident has a scab on the ankle, so the AFO was removed. On 12/8/11 at 9:45 A.M., the surveyor observed Nurse #1 remove the boot and pull back the resident's stocking and exposed an unstageable pressure area. Nurse #1 described the area as a scabbed area surrounded by pink blanchable skin. She said it was most likely caused by the AFO. Nurse #1 said it was an unstageable pressure area. Review of the medical record indicated physician's orders [REDACTED].M. . The orders included: - Discontinue the Right AFO until evaluated by Physical Therapist, - Apply a soft boot when out of bed, and - Monitor the right outer aspect of the ankle for signs and symptoms of infection and inform if changes. On 12/8/11 at 10:45 A.M., during an interview with UM #4 she said that the area on the resident's ankle was noted on (12/5/11) by the 11:00 P.M. - 7:00 A.M. nurse during the weekly skin checks. She said that she sent a referral form on (12/5/11) to the Physical Therapy department notifying them that the resident had a scab on the right ankle and the AFO was off. The UM said the pressure sore was noted 3 days earlier, and the Physician had not been notified, and no treatment was started. On 12/9/11 at 7:30 A.M., the resident was observed by the surveyor lying in bed. Resident #8 was dressed, had a blue boot to the right foot and the AFO to the left ankle/foot. Nurse #1 entered the resident's room, the surveyor asked Nurse #1 to remove the left AFO and pull down the resident's stocking. When the AFO and stocking were removed the surveyor observed a red area on the left ankle. Nurse #1 said, the redness is obviously caused by the splint, and was going to inform the Nurse Practitioner and Physical Therapist. The Surveyor asked Nurse #1 to describe the area, she described it as an pink blanchable area measuring approximately 1.5 cm x 1.5 cm, in the center of the pink area was a red, non blanchable center. On 12/9/11 a 9:40 A.M., 2 hours and 10 minutes after Resident #8's AFO was removed, Nurse #1 and the surveyor again observed the residents left ankle. Nurse #1 said it was a stage one pressure sore measuring 0.5 cm x 0.5 cm, it was dark pink and non blanchable. Review of the medical record indicated physician's orders [REDACTED].M., the orders included: - Discontinue bilateral lower extremity AFOs, - Apply bilateral soft boots when in bed and out of bed, - Have a Physical Therapist evaluate the bilateral AFOs, and - Monitor bilateral outer aspects of the ankles every shift for any change and inform the Nurse Practitioner or Physician. On 12/9/11 at 2:30 P.M., UM #4 gave the surveyor a copy of a physician's orders [REDACTED]. - Wash bilateral ankles with soap and water and pat dry, - Apply skin prep to the left ankle stage 1 area, - Apply skin prep to the right ankle unstageable area (around the scabbed tissue) and, - Cover right ankle with a protective dressing twice daily until resolved. 2. For Resident #3, the facility failed to appropriately assess the residents skin following the removal of bilateral AFOs (Ankle/Foot Orthotics), (also referred to by Physical Therapy as static braces), which caused bilateral Stage II Pressure Ulcers on the resident's left lateral ankle and right lateral foot. Resident #3 was admitted to the facility in 2/2009 with [DIAGNOSES REDACTED]. The resident was readmitted to the hospital in 2/2011, and returned to the facility in 3/2011 with a [DIAGNOSES REDACTED]. Review of a 10/10/11 Annual MDS (Minimum Data Set Assessment) indicated that the resident scored 6 of 15 on the BIMS (Brief Interview for Mental Status Assessment) which indicates the resident had severe cognitive impairment,and the resident had signs and symptoms of [MEDICAL CONDITION] which included inattention, disorganized thinking, and [MEDICAL CONDITION]. The resident also had physical behavioral symptoms directed towards others. The resident did not ambulate, was limited assistance for eating, and was totally dependent on staff for all other aspects of care. The resident utilized a wheelchair, had an indwelling catheter, was always incontinent of bowel, had no pressure ulcers; however, was identified as being at risk of developing pressure ulcers. Review of a current plan of care, originally dated (1/18/10) for the potential for skin breakdown due to poor bed mobility and [MEDICAL CONDITION] (Goal target date of 1/9/2012), had interventions including to assess for skin breakdown with daily care and report any signs of skin breakdown (sore, tender, red, or broken areas). Review of a plan of care dated 4/27/10 identified the potential for foot problems, and had a goal target date of (1/9/2012). One of the interventions indicated to inspect the resident's feet every day and report the emergence of redness. Review of the physician's orders [REDACTED].#1 for PT (Physical Therapy) up to 10 times (10 sessions) between 11/14/11 and '11/31/11' (typographical error). The PT was to inservice nursing on the new brace schedule and Sara lift transfer. Other orders included: - May transfer out of bed with Sara lift, bilateral AFOs (white) and sneakers. - Blue bilateral dynamic AFOs to be worn from P.M. care to A.M. care. This order was obtained on 11/16/11, and signed by the Nurse Practitioner on 11/16/11. Review of a Rehabilitation Inservice Record dated 11/17/11 indicated that PT #1 (Physical Therapist #1) had conducted an inservice regarding Resident #3 with the following objective: "Pt. (patient) changing from Hoyer lift to Sarah Lift in order to increase eligibility to live @ a group home - per request of (family member) - Pt. is able to bear wt (weight) on BLE (bilateral lower extremities) and is appropriate for this TX (treatment)." Two CNAs (Certified Nursing Assistants) attended this inservice on 11/17/11, and one CNA attended the same inservice which was completed again on 11/21/11. A total of 3 CNAs attended the inservice. Review of a weekly skin check completed on 11/24/11 indicated that the resident's legs and feet were clear. Review of a "Nursing to Therapy Referral Form" dated 11/26/11 indicated that the resident had a left outer ankle pressure area (?) secondary from AFO. Review of the November 2011 TAR (Treatment Administration Record) documentation indicated that AFOs were put on hold secondary to the pressure area on the Resident's ankle beginning on 11/26/11. Review of a "Rehabilitation Screen" completed on 11/27/11 by PT #1 indicated, "Open area caused by static braces being worn through day. D/C (discontinue) braces until skin is healed. Will f/u (follow up) 'with' PA (Physicians Assistant) 1X/WK (one time a week) for progression of healing. Review of a "PT/OT (Occupational Therapy) narrative note" form dated 12/1/11, completed by PT #1 indicated, "Checked open area L (left) Lateral Ankle it appears the static braces worn during the day have caused this open area despite intact padding over the screw for Velcro strap. D/C (discontinue) use of braces until skin healed then begin slow wearing process." A nursing note of 12/1/11 indicated that the resident had open areas on both the left lateral ankle and the right lateral foot. On 12/1/11, the Nurse Practitioner (NP assessed the Resident, and wrote a progress note which indicated the following: Left lateral ankle with a 1.3 cm (centimeter) x l.0 cm Stage II area. Wound bed is 90% slough but able to see tissue below which is pink and granulated. Right lateral foot 0.6 cm x 0.5 cm Stage II area, no drainage or infection noted. The following orders were obtained from the NP on 12/1/11: Left Lateral Ankle Stage II - Cleanse with Normal Saline, pat dry, apply a thin layer of Santyl (chemical [MEDICATION NAME] agent) Ointment to slough only, cover with a non-adherent dressing, cover with an abdominal pad and wrap with Kling daily and prn (as needed) until healed. Right Lateral Foot Stage II - Cleanse with Normal Saline, pat dry, apply Hydrogel to wound and skin prep to wound edges, cover with non-adherent dressing followed by an abdominal pad and wrap with Kling daily and prn until resolved. AFOs to be held until healed. [MEDICATION NAME] 1 packet po (by mouth) twice daily until wounds healed. Vitamin C 500 mg (milligrams) po twice daily. Will reassess in 2 weeks. A telephone order was obtained from the NP on 12/1/11 to hold Resident #3s Ted Stockings until the Pressure Ulcers were healed, and to hold the use of the Sara Lift. (Use Hoyer lift until Pressure Ulcers are healed). The NP assessed the resident on 12/8/11 and the Left Lateral Ankle Stage II Pressure Ulcer remained with slough; however, it was loosening. The ulcer measured 1.2 cm x 1.0 cm. The Right Lateral Foot Stage II Pressure Ulcer measured 0.4 cm x 0.3 cm. On 12/12/11 at 10:30 A.M. the surveyor observed Nurse #4 complete the dressing changes to Resident #3's Left Lateral Ankle and Right Lateral Foot: Nurse #4 washed her hands, donned clean gloves, and removed the dirty dressing from the resident's right lateral foot. There was no drainage on the old dressing. The ulcer looked clean, had no depth, and measured approximately .25 cm round. The treatment ordered by the Physician/NP was Hydrogel, and Nurse #4 stated that she felt it was not appropriate at this time after assessing the ulcer. Nurse #4 removed her gloves, donned new gloves, cleansed the ulcer with normal saline, and applied the non-adherent dressing followed by the abdominal pad, and wrapped the foot with Kling. Nurse #4 indicated that she would check with the Physician/NP regarding the appropriate treatment order for the ulcer at this time. Nurse #4 then washed her hands, donned clean gloves and removed the dirty dressing from the resident's Left Lateral Ankle. Small amount of dark red drainage on old dressing. Wound bed with beefy red tissue, no slough noted. Area surrounding ulcer with peeling skin. The ulcer measured 0.9 cm wide x 1.4 cm long with no depth. The treatment ordered by the Physician/NP was Santyl ([MEDICATION NAME] agent), and Nurse #4 stated that she felt it was not appropriate at this time after assessing the ulcer. Nurse #4 removed her gloves, washed her hands, donned new gloves, cleansed the ulcer with normal saline, and applied the non-adherent dressing followed by the abdominal pad, and wrapped the ankle/foot with Kling. Nurse #4 indicated that she would check with the Physician/NP regarding the appropriate treatment order for the ulcer at this time. Following the treatment Bunny Boots were applied to the resident's left and right feet. On 12/12/11 the PA (Physician's Assistant) saw the resident and indicated the following: Right Lateral Foot - Stage I (Healing Stage II) - Continue to pad Stage I with ABD (Abdominal) Pad, but D/C Hydrogel Right Foot. Left Lateral Ankle - Stage II - Use Hydrogel but discontinue Santyl as there is now no slough. Continue to use Bunny Boots. On 12/13/11 at 9:55 A.M., the resident was observed lying in the bed with both feet externally rotated (normal lying position for the resident) with small toe of each foot touching the bed. The resident had no Bunny Boots on as ordered. On 12/13/11 at 10:05 A.M., the surveyor asked CNA #7 why Resident #3 did not have Bunny Boots on. CNA #7 said that she thought the nurse was going to be doing a treatment to the resident. CNA #7 then entered Resident #3's room and put the Bunny Boots on the resident's feet. During discussion with PT#1 on (12/12/11 at 2:30 P.M.), she indicated that Resident #3 had only used the (white) AFOs (which caused the breakdown on the resident's left lateral ankle and right lateral foot) while working with Physical Therapy in the Therapy Room while standing (9/13/11 - 11/16/11). There was no problem with the resident's skin during that time. PT#1 said that the Pressure Ulcers occurred after Resident #3 had been using the (white) AFOs and the Sara lift for about 10 days or so with the CNAs on the Unit. During further discussion on 12/13/11 at 1:25 P.M., PT#1 said that the inservicing completed on 11/17/11 and 11/21/11, regarding the resident changing from the Hoyer lift to the Sara Lift, only included how to use the lift itself. PT#1 said no inservicing had been completed regarding the application of the (white) AFOs, mainly because the CNAs apply and remove AFOs so frequently they should have been familiar with checking the skin after each removal of the AFOs. 3. For Resident #6, the facility failed to assure that the resident remained free from avoidable pressure ulcers. The resident developed an open area on the left thumb which was infected when discovered, from the use of a resting hand splint. The facility also failed to assure Resident #6 had a pressure reducing cushion in the Gerichair and the resident developed an open area on the coccyx. Resident #6 was admitted to the facility in 9/2009 with [DIAGNOSES REDACTED]. Review of an Annual MDS dated [DATE] indicated that the resident was in a persistent vegetative state/no discernible consciousness. The resident required total dependence from staff for all aspects of care, was always incontinent of urine and bowel, had a feeding tube, was at risk for developing pressure ulcers, and had no pressure ulcers. The MDS incorrectly stated that the resident had a pressure reducing device for the chair. Review of the CAA (Care Assessment Area) for Pressure Ulcers completed 9/11 indicated that the resident had a blister on the right side of the j-tube site. "At risk for skin breakdown r/t (related to) decreased mobility, requires assistance with positioning, turning, incontinent of bowel and bladder." Proceed to Care Plan. Review of a current Care Plan originally dated (12/17/09), for risk of skin breakdown included the following interventions: - Notify MD/NP (Medical Doctor/Nurse Practitioner) PRN with any changes in status - Staff to apply Bunny Boots, on at all times, remove and reapply with care - Apply dressing and follow changes a/o (as ordered) by NP/MD - Apply protective barrier after each incontinence episode - Keep clean and dry as possible. Minimize skin exposure to moisture - Report any signs of skin breakdown (sore, tender, red, or broken areas) to MD/NP - Staff to turn/reposition on rounds and PRN - Weekly skin assessment by nurse to monitor for skin breakdown Review of the nursing notes indicated that on 11/25/11 at 3:00 P.M. an entry was made identifying an area had been found on the resident's left thumb measuring 2.1 cm x 1.0 cm x 0.3 cm deep. The wound bed was red with yellow tinged serosanguinous drainage. A new order for the antibiotic medication Keflex 500 mg QID (four times daily) x 10 days was obtained due to the area being infected. The thumb/open wound was identified as red and swollen, blanchable, and warm to touch. Review of the (November and December) 2011 TAR (Treatment Administration Record) indicated that staff would apply a left resting hand splint with A.M. care and remove the resting hand splint with P.M. care daily. During discussion with UM #2 on (12/12/11 at 10:10 A.M.), she said that the resting hand splint had been on hold since the treatment started to the left thumb on 11/25/11. Review of a note written by the PA (Physician Assistant) on 11/25/11 indicated that the Resident had two open areas on the left thumb with red wound beds. The PA diagnosed the Resident with Cellulitus, ordered a wound culture, labs (Complete Blood Count, and Uric Acid level), and an X-Ray for 11/28/11. The treatment to the left thumb ordered by the PA on 11/25/11 was to wash with normal saline, pat dry, apply TAO (triple antibiotic ointment) to open area, cover with non-adherent dressing and Kling, change daily. Review of the Nursing Notes indicated that the Resident had the scheduled X-Ray on 11/28/11 which was positive for fracture, and the PA was notified. The note also indicated that the left thumb wound bed had a pink center with yellow subcutaneous tissue surrounding the center. Open area found above wound #1 measuring 1.0 cm x 1.0 cm x 0.3 cm. (This area had originally been identified by the PA on 11/25/11 when she assessed the resident, and it was documented in the PA progress notes). Wounds draining serosanguinous drainage, moderate amount. Review of the PA progress note of 11/28/11 indicated that the resident was showing some improvement in the cellulitus of the thumb, the thumb was contracted at baseline, but X-Ray suggests non-displaced fracture. ? non-displaced distal phalanx fracture, cellulitus improving. Hand clinic referral - No splint in house, continue Keflex. On 11/29/11 the Resident went to the Hand Clinic for an evaluation and returned with the following recommendations: Keep wounds clean and dry change once daily or more often PRN. No fracture noted. Will follow closely for wound check. Re-evaluate in 1 week at Hand Clinic. Review of a nursing note of 11/30/11 indicated that the nurse observed a new open area on Resident #6's coccyx which measured 1 cm x 0.75 cm. A wound sheet was initiated, and the PA was notified. A new order to cleanse the area with normal saline, dry, apply skin prep to surrounding edges, and apply [MEDICATION NAME] Dressing, and change every 3 days and PRN, and check every shift was obtained. On 12/1/11 the NP assessed the resident's left thumb and changed the treatments to: Left thumb proximal and distal wounds, cleanse with normal saline, pat dry, apply Hydrogel to wound beds only, skin prep to surrounding skin, cover with non-adherent dressing followed by Kling wrap daily and PRN. The NP also ordered [MEDICATION NAME] 1 packet via [DEVICE] twice daily until thumb wounds heal, and Vitamin C 500 mg via [DEVICE] twice daily until wounds healed. On 12/7/11 the area on the resident's coccyx measured 1.0 cm x 1.0 cm with no drainage. The peri wound was pink. The length of the ulcer was slightly larger. Resident #6 returned to the Hand Clinic on 12/8/11. "L (Left) thumb wounds healing without infection. Continue to keep clean and dry. Avoid any topical creams, ointments. May begin to leave open to air. Re-evaluate in 1-1/2 weeks." On 12/8/11 following the Hand Clinic Evaluation, the current treatment order for the resident's left thumb was discontinued and a new order to clean the areas on the thumb with normal saline, pat dry, and apply a dry clean dressing followed by Kling wrap daily, and check every shift and change PRN was ordered by the NP. On 12/12/11 at 10:35 A.M., the surveyor observed the dressing change to the resident's left thumb with Nurse #2. Nurse #2 indicated we would have to do the treatment to the resident's coccyx later in the day. Nurse #2 washed her hands and donned clean gloves and removed the Kling wrap from the Resident's left hand/thumb. The old dressing had a small amount of serosanguinous drainage. Area #1 (Proximal) Drainage is apparent in wound bed tanish/gray in color, wound edges appear macerated. Area is over bony prominence of contracted thumb. Area measured by Nurse #2 - 1 cm long x 1.1 cm wide x 0.2 cm deep. Area #2 (Distal) Dry open area measuring 0.1 cm long x 0.2 cm wide with no depth. During this treatment observation the resident was sitting in a Gerichair. Nurse #2 left the room to see if the PA was in the building to show her that the area had declined, and to check on an appropriate treatment. Nurse #2 returned after approximately 15 minutes with Nurse #3, and indicated the PA was not in the building. The surveyor asked Nurse #2 why Resident #6 was sitting in the Gerichair without a pressure reducing cushion when the resident had a Stage II Pressure Ulcer on the Coccyx. Nurse #2 said she that she did not know. The surveyor asked both Nurse #2 and Nurse #3 if the resident had a pressure reducing cushion for the Gerichair and they both said they did not know. Nurse #2 said she would use the current treatment to the Resident's left thumb and notify the PA of the change in the ulcers. Nurse #2 washed her hands, donned clean gloves, and performed the treatment as ordered. On 12/12/11 at 12:10 P.M., the Surveyor observed the dressing change to the Resident's Coccyx with Nurse #2 and CNA #5. Nurse #2 washed her hands and donned clean gloves. The old dressing was removed from the resident's Coccyx which contained a scant amount of blood tinged drainage. The wound bed was red and Nurse #2 measured the area. The ulcer measured 2.1 cm long x 1.4 cm wide with no depth. The ulcer on 11/30/11 (when it was first noted measured 0.75 cm x 1 cm). Nurse #2 continued the treatment appropriately, cleansed the ulcer with normal saline, patted the ulcer dry, applied skin prep to the surrounding edges, and applied [MEDICATION NAME] dressing as ordered. On 12/12/11 at 12:25 P.M., the surveyor had a discussion with the Director of Rehab (Rehabilitation) regarding Resident #6 not having a pressure reducing cushion in the Gerichair. The Director of Rehab said that during morning meetings the staff usually discuss residents with new open areas, and if nursing needed a pressure reducing cushion they would send a screen to the PT department. The Director of Rehab said that PT never received a screen for Resident #6. Review of Progress Note written by the PA on 12/12/11 indicated that the left thumb had increased drainage with some maceration of tissue. "Will increase frequency of dressing changes to twice daily in order to decrease moisture and drainage." Add Zinc, and follow up with hand clinic. Wound to be re-evaluated in 2 days. On 12/13/11 at 11:00 A.M., during interview regarding Resident #6, Nurse #5 said the resident gets out of bed to the Gerichair daily and goes to life skills programs, mostly for socialization. On 12/13/11 at 11:05 A.M., during interview regarding Resident #6, CNA #10 said the resident usually wears a left hand splint but cannot wear it right now because of the bandage. On 12/13/11 at 11:10 A.M., the surveyor observed two CNAs transfer Resident #6 out of the Hill Rom Wound Surface Air Bed using the Hoyer lift into the Gerichair with no pressure reducing cushion in the Gerichair. One of the CNAs said the Resident was going to attend a musical event in the unit day room. The musical event was over by 11:30 A.M. and the resident was in the unit day room reclined in the Gerichair at 11:55 A.M. On 12/13/11 at 11:55 A.M., the surveyor discussed Resident #6 with UM #2 (Unit Manager #2) regarding the Stage II Pressure Ulcer on the Resident's Coccyx, and the resident not having a pressure reducing cushion in the Gerichair. UM #2 said she was aware that the resident had no pressure reducing cushion after her discussion with the nurses yesterday on (12/12/11). UM #2 then said that she sent a screen down to PT. The surveyor asked UM #2 if the resident ever had a pressure reducing cushion in the Gerichair, and UM #2 said no, and that the resident had not needed one. UM #2 said the resident should have had the pressure reducing cushion in the Gerichair, and the areas on the left thumb were a result of the left hand splint.