Every finding on record at Webster Park Rehabilitation and Healthcare Center

Based on observation, record review, and interview, the facility failed to ensure the physician signed therapeutic diet orders for total parenteral nutrition (TPN- a method of delivering complete nutrition intravenously to patients who cannot use their digestive system), written by a registered dietitian (RD) for one Resident, (#10), out of a total sample of 13 residents.Findings include:Review of 105 CMR 150 Standards for Long Term Care Facilities indicated the RD's role within long-term care facilities to be as follows: -150.009: Dietary Service (A) All facilities shall provide adequate dietary services to meet the daily dietary needs of residents in accordance with written dietary policies and procedures. (2) Dietary services shall be provided directly by the facility, or facilities may contract with an outside food company provided the facility and the food company comply with 105 CMR 150.000; provided the facility or the company has a qualified dietitian who serves, as required in 105 CMR 150.000; and provided the facility and the dietitian provide for continuing liaison with physicians and the nursing staff. -The visits of the dietitian shall be of sufficient duration and frequency to provide consultation, evaluation, and advice regarding dietary personnel, menu planning, therapeutic diets, food production and service procedures, maintenance of records, training programs, and sanitation.Further review of the state regulations failed to indicate that the attending physician could delegate the task of writing dietary orders to the RD.Review of the facility's policy titled Parenteral Nutrition, dated as last revised October 2004, indicated but was not limited to the following:-A provider's order is necessary for this treatment.-The PN order should include the formula or a list of all individual ingredients/nutrients in the base solution, total volume and rate of administration as well as orders for monitoring laboratory results on a routine basis.Resident #10 was admitted to the facility in March 2026 with diagnoses including but not limited to: peritoneal abscess (a localized pocket of infected fluid and pus inside the abdomen) and enterocutaneous fistula (an abnormal tunnel or opening that develops between the intestines and the skin) with short gut syndrome (a condition where the small intestine is too short or damaged to absorb enough water and nutrients from food).Review of the Minimum Data Set (MDS) assessment, dated 3/26/26, indicated Resident #10 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS indicated he/she received parenteral/IV (intravenous, directly into the bloodstream) feeding while a resident.During an interview on 4/2/26 at 2:04 P.M., Resident #10 said he/she had been on TPN for over a year. Review of Resident #10's electronic medical record indicated a Physician's Order, dated 3/20/26, which included but was not limited to: -TPN Electrolytes Solution (Parenteral Electrolytes) Use 120 milliliters (ml)/hour (hr) intravenously two times a day for Supplement,- TPN 1800ml runs over 16-hour cycle add __ml vitamins to the bag,- 120 ml/hr for 14 hrs 60 ml/hr for last 2 hours.Further review of the physician's order in the electronic medical record failed to include the individual ingredients/nutrients and additives. Review of the Pharmacy TPN Order Form, dated 1/23/26, indicated but was not limited to:-TPN infusion time period of 16 hours run at 60ml/hr-120ml/hr- 60ml/hr,-Amino acids - 85 grams (g),-Dextrose- 280 g,-Lipids- 50 g,-Sodium acetate- 50 milliequivalents (mEq),-Sodium chloride- 50 mEq,-Sodium phosphate- 30 mEq,-Potassium acetate- 20 mEq,-Potassium chloride- 20 mEq,-Magnesium sulfate- 20 mEq,-Calcium gluconate- 5 mEq,-Zinc- 5 milligrams (mg),-Multivitamins with potassium- 10 milliliters (mL) and,-Insulin- 10 unitsFurther review of the Pharmacy TPN Order Form indicated the section for physician signature was signed by an RD and had not been signed by a physician. On 4/6/26 at 8:20 A.M., the surveyor observed Resident #10 with his/her TPN infusing. Review of the TPN bag indicated he/she was receiving the ingredients/nutrients and additives, as ordered on the Pharmacy TPN Order Form, dated 1/23/26, which included:-Amino acids - 85 g,-Dextrose- 280 g,-Lipids- 50 g,-Sodium acetate- 50 mEq,-Sodium chloride- 50 mEq,-Sodium phosphate- 30 mEq,-Potassium acetate- 20 mEq,-Potassium chloride- 20 mEq,-Magnesium sulfate- 20 mEq,-Calcium gluconate- 5 mEq,-Zinc- 5 mg,-Multivitamins with potassium- 10 mL and,-Insulin- 10 units During a telephonic interview on 4/6/26 at 12:09 P.M., the Medical Director (MD) said the RD writes the TPN orders/recommendations on the TPN Pharmacy Order Form and then when she reviews the recommendations, she approves the orders by co-signing the TPN Pharmacy Order Form. During an interview on 4/6/26 at 12:42 P.M., the RD said she was not responsible for writing TPN orders because that was beyond her scope of practice. During an interview on 4/6/26 at 3:51 P.M., the Chief Nursing Officer (CNO) said the RD should review hospital orders and then the orders were reviewed and confirmed with the attending physician. The CNO said the orders written in the electronic medical record did not include all the additives in Resident #10's TPN orders. The CNO said the MD did not sign the TPN Pharmacy Order Form that included all the ingredients/nutrients and additives in the Resident's TPN feeding.

Based on observation, interview, and record review, the facility failed to monitor range of motion (ROM) of left knee flexion contracture and implement the care plan to maintain ROM to reduce the risk of worsening the contracture for one Resident (#13), out of a sample of 13 residents. Findings include:Review of the facility's policy titled Resident Mobility and Range of Motion, revised July 2017, indicated but was not limited to the following:-Residents with limited range of motion will receive treatment services to increase and/or prevent a further decrease in range of motion.-Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.-As part of the resident's comprehensive assessment, the nurse will identify the resident's:Current range of motion of his or her joints;-Opportunities for improvement; and-Previous treatment and services for mobility.-The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed.-The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.-Interventions may include therapies, provisions of necessary equipment, and/or exercises and will be based on professional standards of practice to be consistent with state laws and practice acts.-The care plan will include the type, frequency, duration of interventions, as well as measurable goals and objectives. The resident and representatives will be included in determining these goals and objectives.-Documentation of the resident's progress towards the goal and objectives will include attempts to address any change or decline in resident's condition or needs. Resident #13 was originally admitted to the facility in April 2023, then transferred to a secondary facility related to fire damage (December 2025-February 2026), and readmitted to this facility in February 2026 with diagnoses which included dementia, hemiplegia (one sided weakness) affecting left dominant side, paralytic (loss of muscle function) syndrome following cerebral vascular infarction (CVA- stroke), and chronic pain. Review of the Minimum Data Set (MDS) assessment, dated 3/12/26, indicated Resident #13 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated:-Section GG indicated Functional Limitation in Range of Motion: - Lower extremity (hip, knee, ankle, foot) (GG0115B): Impairment on both sides.-Section O indicated special treatments, procedures, and programs: - Therapy services included speech (ST) and occupational therapy (OT). No physical therapy (PT) services, no restorative nursing programs including passive or active range of motion or splint or brace. On 4/2/26 at 1:47 P.M., the surveyor observed Resident #13 sitting in the day room in a specialized adjustable medical wheelchair. Resident #13 was sitting with the left lower extremity externally rotated and the knee flexed to 90 degrees, with the leg positioned lying on the right lower extremity. During an interview on 4/2/26 at 1:48 P.M., Resident #13 said he/she was in pain with the left leg. Resident #13 said they gave him/her pain medication but the leg still hurts; he/she can't straighten it out. During an interview on 4/3/26 at 2:55 P.M., the surveyor observed Resident #13 lying in bed with his/her left knee bent to approximately 90 degrees of knee flex. Resident #13 said he/she was not in pain. Review of Resident #13's Care Plan indicated but was not limited to the following:1. Resident #13 has pain and/or potential for pain status post CVA with resulting hemiplegia, and polyneuropathy (disorder of nerves outside brain).-Encourage me to try non-pharmacological interventions for pain relief as applicable. For example, positioning, relaxation therapy, bathing, heat and cold application, muscle stimulation, ultrasound (Initiated 2/18/26)2. Resident #13 had a CVA, hemiplegia related to an embolism.-Range of motion exercises: If able active range of motion exercises several times per day and assist with passive range of motion for limbs with limitations (Initiate It 2/18/26.)-Therapy consult as needed- PT, OT, and ST. Review of a Rehab Screen, dated 9/26/24, performed by the physical therapist, indicated Resident #13 remains with left lower extremity knee flexion contracture with staff performing passive range of motion daily to reduce the risk of worsening. Review of Rehab Screen, dated 2/18/26, performed by the speech therapist, indicated Resident #13 was screened for readmission to the facility and the elder has experienced a change/decline/improvement: Response was in swallowing and positioning bed/chair. Therapy evaluation section indicated occupational therapy and speech therapy were appropriate. Further review of Occupational Therapy Evaluation and Plan of Treatment, dated 2/18/26, failed to indicate-An assessment of left lower extremity range of motion or strength was performed. However, did establish a contracture was present. -Goals were established for left knee range of motion deficits, contracture management, or pain management. Review of Physical Therapy Evaluation and Plan of Treatment, dated 11/24/23, indicated but was not limited to the following:-Resident #13 was referred to rehab by nursing staff due to abnormal position while sitting in Geri chair recliner. Patient has a significant history of CVA with spastic left hemiplegia, left knee flexion contracture and increased tone in the left lower extremity. Musculoskeletal Assessment: -Left hip, left knee and left ankle. Range of motion impaired. No measured Range of motion available. -No left lower extremity strength testing available related to patient unable to participate in testing due to cognitive limitations and hypertonicity limiting movement. -Contracture functional limitations present due to contracture, yes: Functional limitations as results of contracture include transfers, sitting, bed positioning. -Neuromuscular Assessment. Left extremity tone was spastic: Lower extremity tone severity was Equal to 4 (Considerable increase).-No measurements of left knee contracture are available in evaluation. Review of Physical Therapy Evaluation and Plan of Treatment, dated 4/6/26, indicated but was not limited to the following:-Resident #13 was referred to rehab by nursing due to a presentation of left knee contracture possibly due to increased tone, left lower extremity, pain of left knee joint with movement and abnormal posture. Patients require skilled rehab interventions to prevent worsening of left knee contraction with the use of an orthotic device and a range of motion program.-Musculoskeletal Assessment indicated left lower extremity range of motion: Left hip impaired, Knee impaired (minus 86 degree of left knee flexion contracture). -Contracture functional limitations present due to contracture: Yes, functional limitations because of contracture turning, transferring, repositioning self and functional mobility. Is skilled therapy needed to address impairment? Yes. Review of Resident #13's nursing notes from 2/16/26 through 4/6/26 do not indicate range of motion or positioning for left lower extremity was performed. During an interview on 4/6/26 at 10:06 A.M., Rehab Staff #2 said he was an occupational therapy assistant and is presently seeing Resident #13 for ROM related to contractures in the left hand three times a week. Rehab staff #2 said he does not do any range of motion for the left lower extremity. During an interview on 4/6/26 at 10:14 A.M., the Rehab Director reviewed the rehab screen, which did not indicate the left lower extremity ROM. The Rehab Director believed Resident #13 had been on physical therapy previously and they had recommended his/her chair be changed to a specialized adjustable medical wheelchair. The Rehab Director reviewed the electronic medical record and said the last time Resident #13 was on rehab for PT was in 2013. During an interview on 4/6/26 at 2:15 P.M., Rehab Staff #1 said he had just completed the physical therapy evaluation and Resident #13 had minus 86 degrees of left knee extension. Rehab Staff #1 said he had some ideas that could help the Resident with the left knee contracture. Rehab Staff #1 said the last time Resident #13 was evaluated was in 2023 and he recommended a Broda chair for positioning, and at the time Resident #13 was not agreeable to many of the recommendations. During an interview on 4/6/26 at 4:45 P.M., the Director of Nursing provided the surveyor with Resident #13's medical record documentation and said there was no documentation for nursing staff or certified nursing assistants performing ROM for Resident #13's left leg.

Based on observations and interview, the facility failed to ensure trash, garbage, and refuse were disposed of and properly contained within a receptacle constructed with a tight-fitting lid. Findings include:Review of the 2022 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) by the U.S. Food and Drug Administration (FDA) indicated outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. On 4/2/26 at 1:03 P.M., the surveyor observed an enclosed area with two dumpsters. One filled with cardboard and one filled with bags of trash. The surveyor observed the dumpster filled with bags of trash to be open from the top. Between the dumpsters was a large amount of leaves with empty containers of milk, thickened liquids, juice containers, water bottles, plastic cups, and plates. Next to the dumpster were pieces of lemon and pieces of bread. Behind the dumpsters were disassembled pieces of white piping with wheels on the bottom and a power wheelchair. On 4/6/26 at 1:24 P.M., the surveyor and the Food Service Director observed the enclosed dumpster area. The surveyor and Food Service Director observed the pile of leaves with trash debris including milk cartons, thickened liquid containers and juice containers. The dumpster with trash was observed opened on the top. During an interview at this time, the Food Service Director said the pile of leaves looked as if it had been under the snow previously and now the snow had melted. The Food Service Director said his staff brought trash out to the dumpsters and should be telling him if the area needs to be cleaned. He said the lid on the dumpster was broken and unable to be closed. He said the Maintenance Director had contacted the disposal company for a new one. During an interview on 4/6/26 at 2:49 P.M., the Maintenance Director said the enclosed dumpster area usually had trash debris after the dumpster company would pick up the dumpsters on Mondays, Wednesdays and Fridays. He said he did rounds to the area on those days to check on fallen trash. He said he was not sure why the same trash observed by the surveyor on Thursday was still on the ground on Monday. He said the lid on the trash dumpster had broken during the snowstorm on 2/23/26. He said he had contacted the dumpster company about the broken lid prior to the surveyor inquiry but did not have any documentation to indicate he had notified the company of the need for repair or replacement. During an interview on 4/6/26 at 2:54 P.M., the contracted trash disposal company representative said the facility had contacted them one half hour prior to this call, letting the company know the lid on the dumpster was unable to be closed. She said the facility had not contacted the company prior to this day.

Based on observation, record review, and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of five nurses observed made two errors out of 28 opportunities, resulting in a medication error rate of 7.14%. Those errors impacted two Residents (#22 and #64). Findings include: Review of the facility's policy titled Administering Medications, revised April 2019, indicated but was not limited to the following: -Medications are administered in accordance with prescriber orders, including any required time frame. -Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1. Resident #22 was admitted to the facility in July 2022 and had diagnoses including atrial fibrillation, osteoarthritis, benign intracranial hypertension, and lymphedema (swelling most often in the leg or arm caused by lymphatic system blockage). On 1/27/25 at 8:51 A.M., the surveyor observed Nurse #4 prepare Resident #22's medications and observed the following: 8:51 A.M. - Nurse #4 opened an over-the-counter bottle of generic One-Daily Multi-vitamin with Minerals (includes a combination of various vitamins alongside essential minerals like calcium, iron, and magnesium, while a multivitamin without minerals contains only a blend of vitamins) from the top drawer of the medication cart and added one whole tablet into a medication cup along with five other various whole tablets. 9:06 A.M. - Nurse #4 administered the medications to Resident #22. Review of current Physician's Orders on 1/27/25 at 11:13 A.M., indicated the following: -Multivitamin Tablet (Multiple Vitamin), Give 1 tablet by mouth in the morning for vitamin deficiency, 7/27/22 During an interview on 1/27/25 at 1:28 P.M., the surveyor reviewed the medical record with Nurse #4 who said the order was for a multivitamin tablet, without minerals. She said all medications should be given per physician's orders. 2. Resident #64 was admitted to the facility in January 2021 and had diagnoses including thrombocytopenia (low number of platelets in the blood) and hypercholesterolemia. On 1/27/25 at 9:17 A.M., the surveyor observed Nurse #5 prepare Resident #64's medications and observed the following: 9:17 A.M. - Nurse #5 opened an over-the-counter bottle of generic One-Daily Multi-vitamin with Minerals from the top drawer of the medication cart and added one whole tablet into a medication cup along with another whole tablet. 9:21 A.M. - Nurse #5 administered the medications to Resident #64. Review of current Physician's Orders on 1/27/25 at 11:24 A.M., indicated the following: -Multiple Vitamin Tablet, Give 1 tablet by mouth one time a day for supplementation, 3/18/24 During an interview on 1/27/25 at 1:22 P.M., the surveyor reviewed the medical record with Nurse #5 who said the order was for a multivitamin tablet daily, not a multivitamin tablet with minerals. She said one has just vitamins and the other has minerals added to it. She said medications should be administered per physician's orders. During an interview with the Assistant Director of Nurses and the Director of Nurses (DON) on 1/27/25 at 4:49 P.M., the DON said she was already made aware of the medication errors and both said nursing staff should follow physician's orders for medication administration.

Based on interview and record review, the facility failed to provide care and services consistent with professional standards of practice for three Residents (#85, #15, and #23), out of a total sample of 21 residents. Specifically, the facility failed to ensure: 1. For Resident #85, staff implemented a taper and discontinuation of a Nicotine patch (smoking cessation treatment) recommended by the consultant pharmacist and agreed upon by the Resident's physician; 2. For Resident #15, the consultant wound physician did not perform treatments including invasive surgical procedures, cauterization, ultrasound therapy and substitute skin grafts to the Resident's wounds without obtaining informed consent to do so from the Resident's legal guardian; and 3. For Resident #23, to ensure a left upper extremity (LUE) hand carrot (device designed to position fingers away from the palm protecting the skin from moisture, pressure and other injury) was donned/doffed (put on/ taken off) as prescribed in physician's orders. Findings include: 1. Resident #85 was admitted to the facility in January 2024 with diagnoses including chronic pulmonary embolism and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 12/4/24, indicated Resident #85 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score 13 out of 15 and did not use tobacco. Review of a three-ringed binder labeled with Resident #15's attending physician's name on it indicated Consultant Pharmacist Recommendations to Prescriber, dated 7/20/24, to consider the manufacturer recommended taper schedule: -Nicotine Patch 14 milligrams (mg)/24-hour (hr) everyday x 2 weeks; then -Nicotine Patch 7 mg/24-hr everyday x 2 weeks, then discontinue Nicotine Patch The physician/prescriber response section indicated the physician agreed and signed the recommendation on 7/25/24. Review of the January 2025 Physician's Orders indicated but was not limited to: - Nicotine Patch 24 Hour 14 mg/24 hr Apply 1 patch transdermally one time a day for Smoking Cessation. Remove the old one and remove per schedule (1/15/24) Review of January 2024 through January 2025 Medication Administration Records (MAR) indicated the Nicotine Patch 14 mg/24 hr was applied at 9:00 A.M. and the previous patch removed at 8:59 A.M. daily as ordered. Further review of the entire medical record failed to indicate the Nicotine Patch taper was implemented as agreed upon by the physician on 7/25/24. During an interview on 1/27/25 at 11:00 A.M., Unit Manager #3 said the process for pharmacy recommendations is that the recommendation forms are placed in the physician's three-ringed binder on the unit, the physician reviews them and indicates if they agree or disagree with the recommendation and then signs the form. She said nursing retrieves the signed recommendations from the binder, makes sure they get done, then files the forms in the resident's medical record. She said she doesn't know why Resident #15's signed and approved recommendation from July 2024 was still in the three-ringed binder. She said it should have been implemented when it was signed by the physician. During an interview on 1/28/25 at 1:15 P.M., the Director of Nursing (DON) reviewed Resident #15's entire medical record and said she was unable to find any evidence that nursing followed through with the physician's authorization to initiate the taper or that the Resident refused. 2. Resident #15 was admitted to the facility in February 2019 and had diagnoses including dementia. Review of the MDS assessment, dated 12/4/24, indicated Resident #15 had moderate cognitive impairment as evidenced by a BIMS score of 7 out of 15, and had a legal guardian. Review of the medical record indicated Resident #15 was adjudicated incapacitated by the court and was appointed a legal guardian on 4/10/15. Review of the medical record indicated consultant wound physician (MD #1) performed an initial evaluation on 10/10/24 and identified an unstageable deep tissue injury (a pressure injury where the stage is unclear because the wound is covered by dead tissue) to Resident #15's left heel, a non-pressure wound of the third right toe, and a wound of the right second toe. The note indicated MD #1 performed a sharp selective debridement procedure (a medical technique where a healthcare professional uses sharp instruments like a scalpel, scissors, or forceps to carefully remove only dead or necrotic tissue from a wound, leaving healthy tissue unharmed) to the left heel, surgical excisional debridement procedure to the right, third toe and cauterization (a medical procedure that uses heat to destroy or seal off tissue) for abnormal granulation to the right, second toe. Further review of the note indicated MD #1 performed surgical debridement and wound cauterization without obtaining consent from the legal guardian. Further review of the medical record indicated MD #1 performed 15 additional treatments to the Resident's wounds without obtaining consent from the legal guardian as follows: -10/17/24: sharp selective debridement procedure to the left heel. -10/24/24: sharp selective debridement procedure to the left heel and left second toe; non-contact, non-thermal, low frequency ultrasound. -10/31/24: sharp selective debridement procedure to the left heel. -11/7/24: sharp selective debridement procedure to the left heel. -11/14/24: sharp selective debridement procedure to the left heel. -11/21/24: sharp selective debridement procedure to the left heel and non-contact, non-thermal, low frequency ultrasound. -11/27/24: non-contact, non-thermal, low frequency ultrasound. -12/5/24: the left heel wound underwent the placement of a skin substitute graft (a material used to replace skin that has been damaged or removed). -12/12/24: application of skin substitute graft material was applied to the left heel wound. -12/19/24: sharp selective debridement procedure to the left heel and application of skin substitute graft material was applied to the left heel wound. -12/27/24: application of skin substitute graft material was applied to the left heel wound. -1/3/25: application of skin substitute graft material was applied to the left heel wound. -1/9/25: application of skin substitute graft material was applied to the left heel wound. -1/16/25: application of skin substitute graft material was applied to the left heel wound. -1/23/25: application of skin substitute graft material was applied to the left heel wound. Review of the entire medical record, including nursing progress notes from 10/10/24 through 1/28/25, failed to indicate Resident #15's legal guardian was informed and gave consent for any treatments administered to Resident #15 from 10/10/24 through 1/23/25. During a telephonic interview on 1/27/25 at 12:22 P.M., Resident #15's legal guardian reviewed her documentation and said her last communication with the facility was on 9/17/24 for a care plan meeting and she has not heard from them since that time. The surveyor read the consultant wound physician's notes from 10/10/24 to 1/23/25 to the legal guardian. She reviewed her notes again and she said she was not informed of the wounds by telephone or email, was not provided with any information about treatments and did not give consent for the treatments. She said she should have been informed of the changes and proposed treatment because she is the Resident's legal guardian and must give consent. During a telephonic interview on 1/27/25 at 2:55 P.M., MD #1 said he performed treatments to Resident #15's left heel and toe wounds including surgical debridement, cauterization, ultrasound and skin grafts. He said he was not aware, and facility staff did not tell him that Resident #15 had a legal guardian and was unable to give consent for any of the procedures. He said he obtained consent for the procedures from the Resident. During interviews on 1/27/25 at 3:20 P.M. and 1/28/25 at 7:40 A.M., the DON said that she spoke to Resident #15's legal guardian following surveyor inquiry and said the legal guardian did not give consent for any of the treatment procedures performed by MD #1 from 10/10/24 to 1/23/25. She said the procedures should not have been performed without consent from the Resident's legal guardian. 48362 3. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #23 was admitted to the facility in October 2022 with diagnoses including Parkinson's disease, dementia, and muscle weakness. Review of the MDS assessment, dated 12/31/24, indicated Resident #23 was severely cognitively impaired as evidenced by a BIMS score of 4 out of 15; he/she had a left upper extremity range of motion (ROM) impairment and required extensive assistance for activities of daily living. Review of Resident #23's Physician's Orders included but were not limited to the following: - 1/23/25: LUE carrot daily as tolerated; apply with A.M. care and doff with P.M. care; may remove for skin checks and hygiene; two times a day for skin integrity. - 7/9/24 to 1/23/25: LUE carrot for up to 8 hours; remove for skin checks and hygiene; two times a day for skin integrity. The surveyor observed Resident #23 in bed with no LUE carrot in his/her hand as follows: - On 1/23/25 at 9:45 A.M. - On 1/23/25 at 4:15 P.M. - On 1/27/25 at 8:59 A.M. - On 1/27/25 at 2:58 P.M. - On 1/27/25 at 4:24 P.M. Review of Resident #23's Treatment Administration Record (TAR) for January 2025 indicated Resident #23's LUE carrot was donned and doffed with A.M./P.M. care since 1/23/25 twice daily. Review of Resident #23's medical record failed to indicate refusal to wear the LUE carrot and/or inability to tolerate wearing the LUE carrot. The medical record also failed to indicate any attempts by the Resident to self-remove the LUE carrot. During an interview on 1/28/25 at 8:43 A.M., Certified Nurse Aide (CNA) #7 said Resident #23 only sometimes wears the LUE carrot in his/her hand. CNA #7 said they are able to don/doff the LUE carrot to his/her hand during care. CNA #7 said she was not aware of when or how often the LUE carrot was supposed to be worn or removed. During an interview on 1/28/25 at 8:57 A.M., Occupational Therapist (OT) #1 said she recently did an Occupational Therapy evaluation on 1/24/25 to assess the LUE carrot for Resident #23's hand contracture. OT #1 said she did not initially issue the LUE carrot to the Resident, but she believed it was an appropriate device for their contracture management. OT #1 said she spoke the Unit Manager (UM) about the Resident's wearing schedule and tolerance to the device. OT #1 said she would expect communication back to the Rehabilitation Department if the Resident was refusing to wear the LUE carrot, having difficulty tolerating the LUE carrot or had a change in condition. OT #1 said she had not received any communication about the Resident not being able to wear the LUE carrot since the reassessment on 1/24/25. During an interview on 1/28/25 at 9:17 A.M., Nurse #3 said Resident #23 wears a LUE carrot in his/her hand. Nurse #3 said either nursing staff or OT staff place the LUE carrot on the Resident in the morning. Nurse #3 said the Resident was supposed to wear the LUE carrot for eight hours a day. Nurse #3 said she would let the UM or the therapy department if the Resident was refusing to wear the device or there were complications related to the use of the LUE carrot. During an interview on 1/28/25 at 9:30 A.M., UM #2 said Resident #23 had been wearing a LUE carrot for a while. UM #2 said nursing dons the LUE carrot every morning and it should be worn for eight hours daily. UM #2 said nursing documents on the TAR when the LUE carrot is donned/doffed. UM #2 and the surveyor reviewed the observations made during the survey process. UM #2 said nursing should identify on the TAR if they were unable to don the LUE carrot for the Resident. During an interview on 1/28/25 at 10:52 A.M., Resident Representative (RR) #1 said she visits the Resident several times per week. RR #1 said the Resident does not always have the LUE carrot on when they visit. RR #1 said the LUE carrot is not consistently donned. RR #1 said the Resident had never complained the LUE carrot was uncomfortable or needed to be taken off when they were visiting. During an interview on 1/28/25 at 12:11 P.M., the DON said the Resident often requires multiple attempts to don the LUE carrot. The DON said the expectation would be for the CNA staff to notify the Nurse or UM if the resident was refusing the LUE carrot or taking it off by themselves. The DON said it should be identified and documented if the Resident refused or if multiple attempts were required to don the LUE carrot.

Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 14 of 14 residents attending the resident group meeting during the facility survey, the facility failed to ensure residents were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s). Findings include: Review of the facility's policy titled Grievance and Complaint Procedure, dated January 2022, indicated but was not limited to: -Upon admission, residents are provided with written information on how to file a grievance or complaint within the facility. Such information will also be posted on the resident bulletin board. -Grievances and complaints may be submitted orally or in writing without threat or fear of retaliation. They may also be filed anonymously. On 1/24/25 at 10:30 A.M., the surveyor held a resident group meeting with 14 residents, representing each of the facility's three units, in attendance. The residents said they don't always want to identify who they are when they have a complaint, so they don't fill out a grievance form or say anything to staff. Fourteen of 14 residents in attendance were not aware that they have the right to file a grievance anonymously. During an interview on 1/28/25 at 9:46 A.M., the Activity Director said she coordinates the monthly Resident Council Meeting and records the meeting minutes. She said she is aware that residents don't want to say who they are when they have a complaint, and this is an obstacle to them bringing issues forward. On 1/28/25 at 10:32 A.M. on the second-floor unit and at 11:36 A.M. on the third-floor unit, the surveyor observed a wall mounted file holder with blank grievance forms in a folder at the elevator. A sign was posted alongside the folder and indicated the following: -What is grievance? A grievance is a dispute resolution process that you may use when you have a complaint or concern. -You have the right to: -You may voice grievances without discrimination or reprisal; -Know of a timely resolution of your grievances including those with respect to the behavior of other residents; -You may recommend changes in policies and services to facility staff and/or outside representatives, free from interference, coercion, discrimination, restraint, or reprisal from the facility; -You may voice grievances concerning your care without fear of discrimination; -Be ensured that a method is in place to respond promptly to your complaints or grievances and recommendations. -You may write a grievance on the form located on your neighborhood or express your concern with staff who will then write a grievance form out for you. The posted grievance information failed to indicate residents could file a complaint or grievance anonymously. During an interview on 1/28/25 at 10:50 A.M., the Administrator said he is the Grievance Officer and grievance forms are available on each of the units. He said he was not aware that residents did not know they could file a grievance anonymously. On 1/28/25 at 11:45 A.M., the surveyor and Social Worker toured the first-floor unit and were unable to locate any posting about the grievance process.

Based on record review and interviews, the facility failed to ensure for one Resident (#15), out of a total sample of 21 residents, that the Resident's legal guardian (a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person who is deemed incapacitated) was informed of a change in skin condition by the physician or other practitioner or professional, informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he/she preferred. Specifically, the facility failed to inform the legal guardian when Resident #15 developed wounds on his/her left heel and the second and third toes of the right foot, failed to inform of the risks and benefits of treatment and obtain consent for surgical debridement (surgically cleaning a wound by removing non-viable tissue with a scalpel or other surgical tools) and skin substitute grafting of wounds to the Resident's left heel and/or second and third toes of the right foot on 16 occasions. Findings include: Resident #15 was admitted to the facility in February 2019 and had diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 12/4/24, indicated Resident #15 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15, and had a legal guardian. Review of the medical record indicated Resident #15 was adjudicated incapacitated by the court and was appointed a legal guardian on 4/10/15. Further review of the medical record indicated the consultant wound physician's evaluations and progress notes included but was not limited to: -10/10/24 (initial visit): Patient has wounds on the left heel (unstageable deep tissue injury), right third toe and right second toe. Treatments performed included sharp selective debridement procedure (a medical technique where a healthcare professional uses sharp instruments like a scalpel, scissors, or forceps to carefully remove only dead or necrotic tissue from a wound, leaving healthy tissue unharmed) to the left heel, surgical excisional debridement procedure to the right, third toe and cauterization for abnormal granulation to the right, second toe. Treatment options-risks-benefits and the possible need for subsequent additional procedures on the wounds were explained on 10/10/24 to the patient who indicated agreement to proceed with the procedure(s). Further review of the note failed to indicate the legal guardian was informed of the wounds, risks and benefits of treatment options, and provided consent for surgical debridement and cauterization to be performed. -10/17/24: The patient has a wound on the left heel and left second toe. The wounds on the right third toe and right second toe have resolved. Treatment performed included sharp selective debridement procedure to remove devitalized tissue at margins of a wound on the left heel. Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 10/10/24 to the patient who indicated agreement to proceed with the procedure(s). Further review of the note failed to indicate the legal guardian was informed of the wounds, risks and benefits of treatment options, and provided consent for surgical debridement to be performed. -10/24/24: The patient has wounds on the left heel and left second toe. Treatment included sharp selective debridement procedure to remove devitalized tissue at margins of a wound on the left heel and non-contact, non-thermal, low frequency ultrasound, which was indicated to promote healing based on debridement attempt but aborted due to pain in the left second toe. Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 10/24/24 to the patient who indicated agreement to proceed with the procedure(s). Further review of the note failed to indicate the legal guardian was informed of the wounds, risks and benefits of treatment options, and provided consent for surgical debridement and ultrasound to be performed. -10/31/24: The patient has a wound on the left heel; left second toe wound resolved. Treatment performed included sharp selective debridement procedure to remove devitalized tissue at margins of a wound on the left heel. Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 10/24/24 to the patient who indicated agreement to proceed with the procedure. Further review of the note failed to indicate the legal guardian was informed of the wounds, risks and benefits of treatment options, and provided consent for surgical debridement to be performed. -11/7/24: The patient has a wound on the left heel. Treatment performed included sharp selective debridement procedure to remove devitalized tissue at margins of a wound on the left heel. Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 10/24/24 to the patient who indicated agreement to proceed with the procedure. Further review of the note failed to indicate the legal guardian was informed of the wounds, risks and benefits of treatment options, and provided consent for surgical debridement to be performed. -11/14/24: The patient has a wound on the left heel. Treatment performed included sharp selective debridement procedure to remove devitalized tissue at margins of a wound on the left heel. Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 10/24/24 to the patient who indicated agreement to proceed with the procedure. Further review of the note failed to indicate the legal guardian was informed of the wounds, risks and benefits of treatment options, and provided consent for surgical debridement to be performed. -11/21/24: The patient has a wound on the left heel. Debridement attempted but aborted due to pain. Today this wound underwent treatment with non-contact, non-thermal, low frequency ultrasound. Further review of the note failed to indicate the legal guardian was informed of the wounds, risks and benefits of treatment options, and provided consent for surgical debridement and ultrasound to be performed. -11/27/24: The patient has a wound on the left heel that has been present for greater than 46 days and has failed to respond appropriately for over 30 days despite standard management. The wound was evaluated as a candidate for wound treatment using a skin substitute. The anticipated amount of skin substitute material that is being considered for use on this wound is 12 cm2 (centimeters squared). Discussion of the potential risks and benefits of using this human tissue-based skin substitute graft treatment was held with the patient who expressed that all questions and concerns were addressed. It was agreed upon by all parties to proceed with the placement during the subsequent wound care visit. Today this wound underwent treatment with non-contact, non-thermal, low frequency ultrasound. Further review of the note failed to indicate the legal guardian was informed of the wounds, risks and benefits of treatment options, and provided consent for ultrasound and that the Resident was evaluated for a skin substitute graft. -12/5/24: The patient has a wound on the left heel. During today's visit this full thickness, chronic arterial wound of the left heel underwent the placement of a skin substitute graft. Further review of the note failed to indicate the legal guardian was informed of the risks and benefits of treatment options and provided consent for any procedure to be performed. -12/12/14: The patient has a wound on the left heel. Application of skin substitute graft material was performed today on this wound. Further review of the note failed to indicate the legal guardian was informed of the wound, risks and benefits of treatment options, and provided consent for application of a skin substitute graft to the left heel. -12/19/24: The patient has a wound on the left heel. During today's visit this full thickness, chronic arterial wound of the left heel underwent the placement of a skin substitute graft. In preparation of the wound bed, surgical excisional debridement was performed to remove visible necrosis just prior to skin substitute application. Further review of the note failed to indicate the legal guardian was informed of the wound, risks and benefits of treatment options, and provided consent for surgical debridement and application of a skin substitute graft to the left heel. -12/27/24: The patient has a wound on the left heel. During today's visit this full thickness, chronic arterial wound of the left heel underwent the placement of a skin substitute graft. Further review of the note failed to indicate the legal guardian was informed of the wound, risks and benefits of treatment options, and provided consent for the application of a skin substitute graft to the left heel. -1/3/25: The patient has a wound on the left heel. During today's visit this full thickness, chronic arterial wound of the left heel underwent the placement of a skin substitute graft. Further review of the note failed to indicate the legal guardian was informed of the wound, risks and benefits of treatment options, and provided consent for the application of a skin substitute graft to the left heel. -1/9/25: The patient has a wound on the left heel. During today's visit this full thickness, chronic arterial wound of the left heel underwent the placement of a skin substitute graft. Further review of the note failed to indicate the legal guardian was informed of the wound, risks and benefits of treatment options, and provided consent for the application of a skin substitute graft to the left heel. -1/16/25: The patient has a wound on the left heel. During today's visit this full thickness, chronic arterial wound of the left heel underwent the placement of a skin substitute graft. Further review of the note failed to indicate the legal guardian was informed of the wound, risks and benefits of treatment options, and provided consent for the application of a skin substitute graft to the left heel. -1/23/25: The patient has a wound on the left heel. During today's visit this full thickness, chronic arterial wound of the left heel underwent the placement of a skin substitute graft. Further review of the note failed to indicate the legal guardian was informed of the wound, risks and benefits of treatment options, and provided consent for the application of a skin substitute graft to the left heel. Review of the nursing progress notes from 10/10/24 through 1/28/25 failed to indicate Resident #15's legal guardian was informed of the wounds, informed in advance of the risks and benefits of proposed treatment and gave consent for treatments administered from 10/10/24 through 1/23/25 including surgical debridement of wounds, low frequency ultrasound and weekly application of a substitute skin graft. During a telephonic interview on 1/27/25 at 12:22 P.M., Resident #15's legal guardian reviewed her documentation and said her last communication with the facility was on 9/17/24 for a care plan meeting and she has not heard from them since that time. She said she assumes the Resident's status is stable and has had no changes in condition. The surveyor read the consultant wound physician's notes from 10/10/24 to 1/23/25 to the legal guardian. She reviewed her notes again and said she was not informed of the wounds by telephone or email, was not provided with any information about treatments and did not give consent for the treatments. She said she should have been informed of the changes and proposed treatment because she is the Resident's legal guardian and must give consent. During a telephonic interview on 1/27/25 at 2:55 P.M., the consultant wound physician (MD #1) said he sees Resident #15 weekly for assessment and treatment of the Resident's wounds. The surveyor read aloud his wound evaluation and summary note, dated 10/10/24. He said he obtained consent from Resident #15 to perform surgical debridement of the left heel wound and the right, third toe and also cauterization for the wound on the right, second toe. MD #1 said he was not aware, and facility staff did not tell him, that Resident #15 had a legal guardian and was unable to give consent for any of the procedures. During interviews on 1/27/25 at 3:20 P.M. and 1/28/25 at 7:40 A.M., the Director of Nursing (DON) said that she spoke to Resident #15's legal guardian following surveyor inquiry and said the legal guardian did not give consent for any of the treatment procedures performed by MD #1 from 10/10/24 to 1/23/25. She said the procedures should not have been performed without consent from the Resident's legal guardian. She said she reviewed the Resident's medical record and said nursing documented that the guardian was aware. During an interview on 1/28/25 at 9:10 A.M., Unit Manager #3 said she documented that the guardian was aware of Resident #15's wounds but was not able to confirm that she spoke to the legal guardian or left a message for her regarding Resident #15's wounds and proposed treatment. During a subsequent telephonic interview on 1/29/25 at 12:00 P.M., Resident #15's legal guardian said the facility has both her cell phone number and landline number to use to contact her. She said she reviewed her cell phone records back to October 2024 and did not receive a call, voice or text message from the facility during that timeframe. She said she has had difficulty with her landline since the end of August 2024 and even with the assistance of her telephone provider, has been unable to retrieve any phone records to confirm the facility called her or left a voice message to inform her of the Resident's wounds, proposed treatment, and to obtain consent for surgical debridement and other treatments.

Based on observation, record review, and interviews, the facility failed to ensure the call light was accessible and within reach for one Resident (#37), out of a total of 21 sampled residents. Specifically, the facility failed to ensure the call light switch above Resident #37's bed had a string attached to it to enable the Resident to independently call for assistance. Findings include: Review of the facility's policy titled Answering the Call Light, dated April 2016, indicated but was not limited to: - Purpose: The purpose of this procedure is to respond to the resident's requests and needs. - General Guidelines: 4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Resident #37 was admitted to the facility in January 2018 with diagnoses including chronic obstructive pulmonary disease and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment, dated 12/10/24, indicated Resident #37 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out 15. Further review of Resident #37's MDS indicated he/she required assistance with toileting, bathing, and dressing and was supervised for ambulation. Review of the Facility Assessment, undated, indicated but was not limed to: - Physical Environment -Equipment utilized to care for our resident population includes but is not limited to: - General Facility Equipment: Nurse call system Review of Resident #91's (roommate to Resident #37) MDS assessment, dated 12/19/24, indicated Resident #91 was cognitively intact as evidenced by a BIMS assessment score of 15 out 15. On 1/23/25 at 8:45 A.M., 12:24 P.M., and 3:39 P.M., and on 1/24/25 at 10:32 A.M., the surveyor observed Resident #37 in bed with a call light switch above his/her bed with the call light string attached to Resident #91's bedrail, the call light switch above Resident #37's bed did not have a string attached to the switch and therefore could not be used or reached to call for assistance. During an interview on 1/23/25 at 8:56 A.M., Resident #37 said he/she does not have a call light or any means to independently call for assistance. Resident #37 said he/she would ask his/her roommate to pull the call light string if they needed assistance. During an interview on 1/23/25 at 8:46 A.M., Resident #91 said they share a call light with Resident #37. Resident #91 said when Resident #37 needed assistance he/she would ask Resident #91 to pull the call light string for them to request assistance from the staff. Resident #91 said he/she was the keeper of the call light string because they required more assistance. Resident #91 said when staff would respond to the call light, he/she would tell them they had called for Resident #37. During an interview on 1/27/25 at 12:28 P.M., Resident #91 said on Friday (1/24/25) a maintenance person had come in and fixed Resident #37's call light by adding a pull string to the switch above their bed, after the surveyor had left his/her room. During an interview on 1/28/25 at 8:46 A.M., Nurse #2 said all residents should have their own call light. Nurse #2 said if Resident #37 needed anything he/she would have to walk down to the nurses' station and request it. During an interview on 1/28/25 at 8:48 A.M., Certified Nursing Assistant (CNA) #1 said if a resident needed assistance they would pull their call light string to request assistance. CNA #1 said all residents should have their own call light to request assistance. During an interview on 1/28/25 at 8:53 A.M., CNA #2 said both Resident #37 and Resident #91 are alert and oriented. She said when she would answer the call light in Resident #37's room she would go into the room and ask both Resident #37 and Resident #91 which one of them needed help and then shut off the shared call light. CNA #2 said both Residents should have had their own call light to request assistance. During an interview on 1/28/25 at 8:57 A.M., Unit Manager (UM) #3 said each resident should have their own call light. UM #3 said the strings attached to the call light switches in the wall are cheap and would break easily. UM #3 said she was not sure how long Resident #37 and his/her roommate had been sharing a call light. UM #3 said a new string was attached to the call light switch on Friday (1/24/25) to ensure both Residents had their own access to request assistance using the call light system. During an interview on 1/28/25 at 9:55 A.M., the Director of Maintenance (DOM) said on Friday (1/24/25) he had repaired Resident #37's call light, adding a pull string to the switch so it could be activated, but he was not aware of how long it had been without a string attached to the call light switch. During an interview on 1/28/25 at 1:51 P.M., the Assistant Director of Nursing (ADON) said the expectation was for each resident to have their own call light within their reach to be able to call for assistance.

Based on document review, policy review, and interviews, the facility failed to maintain an infection prevention and control program with a complete and accurate system of surveillance to identify any trends of actual or potential infections within the facility using their predetermined infection definition criteria. Findings include: Review of the facility's policy titled Surveillance of Infections, dated as revised September 2017, indicated but was not limited to the following: - The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections to guide appropriate interventions and prevent future infections. - Criteria for infections are based on current standard definitions of infections. - In addition to collecting data on incidents of infections the surveillance system is designated to capture certain epidemiologically important data that may influence how overall surveillance data is interpreted, for example: surveillance data gathered for residents with a recent hospital stay. During an interview on 10/26/23 at 9:31 A.M., the Infection Preventionist (IP) said the facility uses the laboratory supplied surveillance sheet to document the surveillance of illnesses in the facility and McGeer Criteria to define whether an illness is an infection by criteria protocol. Review of the McGeer Criteria Checklist, in use by the facility, indicated but was not limited to the following: Syndrome: Clostridium difficile (C. Diff or C. difficile) Infection Must fulfill 1 and 2 criteria 1. At least one of the following criteria: -Diarrhea: 3 or greater liquid or watery stools above what is normal for the resident within 24 hours -Presence of toxic megacolon (radiologic finding of abnormal large bowel dilation) 2. At least one of the following diagnostic criteria: -Stool sample positive for C. difficile toxin A or B, or detection of toxin-producing C. difficile by culture in stool sample -Pseudomembranous colitis identified in endoscopic exam, surgery, or histopathologic exam of biopsy specimen Syndrome: Urinary tract infection (UTI) Must fulfill both 1 and 2 criteria 1. At least one of the following sign or symptoms: -Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate -Fever or leukocytosis (a high level of white blood cells), and one or more of the following: -Acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, urgency or frequency. -If no fever or leukocytosis, then two or more of the following: -Suprapubic pain, gross hematuria, new or marked increase in incontinence, urgency and frequency. 2. At least one of the following microbiologic criteria - greater than or equal to 100,000 count of no more than two species of organisms in a voided urine sample, OR - greater than or equal to 50,000 count of any organism(s) in a specimen collected by an in-and-out catheterization Syndrome: Pneumonia Must fulfill 1, 2, and 3 criteria 1. Chest X-ray, with pneumonia or a new infiltrate 2. At least one of the following criteria: -New or increased cough or sputum production, oxygen saturation (O2 sat) less than 94% on room air, new or changed lung exam abnormalities, pleuritic chest pain, respiratory rate of 25 breaths per minute or greater 3. At least one of the following criteria: -Fever, leukocytosis, acute mental status change or acute functional decline. Review of the laboratory surveillance sheet key in use by the facility: -Categories: Gastrointestinal = GI; Urinary tract = UTI; Other = O; Pneumonia = PNU -Status: Healthcare acquired infection = HAI; Community acquired infection = CAI Review of the facility provided surveillance listings indicated the following: July 2023: PACU Unit Resident #411 Category: GI; date of onset: on admit; symptoms: diarrhea; results: positive C. Diff; status: CAI; count: No The surveillance data for Resident #411 indicated McGeer criteria was met, however it was not counted as an actual infection within the facility, indicating the surveillance forms were completed incorrectly. Unit 2 Resident #2 category: UTI; date of onset: 7/24/23; symptoms: blank; results: greater than100,000 Escherichia Coli (E. Coli); status: HAI; count: Yes The surveillance listing for Resident #2 failed to indicate any symptoms (incomplete), making the surveillance incomplete and the count of the infection inaccurate in accordance with the facility's use of McGeer criteria. Unit 3 Resident #410 category: UTI; date of onset: 7/6/23; symptoms: change in mental status, malaise and fatigue; results: greater than100,000 E. Coli; status: HAI; count: Yes The surveillance listing for Resident #410 failed to indicate all criteria was met for this illness to be counted as an infection, making the surveillance sheet inaccurate. August 2023: Unit 2 Resident #2 category: PNU; date of onset: 8/29/23; symptoms: shortness of breath (SOB), decreased O2 sats; results: positive chest x-ray (CXR) at hospital; status: HAI; count: Yes The surveillance listing for Resident #2 did not indicate the symptoms met McGeer criteria for the illness to count as an infection and therefore the information was inaccurate and potentially incomplete. Unit 3 Resident #41 category: other; date of onset: 8/9/23; symptoms: increased white blood cell count (WBC), odor, urgency; results: less than10,000 (with no identified organism); status: HAI; count: Yes The surveillance listing for resident #41 failed to indicate a site of testing, or any identified organism, and never defined the other for the category. The surveillance form was incomplete and undefined. September 2023 Unit 2 Resident #11 category: UTI; date of onset: 9/10/23; symptoms: nausea and vomit; results: greater than100,000 E.Coli; status: HAI; count: Yes Resident #42 category: PNU; date of onset: 9/30/23; symptoms: cough and congestion; results: positive CXR; status: HAI; count: Yes The surveillance listing for Resident #11 and Resident #42 failed to indicate there were documented symptoms that met the facility defined McGeer criteria to count these illnesses as infections within the facility, making the surveillance inaccurate and potentially incomplete. During an interview on 10/27/23 at 11:16 A.M., the IP stated she does not count any community acquired infection even if they meet criteria, so they do not count against the facility. Therefore, no tracking or trending of community acquired infections is completed and any reactivation of an infection would be counted as an HAI. For Resident #411, she said the infection met criteria and was not counted and should have been. For Resident #2, she said the symptoms did not meet criteria to count the infection, although she did and the surveillance was inaccurate. She stated she is unsure what the symptoms were and the surveillance listing was incomplete and did not meet criteria for an infection per McGeer, making the surveillance inaccurate. For Resident #410, she said he/she did not meet criteria for the UTI to count but counted it anyways to ensure the lab would put it in the statistical data for analysis, however the surveillance and therefore the data would be inaccurate. For Resident #41, when asked what the other category meant, she stated she does not know what that means, and the surveillance is inaccurate and should not have been counted. She said it should have been documented on the surveillance listing what other meant, and there is no way to know at this time, rendering the surveillance inaccurate and incomplete. For Resident #11, she said the surveillance data was inaccurate and should not indicate they met the infection criteria. For Resident #42, she said he/she did not meet the criteria and should not be counted, and the information is inaccurate. The IP went on to say she does not always use the McGeer criteria accurately, according to the reviewed line listings and infections, and realizes she should only count the illness as an infection if the resident actually meets the facility defined criteria. She said she understands the data must be accurate for the facility to have an accurate attack rate to track and trend infections. She said the data was not sufficient per the policy of surveillance and she needed some further education on using the updated McGeer criteria. During an interview on 10/27/23 at 4:38 P.M., Consulting Staff Member #2 and the surveyor reviewed the inaccurate and incomplete data on the surveillance listings. Consulting Staff Member #2 said she understood there are issues and room for improvement. She said the facility would not be capable of having accurate data for analysis and said, Garbage in garbage out. She said improvements are needed to ensure the data on surveillance was an accurate reflection of all infections within the facility. 49425

Based on interview, policy review, grievance review, and review of Resident Council Minutes, the facility failed to ensure residents' grievances were brought forward and the grievance process was implemented, and concerns were resolved in a timely manner. Specifically, the facility failed: 1. For Resident #2, to implement the grievance process for lost laundry; and 2. To address and promptly resolve several grievances regarding lost laundry brought forward during the September 2023 Resident Council Meeting. Findings include: Review of the facility's policy titled Grievance and Compliant Procedure, dated January 2022, indicated but was not limited to the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the government agencies without threat or fear of retaliation. -The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or complainant. -Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding their stay at the facility. -Upon receipt of a grievance or complaint, the facility administrator or designee will review and investigate the allegation and compile documentation of such findings within a reasonable time frame of receiving the grievance/complaint. -The administrator and/or designee will review the findings of the investigation to determine what corrective actions, if any, need to be taken. -The administrator or designee will promptly inform the resident, or person filing the grievance on behalf of the resident, of the findings of the investigation and the actions that will be taken to correct any identified problems. 1. Resident #2 was admitted to the facility in May 2023 with the following diagnoses: cancer, heart failure, anxiety, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/15/23, indicated that Resident #2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. During an interview on 10/25/23 at 10:20 A.M., Resident #2 said he/she has no clothes left, they all went to the laundry and never came back. Resident #2 said he/she has been missing clothes and he/she tells the staff and nobody does anything about it. During an interview on 10/26/23 at 1:28 P.M., Resident #2 said he/she has been missing a cranberry-colored jacket, and just noticed this week that he/she is missing two pairs of shorts (one blue and one black), and a sleeveless, blue nightgown. Resident #2 said he/she has told the nurses and the certified nursing assistants (CNAs) about the missing clothes and they just say they will look for them. During an interview with Unit Manager #1 and Consulting Staff #2 on 10/31/23 at 11:13 A.M., Unit Manager #1 said if a resident loses their clothes, they look in the laundry to see if they can find them. If they can't find them, then she is not sure what the next step is. Consulting Staff #2 said if they can't find the laundry, then the staff will fill out a grievance, and if they don't find the missing laundry, the facility will reimburse the resident. During an interview on 10/31/23 at 11:16 A.M., Activity Assistant #1 said Resident #2 told her on 10/29/23 he/she was missing a cranberry-colored jacket. Activity Assistant #1 said if a resident is missing clothing, she did not fill out a grievance for the resident, she just tells the Director of Laundry about the missing clothing. During an interview on 10/31/23 at 11:17 A.M., Nurse #5 said residents do lose their clothes. She said she also just tells the Director of Laundry about the missing clothes. Review of the Grievance Logs from July 2023 to October 2023 indicated there was only one grievance filed for missing laundry which was on 10/19/23 and it was not Resident #2. During an interview on 10/27/23 at 3:55 P.M., the Administrator said staff should be filling out a grievance for the missing laundry. 2. On 10/27/23 at 10:30 A.M., the surveyor conducted a Resident Group Meeting with 12 residents in attendance, who voiced concerns regarding lost clothing. Twelve out of 12 residents unanimously agreed there is a big problem with lost laundry, making the following complaints: -I have a lot of missing clothes, they never find them once they go missing. -We are supposed to write a list of missing clothes and they try to find them. -I am missing a jacket and clothes. -It took a long time to get my blanket back. -During Resident Council meeting, they said they would put all the clothes on a rack and bring it to the next council meeting. -Another resident said they should not have to wait a month for them to bring the rack of clothes to them. -A third resident said we need our clothes now, not in a month. If you send your clothes to the laundry, some clothes never come back. -Two residents said they did not have pants to come to the Resident Council meeting today and the CNA had to get them a pair from the laundry. One of the residents said the pants he/she was given were not even his/hers. -I have been missing three pairs of non-skid socks for three weeks. Review of the 9/27/23 Resident Council Minutes indicated it was attended by eight residents who raised the concern of a lot of missing items to the Laundry Department. The facility response was answered by the Director of Laundry which included the following statement: -The Laundry Department will make sure their protocol of laundry procedure (illegible word) and make sure our staff are well educated. There was no indication grievances were filled out for the residents' complaints of missing clothing expressed in the September 2023 Resident Council Meeting. Review of the Grievance Logs from July 2023 to October 2023 indicated there was only one grievance filed for missing laundry which was on 10/19/2023. During an interview on 10/27/23 at 3:41 P.M., the Director of Laundry said if a resident is missing clothes, he receives an email from the Administrator notifying him of the resident and the missing clothes. He reviewed his file and there was only one resident complaint dated 10/19/23 since July 2023. The surveyor and the Director of Laundry viewed a full rack of clothes that he said were not labeled. He said if a resident is missing clothes, he will bring the resident's family member down and they can look at the rack for their missing clothes. He said he keeps the unlabeled clothes for three months and then he donates them, adding as you can see, we have a lot. During an interview on 10/27/23 at 3:55 P.M., the Administrator said staff should be filling out a grievance for the missing laundry.

Based on observations, policy review, and interview, the facility failed to ensure all drugs and biologicals were secured in locked compartments with only authorized personnel having access. Findings include: Review of the facility's policy titled Storage of Medications, dated November 2021, indicated but was not limited to: -Medications and biologicals are stored safely and securely following manufacturers' recommendations or those of the supplier. -The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 10/27/23 at 8:34 A.M., the surveyor observed Nurse #1 prepare medications to administer to a resident, placing them into a medication cup. Nurse #1 put the medication cup containing the medications in the medication cart and locked the cart, and then walked away from the medication cart and entered the medication room and closed the door. Nurse #1 left the medication cart unattended and not within this eyesight, with the following medications left on top of the medication cart: -Cardizem (used to treat high blood pressure) one capsule laying on the medication cart -a cup with 17 grams (gm) of Miralax (used to treat constipation) -a medication cup with Guaifenesin (cough suppressant) in it just below the 5-milliliter line -Advair Diskus (used to treat chronic obstructive pulmonary disease) -a bottle of Dairy Aid (used to help treat lactose intolerance) -a bottle of Preser Vision (vitamin for the eyes) -a bottle of Cranberry Tabs -a bottle of Vitamin D3 -a bottle of Miralax On 10/26/23 at 8:39 A.M., five minutes after walking away from the above listed medications, Nurse #1 returned to the medication cart and finished preparing the medication. Nurse #1 took the prepared medication cup, Advair Diskus, and the cup with 17gm of Miralax and went into a resident's room. Nurse #1 left the medication cup with Guaifenesin and bottles of Dairy Aid, Preser Vision, Cranberry Tabs, Vitamin D3 and Miralax on top of the medication cart while in the resident's room. The medication cart was left unattended in the hallway and not in direct view of the Nurse. During an interview on 10/27/23 at 8:59 A.M., Nurse #1 said he should not have walked away from the medication cart with medications left on top and available to anyone. Nurse #1 said he did not follow the process for medication storage. 48695

Based on observations, interviews, record review, and policy review, the facility failed to ensure it was free from a medication error rate of greater than 5% when 1 out of 3 nurses observed made 2 errors out of 28 opportunities, resulting in a medication error rate of 7.14%. Those errors impacted one Resident (#56), out of three residents observed. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines, dated November 2021, indicated but was not limited to: - FIVE RIGHTS-Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. - A triple check of the five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away. - Check #2: Prepare the dose- the dose is removed from the container and verified against the label and the medication administration record (MAR) by reviewing the 5 Rights. - The MAR [Medication Administration Record] is always present and used during medication administration, in addition, prior to administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. - Medications are administered in accordance with written orders of the prescriber. Review of Resident #56's Physician's Orders indicated but were not limited to the following: -Cozaar (a medication that treats high blood pressure) oral Tablet 100 milligrams (mg), give one tablet by mouth one time a day: hold for systolic blood pressure less than 100, dated 2/3/23 -Guaifenesin Syrup (a cough syrup that treats congestion) 100 mg/5 milliliters (ml), give 10 ml by mouth three times a day, dated 12/5/19 On 10/27/23 at 8:16 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #56 including: - Cozaar 100 mg tab, the nurse did not measure the Resident's blood pressure, per the physician's order prior to administering the medication. - Guaifenesin 10mg/5 ml, the Nurse poured the liquid medication and did not verify the dosage in the cup; the surveyor observed the liquid to read above the 10 ml line, but below the 15 ml line. During an interview on 10/27/23 at 8:40 A.M., the surveyor asked Nurse #1 if he was ready to administer the medications to Resident #56 to which he responded yes. The surveyor asked Nurse #1 to confirm the dose of Guaifenesin that had been prepared. Nurse #1 said that he had overpoured and he should have only prepared 10 ml. During an interview on 10/27/23 at 10:34 A.M., Nurse #1 reviewed the order and said he should have taken Resident #56's blood pressure prior to administering the medication per the physician's orders. Nurse #1 said that he did not measure the Resident's blood pressure because he did not know that he had too. Nurse #1 said that usually medications that have parameters will have a box that pops up and asks for blood pressure, but this order did not. 48695

Based on interviews and review of the Health Care Facility Reporting System (HCFRS- State agency reporting system), the facility failed to provide written notice to the State agency when a change in the facility's Administrator and a change in Director of Nursing (DON) occurred. Findings include: Review of HCFRS indicated the last time the State was notified of DON and Administrator changes for the facility were: -change in facility DON occurred on 12/9/19 -change in facility administrator occurred on 5/4/22 Further review of HCFRS failed to indicate the State Agency was notified when the change took place for the current Administrator and current DON as required. During an interview on 10/25/23 at 9:03 A.M., the Administrator said that he started on 4/17/23 and the DON started on 4/24/23. The Administrator said that he thought the changes were made in HCFRS. During an interview on 10/26/23 at 8:35 A.M., the Administrator and surveyor reviewed HCFRS together, the last time the Administrator information was updated for the facility was on 5/4/22 and for the DON the last updated change was on 12/9/19. The Administrator said he thought that he had updated the information, but he had not. Review of HCFRS on 10/26/23 at 4:00 P.M., indicated that the Administrator updated the change of the Administrator and DON for the facility on 10/26/23, five months after they started in the facility. 48695

Based on document review, policy review, and interview, the facility failed to ensure their arbitration agreement specifically provides for the selection of a venue that is convenient to both parties. Findings include: Review of the facility's policy titled Binding Arbitration Agreements, undated, indicated but was not limited to the following: -Agreements provide for the selection of a mutually agreed upon neutral arbitrator and venue Review of the arbitration agreement in use by the facility titled Alternative Dispute Resolution Agreement Between Resident and Facility, undated, failed to identify the use or delineation of a venue for arbitration. During an interview on 10/27/23 at 1:34 P.M., the Administrator reviewed the agreement in use by the facility and said he does not see anything specific about a mutually agreed upon venue that is convenient to both parties and would assume the arbitrator would select the venue. During an interview on 10/31/23 at 1:41 P.M., the regional director of operations reviewed Alternative Dispute Resolution Agreement and said he does not see anything specific, in regard to a venue for arbitration disputes in the document the residents receive and sign. 49425

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had no pressure injuries at time of admission to the Facility, was assessed by nursing to be at high risk for the development of a pressure injury, and whose Hospital Discharge Summary indicated physicians orders for the removal of his/her left knee immobilizer brace twice daily for skin checks, the Facility failed to ensure adequate measures were implemented by nursing to maintain his/her skin integrity to prevent the development of a pressure injury after admission. Approximately two weeks after his/her admission Resident #2 was found to have two pressure injuries to his/her lower left leg, and it was also determined that his/her left knee immobilizer brace had not been removed twice daily by nursing to check his/her skin. Resident #2 required evaluation and treatment by a Wound Physician and also required administration of intravenous Vacomycin and [MEDICATION(S)] (antibiotics) to treat his/her wound infection. Findings Include: Review of Facility Policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated, indicated the following; -nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; -the staff and practitioner will examine the skin if newly admitted residents for evidence of existing pressure ulcers or other skin conditions; -nursing shall describe, document, and report the following; full assessment of pressure ulcer, pain assessment, resident's mobility status, current treatments, and all active diagnoses; -the physician will assist the staff to identify the type of wound; -the physician will order pertinent wound treatments; and -the physician will guide the care plan as appropriate. Resident #2 was admitted to the Facility in August 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Hospital Discharge Summary, dated 8/04/22, indicated to continue with left knee immobilizer brace to left lower extremity at all times. The Summary further indicated that physicians orders included that Resident #2's left knee immobilizer brace was to be removed twice daily for skin assessment. Review of Resident #2's Admission Nursing Evaluation, dated 8/04/22, indicated the following skin areas were identified; bruising at his/her right antecubital (inside the elbow joint) space and the back of his/her right hand. Redness to his/her left antecubital space, right lower leg rear portion, and sacrum. Resident #2's left and right heel were boggy, and left brace noted to his/her left leg. Review of Resident #2's Weekly Skin Check, dated 8/04/22, indicated Resident #2 had skin impairment noted by a check mark, however, there was no documentation to support where the area of impairment was located. Review of Resident #2's Norton Plus Scale (assessment to help predict risk for developing skin breakdown, pressure injuries), dated 8/04/22, indicated he/she was a high risk for developing pressure injuries with a score of 10 (15 or below indicates high risk). Review of Resident #2's Physicians Orders, dated for 8/04/22 through 8/19/22, indicated there was no documentation to support nursing obtained an order to remove Resident #2's left knee immobilizer brace twice daily to conduct skin checks. Review of Resident #2's Treatment Administration Records (TAR), dated 8/04/22 through 8/19/22, indicated there was no documentation to support nurses were removing Resident #2's left knee immobilizer brace twice daily or conducting skin checks. Review of Resident #2's Plan of Care, dated 8/05/22, indicated he/she had a potential/actual impairment to skin integrity related to immobility. Further review of the Plan of Care, indicated there was no documentation to support his/her interventions included the need to remove his/her left leg immobilizer twice daily for skin checks, in an effort to maintain his/her skin integrity. Review of Resident #2's Nurse Practitioner Note, dated 8/09/22, indicated he/she was non-weight bearing to his/her left lower extremity with an immobilizer in place at all times. The Note also indicated Resident #2's left knee immobilizer brace was to be removed twice daily for skin checks. Review of Resident #2's Initial Nutrition Assessment, dated 8/11/22, indicated he/she had no wounds, and to refer to weekly skin noted from 8/04/22. Review of Resident #2's Weekly Skin Assessment, dated 8/11/22, indicated there was a small abrasion to the rear of his/her left lower leg. Review of Resident #2's Weekly Skin Assessment, dated 8/18/22 at 7:29 P.M., indicated he/she had an abrasion with gauze bandage/dressing, and left lower leg immobilized with brace. Review of Resident #2's Initial Wound Evaluation, performed by the Wound Physician (MD), dated 8/18/22, indicated he/she had been referred by Resident #2's Physician to evaluate his/her skin. Resident #2's Wound MD Evaluation indicated the following; Wound Site #1) A full thickness (Stage IV) wound to his/her left calf (of at least one day duration) that measured five by four centimeters (cm), with a surface area of 20.00 cm squared, with moderate serous exudate, and 100 percent thick adherent black necrotic (dead tissue). The Evaluation indicated Wound Site #1 required surgical debridement, initiation of antibiotic use for [CONDITION(S)], and treatment with Santyl (ointment used to remove dead tissues from a wound) as ordered by the Physician. Wound Site #2) A partial thickness (Stage III) wound of the left knee (of at least a one-day duration) that measured five by five cm, with a surface area of 25.00 cm squared, no exudate, and dried fibrinous exudate (scab like). The Evaluation indicated Wound Site #2 required the application of skin prep (protective ointment) and dressing as ordered by the Physician. Review of Resident #2's medical record, indicated there was no documentation to support that his/her left knee immobilizer brace was ever removed by nursing, and in addition there was no documentation by nursing to support they assessed Resident #2's skin underneath the left knee immobilizer brace. During an interview on 9/14/22 at 11:57 A.M., the Physical Therapy Assistant (PTA) said Resident #2's left knee immobilizer brace was always noted to be on incorrectly. The PTA said the left knee immobilizer brace was always down by his/her ankle and it was never really on Resident #2 properly. The PTA said he reported this information to the nursing staff and said he provided education. The PTA said he could not remember who he showed. The PTA said he thinks he taught the Nurse Manager on Resident #2's Unit, but said he had not documented the education. The PTA said he never visualized Resident #2's skin. During an interview on 9/12/22, at 3:31 P.M., Nurse #1 said just the Nurse Manager reads the Hospital Discharge Summaries. Nurse #1 said the Unit Manager put all of Resident #2's medication and treatment orders into the computer. Nurse #1 said there is usually a set protocol order in Point Click Care (PCC, the electronic medical record), for any type of brace and said PCC usually states to remove brace for daily care and to check circulation, sensation, and movement (CSM). During an interview on 9/12/22 at 1:14 P.M., the Unit Manager said she did not catch the instructions in the Hospital Discharge Summary to remove Resident #2's left knee immobilizer brace two times a day for skin checks. The Unit Manager said there is no Wound Nurse in the Facility, so it's the Director of Nurses with each of the Unit Managers doing skin rounds. The Unit Manager said she did not have a chance to look at Resident #2's skin weekly. During an interview on 9/13/22 at 1:37 P.M., the Director of Nurses (DON) said nursing missed the order for Resident #2's left leg immobilizing brace to be removed two times a day for skin checks upon admission. The DON said she expects nursing to ensure skin assessments are a priority. On 9/13/22, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the areas of concern as evidence by: A) On 8/18/22, Resident #2 was seen and treated by the Wound MD. Resident #2 was transferred to the Hospital per family request, and did not return to the Facility. B) On 8/23/22, the Facility conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to review the identified issues and discuss the plan of correction. C) On 8/23/22, the Director of Nurses and the Unit Managers completed an in-house skin check on all Residents and did not identify any new wounds. D) On 8/23/22, the Regional Nurse Consultant conducted a review of all Residents with an existing pressure ulcer injuries. E) On 8/24/22, Physical and Occupational therapy assessed all residents with braces and splints. F) On 8/25/22, the DON and Regional Nurse Consultant completed reviews on all Residents with wounds other than pressure injuries and Residents with braces and or splints. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . G) On 8/88/88, the DON provided education to licensed nursing staff on accuracy of documentation of Resident skin conditions upon admission, which included the following; -any wounds present; -completion of weekly skin checks; -physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -physician notification of any alteration in skin; -obtaining treatment orders; and -updating care plans. H) The DON and/or Designee will audit new admissions daily to ensure skin assessments have been conducted accurately, treatment orders are obtained as needed, and care plans are updated. I) The DON and/or Designee will review orders for braces and splints daily to validate orders to include skin checks with removal and care plans are updated. J) The DON and/or Designee will conduct audits to ensure residents receiving treatments for pressure injuries and/or requiring splints, braces, the treatments are consistent with physicians orders. K) The DON and/or Designee will report on the weekly audits to the Facility's QAPI committee. The audits will continue until it has been determined that compliance has been achieved and maintained at which time the audits will be decreased or resolved based on the recommendations of the QAPI committee. L) The DON and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose medical history included [CONDITION(S)] with hallucinations and behavioral issues, the Facility failed to ensure his/her safety was maintained to prevent an incident of elopement. On 10/07/21 at approximately 7:00 A.M., unbeknownst to staff, Resident #1 left the Facility by exiting through an unlocked mechanical room door that had direct access to the parking, he/she was found outside on the front lawn of a home near the Facility, clothed only in a tee shirt, socks, and a brief, and documented weather conditions that morning were cloudy and 58 degrees Fahrenheit. Findings include: Review of Facility Policy titled Safety and Supervision of Residents, undated, indicated that the Facility strives to make the environment as free from accident hazards as possible and resident safety and supervision assistance to prevent accidents are facility-wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs. Resident #1 was admitted to the Facility in September of 2021, diagnosis included [CONDITION(S)] with behavioral disturbances, hallucinations, hypertension, and [CONDITION(S)]. Review of Resident #1's Hospital Discharge Summary, dated 9/25/21, indicated he/she was very forgetful, was having auditory and sensory hallucinations, and medical history included [CONDITION(S)] with behavioral disturbances. Review of Resident #1's Nursing Progress Note, dated 9/25/21, indicated he/she had a diagnosis of memory impairment and hallucinations. Review of Resident #1's Behavioral Health Note, dated 9/30/21, indicated his/her psychiatric diagnosis included [CONDITION(S)] with hallucinations due to physiological condition, dementia with behavioral disturbances, and adjustment disorder with a depressed mood. Review of the report submitted by the Fire Department, dated 10/20/21, indicated they received a call from a passerby stating an elderly woman was walking down the street with no pants on. Review of the report submitted by the Facility via the Health Care Facility Reporting System, dated 10/15/21, indicated Resident #1 went outside of the Facility to look for his/her son. However, the report did not include that Resident #1 was not dressed appropriately, that he/she was not wearing shoes or pants, and that staff had been unaware that Resident #1 had exited the building. During an interview on 11/01/21 at 12:01 P.M., the Director of Maintenance said that a Vendor had been in the Facility on 10/06/21 to take some pipe measurements located in a mechanical room that was adjacent to the post-acute care unit entrance. The Director of Maintenance said he let the two workers into the locked mechanical room with a key, but said he did not stay with them through the completion of their work. The Maintenance Director said that vendor had been in the Facility several times before and knew he needed to lock the mechanical room door when done. The Maintenance Director said that he did not think to go back to ensure the mechanical room door was locked when the vendor left. During an observation on 11/01/21 at 11:15 A.M., the Surveyor observed the following. Resident #1's room was adjacent to two glass doors that lead to the Post Acute Care Unit, that were unlocked. Once through those two doors there is a mechanical room door on the right, approximately 10 feet away, and adjacent to that was the main entrance door that was locked. Additionally, the mechanical room itself had a second door which lead directly out to the Facility parking lot. The Parking Lot is situated on the side of the Facility which is located on a very busy street with high traffic volume. During an interview on 11/01/21 at 1:21 P.M., Nurse #2 said at the end of her 7:00 A.M. to 7:00 P.M. shift on 10/06/21, Resident #1 had become concerned, angry, and visibly upset about not being able to find telephone numbers to reach his/her son or any family members. Nurse #2 said that Resident #1 said, that if he/she did not get their telephone numbers he/she was going to call the police. Nurse #2 said she called Resident #1's Health Care Agent (HCA), but got no response. Nurse #2 said before she left the faciity on [DATE], she went back to Resident #1 and gave him/her the HCA telephone number incase he/she wanted to try calling again later that evening. Nurse #2 said that she did not document the change in Resident #1's mood and behavior in his/her medical record. Nurse #2 said she was still a new nurse and she did not know what she should be documenting on. Nurse #2 said she did report these findings to the Nursing Supervisor before she left for the evening. During an interview on 11/01/21 at 3:50 P.M., the Director of Nurses said she was not aware that Resident #1 was upset and agitated the evening shift before he/she eloped. The Director of Nurses said that based on the investigation that she conducted, the mechanical room door that Resident #1 had eloped from should not have been left unlocked. The DON said that the Director of Maintenance opened the door for the vendors with a key and he told her that the vendor usually locks the door upon completion. During an interview on 11/01/21 at 4:25 P.M., the Administrator said that whenever a vendor comes into the Facility the Maintenance Director is to follows along with them and ensure the work is complete.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was newly admitted to the Facility, and whose physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was not administered his/her physician ordered [MEDICATION(S)], experienced a stroke, required transfer to the Hospital Emergency Department for further evaluation and was admitted . Finding includes: Review of the Facility's Policy titled, Reconciliation of Medications on Admission, undated, indicated the following: -gather information needed to reconcile the medication list using the discharge summary from referring facility; -list all medications from the discharge summary; -list the dose, route and frequency for all medications; -review the list carefully to determine if there are discrepancies/conflicts; -if there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. Review of the National Institutes of Health, U.S. National Library of Medicine, Drug Label Information, last revised 6/15/20, regarding [MEDICATION(S)], indicated the following: IMPORTANT WARNING: If you have [CONDITION(S)] (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body, and possibly causing strokes) and are taking [MEDICATION(S)] to help prevent strokes or serious blood clots, you are at a higher risk of having a stroke after you stop taking this medication. Do not stop taking [MEDICATION(S)] without talking to your doctor. Review of the Facility's Policy titled, Adverse Consequences and Medication Errors, undated, indicated the following: -a medication error is defined as the preparation or administration of drugs or biological's which is not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -examples of medication errors include: omission - a drug is ordered but not administered; -in the event of a significant medication-related error, immediate action is taken, as necessary, to protect the resident's safety and welfare; significant is defined as requiring hospitalization ; Resident #1 was admitted to the Facility in July 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 8/19/21 indicated the following: -the Hospital notified the Facility to inquire about Resident #1's medication list; -the Facility initiated an internal investigation; -Resident #1 was admitted to the Facility for rehabilitation following a stroke on 7/22/21; -On 8/12/21, Resident #1 was noted to be leaning to the right side, unable to hold his/her head up, had right sided facial drooping and an inability to follow simple directions; -chart review indicated that Resident #1 was on [MEDICATION(S)] at the Hospital and the [MEDICATION(S)] was not continued upon admission to Facility; -the Report indicated that the Nurse who admitted Resident #1 on 7/22/21 said she initiated the admission and then passed it onto the next shift for completion; -Facility concluded that there was a medication omission upon Resident #1's admission to the Facility and the medication omission occurred because lack of second nurse follow up. Review of Resident #1's Hospital Medication List, dated 7/22/2021, indicated that his/her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Hospital Discharge Instructions, dated 7/22/21, indicated Resident #1's last dose of [MEDICATION(S)] had been administered by the Hospital staff at 8:00 A.M., on 7/22/21. Review of Resident #1's Hospital Discharge Instructions, dated 7/22/21, indicated to administer [MEDICATION(S)] 5 mg by mouth every 12 hours, and that the next scheduled dose was due at 8:00 P.M. Further review of Resident #1's Hospital Discharge Instructions, dated 7/22/21, indicated that he/she had bilateral strokes including bilateral PCA (posterior cerebral artery strokes which restrict the blood supply of multiple brain regions, including the occipital lobe, the inferomedial temporal lobe, a large portion of the thalamus, and the upper brainstem and midbrain) with basilar artery [CONDITION(S)] (blood clot) and was newly diagnosed [CONDITION(S)] on [MEDICATION(S)] an anticoagulation. Review of Resident #1's Nurse Practitioner Progress Note, dated 7/23/21, indicated that he/she had a cerebral infarction (stroke) due to [CONDITION(S)] (when a blood clot blocks a vein or artery) and was on [MEDICATION(S)] 5 mg every 12 hours. During an interview on 8/31/21 at 12:30 P.M., the Nurse Practitioner (NP) said that on 7/23/21, the next day following Resident #1's admission to the Facility, she reviewed Resident #1's Hospital Discharge Summary and noted that Resident #1 was on [MEDICATION(S)] 5 mg every 12 hours. The NP said that she did not review or sign Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP said that she does not know how the [MEDICATION(S)] was missed because Resident #1 had experienced a new stroke and said the Hospital Discharge Summary clearly indicated that he/she was on [MEDICATION(S)] for anticoagulation. Review of Resident #1's Nurse Progress Situation Background Assessment Response (SBAR) Change in Condition Note, dated 8/12/21, indicated that Resident #1 was noted to be listing (leaning) to right side, unable to hold himself/herself up with right sided facial droop and inability to speak, answer questions or follow simple commands. The Note indicated that the Nurse Practitioner was notified and ordered that Resident #1 be sent to the hospital via 911 (emergency transport). The Note further indicated that Resident #1 was not on any anticoagulant medications. Review of Resident #1's Medication Administration Order (MAR) and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/31/21 at 11:12 A.M., Unit Manager #1 said that on 7/22/21, she was assisting with Resident #1's admission, said she obtained the medication list from the hospital discharge summary and said she started to input Resident #1's medication list into Point Click Care (PCC) electronic medical record. Unit Manager #1 said at approximately 3:30 P.M., she was asked to attend the daily wrap up meeting and said that she told the 3-11 Nursing Supervisor to check Resident #1's medication and treatment orders in PCC and make sure they match the hospital discharge summary. Unit Manager #1 said that she did not review Resident #1's record for completion or accuracy the next day or at any other point and said she was responsible for reviewing new admission records for completion and accuracy. Unit Manager #1 said, that on 8/12/21 she received a phone call from the Hospital asking if Resident #1 had been receiving [MEDICATION(S)] while at the Facility. Unit Manager #1 said that is when she reviewed Resident #1's medication list and did not see that he/she was receiving [MEDICATION(S)]. Unit Manager #1 then said she reviewed Resident #1's Hospital Discharge Summary and said she noted that Resident #1's hospital discharge summary indicated that he/she had orders to receive [MEDICATION(S)] and said that the [MEDICATION(S)] was missed upon admission. During an interview on 8/31/21 at 3:05 P.M., the Nursing Supervisor said that he was asked by Unit Manager #1 to write a treatment order for Resident #1's wounds and enter the order into PCC. The Nursing Supervisor said that he does not recall being asked to complete Resident #1's medication list and enter it into PCC or complete a medication reconciliation for Resident #1. The Nursing Supervisor said he did not review Resident #1's medication list at all. During an interview on 8/31/21 at 3:55 P.M., the Director of Nurses said that there was a break in communication from where Unit Manager #1 left off in Resident #1's admission process and what was left for the Nursing Supervisor to complete, as well as a break in the medication reconciliation process. The Director of Nurses said that there was a medication error involving an omission of Resident #1's anticoagulant medication upon admission and said that staff did not follow the Facility's medication reconciliation policy. On 8/13/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor's with a plan of correction which addressed the area(s) of concern as evidence by: A) The Facility had an Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting the day the error was identified, 8/13/21 and brought to monthly QAPI on 8/26/21, discussing error, plan, and progress. B) The Facility implemented a facility wide audit starting two weeks prior to the identification of the error, dates included 7/29/21 through 8/12/21. Auditing the discharge summary medications from the admitting hospital against the order summary in Point Click Care (PCC), the facilities electronic medical record. C) The DON/ADON educated nursing staff on 8/13/21 and is ongoing of the Admission Process, Medication Reconciliation, Anticoagulation Usage, Interim Medication Regimen Review, and now a second nurse will be required to review and sign final orders with the original nurse verifying all orders are accurate and complete. D) The DON/ADON will audit all new admissions daily at morning meeting the day after admission and add the finding to the New Admission/Readmission Clinical Audit Tool. The Nursing Supervisor will be responsible for any weekend admissions. E) The DON/Designee will report on the audit results at the monthly QAPI meeting for 90 days. F) The Administrator and Director of Nurses are responsible for the overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical/clinical record, including but not limited to the reconciliation of medications upon admission, when his/her [MEDICATION(S)] (an anticoagulant medication used to treat and prevent blood clots and to prevent stroke) was omitted from his/her prescribed admission medications. Findings include: Review of Facility Policy titled Charting and Documentation, undated indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of Facility Policy titled Reconciliation of Medications on Admission, undated, indicated that the purpose of reconciliation is to ensure medication safety by accounting for each of the resident's medications upon admission. The Policy also indicated medication reconciliation purpose is to compare pre-discharge medications to post-discharge medications, reduces medication errors and enhances resident safety, and ensure that medications are accurately communicated to the Attending Physician and care team. Resident #1 was admitted to the Facility in July 2021, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Hospital Medication List, dated 7/22/2021, indicated that his/her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Hospital Discharge Instructions, dated 7/22/21, indicated Resident #1's last dose of [MEDICATION(S)] had been administered by the Hospital staff at 8:00 A.M., on 2/22/21. Review of Resident #1's Hospital Discharge Instructions, dated 7/22/21, indicated to administer [MEDICATION(S)] 5 mg by mouth every 12 hours, and that the next scheduled dose was due at 8:00 P.M. Review of Nurse Practitioner Progress note, dated 7/23/21, indicated Resident #1 was prescribed [MEDICATION(S)] 5 mg by mouth two times a day. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/31/21 at 11:12 A.M., Unit Manager #1 said that on 7/22/21, she was assisting with Resident #1's admission, said she obtained the medication list from the hospital discharge summary and said she started to input Resident #1's medication list into Point Click Care (PCC) electronic medical record. Unit Manager #1 said at approximately 3:30 P.M., she was asked to attend the daily wrap up meeting and said that she told the 3-11 Nursing Supervisor to check Resident #1's medication and treatment orders in PCC and make sure they matched the hospital discharge summary. Unit Manager #1 said that she did not review Resident #1's record for completion or accuracy the next day or at any other point and said she was responsible for reviewing new admission records for completion and accuracy. Unit Manager #1 said on 8/12/21, she reviewed Resident #1's Hospital Discharge Summary and said she noted that Resident #1's hospital discharge summary indicated that he/she had orders to receive [MEDICATION(S)] and said that the [MEDICATION(S)] was missed upon admission. During an interview on 8/31/21 at 3:05 P.M., the Nursing Supervisor said he does not recall being asked to complete Resident #1's medication list and enter it into PCC or complete any medication reconciliation for Resident #1. The Nursing Supervisor said he did not review Resident #1's medication list at all. During an interview on 8/31/21 at 3:55 P.M., the Director of Nurses said that there was a break in communication from where Unit Manager #1 left off in Resident #1's admission process and what was left to be completed, as well as a break in the medication reconciliation process. The Director of Nurses said that Resident #1's medical record was an inaccurate reflection of what medications should have been ordered leading to additional inaccuracies including but not limited to Resident #1's Physician Orders, Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/13/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor's with a plan of correction which addressed the area(s) of concern as evidence by: A) The Facility had an Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting the day the error was identified, 8/13/21 and brought to monthly QAPI on 8/26/21, discussing error, plan, and progress. B) The Facility implemented a facility wide audit starting two weeks prior to the identification of the error, dates included 7/29/21 through 8/12/21. Auditing the discharge summary medications from the admitting hospital against the order summary in Point Click Care (PCC), the facilities electronic medical record. C) The DON/ADON educated nursing staff on 8/13/21 and is ongoing of the Admission Process, Medication Reconciliation, Anticoagulation Usage, Interim Medication Regimen Review, and now a second nurse will be required to review and sign final orders with the original nurse verifying all orders are accurate and complete. D) The DON/ADON will audit all new admissions daily at morning meeting the day after admission and add the finding to the New Admission/Readmission Clinical Audit Tool. The Nursing Supervisor will be responsible for any weekend admissions. E) The DON/Designee will report on the audit results at the monthly QAPI meeting for 90 days. F) The Administrator and Director of Nurses are responsible for the overall compliance.

Based on policy review, observations, and interviews, the facility failed to maintain a sanitary kitchen environment. Specifically, the facility failed to: 1) maintain clean kitchen equipment including carts, floors, and ventilation; and 2) ensure sanitizing solution was at a proper concentration to sanitize surfaces. Findings include: Review of the policy titled Environment, dated 9/2017, indicated, but is not limited to: -the kitchen is to be maintained in a clean and sanitary manner including floors, walls, ceilings, lighting and ventilation; -all food preparation areas & food service areas will be maintained in a clean and sanitary condition; and -routine cleaning schedules will be in place for all cooking equipment, food storage areas, and surfaces. 1. On 6/23/21 at 9:02 A.M., the surveyor observed the following in the main kitchen: -Dust laden vents and air conditioning (AC) unit -Floors with debris and a black, thick substance in the corners -Thick, black/ brown, sticky substance on the floors around the base of the equipment -The slicer stored dirty with food particles on it -The mixer stored dirty with food particles on it During an interview on 6/23/21 at 9:17 A.M., the Food Service Director (FSD) said the vents were very dirty and doesn't believe the Heating Ventilation and Air Conditioning (HVAC) company cleans the vents or the outside of the AC unit. On 6/23/21 at 12:48 P.M., the Regional Dietary Manager (RDM), the FSD and two surveyors made the following observations in the kitchen: -The AC unit was very dirty -A cart had dried food splatter and crumbs on it. In addition, the cart had many gouges in its surface making the surface porous -Food delivery trucks had a ring of a dark brown sticky substance around the perimeter of the base -Two plastic cutting boards (next to the stove) were worn with porous surfaces During an interview on 6/23/21 at 12:50 P.M. with the RDM and FSD, the RDM confirmed the AC unit was dirty and said it should not be in the kitchen in that condition. The RDM said the cart was porous and in disrepair and could not be properly sanitized and therefore unsanitary. The FSD agreed the cart was dirty and therefore the items on it were dirty. The FSD said the delivery trucks needed cleaning. The FSD said they were supposed to be removed from service because the old boards are porous and can hide germs and cannot be sanitized properly. Review of the dietary cleaning schedules and assignments indicated there were 17 items that were not completed and had not been initialed by staff as having been completed. Items not signed off as completed for cleaning tasks included, but were not limited to: food delivery carts, trayline table top and bottom shelf, clean starter station, clean condiment containers, and clean utensil drawers. During an interview on 6/23/21 at 2:31 P.M., the FSD had no explanation as to why the cleaning tasks were not completed. 2. Review of the Sanitizer Bucket/Sink Filling Procedure, undated, indicated the sanitizer (quaternary compound) is to read between 200 and 400 parts per million (PPM) for effective use, based on the guidelines on the test strip container and that the sanitizer should be changed every two hours. During an observation and interview on 6/23/21 at 12:40 P.M., the surveyor observed a red bucket filled with liquid at the prep area by Cook #1. Cook #1 said the bucket filled with sanitizing solution is used to sanitize surfaces. At the surveyor's request, Cook #1 obtained a testing strip and tested the sanitizer concentration. The test strip did not change color (reading of zero on the test chart), indicating the solution was incapable of sanitizing surfaces or killing germs. Cook #1 confirmed the liquid was not at the proper concentration to sanitize surfaces. During an observation and interview on 6/23/21 at 4:45 P.M., the surveyor observed a red sanitizer bucket filled with liquid at the prep area and requested the solution be tested by the FSD. The FSD retrieved a test strip and tested the solution in the bucket. The test strip did not change color (reading of zero on the test chart) indicating there was not a sufficient amount of sanitizer in the bucket. The FSD said the water in the bucket could not be used to sanitize anything and he did not know why the sanitation bucket tested twice today did not contain any sanitizer.

Based on observations, interview, and record review, the facility failed to implement the plan of care for one Resident (#72), out of a total sample of 25 residents. Specifically, the facility failed to cue the Resident during meal time. Findings include: Resident #72 was admitted to the facility in January 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the nursing progress notes, dated 5/6/21, indicated Resident #72 had been coughing during eating. Review of the care plans for Resident #72 indicated: Interventions: -allow extra time to eat; -encourage good food and fluid intake; and -encourage small sips. Review of the Certified Nursing Assistant (CNA) care card indicated the Resident needed cueing to take small bites, take a drink every so often with eating, encourage alternating between solid foods and liquids, encourage small sips, ensure Resident is 90 degrees in bed, remind to eat slowly, to chew thoroughly and to monitor for pocketing of food, prolonged swallow time, coughing or throat clearing. On 6/25/21 at 8:01 A.M., the surveyor observed Resident #72 in bed, sitting at a 75 degree angle (not at 90 degrees as indicated on the care card). The Resident was observed to be breaking up pieces of bread and putting it in the oatmeal. There was no staff with the Resident to provide cueing for safe swallowing strategies. At 8:16 A.M., the Resident was observed to be placing pieces of bread into the cup of coffee; there was no staff with the Resident. During an interview on 6/25/21 at 12:12 P.M., the Speech Therapist (SLP) said Resident #72 ate all meals in the unit dining room. He said the staff had been educated to provide the Resident with cueing to encourage sips between bites and to decrease talking while eating. On 6/29/21 at 8:06 A.M., the surveyor approached the closed room door of Resident #72 and entered the room. The Resident was observed behind a closed privacy curtain, in bed with a breakfast tray on the overbed table. The Resident was observed to be feeding him/herself. There was no staff there to provide the Resident with cueing. During an interview on 6/29/21 at 9:24 A.M., Certified Nursing Assistant (CNA) #2 said she was caring for Resident #72. She said the Resident was provided set-up for meals (opening containers); was independent with eating; and that she did not provide cueing during meals. During an interview on 6/30/21 at 9:23 A.M., Unit Manager #3 said Resident #72 ate independently and sometimes could be reminded to have a drink, but there were no other cues provided. During an interview on 6/30/21 at 9:33 A.M., with the SLP and Unit Manager #3, the SLP said the Resident could eat independently, but needed cueing for small bites and sips between bites. The surveyor inquired as to who was cueing the Resident when he/she was eating in bed, alone. The SLP said he was not aware Resident #72 was eating in his/her room. Unit Manager #3 said she was not aware Resident #72 needed to be eating in the unit dining room for all meals to ensure cueing.