Every finding on record at Williamstown Commons Nursing & Rehab

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her healthcare needs, the Facility failed to ensure he/she was treated in a respectful and dignified manner, when although Resident #1 said the words no and stop to Certified Nurse Aide (CNA) #1 during the provision of care, CNA #1 did not honor Resident #1's wishes, and continued with care. Findings include: Review of the Facility's policy, titled, Resident Rights, dated as revised 10/04/23, indicated the Facility must treat each resident with respect and dignity that promotes maintenance or enhancement of his or her quality of life and recognizing each resident's individuality. The facility must protect and promote the rights of the resident.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) dated, 02/28/26, indicated that after receiving care, Resident #1 kept saying, she hurt me (referring to Certified Nurse Aide (CNA) #1).Review of the Facility Investigation Summary, dated 02/28/26, indicated the following:-On 02/28/26 at approximately 7:40 A.M., the nurse reported Resident #1 stated, I hurt, I hurt, she is bad, she is bad.-The nurse said Resident #1 was unable to elaborate on what he/she was saying.-Upon interview with the Director of Nursing (DON) and the Weekend Supervisor, CNA #1 said she provided care to Resident #1 the morning of 02/28/26, that Resident #1 was not acting him/herself, that he/she said no and stop and said she continued to provide care to him/her.Resident #1 was admitted to the Facility in August 2022, diagnoses included unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 02/17/26, indicated Resident #1 was severely cognitively impaired with a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). The Assessment also indicated Resident #1 was dependent on staff for activities of daily living such as dressing, bathing, and hygiene.Resident #1 was unable to be interviewed due to his/her severe cognitive impairment.During a telephone interview on 03/31/26 at 1:30 P.M, which included a review of her written witness statement dated 02/28/26, Nurse #1 said she was working the day shift on 02/28/26 and knew Resident #1 very well.Nurse #1 said CNA #1 was floated to Unit 3 (where Resident #1 resided) from another Unit after the shift began and she said she saw CNA #1 enter Resident #1's room. Nurse #1 said she went down to Resident #1's room (exact time unknown) to check in with CNA #1 and to go over what her assignment would be for the shift and plans for the day.Nurse #1 said when she entered the room, she observed CNA #1 trying to put a shirt on Resident #1 in an abrupt manner and said she noticed Resident #1 had an anxious look on his/her face.Nurse #1 said she told CNA #1 that she would finish dressing Resident #1, then she (Nurse #1) proceeded to put Resident #1's shirt on him/her without issue. Nurse #1 said she told CNA #1 that she would be right back and said she went and told Nurse #2 she did not like the interaction between CNA #1 and Resident #1. Nurse #1 then said she called the Weekend Supervisor to ask CNA #1 be sent back to Unit 2 and asked her if there was a different CNA with more patience that could come to Unit 3 instead.Nurse #1 said she immediately went back to Resident #1's room, said that Resident #1 was seated at the edge of his/her bed, said he/she appeared anxious and repeated the words, stop, don't hurt me. Nurse #1 said she and CNA #1 assisted Resident #1 into his/her wheelchair and CNA #1 wheeled Resident #1 out to the nurses' station next to Nurse #2. Nurse #1 said she and Nurse #2 contacted the Weekend Supervisor immediately, explained the situation, and per the Supervisor's request, instructed CNA #1 to report to the Supervisor's office.Nurse #1 said if staff are providing care to a resident and they refuse care or ask you to stop, you are supposed to stop what you are doing and try to re-approach them later if possible.During a telephone interview on 03/31/26 at 1:45 P.M., which included a review of her written witness statement, dated 02/28/26, Nurse #2 said she was working on Unit 3 during the day shift on 02/28/26, that she usually works on Unit 3 and knew Resident #1 very well.Nurse #2 said on 02/28/26 at approximately 7:40 A.M., she was at her medication cart next to the nurses' station and CNA #1 wheeled Resident #1 and parked him/her in his/her wheelchair next to her. Nurse #2 said Resident #1 repeated the words, I hurt, I hurt and that he/she was hugging him/herself. Nurse #2 said Resident #1 often has a difficult time expressing him/herself and often speaks in word salad (confused mixture of seemingly random words and phrases) and was unable to verbalize what he/she was upset about.Nurse #2 said if staff are providing care for a resident and they tell you to stop you should not continue, whether they have dementia or not.During a telephone interview on 02/28/26 at 4:15 P.M., the Weekend Supervisor said she was on duty during the day shift on 02/28/26 and was aware of the situation regarding Resident #1 and CNA #1.The Weekend Supervisor said she was aware there was a problem on Unit 3 when Nurse #1 and Nurse #2 called (exact time unknown) to tell her they wanted to send CNA #1 back to Unit #2. The Weekend Supervisor said she instructed Nurse #1 and Nurse #2 to ask CNA #1 to leave Unit 3 and report to the Unit 2 break room.The Weekend Supervisor said Nurse #1 told her that she went to Resident #1's room twice to assist CNA #1 and that Nurse #1 had also said that CNA #1 was not gentle in her approach with regard to caring for Resident #1.The Weekend Supervisor said she attempted to speak with Resident #1, that Resident #1 said something like, she hurt me, said that his/her arms were crossed in front of him/her and said he/she appeared anxious.The Weekend Supervisor said she called the Director of Nursing (DON) told her about the incident, and that the DON interviewed CNA #1 in her presence via speakerphone.The Weekend Supervisor said the DON asked CNA #1 to explain how she provided care to Resident #1 that morning, that CNA #1 said Resident #1 was not acting like him/herself, and said he/she said no and stop while she was providing care.The Weekend Supervisor said the DON asked CNA #1 if she stopped care after Resident #1 said no and stop and that CNA #1 told them she had not stopped. The Weekend Supervisor said CNA #1 refused to write a statement about the incident and that she told them quit.The Weekend Supervisor said it was the expectation of staff, that when they are providing care and a resident is resisting care or verbally says to stop, that the caregiver stops what they are doing.During an interview on 02/28/26 at 4:45 P.M., the DON said on 02/28/26 the Weekend Supervisor called her to tell her nursing reported a concern regarding care provided by CNA #1 to Resident #1. The DON said she provided education to CNA #1 immediately and told her it was expected if a resident ever says no, or stop, that you stop whatever it is you are doing.

Based on observations and interviews the facility failed to ensure its staff prepared, distributed and served food in accordance with professional standards for food service safety. Specifically, facility staff failed to ensure: facial hair was covered by two staff members and, one staff performed hand hygiene when they stepped away from the food tray line, touched other high touch services and, returned to the food tray line, increasing opportunities for cross contamination of exposed food. Findings include: Review of the facility policy titled Dietary: Sanitary Conditions approved on 10/27/22 indicated the following: -Hair nets and beard restraints must be worn when entering the main kitchen area. -Hand washing:.it is critical that staff involved in food preparation consistently utilize good hygiene practices and techniques for hand hygiene. On 3/25/26 from 11:30 A.M. to 12:15 P.M., the following was observed in the kitchen: -two Dietary Aides (Dietary Aide #1 and Dietary Aide #2) on the tray line with facial hair not wearing beard protectors -Dietary Aide #1 stepped off the tray line to answer the phone, picked up a pen from the counter, wrote notes on the notepad, replaced the phone and pen and returned to the tray line without performing hand hygiene. During an interview following these observations the Food Service Director (FSD) said staff should be wearing beard protectors when they have facial hair. The FSD said Dietary Aides #1 and #2 were not wearing beard protectors as required during the tray line. The FSD said when staff leave the tray line at any time, they are required to wash their hands before going back to the tray line. The FSD said when Dietary Aide #1 stepped off the tray line to answer the phone and write down the order, he should have washed his hands before going back to the line to prevent cross contamination. During an interview 3/25/26 at 12:40 P.M., Dietary Aide #1 said he stepped away from the tray line to answer the phone, wrote down an order and went to the walk-in freezer to gather items. Dietary Aide #1 said before he returned to the tray line to finish placing items on the trays, he should have washed his hands and did not.

Based on observations, interviews and records reviewed, the facility failed to maintain a safe and sanitary environment for two Residents with urinary catheters (#102 and #58), of five applicable residents reviewed with urinary catheters, out of a total sample of 26 residents. The facility also failed to ensure hand hygiene was performed during distribution of medications and that shared medical equipment was cleaned and disinfected between resident use on one unit (Unit 3), of three units observed. Specifically,For Resident #102, the facility failed to ensure that the Resident's indwelling urinary catheter drainage bag was not touching the floor on 3/24/26 and 3/25/26, increasing the Resident's risk for infection.For Resident #58, the facility failed to ensure the Resident's indwelling urinary catheter drainage bag and tubing were not touching the floor increasing the potential risk of infection.Nurse #1 failed to perform hand hygiene during medication distribution when she donned gloves, touched the computer and then touched a pill for resident consumption with the same gloved hands. Nurse #1 also failed to ensure hand hygiene was performed throughout medication distribution after doffing used gloves and before applying new gloves. During medication observation, Nurse #1 failed to disinfect shared medical equipment (vitals machine, blood pressure cuff and stethoscope) when used for multiple residents increasing the risk of cross contamination and potential spread of infection. Findings include:1.Resident #102 was admitted to the facility in February 2026, with diagnoses including retention of urine and chronic kidney disease. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #102: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 10 out of a possible score of 15. -had a diagnosis of renal insufficiency, renal failure or End-Stage Renal Disease. Review of Resident #102's Foley Catheter Care Plan, initiated 2/23/26, indicated: -Goal: The Resident would show no signs or symptoms of urinary infection. -Interventions: The Resident has a 14 French 10 milliliter (ml) indwelling Foley catheter. Review of Resident #102's Self-Care Care Plan, initiated 2/18/26, indicated: -The Resident has an alteration in ability to provide self-care/perform Activities of Daily Living (ADL's) due to functional decline and weakness. -Goal: The Resident will maintain comfort, cleanliness, and dignity. Review of Resident #102's active Care Card, undated, indicated: -The Resident is dependent on staff for toileting. -The Resident is maximum assistance for hygiene. -The Resident is maximum assistance for bed mobility. Review of Resident #102's active Order Summary Report indicated: -Urinary catheter: 14 French 10 cubic centimeters (cc) bulb every shift. Start date 3/6/26. On 3/24/26 at 11:07 A.M., the surveyor observed Resident #102 lying in bed, with his/her indwelling urinary catheter attached to the bedframe and hanging onto the floor with a portion of the bag lying on the floor. On 3/25/26 at 8:27 A.M., the surveyor observed Resident #102 lying in bed, with his/her indwelling urinary catheter attached to the bedframe and hanging onto the floor with a portion of the bag lying on the floor. During an interview on 3/25/26 at 8:31 A.M., Certified Nursing Assistant (CNA) #2 said that when the indwelling urinary catheter drainage bag was hanging on the floor, there was a concern for cross-contamination. CNA #2 said the indwelling urinary catheter drainage bag had the potential to touch Resident #102's skin after touching the floor. During an interview on 3/25/26 at 9:49 A.M., Nurse #3 said that indwelling urinary catheter drainage bags should not be touching the floor. She said that the floor is dirty, and the drainage bag's spout could touch the floor, which could lead to an infection in Resident #102. During an interview on 3/25/26 at 4:08 P.M., the Director of Nursing (DON) said that indwelling urinary catheter drainage bags should not be touching the floor. The DON said that when indwelling urinary catheter drainage bags were touching the floor, it would be an infection control concern. 2. Resident #58 was admitted to the facility in facility in January 2026 with diagnoses including Dementia, Bladder Cancer and Acute Urinary Retention. Review of the MDS Assessment, dated 1/9/26 indicated the following relative to Resident #58: -He/She had severe cognitive impairment as evidenced by a score of zero out of 15 possible points on the BIMS exam. -Dependent on staff with toileting, personal hygiene -Required assistance from staff with transfers. -Had an indwelling catheter. Review of the Resident's comprehensive plan of care included the following: -Activities of Daily Living (ADL) Care Plan, initiated 3/5/26, indicated the Resident was dependent on staff for wheelchair locomotion, and toileting needs. The plan of care indicated the Resident had a catheter. -Urinary Catheter Care Plan, initiated 3/4/26, included the following interventions: >secure catheter to prevent pulling and injury (3/6/26) >position the catheter (urinary drainage) bag and tubing below the level of the bladder (3/4/26) Review of the March 2026 Physician's Orders included the following: -Urinary Catheter care every shift, initiated 1/29/26 -Enhanced Barrier Precautions (EBP), initiated 3/5/26, for foley catheter and ESBL (Extended-Spectrum Beta Lactamase: an enzyme produced by certain bacteria that makes them resistant to many common antibiotics) in the urine. -Urinary Catheter: 14 French (Fr= unit of measure) 5 milliliter (ml) balloon, may change as needed .initiated 3/4/26. On 3/25/26 at 7:46 A.M., 8:46 A.M., and 9:02 A.M., the surveyor observed Resident #58 dressed and seated in a specialized wheelchair with the urinary drainage bag and tubing resting on the floor. At 9:11 A.M., a Certified Nurse Aide (CNA) approached the Resident and provided him/her with a tactile activity blanket. During these observations, several staff were observed walking by and occasionally engaging with the Resident. On 3/25/26 at 4:31 P.M., Resident #58 was observed seated in specialized wheelchair in the common area. The urinary drainage bag and tubing remained on the floor. At 4:35 A.M., CNA #1 approached Resident #58 and assisted him/her to the Unit Dining room. While transporting Resident #58 in his/her wheelchair from the common area to the Unit dining room, the urinary drainage bag and tubing could be heard dragging on the carpet. During an interview on 3/25/26 at 4:45 P.M., CNA #1 said Resident #58 was dependent with ADL care and had a urinary catheter. CNA #1 said the Resident would often fiddle with his/her catheter tubing and that the catheter and urinary drainage bag should be positioned low for drainage. At this time, the surveyor and CNA #1 observed Resident #58. CNA #1 said the Resident's urinary drainage bag and tubing were on the floor. CNA #1 said the urinary drainage bag/tubing could get caught and/or punctured because of the positioning and would also be a concern for infection because it is on the floor. During an interview on 3/25/26 at 4:54 P.M., Nurse #2 said Resident #58 consistently pulls on his/her catheter tubing, pant leg and will sometimes put the urinary drainage bag on his/her lap. Nurse #2 said if the Resident's urinary drainage bag and tubing lying on the floor would be an infection control concern. Nurse #2 said Resident # 58 has a history of urinary tract infections, and that staff should be keeping an eye on the catheter tubing and urinary drainage bag and reposition it as needed. During an interview on 3/26/26 at 10:39 A.M., Unit Manager (UM) #1 said Resident #58's urinary catheter tubing and drainage bag should not be on the floor and that this would be an infection control concern. 3. Review of the facility policy titled Environmental Surface Cleaning, revised November 2016, indicated the following: -PDI Super Sani Plus or Clorox Hydrogen Peroxide Canister Wipes should be used by nursing staff to clean all equipment used by multiple residents. This includes thermometers, blood pressure (BP) cuffs and stethoscopes, pulse oximetry monitors Review of the facility policy titled Hand Washing and Hand Hygiene, revised November 2016, indicated hand hygiene is the single most important method to prevent the spread of infection and is an important component of any infection prevention and control program. The policy also included the following: -When to wash or hand rub: >before and after having direct contact with residents/patients >before application of gloves and after removing gloves or other Personal Protective Equipment (PPE) >After contact with objects in the resident/patient environment including equipment or personal items in the resident/patient immediate vicinity On 3/25/26 from 9:22 A.M. through 12:35 P.M., during medication distribution, the surveyor observed Nurse #1 to do the following: -9:22 A.M. returned to medication cart wearing gloves, discarded the gloves in the trash, did not perform hand hygiene, dispensed numerous medications into medication cup, put on new gloves and then touched the computer mouse with the same gloved hands. Nurse #1 took a gloved finger and removed a pill from the medication cup, crushed the remaining medications and added applesauce into the medication cup with the crushed pills and then discarded her gloves into the trash (did not perform hand hygiene). Nurse #1 poured a glass with water, touched straws, then while holding medications, and cups of water and another cup of red juice, approached Resident #58 and took the interactive activity blanket off the floor and put it on the Resident's lap (did not perform hand hygiene), then walked into a Resident's room with the cups of fluid and medications. -9:30 A.M. Nurse #1 exited the resident room, approached another resident who was seated in a wheelchair near the nursing station with putting on his/her slipper, and then returned to medication cart and began dispensing medications (did not perform hand hygiene). -9:58 A.M., Nurse #1 observed to take vitals machine and enter room [ROOM NUMBER]. Surveyor observed the Nurse obtain the Resident's vitals and exit the room but did not clean/disinfect the vitals machine. Nurse #1 placed the vitals machine outside of room [ROOM NUMBER]. -12:27 P.M., Nurse #1 took the vitals machine and approached a Resident who was seated in the activity room. Nurse #1 applied the BP cuff around the Resident's right arm and obtained measurements. Nurse #1 then removed the BP cuff and wheeled the vitals machine near the nursing station (did not disinfect the machine). Nurse #1 then opened the bottom drawer of the medication cart, retrieved a manual BP cuff and stethoscope and completed another set of vitals on the Resident. After the measurements were obtained, Nurse #1 removed the BP cuff from the Resident, folded it up and placed it back in the last drawer of the medication cart along with the used stethoscope (did not disinfect the equipment). During an interview on 3/25/26 at 12:35 P.M., Nurse #1 said when opening medication capsules, touching resident medications, gloves should be worn. Nurse #1 said hand hygiene should occur before entering and after exiting resident rooms and after removing gloves. At this time, the surveyor relayed observations from medication pass and when obtaining resident vitals. Nurse #1 said she did not perform hand hygiene when she removed her gloves and used her gloved hand to remove a medication from the medication cup after touching the computer mouse. Nurse #1 said the vitals machine and the BP cuff and stethoscope are shared medical equipment that is used for multiple residents. Nurse #1 said she did not disinfect the shared medical equipment between resident use because she was not aware that she needed to. Nurse #1 said her understanding was that the shared medical equipment would only need to be disinfected if used for a resident on precautions. During an interview on 3/26/26 at 10:39 A.M., UM #1 said hand hygiene should occur anytime gloves are discarded. UM #1 said there was a potential for cross contamination when Nurse #1 touched the computer mouse with her gloved hands and then touched the pill in the prepared medication cup. UM #1 said shared medical equipment should be disinfected with the approved cleaning product after each use with a resident and prior to using on another resident and shared medical equipment included the vitals machine and the stethoscope and manual BP cuff.

Based on observations, interviews, and record review, the facility failed to ensure each resident received food that was palatable and served at an appetizing temperature for three units (Unit 1, Unit 2 and Unit 3), out of three units, and for three sampled Residents ( #4, #93 and #136), out of a total of 26 sampled residents. Specifically, the facility failed to ensure the food provided during meals was appetizing in taste, temperature and appearance. Findings include: 1. During the initial pool process on 3/24/26 from 8:30 A.M. to approximately 2:39 P.M., residents residing in the facility said the following: -Resident #82, who resided on Unit 2, said the food was terrible, and he/she has lost seven pounds since being admitted to the facility. -Resident #93, who resided on Unit 1, said he/she receives sandwiches and will only eat the filling because the bread does not look fresh. -Resident #4, who resided on Unit 2, said portion sizes for food is never enough and he/she does not receive extra food when requested. -Resident #136, who resided on Unit 2 said the food sucks, is lousy tasting, is bland and he/she is not eating the meals because he/she did not like the taste. On 3/25/26 at 11:30 A.M., the surveyor requested test trays during lunch service for Units 1, 2 and 3 from the Food Service Supervisor. On 3/25/26 at 11:46 A.M. through 11:59 A.M., the meal cart arrived to Unit 3 and the surveyor observed the following: -11:47 A.M. resident meals were distributed by the facility staff. -11:59 A.M. the last resident meal tray was served. The surveyor obtained the test tray from the meal cart and the following temperatures were obtained with the Minimum Data Set (MDS) Nurse: >Meal was served on a divided plate. >Pureed veal with gravy: 110 degrees Fahrenheit (F), not hot, lukewarm and was loose, liquid consistency and did not hold shape/form. Not palatable. >Pureed carrots: 111 degrees F, lukewarm. >Mashed potatoes with gravy: 125 degrees F, warm, bland, was not palatable. >Strawberry ice cream: 20 degrees F, melted around the edges with firmer ball of ice cream in the middle. Not palatable. At 12:13 P.M., the surveyor observed Nurse #1 provide several of the residents who were seated for the lunch meal in the Unit 3 dining room with strawberry milkshakes. During an interview at this time, Nurse #1 said she took the strawberry ice cream and made milkshakes for the residents because the ice cream was melted. On 3/25/26 at 12:07 P.M., the lunch cart arrived to Unit 2. At 12:12 P.M., the last resident lunch meal was distributed, and the test tray was obtained from the meal cart. The surveyor and the Admissions Staff completed the test tray, and the following temperatures were obtained: >Macaroni and cheese: 120 degrees F, not hot >Stewed tomatoes: 95 degrees F, warm On 3/25/26 at 12:17 P.M., the lunch cart arrived to Unit 1. At 12:37 P.M., the last resident lunch meal was distributed, and the test tray was obtained from the meal cart. The surveyor completed the test tray at this time, and the following temperatures were obtained: >Veal cutlet with gravy: 90 degrees F, warm >Mashed potatoes with gravy: 100 degrees F, warmish, bland. Not palatable >Mixed vegetables: 85 degrees F, slightly warm During an interview on 3/25/26 at 4:12 P.M., the surveyor relayed the test tray observations to the Registered Dietitian (RD). The RD said there have been several residents who have complained about the temperature of the food during meals. The RD said when food is pureed, it should hold its shape and not be loose or spread out on the plate when served. During an interview on 3/26/26 at 7:38 A.M., the Food Service Supervisor said she was aware of the residents' concerns pertaining to food temperatures. The Food Service Supervisor said the temperatures of the hot food when provided to the residents should be 150 degrees or hotter and for the cold foods to be 38-39 degrees or colder. The Food Service Supervisor said temperatures are taken frequently during meal service in the facility kitchen and are at the appropriate temperatures for service. The Food Service Supervisor further said the facility previously utilized heated metal inserts to assist with keeping the hot food hot, but these were discarded and not in use for the past several years. The surveyor relayed the test tray observations at this time, and the Food Service Supervisor said the mashed potatoes were instant and did not have flavor, and that the pureed food should maintain its shape and not be loose. The Food Service Supervisor said the cooks should be testing, tasting the resident food and adding additional seasoning to flavor it. 2. Resident # 93 was admitted to the facility in March 2024 and had diagnoses including Dysphagia and Peritonsillar Abscess. Review of Resident #93's MDS Assessment, dated 2/14/26, indicated he/she was cognitively intact and scored a 15 out of possible 15 on the Brief Interview of Mental status (BIMS) exam. During an interview on 3/25/26 at 9:04 A.M., Resident #93 said that he/she did not eat the scrambled eggs and potatoes on the breakfast plate because they were cold. Resident #93 said he/she had put the cold items to the side because they were unappetizing. During an interview on 3/25/26 at 11:25 A.M., Resident #93 said that staff members did not offer to warm up the scrambled eggs and potatoes and if they had, he/she would have eaten them. Resident #93 said that he/ she often received cold food and will not eat it. During an interview on 3/25/26 at 2:43 P.M., Resident #93 said that the eggs are served cold every morning and had not been appetizing to eat. Resident #93 said that he/ she had not eaten the plated breakfast food for the past several weeks because of the temperature. He/she said that staff had not offered to heat up the cold food items and did not provide an alternative option. Resident #93 said that he/she tried to be reasonable but if the food items were served warmer he/she would be able to eat more. During an interview on 3/25/26 at 4:22 P.M., the Director of Nursing (DON) said that if a resident did not eat their meal, staff should ask the resident why they did not eat the meal, and then offer the alternative food items or offer to reheat the meal if the food complaint was that the meal was too cold to eat.

Based on observation, interviews, and records reviewed, the facility failed to ensure that the appropriate enteral feeding (nutrients delivered through a feeding tube directly into the stomach, duodenum or jejunum) treatment was provided for one Resident (#2) of one applicable resident, out of a total sample of 26 Residents. Specifically, for Resident #2, the facility failed to administer enteral nutrition according to the Physician's order and administered more than the prescribed volume of enteral nutrition, placing the Resident at an increased risk for complications of enteral feeding including aspiration pneumonia, diarrhea, and vomiting. Findings include:Review of the facility policy titled Enteral Tube Medication Administration, effective June 2019, indicated that the facility assures the safe and effective administration of enteral formulas.via enteral tubes. Resident #2 re-admitted to the facility in September 2025, with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (stroke), morbid obesity due to excess calories, dementia, and End-Stage Renal Disease. Review of Resident #2's March 2026 Order Summary Report indicated the following:-Nothing by mouth (NPO) diet, NPO texture, NPO consistency, related to dysphagia following cerebral infarction. Start date 2/4/26.-Enteral Feed Order five times a day related to dysphagia following cerebral infarction. Enteral nutrition via gravity or bolus (administration of a limited volume of enteral formula over brief periods of time). Formula: Jevity. Strength: 1.5 calories (cal). Volume to administer: 240 milliliters (ml) five times a day. Total formula volume: 264 ml x 5 bolus. Total free water volume: 60 ml before and after bolus administration. Start date: 2/4/26. Review of Resident #2's Tube Feeding Care Plan, initiated 3/3/26, indicated:- the Resident is dependent with tube feeding and water flushes.- see Physician's orders for current feeding orders. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #2:was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 13 out of a possible score of 15.had a diagnosis of malnutrition/risk for malnutrition.had a feeding tube. On 3/26/26 at 11:50 A.M., during an observation of enteral feeding administration, Nurse #6 administered two containers of Jevity 1.5 cal. Each container of Jevity 1.5 cal was observed to contain 237 ml of enteral nutrition.During an interview on 3/26/26 at 12:12 P.M., Nurse #6 said Resident #2 was ordered to receive 240 ml of Jevity 1.5 cal. Nurse #6 said the Resident received too much enteral nutrition, stating that the Resident received two containers of Jevity 1.5 cal, each containing 237 ml. During an interview on 3/26/26 at 1:29 P.M., Nurse Practitioner (NP) #1 said the expectation was that nurses followed the Provider's orders. NP #1 said Resident #2 would be monitored due to receiving more than the Physician-ordered enteral nutrition. NP #1 said that monitoring for nausea, vomiting, abdominal pain and residuals (volume of stomach contents remaining in the stomach after a feeding) was indicated. During an interview on 3/26/26 at 3:41 P.M., the Director of Nursing (DON) said Resident #2 was being monitored for abdominal distention, abdominal discomfort, vomiting, and residual volume after he/she received more than the Physician-ordered volume of enteral nutrition.

Based on observations, interviews, and records reviewed, the facility failed to ensure that pain management was provided in accordance with the individual goals for care and preferences for one Resident (#80) out of a total sample of 26 residents.Specifically, for Resident #80, the facility failed to implement the order for Morphine (short-acting opioid medication used to treat moderate to severe pain) medication as indicated by the Physician, resulting in an increased risk for physical pain and psychological upset for the Resident.Findings include:Review of the facility policy titled Management of Controlled Substances in Skilled Nursing Facilities, effective February 2009 and revised July 2025, indicated but was not limited to the following:Ordering of controlled substances:.A new order shall be entered into the Medication Administration (MAR). In addition, an electronic prescription from an authorized prescriber shall be transmitted from a software application that meets Drug Enforcement Administration (DEA) requirements. Alternatively, a valid written prescription that is fazed by an authorized prescriber may be provided. Review of the facility policy titled Pain Management Policy, effective May 2005 and revised December 2025, indicated but was not limited to the following:-Policy: Pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.-Procedure.An individualized, interdisciplinary care plan will be developed and include pharmacological.approaches with input from: Resident.Medical Providers. Resident #80 was admitted to the facility in March 2026, with diagnoses including fracture of left patella (kneecap), dislocation of patella, anxiety disorder, and sprain of the right wrist. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #80:was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 15 out of a possible score of 15.was not prescribed an opioid medication.did not receive a scheduled pain medication regimen.had presence of pain frequently, which occasionally effected his/her sleep.pain interfered with day-to-day activities frequentlypain intensity: 8 During an interview on 3/24/26 at 9:37 A.M., Resident #80 said that he/she had fallen, resulting in a fracture of his/her left patella and a torn ligament. Resident #80 said that on 3/13/26 the Physician said he would discontinue the prescribed Naltrexone (a medication used to treat alcohol use disorder, opioid use disorder, eating disorders, and obesity) medication and order Morphine as needed (PRN). Resident #80 said that this change in the treatment plan did not happen as discussed with the Physician. He/she said that the Naltrexone medication was still given to him/her following the discussion with the Physician on 3/13/26, so he/she refused to take the Naltrexone, and the Morphine medication was not available for him/her. Resident #80 said that there had been at least one time that he/she wanted to take more than the prescribed Acetaminophen (medication used to treat mild pain), but the Morphine medication was not available to him/her. He/she said that the pain at that time was maybe a five out of 10. Review of Resident #80's Pain Care Plan, initiated 3/9/26, indicated that the Resident had potential for alteration in comfort/pain related to fracture of the patella, right wrist sprain, and obesity. Interventions included to medicate per Physician's orders (see MAR). Review of Resident #80's Acute Pain Care Plan, initiated 3/16/26, indicated the Resident had a traverse fracture of the left patella, a right wrist sprain, and a urinary tract infection. Interventions included to administer pain medications per order. Review of Resident #80's Order Summary Report between 3/3/26 and 3/26/26 indicated the following:-Acetaminophen oral tablet 325 milligrams (mg). Give 2 tablets by mouth every 6 hours as needed for elevated temperature or pain not to exceed 3 grams in 24 hours. Start date 3/3/26.-Naltrexone HCl oral tablet 50 mg. Give 1 tablet by mouth two times a day for blocking opioid receptors. Hold medication while taking Morphine. Start date 3/9/26.-Morphine Sulfate oral tablet 15 mg. Give 1 tablet by mouth every 8 hours as needed for pain until 3/31/26. Start date 3/26/26, End date 3/31/26. Review of Resident #80's MAR dated March 2026 indicated the following:-Naltrexone HCl oral tablet 50 mg. Give 1 tablet by mouth two times a day for blocking opioid receptors. Hold medication while taking Morphine (Scheduled for 8:00 A.M. and 8:00 P.M.) was not administered at 8:00 P.M. on 3/14/26, at 8:00 A.M. and 8:00 P.M. on 3/15/26, at 8:00 P.M. on 3/16/26, and at 8:00 A.M. on 3/17/26 due to the Resident's refusal. The medication was placed on hold beginning at the 8:00 P.M. dose on 3/17/26. Review of fax records from Nurse #7 to the Physician, dated 3/16/26, indicated:-Nurse #7 wrote: You spoke with this resident on Friday. He/she said you told him/her you would order Morphine for him/her and put his/her on Naloxone (sic) on hold. Currently no orders in place. He/she refused his/her Naloxone (sic) today but there are no Morphine orders if he/she asks.-The Physician responded: I'll order the Morphine PRN. It's OK to stop Naltrexone for now. I spoke with his/her psychiatrist. During an interview on 3/26/26 at 12:43 P.M, the Physician said that on 3/13/26 he had a discussion with Resident #80 regarding his/her pain management treatment plan, and it was agreed upon that the Physician would discontinue the Naltrexone medication order and would order the Resident for Morphine medication as needed. The Physician said that the Resident had wanted a Morphine medication order as needed in case his/her pain had become intolerable again. The Physician said he had sent a script for the Morphine medication to the wrong pharmacy on 3/13/26. He said that the facility contacted him on 3/24/26 regarding the Morphine medication, and it was at that time that he sent the script to the facility's contracted pharmacy. The Physician said that the process for the ordering of controlled substances was that the Provider generated a script in the Provider's software, which would then be sent to the facility's contracted pharmacy. He said that he thought the nurse entered the order into the Resident's Electronic Health Record (EHR), which he would then sign. He said that if he was not able to enter the order into a resident's EHR, he would send the script to the facility's contracted pharmacy. The Physician said that he had provided verbal communication to a nurse on 3/13/26 regarding the change to Resident #80's pain management treatment plan. He said that he did not write a progress note for the visit with Resident #80 with date of service of 3/13/26. The Physician said that Resident #80 should have had an order for Morphine medication to be administered as needed in the Resident's EHR at the time of the interview. During an interview on 3/26/26 at 1:35 P.M., Nurse #7 said that she provided care for Resident #80 on 3/16/26. Nurse #7 said that Resident #80 had refused the prescribed Naltrexone medication, stating that the Resident informed Nurse #7 of a discussion with the Physician on 3/13/26. Nurse #7 said that the Resident told her that the Naltrexone medication was supposed to be placed on hold and he/she was supposed to have a Morphine medication order to be utilized as needed. Nurse #7 said that she then faxed the Physician to inform the Physician that there were not any Morphine medication orders in place for Resident #80 at that time. Nurse #7 said that the Physician responded, and said that he would order Morphine medication as needed and put the Naltrexone medication on hold. Nurse #7 said that her expectation was the Physician would enter an order remotely for the Morphine medication. Nurse #7 said that she placed the Naltrexone medication order on hold at that time. Nurse #7 said that she checked Resident #80's Physician's orders on 3/25/26 and noted that the Resident did not have a Morphine medication order in place at that time. Nurse #7 said that she again faxed the Physician at that time to notify him that Resident #80 did not have a Morphine medication order in place. During an interview on 3/26/26 at 2:46 P.M., the Pharmacist said that the facility's contracted pharmacy received a script for Morphine on 3/24/26 at 5:03 P.M. He said that the Morphine was sent out to be delivered to the facility on 3/24/26 around 10:30 P.M. The Pharmacist said that the pharmacy had not received any scripts for Morphine prior to this date. During an interview on 3/26/26 at 3:17 P.M., the Director of Nursing (DON) said that the expectation was that the nurse entered the Physician's orders into Resident #80's EHR. The DON said that her concern with having a treatment plan that included Morphine medication without an order for the Morphine medication was that the facility should be able to manage pain that Resident #80 was having. The DON said that the Morphine medication order should have been implemented on 3/13/26.

Based on observations, interviews, and records reviewed, the facility failed to provide pharmaceutical services to meet the needs for one Resident (#80) out of a total sample of 26 residents, and maintain accurate records of controlled substances (drugs or chemicals that the government regulates for its manufacture, possession, and use, that are classified into schedules based on their potential for abuse) for one Unit (Unit Two) out of three units reviewed. Specifically,1. For Unit Two, the facility staff failed to maintain accurate documentation in the Controlled Substance Register (Narcotic Book), relative to the recording of prescription numbers and receipt dates being recorded on the individual pages when a new controlled medication was entered into the Register or the information for a medication was transferred from one page to another. 2. For Resident #80, the facility failed to acquire Auvelity (medication used to treat Major Depressive Disorder [MDD]) medication and administer Auvelity medication as ordered by the Physician, resulting in an increased risk for depression symptoms. Findings include: Review of the facility policy titled Management of Controlled Substances in Skilled Nursing Facilities, revised on June 24, 2025, included: -It is the responsibility of staff who administer or otherwise manage medications to safeguard controlled substances in a manner consistent with Federal and State Law, and organizational policy. -Purpose: - to minimize the opportunity for abuse or diversion of controlled substances. - to provide for proper ordering, storage, disposal, and security of controlled substances. - to promote occupational and patient safety. -Storage: -Medication information is logged into the Controlled Substances Register as follows: >Each new Patient Page shall include: >Prescription number and date. >complete transfer information at the bottom of inventory page, two Licensed nursing staff signatures – the recording nurse and the witnessing nurse are required. On 3/25/26 at 8:19 A.M., during a record review and interview, Nurse #3 and the surveyor reviewed the Controlled Substance Record (Narcotic Book) in Book #2025-6. Review of the Record showed that. - the headings on many of the pages were not completed. - four of the index pages were worn out and torn with pieces missing. - one page of Lorazepam (antianxiety) medication 34 tablets did not indicate whether the medication was discontinued, transferred to another page, or destroyed. - two pages of Controlled Substance medications Tramadol (pain) and Lyrica (nerve pain medication) were transferred by one nurse to different pages. Nurse #3 said that the headings should have been completed when the controlled medications were entered into the Record, or when the medications were transferred in the Record from one page to another, but they had not been. Nurse #3 further said two nurses are expected to sign as the transferred and witnessed nurses at the bottom of the page, but they did not. On 3/25/26 at 8:39 A.M., during a record review and interview, Nurse #4 and the surveyor reviewed the Controlled Substance Record (Narcotic Book) in Book #2025-8. Review of the Record showed that: - the headings on many of the pages were not completed. - three of the index pages were worn out and torn with pieces missing. - page 12 of the controlled substance book indicated that a Lorazepam liquid medication 27.25 milliliters (ml) had been removed from count to be destroyed on 12/8/2025, but there was no indication that the medication had been destroyed. - two pages of Controlled Substance medications Dilaudid (pain) and Lyrica were transferred by one nurse to different pages. Nurse #4 said that the headings should have been completed when the controlled medications were entered into the Record, or when the medications were transferred in the Record from one page to another, but they had not been. Nurse #4 further said two nurses are expected to sign as the transferred and witnessed nurses at the bottom of the page, but they did not. On 3/25/26 at 8:51 A.M., during a record review and interview, Nurse #5 and the surveyor reviewed the Controlled Substance Record (Narcotic Book) in Book #2025-7. Review of the Record showed that: - the headings on many of the pages were not completed. - three of the index pages were worn out and torn with pieces missing. - eight pages had no prescription numbers and no dates documented for the receipt of the medications. - six pages were transferred by one nurse to different pages without a second nurse. Nurse #5 said that the headings should have been completed when the controlled medications were entered into the Record, or when the medications were transferred in the Record from one page to another, but they had not been. Nurse #5 further said two nurses are expected to sign as the transferred and witnessed nurses at the bottom of the page, but they did not. During an interview on 3/25/26 at 10:09 A.M., the Director of Nursing (DON) said that when the page number was changed in the Controlled Medication Log, the prescription number and date filled must be transferred to the new page. The DON said that the headings of each page in the Controlled Medication Log should be complete to include the prescription number and date the prescription was filled. The DON said that when Controlled Substance Medication is removed from count, there must be documentation of the destruction in the Book. The DON further said two nurses are expected to transfer pages and sign. 2. Review of the facility policy titled Provider Pharmacy Requirements, effective October 2013, indicated but was not limited to the following: -Policy: Regular and reliable pharmaceutical service is available to provide residents with prescription.medications. -All.new medication orders are received and available for administration on the day they are ordered by the physician or before the time the first dose would ordinarily be administered. -Medications will be delivered by the primary pharmacy or back-up pharmacy. Review of the facility policy titled Arrangements with Non-Contract Pharmacy, effective December 2013, indicated that a resident may request that medications be obtained from a pharmacy other than the facility's provider pharmacy. Resident #80 was admitted to the facility in March 2026, with diagnoses including MDD, anxiety disorder, obsessive-compulsive disorder, panic disorder, and Trichotillomania (hair-pulling disorder). Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #80: was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 15 out of a possible score of 15. was prescribed an antidepressant medication. had little interest or pleasure in doing things nearly every day. was feeling down, depressed, or hopeless nearly every day. was feeling tired or had little energy nearly every day. had poor appetite or overeating nearly every day. felt bad about him/herself nearly every day. During an interview on 3/24/26 at 9:37 A.M., Resident #80 said that upon admitting to the facility, it took nearly three to four days for the facility to have all of his/her prescribed medications available to administer. Resident #80 said he/she was prescribed several psychiatric medications, and it was concerning that they were not available when he/she admitted to the facility. Resident #80 said he/she believed the facility did not have the prescribed Auvelity medication. Resident #80 said that his/her partner had brought in all of his/her medications from home when the Resident admitted to the facility, however the facility explained to the Resident that he/she was not allowed to use his/her home medications. Resident #80 said that the facility additionally ran out of the Auvelity medication about two days ago, and it was not available for his/her use for one evening dose. Review of Resident #80's Mood Care Plan, initiated 3/4/26, indicated that the Resident was at risk for fluctuation in mood related to depression, anxiety, obsessive-compulsive disorder, binge eating, trauma and Trichotillomania. Review of Resident #80's Psychotropic Medications Care Plan, initiated 3/9/26, indicated that the Resident used psychotropic medications related to an extensive psychiatric history including Obsessive-Compulsive Disorder, MDD, anxiety disorder, panic disorder, Trichotillomania, and binge eating disorder. The Care Plan included: -Goal: The Resident will be free of psychotropic drug related complications, including.cognitive/behavioral impairment. -Interventions: Administer psychotropic medications as ordered by the Physician. Review of Resident #80's Order Summary Report between 3/3/26 and 3/26/26 indicated the following: -Auvelity oral tablet Extended Release 45-105 milligrams (mg) (Dextromethorphan Hydrobromide-Bupropion Hydrochloride). Give 1 tablet by mouth two times a day related to MDD. Start date 3/4/26. Review of Resident #80's Medication Administration Record (MAR) dated March 2026 indicated the following: -Auvelity oral tablet Extended Release 45-105 mg (Dextromethorphan Hydrobromide-Bupropion Hydrochloride). Give 1 tablet by mouth two times a day related to MDD (Scheduled for 8:00 A.M. and 8:00 P.M.) was not administered at 8:00 A.M. and 8:00 P.M. on 3/4/26, at 8:00 A.M. on 3/5/26, at 8:00 A.M. on 3/6/26, and at 8:00 P.M. on 3/21/26. Review of Resident #80's Progress Notes indicated the following: -On 3/4/26 at 11:12 A.M. medications (not specified) not available, not in Pyxis (electronic medication dispensing system). Pharmacy notified. Doctor aware. -On 3/4/26 at 8:12 P.M. Auvelity oral tablet Extended Release 45-105 mg medication not available and on order from the pharmacy. -On 3/5/26 at 11:41 A.M. Auvelity oral tablet Extended Release 45-105 mg medication not available. Pharmacy contacted. Medication will be in later on today. Doctor aware. -On 3/6/26 at 10:02 A.M. Auvelity oral tablet Extended Release 45-105 mg Awaiting order from pharmacy. Doctor aware. -On 3/21/26 at 7:29 P.M. Auvelity oral tablet Extended Release 45-105 mg on order. During an interview on 3/26/26 at 2:46 P.M. and a follow-up interview on 3/26/26 at 3:17 P.M., the Pharmacist said that the facility's contracted pharmacy received an order for Auvelity medication on 3/3/26 at 7:16 P.M. The Pharmacist said the medication needed to be special ordered. The Pharmacist said that a 30-day supply of Auvelity medication was sent out to be delivered to the facility on 3/5/26 around 3:00 P.M. The Pharmacist said that the pharmacy would typically recommend that the facility ask residents to bring in their medication from home when the pharmacy could not provide the medication to be administered as ordered by the Physician. The Pharmacist said the Auvelity medication should have been available to administer to Resident #80 on 3/21/26, as the medication should not have run out since the initial delivery of the medication on 3/5/26 to the facility. During an interview on 3/26/26 at 3:17 P.M., the Director of Nursing (DON) said that when a medication was not available to be administered as ordered by the Physician, the Provider should be notified so that there could be a discussion as to whether the medication was available in the Omnicell (electronic medication dispensing system). The DON said that the contracted pharmacy was the only pharmacy the facility utilized. During an interview on 3/26/26 at 4:10 P.M., the Nurse Consultant said that the expectation was that medications were delivered from the pharmacy by the following shift. The Regional Nurse said the facility could have asked Resident #80 to bring in the Auvelity medication from home when it was not available to be administered to the Resident.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment in the facility main kitchen where resident food for consumption was prepared. Specifically, the facility failed to ensure all kitchen equipment was clean and sanitary, including the stove top, oven, and the dishwashing machine. Findings include: During an observation and interview on 12/3/24 at 7:20 A.M., the Food Service Director (FSD) and surveyor observed the following: -Dried elbow noodles and food debris on the left side of the stove top in between the stove top and oven -Built up food debris and drippings on the stove -Right side of the oven, located to the left of the stove top to have dark, grease markings and dried food debris -Dishwasher to have large amounts of white build up with drip like markings on both sides of the dishwasher. The FSD said that the white material on the dishwasher was lime build up and was due to an ongoing water treatment issue. The FSD director said that the food debris in the oven/stove top area and the lime covering the sides of the dishwasher should not be there as there is a cleaning schedule in place. The surveyor requested a copy of the cleaning schedule and log. During a follow-up interview on 12/5/24 at 2:38 P.M., the FSD and Dietician said that there was a cleaning schedule that was utilized, however Kitchen staff had COVID, and the cleaning schedule fell to the wayside. The FSD and Dietician provided the last documented evidence of the cleaning log dated 9/18/24, indicating no additional cleaning logs were available to show that the kitchen had routinely been cleaned and sanitized. The FSD said that all parts of the kitchen should be cleaned every day. He said that staff should make sure their workspace was clean and sanitary after each meal or when they are done in that work area and that the oven and stove were not cleaned as required.

Based on record review and interview, the facility failed to notify the State Mental Health Authority for a resident review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#56) out of a total sample of 26 residents. Specifically, the facility failed to complete and request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness[SMI] and if a Resident is in need of additional specialized support services at the facility) after Resident #56 received emergency mental health interventions and experienced limitations in major life activities due to mental illness. Findings include: Review of the facility policy titled Preadmission Screening and Resident Review (PASRR), revised on 9/22/23 indicated the following in part: -Resident-Significant Change --Referral to DDS (Department of Developmental Services)/DMH (Department of Mental Health) by Affiliate is necessary when resident has experienced a significant change in condition (mental illness or health status) that may impact the residents PASRR disability status, the appropriateness of SNF (Skilled Nursing Facility) placement and/or specialized services. --Requires interdisciplinary review or revision of the care plan; and may result in a positive Level I Screen for SMI (Serious Mental Illness) .or may result in a change in previous PASRR determinations. Resident #56 was admitted to the facility in October 2024 with diagnoses that included Schizoaffective Disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms) and Dementia. Review of the PASRR Level I Screen (initial pre-screening completed prior to admission to a Nursing Facility) dated 10/7/24, indicated the following: -Resident #56 had a documented SMI (Schizoaffective Disorder) -In the past two years the Resident did not have any treatments due to SMI. -In the past six months or currently, the Resident did not have limitations in major life activities due to SMI. -Negative Level I Screen result, indicating a Level II PASRR evaluation was not needed. Review of the Behavioral Health note dated 10/11/24 indicated the following: -Family used to be able to get him/her to take his/her medications but this no longer works. Patient has been physically assaultive towards staff. He/she is verbally assaultive towards others, refusing care, therapy, and medications. Disorganized thinking, pressured speech, paranoid - send to hospital. Review of the hospital discharge paperwork dated 11/6/24 indicated the following in part: -Resident was admitted on [DATE] due to agitation and paranoia, -Psychiatry evaluated patient, recommended long-acting medications, -Resident was not cooperative and was agitated. During an interview on 12/4/24 at 8:40 A.M., Social Worker (SW) #1 said that Resident #56 had been to the facility before, but since the Resident had not been taking his/her medications at home, his/her behaviors had increased this time around. SW #1 reviewed the Resident's medical record and said that the only completed PASRR was the one that was completed for the initial admission, and that a new one had not been completed after being sent out to the hospital due to increased agitation. During a follow up interview on 12/04/24 4:15 P.M., SW#1 said that she spoke with her team and concluded that the PASRR Resident review (Level I Screening Form required if Significant Change in Condition: newly indicated Serious Mental Illness (SMI), exacerbation of SMI, or improvement/decline in condition), should have been completed and then submitted to the PASRR office as the Resident had a significant change in his/her SMI indicating that a Level II PASRR should have been requested.

Based on observation, interview and records reviewed, the facility failed to provide respiratory care and services based on professional standards of practice for two Residents (#47 and #62), of three applicable residents, out of a total sample of 26 residents. Specifically, the facility failed to: -Change the Oxygen tubing as ordered by the Physician. -Follow infection control measures related to the care, handling, and/or storage of nebulizers (delivery device used to administer medication in the form of an aerosol that is inhaled into the lungs) to prevent contamination and the spread of infections. Findings include: Review of the facility policy, titled Oxygen Administration, dated 10/9/13 indicated the following: -Oxygen is set up, delivered, and monitored by a licensed nurse or respiratory therapist. -Replace Oxygen set up every seven days. Date and store Oxygen set up in treatment bag when not in use. 1. Resident #47 was admitted to the facility January 2024 with diagnoses including Chronic Obstructive Respiratory Disease (COPD-a group of lung diseases that block airflow and make it difficult to breath) and Respiratory Failure (occurs when the respiratory system cannot maintain normal levels of Oxygen and Carbon Dioxide in the blood). Review of the Minimum Data Set (MDS) Assessment, dated 9/28/24, indicated the Resident: -had intact cognition as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) Assessment. - used Oxygen. Review of the Physician's orders, dated December 2024, indicated the following: -Continuous Oxygen at two liters via nasal cannula (a thin flexible tube that goes into the nose), start date 1/19/24. -Replace Oxygen tubing every seven days, on Wednesday, night shift, start date 1/19/24. -Albuterol Sulfate 0.0083% Solution (a medication used to prevent and treat wheezing and shortness of breath), one vial by inhalation three times a day, start date 1/19/24. -Replace nebulizer mask and tubing weekly on Wednesday, night shift. Change mask and tubing every seven days, start date 6/11/24. On 12/3/24 at 10:18 A.M., Resident #47 was observed sitting up in bed wearing Oxygen at two liters via nasal cannula. The surveyor observed the Oxygen tubing and humidification bottle to be dated 11/20/24. The humidification bottle was observed to be empty. During an interview on 12/3/24 at 10:30 A.M., Nurse #1 said that she had noticed the dry humidification bottle and old tubing during her medication pass and was in the process of changing it. She said that the tubing should be changed every seven days and should have been done by the night nurse on 11/27/24 but had not been. On 12/4/24 at 3:14 P.M, Resident #47 was observed sitting up in bed wearing Oxygen at two liters via nasal cannula. The surveyor observed a nebulizer machine and tubing on the Resident's bedside table. The nebulizer tubing was not dated, and not stored in a bag. The Resident said he/she had used the nebulizer in the morning. 2. Resident #62 was admitted to the facility May 2019 with diagnosis including Vascular dementia (a condition that involves problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain) and Pulmonary Fibrosis (a lung disease that causes scarring, making it hard to breath). Review of the MDS Assessment, dated 10/18/24 indicated the Resident: -had moderately impaired cognition as evidenced by a score of nine out of a possible score of 15 on the BIMS Assessment. -used Oxygen. Review of the Physician's orders, dated December 2024, indicated the following: -Continuous Oxygen at two liters via nasal cannula, start date 6/11/24. -Replace Oxygen tubing every seven days, on Wednesday, night shift, start date 6/11/24. On 12/3/24 at 9:14 A.M., Resident #62 was observed laying in bed wearing Oxygen at two liters via nasal cannula. The nasal cannula was observed to be undated. On 12/3/24 at 2:58 P.M., Resident #62 was observed laying in bed wearing Oxygen at two liters via nasal cannula. The nasal cannula and the nebulizer tubing were observed to be dated 12/2. During an interview on 12/4/24 at 3:52 P.M., Unit Manager (UM) #1 reviewed the surveyor's findings of the Oxygen and nebulizer tubing for Resident #47 and #62. UM#1 said the Oxygen tubing should have been changed every seven days, and labeled with the day it was opened. She said the nebulizer should have been dated and stored in a drawstring bag when not is use.

Based on interview and record review, the facility failed to ensure that an as needed (PRN) psychotropic medication (medication that affect the mind, emotions, and behavior) was limited to 14 days for one Resident (#9), of five applicable residents reviewed, out of a total sample of 26 residents. Specifically, the facility failed to ensure that PRN Ativan (Lorazepam: anti-anxiety medication) was limited to 14 days and if not limited, included a Physician determined duration for continued use of the medication. Findings include: Review of the facility policy titled Psychotropic Medications, revised on 8/6/24, indicated the following: -As needed (PRN) medications will require a 14-day order -For psychotropic medications other than antipsychotics, for use beyond the initial PRN 14-day order, a prescriber must document the rationale for continuance, and the anticipated duration. Resident #9 was admitted to the facility in November 2024 with the following diagnoses: Anxiety, Depression, and Bipolar Disorder (a mental health condition that causes extreme mood swings). Review of the November 2024 Medical Administration Record (MAR) indicated the following: - PRN Ativan administered nine times: 11/19/24, 11/20/24, 11/22/24, 11/25/24, 11/16/24, 11/28/24 (x2) 11/29/24 and 11/30/24. -Ativan 1 milligram (mg) tablet oral twice daily as needed for anxiety disorder. Order date 11/18/24 with no stop date. During an interview on 12/4/24 at 11:26 A.M., Unit Manager (UM) #2 reviewed the November 2024 MARs and said that the Resident does use the PRN Ativan and that the PRN Ativan should either have a stop date or be reevaluated at day 14, but it did not as required.

Based on observations, interviews, and records and policies reviewed, the facility failed to reduce potential transmission of infection by ensuring that: 1. The appropriate personal protective equipment (PPE) was worn by staff for Residents (#181, #124, #182 and #330), who were identified as requiring Transmission-Based Precautions (used in addition to standard precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission), and hand hygiene was conducted by facility staff, as required; and 2. Facility staff cleaned and disinfected medical equipment after resident use, specifically a glucose monitoring device (meter used to test the concentration of glucose in the blood, and is performed by piercing the skin to draw blood and then applying the blood to a test strip) and a blood pressure cuff (medical device consisting of a piece of rubber or similar material that is wrapped around a resident's arm and then inflated in order to measure their blood pressure) used for multiple residents, on three out of three units observed, as required. Findings include: 1. Review of the facility's policy titled Hand Washing and Hand Hygiene, revised 11/8/16, indicated that hand hygiene is the single most important method to prevent the spread of infection and is an important component of any infection prevention and control program. The policy also included the following: Indication: -when hands are visibly dirty or contaminated (you can see contamination on your skin), wash your hands with either a non-antimicrobial or antimicrobial soap and water for at least 15 seconds -if hands are not visibly soiled (you cannot see any contaminant on your skin), use an alcohol-based hand rub for routine decontamination of hands in the clinical setting When to Wash or Hand Rub: -before or after having direct contact with residents -before application of gloves and after removing gloves or other PPE -when performing a procedure or providing direct care and moving from a contaminated body site to another body site. Remove gloves, sanitize hands and reapply clean (or sterile) gloves to complete procedure -after contact with objects in the resident environment including equipment or personal items in the resident's immediate vicinity -after caring for a resident with spore forming infection or cleaning the environment of a resident with a spore forming infection (C-Diff infection), hand washing with soap and water is recommended. The physical action of washing and rinsing hands under such circumstances is recommended because alcohol and other antiseptic agents have poor effect/activity against spores. Review of the facility's policy titled Procedures for Airborne, Contact and Droplet Isolation, revised 4/11/22, indicated the following: Droplet Precautions: -private room is desirable -wear a mask when entering a droplet precaution room Contact Precautions: -private room is preferred -when a private room is not available, place the resident in a room with another resident with the same organism, but with no other infection. Do not place a resident with a Multi Drug Resistant Organism (MDRO) infection or colonization in a a room that has a different MDRO infection or colonization. -when entering a contact precaution room, staff must do hand hygiene and put on all required PPE before entering the room. -when leaving the room, staff must remove the correct PPE in the room and perform hand hygiene on the way out and it must be correct per the organism the resident has or if the hands are visibly soiled, for example, if Clostridium difficile colitis (C-Diff: inflammation of the colon caused by the bacteria Clostridium difficile characterized by diarrhea, fever and belly pain, and can be transmitted from person to person by spores) During a tour of the three units on 10/22/23 from 8:15 A.M. through 8:40 A.M., the surveyor observed the rooms of Residents #181, #330, #124, and #182 which had precaution signs posted outside of them. During the entrance conference on 10/22/23 at 8:50 A.M., the Director of Nurses (DON) said that there are several residents on precautions. She further said that some residents have Contact Precautions in place because of active C-diff infections. Review of the Resident Roster Matrix, provided by the DON, on 10/22/23 at approximately 2:30 P.M., indicated Residents (#330 and #124) were on Transmission-Based Precautions. It did not indicate Resident #181 or #182 was on Transmission-Based Precautions. A. Resident #181 was admitted to the facility in October 2023 with diagnoses including C-diff infection and abdominal pain. Review of Resident #181's active C-Diff Care Plan, initiated on 10/12/23, indicated the following: -Contact Precautions . -soap/water with hand washing before and after direct contact with the Resident or contact with items in the Resident's environment . Review of the October 2023 Physician's Orders indicated Vancomycin (an antibiotic to treat infections) 125 milligrams (mg) every six hours, was ordered from 10/12/23 through 10/18/23 for C-Diff infection. On 10/22/23 at 3:39 P.M., the surveyor observed a Contact Precautions sign posted outside of Resident #181's room which indicated the following: -Stop, Contact Enteric (occurring in the intestines) Precautions -Everyone Must: clean hands with sanitizer when entering the room, wash with SOAP AND WATER UPON LEAVING ROOM -gown and glove when entering the room A three-drawer bin was observed outside of the room, which contained various types of masks, reusable gowns and eye protection. The surveyor observed bleach wipes and hand sanitizer on top of the bin. The surveyor also observed a sign within the Resident's room taped to the alcohol-based sanitizer dispenser indicating DO NOT USE HAND SANITIZER SOAP & WATER ONLY. During the observation, Unit Manager (UM) # 2 entered Resident #181's room, without performing hand hygiene prior to entering the room or donning (putting on) a gown and gloves and was observed to converse with Resident #181 at his/her bedside. At 3:46 P.M., UM #2 exited the Resident's room. She was not observed to perform hand hygiene (washing with soap and water) prior to leaving the room. During an interview on 10/23/23 at 7:53 A.M., Certified Nurse Aide (CNA) #3, who was caring for the Resident #181 and the roommate in that room, said she was unsure why the Contact Precaution signage was posted outside of Resident #181's room, that it usually meant that one of the residents in the room had C-diff infection, but was not sure which one the sign pertained to. Review of Resident #181's Kardex (Resident specific information the CNAs have relative to care/preferences/safety) indicated no notation that he/she was on Contact Precautions for C-diff infection. On 10/23/23 at 10:11 A.M., the surveyor observed Resident #181 lying in bed within the room. At 10:12 A.M., Dietary Staff #1 was observed to knock and enter the Resident's room. Dietary Staff #1 did not conduct hand hygiene prior to entering the room, nor did she put on a gown and gloves prior to entering the room as indicated on the signage posted outside of the room. Dietary Aide #1 was observed to lean over and converse with Resident #181 at his/her bedside. Shortly after, Dietary Aide #1 was observed to exit the Resident's room, did not wash her hands with soap and water prior to exiting the room and did not conduct hand hygiene upon exiting the room. During an interview on 10/23/23 at 10:14 A.M., Dietary Aide #1 said that she saw the signage posted outside of Resident #181's room, but her understanding was that she did not need to wear a gown and gloves when entering the Resident's room because she was not providing care. She said that she should have completed hand hygiene prior to entering the room and upon exiting the room but she did not. B. Resident #124 was admitted to the facility in August 2023 and Resident #182 was admitted to the facility in October 2023. Both Residents resided in the same room. a. Review of the October 2023 Physician's Orders indicated Resident #124 was started on Dificid (an antibiotic used to treat C-Diff infection) 200 mg twice daily from 10/2/23 through 10/12/23 for C-Diff. Review of Resident #124's active C-diff Care Plan, initiated 10/2/23, indicated the Resident had a C-diff infection which is a spore forming infection that produces toxins that cause damage to the intestinal cells and may cause diarrhea . The Care Plan also included the following: -Contact Precautions . -soap and water hand washing before and after direct contact with the Resident or contact with items in the Resident's environment . Review of Resident #124's Kardex indicated he/she was on Contact Precautions for C-diff infection. b. Review of Resident #182's active Gastrointestinal Care Plan, initiated 10/14/23, indicated the Resident had an alteration in his/her gastrointestinal tract related to C-Diff. Review of the Resident #182's October 2023 Physician's Orders indicated Vancomycin 125 mg twice daily for C-diff was ordered from 10/14/23 through 10/25/23. Review of the October 2023 Medication Administration Record (MAR), indicated Vancomycin was signed off as administered from 10/15/23 through 10/24/23. Review of Resident #182's Kardex indicated no notation that he/she was on Contact Precautions for C-diff infection. On 10/22/23 at 3:50 P.M., the surveyor observed Residents #124 and #182's room. A Contact Precaution sign was posted outside of the entrance to the room, and a sign was observed on the alcohol-based sanitizer dispenser located within the room indicating DO NOT USE HAND SANITIZER SOAP & WATER ONLY. A three-drawer bin was located across from the Residents' room and contained various masks, boxes of gloves, eye protection and reusable gowns. CNA #2 was observed to enter the Residents' room without conducting hand hygiene or donning a gown and gloves, exit the room shortly after without washing her hands, go to the linen cart located across from the room, collect clean linen from the cart and reenter the room, without performing hand hygiene or donning a gown and gloves. CNA #2 exited the Residents' room shortly after, did not perform hand hygiene, and was observed to enter the Nourishment Kitchen, retrieve a covered cup with a straw and then reenter the Residents' room, without performing hand hygiene or donning a gown or gloves. CNA #2 exited the room, did not perform hand hygiene, went to the linen cart, and then entered another resident's room (who was not on Contact Precautions). During an interview on 10/22/23 at 4:00 P.M., CNA #2 said that she regularly worked on Unit Two. She said that Resident #124 (and not Resident #182) had a C-Diff infection. She further said that she quickly went into Resident #124's room to talk to him/her, then left to get the Resident water, reentered the room to give the water to him/her and then washed her hands in the bathroom sink within the room. CNA #2 said she did not put on a gown and gloves because she went into the room quickly. When the surveyor inquired about the Contact Precaution sign posted outside of the Residents' room, CNA #2 said she should have worn a gown and gloves prior to entering. On 10/23/23 at 7:21 A.M., the surveyor observed CNA #1 enter Resident #124 and #182's room wearing only gloves. She was observed to doff the gloves prior to exiting the room, did not perform hand hygiene, retrieved items from the clean linen cart located across from the room in the hallway, and re-enter the room without a gown or gloves in place. At 7:32 A.M., CNA #1 was observed to ambulate with Resident #124 outside of the room. She was observed to re-enter the room, without hand hygiene or donning a gown, and shortly exited the room carrying a plastic bag containing dirty items held in a gloved hand. Resident #182 was observed within the room during the observation. At 7:39 A.M., CNA#1 re-entered the room, without performing hand hygiene, put on gloves but did not don a gown, and was observed to make Resident #124's bed. During an interview on 10/23/23 at 7:44 A.M., CNA #1 said that she was regular staff and has worked at the facility for three years. She further said she should have put on a gown and gloves prior to entering Resident #124 and #182's room. CNA #1 said the Contact Precaution sign posted outside of the Residents' room indicated that the Resident had C-Diff, but she was not sure which Resident was infected. She further said that prior to entering the room, she should don a gown and gloves and doff prior to exiting the room and perform hand hygiene by washing her hands with soap and water within the room. She said that by not wearing the required PPE, she could potentially transmit the bacteria. When the surveyor asked where she would get PPE she pointed to the three-drawer container across the hall from the Residents' room. C. Resident #330 was admitted to the facility in October 2023 with diagnoses of bacterial infection and disorders of the lung. Review of the October 2023 Physician's Orders indicated Ceftazidime (an antibiotic) 2 gram (gm) via Intravenous (IV) every eight hours for a bacterial infection, initiated on 10/20/23. Review of the active Resident Care Plans included the following: -risk of elevated temperature/dehydration related to a bacterial infection of the sputum of unknown etiology, initiated 10/22/23, -Resident infection .bacterial sputum infection . initiated on 10/22/23 Review of Resident #330's Kardex indicated no notation of the precautions that were in place. On 10/23/23 at 10:05 A.M., the surveyor observed a Droplet Precaution sign posted outside of Resident #330's room which indicated the following: -Stop, Droplet Precautions -EVERYONE MUST: clean their hands, including before entering and when leaving the room. -make sure their eyes, nose and mouth are fully covered before room entry (with pictures depicting a face mask and eye protection or face shield as examples) -remove face protection before room exit A three-drawer bin was observed outside of the Resident's room, which contained various masks, boxes of gloves, face shields and reusable gowns. On 10/23/23 at 11:51 A.M., the surveyor observed CNA #1 don a gown and gloves but did not don a face mask or eye protection, and enter Resident #330's room. At 11:59 A.M., CNA #1 exited the room and with one gloved hand, carried a clear bag with dirty items down the hallway. No hand hygiene was observed upon exiting the room. During an interview on 10/23/23 at 12:00 P.M., CNA #1 said she completed hand hygiene after she discarded the soiled items. When the surveyor asked CNA #1 to review the posted signage, CNA #1 said she should have put on a face mask and eye protection prior to entering Resident #330's room but had not. On 10/23/23 at 12:16 P.M., Resident #330 was observed lying in bed and was heard to have a frequent wet productive cough. During an interview on 10/23/23 at 12:38 P.M., Nurse #4, who cares for Residents #124, #181, #182 and #330, said that Residents #124, #181 and #182 have C-Diff infections, and staff are required to don a gown and gloves prior to room entry and wash with soap and water after removing the gown and gloves within the Residents' rooms. She further said that Resident #330 has bacteria in his/her sputum and has Droplet and Enhanced Barrier Precautions (use of gown and gloves when providing direct resident care) in place which require staff to wear a gown, gloves, face mask and eye protection prior to entering the room. During an interview on 10/23/23 at 12:44 P.M., UM #1 said the expectation is for staff to gown and glove prior to entering a Contact Precaution room, and that the staff should be removing the gown and gloves and perform hand washing with soap and water within the room prior to exiting. UM #1 said that staff should put on a gown, gloves, face mask and eye protection prior to entering Resident #330's room, remove the PPE after care and perform hand hygiene upon exiting the room. She further said that all staff, regardless of who they are speaking to or what care they are providing, should put on the required PPE prior to entering the precaution rooms and don the PPE listed on the signage. In a follow-up interview at 3:21 P.M., UM #1 said that the CNAs receive information from the Nurses during round about resident precautions. She further said that the information about specific resident precautions should be included on the Kardex. During an interview on 10/23/23 at 3:03 P.M., the Director of Nurses (DON) said Droplet Precautions were put into place because Resident #330 was actively coughing and a sputum culture was pending. During an interview on 10/23/23 at 3:09 P.M., the surveyor reviewed the observations from 10/22/23 and 10/23/23 with the Infection Preventionist (IP). The IP said that staff should be following the Precaution Signage posted outside of the Residents' rooms. She said that for Contact Precautions, staff should be wearing a gown and gloves prior to entering the room and should be removing the gown and gloves and performing hand washing prior to exiting the room. If the room has multiple residents present, the gown and gloves should be changed and hand washing performed and a new gown and gloves applied prior to working with the other resident. She said that for Resident #330, the staff should be donning a gown, gloves, face mask and eye protection prior to entering his/her room, should remove the PPE and conduct hand hygiene upon exiting the room. 45435 2. Review of the facility's policy titled Blood Glucose Meter Cleaning and Disinfection, dated 10/14/22, indicated the following: -The meter should be cleaned and disinfected after use on each patient. The manufacturer's Information for Use (IFU) will provide the proper requirements for this. Review of the Assure Prism Blood Glucose Monitoring System manufacturer's IFU indicated the following cleaning and disinfection products had been approved for use: -Clorox Germicidal Wipes -Dispatch Hospital Cleaner Disinfectant Towels with Bleach -CaviWipes 1 -PDI Super Sani-cloth Germicidal Disposable wipes On 10/24/23 at 7:30 A.M., during a medication administration pass on Unit Three, the surveyor observed Nurse #1 using an Assure Prism blood glucose monitor to obtain a blood glucose reading. When finished, Nurse #1 placed the meter into a storage container which she placed in the medication cart. She did not clean or disinfect the blood glucose meter and proceeded to pour and pass medications to another resident. During an interview on 10/24/23 at 7:57 A.M., Nurse #1 said that she should have cleaned the blood glucose meter after she used it and before she put it back in the medication cart. She said she was not sure what product she should use to clean and disinfect the blood glucose monitor. On 10/24/23 at 11:10 A.M., on Unit One, the surveyor observed Nurse #3 using an Assure Prism blood glucose monitor to obtain a blood glucose reading. Nurse #3 was observed wiping the glucose meter with an alcohol wipe. During an interview on 10/24/23 at 11:14 A.M., Nurse #3 said that she used an alcohol wipe to clean the glucose monitor between resident use. She said she was not sure what products she should use to clean and disinfect the blood glucose monitor. Review of the Policy titled, General Cleaning and Maintenance of Equipment, dated 6/30/16, indicated that resident care equipment will be cleaned and disinfected after use and will be prepared for reuse by the same or another resident. On 10/24/23 at 8:12 A.M., during a medication pass on Unit Two, the surveyor observed Nurse #2 obtain a blood pressure on a resident. When finished, she placed the blood pressure cuff on top of the medication cart. She did not clean or disinfect the blood pressure cuff and proceeded to pour and pass medications to another resident. During an interview on 10/24/23 at 8:40 A.M., Nurse #2 said that she should have sanitized the blood pressure cuff after she used it. She said that she should have sanitized it with the PDI Super Sani Cloth that she had on her medication cart. She further said that the blood pressure cuff did not belong to the facility and that she brought it into the facility to use on her residents. Manufacturer's information for use was not available for the blood pressure cuff. During an interview on 10/24/23 at 8:44 A.M., Unit Manager #2 said that shared medical equipment should be cleaned and disinfected after use on each individual resident.

Based on observations, interviews, and policy review, the facility failed to ensure the staff reduced the risk of potential physical contamination of resident food by wearing hair restraints while working in the facility kitchen. Findings include: Review of the facility's policy titled Personal Standards, undated, indicated it was the policy of the facility that dietary personnel follow sanitary standards. The policy also included the following: -Hair restraints covering all of the hair must be worn at all times while on duty On 10/22/23 at 7:18 A.M., the surveyor observed two male dietary staff with facial hair (one had a trimmed goatee and the other had a full beard approximately a half inch long), working in the kitchen preparing food for the breakfast service. There were no hair restraints observed covering the exposed hair on either staff member's face. On 10/24/23 at 9:27 A.M., the surveyor observed two male dietary staff with facial hair, working and preparing food/beverages. They were observed to not have hair restraints covering the exposed hair on either staff member's face. During an interview on 10/24/23 at 9:41 A.M., the Food Service Director (FSD) said dietary staff were to wear hair restraints or hats to cover their hair in order to keep hair out of the residents' food/beverages. When the surveyor inquired about facial hair, the FSD said he was unsure if hair restraints for facial hair were required. During an interview on 10/24/23 at 10:30 A.M., the Registered Dietitian (RD) said that there could be food contamination with employee hair in resident food if the hair was not restrained. During a follow up interview on 10/24/23 at 11:02 A.M., the RD said that the facility policy indicated that hair restraints covering all of the hair must be worn while on duty, and that dietary staff will be wearing hair restraints covering facial hair if applicable moving forward.

Based on interview, record review, and policy review, the facility failed to notify and consult the Physician when a significant change in weight was noted for one Resident (#14), out of a total sample of 25 residents. Specifically, the facility failed to notify and consult with the Physician when Resident #14 experienced continued significant weight loss after a significant weight loss was identified over a period of six months. Findings include: Review of the facility's policy titled Physician Notification, revised September 2011, indicated the following: -Purpose: To communicate a change in resident's condition to physician and initiate interventions as needed/ordered. Resident #14 was admitted to the facility in February 2023 with diagnoses including dementia, dysphagia (trouble swallowing), and a history of transient ischemic attack (TIA- mini strokes). Review of the Nutrition Care Plan, with an original date of 3/2/23, indicated the following intervention: -Notify Physician .if persistent weight loss .occurs. Review of the 4/12/23 Nurse Practitioner's Progress Note indicated the Resident had poor oral intake, weight loss, and was being treated for a urinary tract infection (UTI). Further review indicated the Nurse Practitioner spoke with the Resident's Representative to discuss that further interventions may need to be implemented such as palliative care (additional recommendations made to ensure a resident is comfortable at the end of their life or while dealing with a chronic illness) if the Resident continued to decline. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/26/23, indicated the Resident had a significant weight loss of 5% or more in the last month or a loss of 10% or more in the last six months. Review of the Vital Parameters Report of Weights indicated the following: On 6/7/23 the Resident weighed 172 pounds (lbs.) On 7/21/23 the Resident weighed 159 lbs. Indicated a loss of 7.56% in less than three months. Further review of the Vital Parameters Report of Weights indicated the Resident had continued to lose weight and as of 10/20/23 weighed 152.5 lbs., a total weight loss of 11.34% since July 2023. Review of the last quarterly Dietitian's note, dated 8/18/23, indicated the Resident had continued to lose weight over the last three months. Further review of the note indicated no documentation that the Resident's Physician had been updated on the Resident's significant weight loss so further interventions could be explored. Further review of the Resident's medical record indicated no other additional documentation the Resident's Physician had been updated on the Resident's continued significant weight loss. During an interview on 10/23/23 at 11:29 A.M., with the Dietitian and Unit Manager (UM) #3, UM #3 said she could not locate any documentation that the Physician had been updated on the Resident's significant and continued weight loss. UM #3 said the current interventions in place were not maintaining the Resident's weight and he/she should have been reevaluated by the Physician for additional interventions that could have been put into place and this did not happen, as required. During an interview on 10/23/23 at 1:26 P.M., the Nurse Practitioner (NP) said staff should update her when a resident has had a 5 lb. or more weight loss. She said she had been notified of the Resident's weight loss back in April 2023 but had not been notified since that the Resident had a further decline in weight. The NP said she would expect staff to notify her again if a resident continued to lose weight after a month or two and this had not been done. She further said if a resident continued to lose weight she would assess the need for further interventions that would benefit the resident such as new nutritional recommendations or if the resident needed advanced care planning such as palliative care if the weight loss was to be expected, and this had not been done for Resident #14. Refer to F692

Based on interview, policy review, and record review, the facility failed to ensure staff addressed the needs of one Resident (#14) to maintain his/her goal body weight, out of a total of 25 residents sampled. Specifically, the facility failed to reassess interventions to prevent significant weight loss for Resident #14 who had a history of weight loss and was identified as being at risk for further significant weight loss resulting in continued weight loss. Findings include: Review of the facility's policy titled Nutritional Management, revised 6/6/22, indicated the following: -Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice. -Provide nutritional care and services to each resident, consistent with the resident's comprehensive assessment. -Recognize, evaluate, and address the nutritional needs of every resident, including, but not limited to, the resident at risk or currently experiencing impaired nutrition . -Monitor and evaluate the impact of interventions. -Revise the interventions as appropriate. -Use the Dietician Consult Request to initiate consult with dietician when indicated . -Unplanned weight loss or gain (greater than 3 pounds (lbs.) from last recorded weight and/or 5% in one month, 7.5 % in three months, and 10% in six months . -Decreased oral intake (PO intake). Resident #14 was admitted to the facility in February 2023 with diagnoses including dementia, dysphagia (trouble swallowing), and a history of transient ischemic attacks (TIA- mini strokes). During an interview on 10/22/23 at 10:58 A.M., Resident Representative (RR) #1 said Resident #14 had lost weight since being admitted to the facility. RR #1 further said the Resident had decreased PO intake and that he/she came in daily to assist the Resident with their lunch meal. RR #1 said the Resident does get a Magic Cup (brand of high protein high calorie dessert) but he/she was unsure of any additional interventions that had been implemented to help with the Resident's weight loss. Review of the 4/12/23 Nurse Practitioner's Progress Note indicated the Resident had a history of poor PO intake and weight loss. Further review indicated the Nurse Practitioner spoke with RR #1 and said further interventions should be implemented such as palliative care (additional recommendations made to ensure a resident is comfortable at the end of their life or while dealing with a chronic illness) if the Resident continued to decline. Review of the Resident's Nutrition Care Plan, with an original date of 3/2/23, indicated the following goal: -Resident will maintain a weight of 175.8 lbs. [pounds]+/-3.0 lbs. with an effective date of 5/30/23. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/26/23, indicated the Resident had a loss of 5% or more in the last month or a loss of 10% or more in the last six months. Review of the Vital Parameters Report of Weights indicated the following: On 6/7/23 the Resident weighed 172 lbs. On 7/21/23 the Resident weighed 159 lbs. Indicated a loss of 7.56% in less than three months. Further review of the Vital Parameters Report of Weights indicated the following weights since 7/21/23: On 8/28/23 the Resident weighed 157.5 lbs. On 9/15/23 the Resident weighed 157 lbs. On 10/20/23 the Resident weighed 152.5 lbs. Indicating the Resident had continued to lose weight and had a total weight loss of 11.34% since July 2023. Review of the October 2023 Physician's Orders indicated the following nutritional interventions: -Boost Very High Calorie (Boost VHC-a high calorie nutritional shake) 4 ounces (oz.) three times a day (TID) .with a start date of 4/12/23. Further review of the Resident's Medical Record indicated no additional documentation that any new interventions had been implemented to maintain the Resident's goal weight since the new significant weight loss was identified on the 8/26/23 MDS assessment or since the Resident continued to lose weight. During an interview on 10/23/23 at 11:12 A.M., the Dietitian said she was aware the Resident had a significant weight loss. She reviewed her dietary notes and said she was unable to find any documentation that she had coordinated care with the Physician when the significant weight loss was identified on the 8/26/23 MDS assessment. She additionally said no new interventions had been put into place since the significant weight loss was noted or since the Resident continued to have a decline in weight. During an interview on 10/23/23 at 11:29 A.M., with the Dietitian and Unit Manager (UM) #3, the Dietitian said when she identified the significant weight loss on the 8/26/23 MDS assessment she should have implemented new interventions to address the weight loss and she had not implemented any new interventions at that time. UM #3 said she was responsible for documenting the monthly weights and should have updated the Dietitian, Physician, and requested a speech screen because the Resident continued to lose weight over the past few months, and she was unable to locate any documentation that this had been done.

Based on record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#79), out of a total sample of 25 residents. Specifically, the facility failed to recognize that stool softeners and laxatives continued to be administered to a Resident undergoing medical treatment for diarrhea (a condition in which stool is discharged from the bowels frequently and in a liquid form). Findings include: Review of the Davis Drug Guide for Nurses-18th edition, (2023) indicated the following: -Docusate- Adverse reactions/Side effects-abdominal cramps, nausea, vomiting and diarrhea. -Senna- Adverse reactions/Side effects-abdominal cramps, nausea, vomiting and diarrhea. Review of the Davis Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales-16th edition (2022), Chapter 2, Diarrhea, indicated the following: -Review medication, noting side effects and possible interaction. -Change client's routine medications as appropriate. Resident #79 was admitted to the facility in June 2021. Review of the Minimum Data Set (MDS) assessment, dated 10/14/23, indicated Resident #79 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview on 9/22/23 at 9:21 A.M., Resident #79 said that he/she had been having diarrhea for a couple of weeks. Review of the Bowel Review by Day Report, dated 10/23/23, indicated the Resident had at least one episode of loose stools on 10/3/23, 10/4/23, 10/5/23, 10/7/23, 10/8/23, 10/10/23, 10/11/23, 10/15/23, 10/17/23, 10/18/23, 10/19/23, 10/20/23, 10/22/23, and 10/23/23. Review of the Physician's Progress Note, dated 10/19/23, indicated the Resident complained of frequent diarrhea. The note further indicated that a trial of Lomotil (a prescription medication used to treat diarrhea) instead of Imodium (a non-prescription medication used to treat diarrhea) was to be initiated. Review of the Active Orders Report, dated 10/23/23, indicated the following orders: -Lomotil (Atropine Sulfate/Diphenoxylate Hydrochloride) 0.025 milligrams (mg)-2.5 mg tablet, three times a daily for diarrhea, order start date 10/20/23. -Imodium (Loperamide Hydrochloride) 2 mg tablet, 1 tablet three times a day as needed, order start date 10/10/23. -Senna (a stimulant laxative used to treat constipation) 8.6 mg tablet give 1 tablet at 8 P.M. daily for constipation (difficulty passing stool and/or fewer than three stools a week), order start date 9/11/23. -Colace (a stool softener used to treat constipation) 100 mg capsule give 1 tablet at 9 A.M. daily for constipation, order start date 9/11/23. Review of the Medication Administration Record (MAR), dated 10/2023, indicated that the Resident received Senna 8.6mg daily 10/1/23 and 10/2/23, and 10/4/23-10/22/23. Review of the MAR, dated 10/2023, indicated that the Resident received Colace 100mg daily 10/1/23-10/5/23, and 10/7/23-10/19/23, 10/21/23, and 10/22/23. During an interview on 10/23/23 at 9:28 A.M., Unit Manager (UM) #1 said the Physician should have been notified that the Resident was taking the stool softener Colace and the laxative Senna daily while he/she was having diarrhea. She said the Colace and Senna should not have been given once the Resident started to have diarrhea until the situation was reviewed with the Physician. She said she was not sure if the Physician was aware of the continued laxative use, but should have been, as required.

Based on observation, policy review and interview, the facility failed to ensure infection control guidelines were followed to prevent contamination and transmission of microorganisms, on one of two units observed. Specifically, hand hygiene was not performed as required by an outside vendor (an Ultrasound Technician- a person that use imaging equipment and soundwaves to form images of parts of the body to help diagnose and treat medical conditions), after providing ultrasound services to unit residents. Findings include: Review of the facility policy titled, Hand Washing and Hand Hygiene, revised 11/8/16, included, but not limited to: *When to Wash or Hand Rub: A) Before and after having direct contact with residents/patients. B) Before application of gloves and after removing gloves or other Personal Protective Equipment (PPE). C) When performing a procedure or providing direct care and moving from a contaminated body site to another body site. Remove gloves, sanitize hands and reapply clean (or sterile) gloves to complete procedure. D) After contact with objects in the patient/resident environment including equipment or personal items in the resident/patient immediate vicinity On 9/22/23 at 10:30 A.M., the surveyor observed a woman maneuvering two wheeled carts out of a resident room that was occupied by two residents. The woman was observed wearing a pair of blue disposable gloves. She exited one resident room that had a sign indicating, Enhanced Barrier Precautions (EBP-an enhanced approach of targeted gown and glove use during high contact resident care activities, designed to reduce the transmission of Multidrug Resistant Organisms [MDRO-multidrug-resistant bacteria that are resistant to three or more classes of antimicrobial drugs]) and entered the next resident room with the wheeled carts while wearing the same gloves. She did not doff (remove) the gloves, perform hand hygiene and don (apply) new gloves prior to entering the next resident room. The woman left the door of the resident room slightly ajar. The surveyor followed up the hallway observation by knocking on the resident room door, opening the door and observed the woman at one resident's bedside. The woman came to the doorway as requested by the surveyor and identified herself as an Ultrasound Technician. During an interview at the time, the Ultrasound Technician gave short, curt responses to the surveyor's questions. She said she changed her gloves in the resident's room but did not indicate that she had performed hand hygiene between glove changes as required. The surveyor observed that the Ultrasound Technician was still wearing blue disposable gloves. During an interview on 9/23/23 at 11:00 A,M., the Charge Nurse said the Ultrasound Technician should have doffed her gloves, cleansed her hands and donned a new pair of gloves prior to entering the next resident's room. During an interview on 9/23/23 at 11:15 A,M., the Director of Nurses (DON) said there was no formal training concerning hand washing and hand hygiene given to vendors that enter the facility. She further said the formal training should have been provided by the Ultrasound Technician's company.

Based on record review and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal and Influenza Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#A1 and #A2) out of a total sample of five residents, putting them at risk for developing facility-acquired Pneumonia and Influenza. Specifically, 1. For Resident #A1, the facility failed to ensure that staff assessed, offered, and provided education on the recommended Pneumococcal Vaccine. 2. For Resident #A2, the facility failed to ensure that staff assessed, offered, and provided education on the recommended Influenza Vaccine. Findings include: 1. Review of the facility policy titled, Resident Pneumococcal Immunization, revised 4/22/22 indicated the following: -Residents of (the facility) will be offered immunizations to protect them from pneumococcal disease unless the vaccine is medically contraindicated, or the resident has already been immunized. -Pneumococcal immunizations will be provided as recommended by the CDC Advisory Committee for Immunization Practices (ACIP). -Administration of the pneumococcal vaccines or revaccination will be made in accordance with current CDC recommendations at the time of the vaccination. Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (www.cdc.gov) dated 3/15/23, indicated the following: -For adults greater than or equal to [AGE] years old who have never received a Pneumococcal Vaccination, it is recommended to either receive the PCV20(Pneumococcal Conjugate Vaccine 20) or the PCV15 (Pneumococcal Conjugate Vaccine 15) and then receive the PPSV23 (Pneumococcal Polysaccharide Vaccine 23) vaccine at least one year later. -If the adult had received the PPSV23 vaccine at any age, it is recommended to either receive the PCV20 or PCV15 vaccine at least one year after the prior PPSV23 vaccine. -If the adult had received the PCV13 (Pneumococcal Conjugate Vaccine 13) vaccine at any age it is recommended to either receive the PCV20 or the PPSV23 vaccine at least one year after the prior PCV13 vaccine. -If the adult had received the PCV13 vaccine at any age and the PPSV23 vaccine before [AGE] years of age, it is recommended to receive the PCV20 or the PPSV23 vaccine at least five years after the last Pneumococcal Vaccination. Resident #A1 was admitted to the facility in July 2022 and was over the age of 65. Review of the Resident's Medical Record indicated no evidence the Resident was assessed for eligibility and/or his/her Representative were offered, educated and declined the Pneumococcal Vaccination. Review of the Resident's Pneumococcal Conjugate Vaccine (PCV13) Administration Record and Pneumococcal Polysaccharide Vaccine (PPSV23) Administration Record, both undated, indicated no documented evidence the facility staff screened the Resident for contraindications to the vaccines, no documented evidence the Resident and/or his/her Representative was offered the vaccines and no documented evidence the Resident and/or his/her Representative declined the vaccines because the forms were blank. 2. Review of the facility policy titled, Resident Influenza (Seasonal) Immunization, revised 4/8/21 indicated the following: -Residents of (the facility) will be offered immunization against Influenza as recommended by the CDC ACIP. The vaccine will be provided to residents annually between October and March or as otherwise recommended by CDC ACIP. Review of the CDC website: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the ACIP - United States, 2022-23 Influenza Season (www.cdc.gov), dated 8/26/22 indicated the following: -Routine annual influenza vaccination is recommended for all persons greater than or equal to six months of age who do not have contraindications. Resident #A2 was admitted to the facility in November 2022. Review of the Resident's Medical Record indicated no evidence the Resident received the Influenza Vaccination in 2022. Review of the Massachusetts Immunization Information System (MIIS- a web-based immunization registry) print out provided by the facility indicated the Resident did not receive the Influenza Vaccine at any time during 2022. During an interview on 9/22/23 at 2:18 P.M., the Resident's Representative said they was under the impression Resident #A2 had been up to date with all recommended vaccinations, including the Influenza Vaccine. The Resident's Representative further said they did not recall the facility offering the vaccine to the Resident since he/she had been admitted and would like him/her to be assessed and fully vaccinated. During an interview on 9/22/23 at 3:55 P.M., the Director of Nursing (DON) said there was no documented evidence Resident #A1 was assessed for eligibility for the Pneumococcal Vaccine as well as no evidence the vaccination was offered to and/or declined by the Resident and/or his/her Representative. The DON further said there was no documented evidence Resident #A2 was assessed for the Influenza Vaccination and no evidence the Resident and/or his/her Representative were offered the Influenza Vaccination in 2022. In addition, the DON said since Resident #A2 was admitted during Influenza season he/she should have been offered the vaccine upon admission.

Based on record reviews and interviews for two of four sampled employee personnel files (Certified Nurse Aide (CNA) # 1 and CNA # 2, contracted agency employees) the Facility failed to ensure that measures identified in their Abuse Policy related to protecting residents from abuse, were consistently implemented when a Massachusetts Criminal Offender Records Inquiry ([NAME], name-based court arraignment records, created and maintained by the Massachusetts courts) was not conducted, in accordance with facility policy. Findings include: Review of the Facility Policy titled Resident Abuse Prevention, Investigation and Reporting Policy, dated as revised 10/17/22, indicated the Facility does not knowingly hire individuals who have been found guilty of abusing residents by a court of law. The Policy also indicated the Facility would utilize the [NAME] system for criminal background checks, to ensure safe hiring practices. During an interview on 08/09/23 at 8:15 A.M., with the Director of Nursing, the Surveyor requested the personnel records and evidence that a Massachusetts [NAME] was conducted for CNA #1 and CNA #2, who were contracted agency staff. Review of Certified Nurse Aide (CNA) #1's personnel record indicated that she was hired by the Agency and worked her first shift at the Facility 07/10/23. Review of the personnel records provided to the Facility by the Agency indicated a National Background Screening was conducted on 07/03/23 by a third-party employee screening company. CNA #1's Background Screening Report indicated it may not represent 100% coverage of all the criminal records in all jurisdictions and/or sources and that coverage details were available upon request. Further review of CNA #1's Personnel Record indicated there was no documentation to support the Facility and/or the Agency had conducted a Massachusetts [NAME] for CNA #1. Review of Certified Nurse Aide (CNA) #2's personnel record indicated that she was hired by the Agency and worked her first shift at the Facility 07/20/23. Review of the personnel records provided to the Facility by the Agency indicated a National Background Screening was conducted on 07/17/23 by a third-party employee screening company. CNA #2's Background Screening Report indicated that it might not represent 100% coverage of all the criminal records in all jurisdictions and/or sources and that coverage details were available upon request. Further review of CNA #2's Personnel Record indicated there was no documentation to support the Facility and/or the Agency had conducted a Massachusetts [NAME] for CNA #2. During an interview on 08/09/23 at 3:18 P.M., with a Representative at the Employee Screening Company who reviewed the Background Screening Reports for CNA #1 and CNA #2 said the Nationwide search was not compliant with the Massachusetts requirement related to conducting a [NAME]. During an interview on 08/09/23 at 3:30 P.M., the Director of Nurses (DON) said the Facility policy was to conduct a [NAME] on all prospective employees. The DON further said the Agency was responsible for conducting background screenings on the staff they referred and that she assumed the National Search provided by the Agency met the requirements for the Massachusetts [NAME] check. The DON said she was unable to provide any documentation to support that a Massachusetts [NAME] had been conducted for CNA #1 and CNA #2.

Based on observation, interviews, and record review, the facility failed to ensure its staff provided the necessary respiratory care and services consistent with professional standards of practice in accordance with the Resident's care plan for one Resident (#45) out of a total sample of 27 residents. Specifically, 1) The facility failed to ensure its staff provided necessary equipment (a mask) required for the function of a [CONDITION(S)] device (bilevel positive airway pressure device, that provides non-invasive mechanical ventilation that uses pressure to push air onto one's lungs to assist with breathing and maintain an open airway). 2) Substituted a non-equivalent respiratory intervention (Oxygen therapy and inhaled [MEDICATION(S)] medication) for [CONDITION(S)] therapy, and 3) Failed to ensure staff had the proper training and education related to the utilization of Oxygen and respiratory equipment which put the Resident at risk for respiratory compromise. Findings include: Review of the research article titled: Hypoventilation Syndrome, updated 7/22/21, authored by Jazeela [NAME], DO, accessed online at https://emedicine.medscape.com/article/ 1-overview on 10/22/22 included the following: - Obesity-Hypoventilation Syndrome ([NAME]) is defined as a combination of obesity with chronic hypercapnia (too much carbon [MEDICATION(S)] in the blood). - Patients with [NAME] demonstrate an excessive work of breathing and an increase in carbon [MEDICATION(S)] production. - Treatment is aimed at assisting ventilation. Therapies that may be beneficial are non-invasive ventilatory techniques such as [CONDITION(S)]. - Use Oxygen therapy with caution because it may worsen hypercapnia in some situations. Resident #45 was admitted to the facility in June 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 8/13/22, indicated the Resident had mild cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 12 out of a possible 15. Review of the Resident's current plan of care, dated 5/19/21 included the following: -Apnea (temporary cessation of breathing, especially during sleep). -Resident at risk of Apnea, ineffective breathing pattern and cardiac arrhythmia (irregular heartbeat) related to Obstructive Sleep Apnea (OSA- a type of apnea that occurs when your throat muscles intermittently relax and block your airway during sleep). Interventions, dated 4/28/22: -Apply [CONDITION(S)] at ordered settings via nasal mask or face mask. -Remove [CONDITION(S)] in the morning. -Ensure the device/mask is properly fitted. -Respiratory Therapist may be consulted as needed. Review of the October 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Apply [CONDITION(S)] at bedtime (HS) and remove in the morning upon rising. -Apply one liter (L) of Oxygen through [CONDITION(S)], Inspiratory Positive Airway Pressure (IPAP- the amount of pressure with inhalation), set at 16 centimeters (cm) of water (H2O) and Expiratory Positive Airway Pressure (EPAP- the amount of pressure with exhalation), set at 10 cm H2O, initiated 8/31/22. - Please ensure patient is wearing [CONDITION(S)] whenever he/she is sleeping in bed, initiated 6/4/21. - [MEDICATION(S)] HFA (an inhaled medication used to relax and open air passages to the lungs to make breathing easier), 0.09 milligrams (mg) per one actuation (actuate- depression of the inhaler to spray the medicine out of the canister), two puffs every six hours as needed (PRN) for shortness of breath, initiated 1/27/21. - May apply Oxygen (O2) at 2-4 liters per minute (LPM) as needed (PRN) to maintain oxygen saturation levels (the measure of how much oxygen is traveling through your body in your red blood cells) greater than (>) 90 percent (%), initiated 4/7/21. Review of the medical record included the following Progress Notes: 8/31/22 at 9:45 P.M. - [CONDITION(S)] mask is broken. O2 at 2 LPM via Nasal Cannula (NC) in place. 9/1/22 at 8:18 P.M. - Unable to use [CONDITION(S)] (continuous positive airway pressure, a different type of non-invasive therapy), which the writer erroneously identified as the Resident's equipment. 9/3/22 at 12:55 A.M.- Unable to use [CONDITION(S)] -erroneous identification of the Resident's equipment. 9/5/22 at 8:43 P.M. - O2 in place and functioning properly. 9/11/22 at 8:13 P.M. - Oxygen in place at 2 LPM via NC, PRN inhaler ([MEDICATION(S)]) given with positive effect. 9/12/22 at 8:21 P.M. - Resident complains of shortness of breath while in bed, given PRN inhaler and O2 in place. 9/24/22 at 9:27 P.M. - Resident complains of shortness of breath this evening, given PRN inhaler and placed on O2. 10/12/22 at 10:22 P.M. - O2 at 2 LPM via NC, reason: no mask for [CONDITION(S)] 10/13/22 at 3:41 A.M. - No mask for [CONDITION(S)] 10/15/22 at 8:21 P.M. - O2 at 2 LPM via NC, reason: [CONDITION(S)] not useable 10/17/22 at 1:42 A.M. - [CONDITION(S)] not useable Review of the September 2022 Treatment Administration Record (TAR) indicated the administration of the [CONDITION(S)] treatment was documented as being held (not applied) on the following dates: 9/2-9/4/22 9/6-9/7/22 9/9/22 9/13/22 9/17-9/23/22 9/25-9/26/22 9/28-9/30/22 Review of the September 2022 TAR Documentation and PRN Results Report indicated the [CONDITION(S)] treatment was documented as being held for the following reasons: -unable to use -held due to mask broken -held/see progress notes -not currently in use -O2 in place -awaiting repair -not working -machine inoperable Review of the October 2022 TAR indicated the administration of the [CONDITION(S)] treatment was documented as being held on the following dates: 10/2/22 10/5/22 10/7-10/9/22 10/11-10/12/22 Review of the October 2022 TAR Documentation and PRN Results Report indicated the [CONDITION(S)] treatment was documented as being held for the following reasons: -no mask for [CONDITION(S)]-on O2 at 2 LPM via NC -machine inoperable -Resident currently not using, awaiting mask - on O2 at 1 LPM via NC -see progress note -no mask. Review of the September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 9/1/22 at 7:35 P.M. 9/10/22 at 9:01 P.M. 9/11/22 at 7:11 P.M. 9/12/22 at 6:58 P.M. 9/19/22 at 6:51 P.M. 9/21/22 at 6:59 P.M. 9/22/22 at 6:11 P.M. 9/24/22 at 6:41 P.M. 9/28/22 at 6:53 P.M. Review of the October 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 10/3 at 6:57 P.M. 10/4 at 7:52 P.M. 10/6 at 7:25 P.M. 10/9 at 7:05 P.M. 10/10 at 6:54 P.M. 10/11 at 10:53 A.M. 10/13 at 7:09 P.M. Further review of the Medical Record did not include evidence that staff attempted to obtain a replacement [CONDITION(S)] mask for the Resident after his/hers was reported as broken on 8/31/22. During an observation and interview on 10/12/22 at 11:53 A.M., the surveyor observed the Resident's [CONDITION(S)] machine to be without a mask. During an interview at the time of the observation, the Resident said the mask was gone, had been gone for a long time and it was supposed to have been replaced. He/she further said that the nurses administered Oxygen to him/her nightly since he/she was unable to use her [CONDITION(S)] machine. During an interview on 10/14/22 at 4:30 P.M., Unit Manager (UM) #1 said she was aware the Resident's [CONDITION(S)] mask was broken and thought she reached out to the supplier on 10/11/22 to request a new mask. She further said she had not been in the UM position long and was unaware if any facility staff had requested a new mask for the Resident since it was reported as being broken on 8/31/22. The surveyor then reviewed the documentation in the clinical record with UM #1 that indicated nursing staff were utilizing Oxygen via NC in lieu of the [CONDITION(S)] device, as well as signing off as applying the device despite it not being available. UM #1 said she thought that utilizing Oxygen was an equivalent intervention since the Resident was unable to utilize his/her [CONDITION(S)] device, and that the nursing staff should not have signed off that the [CONDITION(S)] was administered, as it remained broken and was unavailable for use. During an interview on 10/18/22 at 8:53 A.M., the Director of Nursing (DON) said O2 via NC was not an appropriate substitution for [CONDITION(S)]. During a telephone interview on 10/18/22 at 11:19 A.M., the Regional Clinical Manager of O2 Safe Solutions, the facility's contracted respiratory durable medical equipment (DME) company, said that utilizing O2 via NC cannot be considered a substitute for treatment with [CONDITION(S)] because a NC will not work to keep an airway open in the event of Apnea, for which this Resident has an active diagnosis. He further said that O2 Safe Solutions did not receive any requests for a replacement mask for this Resident after 8/31/22 when it was reported to have been broken, until 10/17/22. During an interview on 10/18/22 at 1:36 P.M., the Staff Development Coordinator (SDC) said while he had [CONDITION(S)] and [CONDITION(S)] (Continuous Positive Airway Pressure, a type of non-invasive therapy) competencies, he has not utilized them nor has he provided any specific [CONDITION(S)]/[CONDITION(S)] training in the five years he has held the position of SDC.

Based on observations, interviews, and record review, the facility failed to ensure its staff provided quality of care, according to the Residents' plans of care, facility policy, and professional standards of practice for one Resident (#47), out of a sample of 27 residents. Specifically, the facility failed to provide the following care and services for a Resident who was at risk for re-opening a pressure wound located on the coccyx (also known as the tailbone, is a small, triangular bone located at the bottom of the spine) that had been recently resolved and considered to still be a fragile area, and also had a current Urinary Tract Infection ([CONDITION(S)]): 1) reposition the Resident as indicated in his/her plan of care, 2) provide incontinence care per the Resident's care plan, and 3) provide timely care and services when using a bed pan. Finding include: Resident #47 was admitted to the facility in May 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment, dated 5/20/22, indicated the resident required an extensive assist of two people for bed mobility and an extensive assist of one person for toilet use. 1) The facility failed to reposition Resident #47 per his/her care plan. Review of the facility policy titled Pressure Ulcer Prevention Protocol, last revised in 12/2015, indicated to reposition resident in bed and chair at least every two hours. Review of the Skin Breakdown Care Plan, initiated on 5/23/22, indicated to reposition the resident every two hours in bed and every one hour in the chair. 2) The facility failed to provide incontinence care per his/her care plan. Review of the Urinary Incontinence Care Plan, initiated on 5/23/22, indicated the following interventions: -Toilet the Resident during their individual morning and evening care. -Toilet the Resident before and after meals and before going back to bed. -Toilet the Resident if he/she appears restless and if requested. -Provide incontinence care as needed. Review of the [CONDITION(S)] Care Plan, initiated on 5/25/22, indicated the following interventions: -Toileting needs may increase during an active [CONDITION(S)]. -Provide toileting assistance as needed. Review of the October Physician's Orders indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/13/22 the Surveyor made the following observations from 9:37 A.M. through 11:54 A.M., and from 12:41 P.M. through 1:20 P.M: -From 9:37 A.M. through 11:26 A.M. (1 hour and 49 minutes) the Resident was seated in a wheelchair in the day room after breakfast, in the same position (chair tilted back). The facility staff did not reposition the Resident every hour as per his/her plan of care, until 11:26 A.M., when the chair was shifted upright. At 11:54 A.M. the Resident was brought from the day room to the dining room (2 hours and 17 minutes since original observation). The surveyor had not yet observed the Resident to be provided with incontinence care every two hours and was not provided hourly repositioning as per his/her plan of care. -At 12:41 P.M., the surveyor observed the facility staff bring Resident #47 from the dining room to the dayroom immediately following lunch. -At 12:51 P.M., the Resident repeatedly asked for someone to help him/her. -At 12:56 P.M., the Resident said to another resident that he/she needed to go to the bathroom. -At 12:58 P.M., the Activity Aide removed Resident #47 from the dayroom and placed him/her next to the nurse's medication cart near the nurse's station. Unit Manager (UM) #1 asked the Resident what he/she needed, and he/she responded, I need to go to the bathroom. -At 1:01 P.M., the Resident asked facility staff as they passed by if they could help her. -From 1:06 P.M. through 1:20 P.M., the Resident repeatedly said the following phrases, please, help me, take me to the bathroom please, nurse, nurse, nurse with increased volume at times. During continued observation at 1:09 P.M., the Resident asked Nurse #2 to be taken to the bathroom please, repeatedly (approximately ten times). Nurse #2 continued working, said the Resident's name and explained that he/she had to wait until she could find help. -At 1:15 P.M., The surveyor noted the Resident's mouth to be turned down at the corners with a frowning face, and staff indication that more staff were needed to toilet the Resident. -At 1:20 P.M., (29 minutes later) Certified Nursing Assistant (CNA) #1 and Nurse #2 brought the Resident to his/her room to put him/her to bed and to use the bed pan. The surveyor approached the facility staff and requested to observe incontinence care being provided as well as to assess the newly healed pressure wound. While the facility staff were providing incontinence care, the surveyor observed the Resident's buttocks and thighs to have deep creases and the incontinence brief to be saturated with yellow urine. The surveyor held the Resident's urine-soaked brief in a gloved hand and observed it to be heavy. During an interview on 10/13/22 at 1:43 P.M., CNA #1 said that Resident #47 could tell staff when he/she needed to use the bathroom and is able to make his/her basic needs known. CNA #1 said that the Resident was last changed around 10:00 A.M., and should be changed every two hours or sooner if requested and that the Resident was not changed in a timely manner. CNA #1 said that the Resident would sit on the bed pan for a good hour, sometimes even fall asleep, at times will not let staff take him/her off of it. Lastly, she said that the facility policy is every two hours to reposition the resident and/or address their bathroom needs, and that did not occur as required. 3) The facility failed to ensure its staff provided timely care and services when using a bed pan. Review of an article titled, Nursing Bedpan Management, from the National Library of Medicine (at NIH) and last updated on 7/25/22, indicated if a bed pan is to be used, it should be for a short duration. There are countless cases of pressure sores, ulcers and [CONDITION(S)] (damage to the peripheral nerves) from patients being left too long on the bed pan. Review of the Wound Care Specialist Progress Note, dated 10/10/22, indicated the coccyx wound was resolved and had fragile epithelial tissue (thin tissue forming on the outer layer of the body). On 10/17/22 at 9:39 A.M., the surveyor observed the Resident being taken into his/her room by CNA #2. -At 10:38 A.M., the surveyor heard Resident #47 repeatedly yelling out from his/her room, help me. -At 10:40 A.M., the surveyor overheard an employee say that they needed help getting the Resident off the bed pan. On 10/17/22 at 10:46 A.M., the surveyor heard the Resident continuing to yell help me repeatedly at varying volumes. During an interview on 10/17/22 at 10:56 A.M., as CNA #3 exited the Resident's room, she said that she just took the Resident off the bed pan. She said that she was not the one who put the Resident on the bed pan so she could not say how long he/she was on it for, only that it had been a while. During an interview on 10/17/22 at 1:15 P.M., CNA #2 said that when she and another staff person put the Resident back into bed that morning (at 9:39 A.M., the time the surveyor observed CNA #2 bring the Resident to his/her room) they placed him/her on the bedpan. During an interview on 10/17/22 at 3:50 P.M., the Director of Nursing (DON) said that the Resident should not have been left on the bedpan for that long. Refer to F690 and F744

Based on observations, record reviews and interviews, the facility staff failed to follow the plan of care for 2 sampled residents ( #1 and #11) out of 24 residents. Findings include: Review of the Falls Risk Reduction Policy, dated 1/1/09, indicated: -Develop individualized plan of care. -Include fall interventions on Resident Profile and Care plan. 1. Resident #1 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. Review of the Falls Care Plan, dated 12/6/16, indicated chair alarm for safety. Review of the 12/25/16 Significant Change in Status Minimum Data Set (MDS) Assessment indicated the resident had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS). The resident required extensive assist of one person for transfers, locomotion on and off the unit and hygiene. Review of the SBAR (Situation, Background, Assessment, Recommendation) Form dated 12/11/16, indicated the resident had an unwitnessed fall at 3:30 P.M. in the unit dayroom. and was complaining of left hip pain and exhibited external rotation of left leg. Review of the POS [REDACTED]. The Investigation indicated that the chair alarm did not sound during the event. The resident was transferred to the hospital and was diagnosed with [REDACTED]. Review of the Investigative Summary, undated, indicated the resident had been toileted at 3:00 P.M. He/she was then brought to the day room next to the nurse's station. The alarm on the wheelchair was functioning when the Certified Nurse Aide (CNA) had taken the resident to the toilet. Review of staff witness written statements indicated the following: - There was a greater than 1 minute delay before alarm sounded. - The alarm did not sound until after the assessment of the resident had begun. - Chair alarm activated 1 minute status [REDACTED]. During an observation on 9/8/17 at 11:15 A.M., the resident was sitting in a wheelchair by the nurses' station. A chair alarm and anti-tippers were observed on the wheelchair. During an interview on 9/12/17 at 2:15 P.M., Unit Manager (UM) #1 said the chair alarm should have activated as care planned. Review of the 5/2017 Falls Care Plan indicated: - Baby monitor when in bed. - Tab alarm when in bed. - Motion sensor when in bed. Review of the 7/11/17 Incident/Accident Report indicated Resident #1 had been in bed prior to incident. A staff member was walking by the resident's room and observed the resident ambulating alone to the bathroom. The staff member was unable to intervene in time and witnessed the resident fall to his/her left side and did not hit head. Post Fall Investigation, dated 7/11/17, indicated the motion sensor and bed alarm had not sounded during the event. The baby monitor did not indicate any movement or sound in the resident's room. During an observation on 9/12/17 at 10:30 A.M., the resident was sitting in a wheelchair in the unit dayroom and a staff member was encouraging him/her to eat a snack. A chair alarm was in place. During an interview on 9/12/17 at 2:15 P.M., UM #1 said the motion sensor, bed alarm and baby monitor did not sound as they should have and she could not verbalize reason as to why the alarms did not activate when resident was transferring self from bed. 2. For Resident #11, the facility failed to follow the resident's falls care plan relative to the following: bed and chair alarms were not on, safety checks were not conducted, call light was not within reach and the room was not well lit, as planned. As a result of not following the falls care plan, during one of the falls, the resident sustained [REDACTED]. Resident #11 was admitted to the facility in 7/2014. Review of the falls care plan of 10/17/16 indicated the following interventions: provide well lit environment, utilize sneakers/non-skid socks, as tolerated, and bathroom door alarm. Review of the 12/15/16 Progress Note indicated the resident needs frequent reminders to ask for assistance and had been setting off the safety alarms. The note further indicated the bed and chair alarms were in place and audible. Review of the Progress Note of 1/5/17 indicated the resident experienced an unwitnessed fall at 10:35 A.M., with no injury. During review of the falls investigation with UM #2 (on 9/12/17 at 2:45 P.M.), he said the resident's bed alarm was not on, at the time of the fall, as planned. The falls care plan then indicated a bed alarm was placed (although per UM #2, the bed alarm had already been part of the plan of care as confirmed in the 12/15/16 Progress Note). Review of the Progress Note of 1/6/17 indicated the resident experienced an unwitnessed fall at 7:30 P.M., with no injury. During review of the falls investigation with UM #2 (on 9/12/17 at 2:45 P.M.), he said the resident's bed alarm was not on, at the time of the fall, as planned. The falls care plan was updated to include: frequent checks initiated. When the surveyor asked UM #2 to review the frequent checks conducted, he said the checks had not been completed, as planned. The falls care plan was updated on 1/9/17 to include hourly safety checks for 3 days. During an interview with UM #2 (on 9/12/17 at 2:45 P.M.), he said, after checking with the Assistant Director of Nursing (ADON), that the facility had no evidence that the hourly safety checks had been completed, as planned. Review of the Progress Note of 1/13/17 indicated the resident experienced an unwitnessed fall at 11:45 A.M., sustaining a large ecchymotic area on the left inner buttocks. During review of the falls investigation with UM #2 (on 9/12/17 at 2:45 P.M.), he said the resident's chair alarm was not on, at the time of the fall, as planned. The falls care plan was updated to include: chair alarm added (per UM #2 the chair alarm had already been part of the plan of care and further said the chair alarm should have been on, at the time of the fall). The falls care plan was updated on 1/17/17 to include a Velcro alarming seat belt in wheelchair. Review of the Progress Note of 4/18/17 indicated the resident experienced an unwitnessed fall at 7:00 A.M., sustaining an acute compression fracture (T-11) and a hematoma to the back of the head. During interview with UM #2 (on 9/12/17 at 2:45 P.M.), he said the bed alarm was not sounding, at the time of the fall, as planned, and the lighting in the room was poor (not well lit, as planned). The falls care plan was updated to include: Physical Therapy (PT) evaluation and a bladder assessment. Review of the Progress Note of 5/24/17 indicated the resident experienced an unwitnessed fall (on 5/23/17 at 8:00 P.M.), sustaining a small bump on the back of the head. During review of the falls investigation with UM #2 (on 9/12/17 at 2:45 P.M.), he said that at the time of the fall, the call bell was not within the resident's reach, as planned, and that the room lighting was poor and not well lit, as planned. Review of the falls care plan re-written on 7/17/17 indicated the following interventions: well lit environment, frequently used items within reach, bed alarm and Velcro alarming seat belt in wheelchair. During an interview with CNA (Certified Nursing Assistant) #1 on 9/12/17 at 2:30 P.M., she said the resident is confused, very forgetful and that the resident has a bed alarm. During surveyor observation, with the CNA (at 2:35 P.M.), of the resident lying in bed, the surveyor and CNA noticed that the resident's bed alarm was not turned on, as planned. CNA #1 said the bed alarm should have been on (as planned) and immediately turned the alarm box switch on to activate the bed alarm. During an interview with UM #2 on 9/12/17 at 2:45 P.M., a discussion was held regarding the facility failing to follow the resident's falls care plan and as a result the resident sustained [REDACTED].

Based on observation, record review and interview, the facility staff failed to provide adequate supervision and appropriate interventions to prevent falls with injury for 2 sampled residents (#1 and #11) out of a total sample of 24 residents. Findings include: 1. Resident #1 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. Review of the facility Falls Management: Post Fall Policy, dated 1/1/09 indicated; - All residents experiencing a fall will receive appropriate care and investigation of the cause. - Will address any injury, provide care for recovery from fall, and reduce the risk for future falls. - Remove any cause of fall and implement preventative measures to prevent occurrence. Review of the 12/25/16 Significant Change in Status Minimum Data Set (MDS) Assessment indicated the resident had severe cognitive impairment as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS). The resident required extensive assist of one person for transfers, locomotion on and off the unit and hygiene. Review of the SBAR (Situation, Background, Assessment, Recommendation) Form dated 12/11/16, indicated the resident had an unwitnessed fall and was complaining of left hip pain and exhibited external rotation of left leg. Review of the Post Fall Investigation indicated the resident was in the dayroom and stood up from wheelchair and was found on the floor. The chair alarm did not sound during the event. The resident was transferred to the hospital and was diagnosed with [REDACTED]. During an observation on 9/7/17 at 3:00 P.M., the resident was sitting in a wheelchair on the unit hallway. The resident had a waist seatbelt applied. The resident was confused and unable to answer simple questions. During an observation on 9/8/17 at 1:00 P.M., the resident was ambulating with a staff member and his/her daughter. The resident was wearing a gait belt and utilizing a rolling walker. During an interview on 9/12/17 at 2:15 P.M., Unit Manager (UM) #1 said that prior to the 12/11/16 fall, the resident was sitting in a wheelchair, in the unit dayroom. She said the resident's wheelchair was positioned behind a Christmas tree decoration and was not visible to the staff. She said the resident was not supervised as she/he should have been and the chair alarm did not sound. 2. For Resident #11, the facility failed to provide adequate supervision and effective interventions to prevent 7 falls, with one fall resulting in an acute compression fracture (T-11) and scalp contusion. Resident #11, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment of 10/15/16 indicated that the resident was severely cognitively impaired; required assistance with transfers and ambulation; exhibited an unsteady balance and had a history of [REDACTED]. Review of the falls care plan of 10/17/16 indicated the following interventions: provide well lit environment, utilize sneakers/non-skid socks as tolerated, and bathroom door alarm. Review of the Progress Note of 12/5/16 indicated the resident experienced an unwitnessed fall (in bedroom), sustaining a left elbow bruise. The falls care plan was updated to include: bathroom door alarm to be on at all times. Review of the Progress Note of 12/9/16 indicated the resident experienced an unwitnessed fall, with no injury. Review of the 12/15/16 Progress Note indicated the resident needs frequent reminders to ask for assistance and had been setting off the safety alarms. The note further indicated the bed and chair alarms were in place and audible. Review of the Progress Note of 1/5/17 indicated the resident experienced an unwitnessed fall (in bedroom), with no injury. During review of the falls investigation with UM #2 (on 9/12/17 at 2:45 P.M.), he said the resident's bed alarm was not on, at the time of the fall, as planned. The falls care plan then indicated a bed alarm was placed (although per UM #2 the bed alarm had already been part of the plan of care as confirmed in the 12/15/16 Progress Note). Review of the Progress Note of 1/6/17 indicated the resident experienced an unwitnessed fall (in bedroom), with no injury. During review of the falls investigation with UM #2 (on 9/12/17 at 2:45 P.M.), he said the resident's bed alarm was not on, at the time of the fall, as planned. The falls care plan was updated to include: frequent checks initiated. When the surveyor asked UM #2 to review the frequent checks conducted, he said the checks had not been completed, as planned. Review of the quarterly MDS Assessment of 1/7/17 remained essentially unchanged. The falls care plan was updated on 1/9/17 to include hourly safety checks for 3 days. During an interview with UM #2 (on 9/12/17 at 2:45 P.M.), he said, after checking with the Assistant Director of Nursing (ADON), that the facility had no evidence that the hourly safety checks had been completed, as planned. Review of the Progress Note of 1/13/17 indicated the resident experienced an unwitnessed fall (in bedroom), sustaining a large ecchymotic area on the left inner buttocks. During review of the falls investigation with UM #2 (on 9/12/17 at 2:45 P.M.), he said the resident's chair alarm was not on, at the time of the fall, as planned. The falls care plan was updated to include: utilize a gait belt and chair alarm added (per UM #2 the chair alarm had already been part of the plan of care and further said the chair alarm should have been on, at the time of the fall). The falls care plan was updated on 1/17/17 to include a Velcro alarming seat belt in wheelchair. Review of the change of status MDS Assessment of 4/1/17 remained essentially unchanged. Review of the Progress Note of 4/18/17 indicated the resident experienced an unwitnessed fall (in bedroom), sustaining an acute compression fracture (T-11) and a hematoma to the back of the head. During interview with UM #2 (on 9/12/17 at 2:45 P.M.), he said the bed alarm was not sounding, at the time of the fall, as planned, and the lighting in the room was poor (not well lit, as planned). The falls care plan was updated to include: Physical Therapy (PT) evaluation and a bladder assessment. Review of the change of status MDS Assessment of 4/24/17 remained essentially unchanged. Review of the Progress Note of 5/24/17 indicated the resident experienced an unwitnessed fall (on 5/23/17 in the bedroom), sustaining a small bump on the back of the head. During review of the falls investigation with UM #2 (on 9/12/17 at 2:45 P.M.), he said that at the time of the fall, the call bell was not within the resident's reach, as planned, and that the room lighting was poor and not well lit, as planned. Review of the change of status MDS Assessment of 7/15/17 remained essentially unchanged. Review of the falls care plan re-written on 7/17/17 indicated the following interventions: well lit environment, frequently used items within reach, sneakers or non-skid socks on at all times, as tolerated, bed alarm and Velcro alarming seat belt in wheelchair. On 9/12/17 at 9:35 A.M., the surveyor observed the resident undo her/his Velcro alarming seat belt and stood up from the wheelchair. A CNA (Certified Nursing Assistant) approached the resident and assisted her back into her/his wheelchair. During an interview with CNA #1 on 9/12/17 at 2:30 P.M., she said the resident is confused and very forgetful, her/his knees buckle at times, she/he requires assistance with getting up from the wheelchair/bed, she/he will try to get up alone and she/he is not safe transfer or walk alone, and that the resident has a bed alarm. During surveyor observation, with the CNA, of the resident lying in bed, the surveyor and CNA noticed that the resident's bed alarm was not turned on, as planned. CNA #1 said the bed alarm should have been on. During an interview with UM #2 on 9/12/17 at 2:45 P.M., he said the resident is confused, is not safe to transfer/ambulate alone and has poor safety awareness. During discussion regarding the resident's falls with UM #2, he said that alarms are not always effective in preventing falls and that the resident should be receiving more staff supervision to prevent falls. The facility failed to provide effective interventions and adequate supervision to prevent continued falls.

Based on record review and interview, for one of five sampled Residents (Resident #1), who was care planned for use of a wheelchair alarm and never to be left unattended in the bathroom, the Facility failed to ensure adequate supervision of Resident #1 when Certified Nurses Aide (CNA) #1 assisted Resident #1 onto the toilet and then left Resident #1 unattended to go get linen and while CNA #1 was gone Resident #1 experienced a fall that resulted in fractures of thoracic vertebrae #10 and #11. Findings include: The Facility admitted Resident #1 in January, 2013. The admission Minimum Data Set (MDS) assessment, dated 1/24/13, indicated Resident #1's [DIAGNOSES REDACTED]. The MDS indicated Resident #1 had clear speech, understood others and Resident #1 was understood by others. The MDS indicated Resident #1 scored 15 out of 15 possible points on a Brief Interview for Mental Status (BIMS), which represented intact cognitive function. The MDS indicated Resident #1 required extensive staff assistance with transfers, ambulation, toilet use and personal hygiene. The MDS indicated Resident #1 was not steady moving on and off the toilet and was only able to stabilize with staff assistance. A fall risk care plan, updated on 2/26/13, indicated Resident #1 had an unstable balance, exhibited unsafe behavior, fell in the last year and Resident #1's mental status varied. The care plan goal was for Resident #1 to be free from injury related to falls. Care plan interventions included a chair alarm and never leaving Resident #1 unattended in the bathroom. A nurse's progress note (SBAR), dated 4/12/13, indicated at 3:55 P.M. Resident #1 was found on the bathroom floor and Resident #1 had a skin tear to the right forearm and complained of hitting his/her head. The nurse's progress note indicated the fall was unwitnessed. The nurse's progress note indicated Resident #1 complained of pain in the mid-back area and the back of the head. The nurse's progress note indicated Resident #1 was assessed by the Nurse Practitioner, who was in the facility and the Nurse Practitioner ordered Resident #1 sent to the Hospital for evaluation. The Surveyor interviewed the Unit Manager at 1:55 P.M. on 6/14/13. The Unit Manager said she was on her way out of the Facility and heard an alarm sound. The Unit Manager said she went to Resident #1's room and observed Resident #1 seated on the floor in front of the toilet. The Unit Manager said resident #1 seemed scared or afraid. The Unit Manager said Resident #1's wheelchair had an alarm on it, but she was not sure why the alarm sounded because Resident #1 was on the toilet, unless Resident #1 hit the wheelchair on the way down. The Unit Manager said Certified Nurses Aide (CNA) #1 was a float CNA and clearly knew she had made a bad decision leaving Resident #1 unattended on the toilet. The Unit Manager said all staff knew that if a resident had an alarm ordered, the resident should never be left unattended on the toilet, because there was no alarm on the toilet. The Surveyor interviewed Nurse #1 at 2:45 P.M. on 6/7/13. Nurse #1 said she heard the Unit manager yell and responded to Resident #1's room. Nurse #1 said Resident #1 was on the floor between the toilet and the wheelchair. Nurse #1 said Resident #1 was alert, but said he/she did not know what happened. Nurse #1 said Resident #1's pants were about half way up. Nurse #1 said the Nurse Practitioner was in the Facility and assessed Resident #1, who complained of back pain. Nurse #1 said the Nurse Practitioner ordered Resident #1 sent to the Hospital emergency department. Nurse #1 said it was universal practice at the Facility on all units that a resident with an alarm should not be left unattended in a bathroom. The Surveyor interviewed CNA #1 at 3:00 P.M. on 6/7/13. CNA #1 said she had floated to the unit before and had provided care to Resident #1 before. CNA #1 said Resident #1 rang the call light and needed to go to the bathroom, so she assisted Resident #1 into the bathroom and transferred Resident #1 onto the toilet with a gait belt. CNA #1 said Resident #1 requested that the gait belt be removed while he/she was on the toilet, so CNA #1 removed the gait belt. CNA #1 said she normally did not leave anyone unattended on the toilet, but she did not bring any linen into the bathroom with her, so after Resident #1 was on the toilet, she left the bathroom and went across the hallway to the linen cart. CNA #1 said the Unit Manager was walking by in the hallway and then went right into Resident #1's room. CNA #1 said she followed the Unit Manager into the room. CNA #1 said Resident #1 was not even alone for a minute, only as long as it took to walk across the hallway for linen. CNA #1 said she was inserviced on the fact that no resident with an alarm should be left alone in the bathroom. A nurse's note, dated 4/12/13, indicated that Resident #1 returned from the Hospital emergency department at 8:00 P.M. with an order for [REDACTED]. A nurse's progress note (SBAR), dated 4/13/13, indicated Resident #1 experienced a fall last evening and hit his/her head. The nurse's progress note indicated Resident #1 was now vomiting and the physician ordered Resident #1 returned to the Hospital emergency department. Hospital Emergency Department Records, dated 4/13/13, indicated Resident #1 was seen last night related to a fall in which Resident #1 struck his/her head and Resident #1 started vomiting this morning. Hospital Emergency Department Records indicated Resident #1 was diagnosed with [REDACTED].#11. Hospital Emergency Department Records indicated Resident #1 was sent back to the Facility with orders for bed rest for the next 2 to 3 days, Percocet as needed for pain and Zofran (an anti-nausea medication) as needed for nausea. The Surveyor interviewed Resident #1 at 1:30 P.M. on 6/7/13. Resident #1 said he/she recalled the incident very well. Resident #1 said he/she was washing his/her hands at the sink in the bathroom and fell backwards. Resident #1 said he/she had a problem with falling backwards due to the Parkinson's. Resident #1 said he/she hit his/her head on the floor, but also fractured his/her back.

Based on record review and interview, the facility failed to notify the physician for 1 resident (#22) in a total sample of 24 and 1 Resident (ESR #1) in an extended sample of 3 residents. Findings included: 1. For Resident #22, the facility failed to notify the physician when the resident presented with watery diarrhea and poor oral intake, from [DATE] to [DATE]. Resident #22 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Nurses' notes dated [DATE] revealed the resident had 3 plus [MEDICAL CONDITION] in the lower left leg and complained of pain. The physician was called and the resident was transferred to the emergency room . The resident returned from the emergency room at 7:15 P.M., with a [DIAGNOSES REDACTED]. Nurse's note dated [DATE] revealed the resident removed the IV line on the 11:00 P.M. to 7:00 A.M. shift. Nurse's note dated [DATE] revealed the physician saw the resident, discontinued the IV antibiotic and ordered Keflex (antibiotic medication) 500 milligrams (mg) by mouth three times a day, for 10 days. Nurse's note dated [DATE] stated, "One adverse effect was noted. Resident had watery diarrhea at about 2:00 A.M." [MEDICATION NAME] (anti-diarrhea) was administered with effect. Nurse's note dated [DATE] at 3:30 P.M., revealed the resident had diarrhea 2 times on this shift. Blood pressure ,[DATE], temperature 98.6, pulse 74, and respirations 22. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1100 ccs (cubic centimeters). Nurse's note dated [DATE] at 1:00 A.M., stated, ". . . has a side effect to ABT (antibiotic). . . watery diarrhea. [MEDICATION NAME] 2 mg given with good effect." Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1500 ccs. Review of the 24 hour intake for [DATE] was illegible. Nurse's note dated [DATE] at 12:30 P.M., indicated the resident had diarrhea 2 times and [MEDICATION NAME] 2 mg was given for loose stool with "mod" (moderate) effect. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1100 ccs. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1150 ccs. Nurse's note dated [DATE] at 6:00 P.M., indicated the resident's appetite and fluid intake was "poor." Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1280 ccs. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 900 ccs. Nurse's note dated [DATE] at 2:00 P.M., indicated the resident's blood pressure was ,[DATE], temperature 97.6, pulse 72, and respirations 16. Appetite very poor, complained of nausea and refused all medications. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 620 ccs. Nurse's note dated [DATE] at 2:00 P.M., indicated "(the resident) is not well . . . refused lunch." Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 900 ccs. Nurse's note dated [DATE] at 2:30 A.M., indicated the resident complained of diarrhea and [MEDICATION NAME] 2 mg was given with good effect. Nurse's note dated [DATE] at 12:30 P.M., indicated the resident's appetite and fluid intake were poor. Nurse's note dated [DATE] at 10:15 P.M., revealed the resident complained of "GI" (gastrointestinal) upset, appetite poor. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1020 ccs. Nurse's note dated [DATE] indicated the resident had GI upset and diarrhea 3 times, with some relief from [MEDICATION NAME] at 11:30 A.M. Appetite poor. Fluids need much encouragement. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 720 ccs. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake documentation was blank. Nurse's note dated [DATE] at 7:00 A.M., indicated the resident continues to have loose stools, medicated with [MEDICATION NAME]. Nurse's note dated [DATE] at 9:00 A.M., indicated the resident complained of being sick, complained of nausea and abdominal cramping. Stool is slimy, green, foul. Fax to physician to report symptoms. Nurse's note dated [DATE] at 1:00 P.M., indicated the physician returned a fax with new orders to obtain stool for [MEDICAL CONDITIONS], a white blood count and to start [MEDICATION NAME] 500 mg, by mouth, three times a day, for 10 days. Nurse's note dated [DATE] on the 3:00 P.M., to 11:00 P.M. shift revealed the resident's stool sample was positive for [MEDICAL CONDITION]. The resident was ambulating with a walker and a steady gait, and continued to have loose stools. The resident complained of dry heaves, nausea, and cramping. Fluids encouraged in small amounts. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake documentation was blank. Nurse's note dated [DATE] indicated the resident's blood pressure was ,[DATE], temperature 97.1, respirations 12, pulse 90 and thready. The physician was called and the resident was transported to the emergency room . The resident was admitted with [DIAGNOSES REDACTED]. The resident expired on [DATE]. During an interview on [DATE] at 2:30 P.M., the Director of Nursing and Administrator acknowledged that there was no further indication in the clinical record that the physician had been called from [DATE] until [DATE] (13 days), during which time the resident presented with watery diarrhea and poor oral intake. During an interview on [DATE] at 3:10 P.M., Physician #1 did not remember being called between [DATE] and [DATE] (13 days), when the resident presented with watery diarrhea and poor oral intake. Please refer to F 272, Example #1, F327, Example #1, and F514, Example #1. 2. For ESR #1, the facility failed to notify the physician of the Resident's poor oral intake, that this Resident was on a diuretic medication ([MEDICATION NAME]) which increases fluid loss, and the Resident subsequently developed severe dehydration. Findings included: ESR #1 was admitted to the facility in ,[DATE]. The Resident's pertinent [DIAGNOSES REDACTED]. The Nutritional quarterly assessment dated [DATE] revealed the resident's daily fluid requirement was 2280 cc. Review of the Nurse Practitioner's (NP) progress note of [DATE] at 10:00 A.M. revealed that the Resident was seen at the request of nursing, due to lethargy, and a positive urine dipstick. The Resident awoke easily to the NP's voice. On physical examination, the following was written: "(the Resident's) tongue was dry, heart rate was irregular. Lungs CTA (clear to auscultation) anteriorly. No abd (abdominal) tenderness. A (assessment) lethargy ? etiol (etiology) P (plan) check urine, decrease [MEDICATION NAME] (an antipsychotic medication) & [MEDICATION NAME] (an antidepressant), po (by mouth) hydration program." Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 480 cc. Review of the physician's orders [REDACTED]. Interview with Unit Manager #3 (on [DATE] at 1:30 P.M.), indicated that the facility's protocol was as follows: when a resident is started on an antibiotic, intake and output is started. However, the resident was started on intake and output on [DATE]. Review of the Nurse's note of [DATE] at 5:00 P.M. indicated that the Resident refused most of supper. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 180 cc. Review of the Nurse's note of [DATE] at 1:00 P.M. indicated that the Resident took orally 60 cc of fluid each hour which was tolerated well, but the Resident's appetite was fair for breakfast and poor for lunch. This note stated: "(Spouse) concerned about poor appetite & lethargy still arouses easily but dozes off easily." Review of the Nurse's Note of [DATE] at 7:00 P.M., indicated that the Resident's appetite was poor, was eating less than 25% of meals, and oral fluid intake was 200 cc. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 740 cc. Review of the Nurse's Note of [DATE] (no documented time) indicated that this Resident was awake but, "was drooling excessively, slurred speech today, had copious amounts of fluid removed from the oral cavity, and fluids were encouraged and taken well at breakfast." Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 560 cc. Review of the Nurse's note of [DATE] at 5:20 P.M., revealed that the Chest X-Ray results indicated a mild left base infiltrate, and the covering physician indicated to add an additional 3 days of [MEDICATION NAME]. Review of the Nurse's note of [DATE] at 12:00 noon, indicated that the Resident's appetite was less than 25% of meals, and the oral fluid intake was 360 cc. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 960 cc. Review of the Nurse's note of [DATE] at 7:00 P.M. indicated that the Resident's appetite was less than 25%, and there was an oral fluid intake of 300 cc, and intake and output was monitored. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 840 cc. Review of the Nurse's note of [DATE] at 8:45 A.M., indicated: "The Resident was very drowsy but arouses to physical stimuli, appetite for breakfast was fair. Medication intake was questionable, the Resident did not swallow, the Resident pocketed some medications and drools some medications with occasional swallowing." Review of the MAR indicated [REDACTED]. The [MEDICATION NAME] was not taken on [DATE], because the Resident was unable to swallow medications. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 600 cc. Review of the Nurse's note of [DATE] at 11:00 A.M., indicated that frequent mouth care was given to clean pocketed food and drink. No labored respirations, but lips and fingernails are cyanotic. Diminished breath sounds at the bases scattered rhonchi. Oxygen saturation was 83 to 84%. The NP was notified and a new order was given for oxygen at 2 liters to maintain oxygen saturation above 90%. Review of the Nurse's note of [DATE] (no documented time, ambulance run sheets indicated at 11:26 P.M., the Resident was evaluated at the facility and then transported). The Resident had a temperature of 101.2 and oxygen saturation was 88% on 2 liters of oxygen, using accessory muscles to breath, oral intake 370 cc this shift. Call placed to the Resident's physician who ordered to send this Resident to the Emergency Department at the Community Hospital. Review of the Hospital's admission history and physical of [DATE] indicated in the Emergency Department this Resident was found to be severely dehydrated and in acute [MEDICAL CONDITION]. During an interview with UM #3 on [DATE] at 1:33 P.M., the staff member acknowledged that this 24 hour intake would be an insufficient oral intake each day (from [DATE] to [DATE]). UM #3 also acknowledged that there was no evidence that the Nurse Practitioner/Physician had been notified of the insufficient oral intake and unsafe swallowing, as evidenced by pocketed food and drink. Please refer to F272, Example #2, F327 Example #2, and F514, Example #2.

Based on record review and staff interview, the facility failed to provide ongoing assessments for 1 resident (#22) in a total sample of 24 and 1 Resident (ESR #1) in an extended sample of 3 residents. Findings included: 1. For Resident #22, the facility failed to assess, monitor and provide sufficient fluid intake to prevent dehydration, failed to identify signs and symptoms of dehydration, and failed to notify the physician when the resident experienced diarrhea and poor oral intake from [DATE] to [DATE] (13 days). Resident #22 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. The Nutritional quarterly assessment dated [DATE] revealed the resident's daily fluid requirement was 1620 ccs (cubic centimeters). (The resident's weight was 94 pounds on the most recent nutritional statement of [DATE]. Fluid needs calculated at 30 ccs per kilogram of weight is approximately 1260 ccs in a 24 hour period) The resident's overall nutrition status remained stable for the past quarter. Oral intake was fair and weight stable for the last 180 days. No signs and symptoms of dehydration. The Nutritional Care Plan dated [DATE] indicated the resident was at risk for weight loss and dehydration. The interventions included the following: - Monitor intake at all meals, offer alternate choices as needed, alert RD (Registered Dietician) and MD (Medical Doctor) to any decline in intake. - Encourage 100% consumption of all fluids provided. - Document intake regarding % of solids and fluids. The quarterly MDS (Minimum Data Set) assessment completed on [DATE] indicated that the resident had short and long term memory loss, was moderately impaired for daily decision making skills, was independent with transfers, ambulation, dressing, eating, and personal hygiene. Laboratory values dated [DATE] revealed the resident's BUN (Blood Urea Nitrogen) was 21 mg/dl (milligrams per deciliter) (normal levels 7 to 30 mg/dl), a creatinine level of 0.62 (normal levels 0.7 to 1.4 mg/dl), [MEDICATION NAME] 3.7 (normal levels 3.6 to 5.0 G/DL), and total protein 5.9 (normal levels 5.9 to 7.9 G/DL). Nurses' notes dated [DATE] revealed the resident had 3 plus [MEDICAL CONDITION] in the lower left leg and complained of pain. The physician was called and the resident was transferred to the emergency room . The resident returned from the emergency room at 7:15 P.M., with a [DIAGNOSES REDACTED]. Nurse's note dated [DATE] revealed the resident removed the IV line on the 11:00 P.M. to 7:00 A.M. shift. Nurse's note dated [DATE] revealed the physician saw the resident, discontinued the IV antibiotic and ordered Keflex (antibiotic) 500 milligrams (mg) by mouth three times a day, for 10 days. Nurse's note dated [DATE] stated, "One adverse effect was noted. Resident had watery diarrhea at about 2:00 A.M. [MEDICATION NAME] (anti-diarrhea medication) was administered with effect." Nurse's note dated [DATE] at 3:30 P.M., revealed the resident had diarrhea 2 times on this shift. Blood pressure ,[DATE], temperature 98.6, pulse 74, and respirations 22. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1100 ccs. Review of the Laxative and B.M. (bowel movement) Record dated [DATE], indicated the resident had an extra/extra large B.M., a loose large B.M., and a loose medium B.M. Nurse's note dated [DATE] at 1:00 A.M., stated, " . . . has a side effect to ABT (antibiotic) . . . watery diarrhea. [MEDICATION NAME] 2 mg given with good effect." Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1500 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had two loose medium B.M.'s and a small B.M. Review of the 24 hour intake for [DATE] was illegible. Review of the Laxative and B.M. Record dated [DATE] indicated the resident did not have a B.M. Nurse's note dated [DATE] at 12:30 P.M., indicated the resident had diarrhea 2 times and [MEDICATION NAME] 2 mg was given for loose stool with "mod" (moderate) effect. The resident was ambulating well with the walker. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1100 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a large B.M. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1150 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a medium B.M. Nurse's note dated [DATE] at 6:00 P.M., indicated the resident's appetite and fluid intake was "poor." Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1280 ccs. Review of the Laxative and B.M. Record dated [DATE], indicated the resident did not have a B.M. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 900 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a medium and large B.M. Nurse's note dated [DATE] at 2:00 P.M., indicated the resident's blood pressure was ,[DATE], temperature 97.6, pulse 72, and respirations 16. Appetite very poor, complained of nausea and refused all medications. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 620 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had two medium B.M.'s. Nurse's note dated [DATE] at 2:00 P.M., indicated "(the resident) is not well . . . refused lunch." Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 900 ccs. Review of the Laxative and B.M. Record dated [DATE], indicated the resident had a loose medium B.M. Nurse's note dated [DATE] at 2:30 A.M., indicated the resident complained of diarrhea and [MEDICATION NAME] 2 mg was given with good effect. Nurse's note dated [DATE] at 12:30 P.M., indicated the resident's appetite and fluid intake were poor. Nurse's note dated [DATE] at 10:15 P.M., revealed the resident complained of "GI" (gastrointestinal) upset, appetite poor. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1020 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a medium B.M. and a loose large B.M. Nurse's note dated [DATE] indicated the resident had GI upset and diarrhea 3 times, with some relief from [MEDICATION NAME] at 11:30 A.M. Appetite poor. Fluids need much encouragement. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 720 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a medium and small B.M. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake documentation was blank. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a loose B.M., a medium B.M., and a large B.M. Nurse's note dated [DATE] at 7:00 A.M., indicated the resident continues to have loose stools, medicated with [MEDICATION NAME]. Nurse's note dated [DATE] at 9:00 A.M., indicated the resident complained of being sick, complained of nausea and abdominal cramping. Stool is slimy, green, foul. Faxed to physician to report symptoms. Nurse's note dated [DATE] at 1:00 P.M., indicated the physician returned a fax with new orders to obtain stool for [MEDICAL CONDITIONS], a white blood count and to start [MEDICATION NAME] 500 mg, by mouth, three times a day, for 10 days. Nurse's note dated [DATE] on the 3:00 P.M., to 11:00 P.M. shift revealed the resident's stool sample was positive for [MEDICAL CONDITION]. The resident was ambulating with a walker and a steady gait, and continued to have loose stools. The resident complained of dry heaves, nausea, and cramping. Fluids encouraged in small amounts. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake documentation was blank. Review of the Laxative and B.M. Record dated [DATE], indicated the resident had a large B.M., a loose small B.M., and a loose medium B.M. Nurse's note dated [DATE] indicated the resident's blood pressure was ,[DATE], temperature 97.1, respirations 12, pulse 90 and thready. The physician was called and the resident was transported to the emergency room . The resident expired on [DATE]. These findings were discussed with the Director of Nursing and Administrator on [DATE] at ,[DATE] P.M. The Director of Nursing acknowledged that she was not aware of either the length of time or the frequency of loose bowel movements/diarrhea and poor oral intake. She confirmed that this resident had not been fully assessed for the repeated loose bowel movements and poor oral intake that had been ongoing from [DATE] to [DATE]. Please refer to F157, Example #1 and F327, Example #1, and F514, Example #1. 2. For ESR #1, the facility failed to assess and identify this Resident's dehydration. Findings included: ESR #1 was admitted to the facility in ,[DATE]. The Resident's pertinent [DIAGNOSES REDACTED]. Review of the record indicated the quarterly MDS dated of [DATE], identified that the Resident had short and long term memory problems, was moderately impaired for cognitive and decision-making abilities, needed extensive assist with eating, dressing, bathing and hygiene and had no significant weight loss. Record review indicated this Resident was at risk for dehydration secondary to the following: - A urinary tract infection on [DATE] - A left lower lobe infiltrate on [DATE] - Decreased fluid intake and poor appetite from [DATE] to [DATE] - A dry tongue on the physical examination on [DATE] - Mental status changes (lethargy and drowsiness) from [DATE] to [DATE] After the insufficient intake from [DATE] to [DATE], there was no assessment or identification of the dehydration, even though there was a change in the Resident's condition. Record review and interview with Unit Manager #3 on [DATE] at 1:45 P.M., indicated the facility failed to identify and assess this Resident for dehydration. Please refer to F157, Example #2, and F327 Example #2.

Based on record review and interview, the facility failed to provide sufficient fluid to maintain proper hydration and health for 1 resident (#22) in a total sample of 24 and 1 Resident (ESR #1) in an extended sample of 3 residents. Findings included: The facility's policy for "Hydration" stated, "The staff will provide each resident with sufficient fluid to maintain proper hydration." The procedure included, ". . . 3. Closely monitor all residents at risk for dehydration . . ." 1. For Resident #22, the facility failed to assess, monitor and provide sufficient fluid intake to prevent dehydration, failed to identify signs and symptoms of dehydration, and failed to notify the physician when the resident experienced diarrhea and poor oral intake for 13 days. Resident #22 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. The Nutritional quarterly assessment dated [DATE] revealed the resident's daily fluid requirement was 1620 ccs (cubic centimeters). (The resident's weight was 94 pounds on the most recent nutritional statement of [DATE]. Fluid needs calculated at 30 ccs per kilogram of weight is approximately 1260 ccs in a 24 hour period) The resident's overall nutrition status remained stable for the past quarter. Oral intake was fair and weight stable for the last 180 days. No signs and symptoms of dehydration. The Nutritional Care Plan dated [DATE] indicated the resident was at risk for weight loss and dehydration. The interventions included the following: - Monitor intake at all meals, offer alternate choices as needed, alert RD (Registered Dietician) and MD (Medical Doctor) to any decline in intake. - Encourage 100% consumption of all fluids provided. - Document intake regarding % of solids and fluids. The quarterly MDS (Minimum Data Set) assessment completed on [DATE] indicated that the resident had short and long term memory loss, was moderately impaired for daily decision making skills, was independent with transfers, ambulation, dressing, eating, and personal hygiene. Laboratory values dated [DATE] revealed the resident's BUN (Blood Urea Nitrogen) was 21 mg/dl (milligrams per deciliter) (normal levels 7 to 30 mg/dl), a creatinine level of 0.62 (normal levels 0.7 to 1.4 mg/dl), [MEDICATION NAME] 3.7 (normal levels 3.6 to 5.0 G/DL), and total protein 5.9 (normal levels 5.9 to 7.9 G/DL). Nurses' notes dated [DATE] revealed the resident had 3 plus [MEDICAL CONDITION] in the lower left leg and complained of pain. The physician was called and the resident was transferred to the emergency room . The resident returned from the emergency room at 7:15 P.M., with a [DIAGNOSES REDACTED]. Nurse's note dated [DATE] revealed the resident removed the IV line on the 11:00 P.M. to 7:00 A.M. shift. Nurse's note dated [DATE] revealed the physician saw the resident, discontinued the IV antibiotic and ordered Keflex (antibiotic) 500 milligrams (mg) by mouth three times a day, for 10 days. Nurse's note dated [DATE] stated, "One adverse effect was noted. Resident had watery diarrhea at about 2:00 A.M. [MEDICATION NAME] (anti-diarrhea medication) was administered with effect." Nurse's note dated [DATE] at 3:30 P.M., revealed the resident had diarrhea 2 times on this shift. Blood pressure ,[DATE], temperature 98.6, pulse 74, and respirations 22. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1100 ccs. Review of the Laxative and B.M. (bowel movement) Record dated [DATE], indicated the resident had an extra/extra large B.M., a loose large B.M., and a loose medium B.M. Nurse's note dated [DATE] at 1:00 A.M., stated, ". . . has a side effect to ABT (antibiotic). . . watery diarrhea. [MEDICATION NAME] 2 mg given with good effect." Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1500 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had two loose medium B.M.'s and a small B.M. Review of the 24 hour intake for [DATE] was illegible. Review of the Laxative and B.M. Record dated [DATE] indicated the resident did not have a B.M. Nurse's note dated [DATE] at 12:30 P.M., indicated the resident had diarrhea 2 times and [MEDICATION NAME] 2 mg was given for loose stool with "mod" (moderate) effect. The resident was ambulating well with the walker. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1100 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a large B.M., (different from the nurse's note). Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1150 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a medium B.M. Nurse's note dated [DATE] at 6:00 P.M., indicated the resident's appetite and fluid intake was "poor." Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1280 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident did not have a B.M. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 900 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a medium and large B.M. Nurse's note dated [DATE] at 2:00 P.M., indicated the resident's blood pressure was ,[DATE], temperature 97.6, pulse 72, and respirations 16. Appetite very poor, complained of nausea and refused all medications. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 620 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had two medium B.M.'s. Nurse's note dated [DATE] at 2:00 P.M. indicated "(the resident) is not well . . . refused lunch." Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 900 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a loose medium B.M. Nurse's note dated [DATE] at 2:30 A.M., indicated the resident complained of diarrhea and [MEDICATION NAME] 2 mg was given with good effect. Nurse's note dated [DATE] at 12:30 P.M. indicated the resident's appetite and fluid intake were poor. Nurse's note dated [DATE] at 10:15 P.M. revealed the resident complained of "GI" (gastrointestinal) upset, appetite poor. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 1020 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a medium B.M. and a loose large B.M. Nurse's note dated [DATE] indicated the resident had GI upset and diarrhea 3 times, with some relief from [MEDICATION NAME] at 11:30 A.M. Appetite poor. Fluids need much encouragement. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake was 720 ccs. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a medium and small B.M., (different from the nurse's note). Review of the 24 hour intake for [DATE] indicated the resident's fluid intake documentation was blank. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a loose B.M., a medium B.M., and a large B.M. Nurse's note dated [DATE] at 7:00 A.M. indicated the resident continues to have loose stools, medicated with [MEDICATION NAME]. Nurse's note dated [DATE] at 9:00 A.M. indicated the resident complained of being sick, complained of nausea and abdominal cramping. Stool is slimy, green, foul. Faxed to physician to report symptoms. Nurse's note dated [DATE] at 1:00 P.M. indicated the physician returned a fax with new orders to obtain stool for [MEDICAL CONDITIONS], a white blood count and to start [MEDICATION NAME] 500 mg, by mouth, three times a day, for 10 days. Nurse's note dated [DATE] on the 3:00 P.M. to 11:00 P.M. shift revealed the resident's stool sample was positive for [MEDICAL CONDITION]. The resident was ambulating with a walker and a steady gait, and continued to have loose stools. The resident complained of dry heaves, nausea, and cramping. Fluids encouraged in small amounts. Review of the 24 hour intake for [DATE] indicated the resident's fluid intake documentation was blank. Review of the Laxative and B.M. Record dated [DATE] indicated the resident had a large B.M., a loose small B.M., and a loose medium B.M. Nurse's note dated [DATE] indicated the resident's blood pressure was ,[DATE], temperature 97.1, respirations 12, pulse 90 and thready. The physician was called and the resident was transported to the emergency room . The History and Physical dated [DATE] from the hospital stated that the resident was admitted with severe diarrhea, confusion, and abdominal pain. The resident was noted to be cold, clammy extremities and poor peripheral circulation with a history of poor p.o. (oral) intake. The diarrhea has been watery with no blood. On physical exam the resident is lethargic, confused and complained of abdominal pain. Blood pressure is 60 systolic. Oral mucosa, mouth and tongue are dry. Turgor is reduced. BUN 87, creatinine 2.3, higher than the resident's baseline, [MEDICATION NAME] is 2.1, [MEDICAL CONDITION] screen is positive. Assessment and Plan: 1. Severe volume depletion leading to shock with hypovolemia secondary to fluid loss from severe diarrhea and [MEDICAL CONDITION]. The resident was given aggressive fluid hydration in the emergency room . 2. Dehydration and acute [MEDICAL CONDITION] secondary to severe volume depletion. Metabolic acidosis likely secondary to poor perfusion that may have contributed by [MEDICAL CONDITION] too. The Hospital Discharge Summary dated [DATE] included the following Diagnoses: [REDACTED]. 2. [MEDICAL CONDITION]. 3. Significant volume depletion due to third spacing of fluid. 4. History [MEDICAL CONDITION]. 5. Hypertension. 6. Acute [MEDICAL CONDITION] on admit. The resident expired on [DATE]. These findings were discussed with the Director of Nursing and Administrative staff on [DATE] at ,[DATE] P.M. The Director of Nursing acknowledged that there was no indication that the physician was called from [DATE] until [DATE] (13 days), during which time the resident presented with watery diarrhea and poor oral intake. During an interview on [DATE] at 3:10 P.M., Physician #1 did not remember being called between [DATE] and [DATE] (a total of 13 days), when the resident presented with watery diarrhea and poor oral intake. Please refer to F157, Example #1, F272, Example #1, and F514, Example #1. 2. For Extended Survey Resident (ESR) #1, the facility failed to ensure that sufficient fluids were given in order to maintain proper hydration, and failed to prevent the development of dehydration, especially when a diuretic ([MEDICATION NAME]) medication was ordered. Findings included: ESR #1 was admitted to the facility in ,[DATE]. The Resident's pertinent [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated [DATE], identified that the Resident had short and long term memory problems, was moderately impaired for cognitive and decision-making abilities, needed extensive assist with eating, was not coded as dehydrated in the past 14 days, and had received a diuretic (a medication to encourage fluid loss). The Nutritional quarterly assessment dated [DATE] revealed the resident's daily fluid requirement was 2280 cc. The quarterly nutritional note of [DATE] revealed that the resident's overall nutrition status had remained fairly stable for the past quarter. The Resident was on a mechanically altered texture with thickened liquids, secondary to dysphagia, and needed to be feed. Weight had been stable for the last 180 days. No signs and symptoms of dehydration. Review of the Laboratory results indicated the following baseline values for Blood Urea Nitrogen (BUN) and Creatinine: on [DATE], BUN was 20 milligrams per deciliter (mg/dl) (normal 8 to 31 mg/dl) and Creatinine was 1.4 mg/dl (normal 1.1 to 1.8 mg/dl); on [DATE], BUN was 25 mg/dl and Creatinine was 1.40 mg/dl. Review of the facility's policy on hydration, dated [DATE] and [DATE], indicated that the staff will provide each resident with sufficient fluid intake to maintain proper hydration. Review of the facility's policy on intake and output, dated [DATE], indicated that the purpose of intake and output was to monitor for fluid deficit/imbalance. The procedure for monitoring (under #2 of that policy) indicated to record in cubic centimeters (cc) the intake, including the PO (oral intake) amounts taken by mouth. Under #4 of that policy, to total shift amounts, and daily intake and output records. Notify the physician if the resident does not consistently meet the fluid goal, and as clinical assessment of resident indicates. Under #5, Document intake and output in the Resident's medical record, and notify the physician if indicated. Interview with Unit Manager (UM) #3 (on [DATE] at 2:10 P.M.) indicated this Resident's code status was Do Not Resuscitate. She also indicated that this Resident was to be hospitalized , given intravenous fluids if needed, and this Resident was not on comfort care. Review of the Certified Nurse's Aide (CNA) Flow sheets of ,[DATE] indicated this Residents's usual hydration in percent (fluid intake for meals) was as follows: Breakfast was usually 50 to 74% fluid intake. Lunch was usually 50 to 74% Dinner was usually 50 to 74% Review of the Nurse Practitioner's (NP) progress note of [DATE] at 10:00 A.M. revealed that the Resident was seen at the request of nursing, due to lethargy, and a positive urine dipstick. The Resident awoke easily to the NP's voice. On physical examination, the following was written: "(the Resident's) tongue was dry, heart rate was irregular. Lungs CTA (clear to auscultation) anteriorly. No abd. (abdominal) tenderness. A (assessment) lethargy ? etiol (etiology) P (plan) check urine, decrease [MEDICATION NAME] (an antipsychotic medication) & [MEDICATION NAME] (an antidepressant), po (by mouth) hydration program." The hydration program indicated to give 60 cc of nectar liquid by cup by mouth every hour while the Resident was awake. Review of the hydration program with the hourly intake while awake revealed that over 7 days (from [DATE] at 10:00 A.M. to [DATE] at 11:00 P.M., the documentation was not consistent). The amount of fluid taken by the Resident was recorded only 18 times out of 117 opportunities. The remaining 99 spaces for fluid intake had initials, checks, dashes or letters with no amounts recorded. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 480 cc. Review of the CNA Flow Sheet on [DATE] indicated the hydration percent for lunch was 25 to 49% Review of the physician's orders [REDACTED]. Review of the urine culture and sensitivity results (with a run date of [DATE] at 12:10 P.M.) indicated the causative organism was Group D [MEDICATION NAME], which was sensitive to [MEDICATION NAME]. Interview with Unit Manager #3 (on [DATE] at 1:30 P.M.), indicated that the facility's protocol was as follows: when a Resident is started on an antibiotic, intake and output is started. However, the Resident was started on intake and output on [DATE]. Review of the Nurse's note of [DATE] at 5:00 P.M. indicated that the Resident remained drowsy but arousal and the Resident refused most of supper. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 180 cc. Review of the Nurse's note of [DATE] at 1:00 P.M. indicated that the Resident's respirations were slightly labored at times and the oxygen saturation was 92% (less than 90% indicates inadequate oxygen (hypoxemia). The Resident took orally 60 cc of fluid each hour which was tolerated well, but the Resident's appetite was fair for breakfast and poor for lunch. This note stated: "(Spouse) concerned about poor appetite & lethargy still arouses easily but dozes off easily." Review of the Nurse's Note of [DATE] at 7:00 P.M. indicated that the Resident's appetite was poor, was eating less than 25% of meals, and oral fluid intake was 200 cc. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 740 cc. Review of the CNA Flow Sheet on [DATE] indicated the hydration percent for breakfast and lunch were 0 to 24%. Review of the Nurse's Note of [DATE] (no documented time) indicated that this Resident was awake but, "was drooling excessively, slurred speech today, had copious amounts of fluid removed from the oral cavity, and fluids were encouraged and taken well at breakfast." Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 560 cc. Review of the Nurse's Note of [DATE] at 11:00 A.M., indicated the NP was in today, ordered a Chest X-ray, discontinued the 6:00 A.M. [MEDICATION NAME] (an antipsychotic), and changed the 2:00 P.M. dose of [MEDICATION NAME] to as needed. Review of the NP's note of [DATE] (no documented time) stated the following: "(The Resident's) [MEDICATION NAME] was held the past 2 noc (nights) 2 (secondary) to sedation. This A.M. (morning) (the Resident) appears sleepy but responds verbally. (The Resident) Does not follow instruction (1 step) but repeats, 'I'm all right.' T (Temperature) 99, HR (heart rate) irreg (irregular), Lungs with fine, rales RLL (Right lower lobe). This Resident is currently [MEDICATION NAME]([MEDICATION NAME]) will check a CXR (chest X-Ray) and decrease psychiatric medications." Review of the Nurse's note of [DATE] at 5:20 P.M. revealed that the Chest X-Ray results indicated a mild left base infiltrate, and the covering physician indicated to add an additional 3 days of [MEDICATION NAME]. Review of the Nurse's note of [DATE] at 12:00 noon indicated that the Resident's appetite was less than 25% of meals, and the oral fluid intake was 360 cc. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 960 cc. Review of the CNA Flow Sheet on [DATE] indicated the hydration percent for lunch and dinner were 25 to 49%. Review of the Nurse's note of [DATE] at 7:00 P.M. indicated that the Resident's appetite was less than 25%, and there was an oral fluid intake of 300 cc, and intake and output was monitored. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 840 cc. Review of the CNA Flow Sheet on [DATE] indicated the hydration percent for both breakfast and lunch were 0 to 24%. Review of the Nurse's note of [DATE] at 8:45 A.M., indicated: "The Resident was very drowsy but arouses to physical stimuli, appetite for breakfast was fair. Medication intake was questionable, the Resident did not swallow, the Resident pocketed some medications and drools some medications with occasional swallowing." Review of the MAR indicated [REDACTED]. The [MEDICATION NAME] was not taken on [DATE] because the Resident was unable to swallow medications. Review of the 24 hour intake for [DATE] indicated the Resident's fluid intake was 600 cc. Review of the Nurse's note of [DATE] at 11:00 A.M., indicated that frequent mouth care was given to clean pocketed food and drink. No labored respirations, but lips and fingernails are cyanotic. Diminished breath sounds at the bases scattered rhonchi. Oxygen saturation was 83 to 84%. The NP was notified and a new order was given for oxygen at 2 liters to maintain oxygen saturation above 90%. Review of the Nurse's note of [DATE] (no documented time, ambulance run sheets indicated at 11:26 P.M., the Resident was evaluated at the facility and then transported). The Resident had a temperature of 101.2 and oxygen saturation was 88% on 2 liters of oxygen, using accessory muscles to breath, oral intake 370 cc this shift. Call placed to the Resident's physician who ordered to send this Resident to the Emergency Department at the Community Hospital. Review of the Hospital's admission history and physical of [DATE] indicated in the Emergency Department this Resident was found to be severely dehydrated and in acute [MEDICAL CONDITION], and the Chest X-Ray showed an infiltrate in the left lower lobe. On physical exam, this Resident's mucous membranes in the oropharynx were found to be quite dry. Laboratory evaluation indicated this Resident's blood urea nitrogen was 115 mg/dl and creatinine was 3.3 mg/dl. The physician's impressions were as follows: 1. Acute [MEDICAL CONDITION] with severe dehydration 2. Left lower lobe pneumonia, resolving 3. Urinary tract infection Group D [MEDICATION NAME] on treatment. 4. Dementia 5. [MEDICAL CONDITION] Disease 6. [MEDICAL CONDITION] Fibrillation on [MEDICATION NAME] with coagulopathy. During an interview with Unit Manager #3 on [DATE] at 1:32 P.M., she acknowledged that the intake and output on the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Resident's daily fluid requirement was 2280 cc, The following 24 hour intake was recorded: - [DATE] the intake was 480 cc - [DATE] the intake was 180 cc - [DATE] the intake was 740 cc - [DATE] the intake was 560 cc - [DATE] the intake was 960 cc - [DATE] the intake was 840 cc - [DATE] the intake was 600 cc During an interview with UM #3 on [DATE] at 1:33 P.M., she acknowledged that this 24 hour intake would be an insufficient oral intake each day (from [DATE] to [DATE]). She did not feel it was accurately recorded by the nursing staff, and the nursing staff were not using the intake and output work sheets on the unit. At this time, UM #3 also acknowledged that there was no evidence that the Nurse Practitioner/Physician had been notified of the insufficient oral intake and unsafe swallowing, as evidenced by pocketed food and drink. Review of the MAR indicated [REDACTED]. UM #3 acknowledged that there was not enough space on the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 3:00 P.M., and review of the intake and output documentation, indicated that the hydration program documentation on the MAR indicated [REDACTED]'s. The DON also acknowledged that the Resident's intake and output should have been recorded on the intake and output work sheet, and then the 24 hour total should be put on the MAR. The DON acknowledged that the Resident's inadequate 24 hour intakes should have been reported to the nurse practitioner : Interview with the NP on [DATE] at 3:50 P.M., indicated that she was not notified of the Resident's insufficient oral intake. When asked was asked, if she was aware of the Resident's insufficient oral intake, would she have continued the [MEDICATION NAME] (a medication that encourages fluid loss), she responded, that she would probably have discontinued it. During an interview with the DON on [DATE] at 3:00 P.M., she acknowledged that sufficient fluids were not given in order to maintain proper hydration, and accurate monitoring of intake and output was not done, in order to prevent dehydration. Please refer to F157, Example #2, F272, Example #2, and F514, Example #2.

Based on observation, record review and interviews, the facility failed to provide sufficient nursing staff, of sufficient quality, to ensure that residents attained and/or maintained their highest practicable physical, mental and psychosocial well-being, for 3 sampled residents (#3, 11, and 22) out of a total sample of 24 residents and 1 Resident (ESR #1) out of an extended sample of 3. Findings included: 1. Failed to notify the Physician of a significant delay in treatment and changes in condition for Residents #22 and ESR #1. (Please refer to F157) 2. Failed to provide the necessary care and treatment to promote healing of a pressure ulcer for Resident #3. (Please refer to F314) 3. Failed to provide sufficient fluids to prevent dehydration for Residents #22 and ESR #1. (Please refer to F327) 4. Failed to prevent significant medication errors for Resident #11. (Please refer to F333) 5. Failed to assess ongoing diarrhea and poor fluid intake for Residents #22 and ESR #1. (Please refer to F272) 6. Failed to ensure complete and accurate medical records for Residents #22 and ESR #1. (Please refer to F514) Review of the staff education records revealed the Licensed Staff and the Certified Nursing Assistants (CNA) received education "Preventing Dehydration in the Elderly" on 7/6/10, 7/710, 7/8/10 and 7/9/10. Further review of the information presented revealed that the Licensed Staff received the same basic training as the CNAs and there was no education provided on intake and output documentation. Further review of the education documentation revealed that only 20 of 39 Licensed Staff and only 41 of 77 CNAs received the dehydration education. During an interview on 11/9/10 at 3:45 P.M., the Staff Development Nurse acknowledged that the Licensed Staff received the same dehydration education as the CNAs, and there was no education on the documentation of intake and output.

Based on observation, record review and interview, the facility failed to provide the necessary treatment and services to promote healing for 1 of 7 residents with pressure sores (#3) in a total sample of 24. Findings included: For Resident #3, the facility failed to reposition the resident at least every 2 hours to relieve pressure from the stage 3 right ischial pressure sore. Resident #3 was admitted to the facility in 3/06 with a [DIAGNOSES REDACTED]. According to the U.S. Department of Health and Human Services Clinical Practice Guideline: treatment of [REDACTED]. If pressure on the ulcer can be relieved, limited sitting may be allowed. Reposition the sitting individual so the points under pressure are shifted at least every hour. If this schedule cannot be kept or is inconsistent with overall treatment goals, return the patient to bed. Record review indicated that the resident developed a chronic stage 3 pressure ulcer in (12/2008). The quarterly MDS (Minimum Data Set) assessment of 4/28/10 indicated that the resident had short and long term memory loss, was dependent with bed mobility, transfers, hygiene, bathing, dressing and eating, was incontinent of bowel, had an indwelling catheter, and had a stage 3 pressure sore. The Dermal Wound Record indicated that on 8/7/10, the stage 3 right ischium pressure sore measured: 1.0 cm (centimeter) in length by 0.7 cm in width by 2.6 cm in depth. The Dermal Wound Record indicated that on 9/4/10, the stage 3 right ischium pressure sore measured: 1.0 cm (centimeter) in length by 0.7 cm in width by 3.6 cm in depth. The annual MDS assessment of 10/7/10 indicated that the resident had short and long term memory loss, was dependent with bed mobility, transfers, hygiene, bathing, dressing and eating, was incontinent of bowel, had an indwelling catheter, and had a stage 3 pressure sore. The 10/2010 Norton Plus Skin Assessment indicated that the resident was at high risk for skin break down. The Dermal Wound Record indicated that on 10/10/10, the stage 3 right ischium pressure sore measured: 1.0 cm (centimeter) in length by 0.7 cm in width by 4.0 cm in depth. The Interdisciplinary Care Plan for actual skin breakdown, updated on 10/13/10, included: assist resident with turning and repositioning minimum of every 2 hours. The Nurse Practitioner's note of 10/19/10 indicated that the chronic ischial pressure sore was worsening and the wound depth was 4.2 cm. There was malodorous brown drainage on the old dressing. The Dermal Wound Record indicated that on 10/31/10, the pressure sore measured 1.0 cm in length by 1.6 cm in width by 5.0 cm in depth (increases depth). The ADL (Activities of Daily Living)/Resident Assessment Flow Sheet of 11/2010 indicated that the resident's position changes were documented every 2 hours. On 11/1/10 through 11/3/10 at 10:00 A.M. the resident was in bed. Between 12:00 P.M. and 6:00 P.M., the resident was in the wheelchair. At 8:00 P.M., the resident was in bed. physician's orders [REDACTED]. physician's orders [REDACTED]. On 11/3/10 at 11:00 A.M., the resident was observed lying flat on back, on a pressure relieving mattress in bed. There was a mechanical lift pad under the resident. At 11:20 A.M. to 12:00 P.M., the resident was observed in the day room sitting on a mechanical lift pad, on top of a Roho cushion in a high back wheelchair. At 12:15 P.M., the resident was observed sitting in the unit dining room. Between 1:00 P.M. and 4:00 P.M., the resident was observed sitting in a wheelchair in the dayroom. No repositioning was observed. On 11/4/10 at 9:45 A.M., Nurse #1 completed a treatment to the resident's right ischium. The treatment was performed as ordered. The resident was observed to have a stage 3 pressure ulcer on the right ischium. The wound bed was beefy red. On 11/4/10 from 11:00 A.M. to 11:55 A.M. and from 1:00 P.M. to 2:00 P.M., the resident was observed in the day room sitting on a mechanical lift pad, on top of a Roho cushion in a high back wheelchair. From 2:00 P.M. to 3:00 P.M., the resident was observed sitting in a wheelchair in the activity room. On 11/4/10 at 3:15 P.M., interview with CNA #1 (Certified Nursing Assistant) indicated that the resident was dependent with care, remained up in the wheelchair through supper and would be put to bed around 8:00 P.M., and acknowledged that the resident was not repositioned every two hours. On 11/4/10 at 3:45 P.M., the Assistant Director of Nursing acknowledged that the resident should not be out of bed for extended periods of time.