Every finding on record at Willow Brook Rehabilitation and Healthcare Center

Based on observations, record reviews and interviews, the facility failed to keep one Resident (#45) free from neglect out of a total sample of 28 residents. Specifically, the facility failed to provide incontinence care to Resident #45 for a total of 10 hours and assisted him/her with a meal while lying in soiled incontinent briefs, resulting in a new skin impairment to the left buttock. Findings include:Review of the facility policy titled, Abuse and Neglect - Clinical Protocol, dated March 2018, indicated the following:-Neglect as defined at 483.5 means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.-Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example, inadequate prevention or care of pressure ulcers, inattention to advanced directives and resident wishes, inappropriate management of problematic behavior, recurrent failure to provide incontinence care, failure to report or evaluate significant weight loss, repeated failure to check for correct application of restraints, etc.-The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Resident #45 was admitted to the facility in August 2025 with diagnoses of sacrum pressure ulcer, congestive heart failure, stroke and chronic kidney disease. Review of Resident #45's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #45 is incontinent of both bowel and bladder and is dependent on staff for incontinence care. On 9/9/25 at approximately 8:15 A.M., the surveyor observed a strong odor of urine and feces in the corridor outside of Resident #45's room. At 8:19 A.M., the surveyor entered Resident #45's room and the odor was stronger, and the Resident was observed lying on 3 incontinence pads. The Resident was unable to participate in an interview with the surveyor. Resident #45's health care proxy was unable to be contacted during survey due to being hospitalized . On 9/9/25 at 8:48 A.M., the surveyor continued to observe the odor in Resident #45's room as a Certified Nursing Assistant (CNA) entered the room to bring the Resident his/her breakfast. The CNA did not attempt to remove the soiled incontinence pads from under Resident #45 and the CNA was not observed providing any incontinence care to the Resident. The CNA then began to feed the Resident with the strong odor of urine and feces still present. On 9/9/2025 at 9:26 A.M., CNA #1 was observed entering Resident #45's room to provide incontinence care. At 9:36 A.M., the surveyor observed the 3 incontinence pads that had been removed from under Resident #45. All 3 pads were significantly soiled with urine and feces. Review of the Documentation Survey Report for September 2025, indicated the last documented time that incontinence care was provided to Resident #45 on the 9/8/25 over-night shift was 11:15 P.M., 10 hours prior to CNA #1 providing care. This indicated the facility missed 5 possible opportunities for incontinence care during this timeframe (1:15 A.M., 3:15 A.M., 5:15 A.M. and 7:15 A.M.,) in addition to not providing care prior to serving the Resident breakfast. The surveyor confirmed with the Staff Development Nurse that she was reading the time stamp on the Documentation Survey Report correctly and that this was the last time care had been documented as being provided. The surveyor attempted to interview the CNA responsible for Resident #45's care on the 9/8/25 over-night shift and the CNA did not return the surveyors call during survey. Review of the admission assessment, dated 8/24/25, indicated Resident #45 was assessed to be incontinent of both bowel and bladder upon admission and required assistance from staff. Review of Resident #45's urinary incontinence care plan, initiated on 8/24/25, indicated the following intervention:-Check resident approximately every 2 hours and provide incontinence care as needed. -Provide incontinence care and apply moisture barrier as needed. Review of Resident #45's Bowel incontinence care plan, initiated on 8/24/25, indicated the following intervention:-Check resident approximately every 2 hours and provide incontinence care as needed. -Provide incontinence care and apply moisture barrier as needed. Review of Resident #45's activities of daily living care plan, initiated on 8/24/25, indicated the following intervention:-Toileting: I require 2 staff assist with toileting. Review of Resident #45's nursing progress note, dated 9/9/25, the same day as the surveyor's observations, indicated the following:-pt (patient) with new skin failure wound to L (left) buttock noted by wound MD (medical doctor) while doing wound rounds, wound measures 2.6x2x- (centimeters), new order for Triad (wound treatment) daily. Review of the wound visit notes dated 9/9/25 indicated Resident #45 had a new skin impairment to the left buttocks measuring 2.6x 2xnot measurable cm (centimeters) with the etiology of end-stage skin failure. During an interview on 9/9/2025 at 9:36 A.M., CNA #1 said Resident #45 is incontinent of bowel and bladder. CNA #1 said all residents should be checked for incontinence every two hours and provide care as needed. During an interview on 9/11/2025 at 9:04 A.M., Nurse #1 said she was unaware of Resident #45's soiled incontinence pads during the breakfast meal. Nurse #1 said failing to provide incontinent care and leaving a resident in a soiled incontinent brief would be considered a form of neglect and not providing incontinence care could lead to skin breakdown. During an interview on 9/11/25 at 9:20 A.M., Unit Manager #1 said Resident #45 is declining, is incontinent of both bowel and bladder and has fragile skin. Unit Manager #1 said a possible risk factor for developing worsening or new skin impairments would be not providing incontinence care timely and said a resident should not be lying in saturated incontinence pads and care should be provided promptly as it would increase the risk of skin breakdown. Unit Manager #1 said not providing incontinence care to a resident throughout a shift or when visibly soiled is a form of neglect. During an interview on 9/11/2025 at 10:22 A.M., the Director of Nursing said not providing necessary care to a resident, such as incontinence care, is considered neglect. The Director of Nursing said all residents should be checked for incontinence and provided care as needed every two hours and that the risk of developing skin impairments from moisture is higher when care is not provided. The Director of Nursing reviewed the documentation survey report with the surveyor and said if the CNA documented incontinence care was provided at 11:15 P.M. and there was no further documentation, then that was the last time care had been provided to the Resident. The Director of Nursing said staff not providing incontinence care to Resident #45 for an entire shift and when visibly soiled, was neglect. The Director of Nursing also said that she expects the staff to provide residents with necessary care prior to assisting them with a meal and the staff not changing Resident #45 and feeding him/her while soiled was neglect. During an interview on 9/11/2025 at 12:57 P.M., Nurse Practitioner #2 said not providing incontinence care to Resident #45 when he/she was visibly soiled is neglect.

Based on observation, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 Residents (#45, #109, and #7) out of a total sample of 28. Specifically;1.) For Resident #45 the facility failed to provide incontinence care for the entirety of an over-night shift and the start of the morning shift, equaling a total of ten hours, resulting in skin breakdown;2.) For Resident #109 the facility failed to ensure cueing or assistance was provided for meals, resulting in Resident #109 eating 4 of 4 meals, that were not finger foods, with his/her hands; and 3.) For Resident #7, the facility failed to provide assistance with meals. Findings include:Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated as revised April 2025, indicated the following: -Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. -Appropriate care and serviced are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: c. elimination (toileting) d. dining (eating, including meals and snacks). Review of the facility policy titled, Urinary Continence and Incontinence – Assessment and Management, dated as Revised August 2022, indicated the following: -A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. 1. Resident #45 was admitted to the facility in August 2025 with diagnoses of sacrum pressure ulcer, congestive heart failure, stroke and chronic kidney disease. Review of Resident #45's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #45 is incontinent of both bowel and bladder and is dependent on staff for incontinence care. On 9/9/25 at approximately 8:15 A.M., the surveyor observed a strong odor of urine and feces in the corridor outside of Resident #45's room. At 8:19 A.M., the surveyor entered Resident #45's room and the odor was stronger, and the Resident was observed lying on 3 incontinent pads. The Resident was unable to participate in an interview with the surveyor. Resident #45's health care proxy was unable to be contacted during survey due to being hospitalized . On 9/9/25 at 8:48 A.M., the surveyor continued to observe the odor in Resident #45's room as a Certified Nursing Assistant (CNA) entered the room to bring the Resident his/her breakfast. The CNA did not attempt to remove the soiled incontinence pads from under Resident #45 and the CNA was not observed providing any incontinence care to the Resident. The CNA then began to feed the Resident with the strong odor of urine and feces still present. On 9/9/2025 at 9:26 A.M., CNA #1 was observed entering Resident #45's room to provide incontinence care. At 9:36 A.M., the surveyor observed the 3 incontinent pads that had been removed from under Resident #45. All 3 pads were significantly soiled with urine and feces. Review of the Documentation Survey Report for September 2025, indicated the last documented time that incontinence care was provided to Resident #45 on the 9/8/25 over-night shift was 11:15 P.M., 10 hours prior to CNA #1 providing care. This indicated the facility missed 5 possible opportunities for incontinence care during this timeframe (1:15 A.M., 3:15 A.M., 5:15 A.M. 7:15 A.M., and 9:15 A.M.) in addition to not providing care prior to serving the Resident breakfast. The surveyor confirmed with the Staff Development Nurse that she was reading the time stamp on the Documentation Survey Report correctly and that this was the last time care had been documented as being provided. Review of the admission assessment dated [DATE], indicated Resident #45 was assessed to be incontinent of both bowel and bladder upon admission and required assistance from staff. Review of Resident #45's urinary incontinence care plan, initiated on 8/24/25, indicated the following intervention: -Check resident approximately every 2 hours and provide incontinence care as needed. -Provide incontinence care and apply moisture barrier as needed. Review of Resident #45's Bowel incontinence care plan, initiated on 8/24/25, indicated the following intervention: -Check resident approximately every 2 hours and provide incontinence care as needed. -Provide incontinence care and apply moisture barrier as needed. Review of Resident #45's ADL care plan, initiated on 8/24/25, indicated the following intervention: -Toileting: I require 2 staff assist with toileting. Review of Resident #45's nursing progress note, dated 9/9/25, the same day as the surveyor's observations, indicated the following: -pt (patient) with new skin failure wound to L (left) buttock noted by wound MD (medical doctor) while doing wound rounds, wound measures 2.6x2x- (centimeters), new order for Triad (wound treatment) daily. Review of the wound visit notes dated 9/9/25 indicated Resident #45 had a new skin impairment to the left buttocks measuring 2.6x 2xnot measurable cm (centimeters) with the etiology of end-stage skin failure. The surveyor attempted to interview the CNA responsible for Resident #45's care on the 9/8/25 over-night shift and the CNA did not return the surveyors call during survey. During an interview on 9/9/2025 at 9:36 A.M., CNA #1 said Resident #45 is incontinent of bowel and bladder. CNA #1 said all residents should be checked for incontinence every two hours and provide care as needed. During an interview on 9/10/2025 at 12:15 P.M., Unit Manager #1 said all residents should be checked for incontinence every two hours and changed as needed. Unit Manager #1 said a resident should not be lying in saturated incontinence pads and care should be provided promptly as it would increase the risk of skin breakdown. During an interview on 9/11/2025 at 9:04 A.M., Nurse #1 said incontinence care should be provided to all residents every two hours and as needed. Nurse #1 said a risk factor for worsening or new skin impairments would be not providing incontinence care timely. Nurse #1 said she did not know Resident #45 well as she just works per diem in the facility. During a follow-up interview on 9/11/25 at 9:20 A.M., Unit Manager #1 said Resident #45 is declining, is incontinent of both bowel and bladder and has fragile skin. Unit Manager #1 said a possible risk factor for developing worsening or new skin impairments would be not providing incontinence care timely. During an interview on 9/11/2025 at 10:22 A.M., the Director of Nursing said incontinence care should be provided every 2 hours. The Director of Nursing said a possible risk factor for developing worsening or new skin impairments would be not providing incontinence care timely. The Director of Nursing reviewed the documentation survey report with the surveyor and said if the CNA documented incontinence care was provided at 11:15 P.M. and there was no further documentation, then that was the last time care had been provided to the Resident. During an interview on 9/12/25 at 11:43 A.M., the Wound Physician said a possible cause of skin breakdown could be prolonged lack of incontinence care. The Wound Doctor said Resident #45 has multiple skin impairments on his/her body and the new area discovered on 9/9/25 was determined to be skin failure due to the Resident's overall health condition. The Wound Doctor said he was not aware the Resident had been lying on soiled incontinence briefs for an extended amount of time. 2.) Resident #109 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/26/25, indicated Resident #109 scored a 2 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated Resident #109 had no behavior of refusing care. Review of the active Physician orders, included the following order with a start date of 12/13/23: -Heart Healthy diet/Regular texture, Regular/Thin consistency, for Dietary supplement allow finger foods. Review of the current care plan for Resident #109 includes the following care plans: 1. I have an ADL Self Care Performance Deficit r/t (related to) Cognitive Impairment. Interventions include: -Monitor for any changes in ADL ability, potential for improvement, and/or inability to perform ADLs. Caregiver to report changes to Nurse/Physician and document changes in Nurses Notes. (4/1/25) -Encourage me to participate in ADLs to the fullest extent possible. (4/1/25). -EATING: I require supervision with eating and drinking. (6/27/25) 2. I have impaired cognitive function and/or impaired thought processes r/t Dementia. Interventions include: -Cue, reorient and supervise as needed. 3. There is a behavior care plan in place indicating: I have a behavior problem Potential concern r/t (related to) behavior problem Resists Care r/t dementia, he/she can hit, kick, spitting at other residents or staff, throwing food at others, trying to lift tables, and curse with care at times. No behaviors were noted during any observations throughout the survey period and review of the clinical record failed to indicate Resident #109 refused care assistance with meals. Review of the (Nurse Practitioner) NP visit note dated 8/29/25 indicated: -Resident #109 is dependent on caregivers for assistance. On 9/09/2025 at 8:46 A.M., Resident #109 was observed in the unit dining room for breakfast. Resident #109 was eating scrambled eggs and waffles covered with syrup with his/her hands. There were three staff present in the room however Resident #109 was not being provided with assistance or cueing. The surveyor continued to make the following observation: -At 8:56 A.M., Resident #109 had consumed all of the food using his/her, was then rubbing his/her fingers through syrup on the plate and licking them. Staff had not assisted or cued the Resident at any point during the observation period. On 9/09/2025 at 12:16 P.M., Resident #109 was observed in the unit dining room for lunch. Resident #109 picked up a handful of diced potatoes with his/her hands and pushed them in his/her mouth. There was a CNA standing behind a resident that was seated beside Resident #109 however the CNA did not offer assistance or cueing to Resident #109 to use a utensil. The surveyor continued to make the following observation: -At 12:18 P.M., Resident #109 picked up a handful of peas with his/her hands and pushed them in his/her mouth. The CNA was still present however did not offer assistance or cueing to use a utensil. On 9/10/2025 at 8:13 A.M., Resident #109 was observed in the unit dining room for breakfast. A CNA placed breakfast in front of Resident #109, which included an English muffin and scrambled eggs, placed a fork on the plate beside the eggs and walked away. The surveyor continued to make the following observations: -At 8:15 A.M., Resident #109 picked up a fistful of eggs and pushed them into his/her mouth. -At 8:16 A.M., Resident #109 picked up a fistful of eggs and pushed them into his/her mouth. Three staff were at table setting up other residents' meals, however no one intervened or cued the Resident to use a utensil. -At 8:19 A.M., Resident #109 picked up a fistful of eggs and pushed them into his/her mouth. There were seven staff present in the dining room; however, no assistance or cueing was provided to Resident #109. -By 8:23 A.M., Resident #109 had completed entire plate of food by hand. On 9/11/2025 at 8:07 A.M., Resident #109 was observed in the unit dining room for breakfast. A CNA placed breakfast in front of Resident #109, which included toast with jelly and scrambled eggs. A knife was left on plate beside the eggs, but no fork was present. Following placing the meal the CNA walked away, and the surveyor continued to make the following observations: -At 8:08 A.M., Resident #109 picked up a fistful of eggs and pushed them into his/her mouth. There were several staff present in the dining room, including the Assistant Director of Nursing (ADNS), however no assistance or cueing was provided to Resident #109. -By 8:11 A.M., Resident #109 had finished eating all of the scrambled eggs with his/her hands. Review of the Certified Nursing Assistant (CNA) task documentation on 9/11/2025 at 8:27 A.M., indicated the following: -For breakfast on 9/9/25 and 9/10/25 Resident #109 required: Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance. Assistance may be provided throughout or intermittently. -For lunch on 9/9/25 Resident #109 was: Independent - Resident completes the activity by themself with no assistance from a helper. Review of the CNA task documentation failed to indicate Resident #109 refused care assistance 9/9/25-9/11/25. During an interview on 9/11/2025 at 9:32 A.M., Resident #109's CNA #2 said that Resident #109 needs one person assist with care and needs supervision with eating. CNA #2 said that Resident #109 ate his/her entire breakfast that morning independently using a fork, contrary to observation by the Surveyor. The surveyor shared the previous day's observations of Resident #109 eating other meals with his/her hands, including waffles with syrup and he said, the thing is we make sure that residents have sanitized hands before breakfast and then they can have the freedom to eat any of the food with their hands. CNA #2 said that he would not intervene and assist if a resident was eating any food with their hands because that is their right, but that utensils should be available. During an interview on 9/11/2025 at 9:41 A.M., the Assistant Director of Nursing (ADON) said that Resident #109 eats in the unit dining room and doesn't necessarily need help but needs a lot of cueing and supervision with meals. The ADON said that Resident #109 doesn't always use utensils, and we give her more finger foods so he/she can have more independence. The ADON said that staff should be intervening and assisting with meals when a resident needs assistance with eating. During an interview on 9/11/2025 at 10:48 A.M., the Director of Nursing said that if a resident is observed eating non finger food with their hands staff should staff intervene and offer assistance. 3.) Resident #7 was admitted to the facility in September 2024 with diagnoses including dementia and malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/28/25, indicated Resident #7 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. This MDS also indicated Resident #7 was dependent on staff for assistance with eating. Review of Resident #7's plan of care related to ADL self-care performance, revised 8/26/25, indicated: -EATING: I require hands-on assistance for eating and drinking. -EATING: I require total assistance with eating and drinking. Review of Resident #7's kardex (a form indicating the level of assistance needed for resident care), dated 9/12/25, indicated: -EATING: I require hands-on assistance for eating and drinking. -EATING: I require total assistance with eating and drinking. On 9/9/25 at 8:37 A.M. to 8:48 A.M., the surveyor observed Resident #7 eating breakfast in the dining room. Resident #7 was using his/her hands to eat waffles covered in syrup. There were several staff members in the dining room, but none were offering to help or sitting with the Resident. At 8:48 A.M., the surveyor heard a table mate tell staff that Resident #7 needed help and staff said, I will get to her and walked away. On 9/9/25 at 12:17 P.M. to 12:25 P.M., the surveyor observed Resident #7 eating lunch in the dining room. Resident #7 was using his/her hands to pick chicken salad filling out of a sandwich. Resident #7 was also using his/her fingers to eat peas, which he/she dropped many of the peas onto his/her lap. There were several staff members in the dining room, but none were offering to help or sitting with the Resident. At 12:19 P.M., the surveyor heard a table mate tell staff that Resident #7 needed help and staff said He/she is feeding himself/herself like a big girl/boy and walked away. On 9/10/25 at 8:36 A.M. to 8:51 A.M., the surveyor observed Resident #7 eating breakfast in the dining room. There were several staff members in the dining room, but none were offering to help or sitting with the Resident. Resident #7 was using his/her hands to eat and English muffin and scrambled eggs. At 8:20 A.M., Resident #7 attempted to take sip of cranberry juice and spilled half a cup of his/her cranberry juice onto the English muffin and scrambled eggs. Resident #7 continued to use his/her hands to eat scrambled eggs covered in cranberry juice. At 8:30 A.M., a certified nurse assistant (CNA) removed the plate containing half of his/her juice saturated english muffin and scrambled eggs. The CNA offered Resident #7 more cranberry juice but did not offer to get new English muffin or scrambled eggs. The CNA placed a bowl of oatmeal, which was previously out of reach of Resident #7, in front of him/her. The CNA put a spoon in the oatmeal and walked away. Resident #7 stared at the oatmeal for over five minutes before attempting to bring the spoon to his/her mouth backwards, spilling the oatmeal onto his/her lap. Resident #7 dropped the spoon on the floor. Resident #7 then begins to eat oatmeal with his/her fingers, spilling it onto his/her lap. At 8:51 A.M., a CNA asked Resident #7 if he/she was done and Resident #7 said yes. The CNA then asked Resident #7 where his/her spoon was, found it on the floor, and removed the three-quarter full oatmeal. On 9/10/25 at 12:01 P.M. to 12:15 P.M., the surveyor observed staff serve Resident #7 lunch and then walk away in the dining room. Resident #7 picked up pieces of lettuce with his/her hands. Resident #7 picked the top piece of bread of a sandwich at attempted to place it in his/her mouth but dropped it on the floor. At 12:10 P.M., a staff member came and offered to push Resident #7 closer to the table and said it looked like it was hard for him/her to reach his/her meal. At 12:15 P.M., a staff member began assisting the Resident with the meal. During an interview on 9/11/25 at 11:51 A.M., Certified Nurse Assistant (CNA) #9 said CNAs get information of the level of assistance each resident needed with meals through nurse report. CAN #9 said there is no kardex used in the facility. CNA #9 said if the nurse report said a resident required total assistance or hands on assistance with meals, it meant that staff should sit down to assist with the meal as soon as the meal is served. CNA #9 said if a resident required total assistance or hands on assistance with meals, the meal should not be left before assistance is ready or the food could get cold. CNA #9 said Resident #7 did not require total assistance or hands on assistance with meals and staff never sit and assist him/her unless she needs help, which does happen sometimes. During an interview on 9/11/25 at 11:54 A.M., CNA #6 said CNAs get information of the level of assistance each resident needed with meals through nurse report and through the kardex. CNA #6 said CNAs should check the kardex every shift because resident's change and residents with dementia have difficulty communicating their needs. CNA #6 said the kardex interventions should always be followed, or if inappropriate the nurse should be notified. CNA #6 said if a resident required total assistance or hands on assistance with meals, it meant that staff should sit down to assist with the meal as soon as the meal is served. CNA #6 said Resident #7 required only set-up and assistance as needed. The surveyor and CNA #6 visualized the kardex together and CNA #6 said the kardex must be incorrect where it says EATING: I require hands-on assistance for eating and drinking and EATING: I require total assistance with eating and drinking because he/she doesn't need assistance all the time. During an interview on 9/11/25 at 12:04 P.M., the Scheduler said she assisted Resident #7 with breakfast that morning. The Scheduler says she is also a CNA and often helps with meals. The Scheduler said CNAs get information of the level of assistance each resident needs with meals through nurse report and through the kardex. The Scheduler said if a resident required total assistance or hands on assistance with meals, it meant the staff needed to sit down and assist as soon as the meal is served. The Scheduler said Resident #7 should never have had his/her meal dropped off and left without a staff member sitting to assist because he/she requires total assistance just as the Kardex indicated. During an interview on 9/12/25 at 8:48 A.M., Nurse #5 said CNAs get information of the level of assistance each resident needed with meals through nurse report and through the kardex. Nurse #5 said interventions on the care plan and Kardex should always be implemented, and if inappropriate it should be revised. Nurse #5 said if a resident required total assistance or hands on assistance with meals, it meant the staff needed to sit down and assist as soon as the meal is served. Nurse #5 said Resident #7 should never have had his/her meal dropped off and left without a staff member sitting to assist because he/she requires total assistance just as the Kardex indicated. Nurse #5 further said Resident #7 is unable to use his/her right hand at all and his/her left hand is very weak and cannot hold heavier items like his/her cup. During an interview on 9/12/25 at 9:45 A.M., the Director of Nursing (DON) said CNAs get information of the level of assistance each resident needs with meals through nurse report and through the kardex. The DON said interventions on the care plan and Kardex should always be implemented, and if inappropriate it should be revised. The DON said if a resident required total assistance or hands on assistance with meals, it meant the staff needed to sit down and assist as soon as the meal is served. The DON said Resident #7 should have had staff sitting with him/her to assist with meals as indicated in his/her Kardex and care plan.

Based on observations, test trays, and interviews, the facility failed to a.) provide the residents of the facility palatable food on 2 out of 3 units and b.) serve the residents in the facility that are on a pureed diet what was listed on the menu. Findings include:Review of the facility policy titled Food Temperature & Batch Cooking, undated, indicated the following:-Food should be served at proper temperature to ensure food safety and palatability. Batch cooking is encouraged to cook foods in smaller batches and serve immediately to maintain temperature, quality and safety.4. Acceptable serving temperatures are:Item: Minimum: Maximum: Potatoes, pasta, rice: >/=140 but preferably 160-175 degreesVegetables: >/=140 but preferably 160-175 degreesPureed foods, hot: >/=140 but preferably 160-175 degrees Pureed meals were observed on 9/9/25 and 9/10/25 on the Concord Unit. The meals consisted of 3 mounds of unrecognizable food, did not include gravy on the meat and looked unappetizing. Resident council meeting was held on 9/10/25 at 10:31 A.M. During the meeting several residents complained that the hot food served at the facility was cold at times. A test tray of the puree meal was conducted on the Concord Unit on 9/10/2025 at 12:21 P.M. with the following results:-Potatoes with gravy: 112 degrees Fahrenheit, tasted warm not hot. -Pureed meat with gravy: 102 degrees Fahrenheit, tasted lukewarm not hot. The meat was not flavorful, and the surveyor was unable to determine the type of meat it was. -Green vegetable: 98 degrees Fahrenheit, tasted warm not hot. A test tray was conducted on the [NAME] Unit On 9/10/2025 at 12:33 P.M., with the following results:-Eggplant parmesan: 130 degrees Fahrenheit, tasted warm not hot. -Spaghetti: 140 degrees Fahrenheit, tasted warm not hot. -Salad: 70 degrees Fahrenheit, not crispy and not served with dressing. Review of the facility menu indicated the lunch meal on 9/9/25 was pork with potatoes and green peas. During an interview on 9/10/2025 at 1:20 P.M., the Food Service Director (FSD) was informed of the temperatures of the test trays and said the hot food should have been warmer and the cold food colder. The FSD said the main lunch item today was eggplant, however the residents in the facility on a pureed diet received the same lunch left over from yesterday because eggplant doesn't look good pureed. The FSD said residents should not be getting the same meal two days in a row and he did not consult with the Registered Dietitian regarding the menu change. During an interview on 9/10/2025 at 1:33 P.M., the Administrator said the facility does not do test trays to ensure palatability meets the facility expectation. The Administrator said he expects the food served to be at the appropriate temperature and a hot meal should taste hot and a cold meal taste cold. He also said he expects that the meals served is what is on the menu and if the kitchen deviates from the menu that the Registered Dietitian be notified and involved.

Based on record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for three Residents (#2,#34 and #93) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 28 residents. Specifically, the facility failed to ensure the ordered fluid restriction amounts in milliliter were tallied and documented every shift. Findings include: Review of the facility policy titled 'Encouraging and Restricting Fluids', October 2010, indicated the following but not limited to:-Verify that there is a physician's order for this procedure.-The following information should be documented in the resident's medical record; the amount in (ML) milliliter of fluids consumed by the resident during the shift.-If the resident refused the treatment, the reason (s) why and the intervention taken. 1.) Resident #2 was admitted to the facility in July 2025 with diagnoses including end stage renal disease and dependance on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/31/25, indicated Resident #2 scored a 15 out of a total possible 15 on the Brief Interview for Mental Status (BIMS) score indicating intact cognition. The MDS further indicated Resident #2 was dependent on renal dialysis. Review of Resident #2's physician order, dated 7/29/25, indicated the following:-1800 ML fluid restriction: Nursing total 360 ml; 120ml days, 120ml evening, 120ml nights. Dietary total 1440ml; 720ml breakfast, 360ml lunch, 360ml dinner every shift for nutrition. Review of Resident #2's plan of care for dialysis, date initiated 7/25/25, indicated the following:-Maintain fluid restriction as ordered. Review of Resident #2's Treatment Administration Record (TAR) from 7/29/25 to 9/10/25 failed to indicate the total amount of fluids in ML the Resident consumed per shift. During an interview on 9/10/25 at 11:54 A.M., Nurse #3 said fluid restriction should be followed as ordered, nurses are responsible for documenting the amount the residents have consumed per shift and that 11-7 shift nurse would total the entire amount consumed per day. Nurse #3 said if a resident on fluid restriction consumes excessive amounts over their restriction, it could lead to medical complications especially being on dialysis like Resident #2. During an interview on 9/10/25 at 12:11 P.M., Unit Manager #1 said nurses are responsible for documenting the amounts in milliliter consumed by the residents every shift. She further said 11-7 nurses would tally up the total amount consumed in 24 hours. If there is any discrepancy the nurse practitioner is made aware. During an interview on 9/11/25 at 10:25 A.M., the Director of Nursing said the fluid restriction orders are broken down by the amounts and nurses are responsible for documenting the consumed amounts every shift. She further said monitoring fluid restrictions would prevent residents from developing complications such as fluid volume overload. 2.) Resident #34 was admitted to facility in August 2024 with diagnoses including end stage renal disease dependent on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/7/25, indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) score indicating intact cognition. The MDS further indicated that the Resident was dependent on renal dialysis. On 9/9/25 at 12:28 P.M., the surveyor observed Resident #34 having lunch. On his/her tray were the following fluids: milk, cranberry juice and coffee. Resident #34's meal slip did not indicate fluid restriction status. Resident #34 said he was not aware that he/she was on fluid restrictions. Review of Resident #34's physician order, dated 5/16/25, indicated the following:-1800 ML fluid restriction: Nursing total 360 ml; 120ml days, 120ml evening, 120ml nights. Dietary total 1440ml; 720ml breakfast, 360ml lunch, 360ml dinner every shift for nutrition. Review of Resident #34's plan of care for dialysis, date initiated 8/26/25, indicated the following intervention.-Maintain fluid restriction as ordered. Review of Resident #34's Medication Administration Record (MAR) from 5/16/25 to 9/10/25 failed to indicate the total amount of fluids in ML the Resident consumed per shift. During an interview on 9/10/25 at 11:44 A.M., Certified Nursing Assistant (CNA) #2 said he was not aware of any residents on the unit who were on fluid restriction. He said if a resident was on fluid restriction it would be indicated on their meal ticket. During an interview on 9/10/25 at 11:47 A.M., Nurse #2 said Resident #34 was on dialysis and on fluid restrictions. She said the amount of fluids consumed by the resident should be documented in milliliters (ML) in the medication administration record to monitor resident for fluid overload. During an interview on 9/10/25 at 12:11 P.M., Unit Manager #1 said nurses are responsible for documenting the amounts in milliliters consumed by the residents every shift. She further said 11-7 nurses would tally up the total amount consumed in 24 hours. If there is any discrepancy the nurse practitioner is made aware. During an interview on 9/11/25 at 10:25 A.M., the Director of Nursing said the fluid restriction orders are broken down by the amounts and nurses are responsible for documenting the consumed amounts every shift. She further said monitoring fluid restrictions would prevent residents from developing complications such as fluid volume overload. 3.) Resident #93 was admitted to the facility in July 2025 with diagnoses including end stage renal disease, dependence on renal dialysis and acute on chronic diastolic congestive heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/9/25, indicated the Resident scored a 3 out of a total possible 15 on the Brief Interview for Mental Status (BIMS) score indicating severe impaired cognition. The MDS further indicated the Resident was dependent on dialysis. On 9/9/25 at 8:54 A.M., the surveyor observed Resident #93 eating breakfast. On the Resident's tray were the following fluids, milk, juice and coffee. Review of Resident #93's physician order dated 8/22/25, indicated the following:-2000 ML fluid restriction: Nursing total 320ML; 120ML days, 120ML evenings, 80ML nights. Dietary total 1680ML; 720ML breakfast, 480ML lunch, 480ML dinner every shift for nutrition. Review of Resident #93's plan of care for dialysis, date initiated 7/3/25, indicated the following intervention.-Maintain fluid restriction as ordered. Review of Resident #93's Medication Administration Record (MAR) from 8/22/25 to 9/10/25 failed to indicate the total amount of fluids in MLs the Resident consumed per shift. During an interview on 9/10/25 at 12:11 P.M., Unit Manager #1 said nurses are responsible for documenting the amounts in milliliters consumed by the residents every shift. She further said 11-7 nurses would tally up the total amount consumed in 24 hours. If there is any discrepancy the nurse practitioner is made aware. During an interview on 9/11/25 at 10:25 A.M., the Director of Nursing said the fluid restriction orders are broken down by the amounts and nurses are responsible for documenting the consumed amounts every shift. She further said monitoring fluid restrictions would prevent residents from developing complications such as fluid volume overload.

Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, and/or interventions to promote healing and prevent new ulcers from developing for four Residents (#45, #2, #17, and #23), who had pressure ulcers, out of 28 total sampled residents. Specifically,1a.) For Resident #45, the facility failed to implement a wound intervention resulting in deterioration of wound,1b.) For Resident #45, the facility failed to ensure staff provided prompt incontinence care to prevent new skin breakdown,2a.) For Resident #2, the facility failed to address and implement wound clinic recommendations for pressure ulcers to right and left buttocks, 2b.) For Resident #2, the facility failed to assess and document the measurements of the right and left buttock wounds weekly as ordered,3a.) For Resident #17, the facility failed to address and implement multiple wound care treatment recommendations for a left heel pressure related deep tissue injury (DTI) wound as recommended by the hospice wound nurse,3b.) For Resident #17, the facility failed to assess and document the measurements of a left heel pressure related deep tissue injury (DTI) wound at least weekly as required,4a.) For Resident #23, the facility failed to assess, document, measure, and stage pressure ulcers upon admission and weekly as ordered.4b.) For Resident #23, the facility failed to ensure that skin assessments were completed and documented at least weekly as ordered. Findings include: Review of the facility policy titled Pressure Ulcer/Skin Breakdown – Clinical Protocol, dated April 2014, indicated the following: -The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; For example, immobility, recent weight loss, and a history of pressure ulcers. -In addition, the nurses shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. -the physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents have indicated for type of skin alteration. Review of the facility policy titled Prevention of Pressure Injuries, dated April 2020, indicated the following: -Purpose: the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. -Risk assessment: 1. Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes and condition. -Skin Assessment: 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the residence risk factors, and prior to discharge. 3c. Wash skin after any episodes of incontinence. -Prevention: -2. Clean promptly after episodes of incontinence. 1.) Resident #45 was admitted to the facility in August 2025 with diagnoses of sacrum pressure ulcer, congestive heart failure, stroke and chronic kidney disease. Review of Resident #45's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #45 is incontinent of both bowel and bladder and is dependent on staff for incontinence care. 1a.) Review of the skin assessment, dated 8/24/25, indicated Resident #45 was admitted with a skin impairment to the coccyx. The skin assessment failed to both describe what type of skin impairment was on the coccyx or measure the area. Review of the Admission/readmission Screener assessment, dated 8/24/25, indicated Resident #45 was admitted with an open area to the coccyx. The assessment failed to include measurements of the area. Review of the Treatment Administration Record (TAR) for August 2025 indicated the treatment prescribed for Resident #45's coccyx wound, initiated on 8/25/25, was saline wash, pat dry and apply barrier cream every day and evening shift. On 8/26/25, Resident #45 was evaluated by the Wound Physician. The evaluation indicated the following: -Resident #45 had a stage 3 pressure area to the coccyx measuring 1.6 x .9 x .3 cm (centimeters) with a total surface area of 1.44 cm2 (squared centimeters). -Treatment plan: Primary Dressing(s) Alginate calcium apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Secondary Dressing(s) Gauze island w/ bdr (with border) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Review of Resident #45's physician orders failed to indicate this treatment was implemented after the wound physician visit. On 9/2/25, Resident #45 was again evaluated by the Wound Physician. The evaluation indicated the following: -Resident #45 had a stage 3 pressure area to the coccyx measuring 2.2 x 1.4 x .3 cm (centimeters) with a total surface area of 3.08 cm2 (squared centimeters), doubling in size from the previous week. -Treatment plan: Primary Dressing(s) Alginate calcium apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Review of Resident #45's physician orders indicated this treatment was implemented on 9/3/25. Review of the Treatment Administration Record (TAR) for September 2025 failed to indicate the treatment was completed on 9/8/25 and 9/10/25. Throughout survey, Resident #45 and his/her health care proxy were unable to participate in an interview with the surveyor. Review of Resident #45's pressure ulcer care plan indicated the following intervention: -Administer treatments as ordered and monitor for effectiveness. Report Abnormal findings to practitioner. Document findings and interventions. -Follow facility policies/protocols for prevention and treatment of skin breakdown. During an interview on 9/11/2025 at 9:04 A.M., Nurse #1 said the wound physician is at the facility weekly and evaluates and treats any resident with a wound. Nurse #1 said the recommendations made by the wound physician should be relayed to the physician and implemented as an order immediately. Nurse #1 said not following the recommendations of the wound physician or not completing a wound order as written by the physician could result in a worsening pressure wound. Nurse #1 said she only works at the facility per diem and is unaware of communication between the facility and wound physician regarding treatment recommendations. During an interview on 9/11/2025 at 9:20 A.M., Unit Manager #1 said the wound physician comes to the facility weekly and treats any resident with a wound, including Resident #45. Unit Manager #1 said after the wound physician evaluates and treats a resident, he makes treatment recommendations, and it is the responsibility of the facility to notify the medical team of these recommendations so they can be implemented. Unit Manager #1 and the surveyor reviewed the recommendations made by the wound physician on 8/26/25 and Unit Manager #1 said the recommendations were not relayed to the medical team and implemented. Unit Manager #1 said not following the recommendations of the wound physician could result in a worsening wound. Unit Manager #1 and the surveyor also reviewed the September 2025 TAR and Unit Manager #1 said she was unaware Resident #45's wound treatment was not completed on 9/8/25 and 9/10/25 and said this could also contribute to a worsening wound. During an interview on 9/11/2025 at 10:28 A.M., the Director of Nursing said the wound physician is in weekly to evaluate and treat residents with a wound, including Resident #45. The Director of Nursing said there is never an occasion where the recommendations from the wound physician are not implemented by the medical team and that not following the wound physician recommendations could potentially worsen an existing wound. The Director of Nursing and surveyor observed both the 8/26/25 recommendations from the wound physician and the September TAR. The Director of Nursing said she was unaware that the recommendations were never put in place and this could potentially be a cause for Resident #45's coccyx wound. The Director of Nursing also said she was unaware the treatment for the coccyx wound was not completed on two days and that there would be no reason for a nurse not completing the treatment. During an interview on 9/11/25 at 11:43 A.M., the Wound Physician said he has been treating Resident #45 for the past three weeks. The Wound Physician said he expects all wound recommendations he makes to be implemented and has never been told by the physician at the facility that a recommendation was not appropriate. The Wound Physician said Resident #45's skin is very fragile and not following his recommendations could potentially cause the wound to worse. The Wound Physician said he was unaware that from 8/26/25 to 9/2/25 his recommendation of treatment was not followed. During an interview on 9/11/2025 at 12:57 P.M., Nurse Practitioner #2 said she was not made aware of the wound physician recommendations on 8/26/25. Nurse Practitioner #2 said she and the physician always agree with the treatment recommendations made by the Wound Physician because he is the specialist and had she known about the recommendations, they would have been put into place. During an interview on 9/12/25 at 10:01 A.M., Nurse #9 said she worked the day shift on 9/8/25 and did not complete Resident #45's treatment to his/her coccyx. Nurse #9 said her day was too busy and she did not have time to complete the treatment. 1b.) On 9/9/25 at approximately 8:15 A.M., the surveyor observed a strong odor of urine and feces in the corridor outside of Resident #45's room. At 8:19 A.M., the surveyor entered Resident #45's room and the odor was stronger, and the Resident was observed lying on 3 incontinence pads. The Resident was unable to participate in an interview with the surveyor. Resident #45's health care proxy was unable to be contacted during survey due to being hospitalized . On 9/9/25 at 8:48 A.M., the surveyor continued to observe the odor in Resident #45's room as a Certified Nursing Assistant (CNA) entered the room to bring the Resident his/her breakfast. The CNA did not attempt to remove the soiled incontinence pads from under Resident #45 and the CNA was not observed providing any incontinence care to the Resident. The CNA then began to feed the Resident with the strong odor of urine and feces still present. On 9/9/2025 at 9:26 A.M., CNA #1 was observed entering Resident #45's room to provide incontinence care. At 9:36 A.M., the surveyor observed the 3 incontinence pads that had been removed from under Resident #45. All 3 pads were significantly soiled with urine and feces. Review of the Documentation Survey Report for September 2025, indicated the last documented time that incontinence care was provided to Resident #45 on the 9/8/25 over-night shift was 11:15 P.M., 10 hours prior to CNA #1 providing care. This indicated the facility missed 5 possible opportunities for incontinence care during this timeframe (1:15 A.M., 3:15 A.M., 5:15 A.M. and 7:15 A.M.,) in addition to not providing care prior to serving the Resident breakfast. The surveyor confirmed with the Staff Development Nurse that she was reading the time stamp on the Documentation Survey Report correctly and that this was the last time care had been documented as being provided. The surveyor attempted to interview the CNA responsible for Resident #45's care on the 9/8/25 over-night shift and the CNA did not return the surveyors call during survey. Review of Resident #45's nursing progress note, dated 9/9/25, the same day as the surveyor's observations, indicated the following: -pt (patient) with new skin failure wound to L (left) buttock noted by wound MD (medical doctor) while doing wound rounds, wound measures 2.6x2x- (centimeters), new order for Triad (wound treatment) daily. Review of the wound visit notes dated 9/9/25 indicated Resident #45 had a new skin impairment to the left buttocks measuring 2.6x 2xnot measurable cm (centimeters) with the etiology of end-stage skin failure. During an interview on 9/11/2025 at 9:04 A.M., Nurse #1 said she was unaware of Resident #45's soiled incontinence pads during the breakfast meal. Nurse #1 said failing to provide incontinent care and leaving a resident in a soiled incontinent brief, even for a short amount of time could lead to skin breakdown. During an interview on 9/11/25 at 9:20 A.M., Unit Manager #1 said Resident #45 is declining, is incontinent of both bowel and bladder and has fragile skin. Unit Manager #1 said a possible risk factor for developing worsening or new skin impairments would be not providing incontinence care timely and said a resident should not be lying in saturated incontinence pads and care should be provided promptly as it would increase the risk of skin breakdown. During an interview on 9/11/2025 at 10:22 A.M., the Director of Nursing said all residents should be checked for incontinence and provided care as needed every two hours and that the risk of developing skin impairments from moisture is higher when care is not provided. The Director of Nursing reviewed the documentation survey report with the surveyor and said if the CNA documented incontinence care was provided at 11:15 P.M. and there was no further documentation, then that was the last time care had been provided to the Resident. During an interview on 9/11/2025 at 12:57 P.M., Nurse Practitioner #2 said not providing incontinence care to Resident #45 when he/she was visibly soiled could potentially increase risk of skin breakdown. During an interview on 9/12/25 at 11:43 A.M., the Wound Physician said a possible cause of skin breakdown could be prolonged lack of incontinence care. The Wound Doctor said Resident #45 has multiple skin impairments on his/her body and the new area discovered on 9/9/25 was determined to be skin failure due to the Resident's overall health condition. The Wound Doctor said he was not aware the Resident had been lying on soiled incontinence briefs for an extended amount of time. 3.) Resident #17 was admitted to the facility in March 2024 with diagnoses including failure to thrive and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/28/25, indicated Resident #17 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This MDS also indicated Resident #17 had one unstageable pressure injury presenting as deep tissue injury. On 9/10/25 at 7:39 A.M., the surveyor observed Resident #17 in bed with his/her left heel offloaded in a pressure reducing boot. Resident #17 said he/she has a wound on his/her left heel that was caused from his/her mattress. 3a.) Review of Resident #17's nursing progress notes indicated the following written by Unit Manager #2: -8/4/25: CNA (certified nurse assistant) reported new area to left heel. 2x2 (centimeters) DTI (deep tissue injury) on left heel dry, eschar. -8/5/25: Hospice recommendation: if heel intact, paint with betadine (a topical antiseptic containing iodine). If the area opens, apply calcium alginate (a highly absorbent type of wound treatment) and cover with DPD (dry protective dressing). Review of Resident #17's physician orders failed to indicate any wound treatment from 8/4/25 through 8/7/25. Review of Resident #17's physician order, initiated 8/8/25 (three days after first recommended), indicated: -Paint left heel with betadine swab. Review of Resident #17's hospice routine visit progress note, dated 8/11/25, indicated: -Only open area on left heel. Wound not open at present, but looks like it could open so POC (plan of care) updated if that occurs. Family and facility agree with POC. Review of Resident #17's hospice wound recommendation, dated 8/11/25, indicated: -Wound recs (recommendations): Left heel paint with iodine to dry eschar, cover with ABD (abdominal pad, a type of dressing), secure with sock every day. If it opens and drainage starts: clean with cleanser, cut to fit alginate, ABD pad, wrap, change 2-3 times per week. Review of Resident #17's medical record, dated 8/11/25 to 8/25/25 failed to indicate the wound recommendation to cover with ABD pad from hospice was addressed or implemented. The physician's order to paint left heel with betadine swab remained in place during this time. Review of Resident #17's Treatment Administration Record (TAR), dated 8/17/25 to 8/25/25, indicated a new order to document answer to question Is there drainage present? from left heel wound, initiated 8/17/25. This TAR indicated the nurses documented yes there was drainage on 9 out of the 9 days from 8/17/25 to 9/11/25. The physician's order to paint left heel with betadine swab remained in place during this time and failed to indicate any additional physician's orders for any other types of wound dressing. Review of Resident #17's hospice routine visit progress note, dated 8/25/25, indicated: -Heal [sic] is open and advised to use alginate on open area. Wound no changes except drainage small amt (amount) s/s (serosanguineous, a type of wound drainage). Son updated. Family and facility agree with POC. Review of Resident #17's medical record, dated 8/25/25 to 9/11/25, failed to indicate the wound recommendation to use alginate on open wound was addressed or implemented. Review of Resident #17's Treatment Administration Record (TAR), dated 8/26/25 to 9/11/25, indicated the physician's order to answer the question Is there drainage present? from left heel wound, initiated 8/17/25 had nurses documented yes there was drainage on 13 out of the 15 days from 8/17/25 to 9/11/25. The physician's order to Paint left heel with betadine swab remained in place during this time and failed to indicate any additional physician's orders for any other types of wound dressing. On 9/10/25 at 12:09 P.M., the surveyor observed Nurse #7 perform wound care for Resident #17's left heel DTI pressure wound. The surveyor observed a red, open wound approximately the size of a quarter. Nurse #7 said this was an open wound with red granulation tissue in the wound bed. Nurse #7 said there was no dressing in place and that there is no physician's order to apply any dressings. Nurse #7 applied betadine to the wound bed and said this was the only wound treatment ordered to be completed. During an interview on 9/10/25 at 12:48 P.M., Unit Manager #2 said the Hospice Wound Nurse follows Resident #17'S left heel wound, and the Hospice Wound Nurse makes wound treatment recommendations to the Hospice Nurse Practitioner (NP), who would notify them of any necessary orders. Unit Manager #2 said if the wound had drainage then it must be an open wound. Unit Manager #2 said the left heel wound has had a small opening with drainage for quite some time, but since it's only a small opening hospice wishes to continue betadine only without any calcium alginate. Unit Manager #2 said she never notified the facility physician of any wound treatment recommendations for calcium alginate or any other type of dressing. Unit Manager #2 further said she was unaware that ABD pads required a physician's order. During a telephone interview on 9/11/25 at 9:03 A.M., the Hospice Wound Nurse said she had made the recommendation for calcium alginate when the wound opened, but it's the facilities responsibility to notify the facility NP to approve any of the recommendations for wound treatments. The Hospice Wound Nurse said she had observed the nurses apply ABD pads to Resident #17's left heel during her routine visits during the past month and was unaware that there was not an order for an ABD pad. During a telephone interview on 9/11/25 at 10:09 A.M., the facility Nurse Practitioner (NP) #1 said his first day working for the facility was 8/25/25. NP #1 said Resident #7 had an intact DTI and would expect the facility to notify him to approve all hospice wound treatment recommendations. NP #1 was unaware that Resident #17's DTI had opened and had drainage. NP #1 said the facility never notified him of this change but should have. NP #1 said the facility never addressed the hospice recommendation for calcium alginate but would have approved it if he had been notified. NP #1 said any open wound should have a dressing in place to protect from infection and Resident #17 should have had a dressing ordered for his/her open left heel wound. NP #1 further said application of ABD pads to a wound require a physician's order. During an interview on 9/11/25 at 10:45 A.M., the Director of Nursing (DON) said hospice wound treatment recommendations should be reviewed with the facility NP #1. The DON said if NP #1 did not approve the recommendations, then it should be documented somewhere in the medical record. The DON said ABD pads require a physician's order for application. The DON said the wound treatment recommendation for calcium alginate should have been addressed but was not. The DON further said if a wound has drainage, then it should have a dressing on it. The DON said if there was no physician's order for a dressing, the nurse should have notified the provider that it required one but did not. 3b.) Review of Resident #17's plan of care related to left heel suspected deep tissue injury, initiated 8/4/25, indicated: -Evaluate and document healing progress. Report significant changes and declines to the provider and follow-up as indicated. Document findings and interventions in nurse's notes. Review of Resident #17's medical record indicated the last left heel DTI wound measurements documented were on 8/25/25 by the Hospice Wound Nurse, which was 16 days prior. The measurements on 8/25/25 indicated Resident #17's left heel wound was 3 centimeters (cm) in length and 3 cm in width. Review of Resident #17's entire medical record, including consultant hospice progress notes, failed to indicate Resident #17's left heel DTI was measured on 9/2/25 and 9/8/25. During an interview on 9/10/25 at 12:48 P.M., Unit Manager #2 said Resident #17's wound should have been measured weekly by the nurse responsible for the Resident. Unit Manager #2 said this was communicated to the nurses through the physician order on the assigned shift. The surveyor and Unit Manager #2 reviewed Resident #17's electronic medical record, and Unit Manager #2 said there was no physician's order in place. Unit Manager #2 said since this physician's order to measure the left heel DTI was not in place, the wound was not measured but should have been on 9/2/25 and 9/8/25. During this interview, Unit Manager #2 was unaware that hospice had any measurements documented in hospice progress notes and said the facility, not hospice, was responsible for measuring Resident #17's left heel DTI wound. Review of Resident #17's physicians orders, dated 8/4/25 to 9/11/25, failed to indicate need to measure his/her left heel DTI weekly. During a telephone interview on 9/11/25 at 9:03 A.M., the Hospice Wound Nurse said the facility is responsible for measuring Resident #17's left heel DTI, but if she happens to measure it herself, she documents it such as in her hospice progress note on 8/25/25. During a telephone interview on 9/11/25 at 10:09 A.M., the facility Nurse Practitioner (NP) #1 said he expected Resident #17's left heel DTI to be measured weekly by the facility. During an interview on 9/11/25 at 10:45 A.M., the Director of Nursing (DON) said Resident #17's left heel DTI should have been measured weekly but was not. 2.) Resident #2 was admitted to the facility in July 2025 with diagnoses including peripheral vascular disease, type 2 diabetes, muscle wasting and atrophy and dependance on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/31/25, indicated Resident #2 scored a 15 out of a total possible 15 on the Brief Interview for Mental Status (BIMS) score indicating intact cognition. The MDS further indicated Resident #2 had one stage 3 and one unstageable pressure ulcer. On 9/9/25 at 8:38 A.M., the surveyor observed Resident #2 lying in his/her bed on an air mattress, his/her legs had dressing on them dated 9/8/25. Resident #2 said he/she has wounds on her buttocks. Review of Resident #2's physician orders indicated the following: -Date initiated 7/31/25; Normal saline wash (NSW) pat dry apply alginate then border gauze right gluteal every day shift. -Date initiated 9/8/25, Normal saline wash pat dry apply gauze impregnated with 1/4 strength Dakins, cover with gauze island dressing left buttock every day shift. Review of the medical record indicated Resident #2 went to a wound clinic appointment on 8/14/25 with the following wound care instructions. -Plan; bilateral ischial pressure ulcer, irrigate with normal saline, lightly pack wound with 0.125% Dakins moist gauze packing, mepilex border lite dressing or equivalent. Change dressing twice a day. Review of the treatment administration record (TAR) for August 2025 indicated the following treatment orders. -NSW pat dry apply alginate then border gauze to right gluteal every day shift, 8/14/25 through 9/10/25 - Normal saline wash pat dry apply gauze impregnated with 1/4 strength Dakins, cover with gauze island dressing left buttock every day shift. 8/14/25- 9/8/25. Review of Resident #2's medical record, dated 8/14/25 to 9/10/25 failed to indicate that the wound care instructions from 8/14/25 had been acknowledged and transcribed appropriately to indicate treatment to be completed twice a day. Review of Resident #2's progress notes indicated the following: -8/26/25; Dressing done to buttocks wound right buttock foul smelling 100% slough, left buttock red scant serous drainage. Patient left facility to go to hospital wound appointment at 1 pm via ambulance, meds (sic) given prior to leaving. -9/7/25; patient alert and oriented compliant with care able to make needs known, no distress noted, no c/o GI upset, no n/v/d, good appetite, no s/s of hypo/hyperglycemia. No c/o urinary sx, prn dilaudid administered once in the morning for c/o breakthrough pain to ble (bilateral lower extremity) with effect. R buttock wound is stable no s/s of infection, wound bed pink with small amount of slough, mod amount of ss drainage, no odor. L buttock wound unchanged, 100% slough to wound bed, small amount of ss drainage, surrounding skin intact, faint odor, no s/s of infection afebrile. Air mattress in place and functioning, BP elevated prior to meds, received meds as ordered, no s/s of active bleeding, BLE dsg intact, pt prefers to stay in bed will continue to monitor. [sic] -9/11/25; Treatment done to left ischium 100% slough foul smelling area cleansed with normal saline with small amount of frank red blood return after cleansing, measurements 3-centimeter (cm) x 3.5cm x 3cm peri-wound 100% granulation. Right ischium measures 3cm x1cm x0cm, 75% granulation with 25% slough surrounding tissue 100% granulation. Patient tolerated treatment well, denies pain. (Hospital) wound clinic appointment 9/18/25 for follow up scheduled. [sic] During an interview on 9/11/25 at 8:46 A.M., Nurse #4 said Resident #2's wounds to the buttocks are scheduled to be changed once daily. She said when the residents return from any medical appointment the nurses are responsible for any recommendations provided then would notify the nurse practitioner and transcribe them as orders. Nurse #4 said Resident #2's recommendations were not acknowledged as the treatment orders had not changed. During an interview on 9/11/25 at 8:53 A.M., Unit Manager (UM) #1 said the nurses are responsible for acknowledging any recommendations. She said the nurse practitioner is then made aware and the recommendations would be documented as the orders. UM #1 said Resident #2's wound clinic recommendations were not acknowledged. During an interview on 9/11/25 at 10:02 A.M., the Director of Nursing said nurses are responsible for acknowledging the recommendations, she said if the wound recommendations are not followed the wounds could get worse. During an interview on 9/11/25 at 12:58 P.M., Nurse Practitioner (NP) #2 said she does not recall being informed of the wound recommendations for Resident #2, she said she never goes against recommendations not unless there is medical contraindication. 2b.) Review of Resident #2's care plan related to pressure ulcer, initiated 8/9/25, indicated the following. -Monitor and document changes in skin status such as appearance, color, wound healing, s/sx of infection, changes in wound size or stage, to physician or designee as clinically indicated. Review of Resident #2's physician orders indicated the following: -7/27/25- Measure wound weekly location right gluteal every day shift every Tuesday. -7/31/25- Measure wound weekly location left gluteal every day shift every Tuesday. Review of Resident #2's medical record indicated the last recorded wound measurements for the left and right buttock were documented on 8/12/25 by the Wound Physician. The wounds measured as follows. -Left lower buttock stage 4 pressure wound measuring 5.8x 3.9x no measurable cm. -Right lower buttock stage 3 pressure wound measuring 4.8x3.2x0.3cm Review of Resident #2's medical record failed to indicate the wounds were measured from 8/12/25 to 9/10/25. Review of Resident #2's Treatment Administration Record (TAR) from 8/12/25 to 9/10/25 failed to indicate wound measurements were documented. During an interview on 9/11/25 at 8:46 A.M., Nurse #4 said wound measurements should be documented weekly according to the physician orders. She said staff were used to the Wound Physician measuring the wounds but since the resident started going to an outside clinic staff should have been measuring the wounds. During an interview on 9/11/25 at 8:53 A.M., Unit Manager (UM) #1 said the treatment nurse should document the wound measurements weekly on the TAR as it is a physician order. During an interview on 9/11/25 at 10:02 A.M., the Director of Nursing said nurses are responsible for measuring the wounds and documenting in the TAR, especially since Resident #2 was not being followed by the in house Wound physician and that physician orders should be followed. 4.) Resident #23 was admitted to the facility in September 2025 with diagnoses including diabetes, spinal cord abscess, and left heel pressure ulcer. &nb

Based on observation and interview the facility failed to ensure a dignified dining experience for three Residents (#109, #16 and #45) out of a total sample of 28 residents. Specifically,1. For Resident #109, the facility failed to provide assistance with eating, and the Resident resorted to eating non-fingerlike food with his/her hands for four entire meals. 2. For Resident #16, the facility failed to be seated at eye level while feeding the Resident. 3. For Resident #45, the facility failed to provide incontinence care prior to being served and was assisted with his/her meal while lying on top of soiled incontinence pads and with the odor of urine and feces present. Findings include: Review of the facility policy titled Dignity, dated as revised February 2021, indicated: 1.) Residents are treated with dignity and respect at all times. 5.) When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience. 1.) Resident #109 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/26/25, indicated Resident #109 scored 2 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated Resident #109 had no behavior of refusing care. Review of the active Physician orders, included the following order with a start date of 12/13/23: -Heart Healthy diet/Regular texture, Regular/Thin consistency, for Dietary supplement allow finger foods. Review of Resident #109's activity of daily living care plan includes the following interventions: -Monitor for any changes in ADL ability, potential for improvement, and/or inability to perform ADLs. Caregiver to report changes to Nurse/Physician and document changes in Nurses Notes. (4/1/25) -Encourage me to participate in ADLs to the fullest extent possible. (4/1/25). -EATING: I require supervision with eating and drinking. (6/27/25) Review of Resident #109's behavior care plan indicated the following: I have a behavior problem Potential concern r/t (related to) behavior problem Resists Care r/t dementia, he/she can hit, kick, spitting at other residents or staff, throwing food at others, trying to lift tables, and curse with care at times. On 9/09/2025 at 8:46 A.M., Resident #109 was observed in the unit dining room for breakfast. Resident #109 was eating scrambled eggs and waffles covered with syrup with his/her hands. There were 3 staff present in the room, however Resident #109 was not being provided with assistance or cueing. The surveyor continued to make the following observations: -At 8:56 A.M., Resident #109 had consumed all of the food using his/her, was then rubbing his/her fingers through syrup on the plate and licking them. Staff had not assisted or cued the Resident at any point during the observation period. On 9/09/2025 at 12:16 P.M., Resident #109 was observed in the unit dining room for lunch. Resident #109 picked up a handful of diced potatoes with his/her hands and pushed them in his/her mouth. There was a Certified Nursing Assistant (CNA) standing behind a resident that was seated beside Resident #109, however the CNA did not offer assistance or cueing to Resident #109 to use a utensil. The surveyor continued to make the following observations: -At 12:18 P.M., Resident #109 picked up a handful of peas with his/her hands and pushed them in his/her mouth. The CNA was still present, however did not offer assistance or cueing to use a utensil. On 9/10/2025 at 8:13 A.M., Resident #109 was observed in the unit dining room for breakfast. A CNA placed breakfast in front of Resident #109, which included an English muffin and scrambled eggs, placed a fork on the plate beside the eggs and walked away. The surveyor continued to make the following observations: -At 8:15 A.M., Resident #109 picked up a fistful of eggs and pushed them into his/her mouth. -At 8:16 A.M., Resident #109 picked up a fistful of eggs and pushed them into his/her mouth. Three staff were at table setting up other residents' meals, however no one intervened or cued the Resident to use a utensil. -At 8:19 A.M., Resident #109 picked up a fistful of eggs and pushed them into his/her mouth. There were seven staff present in the dining room; however, no assistance or cueing was provided to Resident #109. -By 8:23 A.M., Resident #109 had completed eating his/her entire plate of food by hand. On 9/11/2025 at 8:07 A.M., Resident #109 was observed in the unit dining room for breakfast. A CNA placed breakfast in front of Resident #109, which included toast with jelly and scrambled eggs. A knife was left on plate beside the eggs, but no fork was present. Following placing the meal, the CNA walked away and the surveyor continued to make the following observations: -At 8:08 A.M., Resident #109 picked up a fistful of eggs and pushed them into his/her mouth. There were several staff present in the dining room, including the Assistant Director of Nursing (ADNS), however no assistance or cueing was provided to Resident #109 to use a utensil. -By 8:11 A.M., Resident #109 had finished eating all of the scrambled eggs with his/her hands. No behaviors were noted during any observations throughout the survey period and review of the clinical record failed to indicate Resident #109 refused care assistance with meals. During an interview on 9/11/2025 at 9:32 A.M., CNA #2 said that Resident #109 needs one person assist with care and needs supervision with eating. CNA #2 said that Resident #109 ate his/her entire breakfast that morning independently using a fork, contrary to observation by the Surveyor. The surveyor shared the previous day's observations of Resident #109 eating other meals with his/her hands, including waffles with syrup and he said, the thing is we make sure that residents have sanitized hands before breakfast and then they can have the freedom to eat any of the food with their hands. CNA #2 said that he would not intervene and assist if a resident was eating any food with their hands because that is their right, but that utensils should be available. During an interview on 9/11/2025 at 9:41 A.M., the Assistant Director of Nursing (ADON) said that Resident #109 eats in the unit dining room and doesn't necessarily need help but needs a lot of cueing and supervision with meals. The ADON said that Resident #109 doesn't always use utensils and we give him/her more finger foods so he/she can have more independence. The ADON said that it is not a dignified dining experience for a resident to be eating non finger like food with their hands. During an interview on 9/11/2025 at 10:48 A.M., the Director of Nursing said that it is not a dignified dining experience for a resident to be eating non-finger like food with their hands. 2.) Resident #16 was admitted to the facility in January 2025 with diagnoses including Alzheimer's disease and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/24/25, indicated Resident #16 was assessed by staff to have severely impaired cognition. Review of the active Physician orders for Resident #16, include the following order with a start date of 2/01/25: -Regular diet Mechanical soft texture, regular/thin consistency, give finger food for dietary supplement. Review of the current Activities of Daily Living (ADL) care plan included the following intervention: -EATING: I require supervision with eating and drinking. On 9/09/2025 at 12:15 P.M., Resident #16 was observed seated in the unit dining room for lunch. A Certified Nursing Assistant (CNA) was observed standing behind Resident #16's chair in the dining room. The CNA occasionally leaned over Resident #16's left shoulder to scoop up food with a utensil and feed it to Resident #16. The surveyor continued to make the following observation: -At 12:21 P.M., the CNA sat down in a chair behind Resident #16, leaned over the left side of Resident #16's chair and while petting Resident #16's hair fed him/her a spoonful of food. On 9/10/2025 at 8:17 A.M., Resident #16 was observed seated in the unit dining room for breakfast. A CNA placed a breakfast plate in front of the resident and walked away. The surveyor continued to make the following observations: -At 8:20 A.M., Resident #16 slept at the table and had made no attempt to self-feed. Seven staff were present in the dining room, however none woke the Resident or sat down to offer feeding assistance. -At 8:22 A.M., a CNA stood behind Resident #16's chair, shook his/her shoulder while saying wake up its time to eat, then walked away without sitting down to offer assistance. -At 8:44 A.M., a CNA stood behind Resident #16, put a spoon in his/her hand and put the spoon into the oatmeal then walked away. Resident let go of the spoon, closed his/her and made no attempt to self-feed. During an interview on 9/11/25 at 8:58 A.M., CNA #7 said that Resident #16 requires assist with meal and that staff should be seated if able when feeding resident but sometimes there is furniture or other residents in the way and then it is okay to stand. During an interview on 9/11/2025 at 9:00 A.M., CNA #6 said that it is the expectation that staff be seated at eye level when feeding residents. During an interview on 9/11/2025 at 9:56 A.M., the Assistant Director of Nursing (ADON) she said that staff should be seated at eye level when feeding residents. She said that the hospice CNA often stands while feeding despite education. She said that the CNA working today is new and probably needs more education because it is not okay to stand while feeding. During an interview on 9/11/2025 at 10:45 A.M., the Director of Nursing (DON) said staff should be seated at eye level while providing assistance with feeding. The DON further said that if the ADON is aware that the hospice CNA has been educated repeatedly and continues to stand while feeding, the education is not effective and that the facility CNAs need education. 3.) Resident #45 was admitted to the facility in August 2025 with diagnoses of sacrum pressure ulcer, congestive heart failure, stroke and chronic kidney disease. Review of Resident #45's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #45 is incontinent of both bowel and bladder and is dependent on staff for incontinence care. On 9/9/25 at approximately 8:15 A.M., the surveyor observed a strong odor of urine and feces in the corridor outside of Resident #45's room. At 8:19 A.M., the surveyor entered Resident #45's room and the odor was stronger, and the Resident was observed lying on three incontinence pads. The Resident was unable to participate in an interview with the surveyor. Resident #45's health care proxy was unable to be contacted during survey due to being hospitalized . On 9/9/25 at 8:48 A.M., the surveyor continued to observe the odor in Resident #45's room as a Certified Nursing Assistant (CNA) entered the room to bring the Resident his/her breakfast. The CNA did not attempt to remove the soiled incontinence pads from under Resident #45 and the CNA was not observed providing any incontinence care to the Resident. The CNA then began to feed the Resident with the strong odor of urine and feces still present. On 9/9/2025 at 9:26 A.M., CNA #1 was observed entering Resident #45's room to provide incontinence care. At 9:36 A.M., the surveyor observed the three incontinence pads that had been removed from under Resident #45. All three pads were significantly soiled with urine and feces. During an interview on 9/9/2025 at 9:36 A.M., CNA #1 said Resident #45 is incontinent of bowel and bladder. CNA #1 said all residents should be checked for incontinence every two hours and provide care as needed. During an interview on 9/11/2025 at 10:22 A.M., the Director of Nursing said that eating a meal while soiled with urine and feces is not dignified and care should have been provided to Resident #45 before the staff started assisting him/her with his/her breakfast.

Based on observation, interviews and policy review the facility failed to implement appropriate infection practices. Specifically, a staff did not wear gloves while handling dirty linen. Findings include:Review of facility policy titled 'Personal Protective Equipment-Gloves' dated July 2009, indicated the following but not limited to:-Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non intact skin.-All employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin.-Wash your hands after removing gloves. On 9/9/25 at 9:36 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 open soiled linen with bear hands, the soiled linen consisted of wet used towels, an adult brief with feces and a heavily soiled bed soaker. During an interview on 9/9/25 at 9:36 A.M., CNA #1 said she always wears gloves, and she was not sure why she touched the soiled linen without gloves. During an interview on 9/9/25 at 9:37 A.M., CNA #3 said all staff should wear gloves while providing care and handling soiled linen. During an interview on 9/10/25 at 12:18 P.M., Unit Manager #1 said staff should wear gloves while handling dirty linen as it is for universal precautions for infections. During an interview on 9/11/25 at 10:45 A.M., the Director of Nursing said the expectation is staff would wear gloves while handing dirty linen. During an interview on 9/12/25 at 8:48 A.M., the Staff Educator/ Infection Prevention Nurse said the expectation is that staff wear gloves when handling soiled linen. She further said the expectation is communicated upon hire and with annual competency.

Based on observations, interviews and record review, the facility failed to notify the physician of a significant change in the Resident's skin condition for two Residents (#45 and #17) out of a total sample of 28 residents. Specifically:1.) For Resident #45, the facility failed to notify the provider of a new skin breakdown on the buttocks. 2.) For Resident #17, the facility failed to notify the provider of a change in wound condition and obtain wound care orders when his/her left heel pressure related deep tissue injury (DTI) opened and had new drainage.Findings include: 1.) Resident #45 was admitted to the facility in August 2025 with diagnoses of sacrum pressure ulcer, congestive heart failure, stroke and chronic kidney disease. Review of Resident #45's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #45 is incontinent of both bowel and bladder and is dependent on staff for incontinent care. Review of Resident #45's initial wound evaluation and management summary, dated 8/26/25, indicated the Resident had the following skin impairments on admission: -Stage 3 pressure wound to the coccyx, -DTI (deep tissue injury) to the left lateral foot, -DTI to the left lateral fifth toe, -DTI to the left medial foot, and -DTI to the left medial first toe. Review of the 9/9/25 nursing note indicated the following: -Pt (patient) with new skin failure wound to L (left) buttock noted by wound MD (medical doctor) while doing wound rounds, wound measures 2.6x2x- (centimeters), new order for Triad (wound treatment) daily. Review of the wound visit notes dated 9/9/25 indicated Resident #45 had a new skin impairment to the left buttocks measuring 2.6x 2xnot measurable cm (centimeters) with the etiology of end-stage skin failure. Review of the full electronic medical record failed to indicate the facility notified the nurse practitioner or physician of the new skin impairment on Resident #45's buttock. During an interview on 9/11/2025 at 9:04 A.M., Nurse #1 said all new skin impairments must be reported to the physician or nurse practitioner. Nurse #1 said she works at the facility as a per diem nurse and was not aware if the nurse practitioner or physician were notified of Resident #45's new skin impairment to the buttocks. During interviews on 9/11/25 at 9:20 A.M., and 2:02 P.M., Unit Manager #1 said the physicians and/or nurse practitioners need to be notified of any new skin impairments as it is a change in status for a resident. Unit Manager #1 said Resident #45 has fragile skin and had a recent new skin impairment discovered by the facility on 9/9/25 and she did not notify the physician of the Resident's change in status. During an interview on 9/11/2025 at 10:22 A.M., the Director of Nursing said the development of a new skin impairment would be considered a change of status and she would expect the nursing staff to notify the physician or nurse practitioner of this change. The Director of Nursing said she was unaware if the nursing staff had notified the physician or nurse practitioner and that if they had notified the medical team there would be a nursing note indicating this. During an interview on 9/11/2025 at 12:57 P.M., Nurse Practitioner #2 said she was never notified of the new skin impairment to Resident #45's buttock. Nurse Practitioner #2 said she would have expected the facility to notify her of such a change in status. Nurse Practitioner #2 said she was unaware if the Physician was notified as she was in the facility on 9/9/25. During a follow-up interview on 9/11/2025 at 1:49 P.M., Nurse Practitioner #2 said she had spoken to the Physician who said she was not notified of the change of status to Resident #45's skin. 2.) Resident #17 was admitted to the facility in March 2024 with diagnoses including failure to thrive and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/28/25, indicated Resident #17 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This MDS also indicated Resident #17 had one unstageable pressure injury presenting as deep tissue injury. On 9/10/25 at 7:39 A.M., the surveyor observed Resident #17 in bed with his/her left heel offloaded in a pressure reducing boot. Resident #17 said he/she has a wound on his/her left heel that was caused from his/her mattress. Review of Resident #17's nursing progress notes indicated the following written by Unit Manager #2: -8/4/25: CNA (certified nurse assistant) reported new area to left heel. 2x2 (centimeters) DTI (deep tissue injury) on left heel dry, eschar. -8/5/25: Hospice recommendation: if heel intact, paint with betadine (a topical antiseptic containing iodine). If the area opens, apply calcium alginate (a highly absorbent type of wound treatment) and cover with DPD (dry protective dressing). Review of Resident #17's active physician order, initiated 8/8/25, indicated: -Paint left heel with betadine swab. Review of Resident #17's hospice routine visit progress note, dated 8/11/25, indicated: -Only open area on left heel. Wound not open at present, but looks like it could open so POC (plan of care) updated if that occurs. Family and facility agree with POC. Review of Resident #17's hospice wound recommendation, dated 8/11/25, indicated: -Wound recs (recommendations): Left heel paint with iodine to dry eschar, cover with ABD (abdominal pad, a type of dressing), secure with sock every day. If it opens and drainage starts: clean with cleanser, cut to fit alginate, ABD pad, wrap, change 2-3 times per week. Review of Resident #17's Treatment Administration Record (TAR), dated 8/17/25 to 8/25/25, indicated a new order to document answer to question Is there drainage present? from left heel wound, initiated 8/17/25. This TAR indicated the nurses documented yes there was drainage on 9 out of the 9 days from 8/17/25 to 9/11/25. The physician's order to Paint left heel with betadine swab remained in place during this time and failed to indicate any additional physician's orders for any other types of wound dressing. Review of Resident #17's hospice routine visit progress note, dated 8/25/25, indicated: -Heal [sic] is open and advised to use alginate on open area. Wound no changes except drainage small amt (amount) s/s (serosanguineous, a type of wound drainage). Son updated. Family and facility agree with POC. Review of Resident #17's medical record, dated 8/25/25 to 9/11/25, failed to indicate the wound recommendation to use alginate on open wound was addressed or implemented. Review of Resident #17's Treatment Administration Record (TAR), dated 8/26/25 to 9/11/25, indicated the physician's order to answer the question Is there drainage present? from left heel wound, initiated 8/17/25 had nurses documented yes there was drainage on 13 out of the 15 days from 8/17/25 to 9/11/25. The physician's order to Paint left heel with betadine swab remained in place during this time and failed to indicate any additional physician's orders for any other types of wound dressing. On 9/10/25 at 12:09 P.M., the surveyor observed Nurse #7 perform wound care for Resident #17's left heel pressure wound. The surveyor observed a red, open wound approximately the size of a quarter. Nurse #7 said this was an open wound with red granulation tissue in the wound bed. Nurse #7 said there was no dressing in place and that there is no physician's order to apply any dressings. Nurse #7 applied betadine to the wound bed and said this was the only wound treatment ordered to be completed. During an interview on 9/10/25 at 12:48 P.M., Unit Manager #2 said the hospice wound nurse follows Resident #17's left heel wound, and the hospice wound nurse gives wound treatment recommendations to the Hospice Nurse Practitioner (NP), who would notify them of any necessary orders. Unit Manager #2 said if wound had drainage, then it must be an open wound. Unit Manager #2 said the left heel wound has had a small opening with drainage for quite some time, but since it's only a small opening hospice wishes to continue betadine only without any dressing. Unit Manager #2 said she never notified the facility physician of any wound treatment recommendations for calcium alginate or any other type of dressing. During a telephone interview on 9/11/25 at 9:03 A.M., the Hospice Wound Nurse said she had made the recommendation for calcium alginate when the wound opened, but it's the facilities responsibility to notify the facility NP to approve any of the recommendations for wound treatments. During a telephone interview on 9/11/25 at 10:09 A.M., the facility Nurse Practitioner (NP) #1 said his first day working for the facility was 8/25/25. NP #1 said Resident #7 had an intact DTI and would expect the facility to notify him to approve all hospice wound treatment recommendations. NP #1 was unaware that Resident #17's left heel DTI had opened and had drainage. NP #1 said the facility never notified him of this change but should have. NP #1 said the facility never addressed the hospice recommendation for calcium alginate but would have approved it if he had been notified. NP #1 said any open wound should have a dressing in place to protect from infection and Resident #17 should have had a dressing ordered for his/her open left heel wound. During an interview on 9/11/25 at 10:45 A.M., the Director of Nursing (DON) said hospice wound treatment recommendations should be reviewed with the facility NP #1. The DON said if NP #1 did not approve the recommendations, then it should be documented somewhere in the medical record. The DON said the wound treatment recommendation for calcium alginate should have been addressed but was not. The DON further said if a wound has drainage, then it should have a dressing on it. The DON said if there was no physician's order for a dressing, the nurse should have notified the provider that it required one but did not. REFER TO F686.

Based on observation, record review and interview the facility failed to ensure care was provided in accordance with professional standards of practice for one Resident (#25) out of a total sample of 28 residents. Specifically, for Resident #25 the facility failed to identify a skin area on weekly skin checks and failed to obtain a physician's treatment order for the area. Findings include:Resident #25 was admitted to the facility in November 2023 with diagnoses including Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/27/25, indicated that on the Brief Interview for Mental Status exam Resident #25 scored a 5 out of a possible 15, indicating severely impaired cognition. The MDS failed to indicate any areas on his/her skin. Review of Resident #25's care plan indicates an Activity of Daily Living (ADL) care plan that indicates the following interventions:-Provide skin inspections daily during care. Observe for redness, open areas scratches, cuts, bruises etc. Report abnormal findings to Physician and document in Nurse's notes, start date 3/27/25.-PERSONAL HYGIENE: I am dependent on staff for grooming/personal hygiene, start date 3/27/25. The care plan failed to indicate any skin lesions or areas on Resident #25's nose. Review of the most recent Skin assessment, dated 9/8/25, failed to indicate any skin impairments or lesions on Resident #25's nose. Review of the active Physician's orders, indicated an order with a start date of 6/18/25, for weekly skin checks. The orders failed to indicate a treatment order for the area on Resident #25 nose. Review of the September 2025 Treatment Administration Record (TAR) failed to indicate a treatment order for the area on Resident #25 nose. Review of September 2025 clinical progress notes failed to indicate Resident #25 had an area/lesion on his/her nose or that the Physician was notified of any skin changes. On 9/09/2025 at 8:32 A.M., Resident #25 was observed seated in unit dining room waiting for breakfast. Resident #25 had a red and raised area on his/her nose that appeared approximately 1/5 inch in size with a dried dark red substance on it. On 9/09/2025 at 9:08 A.M., Resident #25 approached the nurse's station and spoke to the Assistant Director of Nursing (ADON). When the ADON turned away, Resident #25 said to the surveyor that the area on his/her nose used to be cancer, and they took care of it but that he/she thinks it is coming back. During a follow-up interview with Resident #25 on 9/12/2025 at 8:17 A.M., the area on Resident #25's nose remained clearly visible. Resident #25 said that it is now really sore and that he/she is sure that the cancer is back but that no one has looked at it or put anything on it. Resident #25 asked the surveyor if help could be obtained to get someone to look at it. During an interview with Resident #25's Certified Nursing Assistant (CNA) #5 on 9/12/2025 at 8:23 A.M., she said that Resident #25 needs assistance with care. CNA #5 said that Resident #25 has a cut on his/her nose that he/she scratches, that he/she has had it for about a week and that she reported it to the Nurse on 9/9/25. During an interview with Resident #25's Nurse #6 on 9/12/2025 at 8:26 A.M., she said that she noticed the area on Resident #25's nose on 9/8/25. Nurse #6 reviewed the record and said that Resident #25 does not have a treatment order for the area on his/her nose and that she had not notified the Physician (MD) or Nurse Practitioner (NP) when she observed it on 9/8/25. She said that the reason the MD/NP would be notified is so that they can give an order for how to treat the area. Nurse #6 said that the area should have been documented on the 9/8/25 skin assessment but had not. During an interview with the Director of Nursing (DON) on 9/12/2025 8:34 A.M., she said that she is aware of the area on Resident #25's nose because it is visible, that it has been there for some time and that Resident #25 often picks at it. The DON said that the area should have been noted on the weekly skin assessments and that the MD/NP should have been notified about the area to determine if they wanted to give a treatment order for it. As well, she said that the family should have been notified by the facility staff when the area was first observed. The DON was not aware that Resident #25 reports a history of skin cancer and said the facility should follow-up with the family. During an interview with Resident #25's daughter on 9/12/2025 at 10:24 A.M., she said that Resident #25 had had the area on his/her nose for about a year but that the facility has never mentioned it to her. The Daughter said that the ADON called her a short while ago and that she reported to the ADON that Resident #25 has had cancer 2-3 times including on his/her nose and one time requiring chemo and radiation.

Based on interviews and record review, the facility failed to ensure one Resident (#109) out of a total sample of 28 residents maintained an acceptable parameter of nutritional status. Specifically, the facility failed to implement weekly weights as ordered by a physician for a Resident who was at risk for, and had experienced, clinically significant weight gain. Findings include:Review of the facility policy titled Weight Assessment and Intervention, revised March 2022, indicated, but was not limited to, the following:-Resident weights are monitored for undesirable or unintended weight loss or gain.-Residents are weighed upon admission and at intervals established by the interdisciplinary team.-Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation.-The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]:-A. 1 month - 5% weight loss is significant; greater than 5% is severe.-B. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe.-C. 6 months - 10% weight loss is significant; greater than 10% is severe.-If the weight change is desirable, this is documented. Resident #109 was admitted to the facility in December 2023 with a diagnosis of hyperlipidemia and morbid (severe) obesity due to excess calories. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #109 scored 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Review of Resident #109's nutrition care plan indicated the Resident had a nutritional problem or potential nutritional problem related to dietary restriction with history of hyperlipidemia and risk for further weight gain with the following interventions:-Obtain weights at ordered intervals. Review of Resident #109's active physician orders indicated the following order:-Weights weekly, initiated 6/18/25. Review of Resident #109's weights/vitals report indicated the following recorded weights:-5/7/25 - 167.9 Lbs. (pounds)-5/15/25 - 168.7 Lbs.-6/4/25 - 171.8 Lbs.-6/25/25 - 170.0 Lbs.-7/2/25 - 173.4 Lbs.-8/1/25 - 182.0 Lbs.-9/2/25 - 186.9 Lbs. Further review of Resident #109's weights indicated that Resident #109 had experienced a clinically significant weight gain of 8.4% of total body weight in three months (from 5/7/25 to 8/1/25). Review of the Resident's weights also failed to indicate that weights were obtained weekly or that a reweight was taken until a month later, which indicating continued weight gain, to confirm the significant weight gain initially recorded on 8/1/25. Review of Resident #109's medical record failed to indicate that the Resident had refused to be weighed. Review of the Registered Dietitian (RD) Assessment, dated 6/21/25, indicated that Resident #109 had a BMI (body mass index) of 33.5 (categorically obese) and that it was appropriate to continue on a heart healthy diet to avoid weight gain. Review of the RD progress note, dated 9/11/25, indicated that Resident #109 had experienced a significant and unplanned weight gain. The RD note indicated the RD discussed the Resident's weight gain with the Nurse Practitioner (NP) and that it was decided to continue with weekly weights. The RD note indicated that a psychiatric evaluation was in place to review the Residents' medication as this may contribute to weight gain and that nursing was educated to provide healthy snacks in between meals. Review of the NP progress note, dated 9/11/25, indicated a recommendation to monitor Resident #109's weekly weights closely, check appropriate labs and that the Resident could benefit from a psychiatric evaluation. During an interview on 9/11/25 at 10:45 A.M., Certified Nursing Assistant (CNA) #4 said that residents are weighed monthly, but a nurse will tell them if a resident needs to be weighed on a weekly basis. CNA #4 said that Resident #109 had been weighed monthly, not weekly. The CNA and RD reviewed the assignment sheets and weight logs on the unit and confirmed that Resident #109 had been getting weighed monthly, not weekly. During an interview on 9/11/25 at 9:12 A.M., Nurse #5 said nurses and CNA's weigh all residents at the beginning of each month and that if there was a weight discrepancy that the staff would reweigh the resident. Nurse #5 said he would expect nurses to enter resident weights into the electronic medical record. Nurse #5 said Resident #109 had gained weight and that he would expect the Resident to be weighed weekly if there was a physician order for it. During interviews on 9/11/25 at 9:25 A.M. and 10:25 A.M., the RD said that she checks the weekly weight report for any weight changes and that she would expect that a resident with a significant weight change to be reweighed immediately. The RD said that she would expect a resident to be weighed weekly if the Resident had an order for weekly weights and that if the Resident refused to have his/her weight taken that this would be documented. The RD said weekly weights should have been taken for Resident #109, as the Resident was at risk for weight gain, but were not. The RD said the Resident should remain on weekly weights to monitor the Residents weight gain. During an interview on 9/11/25 at 10:04 A.M., Physician #2 said Resident #109 had gained weight. Physician #2 said he would expect an order for weekly weights to be followed and that all physician orders should be either followed, discontinued or modified. During an interview on 9/11/25 at 11:24 A.M., the Director of Nursing (DON) said that an order for weekly weights should be followed, and if the order was not necessary that the order should have been modified; the DON said that if a resident refused resident weights that this would be documented.

Based on observation, review of staff employee files and interviews, the facility failed to ensure incontinence care was provided to one Resident (#45) by licensed staff out of a total sample of 28 residents. Findings include: Resident #45 was admitted to the facility in [DATE] with diagnoses of sacrum pressure ulcer, congestive heart failure, stroke and chronic kidney disease. Review of Resident #45's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #45 is incontinent of both bowel and bladder and is dependent on staff for incontinence care. On [DATE] at 9:36 A.M., the surveyor observed two staff providing incontinence care to Resident #45. One staff member was wearing scrubs while the other was dressed in business casual attire. The surveyor asked the staff member not wearing scrubs what her role was in the facility. She said she was the admissions director and also a Certified Nursing Assistant (CNA). The surveyor requested to see the admission Director's employee file with a current CNA license. During an interview on [DATE] at 9:00 A.M., the Administrator said that the admissions director was not licensed as a certified nursing assistant. He further said she should not have been providing direct care to the residents. During an interview on [DATE] at 9:08 A.M., the admission Director said that she was licensed as a certified nursing assistant (CNA), but her license expired in 2022, and she had not renewed it. She said that on the [DATE] when she went by Resident #45's room she saw the resident without clothing and instinctively went in and provided personal care. The admission Director said she does not work as a CNA at the facility and has not received education from the facility regarding providing incontinence care.

Based on record review and interviews, the facility failed to complete daily documentation for one Resident (#45) out of a total sample of 25 residents. Findings include: Resident #45 was admitted to the facility in August 2025 with diagnoses of sacrum pressure ulcer, congestive heart failure, stroke and chronic kidney disease. Review of Resident #45's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #45 is incontinent of both bowel and bladder and is dependent on staff for incontinence care. Review of the (activity of daily living) ADL documentation for the month of September 2025 indicated the following missing documentation:-11 out of 31 eating opportunities for documentation were missing.-6 out of 31 bladder care opportunities for documentation were missing.-6 out of 31 bowel care opportunities for documentation were missing.-6 out of 31 personal hygiene opportunities for documentation were missing.-6 out of 31 dressing opportunities for documentation were missing.-6 out of 31 bed mobility opportunities for documentation were missing.-6 out of 31 transfers opportunities for documentation were missing.-6 out of 31 lying to sitting opportunities for documentation were missing.-6 out of 31 toilet transfer opportunities for documentation were missing.-6 out of 31 wheelchair opportunities for documentation were missing.-6 out of 31 walking opportunities for documentation were missing.-5 out of 11 shower/bath opportunities for documentation were missing. During an interview on 9/12/25 at 8:48 A.M., the Staff Educator said expectation is that staff document completely upon providing care or task completion. During an interview on 9/12/25 at 10:40 A.M., the Director of Nursing said documentation is done on point of care (POC) and ideally should be done as soon as possible. The Director of Nursing said there should be no holes in the documents as this would lead to an inaccurate medical record.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) whose comprehensive care plan indicated he/she required assistance of two staff members for transfers, the Facility failed to ensure staff consistently implemented and followed interventions in his/her care plan, when on 11/17/25, during the evening shift, Certified Nurse Aide (CNA #1), transferred Resident #1 back to bed by physically lifting him/her from his/her wheelchair and putting him/her in bed, without another staff member present to assist with the transfer. Findings include: Review of the Facility's policy, titled Care Plan, Comprehensive Person-Centered, dated as revised in March 2022, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and /or items included in the plan of care. Resident #1 was admitted to the Facility in October 2020, diagnoses included Alzheimer's, Failure to Thrive, Atrial Fibrillation and Aphasia (language disorder that affects a person's ability to communicate effectively). Resident #1 was transitioned to Hospice Services (to be provided in the facility) in September 2024, related to end of life care needs. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/06/24, indicated he/she was severely cognitively impaired with a score of 3 out 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS also indicated that Resident #1 was dependent on staff for bathing, dressing, hygiene, transfers, bed mobility, incontinent care and was non-ambulatory. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her September 2024 MDS, indicated he/she required assistance of two persons with ADL's. The Care plan indicated that Resident #1 required physical assistance of two for all transfers. Review of Resident #1's Care Card (used by the CNAs to determine individual resident care needs) indicated he/she required assistance of two staff members for transfers. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/18/24, indicated that Resident #1 sustained a bump above his/her left eye, bruising to his/her left eye and had left shoulder redness of unknown origin. Review of the Facility's Root Cause Analysis (RCA) document, undated, indicated CNA #1 did not review Resident #1's Care Card, transferred him/her by herself, and did not follow the Care Plan on 11/17/24, when she transferred him/her to bed. During a telephone interview on 03/3/24 at 1:54 P.M., Certified Nurse Aide (CNA) #1 said that she had worked at the Facility since November of 2024 and has been a CNA for [AGE] years. CNA #1 said she worked on 11/17/24, during the 3:00 P.M. through 11:00 P.M. shift and was assigned to provide care to Resident #1. CNA #1 said at some point during the shift (exact time unknown) she transferred Resident #1 back to bed, and had the assistance of CNA #2 with transferring Resident #1 to his/her bed. During a telephone interview on 03/04/25 at 9:14 A.M., Certified Nurse Aide (CNA) #2 said that he had worked at the Facility since November of 2024 and worked on 11/17/24, during the 3:00 P.M. through 11:00 P.M. shift. CNA #2 said that he had not provided care for Resident #1 and did not assist CNA #1 with his/her care or transfers. Although CNA # 1 said that she had an assist by CNA #2 with the transfer into bed of Resident #1, this was inconsistent with staff statements obtained by the facility related to their RCA into how Resident #1 sustained an injury of unknown origin, as well as staff interviews during this survey. During an interview on 02/27/25 at 2:15 P.M., the Director of Nurses (DON) said the Facility began an investigation after Resident #1 was noted to have a bruise on his/her left eye of unknown origin on 11/17/24 by the oncoming staff on the 11:00 P.M. to 7:00 A.M. shift. The DON said that during her investigation she became aware that CNA #1, had transferred Resident #1 on 11/17/24 without assistance of another staff member, as indicated in his/her care plan. The DON said during the investigation that CNA #1 told her she had transferred Resident #1 by herself and that she performed the transfer by reaching her arms around Resident #1's body, like she was hugging him/her, stood Resident #1 up, and pivoted him/her to a sitting position on the bed. The DON said it is her expectation that staff follow the plan of care and in this case, it was not followed.

Based on observations and interviews, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, 1.) The facility failed to ensure medications were dated once opened and discarded as appropriate according to manufacturer's guidelines. 2.) The facility failed to ensure medications were not prepared in advance and stored in original, labeled containers in the medication cart. 3.) The facility failed to properly secure medication carts on one of three units 4.) The facility failed to ensure unauthorized nurses did not have access to medication cart. Findings include: Review of the facility policy titled Medication Storage [sic], revised [DATE], indicated: - All medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by the facility policy. - Medications will be stored in the original, labeled containers received from the pharmacy. - Multi-dose vials which have been opened or accessed (e.g., needle punctured) should be dated and discarded within 28 days unless the manufacturer specifies a differed (shorter or longer) date for the opened vial. - Expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of in accordance with facility policy. 1a.) On [DATE] at 8:10 A.M., the surveyor observed the following on the Concord Unit medication cart #2: - Fluticasone propionate and salmeterol inhaler, dated [DATE], which was 55 days prior to observation. - One bottle of proheal liquid protein, undated. - One open vial of lantus 100u (units)/ml (milliliter) insulin, undated. - One bottle of atropine 1% sublingual drops, undated. During an interview on [DATE] at 8:13 A.M., Nurse #1 said the resident currently used the fluticasone propionate and salmeterol inhaler that was dated [DATE], but it should have been discarded within 30 days after opening based on manufacturers guidelines. Nurse #1 said proheal liquid protein was not dated but should have been because it needs to be discarded 60 days after opening. Nurse #1 said the lantus insulin vial and the atropine drops were not dated but should have been because they need to be discarded 28 days after opening. During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said all inhalers and medications with shortened expiry dates once opened must be dated so they can be discarded according to manufacturer's guidelines. The DON said fluticasone propionate and salmeterol inhaler should have been discarded within 30 days after opening. The DON said proheal liquid protein should have been dated because it needs to be discarded 60 days after opening. The DON said insulin vials and atropine drops should have been dated because they need to be discarded 28 days after opening. 1b.) On [DATE] at 8:20 A.M., the surveyor observed the following on the [NAME] Unit medication cart #2: - One bottle of proheal liquid protein, undated. - One open vial of lantus 100u (units)/ml (milliliter) insulin, dated [DATE], which was 32 days prior to observation. - One lupinhaler, with a capsule preloaded, unlabeled, stored directly on the bottom of the medication cart drawer not in a box. During an interview on [DATE] at 8:24 A.M., Nurse #3 said proheal liquid protein was not dated, but should have been because it needs to be discarded 60 days after opening. Nurse #1 said insulins need to be discarded 28 days after opening. Nurse #1 said the lantus insulin vial should have been discarded on [DATE] but was still being used by the resident. Nurse #3 said the lupinhaler should not have a capsule preloaded because there is not expiration date on the capsule. Nurse #3 said the lupinhaler should be labeled with the resident's name and stored in a box for infection control purposes. During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said all medications with shortened expiry dates once opened must be dated so they can be discarded according to manufacturer's guidelines. The DON said proheal liquid protein should have been dated because it needs to be discarded 60 days after opening. The DON said insulin vials and atropine drops should have been dated because they need to be discarded 28 days after opening. The DON said the lupinhaler should be labeled with the resident's name and stored in a box for infection control purposes. 2a.) On [DATE] at 8:13 A.M., the surveyor observed the following on the Concord Unit medication cart #2: - Three unsealed clear pill packet sleeves containing crushed medications. Each clear pill packet sleeve was labeled a resident name written in black marker. During an interview on [DATE] at 8:13 A.M., Nurse #1 said he had prepared and crushed the medications in advance and was planning on administering to the residents later. Nurse #1 said he wasn't supposed to prepare medications in advance. During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said medications should only be prepared immediately before administering and should never be prepare or pre-poured and stored in the medication cart to administer later. 2b.) On [DATE] at 8:10 A.M., the surveyor observed the following on the Concord Unit medication cart #2: - One unknown, unlabeled pill stored in an orange prescription bottle with a label indicating haloper dec inj (haloperidol decanoate injection, which is an injectable antipsychotic medication) 50 mg (milligrams)/ml (milliliter). During an interview on [DATE] at 8:13 A.M., Nurse #1 said he did not know what that pill was, but it was not a haloperidol decanoate injection. Nurse #1 said the unknown pill should not have been stored in that orange prescription bottle, and should have been stored in the original, labeled container. During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said pills should always be stored in the original, labeled containers, and the unknown pill should not have been in that orange prescription bottle. 3a.) On [DATE] at 8:20 A.M., the surveyor observed Andover Unit medication cart unlocked in the hallway. The nurse was not within sight line of the medication cart. During an interview on [DATE] at 8:22 A.M., Nurse #4 said she should have locked her medication cart before walking away. During an interview on [DATE] at 2:49 P.M., the Director of Nursing (DON) said medication carts should never be left unlocked if unattended. 3b.) On [DATE] at 12:31 P.M., the surveyor observed Andover Unit medication cart unlocked in the hallway. The nurse was not within sight line of the medication cart. During an interview on [DATE] at 12:33 P.M., Nurse #3 said she should have locked her medication cart before walking away. Nurse #3 said medication carts should always be locked if unattended. During an interview on [DATE] at 2:49 P.M., the Director of Nursing (DON) said medication carts should never be left unlocked if unattended. 4.) On [DATE] at 9:27 A.M., the surveyor observed the Assistant Director of Nursing (ADON) preparing and administering medications for a resident from the Andover unit medication cart #2. The ADON said she borrowed the medication cart keys from Nurse #2, who was down the hall in another resident's room. The ADON said she was not authorized to administer medications from this medication cart because she never completed the narcotic count or signed out the medication cart from Nurse #2 but should have before administering medications from the medication cart. On [DATE] at 9:30 A.M., Nurse #2 came back to the medication cart and retrieved the keys from the ADON. During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said only nurses who have completed the narcotic count in order to sign out the medication cart should have access to administer medications from the medication cart.

Based on observations, record reviews, and interviews, the facility failed to maintain professional standards in the management and caring for urinary catheter devices for 4 Residents (#30, #103, #108 and #471). Specifically, 1. For Resident #30, the facility failed to empty urinary drainage bag as ordered. 2. For Resident #103, the facility failed to empty urinary drainage as ordered and maintain urinary drainage bag off the floor. 3. For Resident #108, the facility failed to empty urinary drainage bag as ordered. 4. For Resident #471, the facility failed ensure urinary catheter drainage bags and tubing were not stored directly touching the floor. Findings include: Review of the facility policy titled 'Catheter Drainage Bag', dated January 2023, indicated: -The purpose of this procedure are to prevent the drainage bag from becoming full and allowing urine to flow back into the bladder, to measure output, and to obtain sterile specimen. -Empty the urinary drainage bag at least every eight hours or more often if needed to keep the bag from becoming full. -Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. 1. Resident #30 was admitted to the facility with diagnoses including malignant neoplasm of kidneys except renal pelvis, infection and inflammatory reaction due to indwelling urethral catheter and hematuria (blood in urine). Review of Resident #30's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS further indicated the Resident had an indwelling catheter. On 9/17/24 at 8:54 A.M., the surveyor observed Resident #30 laying in his/her bed. The urinary drainage bag had 1200 (ML)milliliters of urine in it. The Resident said that the staff does not empty the drainage bag frequently. Review of Resident #30's current physician orders indicated the following: -Foley catheter care every shift. -Measure output from indwelling catheter every shift. Review of the current Treatment Administration Record (TAR) indicated the night shift documented the catheter had been emptied a total of 600 milliliters on 9/17/24 Review of the care plan with a focus of indwelling urinary catheter, dated revised 7/5/24, indicated the following intervention: Provide catheter care per policy. During an interview on 9/19/24 at 9:04 A.M., Nurse #3 said the urinary catheters are emptied at the end of the shift. When asked if the drainage bag should contain 1200 milliliters at the beginning of the shift Nurse #3 said no. During an interview on 9/19/24 at 9:26 A.M., the Assistant Director of Nursing said urinary catheters should be emptied every shift as ordered and as needed if the resident is on a diuretic. 2. Resident #103 was admitted to the facility in July 2024 with diagnoses including urinary retention, obstructive and reflux uropathy and hematuria (blood in urine). Review of Resident #103's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident had an indwelling urinary catheter. On 9/17/24 at 8:18 A.M., the surveyor observed Resident #103 laying in his/her bed the urinary drainage bag was lying on the floor. On 9/19/24 at 9:19 A.M., the surveyor observed Resident #103 laying in his/her bed, the drainage bag had 600 ml of bloody urine. Review of Resident #103 current physician orders indicated the following: -Check placement of urinary drainage bag to assure it is hanging below the level of the bladder every shift. -Foley catheter care every shift. Review of the current Treatment Administration Record (TAR) indicated the night shift documented an output of 450 ml for the overnight shift on 9/19/24. Review of care plan with focus of indwelling urinary catheter, dated revised 9/18/24, indicated the following intervention: Provide catheter care per policy. During an interview on 9/19/24 at 9:23 A.M., Nurse #2 said the Resident's catheter should be emptied every shift, and the catheter should be maintained off the floor to prevent infections. She also said the hematuria in the urinary drainage bag was ongoing and that the Resident was being followed by urology. During an interview on 9/19/24 at 9:26 A.M., the Assistant Director of Nursing said urinary catheters should be emptied every shift as ordered and as needed if the resident is on a diuretic. 3. Resident #108 was admitted to the facility in April 2024 with diagnoses including neuromuscular dysfunction of bladder and urinary retention. Review of Resident #108's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS further indicated the Resident had an indwelling catheter. On 9/17/24 at 8:02 A.M., the surveyor observed Resident #108 laying in his/her bed, the urinary drainage bag was hooked to the bed rail and had approximately 600 ml of urine. The Resident said that the staff does not empty his/her catheter and at times his/her parent will empty the catheter when they come to visit the Resident. On 9/18/24 at 7:07 A.M., the surveyor observed the Resident laying in his/her bed and his/her urinary drainage bag had 1200 ml of urine. On 9/18/24 at 1:03 P.M., the surveyor and Nurse #4 observed Resident #108's foley catheter, the Resident had a 16 French 10 ml catheter size. Nurse #4 said the catheter size should match the physician orders. On 9/19/24 at 8:58 A.M., the surveyor observed the Resident laying in his/her bed the urinary drainage bag had approximately 800 ml of urine. Review of current physician orders indicated the following: -Foley catheter care every shift. -Foley catheter 14 French 10 ml continuous drainage bag every shift Review of care plan with focus of indwelling urinary catheter, dated revised 4/16/24, indicated the following interventions: Provide catheter care per policy. Change catheter per policy/medical director (MD) orders. During an interview on 9/19/24 at 9:04 A.M., Nurse #3 said catheters should be emptied every end of shift. During an interview on 9/19/24 at 9:26 A.M., the Assistant Director of Nursing said urinary catheters should be emptied every shift as ordered and as needed if the resident is on a diuretic. During an interview on 9/19/24 at 12:26 P.M., the Director of Nursing said the Resident had been in and out of the hospital and the staff should have ensured that the Resident's catheter was the same as the orders. 48990 4. Review of the facility policy titled Catheter Guidelines, revised January 2023, indicated: Be sure the catheter tubing and drainage bag are kept off the floor. Resident #471 was admitted to the facility in September 2024 with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, brain cancer, and hemiplegia affecting the right dominant side. Review of Resident #471's assessment titled Brief Interview for Mental Status (BIMS) Evaluation, dated 9/16/24, indicated Resident #471 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #471's active physician's orders, initiated 9/15/24, indicated: - Foley Catheter (urinary catheter)12 FR (french size) /10 ML (milliliter) continuous to drainage bag. May Reinsert for dislodgment or malfunctioning, every shift. Review of Resident #471's plan of care related to indwelling urinary catheter, revised 9/15/24, indicated: Provide catheter care per policy. On 9/17/24 at 7:54 A.M., the surveyor observed Resident #471 sitting in a wheelchair. His/her urinary catheter drainage bag was observed attached to the bottom of the wheelchair with the bottom of the bag resting directly on the floor. There was no barrier between the urinary drainage bag and the floor. Resident #471 said staff provides all urinary catheter care, including drainage bag management, because his/her hands shake and can't manage it him/herself. On 9/18/24 at 6:48 A.M., the surveyor observed Resident #471 in bed with a urinary catheter drainage bag attached to the bedframe. The bed was in a low position with the urinary catheter drainage bag and tubing directly on the floor without a barrier. On 9/18/24 at 9:01 A.M., the surveyor observed Resident #471 self-propelling wheelchair in the hall using his/her feet. His/her urinary catheter drainage bag was observed attached to the bottom of the wheelchair and was dragging along the floor without a barrier. During an interview on 9/19/24 at 10:50 A.M., Certified Nurse Assistant (CNA) #3 said urinary catheter drainage bags and tubing should never be directly touching the floor. CNA #3 said she often finds urinary catheter bags on the floor and was unaware of expectations for what to do if they are found on the floor but is worried about the risk of infection. CNA #3 said Resident #471 is physically unable to lower the bed or manage urinary catheter drainage bag/tubing by him/herself because of dexterity in hands. During an interview on 9/19/24 at 12:33 P.M., Nurse #3 said urinary catheter drainage bags should never directly touch the floor because of the risk for infection. Nurse #3 said if for any reason the urinary catheter drainage bag or tubing needed to be touching the floor, a barrier should be placed between the urinary catheter drainage bag/tubing and the floor. During an interview on 9/19/24 at 9:43 A.M., The Director of Nursing (DON) said urinary catheter drainage bags or tubing should never be directly touching floor without a barrier to protect from infection.

Based on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled in the unit kitchenette refrigerators, and that dented cans were not accepted into storage/circulation. Findings include: Review of the facility's undated policy titled Food Storage (Dry, Refrigerated, and Frozen), indicated, but was not limited to, the following: Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure. Review of the facility's undated policy titled Food from Outside indicated, but was not limited to, the following: - Residents have the right to have foods brought in by family and friends. Due to the potential for foodborne illness or interfere with nutritional treatment, family members and/or visitors who bring food in from the outside will be educated on safe food handling practices and the importance of diet order compliance. Food or beverage that is brought in from the outside will be monitored by nursing staff for spoilage, contamination and safety. - Food brought by family/visitors that is left with the resident to consume later will labeled (sic.) and stored in a manner that it is clearly distinguishable from the facility-prepared food. (label will identify resident name, room number, item, date received and discard date). o All refrigerated food shall be discarded within 48 hrs. (hours) o Perishable foods should be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the discard date. - The nursing staff will discard perishable foods on or before the discard date. Resident and/or family should be notified when food is being discarded. On 9/17/24 at 7:17 A.M., the surveyor observed a significantly dented can of pumpkin and a significantly dented can of mandarin oranges on the can rack in the kitchen. On 9/17/24 at 7:53 A.M., the surveyor made the following observations in the Concord unit kitchenette refrigerator: - Two water bottles, opened and filled with a green liquid undated and unlabeled. - A white plastic bag containing two containers of food, the white plastic bag was labeled with a resident name but the food was undated. On 9/17/24 at 8:01 A.M., the surveyor made the following observations in the [NAME] unit kitchenette refrigerator: - Two undated plastic pitchers of cranberry juice. - One undated plastic pitcher of apple juice. - One undated plastic pitcher of orange juice. On 9/17/24 at 11:21 A.M., the surveyor made the following observations in the Andover unit kitchenette refrigerator: - Two undated containers of resident food. During an interview on 9/17/24 at 7:17 A.M., the cook said that dented cans should not go on the can rack and should instead be placed in the office. During an interview on 9/17/24 at 7:55 A.M., Nurse #6 said that all food in the kitchenette refrigerators should be dated and discarded after three days. Nurse #6 said that the bottles of green liquid were brought in for a resident by family members. During an interview on 9/17/24 at 11:03 A.M., the Food Service Director (FSD) said dented cans should be set aside in the office to be returned as they pose a risk for botulism if consumed (a rare but serious illness caused by a toxin that attacks the nervous system and can lead to paralysis and death). The FSD said that juice and resident food in the unit kitchenette refrigerators should be dated and discarded after three days.

Based on observations, interviews and record review, the facility failed to ensure a dignified existence was maintained for two Residents (#471 and #117) out of 27 total sampled residents. Specifically, 1.) For Resident #471, the facility failed to provide a privacy bag for a urinary catheter drainage bag. 2.) For Resident #117, the facility failed to provide a privacy bag for a urinary catheter drainage bag. Findings include: Review of the facility policy titled Resident Rights, revised January 2022, indicated: - Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. 1.) Resident #471 was admitted to the facility in September 2024 with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, brain cancer, and hemiplegia affecting the right dominant side. Review of Resident #471's medical record indicated there was no Minimum Data Set (MDS) data available. Review of Resident #471's assessment titled Brief Interview for Mental Status (BIMS) Evaluation, dated 9/16/24, indicated Resident #471 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #471's active physician's orders, initiated 9/13/24, indicated: - Privacy bag for foley cath (urinary catheter) drainage bag, every shift. On 9/17/24 at 7:54 A.M., the surveyor observed Resident #471 sitting in a wheelchair. His/her urinary catheter drainage bag was observed clipped to the bottom of the wheelchair. There was no privacy bag on the urinary catheter drainage bag and clear, yellow urine was observed. Resident #471 said staff do not offer any type of privacy cover for the urinary catheter drainage bag but would be interested in having one. The following additional observations were made by the surveyor: - On 9/17/24 at 10:12 A.M., Resident #471 was observed talking with staff in the hallway with a urinary catheter drainage bag clipped to the front arm rest of his/her wheelchair. There was no privacy bag on the urinary catheter drainage bag and clear, yellow urine was observed. - On 9/17/24 at 2:16 P.M., Resident #471 was observed in bed with a urinary catheter drainage bag attached to the bedframe. The urinary catheter drainage bag did not have a privacy bag, and the clear, yellow urine was visible from the hallway. Review of Resident #471's plan of care, dated 9/13/24, failed to indicate rejection of care or refusal of privacy bag for his/her urinary catheter drainage bag. During an interview on 9/19/24 at 10:50 A.M., Certified Nurse Assistant (CNA) #3 said urinary catheter drainage bags should always have a privacy bag. During an interview on 9/19/24 at 12:33 P.M., Nurse #3 said urinary catheter drainage bags should always have a privacy bag because the urine should not be visible to others. During an interview on 9/19/24 at 9:43 A.M., The Director of Nursing (DON) said urinary catheter drainage bags should always have a privacy bag, even when in bed, because the urine should not be visible to others. 2.) Resident #117 was admitted to the facility in June 2024 with diagnoses including Parkinson's disease and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident #117 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. This MDS also indicated Resident #117 had an indwelling urinary catheter. Review of Resident #117's active physician's orders, initiated 8/5/24, indicated: - Privacy bag for suprapubic cath (urinary catheter) drainage bag, every shift. On 9/17/24 at 7:54 A.M., 9/17/24 at 8:19 A.M., and 09/17/24 10:02 AM, the surveyor observed Resident #117 in bed with a urinary catheter drainage bag attached to the bedframe. The urinary catheter drainage bag did not have a privacy bag, and the clear, yellow urine was visible from the hallway. During an interview on 9/17/24 at 7:56 A.M., Resident #117 said staff do not offer any type of privacy cover for the urinary catheter drainage bag but would be interested in having one. Review of Resident #117's plan of care, last revised 8/28/24, failed to indicate rejection of care or refusal of privacy bag for his/her urinary catheter drainage bag. During an interview on 9/19/24 at 10:50 A.M., Certified Nurse Assistant (CNA) #3 said urinary catheter drainage bags should always have a privacy bag. During an interview on 9/19/24 at 12:33 P.M., Nurse #3 said urinary catheter drainage bags should always have a privacy bag because the urine should not be visible to others. During an interview on 9/19/24 at 9:43 A.M., The Director of Nursing (DON) said urinary catheter drainage bags should always have a privacy bag, even when in bed, because the urine should not be visible to others.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#48) out of a total sample of 27 residents. Specifically, the facility failed to a.) implement weekly weights as care planned, and b.) develop a care plan for Resident #48's history of suicide attempts. Findings Include: Review of the facility policy, titled Care Plan - Comprehensive, indicated, but was not limited to, the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - Facility utilizes and electronic health record for resident care plans (sic.). - The comprehensive, person-centered care plan will: o Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. o Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights to refuse. o Incorporate identified problem areas. o Incorporate risk factors associated with identified problems. o Reflect currently recognized standards of practice for problem areas and conditions. - Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. Review of the facility policy, titled Weights Assessment and Interventions, revised May 2019, indicated, but was not limited to, the following: - Monthly weights will be obtained each month or as ordered by the physician. - Weights will be recorded in the medical record (electronic medical record where available) for each resident. Resident #48 was admitted to the facility in March 2024 with diagnoses of heart failure (inability of the heart to maintain adequate blood circulation), renal insufficiency, anxiety disorder, depression, and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #48 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. a. Review of Resident #48's care plans indicated the Resident had decreased/alteration in cardiac output related to CHF and hypertension (high blood pressure, defined as repeatedly elevated blood pressure) with the following intervention: Weekly wts (weights), initiated 3/20/24. Review of Resident #48's Weights and Vitals Summary indicated the following weight readings: 7/24/24 - 150 lbs. (pounds) 8/27/24 - 189.4 lbs. 9/4/24 - 192 lbs. 9/11/24 - 192 lbs. 9/18/24 - 188 lbs. Further review of Resident #48's Weights and Vitals Summary indicated that weekly weights were not obtained on the weeks of 7/31/24, 8/7/24, 8/14/24, or 8/21/24, and that the Resident had gained a clinically significant 39.4 lbs. during that time period (26.2% of the Resident's total body weight gained in one month). Review of the Dietitian follow-up note, dated 8/28/24, indicated that Resident #48 had experienced a significant weight gain and that the Resident was placed on diuretic therapy due to increased edema. Review of Resident #48's medical record failed to indicate the Resident had refused to be weighed. During an interview on 9/18/24 at 11:39 A.M., Nurse #3 said certified nursing aides (CNAs) will obtain weights which the nurse then enters into the resident's electronic health record. Nurse #3 said that residents at risk for fluid retention, such as those who have CHF, should be weighed weekly and that she would expect a care plan for weekly weights to be followed. Nurse #3 said that Resident #48 was at risk for weight gain and fluid retention. During an interview on 9/18/24 at 12:20 P.M., the Registered Dietitian (RD) said that CNAs obtain weights which are then entered by the nurse into the electronic health record. The RD said that she would defer to the Nurse Practitioner (NP) for the required frequency of weighing a resident with CHF, and that weight refusals should be documented. During an interview on 9/19/24 at 11:10 A.M., the NP said she would have expected Resident #48 to be weighed weekly throughout the Resident's entire admission. The NP said that the Resident's diuretic needed to be increased recently due to fluid retention, and that the risk of not weighing a resident as often as needed was that the Resident could accumulate fluid. During an interview on 9/18/24 at 1:38 P.M., the Director of Nursing (DON) said that she would expect weights to be recorded in the electronic health record according to the frequency outlined in a resident's care plan. b. Review of Resident #48's active diagnoses indicated the following diagnosis: Personal history of suicidal behavior. Review of the physician note, dated 8/2/24, indicated the Resident had a history of two suicide attempts related to severe depression around the time of his/her gastric bypass surgery. Review of Resident #48's medical record indicated the Resident had gastric bypass surgery in 2020. Review of Resident #48's care plans failed to indicate that a care plan addressing Resident #48's history of suicide attempts was developed. During an interview on 9/18/24 at 11:36 A.M., Nurse #3 said she was currently assigned to Resident #48 and that she was unaware of Resident #48's history of suicide attempts. Nurse #3 said she would expect a care plan to be developed specific to the Resident's history of suicide attempts. During an interview on 9/18/24 at 11:36 A.M., the Social Worker (SW) said she would expect a resident with a history of suicide attempts to have a care plan developed which specifically addresses the history of suicide attempts; the SW said she was unaware of Resident #48's history of suicide attempts. During an interview on 9/18/24 at 1:41 P.M., the Director of Nursing (DON) said she would expect a resident with a history of suicide attempts to have a care plan developed which specifically addresses the history of suicide attempts.

Based on observations, interviews, and record review the facility failed to provide services that met professional standards of quality to two Residents (#473 and #14) out of a total sample of 27 residents. Specifically, 1.) For Resident #473, the facility failed to implement a skin graft wound treatment as ordered by the physician. 2.) For Resident #14, the facility failed to arrange a follow up urology appointment. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1.) Resident #473 was admitted to the facility in September 2024 with diagnoses including diabetes and soft tissue disorder. Review of Resident #473's medical record indicated a there was no Minimum Data Set (MDS) data available. Review of Brief Interview for Mental Status (BIMS) Evaluation, dated 9/16/24, indicated Resident #473 was cognitively intact as evidenced by a score of 14 out of 15. Review of the Clinical Admission assessment, dated 9/13/24, indicated Resident #473 had the following wounds: - Left posterior thigh skin graft. - Left thigh skin graft. - Left inguinal region skin graft. Review of Resident #473's active physician's order, initiated 9/13/24, indicated: - Prescribed treatment: (Wounds with soap and water, pat dry, apply triple-antibiotic to wounds and cover with xeroform (non-adhesive dressing). Secure wound dressing with gauze tape, gauze pads, and/or tap [sic]. Daily or PRN (as needed) when soiled (Location: Left leg wounds). On 9/17/24 at 10:20 A.M., the surveyor observed Nurse #2 perform a wound dressing change on the Resident #473's left leg skin graft wounds. After removing the previous dressing, Nurse #2 cleansed three left leg wounds with normal saline. Nurse #2 then applied xeroform to the three left leg wounds and covered with gauze. During this wound dressing change, Nurse #2 did not apply the triple-antibiotic cream as ordered by the physician. During an interview on 9/17/24 at 2:06 P.M., Nurse #2 and the surveyor reviewed Resident #473's active physician's treatment orders for the three skin graft wounds on his/her left leg. Nurse #2 said she should have applied triple-antibiotic cream to the wound but did not. Nurse #2 said that based on the physician's order in place she should have cleansed the wounds with soap and water, not normal saline. During an interview on 9/19/24 at 9:43 A.M., the Director of Nursing (DON) said physician's orders must be followed as ordered. The DON said Nurse #2 should have applied triple-antibiotic cream during the dressing change and should have washed the wounds with soap and water instead of normal saline. 36876 2. Resident #14 was admitted to the facility in August 2022 with diagnoses including neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, and schizoaffective disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #14 was unable to participate in the Brief Interview for Mental Status Exam and staff assessed him/her as having severely impaired cognitive skills. The MDS also indicated he/she is dependent on staff for activities of daily living and utilized an indwelling catheter. Review of the clinical record indicated Resident #14 was hospitalized in March 2024. Review of the discharge hospital paperwork, dated 4/3/24, indicated: Will need out-patient follow up with urology for management of neurogenic bladder and chronic foley. Review of the clinical record failed to indicate an appointment with urology had been arranged. During an interview on 9/19/24 at 9:56 A.M., Nurse Supervisor #1 said she would look into when Resident #14 had been seen by urology. The facility was unable to provide evidence that Resident #14 had been seen by urology since his/her hospitalization . On 9/19/24 at approximately 3:00 P.M., the Director of Nursing (DON) told the surveyor that Resident #14 has an appointment on 9/25/24 with the urologist for follow up. The DON said that the appointment had been made that day, (9/19/24); approximately five months after Resident #14's hospital discharge.

Based on observation, interviews and record review, the facility failed to ensure the interdisciplinary team was involved in determining whether the self-administration of medications was clinically appropriate for one Resident (#78), out of 27 total sampled residents. Specifically, the facility failed to assess if it was clinically appropriate for Resident #78 to self-administer an injection prior to the Resident self-administering the injection. Findings include: Review of the facility policy titled Self Administration of Medications, revised January 2023, indicated: - Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication. - The staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident upon request. - In addition to general evaluation of decision-making capacity, the nurse will perform a more specific skill assessment, this can be accomplished on paper or through the EHR (electronic health record) system. - The EMAR (electronic medication administration record)/MAR (medication administration record) must identify meds that are self-administered. - If residents are determined to be able to self-administer Resident/Representative will complete a consent for Self-Administration. Resident #78 was admitted to the facility in October 2023 with diagnoses including diabetes and hyperlipidemia. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/6/24, indicated Resident #78 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #78's physician order, dated 7/31/24, indicated: - Trulicity Subcutaneous Solution Pen-Injector 1.5 ml (milliliter)/0.5 mg (milligram), which is an injectable medication used to treat diabetes, Inject 0.5 milliliter subcutaneously one time a day every Wed (Wednesday). Review of Resident #78's medical record failed to indicate any assessment of the Resident's mental and physical abilities by the staff, nurse, or practitioner to determine whether self-administering the trulicity injection was clinically appropriate. Review of Resident #78's physician's orders and September 2024 Medication Administration record (MAR) failed to indicate the trulicity injection may be self-administered. Review of medical record failed to indicate a consent for self-administration was completed. On 9/18/24 at 9:38 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #78 with the Assistant Director of Nursing (ADON) present. Nurse #2 said Resident #78 liked to self-administer the trulicity injection. Nurse #2 handed the injection to the Resident who injected the medication into his/her abdomen. Resident #78 said he/she always self-administered the trulicity injection. Review of Resident #78's nursing progress note, dated 9/18/24, indicated: - Self administered injection w/ (with) good technique and little instruction. During an interview on 9/18/24 at 9:50 A.M., the Assistant Director of Nursing (ADON) said any resident who self-administers medication needs to be assessed to determine if it is clinically appropriate and a consent must be obtained prior to self-administration. The surveyor and ADON reviewed the medical record together and were unable to locate that a self-administration of medication assessment was completed or that a consent for medication self-administration was completed by the Resident/Resident Representative. The ADON said these should have been completed but were not. During an interview on 9/19/24 09:43 A.M., the Director of Nursing (DON) said Resident #78 should have had an assessment completed to determine if self-administration of medication was clinically appropriate and consent for medication self-administration should have been obtained prior to the Resident self-administering the trulicity injection.

Based on interviews and records reviewed, for one of five sampled Residents (Resident #5), the Facility failed to provide supervision for Resident #5 to prevent a fall and as a result, Resident #5 sustained a fractured left hip. Findings include: Resident #5's Minimum Data Set (MDS) Assessment, completed 6/16/17 indicated that Resident #5 was cognitively impaired. The MDS indicated that Resident #5 required the extensive assistance of one staff member with transfers between surfaces and ambulation. Resident #5's care plan concern initiated during February 2016 indicated that he/she was at risk to fall due to impulsivity, poor safety awareness and history of falls. Care plan interventions included anticipating Resident #5's needs and use of a chair alarm while out of bed. Resident #5's Resident Care Card indicated that Resident #5 required the assistance of one staff member when he/she used the toilet, continued supervision and the assistance of one staff member when he/she ambulated, and assistance of one staff member when he/she transferred between surfaces. The Facility Accident Report, dated 9/8/17, indicated that at 3:06 P.M. Resident #5 had an unwitnessed fall in the sitting room. The Accident Report indicated that Resident #5 was found on the floor crying with his/her left leg slightly pronated (with the sole of the foot pointed down). The Accident Report indicated that Resident #5 said he/she wanted to walk, fell down and complained of groin pain. The Accident Report indicated that Resident #5's Nurse Practitioner was notified and ordered that he/she be sent to the hospital for evaluation. The Accident Report indicated that the hospital notified the Facility that Resident #5 was being admitted to the hospital with [REDACTED]. The Surveyor interviewed Nurse #3 at 9:30 A.M. on 1/10/18. Nurse #3 said that she worked in a variety of roles at the Facility and, on 9/8/17, she worked as the Unit Manager for Resident #5's unit. Nurse #3 said she was seated at the nurses' station when Resident #5 fell . Nurse #3 said that moments before the fall, she saw Certified Nurses Aide (CNA) #3 standing in the door way of the sitting room. Nurse #3 said that the sitting room was supervised by a staff member at all times whenever residents were in the sitting room because of residents individual needs for supervision, including risk for fall. Nurse #3 said that sitting room staff coverage was identified on the CNA Assignment. Nurse #3 said that she observed CNA #4 talking with CNA #3 in the doorway of the sitting room and thought CNA #4 began to supervise the sitting room to relieve CNA #3. Nurse #3 said that a moment later she was called to the sitting room by CNA #4 because Resident #5 was on the floor. The Surveyor and Nurse #3 reviewed the CNA Assignments for the 7:00 A.M. to 3:00 P.M. (Day) shift and the 3:00 P.M. to 11:00 P.M. (Evening) shift on 9/8/17. The Surveyor interviewed Nurse #2 at 10:00 A.M. on 1/17/18. Nurse #2 said that he developed the Assignment Form which identified the staff members assigned to supervise the sitting room. Nurse #2 said that the sitting room was always supervised when residents were in it because of the individual supervision needs of the residents. Nurse #2 said that the assignment identified which staff member was assigned to each segment of time on the Day and Evening shift. Nurse #2 said that because the end of shift was typically a busy time when staff members were reporting information to the oncoming shift, coverage of the sitting room was left to anyone who was available. The Surveyor and Nurse #3 reviewed the 3:00 P.M. to 11:00 P.M. shift CNA assignment for 9/8/17. The Assignment indicated that CNA #4 was assigned to supervise the sitting room from 3:00 P.M. to 3:30 P.M. on 9/8/17. The Surveyor interviewed the Administrator at 9:00 A.M. on 1/9/18. The Administrator said that there was a video camera outside of the sitting room where Resident #5 fell and he reviewed the captured surveillance footage and documented what he saw in Resident #5's Accident Report. The Administrator said that the footage was not able to be saved. The Administrator said and his documentation in Resident #5's Accident Report indicated that CNA #3 exited the sitting room at 3:04 P.M. and CNA #4 entered the sitting room at 3:06 P.M. and called out for help after finding Resident #5 on the floor. CNA #3's written statement, dated 9/11/17 indicated that she had been scheduled to supervise the sitting room at 1:30 P.M. and another staff member replaced her at 2:15 P.M., but she remained in the sitting room with the other staff members. CNA #3's written statement indicated that the other CNAs left the sitting room shortly before 3:00 P.M. and she was the only staff member left in the sitting room with residents. CNA #3's written statement indicated she remained in the sitting room until 3:04 P.M. and then went to the nurses' station and asked CNA #4 to go into the sitting room and supervise. CNA #3's written statement indicated that CNA #4 said yes and CNA #3 left the unit. CNA #4's written statement dated 9/8/17 indicated that CNA #3 told her that she was leaving and there was no one supervising residents in the sitting room. CNA #4's written statement indicated that she placed towels in a bathroom and walked to the sitting room where she found Resident #5 on the floor at 3:06 P.M. approximately.

Based on observation, interview and record review the facility failed to follow physician orders [REDACTED].#6) out of a total sample of 22 residents. Findings include: Resident #6 was admitted to the facility in 11/2014 with [DIAGNOSES REDACTED]. According to the Significant Change Minimum Data Set (MDS), dated [DATE], Resident #6 needs extensive assistance with bed mobility and is totally dependent on staff for transfers, bathing, dressing and grooming. Resident #6 has an unstagable pressure area with eschar (dead skin) to the right heel. Review of Resident #6's clinical record indicated: - A physician's orders [REDACTED].# (pounds). Check placement and function every shift. - Resident #6's care plan indicated an air mattress should be utilized. - On 7/29/17, Resident #6's Treatment Administration Record (TAR) indicated that his/her right heel was boggy (tissue that is softer than surrounding tissue, may be an indication of deep tissue injury) and there was a 5 centimeter (cm) by 3 cm reddened area. - On 7/29/17 new physician's orders [REDACTED]. - On 8/9/17, a new physician's orders [REDACTED]. - On 9/7/17, a new physician's orders [REDACTED]. Review of the TAR (Treatment Administration Record) for September 2017 indicated that Resident #6's air mattress had been checked for placement and function, signed off by nursing staff as completed, a total of 59 times between 9/1/17 and 9/20/17, On 9/20/2017 at 12:15 P.M., 9/21/17 at 8:30 A.M., and 9/21/17 at 10:25 A.M., the Surveyor observed Resident #6 lying in bed with no air mattress in place as ordered. On 9/22/17 at 3:40 P.M., Nurse #2 said that Resident #6 should have an air mattress. She further said that an air mattress with a perimeter boarder had been ordered and would be delivered. She said that the mattress had been swiched following a fall on 6/16/17. On 9/22/17 at 10:00 A.M., the Director of Nurses said that the air mattress had been switched as an intervention following a fall and replaced with a regular perimeter mattress. She said a new air mattress with a perimeter boarder had been ordered and would be delivered that afternoon. The facility failed to follow physician order [REDACTED]. Interviews with Nurse #2 and the Director of Nursing, indicated that Resident #6 had been placed on a regular perimeter mattress since 6/16/17. Resident #6 subsequently developed a boggy area to his/her right heel progressing to an unstagable pressure sore.

Based on observation, interview, and record review the facility failed to ensure proper supervision of a resident in order to prevent a resident-to-resident altercation for 2 residents (#13 and #22) out of a total of 22 sampled residents. Findings include: 1. For Resident #13 and Resident #22 the facility failed to ensure proper supervision to prevent a resident to resident altercation resuling in a a tranfer to the emergency room for a laceration repair to the left eyebrow and a head injury for Resident #22 and a bruised, swollen right cheek for Resident #13. Resident #13 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS), dated [DATE], Resident #13 needed assistance with activities of daily living, including bathing, dressing, and grooming. Resident #13 scored a 3/15 on the brief interview of mental status (BIMS), indicating severe cognitive impairment. Resident #22 was admitted to the facility in 9/2017 with a [DIAGNOSES REDACTED].#22 needed assistance with activities of daily living, including bathing, dressing, and grooming. Resident #22 scored a 0/15 on the BIMS, indicating severe cognitive impairment. Review of the facility Accident/Incident form dated 9/17/17, indicated that at approximately 8:10 A.M. staff was called to the room shared by Resident #13 and #22 by the housekeeper, because there were two residents fighting. Resident #22 was on his/her knees holding onto the door handle with blood dripping down the left side of his/her face. Resident #13 kept repeating that Resident #22 punched me in the face so I had to put him down. Resident #22 was sent out to the emergency room where he/she was diagnosed with [REDACTED]. The nurses note indicated that Resident #13 had a bruised and swollen right cheek. During interview with the Director of Nurses (DON) and Administrator on 9/20/17, at 5:00 P.M., the DON said there were no prior issues between Resident #13 and #22. They said that the investigation showed Resident #13 standing in the hallway by the door to his/her room. Resident #22 walked past Resident #13 and into the room. Resident #22 grabbed Resident #13 by the shirt, upper left chest and pushed. Resident #13 responded by grabbing Resident #22 by the shirt and pushed him/her back into the room. The Surveyor reviewed a nurses note that was written on 9/10/17, with the DON and Administraor. The note indicated that Resident #13 made a comment about not liking his/her roommate and a vague threatening comment. The DON and Administrator said that Resident #13 had made a vague threat regarding Resident #22 and had been placed on 15 minute checks for 24 hours. Neither Resident #13 or #22 remembered the event immediately after it happened. They said that Resident #22 had been offered a room change, but the family had declined. Resident #13 was not offered a room change because they felt they did not have an appropriate room available and he/she was settled and nothing further was done. There were no interventions put into place other than reminding Resident #13, who has poor short term memory to ask staff for assistance with Resident #22. During interview with Nurse #2, on 9/21/17, at 9:00 A.M., she said that Activity Staff/CNA #1 had reported to her on 9/10/17 that Resident #13 didn't feel safe and said something to the effect that if Resident #22 keeps coming to my side of the room I will have to show him/her his/her place so she placed Resident #13 on 15 minute checks. She said neither resident remembered the incident and no further intervention was provided to prevent a reoccurrence. During interview with Activity Staff/CNA#1 on 9/21/17, at 10:15 A.M., she said that Resident #22 was getting into the space of Resident #13. She further said that Resident #13 is very particular about his/her stuff and gets agitated if things are moved. She said that Resident #13 meant business that day and she didn't want anyone to get hurt so she told the nurse on duty. During interview with Social Worker (SW) #1, on 9/21/17, at 9:30 A.M., she said that Resident #22 had advanced dementia, was often anxious and suspicious and wandered all over the place into all sorts of rooms. She added that Resident #22 did not like to be told what to do and would get agitated with redirection. She said that Resident #13 gets anxious and moves quickly. Resident #13 is very neat and particular and likes to help people. She was not aware of what triggered the comment of 9/10/17, and thought whatever had happened between the two was over with. She was not aware of any interventions implemented to prevent a reoccurrence. In hindsight she said the facility should have insisted the roommates be separated by room change or supervised closely until Resident #22 was discharged . Review of Resident #22's care plan for behaviors indicates resident exhibits wandering behavior as evidenced by confusion and stating desire to go home. The goal is that Resident #22 will not sustain injury due to wandering through next review. Interventions include: document in the progress notes intensity, duration or frequency of behavior, orient to daily routines, administer medication as ordered by physician, regularly assess and evaluate risks for elopement, wanderguard to left lower extremity. The plan of care failed to include interventions for wandering into other rooms and roommate area. Review of Resident #22's care plan for psychotropic drug use: behavior problem. Resident is on Seroquel for management of behavioral problem advanced dementia. The goal is that Resident #22 will have reduced incidents of mood or behavior change. Interventions include: Administer medications as ordered, assess behavior pattern, assess effectiveness of medication. The plan of care failed to include intervention for wandering into other rooms and roommate area. The facility failed to provide a plan of care to supervise two roommates with dementia after a vague threat was made. They failed to investigate what triggered the comment and put a plan in place to prevent reoccurrence, and 7 days later there was a resident to resident altercation in which Resident #13 received a bruised and swollen right cheek and Resident #22 was sent to the emergency room for a head injury and laceration repair of the left eyebrow.

The Facility must ensure the Resident environment remains as free of accident hazards as is possible; and each Resident receives adequate supervision and assistance devices to prevent accidents. Based on record reviews, observation and interviews, for 1 out of 4 sampled Residents (Resident #1), the Facility failed to ensure alarms where in place and functioning correctly when on 12/16/16, Resident #1 sustained two unwitnessed falls on 12/16/16, the first fall at approximately 12:15 P.M. and the second one at 6:20 P.M. that same day. Two days later on 12/18/16, Resident #1 had a change in mental status and was transferred to a hospital where he/she was diagnosed with [REDACTED]. Findings include: The Facility's Policy titled, Accident/Incident -Code Yellow Instructions (An overhead announcement of name of location, unit name and room number designated staff respond to assist), dated 08/16, indicated the team at the Code Yellow will discuss the fall and come up with an appropriate intervention, which will be documented in the Communication Book, individualized Care Plan will be updated, and the Certified Nursing Assistant Resident Care Cards will be updated. A Falls At Risk Plan of Care, dated 07/20/16, indicated Resident #1's tab alarm to chair at all times. A physician's orders [REDACTED]. alarm to chair at all times. Monitor placement and functioning every shift. The Admission Assessment, dated 09/03/16, indicated Resident #1 history of falls with a recent fall on 09/01/16. A Resident Care Card, dateless, indicated Resident #1 a high risk for fall, bed and chair alarm was documented and a Tab alarm was hand written on Resident #1's Care Card. The Facility's Admission/Annual History and Physical, dated 09/04/16, indicated Resident #1's readmission to Facility revealed a closed head trauma and a pelvic fracture status [REDACTED]. Documentation indicated Resident #1's [DIAGNOSES REDACTED]. A Physical Therapy Discharge Summary, dated 11/10/2016, indicated Resident #1 was discharged from skilled therapy services on 11/10/2016, was a risk for falls and moderate verbal cues for sequencing and assistance to complete an activity as a result of Resident's medical condition. A Facility Accident/Incident Report and Investigation Form Falls, dated 12/16/16, at approximately 6:20 P.M., indicated Resident #1 had a second unwitnessed fall, documentation was not completed and did not indicate if the alarm was sounding at the time of Resident 1's Fall. Resident #1 told staff he/she was trying to get into bed. The Surveyor interviewed Charge Nurse #1 at 11:39 A.M. on 02/02/17. Charge Nurse #1 said on 12/16/16 Resident #1 had an unwitnessed fall approximately noontime and a clinical assessment was completed, neurological checks were started and Nurse Practitioner and Health Care Proxy were notified. Charge Nurse #1 said Resident #1 had no new safety interventions implemented except neurological signs. Charge Nurse #1 said Resident #1 needed to be constantly reminded about safety secondary to his/her memory issues. The Surveyor interviewed Nurse #2 at 2:10 P.M. on 02/02/17. Nurse #2 said she was informed of Resident #1's fall early in the day. Nurse #2 said Resident #1 was sitting near the Nurse Station when he/she had fallen for a second time on 12/16/16 at 6:20 P.M. and Resident #1's alarm did not sound since the alarm was not connected to the box when Resident #1 transferred him/herself out of recliner. There was no tab alarm on Resident #1 at this time. The Surveyor interviewed Nurse #2 at 2:10 P.M. on 02/02/17. Nurse #2 said and documentation indicated Resident #1 was on the floor in front of another Resident's room on his/her left elbow with a bruise and swelling to her left wrist with moderate pain. Nurse #2 said an assessment was performed, neurological checks were continued, Nurse Practitioner and Health Care Proxy were informed about Resident #1's unwitnessed second fall. Nurse #2 said that new orders included to obtain STAT(immediately) X-ray of left wrist and forearm and on the next day 12/17/16 to obtain blood work PT/INR (a test to determine how long it takes blood to clot). The Facility's Radiology Report, dated 12/16/16, indicated, intact left forearm, wrist alignment maintained and no acute fracture or dislocation. Nurse #2 said she informed Nurse Practitioner #1 of the X-ray results and the Nurse Practitioner #1 ordered ice as needed, elevation, Tylenol and Tramadol (non-narcotic pain reliever) PRN (as needed) for discomfort for Resident #1. Nurse #2 documention indicated on Progress Note at 8:42 P.M. dated 12/16/2016 Resident's #1 had a bruise and swelling to his/her left wrist with moderate pain. Nurse #2 said Resident #1's left elbow was swollen, his/her skin turned black and blue in color and was given pain medication. The Surveyor interviewed CNA #5 at 3:52 P.M. on 02/03/17. CNA #5 said on 12/16/16 after dinner she had transferred Resident #1 from the wheelchair to the recliner near the Nurse's station. CNA #5 said she was aware Resident #1 had a previous fall earlier during the day on 12/16/16 and Resident #1 was identified as a safety risk for falls. CNA #5 said Resident #1 had a chair alarm which was functioning earlier, she thought it was still working and did not recheck the alarm. CNA #5 said Resident #1 did not have a tab alarm on when she had transferred him/her to the recliner after dinner on 12/16/16. A Nurse Progress Note at 2:52 P.M., dated 12/18/16, indicated Resident #1 had sudden weakness when transferring to toilet, was not responding to verbal stimuli, unable to bear weight with transfer, unable to verbalize, eyes wide open and staring, hands had noticeable tremors, unable to follow commands and left elbow area appeared with noticeable swelling and redness. The Surveyor interviewed Nurse #3 at 5:14 P.M. on 02/03/17. Nurse #3 said on 12/18/16 CNA #1 informed her Resident #1's difficulty with two assistance transfer back to wheelchair from bathroom and CNA #1 said Resident #1 seemed off. Nurse #3 said on 12/18/16 she assessed Resident #1 she/he was responding to verbal response with a blank stare and had a change of mental status. Nurse #3 said she called the Nurse Supervisor, the Nurse Practitioner and Resident #1 was sent out to an acute hospital for further evaluation. Nurse #3 said she notified Resident #1's Health Care Proxy. The Hospital's Case Management Referral to Nursing home, dated 12/19/16, indicated Resident #1's sustained a Subdural hematoma, with a follow up appointment with Neurosurgery midlevel clinic in 4 weeks and sustained a left Olecranon fracture was placed with a green long arm cast and follow up appointment on 01/03/17 to determine if casting needs to be replaced for the total of 6 weeks. Resident #1 did not return to the facility.

Based on record reviews, observation and interviews, for 1 out of 4 sampled Residents (Resident #1), the Facility failed to ensure alarms where in place and functioning correctly when on 12/16/16, Resident #1 sustained two unwitnessed falls on 12/16/16, the first fall at approximately 12:15 P.M. and the second one at 6:20 P.M. that same day. Two days later on 12/18/16, Resident #1 had a change in mental status and was transferred to a hospital where he/she was diagnosed with [REDACTED]. was implemented as ordered by the Physician and as indicated on the Care Plan. Findings include: The Facility's Policy titled, Accident/Incident -Code Yellow Instructions (An overhead announcement of name of location, unit name and room number designated staff respond to assist), dated 08/16, indicated the team at the Code Yellow will discuss the fall and come up with an appropriate intervention, which will be documented in the Communication Book, individualized Care Plan will be updated, and the Certified Nursing Assistant Resident Care Cards will be updated. A Falls At Risk Plan of Care, dated 07/20/16, indicated Resident #1's tab alarm to chair at all times. A physician's orders [REDACTED]. alarm to chair at all times. Monitor placement and functioning every shift. The Facility's Admission/Annual History and Physical, dated 09/04/16, indicated Resident #1's readmission to Facility revealed a closed head trauma and a pelvic fracture status [REDACTED]. Documentation indicated Resident #1 was on anticoagulants (oral medication prevents the formation of blood clots, causing a tendency toward prolonged or excessive bleeding, which may occur spontaneously or following an injury), and identify as a high risk for falls. A Resident Care Card, dateless, indicated Resident #1 a high risk for fall, bed and chair alarm was documented and a Tab alarm was hand written on Resident #1's Care Card. A Facility Accident/Incident Report and Investigation Form Falls, dated 12/16/16, at approximately 6:20 P.M., indicated Resident #1 had a second unwitnessed fall, documentation was not completed and did not indicate if the alarm was sounding at the time of Resident 1's Fall. Resident #1 told staff he/she was trying to get into bed. The Surveyor interviewed Nurse #2 at 2:10 P.M. on 02/02/17. Nurse #2 said she was informed of Resident #1's fall early in the day. Nurse #2 said Resident #1 was sitting near the Nurse Station when he/she had fallen for a second time on 12/16/16 at 6:20 P.M. and Resident #1's alarm did not sound since the alarm was not connected to the box when CNA #5 transferred him/herself to the recliner. There was no tab alarm on Resident #1 at this time. The Surveyor interviewed Nurse #2 at 2:10 P.M. on 02/02/17. Nurse #2 said and documentation indicated Resident #1 was on the floor in front of another Resident's room on his/her left elbow with a bruise and swelling to her left wrist with moderate pain. Nurse #2 said an assessment was performed, neurological checks were continued, Nurse Practitioner and Health Care Proxy were informed about Resident #1's unwitnessed second fall. Nurse #2 said that new orders included to obtain STAT(immediately) X-ray of left wrist and forearm and on the next day 12/17/16 to obtain blood work PT/INR (a test to determine how long it takes blood to clot). The Facility's Radiology Report, dated 12/16/16, indicated, intact left forearm, wrist alignment maintained and no acute fracture or dislocation. Nurse #2 said she informed the Nurse Practitioner #1 of the X-ray results and the Nurse Practitioner #1 ordered ice as needed, elevation, Tylenol and [MEDICATION NAME] (non-narcotic pain reliever) PRN (as needed) for discomfort for Resident #1. Nurse #2 said Resident's #1's left elbow was swollen, his/her skin turned black and blue in color. The Surveyor interviewed CNA #5 at 3:52 P.M. on 02/03/17. CNA #5 said she was aware Resident #1 had a previous fall earlier during the day on 12/16/16 and Resident #1 was identified as a safety risk for falls. CNA #5 said Resident #1 did not have a tab alarm on when she had transferred him/her to the recliner after dinner on 12/16/16. A Nurse Progress Note at 2:52 P.M., dated 12/18/16, indicated Resident #1 had sudden weakness when transferring to toilet, was not responding to verbal stimuli, unable to bear weight with transfer, unable to verbalize, eyes wide open and staring, hands had noticeable tremors, unable to follow commands and left elbow area appeared with noticeable swelling and redness. The Surveyor interviewed Nurse #3 at 5:14 P.M. on 02/03/17. Nurse #3 said on 12/18/16 CNA #1 informed her Resident #1's difficulty with two assistance transfer back to wheelchair from bathroom and CNA #1 said Resident #1 seemed off. Nurse #3 said on 12/18/16 she assessed Resident #1 she/he was responding to verbal response with a blank stare and had a change of mental status. Nurse #3 said she called the Nurse Supervisor, the Nurse Practitioner and Resident #1 was sent out to an acute hospital for further evaluation. Nurse #3 said she notified Resident #1's Health Care Proxy. On 2/13/17 at 4:13 P.M. the Director of Nursing (DON) provided documentation to the Surveyor which indicated that a late entry had been entered by Charge Nurse #1 on 2/13/17 at 11:38 A.M. This late entry was a progress note that stated May utilize chair sensor alarm when in chair as alternate to tab alarm when needed per NP. However, the DON said a physicians order is required. The Surveyor interviewed Charge Nurse #1 again on 2/16/17 at 4:54 P.M. regarding this late entry and she said that she realized during the investigation, which began on 2/2/17, that she forgot to write a progress note regarding the Nurse Practitioner #2's telephone order for the alternate alarm. However, NP #2 cannot recall giving this order when the Surveyor interviewed her on 2/16/17 at 4:07 P.M. and this conflicts with Facility's Policy. The Hospital's Case Management Referral to Nursing home, dated 12/19/16, indicated Resident #1's sustained a Subdural hematoma, with a follow up appointment with Neurosurgery midlevel clinic in 4 weeks and sustained a left Olecranon fracture was placed with a green long arm cast and follow up appointment on 01/03/17 to determine if casting needs to be replaced for the total of 6 weeks. Resident #1 did not return to the facility.

Based on records reviewed and interviews, for 1 of 4 sampled residents (Resident #4) the Facility failed to ensure that staff performed a thorough clinical assessment, including a neurological assessment, following Resident #4's unwitnessed fall on the evening of 2/8/16. Approximately 10 hours later, on 2/9/16, Resident #4 was found lying in bed with vomit around his/her mouth and on his/her night gown. On assessment Resident #4 had no pulse or blood pressure and was pronounced dead. Findings include: Resident # 4's [DIAGNOSES REDACTED]. A Fall Risk assessment, dated 11/17/15, indicated Resident #4 was identified at high risk for falls and had 2 falls within the past 3 months. A Quarterly Minimum Data Set (MDS) Assessment, dated 12/2/15, indicated Resident #4 required extensive assistance of 2 for bed mobility and transfers, and had impaired mobility with limited range of motion of upper and lower body. The Plan of Care, dated 2/9/16, indicated Resident #4 required extensive assistance of 2 for turning and repositioning. A Physician Order, dated 1/6/16, indicated Resident #4 was to have a bed alarm in place. A Facility Incident Report, submitted to the Department of Public Health (DPH), dated 2/11/16, indicated that on 2/8/16, at approximately 8:50 P.M., staff responded to the sound of Resident #4's bed alarm ringing, and found Resident #4 on the floor next to his/her bed. The Incident Report indicated that upon interview with staff, Resident #4 was demanding to go back to bed, his/her neurological and vital signs were within normal limits and 3 staff members assisted him/her back to bed. The Incident Report indicated Resident #4 received care during routine rounds, he she appeared at baseline and at 5:30 A.M. was found with no pulse and no blood pressure. A Nurse Progress note, dated 2/8/16 and timed at 10:56 P.M., indicated when staff went to investigate they found Resident #4 sitting on the floor. The Progress Note indicated Resident #4 was yelling help, help and was agitated. The Progress Note indicated Resident #4 had no apparent injuries, vital signs (blood pressure, heart rate and respirations, were with in normal limits (WNL), he/she had positive range of motion (ROM), hand grasps were equal, pupils were equal and reacting to light, and he/she had no apparent injuries. The Progress Note indicated Resident #4's Health Care Proxy (HCP) and the Physician #2 was notified, and Physician #2 ordered that staff monitor Resident #4 per house protocol. The Progress Note indicated Resident #4's son called demanding to know how Resident #4 slid to the floor when he/she can barely move. Family were assured Resident #4 had no apparent ill effects and would be monitored. The Facility's Policy titled Neurological Signs, dated 11/15, indicated a neurological assessment will be completed on any resident who sustains a head injury, or when head injury questioned, or following an unwitnessed fall. The procedure indicated neurological signs will be completed promptly after the incident (unless transported to the hospital); if signs are negative, then complete every 2 hours for 48 hours. Neurological signs are inclusive of: -pupils react to light -level of consciousness -change in emotional behavior -change in speech -Change in orientation -Change in strength in extremities -vital signs A Physician Treatment Order, dated 2/8/16, and timed at 10:45 P.M., documented as prescribed by Physician #1, indicated staff were to monitor Resident #4's vital and Neurological signs, status [REDACTED]. Surveyor #1 and Surveyor #3 interviewed Physician #1 at 11:45 A.M. on 3/29/16. Physician #1 said she was not on call on the evening of 2/8/16, she did not give the order to monitor Resident #4's neurological signs every 2 hours, and was not informed of Resident #4's fall until the following morning, 2/9/16 at which time staff told her Resident #4 had was found the previous evening half in and half off the bed. Surveyor #1 and Surveyor #3 interviewed Physician #2, at 4:30 A.M. on 3/29/16. Physician #2 said she was the on-call Physician on 2/8/16 into 2/9/16. Physician #2 said she received a call sometime around 10:00 P.M. on 2/8/16 at which time the Nurse on duty told her Resident #4 slid off the bed and was found with his/her legs hanging off the bed. Physician #2 said the Nurse told her Resident #4 had no injuries and assured her Resident #4 did not hit his/her head. Physician #2 said she asked that staff monitor Resident #4 throughout the night, including vital signs and neurological signs, at a minimum of every 2 hours. Physician #2 said she left instructions that staff call her if Resident #4 had any changes in his/her condition. On 3/21/16, during the onsite follow up survey, the Facility was unable to provide documentation that a thorough clinical assessment, including a neurological assessment, was completed on Resident # 4 following his/her unwitnessed fall, per the Facility's Neurological Signs Policy. A copy of the electronic Medication Administration Record [REDACTED].M. The MAR indicated [REDACTED].M. (3 days after Resident #4's unwitnessed fall) indicating at 11:00 P.M. on 2/8/16, Resident #4's blood pressure (B/P) was 98/66, respirations (R) 17 and heart rate (HR) 66, and on 2/9/16, at 1:00 A.M. B/P was 103/76, R 18 and HR 78, and at 3:00 A.M. BP/98/60, R 18 and HR 56. A neurological assessment was not documented. Surveyor #1 and Surveyor #2 interviewed the DDCO at 1:30 P.M. and throughout the afternoon on 3/21/16. At approximately 2:50 P.M. the DDCO gave the Surveyor a blank copy of a Neurological Assessment tool which she said was no longer in use. The DDCO said staff were to document all Neurological assessments on the electronic MAR. The DDCO said the Facility's records were 100% electronic, and hand written entries were not permissible. The DDCO could not provide any documentation completed by staff indicating that a neurology assessment was performed following Resident #4's unwitnessed fall on 2/8/16. A Nurse Progress Note, dated 2/9/16, indicated at 5:20 A.M. Resident # 4 was found without vital signs, and a small amount of brown liquid, described in a later note timed at 10:53 A.M. as brown emesis (vomit) on the side of his/her mouth, was on Resident # 4's night gown. A call was placed to the Physician informing him of Resident #4's passing. A Nurse Progress Note, dated 2/9/16, indicated a Pronouncement of Death was completed at 6:30 A.M. At 4:30 P.M. on 3/22/16, the Facility faxed a hand written Neurological Assessment tool to the Department of Public Health, with the resident's name redacted and with the names of Nurse #5 and Nurse #6 documented as completing a Neurological Assessment at 11:00 P.M. on 2/8/15, and at 1:00 A.M., 3:00 A.M. and 5:00 A.M. on 2/9/16 (a total of 4 entries). Review of signed Application for Employment Records and Educational records for Nurse #5 and Nurse #6, indicated their signatures did not match the documented signatures on the hand written Neurological Assessment tool forwarded to DPH on 3/22/16. Surveyor #1 and Surveyor #3 interviewed Nurse #5 at 2:10 P.M. on 3/22/16, and at 1:35 P.M. on 3/23/16. During the initial interview, Nurse #5 said he performed a neurological assessment on Resident #4 immediately following the unwitnessed fall and documented his findings in the Nurse Progress Note section of Resident #4's electronic medical record (EMR). Nurse #5 said Resident #4 had no apparent injuries and wanted to go back to bed. Nurse #5 said he gave Resident #4 his/her scheduled night time medications, which included Trazadone (an antidepressant medication, with known side effect of increased sedation) and [MEDICATION NAME] (an antipsychotic medication, with known side effect of increased sedation), and Resident #4 went to sleep. Nurse #5 said he placed a call to the on-call covering Physician and informed him/her of Resident #4 unwitnessed fall. Nurse #5 said the Physician was concerned that Resident # 4 may have hit his/her head during the fall and gave an order to monitor Resident #4's neurological signs. Nurse #5 said he did not check Resident #4's vital signs or neurological signs a second time because Resident #5 was sleeping. Nurse #5 said he reported Resident #4's fall to Nurse #6 who relieved him at the change of shift at 11:00 P.M. Surveyor #1, Surveyor #3, and the Interim Complaint Unit Manager interviewed Nurse #6 at 9:53 A.M. on 3/23/16. Nurse #6 said she got report from Nurse #5 that Resident #4 had slid out of bed and there was a Physician order [REDACTED]. Nurse #6 said Resident #4's vital signs and neurological assessment was within normal limits, and she documented these findings at 1:00 A.M., 3:00 A.M. and 5:00 A.M. in the comment section of the MAR indicated [REDACTED]. Nurse #6 initially said she was one hundred percent certain the only place she documented Resident #4's vital signs and neurological assessment was on the comment section of the MAR indicated [REDACTED]. At 10:15 A.M. on 3/23/16, Nurse #6's phone got disconnected which interrupted the course of the interview conducted by Surveyors. Approximately 3 minutes later Nurse #6 called back. When informed by the Surveyors we were provided with hand written neurological assessment notes, Nurse #6 recanted her initial statement, and provided conflicting information as to whether a neurological assessment was performed on Resident #4 following his/her unwitnessed fall. Nurse #6 said on further recollection she documented Resident #4's neurological assessment on a handwritten form throughout the 11:00 P.M. to 7:00 A.M. shift on 2/8/16 into 2/9/16. Nurse #6 said the form was already filled in half way across the page, when she started to document Resident #4's neurological assessment. This was not consistent with the hand written Neurological Assessment tool forwarded by the Facility to DPH on 3/22/16. During a second interview with Nurse #5 at 1:35 P.M. on 3/23/16, Nurse #5 said on further recollection he started a hand written neurological assessment on Resident #4 and left this at the nurses station for other staff to follow through. Nurse #5 said to the best of his recollection he made only 1 entry on this hand written form. This was not consistent with the hand written Neurological Assessment tool forwarded by the Facility to DPH on 3/22/16. At 1:13 P.M. on 3/23/16, the Facility forwarded a second copy of Resident #4's MAR indicated [REDACTED].M. on 2/8/15, by Nurse #5, and at 2:06 A.M. and 2:28 A.M. on 2/9/16, by Nurse #6. At 10:50 A.M. on 3/25/16, the Facility forwarded a copy of an electronic activity report titled SigmaCare: Resident Audit, to the Department of Public Health via electronic mail. The Report indicated Resident #4's blood pressure, pulse, respirations and oxygen saturation levels were checked at 11:35 P.M., on 2/28/16, and at 2:08 A.M. and 2:31 A.M. on 2/9/16. There was no entry of neurological assessments or further clinical assessments on Resident #4. This documentation was not consistent with initial statements made by Nurse #5 and Nurse #6. Nurse #6 said at approximately 5:30 A.M. an aide asked her to check on Resident #4 because, words to the effect he/she did not look well. Nurse #6 said Resident #4 was lying in bed with his/her head tilted to the right. Nurse #6 said there was wet brown colored vomit, which looked like undigested food, around Resident #4's mouth and on his/her night gown. Nurse #6 said she could not find a heartbeat on Resident #4, he/she had no blood pressure and he/she was not breathing. Nurse #6 said she called the Nursing Supervisor, who confirmed that Resident #4 was dead, and a call was placed to the on-call covering Physician for an order for [REDACTED].>Surveyor #1 and Surveyor # 3 interviewed the Nurse Supervisor at 1:12 P.M. on 3/25/16. The Nurse Supervisor said Resident #4's nursing documentation, with the exception of the RN Pronouncement of Death, was recorded in his/her EMR. The Nurse Supervisor said she did not see a hand written neurological assessment, completed by Nurse #5 and Nurse #6, for Resident #4 dated 2/8/16 - 2/9/16.

Based on record review and interviews for 1 of 3 sampled residents' (Resident #1), the Facility failed to follow acceptable standards of practice when on [DATE], Resident #1 fell from a mechanical lift while being transferred out of bed. - Resident #1 was prescribed [MEDICATION NAME] (an anticoagulation medication used to prevent blood clot formation, but which places an individual at increased risk of bleeding) for the treatment of [REDACTED]. A portable X-ray performed, which was reported on [DATE] at 1:26 P.M. as positive for a new fractures of both lower leg bones. - Staff on the 7:00 A.M. to 3:00 P.M. shift and 3:00 P.M. to 11:00 P.M. shift did not follow up on calls made to the Physician's answering service to inform him of Resident #1's fall and new fractures. - When Nurse #4, who worked the 11:00 P.M. to 7:00 A.M. shift called the Medical Director's on call answering service, the covering Nurse Practitioner (NP) called back and told him that Resident #1 was not her patient and to follow up with the Physician in the morning. - Although following his/her fall Resident #1 initially declined to go to the Hospital for treatment, staff did not inform Resident #1 of his/her new fractures after the X-ray result was reported on the afternoon of [DATE], but once informed on the morning of [DATE], Resident #1 agreed to be transferred to the Hospital. - Resident #1 experienced complications of coagulopathy (a condition in which the bloods ability to clot is impaired, causing a tendency toward prolonged or excessive bleeding, which may occur spontaneously or following an injury), acute [MEDICAL CONDITION] and bleeding. Resident #1 died on [DATE]. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment, dated [DATE], indicated Resident #1 was alert and oriented, and was his/her own responsible person for decision making. The MDS indicated Resident #1 required 2 person physical assistance with bed mobility and transfers. The physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] (an anticoagulation medication used to prevent blood clot formation, but which places an individual at increased risk of bleeding) for the treatment of [REDACTED]. A Facility Incident Report, dated [DATE], indicated Resident #1 was being transferred when he/she fell out of the lift landing on the floor. The Report indicated Resident #1 complained of knee pain and refused to go to the Hospital but did agree to have X-rays performed of his/her knees. The Report indicated Resident #1 had new fractures of of his/her right tibia and left fibula (lower leg bones). The Surveyor interviewed the Director of Nurses (DON) at 11:50 A.M. on [DATE]. The DON said she was notified at approximately 11:00 A.M. on [DATE], that Resident #1 had fallen. The DON said when she got to Resident #1's room, Resident #1 was lying on the floor. The DON said she explained to Resident #1 and Family Member #1 that it would be in Resident #1's best interest to go to the Hospital for evaluation due to his/her increased risk for bleeding, as a side effect of prescribed [MEDICATION NAME], but Resident #1 refused and Family Member #1 agreed with Resident #1's decision. The DON said she asked staff to call the Physician to inform him of Resident #1's fall and to get an order for [REDACTED]. The Surveyor interviewed Nurse #2, at 12:50 P.M. on [DATE]. Nurse #2 said she placed a call to the Physician's answering service and left a message for the Physician to call back, and she then placed a call to have a mobile X-ray performed on Resident #1. (It was later determined this was done without the order of a Physician.) The Surveyor interviewed the Physician at 1:35 P.M. on [DATE]. The Physician said he received a message from his answering service on [DATE], around lunch time, informing him that Resident #1 had fallen and was complaining of pain in both knees. The Physician said when he telephoned the Facility no-one answered his call. An X-ray Report, dated [DATE], indicated Resident #1 had acute proximal new lower leg fractures. The DON said she received a call later that afternoon, from Nurse #2 who reported words to the effect that everything was OK and Resident #1 did not have any fractures. Nurse #2 said there was a lot of writing on the X-ray report and to the best of her recollection she thought there were no fractures were seen. Nurse #2 said by this time the Physician had not returned her first call and she did not place second follow up call to the Physician or the Medical Director to report Resident #1's X-ray result. Nurse 2 said she left a voicemail message for the DON and reported that Resident #1 had no fractures. Nurse #2 said she did not let the DON know that the Physician had not called back or that she did not make any follow up calls to the Physician's answering service. The Surveyor reviewed Resident #1's X-ray Report with Nurse #2. While Nurse #2 did confirm that the documented name of the person the results were reported to was her, she denied she had received the verbal report of the results, she was unable to read documented fax report and said, words to the effect, there were a lot of confusing words which she did not understand. The Surveyor interviewed Nurse #3 at 12:10 P.M. on [DATE]. Nurse #3 said during the change of shift report, at approximately 3:00 P.M. Nurse #3 told her that Resident #2 had fallen earlier in the day and when she (Nurse #3) reviewed the X-ray results with Nurse #2, she noted that Resident #1 had bilateral lower leg fractures. Nurse #3 said Nurse #2 told her she had called the DON and had left a message for the Physician to call back. Nurse #3 said later in the evening, when Nurse Supervisor #1 was doing evening rounds, she informed Nurse Supervisor #1 that the Physician had not called back. The Surveyor interviewed Nurse Supervisor #1 at 3:00 P.M. on [DATE]. The Nurse Supervisor said she was not made aware of Resident #1's fall with fractures, until some time between 7:30 P.M. 8:00 P.M. on [DATE]. Nurse Supervisor #1 said it was practice that typically if a Physician did not return a call within 30 minutes a second call would be placed, and depending on the severity of the medical situation, if no call back within 1 hour, staff were to call the Medical Director. Nurse Supervisor #1 said she asked Nurse #3 to make another call to the on call Physician, who was Resident #1's Attending Physician, and if no call back to notify her. Nurse #3 said she placed a call to the Physician's office but she did not follow up when the Physician did not call back, because, words to the effect, she was too busy. Nurse Supervisor #1 said Nurse #3 did not call her to report a problem with no call back from the Physician and she did not follow up with Nurse #3 prior to the end of the evening shift. The Surveyor interviewed Nurse #4 at 2:08 P.M. on [DATE]. Nurse #4 said when he reported on duty at 11:00 P.M. on [DATE], he received report that Resident #1 had fall at 11:00 A.M. that morning and had fractured both of his/her lower legs. Nurse #4 said that Nurse #3 reported that the Physician had not responded to messages which were left with his answering service. Nurse #4 said he placed a call to the Attending Physician, at approximately 1:00 A.M. but was unable to leave a message because there was no answering service available. Nurse #4 said he then placed a call to the Medical Director's answering service and received a call back from an on call covering NP who told him that Resident #1 was not her patient to to follow up with the Physician in the morning. The Surveyor interviewed the Nurse Practitioner (NP) at 3:10 P.M. on [DATE]. The NP said was awakened from her sleep, in the middle of the night, by a telephone call from Nurse #4. The NP said Nurse #4 told her he was calling to inform someone that Resident #1 had fallen earlier in the day and fractured both lower legs but he/she had refused to go to the Hospital. The NP said she asked who was the Physician who had ordered the X-rays and was he/she informed of the result. The NP said Nurse #4 said staff had tried calling the Physician but had not received any calls back from the Physician. The NP said, words to the effect this is not my patient and to follow up with the Physician in the morning. The NP said she was not aware that Resident #1's refusal to go to the Hospital was made prior to his/her X-rays and she was not aware that Resident #1 was receiving [MEDICATION NAME]. Nurse #4 said he continued to monitor Resident #1 throughout the night and when the 7:00 A.M. to 3:00 P.M. Nurse Supervisor (Nurse Supervisor #2) arrived on duty, she called the Medical Director and got an order to transfer Resident #1 to the Hospital for further evaluation. The Surveyor interviewed Nurse Supervisor #2 at 2:30 P.M. on [DATE]. Nurse Supervisor #2 said she got a frantic call from Nurse #4 on the morning of [DATE], informing her that Resident #1 had broken both of his/her legs and when he had contacted the on call NP she told him that Resident #1 was not her patient. Nurse Supervisor #2 said she went to the care unit were Resident #1 to evaluate him/her. Nurse #2 said Resident #1 had bruising on both lower legs and his her right ankle was inverted with a 3 centimeter protrusion on her right shin. Nurse Supervisor #2 said that initially Resident #1 did not want to go to the Hospital. Nurse Supervisor #2 said she asked Resident #1 if he/she was aware that his/her legs were broken at which point Resident #1 had a shocked look on his/her face, or words to that effect, and said that no-one had told him/her that his/her legs were broken. Nurse Supervisor #2 said Resident #1 agreed to go to the Hospital for further evaluation and treatment after being informed of his/her X-ray results. The Surveyor interviewed the Medical Director at 2:15 P.M. on [DATE]. The Medical Director said it was evident to him there was clear lack of communication between nursing and medical personnel which caused a delay in transferring Resident #1 to the Hospital and follow up treatment. A Hospital Discharge Summary, dated [DATE], indicated Resident #1 died on [DATE] secondary to medical complications [REDACTED].

Based on record review and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to provide Resident #1 with sufficient information in order to make an informed decision regarding his/her medical plan of care, following a fall from a mechanical lift on the morning of [DATE]. - Although Resident #1 at first declined to go to the Hospital for treatment, he/she did agree to have portable X-ray performed which was reported as positive for new fractures of both his/her lower legs. Staff did not inform Resident #1 of his/her new fractures until the following morning, on [DATE], at which time the Medical Director was notified and Resident #1 agreed to be transferred to the Hospital. - Resident #1 experienced complications of coagulopathy (a condition in which the bloods ability to clot is impaired, causing a tendency toward prolonged or excessive bleeding, which may occur spontaneously or following an injury), acute [MEDICAL CONDITION] and bleeding. Resident #1 died on [DATE]. Findings include: Resident #1's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment, dated [DATE], indicated Resident #1 was alert and oriented, and was his/her own responsible person for decision making. The physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] (an anticoagulation medication used to prevent blood clot formation, but which places an individual at increased risk of bleeding) for the treatment of [REDACTED]. A Facility incident Report, dated [DATE], indicated Resident #1 was being transferred when he/she fell out of the lift landing on the floor and hit his/her knees on the floor. The Report indicated at first Resident #1 refused to go to the Hospital but did agree to have X-rays of his/her knees performed, which indicated Resident #1 had fractures of his/her right tibia and left fibula (lower leg bones). The Surveyor interviewed the Director of Nurses (DON) at 11:50 A.M. on [DATE]. The DON said she was notified at approximately 11:00 A.M. on [DATE], that Resident #1 had fallen. The DON said Resident #1's prescribed medications included the use [MEDICATION NAME] which placed Resident at risk for bleeding. The DON said she explained to Resident #1 and Family Member #1 that it would be in Resident #1's best interest to go to the Hospital for evaluation due to his/her increased risk for bleeding, due to Counmadin, but both Resident #1 refused to go to the Hospital and Family Member #1 agreed with Resident #1's decision. The Surveyor interviewed Nurse #2, at 12:50 P.M. on [DATE]. Nurse #2 said she placed a call to the Physician's answering service and left a message that Resident #1 had fallen, and for the Physician to call back. Nurse #2 said she then placed a call to have a mobile X-ray performed on Resident #1. An X-ray Report, dated [DATE], and timed as verbally reported with a follow up fax report, and accepted by Nurse #2 at 1:24 P.M., indicated Resident #1 had acute proximal new lower leg fractures. Nurse #2 said she did not recall receiving a verbal report of Resident #1's X-ray results but when she looked at the X-ray report there was a lot of writing on the report and to the best of her recollection she thought no fractures were seen. The Surveyor interviewed Nurse #3 at 12:10 P.M. on [DATE]. Nurse #3 said during that the change of shift report, at approximately 3:00 P.M. Nurse #2 told her that Resident #1 had fallen earlier in the day and when she (Nurse #3) reviewed the X-ray results with Nurse #2, she saw that Resident #1 had lower leg fractures in both legs. The Surveyor interviewed Nurse #4 at 2:08 P.M. on [DATE]. Nurse #4 said when he reported on duty at 11:00 P.M. on [DATE], he got report that Resident #1 had fallen at 11:00 A.M. that morning and had fractured both of his/her lower legs. Nurse #2, Nurse #3 and Nurse #4 said they did not inform Resident #1 of his/her X-ray results. Nurse #4 said he continued to monitor Resident #1 throughout the night and when the 7:00 A.M. to 3:00 P.M. Nurse Supervisor arrived on duty, she called the Medical Director and got an order to transfer Resident #1 to the Hospital for further evaluation. The Surveyor interviewed Nurse Supervisor #2 at 2:30 P.M. on [DATE]. Nurse Supervisor #2 said she got a frantic call from Nurse #4 on the morning of [DATE], informing her that Resident #1 had broken both of his/her legs. Nurse Supervisor #2 said Resident #1 initially told her he/she did not want to go to the Hospital. Nurse Supervisor #2 said she asked Resident #1 if he/she was aware that his/her legs were broken at which point Resident #1 had a shocked look on his/her face, or words to that effect, and said that no-one had told him/her that his/her legs were broken. Nurse Supervisor #2 said Resident #1 agreed to go to the Hospital for further evaluation and treatment after being informed he/she had two leg fractures. A Hospital Discharge Summary, dated [DATE], indicated Resident #1 died on [DATE] secondary to medical complications [REDACTED].

Based on record review and interviews, for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure that on [DATE], following a fall from a mechanical lift from which Resident #1 sustained bilateral lower leg fractures, that calls placed to the Physicians answering service were followed up. The Medical Director was not notified of Resident #1's fall, with fractures, until the following morning, on [DATE], at which time Resident #1 was transferred to the Hospital for treatment. Resident #1 died the following day from medical complications [REDACTED]. Findings include: The Facility's Policy, titled Changes in a Resident's Condition or Status, which was not dated, indicated nursing services will be responsible for notifying the Attending Physician when there is an accident or incident which results in injury; if there is a change in the resident's physical, mental or emotional status; and if the Resident refuses treatment. Resident #1's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment, dated [DATE], indicated Resident #1 was alert and oriented, and was his/her own responsible person for decision making. The physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] (an anticoagulation medication used to prevent blood clot formation , but which places an individual at increased risk of bleeding) for the treatment of [REDACTED]. A Facility incident Report, dated [DATE], indicated Resident #1 was being transferred when he/she fell out of the lift landing on the floor; Resident #1 denied hitting his/her head but did complain of knee pain. The Report indicated Resident #1 refused to go to the Hospital but did agree to have X-rays of his/her knees performed, which indicated Resident #1 had fractures of his/her right tibia and left fibula (lower leg bones). The Report indicated Resident #1 later agreed, on [DATE], to go to the hospital for further evaluation and treatment, and on [DATE], the Facility was notified that Resident #1 had passed away from medical complications. The Surveyor interviewed the Director of Nurses (DON) at 11:50 A.M. on [DATE]. The DON said she was notified at approximately 11:00 A.M. on [DATE], that Resident #1 had fallen. The DON said when she got to Resident #1's room, Resident #1 was lying on the floor and at that time CNA #1, Nurse #1 and Family Member #1 where in the room. The DON said Resident #1 had extremely arthritic knees, which he/she complained were hurting. The DON said Resident #1's prescribed medications included the use [MEDICATION NAME] which placed Resident at risk for bleeding. The DON said she explained to Resident #1 and Family Member #1 that it would be in Resident #1's best interest to go to the Hospital for evaluation due to his/her increased risk for bleeding, due to Counmadin, but Resident #1 refused to go to the Hospital and Family Member #1 agreed with Resident #1's decision. The DON said she asked staff to help transfer Resident #1 back to bed, to monitor his her vial signs (heart rate, blood pressure and respirations) for signs of any changes in his/her clinical condition and to call the Physician to inform him of Resident #1's fall and to get an order for [REDACTED]. The Surveyor interviewed Nurse #2, at 12:50 P.M. on [DATE]. Nurse #2 said she placed a call to the Physician's answering service and left a message that Resident #1 had fallen, and for the Physician to call back. Nurse #2 said she then placed a call to have a mobile X-ray performed on Resident #1. The Surveyor interviewed the Physician at 1:35 P.M. on [DATE]. The Physician said he received a message from his answering service on [DATE], around lunch time, informing him that Resident #1 had fallen and was complaining of pain in both knees. The Physician said when he telephoned the Facility no-one answered his call. The Physician said he spoke with the staff at the answering service and instructed them if anyone from the Facility contacted them they were to connect them to his cell phone. The Physician said he did not get any more calls from his answering service or the Facility, he assumed that every thing was okay and did not call back to inquire about Resident #1. An X-ray Report, dated [DATE], and timed as verbally reported with a follow up fax report to Nurse #2 at 1:24 P.M., indicated Resident #1 had acute proximal lower leg fractures. Nurse #2 said she did not recall receiving a verbal report of Resident #1's X-ray results but when she looked at the X-ray report there was a lot of writing on the report and to the best of her recollection she thought no fractures were seen. Nurse #2 said the Physician had not called back when she placed the first call and she did not place a second call to him to report Resident #1's X-ray result. Nurse 2 said she left a voicemail message for the DON and reported that Resident #1 had no fractures. Nurse #2 said she did not let the DON know that the Physician had not called back or that she did not make any follow up calls to the Physician's answering service. The Surveyor interviewed Nurse #3 at 12:10 P.M. on [DATE]. Nurse #3 said during that the change of shift report, at approximately 3:00 P.M. Nurse #3 told her that Resident #1 had fallen earlier in the day and when she (Nurse #3) reviewed the X-ray results with Nurse #2, she saw that Resident #1 had lower leg fractures in both legs. Nurse #3 said that Nurse #2 told her she had called the DON and had left a message for the Physician to call back. Nurse #3 said later in the evening, when Nurse Supervisor #1 was doing evening rounds, she told Nurse Supervisor #1 that the Physician had not called back. The Surveyor interviewed Nurse Supervisor #1 at 3:00 P.M. on [DATE]. Nurse Supervisor #1 said it was practice that typically if a Physician did not return a call within 30 minutes a second call would be placed, and depending on the severity of the medical situation, if no call back within 1 hour, staff were to call the Medical Director. Nurse Supervisor #1 said she asked Nurse #3 to make another call to the Physician and if no call back to notify her. Nurse #3 said she placed a call to the Physician's answering service but she did not follow up when the Physician did not call back, and she did not inform Nurse Supervisor #1 and she did not call the Medical Director's answering service, because words to the effect,she was too busy. The Surveyor interviewed Nurse #4 at 2:08 P.M. on [DATE]. Nurse #4 said Nurse #4 said when he reported on duty at 11:00 P.M. on [DATE], he got report that Resident #1 had fallen at 11:00 A.M. that morning and had fractured both of his/her lower legs. Nurse #4 said that Nurse #3 asked him to follow up with the Nurse Practitioner (NP) the following morning as the Physician had not responded to messages left. Nurse #4 said he placed a call to the Attending Physician but was unable to leave a message because there was no answering service available. Nurse #4 said he then placed a call to the Medical Director's answering service and got a call back from an on call covering NP who told him that Resident #1 was not her patient. The Surveyor interviewed the Nurse Practitioner (NP) at 3:10 P.M. on [DATE]/6. The NP said awakened from her sleep, in the middle of the night, by a telephone call from Nurse #4. The NP said Nurse #4 said he was calling to inform someone that Resident #1 had fallen earlier in the day and fractured both lower legs but he/she had refused to go to the Hospital. The NP said she asked who was the Physician who had ordered the X-rays and was he/she informed of the result. The NP said Nurse #4 said staff had tried calling the Physician but had not received any calls back. The NP said, words to the effect this is not my patient and to follow up with the Physician in the morning. The NP said she was not aware that Resident #1's refusal to go to the Hospital was made prior to his/her X-rays and she was not aware that Resident #1 was prescribed [MEDICATION NAME]. Nurse #4 said when the 7:00 A.M. to 3:00 P.M. Nurse Supervisor arrived on duty, she called the Medical Director and got an order to transfer Resident #1 to the Hospital for further evaluation. The Surveyor interviewed the Medical Director at 2:15 P.M. on [DATE]. The Medical Director said it was evident to him there was clear lack of communication between nursing and medical personnel which caused a delay in transferring Resident #1 to the Hospital and follow up treatment. A Hospital Discharge Summary, dated [DATE], indicated Resident #1 died on [DATE] secondary to medical complications [REDACTED].

Based on records reviewed, the Facility failed to ensure they had a sustainable plan of correction related to compliance that staff are trained to perform through clinical assessment following a change in condition, and implement and appropriate interventions for the prevention of falls. The Facility failed to show they re-evaluated implemented changes to the plan of correction, when on [DATE], Resident #4 had an unwitnessed fall and died 10 hours later, and on [DATE], when Resident #5 had an unwitnessed fall and suffered a dislocated right hip; and failed to identify inconsistencies with documentation as part of investigation and QA process. Findings include: 1. The Facility's Plan of Correction in response to Federal regulations F281 and F323, with a compliance date of [DATE], indicated: - Education was provided to all nursing staff for acceptable standards of practice for change in condition following an Incident/Accident. - Resident Care Plans were reviewed and education was provided to all staff on follow through and implementation of use of assistive devices and level of staff assistance. - All Incident/Accident reports will be reviewed daily at clinical meetings to ensure complete investigation, notification and follow through, and acceptable standards/actions post fall. During a Follow up Survey conducted on [DATE], F281, F282 and F323 were not corrected. 2. A Facility Incident Report, submitted to the Department of Public Health, dated [DATE], indicated that on [DATE], at approximately 8:50 P.M. staff responded to the sound of Resident #4's bed alarm ringing, and found Resident #4 on the floor next to his/her bed. The Incident Report indicated that upon interview with staff Resident #4 was demanding to go back to bed, his/her neurological and vital signs were within normal limits and 3 staff members assisted him/her back to bed. The Incident Report indicated Resident # 4 received care during routine rounds, he/she appeared at baseline and at 5:30 A.M. was found with no pulse and no blood pressure. The Facility's Policy titled Neurological Signs indicated a neurological assessment will be completed on any resident who sustains a head injury, or when head injury questioned, or following an unwitnessed fall. A Physician Treatment Order, dated [DATE], and timed at 10:45 P.M., indicated staff were to monitor Resident #4's vital and Neurological signs, status [REDACTED]. On [DATE], the Facility was unable to provide documentation that a through clinical assessment, including a neurological assessment, was completed on Resident # 4 following his/her unwitnessed fall, per the Facility's Neurological Signs Policy and the Physician's Treatment Order. A copy of the electronic Medication Administration Record [REDACTED].M. The MAR indicated [REDACTED].M. (3 days after Resident #4's unwitnessed fall) indicating at 11:00 P.M. on [DATE], Resident #4's blood pressure (B/P) was ,[DATE], respirations (R) 17 and heart rate (HR) 66, and on [DATE], at 1:00 A.M. B/P was ,[DATE], R 18 and HR 78, and at 3:00 A.M. BP/,[DATE], R 18 and HR 56. A neurological assessment was not documented. The Surveyor interviewed the DDCO at 1:30 P.M. and throughout the afternoon on [DATE]. At approximately 2:50 P.M. the DDCO gave the Surveyor a blank copy of a Neurological Assessment tool which she said was no longer in use. The DDCO said staff were to document all Neurological assessments on the electronic MAR. The DDCO said the Facility's records were 100% electronic, and hand written entries were not permissible. The DDCO could not provide any documentation completed by staff indicating that a neurology assessment was performed, per the physician's orders [REDACTED]. A Nurse Progress Note, dated [DATE], indicated at 5:20 A.M. Resident # 4 was found without vital signs, and a small amount of brown liquid, described in a later note timed at 10:53 A.M. as brown emesis (vomit) on the side of his/her mouth, was on Resident # 4's night gown. A call was placed to the Physician informing him of Resident #4's passing. A Nurse Progress Note, dated [DATE], indicated a Pronouncement of Death was completed at 6:30 A.M. 3. An At Risk Falls Plan of Care, dated [DATE], indicated Resident #5 was identified at risk for falls secondary to being in an unfamiliar environment, and interventions included his/her bed was to be kept in a low position, except during care, and staff were to keep Resident #5's call bell/light within his/her reach at all times. Resident #5's Certified Nurse Aide (CNA) Documentation Record, dated [DATE] through [DATE], indicated Resident #5 was coded as requiring physical assistance of one person with ambulation. An Admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #5 required physical assistance of one person with ambulation, toilet use and personal hygiene. A Nurse Progress Note, dated [DATE], indicated at approximately 9:25 A.M., Resident #5 was seen by staff walking in to the bathroom, and several minutes later was heard yelling for help. The Progress Note indicated when staff responded, Resident #5 said as he/she was brushing his/her hair, he/she heard a loud pop in his/her right hip and fell backwards on to the ground. The Progress Note indicated Resident #5's right leg was was externally rotated and was slightly shorter than the left, he/she grimaced in pain, and he/she was transferred to the Hospital for further evaluation. The Facility Incident /Internal Investigation Report, dated [DATE], indicated when staff responded to Resident #5's call for help, they found Resident #5 lying on the floor. The Incident/Internal Investigation Report, indicated Resident #5 was using a walker at the time of his/her unwitnessed fall and was independent in the bathroom. The Incident/Internal Investigation Report, indicated Resident #5 required surgical intervention following loosening hardware in his/her right hip following a fall. The Facility failed to identify that staff provided Resident #5 assistance with ambulation and personal hygiene, at the time of his/her fall, in accordance with the MDS and the CNA Documentation Record.

Based on interview and record review, the Facility failed to implement the falls prevention care plan for 2 of 3 sampled residents (Resident #1 and Resident #2). On 9/04/14, Certified Nurse Aide (CNA) #1 left Resident #1 unsupervised in the dining room in a transport chair. Resident #1 pushed back in the transport chair and tipped over and landed on the floor and sustained a scalp laceration, which required 4 staples to close. On 9/16/14, CNA #3 was supervising residents in the sitting room by herself when she left the room assist another resident to use the toilet. Resident #2 and other residents in the sitting room were left without direct nursing supervision for approximately 25 minutes, during which time Resident #2 fell to the floor and sustained a maxillary (upper jaw) fracture. Findings include: 1. Resident #1's annual Minimum Data Set (MDS), dated [DATE], indicated he/she had significant cognitive deficits and a [DIAGNOSES REDACTED]. The nursing plan of care, dated 8/09/14, indicated Resident #1 was at risk for falling related to poor safety awareness and walking away from his/her walker. Care plan interventions to prevent falls included, "may use wheelchair for transport only." The care plan did not reference Resident #1's required level of staff supervision. The Surveyor interviewed CNA #1 at 11:15 A.M. on 10/08/14. CNA #1 said that on 9/04/14, during the morning, she wheeled Resident #1 in a transport chair into the dining room and placed him/her at a table. CNA #1 said she locked the brakes to Resident #1's transport chair. CNA #1 said she did not transfer Resident #1 out of the transport chair. CNA #1 said CNA #2 was in the dining room and supervising 4 residents, who sat at her table. CNA #1 said she left the dining room and returned to the hallway to bring more residents into the dining room. CNA #1 said when she returned to the dining room she saw Resident #1 lying on the floor, still in his/her transport chair, and surrounded by staff. The Surveyor interviewed CNA #2 at 9:00 A.M. on 10/08/14. CNA #2 said that on 9/04/14, during the morning, she dressed Resident #1 and transferred him/her into a transport chair. CNA #2 said she then wheeled other residents into the dining room. CNA #2 said she then saw CNA #1 wheel Resident #1 into the dining room in the transport chair and place him/her in front of a table. CNA #2 said CNA #1 did not transfer Resident #1 out of the transport chair. CNA #2 said CNA #1 then left the dining room. CNA #2 said there was a table between herself and Resident #1 and Resident #1's back faced her. CNA #2 said staff sometimes brought Resident #1 to the dining room in a transport chair, depending on his/her strength. CNA #2 said staff were supposed to transfer residents out of the transport chair once they arrived to the dining room into a straight back chair because the transport chair was unstable when not handled by staff. CNA #2 said staff were not supposed to leave residents unsupervised in the transport chair because of its unsteadiness. CNA #2 said she was too occupied with feeding and supervising the residents at her table to speak to CNA #1 before CNA #1 left the dining room. CNA #2 said approximately one minute after CNA #1 left the dining room Resident #2 tipped backwards in the transport chair and he/she and the transport chair fell to the floor. The Surveyor interviewed the Staff Developer at 11:35 A.M. on 10/08/14. The Staff Developer said that on 9/04/14, she heard an overhead page for nursing staff to come to the dining room. The Staff Developer said she entered the dining room and saw Resident #1 in his/her wheelchair, lying on his/her back, and CNA #2 was cradling his/her head in her hands. The Staff Developer said residents should never be left alone in a transport chair because it is lightweight and unstable, if not managed by a staff person. The Surveyor observed the dining room at 8:25 A.M. on 10/08/14. The table, which had been occupied by CNA #2 during the 9/04/14 incident, was approximately 6 feet from where Resident #1 fell . However, because CNA #2 was behind the table she would need to walk approximately 15 feet to reach Resident #1. The Hospital report, dated 9/04/14, indicated Resident #1 sustained a small laceration on the back of the head which required 4 staples to close. 2. Resident #2's nursing plan of care, dated 3/06/14, indicated he/she was at a high risk for falls. Care plan goal included being free from injury-related falls. Care plan interventions did not reference Resident #2's required level of staff supervision. The fall risk assessment, dated 8/19/14, indicated Resident #2 was at a high risk for falls. The quarterly MDS, dated [DATE], indicated Resident #2 had moderate cognitive deficits, required limited 2-person staff assistance when walking in a room and he/she was unsteady during transitions and walking. Review of the Facility's inservice, "Sitting Room Duties", dated August 2014, indicated nursing staff was to be in the sitting room at all times when occupied by residents. The inservice indicated there were no exceptions to this rule. The sign-in sheet indicated CNA #3 did not attend. The Surveyor interviewed CNA #3 at 2:05 P.M. on 10/15/14. CNA #3 said that on 9/16/14, from 1:30 P.M to 2:00 P.M., she was scheduled to supervise residents in the sitting room. CNA #3 said she arrived to the sitting room at 1:30 P.M. and supervised Resident #2, as well as other residents. CNA #3 said she was the only nursing staff in the sitting room. CNA #3 said that at approximately 1:35 P.M. a manager from the dietary department asked her to assist another resident to use the toilet. CNA #3 said she left the sitting room and toileted this resident, which lasted for approximately 15 minutes. CNA #3 said a nurse then asked her to perform another task. CNA #3 said shortly before 2:00 P.M. she heard an overhead page calling for nursing staff to come to the sitting room, and when she arrived she learned Resident #2 fell to the floor. CNA #3 said that prior to the incident she was aware she was required to stay in the sitting room to supervise residents during her scheduled shift. CNA #3 said she believed, at the time, the manager's instructions overrode this requirement. The Dietary Aide's written statement, dated 9/16/14, indicated at approximately 1:50 P.M., he was in the sitting room cleaning a refrigerator and there were residents in the room, but no other staff. The Dietary Aide indicated Resident #2's back was turned toward him and he/she quickly stood up and fell . The Hospital report, dated 9/16/14, indicated Resident #1 fell at the Facility and sustained a [MEDICAL CONDITION] maxillary bone and a bruise over the left eye.

Based on interview, record review and observation for 2 of 3 sampled residents (Resident #1 and Resident #2) the Facility failed to ensure Resident #1 and Resident #2 were provided adequate supervision to prevent injuries. On 9/04/14, Certified Nurse Aide (CNA) #1 left Resident #1, unsupervised, in the dining room in a transport chair. Resident #1 pushed back in the transport chair and tipped over and landed on the floor, sustaining a scalp laceration, which required 4 staples to close. On 9/16/14, CNA #3 was assigned to supervise residents in the sitting room when she left the room to toilet a resident. Resident #2 and other residents in the sitting room were left without direct nursing supervision for approximately 20 to 25 minutes and during this time Resident #2 fell to the floor, sustaining a maxillary (upper jaw) fracture. Findings include: 1. Resident #1's annual Minimum Data Set (MDS), dated [DATE], indicated he/she had significant cognitive deficits and a [DIAGNOSES REDACTED]. The nursing plan of care, dated 8/09/14, indicated Resident #1 was at risk for falling related to poor safety awareness and walking away from his/her walker. Care plan interventions to prevent falls included, "may use wheelchair for transport only." The care plan did not reference Resident #1's required level of staff supervision. The Surveyor interviewed CNA #1 at 11:15 A.M. on 10/08/14. CNA #1 said that on 9/04/14, during the morning, she wheeled Resident #1 in a transport chair into the dining room and placed him/her at a table. CNA #1 said she locked the brakes to Resident #1's transport chair. CNA #1 said she did not transfer Resident #1 out of the transport chair. CNA #1 said CNA #2 was in the dining room and supervising 4 residents, who sat at her table. CNA #1 said she left the dining room and returned to the hallway to bring more residents into the dining room. CNA #1 said when she returned to the dining room she saw Resident #1 lying on the floor, still in his/her wheelchair, and surrounded by staff. CNA #1 said she was aware it was the Facility's policy not to leave residents unattended in the transport chair because the transport chair was unstable and could result in a resident's fall. The Surveyor interviewed CNA #2 at 9:00 A.M. on 10/08/14. CNA #2 said that on 9/04/14, during the morning, she dressed Resident #1 and transferred him/her into a transport chair. CNA #2 said she then wheeled other residents into the dining room. CNA #2 said she then saw CNA #1 wheel Resident #1 into the dining room in the transport chair and place him/her in front of a table. CNA #2 said CNA #1 did not transfer Resident #1 out of the transport chair. CNA #2 said CNA #1 then left the dining room. CNA #2 said there was a table between herself and Resident #1 and Resident #1's back faced her. CNA #2 said approximately one minute after CNA #1 left the dining room Resident #2 tipped backwards in the transport chair and he/she and the transport chair fell to the floor. CNA #2 said staff sometimes brought Resident #1 to the dining room in a transport chair, depending on his/her strength. CNA #2 said staff were supposed to transfer residents out of the transport chair into a straight back chair because the transport chair was unstable when not handled by staff. The Surveyor interviewed the Staff Developer at 11:35 A.M. on 10/08/14. The Staff Developer said that on 9/04/14, she heard an overhead page for nursing staff to come to the dining room. The Staff Developer said she entered the dining room and saw Resident #1 in his/her wheelchair, lying on his/her back, and CNA #2 was cradling his/her head in her hands. The Facility's inservice titled, "Transport of Residents", dated 2/19/14 and 2/20/14, indicated, CNA #1 and CNA #2 attended this inservice. The Surveyor interview the Director of Nursing (DON) at 8:55 A.M. on 10/17/14. The DON said she presented the inservice, "Transport of Residents" on 2/19/14 and 2/20/14. The DON said she instructed staff that the transport chair was for transport only. The Staff Developer said residents should never be left alone in a transport chair because it is lightweight and unstable, if not managed by a staff person. The Staff Developer said if staff used a transport chair to bring them to the dining room they should transfer the resident into a straight back chair to maintain safety. The Surveyor observed the dining room at 8:25 A.M. on 10/08/14. The table, which had been occupied by CNA #2 during the 9/04/14 incident, was approximately 6 feet from where Resident #2 fell . However, because CNA #2 was behind the table she would need to walk approximately 15 feet to reach Resident #1. The Hospital report, dated 9/04/14, indicated Resident #1 was status [REDACTED]. The report indicated Resident #1 was treated with 4 staples to close. 2. Resident #2's nursing plan of care, dated 3/06/14, indicated he/she was at a high risk for falls related to an incidence of falls in the past 30 or 60 days. Care plan goal included being free from injury-related falls. Care plan interventions did not reference Resident #2's required level of staff supervision. The fall risk assessment, dated 8/19/14, indicated Resident #2 was at a high risk for falls. The quarterly MDS, dated [DATE], indicated Resident #2 had moderate cognitive deficits, required limited 2-person staff assistance when walking in a room and he/she was unsteady during transitions and walking. Review of the Facility's inservice, "Sitting Room Duties", dated August 2014, indicated nursing staff was to be in the sitting room at all times when occupied by residents. The inservice indicated there were no exceptions to this rule. The sign-in sheet indicated CNA #3 did not attend. The Surveyor interviewed CNA #3 at 2:05 P.M. on 10/15/14. CNA #3 said that on 9/16/14, from 1:30 P.M to 2:00 P.M., she was scheduled to supervise residents in the sitting room. CNA #3 said she arrived to the sitting room at 1:30 P.M. and supervised Resident #2, as well as other residents. CNA #3 said she was the only nursing staff in the sitting room. CNA #3 said that at approximately 1:35 P.M. a manager from the dietary department asked her to assist another resident to use the toilet. CNA #3 said she left the sitting room and toileted this resident, which lasted for approximately 15 minutes. CNA #3 said a nurse then asked her to perform another task. CNA #3 said shortly before 2:00 P.M. she heard an overhead page calling for nursing staff to come to the sitting room, and when she arrived she learned Resident #2 fell to the floor. CNA #3 said that prior to the incident she was aware she was required to stay in the sitting room to supervise residents during her scheduled shift. CNA #3 said she believed, at the time, the manager's instructions overrode this requirement. The Dietary Aide's written statement, dated 9/16/14, indicated at approximately 1:50 P.M., he was in the sitting room cleaning a refrigerator and there were residents in the room, but no other staff. The Dietary Aide indicated Resident #2's back was turned toward him and he/she quickly stood up and fell . The Hospital report, dated 9/16/14, indicated Resident #1 fell at the Facility and sustained a fracture of the left maxillary bone and a bruise over the left eye.

Based on record review and interview, for 1 of 15 sampled residents, Resident #1, the Facility failed to ensure that licensed nursing staff administered the medication [MEDICATION NAME] in a safe manner. From [DATE] to [DATE], nursing staff administered daily doses of [MEDICATION NAME] to Resident #1, despite the fact that the therapeutic and safe frequency of the drug for the treatment of [REDACTED]. On [DATE], Resident #1 died from [MEDICATION NAME] overdose. Findings included: Review of the "Nursing 2011 Drug Handbook" indicates that one of the indications for [MEDICATION NAME] is for the treatment of [REDACTED]. The Handbook indicates that the dosage for [MEDICATION NAME] may be gradually increased to a maximum of 20 mg, weekly. The Handbook indicates that "To avoid administration errors (for [MEDICATION NAME]) know your patient's dosing schedule." Review of Resident #1's physician order [REDACTED].M., once per week. The order indicated that the medication treated the [DIAGNOSES REDACTED]. Review of Resident #1's physician order [REDACTED].M., was discontinued. The record indicated that a new order was written for [MEDICATION NAME] 2.5 mg (3 tablets), for a total of 7.5 mg, to be given at 2:00 P.M. The order did not indicate the frequency of administration. The order did not indicate the [DIAGNOSES REDACTED]. Review of Resident #1's medication administration record (MAR), dated [DATE], indicated that Resident #1 was administered a daily (2:00 P.M.) dose of [MEDICATION NAME] 7.5 mg on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident #1's MAR, dated [DATE], indicated that Nurse #2 administered a daily dose of [MEDICATION NAME] to Resident #1 on [DATE], [DATE], [DATE], [DATE] and [DATE]. Nurse #2 was interviewed on [DATE] at 1:00 P.M. Nurse #2 said that Nurse #2 administered Resident #1's [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE] and [DATE]. Nurse #2 said that Nurse #2 was aware that Resident #1 was prescribed [MEDICATION NAME] for [MEDICAL CONDITION] arthritis, but was not aware of the therapeutic dosing frequency. Nurse #2 said that, because Resident #1 began to display unusual symptoms, on [DATE] Nurse #2 reviewed a nursing drug handbook and learned that [MEDICATION NAME] should be administered once per week, not once per day. Nurse #2 said that Nurse #2 informed the Unit Manager of the dosing frequency error and that Resident #1 was sent to the Hospital that same day for an evaluation. Nurse #2 said that Nurse #2 did not normally review the MAR to determine the last time a dose was given. Review of Resident #1's MAR, dated [DATE], indicated that Nurse #3 administered a daily dose of [MEDICATION NAME] to Resident #1 on [DATE]. Nurse #3 was interviewed on [DATE] at 1:50 P.M. Nurse #3 said that Nurse #3 administered [MEDICATION NAME] to Resident #1 on [DATE]. Nurse #3 said that Nurse #3 administered Resident #1's medications for a number of months and was familiar with the drug and that it was a drug normally administered on a weekly basis. Nurse #3 said that Nurse #3 believed that the [DATE] dose was a weekly dose, not a daily dose. Nurse #3 said that the medication pass screen in the software program did not indicate when the last dose was given and Nurse #3 assumed that it was given one week ago. Nurse #3 said that Nurse #3 did not normally review the MAR to determine the last time a dose was given. Review of Resident #1's MAR, dated [DATE], indicated that Nurse #4 administered a daily dose of [MEDICATION NAME] to Resident #1 on [DATE]. Nurse #4 was interviewed on [DATE] at 10:30 A.M. Nurse #4 said that Nurse #4 did not recall Resident #1, or recall giving Resident #1 a dose of [MEDICATION NAME] on [DATE]. Nurse #4 said that Nurse #4 was familiar with the drug and that [MEDICATION NAME] was to be administered once per week for the treatment of [REDACTED].#1's [MEDICATION NAME] was to be given once per day then Nurse #4 would have held the medication and spoken with the nursing supervisor about the dosage frequency. Nurse #4 said that, based on viewing only the medication pass screen, Nurse #4 would not be able to determine the last date a medication was administered. Nurse #4 said that Nurse #4 did not normally review the MAR to determine the last time a dose was given. Review of Resident #1's MAR, dated October, 2011, indicated that Nurse #5 administered a daily dose of [MEDICATION NAME] to Resident #1 on [DATE]. Nurse #5 was interviewed on [DATE] at 12:20 P.M. Nurse #5 said that Nurse #5 recalled that Resident #1 had a physician's orders [REDACTED]. Nurse #5 said that at the time Nurse #5 administered [MEDICATION NAME] to Resident #1, Nurse #5 was not familiar with the drug or the therapeutic dose frequency. Nurse #5 said that Nurse #5 did not review a drug handbook to learn about the therapeutic dosing frequency, or other drug characteristics. Nurse #5 said that the medication pass screen indicated that [MEDICATION NAME] was to be given at 2:00 P.M. and that Nurse #5 assumed that this meant it was to be given once per day. Nurse #5 said that Nurse #5 noticed the time change and reviewed the physician order [REDACTED]. Nurse #5 said that Nurse #5 did not review the MAR and that Nurse #5 did not normally review the MAR to determine the last time a dose was given. Review of Resident #1's nurse's note, dated [DATE] (9:30 A.M.) indicated that Resident #1's upper lip was swollen and that Resident #1 complained of a hacking, non-productive cough. The note indicated that nursing staff observed a red and spotted rash on Resident #1's back. The note indicated that Resident #1 was sent to the Hospital for further evaluation. Review of Resident #1's Nurse Practitioner's note, dated [DATE], indicated that Facility staff told the Nurse Practitioner that staff administered unscheduled doses of [MEDICATION NAME]. The note indicated that the Nurse Practitioner's assessment was that Resident #1 had an allergic response with perioral swelling, thrush and difficulty swallowing. The note indicated Resident #1 was given a dose of [MEDICATION NAME] and there was a question if this (the symptom) was a response to [MEDICATION NAME]. The note indicated that Resident #1 was sent to the Hospital for an evaluation. Review of the Hospital's discharge note, dated [DATE], indicated that the Resident #1 died on this date and cause of death was due to: 1. Septic shock with multiorgan failure secondary to immunosuppression due to [MEDICATION NAME] toxicity; and 2. Acute [MEDICAL CONDITION] secondary to hypoperfusion resulted from shock and direct toxicity from [MEDICATION NAME]. Review of Resident #1's certificate of death, dated [DATE], indicated that Resident #1's injury was caused by "excess [MEDICATION NAME]" and that the injury occurred at the Facility. The Unit Manager was interviewed on [DATE] at 11:50 A.M. The Unit Manager said that, prior to administering a dose, the Unit Manager and the other nurses in the Facility did not routinely review the MAR to determine the last time a dose was given. The Unit Manager said that when nursing staff administered medications the only screen usually viewed on the computer was the medication pass screen and that this screen did not show previous administration times, unless the medication was given as an as needed (PRN) medication. The Director of Nurses (DON) was interviewed in [DATE] at 8:00 A.M. The DON said nursing staff, during the 11:00 P.M. to 7:00 A.M. shift, were required to review all new orders on the 24-hour new medication order list to determine safety. The DON said that it was the responsibility of these nurses to review Resident #1's rewritten order for [MEDICATION NAME] and to question the excessive dosing frequency. The DON said that this excessive frequency was overlooked by staff and that the order was allowed to be continued. Nurse #1 was interviewed on [DATE] at 2:30 P.M. Nurse #1 said that on [DATE], during the 11:00 P.M. to 7:00 A.M. shift, Nurse #1 reviewed the 24-hour new medication order list. Nurse #1 said that Resident #1's name was not on the list and that there was no indication that a new order for [MEDICATION NAME] had been placed for Resident #1. Nurse #1 said that there was no indication in either Resident #1's hard-copy clinical record, or the electronic record, that there was a new order for [MEDICATION NAME]. Review of the 24-hour new medication order list, dated [DATE], indicated that Resident #1 had a new order, dated [DATE], 3:00 P.M., for [MEDICATION NAME]. The order (entered by the Unit Manager) indicated that the [MEDICATION NAME] was "Special" and to be given at 2:00 P.M. Please refer to F333

Based on record review and interview the Facility failed to identify that 1 of 15 sampled residents, Resident #1, was administered 7.5 milligrams (mg) of [MEDICATION NAME] daily for 8 days rather than the therapeutic dose of 7.5 mg once per week. Resident #1 was hospitalized on [DATE] and died on [DATE]. The cause of death was determined to be [MEDICATION NAME] toxicity with multiorgan failure. Findings included: Review of Resident #1's physician orders, dated February 2011, indicated that Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's physician order [REDACTED].M., once per week. The order indicated that the medication was to treat the [DIAGNOSES REDACTED]. Review of Davis Drug Handbook (2011 edition), indicates that one of the indications for [MEDICATION NAME] is for the treatment of [REDACTED]. The Handbook indicates that the dosage for [MEDICATION NAME] may be gradually increased to a maximum of 20 mg, weekly. The Handbook indicates that "To avoid administration errors (for [MEDICATION NAME]) know your patient's dosing schedule." Review of Resident #1's medication administration record (MAR), dated [DATE], indicated that Resident #1 was to be administered [MEDICATION NAME] 2.5 mg (3 tablets), for a total of 7.5 mg, to be given at 10:00 A.M., once per week. The [DATE] MAR did not indicate the diagnosis, or symptom, treated by the medication. The [DATE] MAR indicated that [MEDICATION NAME] was administered to Resident #1 on [DATE] at 10:00 A.M. Review of Resident #1's physician order [REDACTED].M., was discontinued. The record indicated that on [DATE] a new order was written for [MEDICATION NAME] 2.5 mg (3 tablets), for a total of 7.5 mg, to be given at 2:00 P.M. The order did not indicate the frequency of administration, or the diagnosis, or symptom treated by the medication. Review of Resident #1's MAR, dated [DATE], indicated that Resident #1 was to be administered [MEDICATION NAME] 2.5 mg (3 tablets), for a total of 7.5 mg. The MAR indicated that there was no reference to the frequency of administration, or the diagnosis, or symptom the medication treated. The MAR indicated that the administration time of 2:00 P.M. was selected. The MAR indicated that Facility nursing staff administered a daily (2:00 P.M.) dose of [MEDICATION NAME] 7.5 mg to Resident #1 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident #1's MAR, dated [DATE], indicated that Nurse #2 administered [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE] and [DATE]. Nurse #2 was interviewed on [DATE] at 1:00 P.M. Nurse #2 said that Nurse #2 administered Resident #1's [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE] and [DATE]. Nurse #2 said that Nurse #2 was aware that Resident #1 was prescribed [MEDICATION NAME] for [MEDICAL CONDITION] arthritis, but was not aware of the therapeutic dosing frequency. Nurse #2 said that, because Resident #1 began to display unusual symptoms, on [DATE] Nurse #2 reviewed a nursing drug handbook and learned that [MEDICATION NAME] should be administered once per week, not once per day. Nurse #2 said that Nurse #2 informed the Unit Manager of the dosing error and that Resident #1 was sent to the Hospital that same day for an evaluation. Nurse #2 said that Nurse #2 did not normally review the MAR to determine the last time a dose was given. Review of Resident #1's MAR, dated [DATE], indicated that Nurse #3 administered [MEDICATION NAME] on [DATE]. Nurse #3 was interviewed on [DATE] at 1:50 P.M. Nurse #3 said that Nurse #3 administered [MEDICATION NAME] to Resident #1 on [DATE]. Nurse #3 said that Nurse #3 administered Resident #1's medications for a number of months and believed that the [DATE] dose was a weekly dose and not a daily dose. Nurse #3 said that Nurse #3 did not normally review the MAR to determine the last time a dose was given. Review of Resident #1's MAR, dated [DATE], indicated that Nurse #4 administered [MEDICATION NAME] on [DATE]. Nurse #4 was interviewed on [DATE] at 10:30 A.M. Nurse #4 said that Nurse #4 did not recall Resident #1, or giving Resident #1 a dose of [MEDICATION NAME] on [DATE]. Nurse #4 said that [MEDICATION NAME] was to be administered once per week for the treatment of [REDACTED].#4 assumed that staff administered the medication on a weekly basis. Nurse #4 said that Nurse #4 did not normally review the MAR to determine the last time a dose was given. Review of Resident #1's MAR, dated [DATE], indicated that Nurse #5 administered [MEDICATION NAME] on [DATE]. Nurse #5 was interviewed on [DATE] at 12:20 P.M. Nurse #5 said that, at the time Nurse #5 administered [MEDICATION NAME] to Resident #1, Nurse #5 was not familiar with the drug or the therapeutic dose frequency. Nurse #5 said that the medication pass screen indicated that [MEDICATION NAME] was to be given at 2:00 P.M. and that Nurse #5 assumed that this meant it was to be given once per day. Nurse #5 said that Nurse #5 did not review the MAR and that Nurse #5 did not normally review the MAR to determine the last time a dose was given. Review of Resident #1's nurse's note, dated [DATE], indicated that in the morning Resident #1 complained of a sore throat and refused to eat breakfast. The note indicated that these symptoms resolved by the afternoon. Review of Resident #1's nurse's note, dated [DATE], 12:00 P.M., indicated that Resident #1 complained of a sore throat. Review of Resident #1's nurse's note, dated [DATE], 2:00 P.M., indicated that Resident #1 had a swollen upper lip and complained of slight pain and discomfort from the swelling. The note indicated that nursing staff notified the Nurse Practitioner and administered [MEDICATION NAME] (to decrease the swelling). Review of Resident #1's nurse's note, dated [DATE] (9:30 A.M.) indicated that Resident #1's upper lip had increased in swelling. The note indicated that Resident #1 complained of a hacking, non-productive cough. The note indicated that nursing staff observed a red, spotted rash on Resident #1's back. The note indicated that Resident #1 was sent to the Hospital for further evaluation. Review of Resident #1's Nurse Practitioner's note, dated [DATE], indicated that Facility staff told the Nurse Practitioner that staff administered unscheduled doses of [MEDICATION NAME]. The note indicated that the Nurse Practitioner's assessment was that Resident #1 had an allergic response with perioral swelling, thrush and difficulty swallowing. The note indicated Resident #1 was given a dose of [MEDICATION NAME] and there was a question if this (the symptom) was a response to [MEDICATION NAME]. The note indicated that Resident #1 was sent to the Hospital for an evaluation. Review of Resident #1's patient care referral form, dated [DATE], indicated that on this date Resident #1 was sent from the Facility to the Hospital. The referral form indicated that Resident #1 was prescribed [MEDICATION NAME] for treatment of [REDACTED]. The referral form indicated that nursing staff administered Resident #1's last dose of [MEDICATION NAME] on [DATE]. The referral form indicated that nursing staff questioned if Resident #1's symptoms were due to [MEDICATION NAME] toxicity or an allergy to [MEDICATION NAME]. The referral form did not indicate that Resident #1 received an overdose of [MEDICATION NAME]. Review of the Hospital's discharge note, dated [DATE], indicated that the cause of Resident #1's death included: 1. Septic shock with multiorgan failure secondary to immunosuppression due to [MEDICATION NAME] toxicity; and 2. Acute [MEDICAL CONDITION] secondary to hypoperfusion resulted from shock and direct toxicity from [MEDICATION NAME]. Review of the Facility's copy of the Pharmacy's policy and procedure for medication administration, dated 2009, indicated that "If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to a resident's current [DIAGNOSES REDACTED]." The Unit Manager was interviewed on [DATE] at 11:50 A.M. The Unit Manager said that on [DATE] the Unit Manager consolidated medication pass times and moved the administration time for Resident #1's [MEDICATION NAME] from 10:00 A.M. to 2:00 P.M. The Unit Manager said that, during this process of changing the administration time, the Unit Manager accidentally changed the dosing frequency from weekly to daily. The Unit Manager said that the Unit Manager did not notice the change in frequency. The Unit Manager said that when the Unit Manager rewrote the new order for [MEDICATION NAME], the Unit Manager did not provide information as to the frequency of the administration, the [DIAGNOSES REDACTED]. The Unit Manager said that the Unit Manager then transmitted the new order to the Pharmacy for processing. The Unit Manager said that the Unit Manager and the other nurses in the Facility did not routinely review the MAR to determine the last time a dose was given. The Unit Manager said that when nursing staff administer medications the only screen usually viewed on the computer is the medication pass screen and that this screen does not show previous, or upcoming, administration times, unless the medication is ordered on an as-needed basis (PRN). The Director of Nurses (DON) was interviewed in [DATE] at 8:00 A.M. The DON said nursing staff, during the 11:00 P.M. to 7:00 A.M. shift, were required to review all new orders on the 24-hour new medication order list to determine safety. The DON said that it was the responsibility of these nurses to review Resident #1's rewritten order for [MEDICATION NAME] and to question the excessive dosing frequency. The DON said that this excessive frequency was overlooked by staff and that the order was allowed to be continued. Nurse #1 was interviewed on [DATE] at 2:30 P.M. Nurse #1 said that on [DATE], during the 11:00 P.M. to 7:00 A.M. shift, Nurse #1 reviewed the 24-hour new medication order list. Nurse #1 said that Resident #1's name was not on the list and that there was no indication that a new order for [MEDICATION NAME] had been placed for Resident #1. Nurse #1 said that there was no indication in either Resident #1's hard-copy clinical record, or the electronic record, that there was a new order for [MEDICATION NAME]. Review of the 24-hour new medication order list, dated [DATE], indicated that Resident #1 had a new order, dated [DATE], 3:00 P.M., for [MEDICATION NAME]. The order (entered by the Unit Manager) indicated that the [MEDICATION NAME] was "Special" and to be given at 2:00 P.M. Please refer to F245

Based on record review and interview, for 1 of 15 sampled residents, Resident #1, the Facility failed to provide pharmaceutical services that: 1. ensured the accurate dispensing of methotrexate for Resident #1 when the Pharmacy software was designed to default to a frequency of daily dosing when nursing staff selected a "Special" dosing time from the computerized list of options. The Nursing staff was not specifically instructed on this default limitation. 2. identified a physician's orders [REDACTED]. The Hospital Discharge Note, dated 11/08/11, indicated Resident #1 died from methotrexate toxicity. Findings included: 1. Review of Resident #1's physician order [REDACTED].M. Review of Davis Drug Handbook (2011 edition), indicates that one of the indications for methotrexate is for the treatment of [REDACTED]. The Handbook indicates that the dosage for methotrexate may be gradually increased to a maximum of 20 mg, weekly. The Handbook indicates that "To avoid administration errors (for methotrexate) know your patient's dosing schedule." The Unit Manager was interviewed on 11/15/11 at 10:50 A.M. The Unit Manager said that on 10/12/11 the Unit Manager changed the initial dosing time for Resident #1's methotrexate from 10:00 A.M. to the non-routine, or "Special" time of 2:00 P.M. The Unit Manager said that the physician's orders [REDACTED]. The Unit Manager said that the Unit Manager then transmitted the new/revised methotrexate order to the Pharmacy. The Unit Manager said that when the Unit Manager selected "2:00 P.M." from the drop down menu the Unit manager accidentally changed the dosing frequency from weekly to daily, though this change was not visible on the physician's orders [REDACTED]. The Unit Manager said that the Unit Manager assumed that the order transmitted to the Pharmacy for Resident #1 was for a weekly dose of methotrexate. The Unit Manager said that, at the time of the incident, the Unit Manager was not trained, or instructed, on the effect that selection of "Special" dosing times had on dosing frequency. Review of Resident #1's physician order, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s rheumatoid arthritis. Nurse #2 was interviewed on 11/15/11 at 1:00 P.M. Nurse #2 said that Nurse #2 administered methotrexate 7.5 mg to Resident #1 on 10/13/11, 10/15/11, 10/16/11, 10/17/11 and 10/20/11. Nurse #2 said that the medication pass screen indicated that the dosing time was "Special", though Nurse #2 said that it was unclear what "Special" meant. Nurse #2 said that the Pharmacy's software did not alert Nurse #2 that Resident #1 was receiving unsafe daily doses of methotrexate. Nurse #3 was interviewed on 11/15/11 at 1:50 P.M. Nurse #3 said that Nurse #3 administered methotrexate 7.5 mg to Resident #1 on 10/14/11. Nurse #3 said that "Special" meant that the dosing time of 2:00 P.M. was a non-routine time. Nurse #3 said that "Special" did not mean that the medication was to be given on a daily basis. Nurse #3 said that the Pharmacy's software did not alert Nurse #3 that Resident #1 was receiving unsafe daily doses of methotrexate. Nurse #3 said that the medication pass screen in the software program did not indicate when the last dose was given and Nurse #3 assumed that it was given one week ago. Nurse #4 was interviewed on 11/23/11 at 10:30 A.M. Nurse #4 said that Nurse #4 did not recall Resident #1, or remember giving Resident #1 a dose of methotrexate on 10/18/11. Nurse #4 said that Nurse #4 did not know what "Special" meant. Nurse #4 said that methotrexate was a drug to be given once per week for the treatment of [REDACTED].#4 had known the Resident #1 had been receiving daily doses of methotrexate Nurse #4 would not have administered the drug to Resident #1 on 10/18/11. Nurse #4 said that Nurse #4 did not recall seeing an alert regarding any medications given by Nurse #4 on 10/18/11. Nurse #4 said that, based on viewing only the medication pass screen, Nurse #4 would not be able to determine the last date a medication was administered. Nurse #5 was interviewed on 11/15/11 at 12:20 P.M. Nurse #5 said that Nurse #5 recalled that Resident #1 had a physician's orders [REDACTED].M. Nurse #5 said that Nurse #5 did not think that "Special" related to the frequency of the dosing, but that Nurse #5 did not know what it referred to. Nurse #5 said that Nurse #5 assumed that the medication pass screen instructions meant that the methotrexate was to be given once per day. The Surveyor reviewed the Pharmacy's medication ordering and administration software and determined that a separate field did not exist for the entry of dosing frequency. Review of the Pharmacy's software indicated that the program defaulted to daily dosing when non-routine or "Special" dosing time was selected. Review of the Pharmacy's Nursing Reference Guide and the Pharmacy's Policy and Procedure Manual for Pharmaceutical Care, indicated that there was no reference that "Special" selection would result in a default daily dosing. 2. Review of Resident #1's physician order [REDACTED].M., once per week. The order indicated that the medication was to treat the [DIAGNOSES REDACTED]. Review of Resident #1's physician order [REDACTED].M., was discontinued. The record indicated that a new order was written for methotrexate 2.5 mg (3 tablets), for a total of 7.5 mg, to be given "Special" at 2:00 P.M. The order no longer indicated the frequency of administration, the [DIAGNOSES REDACTED]. The Unit Manager was interviewed on 11/15/11 at 11:50 A.M. The Unit Manager said that on 10/12/11 the Unit Manager consolidated medication pass times and moved the administration time for Resident #1's methotrexate from 10:00 A.M. to 2:00 P.M. The Unit Manager said that, during this process of changing the administration time, the Unit Manager accidentally changed the dosing frequency from weekly to daily. The Unit Manager said that the Unit Manager did not notice the change in frequency. The Unit Manager said that when the Unit Manager rewrote the initial order for methotrexate the Unit Manager did not provide information as to the frequency of the administration, the [DIAGNOSES REDACTED]. The Unit Manager said that the Unit Manager then transmitted the new order to the Pharmacy for processing. The Unit Manager said that the Pharmacy did not contact the Unit Manager, or other Facility staff, to report that Resident #1's medication order for methotrexate was not a therapeutic frequency for the treatment of [REDACTED].#1's medication order for methotrexate did not display the dose frequency. The Unit Manager said that the Pharmacy did not contact the Unit Manager, or other Facility staff, to report that Resident #1's initial medication order for methotrexate included a [DIAGNOSES REDACTED]. The Director of Nurses (DON) was interviewed in 11/15/11 at 8:00 A.M. The DON said nursing staff, during the 11:00 P.M. to 7:00 A.M. shift, were required to review all new orders on the 24-hour new medication order list to determine safety. The DON said that it was the responsibility of these nurses to review Resident #1's rewritten order for methotrexate and to question the excessive dosing frequency. The DON said that this excessive frequency was overlooked by staff and that the order was allowed to be continued. Nurse #1 was interviewed on 11/23/11 at 2:30 P.M. Nurse #1 said that on 10/13/11, during the 11:00 P.M. to 7:00 A.M. shift, Nurse #1 reviewed the 24-hour new medication order list. Nurse #1 said that Resident #1's name was not on the list and that there was no indication that a new order for methotrexate had been placed for Resident #1. Nurse #1 said that there was no indication in either Resident #1's hard-copy clinical record, or the electronic record, that there was a new order for methotrexate. Review of the 24-hour new medication order list, dated 10/12/11, indicated that Resident #1 had a new order, dated 10/12/11, 3:00 P.M., for methotrexate. The order (entered by the Unit Manager) indicated that the methotrexate was "Special" and to be given at 2:00 P.M. The Pharmacy Consultant (employed by the Pharmacy) was interviewed on 11/16/11 at 11:55 A.M. The Pharmacy Consultant said that on 10/12/11, after the Facility transmitted the new physician medication order for Resident #1's methotrexate, a pharmacist at the Pharmacy reviewed and verified the order. The Pharmacy Consultant said that the pharmacist was responsible for verifying that the new order had the appropriate dose and dosing frequency to treat Resident #1's [DIAGNOSES REDACTED]. The Pharmacy Consultant said that the reviewing pharmacist from the Pharmacy approved the order and then the Pharmacy processed and dispensed the order to the Facility.