Chestnut Woods Rehabilitation And Healthcare Ctr

Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one nurse observed made four errors out of 26 opportunities, resulting in a medication error rate of 15.38 %. Those errors impacted three Residents (#85, #99 and #22), out of seven residents observed.Findings include:Review of the facility policy titled, Administering Medications, dated as revised April 2019, indicated the following: Medications are administered in a safe, and timely manner, and as prescribed.3. Staff schedules are arranged to ensure that medications are administered without unnecessary interruptions.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before or after meal orders). Review of the facility policy titled, Insulin Administration, dated August 2021, indicated the following: 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. The following observations were made during the medication pass on the second-floor unit: 1a. Resident #85 was admitted to the facility in July 2025 with diagnoses including type two diabetes mellitus, morbid severe obesity, and anxiety.On 9/10/25 at 8:25 A.M., the surveyor observed Nurse #1 administer the following medications to Resident #85:-6 Units Insulin Lispro (fast-acting medication to manage blood sugar levels), via subcutaneous injection.Review of the active physician's orders indicated the following:- Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 6 unit subcutaneously with meals for Type 2 diabetes. Start Date 7/30/25. Scheduled for 8:00 A.M.The medications were administered after the breakfast meal was consumed by Resident #85.1b. Resident #99 was admitted to the facility in August 2025 with diagnoses including type one diabetes mellitus, encephalopathy, and cognitive communication deficit.On 9/10/25 at 8:27 A.M., the surveyor observed Nurse #1 administer the following medication to Resident #99:-10 Units Insulin Lispro, via subcutaneous injection.Review of the active physician's orders indicated the following:-Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 10 units subcutaneously with meals related to type 1 diabetes mellitus without complications. Start Date 9/4/25. Scheduled for 8:00 A.M.The medications were administered after the breakfast meal was consumed by Resident #99.1c. Resident #22 was admitted to the facility in October 2024 with diagnoses including type two diabetes mellitus and congestive heart failure. On 9/10/25 at 8:42 A.M., the surveyor observed Nurse #1 administer the following medications to Resident #22:-20 Units Insulin Lispro, via subcutaneous injection.-2 Units Insulin Lispro, via subcutaneous injection.Review of the active physician's orders indicated the following:-Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 20 unit subcutaneously in the morning related to type 2 diabetes mellitus without complications. Start Date10/5/24. Scheduled for 8:00 A.M.-Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Greater than 400 give 12 units and call MD/NP, subcutaneously with meals related to type 2 diabetes mellitus without complications. Start Date 10/5/24. Scheduled for 8:00 A.M.The medications were administered after the breakfast meal was consumed by Resident #22. During an interview on 9/10/25 at 9:05 A.M., Nurse #1 said she should have administered the medications prior to or during the breakfast meal and said she took the blood sugar levels at 7:20 A.M. and was unable to complete the insulin administration because she had to assist with checking the breakfast trays and got behind. During an interview on 9/10/25 at 12:50 P.M., the Director of Nursing said nurses should follow the physician order and administer medications as ordered and said the insulin should be given just prior to or with the breakfast meal and not after.

Based on observation, record review and interview the facility failed to maintain accurate medical records for two Residents (#41 and #68) out of a total sample of 25 residents. Specifically, the facility failed to accurately document on the Treatment Administration Record that treatments were not completed as ordered for Resident #41 and Resident #68.Review of the facility policy titled Charting and documentation dated revised July 2017 indicated that documentation in the medical record will be objective, complete and accurate. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol indicated that the physician will authorize pertinent orders related to wound treatments, including wound cleansing and dressings. 1. Resident #41 was admitted to the facility in July 2025 with diagnoses including adult failure to thrive, malnutrition and trochanteric fracture of the right femur.Review of the care plan dated 9/5/25 indicated a focus for the following: I have skin breakdown; non pressure wound of the left heel and unstageable DTI (deep tissue injury, a type of pressure related skin injury) of the right heel. Review of the physician's orders dated September 2025 indicated the following order: Left heel; cleanse with normal saline, pat dry and apply xeroform followed by an island dressing one time a day. Review of the TAR dated September 2025 indicated that on 9/2/25 the wound area on the left heel was c/d/i (clean, dry and intact). Further review indicated that on 9/3/25 through 9/9/25 the wound area on the left heel was open with a scant amount of drainage. Further review indicated that on 9/8/25 the nurse documented that they had completed the treatment to the left heel as ordered. On 9/9/25 at 7:45 A.M., and 10:13 A.M., the surveyor observed Resident #41 in bed with gauze dressings covering both feet including heels. The surveyor then observed each of the dressings were dated 9/7/25. During an interview on 9/9/25 at 1:40 P.M. Nurse #3 and the surveyor observed Resident #41 in bed with a dressing to both feet dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left heel. Nurse #3 said that the nurse should not document in the medical record that they completed a dressing change when they had not. During an interview on 9/10/25 at 12:25 P.M. the Director of Nursing said that the nurses are supposed to follow the physician's orders for dressing changes. The DON then said that nurses should not be documenting in the medical record that they completed a dressing change when they had not.2. Resident #68 was admitted to the facility in July 2025 with diagnoses including pathological trimalleolar fracture of the left lower leg. Review of the physician's orders dated September 2025 indicated the following order: Left shin wound in the evening for left shin wound, clean with NS (normal saline) apply border dressing q (every) day. On 9/9/25 at 8:35 A.M. the surveyor observed Resident #68 with a gauze dressing covering an ABD (abdominal) pad, to the left lower leg dated 9/7/25. Review of the Treatment Administration Record dated 9/8/25 indicted that the nurse documented that they had completed the ordered treatment for the dressing change on 9/8/25 as ordered. During an interview on 9/9/25 at 1:38 P.M. Nurse #3 and the surveyor observed Resident #68 with a dressing to the left shin dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left shin. Nurse #3 also said that the dressing on the wound was not what the physician ordered. Nurse #3 then said that the nurses should not be documenting in the medical record that they had completed a dressing change when they had not.

Based on observations and interviews, the facility failed to ensure staff treated residents in a dignified manner during the dining experience for one Resident (#69) out of a total of 25 sampled residents.Findings include: Review of the facility policy titled Dignity, revised and dated February 2021, indicated the following: - Residents are treated with dignity and respect at all times.-Provided with a dignified dining experience.Resident #69 was admitted to the facility in August 2025 with diagnoses including hemiplegia and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/27/25, indicated that Resident #69 was unable to conduct a Brief Interview for Mental Status exam and was severely cognitively impaired. Further review of the MDS indicated that Resident #69 is dependent on staff for eating and received a mechanically altered therapeutic diet. On 9/9/25 at 8:40 A.M., a staff member was observed feeding Resident #69 who was lying in bed while standing over them, not at eye level. The bed was low to the ground. On 9/9/25 at 12:11 P.M., a staff member was observed feeding Resident #69 who was lying in bed while standing over them, not at eye level. The bed was low to the ground. On 9/10/25 at 8:34 A.M., a staff member was observed feeding Resident #69 who was lying in bed while standing over them, not at eye level. The bed was low to the ground. On 9/10/25 at 12:17 P.M., a staff member was observed feeding Resident #69 who was lying in bed while standing over them, not at eye level. The bed was low to the ground. During an interview on 9/10/25 at 12:30 P.M., Unit Manager #1 said staff should not be standing over residents while assisting them with feeding. During an interview on 9/10/25 at 12:44 P.M., the Director of Nursing said staff should not be standing over residents while assisting them with feeding and should be at eye level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to ensure the building and equipment was in good condition and had a homelike environment in 38 out of 40 rooms.Findings include:Review of the facility policy titled Homelike Environment, dated revised February 2021, indicated the following:Residents are provided with a safe, clean, comfortable and homelike environment .Policy Interpretation and Implementation:2. The facility staff and management maximize, to the extent possible, the characteristics of the facility thatreflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment On 9/10/2025 at 8:30 A.M. the surveyor observed the following in the first-floor rooms:105A and B: the over the bed table laminate was peeling off.106B: the over the bed table laminate was peeling off.107A: the over the bed table laminate was peeling off, the Bathroom wall had paint missing and bubbled.108A: the over the bed table laminate was peeling off, the bathroom wall had 2 small holes.109A and B: the over the bed table's laminate was peeling off110B: the over the bed table laminate was peeling off111A: the over the bed table laminate was peeling off112A and B: the over the bed table's laminate was peeling off113A: the walls were scuffed.114A: the over the bed table laminate was peeling off and taped115A and B the over the bed table's laminate was peeling off. The bathroom doors were scuffed, the ceiling paint was bubbled and had brown spots, and a radiator panel was lifting off.116A: the corner of the wall was broken and gouged. The wall was scraped.117A and B: the over the bed table's laminate was peeling off, the wall next to the sink had holes, the corners of the walls were gouged.118A and B: the over the bed table's laminate was peeling off.119A and B: the over the bed table's laminate was peeling off and the outside wall is scraped.120: the window screen is broken.121B: the over the bed table laminate was peeling off and a radiator panel is lifting off.122A and B: the over the bed table's laminate was peeling off and the window screen was broken.123A: the wall was scuffed and bed B the over the bed table laminate was peeling off.125: the over the bed table laminate was peeling off. On 9/10/2025 at 7:50 A.M. the surveyor observed the following in the second-floor rooms:205: the walls were scraped.207: the walls were scraped, and the bathroom light didn't work.208A and C: the over the bed table's laminate was peeling off. Bed B nightstand edges chipped.209B: the over the bed table laminate was peeling off, and the wall to the left of the door was gouged and scraped.210: the outside wall was scuffed and the over the bed table laminate was peeling off.211: the wall outside the bathroom door was gouged and the bathroom light had multiple dead bugs.212A: the over the bed table laminate was peeling off.213: the outside wall was scuffed.214B: the over the bed table laminate was peeling off.215B: the over the bed table laminate was peeling off, the bathroom wall had holes, and the toilet paper holder was broken.216A: the over the bed table laminate was peeling off and the entry wall scuffed.217A: nightstand chipped, the outside wall was scuffed. Bed B the over the bed table laminate was peeling off. The bathroom had a hole in the ceiling, and the toilet paper holder was missing.218B: the over the bed table laminate was peeling off and there was a hole in the ceiling above bed C.219B: the over the bed table laminate was peeling off, Bed C the over the bed table laminate was peeling off and leaning. The bathroom toilet was full of feces and was covered with a large clear plastic garbage bag.221A and C: the over the bed table's laminate was peeling off and the outside wall was scuffed.222: the wall outside the bathroom was gouged.223B: the over the bed table laminate was peeling off and the bathroom wall was gouged.225: the over the bed table laminate was peeling off.The radiator cover, in the hallway outside room [ROOM NUMBER], was lifting off exposing sharp edges. During an interview on 9/10/25 at 8:25 A.M., Unit manager #1 said that all needed environmental repairs should be entered into the TELS system (used to communicate environmental repair needs to the maintenance department). During an interview on 9/10/25 at 8:28 A.M., the Maintenance Director said that all of the work request orders in the TELS system have been completed as of today. He then said that he checks the system up to 8 times a day. During an interview on 9/10/25 at 10:40 A.M., the Maintenance Director said that he was not aware of any plans to purchase over the bed tables or any furniture for the resident rooms. During an interview on 9/10/25 at 10:48 A.M., the Administrator said that the above concerns should have been entered into the TELS system. The Administrator then said that she and the Maintenance Director do rounds in the facility on a monthly basis. Review of the facility document titled Monthly Environmental rounds, dated 4/30/25, indicated that only 2 over the bed tables need replacement. The document further indicated that 6 rooms on the first floor and 12 rooms on the second floor needed to be painted.Review of the facility document titled Monthly Environmental rounds, dated 5/28/25, failed to indicate that any over the bed tables need replacement. The document further indicated that four of the six rooms on the first floor that needed to be painted were completed and none of the12 rooms on the second floor had been painted.Review of the facility document titled Monthly Environmental rounds, dated 6/30/25, failed to indicate that any over the bed tables need replacement. The document further indicated that the same four of the six rooms on the first floor that needed to be painted were completed and none of the12 rooms on the second floor had been painted.Review of the facility document titled Monthly Environmental rounds, dated 7/30/25, failed to indicate that any over the bed tables need replacement. The document further indicated that the same four of the six rooms on the first floor that needed to be painted were completed and none of the12 rooms on the second floor had been painted.The surveyor then asked for any purchase orders for over the bed tables in the past six months and the Administrator produced a document titled Purchase Order #CWR175978, dated 9/10/25 at 11:34 A.M., for 44 over the bed tables. The Administrator said that she could not find any other purchase orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, policy and record review the facility failed to ensure weights were obtained for one Resident (#17) out of a total sample of 25 residents. Specifically, for Resident #17 who was assessed as malnourished, the facility failed to obtain his/her weight on readmission or his/her weekly weight per the physician's orders. Findings include:Review of the facility policy titled Weight Assessment and Intervention, dated March 2022, indicated Residents are weighed upon admission and at intervals established by the interdisciplinary team. Resident #17 was readmitted to the facility in September 2025 with diagnoses that included traumatic subdural hemorrhage with loss of consciousness, dysphagia, cognitive communication deficit. Review of Resident #17's Minimum Data Set (MDS), dated [DATE], indicated a score of 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Review of Resident #17's physician order, dated 9/4/25, indicated weekly weights. Review of Resident #17's weights indicated:-8/13/25 110 lbs (pounds) -8/20/25 148.8 lbs No other weights were obtained. Review of Resident #17's nutritional risk assessment, dated 8/21/25, indicated the Resident was malnourished. Monitor weekly weights. Review of Resident #17's nutritional care plan, dated 8/21/25, indicated Obtain weights at ordered intervals. During an interview on 9/10/25 at 11:45 A.M., the Dietitian said Resident #17 is a very vulnerable resident and there have been issues obtaining weights in general. The Dietitian said when a resident is readmitted to the facility the expectation is that staff obtain the weight within 24 hours. The Dietitian said she would expect that the Resident's order for weekly weights would be completed. The Dietitian said it is important to know the resident's weight because his/her weight that was originally obtained on admission was most likely wrong, and the Resident should have been reweighed but was not. During an interview on 9/10/25 at 12:10 P.M., Nurse #1 said when a new admission or readmission comes in, we weigh the resident immediately and put the weight in the electronic medical record (PCC). Nurse #1 said if a resident is a weekly weight the nurse will tell the Certified Nurse Aide (CNA) assigned and then document the weight into PCC. Nurse #1 said there is not a weight book on this floor, the CNA's obtain the weight and tell the nurse who is on duty, then the nurse documents it in PCC. During an interview on 9/10/25 at12:11 P.M., CNA #2 said the staff weigh residents right when they come back from the hospital and tell the nurse the weight and they will put the weight into the computer. CNA #2 said if a resident is a weekly weight or if a weight is needed the nurse will tell the CNA to get the weight.

Based on observation, interview, and record review, the facility to ensure that services provided met professional standards for one Resident (#69), out of 25 total sampled residents. Specifically, for Resident #69, the facility failed to ensure that his/her air mattress was functioning.Findings include:Review of the manufacturers User Manual for the air mattress system indicated the following: -Power switch is at the right side of the control unit.-Turn ON/OFF the power, the pump will start/stop operation. -A visible indicator (green) tells the pressure has reached a preset or user-defined level. -A visible indicator (yellow or red) warns the pressure is below a preset or user-defined level. Operating Instructions4. Turn on the control unit's power. The indicator of the power switch will come on. The control unit starts to pump air into the mattress. Resident #69 was admitted to the facility in August 2025 with diagnoses including hemiplegia (weakness on one side of the body) and dysphagia (difficulty swallowing).Review of the most recent Minimum Data Set (MDS) assessment, dated 8/27/25, indicated that Resident #69 was unable to conduct a Brief Interview for Mental Status exam and was severely cognitively impaired. Further review of the MDS indicated that Resident #69 is dependent on staff for Activities of Daily Living. The MDS also indicated that the Resident is at risk for developing pressure injuries and had a pressure reducing device for bed.On 9/9/25 at 7:52 A.M., the surveyor observed Resident #69 sleeping in bed. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.On 9/9/25 at 8:40 A.M., the surveyor observed Resident #69 sitting in bed with a staff member was assisting with the breakfast meal. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.On 9/9/25 at 12:11 P.M., the surveyor observed Resident #69 sitting in bed as a staff member was assisting with the lunch meal. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.On 9/10/25 at 8:06 A.M., the surveyor observed Resident #69 sleeping in bed. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.On 9/10/25 at 8:34 A.M., the surveyor observed Resident #69 sitting in bed as a staff member was assisting with the breakfast meal. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.During an observation and interview on 9/10/25 at 11:10 A.M., Certified Nursing Assistant (CNA) #2 and CNA #3, CNA #2 said the air mattress is on and functioning and said she does not touch the air mattress but know it is on because the resident is comfortable. CNA #3 said the air mattress box does not have lights and said the air mattress is working and proceeded to press her hand into the air mattress leaving an indent in the mattress when she removed her hand. The air mattress on the bed remained deflated and not functioning during this time.During an observation and interview on 9/10/25 at 11:32 A.M., Unit Manager #1 checked the air mattress setting and function on Resident #69's bed. He said the air mattress is not getting power and is not functioning. The surveyor and the Unit Manager observed the electrical cord to the air mattress was unplugged and not getting any power. The surveyor pushed the on/off button, and the unit did not have power. Unit Manager #1 said the power cord is too long and needs an extension cord because it keeps coming out of the wall. Review of most recent Norton Assessment (An assessment to determine a resident's risk for skin breakdown), dated 8/22/25, indicated a score of 12, which indicates high risk for skin breakdown.Review of Resident #69's active physician orders indicated: Air Mattress on bed, check inflation (set according to patient preference) and function q (every) shift. Every shift for Prevention. Start Date 8/27/25.During an interview on 9/10/25 at 11:26 P.M., Nurse #1 said she would have expected the staff who provided care to Resident #69 to notice the air mattress was not functioning. Nurse #1 said that Resident #69 did not have any open skin areas but is on hospice and in bed all day and needs an air mattress to prevent skin breakdown.During an interview on 9/10/25 at 11:36 P.M., Unit Manger #1 said Resident #69's air mattress was unplugged and not functioning and said that staff should have noticed the mattress was not functioning. Unit Manager #1 said air mattresses should have a physician's order indicating the appropriate setting, and to check the function of the mattress. She said a non-functioning air mattress places the resident at risk for skin breakdown.During an interview 9/10/25 at 12:44 P.M., The Director of Nurses (DON) said that all residents on an air mattress should have a physician's order followed and said staff must check the function every shift. The DON said that he would expect any staff who enter the room to notice if the air mattress is not functioning. The DON further said that a non-functioning air mattress places the resident at risk for skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for three Residents (#17, #68 and #41), out of a total sample of 25 residents. Specifically, 1. For Resident #17, the facility failed to ensure a physician's order was obtained for the use of his/her helmet indicating to staff when to wear and safety precautions.2. For Resident #68 the facility failed to follow a physician's order for a dressing change to the left shin wound.3. for Resident #41 the facility failed to follow a physician's order for a dressing change to the left heel wound.Findings include:1. Resident #17 was admitted to the facility in August 2025 with diagnoses that included traumatic subdural hemorrhage with loss of consciousness, dysphagia, cognitive communication deficit.
Review of Resident #17's Minimum Data Set (MDS), dated [DATE], indicated a score of 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS also indicated he/she is dependent on staff for activities of daily living.
On 9/9/25 at 8:01 A.M. and throughout survey, the surveyor observed Resident #17 in bed awake at times, being boosted for meals in bed by staff, being provided care in bed and a helmet was observed on his/her nightstand.
Review of Resident #17's physician orders on 9/9/25 at 10:30 A.M., failed to indicate an order for the use of the helmet or any precautions for his/her craniotomy.
Review of Resident #17's nursing admission note, dated 8/7/25, indicated Pt (patient) underwent evacuation of hematoma. Wears helmet at all times.
Review of Resident #17's initial encounter Nurse Practitioner progress note, dated 8/7/25, indicated: Patient has a surgical incision which was evaluated by neurosurgery on July 10 which has not healed sufficiently. Patient needs to wear helmet all the time.
Review of Resident #17's nursing progress note, dated 8/20/25, indicated Many attempts to get out of bed unassisted, non-compliant with safety precautions, bed in low position, call light in reach, helmet on.
Review of Resident #17's Medical Doctors (MD) and medical directors progress note, dated 8/21/25, indicated Patient needs to wear helmet all the time.
Review of Resident #17's Nurse Practitioner progress note, dated 9/3/25, indicated Patient needs to wear helmet all the time. Keep helmet on to protect patient's skull from trauma.
Review of Resident #17's Occupational Therapy progress note, dated 9/8/25, indicated Precautions / Contraindications: helmet OOB (out of bed) Craniotomy precautions.
Review of Resident #17's fall risk assessment, dated 8/20/25, indicated he/she scored a 12 indicating moderate fall risk.
Review of Resident #17's medical record indicated only a behavioral care plan was developed for a one time refusal of helmet use.
Further review of the medical record indicated on his/her behavioral documentation for the helmet use indicated no refusals and only one documented nursing note indicated a refusal from the Resident.
During an interview on 9/10/25 at 7:55 A.M., Certified Nurse Aide (CNA) #1 said they are unsure of when the helmet needs to be on but could ask the nurse, but the Resident does not have it on now. CNA #1 said the Resident needs to be boosted for meals when in bed and gets his/her activities of daily living in bed and that is done without a helmet on. CNA #1 says the Resident does get out of bed at times and is a fall risk.
During an interview on 9/10/25 at 8:05 A.M., Nurse #1 said she has taken care of Resident #17 before and thinks the helmet only needs to be on when he/she is out of bed. Nurse #1 said the admitting nurse should go through the admission paperwork and write orders for the helmet but did not.
During an interview on 9/10/25 at 10:35 A.M., Nurse Practitioner (NP) #1 said Resident #17 is a very vulnerable resident as he/she recently had a craniotomy and does not have his/her skull to protect part of the brain anymore. The NP said his/her helmet should always be on because that was what neurology had recommended. The NP said he/she is at risk for injury as he/she could fall out of bed as they are a fall risk, and any rolling could cause his/her head to go into the side rail and half of his/her head is very soft. The NP said she would expect an order would be in place so staff are aware that he/she has a helmet and when it should be on.
During an interview on 9/10/25 at 10:52 A.M., the Occupational Therapist (OT) said there should be orders in place for Resident #17's helmet use so the whole team is aware of the plan of care for the Resident. The OT said the Resident is at risk for falls.
During an interview on 9/10/25 at 11:56 A.M., the Director of Nurses (DON) said there should have an order in place on admission for the use of the Resident's helmet, so everyone is aware of what the Resident needs. The Resident is a fall risk and has a craniotomy which leaves the brain at risk.
2. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol indicated that the physician will authorize pertinent orders related to wound treatments, including wound cleansing and dressings.
Resident #68 was admitted to the facility in July 2025 with diagnoses including pathological trimalleolar fracture of the left lower leg.
Review of the physician's orders dated September 2025 indicated the following order: Left shin wound in the evening for left shin wound, clean with NS (normal saline) apply border dressing q (every) day.
On 9/9/25 at 8:35 A.M. the surveyor observed Resident #68 with a gauze dressing covering an ABD (abdominal) pad, to the left lower leg dated 9/7/25.
During an interview on 9/09/25 at 1:38 P.M. Nurse #3 and the surveyor observed Resident #68 with a dressing to the left shin dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left shin. Nurse #3 also said that the dressing on the wound was not what the physician ordered.
During an interview on 9/10/25 at 12:25 P.M. the Director of Nursing said that the nurses are supposed to follow the physician's orders for dressing changes.
3. Resident #41 was admitted to the facility in July 2025 with diagnoses including adult failure to thrive, malnutrition and trochanteric fracture of the right femur.
Review of the care plan dated 9/5/25 indicated a focus for the following: I have skin breakdown; non pressure wound of the left heel and unstageable DTI (deep tissue injury, a type of pressure related skin injury) of the right heel.
Review of the physician's orders dated September 2025 indicated the following order: Left heel; cleanse with normal saline, pat dry and apply xeroform followed by an island dressing one time a day.
Review of the Treatment Administration Record (TAR) dated September 2025 indicated that on 9/2/25 the wound area on the left heel was c/d/i (clean, dry and intact). Further review indicated that on 9/3/25 through 9/9/25 the wound area on the left heel was open with a scant amount of drainage.
On 9/9/25 at 7:45 A.M., and 10:13 A.M., the surveyor observed Resident #41 in bed with gauze dressings covering both feet including heels. The surveyor then observed each of the dressings were dated 9/7/25.
During an interview on 9/9/25 at 1:40 P.M. Nurse #3 and the surveyor observed Resident #41 in bed with a dressing to both feet dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left heel. Nurse #3 then said that she wasn't sure why there was a dressing to the right heel as she was just back from vacation.
During an interview on 9/10/25 at 12:25 P.M. the Director of Nursing said that the nurses are supposed to follow the physician's orders for dressing changes, and the dressing should have been changed on 9/8/25.

Based on observation, record review and interview the facility failed to develop a treatment for a pressure area on the right heel for one Resident (#41) out of a total sample of 25 residents.Findings include:Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 2001, indicated that the physician will authorize pertinent orders related to wound treatments, including wound cleansing and dressings. Resident #41 was admitted to the facility in July 2025 with diagnoses including adult failure to thrive, malnutrition and trochanteric fracture of the right femur. Review of the care plan dated 9/5/25 indicated a focus for the following: I have skin breakdown; non pressure wound of the left heel and unstageable DTI (deep tissue injury, a type of pressure related skin injury) of the right heel. Review of the physician's orders dated September 2025 indicated the following order: Left heel; cleanse with normal saline, pat dry and apply xeroform followed by an island dressing one time a day. Further review failed to indicate a treatment for pressure area of the right heel. Review of the Treatment Administration Record (TAR) dated September 2025 indicated that on 9/2/25 the wound area on the left heel was c/d/i (clean, dry and intact). Further review indicated that on 9/3/25 through 9/9/25 the wound area on the left heel was open with a scant amount of drainage. Further review failed to indicate a treatment to the right heel. On 9/9/25 at 7:45 A.M., and 10:13 A.M., the surveyor observed Resident #41 in bed with gauze dressings covering both feet including heels. The surveyor then observed each of the dressings were dated 9/7/25. During an interview on 9/9/25 at 1:40 P.M. Nurse #3 and the surveyor observed Resident #41 in bed with a dressing to both feet dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left heel. Nurse #3 then said that she was told that Resident #41 had a DTI to the right heel but hadn't seen it yet. During an interview on 9/10/25 at 12:25 P.M. the Director of Nursing said that the nurses are supposed to follow the physician's orders for dressing changes, and the dressing should have been changed on 9/8/25. He then said that all pressure areas should have a treatment order and be monitored.

Based on observation, interview and record review, the facility failed to maintain a safe environment for two Residents (#35, and #6) out of a total sample of 25 residents to prevent accidents/incidents. Specifically:1. For Resident #35, the facility failed to provide a lid for hot coffee and supervision during meals resulting in the Resident spilling hot coffee onto his/her chest, potentially putting the resident at risk for burns.2. For Resident #6, the facility failed to provide a lid for hot coffee and supervision during meals, potentially putting the resident at risk for burns.Findings include:1. Resident #35 was admitted to the facility in April 2014 and has diagnoses that include athetoid cerebral palsy (condition affecting movement and posture), osteoarthritis (joint disease-causing pain and stiffness), gastro esophageal reflux disease (heartburn), and hemiplegia and hemiparesis (complete paralysis of one side of the body, hemiparesis refers to weakness on one side, allowing for some movement), and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 6/18/25, indicated Resident #35 had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 which indicated moderately impaired cognition. Review of the MDS indicated that Resident #35 requires setup assistance with meals. Review of Resident #35's Quarterly Evaluation Packet dated 6/18/25, indicated Resident #35's Hot Liquid Risk Score was 2-4 Moderate Risk. Safety Interventions included:-Resident to use a cup with a lid.-Resident to be screened by PT/OT for hot liquid safety.-Staff to assist Resident with all hot liquids. Review of Resident #35's medical record failed to indicate that he/she was screened by PT/OT for hot liquid safety after the 6/18/25 assessment.Review of Resident #35's ADL (Activities of Daily Living) care plan dated 12/30/24, indicated:- I require set-up assistance [i.e., opening packages, cutting meat, arranging plate, etc.] I am supervised with eating and drinking. Date Initiated: 7/15/25.-PT/OT evaluation and treatment as ordered. Date Initiated: 12/26/22.Review of Resident #35's care plans failed to indicate interventions for hot liquid safety were updated after the 6/18/25 assessment.On 9/9/25 at 12:28 P.M., the surveyor observed Resident #35 sitting, tilted back in a wheelchair in the communal dining room during the lunch meal. Resident #35 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. Staff were present in the dining room passing out breakfast trays, hot coffee and beverages. Resident #35's hands were shaking as he/she was observed spilling the hot coffee onto his/her chest and coffee was visible on his/her shirt. The Resident could be heard saying I spilled it on my shirt. It's hot. Nurse #2 observed the coffee spilling on Resident #35 and said, Are you okay? and then proceeded to walk out of the dining room to assist with passing out breakfast trays.Review of Resident #35's diet slip did not indicate the need for lids with coffee.Review of Resident #35's medical record failed to indicate a skin check was completed after Nurse #2 observed the Resident spill coffee on his/her shirt.On 9/10/25 at 8:04 A.M., the surveyor observed Resident #35 sitting, tilted back in a wheelchair in the communal dining room during the breakfast meal. Resident #35 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. Staff were present in the dining room passing out breakfast trays including hot coffee and beverages.During an interview on 9/10/25 at 8:10 A.M., Supervisor #1 said Resident #35 requires supervision with meals due to cerebral palsy and said he/she can pick up finger foods and drinks but needs help. During an interview on 9/10/25 at 11:40 A.M., Unit Manager #1 said he was not aware that Resident #35 had spilled coffee on his/her chest and said he would expect to be notified and said it is an incident that should have been documented on a skin check and reported.During an observation and interview on 9/10/25 at 11:55 A.M., Supervisor #1 said Resident #35 had a Hot Liquid Assessment completed and needs cups with lids and assistance with hot liquids because he/she has trouble with getting foods and fluids to his/her mouth due to physical limitations and said she was not aware that Resident #35 had spilled coffee on his chest yesterday. Supervisor #1 reviewed the medical record and said there is no documentation that a skin assessment was completed and no progress notes indicating that Resident #35 was assessed by the nurse. Supervisor #1 said Resident #35 must have a skin check and interventions in place to ensure he/she is using lids on the hot coffee cups and is getting assistance with drinking coffee to prevent burns. The Supervisor and the surveyor observed Resident #35's chest and his/her skin was clear. Supervisor #1 said she was going to report the concerns and make sure Resident #35's interventions are implemented. During an interview on 9/10/25 at 12:02 A.M., Nurse #2 said she checked Resident #35's chest after he/she finished eating lunch yesterday, but she did not document it and did not tell anyone about the spilled coffee and said she should have told someone and reported it. Nurse #2 said she worked until 11:00 P.M. yesterday and got busy and forgot. On 9/10/25 at 12:16 P.M., the surveyor walked into the dining room and immediately observed Resident #35 sitting, tilted back in a wheelchair in the communal dining room. Resident #35 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. There were no staff present in the dining room during as they were in the hall passing out lunch trays, hot coffee and beverages. Resident #35's hands were shaking as he/she was observed spilling the hot coffee onto his/her chest and coffee was visible on his/her shirt. The Resident could be heard saying I just spilled coffee on myself again. The surveyor had to alert staff in the hall that the Resident spilled hot coffee on his chest.During an interview on 9/10/25 at 12:25 P.M., Unit Manager #1 said the Resident should not be drinking coffee without a lid, and he/she needs to be supervised and should not have been given hot coffee during the lunch meal.At 12:30 P.M., The surveyor used a thermometer to check the temperature of the coffee cup Resident #35 was drinking from and the temperature of the coffee was 130 degrees Fahrenheit; approximately 14 minutes after the Resident spilled the coffee.During an interview on 9/10/25 at 12:36 P.M., the Director of Nurses (DON) said he was not made aware of the incident and said it is concerning for safety and said a skin assessment should have been done immediately yesterday when the nurse witnessed the Resident spill the coffee on his/her chest. The DON said Resident #35's care plan, Kardex and diet slip should have been updated after the hot liquid assessment and said interventions should have been followed to ensure lids were used and safety was maintained. The DON said staff should have been supervising the Resident in the dining room.During an interview on 9/10/25 at 12:45 P.M., the Regional Nurse said interventions related to the hot liquid assessment should have been followed and said Resident #35 should have been supervised while drinking the hot coffee and said it is concerning for burns. During an interview on 9/10/25 at 2:00 P.M., the Food Service Director (FSD) said Residents who require lids on coffee cups would have it written on the diet slip indicating a lid was needed and said he was notified earlier today that Resident #35 needed a lid, so the diet sip was just updated. The FSD showed the surveyor a form titled Dietary Communication -For Long Term Care Menu. The form indicated Resident #35 required adaptive equipment Needs cup with lid for hot liquids all meals dated 9/10/25 signed by licensed Nurse. The FSD said Resident #35 is the only resident who requires Lids on hot coffee and said no other Residents have that listed on the diet slip.2. Resident #6 was admitted to the facility in March 2021 and has diagnoses that include type two diabetes mellitus, lack of coordination and anxiety disorder.Review of the Minimum Data Set (MDS) assessment, dated 8/6/25, indicated Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 which indicated moderate cognitive impairment. Review of MDS indicated that Resident #6 requires setup assistance with meals. Review of Resident #6's Quarterly Evaluation Packet dated 5/2/25 and 8/5/25, indicated Resident #6 's Hot Liquid Risk Score was 01- Low Risk. Safety Interventions included:-Resident to use a cup with a lid.-Resident to be screened by PT/OT for hot liquid safety.-Staff to assist Resident with all hot liquids. Review of Resident #6's risk for burns care plan date Initiated, 5/2/25, indicated, I am at risk for spills and burns from hot liquids r/t (related to):-Resident to be screened by PT/ OT for hot liquids safety.-Resident to use a cup with a lid.-Staff to assist Resident with all hot liquids.Review of Resident #6's ADL (Activities of Daily Living) care plan dated 8/6/25, indicated:- I require set-up assistance [i.e., opening packages, cutting meat, arranging plate, etc.] eating and drinking. Date Initiated: 08/20/2024On 9/9/25 at 8:36 A.M., the surveyor observed Resident #6 in his/her room, sitting up in bed, during the breakfast meal. Resident #6 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. No staff were present in the room, and the curtain was pulled halfway across the bed. The Resident was not visible from the hall.On 9/9/25 at 12:15 P.M., the surveyor observed Resident #6 in his/her room, sitting up in bed, during the lunch meal. Resident #6 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. No staff were present in the room, and the curtain was pulled halfway across the bed. The Resident was not visible from the hall.On 9/10/25 at 8:01 A.M., the surveyor observed Resident #6 in his/her room, sitting up in bed, during the breakfast meal. Resident #6 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. No staff were present in the room, and the curtain was pulled halfway across the bed. The Resident was not visible from the hall.Review of Resident #6's diet slip did not indicate the need for lids with coffee.During an interview on 9/10/25 at 9:07 A.M., Nurse #1 said Resident #6 does not leave the room for meals and said he/she needs assistance with setup and is independent with eating.During an interview on 9/10/25 at 11:16 A.M., the Supervisor said Resident #6 was evaluated for hot liquids and requires assistance with meal set up and said the care plan must be followed. The Supervisor said Resident #6 should have lids with hot coffee and be supervised during meals to prevent spills from hot liquids during meals and said the diet slip should indicate the need for lids.During a follow up interview on 9/10/25 at 11:22 A.M., Unit Manager #1 said he expects staff to follow care plan interventions for supervision with hot liquids with lids and said the plan of care needs to be followed. The Unit Manager said the diet slip should indicate a need for lids on coffee cups as it is an intervention.During an interview on 9/10/25 at 12:44 P.M., the Director of Nurses (DON) said Resident #6's care plan should have been followed, and the diet slip should have been updated after the hot liquid assessment and said interventions should have been followed to ensure lids were used and safety was maintained. The DON said staff should have been supervising the Resident during the meals due to the risk of burns with the coffee.During an interview on 9/10/25 at 2:02 P.M., the Food Service Director (FSD) said Resident #6 does not have lids listed on the diet slip and said there is only one resident who requires Lids on hot coffee in the facility. The FSD said he has not received any documents or requests for Resident #6 to have lids because he saves all communication logs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician reviewed the pharmacy monthly medication review within 30 days for one (Resident #32) out of a total of 26 sampled residents. Findings include:Review of the facility's policy titled Medication Regimen Review dated July 2025 indicated:A licensed pharmacist reviews the medication regimen of each resident at least monthly.Time Frame for Reporting:- Within three business days of the MRR (medication regimen review), the consultant pharmacist provides a written report to the attending physician for each resident identified as having a medication irregularity that is deemed not life-threatening.- The consultant pharmacist provides the director of nursing services and medical director with a written, signed, and dated copy of all medication regimen reports., the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them. - Irregularities that do not present a risk to a person's life, health, or safety will be addressed within 30 days of receiving the MMR from the consultant pharmacist. Resident #32 was admitted to the facility in August 2025, and has active diagnoses which include diabetes mellitus, kidney disease and hypertension. Review of Resident #32's Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status score of 8, indicating moderately impaired cognition.Review of Resident #32's physician orders on 9/9/25 indicated:Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 MCG/ACT (Fluticasone Umeclidinium Vilanterol) dated 8/6/25.Acetaminophen Oral Tablet 325 MG (Acetaminophen). Give 2 tablets by mouth every 6 hours as needed for pain dated 8/5/25.Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk). Give 17 grams by mouth every 24 hours as needed for Constipation dated 8/5/25.Review of Resident #32's medical record indicated that on 8/7/25 the consulting pharmacist generated an MMR report for the physician to review new recommendations. The medical record did not include this report.On 9/9/25 at 2:17 P.M., the surveyor requested from the Director of Nursing (DON) Resident #32's MMR report dated 8/7/25. The DON provided the report on 9/10/25.Review of Resident #32's MMR Consultant Pharmacist Recommendations to Nursing, dated 8/7/25 indicated:1. Please add a max daily dose of 3 grams to the Acetaminophen orders from all sources.2. Resident is receiving Trelegy Ellipta Inhaler. Please add rinse mouth after using to order and MAR to avoid thrush formation.3. Recommend updating the current polyethylene glycol (Miralax) order to include the following directions: Mix 17 grams (1 capful) in at least 4 ounces of liquid and take by mouth.Review of Resident #32's MMR Consultant Pharmacist Recommendations to Nursing indicated the physician initialed his/her agreement to the recommendations. The physician's initial was not dated. Review of Resident #32's physician's orders on 9/10/25 indicated the consulting pharmacist's recommendations were updated on this same day, 9/10/25; 35 days after the pharmacist wrote the report.The surveyor reviewed Resident #32's physician orders on 9/10/25 and these included:Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 MCG/ACT (Fluticasone Umeclidinium Vilanterol). Rinse mouth to avoid thrust formation dated 9/10/25Acetaminophen Oral Tablet 325 MG (Acetaminophen). Give 2 tablets by mouth every 6 hours as needed for pain. Maximum daily dose of 3 grams dated 9/10/25.Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk). Give 17 grams by mouth every 24 hours as needed for Constipation. Mix 17 grams (1 capful) in at least 4 ounces of liquid and take by mouth dated 9/10/25.During an interview on 9/10/25 at 12:33 P.M., the DON and Regional Nurse said it is the facility's policy to address irregularities that do not present a risk to a person's life, health, or safety within 30 days of receiving the MMR from the consultant pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review, and interview the facility failed to ensure medications with short expirations dates were dated when opened.
Findings include:
Review of the facility policy titled 'Medication Labeling and Storage' revised February 2023, indicated the following but not limited to:
*Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
*Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.
1. During an inspection of the [NAME] unit on 9/12/24 at 6:35 A.M., the following medications were available for administration:
- Two incruse Ellipta inhalers 62.5 (mcg) microgram inhalation powder opened and undated.
- One Advair 100/50 mcg opened and undated.
- One Advair 250/50 mcg opened and undated.
- One albuterol sulfate 90 mcg opened and undated.
- One Symbicort inhaler 80-4.5mcg opened and undated.
- One fluticasone nasal spray 50 mcg opened and undated.
During an interview on 9/12/24 at 6:45 A.M., Nurse #5 said the inhalers should be dated when opened and indicate a date to discard.
During an interview on 9/12/24 at 9:47 A.M., the Director of Nursing said the inhalers are to be dated with an open date and an expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure that one Resident (#64) was free from significant medication errors out of a total sample of 21 residents. Specifically, the nurses did not administer the wrong dispensed dosage of Trazadone (an antidepressant).
Findings include:
Review of the facility policy titled 'Administering Medications' revised April 2019, indicated the following but not limited to:
-If a dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences the person preparing or administering the medication will contact the prescriber the residents attending physician or the facilities medical director to discuss the concerns.
-The individual administering the medication checks the label three times to verify the right resident right medication right dosage right time right method route of administration before giving the medication.
Resident #64 was admitted to the facility in July 2024 with diagnoses including dementia and psychotic disorder.
Review of Resident #64's Minimum Data Set (MDS) dated [DATE], indicated the Resident had impaired short term and long term memory on the Brief Interview for Mental Status (BIMS).
During a medication observation pass on 9/11/24 at 9:41 A.M., Nurse #4 said to the surveyor the medication card containing Trazadone (an antidepressant) 50 milligram tablet half tablets was not the correct dosage per the physician orders. Nurse #4 said she was going to call the pharmacy for clarification and did not administer the half tablets.
Review of the medication blister pack, the following was observed two missing pills out of 30 tablets that had been dispensed by the pharmacy. The label read as following:
-Trazadone HCl tab 50 milligrams. Give one quarter tablet (12.5mg) by mouth two times a day for anxiety.
Review of the medical record failed to indicate that the physician had been notified of the wrong medication that had been dispensed to the facility.
Review of Resident #64's current Medication Administration Record (MAR) indicated the medication trazadone had been administered the last two days.
During an interview on 9/11/24 at 9:45 A.M., Nurse #4 said the two missing medications from the blister pack would be an indication that the medication had been administered.
During an interview on 9/12/24 at 9:44 A.M., the Director of Nursing (DON) said the pharmacy had acknowledged the medication that had been dispensed to the facility was the wrong dosage. The DON said that the nurses should use their judgment during medication pass to prevent administering wrong dosages.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to: 1. ensure medication administration was accurately documented for two Residents (#33 and #35) and 2. failed to accurately document blood pressure readings for one Resident (#37) out of a total of 21 sampled Residents.
Findings include:
1a. Resident #33 was re-admitted to the facility in September 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency.
Review of the Minimum Data Set Assessment (MDS) 8/26/24 indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance with bathing, dressing and toileting.
Review of the September 2024 Medication Administrative Record (MAR) indicated the following medication were not documented as administered on the 7:00 A.M. - 3:00 P.M. shift on 9/8/24:
Aripiprazole (an antipsychotic medication) Oral Tablet 5 MG: Give one tablet by mouth one time a day, 9/4/24.
Aspirin Oral Tablet Chewable 81 MG: Give one tablet by mouth one time daily, 8/14/24
Fenofibrate Micronized (a medication used to lower cholesterol) Oral Capsule 200 MG: Give one tablet by mouth in one time a day, 9/4/24
Fexofenadine HCL (an antihistamine) 180 MG Tablet: Give one tablet by mouth daily, 8/14/24
Furosemide (a diuretic) Oral Tablet 20 MG: Give two tablets by mouth one time a day, 9/4/24
Duloxetine (an antidepressant) HCL Oral Capsule Delayed Release 60 MG: Give one capsule by mouth two times a day, 9/4/24
Fluticasone-Salmeterol Inhalation (an inhaler) 500-50 MCG/ACT: One puff inhale orally every morning and at bedtime, 9/3/24
Levetiracetam (an anticonvulsant) Oral Tablet 250 MG: Give two tablet by mouth, 9/4/24
Gabapentin (a pain medication) Oral Capsule 100 MG: Give two tablets by mouth three times a day related to pain.
Humalog Kwikpen (insulin) Subcutaneous Solution 100 UNIT/ML: inject per sliding scale with meals, 9/4/24
Metformin (a medication used to treat diabetes) HCL Oral Tablet 500 MG: Give one tablet by mouth with meals, 9/4/24
1b. Resident #35 was admitted to the facility in October 2021 with diagnoses including, dementia, cerebral infarction, and diabetes.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #35 scored three out of a possible 15 indicating severe cognitively impairment. The MDS also indicated Resident #35 is dependent on staff for activities of daily living.
Review of the September 2024 Medication Administrative Record (MAR) indicated the following medication were not documented as administered on the 7:00 A.M. - 3:00 P.M. shift on 9/8/24:
Amlodipine Besylate tablet 10 MG (a medication used to treat hypertension): give one tablet via G-tube, 12/14/22
Aspirin Tablet Chewable: Give 81 mg via G-tube one time a day, 6/14/24
Clopidogrel Bisulfate (a medication used to lower risk of a stroke) tablet 75 MG: give one tablet via G-tube one time a day, 12/14/22
Escitalopram Oxalate Tablet (an antidepressant): Give 20 mg via G-tube one time a day, 8/28/24
Ezetimibe (a medication used to lower cholesterol) 10 MG tablet: Give one tablet via G-tube one time a day; 12/14/22
Pantoprazole Sodium Packet (a medication used to treat acid reflux) 40 MG: Give one packet via G-tube one time a day, 12/14/22
Polyethylene Glycol 3350 Kit (a medication used to treat constipation): Give 17 gram via G-tube one time a day; 12/14/22
Venlafaxine (an antidepressant) HCL Oral Tablet 75 MG Give .5 tablet via G-tube one time a day Carvedilol (a medication used to treat hypertension) Tablet 25 MG: Give one tablet via G-tube every morning and at bedtime; 12/14/22
Ferrous Sulfate (used to treat low iron): Give 325 MG via G-tube two times a day; 10/10/22
Sennosides (a laxative) Tablet 8.6 MG: Give 2 tablets via G-tube two times a day; 12/14/22
Humalog Injection Solution (insulin) 100 unit/ml: Inject six unit subcutaneously with meals, 8/13/24
Novolog Flexpen Subcutaneous Solution (insulin) 100 unit/ml: Inject per sliding scale subcutaneously before meals, 7/18/23
During an interview on 9/11/24 at 1:33 P.M., the Director of Nursing said that blank spaces on the MAR could be the result of the nurse forgetting to document the administration of the medication.
2. Resident #37 was admitted to the facility in September 2023 with a diagnosis of end stage renal disease.
Review of the most recent Minimum Data Set (MDS) assessment, dated 8/14/24, indicated that Resident #37 scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating Resident #37 had moderate cognitive impairment. The MDS further indicated Resident #37 received dialysis treatment.
Review of Resident #37's active physician's orders indicated the following:
- No blood draws, IV, BPs (blood pressure) on left arm (shunt/dialysis access arm), every shift related to end stage renal disease. Date initiated 9/11/23.
Review of Resident #37's blood pressure readings indicated nursing obtained his/her blood pressure using his/her left arm on the following dates: 7/5/24, 7/12/24, 7/13/24, 8/10/24, 8/11/24, 8/16/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24, 8/22/24, 8/26/24, 9/3/24, 9/5/24, 9/6/24, 9/7/24, and 9/8/24.
During an interview on 9/11/24 at 9:25 A.M., Resident #37 said staff never take blood pressure readings from his/her left arm, and that staff only use his/her right arm for blood pressure readings.
During an interview on 9/12/24 at 8:40 A.M., Nurse #2 said Resident #37's left arm should not be used to take his/her blood pressure and it should be documented correctly in the medical record. Nurse #2 said it must have been documented in the left arm in error.
During an interview on 9/12/24 at 10:07 A.M., The Director of Nursing (DON) said his expectation was that nurses accurately document which arm the blood pressure was taken from, and that documentation should reflect exactly what was completed by nursing.

Based on observation, record review and interview, the facility failed to 1. ensure staff initiated and followed Enhanced Barrier Precautions for one Resident (#33) out of a total of 21 sampled residents, and 2. failed to ensure shared medical equipment was properly cleaned between the use of residents during the medication pass.
Findings include:
Review of the Enhanced Barrier Precautions policy, dated August 2022 indicated:
1. Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents.
2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not apply otherwise. Gloves and gown are applied prior to performing high contact resident care activity (as opposed to entering the room).
3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP's include: dressing, transferring, device care or use (central line, urinary catheter, feeding tube, etc); wound care.
6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.
10. Signs are posted including the type of precautions and PPE (personal protective equipment) required.
11. PPE is readily available.
1. Resident #33 was initially admitted to the facility in August 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency.
Review of the Minimum Data Set Assessment (MDS) 8/26/24 indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance toileting and did not have an indwelling catheter.
During routine observations on 9/10/24 and 9/11/24, the surveyor observed signs on various doors on the 2nd floor unit indicating the residents in the room were on EBP. There was no sign on Resident #33's door.
On 9/11/24 at 12:59 P.M., the surveyors observed Resident #33 resting in bed with a catheter bag hanging off the side of the bed. The surveyors observed Nurse #1 prepare and complete dressing changes on Resident #33's arms without donning a gown.
Review of Resident #33's clinical record failed to indicate physicians orders or care plans were initiated for EBP.
During an interview on 9/12/24 at 7:49 A.M., Nurse #2 said that Resident #33 had a catheter and should be on EBP. Nurse #2 said residents on EBP have signs posted on their doors to alert staff. Nurse #2 then joined the surveyor and observed there was no signage or cart of PPE outside of Resident #33's room.
On 9/12/24 at 7:55 A.M. the surveyor observed Certified Nursing Aide (CNA) #1 and CNA #2 reposition Resident #33 in bed without wearing gowns.
During an interview on 9/12/24 at 8:05 A.M., CNA #3 said that Resident #33 has had a catheter since he/she was admitted to the unit (on 9/3/24).
During an interview on 9/12/24 at 9:51 A.M., the Director of Nursing (DON) said that residents with catheters should be on EBP.
2. The facility failed to sanitize shared medical equipment after entering a precaution room.
Review of facility policy titled 'Cleaning and disinfecting of Resident-Care Items and Equipment' revised September 2022 indicated the following but not limited to:
-Reusable items are cleaned and disinfected or sterilized between residents.
During a medication observation pass on 9/11/24 at 9:56 A.M., the surveyor observed Nurse #4 remove a blood pressure cuff from the medication cart and brought it into Resident #64's room. The signage on the doorway indicated that the Resident was on enhanced barrier precaution indicating he/she could have the potential for infections. Nurse #4 was then observed bringing back the blood pressure cuff and placed it back in the medication cart without disinfecting it.
On 9/11/24 at 9:59 A.M., the surveyor observed Nurse #4 bring into Resident #64's room a blood pressure tower, Nurse #4 proceeded to check the Resident's blood pressure, she then brought the blood pressure tower machine and left it in the hallway without disinfecting it.
During an interview on 9/11/24 at 12:43 P.M., Nurse #4 said she should have sanitized the blood pressure equipment after using them in the enhanced barrier precaution room.
During an interview on 9/12/24 at 9:44 A.M., the Director of Nursing said shared medical equipment should be sanitized after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for three Residents (#80, #237, and # 27), in a total sample of 21 residents. Specifically:
1) For Resident #80, the facility failed to ensure the MDS accurately reflected the Resident's discharge destination.
2) For Resident #237, the facility failed to ensure the MDS accurately reflected the Resident's type of intravenous line.
3) For Resident #27, the facility failed to ensure MDS accurately reflected the Resident's Special Treatments.
Findings Include:
Review of the facility policy titled Resident Assessments, revised October 2023, indicated, but was not limited to, the following:
- Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.
1. Resident #80 was admitted to the facility in July 2024 with a diagnosis of cancer.
Review of the Discharge Assessment - Return not Anticipated Minimum Data Set (MDS), dated [DATE], indicated that Resident #80 scored an 11 out of a possible 15 on a Brief Interview for Mental Status (BIMS), indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated that Resident #80 was being discharged to a short-term general hospital.
Review of the Care Navigation-Week in Advance Reporting progress note, authored by Social Worker (SW) #1, indicated Resident #80 was discharging from the facility to his/her son's home.
During an interview on 9/11/24 at 11:23 A.M., SW #1 said Resident #80 discharged home with family.
During an interview on 9/11/24 at 12:19 P.M., Consulting MDS staff #1 said that Resident #80 was discharged home and that the discharge MDS was not completed accurately.
During an interview on 9/11/24 at 12:22 P.M., the Director of Nursing (DON) said that Resident #80 discharged home and that he would expect the MDS to be completed accurately. 2. Resident #237 was admitted to the facility in August 2024 with diagnoses including acute gastric ulcer with perforations, dependent on parenteral nutrition.
Review of Minimum Data Set (MDS), dated [DATE], indicated that Resident #237 had a midline intravenous line.
On 9/10/24 at 8:51 A.M., the surveyor observed Resident #237 lying in his/her bed with a dual lumen PICC line to his/her right upper arm.
Review of the medical record indicated the Resident had a (PICC) peripheral inserted central catheter to his/her right upper arm.
During an interview on 9/12/24 at 9:44 A.M., the Director of Nursing said the Resident had a PICC and that should be accurately documented in the MDS.
3. Resident #27 was admitted to the facility in April 2024 with diagnoses including acute respiratory failure with hypoxia (low levels of oxygen in body tissues), chronic obstructive pulmonary disease (COPD) (disease that restricts breathing), anxiety, and congestive heart failure (CHF) (heart does not pump blood as well as it should).
Review of the most recent Minimum Data Set (MDS) assessment, dated 7/24/24, indicated that Resident #27 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS indicated Resident #27 did not require oxygen therapy.
On 9/10/24 at 8:44 A.M., the surveyor observed Resident #27 in his/her bed, his/her oxygen was being administered at three liters per minute via nasal cannula (a device that delivers extra oxygen through a tube and into your nose). Resident #27 said he/she always uses oxygen.
On 9/11/24 at 7:06 A.M., the surveyor observed Resident #27 in his/her bed, his/her oxygen was being administered at four liters per minute via nasal cannula.
Review of Resident #27's active physician's order indicated the following order:
-Oxygen at four liters per minute via nasal cannula every shift initiated 5/9/24.
Review of Resident #27's plan of care related to oxygen therapy, dated 4/9/24, indicated the Resident required supplemental oxygen related to chronic obstructive pulmonary disease, respiratory failure, pneumonia.
Review of Resident #27's nursing progress note, dated 7/19/24, indicated the Resident received oxygen via nasal cannula.
Review of Resident #27 Medication Administration Record (MAR), dated July 2024, indicated oxygen at four liters per minute was administered via nasal cannula.
During an interview on 9/11/24 at 8:20 A.M., Unit Manager (UM) #2 said Resident #27 uses oxygen therapy.
During an interview on 9/11/24 at 12:23 P.M., Director of Nurses (DON) said he would expect the MDS to be documented accurately.
During an interview on 9/11/24 at 12:48 P.M., the MDS nurse said Resident 27's MDS should be coded as using oxygen therapy, but it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement the plan of care related to assistance with meals for one Resident, (#36), out of a total sample of 21 residents.
Findings include:
Review of the facility's Care Plans, Comprehensive Person Centered policy, dated March 2022 indicated:
Policy statement: 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.
7. The comprehensive, person centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being.
Resident #36 was admitted to the facility in June of 2022 with diagnoses including dementia and weakness.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #36 scored 5 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impairment. The MDS also indicated Resident #36 required supervision/touching assistance with eating.
On 9/10/24 at 7:58 A.M., the surveyor observed Resident #36 eating breakfast alone in his/her room. The Resident was served a waffle that was not cut and he/she was attempting to open a container of maple syrup with his/her hands. At 8:21 A.M., Resident #36 was eating with his/her hands and also still attempting to open the container of maple syrup. There were no staff in the area providing supervision and Resident #36 was not observable from the hallway.
Review of Resident #33's care plans indicated:
Focus: I have an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Dementia, Impaired Mobility, Pain, Date Initiated: 06/30/2024
Interventions: Eating: I require set-up assistance [i.e., opening packages, cutting meat, arranging plate, etc] supervision with eating and drinking. Offer bedtime snack.
On 9/11/24 at 7:59 A.M. and 8:10 A.M., the surveyor observed Resident #36 in bed, eating alone in his/her room. There were no staff providing supervision as indicated in his/her plan of care and Resident #36 was not observable from the hallway.
During an interview on 9/11/24 11:44 A.M., Certified Nursing Aide (CNA) #1 said she was assigned to care for Resident #36. CNA #1 said that Resident #36 often eats in his/her room as he/she refuses to get out of bed. CNA #1 said that Resident #36 was independent with eating after his/her tray is set up. CNA #1 said that Resident #36 did not need to be supervised or physically assisted during meals.
On 9/12/24 at 8:10 A.M., the surveyor observed Resident #12 eating his/her breakfast meal alone without staff supervision per the plan of care. Resident #36 was not observable from the hallway.
Review of the CNA documentation from 8/1/24 through 9/10/24 indicated that Resident #36 received supervision or physical assistance with 41 out of 121 documented meals.
During an interview on 9/12/24 at 9:51 A.M., the Director of Nursing (DON) said that care plans should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to meet professional standards of quality for four Residents (#49, #15, #42 and #17), out of a total sample of 21 residents.
Specifically:
1) For Resident #49 the facility failed to follow physician orders for weekly skin checks.
2) For Resident #15 the facility failed to complete skin checks as ordered.
3) For Resident #42 the facility failed to implement air mattress setting as indicated in the physician order.
4) For Resident #17 the facility failed to to obtain weekly weights according to physician's order.
Findings Include:
Review of the facility policy, titled Assessment of Skin Condition and Integrity, adopted March 2021, indicated, but was not limited to, the following:
Skin Assessment:
1) Conduct a comprehensive head-to-toe skin assessment upon admission, weekly, prior to discharge and as needed.
a.) During the skin assessment, inspect for:
i. Presence of skin impairment(s);
ii. Type of skin impairment(s); and
iii. Location of skin impairment(s);
2) Inspect the skin daily when performing or assisting with personal care or ADL's (activities of daily living).
Documentation:
1. The type of skin assessment(s) conducted.
2. The date and time and type of skin care provided, if appropriate.
3. The name and title of the individual who conducted the assessment.
4. The condition of the resident's skin.
5. Any new change(s) in the resident's skin condition, if identified.
a. If a new skin alteration is noted, initiate a weekly wound progress report.
b. Reassess the alteration weekly until the area is healed or the resident is discharged .
6. Develop, review and/or update the resident-centered care plan and interventions, as needed.
7. If the resident refused the skin assessment, document the reason for refusal and the resident's response to the explanation of the risks for refusing the procedure, the benefits of accepting and available alternatives.
1. Resident #49 was admitted to the facility in June 2024 with a diagnosis of diabetes.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #49 scored a 9 out of a possible 15 on a Brief Interview for Mental Status (BIMS), indicating the Resident had moderate cognitive impairment.
Review of Resident #49's Follow-Up Wound Clinic Note, dated 2/13/24, indicated the Resident was seen by an outpatient wound clinic on 2/13/24 and that the Resident had a chronic diabetic ulcer on his/her right foot.
Review of a Nurse Practitioner Progress Note, dated 8/27/24, indicated Resident #49 had an ulcer on his/her right foot.
Review of Resident #49's active physician orders indicated the following order:
- Skin Checks weekly on Friday 7-3 (shift), initiated 7/12/24.
Review of Resident #49's care plans indicated the Resident had skin breakdown and/or potential for skin breakdown r/t (related to) neck collar, and decreased functional status with the following intervention: Document skin checks weekly and PRN (as needed), initiated 7/3/24.
Review of Resident #49's medical record failed to indicate that a skin check was completed on 8/30/24 or 9/6/24 as ordered; indicating a skin check had not been completed in over two weeks.
Review of Resident #49's medical record failed to indicate the Resident had refused skin checks.
During an interview on 9/12/24 at 8:46 A.M., Nurse #4 said skin checks were done weekly and documented in the evaluation section of the electronic medical record.
During an interview on 9/12/24 at 9:05 A.M., Unit Manager #2 said skin checks were done weekly and documented in the evaluation section of the electronic medical record.
During an interview and observation on 9/12/24 at 9:07 A.M., Resident #49 said he/she had a chronic wound on his/her right foot. Unit Manager #2 and the surveyor observed Resident #49's right foot wound.
During an interview on 9/12/24 at 12:32 P.M., Nurse Practitioner #1 said she would expect nurses to follow physician orders.
During an interview on 9/12/24 at 1:59 P.M., the Director of Nursing (DON) said nurses complete skin checks weekly, and that if a resident refuses a skin check that this would be documented.
During a follow-up interview on 9/12/24 at 2:44 P.M., the DON said that he would expect nurses to complete and document a full skin evaluation when completing the physician-ordered weekly skin check.
2. Resident #15 was admitted to the facility in December 2020 with diagnoses including Dementia and Parkinson's disease.
Review of Resident #15's Minimum Data Set (MDS) assessment, dated 6/19/24, indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status indicating he/she was severely cognitively impaired. The MDS further indicated the Resident is dependent of staff for activities of daily living.
Review of the current physician orders indicated the following:
-Skin checks weekly on Thursday 3-11 every evening shift. Every Thursday for monitoring.
Review of the clinical record indicated a skin assessment evaluation had not been completed since 8/8/24.
During an interview on 9/11/24 at 12:25 P.M., Nurse #3 said a weekly skin assessment should be completed as ordered, the nurses document in the treatment administration record and also complete a skin evaluation assessment.
During an interview on 9/12/24 at 8:37 A.M., Unit Manager #2 said weekly skin checks should be completed as ordered and if refusal the nurse would document in the nurse progress notes.
During an interview on 9/12/24 at 9:49 A.M., the Director of Nursing said weekly skin checks should be completed weekly and a skin evaluation assessment completed
3. Resident #42 was admitted to the facility in July 2023 with diagnosis including unspecified abnormalities of gait and mobility.
Review of Resident #42 Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status indicating he/she was cognitively intact.
Review of Resident #42's current physician order indicated the following:
-Air mattress on bed check function and placement set according to weight every shift.
Review of Resident #42's active Activity of daily living (ADL) care plan indicated an intervention dated 10/16/23 'Resident requires air mattress on bed check inflation set according to weight'.
On 9/10/24 at 8:55 A.M., the surveyor observed Resident #42 lying in his/her bed the air mattress was set to 350 lbs (pounds).
On 9/10/24 at 4:02 P.M., the surveyor observed Resident #42 lying in his/her bed the air mattress was set at 350 lbs.
On 9/11/24 at 7:00 A.M., the surveyor observed Resident #42 lying in his/her bed the air mattress was set at 350 lbs.
Review of Resident #42's most recent weight dated 8/5/24 indicated the following:
-140.4 lbs.
During an interview and an observation on 9/11/24 at 9:26 A.M., the surveyor and Nurse #3 observed Resident #42 lying in bed. His/her air mattress was set at 350 lbs. Nurse #3 said the mattress should be set according to the resident's weight.
During an interview on 9/12/24 at 8:38 A.M., Unit Manager #2 said the air mattress setting is based on the resident's weight. She said Resident #42 prefers a firm surface and the orders should reflect that.
During an interview on 9/12/24 at 9:08 A.M., the Director of Nursing said the air mattress should be set per resident's weight. The physician order should be followed as ordered.
4. Review of the facility policy titled Weight Assessment and Intervention dated March 2022, indicated 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 and/or as ordered by the physician.
-Weights are recorded in each unit's weight record chart and in the individual's medical record.
Resident #17 was admitted to the facility in July 2024 with diagnoses including epilepsy, dysphagia, gastrostomy status, and malnutrition.
Review of the most recent Minimum Data Set (MDS) assessment, dated 7/24/24, indicated that Resident #17 was rarely/never understood and a staff assessment for Brief Interview for Mental Status (BIMS) indicated severe cognitive impairment. This MDS indicated Resident #17 was dependent on a feeding tube to administer his/her nutrition and hydration related to difficulty swallowing and malnutrition. Review of this MDS also indicated Resident #17 had unplanned weight loss.
On 9/10/24 at 8:30 A.M., the surveyor observed Resident #17 in his/her room receiving enteral feeding (nutrition delivered through a feeding tube) via electronic pump.
Review of Resident #17's active physician's order indicated the following orders:
-NPO (nothing by mouth) initiated 7/19/24.
-Enteral feed order in the evening down at 10 am Enteral: Jevity 1.5 Cal liquid (a nutritionally fortified formula) via feeding tube every shift, feeding pump set at 95 ml/hour for 16 hours, total volume 1520 ml initiated 7/19/24.
-Free water flushes of 150 ml every four hours initiated 7/19/24.
Review of Resident #17's active physician's orders indicated the following order:
-Weights weekly every Thursday, initiated 7/18/24.
Review of Resident #17's plan of care related to nutrition, dated 7/18/24, indicated the Resident required enteral tube feeding related to malnutrition and dysphagia with the following interventions:
-Weights at ordered intervals.
-Obtain and monitor lab/diagnostic work as ordered.
-Dietitian to evaluate nutritional status and make recommendations as applicable PRN (as needed).
Review of Resident #17's August and September 2024 Medication Administration Record (MAR) indicated weekly weights one time a day every Thursday with the following recorded:
8/2/24- left blank.
8/8/24- left blank.
8/15/24- refused. There was no further documentation that Resident #17 refused to be weighed.
8/22/24- left blank.
8/29/24- left blank.
9/5/24- left blank.
Review of Resident #17's nursing progress notes, dated 8/2, 8/8, 8/22, 8/29 and 9/5 failed to indicate Resident #17 had refused to be weighed or that the physician had been notified that the Resident had not been weighed.
Review of Resident #17's nursing progress note, dated August 15, 2024, indicated patient was off floor and outside with family, unable to obtain weight, physician aware.
Review of Resident #17's weight summary, indicated recorded weights:
7/18/24- 106.4 pounds.
8/19/24- 107.0 pounds.
9/12/24- 105.8 pounds.
Review of Resident #17's nutritional risk assessment, dated 7/25/24, indicated the Resident's estimated ideal body weight (IBW) was 130 pounds and that the most recent recorded weight dated 7/18/24 was 106.4 pounds. Further review of the nutritional risk assessment indicated that the dietitian had recommended to continue with the current nutritional regimen and to monitor weights weekly.
Review of Resident #17's nutrition note, dated 9/10/24, indicated that the Resident continued weekly weight checks, dietitian will continue to monitor and reassess as needed.
During an interview on 9/11/24 at 12:25 P.M., Unit Manager #2 said all residents were discussed during weekly rounds with the clinical team and that the physician reviews all residents. Unit Manager #2 was not aware that Resident #17 did not have a weight recorded since 8/19/24.
During an interview on 9/12/24 at 1:22 P.M., the dietitian said the clinical team meet weekly to discuss weights. Her expectation is for the physician order to be followed. The dietitian said up to date weights are needed to calculate appropriate caloric needs and enteral orders.
During an interview on 9/12/24 at 12:33 P.M., Nurse Practitioner #1 said she would expect a resident receiving enteral nutrition to be weighed at least weekly and that it was important for weights to be obtained correctly so that orders for jevity can be determined.
During an interview on 9/12/24 at 1:04 P.M., the Director of Nursing (DON) said he would expect physician orders to be followed. The DON said if a weight was not obtained that a note should have been written and it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and interview, the facility failed to provide necessary treatment and care for one Resident (#33) out of a total of 21 sampled residents. Specifically, the facility failed to ensure treatment orders were initiated for Resident #33's skin tears.
Findings include:
Review of the Wound Treatment policy, dated April 2024, indicated: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure.
Resident #33 was re-admitted to the facility in September 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency.
Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance with bathing and dressing.
During an interview on 9/10/24 at 8:57 A.M., the surveyor observed Resident #33 in bed. Resident #33's right arm was resting on his/her lap and had a dressing dated 9/7/24 on the forearm. Resident #33 said he/she could not recall what happened to his/her arm or why he/she had a dressing. The surveyor was unable to observe Resident #33's left arm.
Review of the physicians orders on 9/10/24 at 11:30 A.M., failed to indicate any active treatment orders were in place for Resident #33.
Review of Resident #33's care plans failed to indicate he/she had any wounds requiring treatment.
Review of the Weekly Skin Check dated 9/3/24 indicated Resident #93 had open areas on both his/her arms. The skin check did not indicate measurements or descriptions of the wounds
Review of the hospital discharge paperwork dated 9/3/24 indicated Resident #33 had skin tears on his/her right and left forearm requiring dressings.
Review of the hospice note dated 9/4/24 indicated the following: Some bruising noted to upper extremities, bandages to both arms perhaps from IV placements. Pt (patient) declines further assessment of the skin.
Review of the Nurse Practitioner Note dated 9/5/24: Skin: No rash, warm and dry; left forearm dressing clean dry and intact.
On 9/11/24 at 7:31 A.M., the surveyor observed Resident #33 asleep in bed with a bandage on his/her right arm dated 9/10/24. The surveyor was unable to observe Resident #33's left arm.
During an interview on 9/11/24 at 7:43 A.M., Unit Manager #1 said that Resident #33 was admitted with wounds from the hospital that needed daily dressings. Unit Manager #1 said orders for treatment were not in place until yesterday, (9/10/24).
Review of Resident #33's physicians orders on 9/11/24 at 7:44 A.M., indicated:
-Wound Description for Site: RIGHT ARM: Normal Saline Wash, Pat dry and apply Xeroform followed by an Island dressing. Ordered 9/10/24
-Wound Description for Site: LEFT ARM; Normal Saline Wash, Pat dry and apply Xeroform followed by an Island dressing. Ordered 9/10/24
Further review of Resident #33's physicians orders indicated that the treatments for the Resident's wounds were implemented seven days after they were first identified by the facility.
On 9/11/24 at 12:59 P.M. the surveyors observed Resident #33's dressing changes. Nurse #1 removed the dressings and the surveyors observed Resident #33 had skin tears on his/her bilateral forearms with some drainage and swelling.
During an interview on 9/11/24 at 1:33 P.M., the Director of Nursing said that when residents are admitted from the hospital with wounds it is expected that orders to treat the wounds would implemented.

Based on observation, record review and interview, the facility failed to ensure physicians orders and care plans related to the use of a catheter were implemented for one Resident (#33) out of a total of 21 sampled residents.
Findings include:
Review of the Urinary Incontinence - Clinical Protocol policy dated April 2018 indicated:
Assessment and Recognition: As part of the initial assessment, the physician will help identify individuals with impaired urinary continence. For example, review of a hospital discharge summary may reveal that the individual was incontinent with or without catheter placement during a recent hospitalization.
Resident #33 was initially admitted to the facility in August 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency.
Review of the Minimum Data Set Assessment (MDS) 8/26/24 indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance toileting and did not have an indwelling catheter.
Review of Resident #33's physicians orders failed to indicate any orders in place regarding the use or care of a catheter.
Review of Resident #33's care plans indicated:
Focus: I have urinary incontinence r/t (related to) physical limitations. 8/13/24
Interventions: Provide incontinence care and apply moisture barrier as needed. Observe buttocks, peri-area and groin during care for possible skin problems. Offer/encourage toileting prior to bedtime. Check resident approximately every two hours and provide incontinence care as needed.
Focus: I have an ADL (activities of daily living) self care performance deficit r/t deconditioned s/p hospitalization, impaired mobility, weakness. Interventions: Toileting: I require one staff assist with toileting.
On 9/11/24 at 12:59 P.M., the surveyors observed Resident #33 resting in bed with a catheter bag hanging off the side of the bed.
On 9/12/24 at approximately 7:45 A.M., the surveyor observed Resident #33 in bed with a catheter bag hanging off the side of the bed.
During an interview on 9/12/24 at 7:49 A.M., Nurse #2 said that Resident #33 had a catheter.
During an interview on 9/12/24 at 8:00 A.M., Unit Manager #1 said that Resident #33 had previously resided on a different unit then was hospitalized . Unit Manager #1 said that he believed the catheter was implemented during Resident #33's hospitalization.
During an interview on 9/12/24 at 8:05 A.M., Certified Nursing Aide (CNA) #3 said that Resident #33 has had a catheter since he/she was admitted to the unit (9/3/24).
During an interview on 9/12/24 at 9:51 A.M., the Director of Nursing (DON) said that residents should have physicians orders and care plans in place for catheter care, management and monitoring.
During an interview on 9/12/24 at 12:20 P.M., the Nurse Practitioner said that nurses have to put in orders for catheters and she was not aware that Resident #33 had no orders related to his/her catheter use or care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and interviews, the facility failed to provide care and maintenance of a peripheral inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#237), out of a total sample of 21 residents. Specifically, the facility failed to implement dressing changes routinely as required.
Findings include:
Review of the facility policy titled 'Central Venous Catheter Care and Dressing Changes' dated March 2022, indicated the following but not limited to:
-Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g, damp, loosened or visibly soiled).
-Maintain sterile dressing ( transparent semi-permeable membrane (TSM) dressing or sterile gauze for all central vascular access devices. The type of dressing is based on the condition of then resident and his or her preference.
-Change the dressing if it becomes damp loosened or visibly soiled and:
a. Every seven days for TSM dressing
-measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion.
Resident #237 was admitted to the facility in August 2024 with diagnoses including dependent on parenteral nutrition.
Review of Resident #237 Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 12 out of 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 intravenous access line.
On 9/10/24 at 8:50 A.M., the surveyor observed Resident #237 lying in his/her bed with a PICC line to his/her right upper arm. The dressing on the insertion site was transparent and dated 8/25.
Review of the physician orders dated 8/29/24 indicated the following:
-IV (midline, PICC, CVAD) change transparent dressing on admission and then every 7 days. Caps to be changed during dressing change. Every day shift every 7 days.
Review of Resident #237's medication administration record (MAR), dated 8/30/24, indicated nursing implemented the PICC dressing change as ordered.
During an interview on 9/11/24 at 12:29 P.M., Nurse #3 said PICC line dressing changes are done upon admission and then weekly.
During an interview on 9/11/24 at 12:35 P.M., Unit Manager #2 said dressing changes should be done weekly. When asked if the date on the dressing should have been different from 8/25/24 she said yes.
During an interview on 9/11/24 at 12:40 P.M., the Director of Nursing said PICC line dressing should be changed upon admission and every 7 days.

Based on record review, policy review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for one Resident (#7) who had a history of trauma out of a total sample of 21 residents. Specifically, for Resident #7, the facility failed to develop a comprehensive trauma care plan, with individualized triggers.
Findings include:
Review of the facility policy titled Trauma Informed and Culturally Competent Care, dated 8/2022, indicated the following:
Purpose:
-To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice.
-To address the needs of trauma survivors by minimizing triggers and/or re-traumatization.
Definitions:
- Trigger is a psychological stimulus and prompts recall of a previous traumatic event, even if the stimuli itself is not traumatic or frightening.
Resident Care Planning:
-Develop and individualized care plan that addresses past trauma in collaboration with the resident and family, as appropriate.
-Identify and decrease exposure to triggers that may re-traumatize the resident.
-Recognize the relationship between past trauma and current health concerns (e.g. substance abuse, eating disorders, anxiety, and depression).
Resident #7 was admitted to the facility in March 2019, with diagnoses including traumatic Post-Traumatic Stress Disorder (PTSD), major depressive disorder and anxiety.
Review of Resident #7's most recent Minimum Data Set (MDS) assessment, dated 6/19/24, indicated that Resident #7 had a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15 indicating he/she is cognitively intact. Further review of the MDS indicated Resident #7 has an active diagnosis of PTSD and requires partial/moderate to dependent assistance for daily activities.
Review of the care plan on 9/11/24 at 2:02 P.M., last revised 3/31/20, indicated Resident #7 has a diagnosis of PTSD. Further review indicated interventions including the following:
-Accept my current level of function, be consistent, positive, honest and nonjudgmental while working with me.
-After every outburst, discuss with me how my anger escalates.
-Allow me to use displacement when angry by providing things that I can manipulate or destroy (example: clay).
-Encourage me to accept forgiveness from myself and others.
-Encourage me to express my anger verbally rather than physically.
-Help me to regain control and identify sources of emotions so that I may manage outbursts.
-Offer me medications for prevention or treatment of post-traumatic stress disorder as needed; Evaluate responses to these medications.
-Provide me a safe comfortable space when I am overwhelmed or stressed.
-Remind me that setbacks on the process of treatment are not failures but an expected part of therapy.
-When Stress/Anxiety arises allow me to vent/share feelings.
Review of Resident #7's care plan failed to indicate the development of a comprehensive trauma informed care plan with identified triggers and interventions for his/her diagnosis of PTSD.
During an interview on 9/12/24 at 8:45 A.M., Unit Manager #1 said if a resident is identified with a PTSD diagnosis, there should be a care plan developed with specific triggers for staff to better care for the resident.
During an interview on 9/12/24 at 9:34 A.M., Social Worker #1 said residents with PTSD should be formally assessed and a care plan developed with his/her strengths and weaknesses as well as identified triggers.
During an interview on 9/12/24 at 9:55 A.M., the Director of Nursing said if PTSD is identified following a trauma informed assessment, a patient centered care plan will be developed with triggers identified.

Based on records reviewed and interviews for one for three sampled residents (Resident #1), whose Physician's Orders included the administration of an injectable medication used to treat schizophrenia, the Facility failed to ensure the Physician was promptly notified when Resident #1's medication was not administered as ordered.
Findings Include:
The Facility Policy titled Change in a Resident's Condition or Status, undated, indicated that the nurse will notify the resident's attending Physician when there has been a need to alter the resident's medical treatment significantly. The Policy indicated that regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.
Resident #1 was admitted to the Facility in July 2015, diagnoses included major depressive disorder, adult failure to thrive, auditory hallucinations, anxiety, and paranoid schizophrenia.
Review of Resident #1's Physician's Orders, dated 10/05/23, indicated he/she was to be administered Invega Sustenna (anti-psychotic) intramuscular suspension 156 milligrams/milliliter (mg/ml), inject 156 mg intramuscularly one time a day (every twenty-eight days) for schizophrenia.
Review of the Drugs.com article related to Invega Sustenna injections, dated August 2023, indicated the following: The medication is an extended release (long acting) medication given by intramuscular injection and used to treat schizophrenia. The article indicated when starting the medication one dose is administered, the second dose a week later, and there after, only one dose each month is required. The article indicated that it was important to stay on schedule for Invega treatments and indicated that if a dosage is missed, to contact the Physician to reschedule as soon as possible.
Resident #1's Medication Administration Record (MAR), for December 2023, indicated that on 12/02/23 he/she was due for his/her Invega injection at 9:00 A.M. however his/her MAR was coded, by Nurse #3, as medication not administered.
Resident #1's MAR, for January 2024, indicated that, on 01/27/24, he/she was due for his/her Invega injection at 9:00 A.M. however the MAR was not signed off by nursing to indicate his/her Invega had been administered and was left blank.
Review of the Quality Assurance Report, dated 01/27/24, indicated that there was a medication incident involving a missed dose of Resident #1's Invega injection. The Report indicated that the medication had been inadvertently not administered to Resident #1 by Nurse #1 and indicated that his/her Physician had not been notified that his/her Invega had not been administered on 01/27/24 until 02/22/24.
The Surveyor was unable to interview Nurse #3 as he did not respond to the Department of Public Health's telephone calls or letter request for an interview.
During an interview on 03/12/24 at 1:29 P.M., Nurse #1 said that, on 01/27/24, she did not administer Resident #1's Invega to him/her and said she did not call and notify his/her Physician that the medication had not been administered as ordered.
During an interview on 03/20/24 at 1:26 P.M., Resident #1's Physician said that he had not been notified by nursing on the days that Resident #1's Invega injections were due but had not been administered. The Physician said nursing should have notified him at the time the medication was not given as ordered.
During an interview on 03/12/24 at 3:10 P.M., the Director of Nursing (DON) said that if nursing did not administered Resident #1's Invega as ordered by his/her Physician, they should have called the Physician to notify him that the medication was not administered when it was due.
On 03/12/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by:
A) 02/26/24, DON completed initial audits for all residents with anti-psychotic medication orders to ensure physicians were notified if the medications were not administered as ordered.
B) 03/04/24, Assistant Director of Nursing educated nursing staff regarding administering medications as ordered and notifying the Physician if the medication was not administered.
C) DON will continue follow-up audits daily for two weeks, and then monthly, to ensure Physician's were notified if anti-psychotics were not administered as ordered.
D) DON will present Plan of Correction updates and audit results at Quality Assurance Performance Improvement Meeting for one month.
E) DON and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for administration of an anti-psychotic medication once every twenty-eight days, the Facility failed to ensure he/she was free from a significant medication error when he/she was not administered two doses of his/her anti-psychotic medication, placing him/her at risk for an adverse reaction related to a sudden stop in the medication.
Findings Include:
The Facility Policy titled Administering Medications, dated as revised April 2019, indicated that medications are administered in a safe and timely manner and in accordance with prescriber orders, including any required time frame.
Review of the Drugs.com article related to Invega Sustenna injections, dated August 2023, indicated the following: The medication is an extended release (long acting) medication given by intramuscular injection and used to treat schizophrenia. The article indicated when starting the medication one dose is administered, the second dose a week later, and there after, only one dose each month is required. The article indicated that it was important to stay on schedule for Invega treatments and indicated that if a dosage is missed, to contact the Physician to reschedule as soon as possible. Suddenly stopping Invega is not recommended (except if medically necessary) as it can result in the re-emergence of symptoms such a tardive dyskinesia (repetitive, involuntary movements such as grimacing or eye blinking) a condition that could become permanent.
Resident #1 was admitted to the Facility in July 2015, diagnoses included major depressive disorder, adult failure to thrive, auditory hallucinations, anxiety, and paranoid schizophrenia.
Review of Resident #1's Physician's Orders, dated 10/05/23, indicated he/she was to be administered Invega Sustenna intramuscular suspension (anti-psychotic), 156 milligrams/milliliter (mg/ml), inject 156 mg intramuscularly one time a day (every twenty-eight days) for schizophrenia.
Review of Resident #1's Medication Administration Record (MAR), for December 2023, indicated that his/her Invega injection was due for administration at 9:00 A.M. on 12/02/23. The MAR indicated that on 12/02/23, Resident #1's Invega was signed by Nurse #3 and coded as not administered.
Review of Resident #1's MAR, for January 2024, indicated that his/her Invega injection was due for administration on 01/27/24 at 9:00 A.M. The MAR indicated that on 01/27/24, Resident #1's Invega was not signed as administered by nursing and was left blank.
Review of Resident #1's Medical Record indicated there was no documentation to support why his/her Invega had not been administered on 12/02/23 or not signed as administered on 01/27/24. There was no documentation to support that his/her Physician's Order for Invega had changed or that the medication was to be held and not administered on either 12/02/23 or 01/27/24.
Review of the Quality Assurance Report, dated 01/27/24, indicated that there was a medication incident involving a missed dose of Resident #1's Invega injection. The Report indicated that the medication had been inadvertently not administered by Nurse #1.
The Surveyor was unable to interview Nurse #3 as he did not respond to the Department of Public Health's telephone calls or letter request for an interview.
During an interview on 03/12/24 at 1:29 P.M., Nurse #1 said that, on 01/27/24, Resident #1 she did not administer Resident #1's Invega injection to him/her because the Facility did not have the medication.
During an interview on 03/12/24 at 3:10 P.M., the Director of Nursing (DON) said on 12/02/23 Resident #1's MAR was coded that his/her Invega had not been administered and said his/her Invega was also not administered on 01/27/24. The DON said Resident #1 should have been administered his/her Invega according to his/her Physician's Orders.
On 03/12/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by:
A) 02/26/24, DON completed initial audits for all residents with anti-psychotic medication orders to ensure the medications were administered as ordered.
B) 03/04/24, Assistant Director of Nursing educated nursing staff administering medications as ordered and procedure if a medication is not available.
C) DON will continue follow-up audits daily for two weeks, and monthly for one month, to ensure anti-psychotic medications were administered as ordered.
D) DON will present Plan of Correction updates and audit results at Quality Assurance Performance Improvement Meeting for one month.
E) DON and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews for one of two sampled residents (Resident #1), the Facility failed to ensure they maintained complete and accurate Medical Records when Resident #1's Medication Administration Record (MAR) was not consistently completed during the month of December 2023.
Findings Include:
The Facility Policy titled Charting and Documentation, dated as revised 07/2017, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The Policy indicated that medications administered and treatments or services performed were to be documented in the resident medical record. The Policy indicated documentation of procedures and treatments would include care specific details such as the date and time the procedure/treatment was provided, whether the resident refused the procedure/treatment, and signature and title of the individual documenting.
Resident #1 was admitted to the Facility in July 2015, diagnoses included major depressive disorder, adult failure to thrive, auditory hallucinations, anxiety, and paranoid schizophrenia.
Review of Resident #1's Nurse Progress Note, dated 12/30/23, indicated he/she was readmitted to the Facility from the Hospital at 2:00 P.M., however a subsequent Nurse Progress Note, dated 12/30/23, indicated he/she was readmitted to the Facility from the Hospital at 3:00 P.M.
Review of Resident #1's MAR, for the month of December 2023, indicated that he/she was to be administered the following medications during the 3:00 P.M.-11:00 P.M. shift on 12/30/23 at the following times, however the medications were not signed off as administered and were left blank:
4:00 P.M. 6:00 P.M. Valproic Acid (anticonvulsant) (Oral Solution 250 milligram/milliliter mg/ml, give 5 ml via J-Tube
5:00 P.M. Erythromycin Ointment (anti-infective) 5 mg/gram (gm), instill 0.5 inch in right eye
6:00 P.M. Rivaroxaban (blood thinner) Tablet 20 milligrams (mg) one tablet via J-Tube
9:00 P.M. Benztropine Mesylate (anti-tremor) Tablet 0.5 mg one tablet via J-Tube
9:00 P.M. Rivaroxaban Tablet 20 mg one tablet via J-Tube
9:00 P.M. Carnitor (dietary supplement) Solution 1 gram/10 milliliters gm/ml, give 10 ml via J-Tube
9:00 P.M. Lactulose (laxative) Solution 20 gm/ml, give 30 ml via J-Tube
9:00 P.M. Baclofen (muscle relaxant) Tablet 5 mg, give one table via J-Tube
9:00 P.M. Midodrine HCL (treats low blood pressure) Tablet 10 mg, give one tablet via J-Tube
9:00 P.M. Erythromycin Ointment 5 mg/gram (gm), instill 0.5 inch in right eye
Review of Resident #1's MAR, for the month of January 2024, indicated he/she was to be administered Invega Sustenna (anti-psychotic) intramuscular suspension 156 milligrams/milliliter (mg/ml), inject 156 mg intramuscularly at 9:00 A.M. on 01/27/24, however the medication was not signed as administered and the MAR was left blank.
Review of Resident #1's Medical Record indicated there was no documentation to support if he/she had been administered his/her medications during the 3:00 P.M. to 11:00 P.M. shift on 12/30/23 or if he/she had been administered his/her Invega injection on 01/27/24. Further review of Resident #1's Medical Record indicated there was no documentation to support that there were any reasons documented why his/her medications were not signed off as administered or if they had been held for some reason.
The Surveyor was unable to interview Nurse #3 as he did not respond to the Department of Public Health's telephone calls or letter request for an interview.
During an interview on 03/12/24 at 1:29 P.M., Nurse #1 said that, on 01/27/24, Resident #1 was supposed to be administered his/her Invega injection but the medication was not available at the Facility so she did not administer it to him/her. Nurse #1 said she did not sign Resident #1's MAR for the Invega that day and left it blank.
During an interview on 03/20/24 at 12:46 and 2:05 P.M., the Director of Nursing (DON) said Resident #1 was readmitted to the Facility between 2:00 P.M.-3:00 P.M. on 12/30/23 and said Nurse #3 was assigned to him/her on the 3:00 P.M.-11:00 P.M. shift that evening. The DON said Resident #1's medications were not signed off on his/her MAR during the 3:00 P.M.-11:00 P.M. shift on 12/30/23 and said because of that, it could not be determined if the medications had been administered to him/her or not.
The DON said Resident #1's MAR was supposed to be signed whenever medications were administered and said if the medications were not administered, the MAR should have been signed and coded as to why the medications were not administered as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations, interviews and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for one Resident (#2) out of a total sample of 24 residents.
Findings Include:
Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, last revised 3/18, indicated the following:
Policy Statement:
*Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's).
*Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene.
Policy Interpretation and Implementation:
*2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:
D. dining (meals and snack)
Resident #2 was admitted to the facility in August 2018 with diagnoses including dysphagia (difficulty swallowing), unspecified asthma, and unspecified dementia moderate, with other behavioral disturbances.
Review of Resident #2's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had Brief Interview for Mental Status score of 3 out of a possible 15 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that Resident #2 currently requires supervision and physical assistance of one person for eating.
On 9/26/23 at 8:48 A.M., 9/26/23 at 12:38 P.M., 9/27/23 at 8:15 A.M., and 9/28/23 at 8:14 A.M., Resident #2 was observed eating meals alone with food spilled on his/her shirt. There was no staff present to provide supervision or assistance.
Review of Resident #2's medical record on 9/26/23 1:15 P.M., indicated a care plan initiated on 12/23/22 indicating the following: Eating: I require continual supervision with eating and drinking, assist when fatigued. Further review of Resident #2's medical record indicated a Speech Language Pathologist evaluation completed on 9/15/23 recommending close supervision for oral intake.
During an interview on 9/27/23 08:15 A.M., Resident #2 was asked if he/she receives any assistance or supervision during his/her meals. He/she said no.
During an interview on 9/28/23 at 8:44 A.M., Nurse Supervisor #1 said Resident #2 can eat on his/her own, but we check on him/her to encourage them to eat and drink.
During an interview on 9/28/23 at 9:38 A.M., Unit Manager #2 said if a resident requires continual supervision, staff should be in the room with the resident during meals and provide supervision and assistance.
During an interview on 9/28/23 10:00 A.M., The Director of Nursing said if a resident is on continual supervision for meals, staff should be with the resident when he/she is eating.
During an interview on 9/28/23 at 12:39 P.M., The Administrator said the expectation is a staff member would be in the room with the resident during meals and will provide supervision and/or assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide the necessary treatment and services to prevent the development and promote healing of pressure ulcers for one Residents (#49) out of a total of 24 sampled residents.
Resident #49 was admitted to the facility in August 2023 with diagnoses unsteadiness on feet, unstageable pressure ulcer of left buttock, unspecified protein calorie malnutrition and gastrostomy.
Review of Resident #49's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 10 out of possible 15 indicating moderate cognitive impairment. The MDS further indicated Resident #49 had one of more unhealed pressure ulcers at stage one or higher.
On 9/26/23 at 9:14 A.M., the surveyor observed Resident #49 sitting up in bed, a dressing wrapped the left foot and no Prevalon boots (a pressure relieving device for the heels) were observed.
Additional observations were made by the surveyor on 9/26/23 at 4:03 P.M., 9/27/23 at 12:50 P.M., and 9/28/23 at 7:12 A.M., Resident #49 was observed in bed with no Prevalon boots applied to feet.
Review of Resident #49's medical record indicated the following:
-A Physician order dated 8/30/23, indicated Prevalon boots to bilateral feet every shift.
-A Care plan dated 8/3/23, for impaired skin integrity related to pressure wounds, with interventions to administer treatments as ordered and monitor effectiveness.
-A physician progress note dated 9/15/23 indicated Resident #49 had a left stage 2 heel ulcer.
During an interview on 9/28/23 at 10:23 A.M., Certified Nursing Assistant (CNA) #4 said she was unsure if Resident #49 had Prevalon boots. CNA #4 accompanied the surveyor to Resident #49's room observed Resident #49 not wearing Prevalon boots and was unable to locate them in the Residents room.
During an interview on 9/28/23 at 10:36 A.M., Nurse #4 said nursing was responsible for the prevalon boots. Nurse #4 said it was the expectation to follow physician orders. Nurse #4 said she took the booties off in the morning and thought the order was at night time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide behavioral health services as recommended by the behavioral health service Nurse Practitioner for one Resident (#20) out of a total sample of 24 residents.
Findings include:
Resident #20 was admitted to the facility in December 2022 with diagnoses including sepsis, anxiety disorder, major depressive disorder with severe psychotic features.
Review of Resident #20's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #20 had no behaviors.
During an observation on 9/26/23 at 9:17 A.M., Resident #20 was observed lying in bed. Resident #20 told the surveyor the course of events requiring him/her to be in the facility. Resident #20 began crying while talking with the surveyor and expressed being sad. Resident #20 said he/she used to have someone that would come into the facility to talk to him/her but has not come in to talk in about 6 months.
During an observation/interview on 9/27/23 at 12:46 P.M., Resident #20 said his/her emotions were so-so today.
During an observation/interview on 9/28/23 at 8:57 A.M., Resident #20 was visibly crying when the surveyor entered the room. Resident #20 said he/she missed an appointment yesterday due to diarrhea and just wanted to get out of this place.
Review of Resident #20's medical record indicated the following:
-A care plan dated 12/19/22 indicated Resident #20 has major depressive disorder with interventions to arrange for pysch consult and follow up as indicated.
-An initial psychological evaluation was completed on 2/24/23, the clinician indicated Resident #20 had a history of depression and alcohol abuse and was currently very weepy. The clinician indicated a plan for individual psychotherapy to focus on symptoms of depression.
-A psych Nurse Practitioner (NP) initial evaluation was completed on 3/3/23 with a plan to follow up and monitor moods and behaviors.
- A psych NP progress note dated 4/18/23 with a plan to continue to monitor moods/behaviors and to follow up.
-A psych NP progress note dated 5/16/23 indicated recommendations for starting Resident #20 on celexa (an antidepressant medication) and referred the resident to therapy.
-A NP progress note dated, 7/27/23 indicated Resident #20's healthcare proxy was concerned about depression. The NP note further said she had written an order for psych consult in one of the previous visits but had not received any recommendations. The NP started Resident #20 on Zoloft (an antidepressant medication) 50 milligrams daily.
-A Nursing progress note dated 9/13/23 indicated Resident reported feeling sad regarding his/her infection.
During an interview on 9/28/23 at 10:23 A.M., Certified Nursing Assistant (CNA) #4 said she was familiar with Resident #20. CNA #4 said Resident #20 was crying today and seemed upset normally he/she seems angry.
During an interview on 9/28/23 at 1:36 P.M., the Director of Nursing was unaware that Resident #20 had not been seen by the talk therapist as recommended.
During a phone interview on 9/29/23 at 12:56 P.M., the Psych NP said she was calling to clarify the therapy recommendation for Resident #20. The Psych NP said she was unaware that Resident #20 was not being seen by the talk therapist and that it had been approximately 6 months since Resident #20 had been seen. The Psych NP said recommendations for Resident #20 to continue being seen by the talk therapist.

Based on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Review conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for one Resident (#30) out of a total sample of 24 Residents.
Findings include:
Review of the facility policy titled Medication Regimen Reviews, undated, indicated the following:
*The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication at least monthly.
*Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident, the report contains: the resident's name, the name of the medication, the identified irregularity and the pharmacist's recommendation.
*If the physician does not provide a timely response or adequate response, the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or administrator.
*The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it.
Resident #30 was admitted to the facility in April 2014 with diagnoses including cerebral palsy, hemiplegia and hemiparesis and type 2 diabetes mellitus.
Review of Resident #30's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. The MDS further indicated that the Resident required total dependence with all activities of daily living and exhibited no refusal behaviors.
Review of progress notes written by the Pharmacy Consultant indicated the following:
*Written 6/22/23: Medication regimen reviewed. Please see pharmacist report for further detail.
*Written 7/15/23: Pharmacist note: Medications reviewed. Please see the Consultant Pharmacist Report for the recommendations.
Review of Resident #30's document titled Consultant Pharmacist Recommendations to Physician dated 6/22/23 indicated the following:
*Resident #30 is taking Metoclopramide (Reglan). This may lower the threshold for seizures and may also result in several CNS (Central Nervous System) and movement side effects, it should be administered cautiously to patients with a pre-existing seizure disorder. The chronic use of metoclopramide therapy should be avoided in all but rare cases where the benefit is believed to outweigh the risk.
The response to the recommendation provided was left blank and the physician did not acknowledge the recommendation.
Review of the documented titled Consultant Pharmacist Recommendations Summary indicated the following:
*Dated 7/15/23 for Resident #30: Resident has been receiving Reglan chronically. Please re-evaluate continued need/efficacy of this medication and consider D/C (discontinue) at this time?
Review of Resident #30's medical records indicated that the medication metoclopramide (Reglan) was discontinued on 8/8/23, over six weeks after the initial pharmacist recommendation.
During an interview on 9/27/23 at 12:33 P.M., Corporate Nurse #1 said the facility should have reviewed the pharmacy recommendations more timely and the physician should have acknowledged it. She said the expectation is for the facility to review the pharmacist's recommendations.
During an interview on 9/28/23 at 11:51 A.M., the Director of Nursing said pharmacy recommendations should be reviewed and signed off by the physician if they agree with them or not. Corporate Nurse #1 said pharmacy recommendations should be reviewed by the physician within 30 days.

Based on observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of two nurses observed made three errors in 31 opportunities on one of two units resulting in a medication error rate of 9.68%. These errors impacted two Residents (#74 and #27), out of five residents observed.
Findings include:
Review of the facility policy titled 'Administering Medications' revised April 2019, indicated the following but not limited to:
Policy Statement:
Medications are administered in a safe and timely manner, and as prescribed.
Policy Interpretation and Implementation
*Medications must be administered in accordance with the orders, including any required time frame.
* The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.
1. During a medication pass on 9/27/23 at 9:16 A.M., the surveyor observed Nurse #1 prepare and administered the following medications to Resident #74:
*MiraLAX powder (polythene Glycol 3350) half capful mixed in eight ounces of water.
*Vitamin B1 100 mg one tablet by mouth.
Review of current physician's orders indicated the following:
*Polyethylene Glycol 3350 powder, give 17 grams by mouth one time a day for constipation.
*Thiamine HCL (hydrochloride) ( Vitamin B1) oral tablet 250 mg (milligram), give one tablet by mouth one time a day.
During an interview on 9/27/23 at 11:29 A.M., Nurse #1 said she gave the wrong dosage by giving Resident #74 100mg of thiamine instead of the ordered 250 mg. She also said she did not know the measuring cup for polyethylene glycol had measurements for 17 grams and should have filled it to the measuring line.
2. During a medication pass on ACU resident care unit on 9/27/23 at 9:53 A.M., the surveyor observed Nurse #2 prepare and administered the following medications to Resident #27.
*MiraLAX powder (Polyethylene Glycol 3350) half capful mixed in eight ounces of water.
Review of current physician's orders indicated the following:
*Polyethylene Glycol powder (Polyethylene Glycol 1450) Give 17 gram by mouth two times a day for bowel regimen mix in 120 milliliter beverage choices.
During an interview on 9/27/23 at 11:23 A.M., Nurse #2 said not filling the powder to the 17-gram line is the wrong dosage as well as giving 3350 instead of the ordered 1450.
During an interview on 9/28/23 at 11:41 A.M., the Director of Nursing said nurses should follow the five rights of medication administration and follow the physician's orders.

Based on observations, policy review, and interview the facility failed to ensure medications with short expirations dates, were dated when opened, on two out of four medication carts.
Findings include:
Review of the facility policy titled 'Medication Labeling and Storage' revised February 2023, indicated the following but not limited to:
*Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
*Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.
1. During an inspection of SCU medication cart on 9/27/23 at 9:40 A.M., the following medications were available for administration:
-3 Fluticasone furoate/vilanterol elipta inhalation powder 100 mcg (micrograms)/ 25 mcg, opened and undated hence unable to determine the expiration date.
-1 Fluticasone propionate nasal spray 50 mcg opened and undated.
During an interview on 9/27/23 at 9:43 A.M., Nurse #1 said inhalers and nasal sprays should be labeled and dated when opened they should be good for 28 days.
2. During an inspection of ACU medication cart on 9/27/23 at 10:05 A.M., the following medications were available for administration.
-2 Fluticasone propionate 50 mcg nasal sprays opened and undated.
-1 Fluticasone propionate and salmeterol powder 100 mcg/50 mcg opened and undated.
- 1 Timolol maleate ophthalmic solution 0.5% opened and undated.
During an interview on 9/27/23 at 10:11 A.M., Nurse #2 said inhalers, nasal sprays and eye drops should be labeled when opened.
During an interview on 9/28/23 at 11:43 A.M., the Director of Nursing said medications like eye drops, inhalers and nasal sprays should be dated when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dental services for two Residents (#6 and #30) out of a total sample of 24 residents.
1. Resident #6 has had multiple admissions, most recently admitted to the facility in September 2022, with diagnoses including dysphagia (difficulty swallowing), and cerebral infarct.
Review of Resident #6's most recent Minimum Data Set (MDS) dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, indicating he/she has moderate cognitive impairments. The MDS also indicated Resident #6 requires extensive assistance of one person for all self-care activities.
During an interview on 9/26/23 at 9:07 A.M., Resident #6 said his/her dentures had been missing for a few months. Resident #6 was asked if he/she told staff, he/she said yes.
Review of Resident #6's medical record indicated he/she has an oral/dental health care plan initiated on 6/15/23 indicating the following:
*Focus: I am at risk for oral/dental health problem r/t generalized breakdown.
*Interventions:
-Coordinate arrangements for dental care, transportation as needed/as ordered
-Monitor/document/report to physician s/sx (signs and symptoms) of oral/dental problems needing attention: Pain (gums, toothache, palate, Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, lose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth, Ulcers in mouth, Lesions.
-Provide mouth care (i.e: brush teeth, denture care, gum care) as per ADL personal hygiene.
Further review of Resident #6's medical record failed to indicate he/she had been seen by a dentist and indicated he/she was without his/her dentures during Nutrition Risk Assessments completed on 6/15/23 and 9/19/23.
During an interview on 9/27/23 at 2:00 P.M., the Corporate Nurse said Resident #6 had not been seen by the dentist and provided the surveyor with a signed consent form for dental services dated 9/20/21.
During an interview on 9/28/23 at 8:34 A.M., Resident #6 said some foods are more difficult to eat and it takes him/her a much longer time to eat his/her meals.
During an interview on 9/28/23 at 8:42 A.M., Certified Nursing Assistant (CNA) #3 said she was familiar with Resident #6 and said he/she wore dentures. CNA #3 said she was not aware Resident #6's dentures were missing.
During an interview on 9/28/23 at 9:46 A.M., Unit Manager #1 said he was not aware Resident #6's dentures were missing. Unit Manager #1 said if dentures are lost, he will inform the Administrator to start the process of getting the resident new dentures.
During an interview on 9/28/23 at 10:03 A.m., The Director of Nursing said he was not aware Resident #6's dentures were missing, and he would set up an appointment to start the process for Resident #6 to get new dentures.
During an interview om 9/28/23 at 12:41 P.M., The Administrator said she was not aware Resident #6's dentures were missing, and the expectation would be a dental appointment would be set up for the resident to start the process of getting new dentures.
2. For Resident #30, the facility failed to provide consent for dental services resulting in the Resident not seeing dental services since admission.
Resident #30 was admitted to the facility in April 2014 with diagnoses including cerebral palsy, hemiplegia and hemiparesis and type 2 diabetes mellitus.
Review of Resident #30's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. The MDS further indicated that the Resident required total dependence with all activities of daily living and exhibited no refusal behaviors.
The surveyor made the following observation:
*During an interview on 9/26/23 at 11:38 A.M., Resident #30 was observed missing many teeth and had yellow staining on the visible teeth. The Resident said he/she has many missing teeth and he/she would like to get more removed.
During an interview on 9/27/23 at 8:17 A.M., Resident #30 said he/she has broken teeth and it can be hard to chew food sometimes. He/she said he/she has not been to the dentist in years and would like to see one.
Review of Resident #30's physician's orders does not indicate an order to be seen by dental services.
Review of Resident #30's medical record did not indicate any evidence that the Resident was seen by the dentist.
Review of Resident #30's care plan dated 9/7/23 indicated the following:
Focus: I have a nutritional problem or potential nutritional problem r/t (related to) lacking teeth.
Review of the document titled Request for Services/Consultation dated 10/15/18 from the contracted dental company the facility uses was left blank under the section for dental services.
Review of the facility's admission Packet indicated the following option for dental services:
*Dentist: The Resident consents to participate in the Facility's dental program unless the Resident designates, as provided below, a dentist of the Resident's choosing
Review of the Facility Assessment indicated that the facility provides dental services through a contracted or outside service.
During an interview on 9/27/23 at 12:34 P.M., Corporate Nurse #1 said the facility never obtained consent for dental services for Resident #30 upon admission and he/she has not been seen. She continued to say he/she should have received consent and if any resident requests to be seen by a dentist the facility would honor that request.
During an interview on 9/28/23 at 9:55 A.M., Unit Manager #1 said Residents should be offered consent for dental services upon admission and he is currently working on obtaining consents for all residents. He continued to say Resident #30 should have been offered a consent form to be seen by a dentist when he/she was admitted to the facility.
During an interview on 9/28/23 at 9:56 A.M., the Director of Nursing said Resident #30 should have been offered a consent form to be seen by dental services.

Based on observations and interview, the facility failed to properly store food items to prevent the risk of foodborne illness. Specifically, the facility failed to separate personal food items from resident food items in the walk-in refrigerator.
Findings include:
During the revisit to the kitchen on 9/27/23 at 11:38 A.M., the surveyor observed three cups of iced coffee with straws sticking out from the top stored in the walk-in refrigerator in the same area where resident food is stored.
During an interview on 9/27/23 at 12:10 P.M., the Foodservice Director said personal food items should not be stored with resident food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for two Residents ( #49 and #30) out of a total sample of 24 Residents. Specifically,
1) For Resident #49 the facility failed to (a) accurately document the application of prevalon boots and (b) accurately document the implementation of contact precautions.
2) For Resident #30, staff signed off on the Medication Administration Record (MAR) that the Resident was wearing a hand splint while the facility reported it missing and was not being worn by Resident #30.
Findings include:
1 a. Resident #49 was admitted to the facility in August 2023 with diagnoses including unsteadiness on feet, unstageable pressure ulcer of left buttock, unspecified protein calorie malnutrition and gastrostomy.
Review of Resident #49's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 10 out of possible 15 indicating moderate cognitive impairment. The MDS further indicated Resident #49 had one of more unhealed pressure ulcers at stage one or higher.
On 9/26/23 at 9:14 A.M., the surveyor observed Resident #49 sitting up in bed a dressing wrapped the left foot and no prevalon boots were observed.
Additional observations were made by the surveyor on 9/26/23 at 4:03 P.M., 9/27/23 at 12:50 P.M., and 9/28/23 at 7:12 A.M., Resident #49 was observed in bed with no prevalon boots applied to feet.
Review of Resident #49's September 2023 Medication Administration Record indicated the following:
-Order for prevalon boots to bilateral feet every shift start date 8/30/23, indicated they were applied on 9/26/23 on day, evening, and night shift. Documentation also indicated they were applied on 9/27/23 on day and night shift.
During an interview on 9/28/23 at 10:36 A.M., Nurse #4 said the documentation is inaccurate for applying prevalon boots.
1 b. On 9/26/23 at 9:14 A.M., the surveyor observed and interviewed Resident #49 and there were no Contact Precautions at the time being implemented.
Additional observations were made by the surveyor on 9/26/23 at 4:03 P.M. and no Contact Precautions were being implemented.
Review of Resident #49's medical record indicated the following:
-Physician Order dated 9/5/23 for Contact Precautions for C-diff (a Multi drug resistant organism that causes diarrhea) to start 9/5/23 and stop on 9/27/23.
-Medication Administration Record for September 2023 documentation indicated precautions were implemented on September 26th, day, evening and night shift.
During an interview on 9/27/23 at 3:39 P.M., Nurse #4 said Resident #49 was no longer on contact precautions for c-diff and the documentation was not accurate.
During an interview on 9/28/23 at 11:46 A.M., the Director of Nurses said documentation should be accurate.
2. Resident #30 was admitted to the facility in April 2014 with diagnoses including cerebral palsy, hemiplegia and hemiparesis and type 2 diabetes mellitus.
Review of Resident #30's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. The MDS further indicated that the Resident required total dependence with all activities of daily living and exhibited no refusal behaviors.
The surveyor made the following observations:
*On 9/26/23 at 11:38 A.M., Resident #30 was observed in his/her room, he/she was not wearing a hand splint.
*On 9/26/23 at 2:15 P.M., Resident #30 was observed in an activity in the common room, he/she was not wearing a hand splint.
*On 9/27/23 at 8:18 A.M., Resident #30 was observed eating breakfast in bed, he/she was not wearing a hand splint.
Review of Resident #30's physician's orders indicated the following:
*Dated 9/22/21: Left resting hand splint on in AM (morning) and off in PM (night) every day and evening shift
Review of Resident #30's treatment administration record for September 2023 indicated that nursing had been documenting that he/she has been wearing his/her hand splint daily.
During an interview on 9/28/23 at 8:28 A.M., Resident #30 said he/she has not worn his/her hand splint in weeks and does not know where it is.
During an interview on 9/28/23 at 8:55 A.M., Certified Nursing Assistants (CNA) #1 and #2 said Resident #30 should be wearing his/her hand splint when awake daily. The surveyor and CNA #1 went into Resident #30's bedroom and could not find the hand splint. CNA #1 said the Occupational Therapist might be ordering a new one.
During an interview on 9/28/23 at 9:05 A.M., the Occupational Therapist said nursing told her they could not find Resident #30's hand splint for a few days and asked her to order a new one.
During an interview on 9/28/23 at 9:30 A.M., Unit Manager #1 said nursing should not be documenting that Resident #30 is wearing a hand splint if he/she is not wearing one and they lost it. He continued to say he spoke to therapy a few days ago that it is missing.
During an interview on 9/28/23 at 11:52 A.M., the Director of Nursing said nursing should be documenting medical records accurately.