Every finding on record at Adviniacare at Northbridge

Based on observation, interview, and record reviews, the facility failed to ensure that complete and accurate medical records were maintained for two Residents (#11 and #2), out of a total sample of 24 residents. Specifically,1. For Resident #11, the facility staff documented for ten months that the Resident's Foley (indwelling urinary) catheter was being changed monthly as ordered when the Foley catheter was not being changed monthly.2. For Resident #2, the facility staff documented two medications as being administered during a medication pass when one medication was not offered or administered to the Resident and the second medication was unavailable for administration to the Resident. Findings include: 1.Resident #11 was admitted to the facility in January 2025 with diagnoses including Obesity and obstructive and reflux Uropathy. Review of the Minimum Data Set (MDS) Assessment, dated 11/24/25, indicated the Resident #11: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15. -had an indwelling urinary catheter. On 12/3/25 at 9:26 A.M., the surveyor observed Resident #11 had an indwelling Foley catheter in place. During an interview at the time, Resident #11 said he/she had been in the facility for a few months. Resident #11 said his/her indwelling Foley catheter had not been changed by the facility staff. Review of Resident #11's December 2025 Physician's orders indicated: -Change (indwelling) Foley catheter using 18 French (Fr) 10 milliliters (ml) balloon every month, change drainage bag with Foley change every month on the 20th, start date 1/27/25. -Monitor Foley catheter 18 Fr/10 ml for patency every shift, start date 1/27/25. Review of Resident #11's Treatment Administration Record (TAR) indicated: - 2/20/25: initialed as Foley catheter changed (8 - indicates other, with no explanation offered) by Nurse #8 - 3/20/25: initialed (8) by Nurse #8 - 4/20/25: check mark by a Nurse - 5/20/25: initialed (8) by Nurse #8 - 6/20/25: initialed (8) by Nurse #8 - 7/20/25: check mark by Nurse #1 - 8/20/25: initialed (8) by Nurse #8 - 9/20/25: check mark by Nurse #7 - 10/20/25: initialed (8) by Nurse #8 - 11/20/25: check mark by Nurse #5 On 12/4/25 at 9:08 A.M., the surveyor observed that CNA #1 was providing ADL care to Resident #11. During an interview at the time, CNA #1 said the Foley catheter size was 16 Fr and was unable to read the catheter balloon size. On 12/4/25 at 9:18 A.M., the surveyor and Nurse #1 observed Resident #11's Foley catheter. During an interview at the time, Nurse #1 said the Resident's Foley catheter was 16 Fr with 10 ml balloon. The surveyor and Nurse #1 also reviewed Resident #11's December 2025 Physician's orders and Nurse #1 said the Physician's order was for 18 Fr and 10 ml balloon. The surveyor and Nurse #1 reviewed the Resident's TAR and Nurse #1 said she had documented that she changed Resident #11's Foley catheter on 7/20/25 but had not. Nurse #1 said she should not have documented on the TAR that she changed the Foley catheter when she did not. During an interview on 12/4/25 at 11:04 A.M., the Director of Nursing (DON) said Nurses should not initial or sign treatment orders on the TAR when they have not completed treatments. The DON further said it was her expectation that when Nurses provided Foley catheter care, they should ensure the Foley catheter size matched the Physician's order. The surveyor and the DON reviewed the TAR documentation codes, and the DON said Code 8 meant Other, and every time Nurses initialed or signed as other, the Nurses are expected to document what the other meant, but they had not. During an interview on 12/4/25 at 1:44 P.M., Nurse #7 said she had signed/initialed the TAR as having changed Resident #11's Foley catheter on 9/20/25, but she had not changed the Foley catheter. During an interview on 12/4/25 at 1:49 P.M., Nurse #5 said she signed/initialed Resident #11's TAR as having changed the Foley catheter on 11/20/25, but she had not changed the urinary catheter. During an interview on 12/4/25 at 1:50 P.M., Nurse #8 said she had signed/initialed Resident #11's TAR that the Foley catheter was changed on 2/20/25, 5/20/25, 6/20/25, 8/20/25 and 10/20/25, but she did not change the urinary catheter on those dates. During an interview on 12/5/25 at 11:01 A.M., the DON said the Nurses should not have signed/initialed Resident #11's Foley catheter as being changed when the Resident had a history of medical complications in the perineal area and the urinary catheter could only be changed by the Urologist, through interventional radiology. The DON said that the documentation for Resident #11's Foley catheter being changed were inaccurate. 2. Resident #2 was admitted to the facility in February 2025 with diagnoses including Hyperlipidemia, age-related cataracts, other visual disturbances, Diplopia, Exotropia, and Severe Non-proliferative Diabetic Retinopathy with macular edema of the left eye. Review of the facility policy titled Medication Administration Review, revised 1/2023, indicated: -Recheck Medication Administration Records (MAR) to make sure all medications are administered and documented. -When the medication pass is complete, the nurse is to recheck the Medication Administration Records to make sure all medications have been administered and documented appropriately. Review of the Minimum Data Set (MDS) Assessment, dated 11/6/25, indicated Resident #2 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 possible points. On 12/4/25 at 9:14 A.M., the surveyor observed Nurse #4 administering medications to Resident #2 during medication pass. The surveyor did not observe Nurse #4 administer the following medications: -Questran Oral Packet 4 GM (Cholestyramine) give 2 packets by mouth two times a day for diarrhea, to be administered at 8:00 A.M., start date 6/8/25 -Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 % (Refresh/Theratears 0.5%) instill 1 drop in both eyes four times a day for dry eyes, to be administered at 9:00 A.M., start date 9/4/25 Review of the December 2025 MAR for Resident #2 after the medication pass indicated that the following medications were administered by Nurse #4 on 12/4/25 during the surveyor observed medication pass: -Questran Oral Packet 4 GM (Cholestyramine) give 2 packets by mouth two times a day for diarrhea, to be administered at 8:00 A.M., start date 6/8/25. -Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 % (Refresh/Theratears 0.5%) instill 1 drop in both eyes four times a day for dry eyes, to be administered at 9:00 A.M., start date 9/4/25. During an interview on 12/4/25 at 10:06 A.M., Nurse #4 said she did not administer the Questran 8:00 A.M., and Carboxymethylcellulose Sod PF Ophthalmic Solution and 9:00 A.M. medications during the scheduled medication pass completed at 9:14 A.M. Nurse #4 said she had not offered or administered the Questran medication to Resident #2 and should not have signed the MAR as medication administered. Nurse #4 said that she did not administer the Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 % eye drops because the medication was unavailable, and should not have signed off the medication as administered on the MAR. During an interview on 12/4/25 at 10:07 A.M., Resident #2 said that Nurse #4 had not offered the Questran medication during the morning medication pass, but he/she had been refusing the medication and would like it discontinued. During an interview on 12/4/25 at 11:08 A.M., the DON said that Nurse #4 should not have documented the Questran as administered if it was not offered and/or refused. The DON said Nurse #4 should not have documented the Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 % as administered if the medication was unavailable. The DON further said that Carboxymethylcellulose Sodium 0.5% strength was unavailable in the facility and Nurse #4 should have called the Physician for clarification on whether to hold the medication or change the order. The DON said Nurse #4 should not have signed the MAR that a medication was administered when it was not.

Based on observation, record review, and interviews, the facility failed to ensure an environment that was free from accidental hazards for one Resident (#133) out of a total sample of 24 residents. Specifically, for Resident #133, the facility failed to ensure:-that the Resident was provided adequate supervision and assistance during toileting activity to mitigate the risk of a fall.-that a fall sustained by the Resident was investigated, evaluated, and interventions were implemented to reduce fall hazards and risks, and the effectiveness of fall interventions were monitored and modified as required. Findings include: Review of the facility's policy titled Accidents and Incidents, revised October 2022, indicated the following:-It is the policy of the facility to monitor and evaluate all occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrences must be evaluated and investigated.-The Nursing supervisor/charge nurse, unit manager, and/or the department director or supervisor shall be promptly notified and then responsible for assessing, reviewing, documenting, and reporting of the incident and/or accident.-Internal report of accidents/incidents regardless of how minor an accident or incident may be, it must be reported to the Nurse Manager or Nursing Supervisor.-Employees witnessing an accident or incidents involving a resident must report occurrence to the nurse manager or nursing supervisor as soon as practical.-The supervisor must assess resident for any injury, completes an occurrence/incident report, and follow-up with interventions.-Should an employee witness an accident, or find it necessary to aid an accident victim, the employee should render immediate assistance. Do not move the victim until he/she has been examined by a nurse for possible injuries.-Examine all residents who may have experienced an accident/incident.-Notify the medical director or the resident's personal attending physician.-Notify the family as soon as possible concerning accident/incident. Resident #133 was admitted to the facility in November 2025 with diagnoses including repeated falls, difficulty walking, obesity, acute on chronic Diastolic Heart failure, and wedge compression fracture of T7-T8 vertebrae. Review of Resident #133's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible score of 15. On 12/3/25 at 9:12 A.M., the surveyor observed the following:-Loud vocal sounds coming from Resident #133's room. -Two staff members were attending to the Resident. -Resident #133 said to the staff that he/she would not allow staff to ambulate him/her to the bathroom because he/she recently had a fall with staff in the bathroom. -Resident #133 said that staff were denying that the fall had occurred. -Resident #133 said that he/she would only use a bed pan. During an interview on 12/3/25 at 9:16 A.M., Unit Manager (UM) #3 said at 9:12 A.M., she and another staff member were attempting to assist Resident #133 to the bathroom, but the Resident consistently indicated that he/she had fallen two days prior in the bathroom and would not allow staff to transfer him/her to the bathroom. UM #3 said Resident #133 was placed on the bedpan in his/her bed per the Resident's request. UM #3 said there was no documentation or evidence that Resident #133 had experienced a fall while being toileted in the bathroom. During an interview on 12/3/25 at 9:24 A.M., Resident #133 said on 12/1/25 around 6:30 P.M., he/she was seated on the toilet in his/her bathroom, and one staff member lifted him/her up and then the Resident's knees gave out, and he/she fell to the floor. Resident #133 said the staff member picked him/her up from the floor and placed him/her back on the toilet and the staff member called for assistance from a second staff member, and both staff members lifted the Resident from the toilet and placed him/her in a wheelchair. Resident #133 said both staff members used a hydraulic lift to transfer him/her from the wheelchair to bed. Resident #133 further said the staff denied that the fall happened, therefore he/she would not allow the staff to assist him/her to the bathroom. During an interview on 12/3/25 at 9:32 A.M., Resident Representative #1 (who had arrived in the facility to visit Resident #133) said the facility had not informed him/her of any fall incident on 12/1/25 pertaining to Resident #133. During an interview on 12/3/25 at 9:59 A.M., Nurse #5 said Resident #133 continued to state that he/she had a fall two days ago but there was no documentation and no evidence that the Resident had sustained a fall. During an interview on 12/4/25 at 2:16 P.M., Certified Nurse's Aide (CNA) #2 said Resident #133 was assigned to CNA #3 on 12/1/25 for the 3:00 P.M. to 11:00 P.M. shift. CNA #2 said at 6:30 P.M., CNA #3 reached out to CNA #2 for assistance to ambulate Resident #133 to the bathroom. CNA #2 said he and CNA #3 ambulated Resident #133 with a walker from the Resident's bed into the bathroom and assisted the Resident to sit on the toilet. CNA #2 said he left CNA #3 to monitor the Resident. CNA #2 said CNA #3 reached out to him again because she could not assist Resident #133 to a standing position from the toilet. CNA #2 said he attempted to get Resident #133 to a standing position while holding the Resident's arm and the Resident's knees gave out, and the Resident's knee touched the floor. CNA #2 said he quickly lifted the Resident by grabbing both arms and placed him/her back on the toilet. CNA #2 said he then reached out to Nurse #6 for assistance. CNA #2 said both he and Nurse #6 lifted Resident #133 into a wheelchair and then transferred the Resident to his/her bed using the hydraulic lift. During an interview on 12/4/25 at 2:22 P.M., CNA #3 said she was assigned to Resident #133 on 12/1/25. CNA #3 said Resident #133 requested to use the toilet, but CNA #3 could not transfer the Resident by herself and was not sure of the Resident's transfer status, so she reached out to CNA #2. CNA #3 said CNA #2 assisted with ambulating Resident #133 to the bathroom. CNA #3 said she could not assist the Resident to a standing position to clean him/her, so she called CNA #2 for assistance. CNA #3 said CNA #2 assisted the Resident to a standing position, but the Resident's knees buckled, and CNA #2 lifted the Resident and placed him/her back on the toilet. CNA #3 could not provide any further information as she said she could not recall what happened after the Resident was placed back on the toilet. During an interview on 12/4/25 at 3:30 P.M., Nurse #6 said on 12/2/25, CNA #2 reached out to him to assist Resident #133 back to bed from the toilet. Nurse #6 said he and CNA #2 transferred Resident #133 from the toilet into a wheelchair and then used a hydraulic lift to transfer the Resident to his/her bed. Nurse #6 said CNA #2 did not inform him that the Resident's knees had given out and touched the floor. During an interview on 12/4/25 at 4:26 P.M., the Director of Nursing (DON) said there was no documentation that Resident #133 had sustained a fall on 12/1/25. During an interview on 12/4/25 at 4:55 P.M., the DON said she had not been made aware of any incident related to Resident #133. The DON said she would start an investigation and would notify the survey team of any fall related incident for Resident #133. During an interview on 12/5/25 at 9:14 A.M., the Physical Therapist (PT) said she treated Resident #133 on 12/3/25, and the Resident mentioned he/she had sustained a fall while being assisted in the bathroom. The PT said she spoke with Nurse #5 at the time and Nurse #5 said that the incident did not happen. During an interview on 12/5/25 at 9:53 A.M, the Certified Occupational Therapy Assistant (COTA) said she provided Resident #133 with therapy treatment on 12/2/25. The COTA said Resident #133 requested pain medication before he/she would participate in any therapy sessions and the Resident was observed to have trouble standing. The COTA said during the therapy session, Resident #133 said he/she was stuck in the bathroom the night before and that his/her knees gave out during a transfer off the toilet. The COTA said Resident #133 refused all toilet transfer sessions during therapy on 12/2/25. The COTA said she asked UM #3 if there had been any reported fall or incident related to Resident #133 and UM #3 said there was no incident. During an interview on 12/5/25 at 10:47 A.M., the DON said she started an investigation and found that Resident #133 had been lowered to his/her knees by CNA #2 during a transfer off the toilet on 12/1/25. The DON said the CNA #2 did not report the incident and should have reported it.

Based on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for one Resident (#107) out of a total sample of 24 residents.Specifically, for Resident #107, the facility failed to provide toenail care as required and schedule podiatry services as ordered to assist the Resident in maintaining good foot health and preventing podiatric complications. Findings include:Review of the facility policy titled ADL-Nail Care, not dated, included the following:-The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections.-Nail care includes daily cleaning and regular trimming.-Proper nail care can aid in the prevention of skin problems around the nail bed.-unless otherwise permitted, do not trim the toenails of diabetic residents or residents with circulatory impairments. This nail care should be performed by a Licensed Nurse or Podiatrist.-trimmed and smooth nails to prevent the resident from accidentally scratching or injuring his or her skin.-Resident will be referred to the Podiatrist based on assessment of the resident's toenails by nursing staff and MD. Resident #107 was admitted to the facility in October 2025 with diagnoses including paresthesia (tingling, burning, or numb sensation in the hands, arms, legs or feet) of the skin, vascular Dementia, and alcohol abuse with unspecified alcohol induced disorder. Review of the most recent Minimum Data Set (MDS) Assessment completed 11/3/25, indicated Resident #107:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15.-required substantial to maximum assistance with personal hygiene. Review of Resident #107's medical record indicated:- -Physician's order for Podiatry Consult as needed, dated 10/31/25.- -Request for Podiatry Services, signed by the Resident on 10/31/25.- -Weekly skin checks completed on 11/1/25, 11/8/25, 11/19/25, 11/26/25, and 12/3/25, which failed to indicate that Resident #107's toenails had been trimmed. Review of the Activities of Daily Living (ADL) Care Plan initiated 11/3/25, indicated Resident #107:-requires assist with ADLs due to cognitive loss, decreased attention span, easily distracted, lack of balance, unsteady gait, would not initiate or follow through.-requires moderate assist to complete personal hygiene. On 12/3/25 at 8:48 A.M., the surveyor observed Resident #107's toenails were untrimmed with the free edge of all the toenails on both feet grown significantly past the nail bed. The bilateral great toenails were observed to be thickened and opaque. During an interview at the time, Resident #107 said no one had trimmed his/her toenails or offered to schedule a visit to the Podiatrist. Resident #107 said he/she usually keeps his/her toenails trimmed when they were at home. Resident #107 said he/she would like to have his/her toenails cut if it was offered. During an interview on 12/4/25 at 2:24 P.M., the Unit Secretary said Resident #107 had not been put on the list to be seen when the Podiatrist came to the facility on [DATE]. The Unit Secretary further said Resident #107 was not currently on the list to be seen by the Podiatrist and had no appointment scheduled to go and see a Podiatrist in an outpatient setting. During an interview on 12/4/25 at 2:35 P.M., Nurse #3 said when a resident was identified as needing to see a Podiatrist the Nurse sends a referral to the Unit Secretary, and the Unit Secretary puts the resident on the list to be seen. Nurse #3 said the way it was determined if someone needs to see the Podiatrist was through the resident themselves, a family request, or if it is determined during resident care they need to be seen. Nurse #3 said as far as she knew Resident #107 was not referred to the Podiatrist at any time since his/her admission. During an interview on 12/4/25 at 2:42 P.M., Resident #107 said he/she does have numbness and tingling in both feet and would like to have his/her toenails cut if it was offered. On 12/4/25 at 3:26 P.M., the surveyor and the Director of Nursing (DON) observed Resident #107's toenails. During an interview at the time, the DON said Resident #107 should have been referred to the Podiatrist prior to this observation due to the length of the Resident's toenails. The DON said the length of the Resident's toenails and the need for the toenails to be trimmed should have been identified by the staff during the completion of prior weekly skin checks.

Based on observation, record review, and interview, the facility failed to ensure that one Resident (#3) out of a total sample of 24 residents, with impaired vision received the proper assistive devices to maintain their vision. Specifically, for Resident #3, the facility failed to ensure that the appropriate corrective lenses were available for the Resident's use when his/her prescription eyeglasses were missing, and he/she was provided with another person's eyeglasses for use. Findings include: Resident #3 was admitted to the facility in March 2021 with diagnoses including Type 2 Diabetes Mellitus with other Circulatory Complications and Schizoaffective Disorder Bipolar Type. Review of Resident #3's most recent Optometry Exam dated 10/29/24, indicated: -Diagnoses of Cataract nuclear, Dry eye, Glaucoma suspect (narrow angle), Hyperopic astigmatism, and presbyopia. -Glasses required, encourage full-time use for distance and reading. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15 possible points -had impaired vision and required corrective lenses Review of Resident #3's Care Plan indicated: -has impaired visual function r/t (related to) Glaucoma and dry eyes, the Resident will have no indications of acute eye problems through the review date.encourage the use of glasses, ensure they (glasses) are clean and unbroken (initiated 6/11/24, revised11/4/25) -requires assist with ADL's (Activities of Daily Living), dependent for glasses (initiated 11/4/25, revised 11/4/25) On 12/3/25 at 9:56 A.M., the surveyor observed that Resident #3 was not wearing any eyeglasses. During an interview at the time, the Resident said he/she haven't had their eyeglasses for weeks, and that the eyeglasses were missing. On 12/4/25 at 2:33 P.M., the surveyor observed Resident #3 wearing eyeglasses. During an interview at the time, Nurse #2 said that the Resident's glasses were kept in the drawer at the nurses' station because the Resident frequently removes the glasses and puts the glasses in random drawers, making it difficult to find the glasses. Nurse #2 further said that the Resident's eyeglasses had gone missing and that the pair of glasses that the Resident was currently wearing had actually belonged to someone else. During an interview on 12/4/25 at 3:42 P.M., Unit Manager (UM) #1 said that it had just been brought to her attention that the Resident's eyeglasses were missing, and she was unaware that the Resident was wearing prescription eyeglasses that belonged to someone else. UM #1 said the staff should have reported the missing glasses to her but had not done so. On 12/8/25 at 9:30 A.M., the surveyor observed Resident #3 sitting up in his/her wheelchair in the unit day room and wearing different glasses than he/she was observed wearing on 12/4/25. During an interview at the time, Resident #3 said he/she was wearing brand new glasses and they worked well. During an interview on 12/8/25 at 10:00 A.M., UM #1 said she investigated the matter of the Resident's prescription eyeglasses and the glasses were not actually missing but were broken. UM #1 said that one temple piece had been broken off the eyeglasses, but she was unsure how long ago it had happened as she just found out about it. UM #1 said she did not know how long it had been that the Resident was wearing someone else's glasses as it was never reported to her. UM #1 further said that on 12/5/25 the facility acquired new prescription glasses for the Resident. When the surveyor asked if the facility would have acquired new glasses for the Resident on 12/5/25 if the surveyor had not brought it to the staff's attention, UM #1 said no, we probably still wouldn't have realized the oversight. UM #1 said that she was not aware of any report completed for missing or broken glasses. During an interview on 12/8/25 at 4:27 P.M., UM #1 said that all glasses were typically engraved with the resident's name or the glasses were labeled with a small piece of paper with the resident's name. UM #1 said the eyeglasses that Resident #3 had been wearing had no name identified on them. UM #1 said that she was unaware of when Resident #3's eyeglasses were broken or when the Resident started wearing someone else's glasses. UM #1 said that staff should report to her (the UM) as soon as any glasses were broken or missing but they had not done so. UM #1 also said that the Resident should not have been wearing someone else's glasses.

Based on observation, interview, record and policy review, the facility failed to provide care according to professional standards of practice for one Resident (#76) out of a total sample of 21 residents. Specifically, the facility staff failed to: -adequately assess Resident #76 for bruising (when a part of the body is injured and blood from the damaged capillaries [small blood vessels] leaks out and pools under the skin). -provide interventions to reduce the risk for bruising when the Resident was prescribed antiplatelet (prevents platelets from sticking together and decreasing the body's ability to form blood clots) medication and developed bruises on his/her upper extremities, increasing the Resident's risk for bleeding complications. Findings include: Review of the facility's policy titled, Risk and Skin Assessments, dated July 2018 and revised January 2023, indicated the following: -Implement appropriate strategies /plans to: attain/maintain intact skin, prevent complications, promptly identify or manage complications . -Weekly skin checks should be done by a Licensed Nurse weekly and PRN (pro re [NAME]: as the need arises). -When completing skin checks, licensed nurses should identify any current skin concerns as well as any new skin concerns. Review of the Cleveland Clinic's Health Library for Antiplatelet Drugs (https://my.clevelandclinic.org/health/drugs/22955-antiplatelet-drugs), dated 5/5/22, indicated: -Antiplatelet drugs prevent platelets from sticking together and decrease your body's ability to form blood clots. -Aspirin is the most commonly used antiplatelet drug. -The main risk associated with antiplatelet therapy is excessive bleeding. -A side effect of Aspirin use is bruising. Resident #76 was admitted to the facility in February 2024, with diagnoses including Peripheral Vascular Disease (PVD: a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Traumatic Subdural Hemorrhage (bleeding that occurs between the brain and the skull caused by a head injury) without loss of consciousness, Chronic Kidney Disease (CKD: damage that occurs over time that reduces the kidney's abilities to filter waste and fluids from the blood and can increase one's risk for heart disease and stroke), and Dementia (group of symptoms affecting memory, thinking, and daily life activities). Review of Resident #76's Minimum Data Set Assessment, dated 5/17/24, indicated the following: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total points. -The Resident was receiving antiplatelet medication. Review of Resident #76's July 2024 Physician's orders indicated the following order with a start date of 2/17/24 and no end date: -Aspirin (antiplatelet medication) 81 Oral Tablet Chewable; give 81 mg (milligrams) by mouth one time a day related to PVD. Review of Resident #76's Skin Only Evaluation dated 7/23/24, indicated the Resident's skin color was normal and no skin issues were identified. On 7/25/24 at 11:33 A.M., the surveyor observed Resident #76 sitting in a wheelchair in his/her room. The surveyor observed a large, deep purple bruise on the back of the Resident's left forearm, just above the Resident's wrist. During an interview at the time, Resident #76 said he/she was unsure where the bruise came from and that he/she thought he/she just banged it a while ago. On 7/30/24 at 8:56 A.M., the surveyor observed Resident #76 sitting in a wheelchair in the hallway near the nurses station. The surveyor further observed that the large bruise was still present on the back of the Resident's left forearm, just above his/her wrist. The surveyor also observed one round-shaped deep purple bruise on the backs of each of the Resident's hands. During an interview at the time, Resident #76 said he/she had no bruises and there was nothing there. Review of Resident #76's Skin Only Evaluation dated 7/30/24, with a completion time of 11:16 A.M. indicated the Resident's skin color was normal and that no skin issues were identified. Review of Resident #76's clinical record included no documentation relative to the bruises the surveyor observed (on 7/25/24 and 7/30/24) on the back of the Resident's left forearm and the backs of both of the Resident's hands. Further review of the clinical record indicated no instructions to monitor the Resident for bruising and no interventions implemented to reduce the Resident's risk for bruising. During an interview on 7/30/24 at 1:46 P.M. with Nurse #3 and Unit Manager (UM) #2, Nurse #3 said that when she completed weekly skin checks for residents, she documented all new skin issues identified, as well as previously identified skin issues on the Skin Only Evaluation until the skin issues were resolved. Nurse #3 also said if a new skin issue was identified between the weekly skin checks, another Skin Only Evaluation would be completed. Nurse #3 said all residents who received antiplatelet medications, including Aspirin, were to be monitored for bruising and abnormal bleeding and that Resident #76 received a daily dose of 81 mg of Aspirin. Nurse #3 said she completed a scheduled weekly Skin Only Evaluation for Resident #76 on 7/30/24, and no skin issues were identified. When the surveyor asked about the bruises on the Resident's hands and left forearm that were observed by the surveyor, Nurse #3 said she did not indicate the Resident's bruises on the Skin Only Evaluation because the Resident bruised often and the bruises usually improved over a few days time. Nurse #3 said the Resident frequently packed his/her belongings in large bags and positioned them over his/her arms while moving through the hallway in his/her wheelchair. Nurse #3 said she had not seen the Resident bruise when he/she performed this activity, but she thought this may have been what contributed to his/her frequent upper extremity bruising. Nurse #3 then said if she thought the bruises looked like they required treatment, she would document them on the Skin Only Evaluation and notify the Resident's Physician and Healthcare Proxy (HCP: individual identified to make healthcare decisions for someone who cannot make healthcare decisions for him/herself). Nurse #3 said if the bruising did not look like it needed treatment, she would just observe the Resident to ensure the bruising did not worsen. Nurse #3 said she was not sure how other staff at the facility would monitor the Resident's bruises for improvement or worsening when the bruising had not been assessed as the other staff would have no baseline comparison of the bruising. During an interview at the time, UM #2 said she was not sure if 81 mg of Aspirin daily triggered staff to monitor for side effects of bruising or bleeding as 81 mg was a low dose, but whenever a bruise was identified on a resident, the bruise would be documented on the Skin Only Evaluation. UM #2 further said any resident identified with bruising should have monitoring for bruising and bleeding in place and a care plan with interventions to reduce the risk for bruising and bleeding implemented. UM #2 said the bruises observed by the surveyor on Resident #76's left forearm and hands should have been indicated on the Skin Only Evaluation, dated 7/30/24. UM #2 also said nursing staff should have completed Skin Only Evaluations when the Resident's bruises initially occurred and were identified, and that measurements of the bruises should have been obtained for monitoring purposes to ensure the bruises improved and did not worsen. UM #2 said Resident #76's Physician and HCP should have been notified of the bruising and interventions should have been identified and implemented to reduce the Resident's risk for bruising and abnormal bleeding. During an interview on 7/30/24 at 2:01 P.M., the Assistant Director of Nursing (ADON) said she was not made aware that Resident #76 bruised frequently and she had received no communication that Resident #76 had sustained bruises to his/her left forearm and backs of hands. The ADON said a daily dose of 81 mg of Aspirin would not trigger monitoring for bruising or bleeding, but all residents were to be assessed and monitored if they developed bruising. The ADON further said the bruising observed on Resident #76's upper extremities should have been assessed adequately and timely, and should have been monitored for worsening and/or improvement. The ADON said Resident #76 should have had instructions in place to monitor for bruising and bleeding, and should have had a care plan developed with individualized interventions in attempt to reduce the Resident's risk for bruising, but no monitoring instructions were in place and no interventions had been implemented to reduce the Resident's risk for bruising and abnormal bleeding.

Based on observation, interview and policy review, the facility failed to ensure its staff provided a dignified dining experience for one Resident (#103) out of total sample of 21 residents. Specifically, the facility staff remained standing and stood over Resident #103 while assisting the Resident during a breakfast meal. Findings include: Review of the facility policy titled Dining, last revised April 2023, indicated the following: -Meals are served to residents in various locations in accordance with resident preference and or needs: Main Dining Room, Resident's Own Room, Unit Dayroom, and other areas designated for family/visitor dining. -Sit next to residents while assisting them to eat rather than standing over them. On 7/30/24 at 8:40 A.M., the surveyor observed Resident #103 reclining in bed with the head of the bed elevated. The surveyor observed Certified Nurses Aide (CNA) #3 standing over the Resident and his/her bed while assisting him/her with the breakfast meal. During an interview on 7/30/24 at 8:50 A.M., CNA #3 said that Resident #103 needs help eating most of the time. CNA #3 said she does not like to sit next to the bed when assisting Resident #103 with meals and she prefers to stand and be positioned higher than the Resident. During an interview on 7/30/24 at 8:53 A.M., Unit Manager (UM) #1 said staff are supposed to be at eye level with residents when assisting with meals and that CNA #3 should not have been standing over Resident #103 while assisting the Resident with breakfast. During an interview on 7/30/24 at 10:58 A.M., the Assistant Director of Nurses (ADON) said that CNA #3 should not have stood over Resident #103 while assisting him/her with breakfast and should have been seated next to the Resident.

Based on interview, policy and record review, the facility failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN- notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for two Residents (#213 and #215) out of a total applicable sample of three residents, so that the Residents could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume. Specifically, the facility failed to: 1. For Resident #213, issue a SNF ABN when the Resident no longer qualified for Medicare Part A skilled services and chose to remain in the facility. 2. For Resident #215, issue a SNF ABN when the Resident no longer qualified for Medicare Part A skilled services and chose to remain in the facility. Findings include: Review of the facility policy for SNF ABN dated June 2022, indicated that the facility follows the SNF ABN standards as instructed by the Centers for Medicare and Medicaid Services (CMS). Review of the CMS website for SNF ABN last modified 9/6/23, indicated: -Skilled Nursing Facilities (SNFs) must issue a notice to Original Medicare (fee for service - FFS) beneficiaries in order to transfer potential financial liability before the SNF provides: >an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or >custodial care (non-medical assistance with daily tasks and basic living needs for those who are not sick or disabled). 1. Resident #213 was admitted to the facility in April 2024. Review of the medical record indicated that Resident #213 came off (Medicare benefits ended) his/her Medicare benefit on 6/13/24. The facility was unable to provide any SNF ABN notice corresponding with the Resident ending his/her Medicare benefit on 6/13/24, for the surveyor to review. 2. Resident #215 was admitted to the facility in February 2024. Review of the medical record indicated Resident #215 came off his/her Medicare benefit on 2/24/24. The facility was unable to provide any SNF ABN notice corresponding with the Resident ending his/her Medicare benefit on 2/24/24, for the surveyor to review. During an interview on 7/30/24 at 11:56 A.M., the Social Worker (SW) said that the SNF ABN forms should have been issued to Resident's #213 and #215 and/or their Representatives and the SNF ABN forms had not been issued as required.

Based on interview, record and policy review, the facility failed to ensure that the Resident and/or Resident Representative was provided the right to participate in the care planning process for one Resident (#8) out of a total sample of 21 residents. Specifically, the facility failed to ensure that: -quarterly care plan meetings (for March 2024 and June 2024) were conducted as required for Resident #8. -the Resident/Resident Representative participated in the care planning process. -the Interdisciplinary Team (IDT) met quarterly in 2024 to review the plan of care as required. Findings include: Review of the facility policy titled Care Plans, last revised 1/2023, included the following: -Each Resident of this facility shall be involved in the development and review of his/her plan of care along with her/her family member. -Interdisciplinary Team (IDT - two or more disciplines i.e. nursing, medicine, sociology, etc.) conferences shall be held for each resident at 90-day intervals and more often if needed. -Dates of each interdisciplinary care conference and the participants in each conference shall be documented in the resident's medical record. Resident #8 was admitted to the facility in June 2023, with a diagnosis of Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (Depression). Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated that Resident #8 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 12 out of 15. During an interview on 7/25/24 at 9:29 A.M., Resident #8 said that he/she had never heard of care plan meetings occurring at the facility. Review of the MDS Schedule for Resident #8 indicated that the Resident had care plan meetings scheduled for March 2024 and June 2024. Review of Resident #8's clinical record indicated no documented evidence that the Resident/Resident Representative participated in the care planning process or that the IDT met quarterly as required for 2024, to review the plan of care. Further review of the clinical record indicated there were no meetings or refusals to participate in the meetings by the Resident/Resident Representative documented for 2024. During an interview on 7/30/24 at 7:45 A.M., the Social Worker (SW) said that he was unable to find progress notes or sign-in sheets that the care plan meetings had been held and that the Resident and/or Resident Representative had participated in the care plans meetings according to the facility policy.

Based on observation, interview and policy review, the facility failed to follow safe sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety by two staff members (Nurse #2 and Unit Manager {UM} #1) on one unit ([NAME] Unit). Specifically, Nurse #2 and UM #1 failed to appropriately use a plastic scoop from a multi-use container of powdered thickening agent (a substance used to thicken liquids for individuals who have difficulty swallowing) in a sanitary manner for three occurrences pertaining to three residents during a meal tray pass on the [NAME] Nursing Unit. Findings include: Review of the facility policy titled Hand Hygiene, last reviewed 2/1/22, indicated that hand hygiene should be performed after contact with medical supplies and equipment in resident areas. Review of the facility policy titled Dining, last revised 4/2023, indicated that Infection Control practices must be followed during the meal pass process. On 7/30/24 at 8:14 A.M., the surveyor observed UM #1 and Nurse #2 at the breakfast meal cart preparing food trays for residents on the [NAME] Nursing Unit. The surveyor observed UM #1 remove the lid from a multi-use container of powdered thickening agent, reach into the container with a bare hand, retrieve a plastic scoop containing powdered thickening agent from inside the container and add the powder to a liquid container on a resident's meal tray. The surveyor observed UM #1 replace the same plastic scoop back into the multi-use container of powdered thickening agent and secure the plastic lid to the container. On 7/30/24 at 8:22 A.M., the surveyor observed UM #1 remove the lid from a multi-use container of powdered thickening agent, reach into the container with a bare hand, retrieve the plastic scoop containing powdered thickening agent from inside the container and add the powder to a liquid container on a resident's meal tray. The surveyor observed UM #1 replace the same plastic scoop back into the multi-use container of powdered thickening agent and secure the plastic lid to the container. On 7/30/24 at 8:25 A.M., the surveyor observed Nurse #2 remove the lid from a multi-use container of powdered thickening agent, reach into the container with a bare hand, retrieve the plastic scoop containing powdered thickening agent from inside the container and add the powder to a liquid on a resident's meal tray. The surveyor observed Nurse #2 replace the same plastic scoop back into the multi-use container of powdered thickening agent. During an interview on 7/30/24 at 8:43 A.M., UM #1 said that she used the plastic scoop from inside the canister (container) to add the powdered thickening agent to the drinks on resident's meal trays. UM #1 said that she performed hand hygiene prior to beginning the meal tray pass but did not perform hand hygiene at any time during the meal tray pass. UM #1 also said that she did not perform hand hygiene prior to or after retrieving the plastic scoop from the canister of powdered thickening agent. UM #1 said that she should have performed hand hygiene when she retrieved the plastic scoop from inside the canister.

Based on observation, interview, policy and record review the facility failed to ensure that Transmission-Based Precautions (TBP: infection control measures used in addition to standard precautions [infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status] for patients who may be infected with certain infectious agents) were implemented for one Resident (#36) out of a total sample of 21 residents. Specifically, the facility staff failed to follow Contact Precautions (refers to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) for Resident #36 whose urine was infected with extended-spectrum beta-lactamase (ESBL: an enzyme found in some bacteria that is resistant to many antibiotic treatments, and associated with poor outcomes) producing bacteria, resulting in risk for transmission of infection to others. Findings include: Review of the facility policy titled Isolation Precautions, dated 7/2018 with revision date 2/2023, indicated: -It is the facility's policy to foster compliance with Federal and State Regulations, CDC (Centers for Disease Control and Prevention) .to provide guidelines for general infection control while caring for residents. -Transmission Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. -Contact transmission occurs through direct contact with the organism and then contact with another person or surface (examples: infected wounds, urine, or feces). Resident #36 was admitted to the facility in February 2024, with diagnoses including Urinary Tract Infection (UTI: bacterial infection in any part of the urinary system/organs) and Diabetes (disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #36: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15. -was always incontinent (having no or insufficient voluntary control) of urine. Review of the Comprehensive resident-specific Care Plan for Resident #36, dated 7/13/24 with revision on 7/16/24 indicated the following: -Resident treated for urine infection -Maintain Contact Precautions Review of the July 2024 Physician's orders for Resident #36 indicated the following: -Nitrofurantoin (antibiotic used to treat UTI) 100 mg (milligram) by mouth every 12 hours for urinary tract infection (UTI) for 5 days, initiated on 7/13/24 -Maintain Contact Precautions Q (every) Shift for urine, initiated on 7/16/24 -Levaquin (antibiotic used to treat bacterial infection) 500 mg by mouth one time a day for urinary tract infection for 10 days, initiated on 7/29/24 On 7/25/24 at 10:00 A.M. the surveyor observed a sign hanging on the doorway of Resident #36's room that indicated: -CONTACT PRECAUTIONS EVERYONE MUST: >Clean their hands, including before entering and when leaving the room. -PROVIDERS AND STAFF MUST ALSO >Put on gloves before room entry. Discard gloves before room exit. >Put on a gown before room entry and discard gown before room exit. On 7/25/24 at 10:29 A.M., the surveyor observed CNA #1 enter Resident #36's room without performing hand hygiene and donning (putting on) a pair of gloves. The surveyor observed CNA #1 was observed by the surveyor, touching surfaces in the room including the bathroom doorknob, bedside table, and privacy curtains. The surveyor observed CNA #1 doff (remove) her gloves and exit the room without performing hand hygiene and proceeded to access two separate clean linen carts in the hallway and retrieve towels. The surveyor observed CNA #1 return to Resident #36's room and enter the room without performing hand hygiene and donning gloves. During an interview on 7/25/24 at 10:40 A.M., CNA #1 said that she did not think that a gown and gloves were needed because she did not touch Resident #36. CNA #1 further said it is important to remove gloves and clean hands before leaving the room because it could spread germs. On 7/29/24 at 10:45 A.M., the surveyor observed CNA #2 enter Resident #36's room without performing hand hygiene or donning gown and gloves. The surveyor observed CNA #2 touching Resident #36's wheelchair, privacy curtain and bedside table, before exiting the room. During an interview on 7/29/24 at 10:50 A.M., CNA #2 said Resident #36 was on Contact Precautions for a bacterial infection in the urine. CNA #2 said that he did have contact with the surfaces in the room and did not cleanse his hands before entry or put on gown and gloves before entering the room because he did not think he needed to unless he was touching the Resident's urine. CNA #2 said gown and gloves should be worn to protect himself and other residents from spreading germs. During an interview on 7/29/24 at 3:00 P.M., The Infection Preventionist (IP) said Resident #36 was on Contact Precautions for an ESBL urinary infection to prevent the spread of infection to others. The IP said all staff should be cleaning their hands as well as put on gown and gloves before room entry for Resident #36. The IP further said gowns and gloves should be removed and hands cleaned before staff leave the room.

Based on record and policy review, and interview, the facility staff failed to ensure that one Resident (#112) out of two closed records reviewed, was free from significant medication errors. Specifically, the facility failed to accurately reconcile (the formal process of obtaining a complete and accurate list of a patient's current medications) Resident #112's medication when the Resident was admitted to the facility, resulting in routine daily medication not being administered to the Resident as required and increasing the risk for adverse reactions related to the missed doses of the medications. Findings include: The Facility Policy, titled Medication Errors, last revised 8/2019, indicated: -a medication error is any preventable event that may cause or lead to inappropriate medication use or resident harm -significant medication errors are those which require medical intervention and or result in possible or confirmed morbidity or mortality -type of medication errors include: .unordered dose Resident #112 was admitted to the facility in April 2024, with diagnoses including Heart Failure (HF: when the heart is unable to pump blood as it should resulting in fluid buildup in the feet, arms, lungs and other organs), hyperlipidemia (above normal fat levels in the blood), Atrial Fibrillation (A-fib: irregular, rapid heartbeat that can lead to blood clots and other heart related complications) and Hypertension (HTN: high blood pressure). Review of a Nursing Progress Note dated 5/2/24, in Resident #112's medical record indicated: -that the Resident had chosen to leave the facility against medical advice (AMA) -that the Resident's Healthcare Proxy (HCP: the person chosen as the healthcare decision maker when the individual is unable to do so for themself) brought to the Nurse's attention that four of the Resident's medications had been missing from the Resident's medication list: >Eliquis (blood thinner medication) >Buspirone (anti-anxiety medication) >Atorvastatin (anti-hyperlipidemic medication) >Metoprolol (anti-hypertensive medication) -that the Physician had been notified of the medication error and the facility offered to keep the Resident in the facility to start the missed medications and to monitor for adverse effects, which the Resident and HCP declined. Review of Resident #112's Hospital History and Physical Report dated 4/25/24, documented the following active medications with no stop date: -Apixaban (Eliquis) 5 milligrams (mg), give twice daily -Atorvastatin Calcium 40 mg, give at bedtime -Buspirone 5 mg, give twice daily -Metoprolol Tartrate 25 mg, give twice daily Review of Resident #112's Physician's orders did not indicate that the medications listed on the Hospital History and Physical Report dated 4/25/24, had been ordered for the Resident upon admission to the facility through to his/her discharge on 5/2/24. During an interview on 7/30/24 at 3:26 P.M., the Assistant Director of Nurses (ADON) said that Resident #112 should have been provided the listed medications (on the Hospital History and Physical Report, dated 4/25/24) during their stay in the facility and had not been.

Based on interview, policy and record review, the facility failed to provide a Pneumococcal (bacteria often found in the nose and throat, is transmissible to others, and can cause infection) Vaccine to one Resident (#9) out of five applicable residents, out of a total sample of 21 residents. Specifically, the facility staff failed to provide a Pneumococcal Vaccine to Resident #9 when the Resident had previously received Pneumococcal Vaccine doses, was not up-to-date with his/her Pneumococcal Vaccine status, and consented to receive the Pneumococcal Vaccine when it was offered to him/her by the facility. Findings include: Review of the facility's policy titled, Pneumococcal Vaccination, dated 7/2019 and revised 2/2023, indicated: -All residents will be offered Pneumococcal Vaccines to aid in preventing Pneumonia/Pneumococcal infections. -The facility will offer Penumococcal Vaccination to all admitted residents, [AGE] years of age and older, unless such resident has already received vaccination, is not in need of a booster, or is a person for whom it is medically contraindicated. Review of the Centers for Disease Control and Prevention (CDC) Guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, dated 9/22/23, indicated the following for adults age [AGE] years or older who received PCV13 (Pneumococcal Conjugate Vaccine 13) at any age and PPSV23 (Pneumococcal Polysaccharide Vaccine 23) before age [AGE] years: *For older adults who don't have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: -Give 1 dose of PCV20 (Pneumococcal Conjugate Vaccine 20) or PPSV23. Regardless of vaccine used, their series is complete. -The PCV20 dose should be given at least 5 years after the last Pneumococcal Vaccine. -The PPSV23 dose should be given at least 5 years after the last PPSV23 dose. It should also be given at least 1 year after the PCV13 dose. *For older adults who have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: -Give 1 dose of PCV20 or PPSV23. Regardless of vaccine used, their series is complete. -The PCV20 dose should be given at least 5 years after the last Pneumococcal Vaccine. -The PPSV23 dose should be given at least 5 years after the last PPSV23 dose. It should also be given at least 8 weeks after the PCV13 dose. Resident #9 was admitted to the facility in May 2022, with diagnoses including Type Two Diabetes Mellitus (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar levels) and Acute Respiratory Failure (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body). Review of Resident #9's clinical record indicated the following: -The Resident was over the age of [AGE] years when he/she was admitted to the facility. -The Resident received a PPSV23 vaccine on 10/29/96, when the Resident was less than [AGE] years of age. -The Resident received a PCV13 vaccine on 11/19/14 (the Resident's most recent dose of pneumococcal vaccine). -The Resident consented to receive the Pneumococcal Vaccine on 5/18/22. Further review of the clinical record included no evidence that Resident #9 received the Pneumococcal Vaccine after he/she had consented or that the vaccine was medically contraindicated. During an interview on 7/30/24 at 3:40 P.M., the Infection Preventionist (IP) said Resident #9 had resided in the facility since May 2022 and had consented to receive the Pneumococcal Vaccine when he/she was admitted . The IP said the facility adhered to CDC guidelines for administration of Pneumococcal Vaccines and that Resident #9 was not considered up-to-date with his/her Pneumococcal Vaccine, according to CDC guidelines. The IP further said Resident #9's most recent dose of Pneumococcal Vaccine was 11/19/14, and that the Resident was overdue for Pneumococcal Vaccination.

Based on record review and interview, the facility failed to accurately code two Minimum Data Set (MDS) Assessments for one Resident (#82) out of a total sample of 21 residents. Specifically, the facility staff coded Section N (Medications) to indicate Resident #82 had received Insulin (medication used to regulate blood sugar levels) injections (given by use of a needle) one time during the observations periods (period of look-back used for data collection) for each of the two (February 2024 and May 2024) MDS Assessments completed when the Resident did not receive Insulin injections. Findings include: Resident #82 was admitted to the facility in February 2024 with a diagnosis of Type Two Diabetes Mellitus (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar levels). Review of Resident #82's Physician's orders dated 2/27/24, with no stop date, indicated: -Trulicity (medication used to treat Diabetes and reduce blood sugar levels, that is not classified as Insulin) Subcutaneous (under the skin) Solution Pen-Injector 0.75 mg (milligrams)/ 0.5 ml (milliliter) . Inject 0.5 ml subcutaneously one time a day every Tuesday for Type 2 Diabetes Mellitus Review of Resident #82's MDS assessment dated [DATE], indicated the Resident received an Insulin injection one time during the observation period (2/22/24 - 2/27/24) for the Assessment. Review of Resident #82's February 2024 Medication Administration Record (MAR) indicated the following: -The Resident received one dose of Trulicity during the observation period for the MDS assessment dated [DATE]. -The Resident did not receive any Insulin injections during the observation period for the MDS assessment dated [DATE]. Review of Resident #82's MDS Assessment, dated 5/24/24, indicated the Resident received an Insulin injection one time during the observation period (5/18/24 - 5/24/24) for the Assessment. Review of Resident #82's May 2024 MAR indicated the following: -The Resident received one Trulicity injection during the observation period for the MDS assessment dated [DATE]. -The Resident did not receive any Insulin injections during the observation period for the MDS assessment dated [DATE]. During an interview on 7/25/24 at 4:22 P.M., the MDS Nurse said Resident #82's MDS Assessments dated 2/27/24 and 5/24/24 were coded inaccurately. The MDS Nurse said that Resident #82 had received one injection of Trulicity during the observation periods for each of the MDS Assessments and that Trulicity was not Insulin. The MDS Nurse further said that Resident #82 received no Insulin injections during the observation periods for either of the MDS Assessments dated 2/27/24 and 5/24/24.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a court appointed a legal Guardian, the Facility failed to ensure they notified Resident #1's Guardian that Resident #1 refused his/her daily antipsychotic medication and meals for several days, and that Resident #1 was transferred to the Hospital. Findings include: The Facility Resident Rights Policy, dated as last revised 10/2022, indicated that Federal and State laws guaranteed certain basic rights to residents which included, appointing a legal representative, to be notified of his/her medical condition and to be informed of and participate in his/her care planning and treatment. The Facility Notifications Policy, dated as revised 1/2023, indicated that except in a medical emergency, the Facility must notify the resident's designated representative when there is a significant improvement or decline in the resident's physical, mental or psychosocial status, a need to alter treatment significantly or a decision to transfer or discharge the resident from the Facility. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. The Record indicated that the court appointed a Legal Guardian for Resident #1 during April 2023. The Admission Minimum Data Set (MDS) Assessment, dated 3/12/24, indicated Resident #1's mental status was moderately impaired and he/she refused care daily. The MDS indicated Resident #1 was independent with eating, hygiene and was continent of bowel and bladder. The Nursing Clinical Admission Note, dated 3/06/24, indicated Resident #1 was alert and oriented to person, place and time, communicated verbally and took nutrition and hydration orally. During a telephone interview on 3/28/24 at 2:37 P.M., Resident #1's Guardian said that on 3/12/24 the Facility Admission Director told her the Facility might need to send Resident #1 to the hospital, not that he/she had already been transferred. The Guardian said that the Admission Director told her that for several days, Resident #1 hadn't been eating or accepting antipsychotic medications. The Guardian said that the Admission Director told her that in an attempt to get Resident #1 to eat, staff members had purchased food from outside of the Facility for Resident #1 which Resident #1 had not consistently accepted. The Guardian said that although Resident #1 had already resided at the Facility for six days, the call from the Admission Director on 3/12/24 was her first notification of Resident #1's refusal to eat meals and take his/her medication. The Guardian said that during the telephone conversation, she told the Admission Director that if Resident #1 had to be transferred to the hospital, he/she should be transferred to the closest hospital (around 10 miles away.) The Guardian said that the Admission Director told her that it would be a disservice to Resident #1 and unfair to the closer hospital to send Resident #1 there, and that ifResident #1 needed to be transferred to the hospital, the Facility thought he/she should go back to the Hospital that referred him/her to the Facility (which was around 60 miles away). Review of nursing, social work and physician Progress Notes for Resident #1 from 3/06/24 through 3/11/24 indicated there was no documentation to support the Facility having notified Resident #1's Guardian that Resident #1 was not eating and refused his/her antipsychotic medications. During an interview on 3/25/24 at 12:45 P.M., the Licensed Social Work Associate (LSWA) said that she tried to call the Guardian on 3/11/24 to discuss Resident #1's diet and left a message with the Guardian's office. The LSWA said that although she emailed the Guardian on 3/11/24, she subsequently found out that she used an incorrect email address. The Guardian provided the Surveyor copies of email correspondence with the Facility, dated 3/07/24, 3/08/24 and 3/11/24, concerning matters unrelated to Resident #1, which supported the Facility had known how to reach her. The Guardian said that later in the afternoon on 3/12/24, the Hospital notified her that Resident #1 was in their Emergency Department (ED). The Guardian said that the Facility had not notified her when they transferred Resident #1 to the ED. During an interview on 3/25/24 at 12:00 P.M., the Admission Director said that when she informed the Guardian on 3/12/24 that Resident #1 was being transferred to the Hospital, Resident #1 had already left the Facility and was on his/her way.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to permit Resident #1 to remain in the Facility or to ensure that, prior to discharge, Resident #1's Physician documented the danger posed by the Facility's failure to discharge Resident #1 and the Resident's needs which could not be met in the Facility, as required. Findings include: The Facility Discharge/Transfer Policy, dated as revised 10/2022, indicated that each resident will be permitted to remain in the Facility and not be transferred or discharged unless: - a) the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility; - b) the transfer or discharge is appropriate because the Resident's health had improved; - c) the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident; - d) the health of individuals in the Facility would otherwise be endangered; - e) the resident has failed after reasonable and appropriate notice to pay for the stay at the Facility; - f) the Facility ceased to operate, or, - g) the transfer/discharge is resident/family initiated. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. The Record indicated the court appointed a legal Guardian for Resident #1 during April 2023. The Admission Minimum Data Set (MDS) Assessment, dated 3/12/24, indicated Resident #1's mental status was moderately impaired and he/she refused care daily. The MDS indicated Resident #1 was independent with eating, hygiene and was continent of bowel and bladder. The Nursing Clinical Admission Note, dated 3/06/24, indicated Resident #1 was alert and oriented to person, place and time, communicated verbally, was in a pleasant mood and exhibited no unwanted behaviors. During a telephone interview on 3/26/24 at 3:50 P.M., the Hospital Case Manager said that on 3/12/24, the Facility discharged Resident #1 to their Emergency Department (ED). The Case Manager said that on 3/12/24, when case management staff in the ED contacted the Facility, Facility staff refused to permit Resident #1 to return. During a telephone interview on 3/28/24 at 2:37 P.M., the Guardian said that on 3/12/24 a Hospital ED staff person called her and notified her that Resident #1 was in the ED and the Facility refused to permit Resident #1 to return. During an interview on 3/25/24 at 11:00 A.M., the Administrator said that the Facility discharged Resident #1 to the Hospital ED. During an interview on 3/08/24 at 12:45 P.M., the Licensed Social Work Associate (LSWA) said that, on 3/12/24, she faxed a Notice of Transfer or Discharge for Resident #1 to the Long Term Care Ombudsman office, but said she had not provided a copy of the Notice to Resident #1 or to the Guardian. During a telephone interview on 3/26/24 at 3:27 P.M., the Physician said that on 3/12/24 he received a call from the Unit Manager about Resident #1. The Physician said that the Unit Manager told him that Resident #1 was out of control, wasn't caring for him/herself, wasn't eating, was agitated, uncooperative, was not accepting his/her medications and defecated in his/her room. The Physician said that he gave an order to transfer Resident #1 to the emergency department for an evaluation. The Surveyor asked the Physician about Resident #1's discharge from the Facility to the Hospital ED. The Physician that he did not give the Facility an order to discharge Resident #1. The Surveyor asked the Physician whether of not the Facility was unable to meet Resident #1's care needs. The Physician said that it would be difficult for the Facility to claim an inability to meet Resident #1's needs when they had admitted him/her with those needs a week prior and had cared for him/her for a week. Review of Resident #1's Record indicated there was no documentation to support that the Facility identified specific care needs the Facility could not meet and/or the attempts to meet the needs. Furthermore, the Facility was unable to provide any documentation by he Physician that supported that they could not meet Resident #1's needs.

Based on interviews and records reviewed, for one of three sampled resident (Resident #1) the Facility failed to provide a properly completed written Notice of Transfer or Discharge to the resident/resident's representative at the time the Facility initiated discharge for Resident #1, in accordance with the Federal regulations and per Facility Policy. Findings include: The Facility Discharge/Transfer Policy, dated as revised 10/2022, indicated that each resident will be permitted to remain in the Facility and not be transferred or discharged unless: - a) the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility; - b) the transfer or discharge is appropriate because the Resident's health had improved; - c) the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident; - d) the health of individuals in the Facility would otherwise be endangered; - e) the resident has failed after reasonable and appropriate notice to pay for the stay at the Facility; - f) the Facility ceased to operate, or, - g) the transfer/discharge is resident/family initiated. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. The Record indicated the court appointed a legal Guardian for Resident #1 during April 2023. The Admission Minimum Data Set (MDS) Assessment, dated 3/12/24, indicated Resident #1's mental status was moderately impaired and he/she refused care daily. The MDS indicated Resident #1 was independent with eating, hygiene and was continent of bowel and bladder. During telephone interviews on: - 3/25/24 at 1:13 P.M. with the Hospital Director of Regulatory Affairs, and, - 3/26/24 at 3:50 P.M. with the Hospital Case Manager and Hospital Social Worker, they said the following: the Facility discharged Resident #1 to the Hospital Emergency Department (ED) on 3/12/24, that Resident #1 arrived at the ED without a written Notice of Transfer or Discharge from the Facility, with all of his/her personal belongings and when ED case management staff contacted the Facility, the Facility said they would not permit Resident #1 to return. During a telephone interview on 3/28/24 at 2:37 P.M., the Guardian said that on 3/12/24 the Hospital ED called and notified her that Resident #1 was in the ED and the Facility would not permit Resident #1 to return. The Guardian said that the Facility had not provided her with a written Notice of Transfer or Discharge for Resident #1 at the time of his/her transfer to the ED and discharge from the Facility. The Guardian said she was not aware that Resident #1 was entitled to 30-day's notice of the Facility's intention to discharge him/her or that he/she had the right to appeal the Facility's discharge. During an interview on 3/25/24 at 11:00 A.M., the Administrator said that the Facility had not issued a Notice of Transfer or Discharge to Resident #1 or to his/her Guardian. During an interview on 3/25/24 at 12:45 P.M., the Licensed Social Work Associate (LSWA) said that she faxed a Notice of Transfer or Discharge for Resident #1 to the Long Term Care Ombudsman office, however said she had not provided a copy to Resident #1 or to his/her Guardian.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who had a court appointed legal Guardian who specified to Facility staff that if needed that Resident #1 be transferred to the closest hospital (which was only 10 miles away,) the Facility failed to ensure Resident #1's transfer was safe and orderly when, on 3/12/24 a physician order was obtained by nursing for Resident #1 to be transferred to the Hospital Emergency Department (ED) for evaluation however, the Facility instead discharged Resident #1 to an ED approximately 60 miles away, alone via a wheelchair van with all of his/her personal belongings. Findings include: The Facility Resident Rights Policy, dated as revised 10/2022, indicated staff members would treat residents with respect. The Policy indicated that Federal and State laws guaranteed certain basic rights to all residents, which included the right to participate in decision-making regarding their care. The Facility Care Plans Policy, dated as revised 1/2023, indicated each resident of the Facility would be involved in the development of his/her care plan, along with his/her family member. The Policy indicated the interdisciplinary team would collaborate with the resident and family in revising care plans Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. The Record indicated the court appointed a legal Guardian for Resident #1 during April 2023. The Admission Minimum Data Set (MDS) Assessment, dated 3/12/24, indicated Resident #1's mental status was moderately impaired and he/she refused care daily. The MDS indicated Resident #1 was independent with eating, hygiene and was continent of bowel and bladder. Review of the Progress Note, dated 3/12/24 at 12:41 P.M. (written by the Unit Manager), indicated Resident #1 refused care, refused to eat any Facility food and a physician order was obtained by nursing staff to transfer Resident #1 to the Hospital for further evaluation. During a telephone interview on 3/26/24 at 3:27 P.M., the Physician said that on 3/12/24, he received a call from the Unit Manager about Resident #1. The Physician said that the Unit Manager told him that Resident #1 was out of control, wasn't caring for him/herself, wasn't eating, was agitated, uncooperative, was not accepting his/her medications and defecated in his/her room. The Physician said that he gave an order to transfer Resident #1 to the emergency department for an evaluation. During a telephone interview on 3/28/24 at 2:37 P.M., the Guardian said that on 3/12/24 the Facility Admission Director called her and said that the Facility might need to send Resident #1 to the hospital because he/she had, for several days, not been eating or accepting his/her antipsychotic medications. The Guardian said that during the telephone conversation, she told the Admission Director that if Resident #1 had to be transferred to the hospital, he/she should be transferred to the closest hospital (around 10 miles away.) The Guardian said that the Admission Director told her that it would be a disservice to Resident #1 and unfair to the closer hospital to send Resident #1 there, and, if Resident #1 needed to be transferred to the hospital, the Facility thought he/she should go back to the Hospital that referred him/her to the Facility (around 60 miles away). The Guardian provided the Surveyor with an email, dated 3/12/24, to the Facility Unit Secretary, which indicated the Guardian's request that, in the event of a transfer to the hospital, Resident #1 be transferred to the closest hospital and not the Hospital which had referred him/her to the Facility. During telephone interviews on: - on 3/25/24 at 1:13 P.M. with the Hospital Director of Regulatory Affairs, and, - on 3/26/24 at 3:50 P.M. with the Hospital Case Manager and Social Worker, they said the following: on 3/12/24, Resident #1 presented to the Hospital ED alone, with several bags of personal belongings, Resident #1 was brought to the hospital in a wheelchair van, not an ambulance, and the ED had not been prepared for or expecting Resident #1's arrival. The Guardian said that a short while later, the Hospital ED notified her that Resident #1 was in the ED. The Guardian said that despite her request, the Facility had transferred Resident #1 to the Hospital that was 60 miles away and not to the closest hospital. The Guardian said that the Facility had not notified her when they transferred Resident #1 to the ED or told her that they were in fact discharging Resident #1. The Hospital Case Manager, Social Worker and Director of Regulatory Affairs said that on 3/12/24, when case management staff in the ED contacted the Facility, Facility staff told them they would not permit Resident #1 to return to the Facility. The Guardian said that on 3/12/24 the Hospital ED notified her that the Facility refused to permit Resident #1 to return. During an interview on 3/25/24 at 11:00 A.M., the Administrator and the Director of Nurses said that when the Facility arranged transportation to the ED for Resident #1, a wheelchair van was available sooner than an ambulance. They said that because Resident #1 was not having a medical emergency and had no need for life support, the Facility scheduled a wheelchair van for Resident #1 instead of an ambulance. The Surveyor asked the Administrator and the Director of Nurses how Resident #1 and the Guardian were prepared for Resident #1's transfer/discharge to the Hospital. They said that because prior to admission, an arrangement had been made with the referring Hospital that if Resident #1's admission to the Facility did not go well, he/she could return to their Hospital, the Facility staff prepared Resident #1 and the Guardian for the transfer/discharge by telling them that the Facility was sending Resident #1 back to the Hospital. The Surveyor asked the Physician about Resident #1's discharge from the Facility to the Hospital ED. The Physician said he had not given the Facility an order to discharge Resident #1.

Based on interviews and records reviewed for one of three sampled residents (Resident #1), who had a court appointed legal Guardian, the Facility failed to ensure the Guardian was provided with a written notice which specified the duration of the Facility Bed-hold Policy at the time of Resident #1's transfer to the hospital on 3/12/24, as required. Findings include: The Facility Bed Hold Policy, dated as revised 10/2022, indicated that it was the policy of the Facility to provide the resident, responsible party or legal representative with notice of the Facility's Bed Hold Policy at the time of transfer from the Facility to ensure continuity of care and residence post therapeutic leave or hospitalization . The Policy indicated it applied to all residents regardless of payor source and indicated that a written notice including the duration of the State bed hold policy and the reserve bed payment policy would be provided to the resident and/or representative. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. The Record indicated the court appointed a legal Guardian for Resident #1 during April 2023. The Admission Minimum Data Set (MDS) Assessment, dated 3/12/24, indicated Resident #1's mental status was moderately impaired and he/she refused care daily. The MDS indicated Resident #1 was independent with eating, hygiene and was continent of bowel and bladder. Review of the Progress Note, dated 3/12/24 at 12:41 P.M. and written by the Unit Manager, indicated Resident #1 refused care, refused to eat any Facility food and a physician order was obtained by nursing staff to transfer Resident #1 to the Hospital for further evaluation. During an interview on 3/25/24 at 11:00 A.M., the Surveyor asked the Administrator whether a copy of their Bed Hold Policy was provided to Resident #1 and his/her Guardian at the time of Resident #1's transfer to the hospital on 3/12/24 and she said one was not. The Administrator said that the Facility did not provide a copy of the Bed Hold Policy to Resident #1 or the Guardian because the Facility discharged Resident #1 to the Hospital and a bed-hold was not in effect.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to permit Resident #1 to return following an evaluation in the emergency department (ED) when on 03/12/24, the Facility considered Resident #1 discharged at the time of the transfer. Findings include: The Facility Discharge/Transfer Policy, dated as revised 10/2022, indicated that each resident will be permitted to remain in the Facility and not be transferred or discharged unless: - a) the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility; - b) the transfer or discharge is appropriate because the Resident's health had improved; - c) the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident; - d) the health of individuals in the Facility would otherwise be endangered; - e) the resident has failed after reasonable and appropriate notice to pay for the stay at the Facility; - f) the Facility ceased to operate, or, - g) the transfer/discharge is resident/family initiated. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. The Record indicated the court appointed a legal Guardian for Resident #1 during April 2023. The Admission Minimum Data Set (MDS) Assessment, dated 3/12/24, indicated Resident #1's mental status was moderately impaired and he/she refused care daily. The MDS indicated Resident #1 was independent with eating, hygiene and was continent of bowel and bladder. Review of the Progress Note, dated 3/12/24 at 12:41 P.M. and written by the Unit Manager, indicated Resident #1 refused care, refused to eat any Facility food and a physician order was obtained by nursing staff to transfer Resident #1 to the Hospital for further evaluation. During telephone interviews on: - 3/25/24 at 1:13 P.M. with the Hospital Director of Regulatory Affairs, and, - 3/26/24 at 3:50 P.M. by telephone with the Hospital Case Manager and Hospital Social Worker, they said the following: the Facility discharged Resident #1 to the Hospital ED on 3/12/24 and when the ED case management staff contacted the Facility, the Facility would not permit Resident #1 to return. During a telephone interview on 3/28/24 at 2:37 P.M., the Guardian said that on 3/12/24 the Facility Admission Director called her and said the Facility might need to transfer Resident #1 to the hospital due to refusing to eat or take medications. The Guardian said that a short while later, the Hospital ED called her and notified her that Resident #1 was in the ED and the Facility refused to permit Resident #1 to return. The Hospital Director of Regulatory Affairs, Hospital Case Manager and Social Worker said that on 3/13/24, they attended a virtual meeting about Resident #1 with Facility leadership and the Guardian. The Director of Regulatory Affairs, the Case Manager, Social Worker and Guardian said that the Facility refused to permit Resident #1 to return to the Facility during that virtual meeting on 3/13/24. During an interview on 3/25/24 at 11:00 A.M., with the Administrator and Director of Nursing they said they had attended the virtual meeting with Hospital leadership and the Guardian on 3/13/24 concerning Resident #1. The Surveyor asked whether Hospital staff told them during the virtual meeting that Resident #1 was ready to return and they said not specifically, however, they said the Hospital staff repeatedly stated that Resident #1 did not need to be in the Hospital and did not belong in the Hospital. The Administrator and Director of Nursing said that the Facility did not permit Resident #1 to return to the Facility. The Administrator and Director of Nursing said that when Resident #1 was at the Facility, he/she would not allow staff members to enter his/her room to clean, would not allow staff to assist him/her with personal care and would not accept food or medications. The Administrator and Director of Nursing said they determined the Facility could not meet Resident #1's needs. During an interview on 3/26/24 at 3:27 P.M., the Physician said that it would be difficult for the Facility to claim an inability to meet Resident #1's care needs when they had admitted him/her with those same needs a week prior and had cared for him/her for a week. The Physician said that he did not give an order to nursing staff for Resident #1's discharge.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who had a court appointed legal Guardian and complex mental health needs, the Facility failed to ensure they developed an effective discharge plan that addressed his/her needs and availability of services, prior to discharge, as required. Findings include: The Facility Discharge/Transfer Process Policy, dated as revised 10/2022, indicated that that Facility interdisciplinary team and the physician would regularly review a resident's potential for discharge and/or need to transfer to an alternate setting. The Policy indicated that a physician order was required in cases on non-emergent discharge. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. The Record indicated the court appointed the Guardian for Resident #1 during April 2023. The Admission Minimum Data Set (MDS) Assessment, dated 3/12/24, indicated Resident #1's mental status was moderately impaired and he/she refused care daily. The MDS indicated Resident #1 was independent with eating, hygiene and was continent of bowel and bladder. The MDS indicated that there was no active plan for Resident #1 to return to the community. Review of Resident #1's Care Plan concerns, which were initiated 3/06/24, 3/07/24 and 3/09/24 and revised 3/09/24, indicated the Facility developed Care Plans with a focus on Resident #1's Activities, Mobility, Use of Antipsychotic Medication, Fall Risk, Self-care, Advanced Directives, Potential for Malnutrition, history of Suicidal Ideation and Skin Breakdown. Review of the Care Plan indicated there was no documentation to support the Facility having developed a Care Plan with a focus on any discharge plans for Resident #1. During an interview on 3/25/24 at 2:45 P.M., the Unit Manager said that Resident #1's adjustment to the Facility had not gone well and on 3/12/24, she spoke with the Physician about sending Resident #1 to the Hospital. Review of the Progress Note, dated 3/12/24 at 12:41 P.M. and written by the Unit Manager, indicated Resident #1 refused care, refused to eat any Facility food and a physician order was obtained by nursing staff to transfer Resident #1 to the Hospital for further evaluation. During a telephone interview on 3/26/24 at 3:27 P.M., the Physician said that, on 3/12/24, he received a call from the Unit Manager about Resident #1. The Physician said that the Unit Manager told him that Resident #1 was out of control, wasn't caring for his/herself, wasn't eating, was agitated and uncooperative, was not accepting his/her medication and defecated in his/her room. The Physician said that he gave an order to transfer Resident #1 to the emergency department (ED) for an evaluation. During a telephone interview on 3/28/24 at 2:37 P.M., the Guardian said that on 3/12/24 the Facility Admission Director called her and told her the Facility might need to send Resident #1 to the hospital. The Guardian said that during the phone call, the Admission Director told her that Resident #1 wasn't eating and refused his/her antipsychotic medication. The Guardian said that during the telephone conversation, she told the Admission Director that if Resident #1 had to be transferred to the hospital, he/she should be transferred to the closest hospital (around 10 miles away.) The Guardian said that the Admission Director told her that it would be a disservice to Resident #1 and unfair to the closer hospital to send Resident #1 there, and, if Resident #1 needed to be transferred to the hospital, the Facility leadership staff thought he/she should go back to the Hospital that referred him/her to the Facility (which was 60 miles away.) The Guardian provided the Surveyor with an email, dated 3/12/24, to the Facility Unit Secretary, which indicated the Guardian's request that, in the event of a transfer to the hospital, Resident #1 be transferred to the closest hospital and not the Hospital which referred him/her to the Facility. The Guardian said that a short while after her conversation with the Admission Director, the Hospital ED notified her that Resident #1 was in the ED (of the Hospital 60 miles away from the Facility.) The Guardian said that the Facility had not told her when Resident #1 was transferred to the Hospital ED. During telephone interviews on: -3/25/24 at 1:13 P.M. with the Hospital Director of Regulatory Affairs, and, -3/26/24 at 3:50 P.M. and with Hospital Case Manager and Hospital Social Worker, they said the following: on 3/12/24, Resident #1 presented to their ED, alone, with several bags of personal belongings, Resident #1 was brought to the ED by a wheelchair van, that the ED had not been prepared for or expecting Resident #1's arrival, when the Facility was contacted about Resident #1, Facility staff informed the ED that Resident #1 was not permitted to return to the Facility, they said Resident #1 did not need to be in the Hospital and had no where to go. The Guardian said that on 3/12/24 the Hospital ED called her and notified her that Resident #1 was in the ED and the Facility refused to permit Resident #1 to return. The Surveyor asked the Physician about Resident #1's discharge from the Facility to the Hospital ED and he said he had not given the Facility an order to discharge Resident #1. The Surveyor asked the Physician about the Facility's ability to meet Resident #1's needs. The Physician said that it would be difficult for the Facility to claim an inability to meet Resident #1's needs when they had admitted him/her with those needs a week prior and had cared for him/her for a week. During an interview on 3/25/24 at 11:00 A.M., with the Administrator and the Director of Nursing, they said the following: when Resident #1 was referred to the Facility by the Hospital, Hospital leadership told them that Resident #1 could return to the Hospital if his/her admission to the Facility was unsuccessful, the Facility did not develop a discharge plan for Resident #1 given their understanding that he/she could return to the Hospital, and the Facility discharged Resident #1 to the Hospital ED when they decided that the Facility could not meet Resident #1's needs. On 3/27/24, the Facility faxed the Surveyor a copy of Resident #1's Discharge Note. The Note, written by the Physician and dated 3/12/24, indicated that he/she received a phone call from the Unit Manager stating that Resident #1 was not eating, was behavioral and was refusing to care for his/her hygiene. The Note indicated the Physician agreed to transfer Resident #1 to the emergency department for further evaluation. Review of the Discharge Note provided to the Surveyor by the Facility indicated there was no documentation to support the Facility having developed a post-discharge plan of care for Resident #1, with Resident #1's participation and/or his/her Guardian, or having obtained a physician order for discharge, as required.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 4 of 14 applicable residents (#1, #3, #5, and #10) with falls, out of a total sample of 24 residents. The facility also failed to ensure the residents environment remained free from accident hazards relative to the storage of chemical/hazardous solutions. Findings include: 1. For Resident #3, the facility failed to provide effective interventions and adequate supervision to prevent falls in order to provide an effective falls intervention program for the resident. The facility also failed to follow the resident's plan of care relative to assuring the alarm pad was on properly and functioning, the toileting plan was followed, and the anti-rollback mechanism applied to the resident's chair was functioning properly. Resident #3 was admitted to the facility in 1/2012 with [DIAGNOSES REDACTED]. Review of the clinical record revealed that the resident was admitted to Hospice Services on 5/15/13. Review of a nursing note of 7/21/13 indicated that the resident's alarm sounded at 7:20 A.M. and the resident was found on the floor in the bedroom and had fallen out of his/her chair. The fall was unwitnessed. The door to the room had been closed due to the roommate wanting the door closed. A new intervention to get the resident up on the 11:00 P.M. - 7:00 A.M. shift was implemented. The resident had no injury from the fall. The surveyor asked to see the care plan that had been in place at the time of the resident's fall on 7/21/13. The current plan of care for falls originally dated 1/12/2012, (prior to the fall of 7/21/13), the only available care plan, had goal target dates of 3/1/12, 8/7/12, 11/16/12, and 2/15/13. The surveyor was also provided with event logs, which described falls, and new interventions which were hand written in on the care plan but not dated, and contained no goal dates. Approaches included: - Proper footwear/gripper socks in bed - Personal items within reach - Call light within reach - One person assist with Activities of Daily Living ADL's - Physical Therapy (PT)/Occupational Therapy (OT) as ordered as needed - Offer nap in afternoon - Toileting schedule, bring to bathroom at 2:30 and 5:00 P.M. - Offer P.M. care by 7:30 P.M. - 1:1 if out of bed before 7:00 A.M. - Low bed with mat's - Pad alarm at all times Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 8/20/13, indicated that the resident had impaired vision and wore glasses, had short and long term memory impairment and moderately impaired decision making skills, had difficulty focusing attention and disorganized thinking, was feeling depressed, tired, short tempered and easily annoyed, and had behavioral symptoms. The resident was extensive assist of one for transfers, ambulation, locomotion on the unit in the wheelchair, was always incontinent of bladder and bowel, had two or more falls with no injury since prior assessment, and received antipsychotic and antianxiety medications. Review of a nursing note of 8/13/13 indicated that the resident had an unwitnessed fall in his/her room at 11:15 P.M. The resident was found lying on his/her back in the middle of the bedroom. The alarm did not sound as planned. The pad alarm was found on the floor by the bed covered with blankets/bedding. The care plan was updated to include to discontinue (d/c) the resident's side rail to open side of bed, add taped body pillow (to firm it) under fitted sheet in bed, tape alarm to mattress, and change time of Ativan (antianxiety medication). The resident sustained [REDACTED]. Review of a nursing note of 10/2/13 indicated that the resident had an unwitnessed fall at 6:05 A.M. and was found sitting on the floor in his/her bedroom. The resident was previously in bed. The plan of care was updated to include Neurontin (an anti-seizure medication also used for nerve pain) 100 milligrams twice daily. The resident sustained [REDACTED]. A Significant Change of Status Assessment was completed on 11/12/13 (for the discontinuation of Hospice), which remained basically the same, and the resident had one fall with no injury since the prior assessment. Review of a nursing note of 11/17/13 indicated that the resident fell on the 11:00 P.M. - 7:00 A.M. shift. Review of the investigation indicated the resident slid off of the bed to the floor mat at 6:00 A.M. The fall was unwitnessed. The resident was placed on 1:1 supervision for the remainder of the shift (1 hour). The plan was to create a specific toileting schedule for the resident. The resident sustained [REDACTED]. On 11/27/13 the falls care plan was updated to change the toileting schedule to toilet the resident at 12:00 A.M., 3:30 A.M., 6:30 A.M. (when getting resident up out of bed in the morning), 2:30 P.M., 5:00 P.M., after supper, and as needed. Review of a nursing note of of 12/31/13 indicated that the resident had an unwitnessed fall out of his/her bed at 4:30 P.M. The nurse passing by the door of the room saw the resident scooting on her bottom heading toward the bathroom. The alarm had been discontinued. New interventions included: Offer nap in afternoon on couch in the Harmony Heights Living Room (for supervision). If the resident does take a nap in bed during the day, check on him/her every 30 minutes and get resident out of bed as soon as he/she is alert. The resident sustained [REDACTED]. Review of the Nursing note of 1/29/14 indicated that the resident had an unwitnessed fall in his/her room at 4:00 A.M. Certified Nursing Assistant (CNA) # 12 found the resident on the floor on his/her stomach in the middle of the room heading toward the bathroom. Review of the investigation indicated that the resident's toileting schedule had not been followed as planned. The resident's toileting schedule during the night shift was 12:00 A.M., 3:30 A.M., and upon arising at 6:30 A.M. The resident was toileted at 1:30 A.M. and fell at 4:00 A.M. CNA #12 was counseled regarding the importance of resident's toileting schedule. The resident sustained [REDACTED]. Review of a Quarterly MDS Assessment completed on 2/11/14 which remained basically the same, the resident had no indicators of delirium, mood or behavior, and the resident had two or more falls with no injury since the prior assessment. Review of a nursing note of 4/9/14 at 10:45 A.M. indicated that the resident had an unwitnessed fall in the Harmony Heights dining room. The resident fell out of the Broda Chair and was found on the floor in the center of the room with the Broda Chair approximately 10 feet away from the resident. CNA #10 who was supervising the dining room was in the kitchenette, which is adjacent to the dining room, at the time of the fall ; however, she had her back towards the resident as she was making breakfast for another resident. Staff lifted the resident from the floor with the Marisa (Transfer) lift back into the Broda chair. The resident sustained [REDACTED]. The resident was transferred to the hospital for evaluation and x-rays to the left hand, leg and hip. The resident was admitted with a [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] status [REDACTED]. The plan of care was updated to include an anti-rollback mechanism to a new wheelchair for the resident, Dycem, a wheelchair cushion seat cover, and to encourage recreation programs. Review of a Significant Change of Status Assessment completed on 4/15/14 (due to a decline in medical condition), indicated that the resident had an altered level of consciousness, psychomotor retardation, was tired, sleepy, had little energy, was totally dependent for transfers, bed mobility, locomotion in the wheelchair, had a Stage II Pressure Ulcer, had indicators of pain observed daily (vocal, facial, body movements or postures), had a fall within the last 2 to 6 months, and had a fracture related to a fall in the 6 months prior to reentry. Review of Care Area Assessment Summary Report for falls dated 4/28/14 indicated that the resident is status [REDACTED]. (Resident) continues to be at risk due to cognitive loss with poor safety awareness, decreased balance and weakness due to medical status. Care Plan Decision - Yes Review of a Quarterly MDS Assessment completed on 7/15/14 remained basically the same, transfers and bed mobility returned to the resident's baseline at extensive assistance. Review of a nursing note of 8/18/14 indicated that the resident was in the Harmony Heights dining room finishing his/her breakfast and drinking his/her coffee. At 10:20 A.M. The resident stood up from the wheelchair and fell to the floor pulling a straight back chair down on top of him/her. CNA #11 who was supervising the dining room was in the kitchenette at the time of the fall. CNA #11 was also getting another resident their breakfast. The resident complained of his/her elbow and hip hurting. New orders for x-rays were obtained for the left hip and shoulder which were negative for fracture. The investigation indicated that the anti-rollback mechanism was not working properly on the wheelchair so it was replaced by the therapy department. The resident was unable to back up the wheelchair. On 9/3/14 at 9:45 A.M., the surveyor observed the resident in the Harmony Heights activity/dining room in a wheelchair, sitting on a Roho (pressure reducing) cushion, glasses on, with anti-tippers and a anti-rollback mechanism on the back of the wheelchair. On 9/4/14 at 12:15 P.M., the surveyor observed the resident sitting in the wheelchair at a table in the Harmony Heights dining room with another resident waiting for lunch. On 9/4/14 at 12:25 P.M., the surveyor asked CNA #4 if Resident #3 was at risk for falls. CNA #4 said that the resident is different day to day but that his/her care plan included getting him/her out of bed and bringing him/her to a supervised area when he/she wakes up. "If (he/she) is in bed and is awake, (he/she) will try to get up out of the bed." CNA #4 said that the resident, "...always needs to be in a supervised area when awake." CNA #4 also said that the resident also attempts to get out of his/her chair at times and cannot ambulate, then attempts to stand and falls to the floor. During an interview on 9/8/14 at 1:10 P.M., with CNA #10 who was supervising the Harmony Heights dining room on 4/9/14 when Resident #3 fell and fractured her hip, she said that she was making breakfast for another resident in the kitchenette with her back to Resident #3. CNA #10 said she then heard, "Excuse me", turned around and and could see that Resident #3 was on the floor on her left side with her right hand holding the corner of the table. During an interview on 9/8/14 at 2:45 P.M., with CNA #11 who was supervising the Harmony Heights dining room on 8/18/14 when Resident #3 fell , she said that she was in the kitchen area getting another resident their breakfast. "I just turned my back for a second to grab something and as I did I heard a loud bang. When I turned around (the resident) was on the floor with a chair on top of (him/her). During interviews with Unit Manager #1 (UM #1) on 9/8/14 at 1:00 P.M., 3:30 P.M., and with the Director of Nursing (DON), the Administrator, and UM #1 on 9/9/14 at 11:00 A.M., the surveyor reviewed the 8 unwitnessed falls between 7/21/13 and 8/18/14, one of which resulted in a fractured left hip. UM #1 stated after the fall of 8/13/13 the alarm did not sound and the care plan was updated to tape the alarm to the mattress. UM #1 also stated that after the fall of 1/29/14 CNA #12 did not follow the toileting schedule as planned. When Resident #3 fell on [DATE] and sustained the left hip fracture, UM #1 said that she was sitting behind the nursing station completing paper work and did not see the resident fall. UM #1 said that CNA #10 had her back to the resident while making breakfast for another resident. In regards to the fall of 8/18/14, UM #1 said that CNA #11 was getting breakfast for another resident, turned her back for a moment, and heard the resident fall. UM #1 said staff believed it was due to a malfunction of the anti-rollback mechanism on the back of the wheelchair (it would not allow Resident #3 to back up her wheelchair on her own). The surveyor expressed concern regarding the number of unwitnessed falls. The Administrator and Director of Nursing indicated that they have been working on reducing alarms and felt they have had success in reducing the number of falls in the facility. 2. For Resident #5, the Facility failed to ensure adequate supervision and assistive devices to prevent accidents/falls (on 2/27/14, 5/8/14 and 6/8/14), one fall which resulted in a fractured hip. Resident #5 was admitted to the Facility in 10/2013 with Alzheimer's Dementia, Hypertension, Depression and Mood Disorder. Review of the 12/24/13 Quarterly Minimum Data Set (MDS) assessment indicated that Resident #5 had severe cognitive impairment, as evidenced by a score of 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS); was easily distracted, had disorganized thinking, required extensive assist with bed mobility, supervision with transfers, limited physical assist from staff with ambulation in room and on unit, was not steady walking or turning around and was only able to stabilize with staff assistance, utilized a walker; was occasionally incontinent of bladder, and had no falls or fractures in the last 6 months, prior to being admitted to the Facility or since being admitted to the facility. Review of the 12/24/13 "Resident Fall Risk Assessment,"indicated that Resident #5 continued to be a fall risk. The assessment indicated that Resident #5 had fallen/fractured in the past year. Review of the Resident's Falls Care Plan ( dated 10/4/13), indicated that Resident #5 was at risk for falls due to new environment, vision impairment, and has poor safety awareness secondary to dementia with memory loss. Interventions indicated: - Call light and personal belongings within reach. - Gripper socks on in bed. - Assist with Activities of Daily Living (ADLs). - A walker for all mobility. - Proper footwear at all times. The Care Plan goal indicated that Resident #5 would ambulate safely with a walker. Review of a 2/27/14 Nursing note indicated that Resident #5 fell in his/her bedroom, and was found leaning against another resident's bed on the opposite side of the room. The note indicated that Resident #5 complained of pain in the hip, had sustained a skin tear to the left elbow, and was transferred to the Hospital. Review of the 2/27/14 Fall Investigation Report indicated that Resident #5 had an unwitnessed fall at 6:45 A.M., was unable to move and complained of severe hip pain. The report indicated that the Resident had been checked at 5:45 A.M., and Resident #5 was observed by staff in bed. The report indicated that the Resident required a walker for ambulation, and that the walker was not within reach of the Resident at the time of the fall. There was no mention of the Resident's call light being in reach. The written Falls Care Plan was updated 2/27/14 to include keeping the Resident's walker at the bedside. Review of CNA #7's statement document indicated that Resident #5 was seated on the floor in the Resident's bedroom, and was screaming at another resident, who was standing near Resident #5, to get out of the room. Review of CNA #8's statement document indicated that Resident #5 had been swearing, saying that another resident had gone into Resident #5's room, and Resident #5 was trying to get this other resident out of the room. This CNA statement indicated that Resident #5 had shoes on. Review of a 2/27/14 Fall Assessment Log Intervention Care Plan indicated that Resident #5 fractured the left hip, that required surgery (Open Reduction Internal Fixation). Review of the clinical record indicated that Resident #5 was sent to the hospital on [DATE], after falling, and it was identified that the Resident had a hip fracture as a result of the fall. Resident #5 had an Open Reduction Internal Fixation (ORIF) surgical procedure to repair the fracture, and returned back to the Facility in 3/2014. Review of a 3/10/14 Significant Change in Status Assessment indicated the Resident was severely impaired for cognitive status, with a BIMS score of 3 out of a possible 15 (indicating severe cognitive impairment); was now totally dependent on staff for bed mobility and transferring, did not ambulate in room or in corridor; had problems with balance transferring surface to surface (between bed and chair or wheelchair); now used a wheelchair (w/c) for mobility; had a hip fracture; pain observed daily, had a fall and received 7 days of anti-anxiety and 7 days of an anti-coagulant medication injection. Review of the corresponding CAA (Care Area Assessment) indicated that Resident #5 had communication problems due to [DIAGNOSES REDACTED]. fall with hip fracture. Becomes very anxious with transfers and care. Received scheduled and as needed pain medication (Norco). Review of a 3/19/14 Behaviors Care Plan indicated that Resident #5 has a low tolerance for others not following the rules, and may be quick to anger if he/she believes someone is doing something wrong. Resident #5 has new limitations and increased confusion as a result of a hip fracture. The goal indicated that the Resident will be re-directed with 1:1 conversation in a quiet area. The Falls Care Plan was updated again on 3/31/14 to include the provision of a low bed with fall mats and not to use a top sheet (other interventions remained in effect). Review of a 5/8/14 Nursing note indicated that Resident #5 fell from the w/c ( wheelchair) at 5:00 P.M., after having a disagreement with another resident, while in the Unit's Dining Room, and became increasingly agitated. The note indicated that Resident #5 was re-directed to the Resident's bedroom, to look out the window and watch children outside playing. The note indicated that upon recheck, Resident #5 was found on the floor in front of the bedroom window, and that Resident #5 said he/she slipped trying to get up to get the children. There was no indication of an injury at this time. The Resident was transferred back into the w/c and relocated in a quiet area in the common area. Review of the 5/8/14 fall investigation report indicated that Resident #5 had an unwitnessed fall (supervision had not been provided as planned). The report indicated interventions to prevent further falls, was for Resident #5 not to be left in room, and to be re-located to a supervised area when agitated. The report also indicated that Resident #5 was wearing slipper socks and a "boot/cast" at the time of the fall and that a referral had been made to Rehab (Rehabilitation) for seating. A typed document that was attached to the Investigation report indicated that education had been provided to CNA #2 regarding not leaving Resident #5 unsupervised in room, when in w/c, and ensuring Resident #5 had proper footwear on. Resident #5 had been wearing heel floats (boot/cast) and not proper footwear at the time of the fall. Review of the 5/8/14 Fall Assessment Log Intervention Care Plan indicated that CNA #2 was educated regarding not leaving Resident #5 alone in room, in w/c, and for self-propelling when w/c used. In addition, the Falls Assessment Log Intervention Care Plan also indicated to discontinue heel floats in chair and apply sneakers. Review of a 6/8/14 Nursing note indicated that Resident #5 was found on the floor in the Dining Room at 6:35 P.M., after Dinner, and the Resident stated that he/she fell trying to go home. Resident #5 complained of back pain that resolved when seated in w/c again. The note indicated that Resident #5 remained in the w/c, by the Nursing Station, until bedtime to maintain safety and monitor. The 6/8/14 fall investigation report indicated that Resident #5 was found on the floor in the Dining Room between two Dining Room tables. The fall was unwitnessed (supervision had not been provided to ensure safety of the Resident and prevent falls). The Resident's primary mobility was the w/c, and the Resident had agitation/anxiety. Interventions to prevent further falls was for the Dining Room to be more closely monitored. Review of an "Inservice" sign in sheet (staff signatures and dated from 6/9 to 6/15/14), related to this fall indicated that Resident #5 fell , and may have been trying to leave the Dining Room after eating dinner. The interventions indicated that Resident #5 would be taken out of Dining Room after meals, must be in supervised areas, and escorted out of the Dining Room area when finished eating. Review of a 6/9/14 Nursing Request for Therapy report indicated that Resident #5 had a fall and slouches in the w/c at times. Upon further review of this report, Physical Therapy screened Resident #5 on 6/11/14, and indicated that Resident #5 sits well in the w/c, with good midline positioning. The instructions by the Therapy Department indicated that staff should encourage the Resident to re-position self, and if sacral sitting (slouching) encourage back to bed. Review of the 6/10/14 Quarterly MDS Assessment indicated the Resident had both long and short term memory problems, decisions were poor requiring cues/supervision; received extensive assist from staff for all mobility, used a walker and a w/c and had two falls without injury. During interview on 9/2/14 at 2:20 P.M. CNA #1 said that she is Resident #5's primary CNA for the 7:00 A.M. to 3:00 P.M. shift. CNA #1 said that Resident #5 required 2 staff assist for transfers, 2 staff assist for ambulation with a walker, and used a w/c. On 9/2/14 at 2:25 P.M., 3:00 P.M., 4:00 P.M., and 4:20 P.M., the Surveyor observed Resident #5 sitting in a w/c in the Resident's Unit Dining Room. Staff were in and out of the Dining Room areas, thus not providing consistent supervision. On 9/4/14 at 6:20 A.M., the Surveyor observed Resident #5 resting in a low bed. The walker was folded up and rested against the wall. On 9/4/14 at 8:20 A.M., the Surveyor observed Resident #5 sitting up in a w/c wearing soft black-colored slippers (not sneakers). On 9/4/14 at 1:30 P.M., the Surveyor observed Resident #5 sitting up in a stationary chair in the Resident's Unit Dining Room. CNAs #4 and #9 arrived to the Dining Room and assisted Resident #5 from the stationary chair into a w/c using a gait belt. CNA #4 left the gait belt secured around the Resident's waist after the transfer had been complete. Both CNAs exited the Dining. There was no supervision in this Dining Room area. On 9/4/14 at 3:50 P.M., the Surveyor observed Resident #5 sitting with slightly slouched posture in a w/c, in the Resident's Unit Dining Room, behind one of the columns at the far end of the Dining Room area. One Unidentified Nursing staff was sitting at the Nursing Station, some distance away, with her back to Resident #5, as she entered data into a computer (Nursing Desk is high, so cannot observe Residents where she was seated, and with her back to the room). At 3:52 P.M., the Surveyor observed as Resident #5 used nearby Dining Room tables, chairs and the eating counter to pull self forward in the w/c, from the far end of the Dining area, past other residents seated and wandering in the room, toward a piano near a window. Resident #5 leaned forward to grab the edge of the piano and pulled him/herself forward to peer out of the window, still with no supervision. Resident #5 used feet to push w/c backwards away from the window. At 3:55 P.M., the Surveyor observed as Resident #5 dug both heels into the floor to propel the w/c forward, out of the Dining Room, un-escorted, and into the Hallway (Resident now slouching more and sacral sitting). Resident #5 turned left in the w/c, reached, and grabbed the handrail to pull self in w/c forward, forcibly, past other resident's rooms, to the next section of handrail. There was no supervision provided when the Resident was in a common area. At 3:58 P.M., the Surveyor observed Resident #5 stop the w/c at the far end of the hallway, still slouched, shifted weight slightly and removed the gait belt that had been left in place by the unidentified CNAs who transferred Resident #5 earlier, still without supervision. At 4:03 P.M., the Surveyor observed as Resident #5 self-propelled to the opposite, right side of Hallway, leaned slightly to the left, still in a slouched position, and grabbed the handrail to pull him/herself forward, again forcibly, in the w/c. There was still no supervision provided. Resident #5 continued to unsafely propel forward, using the handrail glide along until he/she was at the double doors separating the Resident's Unit and the adjoining Alzheimer's Unit/Neighborhoods. The door to the left was closed, while the door to the right was open. An unidentified male visitor squeezed past Resident #5 who was now trying to pull self forward through doors, attempting to go from his/her Unit into the adjoining Unit. At 4:08 P.M., the Surveyor observed Resident #5 still in a slouched position as the Resident continued to to self-propel forward. The Resident then grabbed onto the Medication (Med) Cart, using it to pull him/herself past the Med Cart, then tried to maneuver and back the w/c to turn. The w/c was now caught on the left side compartment to the Med Cart. No staff intervened, supervised or assisted this Resident. At this time, UM #1 was walking from the Unit where Resident #5 now sat, toward the Resident's Unit, stopped briefly, said hello to Resident #5, and walked away, into the Resident's Unit. During interview with Unit Manager (UM) #1 on 9/4/14 at 4:09 P.M., the Surveyor identified what had been observed since 3:50 P.M., relative to the lack of assistance, lack of supervision, the Resident's unsafe, self-propelling in the w/c from the Dining Room up and down the Unit's hallway, and slouched posture for this Resident who had 3 unwitnessed falls on 2/27, 5/8 and 6/8/14. UM #1 said that it is okay for Resident #5 to be in common areas, as staff are usually around. UM #1 said that the falls care plan just identified that Resident #5 cannot be left alone in a w/c in his/her Room or Dining Room. The Surveyor then pointed out that the unidentified Nurse at the Nursing Desk, was still sitting with her back to the Residents in the Dining Room, and only 1 other unidentified staff member (was with another unidentified resident) was in the Dining Room area. UM #1 said that Resident #5 is allowed to be as independent as possible in the common areas and around the Unit. The care plan calls for the Resident to be in a supervised area. During interview on 9/9/14 at 11:45 A.M., the Surveyors reviewed Resident #5's falls of 2/27, 5/8 and 6/8/14 with the Administrator, the Director of Nursing (DON) and UM #1. 3. For Resident #1 the Facility failed to prevent the resident from sustaining 2 unwitnessed falls in his/her room. Resident #1 was admitted to the Facility in 7/2012 with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 8/1/13, included the following interventions: - Proper footwear/gripper socks in bed. - Personal items within reach. - Ensure the resident uses his/her cane for ambulation. - Glasses on at all times. - Pad alarm in bed. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/22/13, indicated that the resident's short and long term memory was impaired, moderately impaired decision making skills, independent with transfers, limited assistance with ambulation, and had no falls since the last assessment. Review of the nurse's note, dated 1/16/14, indicated that at 9:30 P.M. the resident was sitting in a stationary chair and presumably fell asleep. The nurse's note further indicated that the resident's roommate called out for help and the nurse observed the resident lying on the floor on the left side and assessed the resident. The resident was transferred from the floor to the wheelchair utilizing a mechanical lift. The resident sustained [REDACTED]. hematoma noted to the left upper eye/forehead. there was no mention of the pad alarm being in place and sounding, as planned. Review of the facility's internal investigation, dated 1/16/14, indicated that the resident was toileted at 8:30 P.M., the resident had an acute illness and appeared lethargic and tired. The facility's investigation further indicated that the CNA should have provided evening care and put the resident to bed at 8:30 P.M. The facility provided education to the CNA. Review of the Significant Change MDS Assessment, dated 1/21/14, indicated that the resident's short and long term memory was impaired, severely impaired decision making skills, extensive assistance with transfers and ambulation, and had 1 fall with injury (except major) since the last assessment. Review of the nurse's note, dated 2/12/14, indicated that at 2:50 P.M., the resident was observed on the floor in a seated position. The nurse's note further indicated that the resident attempted to self transfer from the wheelchair to the stationary chair in the hallway. The nurse's note further indicated that the resident hit the back of his/her head on the wall, causing a 2 cm. laceration. Ice was applied and the laceration stopped bleeding. Review of the facility's internal investigation, dated 2/12/14, indicated no new information. Review of the Fall Assessment Log/Intervention Care Plan indicated that on 2/19/14, the care plan was updated to include: - Gait belt on at all times. - Activity box for individual recreation. Review of the nurse's note, dated 3/25/14, indicated that at 7:50 P.M. a CNA found the resident laying on the right side in the bedroom next to a stationary chair. The resident was able to move his/her hands but was showing signs of pain when moving his/her fingers. The ring finger on the resident's right hand was swollen and bent to the side. The nurse's note further indicated that the Nurse Practitioner ordered an x-ray of the resident's right hand. Review of the Facility's internal investigation, dated 3/25/14, indicated that the resident sustained [REDACTED]. Review of the Fall Assessment Log/Intervention Care Plan indicated that on 3/25/14, the care plan was updated to include: - Do not leave the resident unattended in his/her room when in the wheelchair. - Stationary chair removed from the resident's room. Review of the nurse's note, dated 4/8/14, indicated that the resident sustained [REDACTED].M. The resident was alone in his/her bedroom, in the wheelchair. Review of the Facility's internal investigation, dated 4/8/14, indicated that the resident was attempting to self transfer from the wheelchair to the bed. Review of the Fall Assessment Log/Intervention Care Plan indicated that on 4/8/14, the care plan was updated to include: - One to one staffing from 3:00 P.M. to 4:00 P.M. - Recreation staff to alert the nurse if the resident leaves the activity area. - Do not leave alone in room. Review of the quarterly MDS assessment, dated 4/22/14, indicated that the resident's short and long term memory was impaired, severely impaired decision making skills, extensive assistance with transfers and ambulation, and had 1 fall with injury (except major), and 1 fall with no injury since the last assessment. Review of the nurse's note, dated 5/18/14, indicated that at 11:30 A.M. the resident sustained [REDACTED].

Based on record review and staff interview, the facility failed to provide identified interventions (a personal safety alarm) to avoid an accident for 1 sampled resident (Resident #6 ) identified at high risk for fall and injury, from a total sample of 24. Findings include: Resident #6 was admitted to the facility in February 2013 with [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 7/29/13. Review of the Initial Minimum Data Set (MDS) assessment with a reference date of 2/11/13, indicated that the resident had severe cognitive impairment; had delusions and disorganized thoughts; required extensive assistance with transfers and ambulation, and used a wheelchair. The facility's fall risk assessment completed on 2/6/13, identified the resident as a fall risk and the facility developed a written care plan to address this risk. The care plan for the resident to remain safe in the environment initiated 2/6/13 included the following interventions: "pad alarm at all times" and "2 assist to ambulate". Record review revealed that the resident had a witnessed fall on 3/5/13 resulting in a laceration to the nose and a hematoma to the forehead. The resident was transferred to the emergency room for treatment of [REDACTED]. Review of Nurses' Notes, dated 3/5/13, and the Incident and Investigation Report (not dated) revealed the resident fell outside the tub room when self rising from the wheelchair. The investigation indicated that the pad alarm was not in place at the time of the fall. The investigation further indicated the resident had been transported to the tub room in the wheelchair by CNA #1 (Certified Nursing Assistant). When CNA #1 and the resident reached the tub room door, the CNA went into the tub room to assist another staff member transfer a resident from the tub chair to a wheelchair. Per CNA #1's statement, the tub room door stayed open during the transfer and he/she had Resident #6 in sight while assisting the other staff member. CNA #1's statement further read that he/she was within 4 feet of the resident with no obstacles in place when the resident impulsively stood up from the wheelchair and fell to the floor. CNA #1 was not able to reach the resident in time to stop the fall. During interview on 7/30/13 at 2:00 P.M., the DNS (Director of Nursing Services) indicated that CNA #1 had the resident in view at the time of the fall and that a pad alarm was not indicated when the resident was under supervision while receiving care. For Resident #6, the facility failed to have a functional alarm in place to alert CNA #1 (who was assisting another staff member) that Resident #6 was rising out of the wheelchair and as a result of the attempted self transfer fell and sustained an injury.