Every finding on record at Agawam South Rehab and Nursing

Based on observations, interviews, and records reviewed, the facility failed to maintain infection control practices relative to laundry services for three units (A Wing, C Wing and D Wing) out of three total units, placing all facility residents at risk for exposure to unsanitary linens, contamination and the spread of infections. Specifically, the facility failed to maintain infection control practices relative to laundry services when: -Resident #93 and Resident #32 indicated during a resident council meeting that their clothing washed by facility laundry smelled of mildew.-Feces were observed in the washer machine with a load of linens being washed. -the chemical programming box was not set to the correct program to ensure proper sanitization of resident's linens. -Washer machine #2 which was not functioning as required and not properly spinning or draining the linens was being used for one year. -Clean mop heads were being placed wet into a bin and not hung to dry as required. -A washed lift sling that smelled of urine was hung with clean lift slings. -wet linens were left overnight in the washer machine. Findings include: Review of the facility policy titled Laundry Handling and Processing effective March 2018 and revised February 2025, indicated but was not limited to the following: -Laundry.may include bed sheets, blankets, towels, personal clothing, patient apparel, gowns, and other linens. -Employees should collect soiled linens from resident/patient rooms throughout the day. Nursing Department personnel are responsible for physically removing solids (feces and vomit) before placing linens into soiled linen barrels. -The lip of the washer door should be disinfected prior to closing and starting the cycle. This reduces the risk of clean linens contacting soil or microorganisms. -Damp textiles (linens, clothing, etc.) should not remain in machines overnight. Final loads should be timed so that all laundry is dry prior to the end of the shift. -All items should be moved from the washer to the dryer as promptly as is practicable in a manner that minimizes the risk of contamination and/or re-soiling. -To prevent fire hazards, rags and mops should never be dried in a dryer- air dry only. -Do not operate damaged or broken equipment. -Damaged or broken equipment should be marked or communicated as Out of Order or Do Not Operate in a manner than ensures others will not accidentally utilize the equipment while awaiting repairs. Review of the facility policy titled Personal Laundry Handling and Processing effective March 2018 and revised February 2025, indicated but was not limited to the following: -Providing clean personal clothing is critical for resident care and dignity. Review of the Resident Council Meeting Minutes dated 11/28/25, indicated that residents reported that their clothing smelled like mildew. Review of the personal laundry list dated 3/6/26, indicated that Resident #93 and Resident #32 had their personal laundry washed by the facility. Resident #93 was admitted to the facility in December 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke). Review of Resident #93's Minimum Data Set (MDS) assessment dated [DATE], indicated: -was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15. -was dependent for chair/bed-to-chair transfers and toilet transfers. Resident #32 admitted to the facility in January 2025 with diagnoses including Parkinson's disease, dementia, and overactive bladder. Review of Resident #32's MDS assessment dated [DATE], indicated the Resident was moderately cognitively impaired, as evidenced by a BIMS exam score of 11 out of a possible 15. On 3/4/26 at 1:25 P.M., the surveyor observed the following in the facility main laundry room: -A brown solid substance (the size of a walnut) spinning around in the washer machine with the linens being washed. -Washer machine #2 was set to the heavy soil setting. The chemical programming box was set to the personals setting. During an interview at the time, the Housekeeping and Laundry Manager said that the brown solid substance spinning around in the washer machine was feces. The Housekeeping and Laundry Manager said the feces should not be in the washer machine and that she reiterated all the time at morning meetings that feces should not be mixed in with the soiled laundry. The Housekeeping and Laundry Manager said that the washing machines were programmed based on the type of load to be washed. She said the chemical programming box did not work correctly and had to be programmed to the personals setting all the time. The Housekeeping and Laundry Manager said that the process of cleaning mop heads was that the mop heads were washed by the evening shift and then removed from the washer machine the following morning. The Housekeeping and Laundry Manager said the wet mop heads were placed in a bin and were not hung to dry, and in the morning the mop heads sometimes smelled bad. During a Resident Council meeting conducted on 3/4/26 at 2:00 P.M., Resident #32 said that he/she received damp clothing that smelled moldy on more than one occasion. Resident #93 said the linens smelled of urine, including the lift slings. Resident #93 said he/she has to then sit in the lift sling that smelled of urine all day long. Resident #93 said that the facility told them that the washer machines were broken. On 3/5/26 at 7:40 A.M., the surveyor observed the following in the facility main laundry room: -The washer machine (unlabeled) was set to the heavy soils setting, and the chemical programming box was set to white sheets. Bed sheets, towels, and resident gowns were observed in the washer machine. The washer machine was running at that time. -Washer machine #2 was set to the heavy soils setting, and the chemical programming box was set to white sheets. Resident gowns, cloth under pads, and towels were observed in the washer machine. The washer machine was running at that time. On 3/6/26 at 7:05 A.M. through 7:14 A.M., the surveyor observed the following in the facility main laundry room: -A load of wet linens (towels and bed sheets) that had completed washing was sitting in the unlabeled washer machine. -Three lift slings were hanging to dry after being washed. One of the lift slings was observed with a strong smell of urine. During an interview at the time, Housekeeper #1 said the evening staff leave at 9:00 P.M. and the day shift staff arrive at 7:00 A.M. Housekeeper #1 said the load of wet linens observed in the washer machine must have been washed during the evening shift the previous day. Housekeeper #1 said the mop heads were washed by the evening shift and put in the bin while still wet. Housekeeper #1 said the mop heads did not get hung to dry. During an interview on 3/6/26 at 7:14 A.M., the Housekeeping and Laundry Manager said the lift sling smelled of urine and the load of linens observed in the washer machine were washed before the evening shift left at 9:00 P.M. the previous day. The Housekeeping and Laundry Manager said that washer machine #2 did not work on the heavy soiled or whites settings and that these settings had not worked properly for the past year, that the washer machine did not spin or drain correctly and a code indicating that the load was overfilled would alarm frequently. The Housekeeping and Laundry Manager said the facility was still using the washer machine on the heavy soiled and whites settings even though the settings did not work correctly and was setting the chemical programming box to the personals setting. She further said the heavy soil program on the washer machine was for very dirty linens, including linens from isolation rooms or rooms with other identified viruses, as well as towels. The Housekeeping and Laundry Manager said the whites setting on the washer machine was for the washing of blankets and bed sheets. The Housekeeping and Laundry Manager said the chemical programming box setting had to match the setting on the washer machine in order for the chemicals to transfer to the washer machine and when personal laundry was left in residents' rooms for days that it was hard to get the smell out. The Housekeeping and Laundry Manager said she had complaints from residents that their clothes smelled of urine or mildew. The Housekeeping and Laundry Manager said after the observation made by the surveyor on 3/4/26 of feces in the washer machine, she removed the feces, wiped down the outside of the washer machine, and re-washed the load of linens. The Housekeeping and Laundry Manager provided no evidence that the washer machine interior was sanitized prior to re-washing the load of linens. During an interview on 3/6/26 at 8:55 A.M., the Maintenance Director said the service vendor for the washer machines was not notified about the broken settings on washer machine #2 in the past year. The Maintenance Director said the process was that the laundry staff would enter the maintenance issue into the electronic tracking system, and maintenance staff would then be responsible for contacting the vendor to fix the broken machine. During an interview on 3/6/26 at 9:43 AM, the laundry service vendor's Territory Manager said that the vendor provided both the chemicals and the equipment necessary to sanitize the linens and input the chemicals into the washer machines. The Territory Manager said to ensure that the linens were washed with the correct chemicals, the washer machine program should be set to the same setting as the chemical programming box. The Territory Manager further said that the program setting on the chemical programming box would dictate which chemicals and what amount were input into the washer machines. The Territory Manager said that the personals setting on the chemical programming box was for clothes and the personals setting did not include bleach. The Territory Manager said that the heavy soil setting would input the following chemicals: bleach, detergent, softener, and iron control. The Territory Manager said there was a difference between settings and that the heavy soil setting input more chemicals into the washer machine than the whites setting and the vendor recommended the heavy soil setting be used at all times for all healthcare facilities. The Territory Manager said that the heavy soil setting was recommended because healthcare facilities had to clean linens that contained feces, urine, and vomit. During an interview on 3/9/26 at 9:26 A.M., the Administrator said the expectation was that policies and procedures for the management of laundry were followed so residents were not affected. The Administrator said that the mop heads should be hung dry, linens should not be left in the washer machine overnight, lift slings that were still dirty should not be hanging with the clean lift slings, and feces should not be in the washer machine. The Administrator said the concern when laundry infection control practices are not followed is that residents could receive clothing that was not wearable and smelled bad, which could also be a resident dignity issue.

Based on record review and interview, the facility failed to complete comprehensive assessments timely, according to the required Resident Assessment Instrument (RAI) process, for two Residents (#36 and #95) out of a total sample of 19 residents.Specifically, the facility failed to complete comprehensive assessments for Resident #36 and Resident #95 within the required 14 days of the Assessment Reference Date (ARD) date. Findings include:1. Resident #36 was admitted to the facility in November 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia and chronic respiratory failure with hypoxia. Review of the Annual Minimum Data Set (MDS) Assessment with an ARD of 10/23/25, indicated the assessment was completed by the facility staff on 11/11/25, five days late. 2.Resident #95 was admitted to the facility in August 2019 with diagnoses including protein malnutrition, anxiety disorder, mild cognitive impairment and a history of falling. Review of the Annual MDS Assessment with an ARD of 1/27/26, indicated the assessment was completed by the facility staff on 2/23/26, 13 days late. During an interview on 3/9/26 at 8:46 A.M., the surveyor and the MDS Nurse reviewed the most recent comprehensive MDS Assessments for Resident #36 and Resident #95. The MDS Nurse said the Annual MDS for Resident #36 with an ARD of 10/23/25 was not completed within the required 14 days as it was completed by facility staff on 11/11/25, five days after the required due date of 11/6/25. The MDS Nurse further said the Annual MDS for Resident #95 with an ARD of 1/27/26 was not completed within the required 14 days as it was completed by facility staff on 2/23/26, 13 days after the required due date of 2/1/26.

Based on record review and interview, the facility failed to complete quarterly Minimum Data Set (MDS) assessments timely, according to the required Resident Assessment Instrument (RAI) process, for four Residents (#6, #36, #70 and #95) out of a total sample of 19 residents.Specifically, the facility failed to ensure the following quarterly MDS assessments were completed no later than 14 days after the Assessment Reference Date (ARD): for Resident #6 on two occasions, (ARD 9/22/25 and ARD 12/4/25)for Resident #36, on one occasion, (ARD 1/22/26)for Resident #70, on two occasions, (ARD 10/28/25) and ARD 1/27/26) andfor Resident #95, on one occasion (ARD 10/28/25).Findings include:1.Resident #6 was admitted to the facility in June 2025 with diagnoses including chronic respiratory failure, stage 3 kidney disease, and atherosclerosis heart disease.Review of the Quarterly MDS Assessment with an ARD of 9/22/25, indicated the assessment was completed by the facility staff on 10/22/25, 16 days late.Review of the Quarterly MDS Assessment with an ARD of 12/4/25, indicated it was completed by the facility staff on 1/28/26, 41 days late. 2.Resident #36 was admitted to the facility in November 2023 with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, dementia and chronic respiratory failure with hypoxia.Review of the Quarterly MDS Assessment with an ARD of 1/22/26, indicated the assessment was completed by the facility staff on 2/23/26, 18 days late. 3.Resident #70 was admitted to the facility in July 2025 with diagnoses including cerebral infarction, Type II diabetes, depression, and chronic kidney disease.Review of the Quarterly MDS Assessment with an ARD of 10/28/25, indicated the assessment was completed by the facility staff on 11/12/25, 1 day late.Review of the Quarterly MDS Assessment with an ARD of 1/27/26, indicated the assessment was completed by the facility staff on 2/23/26, 13 days late. 4.Resident #95 was admitted to the facility in August 2019 with diagnoses including protein malnutrition, anxiety disorder, mild cognitive impairment and a history of falling.Review of the Quarterly MDS Assessment with an ARD of 10/28/25, indicated the assessment was completed by the facility staff on 11/12/25, 1 day late. During an interview on 3/9/26 at 8:46 A.M., the surveyor and MDS Nurse reviewed the most recent quarterly MDS Assessments for Resident's #6, #36, #70 and #95. The MDS Nurse said the following Resident Quarterly MDS Assessments were not completed within the required 14 days:-Resident #6, MDS Assessments ARD of 9/22/25 and 12/4/25-Resident #36, MDS Assessment ARD of 1/22/26-Resident #70, MDS Assessments ARD of 10/28/25 and 1/27/26-Resident #95, MDS Assessment ARD of 1/28/25.

Based on observation, interview, and record review, the facility failed to accurately code Minimum Data Set (MDS) Assessments for two Residents (#21 and #6), out of a total sample of 19 Residents. Specifically, the facility failed to: 1) For Resident #21, accurately code functional limitation in Range of Motion (ROM- the extent to which a body part can be moved around) when the Resident had an impairment in ROM to one upper extremity. 2) For Resident #6, accurately code the use of an anticoagulant medication (medicine that increases the time it takes for blood to clot). Findings include: 1. Resident #21 was admitted to the facility in December 2023 with diagnoses including osteoarthritis and osteoporosis. Review of the Resident's Occupational Therapy Discharge Summary with dates of service 10/29/24 - 2/9/26, indicated that Resident #21 had a goal to tolerate the most appropriate left hand WHFO (Wrist Hand Finger Orthosis - used to support injured or weak joints affected by stiffness or contractures) to support decreased risk for further contracture. Review of the Resident's MDS Assessments dated 12/9/25, 9/9/25, and 6/10/25, indicated that the Resident did not have a functional limitation in ROM to the upper extremities. During an interview on 3/4/26 at 12:40 P.M., Occupational Therapist (OT) #1 said in October 2024, Resident #21 was started on therapy services to address increased flexion and contracture of the left hand and wrist. OT #1 said the Resident was discharged from therapy services on 2/9/26 with a recommendation for a left-hand palm guard. During an interview on 3/10/26 at 8:53 A.M., MDS Nurse #1 said Resident #21's MDS Assessments with dates 12/9/25, 9/9/25, and 6/10/25, should have been coded to include a functional limitation in Range of Motion for one upper extremity but was not coded. 2. Resident #6 was admitted to the facility in June 2025 with diagnoses including chronic respiratory failure, stage 3 kidney disease, and atherosclerosis heart disease. Review of the most recent MDS assessment dated [DATE] indicated Resident #6 was receiving an anticoagulant medication during the seven-day look back assessment period. Review of the January 2026 Physician orders did not indicate that Resident #6 was prescribed an anticoagulant medication. During an interview on 3/9/26 at 8:46 A.M., MDS Nurse #1 reviewed Resident #6's Physician orders for January 2026 and said the Resident was not on an anticoagulant medication during the assessment period and this was marked in error.

Based on observations, interviews, and record review, the facility failed to ensure that Physician's orders were implemented in accordance with professional standards of practice for two Residents (#17 and #28), out of a total sample of 19 residents.Specifically, 1.For Resident #17, the facility failed to ensure the Wound Provider recommendations from January 2026 were implemented timely for the Resident's right heel and right superior ankle wounds, that new treatment recommendations were implemented in February 2026 for both right heel and right superior ankle wounds, and Physician orders were obtained for the Resident's right heel wound in March 2026, putting him/her at risk of decline in status of the wound and delayed wound healing.2.For Resident #28, the facility failed to ensure: -Physician orders were in place for a bowel regimen, when the Physician recommended initiating a bowel protocol, -Physician orders were in place prior to administering a suppository, and -Documentation was completed relative to bowel regimen interventions, when Resident #28 had complaints of constipation increasing the potential risk of discomfort and bowel obstruction. Findings include: 1. Resident #17 was admitted to the facility in December 2025 with diagnoses including osteomyelitis of right ankle/foot, Type II Diabetes, Peripheral Vascular Disease (PVD), and non-pressure chronic ulcer of the right heel and mid-foot. Review of the facility policy titled Skin Prevention, Assessment and Treatment, revised 10/24/25, indicated: -Purpose: > To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those at risk for skin breakdown. > To promote healing of existing pressure ulcers. -Procedure: >Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions . should be assessed and documented weekly by the Wound Nurse, or designee, in the medical record. >Interventions for prevention or active skin alterations may include but are not limited to: Wound Consultant review . >The goals of wound treatment are to promote healing . >Residents with wounds should be reviewed during weekly Risk Management Committee meetings for progress, interventions, and care plan revisions as appropriate. >The Risk Management Committee should also monitor to assure the facility's policies and protocols are followed. On 3/3/26 at 11:11 A.M., the surveyor observed Resident #17 awake and lying in bed. During an interview at the time, Resident #17 said he/she had a wound on the right foot which started prior to admission. Resident #17 said the facility's Wound Provider followed him/her for the wound. Review of the Minimum Data Set (MDS) Assessment, dated 12/13/25, indicated Resident #17: -Was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 points. -Had range of motion impairment of his/her lower extremity on one side. -Had a diabetic ulcer and infection of the foot. -Had dressings to the feet. Review of Resident #17's clinical record included the following: -Wound Assessment Reports, completed by the Wound Provider on 1/15/26 and on 1/22/26 indicated: >Right heel arterial wound: Recommend the following treatment: cleanse wound with 0.125% (1/4 strength) Dakin's solution, apply collagen particles, Alginate with silver and cover with a dry clean dressing daily and as needed (PRN) for soiling, saturation, or accidental removal. -January 2026 Treatment Administration Record (TAR) indicated: >Right heel wound: cleanse with wound cleanser, pat dry. Apply collagen particles, Alginate with silver, cover with a dry clean dressing daily and PRN, initiated 1/23/26 (eight days after the recommendation was made) and was discontinued on 1/29/26. Further review of the TAR indicated the treatment orders to the right heel did not include to cleanse the wound with 0.125% Dakin's solution until 1/30/26 (15 days after the Wound Provider made the recommendation). Review of Resident's #17 Wound Assessment Report, completed by the Wound Provider on 2/19/26 indicated: >Right heel arterial wound: Recommend the following treatment: Cleanse wound with 0.125% Dakin's solution, apply honey hydrogel and cover with a dry clean dressing daily and PRN . >Right superior ankle, Stage 3 Pressure Ulcer: Recommend the following treatment: Cleanse wound, apply hydrogel and cover with a dry clean dressing daily and PRN . -Review of the February 2026 TAR indicated: >Right heel treatment was initiated on 2/21/26 (as recommended by the Wound Provider) and discontinued on 2/25/26. (Treatment provided for 4 days) >Right superior ankle wound initiated on 2/21/26 (as recommended by the Wound Provider) and discontinued on 3/5/26. -Wound Assessment Report, completed by the Wound Provider on 2/26/26 indicated the following updated recommendations: >Right heel arterial wound: Recommend the following treatment: Cleanse wound with 0.125% Dakin's solution, apply honey gel, Calcium Alginate with silver and cover with a dry clean dressing daily and PRN . >Right superior ankle, Stage 3 Pressure Ulcer: Recommend the following treatment: Cleanse wound with 0.125% Dakin's solution, apply honey gel, Calcium Alginate with silver and cover with a dry clean dressing daily and PRN Further review of the February 2026 TAR indicated: >no scheduled treatment to Resident #17's right heel was provided after it was discontinued on 2/25/26. >no indication that the Wound Provider recommendations from 2/26/26 were initiated for both right heel wound and right superior ankle wound. Review of the March 2026 Physician's Orders included the following: -May be followed by in-house Wound Provider for wound evaluation and treatment, initiated 12/10/25. -Cleanse wound to right superior ankle with wound cleanser, pat dry. Apply Honey hydrogel and cover with a dry clean dressing daily and PRN, initiated 2/21/26. Further review of the March 2026 Physician's Orders did not include any treatment orders for the Resident's right heel. On 3/4/26 at 12:38 P.M., the surveyor observed Resident #17 lying in bed and the Resident's right leg and foot were exposed and elevated on a pillow. The Resident's right foot and heel were observed to be swollen and there were no open areas on the right heel. A large rectangular bandage was observed on the outer side of the Resident's right lower leg and was dated 3/4/26. During an interview on 3/4/26 at 1:50 P.M., Nurse #1 said Resident #17 had two open areas on his/her right outer ankle, one open area was closer to the ankle, and the other open area was closer to the right heel. Nurse #1 said the treatment to both areas was to cleanse the areas with wound cleanser, apply honey hydrogel and a dry clean dressing daily and as needed. Nurse #1 said there have been numerous treatments to the Resident's open areas and that the Wound Provider assesses the areas weekly on Thursdays with the Unit Manager (UM). Nurse #1 said if there were recommendations from the Wound Provider, the UM would enter the new orders into the Resident's clinical record. During an interview on 3/5/26 at 11:42 A.M., UM #1 said Resident #17 was evaluated by the Wound Provider today (3/5/26) and made new recommendations to the Resident's open wound areas. UM #1 said Resident #17 had an open area on his/her right superior ankle and the other was below the right ankle on the lateral foot. UM #1 said she would round with the Wound Provider, and any recommendations from the Wound Provider would be documented and reviewed with the Provider (Physician or Medical Practitioner). If the Wound Provider recommendations were approved, they would be entered into the Resident's Physician's orders. During an interview on 3/5/26 at 11:57 A.M., the Physician Assistant (PA) said she worked in the facility four days a week and the Wound Provider completed wound rounds in the facility weekly on Thursdays. The PA said the Wound Provider would review residents with wounds and would make recommendations for wound care. The PA said she had always approved the Wound Provider's treatment recommendations for Resident #17. On 3/5/26 at 4:13 P.M., the Director of Nursing (DON) said when the Wound Provider makes recommendations, it is expected that the facility would address those recommendations with the Provider within 24 to 48 hours. During a follow-up interview on 3/6/26 at 11:01 A.M., the DON said the Wound Provider will round with facility staff, either the UM, herself (DON) or Assistant DON. The Wound Provider would measure the resident's wounds and make recommendations for treatments which would be reviewed with the facility Provider. The DON said the facility Provider does not typically disagree with the Wound Provider recommendations, but if they did not agree, they would enter a progress note in the resident's clinical record and enter an order for another treatment. The surveyor and the DON reviewed Resident #17's clinical record and the DON said there was no evidence that there was a treatment in place for Resident #17's right heel in March 2026 and that the Wound Provider's recommendations from 2/26/26 were not implemented. The DON said if there were questions about the Wound Provider's recommendations, the facility would clarify them within 24 to 48 hours, and the clarified orders would be implemented. The DON said relative to Resident #17, the Wound Providers' recommendations were never clarified and should have been. The DON said if there were recommendations made by the Wound Provider that were not clarified and implemented, the Resident's wound condition could decline. 2. Resident #28 was admitted to the facility in February 2026 with diagnoses including aftercare following surgery for neoplasm, morbid obesity, mild intellectual disability, muscle weakness, unsteadiness on feet and diverticulosis. Review of the facility Policy titled Bowel Management Program Dietary and Nursing, revised 11/5/25, indicated: -This facility will utilize charting (nursing, Certified Nursing Assistants - CNA's, dietary) to monitor bowel function to identify cause factors that place the individual at risk for constipation. -Nursing will contact residents' provider for bowel management. Review of the facility policy titled Charting and Documentation, revised 10/25/25, indicated: -Documentation will include information on assessment, notifications, interventions and evaluation. During an interview on 3/3/26 at 11:37 A.M., Resident #28 said he/she was having issues with constipation, recently had something put up his/her rectum and that his/her rectum hurt. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #28 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of the February 2026 bowel monitoring flow sheet, titled Documentation Survey Report v2 Feb-26, indicated Resident #28 did not have a bowel movement on 2/25/26 through 2/28/26 (four days). Review of a Consulting Physician Note dated 2/27/26, indicated: -Patient reports constipation -Recommendation. initiate bowel regimen Review of the Nurses' Note dated 2/28/26, indicated the following in part: -Resident had concern of constipation but refused any bowel medication. -Resident stated he/she was given liquid yesterday. -Last documented bowel movement was 2/25/26. Review of Resident #28's February 2026 and March 2026 Physician orders did not include any bowel regimen medications. Review of Resident #28's February 2026 and March 2026 Medication Administration Record (MARs) did not indicate the Resident received any bowel regimen medications. Review of the Nurses' notes from 2/25/26 through 3/1/26, did not indicate the Resident received any bowel regimen medications. Review of the Provider Note dated 3/3/26, indicated the following: -Resident not moving bowels well -Resident had lactulose (laxative medication) yesterday without effect During an interview on 3/9/26 at 1:20 P.M., the DON said she maintained a bowel management list consisting of residents who were at high risk for constipation, and Resident #28 was not on the list. The DON said the CNA's document bowel movements on the computer and if they document no bowel movement three days in a row, it will trigger a warning message on the Nurse's dashboard. The DON said at that point the Nurse would notify the Provider and the resident would then receive lactulose or MiraLAX (medication used to treat constipation). The DON said if the lactulose or MiraLAX did not work, the Nurse would give the resident a suppository. The DON said if those two things were not effective, the Nurse would administer an enema. The surveyor and the DON reviewed the current Physician orders and all discontinued Physician orders since Resident #28's admission and the DON said there were no bowel regimen orders in place, including lactulose or MiraLAX, suppository, or an enema. The surveyor and the DON reviewed the Nurses note dated 2/28/26, and the DON said the Nurses note did indicate the Resident had concerns relative to constipation, that he/she refused bowel medications because he/she had liquid stuff yesterday. The DON further said there was no way to verify what exactly the Resident had received as there were no Physician orders in place for bowel medications nor were there any Nurses notes that indicated what medication had been administered to Resident #28. During an interview on 3/9/26 at 2:37 P.M., the DON said there should be an order for any laxative interventions and there was not. The DON also said if Resident #28 did receive medication she would have expected to see a new Physician's order, a Nurses Note, as well results of said medication and its efficacy. The DON said she would research this concern for Resident #28 to see how the Nurse became aware that the Resident was experiencing constipation and what medication was then administered. During a follow-up interview on 3/9/26 at 3:24 P.M., the DON said she spoke with the Nurse who administered the suppository and learned that the Nurse had not given any liquid to Resident #28 to address the constipation but rather administered a suppository. The DON said the Nurse administered a suppository with no Physician order. The DON further said the Nurse did not follow the facility bowel protocol by first utilizing lactulose or MiraLAX, then a suppository. The DON said the Nurse should have obtained a Physician's order, started lactulose or MiraLAX but went directly to a suppository. The DON said if the Nurse had started with the first step in the constipation protocol maybe such an invasive step such as a suppository could have been avoided. The DON said not only did the Nurse not follow the bowel protocol, but she also administered a medication without an order and did not document this information. During an interview 3/10/26 at 10:59 A.M., with the DON and Unit Manager (UM) #1, the DON said Resident #28 did not have bowel regimen in place when the suppository was administered. The DON said the risk of the Resident not moving his/her bowels could be a bowel obstruction. The DON said Resident #28 had a wound vac (medical device that uses negative pressure therapy to promote wound healing by applying controlled suction to the wound site) in place for recent surgery, and the risk of constipation could also cause the wound to dehiscence (a surgical complication where a closed incision reopens, exposing internal tissues and potentially leading to serious health risks). The DON said if there was a recommendation made from a Consult, it would be the expectation that the order would be reviewed and initiated within 24 hours. The DON also said that the facility had an admission order set in place for bowel protocol and for Resident #28, there were no Physician's orders for bowels medications to be administered and there should have been. During an interview on 3/10/26 at 11:46 A.M., the Physician Assistant (PA) said when residents are admitted to the facility, there is a standard procedure bowel regimen which included scheduled Colace (over-the-counter stool softener) and Lactulose as needed (PRN). The PA further said there is also PRN suppository as a part of the standard bowel regimen, if oral medication medications do not work. The PA said she was notified by the nursing staff that Resident #28 had complaints of constipation last week and usually the facility staff would administer Lactulose, if that didn't work, then they would do MiraLAX, if that did not work, they would use a suppository, if the suppository was not effective, they would then use an enema. The PA said she believed the Resident was given Lactulose after the staff notified her. The PA said she had not been notified of any additional concerns since the first notification. The PA said the nursing staff are not always consistent with documentation, so she makes sure to follow up with the residents when she is in the facility. The surveyor reviewed Resident #28's concerns with the PA, and the PA said the Resident should have had the bowel regimen in place. The PA said she would have expected to be notified that the Resident continued to have complaints of constipation. The PA said if she was going to assess a patient for constipation and medications received, she would refer to the MAR, and it was her expectation that any medications administered would have orders.

Based on observations, interviews and record reviewed, the facility failed to ensure resident meals were palatable and at appetizing temperatures on two (Units A and C), out of two units observed. Specifically, the facility failed to ensure that food served to the residents on Unit A and Unit C was attractive, palatable and hot foods were maintained at/above 135 degrees Fahrenheit (F) when served. Findings include: Review of the facility policy titled Food Preparation, revised February 2025, included the following:-The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F and/or less than 135 degrees F, or per state regulation. Review of the Food and Nutritional Services Meal Assessment Form, reviewed 10/6/13, included the following serving minimum temperatures at point of service:-Entree 135 degrees F-Starch 135 degrees F-Hot beverage 135 degrees F During the initial pool process on 3/3/26 from 7:30 A.M. through 2:30 P.M., facility residents relayed the following concerns to the survey team:-Food was awful, rice was too hard, portions of egg are small, bread was not toasted.-Hot items on meal trays were not hot.-Concerns have been addressed with Head Chef and nothing changes.-Preferences are not honored.-Alternates to meals include grilled cheese sandwiches and the cheese was not always melted or a peanut butter and jelly sandwich with too much jelly.-Food was bland and there was not enough seasoning.-Food was too cooked, alternate foods are usually cold sandwiches which he/she doesn't like. On 3/4/26 at 7:15 A.M., the surveyor requested test trays from the Food Service Director (FSD) with a calibrated thermometer sent to Units C and A as the last trays on the last meal carts. On 3/4/26 from 8:08 A.M through 8:29 A.M., the surveyor observed the following on Unit C:-8:08 A.M., the meal cart arrived on the Unit.-8:10 A.M., several staff began to distribute breakfast meals to residents in their rooms. -8:25 A.M., Resident #17 was observed with his/her breakfast tray. The Resident had an untoasted slice of white bread cut in half on his/her plate. The tray also contained a covered bowl of oatmeal, an unopened container of apple sauce, unopened container of milk, and 4 ounces (oz) of cranberry juice. During an interview at the time, Resident #17 said he/she was not eating breakfast today and he/she did not like the breakfast items served.-8:32 A.M., the test tray was obtained, and the surveyor completed a test tray with Unit Manager (UM) #1, the Director of Nursing (DON) and the Administrator, and obtained the following temperatures:>Square Casserole Bake: 108 degrees F, not palatable to taste and temperature.>Coffee: 102 degrees F, not palatable to taste.>untoasted slice of white bread cut in half: not palatable in appearance or taste.During an interview at the time, the DON said the untoasted slice of white bread was served for residents on a modified texture diet. On 3/4/26 at 8:23 A.M. through 8:42 A.M., the surveyor observed the following on Unit A:-8:23 A.M., the meal cart arrived on the Unit.-8:24 A.M., several staff began to distribute breakfast meal trays.-8:42 A.M., last resident meal tray was served, and the surveyor completed a test tray with Nurse #5 and the Administrator, and obtained the following temperatures:>Oatmeal: 124.2 degrees F, very bland and watery, not palatable to taste. >Coffee: 110.0 degrees F, not hot, not palatable to temperature.>Square casserole bake (egg, bread and cheese bake): 125 degrees F, surveyor was unable to tell what the food item was, tasted bland and was not palatable to taste or temperature.During interviews at the time, Nurse #5 said the square casserole bake did not have taste and she did not like the oatmeal. The Administrator said the square casserole bake and oatmeal were bland. During an interview on 3/6/26 at 10:15 A.M., the FSD said the facility started a new menu and resident meal ticket system in February 2026. The surveyor and the FSD reviewed the results of the test trays completed on Unit A and C on 3/4/26, and the concerns related to the temperatures obtained and palatability of the food/beverage items served/tasted. The FSD said the goal for the hot food/beverage items was 135 degrees F and the temperatures obtained did not meet that goal.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had an actual area of skin breakdown and was assessed upon admission by the Registered Dietitian (RD) to be at risk for nutritional decline, the Facility failed to ensure that Resident #1 was adequately monitored by the RD, and nutritional interventions were put in place in a timely manner in an effort to prevent significant weight loss and promote wound healing. Findings include: The Facility Policy titled Weight Assessment and Interventions, last revised 11/19/24 included but was not limited to: -It is the policy of this facility to prevent significant unplanned or unavoidable weight loss for our residents. -The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: -One month - 5 percent (%) weight loss is significant, greater than 5% is severe -Any weight change of five pounds or more within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Provider and the Dietary Manager/Dietitian. -Recommendations from the Provider and/or Dietitian will be followed. The Facility Policy titled, Skin Prevention, Assessment and Treatment, last revised 10/24/24, included but was not limited to the following: -A nutritional consult should be completed for residents who are at risk for skin alterations -Interventions for prevention or active skin alterations may include but are not limited to: A Registered Dietitian review. Resident #1 was admitted to the Facility in August 2024, diagnoses included Parkinson's disease (a progressive, neurological disorder primarily affecting movement), bacteremia (presence of bacteria in the blood stream), and while at the Facility, he/she developed a pressure injury and experienced a severe weight loss. During an interview on 04/18/25 at 2:50 P.M., Family Member #1 said Resident #1 did not receive the assistance from facility staff he felt he/she required to eat, and as a result he/she lost a lot of weight while he/she was there. Family Member #1 said he brought up his concerns to facility staff, but was told Resident #1 was not eating well, had refused some meals, and said no further information was provided. Family Member #1 said he would plan visits during meal times so he could encourage and provide assistance to Resident #1 to eat, but was not able to be there for all of his/her meals. In addition, Family Member #1 said he could not recall ever speaking to a Dietitian during Resident #1's time at the facility. Review of Resident #1's Initial Dietary Evaluation/Assessment, dated 08/30/24 indicated his/her average food intake was fair (50%), he/she was independent with eating, weight fluctuation was expected due to diuretic use (a medication used to rid the tissues of excess fluids), and that he/she was at risk for malnutrition. Review of Resident #1's Nursing Progress Notes, dated 09/12/24, that indicated he/she had a newly discovered pressure injury. Further review of Resident #1's Consultant Wound Specialist Note, dated 10/16/24, that indicated the following: Resident #1's wound continued to deteriorate and required a surgical consult for wound debridement (a procedure where dead, damaged or infected tissue is removed from a wound to promote healing) and Negative Pressure Wound Therapy (a specialized wound treatment that uses suction to promote healing) on 10/23/24. During a telephone interview on 04/29/25 at 9:00 A.M., the Physician's Assistant (PA) said she did not have Resident #1's clinical information readily available, but she said she remembered him/her, was aware he/she had a pressure injury and significant weight loss, and remembered giving nursing staff a verbal order for nutritional supplements. The PA said she said she could not remember how she learned about the significant weight loss, or exactly what supplement(s) she ordered, when she ordered the supplement(s) or which nurse took the verbal order. Review of Resident #1's Weight Report indicated the following weights: 08/19/24 - 166.8 lbs. 08/26/24 - 168.2 lbs. 09/02/24 - 168.0 lbs. 10/05/24 - 149.4 lbs. (indicates an 11.3% weight loss in one month) 10/22/24 - 146.2 lbs. 10/23/24 - 145.6 lbs. Review of Speech Therapy (ST) documentation for August 2024, indicated that on 08/14/24, his/her diet was changed to 2 gm NA, dysphagia advanced, thin liquids while working, and on 09/04/24, his/her diet was upgraded to 2 gm NA regular diet with thin liquids with added moisture added (gravy, sauces). After working with Speech Therapy and Occupational Therapy Resident #1 was assessed to have improved, and diet was upgraded to regular texture but with added extra moisture (sauce/gravy) and continued to be able to eat independently upon assessment. However review of Resident #1's Medical Record indicated there was no documentation to support the RD was notified of his/her severe weight loss or wound healing needs related to treatment for his/her pressure injury. Review of Resident #1's Nutrition/Wound Progress Note, dated 10/24/24, indicated that as of 10/16/24 wound report, Resident #1 has a Stage 3 wound, no new measurements as of 10/23/24 due to him/her being out on medical leave of absence. Resident #1 was also noted to have significant weight loss (see nutrition/weight note). PO (by mouth) intake variable, 0-100% per staff documentation. Fluids and nutrition intake would not be adequate if he/she eats less than 50% of meals. The Note indicated that on 10/24/24, the RD made the following recommendations: - Discontinue 2-gram Sodium Diet, liberalize to regular diet - Med Pass Supplement 2.0, 4 ounces (oz.) three times per day - Pudding with meals - Probiotic supplement daily (until 11/10/24) - Vitamin C 500 milligrams (mg) twice per day x 30 days (for wound healing) - Zinc Sulfate 200 mg daily x 14 days (for wound healing) - Liquid protein 1 oz three times per day as ordered for additional nutrition/hydration to promote wound healing - Continue to honor dietary preferences - Continue to encourage foods and fluids for nutrition, hydration, wound healing and weight maintenance - Continue to monitor the need for further nutrition intervention -Nutrition/Weight note: Current weight 145.6 lbs. (obtained 10/23/24), One month weight 168 lbs. (obtained 09/02/24). Indicates: 22.4 lb. weight loss in one month (-13.3%) significant. - Director of Nursing and Unit Manager notified. Unclear reasons for significant weight loss unless related to diuretics and/or increased nutrient needs for wound healing. Resident #1 continues on diuretics, weight fluctuations expected. No changes noted to diuretics since admission. - Significant weight loss could be multifactorial due to variable oral intake, diuretics, wounds and antibiotics. During a telephone interview on 04/23/25 at 9:15 A.M., Nurse #2 said weights were obtained by the Certified Nurse Aides (CNAs) and reported to nursing staff to document in the Electronic Health Record (EHR). Nurse #2 said if there was a huge discrepancy between the previously recorded weight and the current weight, a re-weigh would need to be obtained in order to determine whether the weight was valid. Nurse #2 said she documented Resident #1's weight of 149.4 lbs. on 10/04/24, and said if she had noted a large discrepancy from his/her previous weight, she would have had the CNA weigh him/her again to be certain the weight was correct. Nurse #2 said she would not document both weights, only the weight she felt was accurate at the time. Nurse #2 said when a weight is entered into the EHR and there was a large discrepancy, she believed the system would trigger an alert which would be visible to the RD and the Director of Nurses (DON). Nurse #2 said she would notify the Provider if there was a large weight gain or loss if a resident was being closely monitored for cardiac conditions (heart failure) or any other specific condition. During an interview on 04/25/25 at 11:52 A.M., Unit Manager #2 said the CNA's were responsible for obtaining residents' weights and reporting their findings to the nursing staff to record in the EHR. Unit Manager #2 said if the newly obtained weight is five pounds off (either gain or loss), the resident is to be re-weighed to determine whether the weight is accurate. Unit Manager #2 said ideally the Unit Manager should run weekly weight reports to identify trends in weight losses or gains to catch issues early, but said she was only running weight reports monthly. Unit Manager #2 said it is the responsibility of the licensed nurse to report a significant weight change to the Unit Manager, Provider and Resident and/or his/her Representative when they discover the weight gain or loss is significant, and there is no automated process within the EHR that sends out alerts to the interdisciplinary team when there is a significant weight change documented. Unit Manager #2 said Nurse #2 should have notified the Unit Manager, the Provider, and the RD as well as written a progress note identifying the weight loss and who she notified, and said Nurse #2 did not write a progress note. Unit Manager #2 said Resident #1 should have had nutritional interventions (such as added protein for wound healing, dietary modifications and dietary supplements for increased calories) initiated upon discovery of his/her pressure injury on 0912/24, upon discovery of his/her severe weight loss documented 10/05/24, and the interventions initiated by the RD on 10/24/24 were not timely. Unit Manager #2 said there was no evidence the RD was notified of Resident #1's pressure injury or severe weight loss prior to 10/24/24. During a telephone interview on 04/25/25 at 3:44 P.M., Registered Dietitian (RD) #2 said she was the RD at the facility during Resident #1's admission. that she visited the facility one day per week for eight hours, but did not run weekly weight reports when she was in the building due to time constraints, workload, and relied on nursing staff to alert her to any concerns, including residents with pressure injuries and significant weight changes. RD #2 said that nursing staff were aware of when she was in the building, knew where to find her, and said if she was not in the building, said the Unit Managers had her e-mail address. RD #2 said nursing staff would notify her about residents with wounds by sending her the Consultant Wound Provider's notes (if they were involved). RD #2 said she would review the report, determine what the residents' needs would be, initiate interventions (either enter them into the EHR herself or relay them to the Unit Manager), and write a progress note. RD #2 said if nursing staff alerted her to significant weight changes, she would assess the resident to determine the cause of the weight changes (eating poorly, disease process, fluid shifts, medications such as diuretics, etc.) and initiate interventions as needed. RD #2 said if there was no Nutritional Progress Note written until 10/24/24, it was most likely she was not notified of Resident #1's weight loss and wound timely. During an interview on 10/23/24 at 12:55 P.M., the Director of Nurses (DON) said the RD should be notified whenever a resident experiences significant weight gain or loss and/or has treatments for wounds/pressure injuries. The DON said the nurse who documents a weight that indicates a significant change is supposed to notify the Provider and the Unit Manager, then the Unit Manager will notify the RD. The DON said for pressure injuries, the Unit Managers e-mail a copy of the wound log to the RD so they know a resident has a wound. After having an opportunity to review Resident #1's Medical Record, the DON said it did not appear that the RD was aware of Resident #1's pressure injury or severe weight loss until she initiated interventions on 10/24/24 and that there should have been nutritional interventions initiated more timely.

Based on records reviewed and interviews for one of three sampled Residents (Resident #1), who required wound treatments, had significant weight loss, and required assistance with his/her Activities of Daily Living (ADLs), the facility failed to ensure they maintained a complete and accurate medical record when, 1) Weekly Wound Logs and a Weekly Nursing Skin Review User Defined Assessments (UDA) were not consistently completed by nursing staff, 2) nursing documentation in the Treatment Administration Record (TAR) related to wound care was incomplete with blank spaces, and 3) Certified Nurse Aide (CNA) ADL Flow Sheets for August, September, and October 2023 were incomplete with blank spaces. Findings include: Review of the Facility's policy titled, Skin Prevention, Assessment and Treatment, last revised 10/24/24, indicated but was not limited to: Purpose: To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those at risk for skin breakdown. - Findings from the weekly skin assessments should be documented by the licensed nurse. -Any skin impairments, including pressure ulcers (injuries), non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse or designee in the Medical Record. - Documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration (skin damage attributed to prolonged exposure to moisture), color of the ulcer and surrounding tissues, and a description of any drainage, eschar/necrosis (dead tissue), odor, tunneling (a narrow channel extending from the wound surface deep into the underlying tissue, and undermining (erosion of tissue beneath the wound edges). Review of the Facility's policy titled, Charting and Documentation, last revised 11/05/24, indicated but was not limited to: - Each resident will have an active medical record that contains accurately documented information, systematically organized and readily accessible to authorized persons. - An electronic Treatment Administration Record (TAR) shall be maintained, which records indicate care procedures and/or treatments ordered by the physician that is performed and by whom the procedure/treatment was performed. - Narrative documentation/progress notes will be documented under the premise of charting by exception. - Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to refusals of medications/treatments or recommendations, and education provided to the resident and/or responsible party. 1) Resident #1 was admitted to the Facility in August 2024, diagnoses included Parkinson's disease (a progressive, neurological disorder primarily affecting movement), bacteremia (presence of bacteria in the blood stream), and while at the Facility, he/she developed a pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device), and required assistance with his/her Activities of Daily Living (ADLs). Review of Resident #1's Nursing Progress Notes included a note, dated 09/12/24, that indicated he/she had a newly discovered pressure injury. Review of Resident #1's UDAs in the Electronic Health Record (EHR) indicated there was no evidence to support nursing staff completed the following Assessments: -Weekly Nursing Skin Review on 10/07/24 -Weekly Wound Logs on 10/09/24, 10/16/24, and 10/23/24 During a telephone interview on 04/23/25 at 9:15 A.M., Nurse #2 said the licensed nursing staff is responsible for completing weekly skin assessments for every resident and document their findings in the Weekly Nursing Skin Review Assessment UDA in the computer every week. Nurse #2 said the computer alerts the nurse when assessments were due to be completed. Nurse #2 said that the Unit Managers, usually alongside the Consultant Wound Specialist, perform in depth assessments of residents' wounds weekly. Nurse #2 said that after the rounds have been completed, the information from the wound rounds for each resident should be documented in the Weekly Wound Log UDA in the computer. During an interview on 04/22/25 at 10:40 A.M., Unit Manager #1 said nursing staff are required to perform weekly skin assessments on all residents in the facility and document the information in the Weekly Nursing Skin Review Assessment UDA in the EHR. Unit Manager #1 said Weekly Wound Log UDAs are usually completed after the Unit Managers round with the Consultant Wound Specialist and should be entered in the computer every week. Unit Manager #1 reviewed Resident #1's EHR and said there was not a Weekly Nursing Skin Review UDA documented for 10/07/24 and there were no Weekly Wound Log UDAs documented for 10/09/24,10/16/24 and 10/23/24. During an interview on 04/23/25 at 11:52 A.M., Unit Manager #2 said skin assessments should be performed weekly by licensed nursing staff and documented on the Weekly Nursing Skin Review UDA. Unit Manager #2 said while they are rounding with the Consultant Wound Specialist, they (the Unit Managers) handwrite the assessment information for each resident on a weekly wound tracking (paper) form, and after rounding has been completed, the Unit Managers are supposed to transcribe the data from the handwritten form and enter that information into the Weekly Wound Log UDA in the computer. Unit Manager #2 said for Resident #1, there was not a Weekly Nursing Skin Review UDA for 10/07/24 and said that while weekly wound tracking forms were completed on 10/09/24, 10/16/24, and 10/23/24, the assessment data was never documented in the Weekly Wound Log UDA. Unit Manager #2 further said weekly wound tracking forms were not considered part of the medical record. During an interview on 04/23/25 at 12:55 P.M., the Director of Nursing (DON) said that nursing staff are responsible to perform weekly skin checks on all residents in the facility and enter their findings in the computer under the Weekly Nursing Skin Review UDA. The DON said if a resident has a wound, the wound is assessed weekly by the Unit Managers along with the Consultant Wound Specialist and the results of the assessments should be documented in the computer under the Weekly Wound Log UDA. After reviewing Resident #1's EHR with the surveyor, the DON said that nursing staff did not document the Weekly Nursing Skin Review Assessment UDA for 10/07/24, nor did they document the Weekly Wound Log UDAs for 10/09/24, 10/16/24, and 10/23/24, as required. 2. Review of Resident #1's September 2024 Treatment Administration Record (TAR) indicated wound treatments were not signed off as being completed (left blank) on the following dates and shifts: - 09/20/24 - day shift - 09/23/24 - day shift - 09/29/24 - day shift Review of Resident #1's October 2024 TAR indicated wound treatments were not signed off as being completed on the following dates and shifts. - 10/03/24 - day shift (left blank) - 10/03/24 - evening shift (left blank) - 10/4/24 - code 9 other, see nursing note - 10/06/24 - code 9 other, see nursing note Review of Resident #1's Nursing Progress Notes indicated he/she did not receive his/her wound treatments on 10/04/24 and 10/06/24 because he/she was OOB (out of bed). During a telephone interview on 04/22/25 at 3:56 P.M., Nurse #1 said she was on duty from 7:00 A.M. until 7:00 P.M. on both 10/04/24 and 10/06/24. She said that Resident #1 often sat up in his/her wheelchair visiting with his/her spouse for several hours during the day, he/she would often refuse treatments and medications, and that was likely the case on 10/04/24 and 10/06/24. Nurse #1 said she should have written a more comprehensive note other than just saying Resident #1 was out of bed. Nurse #1 said she was certain at some point during her shifts on 10/04/24 and 10/06/24 that she performed the wound treatment for Resident #1, however she never went back to document that she did so. During an interview on 04/22/25 at 10:40 A.M., Unit Manager #1 reviewed Resident #1's September and October 2024 TARs and said blank spaces appear because the nurse failed to document the wound treatments. Unit Manager #1 said for 10/04/24 and 10/06/24, the nursing note was too vague and there was no way to determine from the documentation if Nurse #1 re-attempted the wound treatment later, or if she provided education to Resident #1 about the need to perform the wound treatment at the scheduled time. Unit Manager #1 also said if Nurse #1 did perform the wound treatments on 10/04/24 and 10/06/24, she should have documented as such. During an interview on 04/23/25 at 12:55 P.M., the DON said there should not be blank spaces on the TAR and the blank spaces indicated the nursing staff failed to document they performed the wound treatments. The DON said Nurse #1 should have written a more comprehensive note relative to the wound treatments for Resident #1 on 10/04/24 and 10/08/24, and that just documenting out of bed was not sufficient. The DON further said that if Nurse #1 did the treatments later in her shift, she should have documented it. 3. Review of Resident #1's CNA Activities of Daily Living Flowsheets (Documentation Survey Report) indicated for the following tasks, documentation was incomplete (with many entries left blank): August 2024: -Oral Hygiene three times per day: 23 out of 60 opportunities left blank; -Nutrition (fluid intake) three times per day: 23 out of 60 opportunities left blank; -Nutrition (amount eaten) three times per day: 30 out of 60 opportunities left blank; September 2024: -Oral Hygiene three times per day: 31 out of 90 opportunities left blank; -Nutrition (fluid intake) three times per day: 31 out of 90 opportunities left blank; -Nutrition (amount eaten) three times per day: 29 out of 90 opportunities left blank; October 2024: -Oral Hygiene three times per day: 10 out of 69 opportunities left blank; -Nutrition (fluid intake) three times per day: 10 out of 69 opportunities left blank; -Nutrition (amount eaten) three times per day: 9 out of 69 opportunities left blank; During an interview on 04/22/25 at 2:15 P.M., Nurse Aide (NA) #1 said that they are required to document tasks they perform for all residents throughout the day, and it must be completed by the end of their shift. NA #1 said if a resident refused any care, they are still required to document the refusal and notify the resident's nurse. NA #1 said there should not be any blank spaces on their Flow Sheets and if there were any blank spaces, the documentation was not completed, as required. During an interview on 04/22/25 at 2:15 P.M., NA #2 said they were supposed to complete their documentation by the end of their shift. NA #2 said they use a tablet to document electronically and demonstrated to the surveyor the documentation process. NA #2 said they document all the residents' ADLs, including oral care, meal intake and fluid intake and the amount of assistance a resident requires from staff to complete these tasks. NA #2 said there should not be any blank spaces on the Flow Sheet, and the blank spaces meant the documentation was not completed for those dates and times. During an interview on 04/23/25, CNA #1 said if a resident refused any ADL care, the CNAs were required to document the refusal and notify the nurse. CNA #1 said all their documentation must be completed in the computer by the end of their shift, and the blank spaces on the Flow Sheet meant that the CNAs did not complete their documentation, as required. During an interview on 04/22/25 at 3:10 P.M., Unit Manager #2 reviewed Resident #1's CNA documentation (Documentation Survey Report) and said it was the expectation that CNAs and NAs document the care they provide to the residents throughout the shift and the documentation should be completed by the end of their shift, and the blank spaces in the report meant the documentation was not done. Unit Manager #2 said that the floor nurses were supposed to review CNA documentation at the end of each shift to ensure it had been completed and this did not happen. During an interview on 04/23/25 at 12:55 P.M., the Director of Nurses (DON) reviewed the CNA documentation (Documentation Survey Report) and said there should not be any blank spaces, and the blank spaces meant the CNAs failed to document on those dates and times. The DON said it was the expectation that all documentation was to be completed by the end of the shift.

Based on record review, and interview, the facility failed to ensure that one Resident (#10) out of a total sample of 22 residents, was free from significant medication errors. Specifically, the facility staff failed to adhere to the Physician's orders to hold (not administer) the dose of Midodrine (medication used to treat orthostatic [standing up] hypotension [low blood pressure]) when the blood pressure measured above 130 millimeters of mercury (mmHg) for a Systolic [the pressure in the arteries when the heart contracts] Blood Pressure (SBP). Findings include: Review of the facility policy titled Administering Medication, revised October 2024, indicated: -that medications shall be administered according to the physicians written/verbal orders upon verification of: >the right medication >the right dose >the right route >the right time >positive verification of the resident's identity when no contraindications are identified >the medication is labeled accordingly to accepted standards Resident #10 was admitted to the facility in December 2023, with the diagnoses including End Stage Renal Disease (ESRD -a medical condition where the kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and fluid from the body when the kidneys stop working] or a kidney transplant to maintain life), Type II Diabetes Mellitus (DM II: non-insulin-dependent diabetes where the body does not produce enough insulin hormone and has trouble controlling blood sugar levels), Hypertension (high blood pressure), dependent on Renal Dialysis. Review of the Order Summary Report for active orders as of 11/26/24, indicated the following order: -Midodrine HCL Tablet 5 milligrams (mg). Give 1 tablet by mouth three times a day for hypotension. Hold for Systolic Blood Pressure above 130 mmHg, start date 9/17/24. Review of the Medication Administration Record (MAR) for the month of November 2024, indicated Resident #10 had a SBP over 130 mmHg, was initialed by the Nurse and a check mark was noted (to indicate that the Midodrine medication was administered) when it should have been held because the SBP was higher than the ordered parameters to hold the medication, on the following dates: -11/2/24: SBP 141 -11/3/24: SBP 138 -11/5/24: SBP 145 -11/14/24: SBP 134 -11/22/24: SBP 143 During an interview on 11/26/24 at 8:52 A.M., the surveyor and Nurse #5 reviewed the November 2024 MAR. Nurse #5 said before administering the Midodrine she would take Resident #10's blood pressure (BP). If the BP was outside the parameters (over 130 mmHg) she would note a number 4 on the MAR indicating the Systolic Blood Pressure was outside of the parameters and she would not administer the Midodrine. Nurse #5 said that if there is a check mark in the box on the MAR for the corresponding date and time, with initials, she would assume that the Nurse administered the medication. During an interview on 11/26/24 at 9:56 A.M., Unit Manager (UM) #1 said that the Midodrine should be administered per the Physician order and held when the Systolic Blood Pressure is over 130 mmHg. UM #1 reviewed the November 2024 MAR and said that on the five occasions: 11/2/24, 11/3/24, 11/5/24, 11/14/24, and 11/22/24, the Midodrine was not held when it should have been held.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for three Residents (#346, #47 and #6) out of a total sample of 20 residents, and on three units (A Wing, C Wing, and D Wing) out of a total of three units. Specifically, the facility failed to: 1) ensure that wound care supplies used inside a Resident's room were not removed from the room and stored in the clean utility room on C Wing. 2) ensure infection control standards were maintained during wound care for Resident #346. 3) ensure that staff wore the necessary Personal Protective Equipment (PPE: items such as a gown, gloves, mask, eye protection, etc. to prevent transmission of communicable disease) to maintain contact isolation precautions (used to prevent transmission of a disease spread by touching a contaminated surface or person) for Resident #346 4) ensure that staff performed hand hygiene, wore the necessary PPE to maintain contact precuations for Resident #47 and that shared medical equipment used on Resident #47 was cleaned and disinfected between use on multiple residents. 5) ensure that staff wore PPE to maintain Enhanced Barrier Precautions (EBP: used to prevent a high risk residents from contracting potential infections) while a) administering medication through a feeding tube and b) providing care to Resident #6. Findings include: Review of the facility policy titled Isolation Precautions, revised 10/28/24, indicated the following: -Appropriate communication/notices will identify the resident/room with isolation precautions implemented. -Contact Precautions: prior to entering the isolation room, the following steps are required: >perform hand-hygiene and apply gloves and gown prior to entering the room. 1) During a wound care observation on 11/21/24 at 10:12 A.M. on C Wing, the surveyor observed Nurse #4 to: -bring a new sleeve of gauze into a resident's room -set the gauze sleeve on the resident's bedside table -at the completion of wound care, take the gauze sleeve from the bedside table and bring it out of the resident's room and place it in the C Wing clean utility room. During an interview immediately following the observation, Nurse #4 said she should not have removed the gauze sleeve from the resident's room as this would be a concern for potential spread of infection. 2) Resident #346 was admitted to the facility in November 2024, with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA: a communicable infection caused by a bacterium that is resistant to multiple strains of antibiotics causing increased difficulty treating the infection) and resided on C Wing. During an observation of Resident #346's wound care on 11/21/24 at 10:57 A.M., the surveyor observed Nurse #4: -used scissors to cut off the old dressing from the right lower extremity and placed the scissors directly on the Resident's bed. -picked up the scissors from the Resident's bed and used them to cut Xeroform (a gauze type dressing material that is saturated with petroleum) without cleaning and disinfecting the dirty scissors, placed the Xeroform over the wound bed, and then placed the scissors directly on the Resident's bed again. -picked up the scissors from the bed and used them to cut Calcium Alginate (a super absorbent dressing material) without cleaning and disinfecting the dirty scissors, placed the Calcium Alginate over the xeroform and then covered the dressing as ordered. During an interview on 11/21/24 at 12:00 P.M., Nurse #4 said she should not have used the scissors that had been used to remove a contaminated dressing and placed on the Resident's bed to cut clean dressing materials due to the risk for cross contamination of the wound. 3a) During an observation on 11/20/24 at 9:36 A.M., the surveyor observed Rehabilitation (Rehab) Staff #1 brought Resident #346 back into his/her room where a Contact Precautions sign was present outside the doorway without first putting on (donning) a gown and gloves. The surveyor observed Rehab Staff #1 providing hands-on assistance to Resident #346 to stand and transfer from his/her wheelchair into bed without wearing a gown and gloves as required. During an interview on 11/21/24 at 2:51 P.M., the surveyor reviewed the Contact Precautions sign with Rehab Staff #1. Rehab Staff #1 said the sign indicated Resident #346 was on Contact Precautions and a gown and gloves should be worn in the room and for care including assisting with transfers. Rehab Staff #1 further said that he did not wear a gown and gloves during the observed transfer on 11/20/24, but should have. During an observation on 11/21/24 at 3:01 P.M., the surveyor observed Maintenance Staff #1 approach Resident #346's room, observe the Contact Precautions sign outside the Resident's room, and then enter the room without donning a gown and gloves. Maintenance Staff #1 was observed working on the Resident's wheelchair. During an interview on 11/21/24 at 3:05 P.M., the surveyor reviewed the Contact Precautions sign with Maintenance Staff #1. Maintenance Staff #1 said the sign indicated he should have put on a gown and gloves before going into the room but he had not worn a gown or gloves in the room. 42741 3b) During an observation and interview on 11/21/24 at 10:33 A.M., the surveyor observed Nurse #4 enter Resident #346's room without donning any PPE. Nurse #4 was observed at Resident #346's bedside where her clothing came into contact with the Resident's bed sheets and the privacy curtain. During an interview following the observation the surveyor and Nurse #4 observed the sign outside the Resident's room which indicated the following: >Contact Precautions -Put on gloves before room entry. -Put on gown before room entry. Nurse #4 said she only needed to wear a gown and gloves for high contact care of Resident #346 and she had not donned any PPE to enter his/her room. Nurse #4 further said if she followed the directions on the Contact Precaution sign on the doorway then she should have put on gloves and a gown when she entered Resident #346's room. 37400 4) Resident #47 was admitted to the facility in November 2024 with diagnoses including sepsis ( infection of the blood which is a life-threatening condition that happens when the body's immune system has an extreme response to an infection, causing organ dysfunction), Methicillin-Resistant Staphylococcus Aureus (MRSA) and chronic ulcer (open area) of the skin. Review of the November 2024 Physician's Orders included the following: -MRSA Wound Infection Precautions- Contact Isolation . initiated 11/11/24 -Doxycycline Hyciate (antibiotic) 100 milligrams (mg) twice daily for MRSA . initiated 11/12/24 Review of the Infection Care Plan, initiated 11/11/24, indicated the following: -Resident had MRSA wound/skin infection -educate Resident/Responsible Person on isolation requirements and purpose -Type of precaution: Contact On 11/21/24 at 8:10 A.M., the surveyor observed signage posted outside of the Resident's room which indicated Contact Precautions were in place. The sign indicated the following: -conduct hand hygiene prior to and upon exiting the room -put on a gloves and gown before room entry and discard the gown and gloves before room exit -clean and disinfect reusable equipment before use on another person The surveyor observed a bin with gowns and gloves outside of the Resident's room and Nurse #1 entered the Resident's room and delivered his/her breakfast tray. Nurse #1 did not don a gown and gloves prior to entering the Resident's room. Nurse #1 exited the room shortly after, did not perform hand hygiene, entered the nearby kitchenette, retrieved a poured cup of orange juice and re-entered the Resident's room without a gown or gloves in place. Upon exiting the Resident's room the second time, Nurse #1 performed hand hygiene. On 11/21/24 at 8:55 A.M., the surveyor observed Nurse #1 entering Resident #47's room with a cup of medications and the vitals machine (machine on wheels that measures blood pressure, pulse, body temperature). Nurse #1 did not perform hand hygiene or don a gown or gloves prior to entering the Resident's room. The surveyor observed Nurse #1 standing beside Resident #47's bed. At this time, a Certified Nurses Aide (CNA) entered the Resident's room and retrieved his/her breakfast tray which was located on his/her overbed table. The CNA did not perform hand hygiene and did not don a gown/gloves prior to entering the room. Nurse #1 exited the room shortly after with the vitals machine. Nurse #1 performed hand hygiene upon exiting the Resident's room and rolled the vitals machine to an area across from the nurses station, plugged in the machine and walked away, without disinfecting the machine. At 9:03 A.M., Nurse #1 unplugged the vitals machine and went into two other resident's rooms (42 and 48), obtained vitals using the same machine and did not clean/disinfected the machine after each resident use. During an interview on 11/21/24 at 2:35 P.M., Unit Manager (UM) #1 said Resident #47 was on Contact Precautions for MRSA infection in his/her wounds. UM #1 said the Contact Precautions will remain in place while the Resident is on the antibiotic therapy. During an interview on 11/21/24 at 2:46 P.M., Nurse #1 said Resident #47 was on Contact Precautions. Nurse #1 said a gown and gloves were to be worn when providing care or anytime you come in contact with the Resident including when vitals are obtained. The surveyor and Nurse #1 reviewed the Contact Precaution sign posted outside of the Resident's room. Nurse #1 said the Contact Precautions sign indicated to put on a gown and glove prior to entering the Resident's room. Nurse #1 said she did not have on a gown and gloves when she entered the Resident's room to deliver his/her breakfast tray, administer medications and while obtaining the Resident's vitals using the vitals machine. Nurse #1 said that the vitals machine should have been disinfected with bleach wipes after exiting Resident #47's room and should have been disinfected between each resident use. Nurse #1 said she realized that she forgot to to this. On 11/22/24 at 8:13 A.M., the surveyor observed CNA #6 enter Resident #47's room to deliver his/her breakfast tray. CNA #6 did not perform hand hygiene, and did not don a gown or gloves prior to entering the room. CNA #6 was observed to move the Resident's overbed table and assist with breakfast meal tray set up. Shortly after CNA #6 exited the Resident's room and did not perform hand hygiene. During an interview at the time, CNA #6 said she should have put on a gown and gloves prior to entering Resident #47's room. On 11/22/24 at 9:24 A.M., the surveyor observed Nurse #3 enter Resident #47's room with his/her medications without donning a gown or gloves. Nurse #3 was observed to move the Resident's bedside table, provided his/her medication and checked the setting on the Resident's mattress. During an interview at the time, UM #1 (who was with the surveyor outside the Resident's room), said Nurse #3 should have put on a gown and gloves prior to entering the Resident's room. During an interview on 11/22/24 at 9:26 A.M., Nurse #3 said gown and gloves were not required for Resident #47 because he was just administering medication and that they were not required unless direct care was being given. The surveyor and Nurse #3 reviewed the Contact Precaution sign outside of Resident #47's room. Nurse #3 said the Contact Precaution sign indicated that a gown and gloves were to be put on prior to entering the Resident's room. 42690 5) Review of the facility policy titled Enhanced Barrier Precautions, revised on October 28, 2024 indicated the following: -it is this facility's policy that enhanced barrier precautions EBP's are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or patients environment EBP is used during high contact care activities for residents with chronic wounds or indwelling medical device . -high contact resident care activities include but are not limited to: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care; any skin opening requiring a dressing -Indwelling medical device examples include but are not limited to, central lines, urinary catheters, feeding tubes . Resident #6 was admitted to the facility in January 2003, with diagnoses including Traumatic Brain Injury (TBI- a violent blow or jolt to the head causing temporary or permanent brain injury). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -Ostomy in use - including urostomy, ileostomy, and colostomy -Feeding tube Review of the Order Summary Report for active orders as of 11/25/24 indicated: -G-Tube (Percutaneous Endoscopic Gastrostomy - a feeding tube inserted into the stomach through the abdomen, utilizing an endoscope for guidance) and ostomy: infection precautions enhanced barrier, staff wear gown/gloves when in direct patient contact every shift. Start date 11/12/24. On 11/21/24 at 8:53 A.M., from the hallway outside of Resident #6's room, the surveyor observed the following: -EBP signage hanging on the door frame at the entrance of the Resident's room that indicated for Providers to wear gloves and a gown for high-contact resident care activities. >High-Contact activities included: -dressing, transferring, providing hygiene, changing briefs, device care (urinary catheter), wound care (any skin opening that required a dressing). a) On 11/21/24 from 8:53 A.M. until 9:04 A.M., the surveyor observed the following: -Nurse #5 enter Resident #6's room to administer medications. -Don (put on) gloves. Nurse #5 was not observed to don a gown. -Remove the top bed sheet used to cover Resident #6 -Move Resident #6's hospital gown to access the G-tube -Administer medications through the G-tube without a gown -Doff (take off) gloves and discard them in the garbage can -Wipe the Residents face with an ungloved hand -Adjusted protective sleeve around the Resident's right ankle -Replace the top bed sheet to cover the Resident -Adjust the Resident's sheets -Wash her hands with soap and water in the bathroom prior to exiting the room. During an interview on 11/21/24 at 9:04 A.M., Nurse #5 said that when a Resident is on Contact Precautions you must wear PPE. Nurse #5 said that she does not usually wear a gown when administering medications through the G-tube, just gloves. The surveyor and Nurse #5 reviewed the EBP signage outside of the Resident's room and Nurse #5 said that she did not do any of the other activities that are identified as high contact care on the EBP sign located outside of the Resident's room. b) On 11/21/24 at 10:58 A.M., the surveyor observed CNA #2 and CNA #4 enter Resident #6 's room and close the door. The surveyor did not observe CNA #2 or #4 don gowns before entering the room. On 11/21/24 at 11:10 A.M., CNA #2 exited the room. The surveyor did not observe CNA #2 doff any PPE. On 11/21/24 at 11:12 A.M., the surveyor entered Resident #6's room and observed CNA #4 was in the room, providing care for the Resident wearing only gloves. When the surveyor asked CNA #4 what PPE should be worn when providing care for Resident #6 as he/she had a colostomy and a feeding tube, CNA #4 said that she and CNA #2 were getting the Resident up for the day, provided morning care that included, cleaning the Resident up, getting him/her dressed and transferring him/her out of the bed into his/her wheelchair. CNA #4 said that she and CNA #2 should have had on a gown and gloves and did not, as required. CNA #4 said that the facility used reusable gowns and while there was no PPE readily available near the Resident's room, there was some down the hallway.

Based on observation, and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one Resident (#79) out of a total sample of 20 residents. Specifically, for Resident #79, the facility failed to maintain the resident's wheelchair in a clean and sanitary manner. Findings include: Resident #79 was admitted to the facility in December 2023. On 11/20/24 at 8:27 A.M., the surveyor observed Resident #79's seated in a wheelchair in his/her room. The surveyor observed the wheelchair to have dirt/debris and/or food particles spackled on the chair cushion, frame, brakes, and wheels. On 11/21/24 at 1:18 P.M., the surveyor observed Resident #79 exiting the dining room after having lunch. The surveyor observed the Resident's wheelchair to have dirt/debris and/or food particles on the chair cushion, frame, brakes, and wheels. On 11/25/24 at 9:57 A.M., the surveyor observed Resident #79 sitting in his/her wheelchair in his/her room. The surveyor observed that the Resident's wheelchair remained with dirt/debris and/or food particles on the chair cushion, frame, brakes, and wheels. During an interview and observation on 11/25/24 at 11:41 A.M., the Director of Housekeeping provided the surveyor with the wheelchair cleaning schedule. The Director of Housekeeping said that the housekeeping department is not always able to follow the wheelchair cleaning schedule, but they try. The surveyor and the Director of Housekeeping reviewed the wheelchair cleaning schedule, and the Director of Housekeeping said that the A-wing (unit on which the Resident resided) wheelchairs were scheduled to be cleaned on 11/3/24 and 11/24/24. The Director of Housekeeping said that each units' wheelchairs are cleaned twice a month but was unable to provide evidence of a tracking system of what wheelchairs had been cleaned. The Director of Housekeeping said that all wheelchairs on the unit scheduled to be cleaned, should be cleaned. The Director of Housekeeping said that each wheelchair is sprayed with disinfectant cleaner, showered off, then wiped dry. The surveyor and the Director of Housekeeping observed Resident #79 seated in his/her wheelchair. The Resident's wheelchair was observed to have dirt/debris and/or food particles on the chair cushion, frame, brakes, and wheels. The Director of Housekeeping said that the chair should not look like that and needed to be cleaned. The Director of Housekeeping said she could not speak to when the chair had last been cleaned.

Based on interview, and record review, the facility failed to notify the state mental health authority for a resident review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#12) out of a total sample of 20 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR-and evaluation done to determine if a resident has an intellectual or developmental disability [ID/DD] and/or serious mental illness [SMI] and is in need of additional specialized support services at the facility) after Resident #12 received a diagnosis of Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and experienced limitations in major life activities due to mental illness. Findings include: Review of the facility policy titled Coordination with PASRR Program, dated 2/2/24, indicated the following: -Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the State mental health or intellectual authority for a level ll resident review. Resident #12 was admitted to the facility in March 2024, with diagnoses including Chronic Respiratory Failure (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue) and Obstructive Sleep Apnea (OSA: pauses in breathing due primarily to the collapse of the upper airway during sleep). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12: -was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. -had not been evaluated by a Level II PASRR. -has active diagnoses of Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and Bipolar Disorder. Review of Resident #12's PASRR Level I (initial pre-screening completed prior to admission to a Nursing Facility) screen, dated 3/15/24, indicated: -No diagnosis of mental illness or disorder. -No treatment history for mental illness in the past two years. -No limitation in major life activities. -Negative SMI screen. Review of Resident #12's Behavioral Health Group Note dated 3/22/24, indicated: -diagnosis of Bipolar Disorder. -a long history of Depression and Anxiety. -will continue with therapy with his/her therapist in the community via telehealth. -will be seen be seen by Behavioral Health Group Provider the following week. During an interview on 11/21/24 at 3:32 P.M., the Social Worker (SW) said she had worked at the facility since September 2024 and the PASRR Level I for Resident #12 was completed before her time of employment. The SW said that she did not know what information was available when the PASRR Level I was completed prior to admission, but when it was evident that Resident #12 had a diagnosis of Bipolar Disorder, a Change of Condition should have been done through the portal. The SW checked the Massachusetts Executive Office of Health and Human Services (EOHHS) portal and said that a Change of Condition had not been submitted and should have been.

Based on interview, and record review, the facility failed to ensure a baseline care plan was created within 48 hours of admission to the facility for two Residents (#47 and #36) out of a total sample of 20 residents. Specifically, the facility failed to: 1. for Resident #47, ensure a baseline care plan was created within 48 hours of admission relative to Resident #47 being actively treated for Methicillin-Resistant Staphylococcus Aureus (MRSA - an infection caused by a type of staph bacteria that has become resistant to many antibiotics, that is contagious and easy to spread by both direct and indirect contact requiring special precautions to be in place to prevent further spread) in a wound. 2. For Resident #36, ensure a baseline care plan was created within 48 hours of admission to ensure the Resident received the care and services necessary to care for him/her until a comprehensive care plan could be created. Findings include: Review of the facility policy titled Interim Care Plan, revised 11/6/24, indicated the following: -The purpose of the interim care plan is to guide care until the comprehensive care plan is completed. -To assure that the resident's immediate care needs are met and maintained, a preliminary care plan is developed upon admission. The interim plan of care should be implanted within forty-eight (48) hours of admission. {sic} Review of the facility policy titled Isolation Precautions, revised 10/28/24, indicated the following: -The establish transmission-based precautions for resident who are suspected or confirmed to have communicable diseases/infections that can be transmitted to other. {sic} -Appropriate communication/notices will identify the resident/room with isolation precautions implemented. -Contact Precautions (a set of safety measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact)-Multi-Drug Resistant Organisms (which would include MRSA) . 1. Resident #47 was admitted to the facility in November 2024 with diagnoses including MRSA in left groin wound and sepsis (a life-threatening medical emergency that occurs when an infection triggers the body's immune system to damage its own organs and tissues). Review of the Hospital Discharge/Transfer Note dated 11/5/24, indicated Resident #47 was actively being treated for MRSA infection in a wound on his/her groin with two antibiotics, Cephalexin and Doxycycline. Review of Resident #47's Baseline Care Plan, indicated the following: -the Baseline Care Plan was opened and completed on 11/14/24, eight days after the Resident was admitted to the facility -Resident #47 needed Contact Precautions due to a diagnosis of MRSA. Review of Resident #47's November 2024 Physician's orders indicated no order for Contact Precautions until 11/11/24, six days after the Resident was admitted to the facility. Review of Resident #47's Comprehensive Care Plan, titled I, indicated the Resident currently have an infection due to MRSA, Wound/Skin infection {sic}, and that a Comprehensive Care Plan was not created until 11/11/24. During an interview on 11/25/24 at 12:07 P.M., the Infection Preventionist (IP) said Resident #47 was admitted with a diagnosis of MRSA and needed to be on Contact Precautions when he/she was admitted to the facility. The IP said a Baseline Care Plan should have been created within 72 hours of Resident #47's admission to the facility, that indicated Resident #47 needed to be on Contact Precautions. The IP further said if a Baseline Care Plan had not been created the Resident should have had a Physician's order in place for Contact Precautions so the nursing staff knew how to provide care for the Resident and neither of these things were done at the time the Resident was admitted to the facility. 50563 2. Resident #36 was admitted to the facility in October 2024 with diagnoses including End Stage Renal Disease (ESRD: a medical condition where the kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and fluid from the body when the kidneys stop working] or a kidney transplant to maintain life), and Type 2 Diabetes (DM II: condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar levels). Review of Resident #36's Baseline Care Plan indicated the following: -the Baseline Care Plan had been opened and completed on 11/2/24, four days after admission -a copy of the Baseline Care Plan had not been provided to the Resident. During an interview on 11/26/24 at 8:15 A.M., Unit Manager (UM) #2 said the Baseline Care Plan should be completed within 48 hours of admission. UM #2 further said she reviews the Baseline Care Plan with the residents after it is completed but does not provide the residents with a copy.

Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for one Resident (#346), for one applicable resident reviewed, out of a total sample of 20 residents. Specifically, for Resident #346, the facility failed to ensure the external catheter length and arm circumference were measured as ordered by the Physician when the Resident had a Peripherally Inserted Central Catheter (PICC: a thin, soft tube that is inserted into a vein in the arm, for long-term antibiotics, nutrition, medications, and blood draws. The PICC is a type of CVAD [Central Vascular Access Device] catheter) line) for intravenous administration of antibiotics increasing the potential risk of infiltration (when fluid or medication given by an intravenous [IV] device exits the vein and enters the soft tissues), migration (change in the length of catheter extruding from the insertion site, is a medical emergency and must be addressed immediately), and/or deep vein thrombosis (DVT: a blood clot in a deep vein). Findings include: Review of the facility policy titled PICC/Central Line/Port-a-Cath Maintenance, dated 10/15/23, indicated the purpose was to: -to identify standards of care for patients with PICC lines . -to act as a resource for staff so that errors leading to complications are reduced. -identify and comply with current best practices from infection control and infusion nursing standards. -Maintenance and Care: >dressing change every seven days and as needed (PRN). >measure the length of the lumen (cavity or channel within a tube) from the insertion to the end site. >measure the circumference of the upper arm and document. >this was to be done upon admission, with each dressing change and PRN. >record care provided in the electronic medical record (EMR). Resident #346 was admitted to the facility in November 2024 with diagnoses including open area of the lower leg, right lower extremity Cellulitis (potentially serious bacterial skin infection where the skin is swollen, inflamed, painful and warm to the touch) and Methicillin-Resistant Staphylococcus Aureus (MRSA: strain of gram-positive bacteria resistant to several antibiotics, making it difficult to treat, which spreads through contact with infected individuals). Review of Resident #346's Vascular Access Insertion Note, dated 11/2/24, indicated: -right upper extremity PICC line was inserted. -catheter size measured 4 French (Fr: the French scale, commonly used to measure the size of a catheter or tubing). -catheter length 40 centimeters (cm). -middle arm circumference 10 cm above antecubital fossa (a triangular area inside of the elbow) = 28 cm. -the Vascular Access Insertion Note did not indicate the external catheter length. Review of the Minimum Data Set (MDS) Assessment, dated 11/15/24, indicated: -Resident #346 understands and was understood -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -had a surgical wound and was receiving surgical wound care -received an antibiotic during the assessment period Review of the PICC Line Care Plan, initiated 11/15/24, indicated Resident #346 had Osteomyelitis (inflammation of bone or bone marrow due to infection) and MRSA present in a wound. The PICC Line Care Plan included the following interventions: -administer IV medications and IV fluids as ordered by the Physician ., initiated 11/15/24 -follow Physician orders and facility policy for care and maintenance of IV access and dressing care, initiated 11/15/24 Review of Resident #346's November 2024 Physician's orders indicated: -Daptomycin (antibiotic) 450 milligrams (mg) IV daily for septic (infected) knee until 12/9/24, initiated 11/9/24 -Normal Saline (NS: solution of sodium chloride in water) flush 0.9% use 10 milliliter (ml) IV every shift before/after IV medications and 10 ml IV PRN for prevention, initiated 11/8/24 -change PICC line dressing every seven days, initiated 11/8/24 -Measure the length of the lumen from the insertion to the end site, measure the circumference of the upper arm and document every shift on Saturday and PRN, initiated 11/8/24 -monitor IV site to right arm daily, notify Physician of complications every shift, initiated 11/8/24 Review of the November 2024 Treatment Administration Record (TAR) indicated: -PICC line dressing change every seven days which included instructions to measure and document the length of the lumen from the insertion site to the end site (external catheter site). -measurement of the circumference of the upper arm was signed off as administered on 11/9/24, 11/16/24 and on 11/23/24. -no documented evidence of the obtained measurements for the external catheter length and arm circumference on those dates. Review of Resident #346's clinical record indicated no documented evidence of: -PICC line external catheter length measurement upon insertion or evidence of measurements obtained since admission. -measurements obtained of arm circumference since admission. On 11/20/24 at 9:36 A.M., the surveyor observed Resident #346 dressed and lying in bed. The surveyor observed an IV pole was in the room and a PICC line dressing dated 11/19/24 was in place on the Resident's right inner arm. On 11/26/24 at 11:11 A.M., the surveyor and Nurse #4 reviewed Resident #346's clinical record and Nurse #4 said the Resident's external catheter length and arm circumference should be measured with every PICC line dressing change weekly and as needed. Nurse #4 said the paperwork prior to the Resident's admission indicated the PICC line was 4 Fr and the total catheter length was 40 centimeters (cm), but it did not indicate the measurement of the length of external catheter. Nurse #4 said that she was unable to find evidence in the clinical record that measurements for the external catheter length and arm circumference had been recorded since the Resident's admission. Nurse #4 said it was important to monitor these measurements to ensure that the PICC line catheter had not migrated (moved out of place). Nurse #4 further said if the PICC line moved, then the IV medication may not be administered through the vein as indicated and an infection could occur. On 11/26/24 at 11:25 A.M., the surveyor observed the Resident's PICC line site with Nurse #4 and the following measurements were obtained: -external catheter length was 10 cm -arm circumference was 26 cm During an interview at the time, Resident #346 said that he/she could not recall staff obtaining these measurements since admission. During an interview on 11/26/24 at 11:29 A.M., Unit Manager (UM) #2 said she was unable to find documented evidence of Resident #346's measurements for the external catheter length and arm circumference since his/her admission, that these measurements should have been obtained and documented.

Based on observation, record review, and interview, the facility failed to ensure Activities of Daily Living (ADLs) were provided for one Resident (#45), out of a total sample of 20 residents. Specifically, the facility failed to provide assistance for Resident #45 to ensure daily oral hygiene was completed when the resident was unable to carry out ADLs independently. Findings include: Review of the facility policy titled Activities of Daily Living, initiated on January 23, 2024, indicated the following: -Residents will [sic] provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. -appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . a. Hygiene (bathing, dressing, grooming, and oral hygiene) Resident #45 was admitted to the facility in November 2019 with diagnoses including Epilepsy (seizure disorder), Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment, weight loss, decreased appetite or poor nutrition and inactivity) Apraxia (neurological syndrome characterized by difficulty in performing daily tasks even if the instructions are understood), Aphasia (defect or loss of the power of expression by speech, writing, or signs, or of comprehending spoken or written language, due to injury or disease of the brain centers), and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the following: -Sometimes understands - responds adequately to direct, simple communication only. -Oral hygiene - dependent, (helper does all of the effort) Review of the ADL care plan, initiated on 11/22/19, indicated Resident #45: -Required assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to cognitive decline. -Arrange Resident/patient environment as much as possible to facilitate ADL performance, updated 11/23/19. -Provide Resident/patient with extensive assist to total assist of one for personal hygiene, updated 11/23/19. Review of Resident #45's Dental Group Encounter Note dated 9/9/24, indicated the following: -moderate buildup of soft plaque/food debris -moderate hard calculus deposits Review of the November 2024 task flow sheet for Oral Hygiene, completed daily by the Certified Nurses Aides (CNAs) indicated the following: *Key for Level of care/assistance: -01-Dependent-Helper does ALL of the effort. -06 -Independent -Resident completes the activity by themselves with no assistance from a helper. -05-Set up or Clean up assistance. *Resident #45: -Was dependent for oral hygiene care on the following dates and shifts: >11/1/24 -11/20/24 and 11/22/24 -11/24/24 during the day shift >11/3/24, 11/5/24, 11/7/24 -11/11/24, 11/14/24, 11/17/24, and 11/19/24 -11/24/24 during the evening shift -Was independent for oral hygiene care on the following dates and shift: >11/21/24 during the day shift -Was a set-up for oral hygiene care on the following dates and shift: >11/5/24 on the evening shift -Did not participate in oral hygiene care on the following dates and shift: >11/1/24, 11/2/24, 11/6/24, 11/12/24, 11/13/24, 11/15/24, 11/16/24, and 11/18/24 on the evening shift During an interview and observation on 11/20/24 at 8:48 A.M., the surveyor greeted Resident #45 in the dining room, where he/she was seated at a table with another resident waiting for breakfast to be served. The surveyor asked Resident #45 how he/she was doing today. The Resident responded with a smile and nonsensical words. When Resident #45 opened his/her mouth to speak, the surveyor observed the following: -a strong odor from his/her mouth -front teeth missing -plaque and debris built up on both upper and lower teeth During an interview and observation on 11/21/24 at 10:48 A.M., the surveyor and CNA #2 entered Resident #45's room to observe the Resident's teeth. CNA #2 said she does not always provide care for the Resident and she was not the CNA taking care of the Resident today, but she was familiar with the Resident's care. CNA #2 said that it did not appear that the Resident had brushed his/her teeth yet today. CNA #2 began to search the Resident's room for a toothbrush and toothpaste and was not able to locate either item. At this time, CNA #2 left the room and returned a few moments later with a new toothbrush, toothpaste, a small cup of water and a small kidney shaped container (used to spit into). CNA #2 placed the items on a tray table in front of Resident #45 and applied toothpaste on the toothbrush. Resident #45 smiled, said thank you and immediately picked up the toothbrush and began to brush his/her teeth independently. When the Resident was finished, he/she smiled, showing his/her brushed teeth while nodding his/her head up and down. CNA #2 said she could not speak to when the Resident's teeth had last been brushed or the last time the Resident was set up to independently to brush his/her teeth. During an interview on 11/21/24 at 11:35 A.M., CNA #3 said that she was the CNA assigned to Resident #45 and she did not provide morning mouth care for the Resident. CNA #3 said that she should have either assisted the Resident with brushing his/her teeth or set the Resident up with the items needed for him/her to do his/her own mouth care, as it is part of morning care routine. CNA #3 said that she does not always provide mouth care for Resident #45 because sometimes the Resident's gums bleeds and this makes her nervous. CNA #3 said that as an alternative she will give the Resident a toothette (a small sponge on a stick) to brush his/her teeth, but not an actual toothbrush. The surveyor and CNA #3 observed Resident # 45's brushed teeth that they were clean and did not have a foul odor. Resident #45 smiled and said thank you when his/her teeth were complimented. During an interview on 11/25/24 at 3:27 P.M., the Director of Nursing (DON) said mouth care should be provided every morning and every night. The DON said if a Resident is having a dental issue, we might use a swab (toothette), but other than that we should be using a toothbrush. The DON was not aware of any dental issues with Resident #45.

Based on interview, observation, and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#12), out of one applicable resident, out of a total sample of 20 residents. Specifically, the facility failed to ensure: -a Physician's order was in place for the use of Continuous Positive Airway Pressure (CPAP- a type of non-invasive device that involves the administration of air usually through the nose and/or mouth by an external device at a predetermined level of pressure to keep the airways open) -respiratory equipment was stored in such a manner to prevent contamination and risk of infection. Findings include: Review of the facility policy titled CPAP and BiPAP (Bi-level Positive Airway Pressure - a noninvasive device capable of generating two adjustable pressure levels: inspiratory [IPAP - higher level] and expiratory [EPAP - lower level] that assists with ventilation) Usage/Maintenance, dated 1/10/24, indicated the following: -CPAP may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. -Residents using CPAP/BIPAP will require a Physician's order to include approved order settings, duration of use and use of humidifier . -Verify Physician's order in the residents' chart. -Verify mode and settings on the machine, as prescribed. -Machine cleaning: Wipe machine with warm, soapy water (dish detergent is preferable) and rinse at least once a week and as needed (PRN). -Humidifier (if used): >Use clean, distilled water only in the humidifier chamber. Replace water daily. >Clean humidifier weekly and air dry. >To disinfect, place vinegar-water solution (1:3) in clean humidification chamber. Soak for 30 minutes and rinse thoroughly. -Filter cleaning: rinse washable filter under running water once a week to remove dust and debris. Replace the filter at least once a year. Replace disposable filter monthly. -Masks, nasal pillows, and tubing: clean weekly by placing in warm, soapy water (dish detergent is preferable) and soaking for five minutes. Rinse with warm water and allow air to dry between uses. -Headgear (strap): Wash weekly with warm water and mild detergent as needed. Allow to air dry. -Document the following in the resident's medical record: >Time therapy was initiated. >Mode and settings for the device. >Oxygen concentration and flow (if applicable) Oxygen saturation after application. >Adherence to treatment. Any complication observed. -Notify the Physician if the resident refuses the procedure. Resident #12 was admitted to the facility in March 2024, with diagnoses including Chronic Respiratory Failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly) and Obstructive Sleep Apnea (OSA: pauses in breathing due primarily to the collapse of the upper airway during sleep). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12: -was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. -required substantial/maximal assistance (helper does more than half the effort) for personal hygiene and dressing. -required substantial/maximal assistance to roll left and right in bed. -was dependent (helper does all of the effort. Resident does none of the effort to complete activity) to go from sitting to lying and from lying to sitting. -was dependent for transfers. -used continuous Oxygen. -used CPAP. Review of the Respiratory Care Plan, dated 3/22/24, indicated the following: -Continuous Oxygen at 3 Liter Per Minute (LPM) via nasal cannula (a thin, flexible tube that is used to administer Oxygen through the nose). -CPAP setting: titrated pressure: [sic] cmH2O (centimeter of water-a unit of pressure) via nose mask or full-face mask) on at HS (hour of sleep) off in AM (morning), date initiated 3/22/24. Review of the medical record indicated Resident #12 had been transferred to the hospital on 7/28/24 and returned to the facility on [DATE]. Review of Resident #12's Physician's orders for August 2024, September 2024, October 2024, and 11/1/24 - 11/20/24, indicated no documented evidence that CPAP had been ordered. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2024, September 2024, October 2024, and 11/1/24 - 11/20/24, indicated no documented evidence that CPAP therapy had been utilized. Review of the Nurses Progress Notes, dated 7/31/24 through 11/21/24, indicated no documented evidence that Resident #12 had utilized CPAP therapy. On 11/20/24 at 11:06 A.M., the surveyor observed Resident #12 lying in bed on his/her back with oxygen on via nasal cannula and a CPAP machine located on a table next to the bed. A partially filled bottle of distilled water and an undated, unbagged CPAP mask with tubing was observed next to the CPAP machine. Resident #12 said he/she used the CPAP machine when he/she remembered to ask staff for assistance with putting it on. Resident said he/she would like the Nurses to offer to apply the CPAP at night because he/she forgets and falls asleep and that he/she slept better with the CPAP on and felt more awake the next day. Resident #12 said the Nurses use the distilled water observed next to the CPAP machine when the CPAP device was used, but he/she did not remember when the last time he/she used it. On 11/21/24 at 7:31 A.M., the surveyor observed Resident #12 lying in bed on his/her back with Oxygen on via nasal cannula, the CPAP machine remained on the on the table next to the bed beside, an undated CPAP mask with tubing and a partially filled bottle of distilled water dated 11/15/24. On 11/21/24 at 9:39 A.M., the surveyor observed Resident #12 lying in bed on his/her back with oxygen administered via nasal cannula and the CPAP machine remained on the table next to the bed. The surveyor observed that a CPAP mask with tubing dated 11/21/24, was in a bag on the table with a partially filled bottle of distilled water dated 11/15/24. During an interview at the time, Resident #12 said he/she did not use the CPAP machine last night but that a Nurse had been paying a lot of attention to the machine today and told him/her that there was no Physician order for the use of the CPAP. During an interview on 11/21/24 at 10:31 A.M., Nurse #2 said that there should be Physician's orders for the use of CPAP and that the tubing and mask should be dated when first used and placed in a bag when not in use. Nurse #2 said that she had not worked on the unit for the past month and that she did not replace or label the tubing or distilled water that was in the Resident's room. During an interview on 11/21/24 at 11:02 A.M., Unit Manager (UM) #1 said that she became aware that there was a problem with Resident #12's CPAP orders that morning. UM #1 said she had obtained new CPAP tubing and mask today, labeled the tubing, and placed the mask in a bag for Resident #12. UM #1 said that she had labeled the distilled water 11/15/24 after she had called staff to determine the date the distilled water had been opened. UM #1 said when she looked into the situation, she saw that the CPAP orders had accidentally been omitted from the electronic medical record (EMAR) when the Resident had gone out to the hospital in July. UM #1 further said that when a Resident was transferred to the hospital, all of the Physician orders were discontinued, and when the Resident returns to the facility, all of the orders have to be re-entered into the EMAR. UM #1 said the Nurse that readmitted the Resident to the facility did not re-enter the CPAP orders as she should have, and Resident #12 should have had the CPAP applied every evening since his/her return from the hospital in July. During an interview on 11/21/24 at 11:26 A.M., the Director of Nursing (DON) said the Regional Nurse had done a record review and determined that the Physician orders for the CPAP machine were not obtained during the Resident's re-admission to the facility in July. The DON said the orders for the CPAP should have been in place and the Resident should have been offered the CPAP every evening and but this was not done.

Based on interview and record review, the facility failed to ensure that Medication Regimen Review (MRR) was addressed timely by the Physician and facility for one Resident (#28), of five applicable residents reviewed for unnecessary medications, out of a total sample of 20 residents. Specifically, the facility failed to address the MRR recommendations made by the Consultant Pharmacist pertaining to Resident #28's use of a cholesterol medication and laboratory testing to monitor the Resident's cholesterol levels. Findings include: Resident #28 was admitted to the facility in December 2020, with diagnoses including Hypertension (HTN: high blood pressure. When the blood pressure measures consistently above 130/80 millimeters of mercury [mm Hg]) and hemiparesis/hemiplegia (paralysis on one side of the body) due to Cerebrovascular Accident (CVA: medical term for a stroke - when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel). Review of the Resident #28's clinical record indicated the Consultant Pharmacist conducted an MRR and made a recommendation on the following date: -4/18/24 Further review of the clinical record indicated no documented evidence of the MRR dated 4/18/24. During an interview on 11/22/24 at 1:26 P.M., Unit Manager (UM) #1 said the Director of Nursing (DON) oversees the pharmacy recommendations for the facility and was looking into the MRR requested by the surveyor. On 11/22/24 at 3:30 P.M., the DON provided the surveyor with the MRR dated 4/18/24 which indicated the following: -Resident was currently receiving Atorvastatin (medication used to lower cholesterol and triglycerides (fats) levels to help prevent heart disease, angina (chest pain), strokes, and heart attacks) . -please consider ordering a fasting lipid panel (blood test that measures cholesterol and fat levels in the blood) on the next lab day to monitor therapy and then once yearly thereafter if within normal limits. -the section for the response by the Physician/Prescriber had a handwritten x in the box for agree but was unsigned and undated. Review of the Resident's clinical record indicated no documented evidence that a lipid panel was drawn since the Consultant Pharmacist made the recommendation on 4/18/24. During an interview on 11/22/24 at 3:34 P.M., the DON said when the Consultant Pharmacist makes recommendations, they were sent to her email, printed, and given to the Provider to review. The DON said once the Provider addresses the recommendations, they are given back to the Unit Managers (UMs) to follow through with any new orders and are then filed in the clinical record. The DON said she was unsure who checked off the MRR dated 4/18/24, as it was unsigned and undated but thought it was probably the Nurse Practitioner (NP). The DON said she was unable to find evidence that the MRR dated 4/18/24, was followed through with because a lipid panel had not been drawn since the recommendation was made.

Based on observation, interview and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for one Resident (#28), out of four applicable residents, out of 35 opportunities. Specifically, the medication error rate was observed to be 5.71% when Resident #28 was administered two scheduled medications later than the allowed timeframe. Findings include: Review of the facility policy titled Administering Medication, dated October 2024, indicated the following: -To ensure safe and effective administration of medication in accordance with Physician orders and state/federal regulations. -Medication should be administered within one hour of the prescribed times. Resident #28 was admitted to the facility in December 2020, with diagnoses including Cerebral Infarction (a condition that occurs when blood flow to the brain is blocked, causing brain tissue to die), Vascular Dementia (a general term describing problems with reasoning, planning, judgement, memory and other though processes caused by brain damage from impaired blood flow to the brain), and Gastrostomy (a surgical procedure that creates an opening in the abdomen that allows a feeding tube/ gastrostomy tube (G-tube) to be inserted into the stomach). Review of Resident #28's Physician orders dated 11/22/24, indicated the following: -Gabapentin oral solution (medication used to prevent seizures and relieve nerve pain) 250 milligrams (mg) per five milliliter (ml), give six ml via G-tube three times a day, for neuropathy (weakness, numbness and pain from nerve damage), order date 1/8/24. -Benztropine Mesylate tablet (medication used to treat certain neurological conditions and the side effects of other drugs) 0.5 mg give one tablet via G-tube two times a day, order date 2/8/24. Review of the Medication Administration Record (MAR), dated November 2024 indicated the following: -Gabapentin oral solution 250 mg per five ml, give six ml via G-tube three times a day, scheduled to be administered at 6:00 A.M., 11:00 A.M., and 4:00 P.M. -Benztropine Mesylate tablet 0.5 mg, give one tablet via G-tube two times a day for tremors and stiffness of the muscles, scheduled to be administered at 11:00 A.M., and 8:00 P.M. On 11/22/24 at 12:41 P.M., during a medication pass administration on the D-Wing unit, the surveyor observed Nurse #7 prepare and administer the following medications to Resident #28: -Gabapentin oral solution 250 mg/ 5 ml (one hour and 41 minutes after the scheduled administration time) -Benztropine Mesylate tablet 0.5 mg (one hour and 41 minutes after the scheduled administration time) During an interview on 11/22/24 at 1:39 P.M., Nurse #7 said that she was aware that she had administered the medication scheduled for 11:00 A.M. late, and that she was aware that medications should be given within one hour of the prescribed time. Nurse #7 said this was a system problem. Nurse #7 further said that she had been scheduled today to work on the A-Wing from 7:00 A.M. until 11:00 A.M, where she had 17 residents to administer medications and treatments and complete her documentation. Nurse #7 said that she got to the D-Wing as soon as she could, at about 11:10 A.M. and immediately started the medication pass process. Nurse #7 said there were several residents on the D-Wing that had medications scheduled for 11:00 A.M. and no matter what she did, some of the residents were going to get their medications late. During an interview on 11/22/24 at 2:12 P.M., the Director of Nursing (DON) said Resident #28 should not have received his/her 11:00 A.M. medications at 12:41 P.M.

Based on interview, and record review, the facility failed to obtain lab work as ordered by the Physician for two Residents (#28 and #52), of five applicable residents, out of a total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #28, obtain lab work to monitor his/her valproic acid level (measures the amount of valproic acid [medication used for the treatment of seizures or to manage behaviors] in the blood). 2. For Resident #52, obtain routine lab work to monitor his/her blood glucose levels, thyroid hormone levels, and lipid [fat]/cholesterol levels. Findings include: Review of the facility policy titled Diagnostic Services, revised October 2024, indicated the following: -access to radiologist and clinical laboratory diagnostic services will be available seven days a week, to ensure that diagnostic tests relevant to the residents' health status was provided and reported as required by the physician. -all diagnostic service/test requires an order by the licensed prescriber assigned to the resident. 1. Resident #28 was admitted to the facility with diagnoses including Vascular Dementia with behavioral disturbance (deterioration of memory, language, and other thinking abilities with behavioral and psychological symptoms such as agitation, anxiety, and psychosis), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]) and Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy). Review of the Minimum Data Set (MDS) Assessment, dated 10/31/24 indicated Resident #28: -had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 8 out of 15 -received an anticonvulsant medication Review of Resident #28's November 2024 Physician's orders indicated: -Valproic Acid 250 milligrams (mg)/ 5 milliliters (ml), give 2.5 ml .daily for Bipolar [sic], and give 5 ml .daily for Bipolar, initiated on 1/8/24 -Valproic Acid level every six months, initiated 6/26/23 Review of the Resident's clinical record indicated no documented evidence that the valproic acid level was drawn. On 11/22/24 on 10:06 A.M., Unit Manager (UM) #1 said there was a Physician's order for the valproic acid level to be drawn routinely for Resident #28. UM #1 said she would review the Resident's record to verify that the lab work was drawn as ordered by the Physician. On 11/22/24 at 3:34 P.M., the Director of Nursing (DON) said there was a systems issue with the the facility obtaining routine lab work for residents. During a subsequent interview on 11/26/24 at 10:18 A.M., the DON provided the surveyor with the last obtained valproic acid for Resident #28, which was dated 12/26/23. The DON said the lab work had not been obtained since that date and should have been. 2. Resident #52 was admitted to the facility in May 2019, with diagnoses including Type 2 Diabetes (DM II: non-insulin dependent diabetes - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in variable blood glucose [sugar] levels in the blood), Hyperlipidemia (abnormally high levels of fats (lipids) in the blood, including cholesterol and triglycerides), and Hypothyroidism (when the thyroid gland does not make enough thyroid hormone). Review of the MDS Assessment, dated 10/14/24, indicated Resident #52: -was cognitively intact was evidenced by a BIMS score of 15 out of 15 -received an anticoagulant (medication that decreases the body's ability to form clots), a diuretic (medication that promotes urine production to expel excess fluid from the body), and a hypoglycemic (medication that lowers blood sugar levels) during the reference period. During an interview on 11/22/24 at 9:14 A.M., Resident #52 said he/she had lab work every three months or so. Resident #52 said he/she was was unsure what the lab work was monitoring. Review of the November 2024 Physician's orders included the following: -Abixaban (anticoagulant) 2.5 milligrams (mg), one tablet twice daily, initiated 11/14/23 -Glipizide (hypoglycemic) extended release, 5 mg daily, initiated 12/3/23 -Lasix (diuretic) 20 mg twice daily, initiated 11/13/23 -Levothyroxine (thyroid) 50 micrograms (mcg) daily, initiated 11/12/23 -Simvastatin 40 mg daily, initiated 12/29/23 Review of the Physician Progress Note, dated 10/28/24, indicated the following plan: -HgbA1c (Glycosolated Hemoglobin A1c: measure of the average blood glucose levels over the past two to three months and is a crucial indicator for the management and monitoring of diabetes) was 6.0 % (goal less than 6.5%), repeat ordered and check HgbA1c every six months. -TSH (Thyroid Stimulating Hormorne or thyrotropin, is a hormone that the pituitary gland releases to trigger the thyroid to produce and release its own hormones - thyroxine [T4] and triiodothyronine [T3]) , T3 and T4 levels every 6 months- repeat ordered. -Annual lipid panel (blood test that measures the level of different types of fat [lipid molecules]/cholesterol in your blood) Review of the Resident's clinical record indicated no documented evidence the HgbA1c, TSH, T3 and T4 lab work had been drawn since 2/28/24. Further review of the clinical record indicated no documented evidence that a lipid panel had been obtained for the Resident. During an interview on 11/22/24 at 10:06 A.M., UM #1 said that Resident #52 should have a standing order for routine lab work to be drawn. UM #1 said she would look into it and get back to the surveyor. During an interview on 11/22/24 at 3:34 P.M., the DON said she looked into the issue with the Resident's routine lab work which had been ordered by the Physician. The DON said the routine lab work was accidentally discontinued and should have been renewed and there was no evidence that a lipid panel was drawn or that the HgbA1c, TSH, T3 and T4 had been obtained since 2/28/24. The DON said education needed to be provided to the facility Nurses about the process for reviewing the monthly laboratory sheets that indicated resident lab work that needed to be reviewed/renewed.

Based on observation, interview and record review, the facility failed to follow the dietary plan as recommended by the Registered Dietitian (RD) to meet the nutritional needs and preferences of one Resident (#50), out of a total sample of 20 residents. Specifically, for Resident #50, the facility failed to ensure that food as recommended by the RD and as indicated on the meal tickets were provided to the Resident at meal times. Findings include: Resident #50 was admitted to the facility in April 2023, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and Gastro-Esophageal Reflux Disease (GERD - a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of the Minimum Data Set (MDS) Assessment, dated 8/20/24, indicated Resident #50: -was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. -required set-up/clean-up for eating. -was dependent (helper does all of the effort. Resident does none of the effort to complete activity) for hygiene, dressing, toileting, bed positioning and transfer. -received Hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) care. Review of Resident #50's Dietary Evaluation, dated 8/30/24, indicated the following: -Resident on Hospice, provide foods/fluids for comfort pleasure. -Staff reports meal intake zero to 100 percent (%). -Fluid/nutrition was not adequate if the Resident eats less than 50% of meals. -Recommend liberalizing to regular diet to maximize intake. -Continue ice cream as ordered for comfort/pleasure. Honor preferences. Review of the Nutrition Care Plan, dated 8/30/24, indicated the following: -Provide foods of choice for comfort, date initiated 8/30/24 -Honor dietary preferences, date initiated 8/30/24. -Ice cream as ordered, date initiated 8/30/24. Review of Resident #50's Physician's orders, dated 11/22/24, indicated the following: -Regular diet, regular texture, thin liquid consistency, Ice Cream at 12N (12:00 P.M.) and 5p (5:00 P.M.), date initiated 8/30/24. On 11/21/24 at 8:34 A.M., the surveyor observed Resident #50 was sitting up in bed with his/her breakfast tray which had just been delivered. The breakfast meal ticket, dated 11/21/24, indicated the following items: -cold cereal -apple cinnamon muffin -margarine -eight-ounce whole milk -six-ounce hot coffee x2 -fried egg and cheese sandwich -send empty bowl/silverware The surveyor observed the apple cinnamon muffin and margarine to be missing from the tray. During an interview at the time, Resident #50 said that he/she never received the items on his/her tray that were on his/her meal ticket. Resident #50 further said that he/she would have liked to try the apple cinnamon muffin. On 11/21/24 at 12:40 P.M., the surveyor observed Resident #50 sitting up in bed with his/her lunch tray which had just been delivered. The lunch meal ticket, dated 11/21/24, indicated the following items: -Italian sausage -potato wedges -ketchup -sauteed spinach -dinner roll -sliced pears -ice cream -eight-ounce whole milk -six-ounce coffee x2 The surveyor observed the lunch tray contained buttered noodles (not listed on ticket), and the potato wedges and ice cream that were listed on the meal ticket were observed to be missing from the tray. Resident #50 said that he/she had wanted potato wedges, not noodles, and that he/she had already told the kitchen this. Resident #50 further said that he/she never received the ice cream on his/her tray. On 11/22/24 at 9:00 A.M., the surveyor observed Resident #50 sitting up in bed with his/her breakfast tray. The breakfast meal ticket, dated 11/22/24, indicated the following items: -cold cereal of choice -toast -jelly -margarine -eight-ounce whole milk -six-ounce hot coffee x2 -send empty bowl/silverware -fried egg and cheese sandwich. The surveyor observed the breakfast tray contained fat free milk instead of whole milk (which was listed on the tray ticket). Resident #50 said that he/she used to complain about the incorrect items on his/her tray but now he/she does not bother because nothing changes. During an interview on 11/22/24 at 12:21 P.M., Certified Nurses Aide (CNA) #2 said a Nurse checks the meal trays before the CNAs start distributing them to residents. During an interview on 11/22/24 at 12:22 P.M., Nurse #8 said she checks the trays to make sure the resident diets match the tickets, and the correct food items were on the meal tray. Nurse #8 said that if the resident meal was not correct, or items were missing, she would notify the kitchen. During an interview on 11/22/24 at 2:35 PM, the Food Service Director (FSD) said the residents should receive the items that are listed on the meal ticket. The surveyor and the FSD reviewed photos taken of Resident #50's meal trays with the meal tickets. The FSD said that Resident #50 should have received the apple cinnamon muffin at breakfast on 11/21/24, should have received potato wedges and ice cream at lunch on 11/21/24, and should have received whole milk at breakfast on 11/22/24. The FSD said the Dietary Aide that loads the meal trays onto the cart was responsible for checking that the proper items are on the trays.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members with bed mobility and toileting care needs, the Facility failed to ensure Resident #1 received adequate staff assistance to prevent an accident with injury, when Certified Nurse Aide (CNA) #1 provided care to Resident #1, unassisted by another staff member, and sustained a right humeral (upper arm) shaft fracture. - On 3/12/19, sometime between approximately 10:00 P.M. and 10:30 P.M., Certified Nurse Aide (CNA) #1, who was unassisted by another staff person, was providing incontinence care for Resident #1, rolled Resident #1 over and heard a popping noise. On 03/13/19, Resident #1 was noted to have right shoulder pain, the physician's assistant was notified, an x-ray was obtained and showed an acute right humeral shaft fracture. Findings include: Resident #1 was readmitted to the Facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. The Activities of Daily Living (ADL) Care Plan, revised 08/23/16, indicated Resident #1 was dependent for all ADL care. The Care Plan indicated Resident #1 was dependent on two staff persons for toileting, bed mobility and positioning. The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required extensive assistance of two staff persons for bed mobility and toilet use (includes cleanses self after elimination and changes pads). The MDS indicated Resident #1 had limited range of motion (ROM) to both of his/her upper extremities. A Late Entry Nurse Progress Note for Resident #1, dated 03/12/19, indicated a CNA alerted the nurse that she heard a pop in Resident #1's right arm when doing evening care. The Note indicated the nurse assessed Resident #1's right arm and no injuries or pain was noted. A Nurse Progress Note, dated 03/13/19, indicated Resident #1 experienced a change in condition and Resident #1 had pain to the right shoulder on 03/12/19 at night. The Note indicated the physician's assistant was notified and a stat chest x-ray to the right shoulder was ordered. The Situation Background Appearance and Review (SBAR) and Notify Form, dated 03/13/19, indicated Resident #1 had pain to his/her right shoulder that started on 03/12/19. The SBAR indicated Resident #1 had pain that was new and that he/she had an occasional moan or groan with facial grimacing. A Radiology Report, dated 03/13/19, indicated Resident #1 had a right acute humeral shaft fracture. The Nursing Home to Hospital Transfer Form for Resident #1, dated 03/13/19, indicated the CNA performing care on the 3:00 P.M. to 11:00 P.M. shift on 03/12/19 reported hearing a popping sound and reported this to the nurse and no irregularities were noted. The Form indicated in the morning (exact time not indicated) on 03/13/19, Resident #1 exhibited nonverbal signs of pain, an x-ray was obtained and showed a right comminuted (break or splinter of the bone into more than two fragments) humeral proximal shaft fracture with mild mal-alignment with a conclusion of an acute right humeral shaft fracture. The Facility's Investigation, dated 03/13/19, indicated Resident #1 was grimacing while receiving morning care when his/her right arm was moved and he/she appeared to be in pain. The Investigation indicated Resident #1 had a preexisting condition of [MEDICAL CONDITION] and was dependent for care and transfers. The Investigation indicated CNA #1 said she heard a possible pop that sounded like the bed or Resident #1's right arm while providing incontinence care on the 3:00 P.M. to 11:00 P.M. shift on 03/12/19. The Investigation indicated the physician assistant was notified, an x-ray was ordered, obtained, and showed a comminuted right humeral proximal shaft fracture with mild mal-alignment. The Investigation indicated Resident #1 was transferred to the Hospital Emergency Department for further evaluation. The Hospital Report, dated 03/13/19, indicated Resident #1 had a minimally displaced obliquely (at an angle through the bone) longitudinal (along the axis of the bone) fracture through the proximal (upper) right humeral shaft that was splinted for comfort. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:29 A.M. on 03/22/19. CNA #1 said that on 03/12/19, sometime between approximately, 10:00 P.M. and 10:30 P.M., she was providing evening care to Resident #1, alone. CNA #1 said while Resident #1 was on his/her right side and she was providing incontinence care to Resident #1, she heard a popping noise. CNA #1 said she had her right hand on Resident #1's right shoulder blade, was holding Resident #1 over in place on his/her right side, and was removing Resident #1's brief when she heard the popping noise. CNA #1 said she then positioned Resident #1 onto his/her back and then went to get the nurse. CNA #1 said she did not have anyone else in the room assisting her with Resident #1's care during this time. CNA #1 said she was aware that Resident #1 required two staff members for assistance with bed mobility and that Resident #1 was dependent for toileting needs. CNA #1 said the following day, on 03/13/19 at approximately 10:00 A.M. when she went in to provide Resident #1 with morning care, she noted Resident #1's right arm to be red and swollen and notified the nurse. The Surveyor interviewed Nurse #1 at 3:04 P.M. on 03/22/19. Nurse #1 said that on 03/12/19 at approximately 10:30 P.M., CNA #1 reported to her that she heard a popping noise, thought it could have been the bed, and that CNA #1 said that Resident #1's right arm did not look right. Nurse #1 said she assessed Resident #1's right arm and did not note any injuries and said that Resident #1 denied pain at the time. Nurse #1 said Resident #1 required the assistance of two staff persons for bed mobility and incontinence care. Nurse #1 said after she assessed Resident #1, she assisted CNA #1 with completing Resident #1's care because she knew he/she required two staff persons with care. The Surveyor interviewed Nurse #2 at 2:16 P.M. on 03/22/19. Nurse #2 said on 03/13/19 while she was assisting CNA #1 with Resident #1's care she noted Resident #1 to be grimacing. Nurse #2 said that CNA #1 reported to her that when she was providing care to Resident #1 on the previous evening, that she had heard a popping noise when she was turning Resident #1 in bed. Nurse #2 said she notified the physician's assistant and obtained an order for [REDACTED]. The Surveyor interviewed the Administrator at 1:50 P.M. on 03/22/19. The Administrator said Resident #2 required two staff person assistance for bed mobility and was dependent for incontinence care.

Based on interview and records reviewed, for one of seventeen sampled Residents (Resident #53) the Facility failed to ensure that the Physician was immediately notified of a change in Resident #53's condition first noted around 3:00 A.M. on 8/16/18. Findings include: The Change in Condition Notification Policy dated 11/28/16 indicated that the Facility must immediately consult with the resident's physician when there is a significant change in a resident's physical, mental or psychosocial status. The Physician Notification Policy dated 3/15/16 indicated that a licensed nurse would perform appropriate clinical observation and data collection and report to the provider. Resident #53's most recent Admission Minimum Data Set (MDS) Assessment Form, completed 7/23/18 indicated that his/her cognitive patterns were severely impaired, he/she made himself understood and understood others, he/she exhibited no indicators of mood impairment or behavioral symptoms and he/she required the extensive assistance of one staff member with bed mobility and had impaired range of motion in his/her upper extremities. The MDS indicated that Resident #53 ate with assistance setting up for meals and supervision. The Surveyor interviewed CNA #1 at 8:30 A.M. on 8/20/18. CNA #1 said that she was assigned to care for Resident #53 during the 3:00 P.M. to 11:00 P.M. (Evening) and 11:00 P.M. to 7:00 A.M. (Night) shifts which started on 8/15/18 and ended on 8/16/18. CNA #1 said that it was Resident #53's regular routine during Evening shifts to ring his/her call light or asked his/her roommate to ring the call light every few hours to request drinks, Tums and Tylenol. CNA #1 said that Resident #53 was able to feed him/herself after being set up by staff and refused to eat for several days. CNA #1 said that during the Evening shift on 8/15/18 Resident #53 requested and independently drank several glasses of ginger ale and a cup of hot chocolate. CNA #1 said that after washing Resident #53 and dressing him/her, she emptied his/her catheter and left his/her room. The Surveyor interviewed Nurse #5 at 7:00 P.M. on 8/17/18. Nurse #5 said she regularly cared for Resident #53. Nurse #5 said that Resident #53 was his/her usual self during the Evening shift on 8/15/18. Nurse #5 said that Resident #53 rang the call light and asked for water, ginger ale and Tums during the shift and did not eat dinner which was typical for him/her. Nurse #5 said that Resident #53 refused his/her medications except for a sleeping pill at 9:30 P.M. which was typical. Nurse #5 said that Resident #53 was checked one last time before the Night shift started and he/she appeared to be asleep in bed. The Surveyor interviewed CNA #2 at 8:30 P.M. on 8/17/18. CNA #2 said that she worked at the Facility during the Night shift and regularly worked on Resident #53's unit. CNA #1 and CNA #2 said that they made rounds on Resident #53's unit around 11:30 P.M. and CNA #1 said that Resident #53 requested Tums again and she let Nurse #1 know. CNA #1 said that at 3:00 A.M. on 8/16/18 she answered a call light in Resident #53's room and found Resident #53's call light cord wrapped around his/her neck. CNA #1 said that she called Nurse #1 into Resident #53's room and told Nurse #1 that Resident #53 tried to strangle his/herself. CNA #1 said Nurse #1 did not assess Resident #53. CNA #1 said Nurse #1 stood at the end of the bed and looked at Resident #53 and told CNA #1 that Resident #53 could not strangle him/herself because he/she was too weak. CNA #1 said she gave Resident #53 a cup of water to demonstrate to Nurse #1 that Resident #53 could not even hold his/her cup as he/she had been able to during the Evening shift. CNA #1 said Nurse #1 said that Resident #53 was dying anyway. The Surveyor interviewed Nurse #1 at 10:00 A.M. on 8/22/18. Nurse #1 said that sometime between 2:00 A.M. and 4:00 A.M. on 8/16/18, CNA #1 asked her to come into Resident #53's room because he/she had the call light cord over his/her neck and he/she was pulling it. Nurse #1 said that she was not sure what CNA #1 was reporting. Nurse #1 said that she thought that CNA #1 intended to report to her that someone clipped the call light to the wrong side of Resident #53's bed and as a result the call light cord was draped over him/her. Nurse #1 said that she and CNA #1 went into Resident #53's room together. Nurse #1 said that Resident #53 was alert and was laying in his/her bed with his/her eyes open. Nurse #1 said that she asked Resident #53 whether he/she was feeling OK and he/she said yes in a weak voice. Nurse #1 said that she told Resident #53 that CNA #1 told her he/she was having some trouble and Resident #53 made a sound to the effect of eh or uh. Nurse #1 said that she asked Resident #53 if she could look at Resident #53's neck and when he/she did not answer, she lowered the head of Resident #53's bed. Nurse #1 said that there was no mark on Resident #53's neck and she raised the head of his/her bed and offered him/her some water in a small plastic Dixie cup. Nurse #1 said that although Resident #53 held the sides of the Dixie cup, she and CNA #1 together supported the cup from underneath because Resident #53 could not hold it. Nurse #1 said that she did not know whether this was a change for Resident #53 because she always gave him/her water from a cup with a straw which she held to his lips when administered his/her medications. Nurse #1 said that Resident #53's breathing was easy and regular. Nurse #1 said she did not count Resident #53's respirations, complete a skin check or take his/her vital signs, but she did look at his/her neck. Nurse #1 said that she did not notify Resident #53's physician that CNA #1 said that Resident #53 had the call light cord over his/her neck because nothing seemed out of the ordinary. Nurse #1 said that she did not tell Resident #53's physician that Resident #53 could not hold a Dixie cup of water because she always held the cup for him/her and she did not know this was a change. The Surveyor interviewed Nurse #7 at 2:00 P.M. on 8/22/18. Nurse #7 said that she worked for an Agency and was assigned to care for Resident #53 on 8/16/18 during the Day shift. Nurse #7 said that when she received report from Nurse #1 at 7:00 A.M. Nurse #1 told her that Resident #53 had been refusing medications and food for several days and the Facility was waiting for his/her health care agent to visit and complete paperwork regarding Hospice care and his/her code status. Nurse #7 said that she checked Resident #53 after report and he/she was sleeping. The Surveyor interviewed CNA #3 at 9:30 P.M. on 8/17/18. CNA #3 said that she checked Resident #53 at 7:00 A.M. and Resident #53 was still and quiet. CNA #3 said that she was not surprised that Resident #53 was still and quiet because the last time she worked he/she had been refusing to eat. CNA #3 said that she assisted Resident #53 to take liquids from his/her breakfast tray. CNA #3 said that the liquids she gave to Resident #53 poured right back out of his/her mouth and she reported this to Nurse #7. Nurse #7 said that she checked Resident #53 again and tried to give him/her some orange juice off of a spoon. Nurse #7 said that Resident #53 took two sips of orange juice off of the spoon. Nurse #7 said that she told CNA #3 to attempt to feed him/her again in about an hour. Nurse #7 said that she was not aware that the evening before Resident #53 drank from a cup independently. Nurse #7 said that CNA #3 told her about an hour later that she approached Resident #53 again to assist him/her with breakfast and drinks and he/she pursed his/her lips and liquids poured back out of his/her mouth. Nurse #7 said that she took Resident #53's blood pressure and found it to be low. Nurse #7 said she notified a supervisor and called Resident #53's physician to report Resident #53's condition and obtained an order to send Resident #53 to the hospital for an evaluation. Although Resident #53's nurses' notes did not indicate what time Nurse #7 notified Resident #53's physician of Resident #53's change in condition and Nurse #7 said that she could not recall the specific time, Nurse #7 said that a few minutes after she placed the call another nurse checked Resident #53 and initiated a Code Blue. Resident #53's Code Blue Witness Statements were reviewed and indicated that at 10:56 A.M. the Code Blue was initiated. Resident #53's physician was notified of Resident #53's change in condition shortly before 10:56 A.M. about 7 hours after CNA #1 first noted a change and reported it to Nurse #1.

Based on interviews and records reviewed, for one of 17 sampled Residents (Resident # 53), the Facility failed to provide Resident #53 with necessary care and services when Nurse #1 failed to thoroughly assess Resident #53 after Certified Nurse Aide (CNA) #1 found him/her at 3:00 A.M. on [DATE] with his/her call light cord wrapped at least twice around his/her neck and multiple staff failed to communicate effectively during the next twenty hours to ensure that appropriate caregivers, including hospital staff, knew about the incident. Findings include: The Facility Accidents/Incidents Policy dated [DATE] indicated that in response to Incidents the nurse would examine the resident, notify the resident's physician and document the incident in the resident's record. Resident #53's most recent Admission Minimum Data Set (MDS) Assessment Form, completed [DATE] indicated that his/her cognitive patterns were severely impaired, he/she made himself understood and understood others and he/she exhibited no indicators of mood impairment or behavioral symptoms. The MDS indicated that he/she required the extensive assistance of one staff member with bed mobility and had impaired range of motion in his/her upper extremities. The MDS indicated that Resident #53 ate with supervision. The Surveyor interviewed CNA #1 at 8:30 A.M. on [DATE]. CNA #1 said and review of the Schedule indicated that she worked on Resident #53's unit during the 3:00 P.M. to 11:00 P.M. (Evening) and 11:00 P.M. to 7:00 A.M. (Night) shifts which started on [DATE] and ended on [DATE]. CNA #1 said that at 3:00 A.M. on [DATE] she answered a call light in Resident #53's room and found Resident #53's call light cord wrapped around his/her neck. CNA #1 said that she unwound at least two loops of the call light cord from around Resident #53's neck, lifted the remaining loops over his/her head and placed the call light and cord behind Resident #53's pillow. CNA #1 said Resident #53 breathed in a gasping way which was unusual for him. CNA #1 said that although Resident #53 answered questions and spoke to her during the Evening shift, he/she did not answer her questions after she removed the call light cord from around his/her neck. CNA #1 said that she called Nurse #1 into Resident #53's room and told Nurse #1 that Resident #53 tried to strangle him/herself. CNA #1 said Nurse #1 did not assess Resident #53. CNA #1 said Nurse #1 stood at the end of the bed and looked at Resident #53. CNA #1 said that Nurse #1 told her that Resident #53 was OK and he/she could not strangle him/herself because he/she was not strong enough. CNA #1 said she gave Resident #53 a cup of water to demonstrate to Nurse #1 that Resident #53 could not even hold his/her cup as he/she had been able to during the Evening shift and Nurse #1 said Resident #53 was dying anyway and left Resident #53's room. CNA #1 said that she thought Nurse #1's comments meant that Resident #53 was on Hospice. CNA #1 said she made Resident #53 comfortable in bed and left his/her room. CNA #1 said that she told CNA #2 about the incident. The Surveyor interviewed CNA #2 at 8:30 P.M. on [DATE]. CNA #2 said that CNA #1 answered Resident #53's call light around 3:00 A.M. on [DATE]. CNA #2 said that Nurse #1 went into Resident #53's room a moment later. CNA #2 said that when CNA #1 exited Resident #53's room a few minutes later, CNA #1 told her that she found Resident #53 with the call light cord wrapped around his/her neck. CNA #2 said that CNA #1 was upset because she told Nurse #1 how she found Resident #53 and Nurse #1 had not done anything to help Resident #53. CNA #2 said that CNA #1 told her that Nurse #1 said that Resident #53 was dying anyway. The Surveyor interviewed Nurse #1 at 10:00 A.M. on [DATE]. Nurse #1 said that sometime between 2:00 A.M. and 4:00 A.M. on [DATE], CNA #1 asked her to come into Resident #53's room because he/she had the call light cord over his/her neck and he/she was pulling it. Nurse #1 said that she was not sure what CNA #1 was reporting and said that CNA #1 was excitable. Nurse #1 said that she thought that CNA #1 intended to report to her that someone clipped the call light to the wrong side of Resident 53's bed and as a result the call light cord was draped over him/her. Nurse #1 said that she and CNA #1 went into Resident #53's room together. Nurse #1 said that Resident #53 was alert and was laying in his/her bed with his/her eyes open. Nurse #1 said that she asked Resident #53 whether he/she was feeling OK and he/she said yes in a weak voice. Nurse #1 said that she told Resident #53 that CNA #1 told her he/she was having some trouble and Resident #53 made a sound to the effect of eh or uh. Nurse #1 said that she asked Resident #53 if she could look at Resident #53's neck and when he/she did not answer, she lowered the head of Resident #53's bed. The Surveyor asked Nurse #1 the reason that she looked at Resident #53's neck and she said because CNA #1 told her that the call light had been over his/her neck and he/she pulled on it. Nurse #1 said that there was no mark on Resident #53's neck and she raised the head of his/her bed and offered him/her some water in a small plastic Dixie cup. Nurse #1 said that although Resident #53 held the sides of the Dixie cup, she and CNA #1 supported the cup from underneath because Resident #53 could not hold the weight of the small cup in his/her hands. The Surveyor asked Nurse #1 whether it was unusual for Resident #53 to need support holding a cup and Nurse #1 said that she did not know because on the Night shift she always held resident's cups so they wouldn't spill in their beds. Nurse #1 said that Resident #53's breathing was easy and regular. Nurse #1 said that Resident #53 seemed OK to her and she and CNA #1 tucked him/her back into bed and left his/her room. Nurse #1 said that she did not ask CNA #1 to document the incident with Resident #53 because everything seemed fine. Nurse #1 said she did not document CNA #1 statement's or their interaction with Resident #53 in his/her record because nothing seemed out of the ordinary. Nurse #1 said that she did not interview Resident #53 about what happened, take his/her vital signs or complete a full skin check. Nurse #1 said that she did not report CNA #1's statement or their interaction with Resident #53 to the 7:00 A.M. to 3:00 P.M. (Day) shift or Resident #53's physician. CNA #1 said that in addition to reporting that she found Resident #53 with the call light wrapped around his/neck to Nurse #1 and CNA #2, she reported the incident to CNA #4 and CNA #5 at 7:00 A.M. on [DATE]. The Surveyor interviewed CNA #5 at 11:00 A.M. [DATE]. CNA #5 said that when she arrived for work around 7:00 A.M. on [DATE], CNA #1 told her about something that happened during the shift. CNA #5 said that she did not know what CNA #1 said. CNA #5 said that she wanted to start her shift and wasn't a very social person in the morning. CNA #5 said that CNA #1 is loud and talks a lot and she might have been tuning her out. The Surveyor interviewed CNA #4 at 11:20 A.M. on [DATE]. CNA #4 said that around 7:00 A.M. on [DATE], CNA #1 asked her which Day shift CNA was going to be assigned to care for (Resident #53) whom she identified by bed number. CNA #4 said that she told CNA #1 that she wasn't sure which Day shift CNA would care for Resident #53 and said CNA #1 could tell her the information and she would pass it along to the CNA. CNA #4 said that CNA #1 told her something about Resident #53 tying a Johnny around him/herself. CNA #4 said that she cut CNA #1 off and asked whether she reported the incident to the nurse and CNA #1 told her that she had. CNA #4 said that she told CNA #1 that she was all set and the Day shift would deal with the situation. CNA #4 said that CNA #1 was a bit of a loud talker and she cut her off so that she would stop talking. CNA #5 and CNA #4 said that they did not inform any other Day shift staff member about their interactions with CNA #1. The Surveyor interviewed Nurse #7 at 2:00 P.M. on [DATE]. Nurse #7 said that she worked for an Agency and was assigned to care for Resident #53 on [DATE] during the Day shift. Nurse #7 said that when she received report from Nurse #1 at 7:00 A.M. Nurse #1 told her that Resident #53 had refused medications and food for several days and the Facility was waiting for his/ her health care agent to visit and sign paperwork regarding Hospice care and his/her code status. The Surveyor interviewed CNA #3 at 9:30 P.M. on [DATE]. CNA #3 said that she was Resident #53's assigned CNA during the Day shift on [DATE]. The Surveyor asked Nurse #7 and CNA #3 whether Nurse #1, CNA #1, CNA #3 or CNA #4 told them that CNA #1 found Resident #53 during the Night shift with the call light cord wrapped around his/her neck and they said that they had not. Nurse #7 said that she checked Resident #53 several times during the morning and he/she wouldn't open his/her mouth for medications, food and liquids. Nurse #7 said that when she checked Resident #53's blood pressure around 10:30 A.M. she found it to be low and began to make arrangements to transfer him/her to the hospital for evaluation. Nurse #7 said that while she copied paperwork in preparation for Resident #53's transfer to the hospital another staff member checked Resident #53 and a Code blue was called. Nurse #7 said 911 was called and Resident #53 left the Facility in an ambulance. Nurse #7 said that she provided paper work regarding Resident #53 to the ambulance, but she did not document on the paperwork that Resident #53 was found with the call light cord wrapped around his/her neck at 3:00 A.M. because she was unaware. The Nursing Home to Hospital Transfer Form dated [DATE] at 11:54 A.M. indicated that the reason for Resident #53's transfer to the hospital was that he/she was found unresponsive. There was no mention on the Form that at 3:00 A.M. Resident #53 had been found with a call light cord wrapped around his/her neck. The Surveyor interviewed Nurse #5 at 7:00 P.M. on /,[DATE] and at 12:30 P.M. on [DATE]. Nurse #5 said that when she arrived to the Facility at 3:00 P.M. on [DATE] she learned that Resident #53 had been transferred to the hospital during the Day shift. Nurse #5 said that CNA #1 also arrived at the Facility to work the Evening shift on Resident #53's unit and asked her the reason that Resident #53 had been sent to the hospital. Nurse #5 said that when she told CNA #1 that she did not know the circumstances of Resident #53's transfer to the hospital, CNA #1 told her that she found Resident #53 with the call light cord wrapped around his/her neck at 3:00 A.M. on [DATE]. Nurse #5 said that she had not heard about Resident #53 being found with a call light cord wrapped around his/her neck during the change of shift report and she did not know whether that incident was related to his/her transfer to the hospital. Nurse #5 said that around 6:00 P.M. on [DATE], the hospital called her looking for information about Resident #53. Nurse #5 said that when she reviewed Resident #53's record to provide information to the hospital, she did not see documentation about the incident at 3:00 A.M. with the call light cord that CNA #1 mentioned to her around 3:00 P.M. at the start of the Evening shift. Nurse #5 said she told Nurse #3 about CNA #1's report and asked CNA #1 to write a statement about the incident. Nurse #5 said that after Nurse #3 heard about CNA #1's statement, Nurse #3 notified Unit Manager #1, the Director of Nurses and the Administrator. The Surveyor interviewed Unit Manager #1 at 4:00 P.M. on [DATE]. Unit Manager #1 said that around 6:00 P.M. on [DATE] she received a text from Nurse #3 which asked words to the effect, hypothetically if a Night shift CNA reported that she found a resident the previous Night shift with a call light cord wrapped around his/her neck and the resident coded this morning and went to the emergency department what should (the staff) do. Unit Manager #1 said she called Nurse #3 back at the Facility. Unit Manager #1 said that Nurse #3 and Nurse #5 told her that the emergency department physician called the Facility around 6:00 P.M. and asked for additional information about Resident #53. Unit Manager #1 said that Nurse #3 and Nurse #5 told her that they reviewed Resident #53's records and it seemed as though the incident with Resident #53's call light cord which CNA #1 reported to them was not documented in Resident #53's record or included in the information sent to the hospital with Resident #53. Unit Manager #1 said that Nurse #3 and Nurse #5 told her that the emergency department physician seemed unaware of the incident with Resident #53's call light cord when they spoke. The Surveyor asked Unit Manager #1 whether Nurse #3 and Nurse #5 told the emergency department physician about the incident in which the call light cord was found wrapped around Resident #53's neck and Unit Manager #1 said that they did not. The Surveyor asked Unit Manager #1 whether Nurse #3 and Nurse #5 called the emergency department again to report the incident after speaking with Unit Manager #1 and she said that they did not. The Surveyor interviewed the Director of Nurses at 4:00 P.M. on [DATE]. The Director of Nurses said that around 6:00 P.M. on [DATE] Nurse #5 called and reported to her that CNA #1 said that around 3:00 A.M. she found Resident #53 with the call light cord wrapped around his/her neck. The Director of Nurses said came to the Facility with the Administrator and initiated an internal investigation. The Director of Nurses said that she reviewed CNA #1's written statement and interviewed CNA #1. The Director of Nurses said after learning that CNA #1 found Resident #53's call light cord wrapped around his/her neck, she called the hospital around 7:00 P.M. and inquired about Resident #53's condition and any marks or injuries on his/her neck. The Director of Nurses said that she did not tell hospital staff members that Resident #53 had been found at 3:00 A.M. with a call light cord wrapped around his/her neck. The Hospital Record was reviewed and indicated that Resident #53 expired at the hospital at 11:11 P.M. on [DATE]. There was no indication in the hospital record that hospital staff members were aware that at 3:00 A.M. Resident #53 was found with a call light cord wrapped around his/her neck. Although CNA #1, Nurse #1, CNA #2, CNA #4, Nurse #5, Nurse #3, Unit Manager #1, the Director of Nurses and the Administrator were aware that Resident #53 had been found with the call light cord wrapped around his/her neck, hospital staff members caring for Resident #53 were never made aware of the incident and did not have the benefit of that information as they evaluated his/her condition and provided care.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents, for 1 of 4 applicable residents (#30), in a total sample of 17 residents. Findings include: For Resident #30, the facility failed to provide adequate supervision and effective interventions to prevent 20 falls, with the resident sustaining a laceration to the eye brow, that required 3 sutures to close the wound. Resident #30, with [DIAGNOSES REDACTED]. Review of the 9/14/17 and 9/15/17 Progress Notes indicated that the resident exhibited some confusion. Review of the Admission Minimum Data Set (MDS) assessment of 9/18/17, indicated the resident exhibited difficulty with some recall, although he/she was scored as having no cognitive impairments per the BIMS (Brief Interview for Mental Status); required assist with transfers, dressing, and toileting; supervision/assistance with ambulation and had a history of [REDACTED]. Review of the 9/20/18 Progress Note indicated that the resident exhibited some confusion. Review of the 9/23/17 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated that the resident was trying to pull up (his/her) pants at the time of the fall. The investigation further indicated that the cause of the fall was due to the resident's unsteady gait, poor safety awareness and not being able to balance without assistance. The falls care plan was implemented to include: educate resident to utilize call bell, need to transfer with assist and TABS alarm when in wheelchair. Review of the 10/12/17 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated the resident was attempting to adjust his/her pillows on the bed at the time of the fall. After the fall, the staff again educated the resident to utilize the call bell and to request assist with standing/transfers. During review of the investigation with the Director of Nursing (DON) (on 8/21/18 at 1:22 P.M.), she said the resident's TABS alarm did not sound and that per the investigation, the resident was known to remove/turn off the TABS alarm. The falls care plan (resident at risk for falls due to [DIAGNOSES REDACTED] per documentation) was updated to include: initiate bed alarm, clutter free environment, assist resident in and out of bed, call light within reach and low bed. Review of the 10/17/17 Progress Note indicated the resident is non compliant with wheelchair assist and that he/she continues to turn off the TABS alarm and bed alarm prior to self transfers. Review of the 10/21/17 Progress Note indicated the resident experienced an unwitnessed fall (in room bathroom), with no injury. The investigation indicated the resident self transferred out of bed and was found lying on the floor next to the bed. During review of the investigation with the DON (on 8/21/18 at 1:22 P.M.), she said the resident's call light was not within reach and that the plan was to conduct a voiding diary. Review of the 10/30/17 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated that the resident's roommate informed the Nurse that the resident was on the floor. During review of the investigation with the DON (on 8/21/18 at 1:22 P.M.), she said the resident's alarm did not sound and that per the investigation, the resident exhibited his/her baseline confusion. Review of the 11/2/17 Progress Note indicated that the resident exhibited baseline confusion. Review of the 11/7/17 and 11/9/17 Progress Notes indicated the resident experienced a fall on each date noted. During an interview with the DON (on 8/21/18 at 1:22 P.M.), she said the facility had no evidence that a falls investigation had been completed after both of the falls, therefore, the facility had no knowledge of the details surrounding the 2 falls. The falls care plan was updated to include a perimeter mattress. Review of the 11/21/17 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated the resident was trying to place a pillow on the back of the wheelchair when he/she fell and that after the fall, the staff again educated the resident to utilize the call light. Review of the quarterly MDS assessment of 12/14/17 indicated the resident was unable to identify the correct month, although he/she was scored as having no cognitive impairments per the BIMS, continued to require assist with transfers, dressing and toileting; now required assistance with ambulation and had a history of [REDACTED]. Review of the 12/18/17 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated the resident was found sitting in front of his/her wheelchair and that the cause of the fall was due to the resident being impulsive. During an interview with the DON (on 8/21/18 at 1:22 P.M.), when discussing that this was the resident's 8th fall within 3 months, the DON said the resident should have been supervised more due to (his/her) unsteady gait. Review of the 12/30/17 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated the resident was found sitting on the floor, at the foot of the bed. Review of the 1/6/18 Progress Note indicated the resident experienced a fall (in room), with no injury. The investigation indicated that the cause of the fall was due to the resident not using the call light. The corrective action noted was to encourage the resident to remain in the hallway and to ask for help. The falls care plan was updated to include: offer resident to go back to bed before 8:00 P.M., as he/she allows, a Physical Therapy Screen would be conducted and that the staff would assist resident getting in/out of bed. During an interview with the DON (on 8/21/18 at 1:22 P.M.), she said the resident does not consistently use the call light. Review of the 1/13/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. During an interview with the DON (on 8/21/18 at 1:22 P.M.), she said according to the the Progress Note/Investigation, they indicated that the resident turned off/took off his/her TABS alarm, prior to self transferring to bed, therefore, the alarm did not sound. Review of the 1/16/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated the resident self transferred out of the wheelchair to turn off the TV. The investigation further indicated that the resident's alarm did not sound, as the resident had taken the alarm off. The cause of the fall was noted as the resident did not ask the staff for assistance although it was documented during the Care Plan Meeting (of 12/28/17) that the resident exhibits some confusion and poor insight. During an interview with the DON (on 8/21/18 at 1:22 P.M.), she said that alarms are not effective in preventing falls. Review of the 1/26/18 Progress Note indicated the resident experienced a fall (in room), with no injury. During an interview with the DON (on 8/21/18 at 1:22 P.M.), she said the facility had no evidence that a falls investigation had been completed, therefore, the facility had no knowledge of the details surrounding the fall. Review of the 1/30/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated the resident was found on the floor between the bed and bathroom door. During an interview with the DON (on 8/21/18 at 1:22 P.M.), she said that the resident had turned off the alarm, therefore, the TABS alarm did not sound at the time of the fall. The falls care plan was updated to include: offer toilet/urinal at the beginning of the 3:00 P.M. to 11:00 P.M. shift. The falls care plan was expanded on 2/5/18 to include that the resident is at risk for falls due to cognitive loss, lack of safety awareness and impaired mobility (and the previous Progress Notes of 9/14/17, 9/15/17, 9/20/17, 11/2/17 and 1/16/18 indicated the resident exhibited confusion). During an interview with the facility Administrator (on 8/23/18 at 11:17 A.M.), she said the Physician's Note (of 2/7/18) indicated that the resident did have an increased chance of falling. The falls care plan was updated on 2/9/18 to include: encourage resident to go out into the hallway after toileting in the afternoon. Review of the 3/9/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated that the resident had self transferred out of the wheelchair and was reaching for the wheelchair brake. A referral for a Rehab. (Rehabilitation) screen was made. Review of the quarterly MDS assessment of 3/14/18 indicated the resident scored as having no cognitive impairments per the BIMS, continued to require assist with transfers, dressing and toileting and had a history of [REDACTED]. Review of the 3/20/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated the resident was self transferring from the wheelchair to his/her bed. During an interview with the DON (on 8/21/18 at 1:22 P.M.), she said the TABS alarm did not sound (resident removed the alarm) and that it was documented in the facility investigation (Event Summary Report) that the resident was confused. The falls care plan/corrective action was updated to include: offer resident to go back to bed after lunch. During an interview with the facility Administrator (on 8/23/18 at 11:17 A.M.), she said the resident had a Vision Examination conducted (on 3/24/18), due to the resident complaining of blurred vision. The Vision Consult noted that the resident exhibited moderate [DIAGNOSES REDACTED] in the left eye, likely resulting from the Glio[DIAGNOSES REDACTED]. She further indicated that the resident's eye sight was limited, per the evaluation. Review of the 4/1/18 Progress Note indicated the resident experienced an unwitnessed fall, sustaining an upper scalp abrasion. The investigation indicated the resident was in his/her wheelchair reaching for an alcohol wipe wrapper, on the floor, in the hall. During an interview with the facility Administrator (on 8/21/18 at 1:22 P.M.), she said the investigation and the staff statements were contradictory as to whether the alarm sounded and she could not explain why the details were unclear. The falls care plan/corrective action was updated to include: Therapy Screen for wheelchair positioning. Review of the 4/8/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated the resident was self transferring out of his/her wheelchair. During an interview with the DON (on 8/21/18 at 1:22 P.M.), she said the falls care plan was updated to include: Rehab. screen, TABS alarm was discontinued and a self releasing alarming Seat Belt was initiated. Review of the Progress Note of 4/27/18 and 5/1/18 indicated the resident exhibited confusion per baseline. Review of the Change of Status MDS assessment (due to starting Hospice care) of 5/9/18 indicated the resident continued to require assist with transfers, dressing and toileting; had not been ambulating in the room/hall and had a history of [REDACTED]. Review of the 5/11/18 Progress Note indicated the resident experienced a fall (in room), with no injury. The investigation indicated the resident was confused and exhibited poor safety awareness; was found sitting on the floor by a CNA (Certified Nursing Assistant) and was wearing rubber shoes. The falls care plan was updated to include: offer urinal before and after meals as resident allows, initiate anti-tippers and anti-rollbacks on the wheelchair. During discussion of the resident's falls and interview with the DON (on 8/21/18 at 1:22 P.M.), she said the alarm was not the right intervention to be utilizing with the resident because it was ineffective. Review of the 7/1/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), sustaining a laceration to the left eye brow requiring 3 sutures to close the wound. The investigation indicated the resident exhibited confusion, poor safety awareness and forgetfulness at times, was self transferring out of his/her bed and was found on his/her hands and knees. During an interview with the facility Administrator (on 8/21/18 at 1:22 P.M.), she said during the investigation, she was informed by the CNA, who was sitting by the resident's doorway the majority of the night, that she had left to go down the hall shortly before the fall. The Administrator said the CNA informed her that she sat at the resident's doorway because the resident was known to get out of bed during the night. During the same interview, the DON informed the Surveyor that the resident continued not to consistently use the call light to request assistance. Review of the Nursing Home to Hospital Transfer Form of 7/1/18 indicated that the resident was disoriented. The falls care plan was updated to include: place urinal within reach when resident is in bed. Review of the quarterly MDS assessment of 8/8/18 indicated the resident's vision was impaired, continued to require assist with transfers, dressing and toileting; had not been ambulating in the room/hall and had a history of [REDACTED]. On 8/20/18 at 8:54 A.M., the surveyor observed the resident sitting in a wheelchair, with an alarming seatbelt on, wearing open back rubber clog shoes and was self propelling down the hallway On 8/21/18 at 10:28 A.M., the surveyor observed the resident laying in bed, with his/her wheelchair in front of the resident's closet (not within reach of the bed), with the resident's opened back rubber clog shoes on the top of the wheelchair seat. During an interview with CNA #5, on 8/21/18 at 11:22 A.M., she said the resident is forgetful at times, is very shaky on (his/her) feet, is known to self transfer and is not really safe to transfer alone, (he/she) does shut off the alarming seatbelt and will take the seatbelt off and transfer by himself, does not always use the call bell, can be agitated, gets up and down a lot and is very off balance when on (his/her) feet. During an interview with the DON and Administrator on 8/21/18 at 1:22 P.M., the DON said the resident is forgetful, does exhibit poor safety awareness, requires supervision to 1 assist for transfers and ambulation, uses the call bell at times only, (his/her) memory fluctuates due to the [DIAGNOSES REDACTED] and does self release the seatbelt. During the discussion relative to the effectiveness of the care plan and that 16 out of the 20 falls occurred in the resident's room, the DON said the care plan interventions could have been more personalized. When the Surveyor asked the DON if the resident should have received more supervision to prevent the 20 falls from occurring, she shook her head up and down in agreement.

Based on records reviewed and interviews, for one of 4 sampled residents (Resident #1), the facility failed to ensure freedom from abuse, neglect, misappropriation of resident property, and exploitation. On or about 02/12/17, Certified Nurse Aide (CNA) #1 viewed videos of Resident #1, uploaded to what was identified as a Snapchat account belonging to Nursing Assistant (NA) #1. The female voice on the video, identified as consistent in tone and manner of speaking by multiple staff of the Facility, was heard speaking to Resident #1 in what was describe as a harassing, rude, demeaning, and frustrated manner. There also was no documentation that Resident #1 and/or his/her legal representative consented to the video and audio recordings, or to the posting of such recordings on a social media website such as Snapchat. Although Resident #1 could not be interviewed due to cognitive impairment, a reasonable person would suffer mental anguish after being videotaped without consent, and having that video posted on a social media site. Findings include: Resident #1 was admitted to the Facility in December 2015, with [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set, dated dated [DATE], indicated that he/she had severe cognitive impairment. Resident #1's clinical record did not include a signed authorization by the Administrator and Resident #1 or his/her legal representative, consenting to the photography, video recording, or audio recording of Resident #1, or to the posting of such recordings on a social media website such as Snapchat. The Facility's Personal Cell Phones and Handheld Devices: Use of Policy, revised 09/01/16, indicated that staff could not use cell phones, Bluetooth ear pieces, ear buds, headphones, camera phones, digital cameras, video cameras, audio recorders, or any other personal, handheld device, or other forms of personal communication, image, audio, text, and/or computer devices when in resident care areas including resident rooms, dining areas, community rooms, and adjacent hallways, or while attending to in any area of the location. The policy indicated that it was prohibited to take resident photographs for any reason without both Administrator and resident authorization in writing; to take photographs and/or recordings of residents that were demeaning or humiliating; and, to keep, send, post, or distribute resident photographs or recordings of any kind through multimedia messages or on social media networks. The Facility's Abuse Prohibition - State of Massachusetts policy, revised 11/28/16, indicated that training would be provided to all employees, through orientation, annually, and ongoing sessions as needed. The policy indicated that sessions included the prohibition of staff from using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings of residents that were demeaning or humiliating. The Facility's internal investigation indicated that NA #1 completed abuse prevention training on 11/17/16. The Surveyor interviewed Nurse #1 at 10:17 A.M. on 04/06/17. Nurse #1 said NA #1 had recently completed the Facility's Nurse Aide training program, and had completed orientation approximately 2 days prior to the alleged incident. Nurse #1 said she was horrified that a staff member videotaped a resident and posted it on social media. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:56 P.M. on 04/06/17. CNA #1 said she and NA #1 completed nurse aide training together, and during the training, had exchanged Snapchat usernames so that they could become friends on the application. CNA #1 said that on a Saturday night towards the beginning of February 2017, she watched videos on NA #1's Snapchat account, which included videos of Resident #1. CNA #1 said a female voice heard on the videos was consistent with NA #1's tone of voice and manner of speaking. CNA #1 said that one video showed Resident #1 with his/her hands tucked under the waistband of his/her pants, and NA #1 told Resident #1 to get his/her hand out of his/her pants. CNA #1 said that NA #1's tone of voice made it sound as if Resident #1's actions were inappropriate, like he/she was doing something wrong. CNA #1 said that throughout the videos, NA #1's tone of voice while speaking to Resident #1 was harassing, rude, demeaning, and frustrated. The Surveyor interviewed the Administrator and the Director of Nurses (DON) at multiple times throughout the date of survey. The Administrator and DON said they were notified by CNA #1 that NA #1 had posed a video of Resident #1 on Snapchat. The Administrator and DON said that they and Nurse #1 were able to view the Snapchat video with the assistance of CNA #3. The Administrator, the DON and Nurse #1 said CNA #3 sent a request to the username provided by NA #1 to CNA #1 as NA #1's Snapchat username, and the request was accepted. The Administrator, the DON and Nurse #1 said they were then able to view the Snapchat video, which started with a picture of NA #1 before moving to what appeared to be 2 short videos of Resident #1 taken at the Facility. The Administrator, the DON and Nurse #1 said they were able to record a portion of the video onto the Administrator's cell phone. The Administrator, the DON and Nurse #1 said the backgrounds in the videos of Resident #1 were consistent with areas of the Facility. The Administrator, the DON and Nurse #1 said that the voices heard in the 2 videos were consistent with Resident #1 and NA #1. At multiple times on the date of survey, the Surveyor, the Administrator and the Director of Nurse (DON) viewed a recording of the video of Resident #1 allegedly posted on Snapchat by NA #1. A username observed in the upper left corner of the video was identified by CNA #1 as consistent with the username NA #1 gave her. CNA #1 said the video viewed by the Surveyor was one of the videos she viewed on NA #1's Snapchat account. The Administrator and DON said the video they had did not include the first few seconds of the video, which showed a picture of NA #1. The video showed Resident #1 seated at a table in what was identified by the Administrator and the DON as a dining space in the Facility. Audible conversation was heard regarding a frog in an unidentified person's throat, or words to that effect, between Resident #1 and a voice consistent with NA #1's, as identified by the Administrator and DON. The video then transitioned to Resident #1 seated in what was identified by the Administrator and DON as a hallway in one of the Facility's resident care areas. The video showed Resident #1 with his/her hands tucked flat against his/her abdomen, under the waistband of his/her pants to the wrist. The following verbal exchange, or words to the effect of, was heard between a female voice, consistent with NA #1's voice, and Resident #1: the female voice said, Bad, very bad in a scolding tone; Resident #1 responded yeah?, the female voice replied, yeah in a sarcastic manner, and Resident #1 said, alright; the female voice then said, can you take your hands out your pants? in a scolding manner, and Resident #1 replied, I have to keep my hands on my belly., the female voice replied, why? in a sarcastic tone, and the video ended. It was unclear if the two portions of the video were recorded on the same day. The Surveyor interviewed CNA #2 at 9:16 A.M. on 04/06/17. CNA #2 said Facility policy was that staff could not use or carry cell phones with them during work hours. CNA # said cell phones were to be used before or after a shift, or during breaks only. The Administrator, DON, Nurse #1 and CNA #1 said Facility policy was that staff could not use or carry cell phones with them during work hours. The DON and Nurse #1 said Facility staff needed permission to photograph and/or record a resident.

Based on record review, observations and staff interviews, the facility failed to follow the resident's falls/ADL (Activities of Daily Living) care plans for 2 residents (#4 and #5), in a total sample of 19 residents. Findings include: 1. For Resident #5, the facility failed to follow the resident's falls/ADL care plans relative to the following: gait belt was not being utilized, contact guard assist was not being provided, TV remote was not within reach, TABS was not utilized, non-skid socks/shoes were not on and eye glasses were not being utilized, as planned. Resident #5 was admitted to the facility in 3/2012. The falls care plan of 6/11/15 indicated the following interventions: sign on walker to remind resident to use call light for assistance with transfers, ambulating and toileting, call bell within reach, maintain a clutter free environment and to place all necessary personal items within reach when in bed (i.e. TV remote, eye glasses .). The ADL care plan of 6/11/15 indicated the following interventions: 1 assist for transfers and ambulation with gait belt. Review of the Progress Note of 9/3/15 indicated the resident experienced an unwitnessed fall, sustaining a large bump on the back of his/her head. The investigation indicated that at the time of the fall the resident was wearing regular socks. The falls care plan was updated to include: non-skid socks or shoes at all times. The falls/ADL care plans were reviewed by the staff on 9/24/15 and remained essentially unchanged. Review of the Progress Note of 9/24/15 indicated the resident experienced a second unwitnessed fall, with no injury. The investigation indicated the resident was not utilizing his/her eye glasses at the time of the fall, as planned. The falls care plan was updated to include: place glasses within reach and encourage use. The falls care plan of 10/2/15 was updated to include: chair alarm and motion sensor alarm on bed. Review of Registered Occupational Therapist (OTR) Treatment Notes of 12/2/15 indicated that the resident was observed by the OTR ambulating around the room, with regular socks on and no shoes. The OTR indicated that she notified the Nursing staff that the resident now required a TABS alarm. The resident did not have the non-skid socks/shoes on, as planned. Review of the Progress Notes of 12/5/15 indicated that the resident experienced a fall, sustaining a nasal fracture. During an interview with the previous Director of Nursing (who was the DON at the time of the fall), current DON and Administrator (on 6/6/16 at 11:35 A.M.), the previous DON said that the gait belt was not being utilized, as it should have been, at the time of the fall, as planned. The intervention was to educate the staff to ensure contact guard was utilized, at all times, while the staff were ambulating with the resident. The falls care plan was updated on 12/10/15 to discontinue the intervention of placing the resident's eye glasses within reach. Review of the falls/ADL care plans of 3/3/16 remained unchanged. Review of the Progress Note of 4/3/16 indicated the resident experienced a third unwitnessed fall, with no injury. Further investigation indicated that personal items (i.e. resident's remote control) was not within reach, at the time of the fall, as planned. The care plan was updated to include: TABS alarm when out of bed. On 5/26/16 at 10:30 A.M., the surveyor observed the resident in bed, the TV was on, however, the TV remote was on the TV stand located at the end of the bed The surveyor then observed a CNA assist the resident out of bed, utilizing a gait belt, and assisted the resident into the bathroom. Further observation was of the CNA ambulating with the resident down the hall, without his/her eye glasses on. During further observation at 11:00 A.M. and 3:15 P.M., the surveyor observed the resident sitting in a straight back chair and he/she did not have his/her TABS alarm on, as planned. During observation and interview with the resident on 6/6/16 at 8:40 A.M., the surveyor observed the resident sitting on the edge of the bed, without his/her eye glasses on (as planned), with his/her breakfast tray in from of him/her, with the TV on. The surveyor observed the TV remote on the TV stand located at the end of the bed and was not accessible to the resident, as planned. During an interview with Unit Manager (UM) #1, on 6/6/16 at 9:40 A.M., she said that the resident required contact guard assist/supervision during ambulation and that a gait belt should be utilized. UM#1 said that the resident's eye glasses are kept in the Med. Cart at bedtime (at approximately 8:00 P.M.) and are not returned to the resident until the first medication pass (at approximately 8:00 A.M.). During interview with UM#1 on 6/6/16 at 10:40 A.M., a discussion was held that the facility failed to follow the resident's falls/ADL care plans, and as a result during the (12/5/15) fall, the resident sustained [REDACTED]. Refer to F323. 2. For Resident #4, the facility failed to follow the resident's falls care plan relative to the following: supervision during transfers and ambulation was not provided and 15 minute checks were not consistently conducted, as planned. Findings include: Resident #4 was admitted to the facility in 8/2015. Review of the falls care plan of 9/16/15 indicated that the call bell would be kept within reach. Review of the ADL (Activities of Daily Living) care plan of 12/11/15 indicated the resident required supervision for transfers and ambulation. Review of the falls care plan of 12/24/15 remained essentially unchanged. Review of the 1/24/16 Progress Note indicated the resident experienced an unwitnessed fall, with no injury. During interview with Unit Manager (UM) #1 (on 5/26/16 at 11:00 A.M.), she said that the resident should have been supervised (as planned), at the time of the fall, when she/he was ambulating from the dining room to the bedroom. Review of the 2/4/16 Progress Note indicated another in-service was conducted regarding the resident requiring supervision when ambulating in her/his room (with walker) at all times. Review of the 2/15/16 falls care plan indicated: frequent checks for safety. Review of the 15 minute check sheets indicated that the 15 minute checks were not conducted on 2/19/16 between 7:15 A.M. and 11:00 P.M., as planned. During interview with UM #1 (on 5/26/16 at 2:15 P.M.), she said the facility had no evidence that the 15 minutes checks were conducted on 2/20/16, 2/21/16, 2/22/16, as planned. Review of the 2/24/16 Progress Note indicated the resident experienced an unwitnessed fall, with no injury. During interview with UM #1 (on 5/26/16 at 11:00 A.M.), she said supervision was not being provided while the resident was transferring and ambulating, as planned. Review of the 15 minute check sheets indicated that the 15 minute checks were not conducted on 2/25/16 between 12:00 A.M. and 7:15 A.M., as planned. During interview with UM #1 (on 5/26/16 at 2:15 P.M.), she said the facility had no evidence that the 15 minutes checks were conducted on 3/1/16, 3/4/16, 3/6/16, 3/8/16, 3/9/16 and 3/11/16 (between 3:15 P.M. and 11:00 P.M.), as planned. Review of the 3/15/16 Progress Note indicated the resident experienced an unwitnessed fall, with no injury. The note further indicated that the resident would continue to be on 15 minute checks. The falls care plan was updated to include: utilize scoop mattress and medical work up. Review of the 15 minute check sheets indicated that the 15 minute checks were not conducted on 3/18/16 between 8:15 A.M. and 11:00 P.M., as planned. During interview with UM #1 (on 5/26/16 at 2:15 P.M.), she said the facility had no evidence that the 15 minutes checks were conducted on 3/20/16 and 3/24/16, as planned. The falls care plan was updated on 3/25/16 to include: discontinue frequent checks for safety. On 5/26/16 at 7:45 A.M., the surveyor observed the resident transferring her/his self out of bed, ambulating alone to her/his night stand, picking up a tissue on the night stand then ambulating back to her/his bed and sat back down on the bed. The resident was not being supervised by staff during the transfer/ambulation, as planned. During an interview with CNA (Certified Nursing Assistant) #1 on 5/26/16 at 10:40 A.M., she said the resident has poor safety awareness and needs supervision continually when (she/he) is walking in the her/his room and has to be watched at all times. During an interview with UM #1 on 5/26/16 at 11:00 A.M., it was discussed that the facility failed to follow the resident's falls/ADL care plans. Refer to F323.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 2 of 7 applicable residents (#4 and #5), in a total sample of 19 residents. Findings include: 1. For Resident #5, the facility failed to provide adequate supervision and effective interventions for 6 falls (5 of 6 falls were unwitnessed), resulting in injuries including 2 fractures. Resident #5, with [DIAGNOSES REDACTED]. The falls care plan of 6/11/15 indicated the following interventions: sign on walker to remind resident to use call light for assistance with transfers, ambulating and toileting, motion sensor alarm, call bell within reach, utilize low bed, maintain a clutter free environment and to place all necessary personal items within reach when in bed. The Activities of Daily Living (ADL) care plan of 6/11/15 indicated the following interventions: ensure ankle foot orthotic (AFO) is in the resident's shoe for ankle/foot support during all transfers and ambulation and 1 assist for transfers and ambulation with gait belt. Review of the Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated that the resident required eyeglasses; was severely cognitively impaired; required supervision with transfers and ambulation; had unsteady balance and utilized a walker. Review of the falls care plan of 6/29/15 indicated that the resident's motion sensor on the bed and bathroom door TABS alarm were discontinued. Review of the Progress Note of 8/14/15 indicated the resident experienced an unwitnessed fall, sustaining a right knee abrasion. During an interview with the previous Director of Nursing (DON) (whom the facility requested to speak with the surveyor on 5/26/16 at 10:40 A.M.), she said that a Risk Management System (RMS) investigation was not completed for the fall, as required by the facility. Review of the Progress Note of 9/2/15 indicated the resident was transferred to the hospital and was readmitted to the facility with a [DIAGNOSES REDACTED]. Review of the Progress Note of 9/3/15 indicated the resident experienced a second unwitnessed fall (in room), sustaining a large bump on the back of his/her head. The investigation indicated that at the time of the fall the resident was wearing regular socks. Further review of the investigation indicated that an alarm was added for safety until the resident's UTI was resolved. The falls care plan was updated to include: non-skid socks or shoes at all times. Review of the Annual MDS dated [DATE] indicated that the resident remained essentially unchanged except to note that the resident now had an unsteady balance requiring assistance to stabilize him/her self when moving from a seated to standing position, moving on and off the toilet and during surface to surface transfers. The falls/ADL care plans were reviewed by the staff on 9/24/15 and remained essentially unchanged. The staff was to monitor and assist with toileting needs. Review of the Progress Note of 9/24/15 indicated the resident experienced a third unwitnessed fall (in room), with no injury. The investigation indicated the resident was not utilizing his/her eye glasses at the time of the fall, as planned. The falls care plan was updated to include: place glasses within reach and encourage use. The falls care plan of 10/2/15 was updated to include: chair alarm and motion sensor alarm on bed. Review of the Progress Note of 10/28/15 indicated the resident experienced a fourth unwitnessed fall (in room), sustaining a foot fracture. The falls care plan was updated to include: assist with toileting (already on 9/24/15 care plan) and provide resident/caregiver education for safe techniques. Review of the physician's orders [REDACTED]. Review of the Quarterly MDS dated [DATE] remained essentially unchanged except to note that the resident now exhibited moderate cognitive impairment and utilized a wheelchair. Review of Registered Occupational Therapist (OTR) Treatment Notes of 12/2/15 indicated that the resident was observed by the OTR ambulating around the room, with regular socks on and no shoes. The OTR indicated that she notified the Nursing staff that the resident now required a TABS alarm. The resident did not have the non-skid socks/shoes with AFO, as planned. Review of the Progress Notes of 12/5/15 indicated that the resident experienced a fall (in room), sustaining a nasal fracture. During an interview with the previous Director of Nursing (DON), current DON and Administrator (on 6/6/16 at 11:35 A.M.), the previous DON said that the gait belt was not in use as it should have been, at the time of the fall, as planned. The intervention was to educate the staff to ensure contact guard was utilized, at all times, while the staff were ambulating with the resident. The falls care plan was updated on 12/10/15 to discontinue the intervention of placing the resident's eye glasses within reach. Review of the Quarterly MDS dated [DATE] remained essentially unchanged from the previous assessment. Review of the falls/ADL care plans of 3/3/16 remained unchanged. Review of the Progress Note of 4/3/16 indicated the resident experienced a fifth unwitnessed fall (in room), with no injury. Further investigation indicated that personals item (i.e. resident's remote control) was not within reach, at the time of the fall, as planned. The care plan was updated to include: TV remote near resident when watching TV, staff to offer to turn off resident's TV between 7:30 P.M. - 8:00 P.M. and TABS alarm when out of bed. On 5/26/16 at 10:30 A.M., the surveyor observed the resident in bed, the TV was on, however, the surveyor observed the TV remote was on the TV stand located at the end of the bed and was not accessible, as planned. During further observation at 11:00 A.M. and 3:15 P.M., the surveyor observed the resident sitting in a straight back chair and he/she did not have his/her TABS alarm on, as planned. During observation and interview with the resident on 6/6/16 at 8:40 A.M., the surveyor observed the resident sitting on the edge of the bed, without his/her eye glasses on (as planned), with his/her breakfast tray in from of him/her, with the TV on. The resident asked the surveyor for his/her eye glasses and said .they didn't give them to me The surveyor observed the TV remote on the TV stand located at the end of the bed and was not accessible to the resident, as planned. During an interview with CNA #2, on 6/6/16 at 8:40 A.M., she said that the resident's safety awareness is not good, sometimes (he/she) gets up and goes and attempts to get out of the bed by him/herself. CNA #2 further said the resident requires a gait belt. CNA #2 said that the resident's eye glasses are kept in the Nursing Cart (Medication/Med. Cart) at bedtime and are not returned to the resident until the next morning. During an interview with UM #1, on 6/6/16 at 9:40 A.M., she said that the resident required contact guard assist/supervision during ambulation and that a gait belt should be utilized. She also said that the resident is impulsive, has poor safety awareness, that his/her memory is extremely impaired and that the resident will not remember to use his/her walker nor ring the call bell. UM #1 said that the resident's eye glasses are kept in the Med. Cart at bedtime (at approximately 8:00 P.M.) and are not returned to the resident until the first medication pass (at approximately 8:00 A.M.). During interview with the UM #1 on 6/6/16 at 10:40 A.M., a discussion was held regarding the lack of thoroughness in the investigations. UM #1 said that the investigations were lacking details (i.e.: if walker was being utilized, whether alarm activated prior to the fall, if the call bell was within reach, if eye glasses were on/off or if the glasses were accessible, .) surrounding the falls and that staff statements were not secured at the time of one of the falls, per facility protocol. A discussion was held that the facility failed to provide effective interventions and adequate supervision to prevent continued falls, which resulted in a fractured foot and a fractured nose. 2. For Resident #4, the facility failed to provide effective interventions and adequate supervision to prevent falls. Findings include: Resident #4, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment of 9/3/15 identified the resident as utilizing eyeglasses; exhibiting moderate cognitive impairment and requiring assistance during transfers. Review of the Physician and Nurse Practitioner/ Physician Assistant Progress Note of 9/8/15 indicated the resident had a history of [REDACTED]. Review of the falls care plan of 9/16/15 identified the resident as exhibiting a lack of safety awareness. The falls care plan indicated that the call bell would be kept within reach. Review of the 10/9/15 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. Review of the falls investigation indicated that environmental factors (excess furniture/clutter and poor lighting) may have been the cause of the fall. The falls care plan was updated to include: maintain a clutter-free environment and to remind the resident to use call light when attempting to ambulate or transfer. Review of the quarterly MDS Assessment of 12/10/15 remained essentially unchanged except to indicate that the resident's vision was severely impaired and that the resident no longer required assistance with transfers. Review of the ADL (Activities of Daily Living) care plan of 12/11/15 indicated the resident required supervision for transfers and ambulation. Review of the falls care plan of 12/24/15 remained essentially unchanged. Review of the 1/10/16 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. During interview with Unit Manager (UM) #1 (on 5/26/16 at 11:00 A.M.), she said a staff in-service was conducted, after the falls care plan was updated, to inform the staff that the resident was to request assist with putting on her/his clothing. During further discussion UM #1 said that due to the resident's impaired cognition, the staff should actually be offering and assisting the resident with dressing and not relying on the resident to request the assistance. Review of the 1/24/16 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. During interview with UM #1 (on 5/26/16 at 11:00 A.M.), she said that the resident should have been supervised (as planned) when she/he was ambulating from the dining room to the bedroom. The falls care plan was updated to include: provide verbal cues for safety and sequencing when needed and therapy evaluation. Review of the 1/26/16 Progress Note indicated an in-service was conducted regarding the staff needing to utilize a gait belt and a walker to ambulate the resident to and from the Dining Room and that the resident needs supervision for mobility in room. Review of the 2/4/16 Progress Note indicated another in-service was conducted regarding the resident requiring supervision when ambulating in her/his room (with walker) at all times. The note further indicated that the resident must use a chair and bed alarm (per Occupational Therapy/OT). Review of the 2/15/16 Progress Note indicated that frequent checks were initiated and the alarms were discontinued. The falls care plan was also updated to include: frequent checks for safety. Review of the 15 minute check sheets indicated that the 15 minute checks were not conducted on 2/19/16 between 7:15 A.M. and 11:00 P.M., as planned. During interview with UM #1 (on 5/26/16 at 2:15 P.M.), she said the facility had no evidence that the 15 minutes checks were conducted on 2/20/16, 2/21/16, 2/22/16, as planned. Review of the 2/24/16 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. During interview with UM #1 (on 5/26/16 at 11:00 A.M.), she said supervision was not being provided while the resident was transferring and ambulating, as planned. The falls care plan was updated to include: staff to offer to assist resident in getting dressed between 6:00 A.M. and 7:00 A.M. daily, medical work up and when resident in bed, place all personal items within reach. Review of the Change in Status MDS Assessment of 2/25/16 indicated that the resident required supervision during transfers and ambulation and had experienced falls. Review of the 15 minute check sheets indicated that the 15 minute checks were not conducted on 2/25/16 between 12:00 A.M. and 7:15 A.M., as planned. During interview with UM #1 (on 5/26/16 at 2:15 P.M.), she said the facility had no evidence that the 15 minutes checks were conducted on 3/1/16, 3/4/16, 3/6/16, 3/8/16, 3/9/16 and 3/11/16 (between 3:15 P.M. and 11:00 P.M.), as planned. Review of the 3/15/16 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The note further indicated that the resident would continue to be on 15 minute checks. The falls care plan was updated to include: utilize scoop mattress and medical work up. Review of the 15 minute check sheets indicated that the 15 minute checks were not conducted on 3/18/16 between 8:15 A.M. and 11:00 P.M., as planned. During interview with UM #1 (on 5/26/16 at 2:15 P.M.), she said the facility had no evidence that the 15 minutes checks were conducted on 3/20/16 and 3/24/16, as planned. The falls care plan was updated on 3/25/16 to include: discontinue frequent checks for safety. On 5/26/16 at 7:45 A.M., the surveyor observed the resident transferring her/his self out of bed, ambulating alone to her/his night stand, picking up a tissue on the night stand then ambulating back to her/his bed and sat back down. The resident was not being supervised by staff during the transfer/ ambulation, as planned. During an interview with CNA (Certified Nursing Assistant) #1 on 5/26/16 at 10:40 A.M., she said the resident is very confused and forgetful, has poor safety awareness, needs supervision continually when (she/he) is walking in the room and has to be watched at all times. During an interview with UM #1 on 5/26/16 at 11:00 A.M., it was discussed that the facility failed to provide effective interventions and adequate supervision to prevent falls.

Based on records reviewed and interviews, the Facility failed for one of three sampled residents (Resident #1), to ensure staff implemented the plan of care. Resident #1 required two staff for transfers, and on [DATE], Certified Nurse Aide (CNA) #1 transferred Resident #1 from the wheelchair to the bed, without assistance of another staff person; and Resident #1 sustained a laceration to the right upper extremity which required 13 staples to close. Findings include: The quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance of two persons for transfers. Resident #1's current Care Plan for Activities of Daily Living, initiated [DATE], indicated Resident #1 required extensive assist to total care with activities of daily living related to cognitive loss and muscle weakness. Interventions included transfer of two staff with stand and pivot and a gait belt. The CNA Care Card, utilized by the CNA providing care, indicated Resident #1 needed assist of two people to stand and pivot with a gait belt for transfers. The Nurse's Progress Note, dated [DATE], indicated Nurse #1 was called into Resident #1's room by CNA #1 and upon arrival, observed a skin tear which was actively bleeding, on Resident #1's right forearm. The note indicated Nurse #1 applied pressure, readjusted the skin tear which was flapped over and applied a pressure bandage. The note indicated Resident #1 was combative and Nurse #1 was unable to stop the bleeding. The note indicated Resident #1 was transferred to the emergency room for treatment of [REDACTED]. The Surveyor interviewed CNA #1 at 2:25 P.M., on [DATE]. CNA #1 said he was familiar with Resident #1's care, as he had provided care to him/her on a consistent basis. CNA #1 said Resident #1 was seated in the wheelchair and was uncooperative and combative as he removed his/her jacket in preparation for bed. CNA #1 said Resident #1 was flailing his/her arms as he transferred Resident #1 into the bed without assist of another staff person. CNA #1 said he noticed Resident #1's arm was bleeding as he continued to remove his/her clothing. CNA #1 said he was unaware how Resident #1 was injured, but said he believed the injury may have occurred during transfer from the wheelchair to the bed. Although CNA #1 said he was aware Resident #1 required two staff to transfer, he said he believed he was able to transfer and pivot Resident #1 by himself. CNA #1 said he transferred Resident #1 on other occasions without the assistance of another staff member and had observed on several occasions, others transfer Resident #1 without assist of two. Review of Resident #1's Activity of Daily Living Flow Sheet, utilized by the CNA providing care, dated [DATE] though [DATE], for a total of 81 shifts, included documentation for 22 shifts which indicated staff documented Resident #1 was transferred with physical assistance of one staff. The Surveyor interviewed the Director of Nurses at 8:45 A.M., and throughout the day on [DATE]. The Director of Nurses said it was the expectation that all care providers review care cards and plans of care for appropriate interventions, and that all care be provided per resident's plan of care. Resident #1 was deceased prior to survey.

Based on records reviewed and interviews, the Facility failed for one of three sampled residents (Resident #1), to ensure that Resident #1 was transferred with an assist of 2 staff persons per Plan of Care which resulted in an avoidable injury. On [DATE], Certified Nurse Aide (CNA) #1 transferred Resident #1 without assistance of another staff person. During the transfer, Resident #1 received a laceration to the right front forearm which required 13 staples. Findings include: The quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance of two persons for transfers. Resident #1's current Care Plan for Activities of Daily Living, initiated [DATE], indicated Resident #1 required extensive assist to total care with activities of daily living related to cognitive loss and muscle weakness. Interventions included transfer of two staff with stand and pivot and gait belt. The CNA Care Card, utilized by the CNA providing care, indicated Resident #1 needed assist of two people to stand and pivot with a gait belt for transfers. The Nurse's Progress Note, dated [DATE], indicated Nurse #1 was called into Resident #1's room by CNA #1 and upon arrival, observed a skin tear which was actively bleeding, on Resident #1's right forearm. The note indicated Nurse #1 applied pressure, readjusted the skin tear which was flapped over and applied a pressure bandage. The note indicated Resident #1 was combative and Nurse #1 was unable to stop the bleeding. The note indicated Resident #1 was transferred to the emergency room for treatment of [REDACTED]. The Surveyor interviewed CNA #1 at 2:25 P.M., on [DATE]. CNA #1 said he was familiar with Resident #1 as he had provided care to him/her on a consistent basis. CNA #1 said Resident #1 was seated in the wheelchair and was uncooperative and combative as he removed his/her jacket in preparation for bed. CNA #1 said Resident #1 was flailing his/her arms as he transferred Resident #1 into the bed without assist of another staff person. CNA #1 said once in bed, he noticed Resident #1's arm was bleeding as he continued to remove his/her clothing. CNA #1 said he was unaware how Resident #1 was injured, but said he believed the injury may have occurred during transfer from the wheelchair to the bed. Although CNA #1 said he was aware Resident #1 required two staff to transfer, he said he believed he was able to transfer and pivot Resident #1 by himself. CNA #1 said he transferred Resident #1 on other occasions without assist of two staff members and had observed on several occasions, others transfer Resident #1 without assistance. The Emergency Department Patient Instructions, dated [DATE], indicated Resident #1 was assessed to have a laceration to the right front forearm, which required 13 staples to close the laceration. The Surveyor interviewed the Director of Nurses at 8:45 A.M., and throughout the day on [DATE]. The Director of Nurses said it was the expectation that all care providers review care cards and plans of care for appropriate interventions, and that all care be provided per resident's plan of care. Resident #1 was deceased prior to survey.

Based on record review, observation and interview, the Facility failed to ensure that 1 resident (#16) out of 5 residents with pressure ulcers, in a total sample of 24 residents, received necessary treatment and services to promote healing. Findings include: For Resident #16, the Facility failed to: 1. Ensure that the treatment ordered by the physician was provided appropriately to an unstageable pressure ulcer located on the resident's right outer foot (ankle). 2. Ensure that wound measurements were obtained and documented weekly per policy. 3. Ensure that the AFO (ankle, foot orthotic) was appropriately placed on the resident's foot to reduce pressure. Resident #16 was admitted to the Facility in 12/2014 with [DIAGNOSES REDACTED]. Review of the 12/2014 Treatment Administration Record (TAR) indicated that the resident utilized bilateral AFO's daily (on in the morning and off at bedtime), initiated on 12/12/14. Review of the physician's orders [REDACTED]. Monitor reddened non-blanchable area to right outer ankle. The Admission Minimum Data Set Assessment (MDS), with the Assessment Reference Date of 12/18/14, indicated the resident scored 5 out of 15 (severely impaired cognitive status) on the Brief Interview for Mental Status, required extensive assist for transfers, ambulation, dressing, hygiene and bathing and had an unstageable pressure ulcer. Review of the Skin Integrity Report indicated the following wound measurements: - 12/19/14, the right outer foot pressure ulcer measured 0.2 cm in length, by 0.2 cm in width, by 0.1 cm in depth. - 12/26/14, the right outer foot pressure ulcer measured 0.2 cm in length, by 0.2 cm in width. There were no additional measurements documented. Review of the physician's orders [REDACTED]. A new order was obtained to apply Duoderm to the right outer foot pressure ulcer, check daily and change every 3 days. The order was incomplete and did not include how to cleanse the unstageable pressure ulcer. Review of the 12/2014 TAR indicated the treatment for [REDACTED]. There was no indication that the Duoderm was changed on 12/29/14 (every three days as ordered). On 12/30/14, the TAR documentation indicated the unstageable pressure ulcer on the right outer foot was left open to air, without a physician's orders [REDACTED]. Review of the 1/2015 TAR indicated the following treatment: Apply a Duoderm to the right outer foot pressure ulcer, check daily and change every three days. On 1/1/15 and 1/2/15, the TAR documentation was blank. On 1/3/15, 1/4/15 and 1/5/15, the TAR documentation indicated the left outer foot pressure ulcer was left open to air, still without a physician's orders [REDACTED]. On 1/6/15, at 10:10 A.M., Resident #16's right outer foot pressure ulcer was observed by the Surveyor, the Director of Nursing (DON) and the Regional Nurse. The DON removed the right shoe and sock. The DON removed the AFO, and the Regional Nurse said that the AFO was pressing right on the unstageable pressure ulcer. The AFO lined up directly over the wound bed. There was no Duoderm on the pressure ulcer as ordered by the physician. The pressure ulcer was unstageable with black eschar and the surrounding tissue was dark pink and non-blanchable. The DON measured the wound, which had increased in size and now measured 1.2 cm in length, by 1.0 cm in width. During an interview on 1/6/15 at 10:30 A.M., the DON said that the right outer foot pressure ulcer should not have been left open to air without a physician's orders [REDACTED]. The DON said that the physician would be notified for treatment orders, and the Therapy Department would be notified to re-assess the use of the AFO.

Based on record review and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure that Resident #2 received a pureed diet per the physician order. On [DATE], during the dinner meal, Resident #2 choked on a peanut butter and jelly sandwich, which was not allowed on his/her physician ordered puree diet. The staff performed the Heimlich maneuver, initiated cardiopulmonary resuscitation, the emergency medical technicians transferred Resident #2 to the Hospital, where Resident #2 was admitted . Findings include: The Admission record indicated that the staff admitted Resident #2 to the Facility in [DATE] and Resident #2's [DIAGNOSES REDACTED]. The physician order, dated [DATE], included puree diet. The Surveyor interviewed the Dietician on [DATE], at 9:00 A.M. The Dietician said peanut butter was not allowed on a puree diet. The Surveyor interviewed Nurse #2 on [DATE], at 2:10 P.M. Nurse #2 said she admitted Resident #2 to the Facility. Nurse #2 said Family Member #1 told her that Resident #2 had a history of [REDACTED]. Nurse #2 said Family Member #1 told her that in the past, Resident #2 choked while eating peanut butter, which was not allowed on his/her diet. Nurse #2 said she sent a dietary communication slip to the kitchen that indicated Resident #2 was not to be served peanut butter. Nurse #2 said she did not educate the staff or initiate a plan of care regarding Resident #2's history of grabbing at other residents' food or having a history of choking on peanut butter. There was no evidence in the clinical record that Resident #2 had a plan of care that addressed his/her past choking incident with peanut butter and that he/she grabbed other residents' food. The Surveyor interviewed the Director of Nurses (DON) on [DATE], at 7:20 A.M. The DON said Nurse #2 did not initiate a plan of care to address Resident #2's safety issues with eating. The Admission Minimum Data Set (MDS) assessment, completed on [DATE], indicated that Resident #2 had cognitive impairment, was edentulous, and required assistance with meals. The Surveyor interviewed Nurse #3 on [DATE], at 10:45 A.M. The Nurse interviewed Nurse #4 on [DATE], at 8:15 A.M. The Surveyor interviewed Certified Nurse Aide (CNA) #1 on [DATE], at 2:50 P.M. The Surveyor interviewed CNA #2 on [DATE], at 3:05 P.M. The DON, Nurse #3, Nurse #4, and CNA #1 said prior to the incident on [DATE], they were not aware that Resident #1 took and consumed food from other residents that was not allowed on his/her diet. CNA #2 said prior to [DATE], she observed Resident #2 take food from other residents that was not allowed on his/her diet. The DON, the Dietician, Nurse #3, Nurse #4, CNA #1, and CNA #2 said they were not aware that Resident #2 had a past choking incident with peanut butter. CNA #1 and CNA #2 said Resident #2 ate quickly and they cued him/her to eat slower. The Dietician said one of the residents, who sat at Resident #2's table received a peanut butter and jelly sandwich on his/her tray in addition to his/her regular meal. The Dietician said prior to [DATE], she observed Resident #2 try to take foods, which did not include a peanut butter sandwich from other residents. Resident #2's meal ticket for the dinner meal, dated [DATE], indicated that Resident #2 was to receive a puree diet with large portions. The meal ticket indicated that Resident #2 was allergic to peanut butter. The Surveyor interviewed Diet Aide #1 on [DATE], at 10:00 A.M. Diet Aide #1 said she was assigned to place extra food items, such as a peanut butter sandwich on resident trays during the tray line, when indicated. Diet Aide #1 said Resident #2's meal ticket indicated that he/she was allergic to peanut butter. Diet Aide #1 said although on [DATE], she placed a peanut butter and jelly sandwich on another resident's tray, she did not place a peanut butter sandwich on Resident #2's tray. CNA #1 said on [DATE], she gave Resident #2 his/her meal at dinner time. CNA #1 said she removed the food and fluid items from the tray and placed the food and fluids in front of Resident #2. CNA #1 said she poured the milk in Resident #2's sippy cup and put condiments on the food. CNA #1 said she placed the peanut butter and jelly sandwich in front of Resident #2 and did not unwrap the sandwich. CNA #1 said she did not observe any notation on Resident #2's meal ticket that indicated Resident #2 was allergic to peanut butter. CNA #2 said Resident #2 told her that he/she wanted the peanut butter and jelly sandwich. CNA #2 said she told Resident #2 to eat the other food on his/her plate. CNA #2 said Resident #2 was adamant that he/she wanted the peanut butter and jelly sandwich. CNA #2 said she unwrapped the peanut butter and jelly sandwich for Resident #2. CNA #2 said within a few minutes, she observed Resident #2, who appeared to be choking. The nurse's note, dated [DATE], indicated that Resident #2 ate in the dining room with staff supervision. The nurse's note indicated that the CNA yelled that she needed immediate help. The nurse's note indicated that Resident #2 was unresponsive to verbal and tactile stimuli, had gray color, and sat in the wheelchair. The nurse's note indicated that Resident #2 had a strong heart rate and gasped for air. The nurse's note indicated that the staff performed the Heimlich Maneuver on Resident #2 without success. The nurse's note indicated that the staff assisted Resident #2 to the floor. The nurse's note indicated that the Director of Nurses (DON) initiated a Code Blue and called the emergency medical service. The nurse's note indicated that staff performed cardiopulmonary resuscitation on Resident #2 until the paramedics assumed the care of Resident #2. The physician order, dated [DATE], included: transfer to Emergency Department (ED) for evaluation and treatment of [REDACTED]. The ED Physician report, dated [DATE], indicated that the emergency medical technicians (EMTs) suctioned Resident #1 and he/she had a large amount of emesis and food stuffs. The ED Physician report indicated that the EMT intubated Resident #2. The ED report indicated that upon arrival at the ED, Resident #2 had agonal and shallow respirations. The Ed report indicated that the staff transferred Resident #2 to the intensive care unit. The Transfer summary, dated [DATE], indicated that the Hospital staff treated Resident #2 with steroid, bronchodilator, and antibiotic medications. The DON said she investigated the incident and identified opportunities for improvement that included: 1. The Dietary staff placed a peanut butter and jelly sandwich on Resident #2's tray. The nursing staff failed to recognize that Resident #2 was not to have a peanut butter and jelly sandwich and the CNA served the peanut butter and jelly sandwich to Resident #2. 2. Resident #2 ate the peanut butter and jelly sandwich, choked, and required the Heimlich maneuver and CPR. 3. The diet aide read 4 to 5 meal tickets and ,[DATE] meals were plated (diet aide read out 5 resident meals at the same time and the cook plated 5 meals), which could cause confusion. The DON said she, the Dietician, and the Food Service Supervisor initiated a plan of action that included:' 1. Resident #2's plan of care was revised on [DATE] and included: staff member to sit at Resident #2's table to supervise and prevent him/her from grabbing food from other residents and have a resident, who is dependent with eating sit at Resident #2's table. 2 Facility education included: a) Nursing and dietary staff to follow physician orders regarding residents' diets. b) Licensed nurses were to check resident dietary tickets and the food served on the tray to ensure accuracy, prior to the staff passing the meal trays to residents. c) Each person was to check resident dietary slips on the tray for diet and special dietary needs/concerns prior to serving the tray to residents. d) Review of meal service in resident rooms and dining room service to nursing staff. e) Review of dietary orders and dietary communication to nursing and dietary staff. f) Plating Meals to dietary staff. g) Diets-texture/modification education with a quiz to dietary and nursing staff. 3. Since the incident, the diet aide read 2 meal tickets and 2 meals were plated. 4. The Facility audited all resident records and their meal tickets to ensure that residents had a physician order for [REDACTED]. The Food Service Supervisor, the unit managers, and the nursing supervisors conducted random audits on new admissions/re-admissions, and residents at the Facility to ensure compliance that residents received the physician ordered diets. 5. The nursing staff and the Food Service Supervisor completed meal check accuracy for correct diet served per physician order that was completed almost daily between [DATE] and [DATE] and completed during the week and weekends on the day and evening shifts. Random meal check accuracy would be continued. The DON said she would present the audit results to the Quality Assurance Committee.

Based on record review and interview, the Facility failed to ensure that the physician was immediately notified when one of five sampled Residents (Resident #1) experienced a fall on 1/21/12 at 5:30 A.M., displayed swelling of the left hand at 10:00 A.M. and swelling of the left hand and wrist with bruising on top of the left hand at 12:00 P.M. Nurse #2 failed to notify the physician until 2:00 P.M. and an x-ray ordered by the Physician showed a fracture of Resident #1's distal radius and ulna (wrist). In addition, Hospital medical records indicated Resident #1 also sustained a left femoral neck (hip) fracture. Findings include: The Facility admitted Resident #1 in May, 2004. The January, 2012 physician's orders [REDACTED]. A review of a progress note, completed on 1/18/12 by the Facility's Psychiatric Services Provider, indicated that Resident #1 had impaired memory, impaired judgement, impaired insight, impoverished speech, an illogical thought process, and Resident #1 was oriented to person only. A nurse's note (change in condition), dated 1/21/12 at 8:14 A.M., indicated that Resident #1 experienced an unwitnessed fall at 5:30 A.M. and sustained no injuries. The nurse's note indicated that Resident #1 demonstrated no signs or symptoms of pain. The nurse's note indicated that the physician was notified of the fall. The Surveyor interviewed Nurse #1 at 2:45 P.M. on 2/17/12. Nurse #1 said at 5:30 A.M. Resident #1 was found lying on his/her back on the floor and Resident #1 had no complaint of any pain. Nurse #1 said she assessed Resident #1 and there was no bruising, no swelling, and no leg rotation, so they lifted Resident #1 off the floor with a mechanical lift. Nurse #1 said after Resident #1 was in bed, they rolled him/her to get the lift pad out from under him/her and he/she said, ouch. Nurse #1 said she again asked Resident #1 if he/she had any pain and there was no answer, so they rolled him/her again to see if Resident #1 showed any sign of pain. Nurse #1 said there was no sign of pain. Nurse #1 said about 8:00 A.M., she was charting when a Certified Nurses Aide (CNA) said Resident #1 was in a lot of pain. Nurse #1 said Nurse #2 went to assess Resident #1 and she (Nurse #1) left the facility. The Surveyor interviewed CNA #1 at 2:00 P.M. on 2/10/12. CNA #1 said about 8:45 to 9:00 A.M., she went into Resident#1's room to provide morning care and Resident #1 complained of left leg pain when she attempted to put a sock on his/her left foot. CNA #1 said when she touched Resident #1's left leg, he/she said, ouch. CNA #1 said Resident #1 also said his/her hand hurt. CNA #1 said she told Nurse #2 and he came to the room and assessed Resident #1. CNA #1 said after Nurse #2 assessed Resident #1, he said to get him/her dressed, but leave him/her in bed. A nurse's note, dated 1/21/12, indicated that at 8:00 A.M. Resident #1 had full range of motion of the left hand and wrist with no discomfort to touch. The nurse's note indicated at 10:00 A.M. some swelling was noted on Resident #1's left hand and there was no discomfort to touch and he/she had full range of motion. The nurse's note indicated that at 12:00 P.M. swelling was noted on the left hand and wrist and bruising was observed on top of the left hand, but Resident #1 had full range of motion of the left hand. The Facility's Physician Notification Policy indicated that upon identification of a patient's change in condition a licensed nurse will perform appropriate clinical observations and data collection and report to the physician. The Policy Guidelines indicated that the physician should be notified urgently with any injury or change in status related to a fall. A nurse's note, dated 1/21/12, indicated that at 2:00 P.M. a family member visited and Nurse #2 was asked to look at Resident #1's wrist. The nurse's note indicated that at that time the bruising had spread to the wrist and inner forearm, the swelling increased, and the area was warm to the touch. The nurse's note indicated that the physician was notified. On 1/21/12 at 2:00 P.M. the physician ordered a stat x-ray of Resident #1's left hand, wrist, forearm, and elbow. A review of a Radiology Report, dated 1/21/12, indicated that Resident #1 had a [MEDICATION NAME] fracture through the distal aspect of the radial metaphysis, with mild impaction, and dorsal angulation of the distal fracture fragment. The x-ray also showed a nondisplaced [MEDICAL CONDITION] styloid. A nurse's note, dated 1/21/12, indicated that the physician was notified of the x-ray results and ordered Resident #1 sent to the Hospital emergency department for evaluation and treatment. The nurse's note indicated that Resident #1 was transferred to the Hospital by ambulance at 5:00 P.M. The Surveyor interviewed Nurse #2 at 2:28 P.M. on 2/17/12. Nurse #2 said he was told in report that Resident #1 fell during the night and Nurse #1 assessed Resident #1 and found no injuries. Nurse #2 said he assessed Resident #1 at about 7:00 to 7:30 A.M. and there was no swelling, no bruising, and Resident #1 had no pain. Nurse #2 said he did not recall any CNA informing him of swelling or pain. Nurse #2 said he believed there was no swelling or bruising until about noon. Nurse #2 then told the Surveyor that he only vaguely recalled the incident and did not wish to discuss this any further, because he did not want to say anything that could impact his licensure. The Surveyor interviewed the Nursing Supervisor at 1:45 P.M. on 2/10/12. The Nursing Supervisor said she was the Facility MDS (Minimum Data Set) Coordinator and was at the Facility on the day of the incident from 7:00 A.M. to 5:00 P.M. functioning as the nusing supervisor. The Nursing Supervisor said she had gone to Resident #1's unit several times and spoken to Nurse #2 about other issues and was never made aware that Resident #1 experienced a fall. The Nursing Supervisor said she was never made aware that Resident #1 had any symptoms of injury, that an x-ray had been ordered, or that Resident #1 was transferred to the Hospital. The Surveyor interviewed Unit Manager #1 at 2:10 P.M. on 2/10/12. Unit Manager #1 said the Nursing Supervisor and Physician should have been notified of any swelling or bruising after a fall. Severe cognitive impairment prevented Resident #1 from participating in an interview with the Surveyor. Hospital medical records, dated 1/21/12, indicated that Resident #1 was diagnosed with [REDACTED]. Refer to F 323.

Based on record review, interview, and observation, the Facility failed to ensure that the personal alarm for one of five sampled Residents (Resident #1) was in good condition and functioned properly when Resident #1 experienced a fall during the night and the personal alarm failed to sound. Resident #1 sustained a fracture of the distal radius and ulna (wrist) and a left femoral neck (hip) fracture. In addition, during alarm checks with Unit Manager #1 on the day of survey, the Surveyor observed that one of two remaining Residents (Resident #2) on the unit with alarms was asleep in bed and Resident #2's personal alarm box was lying on the floor with the battery for the alarm lying on the floor next to the alarm box, which rendered the alarm non-functional. Findings include: The Facility admitted Resident #1 in May, 2004. The January, 2012 physician's orders [REDACTED]. A nursing assessment, dated 1/3/12, indicated that Resident #1 was at high risk for falls. A progress note, completed on 1/18/12 by the Facility's Psychiatric Services Provider, indicated that Resident #1 had impaired memory, impaired judgement, impaired insight, impoverished speech, an illogical thought process, and Resident #1 was oriented to person only. A review of a Bed and Chair Alarm Sign Off Sheet indicated that at the beginning of every shift the on-coming CNA and off-going CNA must do alarm checks. The Bed and Chair Alarm Sign Off Sheet, dated 1/20/12, indicated that CNA #2 completed the alarm checks with the 3:00 P.M. to 11:00 P.M. CNA at the beginning of the 11:00 P.M. to 7:00 A.M. shift. The Bed and Chair Alarm Sign Off Sheet indicated that Resident #1's bed and chair alarms were present and functioning. The Surveyor interviewed CNA #2 at 3:08 P.M. on 2/17/12. CNA #2 said Resident #1 had a personal alarm that was used on both the wheelchair and bed. CNA #2 said when she checked Resident #1's personal alarm at the beginning of the 11:00 P.M. to 7:00 A.M. shift, the alarm worked, but the back of the alarm box was missing. CNA #2 said they usually placed tape over the back of the alarm if the back was missing in order to ensure that the battery remained in the alarm and did not fall out, but they did not place tape across the battery on this night, so the battery could just pop out. CNA #2 said she did not tell Nurse #1 that Resident #1's personal alarm was defective, because the back of the box was missing. CNA #2 said it was just an onging problem with the backs of alarms missing. CNA #2 said about 5:30 A.M. Resident #1 was discovered lying on his/her back on the floor near the bed and Resident #1's personal alarm did not sound. CNA #2 said the alarm battery was dislodged, so the alarm failed to sound. A nurse's note (change in condition), dated 1/21/12 at 8:14 A.M., indicated Resident #1 experienced an unwitnessed fall at 5:30 A.M. and sustained no injuries. The nurse's note indicated that Resident #1 demonstrated no signs or symptoms of pain. The nurse's note indicated that the physician was notified of the fall. A review of the Incident Report, dated 1/21/12, (used for clarification) indicated that Resident #1's personal alarm was attached to Resident #1, but failed to sound. The Surveyor interviewed Nurse #1 at 2:45 P.M. on 2/17/12. Nurse #1 said she was not made aware that there was any problem with Resident #1's personal alarm. Nurse #1 said at 5:30 A.M. Resident #1 was found lying on his/her back on the floor and she could not recall hearing the alarm sound. Nurse #1 said she assessed Resident #1 and there was no bruising, no swelling, and no leg rotation, so they lifted Resident #1 off the floor with a mechanical lift. Nurse #1 said about 8:00 A.M., she was doing her charting and finishing up when a Certified Nurse Aide (CNA) said Resident #1 was in a lot of pain. Nurse #1 said Nurse #2 went to assess Resident #1 and she left the facility. A nurse's note, dated 1/21/12, indicated that at 8:00 A.M. Resident #1 had full range of motion of the left hand and wrist with no discomfort to touch. The nurse's note indicated that at 10:00 A.M. some swelling was noted on Resident #1's left hand and there was no discomfort to touch and he/she had full range of motion. The nurse's note indicated that at 12:00 P.M. swelling was noted on the left hand and wrist and bruising was observed on top of the left hand, but Resident #1 had full range of motion of the left hand. The nurse's note indicated that at 2:00 P.M. a family member visited and Nurse #2 was asked to look at Resident #1's wrist. The nurse's note indicated at that time the bruising had spread to the wrist and inner forearm, the swelling increased, and the area was warm to the touch. The nurse's note indicated that the physician was notified. On 1/21/12 at 2:00 P.M. the physician ordered a stat x-ray of Resident #1's left hand, wrist, forearm, and elbow. A review of a Radiology Report, dated 1/21/12, indicated that Resident #1 had a transverse fracture through the distal aspect of the radial metaphysis, with mild impaction, and dorsal angulation of the distal fracture fragment. The x-ray also showed a nondisplaced fracture of the ulnar styloid. A nurse's note, dated 1/21/12, indicated that the physician was notified of the x-ray results and ordered Resident #1 sent to the Hospital emergency department for evaluation and treatment. The nurse's note indicated that Resident #1 was transferred to the Hospital by ambulance at 5:00 P.M. Hospital medical records, dated 1/21/12, indicated that Resident #1 was diagnosed with [REDACTED]. Severe cognitive impairment prevented Resident #1 from participating in an interview with the Surveyor. The Surveyor interviewed Unit Manager #1 at 2:10 P.M. on 2/10/12. Unit Manager #1 said Resident #1 had a personal alarm and the back of the alarm box was missing, so staff usually placed tape over the back of the alarm box to hold the battery in place. Unit Manager #1 said she was not sure how long the alarm had been like that, but she was never made aware that the alarm was broken. Unit Manager #1 said the Facility was in the process of going alarm free, so there were no spare alarms available at the time of Resident #1's fall. Unit Manager #1 said since the incident, all alarms on the unit had been discontinued except for two Residents. Observations made by the Surveyor at 2:55 P.M. on 2/10/12 with Unit Manager #1 indicated that one of the two remaining residents with an alarm in use, Resident #2, who was at high risk for falls, was lying on his/her bed asleep and the personal alarm box was lying on the floor next to Resident #2's bed with the battery out of the alarm box and lying next to the alarm box on the floor. Unit Manager #1 picked up the alarm box and battery, reinstalled the battery, and the alarm then functioned properly.

Based on record review and staff interview, the facility failed to ensure that 2 sampled residents (#8 and #14), in a total sample of 22 residents, received bowel medications as per facility protocol and as ordered by the physician. Findings included: 1. For Resident #8, the facility failed to administer medications as ordered by the physician and per the facility's bowel protocol. The resident experienced fecal impactions. Resident #8 was admitted to the facility in September 2011 with [DIAGNOSES REDACTED]. Review of the facility's bowel protocol indicated the following: -If no bowel movement for 9 shifts, the 3:00 P.M. to 11:00 P.M. shift will administer Milk of Magnesia (MOM) 30 Cubic Centimeters (cc). This protocol indicated this medication should be used first. -If no results from the MOM, the 11:00 P.M. to 7:00 A.M. should administer a [MEDICATION NAME] suppository 10 milligrams. The protocol indicated this medication should be used second. -If no bowel movement from the [MEDICATION NAME] suppository, the 7:00 A.M. to 3:00 P.M. shift should administer a Fleet's enema. If no results from the Fleet's enema the physician should be notified. Review of the physician's orders [REDACTED]. -MOM 30cc daily as needed for constipation (use first). -[MEDICATION NAME] Suppository 10 milligrams daily as needed for constipation if MOM is not effective (use second). -Fleet's enema daily as needed if no effect from [MEDICATION NAME] Suppository (use third). Review of the Resident's Bowel Record for September 23, 24, and 25, 2011 indicated the resident had no bowel movement. However, review of the Medication Administration Sheet (MAR) of September 2011 indicated that the resident was not given the MOM on 9/25/11 on the 3:00 P.M. to 11:00 P.M. shift (the ninth shift with no bowel movement) as per the bowel protocol. Further review of the resident's bowel record indicated the resident did not have a bowel movement on 9/26/11, as well and no bowel medications were given as required. Review of the resident's bowel record indicated the resident had no bowel movement 9/27/11 on the 11:00 P.M. to 7:00 A.M. shift and the 7:00 A.M. to 3:00 P.M. shift. This was 14 consecutive shifts without a bowel movement and no remedial measures were implemented as outlined in the bowel protocol and or physician orders. Review of the resident's record revealed a physician's telephone order of 9/27/11 indicating the physician ordered [MEDICATION NAME] suppository to be given now. However, review of the MAR indicated [REDACTED].M. to 11:00 P.M. shift (this was confirmed during interview with Nurse #2 on 10/28/11 at 11:00 A.M.). The resident experienced a large loose movement following the administration of the MOM. Further review of the resident's bowel movement record indicated the resident had no bowel movement October 12 to October 15, 2011. Review of the October 2011 MAR indicated [REDACTED].M. to 11:00 P.M. shift (the ninth shift with no bowel movement). The resident's bowel protocol was not followed on 10/15/11 (as the resident had no bowel movement that day). Thus the resident now had four days with no bowel movement. The resident did not move his/her bowels on 10/16/11 during the 11:00 P.M. to 7:00 A.M. shift or the 7:00 A.M. to 3:00 P.M., shift and the bowel protocol was not followed. Review of the nurse's note of 10/21/11 indicated the resident's abdominal distention had increased and was now tender to touch. The physician was notified and ordered a bladder scan and a STAT (immediate) KUB ( x-ray of the kidneys, ureters, and bladder). The KUB was repeated 10/22/11 and indicated the following: There is a large amount of stool in the rectum which is either unchanged or slightly larger. There is no evidence of obstruction. There is a large amount of stool in the ascending colon. The impression was Fecal Impaction. During interview on 10/26/11 at 2:00 P.M., the Director of Nurses (DON) acknowledged that the facility failed to administer bowel medications as ordered by the physician to prevent constipation and fecal impaction. During interview on 10/27/11 at 9:55 A.M., the DON and Medical Director acknowledged that the purpose of the bowel protocol ordered for this resident was to prevent constipation and fecal impaction. The DON acknowledged that the bowel protocol was not followed for this resident as outlined above. Please refer to F309. 2. For Resident #14, the facility failed to administer medications to prevent constipation as ordered by the physician and per the facility's protocol. Resident #14 was admitted to the facility July 2004 with [DIAGNOSES REDACTED]. Review of the facility's bowel protocol indicated the following: -If no bowel movement for 9 shifts, the 3:00 P.M. to 11:00 P.M. shift will administer MOM 30cc. The protocol indicated this medication should be used first. -If no results from the MOM, the 11:00 P.M. to 7:00 A.M. should administer a [MEDICATION NAME] suppository 10 milligrams. The protocol indicated this medication should be used second. -If no bowel movement from the [MEDICATION NAME] suppository, the 7:00 A.M. to 3:00 P.M. shift should administer a Fleets enema. If no results from the Fleets enema, the physician should be notified. Review of the physician's orders [REDACTED]. -MOM 30cc daily as needed for constipation (use first). -[MEDICATION NAME] Suppository 10 milligrams daily as needed for constipation if MOM is not effective (use second). -Fleet's enema daily as needed if no effect from [MEDICATION NAME] Suppository (use third). Review of Resident #14's Bowel Record for September 2011 indicated the resident had no bowel movement on September 10, 11, and 12. According to the physician's orders [REDACTED].M. to 11:00 P.M. shift (9th shift with no bowel movement). Review of the September MAR indicated [REDACTED]. Review of the Resident's Bowel Record for September 2011 indicated the resident had no bowel movement from 9/19/11 to 9/23/11 (5 days or 15 shifts) and no bowel medications as per the bowel protocol were given. The resident had a small formed bowel movement on 9/24/11. The resident had no bowel movement from 9/25/11 to 9/29/11 (5 days or 15 shifts) and no bowel medications were given as per the bowel protocol. Further record review indicated the resident had only 1 small formed bowel movement from 9/19/11 to 9/29/11 (a period of 11 days) and the resident did not receive any of the medications as the per the bowel protocol. There was no reference to the bowels in the clinical record during this time frame. Review of the Resident Bowel Record for October 201l indicated the resident had no bowel movement on 10/3/11, 10/4/11, and 10/5/11. According to the physician's orders [REDACTED].M. to 11:00 P.M., shift (9th shift with no bowel movement) but the resident did not receive the MOM on 10/5/11 as ordered. Further review of the Resident Bowel Record indicated the resident did not have a bowel movement on 10/6/11 and no bowel protocol medications were given as ordered. During interview on 10/27/11 at 10:10 A.M., Unit Manager #1 acknowledged that this resident's physician's orders [REDACTED].

Based on record review, observation, and staff interview, the facility failed to ensure that 1 sampled resident (#8), in a total sample of 22 residents, received the necessary care and services to attain the highest level of functioning and well-being possible regarding bowel issues and bowel medications. For Resident #8, the facility failed to administer bowel medications when the resident experienced multiple days without a bowel movement. The resident became constipated, developed a fecal impaction and required additional laxatives. The facility failed to follow the bowel protocol after the first episode of fecal impaction; and, subsequently, the resident developed a second fecal impaction. Findings included: Resident #8 was admitted to the facility in September 2011 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. -MOM (Milk of Magnesia) 30cc (cubic centimeters) daily as needed for Constipation (use first). -[MEDICATION NAME] Suppository 10 milligrams (mg) daily as needed for constipation if MOM is not effective (use second). -Fleet's enema daily as needed if no effect from [MEDICATION NAME] Suppository (use third). Review of the facility bowel protocol (provided by the Director of Nurses) indicated the following medications/treatments to be utilized: -If no bowel movement for 9 shifts, the 3:00 P.M. to 11:00 P.M. shift will administer MOM, 30cc. The protocol indicated this medication should be used first. -If no results from the MOM, the 11:00 P.M. to 7:00 A.M. shift should administer a [MEDICATION NAME] suppository 10 mg. The protocol indicated this medication should be used second. -If no bowel movement from the [MEDICATION NAME] suppository, the 7:00 A.M. to 3:00 P.M. shift should administer a Fleets enema. If no results from the Fleets enema the physician should be notified. Review of the Resident Bowel Record for 9/23/11, 9/24/11, and 9/25/11 indicated the resident had no bowel movement. However, review of the Medication Administration Sheet (MAR) of September 2011 indicated that the resident was not given the MOM on the 3:00 P.M. to 11:00 P.M. shift (the ninth shift with no bowel movement) as per the bowel protocol. Further review of the resident's bowel record indicated the resident did not have a bowel movement on 9/26/11, as well and no bowel medications were given. Review of the resident's bowel record indicated the resident had no bowel movement on 9/27/11 on the 11:00 P.M. to 7:00 A.M. shift and the 7:00 A.M. to 3:00 P.M. shift. This totaled 14 shifts without a bowel movement and no medications were given for the lack of bowel movement. The clinical record did not comment on the lack of bowel movements or why the bowel protocol was not followed. There was no explanation in the record as to why the facility did not give the resident the ordered bowel medications. Although the resident had a history of [REDACTED]. Review of the resident's record revealed a physician's telephone order of 9/27/11 to give the resident a [MEDICATION NAME] suppository now, and a KUB (x-ray of the kidneys, ureters, and bladder) in the morning. However, review of the MAR indicated [REDACTED].M. to 11:00 P.M. shift (this was confirmed with interview with Nurse #2 on 10/28/11 at 11:00 A.M.). The resident experienced a large loose movement following the administration of the MOM. Review of the KUB x-ray results of 9/28/11 revealed the following, "Moderate amount of stool with rectal fecal impaction. No definite bowel obstruction can be appreciated". The Initial MDS (Minimum Data Set) Assessment, with an assessment reference date of 9/28/11, indicated the resident was cognitively impaired with a Brief Interview for Mental Status (BIMS) of 4/15, required extensive assistance from staff for bed mobility, transfers and ambulation. The resident was recorded as being totally dependent on staff for toilet use, frequently incontinent of bladder and occasionally incontinent of bowel. The resident was inaccurately coded not being constipated. Review of the care plan developed for the resident in September 2011 did not indicate any interventions were put in place to treat the fecal impaction identified on the KUB of 9/28/11. Further review of the resident's bowel movement record indicated the resident had no bowel movement 10/12/11, 10/13/11, 10/14/11 and 10/15/11. Review of the physician's orders [REDACTED]. Review of the October 2011 MAR indicated [REDACTED].M. to 11:00 P.M. shift (the ninth shift with no bowel movement). The resident's bowel protocol was not followed on 10/15/11, despite continued lack of a bowel movement. The resident did not move his/her bowels on 10/16/11 during the 11:00 P.M. to 7:00 A.M. shift or the 7:00 A.M. to 3:00 P.M. shift, and the bowel protocol was not followed. Review of the bowel record indicated the resident had a moderate loose stool on 10/16/11 during the 3:00 P.M. to 11:00 P.M., no recorded bowel movements on 10/18/11 and a loose movement on 10/19/11. There was no assessment of why the resident was only experiencing loose movements. Review of the nurse's note of 10/20/11 indicated "slight abdominal distention, no complaint of discomfort or tenderness to touch, positive bowel sounds in all 4 quadrants, resident incontinent of medium soft bowel movement". Review of the nurse's note of 10/21/11 indicated the resident's abdominal distention had increased and was now tender to touch. The physician was notified and ordered a bladder scan and a STAT (immediate) KUB x-ray. The bladder scan showed a residual of 1300 cc of urine and the resident required a straight catheterization. The results of the KUB indicated no obstruction but showed a very large amount of stool present in the rectum consistent with fecal impaction and measuring 11cc [MEDICATION NAME]. The note indicated the physician was notified and ordered the resident be sent to the emergency room . Review of the hospital emergency record indicated that the resident was given [MEDICATION NAME] and a Fleets enema (laxatives) in the emergency room and was sent back to the facility with instructions to continue taking [MEDICATION NAME] for an additional 4 days. The [DIAGNOSES REDACTED]. Review of the nurse's note of 10/22/11 indicated another bladder scan was completed which showed greater that 877 cc of urine in the bladder. The physician ordered the insertion of a indwelling Foley catheter The KUB was repeated 10/22/11 and indicated the following: There is a large amount of stool in the rectum which is either unchanged or slightly larger. There is no evidence of obstruction. There is a large amount of stool in ascending colon. The impression of the KUB was "Fecal Impaction". The physician was notified and ordered Magnesium [MEDICATION NAME] 1 bottle (a saline laxative frequently used before a colonoscopy or surgical procedure ). The resident experienced a large formed stool following administration of the laxative 10/22/11, on the 3:00 P.M. to 11:00 P.M. shift followed by an "extra, extra large formed stool" on 10/23/11 on the 11:00 P.M. to 7:00 A.M. shift. This movement was described on the Treatment Record as [MEDICAL CONDITION] the point that the resident required a shower. Review of the physician's note of 10/24/11 indicated the physician assessed the resident as having experienced fecal impaction/constipation with [MEDICAL CONDITION] and a Foley catheter placement. The note indicated the plan was to clear the fecal impaction/constipation and remove the Foley in two weeks and attempt a voiding trial. The resident pulled the indwelling catheter out on 10/25/11. The physician was contacted and ordered the catheter be left out and a bladder scan every 8 hours and to perform a straight catheterization if the resident's bladder contained more than 250 cc. Review of the bladder scans of (10/25/11 to 10/28/11) revealed the bladder contained less than 100 cc (which indicated the resident was no longer retaining abnormal amounts of urine). During interview (on 10/28/11 at 2:25 P.M.), the acting Unit Manager acknowledged that the [MEDICAL CONDITION] the resident had experienced may have been caused by the fecal impactions. During observation 10/26/11 at 9:00 A.M., the resident was observed lying in his/her bed on the left side with legs drawn up. When asked how the resident was, the resident responded "terrible". The resident was unable/unwilling to provide any additional information to the surveyor. During interview on 10/26/11 at 2:00 P.M. the Director of Nurses (DON) acknowledged that the facility failed to provide the resident with medication that had been ordered by the physician to prevent constipation and fecal impaction. During interview 10/27/11 at 9:55 A.M., the DON and Medical Director acknowledged that the purpose of the bowel protocol ordered for this resident was to prevent constipation and fecal impaction. The DON acknowledged that the bowel protocol was not followed for this resident as outlined above. The Medical Director acknowledged that the bowel protocol should have been followed as ordered and that not administering these medications could lead to fecal impaction.

Based on record review, observation, and staff interview, the facility still failed to ensure that 1 sampled resident (#28), in a total sample of 13 residents, received the necessary care and services promptly to attain the highest level of functioning and well-being possible regarding bowel issues and management of fecal impaction. For Resident #28, the facility failed to act promptly when the abdominal x-ray scan indicated the resident had a fecal impaction. The resident was not treated for [REDACTED]. Findings included: Resident #28 was admitted to the facility in September 2009 with [DIAGNOSES REDACTED]. During the initial tour (on 11/19/11 at 8:15 A.M.), the Unit Manager stated that he/she believed Resident #28 had experienced a recent fecal impaction despite regular bowel movements. The Unit Manager informed the surveyor that he/she would review the record and get back to the surveyor with the information regarding the fecal impaction. Review of the latest Minimum Data Set (MDS) assessment (of 10/14/11) indicated the resident had impaired long and short term memory, was totally dependent on staff for toilet use, and was always incontinent of bowel. This MDS coded the resident as having constipation and a paralytic ileus. Review of the care plan in place 11/18/11 indicated Resident #28 exhibited or was at risk for gastrointestinal symptoms or complications related to chronic constipation, chronic ileus, and Ogilvie's syndrome. The interventions included: -[MEDICATION NAME] (GI) consult as ordered by the physician. -Administer medications as ordered and observe for effectiveness and side effects. Report to physician as indicated. -Assess for and report signs and symptoms of nausea/vomiting, abdominal distention, decrease in bowel movements, decrease in bowel sounds and abdominal pain. -Record bowel movements and encourage fluids. -Provide bowel regimen and assess for constipation. Review of the Physician's progress note of 11/1/11 indicated that the resident had had a recent GI consult and was to have a follow up abdominal CT (computerized tomography x-ray) with contrast. However this progress note indicated the resident would not take the contrast material. This physician's note indicated that an abdominal CT scan would be done without contrast. Further review of the record from 11/2/11 to 12/15/11 did not indicate any documentation that the abdominal CT scan was completed. There was no further nurses' notes or physician's notes that referred to the CT scan. There was no clinical documentation in the record that indicated this CT scan was done. There was no notation in the record that the resident had gone to an appointment for this CT scan. Review of the resident's bowel movement record from 11/1/11 to 12/15/11 indicated the resident moved his/her bowels on a regular basis and did not require any as needed laxatives. Review of the record indicated the resident was seen by the [MEDICATION NAME] on 12/15/11. The report of this exam included the [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. - Senna-S (a laxative) two tablets twice a day. -1 bottle of Magnesium [MEDICATION NAME] (a strong laxative). -[MEDICATION NAME] (a laxative) 15 cc twice a day. -KUB (an x-ray of the kidneys, ureters, and bladder frequently used to determine the presence of fecal impaction) to be done (on 12/19/11). The physician's note of 12/16/11 indicated the resident was recently seen for a GI consult. The physician's note states the consult indicated the resident had constipation and fecal impaction with no bowel obstruction. On 12/16/11 the physician ordered the following additional laxative medications and assessments. -1 bottle of Magnesium [MEDICATION NAME] (a strong laxative used to clean out the colon). -[MEDICATION NAME] 5 mg. by mouth daily. -Nursing to monitor bowel sounds and perform an abdominal assessment every shift. During interview 12/20/11 at 8:00 A.M., the Unit Manager provided the surveyor with a report of a abdominal CT scan for this resident (completed 11/18/11) that was not in the resident's clinical record when reviewed by the surveyor. The results of this CT scan showed: -Stool identified within a distended rectum is consistent with fecal impaction. Clinically correlate. -No evidence of small bowel obstruction. During interview on 12/20/11 at 8:05 A.M., the Unit Manager stated that the facility was unaware of the abdominal CT scan (of 11/18/11) that showed fecal impaction until the facility received the results of a follow-up GI consult (on 12/15/11) which included the [DIAGNOSES REDACTED]. The Unit Manager told the surveyor that the facility had no documentation of the abdominal CT scan done (11/18/11) and no knowledge of the results that showed fecal impaction until after the resident went for follow-up with the GI consult (12/15/11). The Unit Manager stated that the facility had not informed the physician of the CT scan (of 11/18/11) until 12/15/11, 27 days later. The Unit Manager indicated that when the physician was informed of the fecal impaction on 12/15/11 the physician ordered the laxatives listed above. During interview 12/20/11 at 11:00 A.M., the facility Administrator stated the facility provided a staff person (on 11/18/11) to accompany the resident out of the building in a chair car to the resident's appointment for an abdominal CT scan. The Administrator stated that the facility had not obtained the results of the CT scan done (11/18/11) until after the facility received the GI consult (of 12/15/11). The Administrator stated that there was no documentation in the record that the resident had a abdominal CT scan (on 11/18/11) or that the physician was notified of the results that indicated fecal impaction. During interview 12/20/11 at 1:00 P.M., the Director of Nurses (DON) stated that it was the policy of the facility to inform the physician of CT results promptly and to document in the clinical record when the resident leaves the building for a medical appointment. The DON further stated that if the resident returned without documentation from a medical appointment, it was the policy of the facility to obtain documentation of the results of the medical appointment promptly. The DON stated the facility was unaware of the CT scan results (of 11/18/11) that showed fecal impaction until 12/15/11, consequently did not seek treatment for [REDACTED]. The DON stated that when the physician was informed of the [DIAGNOSES REDACTED].

Based on record review and interview, the Facility failed to ensure that the sliding scale insulin coverage was provided to one of three sample residents (Resident #1) per the physician order. Although the physician order, dated [DATE], indicated that Resident #1 was to have a finger stick blood sugar level 3 times a day with sliding scale [MEDICATION NAME]coverage (fast-acting insulin, onset 5 to 15 minutes, peak 1 to 2 hours, duration 3 to 5 hours, and not eating immediately after a dose of this type of insulin may lead to low blood sugar) and an as needed (prn) blood sugar level with no [MEDICATION NAME]coverage, the nurse's note dated [DATE], indicated that at 3:00 A.M., Resident #1 had a blood sugar level of 257; the Physician was not notified, Resident #1 received 8 units of [MEDICATION NAME]without a physician's orders [REDACTED]., Resident #1's blood sugar level registered low on the machine; Resident #1 had no heart rate and no respirations, and Resident #1 required cardiopulmonary resuscitation (CPR). Findings included: The Admission record indicated that Resident #1 was admitted to the Facility in April, 2011 and had [DIAGNOSES REDACTED]. The physician orders, dated [DATE], included: [MEDICATION NAME]50 units (long acting insulin) at 6:00 A.M. and 6:00 P.M.; [MEDICATION NAME] 5 units 3 times per day before meals; finger stick blood sugar 4 times per day with sliding scale [MEDICATION NAME]as follows: call physician if blood sugar level less than 100; blood sugar level ,[DATE], 2 units of [MEDICATION NAME]; blood sugar level ,[DATE], 4 units of [MEDICATION NAME]; blood sugar level ,[DATE], 6 units of [MEDICATION NAME]; blood sugar level ,[DATE], 8 units of [MEDICATION NAME]; blood sugar level ,[DATE], 10 units of [MEDICATION NAME]; blood sugar level ,[DATE], 12 units of [MEDICATION NAME], and call physician if blood sugar level above 400. The nurse's note, dated [DATE], indicated that at 5:30 A.M., Resident #1 complained of diaphoresis and requested that Resident #1's blood sugar be checked. The nurse's note indicated that Resident #1's blood sugar level was 47; the Nurse Practitioner (NP) was notified; the 6:00 A.M. insulin was held; a snack was given; at 6:00 A.M., Resident #1's follow-up blood sugar level was 90; at 6:30 A.M., Resident #1's blood sugar level was 80, and another snack was given to Resident #1. The physician order, dated [DATE], at 5:30 A.M., included: discontinue finger stick blood sugar levels 4 times a day; hold [MEDICATION NAME] 50 units once at 6:00 A.M. related to a blood sugar level of 47, and start finger stick blood sugar levels 3 times a day with sliding scale coverage with [MEDICATION NAME]. The nurse's note, dated [DATE], indicated that Resident #1 had a blood sugar level of 74 at 7:30 A.M. and a blood sugar level of 80 at 11:30 A.M. The nurse's note, dated [DATE], indicated that Resident #1's 4:30 P.M. blood sugar level was 213. The nurse's note indicated that Resident #1 vomited twice after dinner and Resident #1's blood sugar level was 94. The physician order, dated [DATE], at 8:30 P.M., included: hold [MEDICATION NAME] morning and evening scheduled insulin until further notice and blood sugar levels prn. The nurse's note, dated [DATE], indicated that at 5:00 A.M., Resident #1 complained of seeing white spots and said that seeing white spots usually indicated [DIAGNOSES REDACTED]. The nurse's note indicated that Resident #1 had a blood sugar level of 67; Resident #1 was given a snack and breakfast; at 5:30 A.M., Resident #1's blood sugar level was 88; Resident #1 felt better, and the Nurse Practitioner (NP) was notified. The physician order, dated [DATE], at 5:15 A.M., included: hold all scheduled insulin until further notice. The nurse's note, dated [DATE], indicated that Resident #1 returned from [MEDICAL TREATMENT] and Resident #1's 11:30 A.M. blood sugar level was 134. The laboratory study, dated [DATE], indicated that Resident #1 had a critical fasting blood sugar level of 30 that was called to the Facility at 11:42 A.M. The NP's progress note, dated [DATE], indicated that Resident #1 was treated for [REDACTED].. The NP's note indicated that Resident #1's blood sugar levels were all over the map; the scheduled [MEDICATION NAME] and [MEDICATION NAME]were placed on hold, and the sliding insulin scale was to be used to treat Resident #1's blood sugar levels. The physician order, dated [DATE], included diabetic protocol and laboratory studies on [DATE]. The nurse's note, dated [DATE], indicated that Resident #1's morning blood sugar level was 203. The nurse's note, dated [DATE], indicated that Resident #1's blood sugar level at 4:30 P.M. was 197. The nurse's note, dated [DATE], indicated that at 4:30 P.M., Resident #1 had a blood sugar level of 333. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Unit Manager #1 was interviewed on [DATE], at 1:00 P.M.; Nurse #1 was interviewed on [DATE], at 11:13 A.M.; Nurse #2 was interviewed on [DATE], at 3:20 P.M.; Nurse #3 was interviewed on [DATE], at 9:20 A.M.; Certified Nursing Assistant (CNA) #1 was interviewed on [DATE], at 10:15 A.M.; CNA #2 was interviewed on [DATE], at 10:55 A.M., and CNA #3 was interviewed on [DATE], at 7:15 A.M. Unit Manager #1, Nurse #1, Nurse #2, Nurse #3, CNA #1, CNA #2, and CNA #3 said Resident #1 was treated at the Hospital for [MEDICAL CONDITION]. Unit Manager #1, Nurse #1, Nurse #2, Nurse #3, CNA #1, CNA #2, and CNA #3 said they were not aware that Resident #1 had a blood sugar level of 30 on [DATE]. Nurse #1 said there were usually 2 nurses assigned on the night shift to Resident #1's unit. Nurse #1 said the other assigned nurse was responsible for one side of Resident #1's unit and also was the night nursing supervisor. Nurse #1 said on [DATE], there was only one nurse instead of 2 nurses assigned to Resident #1's unit and some of the May, 2011 editing needed to be completed. Nurse #1 said Resident #1's unit was busy. Nurse #1 said there were a lot of call lights during the night shift, a few residents, who had behavioral issues that were addressed, and ,[DATE] [MEDICAL TREATMENT] residents that required personal care and assistance with dressing to be ready for transfer to [MEDICAL TREATMENT] by 5:30 A.M. The nurse's note dated [DATE], indicated that at 3:00 A.M., Resident #1 complained of a headache, had a blood sugar level of 257, and Resident #1 received 8 units of [MEDICATION NAME] per the sliding scale coverage. Interview with Nurse #1 and Nurse #1's written statement, dated [DATE], provided the following information: on [DATE], Resident #1 complained of not feeling well and having a headache; due to Resident #1's history of [MEDICAL CONDITION] and recent hospitalization for [MEDICAL CONDITION], Nurse #1 obtained Resident #1's blood sugar level, which was 257; Nurse #1 reviewed the MAR, observed the [MEDICATION NAME] sliding insulin scale, and administered [MEDICATION NAME] 8 units per the sliding scale protocol and Tylenol 650 mg. Nurse #1 said Nurse #1 did not see the order above the sliding scale insulin that indicated that the sliding scale insulin was to be administered 3 times a day at 7:30 A.M., 11:30 A.M., and 4:30 P.M. Nurse #1 said Nurse #1 did not realize that the sliding insulin scale was for the scheduled blood sugar levels 3 times a day and not for the prn blood sugar level. The Director of Nurses was interviewed on [DATE], at 8:15 A.M. The DON said on [DATE], Nurse #1 administered [MEDICATION NAME]to Resident #1 without a physician order. The nurse's note, dated [DATE], indicated that at 3:20 A.M., Resident #1 sat on the edge of the bed, ate toast, was alert and spoke, and had no signs of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. The nurse's note, dated [DATE], indicated that at 6:30 A.M., Resident #1 said Resident #1 felt OK and had no signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. Nurse #1 said the night CNAs reported no concerns regarding Resident #1. Nurse #1 said on [DATE], at 7:00 A.M. Nurse #1 was not aware of the medication error regarding the prn [MEDICATION NAME]. Nurse #2 said on [DATE], Nurse #2 was not aware that Nurse #1 administered [MEDICATION NAME]to Resident #1 during the night shift. Nurse #2 said on [DATE], at approximately 8:00 A.M., Nurse #2 was entering Resident #1's room to obtain Resident #1's blood sugar level. Interview with Nurse #2 and Nurse #2's written statement, dated [DATE] provided the following information: on [DATE], at 8:00 A.M., Nurse #2 observed the CNA delivering the breakfast tray to Resident #1; Nurse #2 told the CNA that Nurse #2 needed to obtain Resident #1's blood sugar level; Resident #1 was clammy, not responsive, and not breathing;. Nurse #2 quickly obtained Resident #1's blood sugar level, which registered low on the machine, and Nurse #2 yelled for the CNA to stay with Resident #1. CNA #2 said on [DATE], Nurse #2 told CNA #2 that Resident #1 was a Code Blue, which indicated that Resident #1 was not breathing and had no heart rate, and told CNA #2 to go to Resident #1's room. CNA #2 said Resident #1 was not responsive, was not breathing, and CNA #2 initiated CPR. CNA #2 said CNA #2 provided 2 to 3 cycles of CPR; Nurse #2 came to Resident #1's room, and assumed the provision of CPR to Resident #1. Nurse #2 said Nurse #2 asked Unit Manager #1 if Resident #1 was a full code or had a do not resuscitate directive (DNR), Nurse #2 said Resident #1 was a full code; Unit Manager # 1 initiated the Code Blue Protocol via the telephone, and Nurse #2 brought the code cart to Resident #1's room. Nurse #2 said the Respiratory Therapist entered Resident #1's room, ventilated Resident #1, and Nurse #2 provided chest compressions. Nurse #2 said other nurses entered Resident #1's room, Nurse #2 recalled that Resident #1 had a low blood sugar, Nurse #2 yelled out that Resident #1 had a low blood sugar, and continued to provide CPR to Resident #1. Nurse #2 said after 3 to 4 minutes of providing CPR to Resident #1, Resident #1 had a heart rate and shallow breathing. The Diabetic Protocol included a Hypoglycemic Protocol. The Hypoglycemic Protocol indicated that if a resident was unconscious and had a blood sugar level less than 70, [MEDICATION NAME] 1 mg by intramuscular injection was to be immediately administered and if there was no response in 15 minutes, [MEDICATION NAME] 1 mg by intramuscular injection was to be administered There was no evidence that Resident #1 received [MEDICATION NAME] per the Facility Protocol. Nurse #2 said shortly after Resident #1 had a heart rate and breathing, Resident #1 had agonal breathing (abnormal pattern of breathing characterized by shallow, slow {,[DATE] per minute, irregular inspirations followed by irregular pauses).; the emergency medical technician (EMTs) arrived at the Facility, and assumed the care of Resident #1. Nurse #2 said Nurse #2 obtained another blood sugar level that registered low; the blood sugar level was reported to the EMTs, and Resident #1 was transferred to the ED. Unit Manager #1 said the EMTs arrived approximately 10 minutes after the call was placed to emergency medical services. The DON said Resident #1 did not receive [MEDICATION NAME] per the Facility Protocol. The nurse's note, dated [DATE], indicated that at approximately 8:00 A.M., Resident #1 was not responsive, had no pulse, and no respirations. The nurse's note indicated that a Code Blue was called; CPR was initiated; the emergency medical system was called; after 5 minutes, Resident #1 had agonal breathing, and the EMTs transferred Resident #1 to the Emergency Department (ED). The Hospital Discharge/Transfer History and Physical note, dated [DATE],indicated that Resident #1 had an overdose of insulin therapy, had a blood sugar level of 12, and received [MEDICATION NAME]/fluid intravenous therapy with rapid improvement of Resident #1's blood sugar levels.