Every finding on record at Alliance Health at Baldwinville

Based on observation, interviews, and record review, the facility failed to follow professional standards of practice for food storage and environmental cleaning of the facility's main kitchen.Specifically, the facility failed to ensure that:-food items were properly dated, stored, and/or discarded timely in the main kitchen-clean and sanitary surfaces were maintained in the walk-in refrigerator, walk-in freezer, and food preparation areas, placing the facility residents at risk for contamination and foodborne illnesses. Findings include: Review of the facility policy titled, Food Storage, dated 9/1/25, included but was not limited to the following: >Prepared foods in the refrigerator shall be kept covered, labeled and dated. >Food left at room temperature for several hours (2 to 3) cannot be considered safe and therefore shall be discarded. >Never hold left over poultry, . or meat products more than 48 hours at refrigeration temperatures. Anything held longer than 48 hours should be discarded. Review of the facility policy titled, Cleaning Schedules, dated 9/1/25, included the following: >Each Dining Services Department will have a planned program to assure consistent, effective sanitation practices. >Cleaning will be done daily, weekly, monthly, or as needed within the dietary department. All assignments will follow the proper procedures listed in this manual. >The supervisor on duty will be responsible for assigning the cleaning duties for the day to appropriate staff. >Both day and evening supervisors will be responsible to make sure the department is clean before the end of their respective shift. >The Food Service Supervisor must follow up on why cleaning duties were not accomplished. On 12/30/25 at 7:39 A.M., the surveyor observed the following during the initial kitchen walk through: >In the dry food storage room: -A one-gallon sized, clear plastic bag containing 20 pieces of toasted bread, labeled as toast, dated 12/19/25. -Dried yellow, brown and white substances on the floor under the food storage racks. >In the reach-in refrigerator: -A clear plastic cup with a straw through the lid containing a coffee-colored liquid and ice, unlabeled and undated. >In the walk-in refrigerator: -A sealed, zip-lock, one-gallon sized, clear plastic bag labeled as Italian sausage, and dated 12/17/25. -A covered, clear plastic container half filled with a gelatinous yellow substance, unlabeled and undated. -The refrigerator fan casing was covered with a thick layer of dust that was also coating the ceiling above the fan. -Hard chunks of yellow and brown debris under the food storage racks with torn pieces of clear packing tape and cardboard box fragments. >On the shelving unit below the steam table service area: -One opened and uncovered box of cream of wheat cereal. -Three silver metal sheet pans coated with dry white and brown crumb-like material.During an interview at the time Dietary Staff #1 said that the one-gallon sized plastic bag of toast was out-of-date and should have been discarded by 12/22/25. Dietary Staff #1 said that the clear plastic cup in the reach-in refrigerator belonged to staff, probably contained coffee, did not know how long it had been in the refrigerator and that staff should not keep personal food items in the reach-in refrigerator. Dietary Staff #1 said that the italian sausage should only be kept for three days after defrosting and was not dated appropriately when it was removed from the freezer. Dietary Staff #1 said that the clear plastic container half-filled with a gelatinous yellow substance smelled like vanilla pudding and would need to be discarded because it was not labeled or dated appropriately. Dietary Staff #1 said dating and labeling foods were important to prevent illness to the residents. During an interview on 12/31/25 at 11:54 P.M., the Food Service Director (FSD) said that he had not yet developed cleaning assignments for the dietary department. The FSD said that the walk-in refrigerator fan and ceiling was dirty and needed to be cleaned because the dust could blow into the resident's food products in the refrigerator. The FSD said that the open box of cream of wheat cereal should have been covered. The FSD said that the dirty floors in the walk-in refrigerator, dry storage room and the silver sheet pans below the steam table were dirty and should have been cleaned to prevent attracting pests into the main kitchen.

Based on observations, interviews, and record review, the facility failed to provide care and services consistent with professional standards of practice for indwelling urinary catheters (a soft, flexible tube that drains urine from the bladder into a drainage bag) for one Resident (#58) of three applicable residents, out of a total sample of 18 residents.Specifically, for Resident #58, the facility staff failed to ensure that the Resident's urinary drainage bag was positioned off the floor to decrease the risk of contamination and increasing the Resident's risk for indwelling urinary catheter infections. Findings include: Review of the facility's policy titled Catheter Care of Indwelling Urinary, revised 8/5/23, indicated the following: >Always keep the drainage bag below the level of the resident's bladder and off the floor. Resident #58 was admitted to the facility in October 2025 with diagnoses including obstructive and reflux uropathy. Review of the Minimum Data Set (MDS) Assessment, dated 11/6/25 indicated Resident #58: -did not demonstrate rejection of care. -had an indwelling urinary catheter. -required substantial/maximum assistance for showering, toileting and dressing below the waist. Review of Resident #58's Physician's orders indicated the following: -Foley (type of indwelling urine catheter) catheter care every shift (11:00 P.M. - 7:00 A.M., 7:00 A.M. - 3:00 P.M., and 3:00 P.M. - 11:00 P.M.), effective 10/30/25. -May change Foley catheter as needed for leakage/blockage, effective 10/20/25. -Change catheter drainage bag monthly, effective 11/26/25. On 12/30/25 at 9:25 A.M., the surveyor observed Resident #58 sitting in a wheelchair in the dining area with his/her Foley catheter drainage bag connected under his/her wheelchair seat. The surveyor further observed the urinary catheter drainage bag touching the dining area floor without a protective barrier in place. On 12/30/25 at 2:46 P.M. and 12/31/25 at 9:37 A.M., the surveyor observed Resident #58 lying in bed with his/her eyes closed and his/her Foley catheter drainage bag touching the floor without a protective barrier in place. During an interview on 12/31/25 at 1:28 P.M., Certified Nurse's Aide (CNA) #1 said that she was assigned to provide care to Resident #58. CNA #1 said that Resident #58 did not manipulate or handle his/her own urinary drainage bag. The surveyor and CNA #1 observed Resident #58 lying in bed with his/her Foley catheter drainage bag on the floor without a protective barrier. CNA #1 said that the Resident's Foley catheter drainage bag should not be touching the floor and should be in a protective privacy bag. CNA #1 said when the Foley catheter drainage bag touches the floor it can cause infections to Resident #58. During an interview on 12/31/25 at 1:32 P.M., the Infection Preventionist (IP) said that the Resident's Foley catheter drainage bag should be kept off the floor. The IP said that keeping the Resident's drainage bag off the floor was important because germs on the floor could get into the Resident's drainage bag and cause the Resident an infection.

Based on observations, interview, and record review, the facility failed to ensure that activities of daily living (ADL's - activities related to personal care which includes washing, dressing, and personal hygiene [combing hair, applying makeup, washing/drying face and hands, and shaving]) were provided for one Resident (#84) of one applicable resident, out of a total sample of 18 residents. Specifically, the facility staff failed to assist Resident #84 with facial hair removal when the Resident required assistance for ADL care of personal hygiene due to weakness and impaired cognitive and communication skills. Findings include: Resident #84 was admitted to the facility in February 2024 with diagnoses including senile degeneration of brain, cognitive communication deficit, unspecified mental disorder due to unknown psychological condition, and muscle weakness. Review of the Person-Centered ADL Care Plan, last edited on 11/17/25, included but was not limited to the following: -Problem: Resident #84 required ADL assistance due to weakness. -Approach: Resident #84 required set-up with supervision assistance for grooming. Review of the Person-Centered Cognitive Loss/Dementia Care Plan, last edited on 11/13/25, included but was not limited to the following: -Problem: Resident #84 had impaired cognitive and communication skills: Short Term Memory deficit, poor insight, poor judgement. -Approach: Staff to provide cues, prompting, demonstration if unable to complete a task independently. Review of the Certified Nurse Aide (CNA) Care Kardex (a brief overview of a Resident's care needs), last updated 11/11/25 indicated Resident #84: -was confused. -required cues and supervision of another person at wheelchair level in bathroom sink level for grooming. Review of the Nurse Aide Behavioral Flow sheets from December 2025 through 1/5/26 indicated Resident #84: -had not demonstrated resistance to care. Review of the Minimum Data Set (MDS) Assessment, dated 11/13/25, indicated Resident #84: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of one out of a total possible score of 15. -had not demonstrated rejection of ADL care. -required substantial/maximum assistance (helper lifts or holds trunk or limbs and provides more than half the effort) for personal hygiene. On 12/30/25 at 9:25 A.M., the surveyor observed Resident #84 seated in a wheelchair in the Unit One hallway. The Resident was dressed in a shirt, pants, and shoes, with facial hair strands present to the upper lip and chin. On 12/30/25 at 3:02 P.M., the surveyor observed Resident #84 lying in his/her bed with eyes closed, and facial hair remained on his/her upper lip and chin. On 12/31/25 at 3:44 P.M., the surveyor observed Resident #84 was dressed in a sweater, pants and socks, lying on his/her bed with his/her eyes closed. The Resident was observed with facial hair present to his/her upper lip and chin. On 1/5/26 at 7:44 A.M., the surveyor observed Resident #84 seated in a wheelchair at his/her bedside dressed in a sweater, pants and shoes. The surveyor further observed that Resident #84 now had thick facial hair strands present to his/her upper lip, chin and bilateral cheeks. During an interview on 1/5/26 at 9:00 A.M., Certified Nurses Aide (CNA) #1 said she was familiar with Resident #84 and was assigned to provide care to the Resident. CNA #1 said Resident #84 liked to get out of bed early and therefore the night shift (11:00 P.M.- 7:00 A.M.) CNA gets the Resident out of bed and provides morning care each day for washing, dressing and grooming. CNA #1 said morning care for washing, dressing and grooming for the day had been completed for Resident #84 by the night shift CNA. CNA #1 further said Resident #84 does not refuse care and could wash his/her own face when handed a washcloth but was dependent for removal of facial hair. CNA #1 said residents should be assisted to remove facial hair with daily morning care and that Resident #84 was unable to shave him/herself due to forgetfulness and poor recall. At the same time, the surveyor and CNA #1 observed Resident #84's facial hair. CNA #1 said that the facial hair to the Resident's lip, chin and cheeks was long, appeared to be several days of growth, and should have been removed during morning care by the night shift CNA. CNA #1 said when the night shift was unable to remove facial hair during morning care that the day shift (7:00 A.M.-3:00 P.M.) or evening shift (3:00 P.M.-11:00 P.M.) CNAs should shave the Resident's facial hair. CNA #1 said that removal of facial hair was important so that Resident #84 would not get embarrassed at group activities and shaving would provide the Resident with dignity. During an interview on 1/5/26 at 9:20 A.M., the Director of Nursing (DON) said that Resident #84's facial hair should be removed by the night shift during morning care. The DON said that she would have concerns for the Resident to be embarrassed due to the presence of his/her facial hair. The DON said the facility did not have a policy relative to the delivery of ADL care or removal of facial hair for the residents in the facility. During an interview on 1/5/26 at 9:51 A.M., the Staff Development Coordinator (SDC) said that all CNA staff are educated and evaluated for competency during orientation relative to bathing, dressing and grooming. The SDC said the facility did not have policy on ADL care or facial hair removal because it was a standard of practice for ADLs. The SDC said shaving and removal of facial hair was a part of the grooming process for all residents in the facility. The SDC said if a CNA staff member was unable to remove Resident #84's facial hair during morning care the CNA should try again later that same day or the next day.

Based on observations, interviews, and record review, the facility failed to ensure that it was appropriate and safe for medications to be self-administered for one Resident (#68) out of a total sample of 18 residents. Specifically, the facility failed to assess Resident #68 for the self-administration and safe and proper storage of two topical medications, placing the Resident at risk of inappropriately self-administering the medications and not storing the medications in his/her room in a safe and secure manner.Findings include: Review of the facility policy titled Medication: Self Administration, with revision date of 4/28/25, included but was not limited to: Residents may administer their own medications, if requested, once the Facility's interdisciplinary team determines that the practice is safe. >The resident must meet the following criteria: >A score of 13 or greater must be obtained on the Brief Interview of Mental Status (BIMS) exam. >The resident must pass the Self-Administration Medication Assessment. >The above assessment must be completed with results documented in the medical record and updated on a quarterly basis. >If the results indicate the person is capable of self-administration, the physician must be notified to obtain an order for such. >Medications must remain secured at the nursing station except for limited medications, i.e., respiratory hand-held inhalers, Nitroglycerine sublingual tablets or sprays. >Self-administration of medication should be addressed in the care plan with an established plan for continuing to monitor ability to self-administer drugs .if the resident becomes unable to carry out safely.Resident #68 was admitted to the facility in September 2025 with diagnoses including Cognitive Communication Deficit.Review of the Minimum Data Set (MDS) Assessment, dated 12/18/25, indicated Resident #68: >had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of a possible total of 15.>required supervision/touching assistance for toileting, showering, upper body, lower body, footwear application and personal hygiene. On 12/30/25 at 10:45 A.M., the surveyor observed Resident #68 lying in bed with two tubes of one-ounce Diphenhydramine Zinc Acetate (topical analgesic/anti-itch medication) cream and one tube of 30-gram Nystatin (antifungal topical cream) 100,000 units/gram cream within the Resident's reach on the over the bed table. The surveyor failed to observe any facility staff in the immediate area. During an interview at the time, Resident #68 said the creams were used whenever he/she felt an itch to his/her skin. Resident #68 further said that his/her hands, groin and abdomen get itchy sometimes, so he/she rubbed the creams on the itchy areas. Resident #68 said he/she was unaware of how often the creams should be used. Review of Resident #68's medical record included: -A Physician's order for Nystatin cream 100,000 unit/gram; one application topical to groin and scrotum twice a day, start date 9/24/25. -No evidence of a Physician's order for Diphenhydramine Zinc Acetate cream. -No evidence that a self-administration for medication assessment had been completed. -No evidence that a Physician's order for self-administration of medications had been obtained. -No evidence of a Person-Centered Care Plan relative to self-administration of medications and with an established plan for continuing to monitor ability to self-administer drugs. On 12/30/25 at 2:57 P.M., the surveyor observed Resident #68 lying in bed with two tubes of one-ounce Diphenhydramine Zinc Acetate cream and one tube of 30-gram Nystatin, 100,000 units/gram cream within the Resident's reach on the over the bed table. The surveyor did not observe any facility staff in the immediate area. On 12/31/25 at 10:16 A.M., the surveyor observed Resident #68 lying in bed with two tubes of one-ounce Diphenhydramine Zinc Acetate cream and one tube of 30-gram Nystatin, 100,000 units/gram cream within the Resident's reach on the over the bed table. The surveyor did not observe any facility staff in the Resident's room at the time. During an interview on 12/31/25 at 10:19 A.M., Unit Manager (UM) #1 said Resident #68 had two tubes of one-ounce Diphenhydramine Zinc Acetate cream and one tube of 30-gram Nystatin 100,000 units/gram cream within the Resident's reach on the over the bed table. UM #1 said Resident #68 did not have a self-administration of medication assessment, a Physician's order for self-administration of the medications, or a care plan for self-administration of the medications. UM #1 further said Resident #68 should not have the medications left at his/her bedside because the Resident had not been assessed to know if he/she knew how and when to safely use the medications. During an interview on 12/31/25 at 10:46 A.M., the Director of Nursing (DON) said that medications should not be kept at Resident #68's bedside without a self-administration assessment because the Resident may not know how to apply the medications according to the Physician's orders to the right location and the right frequency. The DON said unsecured medications at the bedside were a concern because other residents, wandering residents, staff, vendors from the lab or X-ray and visitors could also have access to the medications.

Based on interviews and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC: notice issued to a resident who is receiving benefits under Medicare Part A when all covered services end) was accurately issued for one Resident (#95) out of three applicable residents, out of a total sample of 18 residents. Specifically, for Resident #95, the facility failed to ensure that a paper copy of the NOMNC was provided to the Resident's responsible party as required. Findings include: Review of the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) Centers for Medicare and Medicaid Services (CMS-10123), indicated the following: -Regardless of whether a paper or electronic version is issued and regardless of whether the signature is digitally captured or manually penned, the beneficiary must be given a paper copy of the NOMNC, with the required beneficiary-specific information inserted, at the time of electronic notice delivery. -The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. Resident #95 was admitted to the facility in June 2025. Review of Resident #95's medical record indicated: -Resident #95 was not responsible for him/herself and had a Healthcare Proxy (HCP) that was activated on 6/21/25. -Resident #95 received Medicare Part A Skilled Services beginning on 6/17/25.-Resident #95's last covered day of Medicare Part A Skilled Services was 7/3/25.-The facility staff had contacted the HCP over the telephone to inform them of the NOMNC information on 7/1/25 at 11:30 A.M. -The facility staff person did not mail a paper copy of the NOMNC form to the HCP. Further review of the NOMNC form and Resident #95's clinical record failed to indicate that a paper copy of the NOMNC form was mailed to the Resident's HCP. During an interview on 12/31/25 at 4:18 P.M., the Regional Clinical Reimbursement staff member said that the facility refers to the CMS guidelines on how to deliver the NOMNC forms to ensure that they are done properly. During an interview on 12/31/25 at 4:25 P.M., the Social Worker (SW) said that she did not have documentation that the NOMNC was provided to Resident #95's HCP in person or that a paper copy was mailed to the HCP after the NOMNC information had been issued over the telephone.

Based on observation, interviews, and records reviewed, the facility failed to coordinate an assessment with the PASRR program when a significant change in mental status was determined for one Resident (#3) out of a total sample of 18 residents. Specifically, the facility failed to refer Resident #3 to the PASRR program for a Level II Resident Review in a timely manner when the Resident: -Had a previous negative PASRR screening for serious mental illness (SMI). -Experienced aggressive behaviors. -Required in-patient psychiatric hospitalization. -Was newly diagnosed with bipolar disorder. -Required newly prescribed antipsychotic medication to be administered. Findings include: Review of the facility policy titled PASRR Preadmission and Review, dated 4/1/25, indicated the following: -The facility will refer all residents with newly evident or possible SMI, ., or related condition for PASRR assessment at resident review upon admission and significant change in status. -The facility must notify the state mental health authority (DMH PASRR) . promptly after a significant change in status is identified. -If a resident triggers for SMI and demonstrates a Treatment History or Life Impairments, a PASRR Level II request must be made to obtain an abbreviated Level II due to categorical determination or a full Level II evaluation. -If new information is obtained post-admission regarding Treatment History or Life Impairment, a new PASRR for Resident Review is needed and should be submitted for Level II review. -Any resident with significant change in status since their original admission to the facility . should be submitted into the PASRR portal. -If the resident's Level I screening form is in the PASRR portal but appears to require a Level II evaluation or Resident Review that is not in the portal, the nursing facility must contact the appropriate PASRR authority. Resident #3 was admitted to the facility in February 2021 with diagnoses including Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting left non-dominant side, and occlusion and stenosis of Unspecified Cerebral Artery. Review of the PASRR Level I Screening, dated 2/12/21, indicated Resident #3: -did not have a documented diagnosis of mental illness or disorder (MI/D) . that may lead to chronic disability. -had not required any of the listed treatments or interventions, which included one or more psychiatric hospitalizations, that was, or may have been, due to MI/D within the previous two years. -screen for SMI was negative due to no diagnosis or suspicion of SMI. Review of Resident #3's Nursing Progress Note, dated 10/5/23, indicated: -The Resident was verbally abusive to a certified Nurse's Aide (CNA). -The Resident stated, If I had a gun I would shoot you all. Review of Resident 3's Nursing Progress Note, dated 10/6/23, indicated: -The Resident had increasing behaviors over the previous few months which included: -Yelling and throwing items at staff. -Refusing medications and care at times. -The Resident had refused antidepressant medication recommended by the Physician. -The facility was concerned for the Resident's overall well-being with hygiene, skin integrity, and medical health related to declining medications. -The Physician wanted the Resident to be sent to the Emergency Department (ED) for psychiatric evaluation. Review of Resident #3's Physician Progress Note, dated 10/6/23, indicated: -The Physician assessed the Resident for an acute visit. -the Resident had been experiencing escalating behaviors (physically and verbally aggressive toward staff; throwing objects, demeaning, aggressive, racial statements, accusatory). -The Resident was non-compliant with his/her behavior modification plan. -The Resident was not agreeable to go to the ED for evaluation. -Due to risk of harm to staff and other residents, ., the Resident was being involuntarily sent to the ED for psychiatric evaluation via Section 12 (temporary, involuntary restraint and transport of an individual posing a serious risk of harm due to mental illness for psychiatric evaluation). Review of the clinical record indicated Resident #3: -was admitted for acute psychiatric hospitalization on 10/7/23. -was newly diagnosed with bipolar disorder, current episode manic severe with psychotic features on 10/7/23, while in the hospital. -had been ordered for Olanzapine (antipsychotic medication) which was administered to the Resident during his/her inpatient psychiatric hospitalization stay. -hospital physician recommended the Resident continue taking Olanzapine following his/her inpatient psychiatric hospitalization. -returned to the facility on [DATE]. -had no evidence the Resident had been referred to the PASRR program. Review of Resident #3's Physician Order, dated 10/16/23 and discontinued 4/26/24, indicated: Olanzapine tablet, 10 milligrams (mg) orally at 8:00 P.M. Review of Resident #3's Physician Orders, dated 4/26/24 and last reviewed 11/26/25, indicated the following: -Olanzapine tablet: 10 milligrams (mg), oral, given with 2.5 mg tab; total dose 12.5 mg daily, once a day at 8:00 P.M. -Olanzapine tablet: 2.5 mg, oral, one tablet with 10 mg; total dose daily 12.5 mg, once a day at 8:00 P.M. Review of the Minimum Data Set (MDS) Assessment, dated 10/16/25, indicated Resident #3: -was able to make him/herself understood, and he/she understood others with clear comprehension. -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 total possible points. -demonstrated verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) one to three days during the MDS observation period. -active diagnoses included bipolar disorder. -received antipsychotic medication on a routine basis. -A gradual dose reduction (GDR) of antipsychotic medication was contraindicated. Review of Resident #3's December 2025 Medication Administration Record (MAR) indicated a total dose of 12.5 mg Olanzapine was administered to the Resident daily, as ordered. Review of Resident #3's clinical record on 12/30/25 failed to indicate any evidence the Resident had been referred to the PASRR program when he/she experienced a significant change in mental status, required inpatient psychiatric hospitalization, was newly diagnosed with bipolar disorder, and required the use of antipsychotic medication. On 12/30/25 at 9:03 A.M., the surveyor observed Resident #3 sitting in a wheelchair in his/her room. During an interview at the time, the Resident responded verbally to the surveyor but did not make eye contact with the surveyor. During an interview on 12/31/25 at 1:05 P.M., the Social Worker (SW) said the facility identified and she became aware in May 2025 that Resident #3 had not been referred to the PASRR program for Resident Review in October 2023 as required, after the Resident had an inpatient psychiatric hospitalization, had been newly diagnosed with bipolar disorder, and required antipsychotic medication to be administered. The SW said she did not refer the Resident to the PASRR program for Resident Review until 9/4/25, at which time the Resident's referral was rejected due to a request for additional information. The SW said that at the time of this interview on 12/31/25, she had not yet submitted the additional information requested by the PASRR office for Resident #3.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the transmission of communicable diseases and infections within the facility on one unit (Unit One) out of a total of two units affecting two Residents (Residents #3 and #6). Specifically, the facility failed to ensure that Personal Protective Equipment (PPE) used to touch surfaces in a resident's environment who had an active COVID-19 (a highly contagious respiratory disease) infection was changed in accordance with professional standards of practice prior to touching surfaces in another resident's environment who was not infected or was recently recovered with COVID-19 placing the non-infected resident at increased risk of contracting COVID-19 infection. Findings include: Review of the undated facility policy titled Transmission Based Precautions indicated the following: -When cohorting (placing residents who have the same infection in a room together) is not achievable, it is very important to consider . the roommate is a high risk for becoming infected Review of the facility policy titled Transmission Based Precautions, dated 8/8/23, indicated the following: -For some diseases that have multiple routes of transmission (e.g. SARS-CoV-2 [the virus that causes COVID-19]) more than one transmission-based precaution category may be used. -This will be determined by guidance from regulatory agencies such as CDC [Center for Disease Control and Prevention], DPH [Department of Public Health] and CMS [Centers for Medicare and Medicaid Services]. Review of the CDC guidance titled Infection Control Guidance: SARS-CoV-2, dated 6/24/24, indicated the following: -HCP [healthcare providers] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH approved particulate respirator with N95 filters or higher [a mask that provides protection from small particles or viruses in the air], gown, gloves, and eye protection Review of the DPH Memorandum to Long-Term Care Facilities titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 5/10/23, indicated the following: -Appendix A: Personal Protective Equipment Used When Providing Care to Resident's in Long Term Care >COVID-19 Positive Residents Recommended Staff PPE: -Full PPE upon entering room to include .gown and gloves if there is any contact with potentially infectious material. -Gown and gloves must be changed between residents. Resident #3 was admitted to the facility in September 2023, with diagnoses including Type 2 Diabetes ((long-term condition where the pancreas is unable to produce enough insulin to regulate blood glucose [sugar] levels resulting in higher than normal blood sugar levels) and Chronic Kidney Disease, Stage 3 (mild to moderate loss of function in the kidneys causing impairment to the body's ability to remove waste and extra fluid from the blood). Review of Resident #3's medical record indicated the Resident tested positive for COVID-19 on 10/8/24. Review of Resident #3's October 2024 Activities of Daily Living (ADL: tasks required to care for oneself daily including transferring in and out of bed, eating, grooming, using the toilet, etc.) flow sheet indicated: -the Resident required set-up or clean-up assistance for eating. Review of Resident #3's Physician orders indicated the following: -an order to maintain Isolation Precautions (measures used to reduce transmission of microorganisms in healthcare and residential settings), initiated 10/8/24 with no stop date Resident #6 was admitted to the facility in January 2022, with diagnoses including Neoplasm (tumor or abnormal growth of cells) of the Brain and Cellulitis (potentially serious bacterial infection that affects the deep layers of the skin and underlying tissues of the skin) of the Left Lower Limb. Review of Resident #6's vaccination history indicated no vaccination for COVID-19 had been received. Review of Resident #6's medical record indicated he/she had not tested positive for COVID-19 during the Unit One outbreak period of 9/27/24 through 10/16/24 or the preceding 30 days. Review of Resident #6's medical record indicated that he/she was at risk for respiratory distress related to Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs). Review of Resident #6's October 2024 ADL flow sheet indicated: -the Resident was independent for eating Review of the Isolation Droplet/Contact Precautions sign hanging outside Resident #3 and #6's room indicated the following: -In addition to Standard Precautions (infection prevention measures that apply to all resident care, regardless of suspected or confirmed infection status) staff and Providers must: >gown: change between each resident >gloves: change between each resident During a meal tray pass on 10/16/24 at 12:34 P.M., the surveyor observed CNA #1 wearing an N95 mask, gown, gloves and goggles enter the room of Resident #3 and Resident #6. CNA #1 was observed to be handed the meal tray for Resident #3 and proceeded to set up the meal tray for Resident #3. CNA #1 returned to the room doorway and was handed the meal tray for Resident #6 and then proceeded to set up the meal tray for Resident #6 including touching cups and dishes as she removed the dish and cup covers and the plate warmer without removing or changing the gown and gloves used to set up and touch items on Resident #3's meal tray. During an interview on 10/16/24 at 12:38 P.M., CNA #1 said that Resident #3 was positive for COVID-19 and Resident #6 was negative for COVID-19. CNA #1 said she had set up Resident #3's tray touching Resident #3's overbed table while wearing the gown and gloves and then using the same gown and gloves to set up Resident #6's tray and should not have. CNA #1 further said she should have set up Resident #6's meal tray first and then set up Resident #3's meal tray to prevent the potential cross-contamination. During an interview on 10/16/24 at 2:05 P.M., the Director of Nursing (DON) said the expectation for meal tray pass in a room with one resident who has COVID-19 and one who is negative for COVID-19 would be that the staff member would put on the required PPE, serve the negative resident first and then serve the positive resident. The surveyor reviewed the observation of CNA #1 with the DON and the DON said CNA #1 should not have served Resident #3 and then Resident #6 due to the potential for cross-contamination.

Based on interview, record and policy review, the facility failed to implement updated timing guidance for Pneumococcal Vaccinations and ensure that Pneumococcal Vaccinations were offered and administered as consented to for three Residents (#62, #46 and #6), of 5 applicable residents reviewed, out of a total sample of 18 residents. Specifically, the facility failed to: 1. Ensure the facility policy relative to Pneumococcal Vaccination was reviewed and updated to include current Centers for Disease Control and Prevention (CDC) guidance. 2. For Resident #62, afford the opportunity to consent to or decline the Pneumococcal Vaccine when the Resident was admitted to the facility. 3. For Resident #46, administer the most up-to-date Pneumococcal Vaccine when he/she was eligible and had given consent. 4. For Resident #6, administer the most up-to-date Pneumococcal Vaccine when he/she was eligible and had given consent. Findings include: Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (cdc.gov), dated 3/1/24, indicated the following: -For adults 65 and over who have not had any prior Pneumococcal Vaccines, then the patient and provider may choose Pneumococcal Conjugate Vaccine (PCV) 20 or PCV15 (Pneumococcal Conjugate Vaccine 15-valent: vaccine used to protect against 15 types of pneumococcal bacteria that commonly cause serious infections in adults), followed by Pneumococcal Polysaccharide Vaccine (PPSV) 23 one year later. -For adults 65 and over who have had Pneumococcal Conjugate Vaccine 13 (PCV13) and PPSV23 and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the PCV20. 1. Review of the facility Immunization of Residents Policy, dated 8/2017, included the following: -All eligible residents will be offered the pneumococcal vaccines unless medically contraindicated. -Education will be provided on the pros/cons of the vaccine prior to administration. There is a right to refuse the vaccination. -Each resident/representative will be asked on admission if they have previously had the PPSV23 or PCV13 vaccine and their age at the time of the vaccination, and for the records also used to determine vaccination status. -If no prior evidence of vaccination, the PCV13 will be offered per the Physician discretion, education will be provided on the pros/cons of the vaccine and the right to refuse -The PPSV23 will then be offered one year later. If one or more doses of PPSV23 have been previously received, the PCV13 will be offered one year after the last PPSV23 dose. During an interview on 9/18/24 at 10:04 A.M., the surveyor and the Infection Preventionist (IP) reviewed the facility's policy for Immunization of Residents. The IP said she was not aware if there was an updated policy but she would look into the matter. The IP said she used the CDC Vax Tracker Tool when determining if Pneumococcal Vaccinations were due for the facility residents. During a follow-up interview on 9/18/24 at 10:51 A.M., the IP provided the surveyor with a signature page indicating the facility policies were reviewed by the medical team, including the Medical Director on 6/4/24. The IP said she had asked about the updated guidance for the Pneumococcal Vaccines and was waiting for an updated policy. During an interview on 9/19/24 at 11:53 A.M., the IP said the facility was working on a new policy for the Pneumococcal Vaccination. The facility did not provide an updated Pneumococcal Vaccination policy to the survey team by survey exit. 2. Resident #62 was admitted to the facility in March 2024, and was over the age of 65. Review of the CDC Vax Finder Tool indicated Resident #62 was eligible to receive the PCV20 vaccine at the time of admission. Review of Resident #62's clinical record indicated no documented evidence that he/she was offered and had the opportunity to consent or decline the Pneumococcal Vaccine. During an interview on 9/18/24 at 11:26 A.M., the IP said there was no vaccine consent or declination form completed upon admission for Resident #62 and there should have been. During a follow-up interview on 9/18/24 at 12:50 P.M., the IP said she obtained consent from Resident #62's Responsible Party to receive the PCV20 vaccination. 3. Resident #46 was admitted to the facility in August 2023, and was over the age of 65. Review of the CDC Vax Finder Tool indicated Resident #46 was eligible to receive the PCV20 vaccine. Review of Resident #46's clinical record indicated the Resident's Representative consented for him/her to receive the Pneumococcal Vaccine (including the PCV20) on 8/11/23. Further review of the clinical record indicated no documented evidence that the PCV20 vaccine was administered to Resident #46 after consent was obtained. 4. Resident #6 was admitted to the facility in July 2020, and was over the age of 65. Review of the CDC Vax Finder Tool indicated Resident #6 was eligible to receive the PCV20 vaccine. Review of Resident #6's clinical record indicated the Resident's Representative consented for him/her to receive the Pneumococcal Vaccine (specifically the PCV20) on 10/20/23. Further review of the Resident's clinical record indicated no documented evidence that the PCV20 vaccine was administered after consent was obtained. During an interview on 9/18/24 at 10:04 A.M., the IP said Pneumoccal Vaccines were reviewed with Residents or their Responsible Party upon admission. The IP said she uses the CDC Vax Tracker Tool to determine which Pneumococcal Vaccine should be offered, and if eligible, she would provide education on the vaccine and ensure that a consent or declination was obtained. During a follow-up interview on 9/18/24 at 11:26 A.M., the IP said consents for the PCV20 vaccines had been previously obtained for Residents #46 and #6, but the PCV20 vaccines had not been administered and should have been.

Based on observation, interview, record and policy review, the facility failed to ensure that Transmission Based Precautions (TBP: used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) were implemented for one Resident #65, out of a total sample of 18 residents. Specifically, the facility staff failed to reduce the potential spread of infection by ensuring that Contact Precautions (precautions intended to prevent transmission of infectious agents which are spread by direct and indirect contact with the patient or the patient's environment) were followed relative to the use of the required personal protective equipment (PPE) for Resident #65 who was diagnosed with and was actively being treated for an infection. Findings include: Review of the facility policy titled Transmission-Based Precautions, revised 8/8/24, indicated the following: -Transmission Based Precautions will be initiated for known or suspected infections for which there are active symptoms, and the route of transmission is known. -TBP categories used in facilities are Droplet Precautions and Contact Precautions .may be used either singly or in combination. Standard Precautions are used in addition to the Transmission-Based Precaution implemented. Review of the Centers for Disease Control and Prevention (CDC) website cdc.gov, titled Precautions to Prevent Transmission of Infectious Agents, indicated the following relative to Contact Precautions: -Application of Contact Precautions for patients infected or colonized with MultiDrug Resistant Organisms (MDROs: microorganisms or bacteria that are resistant to one or more classes of antimicrobial agents) -Healthcare personnel caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. -Donning (putting on) PPE upon room entry and discarding before exiting the room .especially for those who have been implicated in transmission through environmental contamination (for example: Vancomycin-Resistant Enterococcus or VRE: bacteria resistant to some powerful antibiotics and are usually spread from person to person through contact with infected people). Review of the Contact Precaution Signage (CDC and utilized by the facility) included the following: >Stop. Contact Precautions. >Everyone Must: -Cleanse their hands, including before entering and when leaving the room. -Put on gloves before room entry. Discard gloves before room exit. -Put on gown before room entry. Discard gown before room exit. -Do not wear the same gown and gloves for the care of more than one person. -Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Resident #65 was admitted to the facility in August 2024, with diagnoses including left hip joint replacement and cellulitis (potentially serious bacterial infection that affects the deep layers of the skin and underlying tissues). Review of Resident #65's Urinary Tract Infection Care Plan, initiated 9/12/24, indicated the Resident currently had a Urinary Tract Infection and included the following interventions initiated on 9/12/24: -Administer antibiotic therapy as ordered -Maintain Contact Precautions for VRE in the urine Review of the September 2024 Physician's orders included the following: -Maintain Contact Precautions every shift, initiated 9/12/24 -Macrobid (antibiotic) 100 milligrams (mg) every 12 hours, initiated 9/13/24 On 9/18/24 at 11:46 A.M., the surveyor observed a Contact Precaution sign outside of Resident #65's room and a bin containing PPE including gowns and gloves. The surveyor observed that the Resident's call light was initiated and the Resident was seated in a wheelchair next to his/her bed. At 11:48 A.M., the Social Worker (SW) was observed to knock and enter the Resident's room, without donning a gown or gloves. The SW remained in the Resident's room for a short time and was observed to exit the room. During an interview on 9/18/24 at 11:48 A.M., the SW said she responded to Resident #65's call light and that the Resident had requested a snack. The SW said she did not put on a gown or gloves prior to entering the Resident's room. The SW said she was aware that the Resident was on Contact Precautions, but she did not have any contact with the Resident so she was not required to put on PPE. After the interview, the surveyor observed the SW retrieve the requested snacks from the unit kitchenette and re-enter the Resident's room a second time without donning the required PPE indicated on the signage posted at the doorway. During an interview on 9/18/24 at 12:52 P.M., the Infection Preventionist (IP) approached the surveyor and said education was provided to the SW about the requirements for Contact Precautions and the required PPE for Resident #65. The IP said all staff should be performing hand hygiene and putting on a gown and gloves prior to entering a Contact Precaution Room per the instructions on the signage. The IP said she thought there was confusion about the different Precaution signage utilized in the facility and that she would have to complete ongoing education with the facility staff.

Based on observation, interview, record and policy review, the facility failed to provide care consistent with professional standards of practice relative to ensuring interventions ordered and/or recommended for the treatment of an existing wound were implemented for one Resident (#73) of two applicable residents with pressure ulcers reviewed, out of a total sample of 18 residents, with a pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure to the skin). Specifically, the facility failed to ensure that: 1. A specialty (pressure reducing) mattress was at the correct setting as ordered by the Physician, 2. Pressure relief devices (heel booties) were implemented as ordered by the Physician, 3. Recommendations from the Wound Physician for lab work were reviewed by the facility staff for implementation. Findings include: Review of the facility policy Skin Management Program, revised 6/13/19, indicated the purpose was to minimize the development of any type of ulcers and other skin issues through the systemic and regular inspection of the resident's skin, and to ensure early detection and intervention for all skin problems. The policy also included the following: -A care plan will be developed and implemented, and revised as necessary -Additional measures may be taken to protect bony prominences of bedfast or chair bound residents. These measures include the use of heel and elbow protectors . Resident #73 was admitted to the facility in July 2024, with diagnoses including Myasthenia Gravis (chronic autoimmune disease that causes weakness in voluntary muscles by disrupting with communication between the nerves and muscles), Diabetes (condition in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood), limitation of activities due to a disability, and presence of pressure ulcer of the sacral area (triangular bone in the lower back situated between the two hipbones of the pelvis). Review of the Pressure Ulcer Risk Care Plan, initiated 7/31/24, indicated Resident #73 was admitted to the facility with a sacral ulcer and included the following intervention: -Air (specialty) mattress as ordered (initiated 7/31/24) Review of the Minimum Data Set (MDS) Assessment, dated 8/6/24, indicated Resident #73: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15 -had bilateral range of motion deficits of the lower extremities -had a Stage 3 Pressure Ulcer (full thickness loss of skin that extends to the deepest layer of skin made up of fat and connective tissue) that was present on admission Review of the September 2024 Physician's orders included the following: -May refer to Wound Physician, initiated 7/31/24 -Specialty air mattress set at 200 pounds (lbs.), ensure proper setting every shift, 8/16/24 -Booties to bilateral lower extremities, every shift, initiated 8/31/24 -Weekly weights, initiated 9/10/24 Review of the Wound Physician Evaluations, dated 8/6/24 through 9/10/24 included the following recommendations: -8/6/24: Recommend Glycosylated Hemoglobin level (HgbA1c: protein that forms when glucose in the blood sticks to hemoglobin molecules in red blood cells and shows blood sugar regulation over 2-to-3-month period of time), -8/13/24: Recommend PreAlbumin level (measurement of protein in the blood) and HgbA1c level, -8/20/24: Recommend PreAlbumin and HgbA1c levels, -8/27/24: Recommend PreAlbumin and HgbA1c levels, -9/3/24: Recommend HgbA1c level, PreAlbumin was obtained on 8/28/24 (15 days after it was originally recommended), -9/10/24: Recommend HgbA1c level Review of Resident #73's clinical record indicated: -No documented evidence that the Wound Physician's recommendation to obtain a HgbA1c level was addressed by the facility or that a level was drawn since the original recommendation was made on 8/6/24. -Last obtained weight was 173.6 lbs. on 9/12/24 On 9/16/24 at 2:45 P.M., the surveyor observed Resident #73 lying in bed with his/her feet pressed against the foot board of the bed. On 9/18/24 at 2:17 P.M., the surveyor observed the Resident lying in bed watching television. A specialty mattress was in place and was observed to be set at 150 lbs. The surveyor did not observe evidence of booties to his/her lower extremities. On 9/19/24 at 9:00 A.M., the surveyor observed Resident #73 lying in bed with a specialty mattress in place that was set to 150 lbs. The surveyor further observed that the Resident did not have booties on his/her lower extremities and a pillow was placed under his/her calves. On 9/19/24 at 10:15 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 assisting another CNA with the Resident's care. The privacy curtain was partially drawn, and the surveyor observed the Resident's bare feet resting on the bed. The surveyor observed the Resident was seated in a wheelchair and was assisted by the staff to the shower room. During an interview on 9/19/24 at 10:29 A.M., CNA #1 said Resident #73 required assistance with activities of daily living (ADL: activities of personal care which include bathing, dressing, personal hygiene) and transfers. CNA #1 said the Resident has a wound on his/her bottom and utilized a specialty mattress which the Nurses monitor for function. CNA #1 said the Resident required frequent positioning and had pillows placed under his/her arms and legs. When the surveyor asked if booties were utilized for the Resident's feet, CNA #1 said she was unaware of any booties for the Resident's feet. The CNA was observed to look in the Resident's room and said she did not see any booties for the Resident. During an interview on 9/19/24 at 10:36 A.M., Nurse #1 said the Resident's specialty mattress was set by his/her weight and was monitored every shift by the Nurses to ensure it was at the correct setting. Nurse #1 said the Resident also had an order for booties to be worn. At the time, the surveyor and Nurse #1 observed the Resident's room (the Resident not in the room) and the specialty mattress remained set to 150 lbs. After reviewing the Physician's order for the mattress, Nurse #1 said the specialty mattress should be set to 200 lbs. and not 150 lbs. Nurse #1 said she was not sure about the booties for the Resident's lower extremities, but if the Resident had refused them and another intervention was put into place, it should be documented in the Resident's clinical record. Review of the September 2024 Medication Administration Record (MAR) with Nurse #1, indicated the following were signed off as administered every shift from 9/1/24 through 9/19/24 7:00 A.M. to 3:00 P.M. [Day], 3:00 P.M. to 11:00 P.M.[Evening], and 11:00 P.M. and 7:00 A.M.[Night] shifts: -Specialty air mattress set at 200 pounds (lbs.), ensure proper setting every shift -Booties to bilateral lower extremities, every shift, initiated 8/31/24 There was no documented evidence in the clinical record that the Resident had refused the Physician ordered interventions (booties and air mattress) with the only exception on 9/4/24 on the 7:00 A.M. to 3:00 P.M.[Day shift] when it was documented that the Resident did not want the booties to be put on. During an interview on 9/19/24 at 11:32 A.M., the Assistant Director of Nurses (ADON) said she completes wound rounds with the Wound Physician weekly on Tuesdays, and she documents the measurement of the wounds and any recommendations for care made at that time. The ADON said the recommendations made by the Wound Physician would be relayed to the Resident's Physician and would be documented in the clinical record. The ADON said the Physician does not usually decline recommendations made by the Wound Physician. During an interview on 9/19/24 at 12:00 P.M., the Corporate Nurse said there was a problem with how Resident #73's recommendations from the Wound Physician were relayed to the facility staff. The facility staff were unable to provide evidence that the recommendation for the HgbA1c lab work was addressed by the Physician prior to survey exit.

Based on observation, interview, and record review the facility's staff failed to conduct testing and specimen collection in a manner consistent with current standards of practice for conducting COVID-19 tests. Findings included: Review of the Occupational Safety and Health Administration (OSHA) website titled COVID-19 Guidance on Social Distancing at Work (osha.gov), dated OSHA4027-05 2020, indicated: Social (physical) distancing involves maintaining at least six feet of distance between people and is an effective way to help reduce the risk of exposure to the coronavirus. Review of the Centers for Disease Control and Prevention's (CDC) website titled Interim Guidelines for Clinical Specimens for COVID-19 | CDC, updated 2/26/21, indicated the following: Personal protective equipment (PPE) required during specimen collection working within 6 feet of patients includes face mask, eye protection, gloves, and a gown. If handling specimens and not working within 6 feet of a patient, follow standard precautions. Healthcare providers can minimize PPE use if patients collect their own specimens while maintaining at least 6 feet of separation. Review of the facility's policy titled BinaxNOW Rapid Point of Care COVID-19 Testing, revised 8/9/21, indicated the following: -Staff administering the BinaxNOW test must wear appropriate PPE when obtaining the test and handling the specimen. -The PPE required is N95 mask, eye protection, gloves and gown when collecting the specimen. -Staff may perform self-swabbing under the observation of a staff member, the staff member will wear a mask and use gloves as appropriate. Social distancing will be maintained. On 9/15/21 at 9:20 AM the surveyor observed the receptionist escorting a staff member to the facility's COVID-19 testing room off the lobby. The receptionist wore her personal glasses, gloves, and a surgical mask. The staff member being tested wore her surgical mask. The receptionist stood at the counter and unwrapped the testing swab. She turned around and handed the swab to the staff member who lowered her mask, swabbed her own nares (openings to the nose), and handed the swab back to the receptionist. The receptionist and the staff member were standing approximately three feet apart. The receptionist turned around to face the counter, prepared to process the test, and the staff member sat down in a nearby chair to wait for the test result. During an interview at the time of the observation, the receptionist said she was trained to do the testing procedure by the full-time receptionist by observation and return demonstration. She said she was told that she only needed to wear a mask and gloves when testing. She said she was instructed to test unvaccinated staff and any staff that enter the facility from outside vendors. She said the unvaccinated staff wear N95 masks and self-identify that they need testing upon entry to the building. She did not have a list of names of unvaccinated staff who needed to be tested . During an interview on 9/15/21 at 10:25 A.M., the Infection Prevention Nurse (IPN) said that staff are trained in Binax testing using a competency tool developed by the facility's corporate office. The PPE required for the staff member processing the tests are gloves and a face mask if social distancing can be maintained. If unable to maintain a minimum of six-foot distance from the person being tested , the tester should wear a gown and eye protection in addition to mask and gloves. During a subsequent interview on 9/15/21 at 12:13 P.M., the IPN said that the distance between the test processor (receptionist) and the employee being tested was not the six-foot distance as required.

Based on policy review, document review and interview, the facility failed to implement an Antibiotic Stewardship Program. Findings include: Review of the facility's Antibiotic Stewardship policy, dated 11/19/17, included the following: -Antibiotic will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. -The Infection Prevention Program Coordinator (IP) has the role to inform the team of strategies to improve antibiotic use. This is done though tracking of antibiotic starts, and monitoring adherence to evidence-based criteria (McGeers). -Improvement in the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection .and implementing an antibiotic review process known as antibiotic time out. This review will provide the clinician with an opportunity to reassess the ongoing need for and choice of an antibiotic . During an interview on 8/5/21 at 10:08 A.M., the IP reviewed the Antibiotic Surveillance Tracking Form, and showed the surveyor the tracking forms for the month of April 2021, May 2021 and June 2021. The tracking forms indicated the following: -April 2021: the McGeers Criteria was not met 4 out of 17 times and the antibiotic time out was not done 10 out of 17 times. -May 2021: the McGeers Criteria was not met 5 out of 11 times and the antibiotic time out was not done 3 out of 11 times -June 2021: the McGeers Criteria was not met 7 out of 11 times and the antibiotic time out was not done 4 out of the 11 times The surveyor asked the IP nurse to explain the antibiotic time out. She said that 72 hours after a resident started an antibiotic the nurse was supposed to call the Physician and ask if they would like to continue the use of the antibiotic. Then the surveyor asked the IP nurse to explain the McGeers Criteria. The IP nurse said before the nurse called the Physician, they were supposed to complete the McGeers Criteria, an assessment tool, to ensure the resident had signs and symptoms of an infection. The surveyor then asked what was done with the information after the data was collected, and the tracking form indicated the nurses had not followed the protocols. The IP nurse said she had not really done anything with it except some informal individual education. During an interview on 8/5/21 at 11:00 A.M., the Director of Nurses (DON) said that she was aware that the McGeers Criteria had not been followed and had developed a Performance Improvement Plan, but had not initiated it because she had not had the opportunity to review it with the Medical Director. The DON said she was not aware that the antibiotic time out was not being done.

Based on document review, observation and interview, the facility failed to maintain infection control practices during a medication pass, impacting one Resident (#35), out of a total of eight residents observed. Findings include: Review of the Blood Glucose Monitoring Systems manufacturer's guidelines indicated the following: -The meter should be cleaned and disinfected after use on each patient. -Disinfecting procedure is needed to prevent the transmission of blood borne pathogens. On 8/4/21 at 3:38 P.M., the surveyor observed the medication pass and observed Nurse #1 perform a Finger Stick Blood Sugar (FSBS) on Resident # 20. After she completed the FSBS, she placed the glucometer on top of her medication cart. Nurse #1 then performed a FSBS on Resident #35 without disinfecting the glucometer in between the two residents. During an interview on 8/4/21 at 3:55 P.M., the surveyor asked Nurse #1 the facility's procedure for disinfecting the glucometer. Nurse #1 said she would have to ask someone because she had never disinfected the glucometer before. During an interview on 8/4/21 at 3:59 P.M., Unit Manager #1 said the glucometer needed to be disinfected after use on each resident.

Based on observation, record review and interview, the facility failed to ensure the oral assessment, a part of the Minimum Data Set (MDS) assessment, was accurately coded for one Resident (#61) out of a total sample of 18 residents. Findings include: Resident #61 was admitted to the facility in 2015. On 8/4/21 at 8:51 A.M., the surveyor observed Resident #61's teeth to be discolored with multiple missing and broken teeth. Review of the Oral assessment, dated 11/2/20, indicated Resident #61 had obvious or likely cavities or broken natural teeth. Review of the Annual MDS, dated [DATE], indicated no oral or dental concerns in Section L: -Oral/Dental Status During an interview on 8/9/21 at 11:23 A.M., Unit Manager #1, formerly the MDS coordinator, said that based on the oral assessment, the MDS dated [DATE] was incorrectly coded.

Based on record review and interview, the facility failed to complete a comprehensive admission Minimum Data Set (MDS) within 14 days of admission, as required, for one Resident (#58) out of 18 sampled residents. Findings include: Resident #58 was admitted to the facility in April of 2021. Review of the MDS assessments for Resident #58 indicated no comprehensive admission MDS had been completed for his/her admission from April of 2021. During an interview on 08/09/21 at 8:09 A.M., Unit Manager #1, formerly the MDS Coordinator, said Resident #58 did not have a comprehensive admission MDS completed at the time of his/her admission in April and should have had one completed, as required.

Based on document review and interview, the facility failed to ensure completed Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion for seven Residents (#1, #2, #3, #4, #5, #6 and #7), out of a total sample of 18 residents. Findings include: Review of the CMS Long-Term Care Facility Assessment Instrument 3.0 User's Manuel, Version 1.17.1, dated October 2019, indicated the following relative to MDS transmittals: -Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). Document review indicated the date of completed MDS assessments for the following Residents: -Resident #1 had a quarterly MDS completed on 6/16/21 -Resident #2 had significant change in status MDSs complete on 6/23/21 and 7/20/21 -Resident #3 had a quarterly MDS completed on 6/23/21 -Resident #4 had a quarterly MDS completed on 6/30/21 -Resident #5 had a quarterly MDS completed on 6/30/21 -Resident #6 had a quarterly MDS completed on 6/30/21 -Resident #7 had a quarterly MDS completed on 6/30/21 During an interview on 8/06/21 at 12:21 P.M., the Director on Nurses said that the Residents listed above did not have their MDS transmitted to CMS until today. She said they were not submitted within 14 days of completion, as required.

Based on observation, policy, facility report review and interview, the facility's contracted laundry staff (Laundry Worker #1 and the Laundry/Housekeeping Supervisor) failed to ensure effective infection control practices related to the handling of soiled and clean linens. Findings include: Laundry Worker #1 failed to ensure: - a Laundry apron/gown, made of non-permeable material, with long sleeves, had been worn while handling soiled linen, then removing the gown, prior to handling clean linen to prevent cross-contamination; -sorting of bagged, soiled linen, to ensure infectious clothing, such as contamination with feces, vomitus, resident's personal effects, such as eyeglasses, false teeth, hearing aids, jewelry, papers etc. weren't inside and co-mingled with personal laundry; - storage of linens to reduce risk of cross contamination Review of the Contracted Laundry policy, which included a 3-part laundry policy/procedure, training and protocol, provided by the Contracted Laundry/Housekeeping Supervisor (4/18/19 at 3:15 P.M.) included the following: - When sorting linen, open it up and check for any objects, such as false teeth, glasses, hearing aids, jewelry, paper products, etc. - When handing soiled linen, use gloves and a gown. After handling soiled linen, remove gloves and gown. During observation of the laundry room on 4/20/19 at 2:28 P.M. the surveyor observed a pile of linen on the floor in front of the washing machine. Laundry Worker #1 said the linen on the floor was dirty, and she would wash it when the current load was finished. Laundry Worker #1 said that the linen should not have been stored on the floor, but she could not find anything to put it in. The surveyor asked Laundry Worker #1 where soiled linen was sorted. Laundry Worker #1 said soiled laundry is not sorted, and is all washed together. Laundry Worker #1 said as soon as she comes into the laundry room to work,she puts on a smock, and identified the smock she was currently wearing. Laundry Worker #1 said she puts on gloves, goes to each unit, picks up bagged personal laundry in yellow carts, with covers, returns to the Laundry Room, with the yellow carts, removes the bagged clothing, tears the bag open and places the soiled resident clothing directly into the washer. The surveyor then asked Laundry Worker #1 what she wears when handling soiled or potentially infectious precaution laundry. Laundry Worker #1 said, I wear the same smock, whether handling soiled, precaution or clean linen, and all personal clothing is washed together. Laundry Worker #1 said she wears the same smock to remove clean wash from the dryer to fold, hang up then distribute the resident's clothing to the residents on Unit 1 and Unit 2, and was never told to do anything else. The surveyor asked Laundry Worker #1 if there was ever a time Laundry Worker #1 was required to wear a protective barrier gown/apron with long sleeves, especially when handling contaminated or potentially infectious clothing/linen. Laundry Worker #1 said she wears the same smock, and was never told not to wear anything else. Laundry Worker #1 said all laundry is handled the same. The surveyor observed a narrow, short counter to the left of the large sink. Under this counter were two large, clear, plastic bags filled with what appeared to be facecloths and/or towels, stored directly on the floor. Laundry Worker #1 said the plastic bags on the floor under the counter contained new facecloths, and would be washed, if needed or if supply was low. The surveyor observed a laundry basket containing miscellaneous socks, stored underneath the sink. There was a cardboard box, heaped with various colored socks, stored directly on the floor, next to this basket. Laundry Worker #1 said the cardboard box was filled with resident's clean socks that were not labeled, and would be used for residents in need of socks to wear. (Not adequate infection control practices to store open cardboard box with resident's clothing on a floor, or under a sink where splashing, or potential leaking could soil the clean socks).

Based on record review and interview the facility staff failed to maintain accurate and complete records for 2 Residents (#81 and #189) out of a total sample of 18 residents. Findings include: 1. For Resident #81, the facility staff failed to document that the resident was ambulated. Resident #81 was admitted to the facility 1/3/19 with a [DIAGNOSES REDACTED]. Review of the Physical Therapist Discharge Summary, dated 1/25/19, indicated the resident ambulated 25 feet with assist. Review of the Certified Nurses Assistant (CNA) flow sheets, dated 1/25/19 thru 4/22/19 did not include documentation of Resient #81 being ambulated by staff. On 4/23/19 at 8:43 A.M. during an interview with the Rehabilitation Director she said that the licensed rehabilitation staff ambulate the resident. She said that since it is a small facility the rehabilitation department likes to ambulate all of the residents that are able so they can keep track on how each resident is progressing or declining. She said that the rehabilitation staff have an informal calendar that they use. The Rehabilitation Director showed the surveyor the calendar. The calendar did not indicate the distance Resident #81 ambulated. The surveyor asked if the distance the resident ambulated is documented any where. She said that it is not but it probably should be. On 4/23/19 at 8:57 A.M. during an interview with Unit Manager #2 she said the resident's family comes and walks the resident, so she knows that the resident is ambulated by the rehabilitation department and/or the family on a daily basis. 2. For Resident #189, the facility staff failed to obtain accurate physician's orders [REDACTED]. Resident #189 was admitted to the facility in 2/2019. Review of the physician orders, dated 4/2019, indicated, Code Status: Follow MOLST (Medical Orders for Life Sustaining Treatment) Record review indicated there was not a MOLST in the record. On 4/23/19 at 10:05 A.M. during an interview with the Director of Nurses (DON) she said that the resident was a full code based upon the guardianship. The surveyor showed the DON the physician's orders [REDACTED].

Based on observation, record review and interviews, 1 of 3 facility nurses (Registered Nurse (RN) #1, who was also identified as being the Staff Educator, during part of the medication pass, failed to ensure the prevention of a significant medication error, related to Insulin (injectable medication used to treat diabetes, and lower blood sugar levels) administration, for 1 sampled resident (#49), from a total of 18 residents. Findings include: For Resident #49, admitted to the facility in 1/2019 with [DIAGNOSES REDACTED].#1 failed to ensure a significant medication error had been prevented when Insulin ([MEDICATION NAME], fast-acting and works to lower blood sugars in 15 minutes, after injection, peak action in 0.5-2 hours, and keeps working 3-5 hours after injection), had not been administered as ordered. During the medication pass observation on 4/18/19 at 1:45 P.M. on Unit 2 with RN #1, RN #1 said she had to check a blood sugar on Resident #49, to see if the Resident required sliding scale insulin, and proceeded to do so. At 1:49 P.M., the blood sugar test result displayed on the glucometer device was 285. The Resident told the surveyor that he/she ate lunch about an hour ago .ate everything, that included chicken pot pie. Resident #49 then told the surveyor that he/she was not feeling very well today. Review of the physician's orders [REDACTED].M., 11:30 A.M. and 4:30 P.M. The sliding scale dose for a blood sugar between 251 - 300, was for 8 Units of [MEDICATION NAME] to be administered, at the aforementioned times. Further review of the orders (dated 1/18/19) indicated to administer [MEDICATION NAME] Insulin, 8 Units, sc with meals, at 8:00 A.M., 12:00 P.M. and 5:00 P.M. On 4/18/19 at 1:57 P.M., RN #1 injected the 16 units of [MEDICATION NAME] Insulin into the Resident's abdomen subcutaneously (sc). Unit Manager (UM) #1 provided a copy of Resident #49's physician's orders [REDACTED]. RN #1 made a significant error when she administered 16 Units of [MEDICATION NAME] Insulin dose at 1:57 P.M., not before the meal at 11:30 A.M., and per sliding scale results taken at that time. RN #1 did not administer [MEDICATION NAME], 8 Units, sc with the meal at 12:00 P.M., as ordered. RN #1 combined the two doses, for a total dose of 16 units. Upon review of the physician's orders [REDACTED].#1 on 4/18/19 at 2:04 P.M., immediately after review, RN #1 said this was the first time being on the medication cart. RN #1 said that she did give both the 11:30 A.M. and 12:00 P.M. doses of [MEDICATION NAME] together, based on a random blood glucose level obtained an hour after the resident had eaten. During interview on 4/18/19 at 5:25 P.M., the Director of Nursing (DON) said that she had been made aware of the medication error, and education was provided immediately, upon discovery.

Based on observation, record review and interview, the facility failed to provide adequate infection control practices related to keeping the Foley catheter bag off the floor at all times for 1 resident (#82), in a total sample of 20 residents. Findings include: Resident #82 was admitted to the facility in 1/2018, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment, with an Assessment Reference Date of 1/12/18, indicated a Brief Interview for Mental Status score of 5 out of 15 (indicated severe cognitive loss). The resident required assist with bathing, dressing, hygiene, transfers and utilized an indwelling catheter. Review of the 1/2018 and 2/2018 Physician's Monthly Orders included the following orders: Foley catheter #16 French with a 30 milliliter balloon. Observation, on 1/31/18 11:30 A.M., found Resident #82 sitting in a wheelchair in his/her bedroom. The Foley catheter bag was not inside a cover bag. The catheter bag was hooked on the metal frame under the wheelchair seat and was lying directly on the floor. Observation, on 02/01/18 at 10:22 AM, 11:36 A.M. and 1:40 P.M., found Resident #82 sitting in a wheelchair in his/her bedroom. The Foley catheter bag was not inside a cover bag. The catheter bag was hooked on the metal frame under the wheelchair seat and was lying directly on the floor. During an interview, on 2/1/18 at 1:42 P.M., the Surveyor told Unit Manager (UM #2) that the Foley catheter bag was observed numerous times lying on the bedroom floor under the wheelchair. UM #2 said, thank-you for telling me. Resident #82's spouse overheard the conversation, and he/she said that the catheter bag had been like that since admission.

Based on observation, record review, resident, family and staff interviews, the facility failed to ensure adequate supervision and assistive devices to prevent accident for 4 (#5, #7, #8, and #9,) out of 10 applicable residents with falls in a total sample of 19 residents. Additionally, the facility failed to maintain a hazard-free environment for 1 of 2 Unit Shower Suites (Level II Unit) as it related to the storage of potentially harmful devices and chemicals. Findings include: 1. For Resident #7, the facility failed to ensure that the resident received effective supervision and/or functioning sensors/alarms to prevent 6 unwitnessed accidents with injuries that included a laceration with 4 staples and a fractured vertebrae. Resident #7 was admitted to the facility in in 5/2013 with [DIAGNOSES REDACTED]. The resident's Fall Risk Assessment indicated the resident was a "high" risk for falls with scores of 17, 18, 20, 21, 22, and 22 on 10/22/13, 12/14/13, 1/10/14, 3/28/14, and 5/19/14 respectively. Review of the Resident Care Plan for falls, in effect 11/26/13, indicated the resident was at risk for falls, related to confusion, behavior and self transfer with gait/balance deficit, The goal was for the resident to be free of falls/injury. The interventions included: -a Motion, Chair and bed sensor alarms, -Assess for low bed, mat on floor at bedside, anti-skid strips on floor, -Make sure glasses used, -Call light within reach, -Keep environment free from clutter, -Keep Rolling Walker within reach, -Keep bedside table within reach, -Non-skid footwear when Out of Bed, -Diversional activities of choice, -and keep beds, gerichairs, wheelchairs in locked position. Review of Nursing Notes and the Fall Incident Report of 11/27/13 at 12:00 P.M. indicated the resident had an unwitnessed fall when the resident attempted to self transfer from a wheelchair in the Level 2 Activity Room. Staff responded to the clip alarm sounding. No injury was noted. The resident stated he/she had the urge "to pee," despite having an indwelling catheter. The investigation did not mention if the resident was wearing glasses or non-skid footwear at the time of the fall, nor if the resident was engaged in a diversional activity. The resident's care plan was updated on 11/27/13 to provide the resident "close supervision when out of bed," to have the resident sit in the nurse's station area, and not alone in the activity room. Review of Nursing Notes on 11/29/13, on the evening shift, noted the resident attempted to self transfer several times without asking for assistance. Review of Nursing Notes and the Fall Incident Report of 12/14/13 at 6:30 P.M. indicated the resident had a second unwitnessed fall when the resident attempted to self transfer in the bedroom and was found on the floor on knees beside the bed. The resident was noted to have no injury. Staff responded to the bed alarm. The investigation recommended the resident be transferred to a bedroom closer to the nursing station, be toileted before bed and as needed. Again, the resident was not provided close supervision after evening meal. The resident's quarterly Minimum Data Set (MDS) assessment of 1/15/14 indicated the resident had moderate difficulty hearing, made self understood and usually understood others. wore glasses, was severely impaired cognitively, required limited assistance for dressing and personal hygiene, required extensive assistance for transfers, ambulation, toilet use and bathing, was not steady with balance during transitions and walking, utilized a walker and wheelchair, utilized an indwelling catheter for bladder needs, was continent of bowel, had two falls without injury since the last assessment, and was administered antidepressant and diuretic medication daily. Review of Nursing Notes and the Fall Incident Report of 3/31/14 at 2:05 P.M. indicated the resident had a third unwitnessed fall when the resident attempted to self transfer from the resident's "personal," assigned chair at the Nursing Station (lounge) area to toilet self. Staff heard a "thud" as the resident hit his/her head on the wall. The resident's chair sensor alarm was not in place as planned. No injury was noted. The investigation again failed to indicate if the resident wore glasses and wore non-skid footwear. Close supervision was not provided by staff when the resident was out of bed, as planned. The resident's annual MDS assessment of 4/9/14 indicated the resident had severe cognitive impairment, required extensive assistance for hygiene, and had a fall without injury since the last MDS assessment. Review of Nursing Notes and the Fall Incident Report of 5/11/14 at 1:20 P.M. indicated the resident had a fourth unwitnessed fall when the resident left the nursing station lounge area, ambulated into the bedroom, and attempted to self transfer to the bathroom. Staff responded to an alarm, found that the resident had removed his/her shoes and fallen. The resident had hit his/her forehead, causing a laceration. The resident was sent to the local hospital and received 4 staples to close the wound. There was no investigation indication as to why the resident was not placed in the nursing station area for "close supervision," as planned. The care plan was updated 5/11/14 to include a floor and bedroom door alarm. Review of Nursing Notes, and Fall Incident Report of 5/19/14 at 2:05 P.M. indicated the resident had a fifth unwitnessed fall, after the resident had wheeled self unsupervised into the bedroom, like the incident of 5/11/14. The resident attempted to self transfer from the resident's wheelchair to the bathroom. Staff responded to the chair alarm sound and found that the resident on the right side of the bed with the wheelchair behind the resident. No injury was noted, and staff were again reminded to have the resident placed in a stationary chair by the nursing station (lounge area). The quarterly MDS assessment of 6/18/14 indicated the resident was inattentive, required extensive assistance for dressing, and had two falls (one with no injury and one with injury). Review of Nursing Notes and the Fall Incident Report of 8/3/14 at 3:45 P.M. indicated the resident had a sixth unwitnessed fall after the resident had self transferred from the stationary chair at the nursing station lounge area, fell backwards, hitting head on the floor. The resident was sent to the local hospital and returned with a [DIAGNOSES REDACTED]. Although several people were in the area, the resident was not specifically supervised to prevent another fall when the resident attempted self transfer. Additionally, the resident's chair alarm did not function, as planned. Observation on 8/21/14 at 2:15 P.M., indicated the resident ambulating with 2 Certified Nursing Aides (CNA) and a gait belt in the hallway. From 9:30 A.M. to 11:10 A.M., the resident was observed asleep with eyeglasses affixed, seated in a "bouncy" chair (a chair with up and down flexibility) with sensor alarm attached, at the nursing station lounge area. Observation on 8/22/14 at 7:45 A.M. indicated the resident seated in the lounge area across from the nursing station in a stationary chair with seat alarm. The resident got up with a walker, set off the alarm, and walked approximately 10 feet before staff interceded. The resident said he/she had to go to the bathroom. During interview on 8/26/14 at 11:10 A.M., the resident's family member said that the resident was alert and confused, frequently felt the need to void, and the urge to defecate, and attempted to self transfer without asking for assistance. The family member said that the resident was usually found in a stationary chair in the unit lounge area by the nursing station. During visits, the resident would attempt to stand independently, and on occasion, the family member had to toilet the resident as no staff were present when the resident's toileting need arose. During interview on 8/26/14 at 1:10 P.M., the Director of Nursing (DON) said that the facility had relied too much on the use of alarms, which at times did not function, rather than targeting the resident for patterns and periods of time for close supervision, as when the resident had urgency needs. 2. For Resident #8, the facility failed to ensure that the resident received a functioning motion detector alarm to prevent an unwitnessed fall. Resident #8 was admitted to the facility in 5/2014 with [DIAGNOSES REDACTED]. The resident's admission MDS assessment of 5/17/14 indicated the resident had moderate intact mental functioning, wore glasses. required limited assistance for toilet use, extensive assistance for transfers, ambulation, dressing, hygiene and bathing, was continent of bowel and bladder, had moderate back pain, had fallen with a fracture prior to admission, and was administered antidepressants and diuretics daily. Review of the Resident Care Plan for falls, in effect from date of admission, indicated the resident was to be free of falls/injury. The interventions included: -a Motion detector when in bed, -Call light within reach, -Keep environment free from clutter, -Keep Rolling Walker within reach, -And keep bedside table within reach. The quarterly MDS assessment of 7/31/14 indicated the resident required supervision for dressing, limited assistance for ambulation and hygiene, extensive assistance for toilet use, was frequently incontinent of bladder, and had no falls since the last assessment. Review of Nursing Notes, and Fall Incident Report of 8/8/14 at 4:00 P.M. indicated staff heard the resident yelling and found the resident sitting on the bedroom floor. The resident had attempted to get to the wheelchair from the bed, the bed moved as it was not locked, and the resident fell . The motion detector did not sound. No injury was noted. Observation on 8/25/14 at 3:00 P.M. and at 4:25 P.M. indicated the resident dressed and lying in bed with eyeglasses on. The resident was alert and responsive, and indicated personal falls when attempting to transfer out of bed or in the bathroom when he/she sustained fractures at home. On both bedroom visits to the resident, the motion detector on the resident's bureau, across from the resident's bed, did not sound. At 4:30 P.M., Surveyor inquired of Level III Unit Manager (UM #2), if the resident's motion detector was functioning. UM #2 went to the resident's room and said the motion detector was not sounding when motion occurred before it. UM #2 said that the motion detector did not sound when the resident fell in early 8/2014. 3. Based on observation and staff interviews, the facility failed to maintain a hazard-free environment for 1 of 2 unit shower suites (Level II Nursing Unit) as it related to the storage of potentially harmful devices and chemicals. During Environmental tour on 8/20/14, from 7:30 A.M. to 8:15 A.M., the following were observed: The unsecured Level II Unit's Shower Suite: Surveyor observed a pair of metal scissors on the left metal shelf in the left Shower Stall. On top of a small cart to the right entrance to the unsecured storage room were the following opened items: -two 7.5 fluid ounce (fl. oz.) plastic containers of peri-wash with the warning :"Keep Out of the Reach of children." - one 7.5 fl. oz. plastic container of Derma Vera, with the warning for "External Use Only," -one 7.5 fl. oz. plastic container of Derma Daily (body lotion), with the warning "For External Use Only," -two 7.5 fl. oz. plastic containers of Barrier Ointment, with the warning, For External Use Only," -a 1.8 oz. tube of Preparation H, -and a quart plastic container of Enzyme Spray, with the warning "Keep Out of the Reach of Children." Above the cart was an opened metal cabinet with a package of plastic razors and three 7.5 fl. oz, containers of Derma Daily. During observation of the chemical hazards on 8/20/14 at 8:05 A.M. with the DON, she said that the above items were a hazard to residents and should not be left unsecured in the shower suite. 4. For Resident #5, the facility failed provide adequate supervision and assistive devices to prevent 10 falls. Resident #5 was admitted to the facility in 6/2013 with [DIAGNOSES REDACTED]. Review of the plan of care for falls, dated 6/14/13 indicated the following interventions: - chair Sensor, - Bed Sensor, and - Motion Detector on the floor. Review of the Fall Incident Report, dated 8/25/13, indicated the resident had an unwitnessed fall in the bedroom at 8:35 A.M. The report indicated the resident self transferred and fell . The report further indicated the resident is very independent and will not ask for help. Staff encouraged to respond to the resident's alarm immediately. Review of the Quarterly MDS Assessment, dated 9/5/13, indicated the resident was cognitively intact, did not ambulate, and had experienced 1 fall with no injuries. Review of the Fall Checklist (the facility was unable to find the Fall incident Report), dated 11/12/13, indicated the resident had an unwitnessed fall at 2:00 P.M. in his/her bedroom. The resident attempted to transfer self from the chair to the bed. The resident had the wrong alarm at the time of fall and the alarm was not attached therefore did not sound. The staff was educated related to the correct alarm (a chair sensor alarm not a magnetic chair alarm). Review of the Quarterly MDS Assessment, dated 11/20/13, indicated there resident was cognitively intact, was an assistance of 1 with ambulation, and had experienced 1 fall with no injuries. Review of the Fall Incident Report, dated 11/29/13, indicated the resident had an unwitnessed fall at 8:00 P.M. in his/her bathroom. The investigation indicated the chair alarm did not sound because the resident shuts the alarms off so he/she can self transfer. The new intervention was to move the alarm box out of reach so the resident is unable to shut off. Review of the Fall Incident Report, dated 12/11/13, indicated the resident had an unwitnessed fall at 11:50 A.M. in the bathroom. The investigation showed that the resident shut the chair alarm off and self transferred, therefore the alarm did not sound. Further investigation indicated that the wrong alarm was attached to the chair. The facility was using the magnetic clip alarm not the chair sensor alarm and did not move the alarm box out of reach. Review of the Fall Incident Report, dated 1/13/14, indicated the resident had an unwitnessed fall at 12:45 P.M. in the bedroom. The resident was trying to self transfer from the bed to the chair. The alarm did not sound because the bed sensor pad was not attached to the alarm box, and the motion detector was not working. Additional recommendations to prevent the resident from falling again was to encourage out of room activities in a supervised area. Review of the plan of care for falls, dated 3/29/14, included the following interventions; - Chair Sensor, - Bed Sensor, - Bathroom Door Alarm, - Motion Detector on the floor, - Encourage resident to lie down when in bed or sit in wheel chair, - Encourage to attend out of room activities, - Place alarm boxes out of reach, and - Low bed. Review of the Fall Incident Report, dated 2/4/14, indicated the resident had an unwitnessed fall at 8:20 A.M. The resident said he/she slipped of the side of the bed. The new intervention was to get up early in a supervised area and encourage the resident to activities. Review of the Fall Incident Report, dated 3/29/14, indicated the resident had an unwitnessed fall at 6:15 P.M. in his/her bedroom. The resident slid from his/her bed. A Nursing to Rehab (Rehabilitation) Screen request was sent. The Rehab recommended frequent checks and that the resident not be allowed to sit on the edge of the bed, unsupervised, that he/she should either be laying down in bed or up in the wheelchair. Review of the Fall Incident Report dated, 5/5/14, indicated the resident had an unwitnessed fall at 12:10 P.M. in the bedroom when transferring from the bed to the wheelchair. A Nursing to Rehab Screening Request was sent. The Rehab department recommended a door alarm to notify staff when the resident enters the room and the resident participate in as many activities as possible. Also the resident enjoys to sit in the sun. Review of the Fall Incident Report, dated 8/2/14, indicated the resident had an unwitnessed fall at 6:45 P.M. in the bedroom. The report indicated the resident was trying to self transfer from the chair to the bed. Anti-tippers where applied to the resident's wheelchair. Review of the Fall Incident Report, dated 8/4/14, indicated the resident had an unwitnessed fall at 9:45 A.M. in his/her bedroom. The resident was attempting to transfer him/her self from the bed to the chair. The investigation did not mention if the bed alarm or motion sensor sounded. On 8/20/14 at 8:00 A.M. the surveyor observed the resident in the hallway self propelling in a wheelchair. An alarm was attached to the chair. During an interview on 8/21/14 at 10:00 A.M. with the DON she said that the resident can not be supervised because he/she goes where he/she wants. In addition she said that he/she does not like to attend activities, therefore is very difficult to keep an eye on him/her. She said that the facility will have to come up with something to keep him/her safe. 5. For Resident #9, the facility failed to provide adequate supervision and assistance devices to prevent a fall. Resident #9 was admitted to the facility in 11/2011 with [DIAGNOSES REDACTED]. Review of the plan of care for falls, dated 2/2/14, indicated the following interventions: - Magnetic Chair Alarm, - Bed Sensor, - Dycem to wheelchair, - Floor Mats, - Motion Sensor on the floor at night, - Bed in low position at all times. Review of the Annual MDS Assessment, dated 6/12/14, indicated the resident was severely cognitively impaired, needed assistance of 1 for transfers and ambulation, and had not experience any falls since the last assessment. Review of the Fall Incident Report, dated 6/24/14, indicated the resident had an unwitnessed fall at 2:15 P.M. in the bedroom. The investigation indicated the resident did not have the bed sensor or motion sensor in place. On 8/21/14 at 8:10 A.M. the surveyor observed the resident in the hallway sitting in a wheel chair with an alarm attached. During an interview on 8/26/14 at 10:15 A.M. with the DON, she said the staff did not apply the resident's alarms.

Based on observation, record review, resident and staff interviews, the facility failed to ensure that 4 of 19 sampled residents (#5, #6, #9 and #11), ability to ambulate did not diminish. Findings include: 1. For Resident #5, the facility failed to follow the Functional Maintenance Program (FMP). Resident #5 was admitted to the facility in 6/2013 with [DIAGNOSES REDACTED]. Review of the Rehabilitation (Rehab) discharge instructions, dated 1/6/14, indicated he/she was able to ambulate up to 125 feet (ft.) with a minimal assistance of 1 using a rolling walker. Review of the physician's orders [REDACTED]. The resident is able to ambulate 125 ft. with minimal assistance of 1. Review of the Restorative Documentation, dated 1/13/14 - 1/30/14, indicated the resident was ambulating up to 70 ft with extensive assistance of 1 person. Review of the clinical record indicated there was no documentation for the Restorative Nursing for the month of 2/2014. Review of the clinical record indicated a Rehab to Nursing Communication form, dated 2/13/14, indicating the resident was no longer on Restorative Nursing, that the resident was now on FMP. The instructions were for the resident to ambulate with the assistance of 1 person, 20 to 100 ft. Review of the clinical record indicated there was no documentation for the FMP. Review of the Certified Nursing Assistant (CNA) flow sheet, dated 2/2014, indicated the resident ambulated 5-25 ft., 8 out of 28 days. The remainder of the month the resident did not ambulate. Review of the CNA flow sheet, dated 3/2014, indicated the resident ambulated 10-25 ft., 5 out of 31 days. The remainder of the month the resident did not ambulate. Review of the Annual Minimum Data Set (MDS) Assessment, dated 4/18/14, indicated the resident had moderately impaired cognition, and was a limited assistance of 1 for ambulation. Review of the CNA flow sheet, dated 4/2014, indicated the resident ambulated 10-25 ft., 18 out of 30 days. The remainder of the month the resident did not ambulate. Review of the CNA flow sheet, dated 5/2014, indicated the resident ambulated 5-25 ft. on a daily basis. Review of the CNA flow sheet, dated 6/2014, indicated the resident ambulated only 1 day the entire month 10-25 ft. Review of the Nursing to Rehab Screening request, dated 6/27/14, indicated the resident will rarely ambulate with staff and he/she is not picking up his/her legs when taking a step. The Rehab department responded that they will screen the resident on 7/7/14. Review of the Quarterly MDS Assessment, dated 7/1/14, indicated the resident had severe cognitive loss and did not ambulate. Review of the Rehab to Nursing Communication Form, dated 7/7/14, indicated the resident was not screened because he/she was not feeling well and Nursing had requested for the Rehab Department to come back later. Review of the CNA flow sheet, dated 7/2014, indicated the resident did not ambulate for the entire month. Review of the Nursing to Rehab Screening request, dated 8/1/14, indicated the resident is not walking. The Rehab department responded that they would screen the resident when the resident agreed. On 8/5/14, the Physical Therapist (PT) evaluated Resident #5 (40 days after first requested to be screened). The evaluation indicated the resident was unable to ambulate at the time of the evaluation. The goal was to strengthen the resident and set up a FMP program for the resident to follow. Review of the CNA flow sheet, dated 8/1/14 - 8/20/14, indicated the resident ambulated 5-10 ft., 11 out of the 20 days. The other 9 days the resident did not ambulate. During an interview on 8/20/14 at 1:45 P.M., the Director of Nurses (DON) said that the rehab department should have been notified right away that the resident was not ambulating the distance that he/she was ambulating when discharged from rehab. She said that, based on the CNA flow sheets, it looks like the resident stopped ambulating the desired distance immediately. On 8/22/14 at 11:00 A.M., the surveyor observed Resident #5 ambulating in the hallway. The resident ambulated with an extensive assistance of 2 and a rolling walker approximately 15 ft. During an interview on 8/26/14 at 9:15 A.M. with Occupational Therapist (OT) #1, who is also the Director of the Rehab department, she said that the Restorative Nursing Program had stopped in 2/2014. She said that residents are now put on a FMP that is supposed to be documented on the CNA flow sheets. She said that she should have been notified before June, 2014 that the resident was not ambulating up to the 125 ft. She said she was not aware until recently that the resident's ambulation status had declined. 2. For Resident #9, the facility failed to follow the FMP. Review of the PT weekly documentation, dated 9/26/13, indicated the resident was ambulating 250 ft with minimal assistance. Physical therapy was discontinued. Review of the physician's orders [REDACTED]. Review of the Quarterly MDS Assessment, dated 10/23/13, indicated the resident had severe cognitive impairment, had no behaviors of refusing care and was an extensive assistance of 1 for ambulation. Review of the FMP form, dated 10/2013, indicated the resident ambulated 10-25 ft., 29 out of 31 days. The resident ambulated 50-100 ft. for the remainder of the month. Review of the FMP form, dated 11/2013, indicated the resident ambulated 10-25 ft., 21 out of 30 days, and ambulated 100-200 ft. for 5 days. The remainder of the month was left blank. Review of the FMP form, dated 12/2013, indicated the resident ambulated 10-25 ft., 29 out of 31 days, and the remainder of the month was left blank. Review of the Quarterly MDS Assessment, dated 1/8/14, indicated the resident had severe cognitive impairment, had no behaviors of refusing care and needed limited assistance of 1 for ambulation. Review of the FMP form, dated 1/2014, indicated the resident ambulated 5-10 ft., 14 out of 31 days. The resident ambulated 100-200 ft. for 2 days. The resident ambulated 10-25 ft. for the remainder of the month. Review of the FMP form, dated 2/2014, indicated the resident ambulated 5-10 ft., 7 out of 28 days, and the resident ambulated 25-50 ft. for the remainder of the month. Review of the FMP form, dated 3/2014, indicated the resident ambulated 5-10 ft., 15 out of 31 days, and for the remainder of the month, the resident ambulated 25-50 ft. Review of the FMP form, dated 4/2014, indicated the resident did not ambulate 14 out of 30 days. For 6 days, Resident #9 ambulated 10-25 ft, and the remainder of the month was left blank. Review of the FMP form, dated 5/2014, indicated for 11 out of 31 days, the resident did not ambulate. For 9 days Resident #9 ambulated 5-10 ft., and for 2 days he/she ambulated 10-25 ft. For 2 more days the resident ambulated 25-50 ft. and the remainder of the month was left blank. Review of the Quarterly MDS Assessment, dated 6/12/14, indicated the resident had moderately impaired cognition, no behaviors of refusing care and needed extensive assistance of 1 for ambulation. Review of the FMP form, dated 6/2014, indicated the resident did not ambulate 15 out of 30 days. For 3 days, Resident #9 ambulated 5-10 ft.; for 9 more days, the resident ambulated 25-100 ft., and the remainder of the month was left blank. Review of the FMP form, dated 7/2014, indicated the resident did not ambulate 20 out of 30 days. For 6 days, the resident ambulated 25-100 ft., and the remainder of the month was left blank. In the month of 8/2014 the facility no longer utilized the FMP form and now all ambulation documentation was on the CNA flow sheets. Review of the CNA flow sheet, 8/1/14 - 8/20/14, indicated the resident ambulated 10-25 ft., 7 out of the 20 days. The resident did not ambulate for the remaining 13 days. During an interview on 8/21/14 at 4:20 P.M., Unit Manager #1 said that the resident often refused to ambulate, but she does see staff walking the resident about 3 times a week. On 8/22/14 at 9:20 A.M. the surveyor observed Resident #9 ambulating in the hallway with a 2 person assistance and rolling walker. The resident ambulated approximately 100 ft. During an interview on 8/26/14 at 9:45 A.M., OT #1 said she was not aware that the resident was refusing to ambulate on numerous occasions. She said that she should have been made aware so the Rehabilitation Department could screen the resident to ensure nothing was wrong. 3. For Resident #11, the facility failed to follow the FMP. Resident #11 was admitted to the facility in 5/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], indicated the resident was cognitively impaired, and required an extensive assistance of 1 for ambulation. Review of the Physical Therapy Evaluation, dated 3/6/14, indicated the resident had recently declined with ambulating and now required 2 person assistance for ambulation instead of a 1 person assist. It further indicated the resident would benefit from Physical Therapy 3 to 5 times a week for 4 weeks. Review of physician's orders [REDACTED]. Review of the Physical Therapy Progress Note, dated 4/2/14, indicated Resident #11 was now ambulating 50 to 70 ft. with minimal assistance of 1 person and a rolling walker (R/W.) The resident was discontinued from Physical Therapy to a FMP. Review of the FMP Form, dated 4/2014, indicated the resident ambulated on a daily basis 5 to 50 ft. with assistance of 1 person. (The facility then discontinued the use of the FMP Form). Review of the Quarterly MDS Assessment, dated 4/22/14, indicated the resident was cognitively impaired, and required extensive assistance of 1 person for ambulation. Review of the clinical record indicated there was no documentation for the FMP. Review of the CNA Flow sheet, dated 5/2014, indicated the resident ambulated on a daily basis 100-200 ft. with extensive assistance of 1 person. Review of the CNA Flow sheet, dated 6/2014, indicated the resident ambulated 100-200 ft., 25 days out of the month, the remainder of the days the resident ambulated 5 - 25 ft. All ambulation required extensive assistance of 1 person. Review of the Quarterly MDS Assessment, dated 7/9/14, indicated the resident was cognitively impaired, and required an extensive assistance of 1 person for ambulation. Review of the CNA Flow sheet, dated 7/2014, indicated the resident ambulated on a daily basis 5-25 ft. with extensive assistance of 1 person. Review of the CNA Flow sheet, dated 8/1/14 - 8/21/14, indicated the resident ambulated on a daily basis 5-10 ft. with extensive assistance of 1 person. Review of the Nursing to Rehab Screening Request Form, dated 8/19/14, indicated the resident was very unsteady, and the resident is walking on his/her toes. Review of the Rehab to Nursing Communication Form, dated 8/19/14, recommended that Resident #11 now requires a 2 person assistance with a rolling walker for ambulation. On 8/22/14 at 10:30 A.M. the surveyor observed Resident #11 being ambulated with 2 CNAs, a gait belt and a rolling walker. The resident ambulated approximately 100 feet. During an interview on 8/26/14 at 9:40 A.M. OT #1, who is also the Director of the Rehab Department, said that she should have been contacted if the resident had a change in his/her ambulation status. She said the department never received a request to screen Resident #11 and she was not aware of any changes concerning the resident. 4. For Resident #6, the facility failed to maintain the resident's ambulation under the FMP. Findings include: Resident #6 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 4/24/14, indicated the resident was moderately intact cognitively (Brief Interview of Mental Status (BIMS) score of 11/15), and required extensive assistance of one for ambulation in the hallway. Review of Nursing Notes, dated 4/24/14, indicated the resident was working with PT (Physical Therapy) to improve function, with a R/W. Nursing Notes of 5/3/14 on the daytime shift indicated the "Resident says (he/she) exercises so (he/she) can get out of the facility." physician's orders [REDACTED]. with R/W -1A (1 Assist) and W/C (Wheelchair) back up to meals (day and evening meals) 5 X (Times) Wk (Week.). The Falls Prevention care plan, dated 5/27/14, indicated "FMP for ambulation as ordered." Review of the Nurse Aide Flow Sheet daily documentation, from 5/27/14 to 5/31/14, indicated the resident ambulated a total of nine times for a distance of 5-10 ft. with assistance. No ambulation was documented on 5/30/14 on the daytime shift. Review of the 6/2014 Nurse Aide Flow Sheet daily documentation indicated the following: -the resident ambulated with assistance but without any documented distance on the evening shift from 6/1/14-6/18/14, -the resident ambulated with assistance for a distance of 5-10 ft. on the evening shift from 6/19/14-6/30/14, -No ambulation was documented on 6/21/14 and 6/26/14 on the evening shift, -the resident ambulated with assistance for a distance of 5-10 ft. on the daytime shift on 6/1/14, 6/19/14, and 6/21/14, -No ambulation was documented on 6/2/14, 6/24/14 and 6/28/14 on the daytime shift, -the resident ambulated with assistance for a distance of 10-25 ft. on the daytime shift on 6/22/14, -the resident ambulated with assistance 25-50 ft. on the daytime shift on 6/20/14, 6/26/14, 6/27/14, and 6/29/14, -the resident ambulated with assistance 50-100 feet on the daytime shift on 6/30/14, -and the resident only ambulated with assist 100-200 ft. on the daytime shift from 6/16/14-6/18/14, and on 6/23/14 and 6/25/14. Review of the Quarterly MDS Assessment, dated 6/16/14, indicated the resident was cognitively intact BIMS score of 15/15, and required extensive assistance of one for ambulation in the hallway. The Care Plan Update Sheet, dated 6/24/14, indicated the resident was checked as being a FMP resident ambulating 200 feet with R/W, One Assist, Gait Belt and W/C backup. At no time in June, 2014 did the resident ambulate with assist 100-200 feet to meals (day and evening meals) 5 times a week. Review of the 7/2014 Nurse Aide Flow Sheet daily documentation indicated the following: -No ambulation was documented on 7/10/14, 7/13/14, and 7/30/14 on the evening shift. -the resident ambulated with assistance for a distance of 10-25 ft. on the evening shift from 7/1/14-7/9/14, 7/11/14, 7/12/14, and from 7/14/14-7/16/14, -the resident ambulated with assistance 25-50 ft. on the evening shift from 7/17/14-7/26/14, 7/28/14-7/29/14 and 7/31/14, -the resident ambulated 50-100 ft. on the evening shift on 7/27/14, -the resident ambulated with assist for a distance of 5-10 ft. on the daytime shift on 7/5/14, 7/23/14, and 7/28/14, -No ambulation was documented on 7/8/14, 7/12/14, and 7/15/14 on the daytime shift, -the resident ambulated with assist for a distance of 25-50 ft. on the daytime shift on 7/3/14, 7/21/14-7/22/14, 7/25/14-7/26/14, and 7/30/14-7/31/14, -the resident ambulated with assist 50-100 feet on the daytime shift on 7/6/14, -and the resident ambulated with assist 100-200 feet on the daytime shift from 7/1/14-7/2/14, 7/4/14, 7/7/14, 7/9/14-7/11/14, 7/13/14-7/14/14, 7/16/14-7/22/14, 7/24/14, and 7/29/14, At no time in July, 2014 did the resident ambulate with assist 100-200 feet to meals (day and evening meals) 5 times a week. A Nursing to Rehab Screening Request, dated 7/22/14, for a "Strengthening Potential" due to a change in ambulation (independence in a wheelchair), resulted in no Rehab Interventions being warranted, Review of the 8/2014 Nurse Aide Flow Sheet daily documentation, from 8/1/14 to 8/24/14, indicated the following: -No ambulation was documented on 8/19/14 on the evening shift. -the resident ambulated with assist for a distance of 5-10 ft. on the evening shift on 8/24/14, -the resident ambulated with assist 10-25 ft. on the evening shift from 8/5/14-8/9/14, -the resident ambulated 25-50 ft. on 8/1 and 8/4/14, -the resident ambulated 50-100 ft. on the evening shift on 8/3/14 and 8/11/14, -the resident ambulated 100-200 ft. on the evening shift 8/10/14, 8/12/14-8/18/14, and 8/20/14-8/23/14, -No ambulation was documented on 8/4/14 and 8/9/14 on the daytime shift. the resident ambulated with assist for a distance of 5-10 ft. on the daytime shift on 8/7/14, 8/17/14-8/19/14, and 8/22/14-8/24/14, -the resident ambulated with assist for a distance of 10-25 ft. on the daytime shift on 8/5/14, 8/8/14, 8/10/14-8/12/14, 8/14/14, and 8/16/14, -the resident ambulated with assist 25-50 ft. on the daytime shift on 8/13/14 and 8/21/14, -the resident ambulated with assist 50-100 ft. on the daytime shift on 8/2/14, -and the resident ambulated 100-200 ft. on the daytime shift on 8/1/14, 8/3/14, 8/6/14, 8/15/14, and 8/20/14. At no time in August, 2014 did the resident ambulate with assist 100-200 feet to meals (day and evening meals) 5 times a week. During interview with the resident on 8/25/14 at 10:00 A.M. in the resident's bedroom with the resident seated in a wheelchair, the resident said that occasionally he/she ambulated 150-200 ft. to meals by staff, but usually it is only to the bathroom using the rolling walker and one assist. The resident said "I'm not going to get home at this rate." Observation of the resident on 8/25/14 at 10:30 A.M. indicated the resident ambulating with staff with a gait belt, using a R/W with W/C back up to the nail polishing activity in the dining room. Observation of the resident on 8/25/14 at 4:40 P.M. indicated the resident self-propelling the W/C from the nurse's station to the main dining room. No staff assistance or use of the R/W was used per the FMP to the evening meal. During an interview on 8/25/14 at 1:00 P.M., the daytime assigned CNA (Certified Nursing Aide) #1 said that the resident was alert, cooperative and oriented, and usually was ambulated to the bathroom with a R/W, and gait belt with one assist, or approximately 10 feet when toileted. CNA #1 said the resident was independent with W/C ambulation. During an interview on 8/26/14 at 7:50 A.M., OT #1, who was also the Director of Rehabilitation, said that the functional ambulation for Resident #8 was not being followed by the facility.

Based on observations, record review, resident and staff interviews, the facility failed to develop appropriate treatment and services to restore and/or improve normal bladder function to the extent possible for 4 of 8 applicable sampled residents (#2, #4, #6, and #8) who developed bladder incontinence in a total sample of 19 residents. Findings include: Review of the facility Incontinence Policy, adopted 7/15/11, indicated that an assessment tool would be completed for each resident on admission, annually, and with a significant change. An individualized care plan would be initiated to include interventions consistent with the resident's goal of decreased incontinence. 1. For Resident #6, the facility failed to provide treatment and services to address the resident's decline in continence and develop a care plan to restore as much bladder functioning as possible. Resident #6 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) Assessment of 4/24/14 indicated the resident was moderately intact cognitively (Brief Interview of Mental Status (BIMS)) of 11/15, required extensive assistance for transfers, ambulation and toilet use, had an indwelling catheter and occasionally was incontinent of bowel. The resident had a urinary tract infection and was administered antidepressant medication daily. Review of Physician Orders, dated 4/24/14, indicated that the resident's Foley Catheter was removed. Nursing Notes of 4/27/14 indicated the resident was incontinent all shifts. Nurse Aide Flow Sheets of 5/2014 indicated the resident was incontinent of bladder all shifts with the extensive assistance of one. Nursing Notes of 5/6/14, on the nighttime shift, for example, indicated the resident requested toileting four times that shift, and, on 5/10/14, dysuria/burning was denied by the resident upon urination. Nurse Aide Flow Sheets of 6/2014 and Licensed Nursing Summary of 6/2014 indicated the resident was continent of urine all days on the nighttime shift, and incontinent all days on the daytime and evening shifts, all with a limited assistance of one. Review of the quarterly MDS Assessment of 6/16/14 indicated the resident was cognitively intact with a BIMS score of 15/15, was depressed, was frequently incontinent of bowel and bladder but only required limited assistance for toilet use. The Interdisciplinary Resident Care Meeting of 6/11/14 made no mention about the resident's urinary incontinence status. There was no evidence the facility conducted a bladder assessment for incontinence nor a 72 hour bladder patterning. The resident's Care Plan Update Sheet, dated 6/24/14, indicated the resident was incontinent of bladder and continent of bowel, required assistance for toileting, utilized a rolling walker and wore pullups. Nurse Aide Flow Sheets of 7/2014 and the 7/2014 Licensed Nursing Summary indicated the resident was continent of urine on all shifts for the month. The resident was incontinent of bowel on 7/11/14, and 7/19 to 7/22/14 during the daytime shift. Nurse Aide Flow Sheets of 8/2014, from 8/1/14 to 8/25/14, indicated the resident was continent of urine all days on the nighttime shift, all days, with the assistance of two, and continent all days on the daytime shift, with the exception of 8/11/14 to 8/14/14 when the resident was incontinent of urine. He/she required the assistance of one staff member. The resident was documented as continent of urine on the evening shift from 8/1/14 to 8/11/14, and incontinent when toileted from 8/12/14 to 8/24/14 on the evening shifts, all with a limited assistance of one. Observation of the resident on 8/25/14 at 7:58 A.M. indicated the resident in bed with the resident's call bell on the floor on the right side of the bed, out of reach of the resident. At 10:30 A.M. the resident was observed ambulating with staff with a gait belt, using a R/W with W/C back up to the nail polishing activity in the dining room. Observation of the resident on 8/25/14 at 4:40 P.M. indicated the resident self-propelling the W/C to the main dining room. During interview with the resident on 8/25/14 at 10:00 A.M., the resident said that he/she tells staff when he/she needs to be toileted but frequently becomes incontinent if staff do not toilet the resident promptly. "I have to wait too long," said the resident. The resident said he/she was not on a scheduled toileting program. During an interview on 8/25/14 at 1:30 P.M., the assigned daytime CNA (Certified Nursing Aide) #1 said that the resident was alert, cooperative and oriented, and usually was ambulated to the bathroom with a R/W, and gait belt with one assist. The resident was found to be usually incontinent of urine during morning care, but could remain continent on the daytime shift if toileted promptly. The resident was usually incontinent of bowel and wore pull-ups. During an interview on 8/25/14 at 9:50 A.M., Unit Manager (UM) #1 said that the facility had not assessed or care planned for the resident's bladder incontinence, to promote as much resident bladder functioning as possible. 2. For Resident #8, the facility failed to provide assistance and/or devices to promote as much bladder functioning as possible when the resident developed bladder incontinence. Resident #8 was admitted to the facility in 5/2014 with [DIAGNOSES REDACTED]. The resident's Care Plan Update Sheet, dated 5/5/14, indicated the resident was continent of bladder and bowel and was to be offered toileting every 2 hours and as requested. Staff were to watch for increased anxiety, standing unassisted for indications of the resident's need to void. The Continence History Assessment of 5/6/14 indicated the resident had incontinence because the resident could not get to the bathroom in time once the resident felt the need to void, and that the resident had no previous urinary incontinence. The facility's Bladder Assessment, dated 5/6/14, indicated that the resident had a score of 9 representing a candidate for scheduled/Prompted Toileting Plan. The resident's Bladder Care Plan Tool of 5/6/14 indicated the resident had mixed incontinence, was incontinent 2-4 times in small "amounts on the 3-11, 11-?" (shifts). The Plan indicated the resident was continent and requests assist/stands unassisted when need to void. Some incontinence was noted on the evening shift, and the plan was to offer toileting every 2 hours. The resident's admission MDS assessment of 5/17/14 indicated the resident had moderate intact mental functioning (BIMS of 12/15), wore glasses. required limited assistance for toilet use, extensive assistance for transfers, ambulation, dressing, hygiene and bathing, was continent of bowel and bladder, had moderate back pain, had fallen with a fracture prior to admission, and was administered antidepressants and diuretics daily. Review of the 6/2014 Nurse Aide Flow Sheet indicated the resident was hospitalized from [DATE] to 6/16/14. The documentation indicated the following: -the resident was continent of bladder 6/1/14 to 6/3/14 on the nighttime shift with one assistance, -the resident was incontinent of bladder with one assistance on the nighttime shift, from 6/4/14 to 6/11/14 and from 6/17/14 to 6/30/14, -the resident was continent on the daytime shift from 6/1/14 to 6/10/14, from 6/18/14 to 6/23/14, and on 6/30/14 with one assist, -the resident was incontinent on 6/16/14, and from 6/24/14 to 6/29/14 with one assist, -the resident was continent on the evening shift from 6/1 to 6/10/14, and 6/16/14, -and the resident was incontinent from 6/17/14 to 6/30/14 on the evening shift with two assists. The Bladder Care Plan Tool of 6/19/14 indicated the resident was continent and requested assistance for toileting. Review of the 7/2014 Nurse Aide Flow Sheet indicated the following: -the resident was incontinent of bladder all days on the nighttime shift with one assistance, -Except for 7/4/14, the resident was continent of bladder with one assistance on the daytime shift, -and the resident was continent on the evening shift all days with one assistance. The quarterly MDS assessment of 7/31/14 indicated the resident was usually incontinent of bladder with extensive assistance of one. Review of the 8/2014 Nurse Aide Flow Sheet, from 8/1/14 to 8/25/14, indicated the following: -the resident was incontinent of bladder all days on the nighttime shift with one assistance, -Except for 8/1/14 to 8/3/14 when the resident was incontinent of bladder, the resident was continent of bladder with one assistance on the daytime shift, -and the resident was continent on the evening shift all days with one assistance. Observation on 8/25/14 at 3:00 P.M. and at 4:25 P.M. indicated the resident dressed and lying in bed with eyeglasses on. The resident was alert and responsive, and indicated personal falls when attempting to transfer out of bed or in the bathroom when he/she sustained fractures at home. During interview on 8/25/14 at 3:35 P.M., the assigned evening CNA #3 said that the resident was alert and oriented, utilized a wheelchair for ambulation and a rolling walker to go to the bathroom. Staff usually toileted the resident when the resident attempted to stand independently. CNA #3 said that the resident had been incontinent one time on the evening shift this day. During interview on 8/25/14 at 4:30 P.M., Unit Manager (UM #2) said that the facility had not conducted a Scheduled/Prompted Toileting Plan when the resident was assessed in 5/2014, and that the resident had declined in bladder incontinence. 3. For Resident #2, the facility failed to implement the results of a bladder assessment into the resident's care plan to decrease urinary incontinence. Resident #2 was admitted to the facility in 2/2013 and readmitted in 12/2013 with [DIAGNOSES REDACTED]. Review of a Bladder Assessment, dated 12/30/13, indicated the resident was always incontinent. A three day incontinence monitoring record was done from 12/31/13 to 1/2/14. The result of the assessment indicated the resident had mixed incontinence. The plan was to implement a scheduled toileting plan. The resident was to be toileted every 3 to 4 hours during the 7:00 A.M. to 3:00 P.M. shift and the 3:00 P.M. to 11:00 P.M. shift, and during CNA rounds on the 11:00 P.M. to 7:00 A.M. shift. Review of the Initial MDS Assessment, dated 1/10/14, indicated the resident was cognitively intact and was always incontinent of bladder. Review of a Falls/Rehabilitation Care Plan, dated 1/10/14, indicated an intervention to toilet as per CNA Care Plan, and to provide incontinence care and incontinence briefs as necessary. Review of the CNA Care Plan, dated 2/13/14, indicated the resident was incontinent of bladder and required assistance with toileting. No toileting schedule was indicated. Review of the Quarterly MDS Assessment, dated 3/27/14, indicated the resident was always incontinent of bladder. Review of the CNA Care Plan, dated 4/3/14, indicated the resident was continent of bladder, requested assistance to go to the toilet and was to be ambulated to the bathroom. Review of a Care Plan for Urinary Incontinence, dated 6/1/14, indicated the resident was frequently incontinent of bladder. The goal was the resident would be continent 75% of the time. One intervention was, if no change or decline in incontinence, re-evaluate plan. Review of the Quarterly MDS Assessment, dated 6/17/14, indicated the resident was always incontinent of bladder. During an interview on 8/21/14 at 9:00 A.M. with CNA #6, he said the resident will occasionally ask to use the bathroom but is often incontinent. He said there was no scheduled toileting plan, they just took him/her to the bathroom when he/she asked to go. During an interview on 8/21/14 at 11:00 A.M. with UM #2, she said the toileting schedule indicated on the bladder assessment was never incorporated into the care plan. She also said the CNA Care Plan was incorrect and had not been updated since 4/2014. 4. For Resident #4, the facility failed to assess the resident and implement a care plan when the resident had a decline in bladder continence. Resident #4 was admitted to the facility in 6/2013 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS Assessment, dated 11/14/13, indicated the resident was cognitively impaired and always continent of bladder. Review of the 11/2013 CNA Flow Sheet indicated the resident was continent of bladder. Review of the 12/2013 CNA Flow Sheet indicated the resident was continent of bladder for the 11:00 P.M. to 7:00 A.M. and the 7:00 A.M. to 3:00 P.M. shift, but incontinent 25 days for the 3:00 P.M. to 11:00 P.M. shift. Review of the 1/2014 CNA Flow Sheet indicated the resident was continent of bladder. Review of the CNA Care Plan, dated 2/13/14, indicated the resident was incontinent of bladder and wore pull-ups (an adult brief for bowel and bladder incontinence). Review of the CNA Flow Sheets, from 2/2014 to 4/2014, indicated the resident was continent of bladder. Review of the 5/2014 CNA Flow sheet indicated the resident was continent of bladder for the 11:00 P.M. to 7:00 A.M. and 3:00 P.M. to 11:00 P.M. shifts and incontinent 23 days for the 7:00 A.M. to 3:00 P.M. shift. Review of a Significant Change MDS, dated [DATE], indicated the resident had cognitive impairment and was frequently incontinent of bladder. Review of the Care Area Trigger (CAT) worksheet, dated 5/20/14, indicated the resident had urinary incontinence and a care plan would be developed to decrease urinary incontinence. Review of the Interdisciplinary Care Plan Problem Statement and Goal sheet for Urinary Incontinence, dated 5/20/14, indicated the resident was frequently incontinent of urine. The goal was for the resident be continent of urine 75% of the time. Review of the care plan for Pressure Ulcers, dated 5/20/14, indicated an intervention to toilet as per CNA Care Plan. As stated above, the CNA Care Plan, dated (2/14/14), indicated the resident was incontinent and wore pull-ups. No toileting plan was indicated. Review of the 6/2014 CNA Flow Sheets indicated the resident was incontinent 19 days for the 11:00 P.M. to 7:00 A.M. shift and 19 days for the 7:00 A.M. to 3:00 P.M. shift. The resident was continent for the 3:00 P.M. to 11:00 P.M. shift. Review of the 7/2014 CNA Flow Sheets indicated the resident was incontinent daily, on all shifts. Review of the Quarterly MDS Assessment, dated 8/7/14, indicated the resident was always incontinent of bladder. Review of the 8/2014 CNA Flow Sheets, from 8/1/14 through 8/19/14, indicated the resident was incontinent daily, on all shifts. During an interview with MDS Nurse #2 on 8/20/14 at 2:40 P.M., she said no bladder assessment had been done for the resident since admission. She also said the resident's care plan and CNA Care Plan did not have interventions to decrease urinary incontinence. During an interview on 8/20/14 at 3:30 P.M., UM #2 said no bladder assessment had been done when the resident had a decline in bladder incontinence. The CNA Care Plan was incorrect and should have indicated a toileting schedule. At this time, she gave the surveyor an updated CNA Care Plan with an intervention, undated, to toilet the resident every 2 to 3 hours and upon request.

Based on observation, record review and staff interview, the facility failed to provide care in accordance with the written plan of care and/or physician's orders [REDACTED].#5, #7, #8, #9, and #18). Findings include: 1. For Resident #7, the facility failed to follow the plan of care to provide close supervision, diversional activities and functioning alarms to prevent five unwitnessed accidents with injuries that included a laceration with 4 staples and a fractured vertebrae. Resident #7 was admitted to the facility in 5/2013 with [DIAGNOSES REDACTED]. Review of the Resident Care Plan for falls, in effect 11/26/13, indicated the resident was at risk for falls related to confusion, behavior and self transfer with gait/balance deficit. The goal was for the resident to be free of falls/injury. The interventions included: -a Motion, Chair and bed sensor alarms, -and Diversional activities of choice. The resident's care plan was updated on 11/27/13 to provide the resident with close supervision when out of bed and to have the resident sit in the nurse's station area, not alone in the activity room. Review of Nursing Notes and the Fall Incident Report of 12/14/13 at 6:30 P.M. indicated the resident had an unwitnessed fall when the resident attempted to self transfer in the bedroom and was found on the floor on his/her knees beside the bed. No injury was observed. Staff responded to the bed alarm. There was no evidence the resident was provided close supervision when out of bed after the evening meal. Review of Nursing Notes and the Fall Incident Report of 3/31/14 at 2:05 P.M. indicated the resident had another unwitnessed fall when the resident attempted to self transfer from the resident's "personal" chair at the Nursing Station (lounge) area to toilet self. Staff heard a "thud" as the resident hit his/her head on the wall. The resident's chair sensor alarm was not in place, as planned. No injury was noted. Neither diversional activities nor close supervision was provided by staff when the resident was out of bed, as planned. Review of Nursing Notes and the Fall Incident Report of 5/11/14 at 1:20 P.M. indicated the resident had another unwitnessed fall when the resident left the supervised area,wheeled self into the bedroom, and attempted to self transfer to the bathroom. Staff responded to an alarm, found that the resident had removed his/her shoes and fallen. The resident had hit his/her forehead, causing a laceration. The resident was sent to the local hospital and received 4 staples to close the wound. There was no evidence that the resident received close supervision or a diversional activity after the lunch time meal, away from the nursing station area, as planned. The care plan was updated 5/11/14 to include a floor and bedroom door alarm. Review of Nursing Notes and the Fall Incident Report of 5/19/14 at 2:05 P.M. indicated the resident had an unwitnessed fall after wheeling self unsupervised into the bedroom, similar to the incident of 5/11/14. The resident attempted to self transfer from the wheelchair to the bathroom. Staff responded to the chair alarm sound and found that the resident on the right side of the bed with the wheelchair behind the resident. No injury was observed, and staff were again educated to have the resident placed in a stationary chair by the nursing station (lounge area). Review of Nursing Notes and the Fall Incident Report of 8/3/14 at 3:45 P.M. indicated the resident had another unwitnessed fall after the resident had self transferred from the stationary chair at the nursing station lounge area, fell backwards, hitting head on the floor. The resident was sent to the local hospital and returned with a [DIAGNOSES REDACTED]. Although several people were in the area, the resident was not specifically supervised to prevent another fall when the resident attempted self transfer. Additionally, the resident's chair alarm did not function and no diversional activity was identified, as planned. Observation on 8/21/14 at 2:15 P.M., indicated the resident ambulating with 2 Certified Nursing Aides (CNA) and wearing a gait belt in the hallway. From 9:30 A.M. to 11:10 A.M., the resident was observed dozing, staring into space, with eyeglasses affixed, seated in a "bouncy" chair with sensor alarm attached, at the nursing station lounge area. During this time the resident was not provided any diversional activity or close supervision from the nursing station. Observation on 8/22/14 at 7:45 A.M. indicated the resident seated in the lounge area across from the nursing station in a stationary chair with seat alarm. The resident got up with a walker, set off the alarm, and walked approximately 10 feet before staff interceded. The resident said he/she had to go to the bathroom. The resident had no activity to occupy his/her interests at this time. During interview on 8/26/14 at 1:10 P.M., the Director of Nursing (DON) said that the facility had relied too much on the use of alarms, which at times did not function, rather than targeting the resident for patterns and periods of time for close supervision, (particularly when the resident had urgency needs) as well as specific activities (such as interests in animal magazines/visits.) Please refer to F 323. 2. For Resident #8, the facility failed to provide the resident a functioning motion detector alarm to prevent falls. Resident #8 was admitted to the facility in 5/2014 with [DIAGNOSES REDACTED]. Review of the Resident Care Plan for falls, in effect from the date of admission, indicated the resident was to be free of falls/injury. The interventions included: -a Motion detector when in bed. Review of Nursing Notes and the Fall Incident Report of 8/8/14 at 4:00 P.M. indicated staff heard the resident yelling and found the resident sitting on the bedroom floor. The resident had attempted to get to the wheelchair from the bed, the bed moved as it was not locked, and the resident fell . The motion detector did not sound, as planned. No injury was noted. Observation on 8/25/14 at 3:00 P.M. and at 4:25 P.M. indicated the resident dressed and lying in bed with eyeglasses on. The resident was alert and responsive, and indicated he/she had personal falls when attempting to transfer out of bed or in the bathroom when he/she sustained fractures at home. On both bedroom visits to the resident by the surveyor, the motion detector on the resident's bureau, across from the resident's bed, did not sound. At 4:30 P.M., Surveyor #1 inquired of Unit Manager (UM #2), if the resident's motion detector was functioning. UM #2 went to the resident's room and said the motion detector was not sounding when motion occurred before it. UM #2 said that the motion detector did not sound when the resident fell in early 8/2014. Please refer to F 323. 3. For Resident #5, the facility failed to follow the plan of care for 5 out of 9 falls. Resident #5 was admitted to the facility in 6/2013 with [DIAGNOSES REDACTED]. Review of the plan of care for falls, dated 6/14/13, indicated the following interventions: - Chair Sensor, - Bed Sensor, and - Motion Detector on the floor. Review of the Fall Checklist (the facility was unable to find the Fall incident Report), dated 11/12/13, indicated the resident had an unwitnessed fall at 2:00 P.M. in his/her bedroom. The resident attempted to transfer self from the chair to the bed. The resident had the wrong alarm at the time of fall, and the alarm was not attached, therefore it did not sound. The staff was educated related to the correct alarm (a chair sensor alarm not a magnetic chair alarm). Review of the Fall Incident Report, dated 11/29/13, indicated the resident had an unwitnessed fall at 8:00 P.M. in his/her bathroom. The investigation indicated that the chair alarm did not sound because the resident would shut the alarms off so he/she could self transfer. The new intervention was to move the alarm box out of reach so the resident was unable to shut it off. Review of the Fall Incident Report, dated 12/11/13, indicated the resident had an unwitnessed fall at 11:50 A.M. in the bathroom. The investigation showed that the resident shut the chair alarm off and self transferred, therefore the alarm did not sound. Further investigation indicated that the wrong alarm was attached to the chair. The facility was using the magnetic clip alarm, not the chair sensor alarm, and the alarm box was not out of reach as planned. Review of the Fall Incident Report, dated 1/13/14, indicated the resident had an unwitnessed fall at 12:45 P.M. in the bedroom. The resident was trying to self transfer from the bed to the chair. The alarm did not sound because the bed sensor pad was not attached to the alarm box and the motion detector was not on the floor as planned. Review of the plan of care for falls, dated 3/29/14, included the following interventions: - Chair Sensor, - Bed Sensor, - Bathroom Door Alarm, - Motion Detector on the floor, - Encourage resident to lie down when in bed or sit in wheel chair, - Encourage to attend out of room activities, - Place alarm boxes out of reach, and - Low bed. Review of the Fall Incident Report, dated 8/4/14, indicated the resident had an unwitnessed fall at 9:45 A.M. in his/her bedroom. The resident was attempting to transfer him/her self from the bed to the chair. The investigation did not mention if the bed alarm or motion sensor sounded. During an interview on 8/21/14 at 10:00 A.M., the DON said that the plan of care was not followed. Please refer to F323. 4. For Resident #9, the facility failed to follow the plan of care to prevent 1 out of 2 falls. Resident #9 was admitted to the facility in 11/2011 with [DIAGNOSES REDACTED]. Review of the plan of care for falls, dated 2/2/14, indicated the following interventions: - Magnetic Chair Alarm, - Bed Sensor, - Dycem to wheelchair, - Floor Mats, - Motion Sensor on the floor at night, and - Bed in low position at all times. Review of the Fall Incident Report, dated 6/24/14, indicated the resident had an unwitnessed fall at 2:15 P.M. in the bedroom. The investigation indicated the resident did not have the bed sensor or motion sensor in place. During an interview on 8/26/14 at 10:15 A.M., the DON said the staff did not apply or turn on the alarms on as planned. Please refer to F323. 5. For Resident #18, the facility failed to follow a physician's orders [REDACTED]. Resident #18 was admitted to the facility in 7/2014 with [DIAGNOSES REDACTED]. The resident was discharged to the hospital 8/8/14. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. During an interview on 8/26/14 at 10:20 A.M., the DON said the physician's orders [REDACTED].