Every finding on record at Andover Forest Post Acute Care Center

Based on observations, interviews and record review, the facility failed to document accurately in the medical record for four Residents (#29, #13, #82 and #4) out of a total sample of 30 residents. Specifically, 1.For Residents (a.) #29 and (b.) #13, the facility inaccurately documented blood pressure vital signs. 2. For Resident (a.) #82 the facility failed to accurately document the setting of an air mattress. (b). #4 the facility failed to accurately document the use of tubi grips. Findings include:1 (a). Resident #29 was admitted to the facility in March 2026 with diagnoses including dependence on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status exam score of 14 out of 15 indicating intact cognition. Review of Resident #29's dialysis care plan initiated 3/4/26 indicated the following: -I currently have an alteration to my integumentary system due to left arm fistula (a surgically created connection between an artery and a vein in the left arm). Review of Resident #29's April 2026 physician's orders indicated no blood pressure on the left arm. Review of Resident #29's blood pressure vitals indicated nurses documented they took blood pressure on the left arm on the following days: -3/7/26, 3/10/26, 3/23/26 and 4/4/26. During an interview on 4/16/26 at 8:21 A.M., Resident #29 said nurses never take blood pressures on his/her left arm. Resident #29 said he/she would never allow the nurses to take a blood pressure on the left arm because his/her dialysis access is on his/her left arm. During an interview and medical record review on 4/16/26 at 8:59 A.M., the Assistant Director of Nurses reviewed the medical record and said the nurses documented incorrectly in the blood pressure vitals medical record. During an interview and medical record review on 4/16/26 at 9:10 A.M., Nurse #2 reviewed the medical record and said she did not take the Resident's blood pressure on the left arm on 3/23/26 because he/she has an Arteriovenous fistula (AV) on the left arm. Nurse #2 said she documented incorrectly. During an interview on 4/16/26 at 10:26 A.M., the Director of Nurses said nurses should document accurately in the medical record. (b). Resident #13 was admitted to the facility in November 2023 with diagnoses including dependence on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status exam score of 13 out of a possible 15 indicating intact cognition. Review of Resident #13's dialysis care plan initiated on 3/12/24 indicated the following: -I currently have an alteration to my renal dialysis due to end stage renal disease, and I have a left forearm AV Fistula. Review of Resident #13's April 2026 physicians orders indicated no blood pressure on the left arm. Review of Resident #13's blood pressure vitals indicated nurses documented they took blood pressure on the left arm on the following dates: -2/28/26, 3/9/26,3/14/26, 3/27/26, 3/29/26, 3/31/26, 4/2/26, 4/5/26, 4/6/26, 4/7/26, 4/9/26, 4/10/26, 4/12/26, and 4/16/26. During an interview on 4/16/26 at 8:49 A.M., Resident #13 said nurses do not take blood pressure on his/her left arm. Resident #13 said he/she would never allow the nurses to take blood pressure on his/her left arm because the dialysis port is located on his/her left arm. During an interview and medical record review on 4/16/26 at 9:24 A.M., Unit Manager #1 reviewed the medical record and said nurses are documenting blood pressure vitals incorrectly. The Unit Manager said the nurses should document accurately. During a telephone interview and medical record review on 4/16/26 at 3:39 P.M., Nurse #1 reviewed the medical record and said she incorrectly documented the Resident's blood pressure on 3/9/26 and 4/6/26. Nurse #1 said the Resident has an AV fistula on the left arm and blood pressure can only be taken on the right arm. During an interview on 4/16/26 at 10:26 A.M., the Director of Nurses said nurses should document accurately in the medical record. 2 (a). Resident #82 was admitted to the facility August 2022 with diagnoses including Alzheimer's dementia, malnutrition, and depression. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #82 is severely cognitively impaired. Further review indicated that Resident #82 is totally dependent on staff for activities of daily living. Review of the physician orders dated April 2026 indicated an order for air mattress on the setting of black dot. Check function every shift. On 4/14/26 at 8:18, 3:16 P.M., and 4:25 P.M., the surveyor observed Resident #82 lying in bed on an air mattress. The air mattress was not set on the black dot setting as ordered and as indicated on the air mattress pump. On 4/15/26 at 8:12 A.M., the surveyor observed Resident #82 lying in bed on an air mattress. The air mattress was not set on the black dot setting as ordered and as indicated on the air mattress pump. On 4/15/26 at 2:25 P.M., the surveyor and Nurse #1 observed Resident #82 lying in bed on an air mattress. The surveyor and Nurse #1 observed that the air mattress was not set on the black dot setting as ordered and as indicated on the air mattress pump. Review of the Medication Administration Record (MAR) dated 4/14/26 and 4/15/26 incorrectly indicated that the nurse documented that the air mattress was set at the correct setting. During an interview on 4/15/26 at 1:57 P.M, the Director of Nursing (DON) said that physician orders are to be followed as ordered. The DON said that nurses are to accurately document in the medical record and should not have documented that the air mattress was at the correct setting when it was not. During an interview on 4/15/26 at 2:30 P.M., Nurse #1 said that it was the responsibility of the nurses to ensure the air mattresses were set at the correct setting and to accurately document in the medical record. (b). Resident #4 was admitted to the facility in August 2021 with diagnoses including peripheral vascular disease, heart disease and kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated on the Brief Interview for Mental Status exam Resident #4 scored an 11 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated that Resident #4 requires substantial to maximal assistance with activities of daily living. Review of the April 20267 physician orders indicated an order for tubi grips (used for support and compression) on in A.M., and off in P.M., one time a day apply tubi grips and one time a day remove tubi grips. On 4/14/26 at 8:30 A.M.,12:30 P.M., and 4:10 P.M, the surveyor observed Resident #4 sitting in his/her room. The surveyor observed Resident #4 to be wearing a red pair of socks and nothing on his/her legs. Review of the Treatment Administration Record dated 4/14/26 inaccurately indicated that the tubi grips were in place as ordered. During an interview on 4/15/26 at 2:32 P.M., Resident #4 said that he/she has not worn the stockings (tubi grips) for a while. Resident #4 then said that no one offered to put them on today or yesterday. Resident #4 also said that if the physician wants him/her to wear them then he/she would. Resident #4 said that he/she did not refuse to wear the stockings. During an interview on 4/15/26 at 1:57 P.M, the Director of Nursing (DON) said that physician orders are to be followed as ordered. The DON then said that nurses are to accurately document in the medical record and should not have documented that the tubi grips were on the Resident when they were not. During an interview on 4/15/26 at 2:35 P.M., Nurse #4 said that it is the responsibility of nurses to ensure that the tubi grips are placed on residents with orders for them. Nurse #4 then said that nurses are to accurately document in the medical record.

Based on record review and interview the facility failed to accurately complete the Minimum Data Set (MDS) assessments for two Residents (#2 and #5) out of a total sample of 30 residents. Specifically,1.) For Resident #2, the facility coded the Resident as having a diagnosis of Schizophrenia, in error. 2.) For Resident #5 the facility coded the Resident as having had an injection of insulin in error. Findings include:1.) Resident #2 was admitted to the facility in November 2018 and has diagnoses that include vascular dementia with psychotic disturbance and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Director of Nursing (DON) coded on the MDS that Resident #2 has a diagnosis of Schizophrenia. Review of prior MDS's dated 11/28/25, 8/28/25, and 7/10/25 failed to indicate Resident #2 has a diagnosis of Schizophrenia. Review of the Level I PAS (pre-admission screen), dated 11/17/18, failed to indicate a diagnosis of Schizophrenia. Review of Resident #2's care plan fails to indicate a diagnosis of Schizophrenia or a care plan regarding Schizophrenia. Review of Resident #2's most recent Physician /Nurse Practitioner progress note, dated 3/18/26, fails to indicate Resident #2 has a diagnosis of Schizophrenia. Review of the record fails to indicate Resident #2 was assessed by psychiatric services or given a new diagnosis of schizophrenia by a clinician. During an interview on 4/16/26 at 11:39 A.M., the DON said that she had reviewed Resident #2's entire medical record and determined that the MDS was coded inaccurately, as Resident #2 does not have a diagnosis of Schizophrenia 2.) Resident #5 was admitted to the facility in December 2025 with diagnoses including sepsis, bipolar disorder and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) assessments dated 1/21/26 and 1/23/26 indicated that Resident #5 received insulin one time in the past 7 days. Review of the physician orders failed to indicate that Resident #5 had an order for insulin. During an interview on 4/15/26 at 12:57 P.M., the Director of Nursing said that Trulicity is not an insulin and should not be documented on the MDS as an insulin.

Based on observation, record review and interview the facility failed to implement physician orders for two Residents (#4 and #82) out of a total sample of 30 residents. Specifically:For Resident #4 the facility failed to implement tubi grips (used for support and compression) daily.For Resident #82 the facility failed to implement the correct air mattress setting.Findings include:Review of the facility policy titled Physician Orders, dated as revised November 2025, indicated that physician orders are to be implemented in accordance with professional standards. 1. Resident #4 was admitted to the facility in August 2021 with diagnoses including peripheral vascular disease, heart disease and kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #4 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. The MDS further indicated that Resident #4 requires substantial to maximal assist with activities of daily living.On 4/14/26 at 8:30 A.M., 12:30 P.M., and 4:10 P.M, the surveyor observed Resident #4 sitting in his/her room. The surveyor observed Resident #4 to be wearing a red pair of socks and nothing on his/her legs. Review of the physician orders dated April 2026 indicated an order for tubi grips (used for support and compression) on in A.M., and off in the P.M., one time a day apply tubi grips and one time a day remove tubi grips. Review of the progress notes failed to indicate that Resident refused the tubi grips. During an interview on 4/15/26 at 2:32 P.M., Resident #4 said that he/she has not worn the stockings (tubi grips) for a while. Resident #4 then said that no one offered to put them on today or yesterday. Resident #4 also said that if the physician wants him/her to wear them then he/she would. Resident #4 said that he/she did not refuse to wear the stockings. During an interview on 4/15/26 at 2:35 P.M., Nurse #4 said that it is the responsibility of nurses to ensure that the tubi grips are placed on residents with orders for them. Nurse #4 said he did not check because he was focused on passing medications. During an interview on 4/15/26 at 2:36 P.M., Certified Nurse's Aide (CNA) #3 said that it is the responsibility of the CNAs to apply the tubi grips. CNA #3 then said that she was Resident #4's CNA today and she did not offer to apply the stockings. CNA #3 also said that there was not a roll of tubi grip on the unit. 2. Resident #82 was admitted to the facility August 2022 with diagnoses including Alzheimer's dementia, malnutrition, and depression. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #82 is severely cognitively impaired. The MDS further indicated that Resident #82 is totally dependent on staff for activities of daily living. Review of the April 2026 physician orders indicated an order for air mattress on the setting of black dot. Check function every shift. On 4/14/26 at 8:18 A.M., 3:16 P.M., and 4:25 P.M., the surveyor observed Resident #82 lying in bed on an air mattress. The air mattress was not set on the black dot setting as ordered and as indicated on the air mattress pump. On 4/15/26 at 8:12 A.M., the surveyor observed Resident #82 lying in bed on an air mattress. The air mattress was not set on the black dot setting as ordered and as indicated on the air mattress pump. During an interview on 4/15/26 at 1:57 P.M, the Director of Nursing said that physician orders are to be followed as ordered. On 4/15/26 at 2:25 P.M., the surveyor and Nurse #1 observed Resident #82 lying in bed n an air mattress. The surveyor and Nurse #1 also observed that the air mattress was not set on the black dot setting as ordered and as indicated on the air mattress pump. During an interview on 4/15/26 at 2:27 P.M., Certified Nurse's Aide (CNA) #1 said that Resident #82 was on her assignment today. CNA #1 said she did not know how to find out what the air mattress was supposed to be set at and did not know the air mattress was not set at the correct setting. During an interview on 4/15/26 at 2:30 P.M., Nurse #1 said that a physician's order must always be followed and the air mattress setting was not set at the correct level. Nurse #1 then said that it was the responsibility of the nurses to ensure the air mattresses were set at the correct setting.

Based on observation and interview the facility failed to dispose of garbage and refuse properly. Findings include:On 4/14/26 at 8:07 A.M., the surveyor observed the edge of the property to contain the following:a. three rusted metal drum barrels.b. a rusted refrigerator c. a rusted wheelchaird. a grey wheeled plastic cart covered with a white sheete. two nightstandsf. white paper items scattered in the adjoining woodsg.14 plastic red and black milk crates scattered in the adjoining woods. During an interview on 4/15/26 at 3:40 P.M., the Regional Director of Maintenance said that the accumulation of discarded barrels, refrigerator, wheelchair etcetera should not have been allowed to occur. The Regional Maintenance Director said that there was no process in place to ensure that refuse does not accumulate outside.

Based on record review and interview the facility failed to assess 6 Residents (#19, #22, #76, #81, #104 and #120) out of a total sample of 30 residents, using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid) not less frequently than once every 3 months. Findings iclude:1. Resident #19 was admitted to the facility in June 2025 with diagnoses including cancer, heart disease and anxiety. Review of the Minimum Data set (MDS) assessments indicated a quarterly assessment was completed on 1/7/26. Further review indicated that a quarterly MDS dated [DATE] was still in progress. This is more than the 92-day completion date requirement between MDS assessments. 2. Resident #22 was admitted to the facility in April 2022 with diagnosis including cancer, heart disease and high blood pressure. Review of the Minimum Data set (MDS) assessments indicated a quarterly assessment was completed on 12/22/25. Further review indicated that a quarterly MDS dated [DATE] was incomplete. This is more than the 92-day completion date requirement between MDS assessments. 3. Resident #76 was admitted to the facility in December 2024 with diagnosis including multiple sclerosis, diabetes and heart disease. Review of the Minimum Data set (MDS) assessments indicated an annual assessment was completed on 1/13/26. Further review indicated that a quarterly MDS dated [DATE] was in progress. This is more than the 92-day completion date requirement between MDS assessments. 4. Resident #81 was admitted to the facility in September 2025 with diagnoses including dementia, kidney disease and high blood pressure. Review of the Minimum Data set (MDS) assessments indicated a quarterly assessment was completed on 12/25/25. Further review indicated that a quarterly MDS dated [DATE] was in progress. This is more than the 92-day completion date requirement between MDS assessments. 5. Resident #104 was admitted to the facility in June 2024 with diagnoses including stroke, schizophrenia and bipolar disorder. Review of the Minimum Data set (MDS) assessments indicated a quarterly assessment was completed on 12/11/25. Further review indicated that a quarterly MDS dated [DATE] was in progress. This is more than the 92-day completion date requirement between MDS assessments. 6. Resident #120 was admitted to the facility in July 2020 with diagnoses including, stroke, kidney disease and hemiplegia. Review of the Minimum Data set (MDS) assessments indicated an annual assessment was completed on 1/13/26. Further review indicated that a quarterly MDS dated [DATE] was in progress. This is more than the 92-day completion date requirement between MDS assessments. During an interview on 4/15/26 at 11:14 A.M., the Director of Nursing (DON) said that the facility has been without MDS staff since at least November 2025. The DON then said that corporate staff have been completing the MDS's off site and she has no idea why some of them have not been done. During an interview on 4/16/26 at 11:40 A.M., the DON said that the MDS's should have been completed and submitted within the regulated time frames.

Based on record review and interview the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS (Centers for Medicare and Medicaid) system within 14 days after a facility completes a resident's assessment for 2 Residents (#19 and #22) out of a total sample of 30 residents. Findings include:1. Resident #19 was admitted to the facility in June 2025 with diagnoses including cancer, heart disease and anxiety. Review of the Minimum Data set (MDS) assessments indicated a quarterly assessment was completed on 10/15/25 and submitted on 2/22/26. Further review indicated that a quarterly MDS was completed on 1/7/26 and submitted 2/22/26. 2. Resident #22 was admitted to the facility in April 2022 with diagnosis including cancer, heart disease and high blood pressure. Review of the Minimum Data set (MDS) assessments indicated a quarterly assessment was completed on 10/15/25 and submitted on 11/25/25. During an interview on 4/15/26 at 11:14 A.M., the Director of Nursing (DON) said that the facility has been without MDS staff since at least November 2025. The DON then said that corporate staff have been completing the MDS's off site and she has no idea why some of them have not been submitted on time. During an interview on 4/16/26 at 11:40 A.M., the DON said that the MDS's for Residents #19 and #22 should have been completed and submitted within the regulated time frames.

Based on observation, record review and interview, the facility failed to ensure four Residents (#101, #94, #210, and #206) received care in accordance with professional standards of practice, out of a total sample of 27 residents. Specifically, 1. For Resident #101, the facility failed to ensure nursing obtained physician's orders for a cervical collar (a neck brace which is used to support and immobilize a person's neck.) 2a. For Resident #210, the facility failed to ensure the nurse documented acetaminophen as administered timely. 2b. For Resident #94, the facility failed to ensure the nurse documented acetaminophen as administered timely. 3. For Resident #206, the facility failed to obtain and monitor external measurements of a peripherally inserted central catheter (also known as a PICC line, is a long, flexible tube (catheter) that is inserted into a vein in your upper arm. After insertion, the catheter is threaded to a central vein near the heart. The PICC line can be used to deliver fluids and medications, draw blood, or perform blood transfusions.) Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility policy titled 'Physician Orders', revised November 2024, indicated, but was not limited to the following: - Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. - Orders must be recorded in the medical record by licensed nurses authorized to transcribe such orders. - Physician's orders must be documented clearly in the medical record including the required components of a complete order: date and time of receipt of order; name of practitioner providing the order; name of product; specific duration; frequency of administration. 1. Resident #101 was admitted to the facility in March 2025 with diagnoses including C4 compression (pressure on the fourth cervical disc spinal cord segment) and spinal cord injury. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/11/25, indicated Resident #101 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #101 was dependent on staff for dressing, eating, and bed mobility. Review of Resident #101's hospital discharge summary, dated 3/4/25, indicated: - Assessment/plan: Aspen collar (cervical collar) in place until at least neurosurgery appointment. Review of Resident #101's physician admission progress note, dated 3/7/25, indicated: - Neurosurgery recommended that he/she wear an Aspen collar at all times. Review of Resident #101's physician assistant progress note, dated 3/24/25, indicated: - His/her neurology appointment had to be rescheduled. - At this time he/she continues to be wearing the cervical collar at all times except for hygiene while in bed. Patients neurology appointment has been scheduled [sic] until next week. We will follow up on their recommendations when available. Review of Resident #101's physician's order on 3/24/25 at 2:55 P.M., failed to indicate any physician orders for a cervical collar since his/her admission. Review of Resident #101's plan of care on 3/24/25 at 2:55 P.M., failed to indicate the use of or any instructions for use of a cervical collar. Review of Resident #101's Kardex (a summary of a patient's plan of care) dated 3/26/25 at 10:12 A.M., failed to indicate the use of or any instructions for use of a cervical collar. On 3/24/25 at 8:24 A.M., the surveyor observed Resident #101 in bed wearing a cervical collar. Resident #101 said he/she has worn the cervical collar since he/she fell in December and must wear this cervical collar until his/her neck surgery. On 3/24/25 at 12:32 A.M., the surveyor observed Resident #101 in bed without the front of the cervical collar in place. Resident #101 said he/she takes it off because he/she thinks he/she's supposed to. On 3/25/25 at 7:02 A.M., and 2:09 P.M., the surveyor observed Resident #101 in bed wearing a cervical collar. During an interview on 3/26/25 at 10:04 A.M., Certified Nurse Assistant (CNA) #5 said CNAs find out information about patient care through nurse report or the Kardex. CNA #5 said there was no information available in the Kardex or in report about Resident #101's cervical collar. CNA #5 said he/she often doesn't wear the collar, but she had never told the nurse. During an interview on 3/25/25 at 2:18 P.M., Nurse #1 said cervical collars require physician's orders. Nurse #1 said Resident #101 should have had a physician order for the cervical collar including any instructions for when to wear but did not. Nurse #1 said Resident #101 needs to wear the cervical collar at all times, except during hygiene and to check skin integrity. Nurse #1 said if Resident #101 was noncompliant with wearing the cervical collar that should have been reported to and addressed by the provider and documented but was not. During an interview on 3/25/25 at 3:13, the Director of Nursing (DON) said cervical collars require physician's orders. The DON said Resident #101 should have had physician's orders for the cervical collar including any instructions for when to wear. The DON said if Resident #101 was noncompliant with wearing the cervical collar that should have been reported to and addressed by the provider and documented. 2. Review of the Massachusetts Board of Registration in Nursing Standards of Conduct, dated 6/11/21, indicated the following: - Documentation: A nurse licensed by the Board shall make complete, accurate, and legible entries in all records required by federal and state laws and regulations and accepted standards of nursing practice. On all documentation requiring a nurse's signature, the nurse shall sign his or her name as it appears on his or her license. Review of the facility policy titled 'Administering Medications', revised 10/1/24, indicated: - The individual administering the medication shall sign off on the Electronic Medical Administration Record (eMAR) date for the specific day before administering the medication. 2a. Resident #94 was admitted to the facility in November 2024 with diagnoses including failure to thrive and cervicalgia (neck pain). Review of the most recent Minimum Data Set (MDS) assessment, dated 3/5/25, indicated Resident #94 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 3/25/25 at 9:04 A.M., the surveyor observed Nurse #4 prepare and administer the follow medication to Resident #94: - Acetaminophen 325 milligrams (mg), two tablets. Review of Resident #94's physician order, initiated 11/23/24, indicated: - Acetaminophen 325 mg, give two tablets every 6 hours as needed for pain/fever. Review of Resident #94's Electronic Medication Administration Record (eMAR) on 3/25/25 2:59 P.M., five hours and 55 minutes after administration of acetaminophen, failed to indicate it was documented as administered. During an interview on 3/25/25 at 12:59 P.M., the Director of Nursing (DON) said administration of as needed acetaminophen should be documented at the time of administration unless there is an emergent situation. During an interview on 3/25/25 at 2:28 P.M., Nurse #4 said she forgot to document that she administered acetaminophen to Resident #94, but she should have documented it immediately. Nurse #4 said there was not an emergent situation, she just forgot. 2b. Resident #210 was admitted to the facility in March 2025 with diagnoses including hypertension and heart attack. Review of Resident #210's Brief Interview for Mental Status (BIMS), dated 3/17/25, indicated the Resident had moderate cognitive impairment as evidenced by a score of 9 out of 15. On 3/25/25 at 9:59 A.M., the surveyor observed Nurse #3 prepare and administer the follow medication to Resident #210: - Acetaminophen 325 milligrams (mg), two tablets. Review of Resident #210's physician order, initiated 3/16/25, indicated: - Acetaminophen 325 mg, give two tablets every 6 hours as needed for pain/fever. Review of Resident #210's Electronic Medication Administration Record (eMAR) on 3/25/25 2:59 P.M., five hours after administration of acetaminophen, failed to indicate it was documented as administered. During an interview on 3/25/25 at 12:59 P.M., the Director of Nursing (DON) said administration of as needed acetaminophen should be documented at the time of administration unless there is an emergent situation. During an interview on 3/26/25 at 9:48 A.M., Nurse #3 said she got distracted and forgot to document that she administered acetaminophen to Resident #210, but she should have documented it immediately. Nurse #3 said there wasn't an emergent situation, but she got distracted because it was a busy morning. 36876 3. Review of the facility's policy titled PICC/Central Line/Port-a-Cath Maintenance dated as revised 10/5/24 indicated: Policy: A nurse will perform maintenance on a PICC/Central Line/Port-a-Cath as regulations allow. All PICCS/Central lines shall be reviewed daily for line necessity. Maintenance and Care: Dressing change day one after insertion with day of insertion being day zero. Dressing change every seven days and as needed. Measure the length of the lumen from the insertion to the end site. Measure the circumference of the upper arm and document. This is to be done upon admission/dressing change/PRN (as needed). Review of the American Nursing Journal article regarding PICC Line monitoring indicated: Catheter-tip migration: Signs and symptoms of catheter-tip migration include changes in catheter patency or loss of blood return; discomfort in the upper arm, shoulder, jaw, chest, or ear during infusions; and an external catheter length that differs from the length at the time of insertion. For example, if the external length of a PICC was 1 cm at insertion but is now 20 cm, assume the PICC is no longer in the superior vena cava. Resident #206 was readmitted to the facility in March 2025 with diagnoses including Klebsiella Pneumoniae and cognitive communication deficit. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #206 was cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated Resident #206 required assistance with bathing, dressing and bed mobility. Review of the hospital discharge paperwork dated 3/12/25 indicated Resident #206 had a PICC line placed during his/her hospitalization . The hospital discharge paperwork failed to indicate a measurement of the external length of the PICC or Resident #206's arm circumference. Review of the Nursing Admission assessment dated [DATE] indicated: IV access: PICC. IV Location: Right upper arm. Last changed date 3/13/25. The Nursing Admission Assessment notes failed to indicate any measurements of Resident #206's arms circumference or external length. Review of the physician's orders indicated: Change PICC/Central Line Dressing Change: Dressing change q (every) 7 days (PICC Line) & PRN Measure the length of the Lumen from the insertion to the end site. Measure the circumference of the upper arm and Document. THIS IS TO BE DONE UPON EVERY ADMISSION/DRESSING CHANGE/PRN. every evening shift every 7 day(s) for Infection Control initiated 3/13/25. Review of the March 2025 Treatment Administration Record and Medication Administration Record failed to indicate the external length or Resident #206's arm circumference were documented. Review of Resident #206's care plans, nurse progress notes and practitioner notes failed to indicate the external length of the PICC or Resident #206's arm circumference was documented at any time. During an interview on 3/25/25 at 8:39 A.M., Nurse #6 said that he believed Resident #206 was admitted with a PICC line recently. Nurse #6 said that staff are expected to measure the external length of the PICC line and arm circumference but he wasn't sure if it's been completed. During an interview on 3/25/25 at 8:48 A.M., the Assistant Director of Nursing (ADON), said that when residents are admitted to the facility with a PICC line, the expectation would be for staff to measure arm circumference and external length the monitor for possible migration. The ADON said that she would expect staff to contact the hospital to obtain initial measurements if they were not included in the discharge paperwork. The ADON said she was not sure of the policy regarding the frequency of measuring resident PICC lines and would have to look into it.

Based on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for three Residents (#98, #88, #49) out of a total sample of 27 residents. Specifically, the facility failed to: 1. For Resident #98, the facility failed to provide assistance with bathing. 2. For Resident #88, the facility failed to provide supervision while eating during mealtimes. 3. For Resident #49, the facility failed to ensure staff provided assistance with managing denture care and ensuring dentures were available for meals. Findings include: Review of the facility policy titled 'Activities of Daily Living (ADL)', dated 1/23/24, indicated, but was not limited to the following: - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing dressing, grooming, and oral care); d. Dining (meals and snacks). 1. Resident #98 was admitted to the facility in February 2025 with diagnoses including acquired absence of right leg below knee and type two diabetes. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #98 was cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated Resident #98 required substantial/maximal assistance with bathing. During an interview on 3/24/25 at 8:38 A.M., Resident #98 said he/she needs assistance with bathing and he/she was not washed up at all during the weekend (3/22/25 and 3/23/25.). Review of Resident #98's Activities of Daily Living (ADL) care plan dated 3/6/25 indicated: Focus: Resident currently have (sic) an alteration to my ability to care for self and need assistance d/t muscoskeletal impairment. Interventions: Bathing/Showering: [Resident #98] requires extensive assistance on (sic) one staff to provide shower 2 X wk and as necessary. Provide sponge bath when a full bath or shower cannot be tolerated. Personal Hygiene/Oral Care Routine: [Resident #98] is limited on one staff for personal hygiene and oral care. Review of Resident #98's ADL documentation report indicated bathing was not provided to Resident #98 on 3/22/25 and 3/23/25. During an interview on 3/25/25 at 10:39 A.M. the Administrator said she was not aware Resident #98 reported he/she was not bathed over the past weekend. Review of the Grievance Form completed by the Administrator and dated 3/25/25 indicated: [Administrator made aware of grievance from weekend. Resident stated he/she was not washed. [Administrator] asked did you ask to be washed he/she said no. During an interview on 3/26/25 at 9:18 A.M., the Administrator said that Residents should not have to ask staff to be washed. 45984 2. Resident #88 was admitted to the facility in January 2025 with diagnoses including cerebral infarction, dysphagia (difficulty swallowing) and muscle weakness. Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 0 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident required supervision or touching assistance with eating. The surveyor made the following observations: - On 3/24/25 at 8:44 A.M., Resident #88 was eating his/her breakfast while sitting up in his/her bed in his/her room. There were no staff present in the Resident's room while he/she was eating. Resident #88's privacy curtain was drawn, and he/she could not be seen from the hallway. Staff did not check in with Resident #88 while he/she was eating. - On 3/24/25 at 12:34 P.M., Resident #88 was eating his/her lunch while sitting up in his/her bed in his/her room. There were no staff present in the Resident's room while he/she was eating. Resident #88's privacy curtain was drawn, and he/she could not be seen from the hallway. Staff did not check in with Resident #88 while he/she was eating. - On 3/25/25 at 8:30 A.M., Resident #88 was eating his/her breakfast while sitting up in his/her bed in his/her room. There were no staff present in the Resident's room while he/she was eating. Resident #88's privacy curtain was drawn, and he/she could not be seen from the hallway. Staff did not check in with Resident #88 while he/she was eating. - On 3/25/25 from 12:41 P.M. through 12:54 P.M., Resident #88 was eating his/her lunch while sitting up in his/her bed in his/her room. There were no staff present in the Resident's room while he/she was eating. Resident #88's privacy curtain was drawn, and he/she could not be seen from the hallway. Staff did not check in with Resident #88 while he/she was eating. - On 3/26/25 at 8:39 A.M., Resident #88 was eating his/her breakfast while sitting up in his/her bed in his/her room. There were no staff present in the Resident's room while he/she was eating. Resident #88's privacy curtain was drawn, and he/she could not be seen from the hallway. Staff did not check in with Resident #88 while he/she was eating. Review of Resident #88's physician's order dated 1/2/25 indicated the following: Regular diet, pureed texture regular/thin consistency. Review of Resident #88's Kardex (a care card describing the needs of a resident) indicated the following under the Eating/Dietary/Nutrition section: EATING: Supervision with meals Review of Resident #88's care plan dated 1/6/25 indicated the following: Focus: The resident has a swallowing problem related to CVA (Cerebrovascular Accident), dysphagia a/e (as evidenced) by need for puree diet Intervention: Monitor/document/report to nurse/dietitian and MD (medical doctor) PRN (as needed) for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth. Review of Resident #88's alteration to care for self and assistance care plan dated 1/2/25 did not indicate the Resident's level of assistance required for eating during the survey period. Review of Resident #88's Speech Therapy Discharge Summary dated from 1/3/25 through 2/25/25 indicated the following recommendation: Supervision for Oral Intake = Distant supervision. Review of Resident #88's Certified Nursing Assistant (CNA) documentation for Eating indicated that Resident #88 did not receive supervision with meals 69 times out of 72 documented meal opportunities from the last 31 days. During an interview on 3/26/25 at 9:21 A.M., CNA #1 said Resident #88 is set-up only for eating and he/she sometimes will need verbal encouragement while eating but he/she does not require supervision. During an interview on 3/26/25 at 9:49 A.M., Nurse #1 said Resident #88 is independent for eating but the Resident used to pocket his/her food in his/her mouth. Nurse #1 reviewed Resident #88's medical record with the surveyor and said she was not aware he/she required supervision with meals. Nurse #1 said supervision with meals means a Resident needs to be observed while they are eating and frequent checks should be done. Nurse #1 said Resident #88's privacy curtain should not be drawn while he/she is eating so staff can see him/her from the hallway. During an interview on 3/26/25 at 11:52 A.M., the Director of Nursing (DON) said when a resident requires supervision with meals staff are rounding around the unit and keeping an eye on residents from at least the hallway. The DON said Resident #88 should have been receiving supervision while eating if the Speech Therapy notes indicated that he/she should be. 48990 3. Resident #49 was admitted to the facility in January 2022 with diagnoses including dementia and glaucoma. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/12/25, indicated Resident #49 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. This MDS also indicated Resident #49 required partial/moderate assistance with oral hygiene and denture management/cleaning. On 3/24/25 at 8:04 A.M., the surveyor observed Resident #49 in bed, appearing to be asleep. There was a denture under his/her bed directly on the floor. This observation was before the breakfast meal was served. On 3/24/25 at 12:52 A.M., the surveyor observed Certified Nurse Assistant (CNA) #7 deliver lunch to Resident #49. There was a denture under his/her bed directly on the floor, in the same place it was observed before the breakfast meal. Resident #49 was not wearing any dentures. CNA #7 asked Resident #49 if they needed anything else with their lunch meal, but did not ask about his/her dentures, before leaving the room. On 3/25/25 at 8:33 A.M., the surveyor observed Resident #49 putting in his/her upper dentures. Resident #49 said he/she isn't sure where the lower dentures are because they are missing. Resident #49 said staff do not assist with his/her dentures very often and he/she is concerned because he/she always drops and loses them. Resident #49 said he/she didn't have any dentures yesterday during breakfast or lunch and that was hard to eat without them. Resident #49 said he/she would like staff to help with his/her dentures, including keeping them safe and cleaning them. Review of Resident #49's nursing progress notes indicated the following denture concerns: - On 5/20/24, Resident #49 dropped his/her dentures at 4:30 A.M. and broke them in half. - On 12/30/24, was seen by the dentist for missing lower dentures. - On 3/3/25, dentist was consulted for missing dentures and appointment scheduled for 4/8/25. Review of Resident #49's active plan of care, including care plan, physician orders, and Kardex (a summary of a patient's plan of care) on 3/25/25 at 2:00 P.M., failed to indicate use of dentures or any interventions for denture management. During an interview on 3/25/25 at 8:40 A.M., Certified Nurse Assistant (CNA) #3 said Resident #49 always keeps his/her dentures in his/her room and was unable to answer questions about his/her denture care. During an interview on 3/25/25 at 8:43 A.M., CNA #4 said the CNAs get information about any residents who require denture care in the Kardex. The surveyor and CNA #4 review the Kardex together and CNA #4 said it does not include the use of dentures. CNA #4 said Resident #49's Kardex should have information relating to dentures because Resident #49 is confused and unable to manage his/her own dentures. CNA #4 said Resident #49 often gets his/her dentures tangled in the blankets or loses them. CNA #4 said Resident #49's dentures have had to be replaced multiple times in the past year because of being lost or broken by being dropped. CNA #4 said the CNAs are supposed to clean his/her dentures before bed and give them to the nurse to store in the treatment cart but is unsure how that is being communicated to staff, or ensured that it's being done, because it's not in the Kardex. During an interview on 3/25/25 at 2:27 P.M., Nurse #5 said if a resident has dentures, it should be included in the care plan. Nurse #5 said if any resident has difficulty managing their dentures, interventions should be put into place to assist them to manage their dentures effectively. Nurse #5 said these interventions should be included in the Resident's care plan and/or Kardex. Nurse #5 said Resident #49 is confused and requires assistance to manage his/her dentures, so they do not get broken or lost. Nurse #5 said Resident #49 should have had denture care in his/her care plan with individualized interventions to ensure they are managed and available for his/her use. During an interview on 3/25/25 at 3:13 P.M., the Director of Nursing (DON) the staff is responsible to assist with denture management if any residents require assistance. The DON said she would expect Resident #49's care plan, physicians orders, and/or Kardex to include denture management interventions to promote successful denture management.

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, 1. The facility failed to ensure medications with shortened expiration dates were dated once opened in three out of three medication carts observed. 2. The facility failed to ensure the medication room was locked when unattended. 3. The facility failed to ensure treatment carts were locked when unattended. Findings include: Review of the facility policy titled 'Storage, Labeling of OTC (over the counter) Medication, Destruction and Disposal of Medication', revised 11/9/24, indicated: - No discontinued, outdated, or deteriorated medications should be available for use in the facility. All such medications are destroyed per policy. - Expired medications are to be removed from areas medication carts prior to or at the time of expiration. - Compartments containing medications should be locked when not in use. Trays of carts used to transport such items should be left unattended. (Note: Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) - Medications will be stored in accordance with manufacturers guidance and not exceed expiration dates unless a shortened shelf-life once opened. - Eye drops should have resident's record number and date of opening. 1. On 3/25/25 at 9:23 A.M., the surveyor and Nurse #4 observed the following in the second floor A side medication cart: - One novolog insulin pen, dated as opened 2/18/25, available for use 35 days after it was opened. During an interview on 3/25/25 at 9:24 A.M., Nurse #4 said the insulin pen should be discarded 28 days after opening but was not. On 3/25/25 at 9:44 A.M., the surveyor and Nurse #1 observed the following in the third floor B side medication cart: - One basaglar insulin pen, dated as opened 2/6/25, available for use 48 days after it was opened. - One insulin aspart pen, dated as opened 12/23/24, available for use 93 days after it was opened. - One humalog insulin pen, opened and undated. - One bottle timolol eye drops, opened and undated. During an interview on 3/25/25 at 9:45 A.M., Nurse #1 said insulin pens should be dated when opened and should be discarded 28 days after opening. Nurse #1 said timolol eye drops should be dated when opened and discarded 30 days after opening. On 3/25/25 at 10:24 A.M., the surveyor and Nurse #6 observed the following in the first floor A side medication cart: - One symbicort inhaler, opened and undated. - Two breo ellipta inhalers, both opened and undated During an interview on 3/25/25 at 9:46 A.M., Nurse #6 said symbicort inhalers should be dated when opened and discarded 90 days after opening. Nurse #6 said breo ellipta inhalers should be dated when opened and discarded six weeks after opening. During an interview on 3/25/25 at 12:59 P.M., the Director of Nursing (DON) said medications with shortened expiry dates should be dated when opened and discarded according to the manufacturer's guidelines. The DON said this included insulin pens, which should be discarded 28 days after opening. The DON said this also included inhalers and eye drops. 2. On 3/24/25 at 6:52 A.M., the surveyor observed the second floor medication room door was open. The surveyor was able to enter and visualize many bottles of medications. There were no nurses or any staff members within view of this medication room. During an interview on 3/24/25 at 6:55 A.M., Certified Nurse Assistant (CNA) #3 came to the nurse's station where the medication room was located and said the nurse should always keep the medication room locked when unattended. During an interview on 3/25/25 at 12:59 P.M., the Director of Nursing (DON) said medication rooms should always be locked when unattended. 45984 3. The surveyor made the following observations on the third-floor unit: - On 3/24/25 from 7:50 A.M. through 8:02 A.M., a treatment cart containing various ointments and biologicals was opened. The surveyor was able to access the contents. - On 3/25/25 from 6:44 A.M. through 6:57 A.M., a treatment cart containing various ointments and biologicals was opened. Four staff members and one resident walked by the treatment cart. The surveyor was then able to access the contents. During an interview on 3/25/25 at 6:59 A.M., Nurse #2 said the treatment cart should not be left open if it is unattended. During an interview on 3/25/25 at 12:59 P.M., the Director of Nursing (DON) said treatment carts should always be locked when unattended.

Based on record review and interview, the facility failed to ensure advanced directives for one Resident (#94), out of total sample of 27, were executed in accordance with standards of practice. Specifically, the facility failed to ensure Resident #94 signed his/her own MOLST (Medical Orders for Life Sustaining Treatment). Findings include: Review of the Facility's policy, titled Advanced Directive, dated as revised October 2024 indicated, Policy: It is the policy, of this facility to ensure residents 'right to request, refuse, and/or discontinue treatment to participate and refuse to participate in experimental research, and formulate an advice directive'. Definitions: Medical Orders for Life-Sustaining Treatment (MOLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. 12. To be legally binding, the advanced directive must be signed by the resident or legal guardian as recognized by the state. If utilizing a MOLST form, the order will take affect after signatures of the resident/resident representative AND is signed by the Provider, or two nurses receive the order and place the order on the form. Resident #94 was admitted to the facility in November 2024 and has diagnoses that include but are not limited to hemiplegia, unspecified affecting left nondominant side, type 2 diabetes mellitus, and end stage renal disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #94 scored a 15 out of 15, on the Brief Interview for Mental Status exam which indicated he/she as having intact cognition. Further review at Section S of the MDS indicated Resident #94 did not have an invoked Health Care Proxy, (an invoked Health Proxy is a person designated to make informed health care decisions, after a Physician/Nurse Practitioner/Physician Assistant determines and documents a person does not have the capacity to make informed health care decisions). Review of Resident #94's medical record included a MOLST indicating the following: Page 1 was filled out, signed and dated 11/27/24 by someone other than Resident #94. Page 2 of the MOLST, was filled out, signed and dated 11/27/24 and the box indicating who is signing the MOLST was checked as the Health Care Agent. The MOLST was dated and signed 12/4/24 by the Physician Assistant. Review of Resident #94's medical record failed to indicate the Health Care Proxy was invoked and that the Health Care Agent had the authority to make health care decisions. During an interview on 03/25/25 at 3:54 P.M., the Social Worker said Resident #94 speaks Spanish, presents alert and oriented and his/her Health Care Proxy is not invoked. The Social Worker reviewed the MOLST and said she was unsure who signed Resident #94's MOLST. The Social Worker said a MOLST can only be signed by a resident or an invoked Health Care Agent.

Based on observations, interviews, and record review, the facility failed to ensure a safe and homelike environment for one Resident (#405), out of 27 total sampled residents. Specifically, the facility failed to ensure Resident #405's nightstand was functional, safe, and in good repair. Findings include: Review of the facility policy titled 'Equipment and Supplies', revised 11/5/24, indicated: - Equipment in disrepair will be removed from service until in safe and proper working condition. Resident #405 was admitted to the facility in March 2020 with diagnoses including dementia and cataract. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/26/25, indicated Resident #405 was rarely/never understood and had severe cognitive impairment based on a Staff Assessment for Mental Status. This MDS also indicated Resident #405 required supervision or touching assistance to walk up to 150 feet and supervision or touching assistance to eat. On 3/24/25 at 8:07 A.M., the surveyor observed Resident #405 in bed. There was a nightstand directly next to the right side of the Resident's bed, which was within his/her reach. The drawer was ajar about six inches with a large crack through the entire left side of the drawer, which was the side closest to the Resident. This crack had a jagged edge that physically blocked the drawer from being able to be closed. The exterior surface of the nightstand was covered in many scratches and the paint was peeling on a majority of the front exterior surface. Multiple personal belongings were observed in this drawer including a telephone, a small purse, and bagged nebulizer mask. During an interview on 3/24/25 at 8:37 A.M., Resident #405's family member said they were concerned about the Resident's bedside table being broken. They said they had told staff about it and are worried that the jagged edge could cut the Resident's arm when he/she reaches inside of it. During an interview on 3/26/25 at 7:33 A.M., Certified Nurse Assistant (CNA) #3 said Resident #405's nightstand had been broken since at least December 2024. CNA #3 said the jagged edge could cause injury to the Resident or others. CNA #3 said she is afraid she might cut herself on the jagged edge. CNA #3 said she did not report the broken nightstand to maintenance, and she was not aware if anyone else had reported it. CNA #3 said the facility expectation is that broken furniture should be reported to maintenance but was not. During an interview on 3/26/25 at 7:39 A.M., Unit Manager #1 said she was aware that Resident #405's nightstand had been broken since approximately December 2024. Unit Manager #1 said she was not aware of anyone reporting this to maintenance. Unit Manager #1 and the surveyor observed Resident #405's nightstand together, which was within the Resident's reach at time of observation. The drawer was ajar about six inches with a large crack through the entire left side of the drawer, which was the side closest to the Resident. Unit Manager #1 was unable to open and close the drawer until the drawer was emptied of the Residents belongings. Unit Manager #1 said the drawer is not functional and the jagged edge could cause injury. Unit Manager #1 said this nightstand should have been removed from the room and maintenance should have been notified but was not. During an interview on 3/26/25 at 7:54 A.M., the Maintenance Director and surveyor observed Resident #405's nightstand. The Maintenance Director said the inside of the drawer was completely destroyed and that it should have been reported but was not. The Maintenance Director reviewed the TELS system (an electronic system used to report and manage maintenance requests in the facility) and said there was not request/report for Resident #405's nightstand in the TELS history and he was never notified in another way. During an interview on 3/26/25 at 9:01 A.M., the Director of Nursing (DON) said the facility expectation is that maintenance should be notified promptly of any broken resident furniture to request repair/replacement. The DON said any staff member can and should report maintenance requests through the TELS system. The DON said staff had been educated on this in the past and Resident #405's nightstand should have been reported to maintenance.

Based on record review and interview, the facility failed to document the communication needs of one Resident (#97), out of a sample of 27 residents. Specifically, the facility failed to develop a care plan identifying Resident #97's preferred language of communication. Findings include: A review of the facility policy titled 'Residents and Families with Limited English Proficiency' revised 10/16/24 indicated the following: -The facility offers language services at no charge to the individuals with limited English proficiency. -The language and communication needs of the individual are documented in the electronic medical record. Resident #97 was admitted to the facility in February 2025 with diagnoses including dementia. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating Resident #97 had intact cognition. Further review of the MDS indicated that Resident #97's preferred language is Spanish and he/she wants an interpreter to communicate with a doctor or health care staff. A review of Resident #97's care plan failed to indicate a communication care plan specific to the Resident's preferred language. During an interview on 3/25/25 at 10:47 A.M., Resident #97 said he/she does not speak English. During an interview on 3/25/25 at 10:48 A.M., Nurse #3 said she administered medication to the Resident today. Nurse #3 said the Resident speaks Spanish only. Nurse #3 said she is not fluent in Spanish. Nurse #3 said while administering medication to the Resident, she is only able to identify and speak specific words in Spanish such as water, medicine and sugar. Nurse #3 said she is not able to fluently have a conversation with the Resident in Spanish while administering medication. During an interview on 3/25/25 at 10:58 A.M., the Assistant Director of Nurses (ADON) said Resident #97 speaks Spanish only. She said the Resident should be able to fluently have a conversation with staff to ensure all his/her needs are all met. The ADON said a person-centered care plan should be put in place so that staff have directions on how to communicate fluently with the Resident. During an interview on 3/25/25 at 1:15 P.M., the Social Worker said a person-centered communication care plan identifying Resident #97's preferred language of communication should be in place.

Based on observation, record review, and interview, the facility failed to provide care and treatment in accordance with professional standards of practice for one Resident (#62) out of a total sample of 27 Residents. Specifically, for Resident #62, the facility failed to: 1a. ensure there was an active physician's order for the use of an air mattress and 1b. ensure weekly skin checks were being performed and documented as ordered by the physician. Findings include: Resident #62 was admitted to the facility in September 2024 with diagnoses including bipolar disorder, type 2 diabetes and dementia. Review of Resident #62's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental score of 12 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident requires assistance from staff with all activities of daily living and is at risk of developing pressure ulcers. 1a. The surveyor made the following observations: - On 3/24/25 at 8:00 A.M., 3/25/25 at 6:48 A.M. and 3/26/25 at 7:09 A.M., Resident #62 was sleeping in his/her bed which was an air mattress set to 240 pounds. Review of Resident #62's active and discontinued physician's orders did not indicate the use of an air mattress. Further review of Resident #62's medical record including care plans did not indicate the use of an air mattress. Review of Resident #62's most recent weight obtained on 3/10/25 indicated a weight of 145 lbs. (pounds). During an interview on 3/26/25 at 9:23 A.M., Certified Nursing Assistant (CNA) #1 said Resident #62 was transferred from the first floor about one month ago and she thinks that he/she came up with the air mattress. During an interview on 3/26/25 at 9:42 A.M., Nurse #1 said Resident #62 came from the first floor with an air mattress. Nurse #1 said all residents need to have an active physician's order if they are using an air mattress. Nurse #1 said air mattress settings are set to the Resident's weight. During an interview on 3/26/25 at 11:52 A.M., the Director of Nursing (DON) said Resident #62 should have a physician's order for the use of an air mattress if he/she is using one. 1b. Review of Resident #62's physician's order dated 9/27/24 indicated the following: Skin Checks Weekly every evening shift every Wednesday for Preventative. Review of Resident #62's medical record on 3/26/25 indicated that the last completed skin check was dated 2/20/25, indicating that five weeks of skin checks were not in the medical record. During an interview on 3/26/25 at 9:23 A.M., CNA #1 said Resident #62 is not resistive to care. During an interview on 3/26/25 at 9:42 A.M., Nurse #1 said skin checks are done weekly for all residents and if a resident refuses it should be documented in the medical record. Nurse #1 and the surveyor reviewed Resident #62's medical record and Nurse #1 said she was not sure why the Resident's last documented skin check was on 2/20/25. Nurse #1 said even if a resident has no skin issues it still needs to be documented in the medical record. During an interview on 3/26/25 at 11:52 A.M., the DON said skin checks should be done weekly or as ordered by the physician. The DON said whether there are findings or not in the skin checks, they need to be uploaded and documented into the medical record. During a follow up interview on 3/26/25 at approximately 2:00 P.M., the DON said Nurse #1 did not upload and document the skin checks in real time but had just completed them now. The surveyor asked the DON if she would expect the skin checks to be documented once completed and the DON said she would.

Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new ulcers from developing for one Resident (#101), who had a pressure ulcer, out of 27 total sampled residents. Specifically, the facility failed to obtain a physician order for the use of an air mattress for pressure ulcer management and failed to ensure the air mattress was at an appropriate setting. Findings include: Review of the facility policy titled 'Skin Prevention, Assessment and Treatment', revised October 2024, indicated: - Purpose: To promote healing of existing pressure ulcers. - Treatment guidelines: Interventions for prevention or active skin alterations may include but are not limited to: provide pressure relieving device or cushion on surfaces as indicated. Resident #101 was admitted to the facility in March 2025 with diagnoses including a sacral pressure ulcer, C4 compression (pressure on the fourth cervical disc spinal cord segment), and spinal cord injury. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/11/25, indicated Resident #101 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #101 was dependent on staff for bed mobility and had a stage three pressure ulcer. Review of Resident #101's wound consultant 'Initial Wound Evaluation and Management Summary', dated 3/11/25, indicated: - Stage 3 Pressure Wound Coccyx: Recommendations: Low Air Loss Mattress. Review of Resident #101's physician orders on 3/25/25 at 2:10 P.M., failed to indicate any physician orders for the use of an air mattress. Review of Resident #101's active care plan, revised 3/20/25, indicated the Resident was admitted with a pressure ulcer. This care plan failed to indicate the use of an air mattress. On 3/24/25 at 8:24 A.M. and 12:32 P.M., and 3/25/25 at 7:02 A.M. and 2:09 P.M., the surveyor observed Resident #101 in bed on a Medline Supra APL air mattress. The pump was set to 240 pounds (lbs.). Review of Manufacturer's guidelines for Medline Supra APL Mattress System indicated: - To set the Medline Supra APL, first connect the pump and mattress, then power it on and inflate. Adjust the mattress based on the patient's weight. Review of Resident #101's weight summary indicated: - 3/5/25: 166 lbs. - 3/15/25: 152 lbs. - 3/22/25: 153 lbs. During an interview on 3/25/25 at 2:18 P.M., Nurse #1 said air mattresses require physician's orders for use. Nurse #1 said nurses are responsible for checking air mattress settings each shift. Nurse #1 said Resident #101 is on an air mattress to treat his/her coccyx pressure ulcer. Nurse #1 said a physician order should have been obtained when the air mattress was first applied. Nurse #1 said Resident #101's air mattress should have been set according to his/her weight. Nurse #1 said if the setting for weight was not comfortable and needed to be adjusted, the physician should have been notified to obtain new setting orders. During an interview on 3/25/25 at 3:13 P.M., the Director of Nursing (DON) said air mattresses require physician's orders for use. The DON said nurses are responsible for checking air mattress settings daily. The DON said the nurses should have clarified with the physician and obtained a physician order if when checking the settings there was no physicians order in place. During an interview on 3/26/25 at 11:51 A.M., the DON said the facility does not have a written policy for air mattresses, but it is their expectation that manufacturer guidelines are followed for the air mattress system.

Based on observation, record review and interview, the facility failed to ensure professional standards of practice for the care of an indwelling urinary catheter (a tube placed through the urethra into the bladder to drain urine) for one Resident (#46) out of a total sample of 27 residents. Specifically, the facility failed to ensure they obtained physician's orders for the use and care of Resident #46's indwelling urinary catheter. Findings include: Review of the facility policy titled 'Indwelling Catheter', revised 12/10/24, indicated, but was not limited to: - Insertion: Verify physician's order for procedure noting the size, bulb inflation, frequency of change, and frequency of catheter bag change. - Irrigation: Verify physician order for frequency, solution and amount to irrigate. Resident #46 was admitted to the facility in February 2025 with diagnoses including benign prostrate hyperplasia (enlarged prostate) and use of a chronic indwelling urinary catheter. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/13/25, indicated Resident #46 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This MDS also indicated Resident #46 had an indwelling urinary catheter. On 3/24/25 at 8:44 A.M. and 12:21 P.M., and 3/25/25 at 6:58 A.M., the surveyor observed Resident #46 with a urinary catheter drainage bag filled with yellow urine. During an interview on 3/25/25 at 8:07 A.M., the surveyor and Unit Manager #1 observed Resident #46's indwelling urinary catheter system. There was no anchoring system in place to prevent it from accidentally being pulled out or dislodged. Unit Manager #1 said indwelling urinary catheters require a physician's orders for its use and care. Unit Manager #1 said the order should include the catheter size, bulb size, frequency of catheter and/or catheter bag change, irrigation of catheter system, and all necessary catheter care. Unit Manager #1 said Resident #46 should have a physician's orders for his/her indwelling urinary catheter and it's care but did not. Review of Resident #46's physician order, initiated 2/13/25, indicated: - Foley (indwelling urinary catheter) output every shift. Review of physician's orders on 3/25/25 at 8:00 A.M., failed to indicate any physician orders relating to catheter size, bulb size, frequency of catheter and/or catheter bag change, irrigation of catheter system, and other necessary catheter care. Review of Resident #46's nurse progress note, dated 3/7/25, indicated the Resident's indwelling urinary catheter was changed. There was no physician order for urinary catheter change on this date. Review of Resident #46's nurse progress notes, dated 3/21/25, 3/22/25, and 3/23/25, indicated the Resident's indwelling urinary catheter was flushed (irrigated) with sterile water. There was no physician order for irrigation of catheter system on these dates. During an interview on 3/25/25 at 12:59 P.M., the Director of Nursing (DON) said all indwelling urinary catheters require physician orders. The DON said nursing should have obtained physician orders for all necessary care for Resident #101's indwelling urinary catheter upon admission. The DON further said the nurses should have obtained physician orders prior to irrigating or changing Resident #46's indwelling urinary catheter.

Based on record review and interview, the facility failed to provide behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two Residents (#96 and #88), out of a total of 27 sampled residents. Specifically: 1. For Resident #96, the facility failed to offer behavioral health services related to substance abuse timely. 2. For Resident #88, the facility failed to implement recommendations made by the Behavioral Health Nurse Practitioner related to labs. Findings include: Review of the facility's Social Services - Behavioral Health Services - Including Substance Abuse policy, dated as revised 2/5/24 indicated: Purpose: Behavioral health encompasses a resident's whole emotional and well-being which includes, but is not limited to, the prevention and treatment of mental and substance use disorders (SUDs). Each resident is entitled to care and services provided by the facility, to assist him/her to reach and maintain the highest level of mental and psychosocial functioning. 4. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial wellbeing. 6. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes, but is not limited to: b. obtaining history from medical records, the resident and as appropriate, the resident's family and friends, regarding mental, psychosocial and emotional health. d. Ongoing monitoring of mood and behavior. e. Care plan development and implementation. f. Evaluation. 10. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. Examples of individualized non-pharmacological interventions to help meet behavioral health needs of all ages may include but are not limited to: o. Assisting residents with SUDs to access counseling (e.g. individual or group counseling services, 12 step programs and support groups) to the fullest degree possible. 1. Resident #96 was admitted to the facility in February 2025 with diagnoses including alcohol abuse with withdrawal and alcoholic polyneuropathy. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #96 was cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam. Review of the Physiatry note dated 2/17/25 indicated: Patient was noted to have seizures secondary to withdrawal. He/she was treated with phenobarbital. He/she is off of this therapy at this time. Reports that he/she is motivated for sobriety. He/she was continued on folate and thiamine at the outside hospital. We will discuss with medical team regarding reinitiating this. He/she would also benefit from social work consultation for resources out in the community since he/she has just moved back to Massachusetts. We will monitor closely for any barriers this may pose to rehab. Review of the clinical record failed to indicate Resident #96's substance use support services were offered to Resident #96 upon admission. Review of Resident #96's care plans indicated a substance use care plan was not implemented until 2/27/25; 17 days after he/she was admitted to the facility and after he/she was found with alcohol in the facility. Review of the nurse progress note dated 2/27/25 indicated: DON (Director of Nursing) was notified by ADON (Assistant Director of Nursing) that a CNA (Certified Nursing Aid) had observed the patient wheeling himself/herself in the WC (wheelchair) down the hall when an empty bottle of 750mLs of [NAME] vodka fell off of his/her lap. The patient gave the empty bottle to the CNA. The DON and Admin went and spoke with the patient regarding the incident. He/she reported that he/she has been getting deliveries to the facility by services like Door Dash. Explained and educated on the importance of not drinking alcohol with the medications he/she is on and how there could be adverse reactions.DON was made aware of another delivery this morning and when asked if he/she had any other alcohol, the patient at first, denied it but then did tell me that he/she did, in fact, have another bottle delivered this morning. The bottle was a 200ML bottle and the patient confirmed he/she had drank about 100MLs of it already. He/she confirmed he/she had taken his/her morning medications. DON and Admin spoke to him/her about psych services, sud counseling and speaking with the social worker for support around his/her alcoholism. During an interview on 3/24/25 at 10:14 A.M., Resident #96 said he/she has a history of substance use and trauma and was not offered psych services initially upon admission but would have been interested. Resident #96 did not say if the facility had offered substance support services. During an interview on 3/26/25 at 7:57 A.M., the Social Worker said that for resident's admitted to the facility with a known history of substance use, they should be assessed for their use, a care plan should be implemented, and they should be offered support services within the first week of admission. The Social Worker said she did not speak with Resident #96 about his/her substance use or offer supportive services regarding substance abuse until last Friday (3/21/25). The Social Worker said that she placed a referral for behavioral health therapy after Resident #96 was found with alcohol because of Resident #96's self-reported history of trauma. The Social Worker said she was focused on building rapport and discharge planning with Resident #96 and she should have discussed services with him/her sooner. During an interview on 3/26/25 at 9:18 A.M., the Administrator said that for residents admitted to the facility with a known history of substance use disorder, they should be assessed for supports like virtual AA, psych services and other support systems upon admission. The Administrator said she was present with the DON when she offered substance abuse supports to Resident #96 on 2/27/25; 17 days after his/her admission. 45984 2. Resident #88 was admitted to the facility in January 2025 with diagnoses including cerebral infarction, dysphagia (difficulty swallowing) and muscle weakness. Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 0 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident has exhibited verbal behavior symptoms towards others. Review of Resident #88's physician's orders dated 2/2/25: - Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (milligram) Give 2 capsules by mouth one time a day for depression - Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG Give 4 capsule by mouth two times a day for depression Review of Resident #88's Behavioral Health evaluation dated 1/24/25 conducted by the Nurse Practitioner indicated the following: Plan/Recommendations: Depakote level. Lipid Profile, and EKG (electrocardiogram) may be done. Discharge paperwork was evaluated in depth. Recommended Lab Tests: Depakote level, Lipid profile, EKG. Review of Resident #88's Pharmacist's Medication Regimen Review dated 3/18/25 indicated the following recommendation made by the pharmacist: - Resident receives Depakote 250 mg QD and 500 mg BID. Drug level past due, suggest ordering next lab day and adding order for lab schedule every 6 months. Suggest also adding Depakote monitoring order. Review of Resident #88's medical record failed to indicate that a Depakote level, lipid profile or EKG was ever obtained despite the recommendations being made on 1/24/25. The surveyor asked the facility for all completed labs for Resident #88 and none were provided. During an interview on 3/25/25 at 10:51 A.M., the Director of Nursing (DON) said when behavioral health services comes to the facility they will upload their recommendations into the electronic medical record and get sent to the Unit Manager. The DON said the third-floor unit (where Resident #88 resides) does not have a Unit Manager at this time so the Assistant Director of Nursing would handle it. The DON and surveyor reviewed Resident #88's behavioral health recommendations and pharmacy medication review and she said the Depakote level, lipid profile and EKG should have been obtained shortly after they were recommended.

Based on observations, record review and interview, the facility failed to ensure staff maintained an accurate medical record for two Residents, (#42 and #62), out of a sample of 27 residents. Specifically: 1. For Resident #42, the facility documented that he/she was wearing a fracture boot to his/her right leg when he/she was not. 2. For Resident #62, the facility documented that weekly checks were completed when they were not in the Resident's medical record. Findings include: 1. Resident #42 was admitted to the facility in April 2022 with diagnoses including unspecified dementia, unspecified fracture of right toes and muscle weakness. Review of Resident #42's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident does not exhibit any behaviors. Review of Resident #42's physician's order dated 2/18/25 indicated the following: Fracture Boot to Right leg at all times when ambulating. During the survey period from 3/24/25 through 3/26/25, the surveyor observed Resident #42 ambulating throughout the third-floor unit without wearing a fracture boot on his/her right foot. Review of Resident #42's hospital discharge paperwork dated 2/17/25 indicated that Resident #42 had fractured his/her right metatarsal (the bones in a foot). Review of Resident #42's discharge plan indicated the following: Continue with right foot immobilizer. Review of a nursing progress note written on 2/18/25 at 9:48 P.M., indicated the following: Resident readmitted back to the facility at 2:40pm via a wheelchair transport van. Resident has metatarsal fracture on the right foot, bruising on the right great toe and second left toe. Resident to wear right FX (fracture) boot while ambulating at all times. During an interview on 3/25/25 at 7:55 A.M., Resident #42 said he/she leaned over his/her bed and fell on his/her foot and knee and he/she requested to go to the hospital. The Resident then said the hospital provided him/her with a boot to wear on his/her right foot but he/she threw it away on his/her first day into the facility because he/she did not want to wear it. Review of Resident #42's Treatment Administration Record for March 2025 indicated that staff signed off that Resident #42 was wearing his/her fracture boot on 3/25/25 and 3/26/25 even though he/she was not and the boot was no longer accessible. During an interview on 3/26/25 at 9:33 A.M., Nurse #2 said Resident #42 came back from the hospital with a boot to wear since he/she fractured his/her right foot. Nurse #2 said the Resident threw away the boot on his/her first day back. Nurse #2 said staff should be accurately documenting in the medical record and not saying the Resident was wearing his/her boot when he/she was not. During an interview on 3/26/25 at 9:53 A.M., Certified Nursing Assistant (CNA) #1 said Resident #42 came back from the hospital with a boot but she has not seen him/her wearing it. During an interview on 3/26/25 at 11:52 A.M., the Director of Nursing (DON) said Resident #42 had a boot for his/her fractured foot, but he threw it away the day after he/she came back from the hospital. The DON said staff should not be documenting that Resident #42 was wearing his/her boot when he/she was not. 2. Resident #62 was admitted to the facility in September 2024 with diagnoses including bipolar disorder, type 2 diabetes and dementia. Review of Resident #62's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental score of 12 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident requires assistance from staff with all activities of daily living and is at risk of developing pressure ulcers. Review of Resident #62's physician's order dated 9/27/24 indicated the following: Skin Checks Weekly every evening shift every Wednesday for Preventative. Review of Resident #62's Treatment Administration Record (TAR) for February and March 2025 indicated that staff completed a weekly skin check for the Resident on 2/26/25, 3/5/25, 3/12/25, 3/19/25. During the survey period, review of Resident #62's medical record indicated that the last completed skin check was dated 2/20/25 indicating that five weeks of skin checks were not in the medical record. During an interview on 3/26/25 at 9:42 A.M., Nurse #1 said skin checks are done weekly for all residents and if a resident refuses it should be documented in the medical record. Nurse #1 and the surveyor reviewed Resident #62's medical record and Nurse #1 said she was not sure why the Resident's last documented skin check was on 2/20/25. Nurse #1 said even if a resident has no skin issues it still needs to be documented in the medical record. During an interview on 3/26/25 at 11:52 A.M., the Director of Nursing (DON) said skin checks should be done weekly or as ordered by the physician. The DON said whether there are findings or not in the skin checks, they need to be uploaded and documented into the medical record. The DON continued to say skin checks should not be documented as being complete if there is no documented skin check in the medical record.

Based on observation, record review and interviews, the facility failed to ensure for one Resident (#27), out of a total sample of 27 residents, that enhanced barrier precautions were implemented in accordance with infection control standards of care. Findings include: Review of the facility's titled Policy and Procedure, Enhanced Barrier Precautions, dated as revised October 28, 2024, indicated the following: Policy: It is this Facilities policy that Enhanced Barrier Precautions (EBH) are used to prevent the transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. They are strategies in nursing homes to decrease transmission of CDC (Centers of Disease Control)-targeted and epidemiologically important MDRO (multidrug-resistant organism) when contact precautions do not apply. EBP is used during high-contact care activities for residents with chronic wounds, or indwelling medical devise, regardless of MDRO status, in addition to resident who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. Facilities will have some discretion when implementing EBH and balancing the need to maintain a homelike environment for residents. Definition Indwelling medical device-Examples include but are not limited to, central lines . Resident #27 was readmitted to the facility in July 2024 and has diagnoses that include but are not limited to resistance to multiple antimicrobial drugs, and dependence on renal dialysis. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #27 scored 14 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having intact cognition. Further review of the MDS indicated Resident #27 has dialysis treatments. During an observation and interview on 3/24/25 at 8:22 A.M., Resident #27 was standing in his/her room. Resident #27 had gauze covering an area on his/her right chest. Resident #27 said he/she goes to dialysis and pointed to his/her right chest and said it is used for dialysis. Review of Resident #27's medical record indicated the following: -A physician's order dated 7/23/24 Dialysis days: Tuesday Thursday Saturday. Transport to dialysis center. -A care plan dated as initiated 3/12/2024, I have a central line IJ (Internal Jugular) Catheter and am at risk for opportunistic infection to enter my body. Interventions included but were not limited to Enhanced Barrier Precautions during personal CARE During an interview on 3/25/25 at 8:28 A.M., Nurse #5 said Resident #27 has access for dialysis through a chest port (a medical device placed under the skin in the chest, allowing access to a vein). On 3/25/25 11:38 A.M., Resident #27 was observed in his/her room, his/her hair was wrapped in a towel, consistent as just having a shower. There was no enhanced precaution sign on the door. On 3/26/25 at 8:30 A.M., Resident #27 was observed in his/her room. There was no personal protection equipment near the door, nor an 'enhanced precaution' sign, notifying staff of the need for enhanced barrier precautions. During an interview on 3/26/25 at 9:21 A.M., Nurse #7 said Resident #27 goes out to dialysis and has a chest port which is used for dialysis access. Nurse #7 said Resident #27 is not on any infection control precautions other than standard precautions. Nurse #7 reviewed the physician's orders for Resident #27 and said he/she does have an order for enhanced barrier precautions. Nurse #7 said enhanced barrier precautions require staff to put on personal protection equipment (PPE) during high-contact care, that a cart with PPE supplies would be outside the room and a sign identifying the precautions would be on the door to alert staff and others of the need for enhanced barrier precautions. During an interview on 3/26/25 at 10:08 A.M., the Infection Control Preventionist Nurse said the need for enhanced barrier precautions for Resident #27 was discussed, that he/she does have an indwelling medical device, and that the orders should be followed for enhanced barrier precautions including identifying the room with an enhanced barrier precaution sign.

Based on observation, record review and interview, the facility failed to ensure diets as ordered by the physician were served in proper form for one Resident (#68) out of a total of 29 sampled residents. Specifically, on 1/22/24, Resident #68 was served a lunch meal, not in accordance with the diet order, resulting in Resident #68 choking and requiring the Heimlich maneuver (an emergency procedure which involves abdominal thrusts to dislodge foreign bodies or food from the throats of choking victims). Findings include: Review of the facility's Therapeutic Diets Policy, dated November 2022 indicated: Therapeutic diets shall be prescribed by the attending physician. A therapeutic diet must be prescribed by the attending physician and order should match the terminology used by food services. The food services manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. Review of the American Red Cross Resources regarding Adult/Child Choking, undated, indicated: Signs or symptoms: Weak or no cough. High pitched squeaking noises or no sound. Pale or blue skin color. Unable to cough, speak or cry. Panicked, confused or surprised appearance. Holding throat with hand(s). Resident #68 was admitted to the facility in December 2017 with diagnoses including Alzheimer's disease. A diagnosis of dysphagia, (difficulty or discomfort in swallowing), was added to Resident #68's clinical record in July 2019. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #68 scored a 13 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact. The MDS also indicated he/she requires supervision for meals. On 4/10/24, the surveyor attempted to interview Resident #68 who presented as confused and not agreeable to the interview process. On 4/11/24 at 8:43 A.M., the surveyors observed Resident #68 eating his/her breakfast meal in the 2nd floor dining room with other residents. There were no staff in the room to supervise him/her or the other residents for approximately 15 minutes. Review of Resident #68's care plans indicated: Focus: Impaired cognition with fluctuations in reliability and memory dx (diagnosis) Alzheimer's, 2/26/19: Interventions: Break down tasks and provide cuing/assistance as needed. Re-direct/re-orient resident/patient using external cues as needed. Focus: Advanced Directives, HCP (health care proxy) activated, 9/6/22: Interventions: Inform Resident #68 and/or healthcare decision maker of any chance in status or care needs. Promote opportunities for Resident #68/healthcare decision maker to participate in decision regarding care. Additional review of Resident #68's care plans effective 1/1/24 through 4/11/24 failed to indicate the level of assistance or supervision Resident #68's required for eating. Review of Resident #68's Speech Therapy discharge summary dated 6/7/23 indicated: Goal: Pt (patient) will tolerate regular texture solids with chopped meats and thin liquids with no other s/s (signs and symptoms) of aspiration, penetration and/or oral stage dysphagia with 90% accuracy in order to maximize pt's ability to tolerate least restrictive liquid/diet texture. Discharge: 85-95% on regular texture solids with chopped meats and thin liquids. Pt benefited from education/cues at times for maintained seated upright positioning during PO (by mouth) intake and to not attempt to talk during PO intake in order to decrease risks of aspiration. Education/cues at times for decreased intake rate/size on solids and for alternated solids/liquids to assist in breakdown and clearance. Communication: Treatment results communicated to interdisciplinary team. Review of Resident #68's nutritional care plan dated as initiated 1/11/18, indicated that Resident #68 was at nutritional risk secondary to poor meal response, weight loss with the intervention to provide his/her diet as ordered. The care plan focus was updated on 4/8/24 to include Resident #68 had chewing/swallowing difficulty. Review of the nursing progress note dated 1/22/24 indicated: One PM lunch time patient choked and the nurse was called food noted that wasn't cut up and [family member] present. The nurse performed Heimlich maneuver and 3 pieces of meat was [sic] dislodged and patient verbalized to be ok and he/she was able to drink water. Unit manager was notified, NP (Nurse Practitioner) was notified and speech evaluation to be done and downgraded to ground meat and kitchen was notified. Review of Resident #68's physician's order effective 11/19/19 through 1/22/24 indicated: Regular diet, regular texture, chopped meat. The clinical record indicated that after the choking incident, Resident #68 was seen by speech therapy and his/her diet was downgraded to dysphagia mechanical. Review of Resident #68's clinical record failed to indicate any documentation to support that he/she was non-compliant with his/her physician's ordered diet. Review of the therapeutic diet manual indicated when meatballs are served residents on regular diets would receive whole meatballs and residents on dysphagia diets would receive ground meat. Additional review of the diet manual failed to indicate chopped meats as an therapeutic option, however, Resident #68 had a specific physician's order for chopped meat. Resident #68 received whole meatballs not cut up/chopped per the physician's order. During an interview on 4/11/24 at 3:33 P.M. Family Member #1 said she was present when Resident #68 was eating his/her lunch and began to choke. Family Member #1 said she and Certified Nursing Assistants (CNAs) were in the dining room during the lunch meal. Family Member #1 said that Resident #68 was served Swedish meatballs for lunch that were not cut up. Family Member #1 said that while Resident #68 was eating, he/she began coughing which got worse and looked really bad. Family Member #1 said that she ran for help and a CNA got a nurse who then performed the Heimlich maneuver on Resident #68. Family Member #1 said that Resident #68's food should have been cut up before he/she was served. Family Member #1 said that the nurse who performed the Heimlich maneuver saved Resident #68's life. During an interview on 4/11/24 at 10:31 A.M., Nurse #5 said that before serving meals to residents, the nurses are supposed to check the resident meal tickets to ensure residents are being served the correct meal. Nurse #5 said she was working on 1/22/24 and that she heard a call for help and that another nurse (Nurse #9) gave Resident #68 the Heimlich. Nurse #5 said she did not check the meal trays and she thought the other nurse did. During an interview on 4/12/24 at 8:06 A.M., Nurse #9 said on 1/22/24 someone yelled for help and she entered the dining area. Nurse #9 said that Resident #68 did not look good, he/she was holding his/her throat and could not talk. Nurse #9 said she gave abdominal thrusts to Resident #68 and pieces of meat came out. Nurse #9 said that she did not check the trays and thought the other nurse (Nurse #5) did. Nurse #9 said that Resident #68 was served meatballs that were not cut up correctly. During an interview on 4/12/24 at 7:51 A.M., Unit Manager #2 said that she was working, but was not on the unit when Resident #68 choked. Unit Manager #2 said that the nurses are supposed to check the trays to ensure meals are correct before serving them to residents. Unit Manager #2 said that Resident #68 had orders for chopped meat and the meat should have been served to him/her chopped and not whole. On 4/11/24 at 1:25 P.M., the surveyor observed Speech and Language Pathologist (SLP) #1 evaluating Resident #68 during the lunch meal. SLP #1 and the surveyor reviewed Resident #68's physician's diet order in place at the time of the choking incident (1/22/24) and SLP #1 said that Resident #68's meat should have been delivered to the resident cut up. During an interview on 4/12/24 11:12 A.M. SLP #2 said that the expectation for a regular diet, regular texture chopped meat would be that all items on a resident's plate would not be modified except for his/her meat, including meatballs, would be cut up. SLP #2 said that whole meatballs are not considered ground or modified meat. SLP #2 said that chopped is not the same as a ground diet because of the size differences in the food items (pea size versus bite sized). SLP #2 said that meals with specifications like chopped meats should be delivered to the nursing unit from the kitchen in that form. During a follow up interview on 4/12/24 at 11:35 A.M., SLP #1 said that if the Resident had been on a ground diet, Resident #68 would have been cooked ground beef with gravy, not whole meatballs. Resident #68's physicians order, all meat products on his/her tray, including meatballs, should have been cut/chopped, and it should have been delivered from the kitchen in that form. During an interview on 4/12/24 at 10:25 A.M., the Regional Dietary Director said the facility makes its own meatballs and they measure approximately 2 inches in diameter. She said the kitchen was not made aware of the choking incident so were unable to investigate to determine if Resident #68 choked on meatballs, or some other meat or fluid, or if she was served the wrong meal, or wrong texture. Review of the facility's report submitted to the state agency dated 1/26/24, failed to include Resident #68's active diagnosis of dysphagia and indicated that Resident #68 and received a regular house diet per his/her physician orders. However, the report failed to indicate that Resident #68's diet was regular with chopped meat. During an interview on 4/12/24 at 9:22 A.M., the Director of Nursing (DON) said that when residents have orders for chopped meat, their plate should be delivered from the kitchen in that form. The DON said that although there is no formal policy for ensuring meals are correct, the expectation is for nurses to check the tray tickets to ensure the correct diet is delivered. The DON began her employment at the facility in March 2024 and could not speak on Resident #68's choking incident. During an interview on 4/12/24 at approximately 1:30 P.M., the Infection Preventionist (IP) said that she had reached out to the previous IP and was unable to obtain any documentation supporting that staff had been educated related to Resident #68's choking event. The IP was an employee at the facility during the event and said that she had not received education regarding the event. The facility was unable to provide information related to the investigation of the cause of Resident #68's choking incident, or that education was provided to staff after the event, or that the incident was brought to the facility's Quality Assurance Program. The Administrator was provided with the Immediate Jeopardy Template on 4/12/24 at 3:52 P.M.

Based on record reviews, policy review, and interviews, the facility failed to assess for eligibility, and offer pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#49 and #87) out of a total of five residents reviewed. Findings include: Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (cdc.gov), dated 3/15/23 indicated but was not limited to 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 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later. -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (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 20-Valent Pneumococcal Conjugate Vaccine (PCV20). Review of the facility policy, Pneumococcal Vaccination, dated 10/16/23, indicated it is the policy of the facility to have an infection control program that addresses a need to reduce the overall incidence of pneumococcal pneumonia by immunizing high-risk persons: -To provide immunization against bacterial pneumococcal disease, bacteremia and meningitis caused by strains included each of the vaccine type. All residents will be assessed for appropriateness of receiving the pneumococcal vaccine. 1. The pneumococcal vaccine is ordered upon admission by the attending physician. If the vaccine is not ordered, the physician/nurse must document as to reason why not. 2. The resident or the resident's legal representative shall have the opportunity to refuse the immunization. Obtain and document the resident/guardian's consent or refusal and document reason in the medical record. 3. Prior to administering the pneumococcal vaccine each resident or the resident's legal representative shall receive education regarding the risks, benefits and potential side effects of the immunization. Evidence of education is to be documented on the individual resident's medical record. 4. Consent form must be signed prior to administration by the resident or responsible party after reviewing the vaccine information statement. Resident or responsible party may revoke consent by providing facility with request in writing. 9. Documentation in electronic health record immunization tab regarding the administration, type, time, lot, expiration and location of the pneumonia vaccine administration must be input into the Medication Administration Record, 24 Hour Resident Condition Report and Progress Notes. 1.) Resident #49 was admitted to the facility in March 2024 with diagnosis including diabetes. Review of the Minimum Data Set assessment, dated 3/19/24, indicated: O0300. Pneumococcal Vaccine A. Is the resident's Pneumococcal vaccination up to date? No. B. If pneumococcal vaccination not received, state reason. Not Offered. Review of the medical record on 4/12/24, failed to include documentation that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. 2.) Resident #87 was admitted to the facility in March 2021 with diagnoses including dementia and obesity. Review of the MDS assessment, dated 2/21/24, indicated: O0300. Pneumococcal Vaccine A. Is the resident's Pneumococcal vaccination up to date? No. B. If pneumococcal vaccination not received, state reason. Not Offered. Review of the medical record on 4/12/24, failed to include documentation that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. During an interview on 4/12/24 at 12:50 P.M., the Infection Preventionist said the admitting nurse determines if a resident requires the pneumococcal vaccines and obtains consent at that time, either from the resident/family, or mails a request to responsible person for signature. Nursing then enters the vaccine data into the electronic health record immunization menu and scans the consent form into electronic health record under miscellaneous. During an interview on 4/12/24 at 12:30 P.M., the Director of Nursing said the facility did not have documentation to support that either Resident #49 or Resident #87 were educated, offered, or received the pneumococcal immunizations but should have.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired and was observed by several nursing staff to display exit seeking behaviors, the Facility failed to ensure a comprehensive person-centered care plan was developed and implemented related to his/her risk for elopement. On 09/14/23 Resident #1 exited the unit in his/her wheelchair through a fire door exit into a stair well, fell from his/her wheelchair down several stairs onto a landing and sustained a left ankle fracture. Findings Include: Review of the Facility Policy titled Person-Centered Care Plan, dated as revised 10/24/22, indicated a comprehensive individualized Care Plan will be developed within seven days after completion of the comprehensive assessment. The Policy indicated that for newly admitted patients, the comprehensive Care Plan must be completed within seven days of the completion of the comprehensive assessment and no more than twenty-one days after admission. The Policy indicated the Care Plan must be customized to each individual's preferences and needs. The Policy indicated the Care Plans will be communicated to appropriate staff, patient, patient representative, and family and would be reviewed and revised by the interdisciplinary team after each assessment and as needed to reflect the responses to care and changing needs and goals. Review of the Facility Policy titled Elopement of a Patient, dated as revised 10/24/22, indicated an elopement was defined as any situation in which a patient leaves the premises or a safe area without the Facility's knowledge and supervision if necessary. The Policy indicated patients/residents would be evaluated for elopement risk upon admission, re-admission, quarterly, and with a change in condition as part of the clinical assessment process. The Policy indicated those determined to be at risk would receive appropriate intervention to reduce risk and minimize injury. The Policy indicated that for patients identified as at risk, an interdisciplinary elopement prevention patient-centered care plan will be developed. Review of the Facility's Incident Report, dated 09/14/23, indicated that at approximately 4:50 P.M. two Certified Nurse Aides (CNAs) assisted Resident #1 out of bed and at approximately 5:00 P.M., a nurse heard a CNA calling for help at the end of the hallway next to Resident #1's room. The Report indicated that the nurse immediately responded and observed one CNA holding the (fire exit) door open and another CNA was with Resident #1 who was laying on the floor at the bottom of the stairs with blood on his/her left front shin. The Report indicated blood stains were observed from the third stair down to the tenth and that Resident #1 had a laceration to his/her left lower leg. The Report indicated 911 was called and Resident #1 was transferred to the Hospital Emergency Department. The Report indicated that a predisposing situation factor for the incident was he/she was an active exit seeker. Resident #1 was admitted to the Facility in August 2023, diagnoses included pressure injuries to left and right ankles, protein calorie malnutrition, depression, left sided hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction, wheelchair dependence, and altered mental status. Review of Resident #1's Physician Progress Note to Activate Health Care Proxy/Durable Power of Attorney for Health Care, dated 08/29/23, indicated Resident #1 was incapable of making informed decisions due to dementia and indicated the duration of the incapacity was expected to be indefinite. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was dependent on the assistance of two staff members for transfers, and that he/she was non-ambulatory. The MDS indicated Resident #1's had a Brief Interview for Mental Status (BIMS) score of 00 (scores from 0-7 points suggest severe cognitive impairment). Review of Resident #1's Nurse Progress Note, dated 09/04/23, indicated he/she was self-propelling in his/her wheelchair hovering around the elevator stating he/she needed to go home and that staff re-directed him/her with minimal effect. During an interview on 09/26/23 at 1:22 P.M., Certified Nurse Aide (CNA) #1 said she had provided care for Resident #1 on several occasions, he/she typically self-propelled his/her wheelchair all over the unit and said he/she was always trying to get out of the unit. CNA #1 said Resident #1 would say he/she was getting out of here and would not hide it. CNA #1 said Resident #1 would try to get into the elevator and she would see him/her near exit doors. During an interview on 09/26/23 at 2:22 P.M., Certified Nurse Aide (CNA) #3 said she typically worked the 7:00 A.M. to 3:00 P.M. shift, and had provided care for Resident #1 in the past. CNA #3 said she had observed Resident #1 attempt to get into the elevator to go out to smoke since he/she was admitted to the Facility and that it was normal for him/her to do so. CNA #3 said Resident #1 would press the elevator buttons and try to get into the elevator. During an interview on 09/26/23 at 2:48 P.M., Nurse #1 said he had provided care for Resident #1 on many occasions, that he/she was a smoker and would want to go outside alone to smoke. Nurse #1 said once, at the end of August or beginning or September (exact date unknown), Resident #1 went into the elevator in his/her wheelchair and he had to get him/her out of the elevator. Nurse #1 said he had seen Resident #1 sitting by the elevator and verbalizing wanting to go outside on other occasions. During an interview on 09/26/23 at 4:05 P.M., Nurse #3 said although she had never had Resident #1 on her assignment, said she had observed him/her pressing the elevator button, open the elevator door, and get into the elevator. Nurse #3 said went into the elevator to lock it so it did not move and they had to take Resident #1 in his/her wheelchair out of the elevator. Nurse #3 said Resident #1 verbalized that he/she wanted to go home and that he/she felt like he/she was in jail. Nurse #3 said she felt as if Resident #1 was an elopement risk at the time so she attempted to obtain a wander-guard for him/her but was told she could not put one on him/her because there was no Physician's Order, so she had informed the Unit Manager about her concern. During an interview on 09/26/23 at 2:01 P.M., CNA #2 said she typically worked the 7:00 A.M. to 3:00 P.M. shift and said although she was not at the Facility at the time Resident #1 fell down the stairs, said that prior to the day of the incident, Resident #1 would verbalize that he/she was going to go outside to smoke, and would attempt to get into the elevator. Review of Resident #1's Medical Record indicated there was no documentation to support that the Facility assessed his/her risk for elopement upon admission or when nursing staff observed him/her with exit seeking behaviors. There was no documentation to support that a Care Plan was developed, with goals and interventions established related to his/her exit seeking in an attempt to prevent elopement and potential injury when he/she initially displayed exit seeking behaviors. During an interview on 09/26/23 at 1:22 P.M., CNA #1 said on 09/14/23 she worked from approximately 7:00 A.M. to 9:30 P.M. and said a nurse asked her to assist Resident #1 out of bed sometime between 4:30 P.M. and 5:00 P.M. CNA #1 said Resident #1 did not typically want to get out of bed until between 6:30 P.M. and 7:00 P.M. and said before transferring him/her, she asked him/her why he/she wanted to get up and Resident #1 said he/she said did not know. CNA #1 said she then asked Resident #1 what he/she was going to do and said he/she told her that he/she did not know and that he/she was going away. CNA #1 said that when Resident #1 told her that he was going away after she asked him what he/she was going to do (when he/she was out of bed) she thought he/she was joking. CNA #1 said while she was in another Resident's room, two doors down from Resident #1's room and heard a beeping noise but said it sounded like an oxygen machine. CNA #1 said she left the room approximately one minute after she heard the beeping noise sounding and walked down the hall towards the exit door where the sound was coming from. CNA #1 said Resident #2, who was seated at the end of the hall (next to the fire exit door), said someone went out the door. CNA #1 said that at that same time, CNA #4 had just come out of a room and asked where Resident #1 was and Resident #2 said that's who went out the door. CNA #1 said the alarm was still sounding when she opened the (fire) exit door and said she observed Resident #1's wheelchair tilted on the third or fourth stair down and he/she was on the floor laying on his/her side in a fetal position on the landing at the bottom of the stairs. CNA #1 said there was blood on the stairs and on the landing, Resident #1 was moaning in pain and she went back into the hall and yelled for staff to come help. During an interview on 09/26/23 at 3:21 P.M., Nurse #2 said that on 09/14/23 when she worked a 7:00 A.M. to 11:00 P.M. shift, Resident #1 was on her assignment and at approximately 4:15 P.M. she went to his/her room and he/she requested to get up out of bed. Nurse #2 said she asked a CNA to assist Resident #1 out of bed, returned to the nurse's station, and at approximately 5:00 P.M. she heard the CNA yelling. Nurse #2 said she ran down the hall and observed Resident #1's wheelchair stuck between the second and third stair down in the stairwell and he/she was on the landing at the bottom of the first set of stairs. Nurse #2 said Resident #1 was bleeding from his/her left shin, 911 was called, and he/she was transferred to the Hospital Emergency Department. Review of Resident #1's Hospital Emergency Department Visit Summary, dated 09/15/23, indicated he/she had been transferred to the Hospital Emergency Department (ED) on 09/14/23 after he/she got up out of his/her wheelchair and fell down a staircase in an attempt to leave (the Facility) and after being evaluated at the ED, was cleared and discharged back to the Facility. The Visit Summary further indicated that (after Resident #1 was discharged back to the Facility) the Hospital called the Facility and requested they send Resident #1 back to the ED because they had discovered a left ankle fracture on the x-ray that was done on 09/14/23. Review of Resident #1's Hospital Radiology Report, date of service 09/14/23 and signed by a Physician on 09/15/23 indicated he/she had a non-displaced ankle fracture. During an interview on 09/26/23 at 4:28 P.M., the Unit Manager said Resident #1 was admitted to the Facility two to three weeks prior to the incident (on 09/14/23). The Unit Manager said prior to the day of the incident, she had observed Resident #1 hovering near the elevator a couple of times. The Unit Manager said she could not recall if any nursing staff told her that Resident #1 had gotten into the elevator and needed to be re-directed out because several residents had done that over the years. The Unit Manager could not explain why Resident #1 did not have a Care Plan related to his/her exit seeking behaviors or elopement risk. During an interview on 09/26/23 at 4:50 P.M., the Director of Nursing (DON) said nursing had not made her aware that Resident #1 displayed exit seeking behaviors. The DON said if nursing observed Resident #1 displaying exit seeking behaviors, they should have informed management so an Elopement Risk Assessment could have been completed and a Care Plan developed for him/her.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired, was wheelchair bound, and who had been observed since admission to exit seeking behaviors, the Facility failed to ensure he/she was provided with an adequate level of supervision in an effort to maintain his/her safety in an effort to prevent an incident/accident resulting in an injury. On 09/14/23, prior to being transferred out of bed, Resident #1 verbalized to Certified Nurse Aide (CNA) #1 that he/she was going away and shortly afterwards he/she had exited the unit through an alarmed fire exit door and was found on the landing at the bottom of the staircase. Resident #1 was transferred to the Hospital Emergency Department for evaluation and was diagnosed with a left ankle fracture. Findings Include: The Facility Policy titled Elopement of a Patient, dated as revised 10/24/22, indicated an elopement was defined as any situation in which a patient leaves the premises or a safe area without the Facility's knowledge and supervision if necessary. The Policy indicated patients/residents would be evaluated for elopement risk upon admission, re-admission, quarterly, and with a change in condition as part of the clinical assessment process. The Policy indicated those determined to be at risk will receive appropriate intervention to reduce risk and minimize injury. Resident #1 was admitted to the Facility in August 2023, diagnoses included pressure injuries to left and right ankles, protein calorie malnutrition, depression, left sided hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction, wheelchair dependence, and altered mental status. Review of Resident #1's Physician Progress Note to Activate Health Care Proxy/Durable Power of Attorney for Health Care, dated 08/29/23, indicated Resident #1 was incapable of making informed decisions due to dementia and indicated the duration of the incapacity was expected to be indefinite. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was dependent on the assistance of two staff members for transfers, and that he/she was non-ambulatory. The MDS indicated Resident #1's had a Brief Interview for Mental Status (BIMS) score of 00 (scores from 0-7 points suggest severe cognitive impairment). Review of the Facility Incident Report, dated 09/14/23, indicated that at approximately 4:50 P.M. two Certified Nurse Aides (CNAs) assisted Resident #1 out of bed and at approximately 5:00 P.M., a nurse heard a CNA calling for help at the end of the hallway next to Resident #1's room. The Report indicated that the nurse immediately responded and observed one CNA holding the (fire exit) door open and another CNA was with Resident #1 who was laying on the floor at the bottom of the stairs with blood on his/her left front shin. The Report indicated blood stains were observed from the third stair down to the tenth and that Resident #1 had a laceration to his/her left lower leg. The Report indicated 911 was called and Resident #1 was transferred to the Hospital Emergency Department. The Report indicated that a predisposing situation factor for the incident was he/she was an active exit seeker. Review of Resident #1's Hospital Emergency Department Visit Summary, dated 09/15/23, indicated he/she had been transferred to the Hospital Emergency Department (ED) on 09/14/23 after he/she got up out of his/her wheelchair and fell down a staircase in an attempt to leave (the Facility) and after being evaluated at the ED, was cleared and discharged back to the Facility. The Visit Summary indicated that (after Resident #1 was discharged back to the Facility) the Hospital called the Facility and requested they send Resident #1 back to the ED because they had discovered a left ankle fracture on the x-ray that was done on 09/14/23. Review of Resident #1's Hospital Radiology Report, date of service 09/14/23 and signed by a Physician on 09/15/23 indicated he/she had a non-displaced left ankle fracture. During an interview on 09/26/23 at 8:58 A.M., Resident #2 said that on the day he/she observed Resident #1 go out through the fire door (9/14/23), Resident #1 came out of his/her room in his/her wheelchair and appeared to be angry and up to no good. Resident #2 said Resident #1 went over to the fire door and tried to open the door, and that he/she told Resident #1 that he/she could not open the door without a code. Resident #2 said he asked Resident #1 what he/she was doing, told Resident #1 there were stairs there and that he/she could get hurt. Resident #2 said Resident #1 just kept pressing the door handle and after a few seconds the door opened and he/she went out through it. Resident #2 said as he/she was going to get staff and then heard a bump, bump, bump and heard Resident #1 yell. During an interview on 09/26/23 at 1:22 P.M., CNA #1 said she had provided care for Resident #1 on several occasions, he/she typically self-propelled his/her wheelchair all over the unit and said he/she was always trying to get out of the unit. CNA #1 said Resident #1 would say he/she was getting out of here and would not hide it. CNA #1 said Resident #1 would try to get into the elevator and she would see him/her near exit doors. CNA #1 said on 09/14/23 she worked from approximately 7:00 A.M. to 9:30 P.M. and said a nurse asked her to assist Resident #1 out of bed sometime between 4:30 P.M. and 5:00 P.M. CNA #1 said Resident #1 did not typically want to get out of bed until between 6:30 P.M. and 7:00 P.M. and said before transferring him/her, she asked him/her why he/she wanted to get up and Resident #1 said he/she said did not know. CNA #1 said she then asked Resident #1 what he/she was going to do and said he/she told her that he/she did not know and that he/she was going away. CNA #1 said she again asked Resident #1 if he/she was sure he/she wanted to get up, he/she swore at her to get him/her up. CNA #1 said that when Resident #1 told her that he was going away after she asked him what he/she was going to do (when he/she was out of bed) she thought he/she was joking. CNA #1 said while she was in another Resident's room, two doors down from Resident #1's room, she was talking to the resident and heard a beeping noise but said it sounded like an oxygen machine. CNA #1 said she left the room approximately one minute after she heard the beeping noise sounding and walked down the hall towards the exit door where the sound was coming from. CNA #1 said Resident #2, who was seated at the end of the hall (next to the fire exit door), said someone went out the door. CNA #1 said that at that same time, CNA #4 had just come out of a room and asked where Resident #1 was and Resident #2 said that's who went out the door. CNA #1 said the alarm was still sounding when she opened the (fire) exit door and said she observed Resident #1's wheelchair tilted on the third or fourth stair down and he/she was on the floor laying on his/her side in a fetal position on the landing at the bottom of the stairs. CNA #1 said there was blood on the stairs and on the landing, Resident #1 was moaning in pain and she went back into the hall and yelled for staff to come help. During an interview on 09/26/23 at 3:21 P.M., Nurse #2 said that on 09/14/23 when she worked a 7:00 A.M. to 11:00 P.M. shift, Resident #1 was on her assignment and at approximately 4:15 P.M. she went to his/her room and he/she requested to get up out of bed. Nurse #2 said she asked a CNA to assist Resident #1 out of bed, returned to the nurse's station, and at approximately 5:00 P.M. she heard the CNA yelling. Nurse #2 said she ran down the hall and observed Resident #1's wheelchair stuck between the second and third stair down in the stairwell and he/she was on the landing at the bottom of the first set of stairs. Nurse #2 said she observed blood from the third stair down and on the landing and said Resident #1 was bleeding from his/her left shin. Nurse #2 said 911 was called and he/she was transferred to the Hospital Emergency Department. Review of the Incident/Accident Witness Interview Tool, dated 09/14/23 and signed by CNA #4, indicated that at 5:00 P.M., while she was making a bed, she heard alarms sounding and when she left the room, Resident #2 told her that a resident went down the stairs and she then heard a resident ask for help. The Witness Interview Tool indicated CNA #4 opened the door and saw Resident #1 laying on the ground. On 09/26/23 at 5:30 P.M., the Surveyor observed the Director of Nursing (DON) press the fire door handle for fifteen seconds and an alarm which sounded with quick shrill beeps began to sound as she held the door handle down. When the door opened after fifteen seconds, a longer and louder alarm sounded and continued until the DON stopped it. During an interview on 09/26/23 at 4:28 P.M., the Unit Manager said Resident #1 was admitted to the Facility two to three weeks prior to the incident. The Unit Manager said prior to the incident, she had observed Resident #1 hovering near the elevator a couple of times. The Unit Manager said she could not recall if staff told her that Resident #1 had gotten into the elevator and needed to be re-directed. During an interview on 09/26/23 at 4:53 P.M., the Director of Nursing (DON) said nursing staff had not informed her that Resident #1 had displayed exit seeking behaviors (prior to incident on 09/14/23). The DON said Elopement Risk Assessments should be done if residents display signs of risk of elopement and said observations of being near the elevator, verbalizing wanting to go outside to smoke and being able to go smoke on his/her own, getting into the elevator and needed to be removed were signs of being at risk for elopement. The DON said staff should have told the Unit Manager when they observed Resident #1 with exit seeking behaviors so that interventions for the behaviors could have been put into place. On 09/26/23, Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 09/15/12, Resident #1 was moved to a room closer to the nurse's station. B) 09/15/23, Unit Manager developed an at Risk for Elopement Care Plan for Resident #1. C) 09/15/23, Unit Manager completed an Elopement Risk Assessment for Resident #1. D) 09/18/12, Unit Managers completed audits to determine if any other residents have made attempts to leave their units in order to determine need for picture placement in the elopement book and placement of wanderguards (personal alarms that sound at elevator and front door). E) 09/18/23, Nurse Practice Educator and Nursing Supervisors provided to education to staff on that included a demonstration of the sound of the fire exit alarm door, and keeping door codes private from families and visitors. F) Starting effective 09/15/23, Unit Managers will complete on-going audits on all units to review any further attempts to exit out to stairwell and attempts to leave the units weekly for four weeks and then monthly for two months. G) DON will provide updates on Plan of Correction to Quality Assurance Performance Improvement Committee at next meeting at the end of October 2023. H) The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated he/she was dependent on two staff members for bed mobility and positioning, and had a known behavior of sliding him/herself off the bed and onto the floor, with an intervention to keep the bed in the lowest position when in bed, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. On 08/12/23, Certified Nurse Aide (CNA) #1 provided care including turning and repositioning to Resident #1 while he/she was in bed, without another staff member present to assist her. During care CNA #1 left the room to get linens, leaving Resident #1 unattended and unassisted by a staff member, with the bed in the raised position. While CNA #1 was gone, Resident #1 rolled off the bed, hit his/her forehead on the nightstand, and landed on the floor. Resident #1 sustained an injury to his/her left eyebrow area, was transferred to the Hospital Emergency Department, and required five sutures and two staples to close his/her head wound. Findings include: The Facility Policy, titled Person-Centered Care Plan, dated 10/24/22, indicated the Facility would develop and implement a person-centered care plan that included the instructions needed to provide effective person-centered care that met professional standards of quality of care. The Facility Policy, titled Activities of Daily Living (ADLs), dated 05/01/23, indicated ADLs would be provided in accordance with accepted standards of practice, the care plan, the resident's choices and preferences, and the Care Plan would address the resident's ADL needs and goals, including the provision of ADLs if the patient was unable to perform ADLs, and a resident who was unable to carry out ADLs would receive the necessary level of ADL assistance. Resident #1 was admitted to the Facility in July 2020, diagnoses included dementia, muscle weakness, unspecified lack of coordination, and stroke. Review of the Annual Minimal Data Set Assessment, dated 05/10/23, indicated Resident #1 was totally dependent for bed mobility and bathing, and required a minimum of two staff members to help with bed mobility and bathing. Review of Resident #1's ADL Care Plan, dated as revised on 05/25/23, indicated he/she required physical assistance from two staff members for bed mobility and positioning. Review of the Falls Care Plan, dated as revised 05/25/23, indicated Resident #1 had a known behavior of sliding him/herself off the bed and onto the floor, and staff were to position his/her bed in the lowest position to prevent injury. Review of the Lift Transfer Evaluation, dated 08/02/23, indicated Resident #1 required extensive to total physical assistance of two staff members to turn and reposition. Review of the Care Kardex Report (used as a reference guide by CNAs and updated to reflect the most current Care Plan), dated 08/11/23, indicated Resident #1 required physical assistance from two staff members for bed mobility and positioning, and had a known behavior of sliding him/herself off the bed onto the floor. Review of the Fall Note, dated 08/12/23, indicated Nurse #1 heard a loud bang from Resident #1's room, and heard CNA #1 scream for help. The Fall Note indicated Nurse #1 went to Resident #1's room and saw he/she was lying on the floor, was bleeding from his/her head, and was transferred to the Hospital Emergency Department via 911. The Note indicated CNA #1 said she had stepped out of the room to get linen, and that was when Resident #1 rolled off the bed. Review of the Hospital Discharge Summary, dated 08/12/23, indicated Resident #1 had sustained a fall at the Facility, and was treated in the Emergency Department for a laceration to his/her left forehead. The Discharge Summary indicated Resident #1 required five sutures and two staples to close his/her head wound. During interview on 08/29/23 at 12:53 A.M., Certified Nurse Aide (CNA) #1 said that on 08/12/23 at 6:30 A.M., she was providing care for Resident #1 without assistance from another staff member, while he/she was in bed. CNA #1 said she had raised the height of the bed to a comfortable working level for herself, rolled Resident #1 onto his/her right side, and realized she needed to get some linen from the cart, which was on the opposite side of the hall outside Resident #1's room. CNA #1 said she left Resident #1 on his/her side, in bed, which was raised up high, went to get the linen from the cart, and when she returned to the room, she saw Resident #1's fall off the right side of the bed, which was farthest from the door, hit his/her head on the bedside table, and land on the floor. CNA #1 said Resident #1 was lying on the floor on his/her back and was bleeding from a cut on his/her head. CNA #1 said she knew how to access the Resident Care Kardex and knew Resident #1 required two staff members to be present and assist with mobility. CNA #1 said she knew Resident #1 had a history of sliding him/herself off his/her bed and onto the floor and said Resident #1 was known to wiggle around in bed when he/she was left alone. During interview on 08/29/23 at 11:49 A.M., Nurse #1 said that on 08/12/23 at 6:30 A.M., he was at the Nurses' Station and heard a loud bang. Nurse #1 said when he looked up, he saw CNA #1 go into Resident #1's room and heard her scream for help. Nurse #1 said he went to Resident #1's room, saw he/she was lying on the floor on the right side of his/her bed, and bleeding from the left side of his/her forehead. Nurse #1 said Resident #1's bed was in a high position. During interview on 08/29/23 at 8:01 A.M., and throughout the survey, the Director of Nurses (DON) said interventions identified in Resident #1's Care Plan and Care Kardex were that he/she required two staff members to provide physical assistance for bed mobility, and for his/her bed to be in lowest position. The DON said CNA #1 should not have left Resident #1 alone in his/her bed with the height of the bed in the elevated position and should have had another staff member with her to assist with Resident #1's care, but had not, and as a result, Resident #1 sustained a fall and a wound to his/her left forehead.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required physical assistance from two staff members for bed mobility, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in injury. On 08/12/23, Certified Nurse Aide #1, provided care to Resident #1, which included repositioning him/her, without another staff member present to assist her. CNA #1 rolled Resident #1 onto his/her side in bed, left him/her like that , and left him/her alone in bed while she went across the hall to get linen. Resident #1 rolled off his/her bed, hit the left side of his/her forehead on the nightstand, and landed on the floor. Resident #1 sustained an injury to his/her left eyebrow area, was transferred to the Hospital Emergency Department for evaluation and treatment and required five sutures and two staples to close his/her head wound. Findings include: The Facility Policy, titled Falls Management, dated 08/07/23, indicated that a fall was defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming exertional force. The Facility Policy, titled Accidents and Incidents, dated 10/24/22, indicated an accident was defined as any unexpected or unintentional incident which could result in injury or illness to a resident, and an incident was defined as any occurrence not consistent with the routine operation of the center or normal care of the resident. The Facility Policy, titled Activities of Daily Living (ADLs), dated 05/01/23, indicated ADLs would be provided in accordance with accepted standards of practice, the care plan, the resident's choices and preferences, and the Care Plan would address the resident's ADL needs and goals, including the provision of ADLs if the patient was unable to perform ADLs, and a resident who was unable to carry out ADLs would receive the necessary level of ADL assistance. Resident #1 was admitted to the Facility in July 2020, diagnoses included dementia, muscle weakness, unspecified lack of coordination, and stroke. Review of the Annual Minimal Data Set Assessment, dated 05/10/23, indicated Resident #1 was totally dependent for bed mobility and bathing, and required a minimum of two staff members to help with bed mobility and bathing. Review of Resident #1's ADL Care Plan, dated as revised on 05/25/23, indicated he/she required physical assistance from two staff members for bed mobility and positioning. Review of the Falls Care Plan, dated as revised 05/25/23, indicated Resident #1 had a known behavior of sliding him/herself off the bed and onto the floor, and staff were to position his/her bed in the lowest position to prevent injury. Review of the Lift Transfer Evaluation, dated 08/02/23, indicated Resident #1 required extensive to total assistance of two staff members to turn and reposition. Review of the Care Kardex Report (used as a quick reference by CNAs and updated to reflect the most current Care Plan), updated 08/11/23, indicated Resident #1 required assistance from two staff members for bed mobility and positioning, and had a known behavior of sliding him/herself off the bed onto the floor. Review of the Fall Note, dated 08/12/23, indicated Nurse #1 heard a loud bang from Resident #1's room, and heard CNA #1 scream for help. The Note indicated Nurse #1 went to Resident #1's room and saw he/she was lying on the floor, was bleeding from his/her head, and was transferred to the Hospital Emergency Department via 911. The Note indicated CNA #1 said she had stepped out of the room to get linen, and that was when Resident #1 rolled off the bed. Review of the Hospital Discharge Summary, dated 08/12/23, indicated Resident #1 had sustained a fall at the Facility, and was treated in the Emergency Department for a laceration to his/her left forehead. The Discharge Summary indicated Resident #1 required five sutures and two staples to close his/her head wound. During interview on 08/29/23 at 12:53 A.M., Certified Nurse Aid (CNA) #1 said that on 08/12/23 at 6:30 A.M., she was providing care for Resident #1 without assistance from another staff member while he/she was in bed. CNA #1 said she had raised the height of the bed to a comfortable working level for herself, rolled Resident #1 onto his/her right side, and realized she needed to get some linen from the cart, which was on the opposite side of the hall outside Resident #1's room. CNA #1 said she left Resident #1 on his/her side, in bed, which was raised up high, went to get the linen from the cart, and when she returned to the room, she saw Resident #1's fall off the right side of the bed, which was farthest from the door, hit his/her head on the bedside table, and land on the floor. CNA #1 said Resident #1 was lying on the floor on his/her back and was bleeding from a cut on his/her head. CNA #1 said she knew how to access the Resident Care Kardex and knew Resident #1 required two staff members to be present and assist with mobility. CNA #1 said she knew Resident #1 had a history of sliding him/herself off his/her bed and onto the floor and said Resident #1 was known to wiggle around in bed when he/she was left alone. During interview on 08/29/23 at 11:49 A.M., Nurse #1 said that on 08/12/23 at 6:30 A.M., he was at the Nurses' Station and heard a loud bang. Nurse #1 said when he looked up, he saw CNA #1 go into Resident #1's room and heard her scream for help. Nurse #1 said he went to Resident #1's room, saw he/she was lying on the floor on the right side of his/her bed, and bleeding from the left side of his/her forehead. Nurse #1 said Resident #1's bed was in a high position. During interview on 08/29/23 at 8:01 A.M., and throughout the survey, the Director of Nurses (DON) said interventions identified in Resident #1's Care Plan and Care Kardex were that he/she required two staff members to provide assistance for bed mobility, and for the bed to be in lowest position. The DON said CNA #1 should not have left Resident #1 alone in his/her bed with the height of the bed in the elevated position and should have had another staff member with her to assist with Resident #1's care, but had not, and as a result, Resident #1 sustained a fall and a wound to his/her left forehead.

Based on records review and interviews for 1 of 3 sampled residents (Resident #1), who required an assist of two staff members during care, the Facility failed to maintain Resident #1's safety. On 5/4/17, Certified Nursing Assistant #1 failed to wait for an additional staff member to be in place before providing incontinence care, rolled Resident #1 over on his/her side unassisted, and Resident #1 rolled off the bed and onto the floor. Resident #1 sustained left nasal bone and maxillary (upper jaw bone) fractures. Findings Include: A Quarterly Minimum Data Set (MDS) Assessment, dated 3/8/17, indicated that Resident #1's medical [DIAGNOSES REDACTED]. The MDS indicated Resident #1 was cognitively impaired and was unable to participate in a Brief Interview for Mental Status (BIMS). An Activity of Daily Living Care Plan, dated 11/22/16, indicated that Resident #1 required the assistance of two staff members with bed mobility and repositioning. The Event Summary Report, dated 5/4/17, indicated that, at 9:45 P.M. on 5/4/17, while Resident #1 was provided with incontinence care by CNA #1, as Resident #1 was repositioned on his/her side, he/she threw both legs over the side of the bed which caused him/her to slide out of the bed. The Report indicated CNA #1 attempted to intervene but was unable to prevent Resident #1 from falling to the floor. The Report indicated that Resident #1's Care Plan would be updated to include that he/she required 3 staff members to provide incontinence care due to Resident #1's rigidity, contractures, and sudden spastic movements. A Progress Note, timed at 10:12 P.M. and dated 5/4/17, indicated that Resident #1's Physician was notified of Resident #1's fall and orders were obtained to transfer Resident #1 to the Hospital Emergency Department. The Hospital History and Physical, dated 5/5/17, indicated that Resident #1 was diagnosed with [REDACTED]. Resident #1 was admitted to the Hospital for evaluation and treatment. A Progress Note, timed at 7:41 A.M. and dated 5/5/17, indicated that Resident #1 was admitted to the hospital with [REDACTED]. (This information was inconsistent with the Hospital Report, dated 5/5/17.) The Surveyor interviewed Nurse #1 at 11:12 A.M. on 6/19/17. Nurse #1 said, on 5/4/17, she and CNA #1 assisted Resident #1 into bed and Resident #1 had been incontinent of a large amount of loose stool so she asked CNA #2 to assist CNA #1. Nurse #1 said a few minutes later she heard one of the CNA's saying that they needed a nurse and when she arrived in Resident #1's room, she observed Resident #1, on the floor, laying perpendicular to the bed in a fetal position with his/her head closest to the bed and his/her feet closest to the wall and Resident #1 was bleeding from his/her nose. Nurse #1 said that Resident #1 was small in stature and was unsure how Resident #1 could have rolled off the bed with both CNA's present. The Surveyor interviewed CNA #1 at 8:59 A.M. on 6/19/17. CNA #1 said, on 5/4/17, while she was providing incontinence care for Resident #1 she asked Nurse #1 to tell CNA #2 that she needed her to help care for Resident #1. CNA #1 said she was close to the bed washing Resident #1's mid-body when CNA #2 came into the room and when CNA #2 was on the opposite side of the bed at the corner near Resident #1's feet, CNA #1 rolled Resident #1 onto his/her side and because Resident #1's knees were bent and contracted, he/she slid off the bed. CNA #1 said because the level of the bed had been raised to a higher position in order to provide care, as well as her hands being wet, she was unable to prevent Resident #1 from falling to the floor. The Surveyor interviewed CNA #2 at 2:35 P.M. on 6/16/17. CNA #2 said, on 5/4/17, Nurse #1 asked her to assist CNA #1 with incontinence care for Resident #1 and when she went into Resident #1's room, she went to the bathroom to get gloves. CNA #2 said as she approached Resident #1's bed, the curtain was drawn and when she walked around the curtain observed CNA #1 on the other side of Resident #1's bed near the window. CNA #2 said as she approached the bed, while she was approximately 2-3 feet away from the foot of the bed, she observed CNA #1 reach over and roll Resident #1 onto his/her left side towards CNA #1. CNA #2 said she shouted to warn CNA #1 that Resident #1 was going to fall and that CNA #1 was unable to prevent Resident #1 from falling. CNA #2 said it happened quickly. CNA #2 said after Resident #1 fell to the floor she observed blood on Resident #1's head and on the floor. The Surveyor interviewed the Director of Nursing (DON) at 11:45 A.M. on 6/19/17. The DON said when she investigated Resident #1's fall, she got into a bed and asked CNA #1 and CNA #2 to re-enact Resident #1's fall. The DON said CNA #1 demonstrated how she rolled Resident #1 over with the DON acting as Resident #1. The DON said when CNA #1 rolled her on to her side, her body started to roll further than just onto her side. The DON said she asked CNA #1 why she didn't attempt to prevent Resident #1 from rolling off the bed by moving her body up against the bed to prevent Resident #1 from rolling out and CNA #1 told her that she didn't expect that Resident #1 would continue to roll. The DON said Resident #1 required 2 people with bed mobility and she expected that both CNA's should have actively participated with rolling Resident #1 in bed and CNA #1 should have informed CNA #2 that she was going to roll Resident #1 over, but instead did so without CNA #2 being ready to assist. Resident #1 did not return to the Facility.

Based on record review and staff interview, the facility failed to provide services which meet professional standards of quality for pressure ulcer identification, measurement and application of treatments for 8 of 14 applicable Residents (#3, 5, 6, 15, 16, 17, 27 and 28) and Insulin administration of 1 non-sampled (NS) Resident (#NS1) in an original sample of 24 Residents and an extended sample of 6 Residents. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice". The facility had a policy for Skin Integrity Management which included the performance of skin inspections on admission, re-admission and weekly. The policy also includes the following: * Include all patients who have newly identified skin impairments on the Center's 24-hour Summary Report. * Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly and with any deterioration of wound. * Perform daily monitoring of wounds or dressings for any presence of complications or declines. Document on treatment administration record (TAR) and/or nurses' note. * Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. A discrepancy between documentation and observation of a wound for Resident #6 was discovered by Surveyor #1 on 12/5/13. Surveyors #1 and #2 compiled a list of pressure ulcers in the facility, based on treatment sheets. Corporate Clinical Consultant #1 was asked to accompany the Surveyors to ensure that pressure ulcers were documented accurately and treated as ordered. After observing the wounds and Corporate Clinical Consultant #1 re-measuring wounds, it was found that licensed staff had not accurately assessed the appearance (color, granulation/slough and eschar) and measurements of wounds. Nor had licensed staff identified tunneling and undermining of wounds. Corporate Clinical Consultant #1 stated that after discussions with the Surveyors on 12/4/13, she had told all Unit Managers and 3:00 P.M.-11:00 P.M. licensed staff to conduct head to toe skin assessments on every Resident. However, during the skin integrity rounds, on 12/5/13, conducted by Corporate Clinical Consultant #1 and Surveyors #1 and #2, it was discovered that additional wounds observed on 12/5/13 had not been identified by the licensed staff on 12/4/13. Further, it was found that measurements of pressure ulcers, recorded on Skin Integrity Reports (filled out weekly by licensed staff) were identical to measurements recorded by the Wound Physician (Consultant) on weekly wound rounds. However, staff had failed to record changes in depth of wounds after debridement (the Wound Physician, after [MEDICATION NAME] a wound would document further on his report the additional depth after debridement). In addition, neither the Wound Physician, nor licensed nurses had identified undermining or tunneling of wounds and failed to accurately describe the wound bed (granulating tissue, eschar (blackened dead tissue) or slough (yellow or white dead tissue). 1. For Resident #6, the facility failed to identify a pressure ulcer to the coccyx until it was discovered as unstageable (unable to determine depth) with yellow slough (dead or necrotic tissue separated from living tissue or an ulceration) in the wound center and failed to identify a 6 centimeter (cm) x 6 cm bruise to the occipital region (back) of the head as a pressure ulcer until one week after its occurrence. Resident #6 was admitted to the nursing facility in 1/2005, with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS), dated [DATE], and a Quarterly Assessment, dated 9/17/13, identify the Resident as requiring total care of two people for bed mobility and transfers. The Resident has range of motion limitations to bilateral upper and lower extremities. Review of the clinical record revealed that on 11/27/13 a new pressure ulcer was identified. The Sentinel Event Tracking form (this form is used by the facility for all newly identified pressure ulcers to determine if the pressure ulcer was avoidable) documents that a 1.2 cm x 0.6 cm was idenfied on the coccyx which was unstageable. A nursing progress note, dated 11/27/13 documents that the coccyx pressure ulcer is new with 75% of the wound bed covered in slough. The physician was notified and an order was obtained to treat the pressure ulcer. Further review of the nursing progress notes revealed that on 11/28/13 a 6 cm x 6 cm bruise was identified on the right side of the back of the head. A Resident Incident Report was completed on 11/28/13 which documents that a CNA (certified nursing assistant) reported the bruise to nursing. The CNA's written statement documents that upon entering the room at 7:00 A.M., the CNA saw blood on the pillowcase which was dried. The CNA called the nurse and upon examination found a black bruise on the back of Resident #6's head. The Wound Physician saw Resident #6 on 12/3/13 and documented that the coccyx wound measured 0.8 cm x 0.5 cm x 0.3 cm. The Wound Physician removed the necrotic tissue from the wound with a post debridement depth of 0.4 cm (versus the 0.3 cm pre debridement). The Wound Physician also documented that the right posterior head wound (previously identified by nursing as a bruise) was an unstageable pressure wound measuring 5 cm x 5 cm. Unit Manager #3 was interviewed on 12/4/13 at 11:00 A.M. Unit Manager #3 said that she had investigated the bruise to the posterior head and came to the conclusion that the bruise had been caused by the bar of the Hoyer lift while the 3:00 P.M.-11:00 P.M. shift had transferred the Resident on 11/27/13. Unit Manager #3 stated that she had observed CNAs positioning the Resident in bed and when transferring the Resident via a Hoyer lift. Unit Manager #3 stated that the bruising matched the area of the metal bar on the Hoyer lift. Resident #6 was observed on 12/4/13 at 11:15 A.M. lying in bed. The mattress on the bed was identified by staff as a Visco Select Mattress used for pressure relief. Corporate Clinical Coordinator #1 was interviewed on 12/4/13 at 1:00 P.M. regarding Resident #6s pressure areas and the mattress which was being utilized. Corporate Clinical Coordinator #1 stated that the Visco Select Mattress was identified as prevention through single site Stage 3 wounds. When asked if the unstageable wounds could be actual Stage 4 wounds, Corporate Clinical Coordinator #1 stated that the wounds could be higher than a Stage 3 and that an air mattress should have been placed on the Resident's bed when the wounds were identified. Further interview with the Director of Nurses and Corporate Clinical Coordinator #1 on 12/4/13, at 1:15 P.M. revealed that they were now investigating the bruise located on the posterior head as a pressure sore and felt that Unit Manager #3 had come to an incorrect conclusion that the bruise had been caused by a metal bar of the Hoyer during transfer. 2. For Resident #16, the facility failed to properly assess a Stage 4 pressure ulcer which had worsened, with incorrect measurements and lack of documentation of extensive undermining of the wound. The facility also failed to document and identify pressure wounds of the bilateral legs which had resulted from use of Prevalon boots (padded, pressure relieving heel protector). Resident #16 was admitted to the nursing facility in 10/2013, with [DIAGNOSES REDACTED]. The hospital discharge summary documented that the Resident had a pressure ulcer on the buttocks which was left open to air and using 3 M spray. A weekly Skin Integrity Report, dated 10/4/13 documents an unstageable pressure ulcer to the sacrum with 60% necrotic tissue of the wound which measures 6 cm x 12 cm. A physician's orders [REDACTED]. A Wound Physician evaluation, completed on 10/8/13, documented the wound as measuring 7 cm x 10 cm which includes a large periwound area of [DIAGNOSES REDACTED] (inflamed/red) with the actual wound being smaller (although no measurements of the actual wound are documented). On 10/15/13, the Wound Physician documented an unstageable deep tissue injury to the right heel, measuring 6 cm x 5 cm and recommends off loading the heel (reducing pressure). Prevalon boots were ordered. The wound to the sacrum began to be identified as a Stage 4 on 10/28/13 and measurements by both the Wound Physician and the Skin Integrity Reports (which were always exactly the same measurements) document the size as 5.5 cm x 5 cm x 2.2 cm with tunneling at 10 o'clock of 2.3 cm. The wound was debrided each visit by the Wound Physician. (Thus rendering the Skin Integrity Reports inaccurate). On 11/5/13 documentation of the wound indicated undermining at 10 o'clock of 3.5 cm. on the weekly skin report, however, documentation by the Wound Physician indicates that the undermining occurred at 12 o'clock and was 3.5 cm (the tunneling of the wound had increased by 1 cm). The last documented weekly skin check, completed by the nursing facility was on 11/26/13 and documented the wound as 5.5 cm x 4 cm x 1.5 cm with undermining of 3 cm at 12 o'clock. The Wound Physician on 12/3/13, documented the sacrum as 5.5 cm x 3.5 cm x 1.5 cm and after debridement had a depth of 1.6 cm (versus the 1.5 initial depth) with undermining of 3 cm at 12 o'clock. The heels are documented as measuring 5 cm x 5 cm. There is also a right posterior lower leg wound, documented as a large ecchymosis measuring 5 cm x 3 cm and healing with a recommendation to apply skin prep daily. Review of the 12/2013 treatment sheet, on 12/5/13, revealed the same measurements for the wound on the sacrum, but without the change in depth after the debridement,and the heel measurement were the same as documented on 12/3/13 Wound Physician's sheet. The treatment to the sacrum was to cleanse with normal saline, fill with Calcium Alginate with [MEDICATION NAME] and cover with a foam dressing. The right heel was to be treated with Skin Prep. No other areas were noted on the treatment sheet. Observation and measurement (by Corporate Clinical Coordinator #1) of Resident #16's wounds on 12/5/13 at 1:30 P.M. revealed the following: * As the dressing was removed, it was observed that the wound was not filled with the Calcium Alginate rope, but contained only a small piece measuring 1.5 inches. * The sacrum wound was a Stage 4 wound measuring 6.2 cm x 3.5 cm x 2.5 cm (the length and depth being significantly different from both the Wound Physician's and Nursing's measurements). * In addition, the sacral wound had undermining of 3 cm at 12 O'clock as documented. However, there was additional undermining as follows (and which was not documented by either licensed nurses nor the Wound Physician): - 9 o'clock - 0.5 cm - 10 o'clock - 3.0 cm - 11 o'clock - a tunnel measuring 3.8 cm - 1 o'clock - undermining of 2.0 cm - 2 o'clock - undermining of 2.0 cm - 3 o'clock - undermining of 1.0 cm - 4 o'clock - undermining of 1.0 cm Resident #16 was observed to have 5 other areas not documented by nursing to the lower legs. While the Wound Physician had documented an ecchymosis of the right posterior calf, the measurements documented were significantly smaller than the area observed. Observations include: * Left inner ankle - 2.1 cm scabbed area. * Right outer foot - 1 cm x 1 cm scabbed area with darkened center. * Right inner ankle - 1 cm x 1 cm scabbed area. * Right posterior calf - 7 cm x 1 cm blood blister (documented by Wound Physician as 5 cm x 3 cm). * Right outer calf - 5.4 cm ecchymotic area which was slightly elevated. Corporate Clinical Coordinator #1 stated that nursing staff had been instructed on 12/4/13 to conduct complete body/skin checks on every Resident. Clinical Coordinator #1 could not explain how licensed staff had not measured or documented the extensive undermining nor the many areas on the legs which had been caused by the use of the Prevalon boots (which had been discontinued on 12/3/13). 3. For Resident #17, the facility failed to accurately measure, document and assess two areas of tunneling of a sacral pressure ulcer and inaccurately document appearance of the wound bed. Resident #17 was readmitted to the nursing facility in 11/2013 with [DIAGNOSES REDACTED]. Review of the clinical record revealed that Resident #17 had a chronic sacral ulcer which had last been surgically debrided at the hospital in 8/2013. A Skin Integrity Report, dated 11/15/13 documented the sacral wound as a Stage 4, measuring 2.0 cm x 1.2 cm x 1.2 cm. The wound bed is 95% granulation (pink/red) and 5% necrotic (eschar). A physician's orders [REDACTED]. Review of the weekly Skin Integrity Report for 11/22/13 and 11/29/13 revealed the following: * 11/22/13 - Stage 4, 80% granulation, 20% necrosis. 2 cm x 1.5 cm x 1 cm - no undermining or tunneling. * 11/29/13 - Stage 4, 80% granulation, 20% necrosis. 1.8 cm x 1.5 cm x 1 cm - no undermining or tunneling. Treatment sheet documentation for 12/4/13 documented the wound as 2 cm x 1.2 cm x 1.2 cm. No tunneling or undermining documented. Observation of the sacral wound on 12/4/13 at 2:00 P.M. revealed a Stage 4 wound, measuring 2.1 cm x 1.5 cm x 1.8 cm (width and depth differ from treatment documentation done on same day). In addition, the wound was noted to have 75% slough in the wound bed (worsening of wound) and tunneling of 0.5 cm at 12 o'clock and 0.6 cm at 6 o'clock. Corporate Clinical Coordinator #1, who had measured the wound and the Assistant Director of Nurses who had assisted her, both stated that the tunneling did not appear to be newly formed and could not explain why licensed staff had not documented the tunneling. There was no evidence that the physician was aware of the tunneling nor that licensed staff had attempted to notify the physician in order to determine if any additional treatment orders were needed to cleanse and treat the tunneling areas. 4. For Resident #5, the facility staff failed to accurately assess a wound resulting in an increase in slough formation without adequate treatment Resident #5 was admitted to the nursing facility in 5/2012, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that per a nursing progress note, dated 10/4/13, the Resident complained of soreness to the right buttock. Upon inspection, the nursing progress note documented that the buttock fold where an incontinent brief rubs the skin, a circular, reddened, raised and inflamed area is visualized and appears to be a blocked pore/pimple. Protective ointment was applied. On 10/7/13 the right buttock wound is described as being on the right ischium and is documented as having opened and measured 2.2 inches x 0.5 inches with white moist exudate in the center of the wound. Resident #5 was seen by the Wound Physician on 10/8/13, and documented the wound as measuring 2 cm x 2.5 cm with 20% necrosis (black dead tissue), 60% slough/[MEDICATION NAME] (white or yellow dead tissue) and 20% granulation (healthy tissue). The Wound Physician documented the cause of the open area as pressure. Resident #5 was seen weekly by the Wound Physician, the latest documented visit being 12/3/13. Each documented observation of the pressure area documents the size of the wound and that it is stable. The reports after 10/8/13 do not include any documentation of eschar/slough. Skin Integrity Reports, completed by nursing facility licensed staff weekly, reflect the same measurements of the pressure area as the Wound Physician. Slough is documented by nursing up until 10/29/13. Weekly reports by nursing from 11/5/13 through 11/26/13 indicated a percentage of the wound showing granulation tissue (75% to 90% granulation). The percent not granulating is not described (slough versus necrosis). On 12/4/13, a nursing facility skin integrity report documented that the wound is observed with 100% granulating tissue (pink/red). Observation of the wound on 12/5/13 at 11:00 A.M., with Unit Manager #1 revealed that the wound was covered by a [MEDICATION NAME] dressing (protective foam dressing), although the measurements of the wound were correct, the wound bed had only 25% granulating tissue. The remainder of the wound bed was covered in [MEDICATION NAME]/slough (yellow, moist dead tissue). Unit Manager #1 was asked about the documentation of 100% granulation of the wound bed on 12/4/13. Unit Manager #1 at first stated the wound did not have any slough observed on 12/4/13, then stated that the wound observed on 12/4/13 had some slough, but not as much as was observed on 12/5/13. Corporate Clinical Consultant #1 was interviewed on 12/5/13 at 11:15 A.M., regarding the discrepancy in documentation and observation. Corporate Clinical Consultant #1 stated that she had interviewed Unit Manager #1 who told Corporate Clinical Consultant #1 that the wound had some slough on 12/4/13 which she did not document. Clinical Consultant #1 stated that a Nurse Practitioner was in the building and had looked at the wound and agreed that the wound bed contained 75% slough and would be writing a new order to change the treatment. (The physician had not been notified on 12/4/13 when Unit Manager #1 had observed the presence of slough in the wound bed). 5. For Resident #27, the facility failed to ensure that an [MEDICATION NAME] cream was applied to a heel which had an unstageable wound, failed to apply Prevalon boots correctly resulting in the development of a Stage 2 pressure ulcer. The facility failed to ensure that licensed nursing staff report newly identified pressure ulcers to ensure physician notification. The facility failed to ensure that a change in skin condition report was completed after the identification of an unstageable pressure ulcer (per the facility policy). Resident #27 was admitted to the nursing facility in 11/2013, with [DIAGNOSES REDACTED]. The Admission MDS, dated [DATE], documented that Resident #27 is at risk of developing pressure ulcers, with no pressure ulcers present upon admission. Review of the clinical record revealed that physician's orders [REDACTED]. * Skin prep to bilateral heels at bedtime. * Off load heels while in bed. A Skin Integrity Report, dated 12/6/13, documented that the Resident had a in house acquired, unable to stage pressure areas to the right and left heel. The left heel area was documented as being 100% necrotic and measuring 0.8 cm x 0.8 cm. The right heel area was also documented as 100% necrotic and measuring 0.2 cm x 0.2 cm. On 12/6/13, physician's orders [REDACTED]. * Air mattress, setting #2. * Prevalon boots on in bed as resident will allow. * Apply skin remedy repair cream to bilateral lower extremities twice daily. Surveyor #1 asked to see the areas being treated on the bilateral heels on 12/11/13 at 10:35 A.M. The Director of Nurses (DON) and Corporate Clinical Consultant #2 arrived on the nursing unit to observe and measure the areas. The DON stated that staff were in preparing/cleaning the Resident. As the Prevalon boot was removed it was observed to be applied very loosely to the foot allowing the Resident to move the foot back and forth in the boot. It was observed that the Resident had a fluid filled blister on the top of the right foot. The Stage 2 area measured 0.5 cm x 1 cm. The DON stated that if the Prevalon boot had been applied too loosely, then the movement of the foot likely caused enough friction to result in the Stage 2 area. The right heel was observed to have dry, flaky skin with an unstageable area, which measured 0.3 cm x 0.3 cm. The left heel was observed to have dry flaky skin, with a patch which was very dry and brittle. The DON was asked by Surveyor #1 if Resident #27 had received any washing of the feet or lotion to the feet by staff who had been in caring for the Resident (as the DON and Corporate Clinical Consultant #2 had not been aware of the Stage 2 area prior to removing the Prevalon boot). The DON called CNA #2 over and asked if Resident #27 had been provided any foot care during his/her ADL care. CNA #2 stated that he/she had applied an [MEDICATION NAME] cream (identified as Nutrashield) to the Resident's feet (although the feet appeared very dry with large amounts of dry, brittle and flaky skin on the bilateral heels). Corporate Clinical Consultant #2 proceeded to apply the [MEDICATION NAME] cream to Resident #27's left heel and foot. The foot appeared shiny and the dry, flaky skin became soft. CNA #2 pointed to the top of the foot and stated "I applied the lotion." Licensed Nurse #1, who was present, also stated that CNA #2 had applied the lotion, however, not as thoroughly as Corporate Clinical Consultant #2 and not to the heel. CNA #2 then made a quick swiping motion over the foot and stated "I applied like this" (The swiping motion observed was of a quick swipe down each side of the foot and the top of the foot, but not the heel. While Licensed Nurse #1 had been present when the lotion was applied, he/she did not intervene when it was not applied as ordered). After Corporate Clinical Consultant #2 finished rubbing the [MEDICATION NAME] into the left foot, the area in question of being an unstageable area was observed to only be a patch of dry skin which had not fully flaked off of the foot. Licensed Nurse #1 was then asked by the DON if he/she had seen the fluid filled blister which he/she acknowledged that he/she had. However, this had not been reported to Unit Manager #3. Review of assessments completed electronically for a change in condition- skin assessment (which per house policy is filled out upon identification of any skin changes) revealed that an assessment was not completed for the unstageable area on the right heel until 12/11/13 (during survey) and not on 12/6/13 when the area was identified. Review of the 12/2013 treatment sheet on 12/11/13 at 4:00 P.M. revealed that Licensed Nurse #1 had signed off the Prevalon boots, Remedy repair cream and the air mattress usage. However, there was no documentation on the back of the sheet regarding the newly identified Stage 2 area. 6. For Resident #28, the facility failed to identify a pressure ulcer before it became unstageable, despite the application of a moisturizer twice daily to the lower extremities and daily application and removal of TEDS (compression stockings). Resident #28 was readmitted to the nursing facility in 6/2013 with [DIAGNOSES REDACTED]. Resident #28 has current physician's orders [REDACTED]. * Moisturize both lower extremities twice a day (before applying TEDS and upon removal). * TEDS - on in the morning - off at bedtime. Review of the clinical record revealed a nursing progress note, written on 12/6/13 (during survey) documented that a CNA noted a scabbed area to the left ankle on 12/6/13. Nurse #3 examined Resident #28's left outer ankle. Resident #28 told Nurse #3 that he/she had reported the scabbed area to the previous shift's Nurse. Review of the 12/2013 treatment sheets revealed that there was no documentation of the area by the previous shift's Nurse and the information had not been passed on to Nurse #3. The Skin Integrity Report, dated 12/6/13, documented an in-house acquired unstageable area to the left outer ankle measuring 1.2 cm x 0.5 cm. The DON, when interviewed on 12/11/13 could not explain how the area was not identified before becoming unstageable when the Resident receives moisturizer to the lower extremities twice daily and is assisted with putting on and taking off TEDS stockings (treatment sheets had both the moisturizer and TEDS signed off as being done daily) . 7. For Resident #3, the nursing facility failed to accurately assess a Stage 4 pressure ulcer and therefore did not have an appropriate treatment to promote healing of the wound. Resident #3 was admitted to the nursing facility in 9/2012, with [DIAGNOSES REDACTED]. There is a physician's orders [REDACTED]. Review of the Skin Integrity Report and the Wound Physician report of 11/26/13 revealed that both reports documented the sacral wound to measure 1.2 cm x 0.8 cm x 1.4 cm. with 100% granulation of the wound bed. There is 1 cm of undermining at 12 o'clock. The 12/4/13 Skin Integrity Report documented that the wound measured 1.3 cm x 0.8 cm x 1.4 cm with 1 cm of undermining and remains at 100 % granulation of the wound bed. Observation of the wound on 12/5/13 at 1:45 P.M. revealed that the actual measurements of the wound were 1.7 cm x 0.8 cm x 1.1 cm. 25% of the wound base was covered in a thick layer of eschar (which the ordered treatment would not remove in order for the wound to heal). Corporate Clinical Consultant #1 stated that a call would be made to the physician to provide an update on the wound status and obtain a new treatment order. 8. For Resident #15 the facility failed to identify a pressure sore on admission and assess the pressure sore found on admission correctly. Review of Resident #15's clinical record on 12/9/13 indicated that the Resident was admitted to the facility in 12/2013 with [DIAGNOSES REDACTED]. Review of the resident's admission nursing assessment, dated 12/4/13, indicated that the resident had a documented stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough) pressure sore measuring 2 cm by 2 cm on the coccyx. Documentation on the Treatment Administration Record (TAR), dated 12/4/13, indicated that the physician ordered the coccyx area to be cleansed with wound cleanser, followed by wound gel and a dry protective dressing to be changed daily and as needed until healed. On 12/5/13 ar 1:30 P.M. with Corporate Clinical Nurse #1, Surveyors #1 and #2 observed the Resident's coccyx. On observation, a 4.0 cm by 1.3 cm by 0.5 cm pressure sore with slough was seen which indicated a stage III pressure sore. However, the slough was not documented on the initial nursing assessment. Also observed was a 0.2 cm by 0.2 cm stage II pressure sore approximately 3 cm below the original pressure sore. Review of the nursing progress note, dated 12/5/13, indicated there was no documentation that the physician was notified either of the slough found in the first pressure sore or that a second pressure sore was now present below the original pressure sore. Corporate Clinical Nurse #1 said that the nursing staff failed to accurately assess the first pressure sore, failed to notify the physician of the change in the first pressure sore, and failed to identify the second lower pressure sore. Please refer to F314 and F 520. 9. For Resident NS#1, the facility failed to ensure that [MEDICATION NAME] Insulin was administered as ordered and failed to ensure that Medication Nurse #5 was adequately trained to administer medications. A medication pass observation was conducted on 12/9/13 at 9:00 A.M. Medication Nurse #5 was observed to be on a medication cart dispensing medications. When approached, Medication Nurse #5 stated he/she was still in orientation. However, there was no other Nurse directly supervising the medication pass. A second Medication Nurse (Medication Nurse #6) on the unit stated that although he/she had his/her own medication cart and assignment, he/she was available for Medication Nurse #5, should he/she need assistance. Medication Nurse #5 began to check the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s blood sugar as he/she had failed to document the blood sugar level earlier in the shift (Medication Nurse #5 could have checked the history in the glucometer for the blood sugar but did not appear to know this). Resident NS #1's blood sugar was 205. Medication Nurse #5 stated that he/she remembered that the earlier blood sugar had been below 200 and therefore, no sliding scale Insulin had been given. Medication Nurse #5 then began to pour 7 medications for Resident NS #1. While Surveyor #1 observed the medication administration sheet Medication Nurse #5 was pouring medications from, it was observed that an order for [REDACTED]. and before breakfast) had not been signed off as being given. Under this order on the medication administration sheet was physician's orders [REDACTED]. Medication Nurse #5 was asked by Surveyor #1 why the Insulin had not been signed off as given. Medication Nurse #5 stated that he/she had not given the Insulin (which was scheduled) as Resident NS #1 had a finger stick blood sugar of less than 200 and therefore did not require coverage with sliding scale Insulin. Medication Nurse #6 was notified by Surveyor #1 that a physician's orders [REDACTED]. The Director of Nurses and Corporate Clinical Coordinator #1 were informed of the above observations. Corporate Clinical Coordinator #1 stated that she would remove Medication Nurse #5 from the medication cart. The Staff Development Coordinator (SDC) was interviewed on 12/9/13 at 10:00 A.M. The SDC stated that Medication Nurse #5 had been passed off (deemed able to perform) on the medication pass on 11/1/13. The SDC stated that further in-servicing would be provided.

Based on record review, observation and interview, the Facility failed for 9 Residents (#3, 5, 6, 15, 16, 17, 27, 28 and 30) of 14 applicable Residents, in an original sample of 24 Residents and an extended sample of 6 Residents, to ensure a Resident with a pressure ulcer received appropriate treatment and services to promote healing, prevent infection and prevent new pressure sores from developing. The facility failed to accurately identify and measure pressure ulcers and failed to apply treatments as ordered. Findings include: The facility had a policy for Skin Integrity Management which included the performance of skin inspections on admission, re-admission and weekly. The policy also includes the following: * Include all patients who have newly identified skin impairments on the Center's 24-hour Summary Report. * Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly and with any deterioration of wound. * Perform daily monitoring of wounds or dressings for any presence of complications or declines. Document on treatment administration record (TAR) and/or nurses' note. * Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. A discrepancy between documentation and observation of a wound for Resident #6 was discovered by Surveyor #1 on [DATE]. Surveyors #1 and #2 compiled a list of pressure ulcers in the facility, based on treatment sheets on [DATE]. Corporate Clinical Consultant #1 was asked to accompany the Surveyors to ensure that pressure ulcers were documented accurately and treated as ordered. After observing the wounds and Corporate Clinical Consultant #1 re-measuring wounds, it was found that licensed staff had not accurately assessed the appearance (color, granulation/slough and eschar) and measurements of wounds. Corporate Clinical Consultant #1 stated that after discussions with the Surveyors on [DATE], she had told all Unit Managers and 3:00 P.M.-11:00 P.M. licensed staff to conduct head to toe skin assessments on every Resident. However, during the skin integrity rounds conducted by Corporate Clinical Consultant #1 and Surveyors #1 and #2, it was discovered that additional wounds observed on [DATE] had not been identified by the licensed staff on [DATE]. Further, it was found that measurements of pressure ulcers, recorded on Skin Integrity Reports (filled out weekly by licensed staff) were identical to measurements recorded by the Wound Physician (Consultant) on weekly wound rounds. However, staff had failed to record changes in depth of wounds after debridement (the Wound Physician, after [MEDICATION NAME] a wound would document further on his report the additional depth after debridement). In addition, neither the Wound Physician, nor licensed nurses had identified undermining or tunneling of wounds and failed to accurately describe the wound bed (granulating tissue, eschar (blackened dead tissue) or slough (yellow or white dead tissue). The Wound Physician was not interviewed as he was terminated by the facility during the survey. 1. For Resident #6, the facility failed to identify a pressure ulcer to the coccyx until it was discovered as unstageable (unable to determine depth) with yellow slough (dead or necrotic tissue separated from living tissue or an ulceration) in the wound center and failed to identify a 6 centimeter (cm) x 6 cm bruise to the occipital region (back) of the head as a pressure ulcer until one week after its occurrence. Resident #6 was admitted to the nursing facility in ,[DATE], with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS), dated [DATE], and a Quarterly Assessment, dated [DATE], documented the Resident as requiring total care of two people for bed mobility and transfers. The Resident has range of motion limitations to bilateral upper and lower extremities. Review of the clinical record revealed that Resident #6 was determined to be a high risk for skin breakdown (with a previous Stage 3 pressure ulcer, immobility and incontinence). A care plan was in place for potential skin breakdown and included: * Apply barrier cream with each cleansing. * Monitor for signs/symptoms of skin breakdown. * Observe skin condition with ADL (activities of daily living) care daily and report abnormalities. * Pressure redistribution surfaces to chair and bed. * Weekly skin assessment by licensed nurse. Review of the clinical record revealed that on [DATE] a new pressure ulcer was identified. The Sentinel Event Tracking form (the form is used by the facility for all newly identified pressure ulcers to determine if the pressure ulcer was avoidable) documents that a 1.2 cm x 0.6 cm was idenfied on the coccyx which was unstageable. A nursing progress note, dated [DATE] documented that the coccyx pressure ulcer is new with 75% of the wound bed covered in slough. The physician was notified and an order was obtained to treat the pressure ulcer. Further review of the nursing progress notes revealed that on [DATE] a 6 cm x 6 cm bruise was identified on the right side of the back of the head. A Resident Incident Report was completed on [DATE] which documented that a CNA (certified nursing assistant) reported the bruise to nursing. The CNA's written statement documented that upon entering the room at 7:00 A.M., the CNA saw blood on the pillowcase which was dried. The CNA called the nurse and upon examination found a black bruise on the back of Resident #6's head. Written statements were obtained from [DATE] from all CNAs who had worked the third floor nursing unit (from 7:00 A.M. on [DATE] through the 11:00 P.M.-7:00 A.M. shift of [DATE]). The 3:00 P.M.-11:00 P.M. CNA documented that Resident #6 had been gotten out of bed for dinner utilizing a Hoyer lift and had been put back to bed at 7:00 P.M. The 3:00 P.M.-11:00 P.M. CNA did not notice any bruising and documents that Resident #6 had been positioned from side to side and provided incontinent care. The 11:00 P.M.-7:00 A.M. CNAs documented that they had not seen any bruising when turning the Resident side to side during their shift. Review of the CNA flow sheets revealed that all 3 shifts documented on [DATE], [DATE] and [DATE] that they had applied lotion to bony prominence's for skin care prevention and changed the Resident's position every 2 hours to relieve pressure to bony prominence's. The Wound Physician saw Resident #6 on [DATE] and documented that the coccyx wound measured 0.8 cm x 0.5 cm x 0.3 cm. The Wound Physician removed the necrotic tissue from the wound with a post debridement depth of 0.4 cm (versus the 0.3 cm pre debridement). The Wound Physician also documented that the right posterior head wound (previously identified by nursing as a bruise) was an unstageable pressure wound measuring 5 cm x 5 cm. Unit Manager #3 was interviewed on [DATE] at 11:00 A.M. Unit Manager #3 said that she had investigated the bruise to the posterior head and came to the conclusion that the bruise had been caused by the bar of the Hoyer lift while the 3:00 P.M.-11:00 P.M. shift had transferred the Resident on [DATE]. Unit Manager #3 stated that she had observed CNAs positioning the Resident in bed and when transferring the Resident via a Hoyer lift. Unit Manager #3 stated that the bruising matched the area of the metal bar on the Hoyer lift. Resident #6 was observed on [DATE] at 11:15 A.M. lying in bed. The mattress on the bed was identified by staff as a Visco Select Mattress used for pressure relief. Corporate Clinical Coordinator #1 was interviewed on [DATE] at 1:00 P.M. regarding Resident #6s pressure areas and the mattress which was being utilized. Corporate Clinical Coordinator #1 stated that the Visco Select Mattress was identified as prevention through single site Stage 3 wounds. When asked if the unstageable wounds could be actual Stage 4 wounds, Corporate Clinical Coordinator #1 stated that the wounds could be higher than a Stage 3 and that an air mattress should have been placed on the Resident's bed when the wounds were identified. Corporate Clinical Coordinator #1 could not explain how, if the CNAs had been repositioning every 2 hours and applying lotion to bony prominence's every shift, they had failed to identify pressure areas before they became unstageable (as they should have identified the wounds when they began at a Stage 1 (red, unblanchable skin). Further interview with the Director of Nurses and Corporate Clinical Coordinator #1 on [DATE], at 1:15 P.M. revealed that they were now investigating the bruise located on the posterior head as a pressure sore and felt that Unit Manager #3 had come to an incorrect conclusion that the bruise had been caused by a metal bar of the Hoyer during transfer. CNA #1, who had found Resident #6 with a bruise to the posterior head and bloodied pillow on [DATE], was interviewed on [DATE] at 10:30 A.M. CNA #1 stated that the dried blood on the pillow looked like the Resident had been rubbing his/her head side to side on the pillow and that the Resident stated it hurt when the bruised area was examined. 2. For Resident #16, the facility failed to properly assess a Stage 4 pressure ulcer which had worsened, with incorrect measurements and lack of documentation of extensive undermining of the wound. The facility also failed to document and identify pressure wounds of the bilateral legs which had resulted from use of Prevalon boots. Resident #16 was admitted to the nursing facility in ,[DATE], with [DIAGNOSES REDACTED]. The hospital discharge summary indicated that the Resident had a pressure ulcer on the buttocks which was left open to air and was treated with 3 M spray. A weekly Skin Integrity Report, dated [DATE] documented an unstageable pressure ulcer to the sacrum with 60% necrotic tissue of the wound, which measured 6 cm x 12 cm. A physician's orders [REDACTED]. A Wound Physician evaluation, completed on [DATE], documented the wound as measuring 7 cm x 10 cm which includes a large periwound area of [DIAGNOSES REDACTED] (inflamed/red) with the actual wound being smaller (although no measurements of the actual wound were documented). On [DATE], the Wound Physician documented an unstageable deep tissue injury to the right heel, measuring 6 cm x 5 cm and recommended off loading the heel (reducing pressure). Prevalon boots were ordered. The wound to the sacrum began to be identified as a Stage 4 on [DATE] and measurements by both the Wound Physician and the Skin Integrity Reports (which were always exactly the same measurements) documented the size as 5.5 cm x 5 cm x 2.2 cm with tunneling at 10 o'clock of 2.3 cm. The wound was debrided each visit by the Wound Physician. (Thus rendering the Skin Integrity Reports inaccurate). On [DATE] documentation of the wound indicated undermining at 10 o 'clock of 3.5 cm. on the weekly skin report, however, documentation by the Wound Physician indicated that the undermining occurred at 12 o'clock and was 3.5 cm (the tunneling of the wound had increased by 1 cm). The last documented weekly skin check, completed by the nursing facility was on [DATE] and documented the wound as 5.5 cm x 4 cm x 1.5 cm with undermining of 3 cm at 12 o'clock. The Wound Physician on [DATE], documented the sacrum as 5.5 cm x 3.5 cm x 1.5 cm and after debridement had a depth of 1.6 cm (versus the 1.5 initial depth) with undermining of 3 cm at 12 o'clock. The heels are documented as measuring 5 cm x 5 cm. There is also a right posterior lower leg wound, documented as a large ecchymotic measuring 5 cm x 3 cm and healing with a recommendation to apply skin prep daily. Review of the ,[DATE] treatment sheet, on [DATE], revealed the same measurements for the wound on the sacrum, but without the change in depth after the debridement,and the heel measurement were the same as documented on the [DATE] Wound Physician's sheet. The treatment to the sacrum was to cleanse with normal saline, fill with Calcium Alginate with [MEDICATION NAME] and cover with a foam dressing. The right heel was to be treated with Skin Prep. No other areas were noted on the treatment sheet. Observation and measurement (by Corporate Clinical Coordinator #1) of Resident #16's wounds on [DATE] at 1:30 P.M. revealed the following: * As the dressing was removed, it was observed that the wound was not filled with the Calcium Alginate rope, but contained only a small piece measuring 1.5 inches. * The sacrum wound was a Stage 4 wound measuring 6.2 cm x 3.5 cm x 2.5 cm (the length and depth being significantly different from both the Wound Physician's and Nursing's measurements). * In addition, the sacral wound had undermining of 3 cm at 12 o'clock as documented. However, there was additional undermining as follows (and which was not documented by either licensed nurses nor the Wound Physician): - 9 o'clock - 0.5 cm - 10 o'clock - 3.0 cm - 11 o'clock - a tunnel measuring 3.8 cm - 1 o'clock - undermining of 2.0 cm - 2 o'clock - undermining of 2.0 cm - 3 o'clock - undermining of 1.0 cm - 4 o'clock - undermining of 1.0 cm Resident #16 was observed to have 5 other areas not documented by nursing to the lower legs. While the Wound Physician had documented an ecchymosis of the right posterior calf, the measurements documented were significantly smaller than the area observed. Observations include: * Left inner ankle - 2.1 cm scabbed area. * Right outer foot - 1 cm x 1 cm scabbed area with darkened center. * Right inner ankle - 1 cm x 1 cm scabbed area. * Right posterior calf - 7 cm x 1 cm blood blister (documented by Wound Physician as 5 cm x 3 cm ecchymotic area). * Right outer calf - 5.4 cm ecchymotic area which was slightly elevated. Corporate Clinical Coordinator #1 stated that nursing staff had been instructed on [DATE] to conduct complete body/skin checks on every Resident. Clinical Coordinator #1 could not explain how licensed staff had not measured or documented the extensive undermining nor the many areas on the legs which had been caused by the use of the Prevalon boots (which had been discontinued on [DATE]). 3. For Resident #17, the facility failed to accurately measure, document and assess two areas of tunneling of a sacral pressure ulcer and inaccurately document appearance of the wound bed. Resident #17 was readmitted to the nursing facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed that Resident #17 had a chronic sacral ulcer which had last been surgically debrided at the hospital in ,[DATE]. A Skin Integrity Report, dated [DATE] documented the sacral wound as a Stage 4, measuring 2.0 cm x 1.2 cm x 1.2 cm. The wound bed was 95% granulation (pink/red) and 5% necrotic (eschar). A physician's orders [REDACTED]. Review of the weekly Skin Integrity Report for [DATE] and [DATE] revealed the following: * [DATE] - Stage 4, 80% granulation, 20% necrosis. 2 cm x 1.5 cm x 1 cm - no undermining or tunneling. * [DATE] - Stage 4, 80% granulation, 20% necrosis. 1.8 cm x 1.5 cm x 1 cm - no undermining or tunneling. Treatment sheet documentation for [DATE] documented the wound as 2 cm x 1.2 cm x 1.2 cm. No tunneling or undermining documented. Observation of the sacral wound on [DATE] at 2:00 P.M. revealed a Stage 4 wound, measuring 2.1 cm x 1.5 cm x 1.8 cm (width and depth differ from treatment documentation done on same day). In addition, the wound was noted to have 75% slough in the wound bed (worsening of wound) and tunneling of 0.5 cm at 12 o'clock and 0.6 cm at 6 o'clock. Corporate Clinical Coordinator #1, who had measured the wound and the Assistant Director of Nurses who had assisted her, both stated that the tunneling did not appear to be newly formed and could not explain why licensed staff had not documented the tunneling. There was no evidence that the physician was aware of the tunneling nor that licensed staff had attempted to notify the physician in order to determine if any additional treatment orders were needed to cleanse and treat the tunneling areas. 4. For Resident #5, the facility failed to accurately assess a wound resulting in an increase in slough formation without adequate treatment. Resident #5 was admitted to the nursing facility in ,[DATE], with [DIAGNOSES REDACTED]. The Annual MDS, dated [DATE], documented the Resident as requiring the extensive assistance of 2 people for bed mobility, the Resident utilized a wheelchair for mobility and was incontinent of urine. The Resident was documented as having no pressure ulcers. Review of the clinical record revealed that per a nursing progress note, dated [DATE], the Resident complained of soreness to the right buttock. Upon inspection, the nursing progress note documented that the buttock fold where an incontinent brief rubs the skin, a circular, reddened, raised and inflamed area is visualized and appears to be a blocked pore/pimple. Protective ointment was applied. On [DATE] the right ischium was documented as having opened and measured 2.2 inches x 0.5 inches with white moist exudate in the center of the wound. Resident #5 was seen by the Wound Physician on [DATE], and documented the wound as measuring 2 cm x 2.5 cm with 20% necrosis (black dead tissue), 60 % slough/[MEDICATION NAME] (white or yellow dead tissue) and 20% granulation (healthy tissue). The Wound Physician documented the cause of the open area as pressure. A care plan, developed for Risk of Skin Breakdown as evidenced by impaired sensation, history of pressure ulcers to heels, was developed on [DATE] and remains current. There was no care plan for actual skin breakdown. Interventions were added to the Risk of Skin Breakdown on [DATE] to include: * May have an air mattress at all times when in bed. * Reposition every two hours to promote skin integrity. * Utilize positioning devices as appropriate to prevent pressure over bony prominence's. Resident #5 was seen weekly by the Wound Physician, the latest documented visit being [DATE]. Each documented observation of the pressure area documents the size of the wound and that it is stable. The reports after [DATE] do not include any documentation of eschar/slough. Skin Integrity Reports, completed by nursing facility licensed staff weekly, reflect the same measurements of the pressure area as the Wound Physician. Slough is documented by nursing up until [DATE]. Weekly reports by nursing from [DATE] through [DATE] document a percentage of the wound showing granulation tissue (75% to 90% of the wound bed). The percent not granulating is not described (slough versus necrosis). On [DATE], a nursing facility skin integrity report documented that the wound is observed with 100% granulating tissue (pink/red). Observation of the wound on [DATE] at 11:00 A.M., with Unit Manager #1 revealed that the wound was covered by a [MEDICATION NAME] dressing (an occlusive and adhesive wafer dressing), although the measurements of the wound was correct, the wound bed was only 25% granulating tissue. The remainder of the wound bed was covered in [MEDICATION NAME]/slough (yellow, moist dead tissue). Unit Manager #1 was asked about the documentation of 100% granulation of the wound bed on [DATE]. Unit Manager #1 at first stated the wound did not have any slough observed on [DATE], then stated that the wound observed on [DATE] had some slough, but not as much as was observed on [DATE]. Corporate Clinical Consultant #1 was interviewed on [DATE] at 11:15 A.M., regarding the discrepancy in documentation and observation. Corporate Clinical Consultant #1 stated that she had interviewed Unit Manager #1 who told Corporate Clinical Consultant #1 that the wound had some slough on [DATE] which she did not document. Clinical Consultant #1 stated that a Nurse Practitioner was in the building and had looked at the wound and agreed that the wound bed contained 75% slough and would be writing a new order to change the treatment. (The physician had not been notified on [DATE] when Unit Manager #1 had observed the presence of slough in the wound bed). 5. For Resident #27, the facility failed to ensure that an [MEDICATION NAME] cream was applied to a heel which had an unstageable wound and failed to apply Prevalon boots correctly resulting in the development of a Stage 2 pressure ulcer. The facility failed to ensure that licensed nursing staff reported the newly identified pressure ulcers to the physician. The facility failed to ensure that a change in skin condition report was completed after the identification of an unstageable pressure ulcer. Resident #27 was admitted to the nursing facility in ,[DATE], with [DIAGNOSES REDACTED]. The Admission MDS, dated [DATE], documented the Resident as requiring extensive physical assistance of 2 people for bed mobility and transfers. The Resident has range of motion limitations to bilateral lower extremities. Resident #27 is documented as being at risk of developing pressure ulcers, with no pressure ulcers present upon admission. Review of the clinical record revealed that physician's orders [REDACTED]. * Skin prep to bilateral heels at bedtime. * Off load heels while in bed. A Skin Integrity Report, dated [DATE], documented that the Resident had a in house acquired, unable to stage pressure areas to the right and left heel. The left heel area is documented as being 100% necrotic and measuring 0.8 cm x 0.8 cm. The right heel area is also documented as 100% necrotic and measuring 0.2 cm x 0.2 cm. On [DATE], physician's orders [REDACTED]. * Air mattress, setting #2. * Prevalon boots on in bed as resident will allow. * Apply skin remedy repair cream to bilateral lower extremities twice daily (this treatment was on the licensed nurses' treatment sheets). Surveyor #1 asked to see the areas being treated on the bilateral heels on [DATE] at 10:35 A.M. The Director of Nurses (DON) and Corporate Clinical Consultant #2 arrived on the nursing unit to observe and measure the areas. The DON stated that staff were in preparing/cleaning the Resident. As the Prevalon boot was removed it was observed to be applied very loosely to the foot allowing the Resident to move the foot back and forth in the boot. It was observed that the Resident had a fluid filled blister on the top of the right foot. The Stage 2 area measured 0.5 cm x 1 cm. The DON stated that if the Prevalon boot had been applied too loosely, then the movement of the foot likely caused enough friction to result in the Stage 2 area. The right heel was observed to have dry, flaky skin with an unstageable area, which measured 0.3 cm x 0.3 cm. The left heel was observed to have dry flaky skin, with a patch which was very dry and brittle. The DON was asked by Surveyor #1 if Resident #27 had received any washing of the feet or lotion to the feet by staff who had been in caring for the Resident (as the DON and Corporate Clinical Consultant #2 had not been aware of the Stage 2 area prior to removing the Prevalon boot). The DON called CNA #2 over and asked if Resident #27 had been provided any foot care during his/her ADL care. CNA #2 stated that he/she had applied an [MEDICATION NAME] cream (identified as Nutrashield) to the Resident's feet (although the feet appeared very dry with large amounts of dry, brittle and flaky skin on the bilateral heels). Corporate Clinical Consultant #2 proceeded to apply the [MEDICATION NAME] cream to Resident #27's left heel and foot. The foot appeared shiny and the dry, flaky skin became soft. CNA #2 pointed to the top of the foot and stated "I applied the lotion." Licensed Nurse #1, who was present, also stated that CNA #2 had applied the lotion, however, not as thoroughly as Corporate Clinical Consultant #2 and not to the heel. CNA #2 then made a quick swiping motion over the foot and stated "I applied like this" (The swiping motion observed was of a quick swipe down each side of the foot and the top of the foot, but not the heel). After Corporate Clinical Consultant #2 finished rubbing the [MEDICATION NAME] into the left foot, the area in question of being an unstageable area was observed to only be a patch of dry skin which had not fully flaked off of the foot. Licensed Nurse #1 was then asked by the DON if he/she had seen the fluid filled blister which he/she acknowledged that he/she had. However, this had not been reported to Unit Manager #3. Review of assessments completed electronically for a change in condition- skin assessment (which per house policy is filled out upon identification of any skin changes) revealed that an assessment was not completed for the unstageable area on the right heel until [DATE] (during survey) and not on [DATE] when the area was identified. Review of the ,[DATE] treatment sheet on [DATE] at 4:00 P.M. revealed that Licensed Nurse #1 had signed off the Prevalon boots, Remedy repair cream and the air mattress usage. However, there was no documentation on the back of the sheet regarding the newly identified Stage 2 area. 6. For Resident #28, the facility failed to identify a pressure ulcer before it became unstageable, despite the application of a moisturizer twice daily to the lower extremities and daily application and removal of TEDS (compression stockings). Resident #28 was readmitted to the nursing facility in ,[DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated [DATE], documented the Resident as being cognitively intact (with a score of 13 out of 15 on the Brief Interview of Mental Status). Resident #28 was independent in mobility, had range of motion limitations to bilateral upper and lower extremities and was at risk for development of pressure ulcers. Resident #28 has current physician's orders [REDACTED]. * Moisturize both lower extremities twice a day (before TEDS and upon removal). * TEDS - on in the morning - off at bedtime. Review of the clinical record revealed a nursing progress note, written on [DATE] (during survey) documented that a CNA noted a scabbed area to the left ankle. Nurse #3 examined Resident #28's left outer ankle. Resident #28 told Nurse #3 that he/she had reported the scabbed area to the previous shift's Nurse. Review of the ,[DATE] treatment sheets revealed that there was no documentation of the area by the previous shift's Nurse and the information had not been passed on to Nurse #3. The Skin Integrity Report, dated [DATE] documented an in-house acquired unstageable area to the left outer ankle measuring 1.2 cm x 0.5 cm. The DON, when interviewed on [DATE] could not explain how the area was not identified before becoming unstageable when the Resident received moisturizer to the lower extremities twice daily and is assisted with putting on and taking off TEDS stockings. 7. For Resident #3, the nursing facility failed to accurately assess a Stage 4 pressure ulcer and therefore did not have an appropriate treatment to promote healing of the wound. Resident #3 was admitted to the nursing facility in ,[DATE], with [DIAGNOSES REDACTED]. There is a physician's orders [REDACTED]. Review of the Skin Integrity Report and the Wound Physician report of [DATE] revealed that both reports documented the sacral wound to measure 1.2 cm x 0.8 cm x 1.4 cm. with 100% granulation of the wound bed. There was 1 cm of undermining at 12 o'clock. The [DATE] Skin Integrity Report documented that the wound measures 1.3 cm x 0.8 cm x 1.4 cm with 1 cm of undermining and remained at 100 % granulation of the wound bed. Observation of the wound on [DATE] at 1:45 P.M. revealed that the actual measurements of the wound were 1.7 cm x 0.8 cm x 1.1 cm. 25% of the wound base was covered in a thick layer of eschar (which the ordered treatment would not remove in order for the wound to heal). Corporate Clinical Consultant #1 stated that a call would be made to the physician to provide an update on the wound status and obtain a new treatment order. 8. For Resident #15 the facility failed to identify a pressure sore on admission and assess the pressure sore found on admission correctly. Review of Resident #15's clinical record on [DATE] indicated that the Resident was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission nursing assessment, dated [DATE], indicated that the resident had a documented stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough) pressure sore measuring 2 cm by 2 cm on the coccyx. Documentation on the Treatment Administration Record (TAR), dated [DATE], indicated that the physician ordered the coccyx area to be cleansed with wound cleaner, followed by wound gel and a dry protective dressing to be changed daily and as needed until healed. On [DATE] at 1:30 P.M. with Corporate Clinical Nurse #1, Surveyors #1 and #2 observed the Resident's coccyx. On observation, a 4.0 cm by 1.3 cm by 0.5 cm pressure sore with slough was seen which indicated a stage III pressure sore. However, the slough was not documented on the initial nursing assessment. Also observed was a 0.2 cm by 0.2 cm stage II pressure sore approximately 3 cm below the original pressure sore. Review of the nursing progress note, dated [DATE], indicated there was no documentation that the physician was notified either of the slough found in the first pressure sore or that a second pressure sore was now present below the original pressure sore. Corporate Clinical Nurse #1 said that the nursing staff failed to accurately assess the first pressure sore, failed to notify the physician of the change in the first pressure sore, and failed to identify the second lower pressure sore. 9. For Resident #30, the facility failed to prevent a pressure sore from developing on the resident's right buttocks under a protective dressing. Review of Resident #30's clinical record on [DATE] indicated that the Resident was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Further review of the resident's clinical record revealed that the resident had a history of [REDACTED]. The Resident's plan of care for the prevention of skin breakdown included an air mattress on the bed set at "3", turning and repositioning every two hours, incontinence care as needed and treatment to the affected areas as ordered by the physician. Review of the resident's Positioning Sheets dated [DATE] through [DATE], indicated that the resident was not documented as being repositioned on [DATE] from 8:00 A.M. through 10:00 P.M., on [DATE] from 4:00 P.M. to 12:00 A.M., on [DATE] from 4:00 P.M. to 12:00 A.M., and on [DATE] from 12:00 A.M. to 8:00 A.M.. Review of the resident's Treatment Administration Record (TAR), dated [DATE] though [DATE], indicated that on [DATE] from 3:00 P.M. to 11:00 P.M, the resident's right buttock skin was fragile, pink, and blanching. The TAR, dated [DATE] from 7:00 A.M. to 3:00 P.M for cleansing and changing the DuoDerm to the coccyx , had no documentation indicating the condition of coccyx or t

Based on observations, staff interviews, and record review, the facility's Quality Improvement and Performance Improvement (CQI) Committee failed to ensure that the quality assurance program, acted on, identified issues, developed and implemented plans of action for care and services provided to residents, and evaluated that the plans were effective. Findings include: The facility's Quality Improvement (CQI) Committee was responsible for identifying whether quality deficiencies were present (potential or actual deviations from appropriate care processes or facility procedures) that required action. If there are quality deficiencies, the committee was responsible for developing plans of action to correct them and for monitoring the effect of these corrections. The facility's Quality Improvement system failed to identify deficient practice in the area of pressure ulcer prevention, assessment and treatment. On 12/9/13 at 2:45 P.M., the Administrator and the Director of Nursing (DON) were interviewed. The Administrator and the DON said that there was a facility CQI Committee which met monthly and quarterly. On 12/11/13 at 9:25 A.M., during interview, the Administrator said that the facility Policies and Procedures were reviewed yearly. However, the Policy and Procedure Manual the Administrator produced for the survey team was for a sister facility and signed by the sister facility's administrative staff. The Administrator said that there had been multiple changes in administrative staff since the last recertification survey on 10/11/12. The DON had been in the facility for approximately 3 weeks. The DON said she identified that skin (pressure sores) was an issue which the facility had begun to address. However, the DON said she did not realize the extent of the skin issues within the facility until survey began as evidenced by: * incorrect documentation of pressure sore measurements. * failure to identify and document the presence of pressure sores. * failure to correctly perform treatment to the documented pressure sore. During interview on 12/11/13 at 9:00 A.M. by speaker phone with the entire survey team present, the Medical Director said he was not aware of pervasive skin issues concerning assessment of wounds and wound measurements. The Medical Director said he attended the QA (Quality Assurance) meeting monthly and was kept abreast of skin issues and falls by the Administrator. The Medical Director said he was asked by the Administrator to come to the facility on [DATE] to assess a resident's wounds (Resident #16). The Medcial Director said he assessed the resident's wounds and made recommendations for treatment. The Medical Director said he was not told of the difficulty the nursing staff had with the accuracy of pressure sore assessments and the accuracy of measurements for these pressure sores. The Medical Director was interviewed in person on 12/11/13 at 11:00 A.M. by Surveyors #3, #4, and #5. The Medical Director said last Thursday (12/5/13) a problem with facility wounds (pressure sores) was discussed with the Administrator. The Medical Director said the plan was to do 1:1 teaching with the nursing staff to ensure that wound assessments were done accurately. On 12/10/13 the Medical Director said he was awaiting reports from the Administrator to ensure the teaching was complete and to determine when a Wound Specialist would be brought to the facility to evaluate the current wounds. In addition, the Medcial Director said that the administrative staff were responsible for the appraisal of the clinical conditions (wounds) in the facility. The Medical Director could not articulate that there was any formulized discussion of clinical indicators when on the telephone or in person.

Based on record review and interview, the facility failed to provide effective interventions to prevent falls for 1 resident (Resident #4) of 10 applicable residents with falls, out of a total sample of 24 residents. Findings include: 1. For Resident #4 the facility failed to provide effective interventions to ensure that the resident did not have 5 falls including 1 fall that resulted in an L1 - T12 (lumbar 1 - thoracic 12) fracture. Resident #4 was admitted to the facility in 5/2009 with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. The resident required extensive assistance with transfers and ambulation. Review of the plan of care for falls, last updated on 9/12/12, indicated interventions including the following: *Place glasses within reach and encourage use *Resident teaching to wear appropriate footwear at all times *Provide verbal cues for safety and sequencing when needed *Provide verbal cues for proper pacing and energy conservation *Place call light within reach at all times *Remind resident to use call light when attempting to ambulate or transfer *Monitor for and assist with toileting needs Record review revealed the following incidents: On 8/29/13 at 7:00 A.M. the resident was getting out of bed to go to the bathroom and fell . The new intervention to prevent falls was to apply slipper socks at bedtime, however the plan of care already had an existing intervention for resident teaching to wear appropriate footwear at all times. On 10/11/13 at 11:45 A.M. the resident self-toileted himself/herself in the bathroom in the main hallway. The resident began banging on the door and a CNA found the resident sitting against the wall next to the door. The resident sustained [REDACTED]. The new intervention to prevent further falls was for 15 minute checks by staff for safety. The intervention was discontinued at 8:00 P.M. During interview on 12/5/13 at 4:30 P.M. Unit manager #2 said that the facility was unable to find any documentation that the 15 minute checks were completed. An additional intervention was to encourage the resident to ask for assistance when using the bathroom, however an already existing intervention was to monitor for and assist with toileting needs. On 10/11/13 at 3:15 P.M. and at 10/12/13 at 2:30 P.M. the resident complained about back pain and was given Tylenol. Nurses notes on 10/13/13 at 12:41 P.M. indicated that "on this day patient presented with severe lower back pain and difficulty moving in bed. Patient allowed staff to raise HOB (head of bed) up 45 degrees only 2nd to limited ROM (range of motion) to lower back. Patient was observed weeping and asking staff to leave (him/her) alone." The resident was ordered to be sent to the hospital and was admitted with an L1 - T12 fracture and required Kyphoplasty (surgery to treat bones of the spine) of the L1 vertebrae. On 11/13/13 at 10:40 P.M. the resident was found on the floor and was sliding on his/her buttocks toward his/her wheelchair. Although the resident had a pressure alarm, the pressure alarm did not sound. Per the witness statement dated 11/13/13 the CNA had forgotten to plug the alarm in when she put the resident to bed. The alarm was still in the wheelchair. In addition the resident was placed on 15 minute checks while in his/her room, however the 15 minute check logs were either unavailable or incomplete. The care plan was changed on 11/14/13 to include the following interventions: *Resident will have pressure alarm in place while in chair and bed. A significant change MDS dated [DATE] indicated that the resident had Brief Interview for Mental Status (BIMS) score of 10 indicating that the resident was moderately impaired in decision making skills. The resident required extensive assistance of 2 for transfer and extensive assistance with of 1 for ambulation. On 11/17/13, directly after the noon meal, the laundry assistant found the resident on the floor at the end of the hall. The new interventions to prevent falls was for 15 minute checks at all times and pressure alarms at all times. Both of these interventions had been in place prior to this fall and were unsuccessful in preventing the fall. During interview on 12/4/13 at 2:30 P.M. Unit Manager #2 said that the resident had many falls, but was doing much better and had not fallen since moving to the 2nd floor.

Based on record review and interview, for one of four sampled residents (Resident #1), the Facility failed to communicate Resident #1's fall risk status to caregivers per the Falls Management Policy, and the Director of Nurses said the staff did not place an alarm on Resident #1's bed and chair, per the Facility practice. On 1/31/13, at approximately 5:00 A.M., Certified Nurse Aide (CNA) #2 left Resident #1, who had a recent history of falls and required staff assistance with transfer activities and ambulation with a walker, alone in the bathroom. At 5:15 A.M., Nurse #1 observed Resident #1, alone, and without an alarm, on the floor in the bathroom and Resident #1 sustained a right hip fracture. Findings include: The Hospital Discharge summary, dated 1/28/13, indicated that Resident # 1: had been "waxing and waning" with his/her mental status; the cause of altered mental status was due to metabolic [DIAGNOSES REDACTED], and he/she fell more frequently during the last five days at home. The Admission record indicated that the staff admitted Resident #1 to the Facility in January 2013. The Admission record indicated that Resident #1's [DIAGNOSES REDACTED]. The Nursing Admission assessment, dated 1/28/13, indicated that Resident #1 had a fall within the past month and in the last 2 to 6 months, prior to his/her admission to the Facility. The Nursing Admission assessment indicated that Resident #1 had a fracture related to a fall in the 6 months prior to his/her admission to the Facility. The Nursing Admission assessment indicated that Resident #1 was alert and oriented. The Nursing Admission assessment indicated that Resident #1 required extensive staff assistance with mobility and occasionally walked short distances. The Nursing Admission assessment indicated that Resident #1 had bilateral lower extremity weakness. The Nursing Admission assessment indicated that Resident #1 required the use of a gait belt for transfer activities. The Surveyor interviewed the Former Director of Nurses (DON) #1 on 6/24/13 at 12:30 P.M. DON #1 said she spoke briefly to Resident #1, who appeared alert and oriented and appeared able to use the call light when indicated. DON #1 said she was not aware that Resident #1 had cognitive impairment, required staff assistance with transfer activities and ambulation, and was at risk for falls. The Surveyor interviewed Nurse #3 on 6/24/13, at 1:30 P.M. The Surveyor interviewed Nurse #5 on 6/18/13, at 4:30 P.M. The Surveyor interviewed Nurse #7 on 6/20/13, at 12:41 P.M. DON #1, Nurse #3, Nurse #5, and Nurse #7 said residents admitted to the Facility with a history of falls had an alarm placed on their bed and chair until the staff were able to determine a resident's safety status. DON #1 said the staff did not place an alarm on Resident #1's bed and chair per the Facility practice. The Surveyor interviewed Social Worker #1 on 6/18/13, at 12:01 P.M. Social Worker #1 said the family told her that Resident #1 fell at home related to not asking for assistance to use the bathroom. The plan of care, dated 1/29/13, related to Resident #1's decreased functional ability to perform transfers, toileting, and ambulation, included: contact guard and assist for toileting and transfer activities with rolling walker. The Surveyor interviewed Nurse #4 on 6/18/13, at 3:10 P.M. The Surveyor interviewed Certified Nurse Aide (CNA) #3 on 6/19/13, at 11:40 A.M. Nurse #4, Nurse #5, and CNA #3 said Resident #1 was confused and had poor insight regarding safety. The Surveyor interviewed CNA #4 on 6/19/13, at 1:00 P.M. Nurse #4, Nurse #5, CNA #3, and CNA #4 said Resident #1 was impulsive, did not use the call light when he/she needed assistance, and was not safe to be alone in the bathroom. CNA #3 and CNA #4 said they observed Resident #1 try to get out of bed without staff assistance. CNA #3 said Resident #1 required physical assist to transfer out of bed and maneuver the walker when ambulating. The Surveyor interviewed Nurse #2 on 6/20/13, at 12:41 P.M. The Surveyor interviewed CNA #6 on 6/20/13, at 2:30 P.M. Nurse #2 and CNA #6 said Resident #1 was lethargic, stayed in bed, and would not try to get out of bed without staff assistance. Nurse #2 and Nurse #3 said they did not think Resident #1 was at risk for falls. The Surveyor interviewed Physical Therapist #1 on 6/19/13, at 11:25 A.M. Physical Therapist #1 said although Resident #1 appeared to be alert and oriented, Resident #1 was confused, was not able to follow directions, and would not use the call light to request staff assistance. Physical Therapist #1 said Resident #1 had an unsteady gait and required a walker and supervision/assist when ambulating. Nurse #5 said she was aware that Resident #1 was at risk for falls and assumed his/her plan of care included alarms. Nurse #5 said she never observed Resident #1 try to get out of bed without staff assistance. Nurse #5 said on one occasion, she observed Resident #1's feet on the ground and his/her body in the bed, and the staff assisted Resident #1 to a safe position in bed. The Falls Management Policy indicated that residents determined to be at risk for falls were to receive appropriate interventions to reduce the risk of a fall and minimize injury. The Falls Management Policy indicated that the Facility was to communicate a patient's fall risk status to caregivers and develop an individualized plan of care. Nurse #1 said she was rarely assigned to Resident #1's unit and was not familiar with the residents on Resident #1's unit. Nurse #1 said on 1/30/13, the evening nurse told her that Resident #1 was newly admitted to the Facility and had Clostridium Difficile colitis. Nurse #1 said the nurse did not tell her, per Falls Management Policy, that Resident #1 had a history of [REDACTED]. Nurse #1 said she did not provide the above information regarding Resident #1's risk for falls to CNA #2. The Surveyor interviewed CNA #2 on 6/18/13, at 2:00 P.M. CNA #2 said she had not provided assistance to Resident #1 prior to 1/31/13. CNA #2 said she was not aware that Resident #1 did not use the call light and used a walker for transfer activities and ambulation. CNA #2 said she was not aware that Resident #1 tried to get out of bed without staff assistance and did not know that he/she required assistance to transfer out of bed. CNA #2 said residents, who were at risk for falls had alarms on their beds and chairs and Resident #1 had no alarms. CNA #2 said at approximately 5:00 A.M., she observed Resident #1 sitting on the toilet, in the bathroom. CNA #2 said Resident #1 appeared fine and she left the room to check on another resident. CNA #2 and Nurse #1 said they were the only staff assigned to Resident #1 during the night shift. CNA #2 and Nurse #1 said they did not assist Resident #1 to the bathroom. The nurse's note, dated 1/31/13, indicated that at 5:15 A.M., the nurse observed Resident #1 on the floor in the bathroom with his/her right head resting on his/her right arm, on the bathroom trash can. The nurse's note indicated that Resident #1 complained of severe right hip pain and had limited range of motion related to pain. CNA #2 said Resident #1 told her that he/she stood from the toilet and slid to the floor. CNA #2 said she did not recall Resident #1's walker in the bathroom or outside the bathroom door. The nurse's note, dated 1/31/13, indicated that the emergency medical technicians transferred Resident #1 to the Emergency Department (ED) at 6:15 A.M. DON #1 said the staff did not consistently revise and complete care cards on the residents. DON #1 said prior to Resident #1's fall, resident care cards did not accurately reflect the amount of assistance and personal care required by residents and did not always designate residents as being at risk for falls. DNS #1 said she could not recall what information was included on Resident #1's care card and could not verify if Resident #1 had a care card on 1/31/13. DON #1 said after the incident, the staff told her that Resident #1 was alert and was independent with using the bathroom. DON #1 said the staff were not aware of Resident #1's fall risk.

Based on observation, resident interview, record review, and review of facility incident documentation, the facility failed to implement effective interventions to prevent one (Resident #21), out of a total sample of 25 residents, from injury as this resident sustained [REDACTED]. Findings include: 1. For Resident #21, with a history of skin tears, the facility failed to ensure that the Resident's lower extremities were protected when staff assisted this Resident to bed, which resulted in the Resident banging against a sharp metal bolt on the bed which caused a laceration to the Resident's leg which required 15 sutures. Resident #21 was admitted to the facility in June 2012 with [DIAGNOSES REDACTED]. Review of facility incident documentation indicated: On 6/28/12 at 9:00 A.M., when receiving morning care, Resident #21 was noted to have a right upper arm skin tear; Steri strips and a dry pressure dressing were applied. Resident had very fragile skin, on admission had a lot of scabs on upper extremities, due to a fall; The facility's corrective action plan was "continue to monitor skin daily with ADLs and extra care during transfers because patient needs assistance." The Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #21 required extensive assist of two staff for bed mobility, one person assist for transfer, did not ambulate during the assessment period, was not steady, only able to stabilize with staff assistance when moving from seated to standing and during transfer, and had functional limitations in upper extremity range of motion. The facility's incident documentation indicated that Resident #21 continued to have problems with skin tears/lacerations as follows: On 7/23/12 at 1:00 P.M., Resident #21 was having physical therapy in the gym when the Resident's left shin started to bleed with no obvious trauma. Steri strips and dry pressure dressing applied. Corrective Action Plan: Extra care with resident with all activities. On 7/31/12 at 4:45 P.M. Staff was helping resident off the bedpan and while moving resident's pants, noted a (new) skin tear/laceration on left shin. 1.0 centimeter (cm) by 1.0 cm. Skin replaced and approximated with steri strips, covered with dry pressure dressing. Immediate action taken: "Educate Certified Nursing Assistants (CNAs) on understanding fragility of patient's with increased edema and to be careful when assisting them." On 9/17/12 at 5:00 P.M. a staff person was assisting the Resident in picking up a phone call when the Resident brought his/her left leg from elevated position on wheelchair to the floor, then back up on to the footrest. Somewhere along the line, Resident hit self with wheelchair rest pad and sustained a 2 cm triangular skin tear on the left shin. Immediate Action Taken:"Ongoing extra care with bilateral lower extremities to prevent injury secondary frail skin and increased edema." The Corrective Action Plan included on this form was "Declined DermaSavers (padded leg covering to lower extremities) at this time." There was no evidence that the reason for the Resident's rejection of the DermaSavers was explored and no evidence that alternative interventions (i.e. different type of leggings) were tried to protect this Resident's fragile skin from injury. In addition, there was no evidence, at this time, that the Resident's wheelchair was inspected for possible sharp edges, nor was there evidence that protective padding was used to cover the wheelchair leg rests and blunt edges that could cause harm to the Resident's lower extremities. A facility incident report on 10/4/12, at 8:45 P.M., indicated: "Patient was transferring from the wheelchair to the bed with a CNA assisting Resident. When the patient was turning Resident banged right lower leg on the metal knob on the side rail". Description of injury documentation indicated "8 cm deep tissue laceration". the Resident was sent out to emergency room for sutures and returned to facility on 10/5/12 at 2:40 A.M. On 10/5/12 at 9:10 A.M., Resident #21 was observed sitting in a wheelchair in the Resident's room. The Resident's right leg was wrapped with a dressing from below the knee to the ankle. The left lower extremity also had a small dressing on it. At this time, Resident #21 reported that he/she sustained the right shin injury last night when being assisted back to bed by a CNA. The Resident said that he/she was sitting on the side of the bed, toward the mid section of the bed and was told by the CNA to slide up toward the head of the bed. The Resident reported that when he/she did this, the side of the his/her right calf scraped against one of the two screws that were jutting out from the lowered siderail. The surveyor then checked the siderail, and observed two bolts jutting out from the siderail. One of the bolts had rough edges. In addition, the siderails were not observed to be padded at this time. Review of the facility's documentation of this incident, dated 10/5/12, indicated that the facility's corrective action was DermaSavers to bilateral lower extremities and Pad siderails. The following observations indicated that during the survey, Resident #21 was still exposed to the two bolts on the siderail, as well as sharp and blunt edges on the wheelchair legs. On 10/9/12 at 10:56 A.M., the surveyor inspected Resident #21's wheelchair and observed a circular opening (about 3/4 inch in diameter) in the front frame of the chair (where the leg rests attach) and there was a piece of metal, approximately 1/2 inch long and 1/4 inch thickness, protruding from this opening. The position of this metal piece presented a safety hazard to this Resident, who self propelled the wheelchair, without footrests. In addition, the surveyor noted that the baseboard heating unit cover in the Resident's bathroom presented a safety hazard. The metal edge of this heating unit was bent, and jagged and in close proximity to the toilet, presenting a potential danger to the Resident, when transferring to the toilet. Although a facility report to the Department of Public Health Nurses on 10/9/12 indicated that the facility was aware of the Resident's report of injuring his/herself on a bolt on the siderail, observations on 10/11/12 at 9:20 A.M. and 2:44 P.M. revealed that the two bolts on the Resident's siderail were still not padded. During interview on 10/9/12 at 3:30 P.M., the Director of Nurses stated that the facility was aware of the Resident's report of injuring him/herself on the siderail. On 10/11/12, after the facility was made aware of the above concerns by the survey team, the facility added the following interventions to the Resident's plan of care: siderails changed to rail with no knob and wheelchair edges covered with rubber and foam to leg rests to prevent injury. B. Baseboard Radiator Covers On 10/4/12 and 10/9/12, 13 bathrooms in resident rooms ( room #s: 112, 116, 119, 202, 205, 207, 220, 221, 301, 304, 308, 309, and 312) were observed and noted to have metal baseboard radiator covers that had sharp edges on the corners of the units, presenting a potential hazard to residents.