Every finding on record at Baker-Katz Skilled Nursing and Rehabilitation CTR

Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#24 and #199) who were assessed to be at high risk for developing pressure ulcers, out of a total sample of 14 residents. Specifically, 1. For Resident #24, the facility failed to implement a physician's order for a treatment and plan for monitoring a blister. 2. For Resident #199, the facility failed to ensure his/her plan of care was implemented related to skin integrity. Findings include: Review of the facility's policy, not titled, revised 11/1/20 indicated the following: Purpose: To minimize the development of any type of ulcer and other skin issues through the systematic and regular inspections of the resident's skin, and to ensure early detection and interventions for all skin problems. Policy: 2. Residents will undergo a weekly body check by the licensed nurse. The facility will utilize the weekly body check form. 3. Certified Nursing Assistants will inspect the skin of each resident during daily care and whenever skin care is provided and report to the licensed nurse any changes to the resident's skin. 4. Licensed Nurse will respond to the report of skin problems and assess the resident's skin as soon as possible. 5. If skin breakdown is identified the physician will be notified and a treatment will be obtained. 7. Documentation by a member of the Nursing Administration team or designee shall include: - The date of assessment. - The stage of and measurements of pressure ulcer and size of non-pressure ulcer. - Description of drainage. - Description of odor. - The condition of surrounding tissue. - Any evidence of the progress or lack of healing. 8. The Licensed Nurse responsible for treatments on each unit will observe each ulcer in conjunction with treatment times and document the observation of the ulcer and or surrounding tissue on the Treatment Sheet. 9. A care plan will be developed and implemented and revised as necessary. 10. The resident will be followed weekly in the skin focus meeting until any pressure ulcer is resolved. 1. Resident #24 was admitted to the facility in March 2023 with diagnoses that include but are not limited to multiple sclerosis, other muscle spasm, major depression, and general paresis (a condition of muscular weakness caused by nerve damage, partial paralysis). Review of the Minimum Data Set (MDS) Assessment, dated 4/10/25, indicated Resident #24 scored a 13 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having intact cognition. Further, the MDS indicated Resident #24 had functional impairment in range of motion of his/her lower extremities, is dependent on staff for care including personal hygiene, lower body dressing and bathing, is at risk for developing pressure ulcers and did not have any pressure ulcers, or other wounds or skin problems. During an observation and interview on 5/20/25 at 7:58 A.M., Resident #24 was in bed. Resident #24 said he/she was not sure if he/she had any skin issues or areas. Resident #24 said he/she only gets out of bed to be weighed. Resident #24 was observed to be slight in stature and frail. Review of Resident #24's medical record indicated the following: -A physician's order dated 1/8/25 weekly skin check Friday 7-3 Document under Assessment Tab. -A Norton Scale for Predicting Risk of Pressure Ulcers dated 10/18/24, 1/10/25 and 4/4/25 assessed Resident #24 as High Risk for developing pressure ulcers. -A care plan with the focus: Resident has potential for altered skin breakdown r/t (related to) immobility, r/t multiple contracture bilateral ankle, knees, hip, trunk rotation prior to admission resulting in him/her being bedbound, multiple sclerosis, spasm, backpain with sciatica, depression, incontinent of urine and bowel. Can be resistive to care. Date initiated: 3/16/2023. Interventions included but not limited to, skin protocol per house policy, dated 3/16/25. -Weekly skin checks dated 4/11/25 and 4/18/25 indicating Resident #24's skin is intact. The next documented skin check was dated 5/2/25 which was completed 2 weeks later. Review of a Nursing Progress Note: dated 4/28/25 indicated: Aide reported a blister on R (right) lateral ankle, inspected and treated with skin prep and covered with a band aide. Blister is filled but intact. NP (nurse practitioner) notified. Review of a Nursing Progress note dated 5/3/25 at 06:48 (6:48 A.M.), indicated: corrective note: L (left) lateral ankle. This note indicated that the blister was on the left lateral ankle and not on the right as documented in the 4/28/25 nursing progress note. Further review of the medical record failed to indicate a new skin assessment after the identification of the new skin blister on Resident #24 was completed on 4/28/25. Further, the medical record failed to indicate an order for the treatment and monitoring of the identified blister was implemented on 4/28/25 when the blister was identified. Review of the weekly skin check dated 5/2/25, completed 5 days after the blister was documented on 4/28/25 on the lateral ankle, indicated site: left foot blister, the document under length, width depth or stage was left blank, nor was there any documentation of evidence of progress or lack of healing, description of the surrounding skin or odor or drainage. Other: BLE (bilateral Lower extremity) healing blisters. Review of the Treatment Administration Record (TAR) dated April 2025 failed to indicate the administration of a treatment or monitoring of the blister identified on 4/28/25 on Resident #24's right lateral ankle. Review of the TAR dated May 2025 indicated the following: -Blister to left lateral ankle. Apply skin prep and wrap with Kerlix. Every day and evening shift for Blister. The treatment was documented as administered beginning on the evening shift on 5/2/25. This order was implemented five days after the Blister was identified on Resident #24's ankle on 4/28/25. During an interview on 5/21/25 10:16 A.M., Nurse #1 said she was not caring for Resident #24 today but has recently taken care of him/her and that he/she has a blister on his/her foot. Nurse #1 said when a skin tear, blister or skin injury occurs the nurse practitioner is notified, and orders are put in place for treatment and the nurses follow the orders. During an interview on 5/21/25 at 9:24 A.M., the Unit Manager said all residents have weekly skin checks under assessments in the medical record. The Unit Manager said Resident #24 is at risk for pressure/skin injuries. The Unit Manager reviewed Resident #24's assessment tab and said the weekly skin check was not completed on 4/25/25 and should have been. The Unit Manager said she was aware that a blister was reported on Resident #24's foot. The Unit Manager said when an area is identified a new skin assessment is completed and an order for treatment is obtained at the time it is identified. During an interview on 5/21/25 at 9:23 A.M., the Director of Nursing (DON) said if a new skin area is identified on a resident, a skin incident report is completed, a skin check assessment is conducted, the Nurse Practitioner would be notified and an order for treatment would be obtained and entered under orders. The DON said she was not aware of the blister on Resident #24 until 5/6/25, did not have an incident report and expected a skin assessment to be completed and an order put in place for a treatment. During an interview 5/21/25 at 10:31 A.M., the Nurse Practitioner (NP) said Resident #24 has a history of developing blisters. The NP, who is also the Regional Nurse for the facility, said when a new area is identified an assessment including the location, and a complete description of the alteration in skin should be completed. The NP said the monitoring of the area would be part of the order for treatment to include the progress of the wound, odor, drainage, color of surrounding skin. The NP said she was made aware of the blister and ordered skin prep and a protective dressing and was not aware that the order was not implemented on 4/28/25 when the area was identified. The NP reviewed Resident #24's record and said there was no weekly wound documentation, and the treatment order did not include monitoring of the wounds response to treatment and should.2. Resident #199 was admitted to the facility in February 2025 with diagnoses that included dementia, pressure ulcer to sacral region, peripheral vascular disease, and venous insufficiency. Review of Resident #199's most recent Minimum Data Set (MDS) assessment, dated 4/27/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. The MDS further indicated the Resident is at risk for developing pressure ulcers and has one unstageable pressure ulcer. The MDS also indicated that he/she was dependent on staff for bathing, dressing and grooming. On 5/20/25 at 7:40 A.M. and 10:37 A.M., the surveyor observed Resident #199 in bed with his/her feet and heels flat on the mattress, no air boots, foam dressings or lambswool were observed on the Residents' feet. The surveyor observed two large blood blisters on his/her left foot and the top of his/her toes on both feet were red. On 5/21/25 at 7:36 A.M. and 9:11 A.M., the surveyor observed Resident #199 in bed with his/her feet and heels flat on the mattress, no air boots were observed on the Residents feet. The surveyor observed a lambswool only between the left toes and a dressing wrapped around his/her ankle and foot leaving the left heel exposed. The right heel had no dressing in place and the right toes were observed to have no lamb's wool. Review of Resident #199's physician order, dated 1/7/25, indicated Apply wisps of Lambswool between toes daily. Review of Resident #199's physician order dated 2/26/25, indicated apply skin prep to both feet, allow to air dry, apply Allevyn Foam Dressings to both heels, then place air boots on both feet for pressure prevention. Review of Resident #199's physician order, dated 4/23/25, indicated off load heels at all times using pillows. Review of Resident #199's nursing progress note, dated 5/17/25, indicated Patient noted to have 2 blood filled blisters 4(4X2) (4 centimeters by 2 centimeters) and (2x2) on the bottom of the left foot MD (medical doctor) updated skin prep applied and areas LOTA (leave open to air). Review of Resident #199's altered skin care plan, dated 3/26/25, indicated Offload heels. Apply Lambswool between toes daily. Notify MD if treatment is ineffective. Review of Resident #199's Norton Scale for Predicting Risk of Pressure Ulcer dated 4/29/25, indicated he/she scored a four indicating high risk. Review of Resident #199's nursing progress notes and May 2025 Treatment of Administration Record from 5/18/25 through 5/21/25 failed to indicate the Resident refused any treatments. During an interview and observation on 5/21/25 at 9:15 A.M., Nurse #1 said the expectation is that nurses follow physician's orders. Nurse #1 said there is only lambswool and a dressing on his/her left foot, but it does not cover the heel. Nurse #1 said if there is an order in place for a dressing to both heels, air boots to both feet and lambswool to all toes then it should be followed. Nurse #1 said his/her feet and heels are directly on the bed and there are no air boots on the Resident. During an interview and observation on 5/21/25 at 9:17 A.M., Certified Nurse Aide (CNA) #1 said the Resident has had wounds on and off on his/her feet and heels. The CNA said he/she does not remove their dressings or pillows. The CNA said his/her heels are flat on the mattress and not elevated and there is only a dressing and lambswool on the left foot. During an interview on 5/21/25 at 9:19 A.M., the Nurse Practitioner said the Resident is at high risk for developing pressure ulcers and has had multiple pressure ulcers in the past. The NP said the Resident does currently have skin breakdown on his/her feet and said the expectation is that nursing staff are following the plan of care and physician's orders. During an interview on 5/21/25 at 10:25 A.M., the Director of Nurses (DON) said she expects the Residents plan of care to be followed. The DON said this Resident does not refuse wound care or his/her heels to be elevated and said if they did it should be documented in a nursing progress note. The DON said his/her feet are very fragile and that is why the orders are in place to protect his/her skin.

Based on observation, record review and interviews, the facility failed to ensure that respiratory care services, consistent with professional standards of practice, were implemented for two Residents (#16 and #18), out of a total sample of 14 residents. Specifically, facility staff failed to change oxygen and nebulizer tubing in accordance with the physician's orders. Findings include: Review of the facility's policy titled Oxygen Administration and Storage, not dated, indicated the following: -Purpose: Administration of oxygen as ordered by the physician. Ensure safe storage and proper handling of oxygen. -Procedure: 8. Change cannula, humidifier, tubing, and other disposable equipment weekly and as needed. Date, time, and initial tubing when changed. 1a. Resident #16 was admitted to the facility in August 2021 and has diagnoses that include but are not limited to cerebral infarction, chronic diastolic heart failure, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 4/24/25, indicated Resident #16 scored a 10 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #16 as having moderate cognitive impairment. Further, the MDS indicated Resident #16 was dependent on staff for daily care including bathing, toileting and dressing and utilized oxygen therapy. On 5/20/25 at 7:40 A.M., Resident #16 was observed in bed with his/her eyes closed with a nasal cannula administering oxygen at 2 liters. Tape affixed to the oxygen tubing that was administering the oxygen was dated 5/7. Tubing attached to a nebulizer (a nebulizer is a drug delivery device used in the form of a mist inhaled into the lungs) unit on Resident #16's bedside table was dated 5/7. On 5/20/25 at 9:04 A.M., Resident #16 was observed in bed with oxygen running via a nasal cannula. Both the oxygen tubing and nebulizer tubing were dated 5/7. During an interview and observation on 5/20/25 at 9:42 A.M., Resident #16 said he/she uses oxygen all the time. Resident #16 said he/she uses the breathing treatment (nebulizer) every day. At this time the oxygen tubing was dated 5/20/25 and the nebulizer tubing was dated 5/7. Review of Resident #16's physician's orders indicated the following: -Change oxygen tubing and date. also clean concentrator filter weekly on Tuesday 11-7 (11:00 P.M. to 7:00 A.M.) every night shift every Tue, dated 4/25/25. (sic) -Change tubing and date neb (nebulizer) machine tubing every Tuesday 11-7 every night shift every Tue, dated 4/5/25. (sic) -May give supplemental o2 (oxygen) via NC (nasal cannula) to keep saturation above 92% every shift, dated 4/25/24 (the order failed to indicate how many liters of oxygen to administer) -Ipratoplum-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 8 hours for SOB (shortness of breath)/Wheezing via nebulizer x 15 minutes for SOB/Wheezing, dated 8/16/24. Review of the care plan with the focus: Resident has sleep apnea, Dyspnea (Shortness of breath), Asthma and Respiratory failure, date initiated 5/3/22, with the interventions: Change oxygen tubing and date. also clean concentrator filter weekly on Tuesday 11-7, dated 4/25/25. (sic) Change tubing and date neb machine tubing every Tuesday 11-7, date 4/25/25. Resident #16's oxygen tubing and nebulizer tubing were not changed weekly in accordance with the physician's orders and care plan. During an interview on 5/21/25 at 10:20 A.M., Nurse #1 said Resident #16 uses the nebulizer daily and the nursing staff provide the administration of the nebulizer treatment. Nurse #1 said the oxygen tubing and tubing for the nebulizer is to be changed weekly. Nurse #1 said she would expect that the nursing staff would see the date on the nebulizer when administering the nebulizer treatment. During an interview on 5/21/25 at 10:55 A.M., the Director of Nursing said she would expect respiratory equipment to be changed as indicated in the physician's order and would expect the nurses who are providing the daily nebulizer treatments to Resident #16 to see the equipment was not changed as required. 1b. Resident #18 was readmitted to the facility in December 2024 and has diagnoses that include but are not limited to acute and chronic respiratory failure with hypoxia, and chronic respiratory pulmonary disease. Review of Resident #18's MDS, dated [DATE], indicated Resident #18 scored a 9 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #18 as having moderately intact cognition. Further review of the MDS indicated Resident #16 requires assistance with daily care and uses oxygen therapy. During an observation and interview on 5/20/25 at 8:13 A.M., Resident #18 was sitting up in bed with his/her breakfast tray in front of him/her. Resident #18 was wearing a nasal cannula which was administering 2.5 liters of oxygen from a concentrator located next to his/her bed. The oxygen tubing was dated 5/7. Resident #18 said staff change the tubing sometimes. During an observation on 5/20/25 at 10:44 A.M., Resident #18's oxygen tubing administering oxygen via the nasal cannula was dated 5/7. Review of Resident #18's physician's orders indicated the following: -Change tubing and oxygen concentrator every Tuesday on 11-7 and clean filter with warm water. Be sure to label new tubing with Date, every night shift every Tue, dated 4/25/25. -Oxygen as 2L (liters) via NC (nasal cannula) to maintain 02 sats greater than 90% every shift related to Chronic Obstructive Pulmonary Disease, Unspecified Acute and Chronic Respiratory Failure with Hypoxia, Acute and Chronic Respiratory Failure with Hypercapnia, dated 11/13/23. Review of a Care Plan with the focus: Resident has Emphysema/COPD (chronic obstructive pulmonary disease) positive nodule right lung-noncompliant/decreased safety awareness to wear oxygen date initiated 3/6/20, included the interventions dated 3/6/20 Give oxygen therapy as ordered by the physician, change and date tubing weekly. Resident #18's oxygen tubing was not changed weekly as indicated in accordance with the physician's orders and care plan. During an interview on 5/21/25 at 10:40 A.M., the Unit Manager said the oxygen tubing should be changed weekly and that it is written as a physician's order to be changed. The Unit Manager said the date of 5/7 would not have been weekly. During an interview on 5/21/25 at 10:55 A.M., the Director of Nursing said she would expect respiratory equipment including tubing to be changed per the physician's order.

Based on observation, record review and interview, the facility failed to implement infection control practices to prevent the spread of infection. Specifically, two housekeeping staff failed to perform hand hygiene, and one entered a resident's room wearing potentially contaminated gloves. Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene, not dated indicated the following: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation included but was not limited to: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use alcohol-based rub containing 60-95% ethanol or isopropanol for all the following situations: b. before donning sterile gloves, j. After removing gloves. During an observation in the B hall on 5/21/25 at 9:14 A.M., the surveyor observed the following: At 9:15 A.M. Housekeeper #1 exited a resident room wearing gloves on both hands. Housekeeper #1 touched the housekeeping cart in the hall, opened a cabinet on the side and with her gloved hands removed a spray bottle and toilet brush in a holder and entered a different resident room and entered the bathroom wearing the same gloves. At 9:16 A.M., Housekeeper #1 exited the resident's room with the same gloved hands, touched the cart with her gloved hands and put the items back in the cart. Housekeeper #1 then picked up the floor mop and entered the same resident room wearing the same potentially contaminated gloves. At 9:18 A.M., Housekeeper #1 exited the resident room, removed her gloves and without performing hand hygiene placed on new gloves and moved on to the next resident room. At 9:19 A.M., Housekeeper #2 exited a room wearing gloves, reentered the room after placing a rag in the water on the cart. Then exited the room, removed the gloves and put on new gloves without performing hand hygiene. At 9:40 A.M., Housekeeper #1 exited a resident room wearing gloves on both hands, removed the gloves and without performing hand hygiene placed on new gloves. Housekeeper #1 pushed the housekeeping cart a short distance, then removed supplies from the cart and entered a resident's room. During an interview on 5/21/25 at 10:24 A.M., Housekeeper #2 said hands are to be cleaned, pointing to the hand sanitizer dispenser on the wall after gloves are removed or before gloves are placed on and said gloves are not to be worn in the hall. During an interview on 5/21/25 at 10:40 A.M. the Unit Manger said housekeeping staff are to follow infection control procedures. The Unit Manger said staff should not wear dirty gloves in the hall, touching the cart, and should not go into a resident's room wearing dirty gloves. During an interview on 5/21/25 at 10:27 A.M., the Infection Control Preventionist Nurse said staff are to perform hand hygiene before and after putting on gloves, should not be wearing gloves in the hall and should perform hand hygiene and change gloves between tasks and should not wear the same gloves in multiple rooms.

Based on observations and interviews, the facility failed to ensure nursing staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure two of two treatment carts were locked while a nurse was not present. Findings include: Review of the facility policy titled Storage of Medications, dated 2017, indicated The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized with authorized access. On 5/20/25 from 7:06 A.M. to 7:49 A.M., the surveyor observed the treatment cart unlocked and unsupervised in the A hall. Multiple staff members and residents were observed walking by the treatment cart. On 5/20/25 from 7:45 A.M. to 8:11 A.M., the surveyor observed the treatment cart unlocked and unsupervised in the B hall. Multiple staff members and residents were observed walking by the treatment cart. The surveyor was able to access the cart and observed multiple prescription ointments/creams and other treatment supplies. On 5/21/25 from 7:36 A.M. to 8:31 A.M., the surveyor observed the treatment cart unlocked and unsupervised in the B hall. Multiple staff members were observed to walk by the treatment cart. The surveyor was able to access the cart and observed multiple prescription ointments/creams and other treatment supplies. During an interview on 5/21/25 at 9:15 A.M., Nurse #1 said treatment carts should be locked at all times unless the nurse is at the cart. During an interview on 5/21/25 at 9:19 A.M., the Administrator and the Nurse Practitioner said treatment carts should be locked at all times unless the nurse is present at the cart.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 10/26/24, was found lying on the floor by Nurse #1 after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality care, when although Nurse #1 said she assessed Resident #1 prior to moving him/her off of the floor, there was no documentation to support she adequately assessed Resident #1 after his/her fall for potential injury. Findings include: Standard Reference: Standard of Practice Reference: 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 bear full responsibility for systematically assessing health status and recording the related health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated 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. Review of the Facility's policy, titled Resident Assessment, revised 08/30/24, indicated the Facility shall promptly notify the resident, his/her attending Physician and representatives of changes in the residents medical/mental condition and/or status including an accident or incident involving the resident. Review of the Facility's policy, titled Accident and Incident Reports, undated, per Director of Nurses (DON) reviewed annually in December, indicated all accidents or incidents involving residents to notify the following; the attending Physician and follow any orders promptly, the DON within 24 hours of the incident or accident, the oncoming nurse, the family or responsible party and that it is imperative that this information is passed on in report to the oncoming nurse if they need to make a phone call to the family or responsible party. The Policy indicated an unwitnessed fall, document a complete set of vital signs, complete neuro assessment in the nurse's note and document the fall on the 24 hour report book. The Policy indicated the incident report needs to be brought to morning meeting and followed up to ensure that all documentation is completed. Resident #1 was admitted to the Facility in June 2020, diagnoses included dementia, type II diabetes, hypertension, osteoarthritis, schizophrenia, delusional disorders, anxiety, depression, and history of falls. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/07/24, indicated that on 10/26/24, Resident #1 was transferred to the Hospital Emergency Department secondary to a high blood glucose level and mental status changes. The Report further indicated the Facility received a phone call from the Hospital ED Nurse indicating Resident #1 was found to have rib fractures, bruising and sepsis. During a telephone interview on 11/21/24 at 2:37 P.M., Nurse #1 said on 10/26/24, somewhere around 3:00 P.M. she found Resident #1 in an unoccupied room lying on the floor on his/her side. Nurse #1 said Resident #1 was moving around, trying to get him/herself off the floor, but was unable. Nurse #1 said she assessed Resident #1, completed his/her vital signs, checked his/her skin for bumps, bleeding, if he/she had pain and said she did not see anything wrong. Nurse #1 said she asked Nurse #2 to assist her to transfer Resident #1 back to his/her room. However, although Nurse #1 said she assessed Resident #1 after his/her fall, there was no documentation in Resident #1's Medical Record to support Nurse #1 had completed any type of assessment, including that she had obtained Resident #1's vital signs on 10/26/24, after his/her unwitnessed fall. During a follow-up telephone interview on 11/21/24 at 3:28 P.M., Nurse #1 said on 10/26/24, that although she did not document Resident #1's fall on 10/26/24, that she did assess him/her for potential injury before having Nurse #2 help her get Resident #1 up and back to his/her own room. Nurse #1 said she was aware of the Facility's Policy related to Resident Assessment and Accident/Incident Report, the Fall Packet, Procedures, and what was required of nursing if a resident had an unwitnessed fall. Nurse #1 said on 10/29/24, (three days after the incident) she provided a written statement and documented Resident #1's unwitnessed fall in his/her medical record including Resident #1's Neurological assessment. During a telephone interview on 11/21/24 at 12:25 P.M., Nurse #2 said on 10/26/24, Nurse #1 said Resident #1 had fallen and she needed help. Nurse #2 said upon arrival, Resident #1 was in an unoccupied room lying on the floor on his/her right side. Nurse #2 said Nurse #1 told her she had already assessed Resident #1 for potential injury. Nurse #2 said she assisted Nurse #1 to transport Resident #1 to his/her room. Nurse #2 said Resident #1 did not verbalize pain or discomfort. Nurse #2 said Resident #1's facial expression did not show signs of pain or discomfort and Resident #1 was able to ambulate, which was his/her baseline. Nurse #2 said on 10/27/24 she was asked by the Administrator and Director of Nurses if anything had happened on 10/26/24 to Resident #1 since he/she was not doing well. Nurse #2 said she had said no but shared details of the fall. During an interview on 11/20/24 at 10:40 A.M., the Administrator said she had received a phone call from the Nurse that worked the overnight shift on 10/26/27 into 10/27/24 to inform her the Hospital called the Facility to inform them Resident #1 had fractures. The Administrator said she had not been informed of Resident #1's fall on 10/26/24 until during her investigation. During an interview on 11/20/24 at 2:22 P.M., the Director of Nurses said she could not find any documentation in Resident #1's Medical Record regarding his/her fall on 10/26/24, including any assessments or a Fall/Incident Report. The DON said it was her expectation that Nurse #1 should have assessed Resident #1 for injury, initiated obtaining neurological signs (fall was unwitnessed), and completed the Fall Packet.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 10/26/24 was found lying on the floor by Nurse #1 after an unwitnessed fall, the Facility failed to ensure nursing reported the incident to the Physician, his/her Guardian, Administrative staff and to the oncoming Nurse as required, and per Facility policy. Findings Included: Review of the Facility's policy, titled Resident Assessment, revised 08/30/24, indicated the Facility shall promptly notify the resident, his/her attending Physician and representatives of changes in the residents medical/mental condition and/or status including an accident or incident involving the resident. Review of the Facility's policy, titled Accident and Incident Reports, undated, per Director of Nurses (DON) reviewed annually in December, indicated all accidents or incidents involving residents to notify the following; the attending Physician and follow any orders promptly, the DON within 24 hours of the incident or accident, the oncoming nurse, the family or responsible party and that it is imperative that this information is passed on in report to the oncoming nurse if they need to make a phone call to the family or responsible party. Resident #1 was admitted to the Facility in June 2020, diagnoses included dementia, type II diabetes, hypertension, osteoarthritis, schizophrenia, delusional disorders, anxiety, depression, and history of falls. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/07/24, indicated that on 10/26/24, Resident #1 was transferred to the Hospital Emergency Department (ED) secondary to a high blood glucose level and mental status changes. The Report further indicated the Facility received a phone call from the Hospital ED Nurse indicating Resident #1 was found to have rib fractures, bruising and sepsis. Review of the Facility Report, titled Summary of the Investigation, indicated on 10/26/24 Resident #1 had an unwitnessed fall at approximately 3:39 P.M., that the assigned Nurse (Nurse #1) had failed to report the incident to the Facility Physician/Nurse Practitioner, Resident #1's Responsible Party, the on coming shift nurse, or to Emergency Medical Services (EMS) and Hospital Emergency Department (ED) team. Review of Resident #1's Medical Record indicated Resident #1 was appointed a Guardian, that his/her Guardian contact information and Family member contact information were clearly indicated in his/her record. Review of Resident #1's Medical Record indicated that 10/26/24, there was no Nurse Progress Note, no Fall/Incident Report, and no documentation to support Resident #1 Guardian, Physician, Director of Nurses (DON) or the oncoming shift Nurse were notified of Resident #1's fall/incident. During a telephone interview on 11/21/24 at 2:37 P.M., Nurse #1 said on 10/26/24, somewhere around 3:00 P.M. she found Resident #1 in an unoccupied room lying on the floor on his/her side. Nurse #1 said Resident #1 was moving around, trying to get him/herself off the floor, but was unable. Nurse #1 said she had assessed Resident #1, completed his/her vital signs, checked his/her skin for bumps, bleeding, if he/she had pain and said she did not see anything wrong. Nurse #1 said she asked Nurse #2 to assist her to transfer Resident #1 back to his/her room. During a follow-up telephone interview on 11/21/24 at 3:28 P.M., Nurse #1 said on 10/26/24, somewhere around 6:30 P.M. a Certified Nurse Aide (CNA, later identified as CNA #1) approached her and said Resident #1 appeared to be pale, sweaty, and did not look well. Nurse #1 said she went to assess Resident #1 who was in bed, was pale, clammy, sweaty and had an elevated blood sugar. Nurse #1 said the Resident #1 told her that he/she did not eat and only had a small amount of water. Nurse #1 said she was unable to lower Resident #1's blood sugar, so she spoke to the Nurse Practitioner and they sent Resident #1 to the Hospital Emergency Department for further evaluation. Nurse #1 said she did not report Resident #1's fall to the Physician, the Director of Nurses, the Emergency Medical Services, the Emergency Staff Nurse, to the oncoming staff or to the Resident #1's Guardian. During a telephone interview on 11/21/24 at 12:25 P.M., Nurse #2 said on 10/26/24, Nurse #1 said Resident #1 had fallen and she needed help. Nurse #2 said upon arrival, Resident #1 was in an unoccupied room lying on the floor on his/her right side. Nurse #2 said she assisted Nurse #1 to transport Resident #1 to his/her room. Nurse #2 said Nurse #1 was assigned to Resident #1 and would have reported Resident #1's fall and completed his/her documentation relating to the fall, so she did not. During an interview on 11/20/24 at 10:38 A.M., the Director of Nurses (DON) said Nurse #1 did not inform her of Resident #1's fall on 10/26/24. The DON said Nurse #1 had called her on 10/26/24 and reported that Resident #1's blood sugars were elevated, and she was unable to reach the Nurse Practitioner (NP). The Director of Nurses said she was able to reach the NP immediately after speaking to Nurse #1 and the NP gave an order to transfer Resident #1 out to the ED for evaluation. During an interview on 11/20/24 at 10:40 A.M., the Administrator said Nurse #1 did not inform her of Resident #1's fall on 10/26/24. The Administrator said she received a phone call from the Nurse that worked the overnight shift on 10/26/27 into 10/27/24 who had informed that the Hospital called the Facility to inform them Resident #1 had fractures. The Administrator said she begun an investigation on 10/27/24, and was informed of Resident #1's fall on 10/26/24 during her investigation. During a follow-up interview on 11/20/24 at 2:22 P.M., the Director of Nurses said she could not find any documentation in Resident #1's Medical Record regarding his/her fall on 10/26/24, including any assessments or a Fall/Incident Report. The DON said it was her expectation that Nurse #1 should have assessed Resident #1 for injury, initiated obtaining neurological signs (fall was unwitnessed), and completed the Fall Packet. The DON said Nurse #1 should have also notified the Physician, Facility Administration staff, Resident #1's Guardian, documented the fall incident in a progress note, completed a Fall/Incident Report, notified the oncoming shift nursing staff, and obtained staff written statements, but she had not.

Based on record review, policy review and interview, the facility failed to ensure a plan of care was developed for Trauma Informed Care with individualized interventions, for two Residents (#3 and #41) who have a history of Post Traumatic Stress Disorder (PTSD), out of a total sample of 14 residents. Findings include: The facility policy titled Trauma Informed Care, undated, indicated the following: -Traumatic event(s) cause an over-reactive adrenaline response influencing receptor sites. This creates biological changes in the brain. These biological changes persist long after the traumatic event(s). Future situations can make the person be hyper-responsive to these situations. Stress hormones suppress hypothalamic activity which can then create symptoms. Essentially maladaptive learning has been created in the brain. Interventions include: -Utilize all team resources to identify areas of trauma ad triggering events-stimuli -Identify and avoid behavioral triggers -Decrease stimuli that have negative effects 1. Resident #3 was admitted to the facility in January 2018 and had diagnoses that include anxiety disorder, major depressive disorder and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #3 scored a 3 out of 15 on the Brief Interview for Mental Status exam (BIMS), indicating the Resident had severely impaired cognition. The MDS further indicated that Resident #3 had verbal and physically aggressive behavior toward others 4-6 days a week. Review of the most recent PTSD and Trauma Assessment, dated 3/20/24, indicated the following: -Resident #3 has a history of both physical and sexual assault/abuse; The assessment failed to indicate Resident specific triggers for retraumatization. Review of the current PTSD care plan indicated the following: FOCUS: Trauma Care plan At risk for psycho-social decline as evidenced by history of trauma r/t (related to) victim of physical abuse. INTERVENTIONS: -Allow resident to identify positive experiences in their life and successes as a resource such as when they are feeling anxious and overwhelmed. Encourage positive association with resources and name positive sensations that are calming or relaxing when discussing the resource; -Daughters and family are supportive and encourage to have continual contact and arrange for visitation if requested; -Encourage resident to participate in daily activities. Resident #3 enjoys listening to music, watching movies, visiting with dtrs/family, socializing with staff/1:1 visits; -Encourage resident to verbalize their feelings and offer 1:1 support. Involve social service if negative thoughts are being voiced. Provide 1:1 counseling services and psychiatric support. Behavioral Health services as needed; -Nursing staff to assess mood and effect daily. Encourage resident to access staff for support if mood and effect are out of normal limits. The PTSD care plan failed to identify resident specific triggers that may be stressors or may prompt recall of the previous traumatic event and retraumatization. Review of the most recent Psych Note, dated 5/24/24, indicated: -Staff report Resident #3 can be periodically anxious, yelling out, resistance to care, and selective with meds. Review of the Social Service clinical progress notes, dated 3/21/24, 1/04/24, 10/11/23, and 7/18/23, all indicate the following: -Resident #3 acknowledges a history of trauma related to physical and sexual abuse. Review of the current Kardex (resident specific care instructions) indicated Resident #3 was dependent on staff for care. Review of the Treatment Administration Record (TAR) indicated that Nursing documented: -In May 2024 was resistive to care 4 times on the day shift, 16 times on the evening shift -In June 2024 was resistive to care 3 of 4 days on the day shift During an interview on 6/05/24 at 7:47 A.M., Resident #3's Certified Nursing Assistant (CNA) #1 said Resident #3 required total care and was very private. CNA #3 said that Resident #3 wanted the curtain pulled around his/her bed and if it isn't she would hear Resident #3 scream. CNA #1 was not aware if Resident #3 had a preference for female caregivers. During an interview on 6/05/24 at 8:58 A.M., Social Worker (SW) #1 said a care plan should be created upon admission for residents with a history of PTSD including information obtained from the resident and family regarding specific areas that may trigger the resident to become retraumatized. SW #1 said that she completes a PTSD assessment upon admission and quarterly, that identifies resident specific triggers, and that she tells staff to always consider trauma if a resident becomes distressed in situations. SW #1 said Resident #3 doesn't understand English so I don't communicate with him/her as much as I do other people but that the Resident had a very supportive family. SW #1 said that in this case she hadn't discussed the PTSD with the family although the family was very involved. SW #1 further said that she thinks Resident #3 prefers only female caregivers and that she will review Resident #3's care plan which sounds like it is generic. During a follow-up interview on 6/05/24 at 9:48 A.M., SW #1 said she updated Resident #3's care plan to reflect Resident #3's preference for female only caregivers, which should have been an intervention in place on the care plan, but was not. During an interview on 6/05/24 at 10:03 A.M., the Director of Nursing (DON) said that it was her expectation that residents care plans be individualized when they have PTSD with resident specific triggers. 45763 2. Resident #41 was admitted to the facility in April 2024 with diagnoses including anxiety, depression and PTSD (Post Traumatic Stress Disorder). Review of the most recent Minimum Data Set (MDS) assessment, dated 4/07/24, indicated that Resident #41 scored a 9 out of 15 on the Brief Interview for Mental Status exam (BIMS), indicating the Resident was moderately cognitively impaired. Further review of the MDS indicated that the Resident felt down, depressed, or hopeless nearly every day. Review of the most recent PTSD and Trauma Assessment, dated 4/03/24, indicated the following: -Resident #41 had a history of both physical and sexual assault/abuse on at least two occasions. -Resident #41 scored a 0 on section D, indicated the Resident did not acknowledge any ongoing signs of trauma. -Resident #41 does not discuss his/her trauma and that information regarding the trauma was provided by the Resident's son. The assessment failed to indicate Resident specific triggers for retraumatization, and failed to indicate that potential triggers were assessed during the biopsychosocial evaluation with his/her son. Review of Resident #41's PTSD care plan indicated the following: FOCUS: Trauma Care plan: at risk for psycho-social decline as evidence by PTSD, history of trauma r/t (related to) victim of sexual violence. INTERVENTIONS: -Acknowledge resident's physical response to anxiety, fear, etc. -Encourage resident to participate in daily activities she enjoys. -Encourage resident to verbalize their feelings and offer 1:1 support. Involve social services if negative thoughts are being voiced. The PTSD care plan failed to identify resident specific triggers that may be stressors or may prompt recall of the previous traumatic event and retraumatization. Review of the social Service clinical progress note, dated 4/04/24, indicated that Resident #41 had a history of PTSD, and that the Resident's son acknowledged that the Resident had a history of trauma related to sexual assault. Further review of the progress note indicated that the PHQ9 (Patient Health Questionnaire, a self-administered questionnaire that can be used to screen, diagnose, monitor, and measure the severity of depression) indicated the presence of minimal depression symptoms with a score of three, acknowledging the Resident felt down most of the time. During an interview on 6/05/24 at 8:58 A.M., Social Worker (SW) #1 said a care plan should be created upon admission for residents with a history of PTSD including information obtained from the resident and family regarding specific areas that may trigger the resident to become retraumatized. SW #1 said a PTSD and Trauma Assessment would be completed on admission and quarterly which should include potential triggers for retraumatization; SW #1 said that if triggers were assessed and no triggers could be identified that this would be documented in the PTSD and Trauma Assessment. SW #1 said that if a Resident was depressed that trauma would be considered as a possible source. SW #1 said that potential triggers for retraumatization would be assessed even if the Resident scored a 0 on section D of the PTSD and Trauma Assessment. SW #1 said that if a Resident had a history of sexual assault that an intervention for female-only caregivers would be added to the Resident's care plan. During a follow-up interview on 6/05/24 at 9:48 A.M., SW #1 said she updated Resident #41's care plan to include an intervention for female only caregivers, which should have been an intervention in place on the care plan, but was not. During an interview on 6/05/24 at 10:03 A.M., the Director of Nursing (DON) said that it is her expectation that residents care plans be individualized when they have PTSD, with resident specific triggers.

Based on record reviews, observations and interviews, the facility failed to ensure resident centered care plans were implemented for one Resident (#43) out of a total sample of 14 residents. Specifically, for Resident #43, the facility failed to implement TED hose (compression stockings) as ordered by the Physician. Findings include: Resident #43 was admitted to the facility in November 2022 with diagnoses that included cerebral infarction due to embolism of right middle cerebral artery, aortic aneurysm, and essential primary hypertension. Review of Resident #43's most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated Resident #43 scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she has severe cognitive impairment. On 6/03/24 at 12:15 P.M., the surveyor observed Resident #43 seated in the dining room eating his/her lunch. Resident #43 was not wearing compression stocking on his/her legs. On 6/05/24 at 7:43 A.M., the surveyor observed Resident #43 seated in his/her room waiting to go to breakfast. Resident #43 was not wearing compression stockings on his/her legs. Review of Resident #43's nursing notes on 6/5/24 at 10:59 A.M., failed to indicate the Resident refused to wear his/her compression stockings. Review of Resident #43's care plan initiated 5/25/23 indicated the following: -Focus: Resident #43 has impaired cardiac with hypertension. -Intervention: Teds stockings on every AM and remove every bedtime. Further review of Resident #43's active physician order, dated 4/03/23 indicated Teds stockings on every AM and remove every bedtime every day and evening shift for to minimize syncopal (fainting) episodes. During an interview on 6/05/24 at 9:52 A.M., Nurse (#1) said Resident #43 wears an abdominal binder because of his/her syncopal episodes, but that she was unaware Resident #43 requires the use of compression stockings. During an interview on 6/05/24 at 9:43 A.M., with Resident #43's Certified Nursing Assistant (CNA) #2, she said that she was not aware that Resident #43 was supposed to wear compression stockings. During an interview on 6/05/24 at 10:05 A.M., the Director of Nursing said the nurse and CNA should follow each resident's plan of care and would expect the compression stockings to be applied per the physician's order.

Based on record review and interview, the facility failed to 1. accurately document a blood sugar vital sign and 2. a meal percentage for 1 Resident (#27) out of a total sample of 19 residents. Findings include: Resident #27 was admitted in April 2018 with diagnoses including type 2 diabetes. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #27 scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. 1. Review of the Medication Administration Record (MAR) for 4/19/23 indicated that Resident #27 was scheduled to receive a Novolog Insulin (a medication used to treat high blood sugar) injection after a blood sugar vital was obtained at 7:30 A.M. Review of the MAR indicated that Resident #27 had a blood sugar of 245 and received 2 units of Novolog. Review of the record indicated that the blood sugar was obtained at 9:45 A.M., 2 hours and 15 minutes after the scheduled time. During an interview on 4/24/23 at 9:18 A.M., Nurse #2 said that she obtained the blood sugar at 7:30, but documented the vital late in the chart. Nurse #2 said that the standard of practice is to document the vital once you obtain it. 2. Review of the MAR, dated 4/19/23, indicated that Resident #27 at 100 percent of his/her meal at lunch time. During an interview on 4/24/23 at 9:18 A.M., Nurse #2 said that Resident #27 ate very poorly that day at lunch and that the meal percentage was an error on the MAR. Review of the progress note, dated 4/19/23, indicated that Resident #27 took one bite of his/her lunch.

Based on observations, record reviews and interviews, the facility failed to 1.) ensure an air mattress was on the correct setting for 1 Resident (#41) who had actual skin breakdown and 2.) the facility failed to ensure that an air mattress was on the correct setting and his/her foot was elevated per the plan of care for 1 Resident (#2) with actual skin break down out of a total sample of 19 residents. Review of the facility policy titled Alternating Pressure Air Mattress dated 6/20/2022 indicated the following: Policy: To maintain adequate circulation, to relieve pain due to pressure and aide in healing and prevention of pressure ulcers. Procedures: *Verify MD (Medical Doctor) order and settings in according to manufacturer guidelines. *Check setting and function regularly 1.) For Resident #41, he/she had an actual pressure injury to his/her sacrum (tailbone) and right calf (back part of leg), the facility failed to ensure staff provided treatment and services consistent with professional standards of practice to promote wound healing. Resident #41 was admitted to the facility in October 2020 with diagnoses including peripheral vascular disease, anemia, dysphagia and paranoid schizophrenia. Review of the Significant Change in Status Minimum Data Set assessment, dated 2/13/23, indicated Resident #41 was sometimes able to make him/herself understood and sometimes understands others. The MDS indicated Resident #41 was dependent on two staff members for bed mobility and had range of motion impairments of the lower extremities on both sides. The MDS indicated he/she had pressure injures. Review of the physician's order, dated 10/5/22, indicated: -Air Mattress to bed - check function and settings (250) every shift Review of the Norton Scale for Predicting Pressure Ulcer, dated 2/7/23, indicated Resident #41 was at high risk for developing pressure ulcers. Review of the physician's order, dated 3/31/23, indicated: -Sacral wound daily dressing Review of the physician's order, dated 4/22/23, indicated: -Right calf wound twice daily dressing During observations on 4/23/23 at 7:46 A.M., 4/23/23 at 9:05 A.M., and 4/23/23 at 11:37 A.M., Resident #41 was in his/her bed and the air mattress was set to 100. During observations on 4/24/23 at 6:54 A.M., 4/24/23 at 7:29 A.M., 4/24/23 at 8:38 A.M., 4/24/23 at 9:47 A.M., 4/24/23 at 10:34 A.M., 4/24/23 at 11:16 A.M., and 4/24/23 at 1:01 P.M., Resident #41 was in his/her bed and the air mattress was set to 100. During observations on 4/25/23 at 6:47 A.M., 4/25/23 7:34 A.M., 4/25/23 9:26 A.M., and 4/25/23 at 10:10 A.M., Resident #41 was in his/her bed and the air mattress was set to 200. During an interview on 4/24/23 at 10:52 A.M., Certified Nurse Assistant #2 said that the nurse is responsible to make sure Resident #41's air mattress is set to the correct settings each shift. She said that she is not allowed to touch the air mattress settings. During an interview on 4/24/23 at 1:37 P.M., Nurse #3 said she is responsible to make sure Resident #41's air mattress is set to the correct settings each shift. During an interview on 4/25/23 at 7:41 A.M., Nurse #4 said that he is responsible to check to make sure that Resident #41's air mattress is set to the correct settings each shift. During an interview on 4/25/23 at 9:06 AM Nurse #5 said she is responsible to make sure Resident #41's air mattress is set to the correct settings each shift. During an interview on 4/25/23 at 9:32 A.M., the Unit Manager said that nursing should follow the physician's order to ensure the air mattress is set to the correct settings to promote wound healing each shift. During an interview on 4/25/23 at 10:27 A.M., the Director of Nursing said that nursing should follow the physician's order to ensure the air mattress is set to the correct settings to promote wound healing. During an interview on 4/25/23 at 11:37 A.M., the Nurse Practitioner said that nursing should follow the physician's order to ensure the air mattress is set to the correct settings to promote wound healing. 45984 2) For Resident #2 the facility failed to ensure that he/she received treatment and services consistent with professional standards of practice to promote wound healing were implemented. Resident #2 was admitted to the facility in June 2018 with diagnoses that include sacral spinal bifida, pressure ulcer of the left buttock, stage 4, pressure ulcer of the right buttock, unstageable, and paraplegia. Review of Resident #2's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated that Resident #2 has a stage 4 pressure ulcer and unhealed pressure ulcer and requires total dependence on all activities of daily living. The surveyor made the following observations: On 4/23/23 at 9:22 A.M. and 4/23/23 at 12:31 P.M., Resident #2 was observed lying in bed with his/her air mattress set to 350 pounds and his/her left heel was directly on the mattress, not offloaded. On 4/24/23 at 6:50 A.M., 4/24/23 at 8:18 A.M., and 4/24/23 at 9:47 A.M., Resident #2 was observed lying in bed with his/her air mattress set to 350 pounds and his/her left heel was directly on the mattress, not offloaded. Review of Resident #2's physician's orders with a start date of 10/12/23 indicated the following: *Air Mattress to bed - check function and setting (170) every shift if inflated *Offload L (left) heal [sic] while in bed. Review of Resident #2's pressure ulcer care plan initiated on 11/5/2018 indicated the following interventions: *Air mattress, check if inflated. Setting 170. *Follow facility policies/protocols for the prevention and treatment of skin breakdown. *Offload left heel at all times. Review of Resident #2's Wound Care Progress Report dated 3/28/23 indicated the following treatment recommendations: *Continued education to the patient to reposition and offload and reposition every two hours and as needed especially while in bed. *Pressure Relief/Offloading: *Facility pressure ulcer prevention protocol *Pressure redistribution mattress per facility protocol *Per patient's plan of care During an interview on 4/24/23 at 9:50 A.M., Nurse #1 said Resident #2 requires an air mattress to promote wound healing and it should be set by his/her weight or by physician's order and needs to be checked every shift. The surveyor and Nurse #1 checked Resident #2's air mattress settings together and observed it set to 350 pounds. Nurse #1 said it should not be at that setting and he adjusted it. Nurse #1 said an air mattress at the wrong setting could interfere with proper wound healing. Nurse #1 said Resident #2's left heel should be elevated while he/she is in bed. During an interview on 4/24/23 at 10:40 A.M. with the Nurse Practitioner and Administrator, they both said Resident #2's air mattress should have been set per physician's orders and his/her heel should be elevated while in bed.

Based on record review and interview, the facility failed to maintain resident's rights after the removal of shaving razors from 1 Resident's (#29) room, out of a total sample of 19 residents. Findings include: Review of the facility policy, titled Dignity and Respect, dated 8/1/22, indicated the following: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. -Grooming residents as they wish to be groomed (e.g., hair combed and styled, beards shaved and trimmed, nails clean and clipped). (A care plan will be added if unable to safely groom themselves) Resident #29 was admitted in July 2013 with diagnoses including hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #29 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Additional review of the MDS indicated that Resident #29 required one person physical assist with grooming. Review of the medical record indicated that Resident #29 was his/her own person and did not have a healthcare proxy invoked. Review of the care plan did not indicate that Resident #29 was unsafe to shave him/herself. Review of the progress note, dated 3/17/23, indicated that Resident #29 had razor blades in the bedside table and the Administrator determined that Resident #29 was not safe to keep the razors in his/her room. The progress note indicated that Resident #29 was upset and gave the razor blades over. The razor blades were locked in the medication cart. During an interview on 4/23/23 at 12:47 P.M., Social Worker #1 said that the a certified nursing aide told her that Resident #29 had disposable shaving razors in his/her bedside table. Social Worker #1 said that the razors were removed for safety reasons. She was not sure if an assessment had been done to determine if Resident #29 was safe, but was just told to remove them from his/her room. Social Worker #1 said that she was told by the Administrator to remove them and Resident #29 said that he/she was really upset. Social Worker #1 said that she interpreted the Resident was upset due to lack of independence. During an interview on 4/23/23 at 12:57 P.M., the Administrator said that Resident #29's disposable razors were locked in the medication cart and that his/her daughter came to pick up the razors. The Administrator said that Resident #29 has an electric razor for shaving. The Administrator said that if any resident came in and wanted to shave themselves with disposable razors then the razors would be locked in the medication cart and an assessment would be completed. Review of the medical record did not indicate that any shaving assessment had been completed to determine if Resident #29 was a safety risk when shaving. The record also did not indicate if Resident #29 made a choice in his/her preferred shaving method. During an interview on 4/23/23 at 1:05 P.M., Resident #29 said that he/she was upset that staff removed his/her razors from the room. Resident #29 said that staff shave him/her with an electric razor, but he/she prefers being shaved with a disposable razor.

Based on record review and interviews, the facility failed to obtain consent to administer a psychotropic medication for one Resident (#20) out of a sample of 19 Residents. Findings include: Review of the facility policy titled 'Psychotropic Medication Management' effective 10/14/2017 indicated the following: *Obtain physicians order for each psychoactive medication. Ensure that supportive diagnosis and target behaviors are documented and clearly identify the use of the medication is necessary and warranted. *Notify resident or responsible party of initiation of psychoactive medications, and with any changes to dose, and document in record. Resident #20 was admitted to the facility in February 2020 with diagnoses including anxiety disorder and major depressive disorder. Review of the most recent Minimum Data Set (MDS) dated [DATE] indicated that Resident #20 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, indicating intact cognition. A review of Resident #20's Health Care Proxy (HCP) indicated it was invoked (a designated person who makes decisions on the Resident's behalf if the resident is incapable) in 2/26/20. A record review of Resident #20's April 2023 physician's orders indicated the following: *Lamictal 25 milligrams (a medication used as an anticonvulsant but can also be used as a mood stabilizer), give 2 tablets by mouth once a day related to anxiety disorder and major depressive disorder, 2/9/23. A review of Resident #20's April Medication Administration Record (MAR) indicated that Lamictal was administered daily as ordered. A review of a report from a Social Work consulting group dated 4/12/23 indicated the following: *Resident #20, recommend having a new consent signed for Lamictal. A review of the medical chart did not indicate a psychotropic consent was obtained prior to the medication order date on 2/9/23. During an interview with the Social Worker on 4/25/23 at 10:46 A.M., she said she was not sure if Resident #20's psychotropic consent was mailed out to the HCP to obtain a signed consent, she told the surveyor she called the HCP today to obtain verbal consent. During an interview with the HCP on 4/25/23 at 11:02 A.M., she said someone from the facility called her today to obtain verbal consent to administer Lamictal, they also told her they will be mailing her a consent today so she could sign it. During an interview with the Corporate Nurse on 4/25/23 at 7:50 A.M., she said psychotropic medications should not be administered without consent from the responsible party.

Based on records reviewed and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for a fluid restriction for 1 Resident (#10) who had a diagnosis of heart failure and end stage renal disease, out of a total sample of 19 residents. Specifically, Resident #10's physician's ordered fluid restriction did not have a break down for fluids per shift and staff were not aware of Resident #10's nursing fluid allowance. Findings include: Review of the facility policy titled, Fluid Restrictions, undated, indicated the total amount of fluids may need to be restricted in residents who have renal failure or congestive heart failure. All residents who are on fluid restrictions should be on daily intake and output. A nurse and a dietician can divide the total fluids allowed per day in the amount to be used on the 3 meal trays and an amount for nursing to utilize between meals and at night. Resident #10 was admitted to the facility in July 2012 with diagnoses including acute kidney injury, congestive heart failure and end stage renal disease. Review of the Minimum Data Set Assessment, dated 3/27/23, indicated Resident #10 was independent for meals. Review of the physician's order, dated 3/13/23, indicated a fluid restriction of 1000 milliliter (mls) daily. Further review indicated there was no breakdown of the fluid allowance per shift. Review of the plan of care related to potential for dehydration, dated 3/13/23, indicated: - Fluid restriction-1000 milliliter fluid per physician's order. Further review indicated there was no break of fluid allowance per shift. During an interview on 4/24/23 at 10:49 A.M., Certified Nurse Assistant #3 said that Resident #10 is on a fluid restriction and she is not allowed to give Resident #10 any fluids. During an interview on 4/24/23 at 11:34 A.M., CNA #4 said Resident #10 is on a fluid restriction. CNA #4 said she could give Resident #10 fluids but was not sure how much. During an interview on 4/24/23 at 1:39 P.M., Nurse #3 said that Resident #10 is on a fluid restriction and she can give him/her 8 ounces of fluid (240 mls) with each medication pass during her shift. During an interview on 4/25/23 at 7:42 A.M., Nurse #4 said Resident #10 is on a fluid restriction. He said he can give Resident #10 180 mls of fluid during the night shift (11:00 P.M. to 7:00 A.M.). During an interview on 4/25/23 at 9:10 A.M., Nurse #5 said Resident #10 is on a fluid restriction. Nurse #5 said that resident #10 receives 120 mls of fluid during the medication pass. During an interview on 4/25/23 9:37 A.M., the Unit Manager said that Resident #10 is on a fluid restriction. The Unit Manager said that nursing should follow the fluid restriction chart. The Unit Manager provided the surveyor with a fluid restriction chart. The fluid restriction chart, dated 2018, indicated: 1000 mL fluid restriction: -Total fluids by nursing: 300 mL 150 mL on Day Shift (7:00 A.M. to 3:00 P.M.) 150 mL on Evening Shift (3:00 P.M. to 11:00 P.M.) 0 mL on Night Shift (11:00 A.M. to 7:00 A.M.) During and interview on 4/25/23 at 10:36 A.M., the Director of Nursing said nursing should follow Resident #10's fluid restriction and nursing should be aware of the daily allowance. During an interview on 4/25/23 at 11:33 A.M., the Corporate Nurse said the fluid restriction should be broken down in the physician's order so nursing is aware how much fluid is allowed per shift.

Based on observation, record review and interviews, the facility failed to revise the plan of care for 1 Resident (#38) out of a total sample of 19 residents. Specifically, the facility failed to ensure that nursing revised a treatment order after Resident #38 who had a diagnosis of heart failure and edema was unable to wear his/her physician's ordered compression stockings (TEDs) on the left leg because Resident #38 sustained an injury. Findings include: Resident #38 was admitted to the facility in October 2019 with diagnosis including heart failure, atrial fibrillation and edema. Review of the Minimum Data Set assessment, dated 4/3/23, indicated Resident #38 can make himself/herself understood and that he/she understands others. The MDS indicated he/she required one person physician assist with dressing which included applying and removing TED hose. Review of the physician's order, dated 10/22/22, indicated for TEDs to be applied in the morning and removed at bedtime for edema. Review of the Nursing Note, dated 4/4/23, indicated Resident #38 was bleeding heavily from his/her left foot. Review of the physician's order, dated 4/5/23, indicated a treatment for Resident #38's left foot. Review of the Medication Administration Note, dated 4/10/23, indicated that nursing only applied one TED to the right foot because there was a left foot wound. However, further review indicated there was no revision of the physician's order or plan of care. Review of the Treatment Administration Record (TAR), dated April 2023, indicated nursing applied Resident #38's physician's ordered TEDs daily as ordered except on 4/23/23 which was left blank. Review of Resident #38's plan of care related to heart failure, dated as initiated 11/4/19 and reviewed on 4/12/23, indicated for TEDs to be applied in the morning and removed at bedtime. During observations on 4/23/23 at 8:00 A.M., 4/23/23 at 9:02 A.M., 4/23/23 at 11:47 A.M., 4/23/23 at 1:56 P.M., 4/24/23 at 8:27 A.M., 4/24/23 at 1:03 P.M., and 4/25/23 at 10:00 A.M., Resident #38 was sitting on his/her edge of bed with his/her feet in the dependent position. Resident #38 was not wearing his/her physician's ordered TED stocking on his/her left foot and Resident #38's left foot and leg was swollen. During an interview on 4/25/23 at 10:00 A.M., Resident #38 said that he/she only wears one TED stocking. Resident #38 said he/she stopped wearing both TEDs when he/she developed a wound on his/her left foot. During an interview on 4/24/23 at 1:42 P.M., Nurse #3 said that Resident #38 wears one TED stocking. She said Resident #38 has not be able to wear the TED on his/her left foot since he/she sustained a wound to his/her left foot. During an interview on 4/25/23 at 9:45 A.M., the Unit Manager said that Resident #38 is only wearing a TED stocking on his/her right foot. The Unit Manager said that nursing should have updated the physician's order. During and interview on 4/25/23 at 10:29 A.M., the Director of Nursing said that nursing should have updated the plan of care when Resident #38 was only able to wear one TED stocking. During an interview on 4/25/23 at 11:28 A.M., the Nurse Practitioner said that nursing should have updated the physician's order and plan of care when Resident #38 was only able to wear one TED stocking.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically providing assistance with nail care, for one Resident (#17) out of a total sample of 19 residents. Finding included: Review of the facility policy titled, Activities of Daily Living, dated as 1/1/15, indicated Resident's self image is maintained. Resident #17 was admitted to the facility in August 2021 with diagnosis including heart failure, major depression and anxiety. Review of the Minimum Data Set assessment, dated 4/10/23, indicated Resident #17 can make self understood, he/she can understand others and Resident #17 does not have any behaviors. The MDS indicated that indicated Resident #17 required total dependence of one staff member for personal hygiene which included applying makeup and washing hands. During an interview on 4/23/23 at 8:59 A.M., Resident #17 said he/she wanted his/her finger nails trimmed, filed, cleaned and painted. Resident #17 said the staff used to do finger nail care but they have not done his/her nails in a while. The surveyor observed Resident #17's nails, on his/her left hand the thumb nail was long and jagged, there was residue of old nail polish on his/her nail. On the right hand all 5 finger nails were long jagged and uneven with brown matter under the nails and there was chipped nail polish on all 5 nails. During an interview on 4/24/23 at 8:18 A.M., Resident #17 was in his/her room eating breakfast. Resident #17 said she would really like finger nail care. During an interview on 4/24/23 at 10:56 A.M., Certified Nurse Aide (CNA) #2 said that finger nail care including trimming, filing, cleaning and painting is provided by CNAs routinely during care. During an interview on 4/24/23 at 11:28 A.M. CNA #4 said nail care is performed by CNAs. On 4/24/23 at 11:34 A.M., the surveyor was accompanied by CNA #4 to Resident #17's room and observed Resident #17's finger nails. Resident #17 said that he/she bit the 4 finger nails off his/her left hand (exception of the thumb nail) because they were too long. Resident #17 said that he/she would like nail care. CNA #4 said she would provide Resident #17 with nail care on 4/24/23. During an interview on 4/24/23 at 1:43 P.M., Nurse #3 said that nail care can be completed by nursing and activities can provide nail polish. The surveyor made Nurse #3 aware of Resident #17's request for nail care. During an interview on 4/25/23 at 8:07 A.M., Resident #17 said he/she still didn't have his/her nail care provided. The Resident showed the surveyor his/her nails that were still long, jagged and uneven with brown matter under the nails and there was chipped nail polish. On 4/25/23 at 8:12 A.M., the surveyor observed the medical supply closet and there were nail clippers and nail files available for Resident use. During an interview on 4/25/23 at 9:16 A.M., Nurse #5 said that CNAs should perform nail care during activities of daily living. During an interview on 4/25/23 at 9:47 A.M., the Unit Manager said that nail care can be completed by CNAs. On 4/25/23 9:57 A.M., the surveyor accompanied by the Unit Manager to Resident #17's room. The Unit Manager observed Resident #17's finger nails. The Unit Manager said that the CNAs should have provided nail care to Resident #17. During an interview on 4/25/23 at 10:44 A.M., the Director of Nursing sad nail care should be provided during care.

Based on observation, record review and interviews, the facility and its staff failed to ensure that routine assessments and devices used to maintain hearing were provided for one Resident (#17), out of 19 sampled residents. Specifically, the facility staff failed to provide and implement a treatment plan for chronic ear wax and failed to implement the use of hearing aids when Resident #17 complained of difficulty hearing. Findings include: Review of the facility policy titled, Hearing Aide: Care of, dated 9/1/04, indicated to maintain the resident's hearing aide in optimal condition: -periodically check the auditory canal for irritation, drainage, and soreness. -check ear piece for wax build up -over the ear style: if wax build up, use hearing aide cleaning kit to remove wax. If kit no available forward to hearing aide specialist. -in the care plan document the need, and care of the hearing aide. Resident #17 was admitted to the facility in August 2021 with diagnosis including heart failure, diabetes, major depression and anxiety. Review of the Minimum Data Set assessment, dated 4/10/23, indicated Resident #17's hearing was adequate and Resident #17 did not use hearing aides. The MDS indicated Resident #17 could make self understood and he/she could understand others. During an interview on 4/23/23 at 8:59 A.M., Resident #17 said he/she is hard of hearing. Resident #17 said he/she would like his/her ear wax removed. Resident #17 said he/she cannot wear his/her hearing aides because of ear wax build up and would like to see the Audiologist. Resident #17 pointed to a box on his/her table and the surveyor observed a hearing aide in the charger that had wax build up on it. Review of Resident #17's plan of care indicated there was no documentation to support the use of hearing aides. Review of the Audiology Request for Service form, dated 8/21/21, indicated that Resident #17 did not wish for alternative arrangements for audiology services. Review of the Nurse Practitioner's notes, dated 3/9/23, 3/30/23 and 4/13/23, indicated that Resident #17 has earwax. However, there was no documentation to support an ongoing treatment plan for ear wax. During an interview on 4/24/23 at 10:56 A.M., Certified Nursing Assistant (CNA) #2 said that Resident #17 does not wear hearing aides. During an interview on 4/24/23 at 11:28 A.M., CNA #3 said that Resident #17 is hard of hearing and does not wear hearing aides. During an interview on 4/24/23 at 1:43 P.M., Nurse #3 said Resident #17 does not wear hearing aides. During an interview on 4/25/23 at 9:16 A.M., Nurse #5 said that Resident #17 is hard of hearing and he/she refuses to wear hearing aides because of ear wax. Nurse #5 said that Resident #17 has ear wax and thought it was removed by the evening shift . During an interview on 4/25/23 at 9:47 A.M., the Unit Manager said she is not aware of any hearing concerns for Resident #17. The Unit Manager said that she is not aware that Resident #17 has hearing aides. The Unit Manger said that audiology services comes to the facility and Residents with hearing aides should be seen. During an interview on 4/25/23 at 10:44 A.M., the Director of Nursing (DON) said that she was not aware that Resident #17 used hearing aides. The DON said that audiology services are provided on site. During an interview on 4/25/23 at 11:21 A.M., the Nurse Practitioner (NP) said that in the past she has treated Resident #17's ear wax. The NP said she has not set up an ongoing treatment plan to help with the ear wax but she should have. The NP said nursing should have referred Resident #17 to audiology services for his/her hearing but did not.

Based on observations, record review and interview, the facility failed to 1.) ensure Residents received oxygen according to professional standards of practice and in accordance with physician's orders for 2 Residents (#22 and #20) and 2.) failed to maintain a continuous positive airway pressure (CPAP) face mask according to professional standards of practice in a way to prevent possible infections for 1 Resident (#17) out of a total of 19 sampled Residents. Findings include: Review of the facility policy titled 'Oxygen Administration', undated, indicated the following: *A physician order is required for continuous administration of oxygen. The order must include the percentage of oxygen concentration to be delivered expressed as liters/minute. *When oxygen therapy is ordered, the licensed clinician will verify the physician's order. Review of the facility policy titled 'Concentrator Maintenance', undated, indicated the following: Filter Cleaning: *Filters can be cleaned by manually removing dust by wiping with towel and/or shaking particles free or placing them in warm soapy water and allow to air dry. 1a.) For Resident #22, the facility failed to follow professional standards of practice and follow the physician's order to ensure the correct oxygen amount was administered as well as store and maintain oxygen equipment in a way to prevent possible infections. Resident #22 was admitted to the facility in March 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), shortness of breath and acute and chronic respiratory failure. Review of Resident #22's most recent Minimum Data Set (MDS) dated [DATE] indicated that Resident #22 had a Brief Interview for Mental Status score of 11 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS revealed that Resident #22 is on hospice care and exhibits no behaviors. The surveyor made the following observations: *On 4/23/23 at 9:45 A.M. and 12:28 P.M., Resident #22 was observed lying in bed and receiving 3.5 liters of oxygen (O2) via nasal cannula. The foam filters on the sides of the oxygen machine were observed to be covered in white dust particles. *On 4/24/23 at 6:59 A.M. and 11:31 A.M., Resident #22 was observed lying in bed and receiving 3.5 liters of oxygen (O2) via nasal cannula. The foam filters on the sides of the oxygen machine were observed to be covered in white dust particles. *On 4/25/23 at 7:39 A.M., Resident #22 was observed lying in bed and receiving 3.5 liters of oxygen (O2) via nasal cannula. The foam filters on the sides of the oxygen machine were observed to be covered in white dust particles. Review of Resident #22's physician's orders dated 10/12/2022 indicated the following: *Oxygen at 2LPM (liters per minute) via N/C (nasal cannula) continuously - may titrate to maintain O2 Sats (saturation) at or above 90% every shift. Review of Resident #22's document titled Hospice Comprehensive Assessment and Plan of Care Update Report dated 3/1/23 indicated the following order with a start date of 12/21/2022: *Medication: O2 - Oxygen - Humidified, Dose: 2 Liter, Frequency: O2 - continuous, Reason: Shortness of Breath Review of Resident #22's care plan for COPD and oxygen use, dated 3/9/2022, indicated the following interventions: *Oxygen per MD (Medical Doctor) order via nasal cannula. Cue to keep on Oxygen at all times. During an interview on 4/25/23 at 8:48 A.M., Nurse #1 said his expectations are for physician orders to be followed for Resident #22's oxygen administration. He continued to say if a Resident has COPD, and their oxygen levels are too high the accumulation of carbon monoxide can become a problem and the resident has a high risk of exhibiting a worsening of respiratory symptoms related to COPD. The surveyor and Nurse #1 observed Resident #22's oxygen rate together and it was set to 3.5 liters/minute. Nurse #1 said it was too high and not what the physician's order said. When he tested Resident #22's oxygen levels he said it was too high likely as a result of the increase rate of oxygen being administered. When asked to look at the oxygen filter pad, he said it was nasty and it should not be that dirty. He continued to say the overnight staff might not be cleaning them properly. 41019 1b.) Resident #20 was admitted in February 2020 with diagnoses including chronic obstructive pulmonary disorder, major depressive disorder, and anxiety. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #20 scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Additional review of the MDS indicated that Resident #20 requires extensive assist with bed mobility and transfers and is dependent with mobility on the unit. The MDS did not indicate that Resident #20 had any behaviors. During an observation on 4/23/23 at 8:34 A.M., Resident #20's oxygen was in his/her nose and running at 3.5 L/min (liters per minute) The back of the oxygen filter was coated in dust. During an observation on 4/24/23 at 8:44 A.M., Resident #20's oxygen was in his/her nose and running at 3.5 L/min (liters per minute) The back of the oxygen filter was coated in dust. Resident #20 also had a nebulizer dated 3/29/23 next to his/her bed. Resident #20 said that he/she used the nebulizer the night before. Review of the current physician's orders for Resident #20 indicated the following: - Oxygen at 4L via NC (nasal cannula) continuously to maintain O2 (oxygen) sats (saturation) greater than 90% every shift. During an interview on 4/25/23 at 8:00 A.M., Resident #20 said that he/she does not touch the oxygen concentrator or change any of the settings. During an interview on 4/25/23 at 8:48 A.M., Nurse #1 said his expectations are for physician orders to be followed for Resident #22's oxygen administration. 44095 2.) For Resident #17 the facility failed to ensure they maintained a continuous positive airway pressure (CPAP) face mask according to professional standards of practice in a way to prevent possible infections. Resident #17 was admitted to the facility in August 2021 with diagnosis including heart failure, major depression and anxiety. Review of the Minimum Data Set assessment, dated 4/10/23, indicated Resident #17's was totally dependent on staff for personal hygiene. During an observation on 4/23/23 at 8:59 A.M., Resident #17's CPAP face mask was resting on a stuffed animal. During an observation on 4/24/23 at 8:18 A.M., Resident #17's CPAP face mask was resting on a bottle of shampoo that what laying flat on his/her night stand. During an observation on 4/25/23 at 9:57 A.M., Resident #17's CPAP face mask was resting on his/her night stand on top of personal items. During an interview on 4/24/23 at 1:43 P.M., Nurse #3 said that Resident #17's CPAP face mask should be stored in a bag when not is use. During an interview on 4/25/23 at 9:47 A.M., the Unit Manager said the CPAP face mask should be stored in a bag when not in use. During an interview on 4/25/23 at 10:44 A.M., the Director of Nursing said the CPAP face mask should be stored in a bag when not in use.

Based on observation, record review and interview, the facility 1). failed to develop and implement a care plan addressing malnutrition and assess and provide interventions for 1 Resident (#44) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2). failed to provide continuous supervision during meals for 1 Resident (#8), 3). failed to ensure weekly skin checks were completed as ordered for 1 Resident (#14) and 4). failed to ensure weekly weights were obtained for 1 Resident (#43) out of a total sample of 13 residents. Findings include: 1) Review of the facility's Weight Policy and Weight Loss Protocol, dated March 14, 2011, indicated: Policy: The facility will monitor resident weights to ensure their optimal weight is maintained unless a loss/gain is unavoidable *The weights will be done weekly unless otherwise determined. More frequent weights may be done on any resident assessed as a high nutritional risk. *A weight variance is defined as any unplanned gain/loss - +/- 5% in one month *Weights will be measured by the Certified Nursing Assistant as scheduled and reported to the licensed nurse. The nurse will record the weight, determine presences of a variance and request a re-weigh to be done. *For any weight variance, the following should occur: Physician documentation of plan of care with persistent weight loss, tube feeding option discussed as appropriate, nursing documentation of change to plan of care, notifications, resident condition. Registered Dietitian documentation and plan of care revisions as needed. Registered Dietitian for interventions may include liberalization of diet as possible, i.e., super cereals, increased snacks. Start/increase use of supplements-will be administered as ordered to resident with weight loss problems per Dietitian orders and Physician approval. Resident #44 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During observations of Resident #44 on 2/9/22 at 8:11 A.M., he/she was thin and frail. Review of the Nurse Practitioner's note dated 1/6/22 indicated: Assessment: Protein calorie malnutrition Plan: Dietician consult, monitor. Staff reports good intake. Review of Resident #44's weights indicated: 1/6/22: 123 lbs. (pounds) 1/25/22: 116.4 lbs. (a significant weight loss of 5.37% of his/her total body weight) No reweigh was completed following the 1/25/22 weight, as indicated in the facility policy and no other weights were documented for Resident #44 for the month of January per facility policy. Review of Resident #44's clinical record indicated: *No interventions were implemented to address Resident #44's weight loss in January 2022. *Resident #44 had not been screened or assessed by the Dietitian per the request of the Nurse Practitioner or per facility policy. *Resident #44 had no care plans identifying his/her nutritional risk or weight loss concerns. During an interview with the Nurse Practitioner (NP) on 2/10/22 at 11:04 A.M., she said that she was not aware that Resident #44 had experienced a significant weight loss in January 2022 and was not aware that the Dietitian had not assessed him/her. The NP said she had expected staff to weight Resident #44 weekly and was not aware that only 2 weights had been obtained. During an interview with the Dietitian on 2/10/22 at 12:42 P.M., she said that she was not aware that Resident #44 had been initially admitted in January 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Dietitian said she was also not aware that Resident #44 had experienced a significant weight loss at the facility. The Dietician said that she had not assessed Resident #44 at any time during January 2022. During an interview with the Director of Nursing on 2/10/22 at 1:24 P.M., she said that the expectation is for the Dietitian to assess resident nutritional status upon admission. She said that she was not aware that Resident #44 had not been assessed by the Dietitian at any time during January 2022. 2) For Resident #8, the facility failed to provide continuous supervision during meals. Resident #8 was admitted to the facility in March 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #8 had severe cognitive impairment. Further review of the MDS indicated that Resident #8 was totally dependent on staff for hygiene, bathing, dressing, bed mobility, and requires supervision with eating. On 2/9/22 at 7:49 A.M., the surveyor observed Resident #8 having breakfast in bed by himself/herself. The surveyor observed Resident #8 reaching out to feel his/her food on the tray. The surveyor observed the bed at a 20 degree angle and he/she was having difficulty picking up scrambled eggs with his/her hand. No staff member was present or observed near Resident #8's room. Review of Resident #8's Activity of Daily Living (ADL) care plan initiated 12/14/18 indicated that he/she required continuous supervision during meals. Review of the Certified Nursing Assistant (CNA) Kardex (a file system that gives a brief overview of each resident) indicated that Resident #8 required continuous supervision during meals. On 2/9/22 at 11:50 A.M., the surveyor observed a staff member deliver and set up the lunch tray for Resident #8 in bed and then left the room. On 2/9/22 at 12:03 P.M., the surveyor observed Resident #8 eating lunch in bed unsupervised. No staff member was present or near Resident #8's room. On 2/9/22 at 12:19 P.M., the surveyor observed Resident #8 eating lunch in bed unsupervised. The surveyor observed Resident #8 clearing his/her throat. CNA #6 was notified and attended to Resident #8. During an interview with CNA #6 on 2/9/22 at 12:19 P.M., he told the surveyor that Resident #8 likes to eat finger foods and does not require assistance or supervision during meals. He acknowledged that Resident #8 did not have staff supervising him/her during lunch. On 2/10/22 at 10:56 A.M., Nurse #3 was interviewed. She told the surveyor that Resident #8 required continuous supervision during meals due to him/her being legally blind and on aspiration precautions. 3) For Resident #14, the facility failed to ensure weekly skin checks were completed as ordered. Review of the facility's pressure ulcer policy, revised 11/1/20, indicated: *Purpose: To minimize the development of any type of ulcers and other skin issues through the systematic and regular inspection of the resident's skin, and to ensure early detection and intervention for all skin problems. *Policy: Residents will undergo a weekly body check by the licensed nurse. The facility will utilize the weekly body check form. Resident #14 was admitted to the facility in July 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was moderately cognitively impaired and scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of Resident #14's MDS indicated the Resident did not reject care and required assistance with care activities. The MDS further indicated the Resident had 1 unhealed pressure ulcer and was at risk for developing pressure ulcers/injuries. Review of Resident #14's medical record indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's weekly skin checks and treatment record for February 2022 failed to indicate a skin check was completed as ordered on 2/3/22. During an interview on 2/10/22, Nurse #1 said the Resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 acknowledged that Resident #14 did not have a weekly skin check as ordered on 2/3/22. 4) For Resident #43, the facility failed to obtain weekly weights as ordered. Resident #43 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors or delusions and did not reject care. Resident #43's MDS indicated the Resident needs extensive assistance for bed mobility, transfers, walk in room, eating and toilet use and was totally dependent for dressing, and locomotion on and off the unit. Review of Resident #43's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #43's medical record indicated the following weights: 1/19/22: 157 pounds (lbs.) 1/24/22: 155.2 lbs Further review of the Resident's medical record failed to indicate any additional weights were obtained in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 2/11/22 at 8:10 A.M., Certified Nursing Assistant (CNA) #5 said the CNAs are responsible for obtaining weights as ordered. She said the weights are usually obtained at the start of the week and each CNA is responsible for their own residents. She said the weights will be documented in the weight book. She said she did not obtain a weight for Resident #43 this week. On 2/11/22 at 8:49 A.M., Nurse #2 said that residents are usually weighed weekly. Nurse #2 reviewed Resident #43's medical record and acknowledged weekly weights were not documented. Nurse #2 said if the weights aren't recorded on the Medication Administration Record (MAR) or in the weight book they likely weren't completed. During an interview on 2/11/22 at 8:50 A.M., Certified Nursing Assistant (CNA) #4 said she is Resident #43's normal CNA. CNA #4 was unable to say if the Resident had been weighed weekly as ordered.

Based on observation, record review, and interview, the facility failed to ensure residents identified as high risk for falls received adequate supervision and revision of care plan interventions as needed to prevent falls, resulting in falls with injury for two Residents (#35 and #44), out of a total of 13 sampled residents. Findings include: Review of the facility's Fall Prevention and Follow Up Program, undated, indicated: *Purpose: To identify residents at risk for falling. To minimize the incidence of falls among residents identified to be at risk. To prevent reoccurrence of falls by conducting fall analysis. *Post Fall Interventions: The interdisciplinary team reviews/devices the plan of care and evaluates its effectiveness. 1. Resident #35 was admitted to the facility in December 2019 with diagnoses including dementia and [CONDITION(S)]. Review of Resident #35's most recent Minimum Data Set Assessment, date 12/9/21 indicated he/she is severely cognitively impaired and requires two person physical assistance for ambulation. On 2/9/22 at 10:10 A.M., the surveyor observed Resident #35 sitting upright in Broda chair while in his/her room. Despite the chair being in full reclining position, Resident #35 was moving his/her feet towards the ground and attempting to sit forward and get out of the chair, but he/she was unable to do so. Review of Resident #35's fall care plan indicated: Risk for falls due to confusion, gait/balance problems, poor communication, wandering and history of falls. 1/5/2020 Interventions: Ambulate with max assist x 2. Ensure that Resident #25 is wearing appropriate footwear when ambulating. Be sure Resident #35's call light is within reach and encourage to use it for assistance when needed. Sensor Alarm on at all times when in room. Review of Resident ##35's Incident/Fall Check List form indicated the following: 7/16/21: At 2:00 P.M., Resident #35 was found on floor of his/her room. 2:30 P.M. Recommendations/Corrective action taken: winged mattress, toilet before nap, 15 minute checks. (Review of the clinical record failed to indicate the duration the 15 minute checks were supposed to have taken place, or that 15 minute checks were implemented.) 9/19/21: At 10:00 A.M., Resident #35 was found on floor of his/her room. The section indicating Recommendations/Corrective actions was left blank. The section indicating Other Circumstances of Fall Not Listed indicated: When out of bed, make sure resident has proper footwear. (Review of Resident #35's care plan indicated the intervention to wear proper footwear was in place since 1/5/2020.) 10/4/21: At 12:20 P.M., Staff heard a scream and found Resident #35 on the floor of his/her room. Resident #35 was sent to the hospital and required 5 staples. Recommendations/corrective Actions/Other: 15 minute checks. (Review of the clinical record failed to indicate the duration the 15 minute checks where supposed to have taken place, or that 15 minute checks were implemented.) 10/22/21: At 1:30 P.M., Resident #35 was found walking out of his/her room. A Certified Nursing Assistant (CNA) approached him/her to assist him/her and Resident #35 pulled back and was sat on the floor. The section indicating Recommendations/Corrective actions was left blank. 2/5/22: At 1:10 A.M., Staff heard a loud bang and found Resident #35 on the floor of his/her room. Recommendations/Corrective Action taken: CAT scat/X-Rays all negative. (The results of tests are not indicative of interventions to prevent further falls.) During an interview with Nurse #1 on 2/10/22 at 12:26 P.M., she said that Resident #35 has a history of falls. When asked about interventions to prevent falls for Resident #35, she said that Resident #35 gets restless and antsy often and when that happens he/she should be walked by staff. Nurse #1 said that Resident #35 did have have alarms but those ended last month. Nurse #1 did not mention any other interventions. During an interview with the Administrator and the Director of Nursing (DON) on 2/10/22 at 1:03 P.M., the DON said that when a Resident falls, the expectation is for staff re-assess the resident to identify fall risk and update the plan of care with a new intervention. The DON could not provide information regarding 15 minute checks for Resident #35. 2. Resident #44 was admitted to the facility in January 2022 with diagnoses including fall with subdural hematoma (brain bleed). Review of Resident #44's Minimum Data Set assessment dated [DATE] indicated he/she was moderately cognitively impaired and required physical assistance with ambulation. During observations of Resident #44 on 2/9/22 at 8:11 A.M., he/she presented as disoriented and frail. Review of the physician's note dated 1/16/22 indicated the following: This is a patient who has cognition deficit dysphagia, is status post fall and had subdural hematoma. Resident #44 needs healthcare proxy to be activated because of his/her dementia. Review of Resident #44's Fall assessment dated [DATE] indicated he/she was high risk for falls. Review of Resident #44's nursing progress notes indicated: 1/24/22: Ambulating with assist in hallway. Re-education on ambulating independently in room. 1/27/22: Continue ambulating in room. Re-educated. Review of Resident #44's falls careplan's failed to indicate any updates or increased supervision or after Resident #44 had documented instances of ambulating independently despite a high risk of falls Review of the facility's fall report indicated that on 1/31/22 at 3:25 A.M., Resident #44 fell in his/her room. Review of the hospital admission paperwork indicated: Patient sustained rib fractures of the 6 through 8 ribs on the left. During an interview with the Director of Nursing (DON) on 2/10/22 at 1:03 P.M., she acknowledged that Resident #44's falls care plan should have been updated after he/she had documented incidents of ambulating unassisted prior to his/her fall with injury.

Based on observation, record review and interview, the facility failed alert the physician of a significant weight loss for 1 Resident (#44) out of a total of 13 sampled Residents. Findings include: Review of the facility's Weight Policy and Weight Loss Protocol, dated March 14, 2011, indicated: Policy: The facility will monitor resident weights to ensure their optimal weight is maintained unless a loss/gain is unavoidable *The weights will be done weekly unless otherwise determined. More frequ3ent weights may be done on any resident assessed as a high nutritional risk. *A weight variance is defined as any unplanned gain/loss - +/- 5% in one month *Weights will be measured by the Certified Nursing Assistant as scheduled and reported to the licensed nurse. The nurse will record the weight, determine presences of a variance and request a re-weigh to be done. *For any weight variance, the following should occur: Physician documentation of plan of care with persistent weight loss, tube feeding option discussed as appropriate, nursing documentation of change to plan of care, notifications, resident condition. Registered Dietitian documentation and plan of care revisions as needed. Registered Dietitian for interventions may include liberalization of diet as possible, i.e., super cereals, increased snacks. Start/increase use of supplements-will be administrated as ordered to resident with weight loss problems per Dietitian orders and Physician approval. Resident #44 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Nurse Practitioner's note dated 1/6/22 indicated: Assessment: Protein calorie malnutrition Plan: Dietician consult, monitor. Staff reports good intake. Review of Resident #44's weights indicated: 1/6/22: 123 lbs. (pounds) 1/25/22: 116.4 lbs. (a significant weight loss of 5.37% of his/her total body weight) No other weights were documented for Resident #44 for the remainder of his/her stay at the facility. Review of Resident #44's clinical record indicated: *No interventions were implemented to address were implemented to address Resident #44's weight loss in January 2022. *Resident #44 had not been screened or assessed by the Dietitian per the request of the Nurse Practitioner or facility policy. *Resident #44 had no care plans identifying his/her nutritional risk or weight loss concerns. During an interview with the Nurse Practitioner (NP) on 2/10/22 at 11:04 A.M., she said that she was not aware that Resident #44 had experienced a significant weight loss in January 2022 and was not aware that the Dietitian had not assessed him/her. The NP said she had expected staff to weight Resident #44 weekly and was not aware that only 2 weights had been obtained.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was totally dependent and required two staff members for bed mobility, and extensive assistance of two staff members for personal hygiene, the Facility failed to ensure Resident #1 was provided with the necessary level of assistance to maintain safety and prevent incidents or accidents resulting in an injury. On 12/01/21, a Certified Nurse Aide (CNA) #6 provided incontinence care to Resident #1, which included repositioning him/her, without the assistance of another staff member. Resident #1 fell out of bed, sustained a laceration to his/her head and was transferred to the Hospital Emergency Department where he/she required staples to close the head laceration and x-rays revealed a suspected non-displaced right shoulder fracture. Findings Include: The Facility Policy titled Activities of Daily Living/Maintain Abilities, undated, indicated that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Review of the Facility Report submitted to the Department of Public Health (DPH) via the Health Care Facility Reporting System (HCFRS), dated 12/02/21, indicated that, on 12/01/21 at approximately 6:45 P.M., while incontinence care was being provided for Resident #1, he/she fell from his/her bed while a soiled brief and linens beneath him/her were being discarded. The Report indicated that Resident #1 received staples to two lacerations on his/her head and that the Facility was contacted, after Resident #1 returned from the Hospital, and notified that he/she had a possible non-displaced fracture of his/her right shoulder for which a sling was advised. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated diagnoses included non-traumatic [CONDITION(S)], depression, anxiety, and dementia. The MDS indicated that Resident #1 required extensive assistance of two staff members with dressing and personal hygiene and that he/she was totally dependent with assistance of two staff members for bed mobility. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, dated as effective 08/23/21, indicated that he/she was dependent on two staff members for bathing, toileting, and positioning in bed. Review of CNA #6's written Witness Statement, dated 12/01/21, indicated that after turning Resident #1 on to his/her left side, she washed his/her back, removed dirty linen from underneath him/her, and that when she was about to put a clean incontinence brief on Resident #1, he/she started to move his/her leg, and she then heard a loud thump. Review of the Nurse Progress Note, dated 12/01/21 on the 3:00 P.M. to 11:00 P.M. shift, indicated that Resident #1 was transferred to the Hospital Emergency Department at 7:10 P.M. after he/she fell from bed during evening care and sustained a head laceration. Review of the Hospital Emergency Department Summary, dated 12/01/21, indicated Resident #1 had two large cranial lacerations that required staples to close the wounds. Review of the Hospital Radiology Report, dated 12/01/21, indicated that x-ray results were concerning for non-displaced fracture of Resident #1's right shoulder and further work-up was recommended. Review of the Nurse Progress Note, dated 12/01/21 on the 11:00 P.M. to 7:00 A.M. shift, indicated that Resident #1 returned from the Hospital with bruising to his/her right eye and right shoulder and with 19 staples on his/her head laceration. During an interview on 12/14/21 at 12:01 P.M., CNA #1 said that at approximately 7:00 P.M. on 12/01/21, she heard CNA #6 calling for help so she went to Resident #1's room and saw him/her laying on his/her right side on the floor between his/her bed and the roommate's bed. CNA #1 said there was blood on the floor and she went to get a nurse. CNA #1 said CNA #6 told her that Resident #1 had been incontinent and while she was washing Resident #1, he/she slipped off the bed. During an interview on 12/14/21 at 1:16 P.M., Nurse #3 said during the 3:00 P.M. to 11:00 P.M. shift on 12/01/21, he worked on the other side of the unit and was not assigned to Resident #1 but said a CNA came to get him due to an emergency and said when he walked into Resident #1's room, he saw him/her on the floor with his/her head between the bed and the nightstand. Nurse #3 said Resident #1 was bleeding and had a head injury so he applied pressure to the injury until the Emergency Medical Services (EMS) arrived. Nurse #3 said CNA #6 told him that Resident #1 rolled off the bed as she was reaching for a bed pad. During an interview on 12/14/21 at 8:10 A.M. and 2:45 P.M., the Director of Nurses (DON) said that at approximately 6:45 P.M. on 12/01/21, CNA #6 provided personal hygiene for Resident #1 there was no other staff member assisting CNA #6, and Resident #1 rolled off the bed during care. The DON said Resident #1 was supposed to be assisted by two staff members for washing, incontinence care, and positioning in bed. The DON said Resident #1 received 19 staples to close the laceration on his/her head and said at first the Hospital said there was no fracture, but later called the Facility to inform them that he/she had a non-displaced fracture of his/her right shoulder. On 12/14/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by: On 12/14/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) Resident #1 was re-assessed for side rails and two upper side rails were applied to his/her bed on 12/02/21. B) On 12/02/21, nursing staff were re-educated about Resident #1 requiring two staff members while turning and positioning in bed. C) An Audit was completed on 12/03/21 of all resident's Care Plans to ensure proper level of assistance was indicated. D) On 12/07/21, CNA Assignment Sheets were updated to ensure it include level of assistance for residents who required two staff members for ADL care. E) Starting on 12/02/21 through 12/06/21, education was provided to nursing staff about the process of nursing requirements to provide verbal report to CNAs at start of each shift and nurses required to give assignments to the CNAs . F) On 12/08/21, Bed Mobility Competencies were completed with CNAs. G) The DON will conduct random visual checks during shift changes to make sure that assignment were made by nurses and that report was given on each shift. H) The Administrator will conduct random staff interviews to ensure that report was given, staff is aware of the level of assistance required for the residents on their assignment, and know where to look for a residents' level of assistance. I) The Administrator will provide updates to the Quality Assurance Performance Improvement Committee at the next meeting which was not yet scheduled at the time of the Survey and quarterly. J) The Administrator is responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was totally dependent and required two staff members for bed mobility and extensive assistance of two staff members for personal hygiene, the Facility failed to ensure staff implemented and followed interventions from his/her plan of care, when on 12/01/21 during the evening shift, Certified Nurse Aide (CNA) #6 provided incontinence care and personal hygiene, which required repositioning the resident, without another staff person present to assist. Resident #1 fell out of bed, sustained a laceration to his/her head and was transferred to the Hospital Emergency Department where he/she required staples to close the head laceration and x-rays revealed a suspected non-displaced right shoulder fracture. Findings Include: The Facility Policy titled Care Plan Process, dated 04/27/2018, indicated that the Facility would develop Comprehensive Care Plans for each resident that would identify problems, goals, and approaches with specific steps and interventions employed to assist the resident in achieving the specified goal. The Policy indicated that the Care Plan was designed to meet the resident's medical, nursing, and rehabilitative needs and would reflect the current standards of practice, while attempting to prevent avoidable declines in functioning. Review of the Facility Report submitted to the Department of Public Health (DPH) via the Health Care Facility Reporting System (HCFRS), dated 12/02/21, indicated that, on 12/01/21 at approximately 6:45 P.M., while incontinence care was being provided for Resident #1, he/she fell from his/her bed while the soiled brief and linens beneath him/her were being discarded. The Report indicated that Resident #1 received staples to two lacerations on his/her head and that the Facility was contacted after Resident #1 returned from the Hospital, that it was also noted that he/she had a possible non-displaced fracture of his/her right shoulder for which a sling was advised. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated that Resident #1 required extensive assistance of two staff members with dressing and personal hygiene and that he/she was totally dependent with assistance of two staff members for bed mobility. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, dated as effective 08/23/21, indicated that he/she was dependent on two staff members for bathing, toileting, and positioning in bed. Review of CNA #6's Written Witness Statement, dated 12/01/21, indicated that after turning Resident #1 on to his/her left side, she washed his/her back, removed dirty linen from underneath him/her, and that when she was about to put a clean incontinence brief on him/her, Resident #1 started to move his/her leg, and she then heard a loud thump. Review of the Nurse Progress Note, dated 12/01/21 during the 3:00 P.M. to 11:00 P.M. shift, indicated that Resident #1 was transferred to the Hospital Emergency Department at 7:10 P.M., after he/she fell from bed during evening care and sustained a head laceration. Review of the Nurse Progress Note, dated 12/01/21 on the 11:00 P.M. to 7:00 A.M. shift, indicated that Resident #1 returned from the Hospital with bruising to his/her right eye and right shoulder, and with 19 staples to his/her head laceration. Review of the Hospital Emergency Department Summary, dated 12/01/21, indicated Resident #1 had two large cranial lacerations that required staples to close the wounds. Review of the Hospital Radiology Report, dated 12/01/21, indicated that x-ray results were concerning for non-displaced fracture of Resident #1's right shoulder and further work-up was recommended. During an interview on 12/14/21 at 12:01 P.M., CNA #1 said that at approximately 7:00 P.M. on 12/01/21, she heard CNA #6 calling for help so she went to Resident #1's room and saw Resident #1 laying on his/her right side on the floor between his/her bed and the roommate's bed. CNA #1 said CNA #6 told her that Resident #1 had been incontinent and while she was washing Resident #1, he/she slipped off the bed. During an interview on 12/14/21 at 1:16 P.M., Nurse #3 said during the 3:00 P.M. to 11:00 P.M. shift on 12/01/21, a CNA came to get him due to an emergency. Nurse #3 said when he walked into Resident #1's room, he saw him/her on the floor with his/her head between the bed and the nightstand. Nurse #3 said CNA #6 told him that Resident #1 rolled off the bed as she was reaching for a bed pad. During an interview on 12/14/21 at 8:10 A.M. and 2:45 P.M., the Director of Nurses (DON) said that at approximately 6:45 P.M. on 12/01/21, CNA #6 provided personal hygiene for Resident #1 and said there was no other staff member assisting her and Resident #1 rolled off the bed during care. The DON said Resident #1 was supposed to be assisted by two staff members for washing, incontinence care, and positioning in bed. On 12/14/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) Resident #1 was re-assessed for side rails and two upper side rails were applied to his/her bed on 12/02/21. B) On 12/02/21, nursing staff were re-educated about Resident #1 requiring two staff members while turning and positioning in bed. C) An Audit was completed on 12/03/21 of all resident's Care Plans to ensure proper level of assistance was indicated. D) On 12/07/21, CNA Assignment Sheets were updated to ensure it include level of assistance for residents who required two staff members for ADL care. E) Starting on 12/02/21 through 12/06/21, education was provided to nursing staff about the process of nursing requirements to provide verbal report to CNAs at start of each shift and nurses required to give assignments to the CNAs . F) On 12/08/21, Bed Mobility Competencies were completed with CNAs. G) The DON will conduct random visual checks during shift changes to make sure that assignment were made by nurses and that report was given on each shift. H) The Administrator will conduct random staff interviews to ensure that report was given, staff is aware of the level of assistance required for the residents on their assignment, and know where to look for a residents' level of assistance. I) The Administrator will provide updates to the Quality Assurance Performance Improvement Committee at the next meeting which was not yet scheduled at the time of the Survey and quarterly. J) The Administrator is responsible for overall compliance.

Based on observation, record review and staff interview, the facility failed to ensure that 1 resident (#8), was properly supervised and assisted to prevent a fall with injury and 1 resident (#4) who sustained 8 falls in a 6 month period, in a sample of 15 residents. Findings include: 1. For resident #8, the facility failed to properly supervise the resident during a transfer and the resident suffered an injury requiring stitches as a result. Resident #8 was admitted to the facility in 6/2015. The resident's [DIAGNOSES REDACTED]. The resident is alert and oriented to person, place and time and cognition is within normal limits. The Quarterly Minimum (MDS) data set [DATE] identified the resident as having short and long-term memory loss and moderately impaired cognition. In addition, the resident required a 2 person assist in transfers, was non-ambulatory and had a history of [REDACTED]. The resident's care plan addressed the problem of Falls. It indicated the following: * Potential for injury related to: unsteady gait, decreased endurance, impulsive related to long standing mental health issues. Goal: * Resident will be safe and free from any injuries. * Will minimize the potential of significant injury relative to a fall. * Resident will accept assistance from staff for all transfers. Interventions included: Toileting/Transfer Status: Totally dependent. Review of the resident's status sheet (care card) indicated the resident was a 2 person transfer. On 3/29/17, review of the 11/08/16 nursing note at 8:45 P.M., indicated that during a transfer with the certified nurse aide from the wheelchair to the bed, the resident hit his/her forehead on his/her bedside table causing a deep laceration above his/her left eye, approximately 1 inch long. The resident experienced a small amount of bleeding and was sent out to the emergency room . On 3/29/17, review of the facility's Incident/Accident report indicated that on 11/08/16 at 8:45 P.M., the resident was transferred by 1 aide (instead of the required 2 person assist) from his/her wheelchair to bed. The resident slumped down hitting his/her left forehead on the bedside table causing a 1 centimeter laceration. The resident was sent out to the emergency room and received 4 sutures. A review of the incident investigation dated 11/8/16 included a statement by the aide that he/she went to transfer (the resident) to (his/her) bed and during the transfer with (resident) being slumped over (he/she) banged (his/her) head on the corner of the table. The resident was observed on 3/28/17 at 12:00 P.M. eating his/her lunch in the Day room. Shortly thereafter, he was observed wheeling himself/herself down the hallway. On 3/29/17 at 8:25 A.M. and 11:15 A.M. and 3:50 P.M. the resident was observed sitting in his/her wheelchair in his/her room. On 3/30/17 at 2:00 P.M., the 11/08/16 incident was discussed with the Director of Nurses. She said she was only vaguely familiar with the incident as she was only recently hired. She said the aide was re-educated at the time of the incident that the resident requires a 2 person assist in transfers at all times. 2. For resident #4, the facility failed to provide proper supervision and revise and develop effective falls interventions to keep the resident safe. The resident suffered 8 falls over a 6 month period. Resident #4 was admitted to the facility in 9/28/16. The resident's [DIAGNOSES REDACTED]. The fall risk assessments dated 9/28/16 and 10/03/16 identified the resident as scoring at 11 and being at high risk for falls. Record review indicated the resident received Occupational Therapy Services between 9/29/16-10/27/16. The Initial Minimum (MDS) data set [DATE] identified the resident as being alert and oriented and exhibiting behavioral symptoms not directed towards others. He/she required extensive assist of 1 in transfers, ambulation and toileting. In addition, the resident was continent of bowel and bladder and he/she experienced 1 fall with no injury and 1 fall with minor injury since admission or prior assessment. The falls care plan dated 10/03/16 identified the following problem: at risk for falls. Interventions included: *Keep call light and most frequently used personal items within reach. Encourage resident to call for assistance. *Maintain record of falls and evaluate for patterns. Alert staff that resident is at high risk for falls. *Toileting Status: Extensive assist X 1 *No clutter in pathways *Floors clean and dry *Flag door with red heart signifying High Fall Risk resident. Review of a 10/03/16 Incident/Accident Report indicated the resident's roommate was yelling out for help. The resident was observed lying on the floor in urine with socks on next to the bathroom door. He/she sustained a quarter size lump on the left side of his/her head. The resident was sent to the hospital and a CT scan done was negative. The resident was identified as having an unsteady gait, was hurrying out of bed and was not assisted. It was determined the resident had on ill fitting socks and was ambulating himself/herself. Review of the 10/07/16 Incident/Accident Report indicated the resident fell at 12:45 A.M. The resident was observed sitting on the floor by his/her bedside. The resident said that he/she was coming back from the bathroom and tripped over his/her wheelchair that was near his/her bed. No injury noted. The resident was receiving physical therapy and occupational therapy services at the time of the fall. Recommendations made: bed and chair alarms. The resident's fall care plan was updated to include the following interventions: *bed and chair alarm *non-skid socks when not wearing socks at night *make sure room free from clutter *encourage resident to call for assist The resident's fall care plan was updated again on 10/16/16 through 4/08/17 and included the following interventions: *Alert staff that resident is at risk for falls *Redirect and educate for safe practices *Update Physical Therapy (PT), Psych and Pharmacy after every fall *PT/OT (Occupational Therapy) screen and eval if ordered by M.D. *Toilet/Transfer Status:Extensive assist X 1 *Wheelchair with assist Review of the 1/08/17 Incident/Accident Report indicated the resident was heard calling out for help at 8:30 A.M. The resident was observed lying on the floor half way in the bathroom. The resident said he/she lost his/her balance. Additional steps taken to prevent recurrence: chair alarm (this intervention was already in place and noted to not be on at the time of the fall). The Post Fall Report indicated an alarm was not identified as being in use. Review of the Restraint/Positioning Assessment (conducted for those residents who are at high risk for falls) dated 1/08/17 indicated the resident's cognition status was moderately impaired; risk factors included the use of psychotropics, poor balance and agitation. The resident required supervision in ambulation, had an unsteady gait and had moderately impaired judgement/memory. The resident forgets he/she cannot walk independently, has a history of falls/fractures and engages in physically aggressive behavior towards staff/residents. The resident fell again on 1/08/17 at 3:25 P.M. Review of the Incident/Accident Report indicated the resident was found on the bathroom floor. The resident said he/she had slid off the wheelchair while trying to get on the toilet. Additional steps taken to prevent recurrence: chair alarm (this intervention was already in place and noted to not be on at the time of the fall). The Post Fall Report indicated an alarm was not identified as being in use. Review of the 1/10/17 Incident/Accident Report indicated the resident was observed at 4:45 P.M. sitting on the floor next to his/her bed. Urine was on the floor. No injuries were noted. Additional steps taken to prevent recurrence: chair alarm (this intervention was already in place and noted to not be on at the time of the fall. The 1/10/17 Post Fall Report indicated an alarm was not identified as being in use. The resident was identified as having a urinary tract infection. No further recommendations were made. Review of the Nursing screening request on 1/08/17 and 1/10/17 for falls indicated the resident refused Occupational and Physical Therapy treatment. Review of the 1/14/17 Incident/Accident Report indicated the resident was observed sitting on the floor next to his/her wheelchair at the end of his/her bed. He/she said he/she was going to the bathroom. The resident took the alarm off and refused to have it on. The resident did not sustain an injury. Steps taken to prevent recurrence: remind resident to ask for assistance when transferring to the bathroom or bed. The 1/14/17 Post Fall Report indicated the resident's brakes were not locked, an alarm was not in use and had a history of [REDACTED]. Nursing notes written on 1/19/17 and 1/20/17 indicated the resident shut off his/her bed alarm and threw it under the bed. A 1/21/17 nursing note indicated the resident removes alarms. It further indicated they should be on secondary to falls. The Quarterly MDS dated [DATE] identified the resident as being alert and oriented, requiring extensive assist of 1 in transfers ambulation and toileting. The resident was frequently incontinent at the time and had fallen twice with no injuries. Review of the 1/24/17 Incident/Accident Report indicated the resident was observed at 8:30 P.M. sitting on the floor next to his/her bed. The report indicated the resident was attempting to self toilet himself/herself and had disconnected the alarms. The resident was identified as being alert and confused. Additional steps taken to prevent recurrence: Cautioned resident to ring call bell for assistance and not to disconnect his/her alarm for safety. The Restraint/Positioning assessment dated [DATE] indicated the resident's cognitive status was moderately impaired. Risk factors included receiving antihypertensives and psychotropics. The resident required physical assistance in toileting. The Post Fall Report dated 1/24/17 identified the resident as being barefoot. Record review indicated the resident received Occupational Therapy services 1/24/17 through 2/26/17. The reason for discharge was the resident's refusal of treatment. The 2/2017 falls care plan was updated with the following information: Three falls this quarter. Urinary tract Infection during the period of first two falls. Will dis-alarm bed alarm and ambulate/transfer self to bathroom. educated on safety and encouraged to call for assist. continue to monitor. Review of the 3/16/17 Incident/Accident Report indicated the resident was observed sitting on the floor ay 8:50 P.M. beside his/her bed. The resident said he/she was going to the doorway to ask for help to move over the bedside table. No injury. Additional steps taken to prevent recurrence: impulsive. Continue alarms bed/chair. Remind to call for assistance. Refused room change for closer monitoring. Record review indicated the resident refuses Physical Therapy services. A 3/23/17 nursing note indicated the resident's bed and chair alarms were discontinued due to the resident's refusal to have them on. On 3/28/17 at 12:10 P.M., the resident was observed in the small day room eating lunch. On 3/29/17 at 8:20 A.M., the resident was observed awake and resting in bed. A red heart was not on the resident's door to signify the resident was a High Fall Risk, as per facility practice. On 3/29/17 at 2:00 P.M., the resident was observed sitting in the hallway in his/her wheelchair, smiling and waving. The facility failed to provide proper supervision and address the fact that the resident was identified for 7 of 8 falls, between 10/03/16 and 2/06/17, as having either been incontinent or on his/her way to the bathroom. On 3/30/17 an interview was held with the resident's certified nurse aide #2. She said the resident still continues to toilet herself without asking for help and that she had just found her earlier in the bathroom by himself/herself.

Based on observation, interviews, and record review for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1, who had dementia with confusion, did not enter the diet kitchen. On 6/12/13, Certified Nurse Aide (CNA) #5 observed the key inserted into the diet kitchen door lock. CNA #5 opened the diet kitchen door and observed Resident #1 in the kitchen with a hot coffee pot. CNA #5 observed that Resident #1 had spilled the coffee and Resident #1's left hand was reddened. Findings include: The Admission Record indicated that the Facility admitted Resident #1 in January 2012. [DIAGNOSES REDACTED]. The Plan of Care for Resident #1, reviewed 3/20/13, included: oversight and redirection for safety, safety checks every 15 minutes, and a Wanderguard due to cognitive deficits, sundowning, and wandering behaviors. The Nurses' Notes, from 3/26/13 to 6/9/13, indicated that Resident #1 increased his/her wandering behaviors during the evening shift, and occasionally attempted to exit the Facility. The Nurses' Notes indicated that Resident #1 remained on safety checks every 15 minutes to monitor his/her whereabouts in the Facility. The 15-Minute Check Sheet, dated 6/12/13, indicated that at 5:45 P.M., Resident #1 was in the day room. The Nurse's Note, dated 6/12/13 at 6:00 P.M., indicated that staff had observed Resident #1 in the diet kitchen with spilled coffee and a hot coffee pot. The Nurse's Note indicated that Resident #1's left hand was reddened to the wrist. The Nurses's Note indicated that Nurse #1 applied cool water and cool compresses to stop the burning process, contacted the covering Physician, and obtained an order for [REDACTED].#1's left hand. The Nurse's Note, dated 6/13/13, indicated that at 7:00 A.M. Resident #1 was sent to the Hospital for evaluation because his/her left hand swelled and blistered. The Nurse's Note indicated that Resident #1 needed his/her ring cut from his/her left hand due to the swelling. The Nurse's Note indicated that Resident #1 returned to the Facility with orders for Silvadene Cream, non-stick gauze dressings twice daily, and pain medication. The Surveyor conducted a tour of the Facility on 6/24/13 at 7:20 A.M. with the Unit Manager present. The Unit Manager said the diet kitchen door was supposed to remain closed and locked at all times. The Surveyor observed that the key to unlock the diet kitchen door was kept on a hook high up on a cork board just outside the nurses' station. The Surveyor observed that the diet kitchen door did not have a mechanism to keep the door unlocked without using the key. The Surveyor observed that the door could not remain in the open position without propping, because when released, the door automatically shut and locked. The Surveyor interviewed the Director of Nurses (DON) on 6/24/13 at 7:40 A.M. The DON said on 6/12/13 she received a telephone call regarding Resident #1's burn and was informed that the key to the diet kitchen was in the lock when Resident #1 was found in the diet kitchen, and was not hanging on its designated hook. The Surveyor interviewed the Administrator on 6/24/13 at 7:50 A.M. The DON and Administrator said, although it was not written into policy, they expected staff to adhere to the Facility's rule that the diet kitchen door remained closed and locked when unattended and the key remained on its designated hook when not in use. The DON and Administrator said the residents could not enter the diet kitchen at any time. The DON said although she had never observed the diet kitchen unattended with the key left in the door or the door propped open, several staff had reported to her that they had observed the diet kitchen key left in the door or the door propped open. The DON said she reinforced with staff on several occasions the necessity of keeping the diet kitchen door closed and locked and the key on its designated hook when not in use. The Surveyor interviewed the Staff Development Coordinator (SDC) on 6/26/13 at 10:39 A.M. The SDC said the Department heads as well as herself told new staff during their initial tour of the Facility the importance of keeping certain areas of the Facility locked at all times. The SDC said on several occasions she had reinforced with staff the need to keep the diet kitchen door closed and locked. The Surveyor interviewed Nurse #1 on 6/24/13 at 9:52 A.M. The Surveyor interviewed Nurse #2 on 6/24/13 at 10:20 A.M. The Surveyor interviewed Nurse #5 on 6/24/13 at 2:25 P.M. The Surveyor interviewed CNA #2 on 6/24/13 at 10:55 A.M. The Surveyor interviewed CNA #4 on 6/24/13 at 1:30 P.M. The Surveyor interviewed CNA #5 on 6/24/13 at 3:00 P.M. The Surveyor interviewed Dietary Aide #1 on 6/24/13 at 2:15 P.M. The Surveyor interviewed Dietary Aide #2 on 6/24/13 at 3:30 P.M. Nurse #1, Nurse #2, Nurse #5, CNA #2, CNA #4, CNA #5, Dietary Aide #1, Dietary Aide #2 said prior to 6/12/13 they observed the diet kitchen unattended with the key in the door or the door propped open, especially around suppertime when staff were going in and out of the diet kitchen for various items. Nurse #1, Nurse #2, Nurse #5, CNA #2, CNA #4, CNA #5 said they had never observed Resident #1 attempt to enter the diet kitchen. The DON and the Administrator said Resident #1 could not purposefully take the key from the hook and complete the steps to open the diet kitchen door due to his/her cognitive deficits. The DON said she interviewed all staff present in the Facility at the time of the incident. The DON said her investigation could not determine how Resident #1 entered the diet kitchen because all staff denied leaving the key in the diet kitchen door or leaving the door propped open. The DON and the Administrator said the following staff were present in the Facility on 6/12/13 at the time of the incident: Nurse #1, Nurse #3, Nurse #5, CNA # 4, CNA #5, CNA #6, CNA #7, CNA #9, Dietary Aide #1, Dietary Aide #2, and Housekeeper #1. The Surveyor interviewed Nurse #3 on 6/24/13 at 1:25 P.M. The Surveyor interviewed CNA #6 on 6/24/13 at 3:15 P.M. The Surveyor interviewed CNA #7 on 6/25/13 at 8:15 A.M. The Surveyor interviewed CNA #9 on 6/25/13 at 3:25 P.M. The Surveyor interviewed Housekeeper #1 on 6/24/13 at 2:45 P.M. via an interpreter. Nurse #1, Nurse #3, Nurse #5, CNA # 4, CNA #5, CNA #6, CNA #7, CNA #9, Dietary Aide #1, Dietary Aide #2, and Housekeeper #1 said, on 6/12/13, prior to Resident #1's incident, they did not observe the diet kitchen unattended with the key left in the door or the door propped open. Nurse #1, Nurse #3, Nurse #5, CNA # 4, CNA #5, CNA #6, CNA #7, and CNA #9 said they did not see Resident #1 enter the diet kitchen. CNA #5 said she saw CNA #6 and a family member enter the diet kitchen prior to Resident #1's incident. CNA #5 said the family member was the last person she observed entering and leaving the diet kitchen. CNA #5 said she observed the family member leave the diet kitchen and return the key to its designated hook. CNA #6 said she entered the diet kitchen and when finished, she closed the door and returned the key to its designated hook. CNA #6 said she supervised the day room for supper and when Resident #1 finished, CNA #6 escorted him/her to the door of the day room and Resident #1 walked out into the corridor. CNA #6 said she thought Resident #1 went to sit at the nurses' station which was his/her usual routine. CNA #6 said it was approximately 10 minutes prior to Resident #1's incident. CNA #6 said the diet kitchen was located directly across from the day room and she did not observe anyone at the diet kitchen. CNA #5 said she went to the diet kitchen to get a yogurt for another resident and noticed that the key had been left in the diet kitchen door. CNA #5 said the diet kitchen door was shut. CNA #5 said when she unlocked the door she found Resident #1 standing in the kitchen. CNA #5 said the coffee pot was hot and the coffee was spilled. The DON and the Administrator said, as a result of the investigation, the coffee pot was removed from the diet kitchen and placed in the employee breakroom. The DON said all staff were educated regarding keeping the diet kitchen door shut and locked. The Administrator said he was in the process of purchasing a key pad for the diet kitchen door.