Every finding on record at Beaumont Rehab & Skilled Nursing CTR - Natick

Based on observation, interview, and record review, the facility failed to provide safe and secure medication storage for one Resident (#32) out of a total sample of 17 residents. Specifically, for Resident #32, the facility staff failed to ensure that Preparation H ointment was safely stored and secured when the medication was left on the nightstand of the Resident who was unable to self-administer, and readily accessible to wandering residents and unauthorized staff and visitors. Findings Include: Review of the facility policy titled Storage of Medications, revised 8/2020, included but was not limited to the following: -Medications and biologicals are stored safely, securely, and properly .the medication supply is accessible only to licensed nursing personnel .or staff members lawfully authorized to administer medications. -Medication supplies are locked when they are not attended by persons with authorized access. Resident #32 was admitted to the facility in June 2023 with diagnoses including Hemorrhoids. Review of the Minimum Data Set (MDS) Assessment, dated 3/10/26 indicated Resident #32: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) of 15 points out of a total possible 15 points. -was non-ambulatory. -was dependent for chair/bed-to-chair transfer. -required substantial/maximal (helper does more than half the effort) assistance for personal hygiene. -was dependent for toilet hygiene and lower body dressing. Review of Resident #32's April 2026 Physician's orders included but was not limited to: -Preparation H 0.25 -14-74.9% ointment, apply rectal [sic] twice a day as needed (PRN), start date 3/5/26. On 4/1/26 at 7:50 A.M., the surveyor observed Resident #32 lying in bed, and a tube of Preparation H 0.25 - 14-74.9% ointment was on the Resident's nightstand. During an interview at the time, Resident #32 said he/she was groggy to talk now and asked the surveyor to return to his/her room later. There were no staff members present in the room or in the area at the time. On 4/1/26 at 2:09 P.M., the surveyor observed Resident #32 lying in bed and the tube of Preparation H 0.25 -14-74.9% ointment remained on his/her nightstand. During an interview at the time, Resident #32 said that he/she needed the ointment on occasion. Resident #32 said that he/she needed the Nurses to apply the ointment because he/she was unable to apply the ointment himself/herself. Resident #32 said the Nurses leave the ointment there (on the nightstand) sometimes. During an interview on 4/1/26 at 2:10 P.M., Unit Manager (UM) #1 said Resident #32 did not have a Physician's order to self-administer medications. UM #1 said the nursing unit was a locked unit and had residents who lived on the unit that wandered in and out of other residents' rooms. UM #1 said that Resident #32 should not have medications kept at the bedside. The surveyor and UM #1 observed the tube of Preparation H 0.25 - 14-74.9% ointment remained on Resident #32's nightstand. UM #1 said medications were not to be kept at the bedside when not in accordance with physician's orders because of the risk of unauthorized people and wandering residents potentially having access to the medication. UM #1 said she thought a Nurse must have left the tube of Preparation H 0.25 - 14-74.9% ointment tube on the Resident's nightstand by accident. During an interview on 4/2/26 at 7:42 A.M., the Director of Nursing (DON) said she was made aware of the tube of Preparation H 0.25 -14-74.9% ointment that was left at the Resident's bedside and said the medication should not have been left in the Resident's room. The DON said she was aware of the Unit having residents that wander. The DON said only Nurses have permission to administer medications and the unsecured medication was a risk because the medication could be accessed by unauthorized people such as other residents, staff, visitors, housekeeping, and maintenance.

Based on records reviewed and interviews, for three of three sampled residents (Resident #1, #2, and #3), who were cognitively impaired, and therefore were unable to give consent, the facility failed to ensure they were treated in a dignified and respectful manner, when on 7/13/25 during the day shift, although none of the residents had an appointment scheduled with a hairdresser, staff found that they all had been given haircuts, with Resident #1's hair being visually uneven, and the facility was unable to determined when or who cut their hair. Findings include:Review of the Facility Policy titled Resident Rights and Responsibilities, dated as revised 9/05/25, indicated the Facility will protect and promote the rights of each resident as set forth in the Resident [NAME] of Rights, which includes the right to be treated with respect and dignity. Resident #1 was admitted to the Facility in July 2022, diagnoses included Alzheimer's Disease, dementia, and hypertension. Resident #1 was cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 5 out of 15 (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). Resident #2 was admitted to the Facility in December 2024, diagnoses included dementia, congestive heart failure and atrial fibrillation. Resident #2 was cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 4 out of 15.Resident #3 was admitted to the Facility in June 2023, diagnoses included Alzheimer's disease, and cervical disc degeneration. Resident #3 was cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 1 out of 15. Review of the Facility's Investigation Report, dated 7/15/25, indicated that Resident #1 was found to have an uneven haircut on 7/13/25 by the staff on the 7:00 A.M. to 3:00 P.M. shift. The Report indicated that staff reported Resident #1's unusual haircut to the Manager on Duty, an environmental audit was conducted on the unit, and no scissors or hair were found. The Report further indicated that Resident #2 and Resident #3 were also found to have had their haircut, that housekeeping found a small amount of hair in Resident #2's bathroom on the morning of 7/13/25 and that the facility was unable to determine who had cut the residents' hair. During an interview on 9/16/25 at 12:00 P.M., Certified Nurse Aide (CNA) # 1 said that on the morning of 7/13/25 (exact time unknown), he saw Resident #1 with an unusual haircut, and that it was uneven. CNA #1 said when he had Resident #1 on his assignment the day before on (7/12/25) his/her hair was fine, and that he immediately notified the Nurse. During an interview on 9/16/25 at 12:26 P.M., the Director of Social Services said that she had been in the building on 7/12/25, saw Resident #1 and that he/she had his/her regular hairstyle. During an interview on 9/16/25 at 12:17 P.M., the Moving Coordinator (who was the Manager on Duty on 7/12/25 and 7/13/25), said she was notified by staff on 7/13/25 about Resident #1's hair being found cut and uneven, that she conducted an environmental audit and was unable to find scissors or hair. During an interview on 9/16/25 at 1:24 P.M., the Director of Nurses (DON) said that she participated in the investigation of the three residents who were found with haircuts and said they would not have been able to give consent for haircuts due to their cognitive deficits. The DON said they still did not know who did the haircuts. The DON said the facility began education of all staff on residents' rights and dignity. During an interview on 9/16/25 at 1:10 P.M., the Administrator said that a thorough investigation had been done, and the facility was unable to determine who performed the haircuts on the three residents, without proper consent. On 9/16/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 07/16/25, which addressed the area(s) of concern as evidenced by: A. Resident #1, #2, and #3 were offered complimentary haircuts at the facility hair salon.B. On 7/13/25, the Facility immediately conducted an environmental audit; scissors were found on an adjacent unit in a resident's room, and the scissors were removed. C. On 7/14/25, a Facility wide audit was initiated by the Nursing Administration on all residents monitoring their hair and would continue weekly times one month.D. On 7/14/25, Nursing and Certified Nurse Aide (CNA) staff education was initiated by the Director of Nurses on the Resident Rights Policy.E. On 7/13/25, an AD HOC Quality Assurance Performance Improvement (QAPI) meeting was conducted, concern areas were discussed. F. On 7/16/25, the Facility completed the Education of all nursing staff on the Residents Rights Policy, which included haircuts without consent.G. The results of the audits will be reviewed at the next monthly QAPI meeting on 10/22/25. H. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on record review and interview the facility failed to accurately complete two Minimum Data Set (MDS) Assessments for one Resident (#39) out of a total sample of 12 residents. Specifically, the facility failed to ensure that two consecutive MDS Assessments for Resident #39 were accurately coded relative to a diagnosis of Psychotic Disorder (other than Schizophrenia). Findings include: Review of The Centers for Medicare and Medicaid (CMS) MDS 3.0 Resident Assessment Instrument (RAI) Manual dated October 2024 indicated: -Section I: Active diagnoses intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. -Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Resident #39 was admitted to the facility in January 2024 with diagnoses including Lewy Body Dementia (a progressive brain disorder that effects thinking, movement, mood, and behavior), Cerebral Vascular Accident (CVA), and Parkinson's Disease. Review of Resident #39's MDS Assessments indicated: -MDS Assessment completed 8/30/24, Resident #39 had a diagnosis of Psychotic Disorder (other than Schizophrenia). -MDS Assessment completed 11/26/24, Resident #39 had a diagnosis of Psychotic Disorder (other than Schizophrenia). Review of the Resident's clinical record showed no evidence the Resident had been diagnosed with a Psychotic Disorder. During an interview on 1/7/25 at 8:48 A.M., the MDS Nurse said the Psychotic Disorder diagnosis on Resident #39's MDS Assessments completed on 8/30/24 and 11/26/24, were coding errors and the Resident did not have a Psychotic Disorder. The MDS Nurse said the MDS Assessments should not have been coded with a diagnosis of Psychotic Disorder and should be modified.

Based on record review and interview, the facility failed to post the required nurse staffing information daily as required. Specifically, the facility failed to: -post the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses (RN), Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN), and Certified Nurses Aides (CNA). Findings include: During the facility survey, the surveyor observed the nurse staffing information was posted on both the [NAME] and [NAME] Units on 1/2/25. The surveyor observed that the nurse staffing postings on 1/2/25, did not include the total number of hours and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: RNs, LPNs, LVNs, and CNAs. On 1/2/25 at 9:28 A.M., the surveyor requested all facility maintained copies of the nurse staffing information for 2023 and 2024, which was provided by the facility Scheduler. Review of all the nurse staff postings provided by the facility from November 2023 to January 2025 did not include the total number of hours and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: RNs, LPNs, LVNs, and CNAs. During an interview on 1/2/25 at 9:45A.M., the facility Scheduler said that she was unaware that the total number of hours and actual hours worked had to be included in the daily posted nurse staffing information. During an interview on 1/2/25 at 10:15 A.M., the Director of Nursing (DON) said that she had been unaware that the posted nursing staffing forms needed to have the total number of hours and actual hours worked.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure they maintained a complete and accurate medical record including but not limited to hospice services documentation and an integrated plan of care. Findings include: Review of the Facility Services Agreement for Hospice Care, signed however, undated, indicated that Hospice Services means those services provided to a Hospice Patient that are reasonable and necessary for palliation and management of such Hospice Patient's terminal illness and are specialized in a Hospice Patient's Plan of Care. The Agreement also indicated that the Plan of Care means a written care plan established, maintained, reviewed, and modified, if necessary, at intervals identified by the Interdisciplinary Team (IDT). Hospice and Facility will jointly develop and agree upon a coordinated Plan of Care. 1). Resident #1 was admitted to the Facility in December 2023, diagnoses included myelodysplastic syndrome (conditions that occur when the blood-forming cells in the bone marrow become abnormal), hyponatremia (low sodium), dysphagia (difficulty swallowing), and toxic metabolic encephalopathy (acute cerebral dysfunction due to metabolic disturbances). Review of Resident #1's Physician Order, dated 01/24/24, indicated he/she had been admitted to Hospice services. Review of Resident #1's Significant Change Minimum Data Set (MDS) Assessment, dated 02/02/24, indicated he/she had been on Hospice Services. Review of Resident #1's medical record indicated that there was no documentation to support a Hospice Care Plan had been integrated or made accessible to Facility Staff to follow so they could effectively collaborate with Hospice to meet his/her care needs. 2). Resident #3 was admitted to the Facility in March 2024, diagnoses include breast cancer, chronic obstructive pulmonary disease, and pulmonary fibrosis. Review of Resident #3's Physician Order, dated 03/12/24, indicated he/she had been admitted to Hospice services. Review of Resident #3's Significant Change MDS Assessment, dated 03/19/24, indicated he/she had been on Hospice Services. Review of Resident #3's medical record indicated that there was no documentation to support a Hospice Care Plan had been integrated or made accessible to Facility Staff to follow so they could effectively collaborate with Hospice to meet his/her care needs. During a telephone interview on 06/06/24 at 10:28 A.M., the Assistant Director of Hospice Services said that all Hospice patient information is uploaded and stored within Home Care Home Base (their electronic medical record)and the Facility is unable access that information. The Director said that the Facility's Social Worker (SW) is their primary contact, that Hospice had been instructed to e-mail Hospice documents to the SW and that the facility SW would then be responsible for printing and scanning that information into the medical record for each Hospice Resident making the Hospice information accessible for nursing. During an interview on 06/04/24 at 1:26 P.M., the Unit Manager said that she was not certain where Resident #1's and/or Resident #3's integrated Hospice Care Plans were and could not locate them in their medical record. The Unit Manager said the documentation should had been scanned into their medical records under the Hospice tab in Matrix (Facility's electronic medical record) so all of the staff could view and follow the care plans. During a telephone interview on 06/10/24, the Former Assistant Director of Nurses (ADON), said that she had not been aware of the Facility's protocol for Hospice residents related to receipt and integration of their Hospice documentation. The ADON said that the Facility care plan is different from an integrated Hospice care plan and that nurses need to be aware and have access to the information on the Hospice care plan. During a interview on 06/04/24 at 2:27 P.M., the Social Worker (SW) said that she thought the required Hospice documentation automatically got uploaded to each resident's medical record. The SW said she had not known that it was her responsibility to print the documents received by Hospice and upload the information into each of the Hospice resident's facility medical records. During an interview on 06/10/24 at 1:00 P.M., the Director of Nurses said that she had been under the impression that all Hospice documents were being scanned into each of the resident's medical record. The DON said it is the expectation of the Facility to ensure all required Hospice documentation, including but not limited to the integrated plan of care be accessible to Nursing staff caring for any Resident on Hospice.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed and care planned to be totally dependent on two staff members for bed mobility, incontinence care and turning and repositioning in bed, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs, when on the 11:00 P.M. to 7:00 A.M. shift on 11/24/23 into 11/25/23, Nurse Aide #1 provided Resident #1 with incontinence care and repositioning in bed, without the assistance of another staff member. On 11/25/23 on the 7:00 A.M. to 3:00 P.M. shift, Resident #1 was found with a new area of bruising of unknown origin to his/her left upper arm. Resident #1 was transferred to the Hospital Emergency Department, where he/she was diagnosed with an acute left humeral (upper arm bone) fracture. Findings include: Review of the Facility Policy, titled Care Planning, dated as last revised 11/28/18, indicated that the Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Review of the Resident Assessment Instrument (RAI) Manual, dated as last revised 2019, indicated that the comprehensive care plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services that are to be provided by staff to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. Resident #1 was admitted to the Facility in April 2023, diagnoses included advanced dementia, malnutrition, anxiety, depression, and multiple contractures (shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints). Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/03/23, indicated he/she had both long-and short-term memory loss, severely impaired decision-making abilities, rarely/never unable to make his/her needs known, or rarely/never able to understand others. The MDS further indicated he/she was totally dependent on staff for bed mobility, turning and repositioning, transfers, and incontinence care. The MDS indicated he/she had bilateral contractures to his/her lower extremities and contractures to his/her upper extremity. Review of Resident #1's Care Plan, titled Activities of Daily Living, dated as last revised 10/18/23, indicated he/she required total assistance of two staff members to turn and reposition every two hours and as needed (PRN), incontinence care and weight shift in bed or chair every two hours, and totally dependent of two staff members with transfers while utilizing a mechanical lift. Review of Resident #1's Resident Profile, dated as last revised 10/18/23, indicated he/she required total assistance of two staff members to turn and reposition every two hours and PRN, incontinence care or weight shift in bed or wheelchair every two hours, and totally dependent of two staff members with transfers while utilizing a mechanical lift. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 12/06/23, indicated that staff discovered a large bruise on Resident #1 left upper arm of unknown origin, however, after the Facility investigation, the nurse aide (later identified as Nurse Aide #1) on the 11:00 P.M. to 7:00 A.M. (night shift) informed the Director of Nurses (DON) that she had provided incontinence care twice during the shift to Resident #1 and had not asked another staff member for any assistance. Review of the Facility Incident Report, dated 11/25/23, indicated Resident #1 was found with a large irregularly formed ecchymotic area, measuring 14 centimeters (cm) by 8 cm to his/her left upper arm and required transfer to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge Summary, dated 11/29/23, indicated he/she was diagnosed with an acute comminuted displaced fracture through the left humeral surgical neck with the involvement of the greater tuberosity, non-displaced fracture of the proximal end of the left humerus. Review of Nurse Aide (NA) #1's, Written Witness Statement, dated 11/25/23, and review of NA #1's telephone interview with the DON, dated 11/28/23 at 4:00 P.M., indicated that Resident #1 was on her assignment from 11:00 P.M. on 11/24/23 through 7:00 A.M. on 11/25/23. NA #1 said that she checked on him/her when she first arrived and said she provided incontinence care to him/her twice during the night. The DON asked NA #1 if she got help from any other staff and NA #1 said no. The DON explained to NA #1 that Resident #1 should have been a two person assist for care. During a telephone interview on 1/24/24 at 12:00 P.M., Nurse Aide (NA) #1 said she was aware that Resident #1 needed the assistance of two staff to transfer and to change his/her position when he/she was in bed and said she had not asked any other staff member for assistance that night. During a telephone interview on 01/18/24 at 2:01 P.M., the Director of Nurses (DON) said that when she specifically asked NA #1 if she knew Resident #1 was a 2 person assist, she said NA #1 was very vague and did not answer her question. During a telephone interview on 01/25/24 at 10:28 A.M., CNA #8 said she had worked on 11/25/23 at 7:00 A.M. and said Resident #1 was on her assignment. CNA #8 said she and CNA #2 were beginning to get Resident #1 ready for the day and said when she removed his/her night gown they noticed a large red area to his/her left arm (between the shoulder and elbow). CNA #8 said she immediately called the nurses (Nurse #1 and Nurse #2) to see the area. During a telephone interview on 01/23/24 at 1:27 P.M., Nurse #1 said she was working from 11:00 P.M. on 11/24/23 through 7:00 A.M. on 11/25/23 and said that she had explained to NA #1 in the past that Resident #1 was very contracted, fragile and required two assists with all care. Nurse #1 said NA #1 had not asked for any assistance during that shift. Review of CNA # 7's Written Witness Statement, dated 11/25/23, indicated he had no interaction with Resident #1 at all during that night shift. During a telephone interview on 01/25/24 at 2:39 P.M., CNA #5 said she had trained NA #1 on the night shift for some of her orientation and said the first thing she always did was go around and ensure that NA #1 was aware of each resident's level of care on their assignment. CNA #5 said Resident #1 had been on their assignment in the past when NA #1 was in training. During an interview on 01/17/24 at 1:54 P.M., the Director of Rehabilitation Services said Resident #1 requires total care of two nursing staff members at all times, except for eating and oral hygiene. During a telephone interview on 1/18/24, the Nurse Manager said that back in October 2023, Resident #1's Family Member had some concerns with his/her care, considering how fragile and contracted Resident #1's was, and said since then, Resident #1 was care planned to have two nursing staff for all care, except for eating and brushing his/her teeth (that only required one nursing staff member). The Nurse Manager said that was when his/her Care Plan and Resident Profile were updated. The Nurse Manager said it is the Facility's expectation that all CNA's are aware of each resident's functional level prior to actually providing physical care and should be utilizing the Resident Profile for guidance. During a telephone interview on 01/18/24 at 2:01 P.M., the Director of Nurses said it is the expectation of the Facility that all nursing staff are familiar with each resident's care needs prior to providing them with physical assistance. The DON said all nursing staff are expected to follow each resident care plan and care areas are located on each Resident profile for CNA's to access and are expected to ask questions if they are uncertain of how to care for a resident.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be totally dependent on two staff members with bed mobility, turning and repositioning, and incontinence care, the Facility failed to ensure his/her plan of care was followed to maintain his/her safety and prevent an incident or accident resulting in a major injury, when on the 11:00 P.M. to 7:00 A.M. shift on 11/24/23 into 11/25/23, Nurse Aide #1 provided Resident #1 with incontinence care and repositioning in bed, without the assistance of another staff member. On 11/25/23, on the 7:00 A.M. to 3:00 P.M. shift, Resident #1 was found with a new area of bruising of unknown origin to his/her left upper arm. Resident #1 was transferred to the Hospital Emergency Department, where he/she was diagnosed with an acute left humeral (upper arm bone) fracture. Findings include: Review of the Facility's Policy, titled Safe Lifting and Movement Policy, dated as last revised 08/01/18, indicated that employees use safe methods for lifting and moving elders in the nursing facility in order to prevent injury to both the employees and elders. The Policy further indicated that all elders/residents who have any degree of dependency for transfer or movement will be assessed to determine the extent of assistance required and the safest method of assistance. Resident #1 was admitted to the Facility in April 2023, diagnoses included advanced dementia, malnutrition, anxiety, depression, and multiple contractures (shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints). Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/03/23, indicated he/she had both long and short-term memory loss, severely impaired decision-making abilities, rarely/never unable to make his/her needs known, or rarely/never able to understand others. The MDS further indicated he/she was totally dependent on staff for bed mobility, turning and repositioning, incontinence care, and transfers. The MDS indicated he/she had bilateral contractures to his/her lower extremities and contractures to his/her upper extremity. Review of Resident #1's Care Plan, titled Activities of Daily Living, dated as last revised 10/18/23, indicated he/she required total assistance of two staff members to turn and reposition every two hours and as needed (PRN), incontinence care and weight shift in bed or chair every two hours, and totally dependent of two staff members with transfers while utilizing a mechanical lift. Review of Resident #1's Resident Profile, dated as last revised 10/18/23, indicated he/she required total assistance of two staff members to turn and reposition every two hours and PRN, incontinence care or weight shift in bed or wheelchair every two hours, and totally dependent of two staff members with transfers while utilizing a mechanical lift. Review of Occupational Therapy Progress Note, dated 10/31/23, indicated Resident #1 had bilateral (both left and right side) contractures to his/her shoulders, elbows, hips, and knees. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 12/06/23, indicated that staff discovered a large bruise on Resident #1 left upper arm of unknown origin, however, after the Facility investigation, the nurse aide (later identified as Nurse Aide #1) on the 11:00 P.M. to 7:00 A.M. (night shift) informed the Director of Nurses (DON) that she had provided incontinence care twice during the shift to Resident #1 and had not asked another staff member for any assistance. Review of the Facility Incident Report, dated 11/25/23, indicated Resident #1 was found with a large irregularly formed ecchymotic area, measuring 14 centimeters (cm) by 8 cm to his/her left upper arm and required transfer to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge Summary, dated 11/29/23, indicated he/she was diagnosed with an acute comminuted displaced fracture through the left humeral surgical neck with the involvement of the greater tuberosity, non-displaced fracture of the proximal end of the left humerus. Review of Nurse Aide (NA) #1's, Written Witness Statement, dated 11/25/23, and review of NA #1's telephone interview with the DON, dated 11/28/23 at 4:00 P.M., indicated that Resident #1 was on her assignment from 11:00 P.M. on 11/24/23 through 7:00 A.M. on 11/25/23. NA #1 said that she checked on him/her when she first arrived and said she provided incontinence care to him/her twice during the night. The DON asked NA #1 if she got help from any other staff and NA #1 said no. The DON explained to NA #1 that Resident #1 should have been a two person assist for care. During a telephone interview on 1/24/24 at 12:00 P.M., Nurse Aide (NA) #1 said she was aware that Resident #1 needed the assistance of two staff to transfer and to change his/her position when he/she was in bed and said she had not asked any other staff member for assistance that night. During a telephone interview on 01/18/24 at 2:01 P.M., The Director of Nurses (DON) said that when she specifically asked NA #1 if she knew Resident #1 was a 2 person assist, she said NA #1 was very vague and did not answer her question. During a telephone interview on 01/25/24 at 10:28 A.M., CNA #8 said she worked on 11/25/23 at 7:00 A.M. and said Resident #1 was on her assignment. CNA #8 said she and CNA #2 were beginning to get Resident #1 ready for the day and when she removed his/her night gown, they noticed a large red area to his/her left arm (between the shoulder and elbow). CNA #8 said she immediately called the nurses (Nurse #1 and Nurse #2) to see the area. During a telephone interview on 01/23/24 at 1:27 P.M., Nurse #1 said she was working from 11:00 P.M. on 11/24/23 through 7:00 A.M. on 11/25/23 and said that she had explained to NA #1 in the past that Resident #1 was very contracted, fragile and required two assists with all care. Nurse #1 said NA #1 had not asked for any assistance during that shift. Review of CNA # 7's Written Witness Statement, dated 11/25/23, indicated he had no interaction with Resident #1 at all during that night shift. During a telephone interview on 01/25/24 at 2:39 P.M., CNA #5 said she had trained NA #1 on the night shift for some of her orientation and said the first thing she always did was go around and ensure that NA #1 was aware of each resident's level of care on their assignment. CNA #5 said Resident #1 had been on their assignment in the past when NA #1 was in training. During a telephone interview on 01/18/24, the Nurse Manager said that back in October 2023, Resident #1's Family Member had some concerns with his/her care, considering how fragile and contracted Resident #1's was. The Nurse Manager said since then, Resident #1 was care planned for two nursing staff for all care, except for eating and brushing his/her teeth (that only requires one nursing staff member). The Nurse Manager said that was when his/her Care Plan and Resident Profile were updated. The Nurse Manager said it is the Facility's expectation that all CNA's are aware of each resident's functional level prior to actually providing physical care and should be utilizing the Resident Profile for guidance. During a telephone interview on 01/18/24 at 2:01 P.M., the Director of Nurses said it is the expectation of the Facility that all nursing staff are familiar with each resident's care needs prior to providing them with physical assistance. The DON said all nursing staff are expected to follow each resident care plan and care areas are located on each Resident profile for CNA's to access and are expected to ask questions if they are uncertain of how to care for a resident.

Based on observations and interviews, the facility failed to post nursing staff data daily, at the start of each shift, relative to licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility failed to post this data, in a prominent place readily accessible to residents and visitors, to include: a) facility name, b) current date, c) total number and hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurse Aides (CNAs), and d) resident census. Findings include: On 11/14/23 at 7:00 A.M., the surveyor observed the facility's main entrance and lobby area and did not find nursing staff data posted in the area. On 11/14/23 at 7:50 A.M., the surveyor observed the inside area of the elevator and the area outside of the elevator on the second floor where both resident units were located in the facility. No posting of nurse staffing data was observed. On 11/15/23, between the hours of 7:00 A.M. and 4:30 P.M., the surveyor observed no posted nursing staff data in the facility's main entrance and lobby area, the inside and outside area of the elevator, on the second floor elevator area or resident units. On 11/16/23, between the hours of 7:00 A.M. and 8:10 A.M., the surveyor observed no posted nursing staff data in the facility's main entrance and lobby area, the inside and outside area of the elevator, on the second floor elevator area or resident units. During an interview on 11/16/23 at 10:15 A.M., the Administrator said the facility did not have nursing staff data posted and accessible to residents and visitors. During an interview on 11/16/23 at 10:40 A.M., the Director of Nursing (DON) said the facility had not consistently posted nursing staff data because this task had not been assigned to a specific staff member to be completed. The DON said that the facility's nursing staff data had not been posted as required, on any day during the survey period.

Based on review of the facility's Nurse Staff Schedule and interviews, the facility failed to provide evidence that the services of a Registered Nurse (RN) were used for at least eight consecutive hours a day, seven days a week. Specifically, the facility failed to provide evidence that at least eight consecutive hours of RN coverage was provided over three 24-hour periods when no Nurse staff waivers were in place. Findings include: Review of the Weekly Nurse Staff Schedule provided by the facility for 10/15/23 through 10/21/23 indicated no evidence that the required eight consecutive hours of RN coverage was provided on either 10/15/23 or 10/21/23. Review of the Weekly Nurse Staff Schedule provided by the facility for 10/22/23 through 10/28/23 indicated no evidence that the required eight consecutive hours of RN coverage was provided on 10/22/23. During an interview on 11/16/23 at 10:40 A.M., the Director of Nursing (DON) said the facility had difficulty with staffing RNs, no nurse staff waivers were in place, and that she and the Infection Preventioninst (IP), who was also a RN, rotated being on-call for weekend coverage. The DON said if there was no RN scheduled, either she or the IP were always available to facility staff if they called. The surveyor reviewed the dates in question relative to RN coverage (10/15/23, 10/21/23 and 10/22/23) and when asked for evidence that the required RN coverage hours for 10/15/23, 10/21/23, and 10/22/23 were fulfilled, the DON said that either she or the IP were always there. The DON said she would attempt to locate evidence of this for the dates requested. During an interview on 11/16/23 at 1:25 P.M., with Nurse #1, Nurse #2, and Nurse #3, Nurse #1 said she was a RN and worked most weekends, but if there was no RN in the building and services of an RN were needed, staff would call the DON or IP. Nurse #2, who was a Licensed Practical Nurse (LPN), said there may not be a RN in the building on the weekends, but the DON and IP were always available to be called. Nurse #3, who was also a LPN, said the DON and IP took turns being on-call, so they may not be in the building, but they were always available to be called. No evidence was provided to the survey team prior to the end of the survey period that the required eight consecutive hours of RN services were fulfilled for 10/15/23, 10/21/23, and 10/22/23.

Based on record review and interview, the facility failed to ensure its staff accurately coded Minimum Data Set (MDS) assessments, regarding immunizations, for two Residents (#8 and #5) out of eight sampled residents. Findings include: 1.Resident #8 was admitted to the facility in May 2015. Review of the MDS assessment, with Assesment Reference Date (ARD) of 1/17/23, indicated under Section O, that the Resident received the influenza vaccination in the facility for this year's influenza season (beginning October 2022) and it was last administered on 10/19/21. During an interview on 2/16/23 at 2:50 P.M., the MDS Coordinator said the MDS was coded incorrectly. 31240 2. Resident #5 was admitted to the facility in May 2015. Review of the clinical record indicated the Resident was administered Influenza Vaccinations on 9/16/21 and 10/7/22. Review of a MDS assessment, dated 1/3/22, indicated the Influenza Vaccine was administered in the facility during the current Influenza season (October 2022 through March 2023) on 9/16/21. During an interview on 2/16/23, the MDS Coordinator said the dated of the Influenza Vaccination was coded incorrectly and it should have been recorded as 10/7/22.

Based on observation, policy review, record review, and interview, the facility failed to ensure its staff implemented appropriate infection control measures to help prevent transmission of communicable diseases and infections for two Residents (#1 and #3), out of eight sampled residents. Specifically, the facility failed to ensure its staff 1) implemented the use of Personal Protective Equipment (PPE) as indicated for Resident #1, and 2) monitored Resident #1 and #3 for signs and symptoms of COVID-19 every shift during an active COVID-19 outbreak. Findings include: Review of the facility's policy, Contact Precautions, dated 2/1/20, indicated the following: -Use Contact Precautions to prevent the spread of germs by direct or indirect contact with residents or their environments. -Contact Precautions are special safeguards that must be put in place when dealing with residents who are infected with certain germs. -Ensure Precaution sign and equipment are near entrance to the resident's room. -Wear gloves and gown when entering residents' room and remove them when leaving the rooms. Review of the Centers for Disease Control and Prevention (CDC) website, Multidrug-resistant organisms (MDRO) management in Healthcare Settings, indicated that in Long Term Care Facilities (LTCF): -Consider the individual patient's clinical situation when deciding whether to implement or modify Contact Precautions in addition to Standard Precautions for a patient infected or colonized with a target MDRO. -For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living), use Contact Precautions in addition to Standard Precautions. 1. For Resident #1 the facility failed to ensure its staff wore PPE during care when the Resident was on Contact Precautions for an MDRO. Resident #1 was admitted to the facility in September 2022. Review of the clinical record indicated the Resident was receiving Hospice care and had an indwelling urinary catheter (tube inserted through the urethra to the bladder for urine drainage). Review of a laboratory result, dated 12/11/22, indicated Klebsiella Pneumoniae MDRO was present in the urine sample and contact isolation was indicated to prevent the spread. During an observation on 2/16/23 at 8:34 A.M., the surveyor observed two signs on Resident #1's door. One indicated Isolation Precautions (keep door closed, wear gown, gloves and N95 mask to enter) and the other one indicated Contact Precautions (providers and staff must put on a mask, gloves and a gown prior to room entry). During an interview on 2/16/23 at 8:36 A.M., Nurse #1 said the Resident was on Contact Precautions due to having a MDRO in the urine. Nurse #1 said the staff were to wear a gown and gloves when providing care and when they emptied his/her urinary drainage bag as the urine could splash when it was emptied from the bag. Nurse #1 said she did not think the Resident still required Isolation Precautions. During an observation on 2/16/23 at 10:18 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 in Resident #1's room, emptying the Resident's urinary drainage bag, wearing only a surgical mask and gloves. Unit Manager #1 walked by the Resident's room and told CNA #1 that the Resident's door should be shut when she was providing care. During an interview on 2/16/23 at 10:25 A.M., the surveyor observed CNA #1 exit Resident #1's room. The surveyor asked CNA #1 what type of PPE was required when providing care to Resident #1. CNA #1 said she realized she should have worn a gown, but she had not. CNA #1 said she had emptied the catheter bag and provided all morning care to Resident #1 without a gown on. During an interview on 2/16/23 at 2:53 P.M., the Director of Nurses (DON) said Resident #1 should have been on Contact Precautions only, due to the MDRO in the urine. She further said the CNA should have worn a gown when in the Resident's room and providing care. 31240 2. Review of the Commonwealth of Massachusetts Memorandum, Update to Caring for Long Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated October 13, 2022, indicated the following: -On unit (s) conducting outbreak testing, a long term care facility should assess residents for symptoms of COVID-19 during each shift. Resident #1 was admitted to the facility in September 2022. Review of a Physician's order, dated 9/12/22, indicated: COVID Surveillance: Perform respiratory/COVID assessment daily to monitor for signs and symptoms of viral infection, once a day 7:00 A.M.-3:00 P.M. Review of the January 2023 Treatment Administration Record (TAR) indicated COVID Surveillance was documented as completed on the 7:00 A.M.-3:00 P.M. shift, for all days of the month. Review of a Social Worker's note, dated 2/8/23, indicated the Resident tested positive for COVID-19 and the family/representative was notified on that day. Review of a Physician's order, dated 2/15/23, indicated: COVID Surveillance: Perform respiratory/COVID assessment daily to monitor for signs and symptoms of viral infection every shift; nights, days and evenings. Review of the February 2023 TAR indicated COVID Surveillance was documented as completed on the 7:00 A.M.-3:00 P.M. shift from 2/1/23 through 2/14/23. The TAR indicated documented COVID Surveillance was completed for each shift beginning 2/15/23. 3. Resident #3 was admitted to the facility in April 2022. Review of facility documentation indicated that Resident #3 had been COVID-19 tested every other day beginning 1/31/23 through 2/14/23, and had not tested positive. Review of a Physician's order, dated 2/15/23, indicated; COVID Surveillance: Perform respiratory/COVID assessment daily to monitor for signs and symptoms of viral infection every shift; nights, days and evenings. Review of the February 2023 TAR indicated COVID Surveillance was documented as completed for each shift starting 2/15/23. During an interview on 2/16/23 at 8:50 A.M. , both the Unit Manager and the MDS Coordinator said that nurses are monitoring for COVID-19 signs and symptoms on each shift, for all residents. During an interview on 2/16/23 at 8:55 A.M., the Director of Nurse (DON) said that the facility had a COVID-19 outbreak that began 1/31/23. During an interview on 2/16/23 at 2:15 P.M., the DON said that all residents should have been monitored for signs and symptoms of COVID-19 on every shift, since start of the outbreak that began on 1/31/23. The DON and the surveyor reviewed the Physician's orders and the January/February 2023 TARs for Resident #1 and Resident #3. She said neither Resident #1, nor Resident #3 had monitoring done each shift until 2/15/23 when ordered (by the Physician), and that Resident #3 had no documented COVID-19 monitoring on any shift until 2/15/23. She said COVID-19 surveillance had not been done in accordance with the State and Federal guidance and recommendations.

Based on record review and interview, the facility failed to ensure its staff administered the influenza vaccine after obtaining consent for one Resident (#7) and failed to offer the influenza vaccine to one Resident (#4) out of five applicable sampled residents. Findings include: 1. Resident #7 was admitted to the facility in February 2022. Review of the Consent for Immunizations, signed and dated 10/12/22, indicated the Resident/Resident Representative signed consent to receive the annual influenza vaccination. Review of the clinical record did not indicate the influenza vaccination was offered to the Resident after the consent for administration was obtained. During an interview on 2/16/23 at 2:52 P.M., with the Director of Nurses (DON) and Minimum Data Set (MDS) Coordinator, (who were both sharing the role of the Infection Preventionist (IP)), the MDS Coordinator said the process was for the facility staff to get consent in October from either the Resident or the Health Care Proxy (HCP) to consent or decline the annual influenza vaccine. The MDS Coordinator said once the consent was obtained they administered the vaccination. The MDS Coordinator said there should have been evidence in the record that the Resident was offered the influenza vaccine after the consent was obtained. 2. Resident #4 was admitted to the facility in September 2022. Review of Resident #4's medical record indicated no documented evidence that the Resident and/or his/her Representative had received education regarding the risks and benefits of the Influenza Vaccine, nor was there evidence the vaccine was offered, received or declined. Review of Resident #4's Preventive Health Care report in the medical record did not include any documentation relative to the Influenza Vaccine history. During an interview on 2/16/23 at 3:10 P.M., the DON said there was no evidence that Resident #4 had been educated, offered, and received/declined the Influenza Vaccine, but there should have been.

Based on observation and interview, the facility failed to ensure that staff maintained safe food storage and clean equipment, in accordance with professional standards for food service safety to help minimize the risk of food-borne illnesses. Findings include: Review of the facility's Food Safety and Sanitation policy, dated 2008, indicated the following: -Foods that are refrigerated are stored at or below 41 degrees Fahrenheit (F). -Perishable ingredients are refrigerated when they are not being used. -All leftover are labeled, covered and dated when stored. Review of the facility's General Sanitation of Kitchen policy, dated 2008, indicated the following: -The staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedules. Tasks will be addressed as to frequency of cleaning. During a tour of the kitchen on 5/4/22 at 7:32 A.M., the following concerns were observed: -The surveyor observed the dry store room and the following items were undated when opened; a five pound (lb) bag of bread crumbs and two 10 lb bags of pasta. The surveyor also observed two large plastic storage bins, one containing bread flour and the other cake flour. Both bins had scoops stored directly in the flour. -In the main kitchen area, the surveyor observed two large plastic storage bins of dried food products that were unlabeled and undated. -On a food preparation table, the surveyor observed the following condiments that were opened and not refrigerated as required; a gallon container of teriyaki sauce (one third full), a five lb container of teriyaki glaze (one fourth full) and a gallon container of soy sauce (one fourth full). -The surveyor observed the fryolator dirty with food crumbs and oil residue along the edges. -The surveyor observed the large mixer dirty with dried food splashes and particles on the inside edge of the splash guard and the underside of the mixer edges. During a tour of the kitchen on 5/5/22 at 2:20 P.M., with the Food Service Director (FSD), the following concerns were observed: -In the dry store room the following items were open and undated; a five lb bag of corn muffin mix and a large bag of pecans (about one fourth full). The two bins of flour still had scoops stored directly in the flour. -In the main kitchen area, the surveyor and the FSD observed the two large storage bins of dry food products, and both remained unlabeled and undated. -On the preparation table, the surveyor and FSD observed the following condiments that remained stored there and not refrigerated as required; the gallon containers of teriyaki sauce and soy sauce. -The surveyor and the FSD observed the fryolator, and it remained dirty with food particles and oil residue around the edges. Also, the fryolator baskets had chunks of fried food particles in them. The FSD said the fryolator had not been in use. -The surveyor and FSD observed the large mixer and it remained dirty with food splashes on the inner edges of the splash guard and on the underside of the mixer edges. During an interview on 5/5/22 at 2:45 P.M., the FSD said that all opened food should be dated when opened, scoops should not be stored directly in food products, the condiments that were opened should have been refrigerated as required, and all equipment should be cleaned after use.

Based on record review and interview the facility failed to ensure staff provided wound care as ordered for one Resident (#35) out of three closed record sampled residents. Findings include: Resident #35 was admitted to the facility in April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note, dated 4/14/22, indicated the Resident had a left foot lateral aspect of fifth toe ulcer that measured 2 centimeters (cm) x 2.5 cm with 100 % eschar (dead, necrotic) tissue in the wound bed. Left lateral heel ulcer 2 cm x 2 cm with 100% eschar in the wound bed. Right heel ulcer 2.5 cm x 2 cm with 100% eschar in the wound bed. Review of the April 2022 Treatment Administration Record (TAR) indicated the following: -Left base of fifth toe wound, cleanse with normal saline, pat dry and wrap in kerlix daily. -Left lateral heel wound, cleanse with normal saline, pat dry and apply [MEDICATION(S)] (antimicrobial) gel, cover with [MEDICATION(S)] (protects the wound from trauma) non-adhering dressing, dry dressing and wrap with kerlix daily. -Right heel wound, cleanse with normal saline, pat dry and apply [MEDICATION(S)] gel, cover with [MEDICATION(S)] non-adhering dressing, dry dressing and wrap with kerlix daily. Further review of the TAR indicated the treatments listed above were administered on 4/14/22 and discontinued on 4/15/22. Review of the physician's orders did not indicate an order to discontinue the treatments. Review of a physician's order, dated 4/15/22, indicated to apply skin prep (a liquid-forming dressing, that upon application to skin, forms a protective film to help reduce friction) to bilateral heel ulcers twice a day, off load with pillows. Review of a progress note, dated 4/15/22, indicated the Resident was seen by the physician who ordered to apply skin prep to bilateral heel ulcers twice daily, off load heels with pillows. Review of the April 2022 TAR indicated the order for skin prep to bilateral heels was not implemented. During an interview on 5/6/22 at 12:26 P.M., the Unit Manager (UM) said that the Resident came in with vascular ulcers to bilateral heels and outer left foot, and the physician said to start skin prep. She said the Resident was seen by the wound specialist (on 4/26/22) who advised to change the treatment to [MEDICATION(S)] (topical antiseptic that provides infection protection). The UM said the wound specialist saw the Resident and said to use [MEDICATION(S)] but she never wrote a report that the facility could provide the surveyor because the wound doctor was unable to bill, due to insurance. The UM reviewed the April 2022 TAR and said she didn't see that the skin prep order was ever implemented and should have been. During an interview on 5/6/22 at 12:48 P.M., Nurse #2 said that she was the nurse who wrote the order for skin prep and the progress note on 4/15/22. She said that she should have written orders to discontinue the treatments to the heels and toe but never did. She said that she thought the doctor meant to just leave the areas open to air and not to use the skin prep, but she could see how there was confusion since her note and the order written on 4/15/22 indicated otherwise. She said she understood that ultimately there were a total of four orders for treatments to ulcers that were all discontinued or not put on the TAR and there was no evidence that any of them had orders to be discontinued. She said she didn't know what happened.

Based on observation, policy review and interview, the facility failed to ensure that staff maintained proper infection control practices relative to the removal of items from a room where contact precautions had been implemented. Findings include: Review of the facility's Contact Precautions policy, dated 7/19/21, indicated the following: -Use contact precautions to prevent the spread of germs by direct or indirect contact with residents or their environments. During a tour of the [NAME] Unit on 5/4/22 at 8:30 A.M., the surveyor observed a contact precaution sign posted directly outside of room [ROOM NUMBER]. During this same time, the Unit Manager (UM) said the Resident residing in the room was on contact precautions due a [MEDICATION(S)]-resistant Enterococcus bacterial (bacteria that is resistant to the antibiotic,[MEDICATION(S)]) infection. On 5/5/22 at 9:00 A.M., the surveyor observed Certified Nurse Aide (CNA) #2 exiting room [ROOM NUMBER] on the [NAME] Unit. The surveyor observed CNA #2 carrying three ready to eat bowls of Cheerios and a bowl of jelly packets. The surveyor observed her carry them down the hall to the unit kitchen area and place the three bowl of cheerios in a cabinet, and place the bowl of jelly packets on the counter near the meal service area. The breakfast meals were being served at this time. The UM, several CNAs and a Dietary Staff member, were all present when CNA #2 put away the cereal bowls in the cabinet and left the bowl of jelly packets in the meal service area. During an interview on 5/5/22 at 10:46 A.M., the UM said the aide should have thrown away all the food items in the Resident's room and not brought them out of the room. During an interview on 5/5/22 at 11:06 A.M., the Director of Nurses said that none of the food items should have been brought out of the contact precaution room and this was an infection control problem. She said the nursing staff should have stopped CNA #1 from bringing the food items out of the room and placing them in the cabinet. She said proper infection control practices relative to contact precautions were not appropriately maintained by staff.

Based on record review and interview, the facility failed to ensure that staff provided the resident or the resident's representative, education regarding the benefits and side effects of the influenza and/or pneumococcal immunization and the right to consent to or refuse the influenza and/or pneumococcal immunization, for two Residents (#6 and #37), out of 13 sampled residents. Findings include: 1. Review of the facility's Pneumococcal Vaccination of Residents policy, undated, indicated the following: -It is the policy of this facility that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccination and their age at the time. If an immunocompromised resident was [AGE] years of age or less at the time of the initial vaccination and more than five years have elapsed since initial vaccination, one booster dose will be offered. -Pneumococcal candidates for vaccinations include (but not limited to): [AGE] years or older, serious long-term health problem such as [CONDITION(S)] and lung disease, resistance to infection with long-term steroid use and cancer and/or cancer treatment. -Educate resident or responsible party on benefits and risks of pneumococcal vaccine. Resident # 37 was admitted to the facility in July 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy (HCP) form, dated 7/21/16, indicated the Resident #37's HCP was invoked due to Alzheimer's disease and [CONDITION(S)] disease (affects blood flow and blood vessels of the brain). Review of the resident's Preventative Health Care Record indicated the Resident was administered a pneumococcal vaccine prior to admission (1/13/2006) and while inpatient at the facility on 5/10/19. Review of the clinical record indicated no evidence that Resident #37's HCP received education regarding the benefits and side effects of the vaccine and/or consented to the administration of the vaccine. During an interview on 5/5/22 at 11:10 A.M., the Unit Manager (UM) said a consent to administer the pneumococcal vaccine to Resident #37 on 5/10/19 was not found and there was no evidence the Resident's HCP had been educated on the benefits of the vaccine. She said both should have been provided/obtained prior to the vaccine being administered on 5/10/19. 2. For Resident #6 the facility failed to ensure staff obtained consent or provided education regarding the benefits or side effects of the influenza vaccine to the Resident's representative prior to administration. Resident #6 was admitted to the facility in December 2020. Review of the Health Care Proxy (HCP) Invocation Form, indicated the HCP was activated as of 12/7/20. Review of the Preventative Health Care Report, indicated the Resident was administered the influenza vaccine on 9/21/21. Review of the Consent for Immunizations, indicated the Resident's representative signed the consent to administer the influenza vaccine on 10/9/21 (after the vaccine had already been administered). During an interview on 5/05/22 at 8:05 A.M., the UM said that was the only consent for the influenza vaccine she could find for this resident and there was no evidence of education being provided prior to administration.

Based on interview, the facility failed to designate one or more individuals as the infection preventionist (IP); who had completed specialized training in infection prevention and control and worked at least part-time in the facility. Findings include: During an interview on 12/6/21 at 8:50 A.M., the Director of Nursing (DON) said there were no staff members in the facility who had completed specialized training in infection prevention and control. She further said a new IP had been hired but the facility was not planning on having the new IP complete specialized training in infection prevention and control until January 2022. The DON further said there was no IP on staff part-time while the new IP was in orientation and the facility had not had an IP since the end of September 2021. During an interview on 12/6/21 at 11:30 A.M., the IP said she was hired on 11/8/21, but had not completed any specialized training in infection prevention and control yet; she was still doing orientation.

Based on observation and interview, the facility failed to perform appropriate hand hygiene practices before and after contact with a resident on one unit ([NAME] Unit) out of two units observed. Findings include: On 12/6/21 at 9:22 A.M., the surveyor observed Nurse #1 in the [NAME] Unit dining room picking up dirty dishes from in-front of residents and placing them on a table to be picked up by the kitchen staff. Nurse #1 then proceeded to pick up a box of surgical masks without performing hand hygiene. She then proceeded to take a new surgical mask from the box and place the surgical mask on a resident's face without performing hand hygiene. Next, she took a new mask from the box and placed the surgical mask on another resident. Nurse #1 went to retrieve a third surgical mask from the box and was stopped by the surveyor. During an interview on 12/6/21 at 9:27 A.M., Nurse #1 said she should have done hand hygiene after touching the dirty dishes and before and after touching the residents' faces to assist them with putting on surgical masks and she did not do this as required. During an interview on 12/6/21 at 11:28 A.M., the Infection Preventionist said Nurse #1 should have done hand hygiene between patients especially when assisting them with surgical masks and she did not, as required.

Based on observation and interview, the facility staff failed to follow infection control protocol by not changing gloves while disposing of soiled linen and after interacting with residents on 2 of 2 units. Findings include: Review of the Centers for Disease Control (CDC) Guidelines for Hand Hygiene in Health-Care Settings, dated 10/25/02 (https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf) indicated the following: Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients. Review of the CDC's Linen and Laundry Management Guidance dated May 27 2020, (https://www.cdc.gov/hai/prevent/resource-limited/laundry.html) indicated the following: Place soiled linen into a clearly labeled, leak-proof container (e.g., bag, bucket) in the patient care area. Do not transport soiled linen by hand outside the specific patient care area from where it was removed. On 6/23/20 at 8:58 A.M., the surveyor made observations on the(NAME)Unit. The surveyor observed an aide leave a resident's room wearing gloves and holding soiled linen in both of his hands. The aide then placed the soiled linen in a cart and moved on to another task without changing his gloves or performing hand hygiene. On 6/23/20 at 9:15 A.M., the surveyor made observations on the(NAME)Unit. The surveyor observed an aide exit a resident's room wearing two pairs of gloves, enter the kitchen area, open the door to the refrigerator (thus contaminating the refrigerator handle) obtain a beverage from the refrigerator and return to the resident's room. At 9:20 A.M. the surveyor observed another aide on the Eliot Unit exit a resident's room wearing gloves holding a resident's breakfast tray. The aide threw away the tray and removed her gloves in the hallway and held them in her hands, thus contaminating her hands. The aide then entered the residents room without throwing away the contaminated gloves, performing hand hygiene or donning new gloves. During an interview with Unit Manager #1 on 6/23/20 at 9:25 A.M., she said that staff should be changing their gloves and washing their hands after every interaction with a resident, and after leaving a resident's room to prevent the potential spread communicable diseases.

Based on observation, interview and record review, the facility failed to fully implement a pressure ulcer care plan for 1 resident (#4) out of a total sample of 14 residents. Findings include: Resident #4 was admitted to the facility in 3/2019 with [DIAGNOSES REDACTED]. Review of the Quarterly Norton Skin Assessment, dated 9/24/19, indicated the resident's Norton Skin Assessment Score was 10, indicating the resident was at risk for developing a pressure ulcer. The assessment also indicated to continue with the current plan of care. Review of the resident's pressure ulcer care plan, dated 9/24/19, indicated Resident #4 would sit on a Roho cushion (used to relieve pressure) while in a chair. On 9/26/19 at 9:34 [NAME]M., the resident was observed sitting on an alarm pad in a chair. No cushion was observed. On 9/27/19 at 9:14 [NAME]M., the resident was observed sitting on an alarm pad in a chair. No cushion was observed. On 9/27/19 at 10:43 [NAME]M., the resident was observed sitting on an alarm pad in a chair. No cushion was observed. On 9/27/19 at 1:29 P.M., Certified Nurses' Assistant (CNA) #1 and the surveyor observed Resident #4 sitting on an alarm pad in a chair. CNA #1 said the resident always sat on just an alarm pad in the chair. He said the resident did not have a cushion. On 9/27/19 at 1:33 P.M., Nurse #1 and the surveyor observed the resident sitting in the dining room. Nurse #1 said he/she was sitting in a chair and did not have a cushion. The nurse reviewed the resident's care plan with the surveyor and said Resident #4 should have been seated on a Roho cushion to prevent skin breakdown, but was not. She also said the Roho cushion was a care plan intervention since the resident had a reddened area on his/her buttock on admission. On 9/27/19 at 2:45 P.M., Unit Manager #1 said she made an update to the resident's care plan that afternoon discontinuing the cushion, but prior to this update, the resident should have been seated on a Roho cushion.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was free from an accident resulting in an injury when, after Physical Therapy determined that Resident #1 required a two person assist with all transfers, staff were unaware of the change, and while Resident #1 was being transferred by only one staff person, he/she sustained a laceration to his/her left leg requiring sutures to close. Findings include: The Facility's Policy and Procedure titled Interdisciplinary Team Observation and Reporting of Changes in Resident's Condition or Status, dated 07/30/19, indicated unusual symptoms or changes in the resident's physical condition needs to be reported to a nurse who is responsible for that resident as soon as those changes are observed. The Policy indicated any changes in condition will be reflected in a Care Plan update and changes that need to be communicated to the Certified Nurse Aides will be sent to the Plan of Care Profile (Kardex) to reflect their current care needs. Resident #1's face sheet indicated he/she had [DIAGNOSES REDACTED]. Resident #1's Profile (Kardex), dated 07/31/18, indicated Resident #1 required a one to a two person assist with transfers. (Review of the Kardex, on the day of the survey 2/06/19, indicated it was unchanged and had not been updated to reflect Resident #1's change in status requiring two staff for all transfers, after his/her assessment by Physical Therapy on 1/15/19.) Resident #1's Activities of Daily Living/Rehabilitation Potential Care Plan implemented by nursing, dated 07/31/18, indicated he/she can transfer with a one to a two person assist. (Review of the Care Plan, on the day of the survey 2/06/19, indicated that the care plan had not been updated to reflect Resident #1's change in status requiring two staff for all transfers, after his/her assessment by Physical Therapy on 1/15/19.) The Physical Therapy Plan of Care, dated 01/16/19, indicated that based on Resident #1's initial Assessment (conducted on 01/15/19), he/she required maximum assistance of two people for transfers. The Physical Therapy Daily Treatment Note, dated 01/15/18, indicated Resident #1 was lowered to the floor on 01/14/19 while trying to get out of his/her recliner, was reportedly very agitated and nursing reported Resident #1 was more difficult with transfers. Resident #1's Activities of Daily Living/Rehabilitation Potential Care Plan, dated 01/15/19 implemented by Physical Therapy, indicated he/she required services due to decline in ability to transfer with nursing staff. The Care Plan indicated that Resident #1 required moderate to maximum assistance with two people for all transfers between the bed and wheelchair. The Resident Progress Note, dated 01/23/19 and the Event Report, dated 01/24/19, indicated she was called into Resident #1's bedroom at 8:40 P.M. on 01/23/19 by CNA #1. The Note indicated she saw Resident #1 lying in bed with a large blood stain on the bed sheet. The Note indicated Resident #1 had a laceration to the left lateral leg which appeared to be a skin flap. The Note indicated Resident #1's laceration measured 6.5 cm by 1 cm wide and had various areas of depth. The Note indicated pressure was immediately applied and the Nursing Supervisor was called to the bedroom for assistance. The Note indicated Resident #1 was sent to the hospital for evaluation as ordered by the Physician. The Emergency Department Nurse's Notes, dated 01/23/19, indicated Resident #1's laceration to the left leg was sutured by the Physician. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 10:15 A.M. on 02/12/19. CNA #1 said CNA #2 informed him that Resident #1 could be transferred without the assistance of a second CNA. CNA #1 said sometime after 8:00 P.M. on 01/23/19 he brought Resident #1 seated in on the wheelchair from the living room to the bedroom. CNA #1 said he removed the footrests and transferred Resident #1 onto the bed without assistance. CNA #1 said he noticed after the transfer that there was spot of blood on Resident #1's pant leg. CNA #1 said he immediately notified Nurse #1. The Surveyor interviewed the Nursing Supervisor at 11:40 A.M. on 02/06/19. The Nursing Supervisor said at approximately 8:40 P.M. on 01/23/19 Nurse #1 told her CNA #1 transferred Resident #1 to bed and he/she was bleeding. The Nursing Supervisor said she immediately went to the bedroom, saw Resident #1 lying in bed with blood on his/her pants. The Nursing Supervisor said medical attention was provided for the laceration to the left outer leg. The Nursing Supervisor said Resident #1 was sent to the Hospital after his/her Health Care Agent and the Physician were contacted. The Nursing Supervisor said she checked the Kardex and saw it indicated Resident #1 required a one to two person assisted transfer. The Nursing Supervisor said she was unaware at the time of the incident on 01/23/19, that Resident #1 had been assessed by Physical Therapy as requiring a two person transfer. The Surveyor interviewed the Director of Rehabilitation interviewed at 1:15 P.M. on 02/06/19. The Director of Rehabilitation said she conducted her initial assessment of Resident #1 on 01/15/19 which indicated Resident #1 required a maximum assist with two people for transfers. The Director of Rehabilitation said she did not recall if she communicated this change in Resident #1's Plan of Care to the nursing staff. The Director of Rehabilitation said she implemented a Care Plan on 01/15/19 indicating Resident #1 required a maximum assist with two people for transfers, and this approach has remained in effect. The Surveyor interviewed the Director of Rehabilitation at 1:45 P.M. on 02/13/19. The Director of Rehabilitation said she recalled informing staff members that Resident #1 was assessed as requiring a two person assist with all transfers while in attendance at the Risk Meeting (to discuss changes in condition with residents) on 01/16/19. The Surveyor interviewed the Director of Nurses (DON) at 2:00 P.M. on 02/11/19. The DON said the Unit Manager was supposed to update a resident's Plan of Care immediately after Rehabilitation conducts an assessment that requires a change with a resident's ability to perform activities of daily living. The DON said CNAs are required to follow the Kardex which documents the Plan of Care requirements related to activities of daily living, such as transfer status. The DON said Resident #1's Unit was not assigned a permanent Unit Manager, therefore the Staff Development Coordinator and herself assumed the responsibility and tasks at times in the interim. The DON said she had been unaware of that the Director of Rehabilitation's Initial Physical Therapy Assessment determined Resident #1 required a two person assist for transfers and that a Care Plan from Physical Therapy had been implemented.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure his/her Plan of Care, including the Kardex used by Certified Nurse Aides, was consistently updated to reflect a change in his/her transfer status to a two person transfer as was determined by an assessment conducted by Physical Therapy. Resident #1 who required the assistance of one or two staff persons for transfer, experienced a decline in status, was evaluated by Physical Therapy, who determined he/she required two persons for all transfers. Resident #1 was transferred without a two person assist and sustained a laceration to his/her left leg requiring sutures. Findings include: The Facility's Policy and Procedure titled Interdisciplinary Team Observation and Reporting of Changes in Resident's Condition or Status, dated 07/30/19, indicated unusual symptoms or changes in the resident's physical condition needs to be reported to a nurse who is responsible for that resident as soon as those changes are observed. The Policy indicated any changes in condition will be reflected in a Care Plan update and changes that need to be communicated to the Certified Nurse Aides will be sent to the Plan of Care Profile (Kardex) to reflect their current care needs. Resident #1's face sheet indicated he/she had [DIAGNOSES REDACTED]. Resident #1's Profile (Kardex), dated 07/31/18, indicated Resident #1 required a one to a two person assist with transfers. (Review of the Kardex, on the day of the survey 2/06/19, indicated it was unchanged and had not been updated to reflect Resident #1's change in status requiring two staff for all transfers, after his/her assessment by Physical Therapy on 1/15/19.) Resident #1's Activities of Daily Living/Rehabilitation Potential Care Plan implemented by nursing, dated 07/31/18, indicated he/she can transfer with a one to a two person assist. (Review of the Care Plan, on the day of the survey 2/06/19, indicated that the care plan had not been updated to reflect Resident #1's change in status requiring two staff for all transfers, after his/her assessment by Physical Therapy on 1/15/19.) The Physical Therapy Plan of Care, dated 01/16/19, indicated that based on Resident #1's initial Assessment (conducted on 01/15/19), he/she required maximum assistance of two people for transfers. The Physical Therapy Daily Treatment Note, dated 01/15/18, indicated Resident #1 was lowered to the floor on 01/14/19 while trying to get out of his/her recliner, was reportedly very agitated and nursing reported Resident #1 was more difficult with transfers. Resident #1's Activities of Daily Living/Rehabilitation Potential Care Plan, dated 01/15/19, indicated he/she required services due to decline in ability to transfer with nursing staff. The Care Plan indicated that Resident #1 required moderate to maximum assistance with two people for all transfers between the bed and wheelchair which was documented as created on 02/06/19. The Resident Progress Note, dated 01/23/19 and the Event Report, dated 01/24/19, as documented by Nurse #1 indicated she was called into Resident #1's bedroom at 8:40 P.M. on 01/23/19 by CNA #1. The Note indicated she saw Resident #1 lying in bed with a large blood stain on the bed sheet. The Note indicated Resident #1 had a laceration to the left lateral leg which appeared to be a skin flap. The Note indicated Resident #1's laceration measured 6.5 cm by 1 cm wide and had various areas of depth. The Note indicated pressure was immediately applied and the Nursing Supervisor was called to the bedroom for assistance. The Note indicated Resident #1 was sent to the hospital for evaluation, as ordered by the Physician. The Emergency Department Nurse's Notes, dated 01/23/19, indicated Resident #1's laceration to the left leg was sutured by the Physician. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 10:15 A.M. on 02/12/19. CNA #1 said CNA #2 told him that Resident #1 could be transferred without the assistance of a second CNA. CNA #1 said sometime after 8:00 P.M. on 01/23/19 he brought Resident #1, seated in the wheelchair, from the living room to the bedroom. CNA #1 said he removed the footrests and transferred Resident #1 onto the bed without assistance. CNA #1 said he noticed after the transfer that there was spot of blood on Resident #1's pant leg. CNA #1 said he immediately notified Nurse #1. The Surveyor interviewed the Nursing Supervisor at 11:40 A.M. on 02/06/19. The Nursing Supervisor said at approximately 8:40 P.M. on 01/23/19 Nurse #1 told her CNA #1 transferred Resident #1 to bed and he/she was bleeding. The Nursing Supervisor said the foot rests were not attached to the wheelchair from which Resident #1 was transferred from to the bed. The Nursing Supervisor said she checked the Kardex and saw it indicated Resident #1 required a one to two person assisted transfer. The Nursing Supervisor said CNA #1 reported to her that he removed the footrests from the wheelchair and transferred Resident #1 without assistance to bed. The Nursing Supervisor said she was unaware at the time of the incident on 01/23/19, that Resident #1 had a Care Plan implemented by Physical Therapy indicating Resident #1 required a two person assist with transfers. The Nursing Supervisor said she became aware on 02/05/19, when Resident #1 was discharged from Physical Therapy, that Resident #1 required a two person assist for transfers and said the Care Plan from nursing was to be updated to reflect this change following a meeting today (02/06/19). The Surveyor interviewed the Director of Rehabilitation at 1:15 P.M. on 02/06/19. The Director of Rehabilitation said she conducted an initial assessment of Resident #1 on 01/15/19 which indicated Resident #1 required a maximum assist with two people for transfers. The Director of Rehabilitation said she did not recall if she communicated this change in Resident #1's Plan of Care to the nursing staff. The Director of Rehabilitation said she implemented a Care Plan on 01/15/19 indicating Resident #1 required a maximum assist with two people for transfers, and this approach has remained in effect. The Surveyor interviewed the Director of Rehabilitation at 1:45 P.M. on 02/13/19. The Director of Rehabilitation said she reviewed the Care Plan she implemented on 01/15/19 following the interview with the Surveyor on 02/06/19. The Director of Rehabilitation said the Approach she added for moderate to maximum assistance with two people for transfers was added on 01/15/19, and not on 02/06/19 as stated it was created. The Director of Rehabilitation said she did not know why the Care Plan was altered. The Director of Rehabilitation said she entered the system on 02/06/19 only to indicate that Physical Therapy services were discontinued. The Director of Rehabilitation said to not implement the Approach on 01/15/19 that Resident #1 required moderate to maximum assistance with two people for transfers would have placed him/her at risk for his/her safety. The Surveyor interviewed the Director of Nurses (DON) at 2:00 P.M. on 02/11/19. The DON said the Unit Manager was supposed to update a resident's Plan of Care immediately after Rehabilitation conducts an assessment that requires a change with a resident's ability to perform activities of daily living. The DON said CNAs are required to follow the Kardex which documents the Plan of Care requirements related to activities of daily living, such as transfer status. The DON said Resident #1's Unit was not assigned a permanent Unit Manager, therefore the Staff Development Coordinator and herself assumed the responsibility and tasks at times in the interim. The DON said she had been unaware of that the Director of Rehabilitation's Initial Physical Therapy Assessment determined Resident #1 required a two person assist for transfers and that a Care Plan from her had been implemented. The DON said had she known, both the Care Plan and the Kardex initiated by Nursing would have been updated from a one to two person transfer, to a two person transfer for Resident #1.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was not neglected when on two occasions, CNA #1 and CNA #2, Resident #2's primary, consistent care givers, did not follow the plan of care during a transfer, which resulted in injury. - On 6/12/14, certified nurse aide (CNA) #1, knowing Resident #1's plan of care indicated Resident #1 required two persons for transfer, transferred Resident #1 from the wheelchair to the bed by herself. Resident #1 sustained a laceration to the left lower leg which required 12 sutures to close. - On 7/8/14, CNA #2 knowing Resident #1's plan of care indicated Resident #1 required two persons for transfer, transferred Resident #1 from the wheelchair to the bed by himself. Resident #1's healed laceration re-opened, requiring treatment to close the laceration. Findings include: Resident #1 was admitted to the Facility in January 2014 and medical [DIAGNOSES REDACTED]. Resident #1's transfer plan of care, dated 3/6/14, indicated Resident #1 needed two people to stand and pivot him/her to the chair or into bed. The Personal Care Plan, utilized by the CNAs providing care, indicated Resident #1 was a two person assist. The nurse's note, dated 6/12/14 during the 7:00 A.M. to 3:00 P.M. shift, indicated Resident #1 sustained a laceration to the left lower extremity, measuring approximately two inches by one inch, with a moderate amount of sanguinous drainage (bloody) was observed. The nurse's note indicated the laceration was obtained during a transfer on the wheelchair, and Resident #1 was transferred to the Hospital for sutures due to the depth of the laceration. The nurse's note indicated Resident #1 returned to the Facility after receiving 12 sutures to close the laceration. On 7/17/14 at 11:35 A.M., the Surveyor interviewed CNA #1. CNA #1 said that she was Resident #1's consistent caregiver during the 7:00 A.M. to 3:00 P.M. shift. CNA #1 said that she knew Resident #1 was a two person transfer. CNA #1 said on 6/12/14, Resident #1 returned from the hairdresser at about 2:50 P.M. and needed incontinence care. CNA #1 said it was near the change of shift however, the other CNAs were busy, and she did not want to leave the Facility at the end of her shift, which was at 3:00 P.M., before assisting Resident #1 with incontinence care. CNA #1 said she removed the foot rests from the wheelchair before she transferred Resident #1. CNA #1 said she transferred Resident #1 from the wheelchair to the bed by herself. CNA #1 said she stood in front of Resident #1, placed her arms around Resident #1's waist, and as she stood Resident #1, Resident #1 grabbed the arm of the wheelchair. CNA #1 said she sat Resident #1 on the side of the bed, Resident #1's bare legs were visible below his/her pant legs, and she observed bleeding from Resident #1's left leg and called the nurse. CNA #1 said although the CNAs were busy with other residents at the time she transferred Resident #1 by herself, she did not ask a nurse for assistance prior to transferring Resident #1 alone. Physician orders, dated 6/13/14, indicated to remove the sutures from Resident #1's left leg laceration in 14 days. Physician orders [REDACTED].#1, and removed and reapplied each shift after a skin check. On 7/17/14 at 11:15 A.M., the Surveyor interviewed Nurse #1. Nurse #1 said that leg protectors were padded sleeve-like clothing that protected a resident's fragile skin. Nurse #1 said the leg protector covered the skin from below the knee to the ankle. The Treatment Record, dated 6/27/14, indicated Resident #1's sutures were removed from the left leg by the licensed nurse. The nurse's note, dated 6/28/14, indicated that Resident #1's sutures were out, the skin at the site of the laceration was assessed as pink, intact, with no drainage, and no signs or symptoms of infection. The nurse's note, dated 7/8/14 at 9:45 P.M., indicated the CNA transferred Resident #1 back to bed and bumped Resident #1's previously closed laceration on the left lower leg, re-opening the laceration. The nurse's note indicated the area was cleansed with normal saline, steri-strips were applied, and the area was covered with a non-stick dressing. The nurse's note indicated the area had minimal bleeding, the physician was notified, and Resident #1's family member did not want Resident #1 sent out to the Hospital for treatment. On 7/17/14 at 3:00 P.M., the Surveyor interviewed CNA #2. CNA #2 said that he was Resident #1's consistent caregiver during the 3:00 P.M. to 11:00 P.M. shift. CNA #2 said he knew Resident #1's care plan stated Resident #1 required two staff for transfers. CNA #2 said that on 7/8/14, he did not ask for any assistance from the other CNAs or the nurse on the unit prior to assisting Resident #1 into bed alone. CNA #2 said he was aware that Resident #1 recently had the sutures removed from the left lower leg after sustaining a laceration during a transfer however, he thought he would be able to carefully transfer Resident #1 into the bed by himself. CNA #2 said Resident #1 was not wearing the leg protectors at the time he transferred Resident #1 to the bed. CNA #1 said after the transfer, that he observed bleeding from Resident #1's lower left leg, at the site of the previous laceration and called for the nurse. On 7/17/14 at 2:40 P.M., the Surveyor interviewed the Nursing Supervisor. The Nursing Supervisor said that on the evening of 7/8/14, CNA #2 came to her and told her that Resident #1 had a cut on his/her leg. The Nursing Supervisor said CNA #2 was aware that Resident #1 required assistance from two staff for transfers. The Nursing Supervisor said CNA #2 was aware of Resident #1's previous laceration to the left leg as he was Resident #1's consistent caregiver during the 3:00 P.M. to 11:00 P.M. shift.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed on two occasions, to ensure staff implemented the plan of care. Resident #1 required two staff for transfers, and on 6/12/14, certified nurse aide (CNA) #1 transferred Resident #1 by herself from the wheelchair to the bed; and Resident #1 sustained a laceration to the left lower leg requiring 12 sutures to close. On 7/8/14, CNA #2 transferred Resident #1 by himself from the wheelchair to the bed re-injuring Resident #1's left lower leg; and Resident #1 required steri-strips to close the laceration. CNA #1 and CNA #2 said they were aware Resident #1's plan of care required two staff to perform transfer, but did not ask for assistance prior to transferring Resident #1 without assistance. Findings include: Resident #1 was admitted to the Facility in January 2014 and medical [DIAGNOSES REDACTED]. Resident #1's transfer plan of care, dated 3/6/14, indicated Resident #1 needed two people to stand and pivot him/her to the chair or into bed. The Personal Care Plan, utilized by the CNAs providing care, indicated Resident #1 required two staff for assistance. The nurse's note, dated 6/12/14 during the 7:00 A.M. to 3:00 P.M. shift, indicated Resident #1 sustained a laceration to the left lower extremity during a transfer from the wheelchair to the bed, which required 12 sutures to close, due to the depth of the laceration. On 7/17/14 at 11:35 A.M., the Surveyor interviewed CNA #1. CNA #1 said that she was Resident #1's consistent caregiver during the 7:00 A.M. to 3:00 P.M. shift. CNA #1 said that she knew Resident #1 required assistance from two staff for transfers. CNA #1 said on 6/12/14, Resident #1 returned from the hairdresser at about 2:50 P.M. and needed incontinence care. CNA #1 said it was near the change of shift however, the other CNAs were busy, and she did not want to leave the Facility at the end of her shift, which was at 3:00 P.M., before providing incontinence care to Resident #1. CNA #1 said she removed the foot rests from the wheelchair before she transferred Resident #1. CNA #1 said she transferred Resident #1 from the wheelchair to the bed by herself. CNA #1 said she stood in front of Resident #1, placed her arms around Resident #1's waist, and as she stood Resident #1, Resident #1 grabbed the arm of the wheelchair. CNA #1 said she sat Resident #1 on the side of the bed, Resident #1's bare legs were visible below his/her pant legs, and she observed bleeding from Resident #1's left leg and called the nurse. CNA #1 said although the CNAs were busy with other residents at the time she transferred Resident #1 by herself, she did not ask a nurse for assistance with Resident #1's transfer prior to performing the transfer alone. Physician orders, dated 6/13/14, indicated to remove the sutures from Resident #1's left leg laceration in 14 days. Physician orders [REDACTED].#1, and removed and reapplied each shift after a skin check. The Treatment Record, dated 6/27/14, indicated Resident #1's sutures were removed from the left leg by the licensed nurse. The nurse's note, dated 6/28/14, indicated that Resident #1's sutures were out, the skin at the site of the laceration was assessed as pink, intact, with no drainage, and no signs or symptoms of infection. The nurse's note, dated 7/8/14 at 9:45 P.M., indicated the CNA (CNA #2) transferred Resident #1 back to bed and bumped Resident #1's old left leg laceration, causing the laceration to re-open. The nurse's note indicated the area was cleansed with normal saline, steri-strips were applied, and the area was covered with a non-stick dressing. The nurse's note indicated the area had minimal bleeding, the physician was notified, and Resident #1's family member did not want Resident #1 sent out to the Hospital for treatment. On 7/17/14 at 3:00 P.M., the Surveyor interviewed CNA #2. CNA #2 said that he was Resident #1's consistent caregiver during the 3:00 P.M. to 11:00 P.M. shift. CNA #2 said he knew Resident #1's care plan stated that Resident #1 required the assistance from two staff for transfers. CNA #2 said that on 7/8/14, he did not ask for any assistance from the other CNAS or the nurse on the unit to assist Resident #1 into bed. CNA #2 said he was aware that Resident #1 recently had the sutures removed from the left lower leg after sustaining a laceration during a transfer however, he thought he would be able to carefully transfer Resident #1 into the bed by himself. CNA #2 said Resident #1 was not wearing the leg protectors at the time he transferred Resident #1 to the bed. CNA #1 said after the transfer, he observed bleeding from Resident #1's lower left leg, at the site of the previous laceration. CNA #2 said he immediately called for the nurse. On 7/17/14 at 2:40 P.M., the Surveyor interviewed the Nursing Supervisor. The Nursing Supervisor said that during the evening of 7/8/14, CNA #2 told her Resident #1 had a cut on his/her leg. The Nursing Supervisor said CNA #2 was aware Resident #1 required two staff persons for transfers. The Nursing Supervisor said CNA #2 was aware of Resident #1's previous laceration to the left leg as he was Resident #1's consistent caregiver during the 3:00 P.M. to 11:00 P.M. shift.

Based on record review and interview, the facility failed for 1 sampled resident (Resident #9), of 3 applicable residents with pressure ulcers, out of a total sample of 14 residents, to prevent two pressure ulcers from developing. The facility failed to consistently assess and monitor the Resident's skin under a poorly fitting right knee immobilizer, according to the facility's Pressure Ulcer Prevention Protocol. Findings include: 1. For Resident #9, the facility failed to prevent the development of a new Stage III right lower leg pressure ulcer (full thickness loss of skin involving necrosis of subcutaneous tissue), by failing to remove a knee immobilizer to monitor skin integrity daily for shearing and pressure, according to the facility's Pressure Ulcer Prevention Policy. Both pressure ulcers required numerous surgical debridements by a wound specialist. Review of the Resident's clinical record on 04/04/14, indicated that the Resident was admitted to the facility in 3/2013 with the following Diagnoses: [REDACTED]. On 3/8/14 during pre-survey preparation, review of the facility's incident report dated 3/12/14, indicated that the Resident had an unwitnessed fall on 3/5/14, which resulted in a right distal femur fracture with the application of a right knee immobilizer. On 4/4/14, review of the 3/8/13 Transfer Report and Hospital Discharge instructions indicated the following: 1.) Non-weight bearing to right lower extremity until cleared by Orthopedics 2.) Continue knee immobilizer to the right lower extremity (without instructions to inspect skin under knee immobilizer). 3.) Follow-up with orthopedic surgeon in 1-2 weeks. On 4/4/14 review of the Physician's Orders dated 3/8/13 indicated the following: "knee immobilizer at all times." The skin check section of the pre-printed orders was blank, with no specific days or shift to be completed for skin inspections. Review of the Resident's Admission Minimum Data Set Assessment (MDS), dated [DATE] (prior to identification of pressure ulcers) for skin conditions indicated that the Resident is at high risk of developing a pressure ulcer, but had "0" pressure ulcers present at this time. Review of the Quarterly MDS dated [DATE] for skin conditions indicated 1 stage III (5.2 cm. x 1.5 cm. x 0.4 cm.) and necrotic tissue (dead tissue)present (2.5 centimeter=1 inch). On 4/4/14 review of the Admission Nursing Assessment, dated 3/8/13 indicated the Resident's skin integrity as pale, warm, normal and intact with a Norton Skin Assessment Score of 10 (a score below 9 indicates very high risk of skin breakdown). A care plan dated 3/28/13 indicated the following interventions (without specific instruction to remove immobilizer for skin integrity checks): * Pressure relief mattress and cushion to chair * Broda Chair (after pressure ulcers identified) * Diabetic foot care * Turning schedule as appropriate * Prostat daily and multivitamins (after pressure ulcers identified) Review of the facility's "Pressure Ulcer prevention Protocol", effective 12/21/12 indicated the following: * Norton Plus Skin Assessment Scale will be done on admission, weekly for the first four weeks following admission, quarterly and with any change of condition. * Bony prominences will be inspected with all personal care and any changes will be reported to the charge nurse and MD. * Institution of measures to reduce the effects of pressure, friction and sheer. On 4/4/14, review of the Skilled Nursing Notes from 3/9/13 to 3/19/13 (7 A.M.-3:00 P.M. shift) indicated that the knee immobilizer was in place with positive circulation, sensation and motion (csm) and positive pedal pulse, however, there was no nursing documentation indicating that the knee immobilizer had been removed for skin inspection. Further review of the Skilled Nursing Notes on the following dates indicated that the (aphasic) Resident was resistive to wearing the knee immobilizer: 3/8/14 (4:45 P.M.): "became agitated shortly after returning from hospital, attempting to remove brace" 3/13/14 (3-11:00 P.M. shift): "agitated, trying to pull brace off, attempting to strike staff when brace was re-secured." 3/17/14 (3-11:00 P.M. shift): "restless at beginning of shift, but behavior improved after scheduled [MEDICATION NAME]." 3/20/14 (3-11:00 P.M.): "shifting weight in chair and grimacing" 3/25/14 "agitated and constantly moving, causing shifting of the immobilizer." Review of the Physical Therapist's Report of Consultation dated 3/27/13 also indicated that the Resident was resistive to wearing the knee immobilizer: "The patient tends to loosen straps and attempts to remove brace which is shifting causing obvious skin issues." Review of the Treatment Administration Record (TAR) from 3/2/13 through 3/23/13 indicated entries by nursing staff of "knee brace in place" and "circulation, sensation and motion (csm) positive (+), but no documentation of taking off the knee immobilizer and inspecting the skin for pressure and shearing, according to the facility's Pressure Ulcer Prevention Protocol. Review of the Nurse Practitioner (NP) Note dated 3/25/13, indicated the identification of a new pressure ulcer (17 days following the application of the knee immobilizer): "Asked to see patient by nursing to evaluate skin breakdown on right calf due to friction from ill fitting brace." Measurement at first identification was 8 centimeters (cm.) x 3 cm. with necrosis (dead tissue) at 2 x 3 cm. The wounds required surgical debridement on 6/5/13 to remove dead tissue. (1 inch =2.5 cm.) The NP Assessment/Plan indicated: "Pt has follow-up appointment with ortho tomorrow and will be fitted for a proper brace-add Santyl Ointment daily and an ABD dressing-will monitor closely. Review of the Nurse Practitioner Visit note dated 3/28/13 indicated the following: "Skin breakdown-Pt. has a new, smaller leg brace which will cause less friction and shearing-consider referral to wound MD if not better in one week." Review of the initial Wound Report of Consultation dated 5/22/13 indicated that the Nurse Practitioner was requesting consultation for wound care from right knee immobilizer which lead to an open area on right calf, now with intermittent fever 100-101 degrees Fahrenheit. The initial Wound Report measurement indicated: right calf upper =6.5cm. x 2.2 x 1.5 and right lower calf 3cm. x 2 cm. The Wound Report dated 4/8/14 indicated: both wounds are progressing well- right calf upper= 1.3 x 0.3 cm. and right lower calf = 2.2cm. x 1.9cm. The Surveyor requested to observe the wound treatment in the facility, however the Unit Manager told the surveyor that all wound treatments were performed only by the wound physician at his office. On 4/4/14 at approximately 10:30 A.M., the Surveyor interviewed Unit Manager #1 (UM) in the conference room. The UM said that the nursing staff did not specifically report taking down the knee immobilizer to inspect the skin. She also said that she had worked with the staff in-servicing them on pressure ulcer prevention following this incident for approximately one month. The UM was currently tracking the progression of wound healing with weekly wound assessments according to the facility policy, following the identification of the pressure ulcer. On 4/11/14 at approximately 2:30 P.M. the Surveyor interviewed the Nurse Practitioner (NP) over the telephone. The NP could not recall the details of the Resident's plan of care, however she did say that she would expect staff to remove a brace or immobilizer to inspect skin integrity even if the physician's orders did not specify that. On 4/22/14 at 9:25 A.M., the Surveyor interviewed the consulting wound physician over the telephone. The wound consultant said that the pressure ulcers were caused by the knee immobilizer and that in his opinion, considering the 2cm. x 3cm. necrotic area observed on the first wound consult visit, that the wounds had been present for several weeks prior to the facility's 3/25/14 initial identification of the 2 calf pressure ulcers. He also said that the Resident's ankle was quite swollen and that staff would have seen the pressure ulcers, if the knee immobilizer was taken off for skin inspection. The wound consultant said that the Resident had undergone several surgical wound debridements and that one calf pressure ulcer is healed, but the second pressure ulcer is still healing and that it will take time.

Based on record review and staff interview, the facility failed to ensure adequate supervision in the facility's activity room to prevent a fall with femur fracture for 1 (Resident #9) of 5 applicable residents with falls, out of a total sample of 14 residents. Findings include: Resident #9 was admitted to the facility in 2/2013 with vascular dementia, insulin dependent diabetes mellitus, a history of stroke (2010) with residual aphasia (a language disorder, commonly caused by stroke and ranging from having difficulty remembering words to losing the ability to speak) and an unwitnessed facility fall with right femur fracture on 3/5/13. The Resident suffered an acute blood loss anemia from the femoral shaft fracture and required blood transfusion. Review of the Initial Care Plan of 3/28/13 indicated that Resident #9 is a high risk for falls, frequently makes attempts to self-rise, wears a pad alarm at all times and can't be left alone in room or during toileting. On 4/3/14, review of the Minimum Data Set (MDS) with an assessment reference date of 3/13 indicated that Resident #9 had a Brief Interview for Mental Status (BIMS) score of "05". A BIMS score of 0-7 indicates severe cognitive impairment. Functional status for locomotion off of the unit indicated "4" for total dependence with "2" indicating a one person physical assist. On 4/4/14, review of the Occupational Therapy Evaluation and Plan of treatment dated 2/26/13-3/27/13 indicated that Resident #9 required constant supervision due to impaired cognition and confusion, was assessed as a fall risk and mobility was weight bearing as tolerated and rolling walker with one assist. On 4/4/14 review of the Fall Incident report and investigation with an incident date of 3/5/13 at 2:30 P.M. indicated that at the time of the fall, the recreation program was a religious activity for both the skilled facility and assisted living residents. Two recreation assistants from the assisted living facility were in attendance. One assistant was transporting assisted living residents back to their residences. The other assistant left the community room (activity) to assist a resident who was exit seeking. An occupational therapist (OT) statement indicated that she had transported Resident #9 to the community room and left him/her with the recreational assistants. The OT statement also indicated that Resident #9's clip alarm was not on at that time and that the string and clip were later found several feet away under a staff member's paperwork. Further review of the incident report indicated that Resident #9 stood from his/her wheelchair and sustained an unwitnessed fall because the staff had left the residents unattended in the recreation room. The Resident complained of right leg pain, was assessed by facility staff and transported to the hospital for evaluation. An x-ray confirmed a right distal fracture of his/her femur which could not be surgically repaired, therefore the Resident was placed in a right knee immobilizer brace for 4 weeks with non-weight bearing status. On 4/8/14, during the Quality Improvement Interview with the Director of Nursing (DON), the DON said that the transporting process had been re-evaluated and now included 2 skilled facility staff with "walkie talkies" at all times. Facility safety in-servicing was initiated and the DON monitors the out of neighborhood transporting of all residents.