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

Based on observations, record reviews and interviews, the facility failed to ensure services provided by the kitchen were in accordance with professional standards for food service safety to prevent the risk of foodborne illness for residents residing in the facility. Specifically,a. Dietary staff failed to label and date food available for use in the walk-in refrigerator and dietary staff failed to properly store frozen meat patties.b. Dietary staff failed to wash their hands in between gloves changes and between tasks.c. Staff in the kitchen failed to wear hair restraints in the food prep areas. Findings include:Review of the facility's policy, titled 'Food Production and Food Safety', dated 1/1/2010, indicated food storage, it is the policy of the facility that sufficient, clean, well-ventilated storage areas are provided to keep foods safe and fresh. Food stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination. Review of 'Procedures' included but was not limited to 11. Refrigeration: e. All foods should be covered, labeled and dated. 12. Frozen Foods: c. Foods should be covered, labeled and dated. a. During an observation with [NAME] #1 on 5/26/26 at 7:03 A.M., the following was observed in the kitchen walk-in refrigerator: -A large shallow hotel pan containing a brown food substance was not labeled or dated. -A shallow hotel pan containing a food product, was not labeled or dated.-A hotel pan filled with food resembling sweet potatoes not labeled or dated. -A small hotel pan, located next to defrosting meat, filled with food resembling chocolate cupcakes not labeled or dated. -Two large deep clear plastic pans containing food resembling melon and cantaloupe not labeled or dated. During an interview on 5/26/26 at 7:03 A.M., [NAME] #1 said food in the refrigerator should be labeled with the date prepared, and the use by date. During an observation on 5/26/26 at 7:04 A.M., the surveyor observed the walk-in freezer which revealed an open box of beef patties; The inside bag was not secure, leaving the beef patties to be exposed and not covered. During an interview on 5/27/26 at 11:27 A.M., the Food Service Director (FSD) said all food stored in the refrigerator should be labeled and dated. During an observation and interview on 5/27/26 at 1:54 P.M., with the surveyor and the FSD, the following was observed: -A large deep clear pan containing cut melon and cantaloupe in the walk-in refrigerator, without a label or date. The FSD said it should be labeled and dated. -A box containing frozen beef patties in the walk-in freezer, that was open with the bag inside was open, leaving the beef patties exposed and not covered. One beef patty had a buildup of ice on it. The FSD said they are used frequently, and the inside bag in the box should be secure to prevent freezer burn. b. Review of the facility's policy, titled 'Sanitation and Infection Control' Policy: Hand Washing, dated 1/1/2010 indicated, Procedures: Clean hands and exposed portions of arms (or surrogate prosthetic devices) immediately before engaging in food preparation including working with exposed food. 1. When to Wash Hands: after handling soiled equipment or utensils, during food preparations, as often as necessary to remove soil and contamination and to prevent cross, contamination when changing tasks, before donning (put on) gloves for working with food, after engaging in other activities that contaminate hands. Review of the facility's policy, titled 'Sanitation and Infection Control' 'Glove Use', dated 1/1/2010 indicated, 1. If used, single use gloves shall be used for only one task (such as working with ready to eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled and when interruptions occur in the operation. 2. Hands are to be washed when entering the kitchen and before putting on the plastic gloves. 4. Remember gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, gloves must be changed. During an observation on 5/26/26 beginning at 7:03 A.M., [NAME] #1 was wearing gloves on both hands and handling pans in the food prep area. [NAME] #1 then removed her gloves while walking, stopped and picked up trash on the floor and placed the gloves and trash into the trash receptacle. Cooked #1 then walked back to the stove side of the food prep area, reached in a box for gloves and placed them on both hands without washing her hands. [NAME] #1 then with potentially contaminated gloved hands then picked up a shallow large pan of eggs with her gloved hands on the perimeter of the pan and touched the service utensil. During an observation on 5/27/26 at 11:27 A.M., [NAME] #2 was observed wearing gloves on both of his hands. [NAME] #2 was using his gloved hands to hold lemons while cutting them into pieces. [NAME] #2 then left the area to another part of the kitchen and grabbed a long-handled strainer walked back to the food prep area and placed it down on the counter. [NAME] #2 then walked with his same gloved hands to the walk-in refrigerator and opened the door to the refrigerator and then exited with a food product. At no point during the observation did [NAME] #2 remove his gloves and wash his hands. During an interview on 5/27/26 at 1:54 P.M., [NAME] #2 said gloves should be removed between tasks like preparing food and going from one area to another in the kitchen or between tasks. [NAME] #2 said before putting on gloves you must wash your hands. [NAME] #2 said he moved from one area to another and did not remove his gloves. During an interview on 5/27/26 at 2:17 P.M., the surveyor shared the observations of [NAME] #1 and [NAME] #2 with the FSD. The FSD said proper use of gloves and hand washing is required for food safety. c. Review of the facility's policy Hair Restraints, Dining Service Personnel will wear restraints to prevent from the direct and indirect food contamination. 2. Dining Service personnel must wear hair restraints such as hats, hair coverings or hair nets, beard/mustache restraints, and clothing that cover body hair. Hair restraints must be designed and worn to effectively keep hair contacting exposed food, clean equipment, utensils and dishware. During an observation and interview in the kitchen on 5/26/26 beginning at 7:03 A.M. a staff member was standing next to [NAME] #3 at the flat-top grill actively cooking omelets and talking with each other. The staff member was not wearing a hair restraint. The staff person moved through the kitchen and said she was a dining coordinator for the assisted living. [NAME] #3 said the grill and food prep areas are used for both assisted living and skilled nursing facility. During an interview, observation and interview on 5/27/26 1:54 P.M., the FSD was on the food prep area of the kitchen, walking around the kitchen where food is prepared and not wearing a hair restraint. When asked by the surveyor about the hair restraint the FSD said he had removed it in his office and forgot to put it back on and should have. The FSD said he expects staff or anyone near food preparation to wear something to cover their hair.

Based on interviews, observations, and policy review, the facility failed to ensure staff treated residents in a dignified manner. Specifically, on the Dementia Specialty Care Unit, the facility failed to provide a dignified dining experience in the dining room where not all residents were served their meal timely. Findings include:Review of the facility titled Residents' Rights, dated 9/5/25, indicated Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence.On 5/26/26, the surveyor observed three residents seated at their dining table on the Dementia Care Specialty Unit. The first two residents received their meal at 12:30 P.M. The surveyor then observed the third resident received their meal tray at 12:39 P.M., nine minutes after the first two residents received their meals. On 5/26/26, the surveyor observed three residents seated at their dining table on the Dementia Care Specialty Unit. The first two residents received their meal at 12:30 P.M. The surveyor then observed the third resident received their meal tray at 12:43 P.M., thirteen minutes after the first two residents received their meals. The first two residents finished their meal before the third resident received their meal tray.On 5/26/26, the surveyor observed four residents seated at their dining table on the Dementia Care Specialty Unit. The first three residents received their meal at 12:34 P.M. The surveyor then observed the fourth resident receive their meal tray at 12:39 P.M., five minutes after the first three residents received their meals. On 5/27/26, the surveyor observed two residents seated at their dining table on the Dementia Care Specialty Unit. The first resident received their meal at 8:43 A.M. The surveyor then observed the second resident receive their meal tray at 8:51 A.M., eight minutes after the first resident received their meal. On 5/27/26, the surveyor observed two residents seated at their dining table on the Dementia Care Specialty Unit. The first resident received their meal at 8:44 A.M., the second resident was observed trying to take food items off the first resident's tray. The surveyor then observed the second resident receive their meal tray at 8:54 A.M., ten minutes after the first resident received their meal. On 5/27/26, the surveyor observed four residents seated at their dining table on the Dementia Care Specialty Unit. The first three residents received their meal at 8:44 A.M. The surveyor then observed the fourth resident receive their meal tray at 8:51 A.M., seven minutes after the first three residents received their meals. On 5/27/26, the surveyor observed three residents seated at their dining table on the Dementia Care Specialty Unit. The first two residents received their meal at 8:43 A.M. The surveyor then observed the third resident received their meal tray at 8:49 A.M., six minutes after the first three residents received their meals. On 5/27/26, the surveyor observed two residents seated at their dining table on the Dementia Care Specialty Unit. The first resident received their meal at 8:51 A.M. The surveyor then observed the second resident receive their meal tray at 9:01 A.M., ten minutes after the first resident received their meals. On 5/27/26, the surveyor observed four residents seated at their dining table on the Dementia Care Specialty Unit. The first and second residents received their meal at 12:26 P.M. and 12:28 P.M. The surveyor then observed the third resident receive their meal tray at 12:34 P.M., the fourth resident was observed to be taking fruit off the third resident's tray saying, I am hungry and grabbing for the other resident's utensils. The fourth resident was observed to receive their lunch tray at 12:39 P.M., thirteen minutes after the first resident received their meal. On 5/27/26, the surveyor observed three residents seated at their dining table on the Dementia Care Specialty Unit. The first resident received their meal at 12:26 P.M. The surveyor then observed the second resident received their meal tray at 12:36 P.M. not set up for consumption. The surveyor then observed the third resident receive their meal tray at 12:40 P.M., fourteen minutes after the first resident received their meal. Due to the residents' cognition level, they were unable to participate in the interview process.During an interview on 5/27/26 at 12:42 P.M., Certified Nurse Aide (CNA) #1 said the meal tray pass should be passed out for each table so each table can eat together but that is not happening. CNA #1 said a lot of residents have to wait a long time for their meals.During an interview on 5/27/26 at 12:43 P.M., Nurse #3 said meals should be passed out in order so it should go table by table. Nurse #3 said it is not fair for some residents to wait so long and watch others eat at their table. During an interview and observation on 5/27/26 at 12:48 P.M., Unit Manager #1 said tray pass should go in order for each table, residents should not have to wait more than a couple minutes to receive their meals, but they are. Unit Manager #1 said residents should not have to watch their table mate eat while they wait for their meal.During an interview on 5/27/26 at 12:59 P.M., the Therapeutic Activity Director (TAD) said the staff's goal is to serve each meal in order of each table. The TAD said no resident should have to wait more than a minute or two while their table mates are eating for their meal.

Based on observations and interviews the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure both medication carts were locked while a nurse was not present on the Dementia Specialty Care Unit. Findings include:Review of the facility policy titled Medication Storage in the Facility, dated July 2024, indicated Medications and biologicals are stored safely, securely, and properly. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. On 5/26/26 at 7:46 A.M., the surveyor observed the Dementia Care Specialty Unit medication cart A unlocked and unsupervised. On 5/27/26 from 8:12 A.M. to 8:14 A.M., the surveyor observed the Dementia Care Specialty Unit medication cart A unlocked and unsupervised. The surveyor observed staff and residents walking by the medication cart. On 5/27/26 at 11:31 A.M., the surveyor observed the Dementia Care Specialty Unit medication cart B unlocked and unsupervised. The surveyor observed a resident in front of the cart in his/her wheelchair. The surveyor was able to access the medications. During an interview and observation on 5/27/26 at 11:33 A.M., Nurse #3 said she should have locked her medication cart when she left it but did not. On 5/27/26 at 12:24 P.M., the surveyor observed the Dementia Care Specialty Unit medication cart B unlocked and unsupervised. During an interview on 5/27/26 at 12:54 P.M., Unit Manager #1 said nurses are expected to have their medication carts locked at all times unless they are present at the cart. The Unit Manager said it is a danger to residents to leave the medication carts unlocked.

Based on record review and interview, the facility failed for one Resident (#2) out of 19 sampled residents to notify the provider of a change in medical status. Specifically, facility staff failed to notify Resident #2's provider of an abnormal urine odor. Findings include: Review of the facility's policy Notification of Change in Resident's Condition dated 7/30/14, indicated: The facility will promptly notify the resident, consult with his or her attending physician, and if known, notify the resident's legal representative of changes in the resident's condition and/or status.Resident #2 was admitted to the facility in March 2026 and has active diagnoses which include stroke, benign prostatic hyperplasia and urinary tract infections (in the last 30 days).Resident #2's Minimum Data Set date 4/3/26 indicated a Brief Interview for Mental Status examination score of 5, signifying severe cognitive impairment, and intermittent urinary catheterization. Resident #2's care plan for urinary retention dated 4/23/26, indicated he/she required staff to obtain a post-void residual every shift and straight catheterization only if needed.Resident #2's physician progress note dated 5/5/26 indicated: Urinary retention. Continues with retention but at times is voiding better now. Will change orders to PVR (post-void residual) every shift and straight catheterization only if needed and greater than 400 milliliters.Resident #2's nursing note (entered by Nurse #1) dated 5/24/26, indicated the Resident's post-void residual measured 427 milliliters, and his/her briefs were saturated. A straight catheterization was completed. Patient urine has foul smelling fishy odor present. Further review of Resident #2's medical record indicated there was no additional reference to his/her urine odor or that nursing staff notified the provider of this change in condition.During an interview on 5/27/26 at 10:20 A.M., Nurse #1 said that on 5/24/26 Resident #2's urine smelled abnormal and she informed the nurse in charge, Nurse #2, of the condition. Nurse #1 said that Nurse #2 was responsible for updating the provider about Resident #2's abnormal urine odor.During an interview on 5/27/26 at 10:37 A.M., Nurse #2 said that on 5/24/26 Nurse #1 told her that Resident #2's straight catheterization urine had a foul odor. Nurse #2 said the abnormal odor represented a change in the Resident's medical status. Nurse #2 said she intended to contact and update the on-call provider, but she forgot.During an interview on 5/27/26 at 10:50 A.M., Physician #1 said staff had not made her aware of Resident #2's abnormal urine odor. Physician #1 said she would have considered this a change in the Resident's condition and expected nursing staff to inform her of this change. Physician #1 said that Resident #2 had a history of urinary tract infections and abnormal urine odor was a symptom of an infection. Physician #1 said that if she had been made aware of the urine odor, she would likely have ordered a culture and sensitivity laboratory test to determine if the Resident had a urinary tract infection. Physician #1 said that Resident #2 had a history of urinary tract infections. Physician #1 said that untreated urinary tract infections can lead to more significant infections within the body.During an interview on 5/27/26 at 11:01 A.M., the Director of Nursing (DON) said it is her expectation for staff to inform the provider when there is a change in a resident's status, which includes abnormal urine. The DON said that abnormal smelling urine is a symptom of a urinary tract infection and, left untreated, can lead to more significant infections.

Based on observation, interview and record review, the facility failed to implement a physician's order for fortified foods to prevent further weight loss for one Resident (#58) out of a total sample of 19 Residents. Specifically, the facility failed to provide fortified cereal and fortified mashed potatoes with meals for weight loss as recommended by the Registered Dietitian and as ordered by the physician.Findings include:Review of the facility policy titled Weight Management, dated and revised 6/24/22, indicated the following:- The Registered Dietitian will review monthly weights and calculate significant change over one, three and six months and complete a monthly weight loss report.- The Interdisciplinary Risk Team will review and assess residents experiencing a weight change at the Risk Meeting. The Risk team will review and document on all significant weight changes with appropriate referrals to appropriate disciplines such as Registered Dietitian (RD).Resident #58 was admitted to the facility in April 2023 with diagnoses including dementia, type 2 diabetes mellitus and dysphagia. Review of Resident #58's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status exam score of 8 out of 15 indicating moderation cognitive impairment. Further review of the MDS indicated that the Resident does not have a history of refusing care. Review of Resident #58's physician's dietary order dated 4/16/26 indicated the following: House, soft bite sized, Special Instructions: Add fortified cereal with breakfast, fortified mashed potatoes lunch and dinnerReview of Resident #58's weight history indicated the following:-2/4/26: 139.2 lbs. (pounds)-3/18/26: 125.1 lbs.-3/18/26: 129 lbs.-4/2/26: 129 lbs.-5/7/26: 125.6 lbs.-5/26/26: 126 lbs.From 2/4/26 through 3/18/26, Resident #58 had a 10-pound weight loss indicating a significant weight loss of 7.19%.Review of a progress note written by the Registered Dietitian (RD) on 4/10/26 at 11:23 A.M., indicated the following:-Annual Nutritional Assessment: Resident #58 reweigh 4/2/26 129# (pounds) validates weight loss (7% over past month). Fortified foods added to maximize intake along with house supplement offered TID (three times daily). Review of Resident #58's most recent annual Nutrition Comprehensive Assessment completed by the Registered Dietitian dated 4/10/26 indicated the following:- Current Diet Order: Fortified Foods 4/6/26.- Weight Status: Weight Loss 7% x 30d (thirty days).- Nutrition Interventions: diet and supp (supplement) as ordered.The surveyor made the following observations:- On 5/26/26 at 8:52 A.M., Resident #58 was eating breakfast in the third-floor dining room. There was no fortified cereal on his/her breakfast tray. The Resident's meal ticket did not indicate fortified cereal should be with his/her breakfast.- On 5/26/26 at 12:31 P.M., Resident #58 was eating lunch in the third-floor dining room. There was no fortified mashed potatoes on his/her lunch tray. The Resident's meal ticket did not indicate fortified mashed potatoes should be with his/her lunch.- On 5/27/26 at 8:46 A.M., Resident #58 was eating breakfast in his/her room with the assistance of the Director of Nursing (DON). There was no fortified cereal on his/her breakfast tray. The Resident's meal ticket did not indicate fortified cereal should be with his/her breakfast.- On 5/27/26 at 12:28 P.M., Resident #58 was eating lunch in the third-floor dining room. There was no fortified mashed potatoes on his/her lunch tray. The Resident's meal ticket did not indicate fortified mashed potatoes should be with his/her lunch.- On 5/28/26 at 8:58 A.M., Resident #58 was eating breakfast in the third-floor dining room. There was no fortified cereal on his/her breakfast tray. The Resident's meal ticket did not indicate fortified cereal should be with his/her breakfast.During an interview on 5/27/2026 at 2:17 PM the Food Service Director (FSD) said fortified foods like fortified cereal and mashed potatoes are on the tray ticket. He said the diet orders come from nursing and they get a report from the facility's electronic medical record and recommendations get manually entered in the online tray ticket system. During an interview on 5/28/26 at 8:00 A.M., the RD said nursing will obtain weights monthly and during risk meeting the facility will go through the weights. The RD said when a resident has a significant weight loss she will add fortified foods such as cereal and mashed potatoes to meal trays. The RD then said she will send her recommendations to the physician or nurse practitioners who will approve her recommendations and input a physician's order. From there, the Dining Room Coordinator will get notified to add the fortified foods into the online tray ticket system so they appear on the meal tickets so the kitchen knows to include them with meals. The RD said Resident #58 had a significant weight loss within one month recently and she added fortified foods to his/her diet. The RD said she would expect Resident #58 to receive the fortified foods to combat the weight loss and she was not aware they were not on his/her meal ticket.During a follow up interview on 5/28/26 at 9:02 A.M., the RD said there was a systems breakdown between the electronic medical record system and the online tray ticket system causing the fortified foods to not be added to Resident #58's meal tickets. The RD said Resident #58's family member has been filling out the menus for a few weeks now and she just found out today that Resident #58 does not like hot cereal and if she knew sooner, she would have tried a different option.During an interview on 5/28/26 at 9:06 A.M., the Dining Room Coordinator said Resident #58's family member has been selecting the Resident's meals recently and has not been circling oatmeal. The surveyor asked if oatmeal and fortified cereal were different, the Dining Room Coordinator said they were. The FSD then said half-and-half is added to the fortified foods to add calories. The Dining Room Coordinator said Resident #58 should still be getting the fortified cereal and the fortified mashed potatoes never got added to his/her meal ticket because the online systems were not communicating with one another. The Dining Room Coordinator said if she was aware that Resident #58 did not want hot cereal, she would have notified the RD so an alternate fortified option could be trialed.During an interview on 5/28/26 at 9:29 A.M., the Director of Nurses (DON) said Resident #58 should be receiving fortified foods if the RD recommended them and if there is a physician's order for them. The DON then said she does not remember seeing fortified mashed potatoes on the Resident's lunch yesterday when she was assisting the resident with eating. The DON continued to say there is clearly some type of breakdown between the electronic medical record and the online tray ticket system.

Based on observation and interview the facility failed to transport dirty and soiled laundry in accordance with accepted national standards. Specifically, the facility failed to bag and cover dirty and soiled linen in the laundry chute and in the dirty linen area. Findings include: The Center for Disease Control Linen and Laundry Management in Health Care Settings dated 3/19/24, indicated soiled linen should be placed in a leak proof container during transport.Review of the facility's Laundry and Housekeeping policy (undated) indicated: If soiled linen are sent by chute, the aids need to put in a plastic bag and housekeeping will follow the rest of the procedure.On 5/26/26 at 12:31 P.M., the surveyor observed the side of the laundry room where dirty/soiled linen was kept. Two large carts were located beneath the dirty laundry chute. Both carts held dirty clothing and linen, including soiled towels. The dirty laundry was exposed and not stored in plastic bags.On 5/26/26 at 2:36 P.M., the surveyor observed the side of the laundry room where dirty/soiled linen was kept. The two large carts still contained dirty and soiled laundry, and more laundry had been added to one of the carts. The dirty laundry was exposed and not stored in plastic bags. During an interview with the Director of Housekeeping and Laundry on 5/26/26 at 2:42 P.M., he observed the unbagged, dirty and soiled laundry in the two carts. The Director of Housekeeping and Laundry said dirty laundry should be bagged by staff before sending them down the laundry chute.

Based on observations, and interviews, the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, the facility failed to ensure that resident food was prepared and distributed appropriately to prevent the potential for cross contamination by staff in the main kitchen when: -Dietary Staff #1 was observed handling food items and food trays and walked around other areas of the main kitchen touching surfaces using the same gloves. Dietary Staff #1 was also handling dirty trays and resident food items on the food service line and did not change gloves or perform appropriate hand hygiene. -Dietary Staff #2 did not change gloves or perform appropriate hand hygiene between working on the resident food service line, moving around other areas of the kitchen and returning to the serving line. Findings include: Review of the facility policy for Glove Use in the Dining Services Department, last revised 4/1/25, indicated: -plastic gloves will be worn when handling food that will not be cooked further to ensure that bacteria are not transferred from the food handler's hands to the food product being served. -if used, single use gloves shall be used for only one task, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. -hands are to be washed when entering the kitchen and before putting plastic gloves on. -wash hands after removing gloves. Review of the facility policy for Food Services- Hand Hygiene last revised 4/1/25, indicated that hands should be washed with soap and water at the following times: -before each shift -before putting on (donning) gloves -between handling raw and cooked foods -after handling soiled silverware/utensils -after handling garbage -after removing gloves -after any activity that may contaminate hands On 6/23/25 the surveyor observed the following during the breakfast meal service in the facility main kitchen: -At 8:29 A.M., the surveyor and the Food Service Director (FSD) observed Dietary Staff #1 step away from the serving line with gloved hands to walk to the corner of the kitchen to grab a tray of muffins. Dietary Staff #1 placed the tray on a table closer to the food she was serving, took a muffin off the tray with her gloved hand and placed it on a resident's tray. Dietary Staff #1 then proceeded to continue to serve food on the resident trays with the same gloved hands. The surveyor observed the FSD instructing Dietary Staff #1 to remove her gloves and wash her hands. During an interview at the time, the FSD said that Dietary Staff #1 should have changed her gloves and washed her hands as soon as she stepped away from the serving line and she did not. -At 8:34 A.M., the surveyor observed Dietary Staff #1 step away from the serving line to take a dirty metal tray to the dirty dish area of the kitchen. Dietary Staff #1 did not remove her gloves, wash her hands or don a new pair of gloves prior to returning to the serving line and proceeding to serve breakfast with the same gloved hands. -At 8:36 A.M., the surveyor observed Dietary Staff #2 step away from the serving line to retrieve a serving utensil from another area of the kitchen. Dietary Staff #2 did not remove her gloves, wash her hands or don a new pair of gloves prior to returning to the serving line and proceeding to serve breakfast with the same gloved hands. The surveyor then observed the FSD instructing both Dietary Staff #1 and Dietary Staff #2 to remove their gloves and wash their hands prior to returning to the serving line. During an interview at the time, the FSD said that Dietary Staff #1 and Dietary Staff #2 should have removed their gloves and washed their hands after stepping away from the food serving line and they did not.

Based on observation, and interview, the facility failed to ensure that patient care equipment was maintained in safe operating condition for one Resident (#47) out of a total sample of 18 residents. Specifically, for Resident #47, the facility failed to ensure that an air mattress ordered by the Physician was appropriately functioning as required when the air mattress was plugged into a non-functioning electrical outlet and the Resident was not receiving the pressure relieving benefit of the air mattress. Findings include: Review of the Medline Supra CXC User Manual, undated, indicated: -Troubleshooting >power is not on. Solution: check if the plug is connected to the mains, check if there is any blown fuse. >patient is bottoming out. Solution: pressure setting might be inadequate for the patient. Adjust pressure to a higher level and wait a few minutes. Resident #47 was admitted to the facility in July 2024 with diagnoses including Dementia and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #47: -was unable to complete the Brief Interview for Mental Status exam because they are rarely or never understood -was significantly cognitively impaired -was dependent on staff for all Activities of Daily Living (ADLs) -was at risk for developing pressure ulcers and utilized a pressure relieving device for bed and chair -was receiving Hospice services Review of Resident #47's Care Plan for Skin Breakdown, last revised 5/2/25, indicated: -the Resident is at risk for skin breakdown due to incontinence and decreased mobility -an intervention for an air mattress to bed Review of Resident #47's June 2025 Physician's orders indicated: -order for an air mattress with bolsters applied to the bed -monitor mattress for comfort setting per resident preference every shift, start date 4/28/25. On 6/17/25 at 8:45 A.M., the surveyor observed Resident #47 asleep in bed on an air mattress which had been plugged into a red electrical outlet (electrical outlet connected to emergency backup power). The surveyor observed the power to the Resident's mattress was not on and the mattress was deflated when the surveyor touched it. On 6/17/25 at 4:27 P.M., the surveyor observed Resident #47's lying in bed with an air mattress in place and plugged into a red outlet. The surveyor observed that the power to the air mattress was not on and the mattress was deflated upon examination. On 6/18/25 at 7:48 A.M., the surveyor observed Resident #47 asleep in bed on an air mattress that was plugged into a red outlet, but the power was not turned on and the air mattress was deflated on examination. Review of the Resident #47's June 2025 Medication Administration Record (MAR) indicated that the Resident's air mattress had been checked daily every shift for comfort. During an interview on 6/18/25 at 8:40 A.M., the surveyor and Nurse #1 observed Resident #47 asleep in the bed with an air mattress in place. Nurse #1 said that the red outlet did not appear to be working, that nursing staff should have been checking the air mattress every shift, according to the Physician's orders and they had not been. During an interview on 6/18/25 at 8:41 A.M., the Director of Nurses (DON) said that Resident #47's air mattress should have been working, but it had not been and that she intended to notify the maintenance department.

2. Resident #10 was admitted to the facility in July 2020 with diagnoses including open wound of the abdominal wall and atherosclerosis of native arteries of left leg with ulceration of heel and midfoot. Review of Resident #10's Physician's order for June 2025, indicated: -Enhanced Barrier Precautions (EBP) related to lower leg wounds. >Special Instructions: Gown/Glove Use for High Contact Care: dressing, bathing/showering, transferring, providing hygiene, changing linens. On 6/20/25 at 8:01 A.M., the surveyor observed CNA #2 remove soiled linen from Resident #10's bed and place the linen in a bag on the floor next to the Resident's bed in his/her room. CNA #2 was observed wearing gloves but not wearing a gown. CNA #2 was further observed to exit Resident #10's room with the soiled gloves still in place, and proceed into the hallway and remove clean linen from a linen cart in the hallway. The surveyor observed CNA #2 go back into Resident #10's room with the clean linen and make the Resident's bed with the soiled gloves still in place. When CNA #2 finished making the bed, she doffed the dirty gloves and sanitized her hands. During an interview on 6/20/25 at 8:10 A.M., CNA #2 said she was aware Resident #10 was on EBP related to leg wounds. CNA #2 said she did not don a gown because she was not providing high contact care to Resident #10. The surveyor and CNA #2 reviewed the EBP sign at the Resident's door and CNA #2 said she should have worn a gown while changing Resident #10's bed, but she did not. CNA #2 further said she should have removed her gloves and sanitized her hands before exiting the Resident's room to obtain clean linen, but she did not. During an interview on 6/20/25 at 8:14 A.M., Unit Manager (UM) #1 said she was unsure whether the CNAs are expected to wear gowns or gloves when changing linens on the bed for residents on EBP and would get back to the surveyor. During an interview on 6/20/25 at 8:42 A.M., UM #1 said that CNAs were expected to wear gowns and gloves when changing linens for residents on EBP. UM #1 said that CNA #2 should have worn a gown when making Resident #10's bed but she did not. During an interview on 6/20/25 at 10:17 A.M., the Chief Nursing Officer (CNO) said that CNA #2 should have worn gloves and a gown when she made Resident #10's bed, but she did not. Based on observation, and interview, the facility failed to adhere to infection control standards of practice, increasing the risk of contamination and spread of infections on one unit ([NAME] Unit) out of two units, and for one Resident (#10) out of a total sample of 18 residents. Specifically, the facility failed to: 1. ensure that the staff on the [NAME] Unit wore the indicated personal protective equipment (PPE-items such as gowns and gloves worn by staff to decrease the spread of infections) when providing high contact care for residents on Enhanced Barrier Precautions (EBP-measures using protective barrier gowns and gloves as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDRO) during high contact resident care) when a Certified Nurses Aide (CNA) provided denture hygiene care for a unit resident. 2. For Resident #10, ensure that staff followed the EBP ordered by the Physician when removing the Resident's dirty bed linens and performed appropriate hand hygiene and glove use when applying clean bed linens. Findings include: Review of the facility policy titled Enhanced Barrier Precautions (EBP), dated 4/6/23, indicated: -Enhanced Barrier Precautions expands the use of PPE and refer to the use of gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing -MDRO's may be indirectly transferred from resident to resident during these high contact care activities -The use of gown and gloves for high contact resident care activities is indicated when contact precautions do not otherwise apply for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. -Examples of high-contact resident care requiring gown and glove for use of enhanced barrier precautions include: >dressing >bathing/showering >transferring >providing hygiene >changing linens >changing briefs or assistance with toileting 1. On 6/18/25 at 8:22 A.M., the surveyor observed the following: -Certified Nurses Aide (CNA) #1 enter a room on the [NAME] unit with posted signs for EBP which indicated: >Everyone must clean their hands, including before entering and when leaving the room >providers and staff must also: -wear gloves and a gown for the following high contact resident care activities: >dressing >bathing/showering >transferring >changing linens >providing hygiene >changing briefs or assisting with toileting >device care or use: central line, urinary catheter, feeding tube, tracheostomy >wound care: any skin opening requiring a dressing -CNA #1 was observed donning gloves but no gown, and entering the EBP room. -CNA #1 was observed to take a denture cup from the resident and then bring the denture cup into the resident's bathroom. -CNA #1 returned from the resident's bathroom with the dentures on a paper towel and handed the dentures to the resident. -CNA #1 doffed her gloves, performed hand hygiene and exited the room. During an interview on 6/18/25 at 8:26 A.M., CNA #1 said she was washing the resident's dentures in the bathroom. CNA #1 said she did not know why the resident was on precautions because she does not normally work on the [NAME] Unit. CNA #1 said she did not think she needed a gown because she had gloves on and was only cleaning the resident's dentures. During an interview on 6/23/25 at 12:20 P.M., the Director of Nursing (DON) said the resident on the [NAME] Unit observed by the surveyor was on EBP because the resident had a Peripherally Inserted Central Catheter (PICC line). The DON said that CNA #1 should have been wearing a gown when completing denture care for the resident because denture care is considered high contact care.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff implemented and followed their abuse policy, when on 7/22/24 an Activity Aide (AA) witnessed another staff member interact with and handle Resident #1 in a potentially abusive manner, however the AA did not immediately report the incident as required, and Administrative staff did not become aware of the incident until the following day (7/23/24) when a visitor, who was also present during the incident reported it to the facility. Findings include: Review of the Facility Policy titled Abuse Prevention and Prohibition, dated as revised 04/01/2019, indicated the Facility assured an environment free of abuse, neglect, mistreatment, and misappropriation of resident property. The Policy indicated that staff who witness or have knowledge of abuse, mistreatment, neglect, misappropriation of resident property or exploitation are required to report it immediately to the nursing supervisor. Resident #1 was admitted to the Facility in August 2023, diagnoses included Neurocognitive Disorder, Lewy Bodies Dementia, and Parkinson's disease. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 05/15/24, indicated he/she scored a 3 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact. Further review of the MDS Assessment, indicated Resident #1 required substantial to maximal assistance of one staff member for transfers and ambulation. Review of Resident #1's Activites of Daily Living (ADL) Care Plan, reviewed and renewed with his/her May 2024 Quarterly MDS Assessment, indicated he/she required partial to moderate assistance of one staff member for sit to stand and required reminders to stay seated in the activity room. Review of Resident #1's Cognitive Loss/Dementia Care Plan, reviewed and renewed with his/her May 2024 Quarterly MDS Assessment, indicated staff would anticipate and meet his/her needs when he/she was unable to communicate them. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) dated as submitted on 7/23/24 indicated that on 07/22/24 at approximately 4:30 P.M., a Family Member of another Resident witnessed CNA #1 in the activity room being rough with Resident #1 and said the Activity Aide also witnessed the event. Per the Report, the Family Member reported the incident the following day on 7/23/24. Further review of the Report indicated the Activity Aide witnessed Resident #1 in the activity room, attempting to stand and that CNA#1 pushed down on his/her shoulders in a rough manner. The Report indicated that an investigation was initiated on 7/23/24 as soon as it was reported, CNA #1 was interviewed, denied the allegations, and was suspended pending further investigation and ultimately terminated. During an interview on 08/29/24 at 1:25 P.M., the Activity Aide said on 7/22/24 at approximately 4:30 P.M., she witnessed CNA# 1 push Resident # 1 on his/her bilateral shoulders down onto the chair in a rough manner when he/she stood up in the activity room. The Activity Aide said she did not report the incident until 7/23/24, but said she should have reported it immediately to a nursing supervisor. During an interview on 08/29/24 at 1:01 P.M., the Director of Nurses (DON) said that on 7/23/24 at approximately 2:30 P.M., a Family Member attending the care plan meeting of another Resident reported she witnessed a CNA being rough with Resident #1 and that an Activity Aide was also present and witnessed the event. The DON said that on 07/23/24, after the Family Member report, she began an investigation into the allegation of abuse and reported the allegation of abuse to the Department of Public Health (DPH) as required. The DON said that the allegation of abuse should have been reported by the Activity Aide immediately to Administration on 7/22/24 and that education on the abuse policy and timely reporting had been conducted with all staff.

Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility failed to have an RN working at least eight consecutive hours for four days between 10/1/23 to 12/31/23, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Findings include: Review of the Fiscal Year Quarter One (dated 10/1/23 through 12/31/23) Payroll Based Journal (PBJ: reporting system to which nursing facilities report on staffing data) Report indicated that the facility reported No RN in the facility for eight consecutive hours on the following dates: -10/1/23 -10/29/23 -11/12/23 -12/3/23 During an interview on 5/7/24 at 8:36 A.M., the facility Administrator said the facility had no Nurse staffing waivers. During an interview on 5/9/24 at 11:12 A.M., the surveyor and the Facility Scheduler reviewed the staffing schedule and the Facility Scheduler said that there was no RN scheduled for eight consecutive hours on 10/1/23, 10/29/23, 11/12/23 and 12/3/23. During an interview on 5/9/24 at 12:04 P.M., the Director of Nurses (DON) reviewed the staffing schedule and said there was no RN scheduled for the identified days reported on the PBJ report. During an interview on 5/9/24 at 1:07 P.M., the facility Administrator said there was no RN in the facility for the required eight consecutive hours on the dates reported on the PBJ report.

Based on observation, interview, record and policy review, the facility failed to ensure that two Residents (#54 and #61), out of a total sample of 20 residents were provided with necessary assistance during dining service to decrease the risk of reduced nutritional intake. Specifically, the facility staff failed to: 1. For Resident #54, offer to provide physical assistance to set up meal trays by opening opening containers and placing meal items in an accessible manner that would enable the Resident to consume his/her meals. 2. For Resident #61, assist the Resident in setting up their meal tray for ease with dining by cutting up food items as needed and ensuring meal items were accessible. Findings include: Review of the facility's Dining Program Policy, undated, indicated the following: -It was the facility's policy to provide an enhancing resident-centered dining service that encourages nutritional intake, resident independence, social relationships, and overall well-being. -Proper assistance and encouragement will be given to residents as needed or care planned. 1. Resident #54 was admitted to the facility in November 2023, with a diagnosis of Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) with agitation (state of anxiety or nervous excitement). Review of Resident #54's Activities of Daily Living (ADL) Care Plan, initiated 11/16/23 and edited 11/29/23, indicated the Resident required setup/clean-up assistance for eating. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired as evidenced by a BIMS score of zero out of 15 total possible points. Review of Resident #54's Functional Abilities for Eating Record for 5/1/24 through 5/6/24 indicated the Resident's functional abilities for eating varied from requiring partial/moderate assistance to independent. On 5/7/24, between 9:10 A.M. and 9:47 A.M., the surveyor observed the following in the Dementia Special Care Unit (DSCU) Dining Room: -Resident #54 was sitting at a dining table with two other residents. -The Resident's meal tray was in front of him/her at the table and included the following items: >One breakfast sandwich, cut in half. One half of the sandwich was off the back of the plate. >One partially eaten muffin on the plate. >One banana, unpeeled, on the tray, behind the plate and out of view of the Resident. >One covered, unopened plastic cup of water. >One unopened carton of milk. >One uncovered bowl of oatmeal. >One uncovered ice cream cup. >One unopened plastic cup of orange juice with a tin foil cover. -Resident #54 held a spoon and knife and was rubbing them together. -At 9:12 A.M., the surveyor observed Resident #54 pick up the milk carton and attempt to pull on the top of the carton repetitively. -At 9:14 A.M., the surveyor observed Resident #54 holding the unopened milk carton in his/her left hand and the uncovered pudding cup in his/her right hand. -The Resident placed the ice cream cup back on the tray, continued to hold the unopened carton of milk and began pulling at the top of the carton again. -The Resident then placed the unopened milk carton back on the tray, placed the fingers on his/her right hand into the bowl of oatmeal, removed his/her fingers from the bowl and licked them. -Resident #54 picked up the ice cream cup and attempted to drink it, but no pudding came out of the cup. -At this time, the surveyor observed no staff in the immediate dining area. -At 9:18 A.M., the surveyor observed a staff member entered the Dining Room and walked by the Resident, into the adjacent dining area, but did not stop to assist Resident #54. -At 9:19 A.M., the surveyor observed Resident #54 take his/her spoon and repeatedly push it into the side of the unopened milk carton. -At 9:25 A.M., the surveyor observed another resident at the table take Resident #54's unopened milk carton and attempt to open it using a fork. -The surveyor observed the other Resident then stood and reached onto Resident #54's plate, picked up one half of Resident #54's breakfast sandwich, and took a bite, then picked up Resident #54's pudding cup and ate the pudding. -At this time, Resident #54 placed the unopened orange juice and what was left of the breakfast sandwich on his/her plate with the partially eaten muffin, then pushed him/herself away from the table. On 5/8/24, from 8:32 A.M. through 8:40 A.M., the surveyor observed the following in the DSCU Dining Room: -Resident #54's breakfast tray was on the table where the Resident was sitting. -The breakfast tray included the following items: >One uncovered plate with a muffin and one breakfast sandwich that was cut in half. >One unopened cup of orange juice with a tin foil lid. >One unopened fruit cup with a plastic lid. >One unopened bowl of oatmeal with a plastic lid. >One unopened carton of milk. >One unopened cup of water with a plastic lid. >One unopened ice cream cup. -Resident #54 picked up the unopened fruit cup from the meal tray, attempted to grasp the edge of the lid, then began twisting the lid repeatedly before shaking his/her head side to side, then placing the fruit cup back on the tray. -At 8:35 A.M., Resident #54 pushed him/herself away from the table, then moved him/herself forward in his/her wheelchair, bumping into another resident's chair. -At this time, the other resident began to push Resident #54's wheelchair away from him/her and Resident #54 vocalized an expletive. -No staff were observed to intervene and assist Resident #54 until 8:37 A.M. when the MDS Nurse intervened and asked Resident #54 if she could assist him/her. -At this time, the MDS Nurse assisted Resident #54 back to the table and offered to open the Resident's food items that had not been previously opened. -Resident #54 said yes to allowing the MDS Nurse to open his/her orange juice and oatmeal, and also accepted a plastic cup with a lid and straw containing a soft drink. -Resident #54 then ate some oatmeal and drank all of the soft drink. During an interview on 5/10/24 at 11:15 A.M., the MDS Nurse said Resident #54 would allow staff to assist him/her at times, and would also refuse assistance at times. The MDS Nurse said when staff provide Resident #54 with his/her meal tray, staff should always offer to open the food items, and if the Resident refuses, then staff should wait and re-approach. The MDS Nurse also said if the Resident showed interest in specific food items and was having difficulty accessing or opening the food items, staff would need to intervene and provide assistance for the Resident. 2. Resident #61 was admitted to the facility in April 2021, with diagnoses including: Dementia, Parkinson's Disease (chronic and progressive movement disorder that initially causes tremors and impaired muscular coordination), and Insomnia (sleep disorder with trouble falling and/or staying asleep). Review of Resident #61's MDS Assessment, dated 4/3/24, indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) of three out of 15 total possible points. Further review of the MDS Assessment indicated the Resident required setup and clean-up assistance for eating. Review of Resident #61's ADL Care Plan, initiated 10/2/23 and edited 4/15/24, indicated the Resident was independent for eating following setup/clean-up. Review of Resident #61's Functional Abilities for Eating Record for 5/1/24 through 5/7/24 indicated the Resident's functional abilities for eating varied from requiring substantial/maximal assistance to setup or clean-up assistance. On 5/8/24, from 8:45 A.M. through 9:01 A.M., the surveyor observed the following in the DSCU Dining Room: -Resident #61 was sitting at a table with his/her breakfast tray in front of him/her. The breakfast tray included: >Two whole pancakes, stacked. >One uncovered bowl of oatmeal. >One uncovered cup of orange juice. -Resident #61 held a spoon in his/her right hand, pushed it under one of the pancakes and attempted to pick it up several times, but the pancake fell off the spoon. -Resident #61 brought the spoon to his/her mouth after each attempt to pick up the pancake, but the spoon had nothing on it. -The surveyor then observed Resident #61 use the spoon to scoop across the table cloth, then bring the spoon to his/her mouth. -Resident #61 then picked up another spoon and a fork from the table so that he/she was holding two spoons and one fork in his/her hands. -Resident #61 placed the spoons and fork onto the plate and began closing his/her eyes. -No staff were observed to assist Resident #61 with his/her breakfast meal until 9:01 A.M. when the DSCU Program Director intervened. During an interview on 5/8/24 at 10:15 A.M., the DSCU Program Director said Resident #61 normally fed him/her self after being provided setup assistance for meals. The DSCU Program Director said she knew Resident #61 did not sleep well the night before, so the Resident was tired and required more assistance that day with breakfast. When the surveyor asked what staff should do to assist residents when they require more assistance, the DSCU Program Director said that she could not speak to the facility's expectation for the level of assistance staff should provide for residents during meal time, based off the residents' status. The DSCU Program Director said Unit Manager (UM) #2 would know more about how staff provided assistance to residents based on the residents' needs. During an interview on 5/8/24 at 10:45 A.M., UM #2 said when staff provided meal trays to residents on the Unit, all food items were to be cut up and covered/sealed items were to be opened for the residents. UM #2 said if residents' status' varied and they needed more assistance, then staff were expected to provide the assistance needed in a timely manner. UM #2 said staff should have provided assistance to set up breakfast meals for Resident #54 on 5/7/24 and 5/8/24 and for Resident #61 on 5/8/24, by cutting up the food items and ensuring all food and drink items were accessible to the Residents.

Based on interview, record and policy review, the facility failed to provide privacy and confidentiality for one Resident (#27) out of 19 sampled residents. Specifically, for Resident #27, the facility staff failed to ensure that personal privacy of the Resident's own body was provided when he/she was observed to be naked and attempting to get dressed in their bedroom. Findings include: Review of the facility policy titled Resident's Rights, last revised 9/19/23, indicated that Federal and state law guarantee certain basic rights to all residents of this facility including: -a dignified existence -privacy and confidentiality Resident #27 was admitted to the facility in May 2023, with diagnoses including vascular Dementia (problems with reasoning, planning, memory, judgement, and other thought processes caused by brain damage from impaired blood flow to the brain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #27 was unable to complete the Brief Interview for Mental Status (BIMS) exam and was cognitively impaired. On 5/7/24 at 8:03 A.M., the surveyor observed from the Resident's bedroom doorway that Resident #27 was located in his/her bedroom, was naked, and attempting to dress him/herself while sitting in his/her wheelchair. On 5/7/24 at 8:11 A.M., the surveyor asked Nurse #1, who was in the vicinity of the Resident's doorway, if Resident #27 required assistance with dressing. The surveyor observed that Nurse #1 looked into the room at Resident #27 and said that he/she did not require any assistance with dressing. The surveyor further observed that Nurse #1 continued with the task she was doing and did not attempt to enter the Resident's room to draw the Resident's privacy curtain, close the door, or cover the Resident's body. On 5/7/24 at 8:18 A.M., the surveyor observed Certified Nurses Aide (CNA) #2 enter Resident #27's room to obtain an item for the Resident's roommate. The surveyor observed that the Resident was still naked and sitting in his/her wheelchair. The surveyor observed CNA #2 exiting the room without covering the Resident's body or drawing the privacy curtain and leaving the Resident naked, where he/she could still be seen from the doorway by anyone looking into the bedroom. During an interview on 5/8/24 at 8:15 A.M., Nurse #1 said that Resident #27 should have been covered or a privacy curtain should have been drawn and that was not done. During an interview on 5/8/24 at 8:17 A.M., CNA #1 (who also worked on the Resident's unit) said if she saw a Resident naked from the hallway, she would go and help them by covering them with a sheet, when the surveyor asked what she would do in this situation. During an interview on 5/8/24 at 12:18 P.M., Unit Manager (UM) #1 said that the staff should have covered Resident #27 when he/she was exposed. During an interview on 5/9/24 at 10:01 A.M., CNA #2 said that he saw Resident #27 naked in his/her room. CNA #2 also said that he told the CNA on the Resident's assignment what he had seen, but did not cover the Resident's body or draw the curtain for privacy.

Based on record review and interview, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for two Residents (#27 and #28) out of a total sample of 19 residents. Specifically, the facility failed to: 1. For Resident #27, ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #27's invoked (made active by a Physician) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so). 2. For Resident #28, ensure that the MOLST form was valid and reflected the signature of the Resident's appointed/invoked HCP. Findings include: Review of the facility policy titled Advanced Directives and Massachusetts Health Care Proxy, last revised 2/25/24, indicated the following: -On admission determine if the patient has a validly executed MOLST form or copy of the form. -The Admissions Director or Social Worker will determine if the form has been validly executed and contains the signature of the Resident and the signature of the Physician, Nurse Practitioner (NP) or Physician Assistant (PA). -At the time of the Quarterly Care planning, the Advanced Directives will be reviewed with the patient, or health care agent to determine if they remain valid. 1. Resident #27 was admitted to the facility in May 2023, with diagnoses including vascular Dementia (problems with reasoning, planning, memory, judgement, and other thought processes caused by brain damage from impaired blood flow to the brain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #27 was unable to complete the Brief Interview for Mental Status (BIMS) exam and was cognitively impaired. Review of the clinical record revealed a MOLST form that was signed by someone other than the Resident, or Resident #27's appointed HCP on 10/31/14. Review of the Massachusetts Health Care Proxy Designation Form indicated Resident #27 had appointed a HCP on 2/11/16. Review of the clinical record indicated that the Physician had invoked Resident #27's Health Care Proxy (HCP) on 5/17/23. During an interview on 5/8/24 at 12:02 P.M., the Director of Nurses (DON) said the facility did not have evidence that Resident #27's HCP had been activated prior to the date the MOLST form was signed on 10/31/14. The DON also said that a new MOLST form should have been completed on the Resident's admission to the facility and that the MOLST form that was currently on file was not valid. 44337 2. Resident #28 was admitted to the facility in December 2023 with a diagnosis of Malignant Neoplasm (Cancer). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #28 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment of 14 out of a total possible score of 15. Review of the Massachusetts Health Care Proxy Designation Form indicated Resident #28 had appointed a HCP on 9/5/13. Review of the HCP Invocation Form for Resident #28 indicated that the Resident's HCP had been invoked on 2/7/24. Review of the MOLST form for Resident #28 indicated that the MOLST form was signed by someone other than the Resident or appointed HCP and was dated 12/15/23. During an interview on 5/8/24 at 12:09 P.M., the DON said that the Resident's MOLST form was invalid because it had been signed by verbal authorization of a person who was not Resident #28's HCP on 12/15/23. The DON said a new MOLST form should have been signed by Resident #28's designated HCP when the Resident was admitted to the facility.

Based on observation, interview, record and policy review, the facility failed to provide an environment as free of accidental hazards as possible, consistent with the needs of one Resident (#84) out of a total sample of 20 residents. Specifically, the facility staff failed to provide adequate supervision and assistance for Resident #84 during meal time, when the Resident was assessed and ordered for a pureed (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) diet texture, but was able to obtain and ate regular textured food from another Resident's (#54's) meal tray, increasing the Resident's risk for complications and illnesses. Findings include: Review of the facility's Dining Program Policy, undated, indicated the following: -It was the facility's policy to provide an enhancing resident-centered dining service that encourages nutritional intake, resident independence, social relationships, and overall well-being. -Proper assistance and encouragement will be given to residents as needed or care planned. -Therapeutic diets and consistencies will be adhered to. Review of the American Cancer Society's document titled Living as an Oral Cavity and Oropharyngeal Cancer Survivor, dated 3/23/21, indicated the following: -Cancers of the mouth and throat can sometimes cause problems making it hard to eat. -Some people might need to adjust what they eat during and after treatment . -Surgery . can lead to problems with speech, swallowing, . -Speech Therapists are knowledgeable about speech and swallowing problems and can help one learn to manage them. Resident #84 was admitted to the facility in October 2023 with diagnoses including: Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Malignant Neoplasm (cancerous tumor) of the Hard Palate (the roof of the mouth, separating the cavities of the nose and the mouth). Review of Resident #84's Health Care Proxy (HCP: person who makes health care decisions for someone who is not able to make health care decisions for themselves) Invocation Form, dated 10/25/23, indicated the Resident's Physician permanently invoked (made active) the Resident's HCP on 10/25/23 due to progressive Dementia. Review of Resident #84's Speech Therapy Evaluation and Plan of Treatment, dated 10/26/23, indicated the following: -The Resident had a history of Malignant Neoplasm of the Hard Palate. -The Resident was status post palatal resection (portion of the palate removed and presents swallowing difficulty) due to palatal cancer. -The Resident had a prosthesis (artificial body part) for the hard palate, but did not tolerate using it due to Dementia/confusion. -The Resident had been eating pureed foods since the palate resection. -The Resident's HCP reported that the Resident occasionally experienced nasal regurgitation (swallowing disorder that occurs when food or fluid comes up into the nose while eating or drinking)/emission (discharge) of material in the Resident's mouth. -The Resident was expected to remain on a pureed diet unless he/she wore his/her palate prosthesis. Review of Resident #84's Speech Therapy Discharge Summary, dated 1/30/24, indicated: -The Resident's swallow status was stable. -The Resident required a pureed diet. -Attempt use of palatal prosthetic. Review of Resident #84's Physician's order dated 1/18/24, with no stop date, indicated: -The Order was a Dietary Order. -The Resident required a House (regular), Pureed diet. Review of Resident #84's Minimum Data Set (MDS) Assessment, dated 4/24/24, indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) due to the Resident being rarely/never understood. Further review of the MDS Assessment indicated: -The Resident wandered one to three days during the assessment period. -The Resident required a mechanically altered (changed by means of whipping, blending, chopping, or mashing) diet. Review of Resident #84's Behavioral Symptoms Care Plan, edited 5/3/24, indicated: -The Resident had a behavior of wandering. -The Resident's needs would be anticipated to limit behaviors. -Staff were to provide re-direction and re-approach as needed. Review of Resident #84's Nutritional Status Care Plan, edited 4/9/24, indicated: -The Resident presented with nutritional concerns. -The Resident was missing part of his/her hard palate. -The Resident required a mechanically altered diet. -Diet as ordered. On 5/8/24, between 8:32 A.M. and 9:17 A.M., the surveyor observed the following: -Resident #84 was seated at a table in the Dining Room, next to Resident #54. -Staff provided Resident #84 with his/her meal tray which contained pureed texture food items. -Staff provided Resident #54 with his/her meal tray which included one breakfast sandwich and one muffin. -Resident #54 left the table at 8:56 A.M. and staff removed the Resident's breakfast tray which included a partially eaten breakfast sandwich and one whole muffin. -Resident #84 was still sitting at the table and had eaten all of his/her own food. -Resident #54 returned to the table, next to Resident #84, at 9:02 A.M. -Staff returned Resident #54's breakfast tray to him/her which included the partially eaten breakfast sandwich and the muffin. -At this time, the surveyor observed Resident #84 stand up and begin walking through the dining room. -The Activities Assistant (AA) offered to walk out in the hallway with Resident #84. -The Resident began to walk with the AA, but turned back to the dining room and sat down next to Resident #54 while Resident #54 ate a portion of the breakfast sandwich. -The AA remained in the hallway with another resident at this time. -Resident #54 then left the table and Resident #84 remained seated at the table with Resident #54's meal tray next to him/her on the table. -At this time, the surveyor observed the Dementia Special Care Unit (DSCU) Program Director in the dining area assisting another resident. The DSCU Program Director's back was toward Resident #84 and no other staff were present in the immediate area. -At 9:16 A.M., Resident #84 looked at the surveyor and spoke softly, without enunciating any words, and the surveyor was unable to understand what the Resident said. -At 9:17 A.M., the surveyor observed Resident #84 pick up the muffin from Resident #54's meal tray and take a bite. -The surveyor immediately notified the DSCU Program Director when the surveyor observed that Resident #84 was eating the muffin from Resident #54's tray. -The DSCU Program Director made several attempts to instruct Resident #84 to follow her to the Nurse who was in the hallway. The surveyor observed that by the time the Resident followed the DSCU Program Director instructions and reached the Nurse in the hallway, the Resident had already swallowed the piece of muffin. During an interview on 5/8/24 at 10:15 A.M., the DSCU Program Director said Resident #84 often wandered and picked up items that belonged to other residents. The DSCU Program Director said that she could not speak to the level of supervision and assistance provided for residents for meals, and that Unit Manager (UM) #2 could probably speak better to the level of supervision and assistance provided to residents based on the residents' status. The DSCU Program Director said she did not see Resident #84 retrieve the muffin from Resident #54's tray and take a bite, because she was assisting another resident. During an interview on 5/8/24 at 10:45 A.M., UM #2 said she thought Resident #84 was on a House Diet, so the Resident could eat whatever he/she wanted, but that he/she should not be eating from other residents' trays. UM #2 said Resident #84 should not have had access to retrieve food items from Resident #54's meal tray. During an interview on 5/9/24 at 11:00 A.M., the Speech Language Pathologist (SLP) said she had provided services relative to swallowing for Resident #84. The SLP said Resident #84 previously had a palate resection and had been provided with a palate prosthesis, but the Resident did not tolerate wearing the prosthesis so the prosthesis was not in use. The SLP said that without the use of the prosthesis, there was an opening in the top of the Resident's mouth that made it difficult for the Resident to speak intelligibly and that could impact the Resident's ability to manage food. The SLP said that Resident #84 was admitted to the facility on a pureed diet and SLP had not assessed Resident #84's ability to manage regular diet texture food items, so when the Resident was discharged from Speech Therapy services, it was recommended the Resident remain on a pureed diet. The SLP said that Resident #84 demonstrated sufficient strategies to clear pureed food items from the opening in the top of his/her mouth, but she could not say that the Resident could sufficiently and safely manage regular food textures as this had not been assessed for the Resident. The SLP said since the Resident did not use his/her palate prosthesis, there was no way to close the opening in the top of the Resident's mouth. The SLP said if the Resident accessed and ate regular texture food items for which he/she was not assessed, there was a risk the food items could enter into the opening in the top of the Resident's mouth and a potential the Resident would not be able to clear the food items from the opening. The SLP said if the Resident was unable to clear food items that entered into the opening in the top of the Resident's mouth, there was a risk for the food to remain in that space, which would increase the Resident's risk for bacterial growth and illness. The SLP further said she recommended that Resident #84 remain on a pureed diet at this time as a pureed diet was the safest diet texture for the Resident.

Based on observation, interview, policy and record review, the facility failed to provide appropriate care, services, and monitoring of a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication, also referred to as a feeding tube) for one Resident (#242) out of a total sample of 19 residents. Specifically, the facility staff failed to obtain Physician's orders to check for gastric residual volume (amount of fluid remaining in the stomach after enteral [passing through the gastrointestinal (GI) tract] nutritional feeding has been given) of a G-tube to identify and prevent complications associated with enteral feeding. Findings include: Review of the facility policy titled Enteral Feedings, last revised 4/30/24, indicated: -to check for gastric residual. -hold the feeding and notify per Physician's orders. -Checking residuals- the nurse should check for residuals once per shift or per Physician order to minimize the potential complications with vomiting, distention and aspiration. Resident #242 was admitted to the facility in April 2024 with diagnoses including cerebral infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) and dysphagia (difficulty swallowing) and G-tube. Review of Resident #242's Care Plan for Tube Feedings, dated 4/30/24, indicated an intervention for enteral feeding management per Physician's orders. Review of the May 2024 Physician's orders, with start date of 5/7/24, indicated: -an order to check residuals every shift -notify Physician if residual is greater than 500 cubic centimeters (cc's) -follow Physician directions Review of Resident #242's Medication Administration Record (MAR) for April 2024 and May 2024 did not indicate that the Resident had been ordered for and checked for gastric residuals until 5/7/24. Review of Resident #242's clinical record did not indicate that the Resident had been checked for gastric residuals from the time of admission to 5/7/24 (the first day of DPH survey). During an interview on 5/8/24 at 12:18 P.M., Unit Manager (UM) #1 said that the Physician's order to check for gastric residuals should have been in place per the facility policy upon the Resident's admission and it had not been. UM #1 said that the facility was not following their policy.

Based on interview, record and policy review, the facility failed to perform trauma assessments at the time of admission to the facility for two Residents (#45 and #79) out of a total sample of 19 residents. Specifically, the facility staff failed to: 1. For Resident #45, complete a trauma assessment to determine whether the Resident had any history of trauma (emotional response to a deeply distressing or disturbing experience), and/or determine any triggers which may cause re-traumatization. 2. For Resident #79, screen the Resident for a history of trauma since his/her admission to the facility, to recognize and respond to any signs and symptoms of trauma. Findings include: Review of the facility policy titled Trauma Informed Care, effective October 2022, indicated the following: -It is recognized that residents may have experienced trauma in their past that could potentially impact their care or response to care. -All residents are assessed upon admission, as part of their social service history and asked if they have experienced any trauma in their life. 1. Resident #45 was admitted to the facility in June 2023, with a diagnosis of Dementia (a group of symptoms that affect memory, thinking and interferes with daily life) and Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #45's clinical record included no evidence that the facility staff assessed the Resident for a history of trauma (emotional response to a terrible or threatening event). During an interview on 5/9/24 at 10:25 A.M., the Social Worker (SW) said that she interviewed families and residents upon admission and would ask them about any history of trauma. The SW said that a trauma assessment would not have been completed if a history of trauma had not been identified. 42761 2. Resident #79 was admitted to the facility in May 2023, with diagnoses including: Dementia and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident #79's clinical record included no evidence that the facility staff assessed the Resident for a history of trauma. During an interview on 5/9/24 at 10:57 A.M., the Social Worker (SW) said she was responsible for screening all residents for a history of trauma when the residents were admitted to the facility. The SW said that there was no evidence that Resident #45 and Resident #79 had ever been screened for a history of trauma since their admission to the facility.

Based on observation, interview, and record review, the facility failed to ensure that medications were stored and administered in a secure and safe manner, according to professional standards for one Resident (#47), out of a total sample of 19 residents. Specifically, the facility staff failed to adhere to safe medication administration practices when medications were left unattended in a medication cup at Resident #47's bedside. Findings include: Resident #47 was admitted to the facility in July 2023 with diagnoses including Arthrosclerosis (a buildup of plaque and fat inside arteries) of arteries in both legs, Atrial Fibrillation (quivering or irregular heartbeat), mild cognitive impairment of unknown cause, and Dysphagia (difficulty or discomfort in swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible score of 15. Review of the facility policy titled Storage of Medications, last revised August 2020, indicated the following: -Medications are stored safely, securely, and properly . -Only licensed nurses, pharmacy personnel and those lawfully authorized are permitted to access medications. -Medication rooms, carts and medication supplies are locked when they are not attended to by persons with authorized access. Review of the facility policy titled Administration Procedure for All Medications, last revised August 2020, indicated the following: -Medications will be administered in a safe and effective manner. -After administration, return to (medication) cart, and document administration in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Review of the facility Self-Administration of Medication assessment dated [DATE], indicated that due to Resident 47's cognitive, physical or visual ability, the interdisciplinary team (IDT) feels that Resident #47 was not a candidate for self-administration of medications. On 5/7/24 at 10:53 A.M., the surveyor observed a small plastic cup containing multiple pills on the bedside table next to Resident #47. During an interview at the time, Resident #47 said that the staff trust him/her to take the medications so they usually leave his/her medications on the bedside table. Resident #47 said it takes a while for him to take all the medications because he/she takes the pills one at a time. During an interview on 5/7/24 at 11:00 A.M., Nurse #2 said she left Resident #47's medications on the table next to the bed because Resident #47 likes to take the medications independently. Nurse #2 said that she should have watched Resident #47 take the medications and should not have left Resident #47's medications at the bedside. During an interview on 5/7/24 at 11:53 A.M., Unit Manager (UM) #1 said that Resident #47 had not been assessed to safely administer his/her own medications and Nurse #2 should not have left any medications at Resident #47's bedside unattended.

Based on record review and interview, the facility failed to provide pain management consistent with professional standards for one Resident (#28) out of a total sample of 19 residents. Specifically, the facility staff failed to appropriately assess Resident #28 for the presence of pain and intensity of pain on each shift. Findings include: Review of the facility policy titled Pain Management last revised April 2017, indicated the following: -Purpose: to provide each resident who is experiencing acute or chronic pain effective assessment and management of symptoms . -The resident will be screened for the presence and intensity of pain on each shift using the Medication Administration Record (MAR) to record the results. -Resident's self-report of pain is to be used as the single most reliable indicator of the existence and intensity of pain. -Pain scale tools which are appropriate for the resident's developmental, physical, emotional, and cognitive status are used to evaluate and assess the effectiveness of a pain management plan. They are: Numerical (0-10), Verbal or Non- Verbal for the cognitively impaired. -Consistent documentation of the effectiveness of pain management is done in the Electronic Medication Administration Record (eMAR) and at intervals on the care plan. Resident #28 was admitted to the facility in December 2023, with diagnoses including malignant neoplasm of reproductive system (Cancer) and Mild Cognitive Impairment (trouble with memory, language or judgement) of unknown cause. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #28: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of a possible score of 15. Review of the Physician's orders dated 4/8/24 to 5/8/24 indicated the following: -Pain Assessment Every Shift, assess for level of comfort via Verbal Pain Scale: -0 = no pain -1-2 = slight pain -3-4 = mild pain -5-6 = moderate pain -7-8 = severe pain -9-10 = very severe pain. Check off pain three times a day. Start date 12/20/23. -Dilaudid (Hydromorphone: opioid pain medicine) Schedule II, oral liquid, 1 milligram (mg) per milliliter (ml), give 2 mg per 2 ml orally as needed for moderate pain every four hours. Start date 4/4/24 -Dilaudid, Schedule II oral liquid, 1 mg per 1 ml, give 4 mg/4 ml orally as needed for severe pain. Start date 4/4/24. -Dilaudid, Schedule II oral liquid 1 mg per 1 ml, give 2 mg orally twice a day at 6:00 A.M. and 8:00 P.M. for pain. Start date 4/9/24. During an interview on 5/7/24 at 11:51 A.M., Resident #28 said he/she had terminal cancer and is supposed to get pain medicine around the clock for the pain in his/her stomach. Resident #28 said that one night the Nurse only gave him/her half of the pain medication that was ordered. Resident #28 said that if he/she did not keep on top of the pain then he/she is in too much pain to do anything. On 5/8/24 at 8:58 A.M., the surveyor observed Resident #28 sitting a wheelchair, dressed and eating breakfast. Resident #28 said the pain was in his/her stomach and his/her pain level was a four out of 10. Resident #28 also said he/she just received his/her pain medication. On 5/8/24 at 1:44 P.M., the surveyor observed Resident #28 sitting in a recliner. Resident #28 said his/her pain level was a six out of 10 and he/she has not asked for any additional pain medication. During an interview on 5/8/24 at 1:49 P.M., Nurse #2 said that Resident #28 received scheduled doses of Dilaudid twice a day and as needed doses of Dilaudid if he/she has additional pain and asks for the medication. Nurse #2 said that she used the 1-10 numeric pain scale to assess Resident 28's pain and documented the pain level on the Treatment Administration Record (TAR). Review of the December 2023, January 2024, February 2024, March 2024, April 2024 and May 2024 MARs and TARs for Resident #28 indicated no evidence that a numeric pain scale assessment tool had been implemented to assess the presence and intensity of Resident #28's pain level. During an interview on 5/8/24 at 2:02 P.M., Charge Nurse #3 said that pain levels were assessed using the 1-10 numerical pain scale and the numerical pain level was documented on the TAR in the spaces corresponding to the order. The surveyor and Charge Nurse #3 reviewed the clinical record and Charge Nurse #3 said there was no evidence that Resident #28's pain levels had been assessed every shift as ordered, because there were no numerical pain levels documented for the Resident. During an interview on 5/8/24 at 2:11 P.M., Unit Manager (UM) #1 reviewed the clinical record and said that she could not provide any documentation that Resident #28's pain level had been assessed every shift as ordered. UM #1 said the numeric pain assessment should have been documented on the TAR but the numeric pain assessment had not been documented because the Physician's order had been entered into the computer incorrectly.

Based on observations and interviews, the facility failed to ensure its staff maintained the minimum wash temperature necessary for the dish machine utilized for cleaning dishware for resident use in the main facility kitchen. Specifically, Dietary Aide (#1) was operating the dish machine after lunch service that was registering below 160 degrees Fahrenheit (F) for the wash cycle. Findings include: Review of the Champion (type of dish machine) Operation, Cleaning and Maintenance Manual, dated 8/1/17, indicated the following: -READY: the status bar indicates 'Ready' when the machine is full of water. WAIT FOR THE WASH TEMPERATURE to read 160 degrees F before inserting a dish rack into the machine. -slide the dish rack into the machine until the wash pump (s) start. The conveyor will catch the rack and move it through the machine. The minimum wash temperature displayed must be 160 degrees F when the rack is in the wash zone. During a walk through of the kitchen with the Food Service Director (FSD) on 12/29/22 from 1:00 P.M.-1:25 P.M., the surveyor observed the following: -The dish machine was running and Dietary Aide #1 was working on dirty end of the machine and was pre-rinsing, loading dirty dishware/meal trays onto dish racks and placing them within the dish machine to be washed. During this process, the dish machine wash temperature was observed to fluctuate and was maintaining temperatures below 160 degrees (F) (154-159 degrees F). -During an interview at this time, Dietary Aide #1, who has worked at the facility for eight years, said that the minimum wash temperatures needed to utilize the dish machine were between 140-160 degrees F. -At this time, the FSD provided verbal education to Dietary Aide #1 and said the wash temperature for the dish machine needed to be 160 degrees or higher. The FSD proceeded to show the surveyor and Dietary Aide #1 the sticker on the upper side of the machine (which was located behind a red bucket containing a cloth and sanitation solution) that indicated the required minimum dish machine temperatures for the wash and the final rinse cycles. An observation of the sticker indicated that the minimum wash temperature was 160 degrees F. -The FSD was observed instructing Dietary Aide #1 to stop the dish machine, let the temperature for the wash rise so that it was over 160 degrees F prior to restarting the machine for use. She further instructed the dietary staff to run the previously run racks back through the dish machine once the minimum wash temperature of 160 degrees F was obtained. -The surveyor observed Dietary Aide #1 stop the machine, wait for the wash temperatures to reach over 170 degrees F and then re-wash a rack of bowls. After the rack of bowls was cleaned, the dish machine temperature was observed to fall below 160 degrees F. Dietary Aide #1 proceeded to utilize the dish machine despite the education of the minimum temperature required for use. -The FSD intervened again to instruct Dietary Aide #1 to stop the machine and wait for the temperatures to rise above the required minimum temperature prior to restarting. At this time, the FSD left the dish area and the surveyor continued to observe the process. -Dietary Aide #1 was observed to again utilize the dish machine when the wash temperature was below 160 degrees F. The surveyor intervened and she was observed to stop the machine and wait for it to rise above 160 degrees F. After continued observation, the surveyor noted that the wash temperatures of the dish machine would indicate over 170 degrees when stopped and drop drastically to below 160 when running after a single rack of dishware was run through. During an interview on 12/29/22 at 1:30 P.M., the FSD said that the dish machine was purchased new about two years ago and that there have been continued issues with maintaining the wash temperatures. She said that they recently had a part placed on 12/14/22 which seemed to help but for the last several days, she noticed the wash temperatures were decreasing and had contacted the vendors for the dish machine repair. When the surveyor asked if the dish machine temperatures were logged during use, the FSD showed the surveyor the temperature logs which were located on a clip board outside of the dish room. The last entry on the log sheet was dated 12/28/22 for breakfast and indicated the wash temperature was 161 degrees F. There were no other entries for breakfast, lunch and dinner after this date/time. Further review of the Dish Machine Temperature and Sanitizer Log did not indicate what the minimum wash and final rinse temperature required for the dish machine. The FSD said that if the dish machine temperatures fall below the required temperatures, she had the ability to switch the chemical sanitizer for the final rinse that was used for low temperature dish machines. The FSD said that because the dish machine temperatures were not consistently holding at 160 degrees, she would switch the chemical sanitizer for the final rinse immediately so that the dish machine was safe to use. The surveyor asked about education provided to dietary staff about the the minimum requirements for safe operation of the dish machine. During a follow up interview on 12/29/22 at 3:17 P.M., the surveyor relayed the concern for safe operation of the dish machine despite verbal education with Dietary Aide #1 regarding the minimum temperature requirements. The FSD said that she understood the concern. During an interview on 12/29/22 at 3:30 P.M., with the Administrator and FSD, the Administrator said that he was made aware of the wash temperature concerns for the dish machine. The Administrator said that he understood the concern of the surveyor relative to the operation of the dish machine by Dietary Aide #1 despite numerous education/interventions about the minimum temperatures required for use. Prior to survey exit, there was no documented evidence that education had been provided to the Dietary staff relative to the minimum temperatures required for the safe operation of the dish machine.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to prevent Resident #1 from experiencing unintended significant weight loss and failed to provide adequate hydration that resulted in Resident #1 becoming dehydrated and Resident #1 to be transferred to the hospital emergency department for evaluation. Findings include: The Facility policy titled Nutritional Services, Obtaining Weights, dated 01/01/10, indicated new residents will be weighed weekly for the first four weeks from admission. The Policy indicated weights will then be monthly, unless a physician's orders [REDACTED]. 1. Resident #1 was admitted to the Facility in (MONTH) (YEAR) and then readmitted to the Facility in (MONTH) (YEAR). A Nutrition Comprehensive Assessment, dated 02/20/18, indicated Resident #1 required supervision and cueing at meals, intake was 75-100 % at meals, had trace bilateral lower extremity [MEDICAL CONDITION], and weight taken at previous facility on 01/30/18 was 197.2 pounds (lbs). An Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required supervision of one staff member with eating. Review of Resident #1's Order History, dated 02/01/18 through 04/30/18, indicated there was a physician's orders [REDACTED].#1 weekly on Wednesday on the 3:00 P.M. to 11:00 P.M. shift. Review of the Vital Signs Report, dated (MONTH) (YEAR) through (MONTH) (YEAR), indicated the weight recorded for Resident #1 on 02/23/18 was 241.4 lbs. (9 days after admission), on 03/15/18 was 202.4 lbs., and a weight on 04/03/18 was 190.2 lbs. (13 days after readmission). Review of Resident #1's medical record indicated there was no documentation to support the nursing staff obtained an admission weight in (MONTH) (YEAR). The Record indicated a weight of 241.4 lbs dated 2/23/18 which was nine days after his/her admission. There was no documentation in Resident #1's medical record to support that he/she was weighed upon re-admission to the Facility in (MONTH) (YEAR), or that weekly weights were obtained on Resident #1, as ordered by the physician. A Dietary Note, dated 03/19/18, indicated the admission weight of 241 lbs. was likely inaccurate as Resident #1's baseline weight was noted to be 200 lbs., plus or minus 5 lbs. The Note indicated a re-weigh was done and Resident #1 was 202 lbs. which was baseline and within normal limits (WNL). A Dietary Note, dated 03/29/18, indicated Resident #1's oral (PO) intake was averaging 50-75%, had improved after being re-acclimated but was poor initially, and Resident #1 had a recent hospitalization for pneumonia. The Note indicated weight was done on 03/15/18, and questioned accuracy of weight done on 02/23/18. The Note indicated a re-weigh from nursing was requested. Review of Resident #1's medical record indicated there was no documentation to support the nursing staff obtained a re-weigh on 03/29/18 for Resident #1. Review of Resident #1's Nutritional Care Recommendations, dated 04/19/18, indicated Resident #1 had poor PO intake, was playing with his/her food, had advancing dementia, and had a significant weight loss since 04/03/18. A Dietary Note, dated 04/19/18, indicated Resident #1 continued with poor PO intake, was observed playing with his/her food, staff trialed finger foods but his/her PO intake remained poor, and and his/her weight indicated a significant weight loss for one month. The Note indicated that the last weight was obtained on 04/03/18 and that the registered dietitian (RD) had requested weights weekly since readmission from the hospital. The Note indicated it was discussed with nursing the importance of regular weight monitoring as Resident #1 is at risk for weight loss. The Surveyor interviewed the Dietitian at 11:58 A.M. on 09/19/18. The Dietitian said she noted on 04/19/18, that the last weight obtained on Resident #1 was 190.2 lbs. on 04/03/18, and the weight obtained previous to that was 202.4 lbs. on 03/15/18. The Dietitian said Resident #1 had experienced an unexpected significant weight loss of 5.9 percent in less than one month. The Dietitian said Resident #1 did not have a weight done on admission, or readmission to the Facility, and that weights were not done weekly as ordered by the physician. The Surveyor interviewed the Director of Nurses (DON) at 3:33 P.M. on 09/19/18. The DON said Resident #1 should have had a weight done on admission, on readmission from the hospital, and weekly as the physician ordered. 2. Review of Resident #1's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), signed and dated by the invoked Health Care Proxy, indicated to use artificial hydration. Review of the Care Plan for receiving diuretic medication, dated 03/06/18, indicated to assess and report for dehydration, and to offer and encourage fluids as tolerated. Review of the Order History, dated 02/01/18 through 04/30/18, indicated the following orders for Resident #1: - an order dated 03/07/18 for [MEDICATION NAME] (a diuretic medication) 20 milligrams (mg) every other day. - an order dated 04/11/18 to document intake every shift. Review of Resident #1's Medication Administration Record, [REDACTED] - there was no intake documentation recorded on 04/11/18 through 04/14/18. - 04/15/18 intake on the night shift was written and documented as noted and did not indicate an actual amount consumed. - 04/16/18 intake was written and documented as noted and did not indicate an actual amount consumed for the day and evening shift, and 60 milliliters (ml) at night. - 04/17/18 intake was written and documented as noted and did not indicate an actual amount consumed for the day, evening, and night shift. - on 04/18/18 intake was documented as 50-100% on day shift, and 360 ml on evening shift, and 200 ml on the night shift. - 04/19/18 24-hour intake total was 990 ml. - 04/20/18 24-hour intake total was 330 ml - 04/21/18 24-hour intake total was 460 ml. - 04/22/18 24-hour intake total was 900 ml. - 04/23/18 24-hour intake total was 720 ml. - 04/24/18 24-hour intake total was 1240 ml. - 04/25/18 intake was documented as 200 ml for the day shift. A Physician's Assistant Note, dated 04/25/18, indicated Resident #1 had a change of condition, had eaten 50-75% of breakfast, and 1-25% of lunch and supper on 04/24/18, and did not eat breakfast on 04/25/18. The Note indicated Resident #1's mucous membranes were dry and that he/she appeared dry. The Note indicated to obtain blood work. Review of a Blood Laboratory Report, dated 04/25/18, indicated Resident #1's had a sodium level of 171 was high(reference range is 133-145), a BUN (blood, urea, nitrogen) of 48 was high (reference range is 10-24), and a creatinine of 1.7 was high (reference range is 0.7-1.5) which are all indicators for dehydration. Review of Resident #1's medical record indicated there was no documentation to support that nurses assigned to Resident #1 continually assessed Resident #1 on the 7:00 A.M. to 3:00 P.M. shift for a change of condition. A Nurses Progress Note, dated 04/26/18 at 12:58 A.M. written by Nurse #1 indicated Resident #1 was reported as lethargic and did not tolerate any PO intake this morning. Blood laboratory work results were reported to the Physician's Assistant and Resident #1 was transferred to the hospital emergency department for evaluation. A Nurses Note, dated 04/26/18, indicated Resident #1 was admitted to the Intensive Care Unit (ICU) with a primary [DIAGNOSES REDACTED]. The Surveyor interviewed the Physician's Assistant at 12:42 P.M. on 09/19/18. The Physician's Assistant said she was not informed of Resident #1's change of condition until 04/25/18. The Physician's Assistant said the elevated sodium, BUN, and creatinine were indicative of dehydration. The Surveyor interviewed the Director of Nurses (DON) at 3:33 P.M. on 09/19/18. The DON said staff should have been documenting what Resident #1's intake was for their entire shift in milliliters and that the staff should have notified the Physician sooner of Resident #1's decreased oral intake.

Based on record review and staff interview the facility failed to ensure staff administered short acting insulin per standards of practice and Manufacturer's directions for use for one resident (#19) out of a total sample of 19 residents. The facility staff failed to ensure the resident received a meal 15 minutes after Insulin administration to avoid an episode of low blood sugar ([DIAGNOSES REDACTED]) and transfer to the emergency room . Review of the Lippincott Nursing2016 Drug Handbook(page 762) regarding Humalog ([MEDICATION NAME]) Insulin, indicated that Humalog should be administered, within 15 minutes before a meal or immediately after a meal. Information for use of [MEDICATION NAME] provided by Eli Lilly and Company, copyright 2015, subcutaneous injection: Administer the dose within 15 minutes before a meal or immediately after . Resident #19 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment (MDS) of 9/6/16 indicated the resident: was alert and oriented; did not ambulate; required extensive assistance from staff for activities of daily living; received Insulin injections daily and had a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A physician's orders [REDACTED]. The Insulin was written on the Medication Administration Record [REDACTED].M., 11:30 A.M. and 4:30 P.M. There was no evidence in the medical record to ensure the resident would receive meals right after the short acting Insulin was administered to avoid a hypoglycemic emergency. A physician's orders [REDACTED]. reading). This order was on the physician's orders [REDACTED]. Review of the 9/2016 MAR indicated [REDACTED].-7:00 A.M. nurse (Nurse #6) obtained a FSBS on 9/15/16 of 94 which was within normal limits, then administered 7 units of fast acting Insulin at 7:30 A.M. A Nurse's Progress Note of 9/15/16 written at 2:44 P.M., indicated that Nurse #1 was administering the resident's 8:00 A.M. medications prior to breakfast. The resident stopped talking, became unresponsive, and was slumped in the chair, drooling. The resident was put back to bed and a blood sugar indicated a reading of 42 (a normal reading is approximately 70-130). Despite Resident #19 being unresponsive, facility staff did not administer the [MEDICATION NAME] injection, but instead attempted to administer Glucose orally, however, the resident was unresponsive and unable to swallow. A call was made to 911 to transport the resident out to the hospital at approximately 8:45 A.M. (per Director of Nurses on 12/19/16 at 11:00 A.M.). The Hospital's Discharge Instructions indicated the resident was seen for [DIAGNOSES REDACTED] caused by receiving Insulin too early and not eating. The note also indicated that the facility should absolutely not administer Insulin too early and especially if the resident is not going to eat. During interview on 12/19/16 at 11:00 A.M., the Director of Nurses (DON) said that Resident #19 did not eat after receiving the Insulin injection. During interview on 12/19/16 at 1:00 P.M., Nurse Manager #2 said that the resident received the fast acting Insulin at 7:30 A.M., and that the resident is served breakfast between 8:15-8:30 A.M., and not 15 minutes prior to a meal or immediately after according to Manufacturers Directions for Use and standards of practice.

Based on record review and staff interview, facility staff failed to ensure that two residents (#13 and #19) in a total sample of 19 residents, received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the residents' comprehensive assessment and plan of care. Findings include: 1. For Resident #19, facility staff failed to ensure the resident received a meal 15 minutes after Insulin administration to avoid an episode of low blood sugar ([DIAGNOSES REDACTED]) and transfer to the emergency room . Resident #19 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment (MDS) of 9/6/16 indicated the resident: was alert and oriented; did not ambulate; required extensive assistance from staff for activities of daily living; received Insulin injections daily and had a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A physician's orders [REDACTED]. The Insulin was written on the Medication Administration Record [REDACTED].M., 11:30 A.M. and 4:30 P.M. There was no evidence in the medical record to ensure the resident would receive meals right after the short acting Insulin was administered to avoid a hypoglycemic emergency. Review of the Lippincott Nursing2016 Drug Handbook(page 762) regarding Humalog ([MEDICATION NAME]) Insulin, indicated that Humalog should be administered, within 15 minutes before a meal or immediately after a meal. A physician's orders [REDACTED]. reading). This order was on the physician's orders [REDACTED]. Review of the 9/2016 MAR indicated [REDACTED].-7:00 A.M. nurse (Nurse #6) obtained a FSBS on 9/15/16 of 94 which was within normal limits, then administered 7 units of fast acting Insulin at 7:30 A.M. A Nurse's Progress Note of 9/15/16 written at 2:44 P.M., indicated that Nurse #1 was administering the resident's 8:00 A.M. medications prior to breakfast. The resident stopped talking, became unresponsive, and was slumped in the chair, drooling. The resident was put back to bed and a blood sugar indicated a reading of 42 (a normal reading is approximately 70-130). Despite Resident #19 being unresponsive, facility staff did not administer the [MEDICATION NAME] injection, but instead attempted to administer Glucose orally, however, the resident was unresponsive and unable to swallow. A call was made to 911 to transport the resident out to the hospital at approximately 8:45 A.M. (per Director of Nurses on 12/19/16 at 11:00 A.M.). The Hospital's Discharge Instructions indicated the resident was seen for [DIAGNOSES REDACTED] caused by receiving Insulin too early and not eating. The note also indicated that the facility should absolutely not administer Insulin too early and especially if the resident is not going to eat. During interview on 12/19/16 at 11:00 A.M., the Director of Nurses (DON) said that Resident #19 did not eat after receiving the Insulin injection. During interview on 12/19/16 at 1:00 P.M., Nurse Manager #2 said that the resident received the fast acting Insulin at 7:30 A.M., and that the resident is served breakfast between 8:15-8:30 A.M., and not 15 minutes prior to a meal or immediately after according to Manufacturers Directions for Use and standards of practice. 2. For Resident #13, facility staff failed to ensure monitoring and documentation for a central venous catheter (CVC), used to remove and return blood during [MEDICAL TREATMENT]. Resident #13 was admitted to the facility in 11/2016 with a [DIAGNOSES REDACTED]. Review of the hospital discharge summary, dated 11/9/16, indicated the resident received [MEDICAL TREATMENT] through a CVC in the chest wall. Review of the facility's policy for [MEDICAL TREATMENT] Care, dated 1/9/10, indicated the nurse would establish baseline information to individualize plan of care (i.e. fluid restriction, medication, weights, lab work etc.) The policy did not indicate a protocol or reference for the care of a CVC. Review of the Physician orders [REDACTED]. Review of the Treatment Administration Record (TAR), dated 11/9/2016 to 12/16/2016, indicated no documentation for the care and services of a CVC. On 12/16/16 at 11:40 A.M., the resident was observed with Unit Manager (UM) #2. UM #2 showed the surveyor the [MEDICAL TREATMENT]. The site was located on the resident's left chest wall, and was covered with an intact dressing. The limb of the CVC was protruding from the dressing. The end of the catheter was protected by a dressing and tape. During an interview on 12/16/16 at 11:45 A.M., UM #2 said the chart should have had physician's orders [REDACTED]. She also said the TAR should have included documentation to show the CVC site was monitored.

Based on observation, record review and interview the facility failed to ensure that 1 (#10) out of 4 applicable residents in a total sample of 19 residents did not develop a pressure ulcer and, once the pressure ulcer was developed, the facility failed to provide the necessary treatment and services to promote healing. Findings include: For Resident #10, the facility failed to prevent the development of a pressure ulcer, and once the pressure ulcer had developed, failed to provide the necessary treatment to promote healing. Resident #10 was admitted to the facility in 7/2012 with a [DIAGNOSES REDACTED]. Review of the Norton Skin Assessment, dated 8/3/15, indicated the resident was at risk for skin breakdown as evidenced by a score of 11. A score of 14 or less indicates a risk for skin breakdown. Review of the Quarterly Minimum Data Set (MDS)assessment dated [DATE] indicated that, based on the staff assessment, the resident had severe cognitive impairment, was an assist of one for positioning in bed, transfers and ambulation, was incontinent of bowel and bladder and did not have a pressure ulcer. Review of the Certified Nursing Assistant (CNA) Flow sheet, dated 8/2015, indicated the resident was not provided any pressure relieving skin care to his/her heels. Review of the nurse's note, dated 8/16/15, indicated a 2.5 centimeter (cm.) x 2.5 cm. blister on the resident's left heel had been observed. Review of the physician's orders [REDACTED]. - Apply skin prep (protective film) to left heel two times a day, - Measure wound weekly on Mondays, and - Elevate feet on a pillow when in bed. Review of the Weekly Pressure Ulcer Assessment, dated 8/17/15, indicated the resident developed a facility acquired Stage 2 pressure ulcer on the left heel from the shoe. The pressure ulcer measured 2.5 cm. x 2.5 cm. and was an intact blister. Review of the Weekly Pressure Ulcer Assessment, dated 8/24/15, indicated the pressure ulcer had not been measured or assessed as ordered. Review of the At Risk meeting note, dated 8/25/15, indicated the resident had an intact blister to the left heel and the facility needed to keep the residents shoes off until healed. Review of the plan of care for pressure, dated 8/26/15, indicated the resident had a fluid filled blister on the left heel secondary to the sneakers he/she was wearing. Interventions included: - No shoes or sneakers, - Apply skin prep as ordered, - Medix boot when in bed (initiated 8/28/15), and - Multi podus boot when out of bed (initiated 8/28/15). Review of the physician's orders [REDACTED]. - Medix boot to left foot when in bed, and - Multi podus boot to left foot when out of bed. Review of the Weekly Pressure Ulcer Assessment, dated 9/1/15, indicated the pressure ulcer measured 4.0 cm x 7.0 cm. The pressure ulcer was now opened with scant amount of brown drainage. Review of the clinical record record indicated no change in treatment even though the pressure ulcer was now was open, larger and had drainage. Review of the Weekly Pressure Ulcer Assessment indicated the weekly measurements and assessments were not completed on 9/7/15 or 9/14/15 as ordered. Review of the nurse's note dated 9/14/14, indicated the treatment to the left heel was done and 50% of the wound bed was necrotic. Review of the physician's orders [REDACTED]. Review of nurse's note, dated 9/18/15, indicated the treatment was performed to the left heel. The skin above the blister was very fragile and nonblanchable, the open area was bigger than last time, noted with 20% slough (dead tissue). Review of the Weekly Pressure Ulcer Assessment, dated 9/22/15, indicated the pressure ulcer measured 4.0 cm. x 6.0 cm. The wound bed was pink with a moderate amount of drainage. Review of the physician's orders [REDACTED]. Apply skin prep to the peri-wound and cover with [MEDICATION NAME]. Review of the Weekly Pressure Ulcer Assessment, dated 9/28/15, indicated the pressure ulcer measured 4.0 cm. x 2.5 cm. The wound bed was brown/red color and nonblanchable with small amount of drainage. On 10/2/15 at 6:50 A.M., the surveyor observed Resident #10 in bed. The resident did not have the Medix boot on as ordered. On 10/2/15 at 7:05 A.M. during interview Nurse #1 said she had noticed the boot was not on, so she applied it. On 10/2/15 at 7:25 A.M. the surveyor observed Nurse #1 and Nurse #3 change the resident's dressing. Nurse #3 said that 2 days ago when she did the dressing the wound bed was beefy red. It was now an unstageable pressure ulcer because she could not see the wound bed. Nurse #3 described the wound as an unstageable pressure ulcer, 90 % of the wound bed covered by dark eschar (dead tissue) and 10 % yellow slough. Nurse #3 said the measurements were unchanged from 9/28/15. On 10/2/15 at 10:00 A.M. during interview the Director of Nurses (DON) said that the facility does not do formal weekly skin checks. The surveyor asked how the facility ensured the resident's skin was assessed for any skin breakdown. She said all staff were responsible for checking the resident's skin, but it was not documented. The surveyor asked what preventive measures were in place to prevent the left heel pressure ulcer for Resident #10. The DON said the resident was assisted with positioning, and all the beds in the facility were pressure reduction mattresses. The surveyor asked how the pressure area was caused. The DON said that it was caused by the resident's sneaker. The surveyor then showed the DON the plan of care for the pressure ulcer which indicated the sneaker was not removed, per the plan of care until 8/26/15, 10 days after the development of the left heel pressure ulcer. The DON said the shoe must have been removed before that, but there was no documentation to indicate when it was removed. The surveyor then reviewed the Weekly Pressure Ulcer Assessments. The DON said that weekly measurements were not done as ordered.

Based on interview and record review, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 remained free of restraints imposed for staff convenience. On 6/20/14, at approximately 4:30 P.M., Certified Nurse Aide (CNA) #1 and Activity Assistant #1 placed Resident #1 (who was in a wheelchair) in a corner of the activity room and then positioned a table over his/her lap to prevent him/her from standing and walking. Later, CNA #1 locked Resident #1's wheelchair wheels and pulled Resident #1's sweatshirt over the back of his/her wheelchair to prevent him/her from standing and walking. Resident #1 responded, "Why am I chained?" or words to that effect, and became upset and tearful. Findings include: The Facility's physical restraints policy and procedure, dated 2/10/2010, indicated physical restraints may be used on a resident when it is required to treat a medical symptom and other alternatives have failed and an assessment must be performed. The policy indicated if emergency restraints are required, staff must notify the responsible party; and the physician must write an order for [REDACTED]. Resident #1's quarterly minimum data set assessment, dated 4/30/14, indicated Resident #1 had significant cognitive deficits; rejected care on a daily basis and frequently wandered; required staff assistance for walking due to unsteadiness; and used a wheelchair for locomotion. The Surveyor interviewed Activity Assistant #1 at 1:50 P.M. on 7/24/14. Activity Assistant #1 said at approximately 4:30 P.M. on 6/20/14 Resident #1 was in the activity room and repeatedly stood up from his/her wheelchair and walked. Activity Assistant #1 said Resident #1 was at risk for falls if left unsupervised so he initially walked with Resident #1, but then he needed to do other activity-related tasks and returned Resident #1 to his/her wheelchair. Activity Assistant #1 said Resident #1 continued to try to stand up and he and CNA #1 frequently "pushed" Resident #1 back down into the wheelchair to sit, or words to that effect. Activity Assistant #1 said he and CNA #1 then relocated Resident #1 in his/her wheelchair to a corner of the room and placed a table in front of him/her to prevent Resident #1 from standing. Activity Assistant #1 said Resident #1 remained behind the table for approximately 10 minutes and continued to try to stand but was only able to partially rise from the seat before needing to sit down again. The Surveyor contacted CNA #1 by telephone and letter, dated 7/25/14, but as of 8/1/14, CNA #1 did not respond to the Surveyor's request to be interviewed. The Surveyor interviewed Activity Assistant #2 at 10:25 A.M. on 7/24/14. Activity Assistant #2 said at approximately 4:30 P.M. on 6/20/14, she and CNA #1 were supervising a number of residents in the activity room, which included Resident #1. Activity Assistant #2 said she observed Resident #1 standing up from his/her wheelchair and CNA #1 pulled the sweatshirt Resident #1 was wearing over the back of the wheelchair and the back handles. Activity Assistant #2 said CNA #1 pushed Resident #1's wheelchair against the wall and locked the wheels. Activity Assistant #2 said Resident #1 tried to stand up but was unable and he/she asked, "Why am I chained?" or words to that effect, and became upset and tearful. Activity Assistant #2 said she asked CNA #1 what he was doing and he responded (in the presence of Resident #1), "Leave it. Now (he/she) can't get up. You've chained my people, now I can chain your people," or words to that effect. Activity Assistant #2 said she removed Resident #1's sweatshirt from the back of the wheelchair and walked with Resident #1 toward the nursing station. The Surveyor interviewed Nurse #1 at approximately 4:33 P.M. on 7/24/14. Nurse #1 said she observed Resident #1 immediately following the incident and Resident #1 appeared extremely upset and was crying. Nurse #1 said she interviewed CNA #1 and he told her that he and Activity Assistant #1 positioned Resident #1 in his/her wheelchair close to a wall in the activity room and then placed a table in front of him/her. The Surveyor interviewed the Evening Nurse Supervisor at 3:50 P.M. on 7/24/14. The Evening Nurse Supervisor said on 6/20/14 Activity Assistant #2 and Resident #1 approached her at the nursing station and Resident #1 was crying and very upset. The Evening Nurse Supervisor said Activity Assistant #2 told her that CNA #1 pulled Resident #1's shirt over the back of his/her wheelchair to prevent him/her from standing. The Evening Nurse Supervisor said she asked CNA #1 why he would put Resident #1's shirt over his/her wheelchair and CNA #1 replied, words to the effect of, "I don't know why I did that." Resident #1's care plan, dated 4/24/14, did not include any information to indicate he/she had a medical symptoms which required the use of a physical restraint. Resident #1 was not assessed for use of a physical restraint and there was not a physician's orders [REDACTED]. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 10:50 A.M. on 7/14/14. The ADON said the Facility never assessed Resident #1 for restraints because there were no medical symptoms to warrant an assessment. The ADON said none of the licensed nursing staff instructed CNA #1 (who was assigned to work as an activity assistant for the shift) or Activity Assistant #1 to physically restrain Resident #1 and he/she did not require an emergency restraint. The ADON said if Resident #1 did require a restraint a table or a sweatshirt was not an acceptable form of restraint. According to the reasonable person's concept, though Resident #1 had dementia and memory impairment, a reasonable person would feel emotional psychological harm as a result of being restrained and prevented from rising and walking.

Based on record review and interview for one of three sampled residents (Resident #1), the Facility failed to implement Resident #1's behavioral care plan. Resident #1's [DIAGNOSES REDACTED]. On 6/20/14 Resident #1 repeatedly stood up from his/her wheelchair; Facility staff placed Resident #1 against a wall and positioned a table over his/her lap to prevent Resident #1 from rising and walking, and later staff pulled Resident #1's sweatshirt over the back of his/her wheelchair to prevent him/her from rising, which was not consistent with Resident #1's plan of care. Findings include: Resident #1's quarterly minimum data set assessment, dated 4/30/14, indicated Resident #1 had significant cognitive deficits; behavioral symptoms placed him/her at significant risk for significant risk for physical injury, interfered with care and ability to participate in activities and social interactions. The assessment indicated Resident #1 frequently wandered which placed him/her at significant risk of getting to a potentially dangerous place; required limited one-person assistance for walking due to unsteadiness. Resident #1's behavioral plan of care, dated 5/05/14, indicated he/she had a [DIAGNOSES REDACTED]. Care plan interventions included for staff to allow Resident #1 as much control over decisions in the daily routine as much as possible; encourage involvement in activities; monitor verbal and non-verbal signs of comfort; provide a baby doll, ice cream. talk to him/her about Cape Cod and the beach; attempt to ambulate using a gait belt and one-person assist; and play music. The Surveyor interviewed Activity Assistant #1 at 1:50 P.M. on 7/24/14. Activity Assistant #1 said at approximately 4:30 P.M. on 6/20/14 Resident #1 was in the activity room and repeatedly stood up from his/her wheelchair and walked. Activity Assistant #1 said Resident #1 was at risk for falls if left unsupervised so he initially walked with Resident #1, but then he needed to do other activity-related tasks and returned Resident #1 to his/her wheelchair. Activity Assistant #1 said Resident #1 continued to try to stand up and he and Certified Nurse Aide (CNA) #1 (who was assigned to work as an activity assistant for the shift) frequently "pushed" Resident #1 down into the wheelchair to sit, or words to that effect. Activity Assistant #1 said he and CNA #1 then rolled Resident #1 in his/her wheelchair to a corner of the room and placed a table in front of him/her to prevent Resident #1 from standing. Activity Assistant #1 said Resident #1 remained behind the table for approximately 10 minutes and continued to try to stand but was only able to partially rise from the seat before needing to sit down again. Activity Assistant #1 said he may have placed a puzzle on the table for Resident #1, but he was unsure of this recollection. The Surveyor contacted CNA #1 by telephone and letter, dated 7/25/14, but as of 8/1/14, CNA #1 did not respond to the Surveyor's request to be interviewed. The Surveyor interviewed Activity Assistant #2 at 10:25 A.M. on 7/24/14. Activity Assistant #2 said at approximately 4:30 P.M. on 6/20/14, she and CNA #1 were supervising a number of residents in the activity room, which included Resident #1. Activity Assistant #2 said she observed Resident #1 standing up from his/her wheelchair and CNA #1 pulled the sweatshirt Resident #1 was wearing over the back of the wheelchair and the handles. Activity Assistant #2 said CNA #1 pushed Resident #1's wheelchair against the wall and locked the wheels. Activity Assistant #2 said Resident #1 tried to stand up but was unable and he/she asked, "Why am I chained?" or words to that effect, and became upset and tearful. Activity Assistant #2 said she removed Resident #1's sweatshirt from the back of the wheelchair and walked with Resident #1 toward the nursing station. Activity Assistant #2 said she did not recall anyone walking with Resident #1 prior to the incident, or seeing Resident #1 engaged in any activity. The Surveyor interviewed Nurse #1 at approximately 4:33 P.M. on 7/24/14. Nurse #1 said she observed Resident #1 immediately following the incident and Resident #1 appeared extremely upset and was crying. Nurse #1 said staff were supposed to keep Resident #1 occupied and safe and not to restrain him/her in response to his/her behaviors. The Surveyor interviewed the Evening Nurse Supervisor at 3:50 P.M. on 7/24/14. The Evening Nurse Supervisor said on 6/20/14 Activity Assistant #2 and Resident #1 approached her at the nursing station and Resident #1 was crying and very upset. The Evening Nurse Supervisor said Activity Assistant #2 told her that CNA #1 pulled Resident #1's shirt over the back of his/her wheelchair to prevent him/her from standing. The Evening Nurse Supervisor said Resident #1 often tried to stand up from his/her wheelchair and walk, but that staff were supposed to either walk with Resident #1 or engage him/her in an activity, not restrain Resident #1.

Based on record review and interview for one of three sampled residents (Resident #1), the Facility failed to implement Resident #1's behavioral care plan. Resident #1's [DIAGNOSES REDACTED]. On 6/20/14, at approximately 4:30 P.M., Resident #1 repeatedly stood up from his/her wheelchair; Facility staff placed Resident #1 against a wall and positioned a table over his/her lap to prevent Resident #1 from rising and walking, and later staff pulled Resident #1's sweatshirt over the back of his/her wheelchair to prevent him/her from rising. In response to being restrained, staff said they observed Resident #1 upset and crying in her wheelchair, "Why am I chained?" or words to that effect. A reasonable person would feel emotional and psychological harm as a result of being restrained. Findings include: Resident #1's quarterly minimum data set assessment, dated 4/30/14, indicated Resident #1 had significant cognitive deficits; behavioral symptoms placed him/her at significant risk for significant risk for physical injury, interfered with care and ability to participate in activities and social interactions. The assessment indicated Resident #1 rejected care on a daily basis; frequently wandered which placed him/her at significant risk of getting to a potentially dangerous place; required limited one-person assistance for walking due to unsteadiness and used a wheelchair for locomotion. Resident #1's behavioral plan of care, dated 5/05/14, indicated he/she had a [DIAGNOSES REDACTED]. Resident #1 exhibited "self-rising," exit seeking, impulsivity, poor safety awareness, agitation and an anxious mood. Care plan interventions included for staff to allow Resident #1 as much control over decisions in the daily routine as much as possible; encourage involvement in activities; monitor verbal and non-verbal signs of comfort; provide a baby doll, ice cream. talk to him/her about Cape Cod and the beach; attempt to ambulate using a gait belt and one-person assist; and play music. The Surveyor interviewed Activity Assistant #1 at 1:50 P.M. on 7/24/14. Activity Assistant #1 said at approximately 4:30 P.M. on 6/20/14 Resident #1 was in the activity room and repeatedly stood up from his/her wheelchair and walked. Activity Assistant #1 said Resident #1 was at risk for falls if left unsupervised so he initially walked with Resident #1, but then he needed to do other activity-related tasks and returned Resident #1 to his/her wheelchair. Activity Assistant #1 said Resident #1 continued to try to stand up and he and Certified Nurse Aide (CNA) #1 (who was assigned to work as an activity assistant for the shift) frequently "pushed" Resident #1 down into the wheelchair to sit, or words to that effect. Activity Assistant #1 said he and CNA #1 then rolled Resident #1 in his/her wheelchair to a corner of the room and placed a table in front of him/her to prevent Resident #1 from standing. Activity Assistant #1 said Resident #1 remained behind the table for approximately 10 minutes and continued to try to stand but was only able to partially rise from the seat before needing to sit down again. Activity Assistant #1 said he may have placed a puzzle on the table for Resident #1, but he was unsure of this recollection. The Surveyor contacted CNA #1 by telephone and letter, dated 7/25/14, but as of 8/1/14, CNA #1 did not respond to the Surveyor's request to be interviewed. The Surveyor interviewed Activity Assistant #2 at 10:25 A.M. on 7/24/14. Activity Assistant #2 said at approximately 4:30 P.M. on 6/20/14, she and CNA #1 were supervising a number of residents in the activity room, which included Resident #1. Activity Assistant #2 said she observed Resident #1 standing up from his/her wheelchair and CNA #1 pulled the sweatshirt Resident #1 was wearing over the back of the wheelchair and the handles. Activity Assistant #2 said CNA #1 pushed Resident #1's wheelchair against the wall and locked the wheels. Activity Assistant #2 said Resident #1 tried to stand up but was unable and he/she asked, "Why am I chained?" or words to that effect, and became upset and tearful. Activity Assistant #2 said she asked CNA #1 what he was doing and he responded (in the presence of Resident #1), "Leave it. Now (he/she) can't get up. You've chained my people, now I can chain your people," or words to that effect. Activity Assistant #2 said she removed Resident #1's sweatshirt from the back of the wheelchair and walked with Resident #1 toward the nursing station. Activity Assistant #2 said she did not recall anyone walking with Resident #1 prior to the incident, or seeing Resident #1 engaged in any activity. The Surveyor interviewed Nurse #1 at approximately 4:33 P.M. on 7/24/14. Nurse #1 said she observed Resident #1 immediately following the incident and Resident #1 appeared extremely upset and was crying. Nurse #1 said she interviewed CNA #1 and he told her that he and Activity Assistant #1 positioned Resident #1 in his/her wheelchair close to a wall in the activity room and then placed a table in front of him/her. Nurse #1 said staff were supposed to keep Resident #1 occupied and safe and not to restrain him/her in response to his/her behaviors. The Surveyor interviewed the Evening Nurse Supervisor at 3:50 P.M. on 7/24/14. The Evening Nurse Supervisor said on 6/20/14 Activity Assistant #2 and Resident #1 approached her at the nursing station and Resident #1 was crying and very upset. The Evening Nurse Supervisor said Activity Assistant #2 told her that CNA #1 pulled Resident #1's shirt over the back of his/her wheelchair to prevent him/her from standing. The Evening Nurse Supervisor said she asked CNA #1 why he would put Resident #1's shirt over his/her wheelchair and CNA #1 replied, "I don't know why I did that." The Evening Nurse Supervisor said Resident #1 often tried to stand up from his/her wheelchair and walk, but that staff were supposed to either walk with Resident #1 or engage him/her in an activity, not restrain Resident #1. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 10:50 A.M. on 7/14/14. The ADON said the Facility never assessed Resident #1 for restraints because there were no medical symptoms to warrant an assessment. The ADON said none of the licensed nursing staff instructed CNA #1 or Activity Assistant #1 to physically restrain Resident #1 and he/she did not require an emergency restraint. The ADON said if Resident #1 did require a physical restraint, a table or a sweatshirt was not an acceptable mechanism of restraint. According to the reasonable person's concept, though Resident #1 had dementia and memory impairment, a reasonable person would feel emotional and psychological harm as a result of being restrained and prevented from rising and walking.

2. For Resident #17, the facility failed to follow the resident's falls care plan relative to the following: not to be left alone in room, and 1:1 on 3:00 - 11:00 P.M. shift as planned. Resident #17 was admitted to the facility in 3/2012 with [DIAGNOSES REDACTED]. Review of the clinical record revealed there was no interim care plan for falls for Resident #17. During discussion with the DON (Director of Nursing) on 9/25/12 at 11:00 A.M., she stated that the facility uses the CNA Care Cards as their interim care plans; however, they are done in pencil and get erased and updated as the resident's status changes. The DON also said the March 2012 Falls Care Plan was incorrectly dated (3/12) which was prior to Resident #17's admitted ; however this was the falls care plan for the Resident and it indicated the following: High risk for falls related to impulsive behavior, unsteady gait, difficult to redirect secondary to dementia and [MEDICAL CONDITION] drug use. The interventions included: - Pad alarms on chair - Bed against the wall - Fall mat near bed mattress - Pad alarm on bed - Ambulate with 1 assist and rolling walker - Will receive lowest therapeutic dose of [MEDICAL CONDITION] medications Nursing note written on 3/25/12 at 11:00 A.M. indicated that at 6:20 A.M. the resident was found by the CNA sitting on the fall mat next to the bed. Fresh bruising was noted to the right knee. The care plan was updated to add a thick mattress next to the resident's bed. On 4/3/12 the care plan was changed and the thick mattress was removed from the side of the resident's bed. On 4/4/12, the care plan was revised to apply the thick mattress beside the bed again (at night only) and to apply alarms to the resident (at night only). On 4/19/12, the resident was d/c'd from PT (Physical Therapy) and OT (Occupational Therapy). The resident was able to transfer and ambulate independently with the rolling walker, and needed supervision with rolling walker for toilet transfers. On 5/3/12 at 10:00 A.M., the resident had an unwitnessed fall and was found on the floor in front of his/her bed, with head against the bed. New interventions included to put the resident back to bed in the morning if he/she was up all night. On 5/9/12 at 3:40 P.M., the resident fell in the room and hit his/her head on the dresser drawer causing a laceration requiring a hospital evaluation and 3 sutures. The plan of care was updated to include: - Will be 1:1 while therapy evaluates - Not to be allowed alone in room - Low bed, floor mat, and parameter mattress Nursing note of 5/31/12 indicated that at 3:45 P.M. the resident was found sitting on the floor in the bedroom. The resident was alone in the room when he/she fell , despite the new interventions following the fall of (5/9/12), indicating the resident was not to allowed to be alone in the room. Review of the circumstances surrounding the fall indicated the resident was brought to the hall by recreation (activities) and left unattended, when he/she had to use the bathroom. The resident wheeled self into his/her room (unwitnessed), stood up from the wheelchair and fell . The resident sustained [REDACTED]. The nursing note indicated the intervention was to continue with 1:1 supervision, despite the resident not being on 1:1 supervision during the incident, and to bring the resident directly to the nurse if the resident needs to use the bathroom. The Plan of Care for Falls was re-written on 6/20/12 and indicated, "High risk for falls R/T (related to) impulsive behaviors, unsteady gait, difficult to redirect, [MEDICAL CONDITION] med (medication) use, (secondary to) dementia. The interventions included: - Low bed against the wall - Mat on floor near bed - Pad alarm on bed - Ambulate with 1 assist with rolling walker - Will receive lowest therapeutic dose of [MEDICAL CONDITION] medications - Allow resident to go to bed if up all night - 1:1 on 3-11 shift - 1:1 on other shifts as needed - Not to be left in room alone (6/23/12) despite the intervention being implemented after the 5/9/12 fall On 6/23/12 at 4:00 P.M., the resident was found on the floor mat beside the bed. The fall was not witnessed. The resident was alone in the room, despite the intervention following the fall of 5/9/12 indicating the resident was not to be alone in the room. The plan of care was also not followed regarding 1:1 supervision on the 3:00 - 11:00 P.M. shift. New interventions included to take resident out of room at 3:00 P.M. Review of the circumstances indicated that the 1:1 staff assigned to the resident was late coming in. The resident sustained [REDACTED]. Nursing note of 7/8/12 at 6:00 A.M. indicated that the resident was found sleeping on the mat on the floor with a pillow under his/her head. The resident had unpinned the alarm. New interventions included changing the tab alarm to a pad alarm. During discussion with the Director of Nursing on 9/19/12, she stated that the 1:1 with the resident was not always provided. Please refer to F323 3. For Resident #9, the facility failed to apply a "heel lift" to the Resident's left foot as ordered by the Physician. Resident #9 was admitted to the facility in 9/2008. Review of the September 2012 TAR (Treatment Administration Record) revealed that the resident had a physician's orders [REDACTED]. During observation of the resident on 9/17/12 at 8:10 A.M., the resident was lying in the bed without the heel boot on, and the heels were lying directly on the mattress. On 9/17/12 at 2:45 P.M., the surveyor observed the resident taking a nap in bed. Two foam heel boots were observed in the chair next to the resident's bed. The resident's heels were lying directly on the mattress. On 9/17/12 at 4:20 P.M., the surveyor entered the resident's room and observed the heel boots were still on the chair and found Nurse #1. Nurse #1 indicated that the heel boots (especially the left), should be on the resident at all times. Nurse #1 stated the resident previously had a pressure sore on the left foot. Observation of the left heel revealed the heel was red, blanchable, boggy and intact. Nurse #1 placed the heel boots on Resident #9. Based on observation, record review, and staff interview, the facility failed to ensure that physician's orders [REDACTED].#5, #9, #15, and #17) in a total sample of 19. Findings include: 1. For Resident #5, the facility failed to: - Provide treatments for an ulcer on the resident's left lower leg according to physician's orders [REDACTED]. - Provide diabetic foot care per facility policy; - Elevate the resident's legs per physician's orders [REDACTED]. - Discontinue the resident's [MEDICATION NAME] socks per physician's orders [REDACTED]. Resident #5 was admitted to the facility in 05/2012. [DIAGNOSES REDACTED]. Review of the admission nursing assessment revealed the skin on the resident's legs and feet were clear and intact with no scabbed areas. The facility policy titled "FOOT CARE - DIABETIC" indicated that diabetic residents would receive diabetic foot care every day by nursing personnel. Review of the plan of care addressing Nutrition and diabetes, developed on 6/3/12, included approaches for diet, weights, and blood sugars. The care plan did not address monitoring of the resident's skin and the risk for skin breakdown. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated the resident: could understand others and was understood by others; had no foot problems, and required extensive assistance from staff for bed mobility, transfers, ambulation, dressing, toilet use and bathing. Review of the CNA (Certified Nursing Assistant) Resident Personal Care Plan (updated 6/13/12) indicated the resident would receive diabetic foot care daily at bedtime. The Activity of Daily Living Flow Records (CNA flow sheets) for 6/2012, 7/2012, 8/2012, and 9/2012 had no documentation that diabetic foot care was provided per policy. Review of Treatment Records for 6/2012, 7/2012, 8/2012, and 9/2012, also had no documentation that diabetic foot care was provided. A physician's orders [REDACTED]. Change daily on 3-11 and PRN, until healed." Review of the clinical record and documentation provided by the facility (Report Book) indicated the resident's right lower leg wound dressing was not conducted on the following dates: - 8/15/12, no documentation that the dressing was changed. - 8/16/12, no documentation that the dressing was changed. - 8/17/12, no documentation that the dressing was changed. - 8/19/12 - 8/24/12, no documentation that the dressing was changed. The physician's orders [REDACTED]. On 9/11/12, the resident saw the Wound Consultant. Recommendations included: - Limit sit time to 30-45 minutes three times daily; - Elevate both legs while sitting. On 9/17/12 at 4:15 P.M., the surveyor observed the resident lying in bed with the foam boots on. Both feet were turned in the boots so that that there was direct pressure on the right leg wound and on the left malleolus. Neither leg was elevated. On 9/18/12 at 8:20 A.M., the surveyor observed the resident lying in bed with the foam boots on. Both feet were turned in the boots so that there was direct pressure on the right leg ulcer and on the left malleolus. This was also observed by Nurse #3, who told the surveyor that it was obvious the pressure relief boots were not effective. On 9/18/12 from 8:45 A.M. to 10:45 A.M. the resident was observed by the surveyor sitting in the dining area in a reclining chair. The chair was not reclined in order to elevate the resident's legs and feet. Both feet were on the floor the entire time. On 9/19/12 at 8:20 A.M., the surveyor observed the resident lying in bed. The resident was wearing the [MEDICATION NAME] socks that had been discontinued the day before. During interview on 9/19/12 at 10:30 A.M., Nurse #5 told the surveyor that she had incorrectly transcribed the order for the wound dressing onto the Treatment Record, and then on 8/27/12 discovered her own error and wrote another order to continue the same treatment. Please refer to F309. 4. For Resident #15, the facility failed to follow the Resident's Falls care plan related to personal alarms, call bell within reach and Dycem to the wheelchair. Resident #15 was admitted to the facility in 9/2010 with [DIAGNOSES REDACTED]. Review of the Resident's Falls care plan included the following interventions; - Bed alarm, - Chair alarm, - Call Bell within reach, - Parameter mattress (initiated 12/13/11), - Do not allow in bedroom alone, unless in bed (initiated 12/14/11), - Low bed, fall mat and bed against the wall (initiated 4/2/12), - Toilet at 12:00 A.M. and 4:00 A.M. (initiated 7/12/12) and, - Dycem to the wheelchair (initiated 8/27/12). Review of the Incident and Investigation Report, dated 11/7/11, indicated the Resident had an unwitnessed fall at 10:20 P.M. in the bedroom. The Resident said, he/she was going to the bathroom. The bed alarm did not sound per plan of care. The new intervention was to fix the alarm. Review of the Incident and Investigation Report, dated 12/13/11, indicated the Resident had an unwitnessed fall at 2:00 P.M. in the bedroom. The Resident said, he/she was going to the bathroom. The call bell was not within reach, per the plan of care and the bed alarm was sounding, but quietly. The new intervention included changing the battery to the alarm. Review of the Incident and Investigation Report, dated 12/14/11, indicated the Resident had an unwitnessed fall at 2:00 P.M. in the bathroom. The Incident Report indicated the call bell was not within reach and it does not indicate if the alarm was sounding. The new intervention included not leaving the Resident alone in the room except when in bed. Review of the Incident and Investigation Report, dated 4/2/12, indicated the Resident had an unwitnessed fall at 2:45 P.M. in the bedroom. The Resident said he/she needed to go to the bathroom. The Incident Report indicated the alarm did not sound, because the battery was not functioning. Review of the Incident and Investigation Report, dated 8/27/12, indicated the Resident had a witnessed fall at 6:00 P.M. in the dining room. The Resident was witnessed sliding out of the wheelchair. The new intervention was to put dycem on the seat of the wheelchair. On 9/20/12 at 11:35 A.M., during an interview with UM #1, she said that she could not recall why the alarms did not sound, most of the time it was because of the batteries needed to be changed. She also said the staff know that the call bell needs to be within reach when the Resident is in bed. After the interview the surveyor asked UM #1 to enter into the dining room where the Resident was seated to ensure the Resident was sitting on the dycem per the plan of care. UM #1, with assistance from another staff member, stood the Resident up. There was no Dycem in place per the plan of care. UM #1 said that she would get the Dycem right away. Please refer to F323

Based on observation, record review, and staff interview, the facility failed to ensure that 2 of 7 applicable residents with ulcers (#5 and #8), in a total sample of 19 residents, received the necessary treatment and services to prevent sores from developing, and to promote healing. Findings include: 1. For Resident #5, the facility failed to monitor a scabbed area on the resident's right outer calf, despite [DIAGNOSES REDACTED]. The facility also failed to treat the area according to physician's orders [REDACTED]. Resident #5 was admitted to the facility in 05/2012. [DIAGNOSES REDACTED]. Review of the admission nursing assessment revealed the skin on the resident's legs and feet were clear and intact with no scabbed areas. The facility policy titled "FOOT CARE - DIABETIC" indicated that diabetic residents would receive diabetic foot care every day by nursing personnel. Review of the plan of care addressing Nutrition and Diabetes, developed on 6/3/12, included approaches for diet, weights, and blood sugars. The care plan did not address monitoring of the resident's skin and the risk for skin breakdown. The Admission MDS (Minimum Data Set) Assessment, dated 6/5/12, indicated the resident: could understand others and was understood by others; had no foot problems, and required extensive assistance from staff for bed mobility, transfers, ambulation, dressing, toilet use and bathing. Review of the clinical record revealed no plan of care for the risk for diabetic ulcers despite [DIAGNOSES REDACTED]. Review of the CNA (Certified Nursing Assistant) Resident Personal Care Plan (updated 6/13/12) indicated the resident would receive diabetic foot care daily at bedtime. The Activity of Daily Living Flow Records (CNA flow sheets) for 6/2012, 7/2012, 8/2012, and 9/2012 had no documentation that diabetic foot care was provided per policy. Review of Treatment Records for 6/2012, 7/2012, 8/2012, and 9/2012, also had no documentation that diabetic foot care was provided. Review of the clinical record indicated the resident was transferred from the third floor to the second floor on 8/8/12. A physician's orders [REDACTED]. Change daily on 3-11 and PRN, until healed." Review of the 8/2012 Treatment Record (TAR) revealed that when the above order was transcribed onto the TAR, it incorrectly indicated the treatment was to be done on an as needed basis (PRN), and not daily as ordered. A nurse's note of 8/11/12 on the 7:00 A.M. to 3:00 P.M. shift revealed the right lower extremity wound measured 2.0 x 1.0 cm (centimeter) with 1.0 x 1.0 cm of slough. The note also indicated that the perimeters of the wound had increased redness and [MEDICAL CONDITION]. The Physician was notified and ordered the anti-infective medication Keflex 250 mg (milligrams) by mouth four times daily for 7 days. Documentation regarding the right lower leg in the Nurses' notes and Report Book included: - 8/13/12, right lower leg wound macerated, peri (perimeter) wound reddened. Small amount serous drainage noted. - 8/14/12, right lower leg wound macerated. Peri wound reddened. Treatment as ordered. - 8/15/12, no documentation that the dressing was changed. - 8/16/12, no documentation that the dressing was changed. - 8/17/12, no documentation that the dressing was changed. - 8/18/12, indicated the Keflex was administered, and the wound had no signs or symptoms of infection. There were no measurements. - 8/19-8/24/12, no documentation that the dressing was changed. - 8/25/12, Nurse's note indicated the dressing was changed, and that the wound had green slough with a reddened perimeter. There were no measurements. - 8/27/12, review of the 8/2012 TAR revealed another order to apply Santyl ointment after washing with Normal Saline. A Podiatry consult dated 8/29/12, indicated the resident had some [MEDICAL CONDITION] and poor circulation (cool to touch, no hair and decreased feeling). A physician's orders [REDACTED]. A Physician's Progress Note of 9/4/12 indicated that the Physician was aware of the area on the resident's right lower leg. The Physician, at this time, indicated the area was infected, and possibly caused by pressure from the side of the wheelchair. The wound was described by the Physician as purulent drainage with a surrounding area of [MEDICAL CONDITION]. The note continued to say that the resident has had a weak pulse in the affected foot in the past. The Physician indicated that Nursing Staff claimed the wound was first noticed one week prior (documentation indicates the area was first noted on 8/11/12), and that the resident "apparently had a small lesion while upstairs also before transfer to the second floor...." There was no documentation in the clinical record that the resident had a lesion or that a lesion was being monitored by staff. The Physician spoke with the family who preferred to have the resident treated with antibiotics at the facility and not in hospital. The physician's orders [REDACTED]. - re-culture the wound; - Give the anti-infective medication [MEDICATION NAME] 1 gram intramuscularly now, then give intravenously daily for 7 days; - Call wound clinic for an appointment ASAP (as soon as possible), and - Elevate right leg please. A Physician's Progress Note of 9/5/12 indicated the resident had an x-ray of the right foot which indicated, bony erosions to suggest osteo[DIAGNOSES REDACTED], the lesion today is essentially unchanged, already on antibiotics. It is surrounded by area of [MEDICAL CONDITION]. Will continue with IV (intravenous) antibiotics and elevation, pending dermatology evaluation here. Culture pending. A Physician's Progress Note of 9/6/12 included the resident was "pain free probably due to the fact he/she has peripheral diabetic [MEDICAL CONDITION], which might have contributed to this injury to begin with...." A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Physician's Progress Note of 9/10/12 indicated the resident's culture was positive [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus). The new order was to administer the anti-infective medication [MEDICATION NAME] 100 mg twice daily for 2 weeks. On 9/11/12, the resident saw the Wound Consultant. Recommendations were: - Waffle Boots to both heels at night; - Limit sit time to 30-45 minutes three times daily; - Elevate both legs while sitting; - Cleanse wound with Normal Saline; - Mesalt (Sterile Alginate dressings intended for the management of moderate to heavily draining and/or infected wounds). Change daily; -Moisture barrier to surrounding skin; - [MEDICATION NAME] (elasticized bandage to improve circulation in the legs) doubled to both lower legs from below toes to just below knee after elevating leg for 30 minutes. Remove at bedtime. - [MEDICATION NAME] (soft and very comfortable foam dressing that absorbs wound fluid (exudate), but keeps your wound sufficiently moist) to LEFT lateral malleolus - change 2 times weekly. Protective dressing for another open area. A Nurse's note of 9/17/12 indicated the resident's wound dressing was changed. The wound was measured (first measurements since the first ones done on 8/11/12). The wound was 6.0 x 4.8 x 0.1 cm and 40% covered with slough. The Physician was notified who ordered Santyl and Iodosorb dressing (highly absorbent dressing). On 9/17/12 at 4:15 P.M., the surveyor observed the resident lying in bed with the foam boots on. Both feet were turned in the boots so that that there was direct pressure on the right leg wound and on the left malleolus. Neither leg was elevated. On 9/18/12 at 8:20 A.M., the surveyor observed the resident lying in bed with the foam boots on. Both feet were turned in the boots so that there was direct pressure on the right leg ulcer and on the left malleolus. This was also observed by Nurse #3, who told the surveyor that it was obvious the pressure relief boots were not effective. On 9/18/12 from 8:45 A.M. to 10:45 A.M., the resident was observed by the surveyor sitting in the dining area in a reclining chair. The chair was not reclined in order to elevate the resident's legs and feet. Both feet were on the floor the entire time. On 9/18/12 at 2:30 P.M., the surveyor observed the Wound Nurse (Nurse #4) change the dressing on the resident's left lower leg. The Nurse removed the [MEDICATION NAME] socks. When the socks were removed, the surveyor and Nurse #4 saw that there were pressure ridges from the socks all along the leg including the wound. The skin right around the wound had some darkening (dark bluish-red) with pressure marks from where the socks were. Nurse #4 told the surveyor that he would call the Physician and have the socks discontinued until the Physician could observe the area. When the old dressing was removed, it was saturated with exudate. The wound was 75% filled with a thick, deep yellowish-gray slough. The wound was cleansed with Normal Saline and patted dry, then covered with the Santyl as ordered, and covered with a foam dressing. During interview on 9/18/12 at 3:30 P.M., the Wound Nurse told the surveyor that he recalled the resident having a scabbed area on the lower right calf while the resident was residing on the third floor, but that there was no documentation that the area was monitored despite having a [DIAGNOSES REDACTED]. On 9/19/12 at 8:20 A.M., the surveyor observed the resident lying in bed. The resident was wearing the [MEDICATION NAME] socks that had been discontinued the day before. During interview on 9/19/12 at 8:25 A.M., Unit Manager #1 told the surveyor that she was not aware that the [MEDICATION NAME] socks had been discontinued. The surveyor showed the Unit Manager the new order dated 9/18/12. During interview on 9/19/12 at 10:30 A.M., Nurse #5 said the day after the resident was transferred to the second floor from the third floor (8/9/12), she noticed a scabbed area on the resident's right outer lower calf that just didn't "look right." This nurse told the surveyor that on 8/10/12, she called the Physician to report the area was now open and was draining. Further interview with this nurse revealed that it was she who transcribed the order onto the TAR, and that on 8/27/12 discovered her own error and wrote another order to continue the same treatment. This nurse told the surveyor that she did not do any measurements, but that the wound was much larger, covered with a greenish slough, and was not healing. 2. For Resident #8, the facility failed to ensure that the treatment ordered by the Physician was provided for a Diabetic ulcer on the Resident's toe in order to promote healing and prevent the ulcer from worsening. Resident #8 was admitted to the facility in 6/12. The Resident's pertinent [DIAGNOSES REDACTED]. The 6/19/12 Initial MDS Assessment indicated that the Resident had memory problems, with impaired cognitive abilities; was extensive assist for bed mobility and ADLs (Activities of Daily Living); had functional limitation in range of motion to one lower extremity, was at risk for pressure ulcer development with no pressure, vascular or [MEDICAL CONDITION], had a surgical wound and received 7 days of Insulin injections. The 7/31/12 nursing note indicated that a bloody sock was found in the Resident's room. Resident #8 was found to have an ulcer on the 3rd toe of the right foot. The Resident had a peripheral IV (Intravenous) line inserted, and an antibiotic was administered. The plan indicated that an appointment would be made for Resident #8 to go to the Wound Clinic. The 8/1/12 nursing note indicated that the Resident had an X-Ray of the right foot to rule out a bone infection. The X-Ray was negative. The note indicated that the tip of the Resident's 3rd toe area measured 0.3 cm deep and had a moderate amount of bleeding. According to the clinical record, Resident #8 was transported to an appointment on 8/2/12 relative to the 3rd toe ulcer. The Resident was transported from the appointment to the Hospital and was admitted . Review of the Hospital report of 8/2/12, indicated that the Resident had an acute infection of the 3rd toe and received IV antibiotics. On 8/3/12, the Resident had a distal, right 3rd toe partial phalangectomy (excision of a bone from the toe), 3rd toe debridement and closure. The Resident was discharged back to the facility on [DATE] with a treatment to the closed incision site. The care plans (updated 8/13/12) relative to the resident's risk for skin breakdown secondary to Diabetes, history of toe amputation, [MEDICAL CONDITION], and 3rd toe infection s/p debridement and partial amputation indicated interventions which included special gauze and Kling wrap to the 3rd toe. During the initial tour of the Resident's Unit with UM (Unit Manager) #2 (on 9/17/12 at 7:20 A.M.), UM #2 said to the surveyor that Resident #8 was a Diabetic, currently had a Diabetic ulcer on the right foot, and wore a specialized open toe shoe to relieve pressure to the area. Review of the 8/31/12 physician's orders [REDACTED]. During a treatment observation with Nurse #2 on 9/17/12 at 11:35 A.M., Nurse #2 removed a specialized open toe shoe and a beige-colored sock from the Resident's right foot. Nurse #2 removed a dressing from the Resident's 3rd toe. There was a moderate amount of blood tinged yellow drainage on the old dressing. There was a cratered ulcer which covered the top surface of the partially amputated 3rd toe. The open ulcer was approximately 1.3 cm wide x 0.8 cm in length. There was a thin film of yellow-colored tissue in the shallow cratered wound bed (depth could not be determined). The outer margin of the wound bed was swollen and red. There was dried, peeling tissue on the lateral wound margin. Nurse #2 poured N/S onto 3 gauze pads, picked up the moistened gauze pads and washed the open, draining ulcer. Nurse #2 used a dry gauze pad to dry around the periphery of the ulcer. Nurse #2 opened a large [MEDICATION NAME] bandage and applied the dry dressing to the Resident's ulcer (not a wet to dry dressing). The surveyor met with Nurse #2 and UM #2 directly following the treatment to the 3rd toe on 9/17/12 at 12:10 P.M. Nurse #2 said that he thought the ulcer was wet enough, and so he just applied a dry dressing. UM #2 said that a wet to dry dressing meant that a dressing had to be applied to the wound as wet then covered with a dry dressing. Nurse #2 said that he did not apply a wet dressing before applying the dry one. On 9/17/12, the surveyor was told that the facility utilized "Lippincott Manual of Nursing Practice Eighth Edition" as policy for wet to dry dressings, and identified page 131. This page indicated a wet to dry dressing application, and included that a gauze, saturated with sterile saline, is packed into the wound and that the wet dressing is covered by a dry dressing. As drying occurs, wound debris and necrotic tissue are absorbed into the gauze dressing. During interview with the DON (Director of Nursing) on 9/18/12 at 3:30 P.M., she said that Nurse #2 was a new nurse, and had been working as a nurse in the facility for about one year. The DON showed the surveyor a wound care training document (provided by the facility's Wound Nurse), indicating that Nurse #2 had training in the application of a wet to dry dressing. The DON said that re-education would be provided again to Nurse #2 to ensure the appropriate dressing would be applied to Resident #8's Diabetic ulcer, located on the Resident's 3rd toe. Please refer to F314.

Based on record review, observation and interview, the facility failed to ensure necessary care and services were provided relative to the prevention of pressure ulcer development for 1 of 7 applicable sampled residents (#8) with ulcers, from a total sample of 19. Findings include: For Resident #8, the facility failed to identify a new pressure ulcer on the Resident's right ankle. Resident #8 was admitted to the facility in 6/12. The Resident's pertinent [DIAGNOSES REDACTED]. The 6/19/12 Initial MDS (Minimum Data Set) Assessment indicated that the Resident had memory problems, with impaired cognitive abilities; was extensive assist for bed mobility and ADLs (Activities of Daily Living); had functional limitation in range of motion to one lower extremity, was at risk for pressure ulcer development with no pressure, vascular or [MEDICAL CONDITION] and received 7 days of Insulin injections. The 6/12 care plan relative to the resident's risk for skin breakdown included interventions for a skin assessment to be completed every shift with care. The 8/21/12 "Resident Personal Care Plan" included interventions to apply an "Ortho Shoe" on the right foot. According to the clinical record, Resident #8 sustained a 1 cm (centimeter) x 1 cm skin tear to the left, inner ankle on 8/20/12 from scratching it on the side rail. During a treatment observation with Nurse #2 on 9/17/12 at 11:35 A.M., Nurse #2 removed a surgical/Ortho shoe and a beige-colored sock from the Resident's right foot. Nurse #2 provided a treatment to the Resident's right 3rd toe. The surveyor observed an ulcerated area on the Resident's right, lateral ankle. The area was approximately 0.5 cm (centimeters) in diameter, and was surrounded by [DIAGNOSES REDACTED]. The wound base had a thin, superficial scab-like formation. Nurse #2 said that he was done. Nurse #2 replaced the Resident's sock and surgical/Ortho shoe. The surveyor inquired about the new ulcer. Nurse #2 said that he thought it was from when the Resident "scraped" it on the bed about a month ago (clinical record indicated left inner ankle). The surveyor asked Nurse #2 if this area was assessed every shift, and documented, as the care plan indicated. Nurse #2 said that Diabetic Foot care is completed by the 3:00 P.M. - 11:00 P.M. shift nurse, and that the nurse would have documented something on the Treatment Record about the ankle. Nurse #2 checked the TAR (Treatment Administration Record) and identified that there was no Diabetic foot care even provided. Nurse #2 said that every Diabetic resident has documented Diabetic foot care by the Nurse, and that the integrity of the skin is documented. Review of the 9/17/12 documentation made by Nurse #2 only identified the 3rd toe dressing. Nurse #2 did not document anything regarding the new ulcer on the Resident's right lateral ankle. The surveyor met with UM (Unit Manager) #2 on 9/17/12 at 12:50 P.M., and informed her about the new area on the right lateral ankle. UM #2 said that there was nothing in the clinical record to indicate that this Resident even had anything on the right lateral ankle. UM #2 said that there was no Diabetic foot care documented as being checked as done by the Licensed Nurse every night, and there should have been. UM #2 said that Resident #8 did have a skin tear on the left ankle that had healed a while ago. UM #2 said that she would have the facility's Wound Nurse (Nurse #4) come in to assess the new ulcer. On 9/18/12 at 4:20 P.M., the surveyor met with Nurse #4 (Wound Nurse). Nurse #4 said that he assessed the new ulcer on the Resident's right, lateral ankle this morning. Nurse #4 said that the area was a "pressure ulcer," and that he felt that the new pressure ulcer was from pressure related to the surgical/Ortho shoe pressing on the lateral ankle. Nurse #4 provided the surveyor with a copy of a "Pressure Ulcer Record" report. The report indicated the that the new area, located on the right lateral ankle was an unstageable pressure ulcer measuring 0.5 cm x 0.4 cm. On 9/19/12 from 7:00 A.M. to 7:06 A.M., the surveyor observed Resident #8 sitting up in a W/C (wheelchair) in the Unit's Dining Room with the surgical/Ortho shoe on, despite that fact this was the cause of the new pressure ulcer. Please refer to F328.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 3 of 7 applicable residents (#5, #15, and #17) out of a total sample of 19 residents. Findings include: 1. For Resident #17, the facility failed to provide effective interventions and adequate supervision to prevent falls in order to provide an effective falls intervention program for the resident. The facility also failed to follow the resident's falls care plan relative to the following: not to be left alone in room, and 1:1 on 3:00 - 11:00 P.M. shift as planned. Resident #17 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of a nursing note of [DATE] indicated that the resident was alert and confused, self rising times 3, and needed 1:1 supervision on the 3:00 - 11:00 P.M. shift. Review of a nursing note of [DATE] on the 11:00 P.M. - 7:00 A.M. shift indicated that the resident was very behavioral, continued self rising times 3, and was found on the floor at 6:35 A.M. Review of the circumstances surrounding the fall indicated that the fall was unwitnessed, and that prior to the fall the resident was sitting in a stationary chair in the dining room. New interventions included: Resident to have both tab alarm and bed alarm at all times. The resident sustained [REDACTED]. Review of a nursing note of [DATE] indicated that the resident was seated in the MDR (main dining room) in the morning and complained of being tired and wanted to lay down. The resident was put back to bed. At 8:30 A.M. the alarm sounded and the resident was found lying down on his/her right side on the floor in the bedroom. The resident got up from the bed, lost balance and fell . No injuries were noted from the fall. New interventions included to move the resident closer to the nursing station, apply a fall mat to the side of the bed, and put the other side of the bed against the wall. Review of the Initial MDS (Minimum Data Set) Assessment of [DATE] indicated that the resident had moderate difficulty hearing, adequate vision with glasses, and the resident scored 3 of 15 on the (BIMS) Brief Interview for Mental Status Exam which indicated the resident had severely impaired short and long term memory. The resident had little interest or pleasure in doing things; was was feeling down, depressed, and hopeless; feeling tired; had trouble concentrating; had physical behavioral symptoms; verbal behavioral symptoms; and rejected care. The resident required extensive assistance/two person physical assist for bed mobility, extensive assistance/one person physical assist for transfers, dressing, toilet use, personal hygiene, and bathing, limited assist/one person physical assist for walking in room and corridor, and locomotion on and off unit. The resident utilized a walker, was frequently incontinent of bladder, had falls prior to admission, and had 2 or more falls with no injury since admission to the facility, and was receiving antipsychotic and antidepressant medications. Nursing note of [DATE] (11:00 P.M.-7:00 A.M.) shift indicated that the resident was awake and very busy most of the shift and non-compliant with his/her walker. The resident was redirected with only fair effect. At 2:00 A.M. the nurse administered 12.5 mg (milligrams) Trazodone (antidepressant medication sometimes used to treat anxiety) prn (as needed) with fair effect. Nursing note written on [DATE] at 11:00 A.M. indicated that at 6:20 A.M. the resident was found by the CNA sitting on the fall mat next to the bed. Fresh bruising was noted to the right knee. The resident complained of pain to the left shoulder and the left hip. Orders for STAT (immediate) x-ray's of the left hip, left shoulder and pelvis were obtained from the physician. X-ray's of the left shoulder and pelvis were negative for fracture. X-ray of the left hip revealed osteoarthritis, no fracture. The care plan was updated to add a thick mattress next to the resident's bed, and 1:1 supervision for 3 days. Review of a nursing note of [DATE] indicated that the resident was very combative, hitting staff with his/her walker, and very difficult to redirect. The nurse attempted to give the resident the prn medication Trazodone; however, the resident refused. The resident later took the Trazodone 12.5 mg which had some effect. On [DATE] the care plan was changed and the thick mattress was removed from the side of the resident's bed. (The resident was beginning to ambulate and transfer independently with Physical Therapy). On [DATE], the care plan was revised to apply the thick mattress beside the bed again (at night only) and to apply alarms to the resident (at night only). On [DATE], the resident was d/c'd (discharged ) from PT (Physical Therapy) and OT (Occupational Therapy). The resident was able to transfer and ambulate independently with the rolling walker, and needed supervision with rolling walker for toilet transfers. The resident was seen by the facility's Psychiatric Consultant on [DATE] who assessed the resident and indicated to maintain the current psychopharmacology. The resident was receiving the antidepressant medication Remeron 45 mg at hs (bedtime), the antipsychotic medication Zyprexa 10 mg at hs, and the antidepressant medication Trazodone 12.5 mg three times daily as needed. The consult also indicated that the Psychiatric Service would follow-up, and recommended to: Check FBS (Fasting Blood Sugar); WBC (White Blood Cells); and Sodium every 3 months secondary to psychopharmacology. Nursing note of [DATE] indicated that at 6:15 A.M. the resident had an unwitnessed fall. The resident was sitting in a chair in the dining room, and leaned over to pick up crumbs off of the floor. The resident stated he/she did not hit head and denied pain/discomfort. A new intervention for staff to utilize the carpet sweeper to decrease the crumbs under the table was implemented. On [DATE] at 10:00 A.M., the resident had another unwitnessed fall and was found sitting on the floor in front of his/her bed, with head against the bed. The resident complained of pain to the right hip; an x-ray was negative for a fracture. New interventions for a medication review (completed by the resident's Physician on [DATE]), and to offer assist to put the resident back to bed if up all night due to weakness were initiated. On [DATE] at 3:40 P.M., the resident's alarm was sounding, and the resident was found on the floor in the room with his/her head leaning against the dresser drawer. The resident was bleeding from the left side of the head (occiput), and complaining of pain in the head and back and feeling nauseous. The physician was notified and the resident was sent to the hospital for an evaluation. The resident returned to the facility at 10:50 P.M. Review of the the emergency room Report indicated the resident had a 1.5 cm (centimeter) laceration that was 0.5 cm deep which required 3 staples for wound closure. New interventions included: - Will be 1:1 while therapy evaluates - Not to be allowed alone in room - Low bed, floor mat, and parameter mattress A PT Eval (Evaluation) was completed on [DATE] after the resident's fall and the resident began receiving skilled PT services. Nursing note of [DATE] indicated that at 3:45 P.M. the resident was found sitting on the floor in the bedroom. The resident was alone in the room when he/she fell despite the new interventions following the fall of ([DATE]) indicating the resident was not to be allowed alone in the room. Review of the circumstances surrounding the fall indicated the resident was brought to the hall by recreation, (activities), when he/she had to use the bathroom. The resident wheeled self into his/her room (unwitnessed), stood up from the wheelchair and fell . The resident sustained [REDACTED]. The nursing note indicated the intervention was to continue with 1:1 supervision, despite the resident not being on 1:1 supervision during the incident, and to bring the resident directly to the nurse if the resident needed to use the bathroom. The resident was discharged from Physical Therapy on [DATE] and required CGA (Contact Guard Assist) for functional transfers, and ambulation with rolling walker. Review of a Quarterly MDS completed on [DATE] indicated that the resident had little interest or pleasure in doing things; was feeling down, depressed, and hopeless; had trouble sleeping; was feeling tired and had little energy; had a poor appetite; felt bad about self; had thoughts of being better off dead; rejected care; and had wandering behaviors. The resident required extensive assistance/two person physical assist for bed mobility, extensive assistance/one person physical assist for transfers, dressing, toilet use, personal hygiene, and bathing, limited assist/one person physical assist for walking in room and corridor, and locomotion on and off unit. The resident required supervision and set up help for eating. The resident utilized a walker, was continent of urine and occasionally incontinent of bowel. The resident had 1 fall with injury (except major), and 2 or more falls with no injury since the prior assessment, and was receiving antipsychotic and antidepressant medications. The Plan of Care for Falls was re-written on [DATE] and indicated, "High risk for falls r/t (related to) impulsive behaviors, unsteady gait, difficult to redirect, psychotropic med (medication) use, (secondary to) dementia. The interventions included: - Low bed against the wall - Mat on floor near bed - Pad alarm on bed - Ambulate with 1 assist with rolling walker - Will receive lowest therapeutic dose of psychotropic medications - Allow resident to go to bed if up all night - 1:1 on ,[DATE] shift - 1:1 on other shifts as needed - Not to be left in room alone ([DATE]) despite the intervention being implemented after the [DATE] fall On [DATE] at 4:00 P.M., the resident was found on the floor mat beside the bed. The fall was not witnessed. The resident was alone in the room, despite the intervention following the fall of [DATE] indicating the resident was not to be alone in the room. The plan of care was also not followed regarding 1:1 supervision on the 3:00 - 11:00 P.M. shift. New interventions included to take resident out of room at 3:00 P.M. Review of the circumstances revealed that the 1:1 assigned to the resident was late coming in. The resident sustained [REDACTED]. Nursing note of [DATE] at 6:00 A.M. indicated that the resident was found sleeping on the mat on the floor with a pillow under his/her head. The resident stated that he/she unpinned the tab alarm when asked. "Just wanted to lay down." The resident had no apparent injuries. New interventions included changing the tab alarm to a pad alarm. Nursing note of [DATE] indicated that several attempts were made to get the resident up and out of bed for breakfast; however, the resident refused to get out of bed. At 10:00 A.M. the resident's bed alarm sounded, and the nurse went into the resident's room and found the resident sitting on the floor against the stationary chair in the room. A large amount of blood was noted on the floor, the resident's hands, and the back of the resident's head. There was a 1.5 cm x 0.5 cm laceration on back of head. The resident stated, "I hit my head on the floor when I fell ." The Physician was notified and the resident was sent to the hospital for an evaluation. The resident was admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE] and upon return assessment the resident's right leg was slightly swollen and the resident was complaining of pain. The Physician was notified and ordered an x-ray of the hip in the A.M. On [DATE] the resident was sent back to the hospital where a right hip fracture was diagnosed . The resident was placed on Comfort measures and expired on [DATE]. On [DATE] at 4:00 P.M., during discussion with the DON, she indicated that the resident did have 10 falls since admission to the facility in ,[DATE]. 2. For Resident #5, the facility failed to use effective interventions and devices to avoid falls. Resident #5 was admitted to the facility the end of ,[DATE]. [DIAGNOSES REDACTED]. On admission to the facility, the resident was found to be at risk for falls due to a history of falls and dementia as evidenced by numerous areas on the Fall Risk Assessment that required intervention or further assessment. This assessment did not have a numerical score, and only indicated if the resident was at risk. Nurses' notes of [DATE] included, "Resident is non-compliant with ringing light for help with ambulating with RW (rolling walker)." The note indicated the resident was found in the bathroom, and was unsteady. The note indicated the resident had poor safety awareness, and was using a low bed. Another note of [DATE] indicated the resident was still attempting to ambulate unassisted, and that re-direction was poor due to short term memory loss. A nurse's note of ,[DATE] indicated the resident continued to self rise from chairs without assistance and that redirection worked well for short periods. A nurse's note of [DATE] indicated the resident was, "non-compliant with fall precautions, self transfers. Doesn't use call bell when needing something. The nurse spoke with the resident, and the resident assured the nurse that the call light would be utilized (despite documented short term memory loss and dementia). The Admission MDS Assessment, dated [DATE], indicated the resident: had some short term memory loss; required extensive assistance from staff for bed mobility, transfers, ambulation (room and corridor), dressing, toilet use, and bathing; utilized a rolling walker and a wheelchair for locomotion; had falls prior to admission, and balance was poor. The plan of care addressing falls included: - Pad alarm in bed and chair at all times; - low bed with falls mat on floor; - quarterly fall assessment; - ambulate with rolling walker and assist - monitor for unsafe behaviors. Another nurse's note of [DATE] indicated the resident continued to self rise all shift and was non-compliant with asking for assistance. The note included, "Res (resident) knows how to shut off alarm. Re-direction poor." Nurses' notes with the above remarks were written on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. Review of the Resident Personal Care Plan (CNA Care Plan) indicated that it was updated on [DATE]. The plan indicated: the resident was a fall risk; had a pad alarm in the chair; a low bed with a fall mat; required assistance with toilet use; required supervision when in the bedroom, and to keep the alarm where the resident could not reach it (added to the care plan on [DATE]). A Nurse's note of [DATE] indicated the resident had increased confusion and depression, requiring more assistance for eating. The note included, "...cognitive ability seems to be declining. He/she can follow simple commands...." Nurses' notes regarding self rising without assistance were written on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE] (very forgetful, needs to be re-oriented despite cognitive deficits). Review of the Incident and Investigation Report, dated [DATE], indicated the resident was found on the floor in the bedroom at 7:15 P.M., after disconnecting the pad alarm on the chair. The resident was sent to the emergency room and received 4 staples to the back of the head. The investigation indicated the resident was not wearing appropriate footwear at the time of the fall (socks only and not non-skid socks). New interventions added to the care plan were: - non-skid socks - place the alarm out of reach, so the resident could not disconnect it - add a glider rocker for the resident for comfort. Review of Nurses' notes of ,[DATE], ,[DATE], and [DATE] all indicated the resident continued with poor safety awareness and self rising from the wheelchair. The note of [DATE] indicated the resident was still attempting to transfer without assistance, and was "constantly bending over" in the wheelchair to pick up things on the floor. The note indicated the resident was redirected with poor effect and had poor safety awareness. A nurse's note of [DATE] indicated the resident was found on the floor in the bedroom after attempting to self transfer from the wheelchair to the bed at 6:00 P.M. There were no apparent injuries. Review of the Incident and Investigation Report revealed the alarm was not in use at the time of the fall. The new intervention added to the care plan was to offer a snack and put the resident to bed after dinner. During interview on [DATE] at 1:20 P.M., the Director of Nurses told the surveyor that the resident was able to disconnect the alarm, deeming this device ineffective, unless the box was placed out of reach of the resident which it was not on [DATE], despite the resident being able to disconnect it, as evidenced by the nurse's note of [DATE]. 3. For Resident #15, the facility failed to provide adequate supervision and implement new interventions to prevent falls. Resident #15 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of Resident's care plan for High risk for falls included the following interventions; - Bed alarm and - Chair alarm. Review of the Quarterly MDS, dated [DATE], indicated the resident was cognitively impaired, was a limited assistance for transfers, ambulation and toileting, and had not experienced a fall in the last quarter. Review of the Incident and Investigation Report, dated [DATE], indicated the Resident had an unwitnessed fall at 10:20 P.M. in the bedroom. The Resident said, he/she was going to the bathroom. The bed alarm did not sound. The new intervention was to fix the alarm. Review of the Incident and Investigation Report, dated [DATE], indicated the Resident had an unwitnessed fall at 2:00 P.M. in the bedroom. The Resident said, he/she was going to the bathroom. The bed alarm was sounding, but quietly. The new intervention included changing the battery to the alarm and a parameter mattress was added to the bed. Review of the Incident and Investigation Report, dated [DATE], indicated the Resident had an unwitnessed fall at 2:00 P.M. in the bathroom. The incident report does not indicate if the alarm was sounding or not. The new intervention included not leaving the Resident alone in the room except when in bed. Review of the Change in Status MDS, dated [DATE], indicated the resident was cognitively impaired, was a limited assistance for transfers, ambulation and toileting and had two or more falls in the last quarter. Review of the Incident and Investigation Report, dated [DATE], indicated the Resident had an unwitnessed fall at 2:45 P.M. in the bedroom. The Resident said he/she needed to go to the bathroom. The incident report indicated the alarm did not sound, because the battery was not functioning. The new interventions included a low bed, a floor mat and placing the bed against the wall. Review of the Quarterly MDS, dated [DATE], indicated the resident was cognitively impaired, was a limited assistance for transfers and ambulation. The Resident required extensive assistance for toileting and had one fall in the last quarter. Review of the Incident and Investigation Report, dated [DATE], indicated the Resident had an unwitnessed fall at 1:30 A.M. in the bedroom. The CNA responded to an alarm sounding and found the Resident kneeling on the floor mat. The Resident said he/she needed to go to the bathroom. The new interventions included toileting the Resident at 12:00 A.M. and at 4:00 A.M. Review of the Incident and Investigation Report, dated [DATE], indicated the Resident had an unwitnessed fall at 2:20 P.M. in the bedroom. The CNA responded to the alarm and saw Resident #15 sitting on the floor mat. There were no new interventions put into place. Review of the Incident and Investigation Report, dated [DATE], indicated the Resident had an unwitnessed fall at 7:30 A.M. in the bedroom. The CNA found Resident #15 sitting on the floor mat next to the bed. There were no new interventions put into place. Review of the Incident and Investigation Report, dated [DATE], indicated the Resident had a witnessed fall at 6:00 P.M. in the dining room. The Resident was witnessed sliding out of the wheelchair. The new intervention was to put dycem on the seat of the wheelchair. On [DATE] at 7:45 A.M., the surveyor observed Resident #15 in the bedroom with a staff member. The Resident was in bed, dressed with sneakers on. Fall interventions were in place. On [DATE] at 11:35 A.M., during an interview with UM #1, she said the goal on the care plan has been changed to keep the Resident free from injury when the Resident falls, not free from falling. UM #1 said she did not know what else to do for the resident to keep him/her from falling.