Every finding on record at Birch Healthcare Center

Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 3 residents reviewed for abuse. (Resident identifiers are #8 and #70). Findings include: Resident #70 Interview on 8/13/26 at approximately 11:15 a.m. with Resident #70 revealed that around December 2025, on Christmas Day or the following day, Staff H (Licensed Nursing Assistant (LNA)) spun him/her in their wheelchair after he/she had asked Staff H multiple times to assist him/her back to bed. Resident #70 stated that he/she was upset about Staff H's actions and reported the incident to Staff K (previous Director of Nursing (DON)). Resident #70 further revealed that he/she did not know the outcome of his/her report and that Staff H continued to work at the facility. Resident #70 also revealed that he/she reported the incident a second time during a care plan meeting in June 2026. Review on 8/13/26 of Resident #70's grievance form, dated 6/16/26, revealed that on December 2025, Staff H spun him/her in their wheelchair without consent and did not want Staff H as their LNA. Interview on 8/13/26 at approximately 1:51 p.m. with Staff I (Social Worker) confirmed that Resident #70 had a concern about Staff H that occurred around December 2025. Staff I revealed that Resident #70 wanted to file a formal grievance which he/she started, reported the concern to Staff K, he/she provided emotional support to Resident #70. Review on 8/13/26 of Staff H's corrective action form, dated 7/21/26, revealed that Staff H was provided a verbal warning for multiple complaints regarding his/her resident interaction and performance of assigned duties. The concerns reported included speaking to residents in a rude, disrespectful, or unprofessional manner; failing to complete assigned resident tasks; leaving residents wet or soiled for extended periods after providing care; failing to change bed linens when soiled or required; and inconsistent adherence to established standards of resident care. Interview on 8/13/26 at approximately 8:55 a.m. with Staff G (DON) was unaware of the alleged violations reported by Resident #70 and confirmed that Staff H received a verbal warning in regards to the above mentioned alleged violations noted in Staff H's corrective action form dated 7/21/26. Staff G was unaware of the nature of the alleged violations mentioned in the corrective action form.Resident #8Interview on 8/11/26 at approximately 9:10 a.m. with Resident #8 revealed that he/she had a concern about a staff and that management was aware. Resident #8 did not disclose further information about his/her concern. Review on 8/13/26 of Resident #8's grievances form, dated 6/14/26 revealed that Resident #8 complained that Staff H was rough with him/her while being showered and it hurt their shoulder. Further review revealed that Staff K investigated this allegation of rough care and had a verbal discussion with Staff H on 7/19/26. Review on 8/13/26 of Resident #8's grievance form, dated 8/3/26, revealed that Resident #8 complained that Staff H assisted him/her removing their shirt and pulled their shirt off not gently hurting their shoulder and yanked their pants off and threw it on the floor. Interview on 8/13/26 at approximately 8:56 a.m. with Staff G confirmed that he/she was notified on 8/4/26 of Resident #8's allegation of rough care by Staff H. Staff G stated that the allegation was investigated, verified, and resulted in the termination of Staff H's employment on 8/4/26. Review on 8/13/26 of the facility's policy titled, Abuse, Neglect, and Exploitation, reviewed/revised date of 10/23/24, revealed, .Prevention of Abuse, Neglect and Exploitation .A. Establishing a safe environment .B. Identifying, correcting, and intervening in situations in which abuse, neglect .is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual's care needs, and behavioral symptoms .Identification of Abuse, Neglect, and Exploitation .Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse .failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & [and] repositioning .Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after investigation .

Based on interview and record review, the facility failed to report alleged violation to the State Survey Agency (SSA) for 2 of 3 residents reviewed for abuse. (Resident identifiers are #8, and #70.) Findings include: Resident #8Review on 8/13/26 of Resident #8's grievance form, dated 6/14/26, revealed that Resident #70 complained that Staff H (Licensed Nursing Assistant (LNA)) was rough with him/her while providing him/her a shower and that Staff K (previous Director of Nursing) investigated this allegation. Review on 8/13/26 of the Facility Reported Incidents from 6/14/26 to 7/14/26 revealed that the above incident was not reported to the SSA.Resident #70 Review on 8/13/26 of Resident #70's grievance form, dated 6/16/26, revealed that on December 2025, Staff H spun him/her in their wheelchair without consent and did not want Staff H to be their LNA. Further review revealed that Staff K investigated the alleged violation. Review on 8/13/26 of Staff H's corrective action form, dated 7/21/26, revealed that Staff H was provided a verbal warning for multiple complaints regarding his/her resident interaction and performance of assigned duties. The concerns reported included speaking to residents in a rude, disrespectful, or unprofessional manner; failing to complete assigned resident tasks; leaving residents wet or soiled for extended periods after providing care; failing to change bed linens when soiled or required; and inconsistent adherence to established standards of resident care. Interview on 8/13/26 at approximately 8:52 a.m. with Staff G (Director of Nursing) revealed that he/she was unable to provide an explanation or documentation that these alleged violations had been reported to the SSA. Review on 8/13/26 of the Facility Reported Incidents from 6/16/26 to 7/30/26 revealed that the above incidents were not reported to the SSA. Review on 8/13/26 of the facility's policy titled, Abuse, Neglect, and Exploitation, reviewed/revised date of 10/23/24, revealed, .Identification of Abuse, Neglect, and Exploitation .Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse .failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & [and] repositioning .Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after investigation .Reporting/Response .Reporting of alleged violation to the Administrator, state agency, adult protective services, and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes .

Based on interview and record review, it was determined that the facility failed to ensure that residents received scheduled medications on days that they attended dialysis for 1 of 1 resident reviewed for dialysis in a final sample of 28 residents (Resident Identifier is #6).Findings include: Interview on 9/16/25 at approximately 1:41 p.m. with Resident #6 revealed that he/she attended dialysis on Mondays, Wednesdays, and Fridays for a diagnosis of Stage 5 Kidney Disease. Interview on 9/17/25 at approximately 2:00 p.m. with Staff B (Medication Nursing Assistant) revealed that Doxazosin medication was not given on days of dialysis. Review on 9/18/25 of Resident #6's medication administration record (MAR) revealed an order for Doxazosin Mesylate tablet 1 MG, give 1 tablet by mouth in the afternoon for HTN [Hypertension], dated of 6/5/25. Resident #6's MAR revealed that his/her Doxazosin was not given on the following dates: 8/6/25, 8/8/25, 8/10/25, 8/13/25, 8/15/25, 8/18/25, 8/22/25, 8/25/25, 8/27/25, 9/1/25, 9/3/25, and 9/17/25. Interview on 9/18/25 at approximately 11:16 a.m. with Staff C (Unit Manager) confirmed the above findings and revealed there was no documentation that the provider was notified when the resident missed the above medications. Interview on 9/18/25 at approximately 11:24 a.m. with Staff I (Nurse Practitioner) revealed that Staff I was not aware that the Doxazosin was not given on dialysis days and that he/she was not notified.

Based on interview and record review, it was determined that the facility failed to report an alleged violation of abuse no later than 24 hours to the State Survey Agency (SSA) for 1 of 2 residents reviewed for abuse in a final sample of 18 residents (Resident identifier is #67).Findings include:Interview on 9/16/25 at approximately 9:22 a.m. with Resident #67 revealed that he/she had an alleged verbal and physical altercation with Resident #68 on 9/14/25 after Bingo. Resident #68 grabbed Resident #67's upper arm. Resident #68 swore at Resident #67 and told them to die. Resident #67 said they reported the incident on 9/15/2025 to Staff F (Rehabilitation Director). Interview on 9/18/25 at 9:25 a.m. with Staff F revealed that Resident #67 informed them about the verbal and physical altercation. Staff F revealed that he/she notified Staff E (Social Service Director) and Staff G (Administrator). Interview on 9/18/25 at 9:35 a.m. with Staff G confirmed that they became aware of the resident to resident incident on 9/15/25. Staff G revealed that the allegation of abuse was not reported to the SSA. Interview on 9/18/25 at 9:58 a.m. with Staff H (Director of Nursing) revealed that the resident to resident incident was reported to her on 9/15/2025 and she had not spoken to both residents involved. Staff H confirmed that the allegation of abuse was not reported to the SSA. Review on 9/18/25 of the facility's policy titled, Reporting Alleged Violations, revision date of 8/01/21, revealed, .1. All alleged violations involving abuse, neglect, exploitation or mistreatment must be reported immediately.2. If the alleged violation involves abuse it must be reported immediately but no later than 2 hours after the allegation is made. Definitions, Verbal Abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families.

Based on interview and record review, it was determined that the facility failed to document that the resident and/or the resident's representative was fully informed of the risk and benefits of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents. (Resident identifier is #10.) Findings include:Review on 9/18/25 of Resident #10's diagnosis list revealed that he/she had diagnoses of Dementia, Depression and Cognitive communication deficit.Review on 9/18/25 of Resident #10's physician orders revealed Resident #10 was prescribed the following psychotropic medications:Trazodone HCL (hydrochloride) Oral tablet 100 MG (milligrams) Give 1 tablet by mouth at bedtime for insomnia, order date was 6/24/25Risperidone Oral tablet 0.5 MG Give 1 tablet by mouth two times a day for Depression, order date was 6/25/25Sertraline HCL Oral tablet 50 MG Give 1 tablet by mouth one time a day for Depression, order date was 6/25/25. Review on 9/18/25 of Resident #10's medical record revealed that there was no evidence Resident #10 was informed of the risk and benefits of the above medications prior to initiation of the medications.Interview on 9/18/25 at approximately 1:31 p.m. with Staff A (Clinical Resource Nurse) confirmed the above findings.

Based on record review, observation, interview, and policy review, it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) for 1 of 6 residents reviewed for infection control (Resident Identifier #55) and the facility failed to perform hand hygiene during medication administration for 3 of 5 residents observed (Resident Identifiers are #21, #44 and #49). Findings Include: Resident #55: Review on 8/27/24 of Resident #55's medical record revealed they had an order for EBP for medication received through a peripheral line and an infected wound. Observation on 8/27/24 at approximately 10:00 a.m. of Resident #55 revealed an EBP sign and PPE inside the resident's room. Staff B (Licensed Nurse Aide) was observed assisting Resident #55 with transfers and positioning without wearing a gown or gloves. Interview on 8/27/24 at approximately 11:35 a.m. with Staff B confirmed the above finding and revealed that they were aware that Resident #55 was on EBP. Review on 8/29/24 of Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) on the CDC website, found at https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html and updated on 7/12/22, revealed: .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing [11-15]. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs [3,5,6]. 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 activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering,Transferring,Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheotomy/ventilator, Wound care: any skin opening requiring a dressing. Review on 8/29/24 of the facility's policy titled, Enhanced Barrier Precautions, last revised 5/31/24 revealed: An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds .PICC lines .3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of resident's room .4. High-contact resident care activities include: a. Dressing .c. Transferring . Unit A Wing Medication Administration: Observation on 8/28/24 from 7:30 a.m. to 7:50 a.m. of medication administration of 3 residents (#21, #44, and #49) revealed Staff C (Medication Nurse Assistant) did not perform hand hygiene between each of the 3 residents. Interview on 8/28/24 at approximately 8:00 a.m. with Staff C confirmed the above finding. Review on 8/29/24 of the facility's policy titled, Medication Administration, last revised 3/19/24 revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician .in a manner to prevent contamination or infection .Wash hands prior to administering medication per facility protocol and product. Review on 8/29/24 of the facility's policy titled, Hand Hygiene, last revised 6/14/23 revealed: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure open injectable medications were labeled in accordance with the manufacturer's instructions in 1 out of 2 medication carts observed. Findings include: Observation on 8/27/24 at approximately 8:30 a.m. of the orange medication cart on the B wing revealed an open multiple-dose vial of Lantus (Insulin Glargine) Solution without an open date and/or an open expiration/discard date that was in use for Resident #50. Interview on 8/27/24 at 8:40 a.m. with Staff A (Licensed Practical Nurse) confirmed the above finding. Review on 8/27/24 of the Lantus (Insulin Glargine) manufacturer's instructions revealed: The Lantus vials you are using should be thrown away after 28 days, even if it has insulin left in it.

Based on interview and record review, it was determined that the facility failed to ensure that staff use equipment properly during transfers, resulting in a fall with a fracture for 1 of 1 residents reviewed for accidents (Resident Identifier #1). Finding include: Review on 4/16/24 of Resident #1's nurse's note dated 3/25/24 revealed that Staff A (Registered Nurse) heard a loud noise in Resident #1's room. Upon entering, Resident #1 was on the floor. The Licensed Nursing Assistants (LNAs) informed Staff A that Resident #1 slid off the Hoyer pad while being lifted. Resident #1 was complaining of back pain. Resident #1 was sent to the hospital for further evaluation. Resident #1 returned to the facility from the hospital and the hospital nurse reported that Resident #1 had a first lumbar (L1) fracture. Review on 4/16/24 of Resident #1's diagnostic imaging reports from the hospital dated 3/25/24 revealed that the indication for the diagnostic imaging was for fall and trauma. Further review of the diagnostic imaging reports revealed that Resident #1 was found to have an acute L1 compression fracture and a tiny avulsive fracture to the dorsal aspect of the right talar neck (right foot). Interview on 4/16/24 at 10:46 a.m. with Staff B (LNA) revealed that on 3/25/24 while Staff B and Staff C (LNA) were Hoyering Resident #1 from the bed to the chair, Staff B noticed the strap was slipping, Resident #1 was tilted and Staff B guided Resident #1 to the floor. Resident #1 landed on [pronoun omitted] right side. Staff B stated that after the incident, it was identified that the top Hoyer pad strap was twisted. Interview further revealed Staff B would use any Hoyer pad found in the resident's room or get one from stock but was not aware residents were assessed for Hoyer pad size. Staff B would use his/her judgement based on what size he/she needed. Interview on 4/16/24 at 11:07 a.m. with Staff D (LNA) revealed that he/she was unaware that there were specific Hoyer pads for specific residents and used what was available. Interview on 4/16/24 at 11:15 a.m. with Staff E (LNA) revealed that he/she visualized what size Hoyer pad to use based on the size of the resident and was not aware residents were assessed for Hoyer pad size. Interview on 4/16/24 at 11:16 a.m. with Staff F (Unit Manager) revealed that if it was determined that a resident required lift assistance an assessment would be done to determine what size Hoyer pad to use based on the resident's weight. Review on 4/16/24 of Resident #1's device/transfer evaluation dated 3/13/24 revealed that Resident #1's transfer/mobility assessment indicated Resident #1 met the criteria for total mechanical lift (for example Hoyer lift) and Resident #1's sling size was an extra large. Review on 4/16/24 of Resident #1's weight records revealed a weight of 153 pounds dated 3/1/24. Review on 4/16/24 of the manufacturer's instructions for the Proactive Medical Products: Full Body Sling revealed .Features and Benefits: Sling size can vary significantly depending on the patients' weight and girth .Patient Sling Guide: It is very important to use the correct sized sling and make sure it is fitted properly prior to lifting .Limited Life Warranty .Useful life of this product is size months from date of purchase under normal use .Size and Weight Range Guide .Small (S): 75-150lbs [pounds] 59[inches]-64, Medium (M): 125-200lbs 63-68, Large (L): 175-300lbs 67-72, Extra Large (XL): 275-500lbs 71-76, Extra Extra Large (XXL): 350-600lbs Determine PRN . Review on 4/16/24 of the manufacturer's instructions for the Lumex: LF 1090 Bariatric Patient Lift revealed: .WARNING: Ensure that lifting sling loops are correctly attached to the hooks to prevent the patient from sliding or falling out of the sling, which could result in personal injury . Review on 4/16/24 of the facility's policy titled Safe Resident Handling/Transfers revised 11/29/23, revealed .14. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device . Interview on 4/17/24 at 8:30 a.m. with Staff G (Director of Nursing) confirmed the above findings. Staff G stated that it was identified that Resident #1 was in the wrong Hoyer sling on the day of the incident.

Based on interview and record reviews, it was determined the facility failed to follow physician orders related to notifying the provider when blood sugar level was above 400 milligram/deciliter (mg/dl) for 1 of 5 residents reviewed for unnecessary medications (Resident Identifier is #38). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th edition St. [NAME], Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders, The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients . Review on 7/25/23 of Resident #38's active physician orders revealed the following orders: 1. Insulin Lispro 100 units/milliliters (ml) inject 10 units subcutaneously before meals for a diagnosis of diabetes mellitus type 2, notify the physician or nurse practitioner for blood sugar levels less than 60 or greater than 400 mg/dl with a start date of 6/6/23, scheduled for 7:30 a.m., 11:00 a.m., and 4:00 p.m. 2. Insulin Lispro 100 units/ml inject 7 units subcutaneously at bedtime for a diagnosis of diabetes mellitus type 2, notify physician or nurse practitioner for blood sugar levels less than 60 or greater than 400 mg/dl with a start date of 6/6/23, and scheduled for 8:00 p.m. Review on 7/25/23 of Resident #38's July 2023 Electronic Medication Administration Records revealed the following blood sugar level above 400 mg/dl corresponding to the above-mentioned physician's orders: 7/2/23 at 4:00 p.m. blood sugar of 444 mg/dl 7/5/23 at 8:00 p.m. blood sugar of 400 mg/dl 7/6/23 at 7:30 a.m. blood sugar of 417 mg/dl 7/7/23 at 7:30 a.m. blood sugar of 403 mg/dl 7/9/23 at 11:00 a.m. blood sugar of 400 mg/dl 7/11/23 at 7:30 a.m. blood sugar of 415 mg/dl 7/12/23 at 4:00 p.m. blood sugar of 400 mg/dl 7/16/23 at 7:30 a.m. blood sugar of 414 mg/dl 7/16/23 at 8:00 p.m. blood sugar of 402 mg/dl 7/17/23 at 4:00 p.m. blood sugar of 532 mg/dl Review on 7/25/23 of Resident #38's July 2023 medical records revealed that there was no documentation of physician and/or nurse practitioner notifications of Resident #38's blood sugar above 400 mg/dl, on the above-mentioned dates and times, which were within the timeframe of when the blood sugars were obtained. Review on 7/26/23 of the nurse practitioner communication book revealed no documentation that the provider was notified of the blood sugar above 400 mg/dl on above mention dates and times. Interview on 7/26/23 at 8:37 a.m. with Staff D (Licensed Practical Nurse) revealed that if there was an order to notify the provider for blood sugar above 400 mg/dl, he/she would notify the provider at close proximity of the time when blood sugar was obtained by phone or by the nurse practitioner communication book. Staff D also stated that he/she would document the notification in the nurse's notes and/or the medication administration notes. Interview on 7/26/23 at 10:26 a.m. with Staff E (Regional Registered Nurse) confirmed the above findings on Resident #38. Staff E was unable to provide documentation of physician or nurse practitioner notifications of Resident #38's blood sugar above 400 mg/dl per physician order. Interview on 7/26/23 at 11:06 a.m. with Staff F (Medical Director) revealed that he/she was not notified of Resident #38's blood sugar above 400 mg/dl during the above-mentioned dates and times. Review on 7/26/23 of the facility policy titled, blood glucose monitoring, reviewed/revised date of 3/22/22, revealed: .Procedure: Verify the physician's order .report critical test results to the physician timely .Document the procedure.

Based on observation, interview, and record review, it was determined that the facility failed to store refrigerated medications within required temperatures per manufacturer's specification for 1 of 1 medication room observed (Birch Unit, A-Wing, medication room). Findings include: Observation on 7/24/23 at 8:45 a.m. of the medication room refrigerator revealed 2 unopened vials of Novolog insulin, 2 unopened vials of Humalog insulin, an unopened Levemir insulin pen, an unopened Lantus insulin pen, and an unopened Trulicity insulin pen stored up against an ice-frosted wall in the refrigerator. Review on 7/24/23 of manufacturer specifications for Novolog, Humalog, Levemir, Lantus, and Trulicity for insulin vials and pens indicates to store unopened items refrigerated between 36 degrees Fahrenheit ( F) to 46 F. Review on 7/24/23 of the medication room Refrigeration Temperature Log revealed no temperature recordings on July 22 and 23, 2023, and temperatures were out of required range on 6/2/23 (34 degrees F), 6/23/23 (34 F), 5/12/23 (32 F), and 5/14/23 (34 F), with no follow-up noted by staff. Interview on 7/24/23 at 12:15 p.m. with Staff B (Unit Manager) confirmed the above findings.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure food was prepared and served in a sanitary environment in 1 of 1 main kitchens observed. Findings include: Observation on 7/24/23 at 8:44 a.m. in the main kitchen with Staff A (Food Service Director) revealed that the range hood was last inspected on 11/20/22 with a next service date of 180 days (approximately 5/20/23). Further inspection revealed dust particles encapsulating the light fixtures under the hood. In addition, all fire suppression discharge nozzles under the hood had dust particles on them. Interview on 7/24/23 at 8:48 a.m. with Staff A confirmed the above findings. Review on 7/27/23 of the facility's policy titled, Sanitation Inspection, last revised 3/20/23 revealed: All food service areas shall be kept clean, sanitary, free from litter, and rubbish, and protected from rodents, roaches, flies, and other insects. Review on 7/27/23 of the FDA [Food and Drug Administration] Food Code, dated 2022, retrieved from: https://www.fda.gov/media/164194/download, revealed . 4-602.13 Nonfood Contact Surfaces Nonfood contact surfaces or equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure a safe and sanitary environment in 7 of 41 resident rooms observed on the Birch Unit. Findings include: Birch Unit Observation on 7/24/23 at approximately 11:30 a.m. revealed the following: Resident room [ROOM NUMBER] the bathroom door had large black scrapes along the bottom of the entire door that went up approximately 2 feet high. The bathroom door frame also had dark black marks from the bottom of the frame to approximately 12 inches high. Resident room [ROOM NUMBER] had approximately 10 white drywall patches on the wall behind the television. Each patch was approximately 2 inches by (x) 5 inches. Further inspection revealed a 12 inch x 2 inch large hole behind bed A. Resident room [ROOM NUMBER] the bathroom had black writing approximately 4 feet high on the wall opposite the toilet. This area was approximately 3 inches x 2 inches. The bathroom door had large black scrapes along the bottom of the entire door that went up approximately 2 feet high. The bathroom door frame also had dark black marks from the bottom of the frame to approximately 12 inches high. Resident room [ROOM NUMBER] the radiator cover had large black marks running the entire length of the radiator cover. In addition, the cover that attaches the two pieces of the radiator cover together was missing. This revealed the inner parts of the radiator which showed the fins of the radiator which were jagged and had a sharp edge. The resident was sitting in their wheelchair approximately 12 inches away from the radiator. Observation on 7/25/23 at 12:30 p.m. with Staff C (Regional Director of Operations) revealed the following environmental findings on the Birch Unit: Resident room [ROOM NUMBER] the bathroom had cracked (un-cleanable surface) floor tiles around the toilet with brown debris and mal-odor of urine and had 4 broken plastic blinds approximately 4 inches in length. Resident room [ROOM NUMBER] the bathroom had a missing seal around the toilet exposing brown debris and and mal-odor of urine and had 5 broken plastic blinds approximately 4 inches in length. Resident room [ROOM NUMBER] had two floor mats in use that were frayed across the surface and at the corners exposing foam that was an un-cleanable surface. Interview on 7/25/23 at 12:30 p.m. with Staff C confirmed the above findings. Staff C acknowledged the need for environmental repairs. Review on 7/24/23 of facility policy titled, Environmental Services Inspection, last revised 5/2/23, revealed: It is the polity of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.

Based on observation, interview, and record review, it was determined that the facility failed to assess residents' ability to self-administer medications for 2 of 2 residents reviewed for self-administration of medication in a final survey of sample of 20 residents (Resident identifiers are #4 and #56). Findings include: Resident #4 Observation on 2/5/23 at approximately 9:30 a.m. of Resident #4's room revealed a bottle of prescription Ammonium Lactate 12 percent (%) lotion on the bedside table. Interview on 2/5/23 at approximately 9:30 a.m. with Resident #4 revealed that he/she is capable of applying lotion to the upper portion of his/her legs, not entire length of legs. Interview on 2/6/23 at approximately 1:00 p.m. with Staff C (Regional Nurse) confirmed Resident #4 did not have an order for self-administration of the topical medication. Resident #56 Observation on 2/5/23 at approximately 10:00 a.m. in Resident #56's room revealed an opened bottle of antacid tablets, 1000 milligrams (mg) on his/her night stand. Interview on 2/5/23 at approximately 10:00 a.m. with Resident #56 revealed that he/she takes the antacid tablets whenever he/she needs to take them. Interview on 2/5/23 at approximately 12:00 p.m. with Staff D (Licensed Practical Nurse) confirmed Resident #56 did not have an order for self-administration of the antacid. Review on 2/7/23 of the facility policy titled, Resident Self-Administration of Medication, revision date 5/4/22 revealed: A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safety.

Based on record review and interview, it was determined that the facility failed to follow physician's orders and standards of practice regarding a psychiatric consult for 1 of 1 residents (Resident identifier is #57). Findings include: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th edition St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders, The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders . Review on 2/6/23 of Resident #57's record revealed a diagnosis of unspecified dementia with psychiatric and behavioral disturbance and an antipsychotic medication order for Quetiapine Fumarate 50 milligram (mg) tablet for agitation/anxiety. Further review on 2/6/23 of Resident #57's record revealed a physician order dated 12/14/22 for a psychiatric consult for gradual dose reduction (GDR) and the current care plan states, prescribed psychotropic medication .psychiatric evaluation as ordered . Interview on 2/7/23 at approximately 9:15 a.m. with Staff B (Licensed Practical Nurse) revealed Resident #57 experiences some delusional thought process, and that the psychiatric provider had not yet met with the resident per physician orders. Interview on 2/7/23 at approximately 11:15 a.m. with Staff C (Regional Nurse) revealed the psychiatric provider had been in the facility 3 times (12/22/22, 1/11/23, and 1/25/23) since the psychiatric consult order dated 12/14/22 and confirmed the finding. Review on 2/7/23 of the facility policy titled, Behavioral Health Services, Revision Date 1/29/23 revealed: It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychological functioning.

Based on interview and record review, it was determined that the facility failed to notify the resident and the resident's representative, in writing, of a transfer to the hospital; and also failed to send a copy of the transfer notice to a representative of the Office of the Long-Term Care (LTC) Ombudsman for 1 of 1 resident reviewed for hospitalization in a final sample of 20 residents (Resident identifier is #66). Findings include: Review on 2/6/23 of Resident #66's electronic medical record revealed that Resident #66 was admitted to the facility on [DATE]. Review on 2/6/23 of Resident #66's nurse's notes revealed the following: - On 11/24/22 Resident #66 had an oxygen saturation of 85 percent (%) in room air, shortness of breath at rest, and was sent to the hospital for evaluation. The provider and Resident #66's daughter was notified. - On 12/2/22 Resident #66 returned to the facility. - On 12/19/22 Resident #66 had hypotension, abdominal pain, minimal urine output, low oxygen level on oxygen, pale and lethargic. The provider was notified, Resident #66 was sent to hospital, Resident #66's spouse was notified. Interview on 2/7/23 at approximately 10:00 a.m. with Staff A (Social Worker) revealed that Staff A did not provide Resident #66 or Resident #66's representative a written notice of transfer for transfer to the hospital on 11/24/22 and 12/19/22. Staff A was unable to provide any documentation of a written transfer notice for Resident #66's transfer to the hospital on 11/24/22 or 12/19/22 or documentation that transfer notice was sent to the Office of the LTC Ombudsman. Staff A stated that he/she was the one that fills out the written discharge/transfer notice form and sends the notices to the Office of the LTC Ombudsman. Staff A also stated that he/she did not have to provide any residents or resident's representative or the Office of LTC Ombudsman with a transfer notice if the transfer was to a hospital.

Based on interview and record review, it was determined that the facility failed to provide adequate supervision to prevent a fall which resulted in actual harm that was immediate in which resident sustained a [CONDITION(S)] and eventual death for 1 of 3 residents reviewed for falls (Resident identifier is #1). The facility also failed to provide adequate supervision to prevent elopement for 1 of 3 residents reviewed for elopement risk. (Resident identifier is #3.) Findings include: Resident #1 Interview on 9/14/22 at approximately 3:36 p.m. with Resident #1's responsible party revealed that Resident #1 fell and broke their hip at the facility and later passed away. Resident #1's responsible party stated that they were told the death was related to the fall with fracture. Review on 9/15/22 of Resident #1's nurse's notes dated 8/18/22 at 1:21 a.m. revealed Resident heard yelling from room for help, unwitnessed fall, Resident was found down on the bathroom floor without injury. Transferred from floor to WC [wheelchair] to bed without incident. Resident comfortable. Review on 9/15/22 of Resident #1's nurse's notes dated 8/18/22 at 4:30 a.m. Post unwitnessed fall earlier this am [morning], Resident c/o [complained of] discomfort over 3 hours, progressively worsening, also c/o testicular pain that had also started after [pronoun omitted] unwitnessed fall. Resident discussed going to the hospital for evaluation and possible treatment. Resident and this nurse agree. EMS [Emergency Medical Services] dispatched and resident transported to [facility name omitted] with no further incident. Daughter was called at 0440 [4:40 a.m.] and made aware of above . Further review of Resident #1's nurses notes revealed no other falls or incidents occurred. Review on 9/15/22 of Resident #1's August 2022 Medication Administration Record revealed that on 8/18/22 at 2:00 a.m. Resident #1 received Acetaminophen extra strength 1000 mg (milligrams) for 4/10 pain. Interview on 9/15/22 at approximately 11:00 a.m. with Staff C (Director of Nursing) confirmed the above information. Staff C stated they were unaware of the outcome of the hospitalization for Resident #1 as they never returned to the facility. Interview on 9/15/22 at approximately 12:00 p.m. with Staff A (nurse) revealed that Resident #1 had fallen at the facility on 8/8/22 and 8/18/22. Staff A stated that on 8/18/22 Resident #1 was found in the bathroom on the floor, nothing abnormal was noted with a visual assessment for injury and proceeded to get other staff to assist with getting Resident #1 off the floor and back to bed. Staff A did not recall if the provider was notified at the time of the fall. Staff A also stated that they had gone back into check on Resident #1 noted the pain, administered Acetaminophen and when they went back to check effectiveness they noted Resident #1 was still in pain and that is when they called to have Resident #1 transported to the hospital and notified the family. Further interview with Staff A revealed that on 8/8/22, Staff A found Resident #1 on the floor by bed unresponsive and observed what appeared to be foam coming out of their mouth. Staff A called 911 and had Resident #1 sent to the hospital. Staff A stated they did not notify the provider as they were not aware they needed to do so until later. Review on 9/15/22 of Resident #1's medical record revealed the following: -Census report revealed that Resident #1's initial admission to facility on 8/5/22, -No documentation of a fall risk assessment for Resident #1 on admission, -Resident #1's hospital discharge summary dated 8/5/22 revealed that Resident #1 was admitted to hospital from home with septic shock, ambulatory status was severely limited due to decreased strength and endurance. -Physical therapy notes dated 8/7/22 revealed that Resident #1 had poor initiation of requesting staff for transfers in room despite demonstrating independence with call bell use. Resident #1 appeared to have decreased insight into fall risk. And that physical therapy updated nursing on Resident #1's transfer status for contact guard assist with rolling walker in room. -No documentation of Resident #1 found on floor unresponsive and was sent to hospital on 8/8/22, -No documentation of Resident #1 fall assessments, vital signs, and neurological assessments for 8/8/22 incident, -Census report revealed that Resident #1 was discharged out of the facility on 8/8/22, -Census report revealed that Resident #1 was readmitted to the facility on [DATE], -Resident #1's hospital discharge summary dated 8/16/22 revealed that reason for 8/8/22 admission to hospital was septic shock and acute metabolic [CONDITION(S)], -Resident #1's Morse Fall Scale dated 8/16/22 revealed that Resident #1 has history of falls, Resident #1 required cane or walker for ambulation, Resident #1 exhibited weak gait, Resident #1 was forgetful of own safety limits, -Physical therapy note dated 8/16/22 revealed that nurses were updated by physical therapist on recommended transfer status as well as high fall risk and need for frequent checks during evening. -Nurse's notes revealed that Resident #1 was found on floor on 8/18/22 as mentioned above, -No documentation of Resident #1's vital signs and neurological assessments for 8/18/22 unwitnessed fall, -Census report revealed that Resident #1 was discharged out of the facility on 8/18/22, -Physical therapy assessment note dated 8/18/22 revealed that nursing reported that Resident #1 experienced an unwitnessed fall morning of 8/18/22 and was admitted to the hospital due to lower extremity fracture. -Resident #1's care plan revealed that the only care plans in place were for Diagnosis [CONDITION(S)] ([CONDITION(S)]) / CHF ([CONDITION(S)]) and for emotional state. Further review of Resident #1's medical records revealed no plan of care for adequate supervision to prevent falls. Review also revealed no documentation of frequent checks related to physical therapy recommendations. Interview on 9/16/22 at approximately 10:30 a.m. with Staff D (Licensed Nursing Assistant) revealed that on 8/18/22 they went to Resident #1's room to assist with fall. Staff D stated that Resident #1 was on the floor and at the nurse's direction, 4 staff assisted Resident #1 off the floor to the wheelchair and then back to bed. Interview on 9/16/22 at approximately 11:30 a.m. with Staff C confirmed that Resident #1 had no fall care plan to adequately supervised Resident #1 to prevent falls. Review on 9/16/22 of Resident #1's Certificate of Death revealed, .Cause of Death a. complications of left [CONDITION(S)] .Describe how injury occurred fall from stand height . Review on 9/16/22 of facility policy titled Falls Prevention Program, revised on 8/1/22, revealed the following: .3. the nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan in accordance with the resident's level of risk .8. When any resident experiences a fall , the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury . Resident #3 Review on 9/15/22 of Resident #3's elopement assessment dated [DATE] revealed a score of 10 out of 15 that indicated that the Resident #3 was at risk for wandering. Review on 9/15/22 of Resident #3's nurse's note dated 7/9/22 at 7:01 p.m. revealed At 1800 [6:00 p.m.] [pronoun omitted] from PT [physical therapists] came to report that [pronoun omitted] had just picked up [pronoun omitted] walking up on Rochester St. by [facility name omitted] . Review on 9/15/22 of Resident #3's nurse's note dated 7/26/22 at 1:21 p.m. revealed Patient [Resident #3] was found at the front entrance door at 1200 [12:00 p.m.]. Patient told the writer of this note that [pronoun omitted] was looking to take a plane to Manchester NH and from there a plane to California. The writer of this note convinced patient to take a walk back to [pronoun omitted] familiar wing where patient said [pronoun omitted] agreed to stay another day. Gave patient a snack which calmed patient down. Review on 9/15/22 of Resident #3's medical record revealed that no elopement interventions were in place after initial elopement risk was identified. Interview on 9/15/22 at approximately 1:40 p.m. Staff C confirmed that there were no interventions put in place after the elopement on 7/26/22.

Based on interview and record review, it was determined that the facility failed to ensure that a resident's right to leave the nursing home for activities was protected for 1 of 2 residents reviewed for resident rights. (Resident identifier is #2.) Findings include: Review on 9/15/22 of Resident #2's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 9/15/22 of Resident #2's medical record revealed that Resident #2's daughter was the appointed guardian over Resident #2. Interview on 9/15/22 at approximately 1:50 p.m. with Staff C (Director of Nursing) confirmed that Staff E (Medical Director) had written an order that stated Resident #2 could not go on LOA from the facility. Staff C stated that there was no communication with Resident #2's guardian about Resident #2 not being allowed to go on LOA with the guardian or family. Interview on 9/15/22 at approximately 4:20 p.m. with Resident #2 revealed that Resident #2 verbalized that she/he was very involved with family and was very appreciative that they took Resident #2 out for visits. Resident #2 stated that she/he misses going out with family and started crying. Interview on 9/19/22 at approximately 9:18 a.m. with Resident #2's guardian revealed that Resident #2 informed the family that Staff E wrote an order stating that Resident #2 was not allowed to go on LOA related to safety concerns. Resident #2's guardian stated they provide a safe environment when Resident #2 visits. Resident #2's guardian confirmed that she/he was not notified of this order by the facility or by Staff E. Interview on 9/16/22 at approximately 11:30 a.m. with Staff E confirmed the above mentioned physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff E stated that he/she has not discussed the above mentioned physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, it was determined that the facility failed to develop and implement a baseline care plan for 1 of 6 residents reviewed for falls. (Resident identifier is #1.) Findings include: Review on 9/15/22 at approximately 10:00 a.m. of Resident #1's medical record revealed that Resident #1 had been initially admitted to the facility on [DATE] and then discharged to the hospital on 8/8/22, readmitted back to facility on 8/16/22 and discharged to the hospital on 8/18/22. Further review of Resident #1's medical record revealed a nursing note that dated 8/18/22 at 1:21 a.m. revealed Resident heard yelling from room for help, unwitnessed fall, Resident was found down on the bathroom floor without injury. Transferred from floor to WC [wheelchair] to bed without incident. Resident comfortable. Interview on 9/15/22 at approximately 12:00 p.m. with Staff A (nurse) revealed that Resident #1 had fallen at the facility on 8/8/22 and 8/18/22, where Resident #1 was discharged to the hospital on both occasions. Review on 9/15/22 of Resident #1's active care plan revealed the only care plans in place were for Diagnosis [CONDITION(S)] ([CONDITION(S)]) / CHF ([CONDITION(S)]) and for emotional state. Further review of the care plan revealed no fall care plan was implemented within 48 hours of Resident #1's initial admission on 8/5/22 and readmission on 8/16/22. Review on 9/16/22 at approximately 11:00 a.m. of Resident #1's Physical Therapy note dated 8/7/22 revealed that .Pt [patient] cooperative during session but poor initiation of requesting staff for transfers in room despite demonstrating I [independence] with call bell use; appears to have dec [decreased] insight into fall risk. PT [physical therapist] updated nursing on pt [patient] transfer status for CGa [contact guard assist]with rw [rolling walker] in room . Review on 9/16/22 of Resident #1's Physical Therapy note dated 8/16/22, revealed that .presenting for [pronoun omitted] skilled rehab [facility name omitted] as [pronoun omitted] was found on the floor . Further review of Physical Therapy notes revealed an entry on 8/16/22 PT [Physical Therapist] assessed pt [patient] for and issued loaner rw [rolling walker] for use with transfers with LNA's [Licensed Nursing Assistants]. Pt [Physical Therapist] initiated pt [patient] education on use of call bell placed within [pronoun omitted] reach; pt [patient] able to verbalize and demonstrate how to use but showed poor carryover with use of call bell to request staff A [assistance] for mobilization to toilet as PT [Physical Therapist] returned to room to issue cushion 1 hr [hour] after eval and observed pt [patient] seated in bathroom on toilet with unlocked wc [wheelchair] by his side no call bell activated. PT [Physical Therapist] educated pt [patient] on plan to trial signage in room to assist pt [patient] with recall of importance to request staff assist for all transfers; 3-11 LNA [Licensed Nursing Assistant] and nurse were updated by PT [Physical Therapist] on recommended transfer status, supervised dining in DR [dining room] as well as high falls risk and need for frequent checks during pm [evening] . Interview on 9/16/22 at approximately 11:30 a.m. with Staff C (Director of Nursing) confirmed that Resident #1 had no falls care plans in place. Review on 9/16/22 of facility policy titled Baseline Care Plan, initiated on 2/1/20, revealed The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care . Review on 9/16/22 of facility policy titled Fall Prevention Program, revised on 8/1/21, revealed .3. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan .8. When any resident experiences a fall, the facility will: .e. Review the resident's care plan and update as indicated .

Based on interview and record review, it was determined that the facility failed to ensure that alleged violations of abuse were reported to the State Survey Agency within 24 hours for 2 of 3 residents reviewed for abuse. (Resident identifiers are #1, and #2.) Findings include: Resident #1 Review on 9/15/22 at approximately 10:00 a.m. of Resident #1's nursing notes revealed the following: On 8/18/22 at 1:21 a.m. Resident heard yelling from room for help, unwitnessed fall, Resident was found down on the bathroom floor without injury. Transferred from floor to WC [wheelchair] to bed without incident. Resident comfortable. On 8/18/22 at 4:30 a.m. Post unwitnessed fall earlier this am [morning], Resident c/o [complained of] discomfort over 3 hours, progressively worsening, also c/o testicular pain that had also started after [pronoun omitted] unwitnessed fall. Resident discussed going to hospital for evaluation and possible treatment. Resident and this nurse agree. EMS [Emergency Medical Services] dispatched and resident transported to [facility name omitted] with no further incident . Interview on 9/15/22 at approximately 12:00 p.m. with Staff A (nurse) revealed that Resident #1 had fallen on 8/8/22 as well as 8/18/22. Staff A stated that on 8/18/22 Resident #1 was found in the bathroom on the floor, nothing abnormal was noted with a visual assessment for injury and proceeded to get other staff to assist with getting Resident #1 off the floor and back to bed. Staff A did not recall if the provider was notified at the time of the fall. Staff A also stated that they had gone back into check on Resident #1 noted the pain, administered Acetaminophen and when they went back to check effectiveness they noted Resident #1 was still in pain and that is when they called to have Resident #1 transported to the hospital and notified the family. Interview with Staff A also revealed that the on 8/8/22, Staff A found Resident #1 on the floor by the bed unresponsive and what appeared to be foam coming out of their mouth. Staff A called 911 and had Resident #1 sent to the hospital. Staff A stated they did not notify the provider as they were not aware they needed to do so until later. Review on 9/16/22 at approximately 10:00 a.m. of the Physical therapy assessment summary documented on 8/18/22 revealed .Nursing reported pt [patient] experienced unwitnessed fall morning of 8/18/22 and was transferred to hospital for further evaluation. Pt [patient] was admitted to hospital due to LE [lower extremity] fracture per nsg [nursing] f/u [follow up] late AM [morning]. Interview on 9/16/22 at approximately 11:00 a.m. with Staff C (Director of Nursing) stated that no reports to the State Survey Agency were completed for Resident #1. Resident #2 Review on 9/15/22 of Resident #2's podiatry note dated 8/18/22 revealed that Resident #2's right hallux had mild [CONDITION(S)] (swelling), [CONDITION(S)] (redness) along distal half of digit, positive tenderness with palpation especially along distal tip of toe, no open [CONDITION(S)], positive calor was noted on right great toe. Further review of the podiatry note revealed a recommendation to X-Ray right foot in the following views: AP [Anteroposterior], Lateral, Oblique of right foot and Up-close of Right great toe in AP and Lateral view; Obtain X-Ray report. Review on 9/15/22 of Resident #2's medical record revealed a radiology results report dated 8/19/22 that revealed an acute fracture involving the right 5th proximal phalanx with minimal displacement. Interview on 9/15/22 at approximately 1:50 p.m. with Staff C (Director of Nursing) confirmed the above findings. Staff C stated that the above mentioned fracture was an injury of unknown origin. Staff C also stated that this injury of unknown origin was not reported to the LTC (Long Term Care) Ombudsman and Survey State Agency. Review on 9/16/22 of facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revised on 8/1/22, revealed .4. Identification: The facility will identify events, occurrences, patterns and trends that may constitute: a. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. B. Abuse: .d. injuries of unknown source: includes circumstances when both the following conditions are met; i. The source of the injury was not observed by any person or could not be explained by the resident. ii. The injury is suspicious because of the extent of the injury, location of injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time .8. Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences .2. The Director of Nursing Services, Administrator, or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after the discovery or forming the suspicion .3. The Administrator should follow up with government agencies, during business hours, to confirm the report was received and to report the results of the investigation when final as required by state agencies .

Based on interview and record review, it was determined that the facility failed to ensure that alleged violations of abuse were thoroughly investigated to prevent further potential abuse and neglect for 3 of 3 residents reviewed for abuse. (Resident identifiers are #1, #2, and #3.) Findings include: Resident #1 Review on 9/15/22 at approximately 10:00 a.m. of Resident #1's nursing notes revealed the following: On 8/18/22 at 1:21 a.m.Resident heard yelling from room for help, unwitnessed fall, Resident was found down on the bathroom floor without injury. Transferred from floor to WC [wheelchair] to bed without incident. Resident comfortable. On 8/18/22 at 4:30 a.m. Post unwitnessed fall earlier this am [morning], Resident c/o [complained of] discomfort over 3 hours, progressively worsening, also c/o testicular pain that had also started after [pronoun omitted] unwitnessed fall. Resident discussed going to hospital for evaluation and possible treatment. Resident and this nurse agree. EMS [Emergency Medical Services] dispatched and resident transported to [facility name omitted] with no further incident . Interview on 9/15/22 at approximately 12:00 p.m. with Staff A (nurse) revealed that Resident #1 had fallen on 8/8/22 as well as 8/18/22. Staff A stated that on 8/18/22 Resident #1 was found in the bathroom on the floor, nothing abnormal was noted with a visual assessment for injury and proceeded to get other staff to assist with getting Resident #1 off the floor and back to bed. Staff A did not recall if the provider was notified at the time of the fall. Staff A also stated that they had gone back into check on Resident #1 noted the pain, administered Acetaminophen and when they went back to check effectiveness they noted Resident #1 was still in pain and that is when they called to have Resident #1 transported to the hospital and notified the family. Further interview with Staff A revealed that on 8/8/22, Staff A found Resident #1 on the floor by the bed unresponsive and observed what appeared to be foam coming out of their mouth. Staff A called 911 and had Resident #1 sent to the hospital. Staff A stated they did not notify the provider as they were not aware they needed to do so until later. Interview on 9/16/22 at approximately 11:30 a.m. with Staff C (Director of Nursing) confirmed that there was no investigation conducted for Resident #1's fall on 8/8/22 and 8/18/22. Review on 9/16/22 of facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revised on 8/1/22, revealed .4. Identification: The facility will identify events, occurrences, patterns and trends that may constitute: a. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. B. Abuse: .d. injuries of unknown source: includes circumstances when both the following conditions are met; i. The source of the injury was not observed by any person or could not be explained by the resident. ii. The injury is suspicious because of the extent of the injury, location of injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time .6. Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response .2. The Director of Nursing Services, Administrator, or designee will: b. Obtain statements from direct care staff . Resident #2 Review on 9/15/22 of Resident #2's podiatry note dated 8/18/22 revealed that Resident #2's right hallux had mild [CONDITION(S)] (swelling), [CONDITION(S)] (redness) along distal half of digit, positive tenderness with palpation especially along distal tip of toe, no open [CONDITION(S)], positive calor was noted on right great toe. Further review of the podiatry note revealed a recommendation to X-Ray right foot in the following views: AP [Anteroposterior], Lateral, Oblique of right foot and Up-close of Right great toe in AP and Lateral view; Obtain X-Ray report. Review on 9/15/22 of Resident #2's medical record revealed a radiology results report dated 8/19/22 that revealed an acute fracture involving the right 5th proximal phalanx with minimal displacement. Interview on 9/15/22 at approximately 1:50 p.m. with Staff C (Director of Nursing) confirmed the above findings. Staff C stated that the above mentioned fracture was an injury of unknown origin. Staff C also stated that they did not conduct an investigation on Resident #2's right toe fracture. Resident #3 Review on 9/15/22 of Resident #3 ' s medical record revealed the following nursing notes: On 7/9/22 at 7:01 p.m. At 1800 [pronoun omitted] from PT [physical therapist] came to report that [pronoun omitted] had just picked up [pronoun omitted] walking up on Rochester St. by [facility name omitted] . On 7/26/22 at 1:21 p.m. Patient [Resident #3] was found at the front entrance door at 1200 [12:00 p.m.]. Patient told the writer of this note that [pronoun omitted] was looking to take a plane to Manchester NH and from there a plane to California. The writer of this note convinced patient to take a walk back to his familiar wing where patient said [pronoun omitted] agreed to stay another day. Gave patient a snack which calmed patient down. Interview on 9/15/22 at approximately 1:50 p.m. with Staff C (Director of Nursing) confirmed that the facility did not conduct an investigation on Resident #3's elopement on 7/9/22 and 7/26/22.

1. Based on observation, interview, and record review, it was determined that the facility failed to restrict health care personnel with signs and symptoms of COVID-19/respiratory illness from work in the facility. The facility's failure to restrict acutely ill healthcare personnel from work over 4 different days increased the likelihood of exposure to pathogens for the facility's census of 53 residents and staff. The facility failed to ensure that COVID-19 screenings for residents were completed per CDC guidelines for 3 out of 3 residents reviewed for resident COVID-19 assessments in a final sample of 19 residents. (Resident identifiers are #50, #38 and #24). Findings include: Review on 12/13/21 of the CDC (Center of Disease Control and Prevention) website titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated date of 9/10/21, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed .Evaluating and Managing Personnel and Residents Refer to CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic for more information. .HCP should not work while acutely ill, even if [CONDITION(S)]-CoV-2 testing is negative, in order to minimize the risk of transmission of other infectious pathogens, including respiratory pathogens such as influenza. -Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that support HCP to stay home when ill Observation and interview on 12/13/21 at approximately 8:30 a.m. with Staff E (Registered Nurse) revealed that Staff E was coughing and stated, I am sick, and no it isn't COVID-19. Staff E indicated that they have been testing on a regular basis. Observation on 12/13/21 at approximately 8:35 a.m. during entrance conference revealed Staff E coughing multiple times during the meeting and wearing a facemask. Review on 12/13/21 of the facility's Center Entry Screening for COVID-19 form for employees revealed the following: On 12/9/21, Staff E documented Yes to having the following symptoms: cough, shortness of breath, congestion or runny nose, fatigue, muscle or body aches, and headache. It was noted on this form that a rapid test was negative and that Staff E was okay to work. On 12/10/21, Staff E documented Yes to having the following symptoms: cough, shortness of breath, congestion or runny nose, fatigue, muscle or body aches, and headache. It was noted that on 12/6/21 a COVID-19 PCR (polymerase chain reaction) test was negative and that Staff E was okay to work. -On 12/13/21, Staff E documented Yes to having the following symptoms: cough, shortness of breath, congestion or runny nose, fatigue, muscle or body aches, and headache. It was noted that on 12/6/21 a COVID-19 test was negative and that Staff E was okay to work. Interview on 12/13/21 at 10:15 a.m. with Staff C (Regional Nurse) stated that Staff E was sent home due to being ill. Interview on 12/13/21 at 10:45 a.m. with Staff C revealed that Staff E has not been testing since a point of care test on 12/9/21. Review on 12/13/21 of Staff E's timecard detailed report revealed that Staff E worked on 12/9/21 for approximately 6 hours, 12/10/21 for approximately 8 hours, and 12/13/21 for approximately 2.75 hours. Review on 12/14/21 of the facility's daily census meetings revealed that on 12/9/21 Staff E attended the meeting with other facility department heads. Review on 12/14/21 of the facility's policy titled Coronavirus Surveillance, dated 11/15/21 revealed .Policy: This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness .5. Staff who report or have signs and symptoms of a respiratory infection or COVID-19 shall not report to work Review on 12/14/21 of the facility's policy titled Novel Coronavirus Prevention and Response, dated 8/1/21 revealed .Policy: This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus .5. Interventions to prevent the introduction of respiratory germs into the facility .b. Enforce sick leave policies that allow employees to stay home if they have symptoms of respiratory infection .f. Assess .healthcare personnel for symptoms of COVID-19 .This can included, but is not limited to: . Any employee .with signs or symptoms of COVID 19 and/or a temperature greater than 100.0 F (Fahrenheit), they will not be allowed to enter the Center .d. Monitor staff for fever or respiratory symptoms. Restrict from work and follow current guidance about testing and returning to work Review on 12/16/21 of the facility's entry screening for COVID-19 form for employees revealed that on 12/14/21 Staff K (Therapy Staff) answered yes to having contact with a person diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that on 12/14 a rapid test was negative. The form did not indicate if Staff K was okay to work. Review on 12/16/21 of Staff K's work assignment on 12/14/21 revealed that Staff K worked with 4 residents, including Resident #50 who was not COVID-19 vaccinated. Interview on 12/16/21 at 9:34 a.m. with Staff K confirmed that he/she had worked on 12/14/21 with a cough and sore throat. Staff K stated that he/she continues to have a cough, sore throat and stuffy nose. Review on 12/17/21 of Staff E's final laboratory result for [CONDITION(S)]-CoV-2, collected 12/15/21 and reported 12/16/21 was positive. Review on 12/20/21 of the facility's Positive Line Listing revealed that there were 4 COVID-19 positive staff members on 11/16/21, 1 positive staff member on 1/17/21, 1 positive staff member on 11/25/21, 1 positive staff member on 12/15/21 and 1 positive staff member on 12/17/21. Review on 12/20/21 of the CDC website titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated on 9/10/21, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed, .Evaluate Residents at least Daily .Actively monitor all residents upon admission and at least daily for fever (temperature ?100.0°F) and symptoms consistent with COVID-19 .symptoms of COVID-19: Fever, Cough, Shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea Review on 12/14/21 of Resident #50, #38, and #24's December 2021 Treatment Administration Record (TAR) and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 12/14/21 at 12:04 p.m. with Staff C (Corporate Nurse) confirmed that the daily monitoring of residents for COVID-19 did not include nausea, vomiting and diarrhea. Review on 12/15/21 of the facility's policy titled Coronavirus Surveillance dated 11/15/21 revealed .7. Resident will be monitored for signs and symptoms of coronavirus illness at least daily: .nausea or vomiting, diarrhea

Based on observation, interview, and record review, it was determined that the facility failed to ensure that residents with an indwelling catheter were assessed for the use and removal of the catheter; that a resident who entered the facility without an indwelling catheter was not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and that residents received the appropriate care and services for catheter care for 2 of 2 residents reviewed for indwelling catheters in a final sample of 19 residents. (Resident identifiers are #50 and #38). Findings include: Resident #50 Interview on 12/13/21 at approximately 10:00 a.m. with Staff B (Unit Manager) revealed that Resident #50 had an indwelling catheter in place. Observation on 12/14/21 at 9:17 a.m. of Resident #50 revealed an indwelling catheter draining dark urine. Review on 12/15/21 of Resident #50's medical record revealed that Resident #50 did not have a physician's order, assessment or a care plan for the indwelling catheter use. Review on 12/15/21 of Resident #50's November 2021 Treatment Administration Record (TAR) revealed the resident admitted to the facility on [DATE]. There was a physician's order dated 11/20/21 If patient has not voided during shift Bladder Scan and Straight Catheter patient if retaining 300 milliliters or more of urine There were no notations on the TAR that the bladder scan or the straight catheter had been done from 11/20/21 to 11/30/21. Review on 12/15/21 of Resident #50's nursing progress notes revealed the following: -On 11/20/21 at 11:31 p.m.has not voided Straight [catheter] at [10:00 p.m.] and 300 cc (cubic centimeter) of dark amber urine. Will pass on to next shift There was no documentation that a bladder scan had been performed. -On 11/22/21 at 10:43 p.m. did not void this shift Straight [catheter] done end of shift and 600 cc dark tea colored urine There was no documentation that a bladder scan had been performed. -On 11/30/21 at 1:58 p.m. This nurse [Staff B] obtained an order to send [to a local hospital] for evaluation and treatment. LNA [Licensed Nursing Assistant] on duty requested this nurse assess [name omitted] as [pronoun omitted] had what appeared to be 200 cc of frank red blood in gravity bag [from indwelling catheter]. [Resident #50] stated [pronoun omitted] felt 'light headed and dizzy.' -On 12/2/21 at 2:30 p.m. there was a progress note that Resident #50 readmitted from the hospital with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -There was no documentation of when the urinary catheter had been inserted on 11/30/21. Review on 12/15/21 of Resident #50's Physician Discharge Summary dated 12/2/21 from the hospital revealed . Hospital Course .presents to the [Emergency Department] with concerns for blood in foley catheter. Hematuria due to traumatic insertion: foley catheter just inserted 11/29 per [family member]. Unclear why it was placed at facility Interview on 12/15/21 at 11:23 a.m. with Staff B (Unit Manager) confirmed that he/she had sent Resident #50 to the hospital on 11/30/21 due to frank red blood in the urinary catheter bag and complaints of being lightheaded and dizzy. Staff B confirmed that there was not a physician's order to insert an indwelling catheter. Staff B confirmed that bladder scans were not documented in Resident #50's medical record. Interview on 12/15 at 11:44 a.m. with Staff I (Licensed Practical Nurse) confirmed that he/she had inserted an indwelling catheter into Resident #50 and left it in. Staff I stated during the catheter insertion, Resident #50 was in pain. Staff I stated he/she could not recall if he/she used the bladder scan or if he/she had documented in Resident #50's medical record. Staff I stated he/she did not notify the physician. Interview on 12/15/21 at 12:30 p.m. with Staff B confirmed that Resident #50 had an indwelling catheter since readmitting on 12/2/21 and that there was no physician's order, assessment, or care plan for the catheter prior to 12/14/21. Staff B confirmed that the facility had a bladder scanner on the unit. Resident #38 Observation of Resident #38 on 12/13/21 at approximately 1:18 p.m. of catheter bag attached to Resident #38's wheelchair filled with dark urine. Review on 12/14/21 at approximately 12:15 p.m. of Resident #38's medical record revealed that Resident #38 did not have a physician's order, a supporting diagnosis, or a care plan for the catheter. Interview on 12/14/21 at approximately 12:20 p.m. with Staff A (Unit Manager) confirmed that Resident #38 did have a Foley catheter and did not have documentation in the medical record or a physician's order for the catheter. Review on 12/15/21 of the facility's policy titled Appropriate Use of Indwelling Catheters dated 11/17/21 read, in part, Policy: .An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary 1. It is the policy of this facility to ensure each resident with urinary incontinence: a. Who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrated that catheterization was necessary. b. Who is admitted with an indwelling urinary catheter, or each resident who subsequently receives an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary 3. Any decision regarding the use of an indwelling urinary catheter will be based on the resident's condition and goals for treatment. The resident and/or representative will be included in discussions about the indications, use, potential benefits and risks of urinary catheters, and alternatives to help support the resident's right to make an informed decision. 4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Documentation to support decision making will be included in the medical record . 7. Indwelling urinary catheters will be used on a short-term basis, unless the resident' clinical condition warrants otherwise. The interdisciplinary team with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the insertion, continuation, or removal of an indwelling urinary catheter 9. The plan of care will address the use of an indwelling urinary catheter, including strategies to prevent complications. Review on 12/15/21 of the facility's policy titled Catheter Care dated 8/1/21 read, in part, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care 24. Document care and report any concerns noted to the nurse on duty.

Based on observation, interview, and record review it was found that the facility failed to provide 1 of 10 residents who had pressure sores in a survey sample of 16 the necessary treatment and services to promote healing and prevent new sores from developing. (Resident identifier is #6.) Findings include: Based on the initial tour of the facility on 4/17/12 it was observed that Resident #6, while sitting in his wheelchair, had a sneaker on the right foot with a black walking boot on the left foot. On 4/18/12 Resident #6 was observed again in the morning in his wheelchair with the sneaker on the right foot and the black walking boot on the left foot. Resident #6's BIMs (Brief Interview for Mental Status) score is 15 (15 meaning cognitively intact) on a scale of (0-15)on his quarterly MDS (Minimum Data Set) dated 2/14/12, and Staff A(Unit Manager B Wing) stated that resident is a very good historian and knows every thing that has happened with his care. It was confirmed on 4/18/12 through interview with Resident #6 that he spends all his days up in his wheelchair and only is in bed in the evenings. Resident #6 was asked about having a boot on the left foot and a sneaker on the right foot. In response Resident #6 stated he would put them on himself sometimes because that is what the staff made available for him to wear at the side of his bed and there was nothing else he could put on his feet because that's all that had been given to him. This statement was confirmed through interview with Staff A on 4/18/12 who though the resident had the proper boot for his heel. On review of the MAR (Medication Administration Record) for April it states "heel boot walker right foot for transfers (sic) preesure (sic) reduction bedding Start Date: 3/23/12," "left lower extremities total non weight bearing Start Date: 2/24/12." On 4/18/12 Resident #6 was interviewed with Staff A present and was asked where the black walking boot that was on Resident #6's left foot came from. Resident #6 stated that the boot used to be on the right foot after having his toe amputated, to help him walk so he did not put pressure on his toes (this boot is an off-loading toe boot). Then Resident #6 stated that when he developed a pressure sore on his left heel as stated by the nurses note dated 3/22/12 "...(left) heel red/dryskin/(no) drainage tender to touch boggy. area irregular measuring 3 cm x 2 cm..." they (the doctor) changed the boot from his right foot and put it on his left foot where he has been wearing it everyday since the pressure sore developed on his left heel, with his sneaker on the right foot. On 3/30/12 a nurses note was written by the wounds team that states "Wound note:...wound left heel stage II (times) 2 areas. One measuring 1.1 x 2 x 0.2 (and) the other measuring 1.1 x 2.0 x 0.2 cm (with) slough minimal; wound base color Red/Yellow; Granulation periwound (sic) intact...". On review of the nurses notes dated 4/3/12 it states "...Resident #6 declined therapy last week (due to) nonambulatory due to (left) heel wound...". On both days of observation 4/17/12 and 4/18/12, Resident #6 was observed in his wheelchair with both heels on the floor wearing a sneaker on the right foot and the walking boot on the left. On 4/18/12, Staff A was asked to observe Resident #6's heels, Staff A asked Staff D (Medication Nurse) on 4/18/12 if Resident #6's heels could be observed and Staff D stated Resident #6 does not have a dressing change until 4/19/12. On 4/19/12 Resident #6's heels were observed by surveyor and a nurse's note was written that states "...(left) heel (dressing) changed (moderate amount) of, sero-sanguinous drainage, (no) odor/pain, healthy appearance of surrounding skin. Wound bed bright red in color. (Right) heel wound changed, (no) drainage, skin intact, (dark) red/brown in color, healthy appearance of surrounding skin,...Heels wrapped in Kerlix, socks on (no) shoes or boot on. (Patient) aware (and) knows not to wear shoes as discussed (with) this writer...". Surveyor's observation was that Resident #6's left heel was a healing Stage II to the left heel, with a quarter size unstageable black heel on the right. CROSS REFERENCE TO F311

Based upon staff interview, resident record review, facility investigation reports and a staff Record of Counseling report the facility failed to ensure that 2 of 15 sampled residents received the appropriate staff supervision and assistive devices to prevent accidents resulting in fractures being sustained by both residents (Resident identifiers are #5 and #10). On 4/9/11 at 8:00 p.m. Resident #10 was, according to nurses notes, assisted outside by Staff C, LNA "to smoke." Staff C, nurses notes stated, then brought Resident #10 inside to the Village Green where Resident #10 fell . Resident #10's comprehensive care plan indicated that when Resident #10 ambulated they required "maximum assist using an adaptive walker." A facility investigation and Record of Counseling report revealed that Staff C had failed to use either a walker or gait belt as required by the facility when ambulating Resident #10. This was confirmed through a 5/26/11 interview with Staff D, Administrator who also revealed that Resident #10 sustained a fractured shoulder as a result of this fall. Resident #5 was admitted to the facility on [DATE] after being discharged from the hospital with a [DIAGNOSES REDACTED]. On review of the care plan record dated 2/16/11 under risk for falls the interventions are as follows: *Educate resident on Safety Risks *Encourage resident to communicate needs/ask for assistance *Encourage resident to transfer and change positions slowly *Ensure environment is free of clutter *Have commonly used articles within easy reach *Place call light within easy reach of resident *Reinforce need to call for assistance *Remind resident to use call light prior to ambulating or transfer *Remove all objects near bed to prevent injury if resident falls from bed *Side rails up X2 while in bed as an enabler *When resident is in bed, place all necessary personal items within reach *Encourage resident to use handrails or assistive devices properly *Resident to wear non slip footwear *Bed and chair alarms On review of the nursing notes dated 2/27/11 it states "Pt (patient) found on floor by commode...". Review of the incident report state "LNA did not follow care plan regarding leaving patients unattended who are on alarm fall prevention devices". Nurses notes dated 2/28/11 states "0515... Patient requested Tylenol (related to) leg pain with good effect" "1230 ...(patient complaining of) pain a short distance proximal (and) distal to (left) knee, this may be consequences of his fall..." Nurses notes dated 3/1/11 state "1115 ...(patient) continues to (complaining of) pain to (left) hip medicated (with) Tylenol...mobile here this A.M. for X-rays results faxed...(fracture of (left) hip and (left) femur. (Physician) notified and order received to send to (Hospital)...". Interview with Staff A (Director of Nurses) on 5/25/11 confirmed that the facility failed to provided resident #5 with the proper supervision and assistance devices to prevent accidents.

Based upon Staff interview, resident record review and a staff Record of Counseling report the facility failed to ensure that 2 of 15 sampled residents received supervision sufficent to prevent them from being subjected to neglect (Resident identifiers are #5 and #10). Finding include: Resident #10. On 4/9/11 at 8:00 p.m. Resident #10 was, according to nurses notes, assisted outside by Staff C, LNA "to smoke." Staff C, nurses notes stated, then brought Resident #10 inside to the Village Green where Resident #10 fell . Resident #10's current comprehensive care plan indicated that when Resident #10 ambulated they required "maximum assist using an adaptive walker." A facility investigation and Record of Counseling report revealed that Staff C had failed on 4/9/11 at 8:00 p.m. to use either a walker or gait belt as required by the facility when ambulating Resident #10. This was confirmed through a 5/26/11 interview with Staff D, administration who also revealed that Resident #10 sustained a fractured shoulder as a result of this fall. Resident #5 was admitted to the facility on [DATE] and on 2/27/11 nursing notes stated "(Patient) found on floor by commode...". On review of Resident #5's care plan dated 2/15/11 it shows that a bed and chair alarm were being used. Also on review of the therapy notes dated 2/15/11 it states that Resident #5 uses a commode and needs (moderate assistance with maximal verbal cues) when using the commode. On 2/27/11 Resident #5 was left alone on the commode without any means to call for assistance, due to the call bell being out of reach as stated by Resident #5 during interview on 5/24/11, and Resident #5 fell trying to reach the call bell and fractured left hip. Based on this the facility failed to provide services necessary to avoid physical harm which Resident #5 received after falling off the commode.

Based upon staff interview, resident record review, a facility investigation report and a Record of Counseling report the facility failed to implement the comprehensive care plan for 1 of 15 sampled residents (Resident identifier is #10). Findings include: On 4/9/11 at 8:00 p.m. Resident #10 was, according to nurses notes, assisted outside by Staff C, LNA "to smoke." Staff C, nurses notes stated, then brought Resident #10 inside to the Village Green where Resident #10 fell . Resident #10's comprehensive care plan indicated that when Resident #10 ambulated they required "maximum assist using an adaptive walker." A facility investigation and Record of Counseling report revealed that Staff C had failed to use either a walker or gait belt as required by the facility when ambulating Resident #10. This was confirmed through a 5/26/11 interview with Staff D, Administrator who also revealed that Resident #10 sustained a fractured shoulder as a result of this fall.

Based on record review, interview, observation and review of the facility policy and procedure the facility failed to prevent avoidable bilateral heel pressure ulcers from developing, failed to prevent one of them from progressing to a Stage IV and failed to follow the facility's policy and procedure in the monitoring of this same pressure ulcer in one of four residents with pressure sores in a standard survey sample of 15 residents. (Resident identifier is #1.) Findings include: Standard: Review of the February 2007 National Pressure Ulcer Advisory Panel guidelines (www.npuap.org) for the definition of a pressure ulcer and the stages of pressure ulcers, included the original 4 stages and added 2 stages for deep tissue injury and unstageable pressure ulcers. The guideline reads in part: "Pressure Ulcer DefinitionA pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers..." "Pressure Ulcer Stages (partial list)Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a stage IV pressure ulcer varies by anatomical location....Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] possible. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed." Policy and Procedure for Skin Care & Pressure Ulcer Management Program Review of the facility policy and procedure entitled "Skin Care & Pressure Ulcer Management Program" dated January 2010 reveals on page 3 under "Objectives ....this guideline helps the interdisciplinary team to: 1. Prevent pressure ulcers from developing in residents identified as being at risk, 2. Create care plans for residents who are at risk .... ." On page 7 this policy reviews the steps to be taken when a resident is admitted including "the licensed nurse ...completes a head-to-toe assessment, documenting findings on the Nursing Assessment. This process provides the team with an accurate description of the resident's actual skin condition at the time of admission. If the resident has a pressure ulcer or other wound at the time of admission, treatment begins promptly according to physician orders. The licensed nurse continues the evaluation process to determine the risk of additional breakdown, ...and prepares a plan of care for the existing condition and prevention of additional skin breakdown." On page 12 is written the steps the facility is to use to investigate and monitor a pressure area. They include "...Complete a Pressure Ulcer Documentation Form to document the status of the pressure ulcer. -Assess and document pressure ulcers at least weekly. - Document only one area or site per form. Use additional forms if more than one site is involved. - Determine the stage of the pressure ulcer. - Measure the pressure ulcer -length x width x depth." On page 18 this policy explains facility procedure for "Weekly Wound Rounds." It states "The team makes rounds weekly to evaluate wound treatment and other care interventions. The licensed nurse evaluates the pressure ulcer and documents pressure ulcer healing using the pressure ulcer documentation form. If a pressure ulcer fails to show progress toward healing within 2 weeks, the team evaluates the treatment plan to determine whether to modify the current interventions." Resident #1 This resident was admitted to the facility on [DATE] from the hospital after surgery for [REDACTED]. Review of the initial "Nursing Assessment" dated and signed by the nurse following completion on 8/26/10 reveals no pressure sores on the bilateral heels but does document six staples on the right hip and thigh, a reddened area on the right ankle, a small scabbed area on the right inner lower calf, a red area on the top of the right foot and an area on the coccyx described as follows "[MEDICATION NAME] ecchymotic area skin peeling." Review of the "Norton Plus Pressure Ulcer Scale" also dated 8/26/10 reveals a total Norton Plus Score of 6. Beside this score is an explanatory note found on the form which reads "Score 10 or less = High Risk." Review of the care plan implemented on 8/27/10 reveals a care plan for "Potential for skin breakdown related to decreased mobility". Review of this care plan reveals no intervention to prevent pressure to or skin breakdown of the heels. Further review of the medical record reveals no documented evidence of any interventions (i.e.off loading of the heels or Multi Podus boots) in use from 8/26/10 till 9/6/10 (10 days later) to prevent the development of pressure ulcers on Resident #1's heels. Review of the care plan problem "Resident has impaired skin integrity related to pressure ulcer secondary to immobility, friction intact blisters bilateral heels " reveals it was initiated 9/6/10 and has as an intervention/approach "off load heels at all times, mpb (Multi Podus boots) when in bed." Review of the care plan problem "Alteration in skin integrity related to ecchymosis anterior (front) right foot; 4 cm (centimeter) x 4 cm (centimeter) intact ulcer to right heel" has an intervention/approach which is dated 9/6/10 and reads "[MEDICATION NAME] to right heel. Float heels off bed." Review of the care plan problem "Pain/Potential for pain related to Fracture of hip, immobility, skin wounds" has an intervention/approach which is dated 9/6/10 and reads "Will float heels to decrease pressure on right heel." Review of the "Pain Evaluation" for Resident #1 dated 9/6/10 under reason for evaluation has checked off "Pressure Ulcer (date and stage)" with the date of 9/6/10 handwritten beside it but no stage indicated. Further review of this same form reveals an anatomical diagram with both the left and right bilateral heels circled by the nurse doing the assessment to indicate the area of pressure sores/pain. Review of the nursing notes reveals a nursing note dated 9/6/10 at 2230 which reads "Patient with 4 cm x 4 cm purple/black ulcer to right heel. [MEDICATION NAME] applied. Heel floated. DON (Director of Nurses) and MD (physician) notified. Care plan updated. ... . " Further review reveals a late entry dated 9/7/10 which reads "bilateral intact blisters noted heels. Both heels are fluid filled blisters, deep redness surrounding both sites ... . Left heel blister measuring 4 cm x 4 cm and right also measuring 4 cm x 4 cm. Will continue to monitor and treat." Further review of the nursing notes in Resident #1's medical record dated from admission on 8/26/10 through when the bilateral heel blisters developed reveals no documentation regarding the heels and no documented evidence in any of these nursing notes of any interventions provided by the facility to relieve pressure on the heels of Resident #1 until 9/6/10. During an interview on 5/25/11 in the morning with Staff A (DON), Resident #1's record was reviewed including the finding that the facility failed to initiate any measures until 9/6/10 to prevent pressure ulcers in the bilateral heels of this resident who was at high risk for developing pressure ulcers due to the [DIAGNOSES REDACTED]. During the same interview Staff A said once the blisters developed on 9/6/10, Multi-Podus boots were introduced and Resident #1's legs were elevated on pillows. The area on the right heel progressed to a stage III area which was confirmed by Staff A. Review of the facility "Pressure Ulcer Documentation Form (s)" for the Right heel from 9/6/10 through 5/17/11 reveals the facility failed to follow their policy and procedure for wound management by not staging and recording wound measurements on the "Pressure Ulcer Documentation Form" for 10/27/10, 11/10/10 through 11/22/10 and 12/7/10 through 3/15/11, and did not record wound measurements on 4/12/11. Written across the lines where this information is to be recorded for all the dates mentioned above is "Assessment per WHI (Wound Healing Institute)." No documented evidence was found that the facility had a wound tracking system in place to monitor the size and stage of this pressure area as required in their policy. Review of the facility "Pressure Ulcer Documentation Form" shows the facility did stage the right heel as a stage II pressure area from 9/6/10 - 10/9/10. On 10/14/10 the Wound Healing Institute saw the area and review of their note for that date reads "Nursing requested my assessment of resident's right heel ulcer today. Nursing concerns that right heel ulcer is not improving. Resident has been refusing to wear off loading shoe boot and only using pillows to off load right heel. Resident did finally agree today to wear boot....Nursing reports area to right heel was initially a blister. I assessed right heel ulcer today while resident was sitting up in her w/c (wheelchair). Ulcer to right heel is unstageable. Area is covered with 95% soft gray/whitish necrotic tissue. 5% red tissue to peri-wound...." Review of the 11/2/10 Wound Healing Institute note reveals under "Problem: Ulcer,...right heel" description as a stage III pressure area with full-thickness wound with "Tissue loss -exposed [MEDICATION NAME]/slough and subcutaneous." The wound bed is described as having "pink granulation" and the peri wound as being "[DIAGNOSES REDACTED]tous and callous" with "30% granulation." The wound measured 2 cm x 2.3 cm x 0.1 cm per this same note. Observation on 5/26/11 of the pressure ulcer for Resident #1 with Staff H (RN/CWOCN/WHI) revealed a resolving Stage III (staged by Staff H) pressure ulcer of the right heel showing a full thickness tissue loss. The Covering slough had been manually debrided by the ARNP just before my observation according to Staff H. The area was clean revealing red beefy granulation and by observation approximately 0.5 cm x 0.5 cm with little depth. On interview, at the time of the observation, Staff H stated that this right heel Stage III pressure ulcer was first seen by the WHI (Wound Healing Institute) on 10/26/10 and was Unstageable at that time.