Every finding on record at Blaire House of Worcester

Based on observation, interview, and record review, the facility failed to establish an infection prevention and control program (IPCP) to identify and prevent the potential spread of communicable diseases for 14 Residents (#55, #21, #51, #3, #23, #38, #60, #41, #12, #5, #31, #6, #39, #57), out of a total sample of 17 Residents. Specifically, the facility failed to:1. For Resident #55, identify Covid-19 infection when the Resident was exhibiting symptoms of a respiratory infection.2. For Resident #21, to appropriately disinfect a shared hallway bathroom after use when the Resident who used the shared bathroom tested positive for Covid-19.3. ensure staff performed proper hand hygiene and donned PPE (Personal Protective Equipment) upon entering and exiting Resident rooms when posted signage indicated it was required.4. For Residents (#51, #3, #23, #38, #60, #41, #12, #5, #31, #6, #39, #57), follow infection control practices by determining the type and duration of the isolation, depending upon the infectious agent or organism involved, and maintaining precautions for Residents with Covid-19, when the Residents were unable to maintain a mask outside of their rooms.5. utilize updated infection control signage outside of resident rooms, to provide appropriate guidance for staff on specific PPE required upon entering the resident rooms.6. For Resident #5, adhere to Enhanced Barrier Precautions (EBP) when providing direct care for the Resident, who had multiple open wound areas. Findings include: Review of the facility's policy titled Coronavirus Covid-19 Policy, revised 1/2024, indicated the following: -The facility will comply with the requirements of the most recent DPH LTC Testing guidance, which may be updated from time to time in response to further recommendations by DPH, CMS, or the Centers for Disease Control and Prevention (CDC). -The facility must conduct testing of all residents and staff if symptomatic. -Residents who have signs and symptoms of Covid-19 must be tested. Once test results are obtained, the facility must take the appropriate actions based on the results. -Compliance with the testing program is required. -Once a positive resident and /or staff member has been identified, then outbreak testing and contact tracing begins according to established regulatory Guidelines. -When prioritizing individuals to be tested, facilities should prioritize individuals with signs and symptoms of Covid-19 first, then perform testing triggered by an outbreak. -Residents and staff who have symptoms of an illness with Covid-19 should be tested using the FDA/EUA Antigen test: >Fever (100.0) Fahrenheit or higher, chills, or shaking chills >Cough >Difficulty breathing or shortness of breath >New loss of smell or taste >Sore throat > Headache >Muscle Aches or body aches >Nausea, vomiting, diarrhea, >Fatigue >Nasal congestion or runny nose -Separation of Covid-19 Residents: -These residents should not share a bathroom with others who are not Covid-19 positive. -Residents with Covid-19 may be released from isolation after five days of symptom onset , if without a fever for at least 24 hours, any symptoms have improved, and they have a negative viral test collected on day 5 or later , or, if asymptomatic after five days from specimen collection date of the positive Covid-19 test and have a negative viral test collected on day 5 or later. -These residents must be able to tolerate and wear a mask around others day 6 through 10. >Personal Protective Equipment (PPE) and Hand Hygiene: -Post precaution signs immediately outside of resident rooms indicating appropriate infection control and prevention precautions. See DPH Precautions Signs. -DPH recommends that a fit-tested N95 filtering facepiece respirator or alternative, eye protection, isolation gown and gloves be used for patients with suspected or confirmed Covid-19 or confirmed exposure. -Covid-Positive Residents: >Full PPE upon room entry to include N95 respirator or alternative Faceshield/goggles, gown and gloves, gown and gloves must be changed between residents. >Isolation sign -Isolation and Quarantine Chart for Residents>Isolate for 10 days with release on day 11 or release after day 5 with a negative test or later. If released before day 11, residents must be ablet to wear a mask around others through day 10 and must have substantial improvement in symptoms (if any). 1. Resident #55 was admitted to the facility in April 2024 with diagnoses including Alzheimer's Disease and unspecified Dementia. Review of Resident #55's Physician orders indicated but was not limited to the following: -May conduct Covid-19 test as indicated in accordance with CDC and MA DPH guidance, initiated 4/4/24. -Review of Resident #55's Nursing Progress Notes dated 8/14/25 at 14:52, indicated: >presented with a fever of 104 F (Fahrenheit) >facial paleness >wheezes heard upon lung assessment >occasional cough >Pox (pulse oximetry): 80% Review of Resident #55's Nursing Progress Note dated 8/14/25 at 20:16, indicated: >presented as hypoxic with Pox: 76% on 2.5 (L) liters via NC (nasal cannula). >Non-rebreather mask applied at 15 L. >sent out to the emergency room due to a change in condition with hypoxia. Review of Resident #55's Nursing Progress Note dated 8/22/25 at 16:34, indicated: -Resident returned from the hospital. -Discharge diagnoses included Acute Hypoxemic Respiratory Failure, Covid Positive, Pneumonia. During an interview on 8/27/25 at 11:44 A.M., the Director of Nursing (DON) said that Resident #55 presented with symptoms of Covid-19 on 8/14/25 and should have been tested in the facility prior to being sent out to the hospital but was not tested. The DON said the hospital called the facility on 8/15/25 to alert them that Resident #55 tested positive for Covid-19 by test on 8/14/25. The DON said that it would have been important for the facility to conduct a Covid-19 test for Resident #55 when he/she presented with symptoms, so that the facility could have initiated outbreak testing in a timely manner and could potentially have prevented the spread of Covid-19 to other residents. The DON said they initiated outbreak testing in the facility on 8/16/25 but it should have been initiated on 8/14/25. 2. Resident #21 was admitted to the facility in August 2025 with diagnoses including non-traumatic Brain Dysfunction. Review of the provided list of Covid-Positive Residents indicated Resident #21 tested positive for Covid-19 on 8/24/25 and was on Precautions. On 8/28/25 at 9:20 A.M. - 9:41 A.M., the surveyor observed Resident #21 exit his/her room which had a Droplet/Contact Precaution sign, without wearing a mask and entered a hallway bathroom. Resident #21 was observed yelling for assistance from the bathroom and a staff member donned PPE and assisted the Resident from the hallway bathroom back to his/her room. The surveyor observed that the hallway bathroom was not sanitized after being used by Resident #21, before another resident who was self-propelling a wheelchair in the hallway opened the hallway bathroom door, went into the bathroom touching the doorknob and door surface, and then proceeded to propel the wheelchair down the hallway by pulling on the hallway handrails and using other resident doorknobs for movement assistance, while contaminating all the areas being touched. During an interview on 8/28/25 at 10:33 A.M., the Housekeeping Director (HD) said that if a Covid-Positive resident uses a bathroom, a CNA is supposed to alert housekeeping right away so that the bathroom can be sanitized. The HD said that he and his staff did not receive notification from the nursing staff that Resident #21 had used the hallway bathroom and therefore the bathroom was not sanitized in a timely manner to prevent possible cross contamination. During an interview on 8/29/25 at 11:20 A.M., the DON said that the nursing staff is responsible to alert housekeeping right away if a Covid-19 positive resident uses a bathroom because the bathrooms are all shared. The DON said that the nursing staff did not alert housekeeping after Resident #21 used the hallway bathroom but should have. 3. Resident #6 was admitted to the facility in November 2024 with diagnoses including unspecified Dementia and Anxiety. Review of Resident #6's Nursing Progress notes indicated Resident #6 tested positive for Covid-19 on 8/22/25. Resident #51 was admitted to the facility in June 2021 with diagnoses including unspecified Dementia with mood disturbance. Review of Resident #51's Nursing Progress Notes indicated Resident #51 tested positive for Covid-19 on 8/20/25. Resident #39 was admitted to the facility in May 2024 with diagnoses including Dementia with other behavioral disturbances. Review of Resident #39's Nursing Progress Notes indicated Resident #39 tested positive for Covid-19 on 8/22/25. On 8/27/25 at 8:28 A.M., the surveyor observed Housekeeping Staff #1 enter Resident #6's room and changed the trash bag. Housekeeping Staff #1 was not observed to don PPE or perform hand hygiene upon entering or exiting the Resident's room. Housekeeping Staff #1 was then observed entering Resident #51's room and changed the trash bag, without donning PPE or performing hand hygiene prior to entering or exiting Resident #51's room. On 8/27/25 at 9:37 A.M., the surveyor observed Housekeeping Staff #1 standing at the trash container in Resident #39's room and was not wearing gloves or a gown. Housekeeping Staff #1 was observed to exit the Resident's room without performing hand hygiene. Housekeeping Staff #1 was further observed to reach into a plastic bin in the hallway and remove a stack of clean facecloths and delivered them to the clean laundry closet located in the hallway. During an interview at the time, Housekeeping Staff #1 said that a Droplet/Contact Precautions sign was on Resident #39's door because the Resident had Covid-19, but Housekeeping Staff #1 was not wearing PPE because he was only delivering plastic trash bags inside the Resident's room. During an interview on 8/27/25 at 11:44 A.M., the DON said that Housekeeping Staff #1 should have performed hand hygiene and donned PPE before entering Resident's #6, #51 and #39's rooms because the Residents were still on Precautions for Covid-19, because they could not maintain a mask. During an interview on 8/27/25 at 1:58 PM, the HD said that Housekeeping Staff #1 should have donned PPE according to the signage that was posted outside of the rooms to avoid spreading Covid-19 to others. The HD said that regardless of which resident in the room has Covid-19, staff should be donning PPE prior to entering the entire room. On 8/28/25 at 9:25 A.M., the surveyor observed Activity Aide (AA) #1 enter room [ROOM NUMBER] without donning PPE, assisted a resident to sit on the side of the bed and then left the room without performing hand hygiene. The surveyor observed a sign posted on room [ROOM NUMBER]'s door that indicated Droplet/Contact Precautions. During an interview at the time, AA #1 said that she should have performed hand hygiene and worn gown and gloves into the room but did not. AA #1 said she thinks one of the residents in the room had Covid-19 but was unsure of whom because she was told there were no positive cases of Covid-19 that day. During an interview on 8/28/25 at 11:23 A.M., the DON said that AA #1 should have followed what the Droplet/Contact Precaution signage indicated on the outside of room [ROOM NUMBER]'s door. The DON said AA #1 should have performed hand hygiene and donned PPE because one of the residents in the room was positive for Covid-19 on 8/24/25. 4. Review of the facility Covid-19 Positive Resident list, provided on 8/28/25, indicated the following Residents were removed from Isolation Precautions prior to day 10 of their Covid-19 infection and were unable to maintain a mask: -Resident # 51 tested positive for Covid-19 on 8/20/25 and was removed from Isolation Precautions on 8/27/25. -Resident #3 tested positive for Covid-19 on 8/20/25 and was removed from Isolation Precautions on 8/25/25. -Resident #23 tested positive for Covid-19 on 8/20/25 and was removed from Isolation Precautions on 8/25/25 -Resident #38 tested positive for Covid-19 on 8/20/25 and was removed from Isolation Precautions on 8/25/25. -Resident #60 tested positive for Covid-19 on 8/22/25 and was removed from Isolation Precautions on 8/27/25. -Resident #41 tested positive for Covid-19 on 8/22/25 and was removed from Isolation Precautions on 8/27/25. -Resident #12 tested positive for Covid-19 on 8/22/25 and was removed from Isolation Precautions on 8/27/25. -Resident #5 tested positive for Covid-19 on 8/22/25 and was removed from Isolation Precautions on 8/27/25. -Resident #31 tested positive for Covid-19 on 8/22/25 and was removed from Isolation Precautions on 8/27/25. -Resident #6 tested positive for Covid-19 on 8/22/25 and was removed from Isolation Precautions on 8/27/25. -Resident #39 tested positive for Covid-19 on 8/22/25 and was removed from Isolation Precautions on 8/28/25. -Resident #57 tested positive for Covid-19 on 8/22/25 and was removed from Isolation Precautions on 8/27/25. During an interview on 8/28/2025 at 8:05 A.M., Nurse #4 said that Resident #39 and Resident #5 had tested negative for Covid-19 and were no longer on Droplet Precautions. During an interview on 8/28/25 at 8:15 A.M., the ADON said that Resident #5 was positive on 8/22/25 and tested negative on 8/27/25 (day 5) of Covid-19 illness. The ADON said she was unsure if the Resident should remain on Droplet Precautions and was not sure if Droplet/Contact Precaution signage should remain on his/her door. During an interview 8/28/25 at 8:34 A.M., the Facility Scheduler said that she is responsible for resident and staff Covid-19 testing. The Facility Scheduler said that if resident tests negative on day 5, we remove the signs for Precautions. On 8/28/25 at 9:05 A.M., the surveyor observed Resident #5 sitting in the hallway next to other residents and at the side of the nurse's medication cart. The surveyor observed that no Isolation Precautions signage was on the Resident's door. On 8/28/25 at 9:12 A.M., the surveyor observed Resident #39 ambulating in the hallway, then stood at the nurse's medication cart. Resident #39 was observed not wearing a mask. 5. During an interview on 8/28/25 at 1:41P.M., the DON said that there was confusion amongst the staff and Residents had been removed from Droplet/Contact Precautions too early. The DON said that Residents #51, #3, #23, #38, #60, #41, #12, #5, #31, #6, #39, and #57 were removed from Droplet/ Contact Precautions when they tested negative prior to day 10 of their Covid-19 infection, but should not have been removed from Precautions because the Residents were unable to maintain a mask outside of their room and still had the potential of spreading Covid-19 to others. During an interview on 8/29/25 at 11:20 A.M., the DON said that the facility has been utilizing the yellow Droplet/ Contact Precaution signage for when a resident is Covid-19 positive, but those signs were outdated and instructed staff to only use a gown for high contact care. The DON said that the facility should have been utilizing the updated signs from DPH that indicated staff should use gowns, gloves, N95 and eye protection, to enter the room of any resident that is positive for Covid-19 but was not utilizing the updated signs. 6. Review of professional standards on Enhanced Barrier Precautions (EBPs), titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revised on June 28, 2024, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, indicated: -Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. -EBPs focus on the use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of Multi-Dru Resistant Organisms (MDROs) to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. -EBPs are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Resident #5 was admitted to the facility in March 2025 with diagnoses including Stage 3 Pressure Ulcer and Impaired Mobility. Review of the Minimum Data Set (MDS) Assessment, dated 8/14/25, indicated Resident #5: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of zero out of a total possible score of 15. -had one unhealed pressure ulcer -was dependent on staff for activities of daily living (ADL'S - Bathing, grooming, dressing). Review of Resident #5's Physician orders dated 8/27/25, indicated: -Right heel pressure wound stage 3, cleanse with wound cleanser (a sterile solution used to clean and irrigate wounds), pat dry, apply Santyl (medication used to clean and remove dead tissue from chronic skin ulcers), followed by Calcium Alginate (used to manage moderate to heavily draining wounds), followed by ABD pad (absorbent dressing used to manage large, heavily draining wounds), followed by rolled gauze two times a day, start date 7/31/25. -Enhanced Barrier Precaution (EBP) every shift, start date 6/24/25. On 8/27/25 at 12:14 P.M., the surveyor observed the following while Nurse #5 and Certified Nurse Aide (CNA) #3 were providing wound care to Resident #5: -Signage posted outside of Resident #5's room indicating that the Resident was on Enhanced Barrier Precaution. -Nurse #5 and CNA #3 failed to don gowns prior to entering Resident #5's room. -Nurse #5 performed wound dressing changes and CNA #3 assisted in positioning for Resident #5, both without donning gowns to provide direct contact care. -Nurse #5 was observed to not perform hand hygiene after doffing soiled gloves and before donning new gloves between the wound dressing changes. During an interview on 8/27/25 at 12:34 P.M., CNA #3 said Resident #5 was not on Precautions and there was no need to wear a gown when providing direct contact care. During an interview on 8/27/25 at 12:28 P.M, Nurse #5 said there was no need to wash/sanitize her hands between removal of gloves since the dressing changes were being performed on the same Resident. Nurse #5 said the Enhanced Barrier Precaution did not apply to Resident #5 and the EBP signage at the door was to remind staff to sanitize their hands before they entered the Resident's room. Nurse #5 said there was no need to wear a gown as the Resident was not on any form of Precautions. During an interview on 8/27/25 at 1:58 P.M., the surveyor, Nurse #5, and the Unit Manager (UM), reviewed Resident #5's treatment orders, and Nurse #5 said she had never been educated on the use of EBP and was not aware of the need for EBP for Resident #5. During a follow-up interview on 8/27/28 at 4:00 P.M., the UM said Nurse #5 and CNA #3 should have worn gowns before they entered Resident #5's room. The UM said Nurse #5 should have changed gloves after the removal of the old dressings and sanitized her hands before donning new gloves, but she did not.

Based on interview and record review, the facility failed to complete a performance review of every Certified Nurse Aide (CNA) at least once every 12 months, for five Certified Nurse Aides (#4, #5, #6, #7, and #8), out of five total records reviewed. Specifically, the facility failed to ensure that annual performance reviews to identify any areas of weakness were completed every 12 months, with regular in-service education provided based on the outcome of those performance reviews. Findings include: Review of the Employee Policy Manual, revised 6/2025 indicated: -Employees will be evaluated after 90 days of employment and after 12 months of employment. -Employees continuing their at-will employment will be evaluated at the end of each 12-month period. The employee's evaluation, known as a performance appraisal is made on a standard form that is signed by you and your supervisor and is reviewed by the administrator. -These evaluations are an opportunity for you and your supervisor to discuss your performance to date and, at the same time, to set goals for the future. -Your evaluation becomes part of your permanent personnel record. -Performance appraisals, attendance and length of employment are some of the elements considered for granting of pay increase. Review of the facility provided CNA Active Employee Listing, undated, indicated the following: -CNA #4 was hired 12/18/23. -CNA #5 was hired 6/24/13. -CNA #6 was hired 5/16/17. -CNA #7 was hired 11/30/06. -CNA #8 was hired on 2/1/24. Review of the Employee Records for CNA's #4, #5, #6, #7, and #8, failed to indicate that an annual performance review was completed as required. During an interview on 8/29/25 at 10:04 A.M., the Administrator said CNA's #4, #5, #6, #7, and #8, did not have a performance review in the past 12 months. The Administrator said that each CNA should have a performance review completed by the nursing department at least every 12 months and the facility should have provided education based on the outcome of those performance reviews.

Based on observation, interview and record review, the facility failed to provide specialized rehabilitative services consistent with the comprehensive plan of care for one Resident (#9) out of a total sample of 17 residents. Specifically, for Resident #9, the facility failed to ensure that lateral supports were implemented on the Resident's wheelchair as recommended by the Occupational Therapist (OT) and ordered by the Physician to ensure appropriate positioning, placing the Resident at potential risk for poor positioning, accidents related to falls, skin conditions, and pain. Findings include:Resident #9 was admitted to the facility in October 2021 with diagnoses including Dementia with behavioral disturbance, weakness, abnormal gait and mobility, low back pain, and Scoliosis. On 8/26/25 at 9:15 A.M., the surveyor observed the following:-Resident #9 was dressed and seated in a wheelchair in the hallway and leaning heavily on his/her right side of the wheelchair with his/her arm and upper body hanging over the right side of the wheelchair.-Numerous facility staff were observed in the hallway and walking by Resident #9 without providing assistance with the Resident's positioning in the wheelchair. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9:-was rarely/never understood or understands, speech was unclear.-Staff interview indicated the Resident was severely cognitively impaired.-was dependent on staff for activities of daily living (ADLs).-required substantial to maximum assistance of staff with transfers and repositioning. Review of Resident #9's Certified Nurse Aide (CNA) Care Card, undated, indicated:-Lateral supports while in the scoot chair (type of wheelchair) . Review of Resident #9's August 2025 Physician's orders indicated:-Lateral supports while in the scoot chair (type of wheelchair), every shift, initiated on 4/10/25. Review of Resident #9's August 2025 Treatment Administration Record (TAR) indicated the lateral supports were signed off by the nursing staff as administered from 8/1/25 through 8/29/25 on the 7:00 A.M. to 3:00 P.M. (Day) shift. Review of Resident #9's Impaired Mobility Care Plan, initiated 11/21/21, included the following intervention added 4/10/25:-Lateral supports while in scoot chair. The surveyor observed Resident #9 seated in his/her scoot chair and heavily leaning to the right over the right armrest on the following dates and times:-8/26/25 at 2:56 P.M.-8/27/25 at 8:59 A.M. (a folded blanket was observed on inside of the Resident's right side of the wheelchair against the arm rest)-8/28/25 at 3:40 P.M. During an interview on 8/29/25 at 10:25 A.M., CNA #9 said the following relative to Resident #9:-required total care assistance from staff.-can self-propel in his/her scoot chair.-leans to the right while seated in his/her scoot chair so the staff place a pillow or folded blanket on the Resident's right side.-removes the blankets/pillows positioned on the right side of his/her scoot chair so the facility staff have to replace them. On 8/29/25 at 12:50 P.M., the surveyor and the Director of Nursing (DON) observed the following:-Resident #9 was seated in a scoot chair in the hallway.-Resident #9 was leaning heavily on the right side of the wheelchair with his/her head against the chair rail on the wall.-there were no lateral supports in place on the scoot chair, nor pillow or folded blanket on the Resident's right side. During an interview on 8/29/25 at 12:55 P.M., the OT said he was able to locate the back portion of the lateral supports in Resident #9's room and that he was unsure where the side cushions for the lateral supports were at this time. The OT said the lateral support attach to the wheelchair and has a back cushion and two side cushions, one on each side, which supported the Resident so that he/she was in a more upright position. The OT said Resident #9 did not have lateral supports in place. During a follow-up interview on 8/29/25 at 12:57 P.M., CNA #9 said the following:-Resident #9 did not have lateral supports that she was aware of.-Resident #9 had a scoot chair so staff were trying other things to assist with his/her positioning while in the scoot chair.-It would be the decision of the Physician and Rehabilitation Staff to decide if Resident #9 needed lateral supports while in the wheelchair. During interviews on 8/29/25 at 1:03 P.M. and 1:25 P.M., with Nurse #4 while observing Resident #9, Nurse #4 said Resident #9 leans to the right side when in his/her scoot chair. Nurse #4 said the staff try to use a pillow or blanket to position the Resident while in the scoot chair. Nurse #4 said she was not aware of any other devices for positioning for Resident #9, and he/she did not currently have lateral supports in place. Nurse #4 said relative to the TAR which indicated the lateral supports were in place, she could maybe recall that the Resident used to have lateral supports but no longer had them and could not remember the reason as to why. Nurse #4 said if the Resident's lateral supports were not in place, the Nurses should be entering a code on the TAR and documenting in the medical record that the lateral supports were not in place. During a follow-up interview on 8/29/25 at 2:02 P.M., the OT said the lateral supports were implemented for Resident #9 to assist with his/her right sided leaning while in the wheelchair. The OT said Resident #9's leaning to the right put him/her at risk for injuries including skin tears, pain including low back pain associated with poor positioning and at risk for skin integrity issues because the Resident was often leaning heavily to the right. During an interview on 8/29/25 at 3:04 P.M., the surveyor and the Unit Manager (UM) reviewed Resident #9's medical record, and the UM said there was no indication that the Resident's lateral supports were refused, discontinued or not available. The UM also said the August 2025 TAR was signed off by the Nursing staff that the lateral supports were in place. The UM further said the Nurses should not be signing off that the lateral supports were in place if they were not. Please Refer to F842

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for wound care for one Resident (#5), of two applicable residents with pressure ulcers, out of a total sample of 17 residents.Specifically, for Resident #5, the facility staff failed to:-adhere to the Physician's orders when completing dressing changes for the Resident's Stage 3 Pressure Ulcer, right hip pressure wound, and left elbow skin tear.-implement infection control practices during the Resident's dressing changes to prevent the potential for infection and/or deterioration of the wounds. Findings include: Review of the facility policy titled Wound Care, revised September 2013, indicated:-Purpose is to provide guidelines for the care of the wounds to promote healing.-Verify Physician's order.-Wash your hands thoroughly.-Put on exam glove. Loosen tape and remove dressing.-Pull glove over dressing and discard into appropriate receptable. Wash and dry your hands thoroughly.-Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from the containers. -Wear sterile gloves when physically touching the wound or holding a moist surface over the wound.-Wipe reusable supplies with alcohol as indicated.-Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart.-Wash hands and dry your hands thoroughly. Review of professional standards on Enhanced Barrier Precautions (EBP), titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revised 6/28/24, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, indicated:-Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures.-They focus on the use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of Multi-Drug Resistant Organisms (MDROs) to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated.-Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).-Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Resident #5 was admitted to the facility in March 2025 with diagnoses including Stage 3 Pressure Ulcer and Impaired Mobility. Review of the Minimum Data Set (MDS) Assessment, dated 8/14/25, indicated Resident #5:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of zero out of a total possible score of 15.-had one unhealed pressure ulcer.-was dependent on staff for activities of daily living (ADL'S - Bathing, grooming, dressing). Review of Resident #5's Physician orders dated 8/27/25, indicated:-Right heel pressure wound Stage 3, cleanse with wound cleanser (a sterile solution used to clean and irrigate wounds), pat dry, apply Santyl (medication used to clean and remove dead tissue from chronic skin ulcers), followed by Calcium Alginate (used to manage moderate to heavily draining wounds), followed by ABD pad (absorbent dressing used to manage large, heavily draining wounds), followed by rolled gauze, two times a day, start date 7/31/25.-Enhanced Barrier Precaution (EBP) every shift, start date 6/24/25.-Right hip open area, cleanse with wound cleanser, pat dry followed by Calcium Alginate then cover with bordered foam, daily and prn (as needed), start date 7/30/25.-Left elbow skin tear, wash with normal saline (a sterile solution containing 0.9% sodium chloride in water) and cover with dry clean dressing, monitor for signs and symptoms of infection, start date 8/22/25. On 8/27/25 at 12:14 P.M., the surveyor observed the following during wound care performed by Nurse #5 and Certified Nurse Aide (CNA) #3:-Signage posted outside of Resident #5's room indicating that the Resident was on Enhanced Barrier Precaution (EBP).-Nurse #5 and CNA #3 did not don a gown before entering the Resident's room.-Nurse #5 donned (put on) gloves, cut off the old dressing with scissors and removed the old dressing from the Resident's right heel. -Nurse #5 patted dry the wound bed of the right heel, with moistened gauze.-Nurse #5 sprayed the entire wound bed of the right heel with skin prep spray (spray that creates a film-like barrier on the skin to prevent irritation and damage from adhesives, friction, and bodily fluids).-Nurse #5 cut the Aquacel pad with scissors, applied Santyl on the aquacel pad and placed the pad into the right heel wound bed.-Nurse #5 wrapped the Resident's right heel with a rolled gauze, then dated the wound dressing.-Nurse #5 doffed (removed) her gloves and donned new gloves.-Nurse #5 repositioned the Resident to his/her left side with the assistance of CNA #3.-Nurse #5 removed the old dressing from the Resident's right hip.-Nurse #5 wiped the Resident's right hip with a wet gauze, sprayed skin prep spray over the entire wound, then covered the wound with a foam dressing and dated the wound.-Nurse #5 doffed her gloves and donned new gloves.-Nurse #5 then repositioned the Resident to his/her right side with the assistance of CNA #3.-Nurse #5 wiped the Resident's left elbow with wet gauze, sprayed skin prep spray on the wound bed, applied foam dressing and dated the wound. During an interview on 8/27/25 at 12:34 P.M., CNA #3 said Resident #5 was not on precautions and there was no need to wear a gown when providing direct contact care. During an interview on 8/27/25 at 12:28 P.M, Nurse #5 said the following pertaining to Resident #5's wound care treatment:-there was no need to wear a gown as the Resident was not on any form of precautions.-there was no need to wash/sanitize hands between removal of gloves since the dressing changes were being performed on the same Resident.-the Enhanced Barrier Precaution (EBP) did not apply to Resident #5. The EBP signage at the door was to remind staff to sanitize their hands before they entered the Resident's room.-she sprayed the entire wound bed with skin prep spray to allow the dressing to stay on the wound. -there was no need to obtain Physician's order for the skin prep spray as this was her (Nurse #5's) practice to ensure the dressing adhered to the Resident's wound. During an interview on 8/27/25 at 1:58 P.M., the surveyor, Nurse #5 and the Unit Manager (UM) reviewed Resident #5's treatment orders, and Nurse #5 said she had never been educated on the use of EBP and was not aware of the need for EBP for Resident #5. Nurse #5 said it had always been her practice to spray skin prep spray on resident's wound beds to allow the dressings to adhere to the wounds. During a follow-up interview on 8/27/28 at 4:00 P.M., the UM said when Nurse #5 sprayed skin prep spray into Resident #5's wound bed, the skin prep spray would prevent the Santyl ointment from debriding the wound to allow for wound healing. The UM said Nurse #5 and CNA #3 should have worn gowns before they entered the Resident's room. The UM said Nurse #5 should have changed gloves after removal of the old dressings and sanitized her hands before wearing new gloves, but she did not. Please Refer to F726

Based on interview, observation and record review, the facility failed to ensure that the appropriate competencies related to wound care services were completed for one Licensed Nurse (Nurse #5) and one Certified Nursing Assistant (CNA #3), out of 5 staff records reviewed.Specifically, the facility failed to provide documentation that Nurse #5 and CNA #3 had completed the appropriate nursing competencies for wound care and infection control practices. Findings include: Review of the facility policy titled, Clinical Competency Training for Licensed Nursing Staff, revised 7/2024, indicated:-The Director of Nursing (DON) will be responsible for coordinating a clinical competency program for all licensed nursing staff twice a year, according to the mandatory educational in-service schedule.-All licensed nurses will be required to attend clinical programs and competency programs yearly.>The following nursing modules and topics shall be covered, and tests will be given.-Infection control.-Nursing assessment, .-Clinical day for licensed nursing staff may also include any other topics that the facility has noted to be significant through the quality assurance process.-Based on training, further individualized in-servicing may be necessary and shall be carried out by nursing administration. Review of the facility policy titled, Clinical Day for Certified Nursing Assistants, revised 10/2024, indicated:-Director of Nursing will be responsible for coordinating a clinical competency program for all certified nursing assistants twice a year, according to the mandatory educational in-service schedule.>The following nursing modules and topics shall be covered, and tests will be given.-Infection control. Review of professional standards on Enhanced Barrier Precautions (EBP), titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revised on June 28, 2024, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, indicated:-Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures.-EBP focus on the use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of Multi-Dru Resistant Organisms (MDROs) to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated.-EBPs are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).-Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. On 8/27/25 at 12:14 P.M., the surveyor observed the following during wound care being provided to Nurse #5 and CNA #3 to Resident #5:-Signage outside of Resident #5's room indicating that the Resident was on Enhanced Barrier Precautions (EBP).-Nurse #5 and CNA #3 failed to don (put on) a gown before entering Resident #5's room.-Nurse #5 was not wearing a gown while providing wound care and CNA #3 did not wear a gown while assisting Nurse #5 with repositioning Resident #5 during the wound dressing changes.-Nurse #5 failed to remove her gloves after removing the old dressing from the Resident's right heel wound.-Nurse #5 failed to wash/sanitize her hands after doffing (removing) soiled gloves.-Nurse #5 sprayed skin prep spray on all of Resident #5's wound areas. -Nurse #5 failed to disinfect the scissors after using the scissors to cut the old dressing. During an interview on 8/27/25 at 12:34 P.M., CNA #3 said the Resident was not on precautions and there was no need to wear a gown when providing direct care. During an interview on 8/27/25 at 12:28 P.M, Nurse #5 said there was no need to wash/sanitize her hands between removal of gloves since the dressing changes were being performed on the same Resident. Nurse #5 said the Enhanced Barrier Precautions did not apply Resident #5 and the EBP signage at the door was to remind staff to sanitize their hands before they entered the Resident's room. Nurse #5 said there was no need to wear a gown, and the Resident was not on any form of precautions. During an interview on 8/27/25 at 1:58 P.M., the surveyor, Nurse #5 and the Unit Manager (UM) reviewed Resident #5's treatment orders, and Nurse #5 said she had never been educated on the use of EBP and was not aware of the need for EBP for the Resident. Nurse #5 said it had always been her practice to spray skin prep spray on resident's wound beds to allow the dressings to adhere to the wounds even though there was no Physician's order for skin prep spray. During a follow-up interview on 8/27/28 at 4:00 P.M., the UM said there was no evidence that Nurse #5 had received nursing competency evaluation on infection control practices and wound care. The UM said there was no evidence that CNA #3 had received competency on assisting with wound care management and infection control practices. The UM further said wound care and infection control practice competencies should have been completed but they were not.Refer to F880

Based on observations, and interview, the facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional standards of practice on one out of one nurses station. Specifically, the facility to properly secure topical medications that were stored under the desk at the nurses station and was easily accessible to residents or staff. Findings include: Review of the policy title Storage and Expiration Dating of Medications and Biologicals, dated [DATE], indicated the following: -Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked in a medication room that is inaccessible by residents and visitors. -Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law, and in accordance with policy. -Facility should inspect nurses station storage areas for proper storage compliance on a regularly scheduled basis. On [DATE] at 9:26 A.M., the surveyor and Nurse #5 found an unsecured bag of medications containing Skin prep swabs, Antifungal cream, Santyl Cream, Zinc Oxide, Bacitracin ointment, and [NAME] Cream under the desk at the nurses station. Nurse #5 said that the medications should not have been kept under the desk because the residents could access that area and could potentially consume the medications. Nurse #5 said the door to the nurses station was sometimes left unlocked. During an interview on [DATE] at 3:03 P.M., the Assistant Director of Nurses (ADON) said she was unsure how long the bag of medications had been stored under the desk at the nurses station. The ADON said the medications should not have been kept there because the desk at the nurses station was not considered a secure area.

Based on observation, interview, and record review, the facility failed to ensure that complete and accurate medical records were maintained for two Residents (#1 and #9), out of a total sample of 17 residents.Specifically, the facility failed to: 1. For Resident #1, ensure documentation relative to residuals (the amount of fluid that remains in the stomach between feedings when a person is fed through a gastrostomy tube [G-tube: tube inserted directly into the stomach to provide fluid and nutrition when it cannot be taken orally]) checks were accurately recorded in the medical record for the Resident with a history of Aspiration Pneumonia, putting the Resident at risk for complications relative to his/her G-tube.2. For Resident #9, ensure an accurate medical record when the nursing staff were documenting in the Treatment Administration Record (TAR) that lateral supports were in place on the Resident's wheelchair. Findings include: Review of the facility policy titled Charting and Documentation, revised July 2017, indicated the following: -Documentation in the medical record will be.complete, and accurate. 1.Resident #1 was admitted to the facility in April 2025 with diagnoses including Dysphagia, history of Aspiration Pneumonia, reduced mobility, muscle weakness, had a G-tube, and was NPO (nil per os - nothing by mouth). Review of Resident #1's August 2025 Physician's orders indicated: -Every shift check for residual if above 100 milliliters (ml), hold feeding for one hour and recheck. If below 100 ml then resume feeding, if greater than 100 ml notify Nurse Practitioner (NP)/Medical Doctor (MD), start date 7/14/25. Review of the August 2025 Treatment Administration Record (TAR) from 8/1/25 through 8/28/25 indicated the following residuals were obtained for Resident #1: -8/1/25: 350 ml -8/10/25: 120 ml -8/12/25: 240 ml Further review of the August 2025 TAR Failed to indicate that residual amounts were obtained for the following: -Shift Two (3 P.M. to 11 P.M.): 8/2/25, 8/3/25, 8/9/25, 8/16/25, 8/17/25, and 8/27/25 -Shift Three (11 P.M. to 7 A.M.): 8/17/25 Further review of Resident #1's medical record failed to indicate documentation on 8/1/25, 8/10/25, and 8/12/25 that Resident #1's feeding was held for an hour, residuals were rechecked, and feeding was restarted or that the NP or MD was notified if the residual remained over 100 ml. Resident #1's medical record also failed to indicate documentation as to why residual amounts were not recorded on 8/2/25, 8/3/25, 8/9/25, 8/16/25, 8/17/25, and 8/27/25. During an interview on 8/28/25 at 10:13 A.M., the surveyor and Nurse #2 reviewed Resident #1's residual amount recorded on Shift Two on 8/1/25. Nurse #2 said she was the Nurse who recorded the 350 ml as the residual amount obtained but that was inaccurate documentation and Resident #1 never had residuals over 100 ml. Nurse #2 said she could not recall what the accurate residual amount on 8/1/25 was, but the accurate amount should have been recorded on the TAR and it was not. During a phone interview on 8/28/25 at 10:20 A.M., with Nurse #1, the surveyor reviewed documentation from Resident #1's August 2025 TAR indicating that Nurse #1 had recorded a residual of 120 ml on Shift Two on 8/10/25. Nurse #1 said she was the nurse working that day and that the 120 ml was inaccurate documentation. Nurse #1 said Resident #1 never had a residual amount over 10 ml and the amount recorded on the TAR was inaccurate. During an interview on 8/28/25 at 12:46 P.M., the Director of Nursing (DON) said Resident #1 had residual amounts checked every shift and the amount obtained was documented to ensure he/she was tolerating his/her feedings through his/her G-tube. The DON said Resident #1 had a history of Aspiration Pneumonia and it was important for staff to ensure accurate residual amounts were documented to make sure Resident #1 was not retaining too much fluid in his/her stomach and was tolerating his/her G-tube feeding. The DON said too much fluid left in the stomach could lead to Aspiration Pneumonia. The surveyor and the DON reviewed the August 2025 TAR and the DON said on 8/1/25, 8/10/25, and 8/12/25, if the Resident had residual amounts documented that were above 100 ml, there should have been documentation to show the Resident's feeding was held and residuals were rechecked after an hour. The DON said she was unable to find documentation to show this was done and the documentation on the TAR must be inaccurate. The DON further said on 8/2/25, 8/3/25, 8/9/25, 8/16/25, 8/17/25, and 8/27/25, residual amounts should have been recorded on the TAR or if they were not obtained documentation should have been completed in a nursing note as to why residuals were not obtained, and on those dates the medical record was incomplete. The DON said she was unaware there was inaccurate and incomplete documentation related to Resident #1's G-tube residuals and currently there was no way to monitor for residual amounts that fell outside a set parameter or for missing residual documentation. 2.Resident #9 was admitted to the facility in October 2021 with diagnoses including Dementia with behavioral disturbance, weakness, abnormal gait and mobility, low back pain, and Scoliosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9: -was severely cognitively impaired as idicated by Staff Interview. -was dependent on staff for activities of daily living (ADLs). -required substantial to maximum assistance of staff with transfers and repositioning. Review of the August 2025 Physician's orders indicated: -Lateral supports while in the scoot chair (type of wheelchair), every shift, initiated 4/10/25. Review of the August 2025 Treatment Administration Record (TAR) indicated the lateral supports were signed off by the nursing staff as administered from 8/1/25 through 8/29/25 on the 7:00 A.M. to 3:00 P.M. (Day) shift. The surveyor observed Resident #9 seated in his/her scoot chair and heavily leaning to the right over the right arm rest with no lateral supports in place, on the following dates/times: -8/26/25 at 9:15 A.M. -8/26/25 at 2:56 P.M. -8/27/25 at 8:59 A.M. -8/28/25 at 3:40 P.M. -8/29/25 at 12:50 P.M. During an interview on 8/29/25 at 1:03 P.M. and 1:25 P.M., Nurse #4 said relative to the TAR which indicated the lateral supports were in place, that she could maybe recall the Resident used to have lateral supports but no longer had them and could not remember the reason as to why. Nurse #4 said if the Resident's lateral supports were not in place, the Nurses should be entering a code on the TAR and documenting in the medical record that the lateral supports were not in place. On 8/29/25 at 3:04 P.M., the surveyor and the Unit Manager (UM) reviewed Resident #9's medical record, and the UM said there was no indication that the Resident's lateral supports were refused, discontinued or not available.The UM said the August 2025 TAR was signed off by the Nursing staff that the lateral supports were in place and the Nurses should not be signing off that the lateral supports were in place if they were not.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who was alert, disoriented, unable to make his/her needs known and was dependent on staff for transfers between surfaces, dressing and hygiene, the Facility failed to ensure Resident #1 was free from the use of physical restraint when, on 9/24/24 around 7:20 A.M., the Scheduler and the Activity Director observed Resident #1, who was seated in a wheelchair at a table in the dayroom with a gait belt around him/her that was also wrapped around the back of the wheelchair. The gait belt was clasped closed behind the wheelchair, unable to be removed or unlocked by Resident #1 and therefore restraining his/her ability to get up, if desired. Findings include: Review of the Facility Policy titled Device/Restraints Policy & Procedure, effective 10/10/00, indicated the resident has the right to be free from physical restraints imposed for the purposes of discipline and convenience and not required to treat the resident's medical condition. The Policy defined physical restraint to include any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body, that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Review of Resident #1's clinical record indicated that he/she was admitted to the Facility during September 2024 and his/her diagnoses included dementia, brief psychotic disorder and generalized anxiety disorder. Review of Resident #1's most recent Admission Minimum Data Set Assessment, dated 9/21/24, indicated his/her cognitive patterns were severely impaired, he/she did not ambulate and he/she was dependent on the assistance of staff members when transferring between surfaces and for dressing and hygiene. Resident #1's Care Plan related to Falls, dated as initiated 9/23/24, indicated that Resident #1's risk for falling and for significant injury would be minimized daily. Additional interventions, dated as initiated 9/23/24, indicated staff were to remind and encourage Resident #1 to call for assist prior to transfer and ambulation. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 9/24/24, indicated that a staff member reported that Resident #1 was sitting in a wheelchair restrained with a gait belt. During a telephone interview on 10/22/24 at 1:00 P.M., the Activity Director said that on 9/24/24 around 7:00 A.M. she arrived to the Facility and went to her office which was adjacent to the day room (on the Unit where Resident #1 resided). The Activity Director said that after leaving her belongings in her office, she turned on the television in the day room. The Activity Director said Resident #1 was seated in his/her wheelchair at a table facing the television. The Activity Director said that as she walked closer to Resident #1, she saw that there was gait belt around Resident #1 and his/her wheelchair, and it was latched closed behind the wheelchair back. The Activity Director said that she went closer to Resident #1 and saw that although the gait belt was across Resident #1's torso, his/her shirt was pulled over the belt so that it was not visible from the front. The Activity Director said that she saw the Scheduler in the hallway and asked her to come into the day room. During an interview on 10/21/24 at 11:00 A.M., the Scheduler said that, on 9/24/24, around 7:00 A.M., the Activity Director called her into the day room where Resident #1 was seated in his/her wheelchair at a table. The Scheduler said that the Activity Director showed her that there was a gait belt around Resident #1 and his/her wheelchair and it was latched closed behind the back of the wheelchair. The Scheduler said that she removed the gait belt and reported the incident to Nurse #1, Nurse #2 and the Director of Nursing. During an interview on 10/21/24 at 1:00 P.M., the Director of Nursing said that on 9/24/24 the Scheduler reported that Resident #1 had been found with a gait belt around him/her in a wheelchair, latched closed behind Resident #1's back. The Director of Nursing said that she initiated an internal investigation including obtaining Written Witness Statements from the Facility staff members on duty during the 11:00 P.M. to 7:00 A.M. shift starting on 9/23/24 and ending on 9/24/24 and the staff members on duty during the 7:00 A.M. to 3:00 P.M. shift on 9/24/24. The Director of Nursing said, and review of the Written Witness Statements indicated, that none of the staff members on duty during the 11:00 P.M. to 7:00 A.M. shift starting on 9/23/24 and ending on 9/24/24 saw the gait belt around Resident #1 and the wheelchair, or admitted they had applied it. During interviews on: -10/21/24 at 11:45 A.M. with Nurse #1, -10/21/24 at 1:55 P.M. with Certified Nurse Aide (CNA) #1, and -10/21/24 at 3:30 P.M. with CNA #2, they said the following: Nurse #1, CNA #1 and CNA #2, said they were the staff working on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. starting on 9/23/24 and ending on 9/24/24. They said Resident #1 was restless during the shift and CNA #1 spent much of the shift seated in the doorway of his/her room monitoring him/her. CNA #1 and CNA #2 said that they provided incontinence care to Resident #1 between 5:30 A.M. and 6:00 A.M. and left him/her seated in his/her room in his/her wheelchair. CNA #1, CNA #2 and Nurse #1 said they did not see the gait belt around Resident #1 or the wheelchair, they all denied putting it there, and said they did not know who applied it. The Director of Nursing said that while interviewing staff members about the gait belt found around Resident #1's wheelchair, she learned that, on 9/24/24 around 6:30 A.M., CNA #3 had dressed Resident #1 at his/her bedside and brought him/her from his/her bedroom to the day room. During an interview on 10/21/21 at 1:30 P.M., CNA #3 said that she arrived to the facility on [DATE] around 6:30 A.M. and one of her first tasks was to dress Resident #1 and bring him/her to the day room. CNA #3 said that when she entered Resident #1's room, she found Resident #1 in his/her wheelchair, at the foot of his/her bed. CNA #3 said that Resident #1 was dressed in pants, one sock and a johnny. CNA #3 said that because the johnny was knotted in the back, she lifted it over Resident #1's head to remove it rather than untying it. CNA #3 said that she dressed Resident #1 in loose blouse and wheeled him/her to the day room in his/her wheelchair. CNA #3 said that later in the morning she learned that Resident #1 had been found in the day room with a gait belt around him/her and latched closed behind the back of the wheelchair. CNA #3 said that she did not apply the gait belt around Resident #1. CNA #3 said that she did not see the gait belt around Resident #1 and the wheelchair when she changed Resident #1's shirt. CNA #3 said that because Resident #1 had been provided with incontinence care and was already dressed in pants and transferred to the wheelchair by staff members on the 11:00 P.M. to 7:00 A.M. shift, she did not have to transfer or position Resident #1 in the wheelchair. CNA #3 said it was possible that the gait belt was around Resident #1 and the wheelchair and latched closed behind the back of the wheelchair when she changed Resident #1 from the johnny into a blouse and she did not see it. Although Nurse #1, CNA #1, CNA #2 and CNA #3 all denied putting the gait belt around Resident #1 in the wheelchair, thereby restricting his/her movement, they were the staff members working on the unit during that time and were assigned to his/her care, Resident #1 was totally dependent on staff for care and physically incapable of doing it. On 10/21/24 the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A. On 9/24/24, skin and pain assessments were completed by the Unit Manager for Resident #1 without findings of injury related to the alleged incident. B. On 9/24/24, the Administrator/Director of Nursing suspended CNAs #1, #2 and #3 pending the outcome of their investigation and requested that the Agency no longer assign Nurse #1 shifts at the Facility. C. Between 9/24/24 and 10/02/24, nursing staff reviewed and updated Resident #1's care plan concerns regarding behavioral symptoms and falls prevention, to include interventions such as use of gerichair or Broda chair. D. On 9/24/24, Resident #1 was evaluated by Behavioral Health Services with recommendations made and on 9/27/24, Resident #1 was examined by the Physician. E. On 9/25/25, the Facility Social Worker met with Resident #1 to offer on-going support. F. Between 9/24/24 and 9/27/24, all Facility staff were trained on the Facility Patient Abuse Policy and prohibitions on restraints. G. The Director of Nursing, Unit Manager and Case Manager continue to make rounds of the Facility Units 3 to 5 times daily, on all shifts, observing for proper uses of devices and equipment. Observation findings are reviewed with clinical team members during the daily clinical meeting. H. Results of the Internal Investigation and observations made during rounds will be reviewed during the the Facility QAPI Meetings. I. The Administrator/designee are responsible for overall compliance.

Based on interview and record review, the facility failed to ensure documentation was available to show that Nurse Aide registry checks were completed for three Staff Members (#1, #2, and #3), out of five staff members personnel files reviewed. Specifically the facility failed to provide documentation that showed Nurse Aide registry checks were completed for screening of Staff Members #1, #2, and #3, prior to the staff members working with residents in the facility. Findings include: Review of the facility policy titled Abuse Prevention Policies and Procedures, revised 4/17, indicated the following: -All applicants for employment shall provide professional references. -The facility shall conduct application reference checks to the extent possible. -In addition, the facility will conduct further screening (s) as required including but not limited to Board of Nursing license verification, Nurse Aide Registry . 1. Review of Staff Member #1's personnel record indicated that Staff Member #1 had been working at the facility since February 2024. Further review of Staff Member #1's personnel record indicated no documentation that a Nurse Aide registry check had been performed prior to him/her starting work in the facility. 2. Review of Staff Member #2's personnel record indicated that Staff Member #2 had been working at the facility since June 2024. Further review of Staff Member #2's personnel record indicated no documentation a Nurse Aide registry check had been performed prior to him/her starting work in the facility. 3. Review of Staff Member #3's personnel record indicated that Staff Member #3 had been working at the facility since June 2023. Further review of Staff Member #3's personnel record indicated no documentation a Nurse Aide registry check had been performed prior to him/her starting work in the facility. During an interview on 6/27/24 at 11:37 A.M., the Human Resources (HR) Staff Member said Nurse Aide registry checks should be performed on all staff members prior to them working in the facility. The HR Staff Member said she was unable to provide any documentation to show Staff Member's #1, #2, and #3 had Nurse Aide registry checks performed prior to the Staff Members working in the facility. The HR Staff Member further said there should have been documentation in each of the staff member's personnel records to show Nurse Aide registry checks were performed and there was not.

Based on observation, interview, record and policy review, the facility failed to ensure that infection surveillance was implemented for skin infections requiring medical intervention for eight Residents (#9, #8, #52 #2, #45, #59, #20, and #61) out of a total sample of 20 residents. Specifically, the facility failed to track and trend skin disorders in order to assess/evaluate rashes that developed for Resident's (#9, #8, #52 #2, #45, #59, #20, and #61), and to implement strategies to minimize the potential risk of transmission of infections. Findings include: Review of the facility policy titled Surveillance for Infections, revised September 2017, indicated the Infection Preventionist (IP) will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require Transmission-Based Precautions (TBP: infection control measures used in addition to standard precautions for patients who may be infected with certain infectious agents) and other preventative interventions. The policy included the following: -The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and to prevent future infections. -The criteria for such infections are based on the current standard definitions of infections. -Infections that will be included in routine surveillance include those with: >evidence of transmissibility in a healthcare environment >available processes and procedures that prevent or reduce the spread of infection >clinically significant morbidity or mortality associated with infection (for example: pneumonia, urinary tract infections .) >pathogens associated with serious outbreaks (for example: Norovirus, influenza, scabies .) -Infections that may be considered in surveillance include those with limited transmissibility in a healthcare environment; and/or limited prevention strategies -Nursing Staff will monitor residents for signs and symptoms that may suggest infection, according to the current criteria and definitions of infection, and will document and report suspected infections to the Charge Nurse as soon as possible -If a communicable disease outbreak is suspected, this information will be communicated to the Charge Nurse and the IP immediately. -The Charge Nurse will notify the Attending Physician and the IP of suspected infections. >The IP and the Attending Physician will determine if laboratory tests are indicated, and whether special precautions are warranted. >The IP will determine if the infection is reportable. >The Attending Physician and interdisciplinary team (IDT) will determine the treatment plan for the resident. Review of the facility policy titled Infection Prevention Control, revised October 2020, indicated the purpose of the policy was to maintain an infection control and prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The policy indicated the infection prevention and control program will include the following: -System for preventing, identifying, reporting, investigating and controlling infections and communicable disease for all residents, staff . -System of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility -When and whom possible incidents of communicable diseases or infection should be reported -Standard and Transmission-Based Precautions (TBP) to be followed to prevent the spread of infections Review of the Centers of Disease Control and Prevention (CDC) Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, indicated the following: -Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered -Monitor the incidence of infections that may be related to care provided at the facility and act on the data and use information collected through surveillance to detect transmission of infectious agents in the facility. -Develop and implement systems for early detection and management (e.g. use of appropriate infection control measures, including isolation precautions, Personal Protective Equipment or PPE) of potentially infectious persons . -Implement additional precautions (i.e.Transmission-Based Precautions) for patients with documented or suspected diagnoses where contact with the patient, their body fluids, or their environment presents a substantial transmission risk despite adherence to Standard Precautions -Implement Transmission-Based Precautions based on the patient's clinical presentation and likely infection diagnoses (e.g. syndromes suggestive of transmissible infections such as diarrhea, meningitis, fever and rash, respiratory infection) as soon as possible after the patient enters the healthcare facility (including reception or triage areas in emergency departments, ambulatory clinics or Physicians' offices) then adjust or discontinue precautions when more clinical information becomes available (e.g. confirmatory laboratory results). During the initial pool process conducted on 6/25/24 at 9:40 A.M., the surveyor observed Resident #9 ambulating in the hallway. The Resident approached the surveyor and asked the surveyor to look at his/her body and started to disrobe the shirt that he/she was wearing, stating he/she was very itchy. The surveyor observed the Resident to be scratching at his/her upper chest. The surveyor was able to re-direct the Resident and said that she would notify the Nurse of his/her itchiness and have them assess him/her. The surveyor immediately notified the Nurse who was present a few feet away of the Resident's concern relative to itchiness. On 6/25/24 from 2:40 P.M. through 4:28 P.M., the surveyor observed Resident #9 dressed and seated in a stationary chair in the day room with numerous other residents during activities. He/she was observed to be frequently rubbing his/her back against the back of the stationary chair as well as scratching his/her right lower abdomen, upper chest, left leg, left knee and face. While Resident #9 was seated in the day room during the activities of coloring and pet videos with facility staff, the surveyor observed other residents to be intermittently scratching their arms, back and/or stomach. One resident who was seated at a table in a stationary chair coloring with another resident, was observed to take a colored pencil and use it to scratch his/her upper back repeatedly and then place the colored pencil back on the table. Another Resident (#8), who was seated in a stationary chair during the activity, was observed to continuously scratch his/her stomach and at one point, lifted up his/her shirt exposing the abdomen which had multiple red, open dime sized areas which he/she was scratching. A Certified Nurses Aide (CNA) approached Resident #8 and assisted him/her out of the day room while stating that he would inform the Nurse about the Resident's itchiness. On 6/26/24 at 7:27 A.M. through 7:58 A.M., the surveyor observed Resident #9 seated in a stationary chair in the day room with other residents during the breakfast meal. The Resident was observed to get up during the meal and state that he/she was itchy all over. A CNA was observed to approach the Resident at the time and tell the Resident that he could apply some lotion for the itchy skin, and redirected the Resident back to his/her breakfast tray. During the observation, the Resident was scratching his/her chest, upper arms and lower legs. During an interview on 6/26/24 at 10:15 A.M., Unit Manager (UM) #1 said that the NP evaluated Resident #9 today and put in orders relative to his/her rash. UM #1 said the Resident had been complaining of being itchy all over his/her skin, the NP was notified, assessed the Resident and gave new orders for treatment today. UM #1 said that she completed a skin assessment on the Resident today and there were no open areas or raised bumps, but there were areas on the Resident's underarms and legs that were irritated and red from scratching. On 6/26/24 at 3:50 P.M., the surveyor observed Resident #52 enter the dining room, sit on a stationary chair, remove his/her left sock and scratch his/her left lower leg and feet repeatedly. The surveyor observed that the Resident's lower leg had numerous bumps and/or red open areas on the ankle, upper toes and between the toes. The surveyor also observed multiple red areas/bumps on his/her arms. UM #1 entered the dining room and also observed Resident #52. When the surveyor asked about the Resident's skin and observed itchiness, UM #1 said that Resident #52 has had a rash about three weeks ago and UM #1 said she thought the incidences of resident rashes started with Resident #52. UM#1 said Resident #52 had Triamcinolone cream to treat the rash previously, but it looked like he/she still had the rash. UM #1 said she was not aware of the Resident's current rash and would check in with the Resident's Nurse. When the surveyor asked UM #1 about her reference to the rash starting with Resident #52, and if there was any more information or tracking/trending of the resident rashes, UM #1 said she was unsure if anyone was tracking the residents with rashes. On 6/26/24 at 4:25 P.M., the surveyor reviewed the observations of numerous residents with itchiness, scratching of skin and observations of rashes with the Director of Nursing (DON). The DON said she was aware that there were residents who have had rashes, the Providers were aware, and treatments have been ordered. The DON said the clinical team met daily, reviewed resident progress notes and discussed resident conditions so follow-up could occur. During an interview on 6/27/24 at 10:18 A.M., the DON said she reviewed the clinical records for Resident's #9 and #52. The DON said upon review, there was not much documentation relative to the skin concern/rash for Resident #9. The DON said Resident #52 was noted yesterday (6/26/24) to have a rash that was itchy and spreading and the rash required a treatment. The DON said the facility completed an audit and identified eight residents who had skin concerns related to rashes. The DON further said that the facility was aware of some of the residents identified and that 6 of the 8 residents with rashes had treatments in place. The DON said one of the treatments prescribed for one of the residents was not working so they had requested that the Provider assess for a new treatment. The DON said the facility had not been tracking the presence of resident rashes to identify if there were trends. The DON further said that the NP was coming to assess Resident #8 today. Review of the List of Residents with Rashes, provided by the DON on 6/27/24, indicated the following Residents were impacted: -Resident #9 -Resident #8 -Resident #52 -Resident #2 -Resident #45 -Resident #59 -Resident #20 -Resident #61 During an interview on 6/27/24 at 12:26 P.M., the NP said that he assessed Resident #8 relative to his/her rash. The NP said Resident #8 had the rash for months, that the initial occurrence of the rash started with Resident #8. The NP said Resident #8's current rash was a re-occurrence, was previously treated with a steroid cream which made it worse, so he was going to change the treatment. When the surveyor asked about whether the rash could be transmittable, the NP said that it could be bacterial which could be transmitted to others. The NP said Resident #8 was placed on Contact Precautions, which would be difficult to maintain because he/she was mobile and frequently touching things, and that new medication/treatment orders were added for the treatment of his/her rash. The NP further said the facility had provided him with a list of residents identified with rashes to be reviewed today, that he was aware that there have been several residents who have developed rashes and was not aware if there was any tracking and/or trending of the resident rashes. During an interview on 6/27/24 at 2:00 P.M., the DON said the facility had not tracked the occurrence of resident rashes and had no line listing for infections other than for COVID-19, Influenza or for other infections requiring antibiotics. During an interview on 6/27/24 at 2:39 P.M., CNA #1 said there were several residents on his assignment who have itchy rashes and have been observed to be scratching. CNA #1 said one of the Residents (#38) had a rash on his/her arms and back a few weeks ago which has since resolved, and currently two residents (Resident #55, who was not identified on the list provided to the survey team by the DON, and Resident #61) had rashes on their chest, back and hands. When the surveyor asked about what the process was for identifying skin conditions, CNA #1 said if he observed any resident scratching or had skin rashes/irritation, he would notify the Nurse. During an interview on 6/27/24 at 2:45 P.M., CNA #2 said there were three Residents on his assignment with rashes (Resident's #9, #35 and #52). CNA #2 said these Residents were itchy, had rashes that are red and bleed from scratching. CNA #2 further said that if he observed any change in a resident's skin conditions, he would notify the Nurse. During an interview on 6/27/24 at 2:50 P.M., CNA #3 said that she noticed that there were residents who say they are itchy or are observed to be itchy and scratching their skin. CNA #3 said when she observes this, she would notify the Nurse. When the surveyor asked if there were residents that had rashes/itchy skin, CNA #3 said Resident #8 and Resident #9 currently had itchy rashes. During an interview on 6/27/24 at 3:51 P.M., the surveyor discussed with the DON that several staff were interviewed and reported resident rashes (Resident's #38, #55 and #35) who were not included on the list provided to the survey team. The DON said she would follow-up with the staff and the Residents not on the list, to assess their skin. The DON further said that the facility was continuing to work with the Providers and the Epidemiologist.

Based on interview, record and policy review, the facility failed to offer Pneumococcal Vaccinations as recommended for three Residents (#42, #56, and #14) out of five applicable Residents, out of a total sample of 20 residents, putting the Residents at risk for developing facility acquired Pneumonia. Specifically, the facility failed to ensure that Pneumococcal Vaccinations were offered, received, or declined to Resident's #42, #56 and #14 per Physician's orders and after obtaining consent from the Residents and/or their Representatives. Findings include: Review of the CDC (Centers for Disease Control) website: Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (cdc.gov), dated 3/15/23, indicated but was not limited to the following: -For adults 65 and over who have not had any prior Pneumococcal Vaccines, then the patient and Provider may choose Pneumococcal Conjugate Vaccine (PCV) 20 or PCV15 followed by Pneumococcal Polysaccharide Vaccine (PPSV) 23 one year later. -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV 13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV 23), and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine Provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV 20). Review of the Facility Vaccine Procedure, revised 11/2023, indicated but was not limited to: -The licensed Nurse under the direction of the Director of Nursing (DON) will administer recommended immunization to residents/employees -Obtain informed consent from each resident, responsible party .to receive recommended vaccinations. -The licensed Nurse will obtain a Physician order .and administer the vaccine per the Physician order. -The licensed Nurse will administer the designated vaccine to all residents who have signed the informed consent requesting to be vaccinated. 1. Resident #42 was admitted to the facility in November 2023 with a diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) and was over the age of 65. Review of the Pneumonia Vaccine Informed Consent Form located in the Resident's chart indicated that the Resident's Representative consented for the Resident to receive the Pneumococcal Vaccine on 12/17/23. Review of the Resident's Medical Record indicated the following Physician's orders: -May receive Pneumococcal Conjugate 13 Valent (PCV 13) vaccine in accordance with CDC current recommended immunization schedule for adults, with documented informed consent and if not otherwise contraindicated, initiated 11/25/23 -May receive Pneumococcal Polysaccharide 23 Valent (PPSV 23) vaccine in accordance with CDC current recommended immunization schedule for adults with documented informed consent and if not otherwise contraindicated, initiated 11/29/23 Review of the Resident's immunization history in the facility's electronic health record (EHR) indicated no evidence the Resident received any Pneumococcal Vaccinations. Review of the MIIS (Massachusetts Immunization Information System) record provided by the facility indicated no history of Resident #42 ever having received a Pneumococcal Vaccination. Review of the CDC Pneumovax Advisor tool indicated the following recommendation for Resident #42 based on his/her history of Pneumococcal Vaccination: -Give one dose of PCV15 or PCV 20. If PCV 20 is used, the Pneumococcal Vaccinations are complete. Review of the Medical Record failed to indicate Resident #42 had a medical contraindication to or had been offered, received, or declined the appropriate Pneumococcal Vaccination. 2. Resident #56 was admitted to the facility in June 2023, with a diagnosis of Dementia and was over the age of 65. Review of the Pneumonia Vaccine Informed Consent Form located in the Resident's chart indicated the Resident's Representative consented for Resident #56 to receive the Pneumococcal Vaccine on 6/6/23. Review of the Resident's Medical Record indicated the following Physician's orders: -May receive Pneumococcal Conjugate 13 Valent (PCV 13) vaccine in accordance with CDC current recommended immunization schedule for adults, with documented informed consent and if not otherwise contraindicated, initiated 6/7/23 -May receive Pneumococcal Polysaccharide 23 Valent (PPSV 23) vaccine in accordance with CDC current recommended immunization schedule for adults with documented informed consent and if not otherwise contraindicated, initiated 6/7/23 Review of the Resident's immunization history in the facility's EHR did not indicate evidence that the Resident received any Pneumococcal Vaccination. Review of the MIIS (Massachusetts Immunization Information System) record provided by the facility indicated no history of Resident #56 ever having received a Pneumococcal Vaccination. Review of the CDC Pneumovax Advisor tool indicated the following recommendation for Resident #56 based on his/her history of Pneumococcal Vaccination: -Give one dose of PCV15 or PCV 20. If PCV 20 is used, the Pneumococcal Vaccinations are complete. Review of the Medical Record failed to indicate that Resident #56 had a medical contraindication to or had been offered, received, or declined the appropriate Pneumococcal Vaccination. During an interview on 6/26/24 at 1:55 A.M., the DON said both Resident #42 and #56 did not receive Pneumococcal Vaccinations until today, after the surveyor inquired as to whether the required immunizations had ever been provided to the Residents. The DON further said that both Residents should have received the vaccinations shortly after consenting, and it should not have taken this long for them to have received the vaccinations. 50563 3. Resident #14 was admitted to the facility in May 2023 with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease (COPD-a condition of the lungs that causes decreased air flow and breathing problems), Dysphagia (difficulty swallowing), Heart Failure (when the heart can no longer pump blood as well as it should resulting in fluid buildup in the feet, arms, lungs and other organs) and was over the age of 65. Review of the MIIS record provided by the facility indicated the following Pneumococcal Vaccination history: -PCV 13 administration date of 10/24/18. Review of the Pneumococcal Vaccination Informed Consent Form indicated Resident #14 's Representative consented for the Resident to receive the Pneumococcal Vaccination in accordance with CDC recommendations on 5/5/23. Review of the June 2024 Physician's orders included the following: -May receive PPSV 23 Vaccine in accordance with CDC current recommended immunization schedule for adults with documented informed consent and if not otherwise contraindicated, initiated 5/9/23. Review of the Resident's clinical and immunization record indicated no documented evidence the Resident had received any Pneumococcal Vaccinations after consent was obtained on 5/5/23. Review of the CDC Pneumovax Advisor tool indicated the following recommendation for Resident #14: -Give one dose of PCV 20 or, -Give a second dose of PPSV 23 During an interview on 6/26/24 at 2:01 P.M., the DON/Infection Control Preventionist (ICP) said Resident #14 had been due for the PCV 20 Vaccination. The DON/ICP said the PCV 20 Vaccination was administered today and should have been administered shortly after consent was obtained. During an interview on 6/27/24 at 11:17 A.M., the Nurse Practitioner (NP) #1 said he had received information from the DON relative to residents and their Pneumococcal Vaccination status this week. NP #1 said he was reviewing the resident list and was utilizing the CDC recommendations in order to determine the type of Pneumococcal Vaccination required for the residents who were due to receive them.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who required the use of a Hoyer lift (mechanical lift system used to transfer a medically dependent person from point A to point B) with the assistance of two staff members for transfers from bed to chair, the Facility failed to ensure he/she was provided with the necessary assistance during a Hoyer lift transfer. On 12/22/23, prior to attempting to transfer Resident #1 by the Hoyer lift, the two certified nurse aides (CNA's) had not checked to see if the lower straps of the Hoyer lift sling/pad were properly connected to the Hoyer, and as they started to raise Resident #1 up, he/she slid out of the sling/pad, fell to the floor and hit his/her head. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a laceration (open wound) to the back of his/her head related to the fall, which required two staples to close. Findings Include: The Facility Policy titled Lifting Machine, Using a Mechanical, dated as revised July 2017, indicated the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device and that it not a substitute for manufacturer's training or instructions. The Policy indicated steps in the procedure that included: -Measure the resident for proper sling size and purpose, according to manufacturer's instructions. -Make sure the sling is securely attached to the clips and that it is properly balanced. -Check to make sure the resident's head, neck, and back are supported. -Before resident is lifted, double check the security of the sling attachment. -Examine all hooks, clips, or fasteners. -Lift the resident two inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. Resident #1 was admitted to the Facility in November 2013, diagnoses included Alzheimer's, Dementia, Muscle weakness, Abnormalities of gait and mobility, Abnormal posture, and Osteoarthritis. Review of Resident #1's Fall Assessment, dated 11/02/2023, indicated that he/she was at increased risk for falls. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated that he/she was severely cognitively impaired and dependent for chair/bed-to-chair transfers with the assistance of two or more staff members. Review of Resident #1's Care Plan related to Mobility, reviewed and renewed with his/her November 2023 MDS, indicated that he/she required the use of a Hoyer lift with the assistance of two staff members for transfers related to impaired balance. Review of the Facility Incident Report, dated 12/22/23, indicated at approximately 8:45 A.M. Resident #1 was being transferred from bed to chair, he/she slid from (slid out of) the mechanical lift sling/pad onto the floor and sustained a laceration to the back of his/her head. The Report indicated Resident #1's Physician was notified, and he/she was sent to the Hospital ED for evaluation. Review of Certified Nurse Aide (CNA) #1's written Witness Statement, dated 12/22/23, indicated that at approximately 8:45 A.M., she (CNA #1) and CNA #2 were transferring Resident #1 from his/her bed using the Hoyer lift, he/she slid down from (slid out of) the Hoyer lift, fell on the floor hitting his/her head and they called the nurse in charge for help. The Surveyor was unable to interview CNA #1, as she did not respond to the Department of Public Health's telephone or letter requests for an interview. Review of CNA #2's written Employee Witness Statement, dated 12/22/23, indicated that she (CNA #2) and CNA #1 were transferring Resident #1 using the Hoyer lift and they forgot to crisscross the straps on the Hoyer sling/pad, Resident #1 slid from (slid out of) the Hoyer sling/pad, they both (CNA #2 and CNA #1) lowered him/her to the floor, suddenly he/she hit his/her head and they called for the nurse in charge. During an interview on 01/04/24 at 12:11 P.M., CNA #2 said that on 12/22/23, CNA #1 asked her (CNA #2) to assist her (CNA #1) to transfer Resident #1 from the bed to his/her chair with the Hoyer lift. CNA #2 said that CNA #1 had placed the Hoyer lift sling/pad under Resident #1, then they each hooked one side of the upper and lower straps of the sling/pad to the hooks of the Hoyer lift. CNA #2 said that CNA #1 raised the Hoyer lift, and as they started to move the Hoyer lift over to Resident #1's chair, he/she started to slide out of the sling/pad. CNA #2 said they tried to lower him/her to the floor but Resident #1 slid out the sling/pad, landed on the floor and hit the back of his/her head on the floor. CNA #2 said that she and CNA #1 called the nurse for help. CNA #2 said it all happened so fast. CNA #2 said she realized after Resident #1 had slid out of the Hoyer sling/pad onto the floor, that they had not crisscrossed the lower straps of the sling/pad before hooking the straps to the Hoyer lift. CNA #2 said the CNA's had been trained on how to use the Hoyer lift and how to attach the sling/pad, and said that they both (CNA #2 and CNA #1) forgot to do it that day. CNA #2 said they should have checked the placement of the sling/pad straps before transferring Resident #1, to make sure they were attached correctly. During an interview on 01/04/24 at 1:04 P.M., Nurse #1 said that on 12/22/23 around 8:45 A.M., CNA #1 called her to Resident #1's room because there was an emergency. Nurse #1 said when she went to Resident #1's room, she observed him/her lying on his/her back on the floor next to his/her bed, Nurse #1 said the Hoyer sling/pad was hanging from the Hoyer lift, and that CNA #2 was supporting Resident #1's head off the floor. Nurse #1 said she assessed Resident #1, and that he/she had a laceration on the back of his/her head that was bleeding, and she obtained an order to send him/her to the Hospital Emergency Department for evaluation. Review of the Hospital ED Notes and Discharge Summary, dated 12/22/23, indicated Resident #1 had a fall while being transferred, fell , hit his/her head, had sustained a laceration that was 4 centimeters (cm) in length and 2 millimeters (mm) in depth to his/her posterior scalp and the wound was closed with two staples. During interview on 01/03/24 at 2:54 P.M., the Director of Nursing (DON) said she was notified on 12/22/2023 by Nurse #1 that Resident #1 had slid out the Hoyer lift sling/pad while being transferred by two CNA's, and had landed on the floor, hitting the back of his/her head and sustained a laceration. The DON said she investigated Resident #1's incident, and determined the type of lift pad used to transfer Resident #1 was called a divided leg lift sling/pad. The DON said for that type of lift sling/pad, the lower straps needed to be crisscrossed (to support each leg individually) prior to being attached to the lift. The DON said that CNA #1 and CNA #2 had not crisscrossed the lower straps of the sling/pad when they attached them to the hooks to the Hoyer lift, which caused Resident #1 to slide out of the lift sling/pad and onto the floor. The DON said that both CNA's (CNA #1 and CNA #2) had received training and knew how to use the Hoyer lift and how to attach the sling/pads correctly to the lift. The DON said that she expects all CNAs to attach Hoyer lift sling/pads correctly to the Hoyer lift and then double check to make sure they are attached correctly before transferring a resident.

Based on observation, record review, and interview, the facility failed to ensure that its staff implemented a plan of care for one Resident (#12), out of a total sample of 15 residents. Specifically, the facility failed to implement a Physician's order and care plan intervention for the use of an AFO (Ankle-Foot Orthoses - an orthopedic appliance, brace or splint devised to control, limit, or assist foot and ankle motion and provide leg support). Findings include: Review of the facility policy for Care Planning- Comprehensive, last revised 5/2017, indicated that the Residents have the right to receive the services and/or items included in the plan of care. Resident #12 was admitted to the facility in January 2023 with diagnoses including the need for assistance with personal care, age related physical debility, and weakness. Review of Resident #12's Minimum Data Set Assessment (MDS), dated [DATE], revealed that the Resident had a Brief Interview of Mental Status (BIMS) exam score of 3 out of 15 indicating severe cognitive impairment and that he/she received extensive assistance for dressing [how resident puts on, fastens and takes off all items of clothing, including donning (putting on)/removing a prosthesis (an artificial device that replaces a missing body part) or TED hose (stockings that help to prevent blood clots and leg swelling)]. Review of Resident #12's Physician's order, dated 2/28/23, indicated to apply the AFO to the right leg and monitor the skin from 7:00 A.M. to 3:00 P.M., until signs and symptoms improve. Review of Resident #12's Kardex, dated 3/7/23, indicated that staff need to apply the AFO to right leg when assisting the Resident with Activities of Daily Living. On 3/6/23 at 9:55 A.M., the surveyor observed Resident #12 sitting in his/her room. The AFO was not applied to the Resident's right leg. On 3/7/23 at 10:24 A.M., the surveyor observed Resident #12 sitting in his/her room. The AFO was not applied to the Resident's right leg. During an interview on 3/7/23 at 11:11 A.M., Nurse #1 accompanied the surveyor to Resident #12's room and observed the Resident in the room. Nurse #1 said that the AFO should have been applied to Resident #12's right leg as ordered, but it was not. She was unable to locate the AFO in the room and said that it might be with a staff member in the therapy department.

Based on observation, record review, and interview, the facility failed to ensure that its staff provided an environment that remained as free of accident hazards as possible and utilized assistive devices to prevent accidents for one Resident (#34), out of a total sample of 15 residents. Specifically, the facility staff failed to utilize a mechanical lift for transferring Resident #34 as ordered by the Physician and according to the plan of care. Findings include: Resident #34 was admitted to the facility in April 2021 with diagnoses including unspecified Dementia, Osteoarthritis (a type of degenerative joint disease), and Peripheral Neuropathy (weakness, numbness, and pain from nerve damage). Review of March 2023 Physician's Orders indicated to utilize a mechanical lift for all transfers for Resident #34, initiated 9/26/2022. Review of the Kardex (a brief overview of each resident's care) for Resident #34 indicated that for Activity and Weight Bearing to use a mechanical lift for all transfers. On 3/7/23 at 12:00 P.M., the surveyor observed Certified Nursing Assistant (CNA) #1 enter the Resident's room with two other staff members. The Resident was in bed when the staff entered the room, and no mechanical lift could be seen in the room. CNA #1 closed the bedroom door. The surveyor remained directly outside the Resident's door and did not see a mechanical lift being brought to the room. The Resident's door opened and CNA #1 and the two other staff members exited the room bringing the Resident, who was now sitting in a recliner chair, into the hallway. When the surveyor asked how the Resident was transferred to the recliner chair, CNA #1 said that she transferred the Resident to the recliner chair with the assistance of the other two staff members. When the surveyor asked if a mechanical lift was used, CNA #1 said no, and further said that she was not aware that staff were supposed to use a mechanical lift to transfer the Resident. During an interview on 3/7/23 at 1:30 P.M., the Director of Nursing (DON) said that the Resident was unable to bear any weight and that the staff should always use a mechanical lift for all transfers for the Resident per the Physician's Orders, Kardex, and plan of care.

Based on observation, record review and interview, the facility failed to ensure its staff provided adequate nutritional and hydration services, according to their plan of care, for one Resident (#51), out of a total sample of 15 residents. Specifically, for Resident #51, who was identified as a nutritional risk and had an unplanned weight loss of greater than 5%, the facility staff failed to: 1) offer a breakfast and lunch meal on 3/7/23 2) implement weekly weight monitoring 3) adequately implement an order for fluid intake to maintain proper hydration and health and notify the Physician when that order had not been implemented, and 4) Notify the responsible party or family of the Resident's significant unplanned weight loss Findings include: Review of the facility policy titled Resident Nutritional Policy and Procedure Weight Monitoring, last reviewed 5/2018, indicated the Director of Nurses (DON) will ensure Physician orders are implemented and the family/responsible party is notified regarding a significant change. Resident #51 was admitted to the facility in August of 2022 with a diagnosis of Dementia. Review of the Minimum Data Set (MDS) assessment, dated 2/16/23, indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of one out of a total possible score of 15. Review of the Resident's Physician orders for February 2023 indicated the following: -TwoCal HN (a high nutrition liquid supplement drink), 120 mls (milliliters), three times a day, initiated on 12/8/22 -House Ground diet, thin liquids, Super cereal at breakfast, initiated 12/16/22 -Encourage by mouth fluids to 1800 mls per day, initiated on 2/3/23 Review of the Resident's current Physician orders for March 2023 indicated the following: - TwoCal HN Suspension,120 mls, four times a day initiated on 2/10/23 - House Liquefied Puree diet, thin liquids, Super cereal at breakfast, initiated 3/2/23 - Encourage by mouth (orally) fluids to 1800 ml/day, daily, initiated on 3/2/23 Review of the Resident's care plan, last revised 2/21/23, indicated Resident #51 was at risk for weight loss related to a diagnosis of Dementia, weight less than ideal body weight on admission, refuses a meal at times and had a significant weight loss for 1 month on 2/20/23. Further review of the care plan indicated the following interventions: - Dietary supplement as ordered, initiated 8/19/22 - Monitor weights weekly, initiated 8/19/22 - Encourage high protein foods, encourage fluids with meals and nourishment pass, initiated 1/26/23 - Resident is primarily fed as needed and as Resident allows, initiated 2/21/23 Further review of the clinical record and documentation by the Dietitian, on the facility interdisciplinary communication form dated 2/9/23, indicated: -the Resident had a significant weight loss of 12.2% for one month -weight measurement changes had decreased from 82 pounds to 72 pounds -the Resident often had poor intake during meals. Documentation in the Quarterly Nutrition assessment dated [DATE] indicated the Resident's Ideal Body Weight (IBW) was 90 - 110 pounds. 1) On 3/7/23 at 7:50 A.M., the surveyor observed Resident #51 in bed with the head of the bed elevated. The Resident appeared cachectic (loss of body weight and muscle mass), and his/her lips looked dry and cracked. The surveyor did not observe a breakfast tray or fluids at the Resident's bedside or in the Resident's room. On 3/7/23 at 8:30 A.M., the surveyor did not observe a breakfast tray in the Resident's room. On 3/7/23 at 11:43 A.M., the surveyor observed Resident #51 in bed, the surveyor did not observe a lunch tray in the Resident's room. On 3/7/23 at 12:50 P.M., the surveyor did not observe a lunch tray in the Resident's room and the Resident remained in bed. During an interview on 3/7/23 at 2:20 P.M., Certified Nursing Assistant (CNA) #1 said that she worked at the facility as a regular full-time employee. She said the Resident needed to be fed but the Resident refused to eat most of the time. She said she did not bring a breakfast tray or lunch tray to the Resident today. She said she did not assist the Resident with any meals today because he/she refused to eat most of the time and because the Resident received Ensure (supplement) from the nurse. 2) Review of the weight measurement summary report provided by the facility indicated the following weights for Resident #51: -1/4/23: 82 pounds -2/6/23: 72 pounds -2/14/23: 71 pounds -2/24/23: 71 pounds -3/6/23: 68 pounds No weekly weights were documented in the clinical record for the weeks between 1/4/23 and 2/6/23. 3) Review of the Medication Administration Record (MAR) for February 2023 did not show any evidence that the Resident had received 1800 mls per day of fluid hydration as ordered. Review of the Treatment Administration Record (TAR) for March 2023 did not show any evidence that the Resident had received 1800 mls of fluid hydration per day as ordered. Review of the Progress notes for February 2023 and March 2023 did not show any evidence the Physician was notified the Resident had not received the 1800 mls per day of fluid hydration as ordered. 4) Further review of the progress notes for February 2023 and March 2023 did not indicate that the Resident's Representative or family had been notified of the Resident's significant weight loss that was identified on 2/9/23 by the interdisciplinary team. During an interview and record review on 3/8/23 at 11:28 A.M., Unit Manager (UM) #1 said that she did not know why Resident #51 was not provided with a breakfast and lunch tray on 3/7/23 but he/she should have been provided with the meal trays. She said there should be no meal intake percentages recorded for 3/7/23 for breakfast or lunch because the Resident did not receive those meals. UM #1 said she could not find any documentation on the Resident's MAR or TAR for February 2023 or March 2023 related to the amount of fluid the Resident had received. She said that the nurses should have documented the amount of fluid the Resident was drinking each shift in the spaces next to the fluid order on the MAR or TAR but they did not document the amount of fluid. UM #1 further said that she could not find any documentation in the Resident's record indicating that the Physician was made aware the Resident was not receiving the 1800 mls per day as ordered. She said the Physician should have been notified the first day the order was not met. UM #1 also said there was also no evidence in the Resident's record that the Resident's Representative or family had been notified of the Resident's significant weight loss identified on 2/9/23. During a telephone interview on 3/9/23 at 9:02 A.M., with the Dietitian, she said that she worked in the facility ten hours a week and was familiar with Resident #51. She said that she first identified a significant weight loss for the Resident on 2/9/23 and documented her findings on an Interdisciplinary Communication form. The Dietician further said she was aware that the Resident had gone from 1/4/23 to 2/6/23, without having a weekly weight measurement done. She said that the Resident's last weight measurement on 3/6/23 was 68 pounds. She said she monitors the Resident's meal intake status by looking at the facility meal intake report but was unable to verify the amount of the TwoCal HN supplement the Resident received because the nurses did not document the amount of the supplement taken by the Resident but they should have documented the amount.

Based on record review and interview, the facility failed to ensure its staff provided a Pneumococcal (serious infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus) Vaccination, according to Centers for Disease Control and Prevention (CDC) recommendations, for one Resident (#12) out of five applicable sampled residents. Specifically, the facility failed to ensure its staff provided the Resident with one dose of Pneumococcal Vaccine, when informed written consent had been obtained for the vaccine and the Resident was due for the dose to be up to date with his/her pneumococcal vaccine status, based on CDC recommendations. Findings include: Review of the CDC Pneumococcal Disease Risk Factors and how it Spreads, dated 9/1/20, included the following: -Adults [AGE] years or older are at increased risk for Pneumococcal disease. -Adults of all ages are also at increased risk for Pneumococcal disease if they have alcoholism or liver disease. Review of the CDC Pneumococcal Vaccine Timing for Adults, dated 2/8/23, included: -For adults [AGE] years of age or older who received a dose of pneumococcal polysaccharide (PPSV23: one type of vaccine used to prevent pneumococcal disease) at any age, to be considered up to date with Pneumococcal vaccination, one dose of PCV (pneumococcal conjugate: type of vaccine to prevent Pneumococcal disease) 15 or PCV20 should be administered greater than or equal to one year following the administration of the dose of PPSV23. Resident #12 was admitted to the facility in January 2023 with a diagnosis of alcoholic cirrhosis of the liver. Review of the Pneumococcal Vaccination Informed Consent for Residents, dated 1/11/23, indicated informed written consent had been obtained for Resident #12 to receive Pneumococcal Vaccination in accordance with CDC recommendations. Review of the March 2023 Physician's Orders for Resident #12 included an active order, dated 1/9/23, as follows: May receive pneumococcal conjugate (used to prevent pneumococcal disease) .vaccine in accordance with CDC current recommended immunization schedule for adults, with documented informed consent, and if not otherwise contraindicated . Review of the Resident's clinical record indicated he/she was over the age of [AGE] years. Further review of the record included no evidence a Pneumococcal Vaccine had been provided for Resident #12 since informed consent was obtained, or that any Pneumococcal Vaccine had ever been received historically by the Resident. The record also included no evidence that Pneumococcal Vaccination had been identified as contraindicated for the Resident. During an interview on 3/8/23 at 8:36 A.M., the Infection Preventionist (IP) said Pneumococcal Vaccines were offered to residents based on current CDC guidance. The IP reviewed the Resident's record and said there was no indication in the record that Resident #12 had ever received a Pneumococcal Vaccine. The IP then reviewed the Massachusetts Immunization Information System (MIIS) Vaccine Administration Record for Resident #12 and said he/she had received a dose of PPSV23 on 4/4/11. The IP further said she would have to investigate whether the Resident was due for an additional dose of Pneumococcal Vaccine and would get back to the surveyor. During a follow-up interview on 3/8/23 at 1:30 P.M., the IP said she spoke with the Resident's Non-Physician Practitioner (NPP) and the NPP said the PCV20 should have been administered since it had been [AGE] years since the Resident's last Pneumococcal Vaccine dose.

Based on record review and interview, the facility failed to ensure its staff completed Minimum Data Set (MDS) assessment timely for one Resident (#46), out of a total sample of 15 residents. Specifically, the facility failed to ensure its staff completed the Entry Tracking Record within seven days of the Resident's re-entry to the facility, as required. Findings include: Review of the Centers for Medicare and Medicaid (CMS) Services Resident Assessment Instrument Version 3.0 Manual, dated October 2019, included that Entry Tracking Records were to be completed no later than seven calendar days following a resident's entry date to the facility. Resident #46 was admitted to the facility in April 2022. Review of the Resident's clinical record indicated the following: -The Resident was discharged from the facility on 9/13/22 and re-entered the facility on 9/18/22. -An Entry Tracking Record MDS Assessment had been completed with an assessment reference date of 9/18/22. Review of Section Z Assessment Administration for the Entry Tracking Record, dated 9/18/22, indicated the Assessment was not completed until 9/29/22 (more than seven calendar days following the Resident's re-entry to the facility). During an interview on 3/8/23 at 10:23 A.M., the MDS Nurse said entry tracking records were required to be completed no later than seven days following the day a resident re-entered the facility. She said the Entry Tracking Record dated 9/18/22 was not completed until 9/29/22, which was more than seven days following the Resident's re-entry date to the facility, and she did not know why it was not completed timely.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #2's door jam to prevent him/her from opening the door and being able to come out of his/her room at night. Findings include: The Facility Policy titled Abuse Prevention Policies and Procedures, dated 04/2017, indicated that Facility residents had the right to be free from involuntary seclusion. Review of the Facility's Investigation Narrative, dated 01/09/22, indicated that Rapid Response Nurse #1 forwarded an e-mail to the Facility Administrator on 01/09/22 at 10:49 A.M. The e-mail indicated that both CNA #1 and CNA #2 were performing rounds and noticed CNA #3 had stuck a towel in a door jam to a residents' room (later identified as Resident #2) to keep a resident in his/her room. The e-mail indicated that CNA #1 and CNA #2 told Nurse #2 about the door (to Resident #2's) room being jammed closed with a towel. The e-mail indicated Nurse #2 said this was something staff did to keep residents in their rooms, and said it was not the first time this has happened. Resident #2 was admitted to the Facility in July 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 01/13/22, indicated Resident #2 had moderate cognitive impairment, behaviors included wandering, and that this occurred daily. Review of Resident #2's Behavior Plan of Care, reviewed and revised 01/2022, indicated that Resident #2 wandered at very fast pace, was intrusive, and interventions included that staff were to redirect when wandering. During an interview on 02/02/22 at 12:50 P.M., CNA #2 said on 01/08/22, she and CNA #1 were doing rounds on the Resident #2's unit. CNA #2 said, both she and CNA #1 observed CNA #3 standing in the doorway of Resident #2's room with towels in his hand. CNA #2 said she did not know what CNA #3 was doing with the towels. CNA #2 said she that the door to Resident #2's room was closed, and said when she tried to open the door she was unable to. CNA #2 said she then noticed that a towel had been wedged into the door jam. CNA #2 said she asked for help from CNA #1 in getting the door open and said CNA #1 was also unable to open Resident #2's door. CNA #2 said she reported this immediately to Nurse #2, who came to open the door. CNA #2 said it took Nurse #2 to use all her body weight to push open the door. Review of Nurse #2's Written Witness Statement, dated 01/09/22, indicated during the overnight shift (11:00 P.M.-7:00 A.M.), Certified Nurse Aides (CNA) would lock residents in their rooms so they could not wander. The statement indicated CNAs would lock the residents in their rooms by wedging a towel in the door jam. During an interview on 02/03/22 at 10:30 A.M., Nurse #2 said on 01/08/2022, at the beginning of her shift around 11:00 P.M., while she was performing rounds she noticed a towel in the door jam of Resident #2's door, Nurse #2 said she removed the towel and opened the door. Nurse #2 said she could recall two other times that she found towels wedged in the door jam to Resident #2's room, and said she would remove the towels and open the door. During an interview on 02/07/22 at 9:30 A.M., CNA #1 said on 01/08/22, she and CNA #2 were performing rounds on the unit, at the start of night shift. CNA #1 said, both she and CNA #2 observed CNA #3 with towels standing at the doorway of Resident #2's room. CNA #1 said Resident #2's door was closed, and when she attempted to then open the door she was unable. CNA #1 said a towel was wedged in Resident #2's door jam and the door was stuck. CNA #1 said she reported this immediately to Nurse #2. CNA #1 said Nurse #2 had to use all of her body weight to push open the door. During an interview on 02/09/22 at 11:15 A.M., CNA #3 denied placing a towel in Resident #2's door jam. During an interview on 02/01/22 at 2:30 P.M., the Administrator said she received an email from Rapid Response Nurse #1 on 01/09/22 which had been forwarded from CNA #1. The Administrator said that the email indicated that both CNA #1 and CNA #2 had found a towel wedged into Resident #2's door jam. The e-mail also indicated that staff were unable to open the door, until Nurse #2 used all of her body weight to push the door open. The Administrator said during the Facility's investigation, Nurse #2 said she had observed on other days she worked, that towels had been placed in other residents door jams and residents were unable to open the doors.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure staff implemented and followed the Facility Abuse Policy to report an allegation of abuse, when staff were aware that on more than one occasion that a towel had been wedged in the door jam to Resident #2's room to prevent him/her from wandering on the night shift, however the Executive Director was not immediately notified. Findings Include: The Facility Policy titled, Abuse Prevention Policies and Procedures, dated 04/2017, indicated that it is the policy of the Facility to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegations do not involve abuse and do not result in serious bodily injury, to the Executive Director of the Facility. Review of Nurse #2's Written Witness Statement, dated 01/09/22, indicated during the overnight shift (11:00 P.M.-7:00 A.M.), Certified Nurse Aides (CNA) would lock residents in their rooms so they could not wander. The statement indicated CNAs would lock the residents in their rooms by wedging a towel in the door jam. During an interview on 02/03/22 at 10:30 A.M., Nurse #2 said that 01/09/22 was not the first time towels were found wedged in residents door jams on that unit. Nurse #2 said she could recall two other times that she had to remove towels from Resident #2's door jam. Nurse #2 said she would remove the towels and open the door. Nurse #2 said she did not report the incidents since she had never witnessed who placed the towels in the door jams and said they already did not have enough CNAs to work. During an interview on 02/01/22 at 2:30 P.M., the Administrator said their Investigation findings included that Nurse #2 had failed to report other incidents of alleged abuse (involuntary seclusion with towels being wedged in door jams) immediately and said Nurse #2 failed to follow the Facility's Abuse Policy.

Based on observation, interview, and policy review the facility failed to ensure that only authorized personnel had access to the storage of drugs and biologicals in one of out one medication rooms. Findings include: On 1/20/22 from 8:22 A.M. through 8:35 A.M. the surveyor observed the medication room door was propped open and unoccupied. Upon closer inspection, the surveyor observed the latch (the part of the lock that extends from the door and into the frame to hold it closed) was in the extended/locked position, but not engaged with the door frame. This allowed the door to be propped open and did not limit access to the medication storage room. The surveyor observed there was no staff at the adjacent nurses' station. The medication room was located in a hall adjacent to a resident room that was occupied by three residents. During an interview on 1/20/22 at 8:35 A.M. Nurse #1 said she had just entered the facility and was not sure why the medication room was unlocked/propped open or how long it had been left like that. She further said the medication room was supposed to be locked at all times and access was limited to the nurses passing medications on that shift. Review of wall postings indicated the entire facility was a Dementia Specialty Care Unit. Over the course of the survey, the surveyor observed several wandering and ambulatory residents. Review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals, revised 1/1/22, included but was not limited to the following: *Facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law. During an interview on 1/20/22 at 4:03 P.M. the Director of Nurses said the medication room was supposed to be locked at all times and only the nurses assigned to the carts that day should have had access to the room.

Based on records reviewed and interviews, for one of three sampled Residents (Resident #1) the Facility failed to ensure that an allegation of abuse was reported to the Department of Public Health within two hours. The Director of Nurses said on 01/18/17 it was reported, Dietary Aide #1 said on 01/17/17 she heard Nurse #1 yelling loudly at Resident #1 while delivering the breakfast cart, grab Resident #1's geriatric chair from behind moving it backwards abruptly and Resident #1 responding, What did I do wrong? What did I do wrong? or to words to that affect. The Director of Nurses said an investigation was initiated into the allegation of abuse and the incident was reported to the Department of Public Health on 01/18/17, twenty four hours after the incident occurred. Findings include: The Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was severely cognitively impaired with the following Diagnoses: [REDACTED]. The Facility's Abuse Prevention Policies and Procedures, dated 05/19/09, indicated the existence of any of the defined conditions as identified by the resident, any staff person/family member, or concerned individual should have immediate attempt to cease defined condition and the incident should be brought to the attention of the charge nurse, supervisor, Director of Nursing Services or the Executive Director immediately. The Facility's Incident Report Form indicated the date of the incident was on 01/17/17 at 7:43 A.M The Health Care Facility Reporting System (HCFRS) indicated the Facility reported Resident #1 Abuse on 01/18/17 at 4:36 P.M., thirty four hours and nineteen minutes after the alleged incident. The Facility's Abuse Prevention Policies and Procedures, dated 05/19/09, indicated the facility will insure that all alleged violations involving abuse, neglect, mistreatment, involuntary seclusion of a resident, or misappropriation of resident's property and any injury of the unknown source be thoroughly investigated and reported to the Operations Office as well as the Department of Public Health within 24 hours of the alleged violation. The investigation of the reported incident shall be conducted by the Executive Director, Director of Nurses or their designee. The Facility's Policy does not indicate new Federal Regulations. A Department of Public Health Incident Report Form, dated 01/18/17, indicated on 01/17/17 at 7:43 A.M., Dietary Aide #1 witnessed Nurse #1 Yank Resident #1's chair from the back aggressively while yelling her to Shut Up and then returned to the kitchen. The report indicated CNA #1 said she heard yelling while providing care to her Resident and ran to the dining room and had asked Nurse #1 what was going on. Nurse #1 said to CNA, I did it, I told her to Shut Up, words to that effect and CNA #1 returned to providing care. The Dietary Aide #1 written statement, dated 01/18/17, indicated on 01/17/17, Dietary Aide #1 heard yelling and screaming from the kitchen, came out to bring the breakfast cart, witnessed Nurse #1 screaming at Resident #1 and pulled the Resident #1's chair from behind very aggressively. The written statement indicated shift Supervisor/Cook #1 was notified about the incident. However, staff did not report to DON or Administrator on 01/17/17. The Surveyor interviewed Dietary Aide #1 at 4:15 P.M. on 03/16/17. Dietary Aide #1 said on 01/17/17, she was in the kitchen and heard two woman voices very loudly yelling prior to transport of the breakfast food cart. Dietary Aide #1 said as she was pushing the breakfast food cart to the dining area she witnessed Nurse #1 grab the back of Resident #1's chair, pulled it roughly backwards and Nurse #1 continued yelling at Resident #1. Dietary Aide #1 said Nurse #1 stopped yelling at Resident #1 when CNA #1 came into the dining room and moved away from Resident #1. The Dietary Aide #1 said Resident #1 said, What did I do wrong? What did I do wrong? to words to that effect. The Shift Supervisor/Cook #1 written statement, dated 01/20/17, indicated on 01/17/17 approximately 7:40 A.M., Dietary Aide #1 brought to his attention Nurse #1 showed a violent outbursts towards Resident #1 Screaming and violently moving his/her chair. The Shift Supervisor #1 indicated on his written statement upon being given this information he encouraged Dietary Aide #1 to report this incident to the DON, Assistant Director of Nursing (ADON) or the Administrator. The Surveyor interviewed Shift Supervisor/Cook #1 at 10:50 A.M. on 03/16/17. The Shift Supervisor/Cook #1 said Dietary Aide #1 said Nurse #1 was being rough, shouting and yanking at a Resident #1, or word to that effect. The shift Supervisor/Cook #1 said he stayed in the kitchen since the incident had already occurred and encouraged Dietary Aide #1 to report it to the DON or Administration. The shift Supervisor/Cook #1 said he unfortunately could not push her to tell the DON or Administration, Dietary Aide #1 said that she was going to report the incident and did not until the following day on 01/18/17. The Shift Supervisor/Cook #1 said he did not follow through to see if Dietary Aide #1 reported the incident on 01/17/17. The Surveyor interviewed Shift Supervisor/Cook #2 at 11:50 A.M. on 03/16/17. The Shift Supervisor/Cook #2 said Dietary Aide #1 came into the Kitchen, waving her arms in the air, saying she was upset and saw Nurse #1 yelling at Resident #1. The Supervisor/Cook #2 said that Dietary Aide #1 spoke with the Shift Supervisor/Cook #1 and she did not speak about the incident there after and reported the incident on 01/18/17. However, shift Supervisor/Cook #2 did not report to DON or Administrator on 01/17/17. The Surveyor interviewed Food Service Director at 5:15 P.M. on 03/16/17. The Food Service Director said he did not hear about the Incident until 01/18/17. The Food Services Director said the Incident on 01/17/17 needed to be reported immediately and the Shift Supervisor/Cook is responsible to ensure it was reported if they were informed of the incident. The Surveyor interviewed Director of Nurses (DON) at 5:58 P.M. on 03/16/17. The DON said on 01/18/17 the allegation was brought to her attention, spoke with the Administrator and started the investigation process immediately on 01/18/17. The DON said she observed the footage of the video with the Administrator and saw Nurse #1 roughly pull back Resident #1's geriatric chair prior to breakfast on 01/17/16. The DON said staff need to report immediately and any allegations of abuse if it is reported to the Supervisor of the department, the Supervisor needs to ensure it is reported immediately to DON or Administrator.

Based on records reviewed and interviews, the Facility failed to promote an environment that maintains or enhances Resident #1's dignity and respect in full recognition of his/her individuality when Nurse #1 was witnessed yelling at Resident #1 and aggressively pulled the chair from behind without informing him/her who is diagnosed with [REDACTED]. The Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was severely cognitively impaired with the following Diagnoses: [REDACTED]. The Dietary Aide #1 written statement, dated 01/18/17, indicated on 01/17/17 Dietary Aide #1 heard yelling and screaming from the kitchen, came out to bring the breakfast cart, witnessed Nurse #1 screaming at Resident #1 and pulled Resident #1's chair from behind very aggressively. The Surveyor interviewed Dietary Aide #1 at 4:15 P.M. on 03/16/17. Dietary Aide #1 said on 01/17/17, Resident #1 was sitting in his/her geriatric chair and Nurse #1 was standing over Resident #1 on his/her left side yelling down at Resident #1 approximately 2 inches away. Dietary Aide #1 said Nurse #1 grabbed the back of Resident #1's chair without explaining to Resident #1 she/he was going to be moved away from the table. Dietary Aide #1 said Resident #1 said What did I do wrong? What did I do wrong? or words to that effect after Nurse #1 pulled the chair. The Dietary Aide #1 said Resident #1 when she/he speaks repeats over and over again, Where am I? What is going on? or words to that affect since he/she is blind. Dietary Aide #1 said she heard Resident #1 say to Nurse #1 You must be in a bad mood? and Nurse #1 replied, You make me this way, or words to that effect. The Surveyor interviewed Nurse #1 at 2:11 P.M. on 03/27/17. Nurse #1 said Resident #1 was yelling I am hungry, I am hungry, I want to eat, I want to eat, and I want to eat and Nurse #1 said Resident #1 was yelling louder each time she/he was saying this. Nurse #1 said Resident #1 continued to repeat I want to eat and I am too close to the table. Nurse #1 said she was calling his/her name repeatedly in a normal tone and as Resident #1 was getting louder she was getting louder so he/she could hear her. Nurse #1 said Resident #1 does not have any issues with his/her hearing, can hear better than us and he/she is blind. Nurse #1 said I told Resident #1 Will you Stop It. Nurse #1 said she moved Resident #1 back two to three inches away from the table. Nurse #1 said CNA #1 came into the room thinking two Resident's where fighting and I said, No, No, No to CNA #1. Nurse #1 said she observed the video with the Administrator and said during the incident on 01/17/17 she was unable to see her move Resident #1's chair backwards or what she was saying to Resident #1 in the video. Nurse #1 said Resident #1 was upsetting the other Residents in the dining room and she needed to be louder him/her. Nurse #1 said she did not want to be loud and was not mean to Resident #1. The Surveyor interviewed CNA #1 at 1:15 P.M. on 03/16/17. CNA #1 said she heard yelling from the dining room on 01/17/17 while taking care of another Resident and it was a voice louder than Resident #1 saying Hello, Hello, Hello, and in a quick loud tone of a voice saying Would you and CNA #1 said unable to hear the entire statement since it was in a loud tone. CNA #1 said she went to the dining room since she was concerned about Resident #1 being blind, in her wheelchair and was afraid another Resident was hurting him/her and would not be able to defend himself/herself. CNA #1 said as she was entering the dining room, Dietary Aide #1 was leaving the dining room and her facial expression was eyes and mouth wide opened. CNA #1 said she asked Nurse #1 what happened and Nurse #1 was standing away from Resident #1 and said she told Resident #1 to stop, he/she does not stop and it is crazy in words to that effect. CNA #1 said she left the room to go back to Resident care and felt safe to do so since she had not witnessed anything. CNA #1 said on 01/18/17 Dietary Aide #1 approached her and said what occurred on 01/17/17 between Nurse #1 and Resident #1. CNA #1 said to Dietary Aide #1 it needs to be reported immediately despite if Nurse #1 is a friend and she was a mandatory reporter. The Surveyor interviewed the DON at 5:58 P.M. on 03/16/17. DON said she observed the video with the Administrator of the incident on 01/17/17 and was concerned of what they reviewed in regards to Nurse #1 interacting with Resident #1. DON said Nurse #1 was surprised when she was educated about the allegation and her response was Wow when she observed the video of herself with Resident #1. The Surveyor observed the video with the Administrator on 01/03/17 and the Administrator identified the staff in the video as Nurse #1, CNA #1 and CNA #2. The Surveyor observed the video recorded on 01/17/17 which indicated the following; At 8:32:59 A.M. Beginning of the video, CNA #2 was in and out of room setting up Residents in dining room for breakfast. At 8:39:54 A.M. Resident #1 arrived to the dining room by CNA #1. At 8:41:32 A.M. Nurse #1 arrived to the dining area and is directly behind Resident #1 and moves her hand across Resident #1's right side of his/her head quickly and walks away. At 8:41:33 A.M. Nurse #1 is out of the view of the camera. At 8:42:37 A.M. Nurse #1's clothing is in view of the camera on the left side of the room, Resident #1 continues to sit in geriatric chair, moving head and facial right cheek is moving. At 8:43:36 A.M. Nurse #1 in the view of camera and she turned her body around quickly, as you see a piece of paper being quickly swept across the floor with her turn, facing towards Resident #1 continuously speaking, moving fast towards the left side of Resident #1, approximately 2 inches away, leaning towards him/her, Nurse #1 facial expression no smile and eyes wide. At 8:43:38 A.M. Nurse #1 turns her body away from Resident #1 about 1 inch away from him/her to walk away heading to left of the room. At 8:43:39 A.M. Nurse #1 in a half second turns her body quickly, charges towards Resident #1, goes behind his/her geriatric chair, grabs the chair, forces her chair backwards abruptly and unable to see Resident #1 or Nurse #1 since they are not in view of the camera. At 8:43:41 A.M. Nurse #1 in view of the camera, walks quickly towards the left side of the room away from Resident #1 and kicks the piece of paper on the floor to the left and continues. At 8:44:08 A.M. CNA #1 walked in the room briefly and left out of the view of camera. At 8:44:47 A.M. Nurse #1 serves the 1st breakfast tray to a Resident at the other end of the room. At 8:45:25 A.M. Ending of the tape and Resident #1 did not return in view of the camera.

Based on record review, observations and interviews, the facility failed to provide adequate supervision to prevent accidents and resident to resident altercations. In addition, they failed to insure that the environment remained as free of accident hazards as possible for 5 residents (#1, #2, #3, # 4 and #14), out of 11 residents with falls, out of a total sample of 15 residents. Findings include: 1. For Resident #1, the facility failed to provide adequate supervision to prevent 14 falls, a clear corridor/passage ways to ensure the resident's environment was free of hazards, and supervision to prevent resident to resident assaults. This Resident had 10 unwitnessed falls, 7 of the 10 unwitnessed falls were in the hallway. Major injuries were sustained for 2 falls, rib fractures and minor injuries were sustained for 2 other falls, bruising to the forehead with bleeding and a facial abrasion. Resident #1, was admitted to the facility 7/2013, with [DIAGNOSES REDACTED]. Review of the nurse's note of 1/5/14 indicated the resident fell . Review of the fall investigation indicated the resident fell at 8:00 A.M., in the day room. The investigation team assessment indicated the fall was due to the resident tripping over a gerichair in a crowded room. The new intervention was to place the resident in a different area of the room. The cause of the fall was determined to be a chair that blocked the resident's pathway. This was a witnessed fall and no injury was sustained. Review of the nurse's note of 1/30/14 indicated the resident fell . Review of the investigation of the fall indicated the resident fell in the hallway at 10:00 A.M., and complained of pain in his/her back. The fall was not witnessed. An X-Ray was order of the resident's ribs. The results of the X-Ray concluded that the resident had an acute or subacute fracture of the fifth, sixth, seventh and possible the fourth and eighth ribs. The intervention to prevent further falls was to have the resident screened by Physical Therapy. Review of the nurse's note of 3/20/14 indicated the resident fell . Review of the investigation indicated the resident fell at 4:50 P.M., in the resident's room. The fall was not witnessed. The resident was found face down on the floor in front of the bed. Although the investigation indicates the resident "rolled out of bed", the employee who found the resident on the floor indicated the resident was in front of the bed. No injuries were observed. A Perimeter mattress was the intervention added to prevent further falls. Review of the quarterly Minimum Data Set (MDS) Assessment of 3/25/14 indicated the resident had impaired long and short term memory problem with severely impaired decision making ability. The resident was coded as displaying wandering behavior 1 to 3 days during the assessment period, required limited assistance of 1 staff for transfers, walking in his/her room and corridor with limited assistance and supervision. The resident required limited assistance of two staff for dressing. The resident was coded for his/her balance not being steady, but able to stabilize without staff assistance for walking and transfers. The resident was coded as having two falls since the last assessment, one fall with a major injury sustained. Nurses' notes of 5/1/14 and 5/14/14 indicated the resident was wandering the hallway. Nurses' notes of 5/15/14 and 5/19/14 indicated the resident required redirection by staff. Review of the nurse's note of 6/8/14 indicated that the resident was pushing a dirty clothes hamper around in the hallway. When staff attempted to remove the hamper, the resident became assaultive to staff. Review of the nurse's note on 6/9/14 indicated the resident was difficult to redirect and was attempting to wear other resident's clothing. On 7/1/14 the nurse's note indicated the resident was assaultive to staff and was pushing wheelchairs around. The nurse's note of 7/11/14 indicated the resident assaulted a staff member, disrobed, required 1 to 1 supervision and medication at 5:00 P.M. This note indicated the resident was left alone sitting on his/her bed at 5:00 P.M. The resident was found on the floor in the hallway at 5:30 P.M. Resident #4 was also found on the floor. Review of the investigation of the fall indicated that the fall was not witnessed. The investigation concluded that Resident #1 pushed Resident #4 and that both residents fell , in the hallway, past room 105. Neither Resident #1 or Resident #4 resided in room 105. Further review of the Post Falls Investigation indicated an incorrect assessment of the medications given to Resident #1. The investigation indicated the resident was on two antipsychotic medications but failed to include the Trazodone (given to the resident at 5:00 P.M.) in the assessment. There is no explanation as to why the resident was not monitored (at 5:30 P.M., when the resident to resident event occurred) as the resident had been combative requiring medication at 5:00 P.M. No injury was sustained. Review of the nurse's note of 7/14/14 indicated the resident attempted to hit staff and other residents in the hallway requiring staff intervention and medication. Review of the nurse's note of 7/15/14 indicated the Psychiatric consultant was notified of the residents' increased behaviors. This physician declined hospitalization as he first wanted to attempt medication changes. There was no mention of increased supervision despite increase episodes of aggressive behaviors. Review of the nurse's note of 7/16/14 at 10:05 A.M., indicated the resident was increasingly agitated and attempted to hit staff. The resident was redirected to his/her room. At 12:30 P.M., the resident was resistive and attempted to hit staff. The resident was redirected to his/her room where he/she pushed a staff member onto his/her bed. Following this episode the resident was running down the hall chasing staff. The resident was returned to his room but shortly after was calmly eating lunch in the dining room. However, at 1:41 P.M., another resident wandered into Resident #1's room. The nurse's note indicated Resident #1 hit the resident entering the room. No injuries were noted. There is no indication as to why the resident was not monitored closely to prevent this resident to resident event in light of the events that had already occurred that day. After this event the resident was placed on close supervision until transferred to the hospital due to aggressive behavior. The resident was readmitted to the facility on [DATE]. Review of the nurse's note of 8/2/14 indicated the resident was independently ambulating around the unit and in his/her room. Nurses note of 8/2/14 indicated the resident required verbal and physical redirection for intrusive wandering. Review of the nurse's note of 8/21/14 indicated the resident attempted to pull up his/her socks in the hallway and fell . Review of the Incident Report indicated this fall occurred at 12:50 P.M. and was not witnessed. The resident sustained [REDACTED]. Ice was applied. There was no investigation of this fall available for review. Review of the quarterly MDS of 9/9/14 identified the resident as having long and short term memory problems with severely impaired decision making ability. The resident was coded for wandering 1 to 3 days during the assessment period. The resident was coded as requiring supervision with walking with one person physical assist. The resident was coded as having fallen with minor injury. The falls care plan of 8/22/14 included the following interventions: -Ortho blood pressure every shift for 72 hours following a fall. -Jumpsuit daily. -Toilet at 5:30 A.M., 2:00 P.M. and 5:30 P.M. -Call bell in reach when in bed. -Observe for changes in gait and balance -Encourage rest periods. -Provide Diversional activity. -Provide non-continual supervision for ambulation. -Encourage Proper footwear. -Rehab. evaluation as ordered by physician. Review of the nurse's note of (9/18/14) indicated the resident was status [REDACTED]. Review of the investigation into a fall that occurred 9/17/14 (no nurses's note regarding this fall on 9/17/14) indicated the resident was found on the floor in the hallway at 5:00 P.M. The fall was not witnessed. The investigation indicated staff heard a noise and found the resident on the floor. This investigation indicated the Video Camera used by the facility indicated the resident's left knee buckled and he/she fell . The falls investigation does not indicate an injury occurred. However, the nurse's note of 9/18/14 indicated that an X-Ray of the left ribs were ordered by the physician due to pain in the left rib area. Review of the nurse's notes of 9/19/14 indicated the resident fell (no time given). Review of the Fall prevention care plan indicated the resident fell [DATE] getting up from a chair. This assessment indicated the resident's care plan was effective due to the fact that the resident did not get injured. There was no notation of how to prevent further falls. The location and time of this fall was not included in this assessment. Review of the X-Ray report completed 9/19/14 indicated the resident had a new fracture of the left 5th rib. Healed fractures of the 4th and 5th ribs were also noted on the X-Ray report. Despite the fall with the fracture (second fall with fracture) the resident continued to be an independent ambulator. Review of the nurse's note of 9/21/14 indicated the resident was found on the floor in the hallway at 3:30 P.M. There was no witness to the fall. No apparent injury occurred. Review of the falls investigation indicated the Video Camera review showed the resident was adjusting his/her socks and fell (second fall adjusting socks). Although this was the third fall in four days (one fall resulting in a fractured rib), the resident was allowed to continue to ambulate independently. Review of the nurse's note of of 9/21/14 indicated the resident had a poor intake (on 9/21/14) and refused all medications. The physician was notified. Review of the nurse's note of 9/22/14 indicated the resident was experiencing moderate rib pain and was transferred to the hospital at 3:49 P.M., for further evaluation of the rib fracture. Review of the Hospital Emergency Note of 9/22/14 indicated the resident had fallen twice over the weekend, sustained a rib fracture and was now complaining of increased left sided pain with swelling. This note indicated a pneumothorax had been ruled out. Review of the nurse's note of 9/23/14 indicated the resident was returning from the hospital with a [DIAGNOSES REDACTED]. The resident was placed on Vicodin for pain management. Review of the Physical Therapy note of 9/23/14 indicated the resident was now considered a contact guard assist of one for walking on a level surface. Review of the nurse's note of 10/5/14 indicated the resident was found on the floor in the dining room. Review of the falls investigation indicated the fall was not witnessed. This investigation indicated the fall occurred at 6:40 P.M. The Video Camera indicated the resident stood up, attempted to move chair, lost balance and fell backward. No injury occurred. The investigation did not indicate why the resident was allowed to get out of the chair unsupervised as the Physical Therapist had evaluated the resident to be a moderate assist from sit to stand (on 9/23/14). Review of the Physical Therapy note of 10/20/14 indicated the resident was now able to ambulate alone, safely. Review of the nurse's note of 10/26/14 indicated the resident was found on the floor in the hallway at 3:30 A.M. This note indicated the resident's TED stockings were too big, sliding down the resident's legs and the resident was constantly removing the stockings. The physician was notified and discontinued the TED stockings. The resident's left arm was observed to have a "subtle twitching of left side lasting about 90 seconds". Hip protectors were applied. Review of the falls investigation of 10/26/14 indicated the staff observed the Video Camera and question seizure activity prior to the fall. A Neurology Consultation was scheduled (for 4/30/15). Review of the nurse's note of 11/3/14 indicated the resident was found on the floor in the resident's room at 4:00 P.M. Review of the falls investigation indicated the fall was not witnessed. No injury occurred. A bed alarm was initiated. A Canoe Mattress was added to the bed. Review of the nurse's note of 11/6/14 indicated the resident fell . Review of the falls investigation of 11/6/14 indicated the resident fell at 6:10 A.M., and was found on the floor, next to the bed, with the alarm sounding. Review of the nurse's note of 11/17/14 indicated the resident fell in the day room. Review of the falls investigation indicated the resident fell at 9:15 P.M. The fall was witnessed by staff who indicated the resident was observed to be pushing a table in the dining room, lost his/her balance and fell before staff could intervene. No injuries were noted. Observation of the resident on 12/2/14 at 9:00 A.M., was of the resident, in the hallway, ambulating independently with slipper socks on. During an observation of the dining room on 12/2/14 at 9:40 A.M., the surveyor heard the activity staff say that a resident was on the floor in the hallway. The surveyor entered the hallway outside the dining room and observed Resident #1 on the floor, on his/her right side, holding his/her face, with his/her left hand. The surveyor observed bruising on the forehead with a small amount of bleeding. The resident was barefoot. Two licensed staff assessed the resident and assisted the resident to bed. Review of the nurse's note of 12/2/14 indicated the resident was found on the floor in the hallway. The resident sustained [REDACTED]. Ice was applied and the physician was notified. During interview on 12/2/14 at 9:50 A.M., the Unit Manager said that the resident did not have slipper socks on, as care planned, because he/she had removed them prior to the fall and placed them in the wastebasket next to the door, in the hallway. The surveyor observed two slipper socks in the wastebasket next to the door. During interview on 12/2/14 at 10:10 A.M., the Director of Nurses (DON) said that she had reviewed the video of the fall that occurred on 12/2/14 and that she felt it could have been seizure related. On 12/2/14 at 10:15 A.M., the surveyor observed the Video of the fall involving Resident #1. The surveyor observed the resident standing next to a exit doorway to the unit. The resident was observed attempting to remove his/her socks. A maintenance/housekeeping staff was observed on the opposite side of the door, pointing to the resident. The maintenance/housekeeping staff entered the door and kept walking down the hallway. The housekeeping staff did not aid or stay with the resident. The resident then fell to the floor. The surveyor observed the resident moving his left arm prior to the fall but the cause of the movement was not determined. During interview on 12/2/14 at 10:15 A.M., (during review of the Video), the DON said that the resident did remove his/her socks prior to the fall and that this was the third time the resident fell after attempting to remove his/her socks. The DON said that the Maintenance/Housekeeping staff person entered the unit, did not assist the resident and the resident fell to the ground. The DON said that other staff could not get to the resident in time to prevent the fall. Observation of the resident on 12/4/14 at 10:00 A.M., was of the resident ambulating in the hallway. The resident was ambulating alone. No staff were observed to be near the resident. The resident's eyes and forehead were observed to be bruised. During interview with the Physical Therapist on 12/8/14 at 10:40 A.M., the Physical Therapist (PT) said that Resident #1 had received PT several times since January 2014. This PT said that the resident was able to walk independently but that the resident had poor decision making ability and had had multiple falls. During interview on 12/8/14 at 1:10 P.M.. the DON said that Resident #1 had been assessed to have impaired long and short term memory and severely impaired decision making ability. The DON said that the resident had poor safety awareness and had experienced multiple falls and resident to resident assaults since admission to the facility. It was discussed with the DON that suspected seizure activity, and a history of multiple falls with injury, warranted closer monitoring to prevent falls and injury. 2. For Resident #3, the facility failed to provide adequate supervision and failed to ensure that this Resident's environment in the hallway was free from accident hazards (a cart on wheels and another resident who pushed this Resident) to prevent 4 falls in a 4 month period of time. Two of the 4 falls were unwitnessed. One of these falls resulted in a fracture to the right mid distal shaft of the ulna (arm bone). All 4 falls occurred in the hallway. Resident #3 was admitted to the facility in 5/2014. This Resident had the following pertinent Diagnoses: [REDACTED]. Review of the facility's Falls Policy and Procedure dated 4/19/2013, it states, "The purpose was to identify residents at risk for falls and adequately implement protocols to prevent falls." Under, "Fall Assessment (for Residents at Risk for Falls)," it states, "The licensed nurse must implement a preventive protocol to promote resident safety based on the resident's risk factors." Review of a Fall Risk Assessment Report dated 5/28/14 indicated the resident scored 12, at risk for falls. This Assessment indicated this Resident had a normal gait and balance. Review of the Initial Minimum Data Assessment (MDS) of 6/3/14, indicated this Resident was coded as having highly impaired vision, short and long term memory impairment and was severely cognitively impaired. For bed mobility and transfer, this Resident needed limited assistance of 2 persons. For ambulation in the hallway and room, this Resident needed supervision and setup help. Under Section G0300, Balance During Transitions and Walking, the MDS indicated this Resident was unsteady with walking and moving from a seated to standing position, but was able to stabilize without staff assistance. For surface to surface transfers (between bed and chair or wheelchair), this Resident was not steady and was only able to stabilize with staff assistance. Review of the falls plan of care for 6/2014 indicated this Resident was at risk for falls related to recent decline, recent hospitalization , also confusion secondary to dementia with behavioral disturbances. The pertinent interventions included the following: - Assess for fall risk - Encourage him/her to ask for assistance when tired or decreased safety awareness is noted. - Physical Therapy and/or Occupational Therapy screens as indicated. - Encourage rest periods daily to avoid fatigue Review of the Self Care Deficit care plan for 6/2014 indicated this Resident is confused secondary to dementia and behavior disturbances. The intervention of 6/26/14 indicated this Resident ambulates and transfers independently without assistive devices. Review of the nursing note and fall investigation of 6/19/14, indicated this resident sustained [REDACTED].M., at the end of the hallway. Resident #3 attempted to assist another Resident (who was on the floor) up to a standing position. The other Resident then pushed Resident #3, causing Resident #3 to fall backward to the floor. Prior to this fall, Resident #3 was ambulating in the hall. This Resident's gait was unsteady. After the fall, the Resident was "mildly shaken up," but there was no injury sustained. Following this fall, the care plan and activities of living section of the investigation form were not modified or updated. Review of the nursing note of 7/7/14, indicated this resident sustained [REDACTED].M. Resident #3 was observed lying in the hallway on his/her left side. After this fall the Resident appeared to be in pain, with a pain score of 6 out of 10 (0 is no pain, 5 is moderate pain, and 10 is severe pain) as evidenced by facial grimacing while grabbing his/her right wrist. The Nurse Practitioner was notified. A right wrist X-Ray on 7/7/14 was ordered and it was negative for a wrist fracture. However, secondary to this Resident's persistent right upper extremity pain (another X-Ray was done higher up the right extremity) according to the Radiology report of (7/10/14), this Resident was found to have a fracture of the right mid distal shaft of the ulna (lower arm bone above the wrist). Review of the nursing note of 7/7/14 at 10:54 P.M. indicated the Resident appeared tired and was pointing to his/her right hand. Review of the nursing note of 7/8/14 at 4:11 P.M. indicated this Resident was complaining of right hand pain. Two doses of Tylenol (a pain medication) were administered with fair effect (relief from pain). Review of the nursing note of 7/8/14 at 9:09 P.M., indicated that this Resident was observed supporting his/her right hand/wrist with left hand and appeared to be in pain. The Nurse Practitioner was notified and ordered scheduled Tylenol and Capsaicin Cream (a topical pain medication) to the right wrist. An Occupational Therapy consult was ordered. In addition, a referral was made to a orthopedic clinic for this Resident's right hand/wrist pain, "status [REDACTED]. Review of the Nurse Practitioner's (NP) note of 7/8/14 indicated the NP was notified by a Nurse that this Resident was still having hand and wrist pain. The note stated that this Patient had a recent fall with complaints of right hand and wrist pain. This Patient was holding the hand during the visit, with increased pain with wrist movement and guarding. Review of the Occupational Therapy Evaluation of 7/10/14 stated that this Resident was referred to Rehabilitation due to right hand/wrist pain, X-Ray to the wrist/hand area was negative. Distal forearm area was swollen and (he/she) complains of pain. The report recommended a repeat X-Ray of the forearm, use of an arm sling for comfort and a rescreen after the X-Ray. Review of the Radiology Report of 7/10/14 of the right forearm (lower arm) indicated this Resident had a recent fracture of the mid distal shaft of the right ulna. Review of the physician's orders [REDACTED]. Review of the Emergency Physician's note of 7/10/14 indicated the Resident was here for an evaluation of the right forearm after he/she sustained a fall 3 days ago (7/7/14). The Resident's family noted the Resident was not using the arm much and wanted it checked. The Resident was diagnosed as having a Ulnar shaft fracture and a cast was applied. Review of the nursing note and fall investigation on 7/26/14, indicated this resident sustained [REDACTED].M. Resident #3 was found on the floor in the hallway. No injury was sustained. There was no update to the falls care plan. The fall investigation indicated the fall prevention care plan was reviewed and the box was checked that states, "Current plan appears effective in maintaining resident safety." Review of the nursing note and fall investigation on 10/9/14, indicated this resident sustained [REDACTED].M. The staff observed Resident #3 holding onto a rolling kitchen cart in the hallway. The cart he/she was holding onto rolled and the Resident lost balance and fell backwards. The staff was educated not to leave the kitchen cart in the hallway after meal times. No injury was sustained. Observation of this Resident on 12/2/14 at 2:40 P.M., was of this Resident walking in the hallway independently. Observation of this Resident on 12/4/14 at 8:40 A.M., was of this Resident sitting at the side of the bed in his/her room. A Certified Nurses Aide assisted the Resident to a standing position. This Resident's gait was initially unsteady upon standing and taking the first 2 steps. During an interview with the Unit Manager (UM) on 12/5/14 at 3:30 P.M. and review of the fall documentation of 6/19/14, she said, "This Resident had his/her shoes on and had an unsteady gait." The UM stated that this Resident's care plan was not updated but the Resident who pushed him/her to the floor had his/her care plan updated. During an interview with the Director of Nurses (DON) on 12/5/14 at 9:30 A.M., she said that she had been on vacation when this Resident fell on [DATE]; she reviewed the video footage of this Resident's fall and said this Resident hit another Resident minutes before he/she fell and that had caused the arm fracture. The Surveyor asked to view this video footage. On 12/15/14 at 3:20 P.M., when the videos footage could not be located during this survey the DON said, "May be it was someone else (referring to this Resident hitting someone else)." During an interview with the UM on 12/5/14 at 3:30 P.M. and review of the fall documentation of 7/7/14, she said, "It was an unwitnessed. This fall was in the hallway and {he/she} fractured {his/her} right arm from the fall. Initially we did not know of the injury; {he/she} just complained of pain." The Surveyor asked, "Did you see video footage of this Resident hitting another Resident on 7/7/14?" The UM said, "No." The Surveyor said, "Did any of your staff witness this Resident hitting another Resident on 7/7/14?" The UM said, "No." She said, "The falls care plan was updated for an Occupational/Physical Therapy screen. We do this after each fall." During an interview with the UM on 12/5/14 at 3:30 P.M. and review of the fall documentation of 7/26/14, the Surveyor said, "Was this the 3rd fall for this Resident in the hallway?" She said, "Yes and (he/she) had the cast on (referring to the lower right arm cast from the fall of 7/7/14) when (he/she) fell ." The Surveyor asked do you see the pattern of falls for this resident in the hallway? She said yes have fall monitors during the day shift. The Surveyor said that 3 of this Resident's 4 falls were on the evening shift. During an interview with the UM on 12/5/14 at 3:30 P.M. and review of the fall documentation of 10/9/14, the Surveyor said, "Was this the 4th fall for this Resident in the hallway?" The UM said, "Yes." The Surveyor said, "What did the cart look like?" She said, "It was a short cart (describing the height as waist level) for meal trays after dinner." The Surveyor asked, "Should the cart have been there at 8:17 P.M. in the hallway?" She said, "No, it should have been removed." The Surveyor said, "Did the cart pose a safety risk in this Resident's environment?" She said, "Yes." 3. For Resident #4, the facility failed to provide adequate supervision to prevent 12 falls from April to October 2014. Resident #4 was admitted to the facility in 2/2013, with [DIAGNOSES REDACTED]. Review of the clinical record indicated the resident had a history of [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment of 4/1/14 indicated the resident had impaired long and short term memory impairment, was unable to complete a Brief Interview of Mental Status (BIMS) and had severely impaired decision making ability. The resident was coded as having behaviors directed at others, rejecting care, wandering 1 to 3 days during the assessment period, The resident was coded as requiring limited assistance of 1 staff for transfers and locomotion. The resident was coded as having falls with minor injury since the last assessment. Review of care plan interventions for falls related to a history of falls and lack of safety awareness, included the following interventions: -Remind to use walker -Assist to ambulate with a rolling walker as needed. -Assess for fall risk. -Appropriate footwear before ambulation and transfers. -Low bed locked -PT and OT as indicated. -Encourage rest periods. Review of the nurse's note of 4/14/14 indicated the resident fell at 4:00 A.M., in the hallway attempting to pick items up off the floor. The resident was reminded not to pick things up off the floor despite the resident's impaired memory problems. Hipsters at all time was added to the care plan. Review of the nurse's note of 5/6/14 indicated the resident was found on the floor, in another resident's room, at 6:30 A.M. Review of the investigation indicated this fall was not witnessed. The resident was found on the floor by housekeeping. The resident's gait was unsteady at the time of the fall. The intervention was to encourage the resident to rest and ask "aides" to be aware of resident in the hallway, when out of bed. Review of the nurse's note of 5/6/14 indicated the resident fell at 10:30 P.M. in the hallway. The resident was tangled up with another resident who fell on the resident. Review of the investigation indicated the resident fell when another resident tried to take his/her walker. The resident lost his/her balance when the resident attempted to take back his/her walker from the other resident. There was no explanation as to why staff could not intervene as the fall was witnessed. No injuries occurred. Review of the nurse's note of 6/15/14 indicated the resident fell . Review of the falls investigation indicated the resident fell while ambulating in the hallway at 12:30 A.M. Although the falls investigation indicated the fall was witnessed, the witness statements do not state the fall was observed. Review of the witness statements indicated the following "{he/she} said {he/she} lost {his/her} balance as {he/she} was walking with {his/her} walker". The witness did not state he/she observed the resident fall. The second witness listed on the investigation of the fall said the following: "The only thing I know is from the resident {himself/herself} who said {he/she} fell because {he/she} was walking fast and lost {his/her} balance. This witness also said, before the resident told him of the fall he was unaware of the fall. The new intervention was to encourage the resident not to walk fast and use his/her walker. Review of nurse's note of 6/19/14 indicated the resident was found on the floor, next to his/her bed. The resident denied falling (mental status was impaired long and short term memory with severely impaired decision making ability). No further documentation was provided concerning this fall. Review of the nurse's note of 6/25/14 indicated the resident was found on the floor, in the resident's bedroom, at 3:30 A.M. The resident indicated he "hurt all over." The resident's back was slightly red. Review of the investigation into this fall indicated the fall was not witnessed. The investigation indicated the resident was found holding onto crackers in his/her left hand. Interventions to prevent further falls included a bed alarm, encourage resident to use both hands when using a walker (resident is memory impaired). A basket was to be added to his/her walker. Review of the nurse's note of 6/29/14 indicated the resident was found on the floor, in the hallway, at 7:45 A.M. Review of the fall investigation indicated the fall was not witnessed. The intervention to prevent falls was continual supervision while ambulating, staff assistance while ambulating. Review of the nurse's note of 6/30/14 indicated the resident was ambulating well with a walker and would be monitored closely. Review of the nurse's note of 7/11/14 indicated the resident was found on the floor in the hallway. The resident said "he pushed me", pointing to Resident #1. Review of this fall's investigation indicated the resident was found on the floor at 5:30 P.M., in the hallway. The fall was not witnessed. No injury occurred and there was a question of a resident to resident assault causing this fall. Review of the nurse's note (of 7/18/14) indicated the resident was found on the floor in the hallway. Review of the falls investigation indicated that the fall was not witnessed. No

Based on observation, record review and interview the facility failed to provide treatment to prevent a reduction in range of motion for 1 (#10) Resident out of 8 applicable Residents out of a total sample of 19. Findings include: For Resident #10, the facility failed to evaluate and provide treatment once bilateral hand contractures were identified for a resident who previously did not have contractures. Resident #10 was admitted to the facility in 4/04 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessments, dated 2/28/12 and 5/22/12, indicated the resident was cognitively impaired, dependent on staff for bathing, dressing, grooming and eating. It further indicated the resident had no impairment with range of motion (ROM) to the upper or lower extremities. Review of Occupational Therapy Evaluation, dated 6/11/12, indicated the resident's upper extremities, including the hands, were not contracted. The Occupational Therapist (OT) treated the resident for positioning in a wheelchair, and was discontinued from services on 6/21/12. Review of the Annual MDS Assessment, dated 8/14/12, indicated the resident was cognitively impaired, dependent on staff for bathing, dressing, grooming and eating. It further indicated the resident had no impairment with ROM to the upper or lower extremities. Review of Nurse's note, dated 9/12/12, indicated, "Res (Resident) was noted being resistive to open both hands during care. A referral was made to PT (Physical Therapy) eval ? contractures. ... scheduled dose of Tylenol... with good effects." On 10/18/12 at 8:20 A.M. the surveyor observed the resident in his/her bedroom sitting in a wheelchair with bilateral foot rests. Both hands were closed in a fist-like position on the resident's lap. During an observation on 10/18/12 at 9:50 A.M., the surveyor observed the resident sitting in a wheelchair in his/her bedroom. The resident's hands were closed in a fist-like position. Certified Nursing Assistant (CNA) #1 entered the bedroom. The surveyor asked the CNA if she took care of Resident #10 and she said, yes. The surveyor then asked if the resident's hands are usually in a fist-like position and if so, how do the CNAs clean the resident's hands and trim the nails. CNA #1 said she was not sure. She attempted to open the resident's left hand. The resident immediately pulled his/her hand back, winced and had facial grimacing. The surveyor asked the CNA to stop what she was doing and please get a nurse to assess the resident. On 10/18/12 at 9:55 A.M. the Director of Nurses (DON) and the Charge Nurse entered the resident's room. With assistance from the Charge Nurse, Resident #10 was able to open the right hand enough to view the palm of the resident's hand and the resident's fingernails. The Charge Nurse was unable to open the resident's left hand without the resident wincing and pulling his/her hand back. The DON said that she would follow up with the rehabilitation department to check if the resident was assessed for contractures. On 10/18/12 at 10:45 A.M. the Physical Therapist (PT) entered Resident #10's room to assess the resident's hands. The PT said the resident definitely needed hand rolls to keep the hands open, but was not able to fully assess the resident due to pain. The PT said that the resident needed pain medication before an assessment could be completed. On 10/18/12 at 11:10 A.M. the DON approached the surveyor and explained that the nurse completed the paperwork on (9/12/12) to have PT evaluate the resident, but the DON was unable to locate any information that a screen or evaluation had been completed. During an interview on 10/18/12 at 5:15 P.M. with the OT and PT, they explained that after the resident received pain medication they were able to evaluate the resident's bilateral hand contractures. They said they spent about 1.5 hours with the resident. The left hand was soaked for 45 minutes in warm water. They were then able to then gently open the hand with the exception of the 3rd digit. They said the left hand was open enough to position a soft cloth so the resident's fingers were not digging into the palm of the hand. In addition they were able to place a hand roll in the right hand. Review of the Occupational Therapy Evaluation, dated 10/18/12, indicated the resident had bilateral hand contractures and was making facial grimaces with any movement of the body, but especially the hands. The justification for skilled services included, the necessity to address the limited ROM of both hands, to prevent further loss of ROM, contracture formation and for splint management. The short term goals included; - Gentle ROM to the left hand with minimal signs of pain, - Resident will tolerate a hand roll to the left hand for at least 1 hour daily with no signs of pain, - Increase bilateral ROM, - Resident will tolerate gentle stretch exercised in order to increase ROM and, - Resident will tolerate warm soaks in order to tolerate ROM. The long term goals of therapy included; - Resident will tolerate a hand roll to both hands for at least 6 hours a day, - ROM to the left hand will improve and, - Good skin integrity to bilateral hands. On 10/19/12 at 10:30 A.M. during an interview with the DON, OT, PT and MDS Nurse, the MDS nurse said that she did assess Resident #10 during the last assessment period of (8/14/12) and the resident did not have bilateral hand contractures at that time. The PT again explained the evaluation, completed on (10/18/12), and said the contractures were not treated and could have been avoided, if treated in a timely manner. OT will be working with the resident to soak the hands in warm water and perform gentle ROM exercises to prevent further contractures and pain.

Based on observation, record review and interview the facility failed to provide sufficient fluids to maintain proper hydration for 1 (#2) resident out of a total sample of 19. Findings include: For Resident #2, the facility failed to maintain hydration by providing adequate fluids and monitoring fluid intake when the resident was at high risk for dehydration secondary to diarrhea. Resident #2 was admitted to the facility in 7/12 with [DIAGNOSES REDACTED]. Review of the admission paperwork included laboratory data done at the hospital, dated 7/8/12. The lab work indicated the resident was not dehydrated. The BUN (blood urea nitrogen) was 24 mg/dL (deciliter)(normal 5-25) and the Creatinine was 1.27 mg/dL (normal range 0.6 - 1.3). Review of the admission physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - 7/11/12 at 2:00 P.M., - 7/12/12 at 6:00 A.M. and 2:00 P.M., - 7/13/12 no time indicated and, - 7/14/12 at 1:00 P.M. Review of the Nursing Notes indicated; - 7/11/12 on the 11:00 P.M. - 7:00 A.M. shift the resident had three large loose stools. On the 7:00 A.M. - 3:00 P.M. shift the resident had one loose stool. - 7/12/12 on the 7:00 A.M. - 3:00 P.M. shift the resident had one loose stool. - 7/13/12 on the 11:00 P.M. - 7:00 A.M. shift the resident had a large loose stool. On the 7:00 A.M. - 3:00 P.M. shift the resident had one loose stool. - 7/14/12 on the 7:00 A.M. - 3:00 P.M. shift the resident had one loose stool, and on the 3:00 P.M. - 11:00 P.M. shift the nurse indicated the resident had loose stools one time. Review of the Nurse's note, dated 7/15/12 on the 7:00 A.M. - 3:00 P.M. shift, indicated that the nurse assessed the resident because the resident did not look like right. The vital signs were; blood pressure 138/95, pulse 115, respirations 24 and temperature 99.8 degrees Fahrenheit. Residents #2's pulse oximetry (measurement of oxygen in the blood) was 88% (a low reading). The nurse applied oxygen, and called the Nurse Practitioner (NP) who gave an order to obtain lab work and a chest X-ray. Continued review of the Nurse's notes, dated 7/15/12, on the 3:00 P.M. - 11:00 P.M. shift indicated lab results were obtained and the NP was notified. An order was obtained to send the resident to the hospital for [MEDICAL CONDITION]. Review of a laboratory report, dated 7/15/12, indicated the resident was dehydrated and in acute [MEDICAL CONDITION]. The results were; - BUN was 103 mg/dL, - Creatinine was 3.9 mg/dL and, - GFR (Glomular Filtration Rate) was 15 (GFR less then or equal to 15 indicates Kidney Failure). Review of the Admission Minimum Data Set, dated dated [DATE], indicated Resident #2 was cognitively impaired, was supervised for eating and occasionally incontinent of bowels. Review of the NP's readmission note, dated 7/27/12, indicated the resident was admitted to the hospital with [REDACTED]. The NP's note also indicated the plan of care for the resident was to push fluids. On 10/16/12 at 11:30 A.M., the surveyor observed the resident being pushed in a wheelchair to the dining room. The resident's left wrist and hand were contracted, and a splint was applied to the left lower extremity. During an interview on 10/17/12 at 7:20 A.M. with the Charge Nurse, she said the nurses were not monitoring the resident's fluid intake. She said the Certified Nursing Assistants (CNA) enter the meal % a resident consumes on a computer system, but the system only monitors the % of meal intake, not the fluid intake. She said they rely on the CNAs to tell them if a resident is not drinking enough fluids. The Charge Nurse said the nurses were not monitoring fluid intake but should have been because the resident had diarrhea. the facility policy for Intake, Measuring and Recording, dated 9/2005, does not instruct the staff when to obtain a Physician/Np order to initiate Intake measuring and recording. On 10/17/12 at 8:00 A.M., the surveyor observed the resident in the dining room eating breakfast. The resident was drinking a white thickened substance from a clear plastic cup. During an interview on 10/17/12 at 1:15 P.M. with the Director of Nurses, she said that because of the diarrhea, the resident should have been monitored for fluid intake and signs and symptoms of dehydration, and was not.

Based on record review, interviews, and observation, the facility failed to provide the necessary care and services related to the prevention of scrotal tissue breakdown for 1 sampled resident (#1); and for 1 sampled resident related to pain (#12), from a total sample of 15. Findings included: 1. For Resident # 1, the facility failed to ensure the prevention of an ulcerated scrotum. Resident #1 was admitted to the facility in 2/11. The resident's [DIAGNOSES REDACTED]. The 2/11/11 Initial MDS (Minimum Data Set) Assessment revealed that the resident had memory problems; was extensive assist for bed mobility and toilet use; was dependent for transfer; did not ambulate; was dependent for dressing, bathing and hygiene; was always incontinent of bowel and bladder, and had no skin problems. The 5/3/11 Quarterly MDS Assessment was essentially unchanged, and revealed that the resident had no skin problems. During the initial tour of the resident's unit with Nurse #3 (on 8/3/11 at 8:05 A.M.), Nurse #3 told the surveyor that Resident #1 has a Foley catheter (F/C); and recently healed areas on the penis. The surveyor observed Resident #1 resting flat in bed. Nurse #3 told the surveyor that the resident developed the necrotic wound on the scrotum when the wrinkled skin surfaces of the scrotal tissue adhered to itself, and "tore" when "not enough" N/S (Normal Saline) was used before attempting to pry the adhered tissue apart, causing a wound that deteriorated. The 7/20/11 nursing note revealed that the resident had an "excoriated" scrotum and reddened peri area, and that a protective cream was applied QS (every shift). The 7/25/11 nursing note revealed that the resident now has two necrotic areas at the base of the scrotum, and a small open area on the foreskin. The 7/25/11 physician's orders [REDACTED]. on scrotum and thigh twice daily. The 7/26/11 Quarterly MDS Assessment revealed that the resident has one "Unhealed Pressure Ulcer," measuring 5 cm (centimeters) x 4.2 cm; one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar; and one Pressure ulcer described as necrotic (eschar). "Ulcer care" and "Applications of ointments / medications other than to feet," were coded as being provided. The 7/26/11 nursing note revealed that the resident's scrotal areas remain necrotic. The 7/27/11 nursing note indicated that the resident is on an antibiotic for an infected scrotum, and that the scrotum remains necrotic. The 7/28/11 physician's orders [REDACTED]. The 7/28/11 nursing note revealed that the NP (Nurse Practitioner) came in and inserted a F/C. The 7/29/11 physician's orders [REDACTED]. During discussion with Nurse #1 on 8/3/11 at 3:35 P.M., Nurse #1 stated that Resident #1 has a "necrotic scrotum, but was a little better today." When the surveyor inquired as to the treatment, Nurse #1 stated that, "Santyl is applied with [MEDICATION NAME] Powder several times throughout the day" to the scrotum and inner thigh, because it "rubs off in the bed" and "when the resident is incontinent." Nurse #1 stated that the necrotic area on the resident's scrotum was not a pressure ulcer, but developed due to bladder incontinence. The surveyor observed Resident #1 sitting up in a geri chair recliner in the resident's room (on 8/4/11 at 8:15 A.M., 9:00 A.M. to 9:22 A.M., 12:00 P.M. to 12:11 P.M., and 1:00 P.M. to 1:19 P.M.). The resident was wearing gray-colored sweat pants that were twisted, and tight fitting in the crotch area (no indication that the resident's scrotum could be elevated, in accordance with the 7/25/11 physician's orders [REDACTED]. On 8/4/11 at 1:19 P.M., the surveyor observed as CNA #6 and CNA #10 transferred Resident #1 from the geri chair into bed, using a Hoyer lift mechanical device. Resident #1's eyes were closed, and the resident moaned intermittently, during the transfer. The resident was wearing an incontinent brief. There was a leg bag F/C drainage system attached with two tight rubberized straps to the resident's right lateral/posterior upper thigh. CNA #6 rolled Resident #1 onto the left side. The surveyor observed the resident's scrotum wedged between the resident's inside, upper thighs. CNA #6 used an index finger and thumb to separate the reddened, wrinkled skin folds of the resident's scrotum, revealing a large, raw cratered wound. The wound edges had thick, yellow slough. There was no treatment or dressing observed on this area (Santyl and [MEDICATION NAME] Powder). The surveyor observed a red, moist pressure ulcer on the left buttock, with no treatment applied to that area either. CNA #6 stated that Resident #1 had been in the geri chair since "about 8:30 A.M...was not positioned, because "Resident #1 is a Hoyer lift," and stated that the resident has a "catheter on now." CNA #6 said that Resident #1 was "better today," so the resident "stayed up" out of bed for the day." CNA #6 said that Resident #1 is incontinent of bowel, "just goes in the diaper." Nurse #1 entered the resident's room (8/4/11 at 1:40 P.M.) and observed the area on the resident's scrotum, stating, "It looks better, the eschar scab must have fallen off." Nurse #1 said that he/she does not place a dressing on the scrotum because the resident was incontinent. Nurse #1 said that there was no treatment to elevate the resident's scrotum therefore, it was not done. Nurse #1 confirmed that there was a physician's orders [REDACTED]. Findings were reviewed with the Director of Nursing and Assistant Director of Nursing on 8/16/11 at 4:50 P.M. Please refer to F282, Example #1, F314, Example #1, F315, Example #2 and F514, Example #1. 2. For Resident #12, the facility failed to ensure that pain management was provided for this resident diagnosed as having a traumatic wound on the penis and scrotal area. Resident #12 was admitted to the facility in 9/10. The resident's pertinent [DIAGNOSES REDACTED]. The 9/27/10 nursing note identified that the resident has a F/C (Foley Catheter), and was in no apparent discomfort. The 9/27/10 physician's orders [REDACTED]. The 9/30/10 Initial MDS (Minimum Data Set) Assessment revealed that the resident has a Legal Guardian, and the family member was responsible. The MDS revealed the resident had both short and long term memory problems; severely impaired cognitive and decision-making abilities; sometimes understood, and sometimes understands, and had no pain. The 10/27/10 nursing note indicated that the resident's urethral meatus and foreskin were excoriated (abrasion to the skin). The 12/2/10 TAR (Treatment Administration Record) revealed that a "deep skin tear" was found from the meatus down the penis. The Quarterly MDS (Minimum Data Set) Assessment, dated 12/21/10, was essentially unchanged, and identified that the resident had no pain. A 1/26/11 care plan for the "penile erosion" included in the goal section of the care plan that the resident should show no signs of pain. The 3/5/11 nursing note revealed that the resident fell . The 3/15/11 Quarterly MDS Assessment was essentially unchanged, and indicated that the resident had no pain. The 3/23/11 nursing note revealed that Resident #12 had been sent out on the previous shift (7:00 A.M. to 3:00 P.M.) for a Urology appointment, but was diverted to the ER (emergency room ). The 3/23/11 ER report revealed that the resident appeared uncomfortable, was listless with [MEDICAL CONDITION](unusually fast heart rate) at 136 beats per minute and achy (unusually fast breathing) with a rate of 36. Treatment was provided, and per the family request, Resident #12 returned back to the facility. The 3/24/11 nursing note revealed that the F/C was flushed; resident was grimacing at times, and was administered Tylenol (mild pain medication) with positive effect. The 5/25/11 nursing note identified that the resident was found on the floor at 8:30 P.M.. The resident received APAP (generic Tylenol) for pain/discomfort. The 7/20/11 nursing note revealed that the resident pulled out the F/C, with the balloon inflated, and later at 3:13 P.M. revealed the split to the resident's penis worsened, but the resident did not appear to be in pain. The 7/22/11 nursing note revealed that the Physician spoke with family and decided to leave everything the way it is for now, as the resident does not appear to be in pain. On 8/8/11 from 1:20 P.M. to 2:00 P.M., the surveyor observed Resident #12 sitting up quietly in a w/c in the hallway. The resident was wearing gray-colored sweat pants. The surveyor observed Resident #12 resting in bed on 8/8/11 at 3:30 P.M. with a F/C attached to a large drainage bag. CNA #3 was providing care to Resident #12, and lifted the resident's penis. The surveyor observed the underside shaft of the penis filleted wide open, exposing the urethral mucosa, extending into the proximal centermost aspect of the scrotum. Resident #12 grimaced when the genital area was touched. CNA #3 covered the resident with a sheet, then exited the room. The surveyor observed Nurse #4 provide a treatment on 8/8/11 from 3:40 P.M. to 4:00 P.M.. The resident grimaced, and arched his/her neck against the pillow each time Nurse #4 touched the resident's genital area during the treatment. CNA #1 and CNA #3 entered the resident's room on 8/8/11 at 4:16 P.M., and provided care to Resident #12. CNA #1 washed the resident's genital area. Resident #12 grimaced and moaned, grabbing out periodically. CNA #3 held onto the resident's hands, while CNA #1 continued to cleanse the resident's compromised genital area. CNA#1 and CNA #3 rolled Resident #12 onto the left side. CNA #1 washed the resident's peri-rectal area. Resident #12 held fast to the side rail, grimaced and moaned. CNA #1 stated that perhaps the bath water was "too cold." During interview with the DON (Director of Nursing) on 8/8/11 at 4:38 P.M., directly after what had been observed during care and the treatment near the F/C, the DON acknowledged that the resident's pain should have been evaluated and assessed, especially giving the nature of the trauma to the genital area from the F/C. Please refer to F315, Example #1, and F441, Example #1.