Every finding on record at Boston Home, Inc (The)

Based on observations, interviews and record review, the facility failed to provide a dignified and respectful existence by 1.) failing to respect a resident's personal room environment for 1 Resident (#45) and 2.) speaking in a language other than English while in Resident areas and while providing care in 2 of 2 units out of a sample of 20 residents. Findings include: Review of the facility policy titled 'The Fundamentals of Resident Rights-Dignity and Respect' with no revision date indicated the following: *A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. *The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. *Each resident has the right to be treated with dignity and respect. All staff activities and interactions with residents must focus on assisting the resident in maintaining and enhancing his or her self esteem and self-worth and incorporating the resident's preferences and choices. Staff must respect each resident's individuality when providing care and services while honoring and valuing their input. 1. Resident #45 was admitted to the facility in November 2020 with diagnoses including multiple sclerosis, depression, schizophrenia and a history of suicidal ideation. A review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status Exam (BIMS) score of 13 out of a possible 15 indicating intact cognition. Further review of the medical record indicated Resident #45 makes his/her own decisions and his/her health care proxy (HCP) is not activated. During a review of Resident #45's medical record on 3/2/23, at 8:29 A.M., social work progress notes written on 2/21/23, and 2/22/23, indicated the following: *Social Worker (SW) met with Resident #45 for a psychosocial visit, the resident stated he/she was upset because someone had voiced discomfort with pictures hanging on his/her wall containing nudity. SW provided support and validation, the resident and SW discussed the content in the pictures and the importance of ensuring that residents and staff feel safe physically and emotionally where they live and work, SW explained the importance of being sensitive to others and the role trauma plays in situations like this. The resident initially voiced disagreement and frustration about this. SW validated the resident's frustration. The resident stated he/she would take down the pictures. The SW clarified that this was not the request. The resident gave the SW permission to speak to his/her HCP about this. SW recommended that the resident keep the pictures in an area of his/her room that is not immediately visible to those entering the room. SW will continue to monitor and support the resident. *SW met the resident for a psychosocial visit, the resident stated he/she felt better but still felt frustrated, the resident stated that he/she hoped more people will come to embrace diversity in all forms and he/she appreciates all efforts the facility has done to continue to give him/her support. During an interview on 3/2/23, at 9:19 A.M., Resident #45 told the surveyor that staff were suggesting he/she take his/her art down. Resident #45 who identifies as gay, described his/her art as eclectic. The surveyor observed the pictures which were non-pornographic pictures of models. There were no pictures hanging in Resident #45's room of fully naked people with visible genitalia or breasts exposed. The pictures staff described as nude were male models with their shirts off and in one of the pictures, were two men sitting with the upper portion of their buttocks exposed. The picture was small, framed and hung towards the bottom of the wall near the window and not visible to anyone walking past the room. Resident #45 said when the Social Worker met with him/her to discuss the picture, the possibility of taking them down and hiding them away from the staff and resident's view, he/she was frustrated. Resident #45 said that he/she felt horrible, angry, and felt as if his/her personhood was being questioned. Resident #45 then said it is 2023 and he/she could not believe this was happening. Resident #45 said other residents are not able to wander in his/her living area due to their diagnoses. Resident #45 then said that his/her privacy curtain is always drawn for his/her privacy and his/her roommate's privacy. Resident #45 said when he/she was admitted to the facility, he/she was assured that he/she could express himself/herself in a way that made him/her comfortable. During an interview on 3/2/23, at 10:10 A.M., Unit Manager (UM#2) said Nurse #1 approached her with concerns about naked pictures in Resident #45's room. UM #2 then said that when she went to Resident #45's room to look at the pictures, she decided to ask the Social Worker to address the concern. During an interview on 3/2/23, at 10:33 A.M., Nurse #1 said she was the one who brought up the concern with the pictures in Resident #45's room due to the nakedness they expressed. Nurse #1 said the nakedness made her uncomfortable, and she was also worried about Resident #45's roommate's privacy. The surveyor asked Nurse #1 about Resident #45's roommate's cognition. Nurse #1 said Resident #45 roommate has cognitive deficits. During an interview on 3/2/23, at 11:24 A.M., the Social Worker said she was concerned about staff and visitors being triggered by the naked pictures in Resident #45's room. The Social Worker said she felt it was her duty to protect the staff and the visitors. The Social Worker then said that other naked pictures, for example male and female bikini pictures, naked baby pictures would have had less of a negative reaction from staff. The surveyor and the Social Worker both walked by the Resident #45's room, the privacy curtain was pulled and neither Resident #45 or the pictures were visible from the hallway, Resident #45's roommate could not see into Resident #45's side of the room. The Social Worker acknowledged the observation. The Social Worker said that she expects staff from different cultural backgrounds to respect the residents wishes. During a telephone interview on 3/3/23, at 3:34 P.M., Resident #45's partner and HCP said Resident #45 reached out for support after the Social Worker met with him/her about the pictures in his/her room. The HCP said that Resident #45 was distraught, upset and frustrated about the situation. Resident #45's partner told him/her to not take the pictures down, the facility was aware that Resident #45 is openly gay and that the facility, at admission, told him/her that he/she could create a space in his/her room to his/her liking. During an interview on 3/2/23, at 1:35 P.M., with the Director of Nursing said that residents are the first priority in the facility, their rights should be respected at all times by staff, even though staff may not agree with the resident's beliefs and expressions, it is their responsibility to take care of the resident and not judge or impose their own beliefs and value system. 36876 2. The facility failed to provide a dignified experience for residents in 2 of 2 units evidenced by staff speaking in languages other than English in resident areas and while providing care. During initial interviews on 3/1/23, multiple residents reported to the surveyor that Certified Nursing Assistant staff speak in foreign languages in front of residents during care. resident's reported that this makes them feel uncomfortable or that staff could be speaking about them negatively without them knowing. On 3/2/23, at 12:15 P.M. the surveyor observed staff providing care to a resident in a room on the 1st floor and could be heard speaking in a language other than English. On 3/2/23, at approximately 12:25 P.M. the surveyor observed three staff in the hallway of the 2nd floor unit speaking in a language other than English. On 3/3/23, at 7:23 A.M., the surveyor observed staff on the 2nd floor nursing unit bringing a resident into the shower unit. The staff person and other staff in the shower room were speaking in a language other than English. The surveyor was informed on 3/3/23, that the facility has no written policy regarding language. During an interview on 3/3/23, at 9:24 A.M. the Director of Nursing said that the expectation is for staff to speak in a language that residents understand at all times.

Based on interview and record review the facility failed to ensure an allegation of abuse by one Resident (#50) was reported to the Department of Public Health's (DPH) Health Care Facility Reporting Systems (HCFRS) within the required two hour time frame, out of a total 20 sampled residents. Findings include: The facility policy titled Protecting Residents from abuse, neglect and misappropriation of property, updated 11/23/22, indicated the following: * Employees of the Boston Home (TBH) will treat residents and their personal property with respect and will provide care to the resident as defined in the Resident's Care Plan. * The Administration of the Boston Home will provide an environment that is conducive to quality patient care and which protects patients from abuse, neglect, mistreatment, misappropriation of patients property or exploitation by staff, visitors, family members or other residents. * The Administration will report to DPH within 2 hours using the HCFRS: -allegations of abuse or knowledge of serious bodily injury of unknown origin. * The Administration will report within 24 hours to DPH using the HCFRS: -neglect exploitation or mistreatment. Resident #50 was admitted to the facility in April 2017 and had diagnoses that included paraplegic with advanced Multiple Sclerosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/3/23, indicated Resident #50 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. The MDS further indicated Resident #50 had no behaviors and was totally dependent on staff for Activities of Daily Living (ADLs), including bathing. Review of a Social Worker (SW) progress note dated 12/19/22, indicated the following: On 12/19/2022, SW and Nurse Manager spoke with Resident #50 about a concern he/she had voiced. CEO was notified immediately and investigation began. The Resident stated he/she feels safe at TBH. SW notified the ombudsman. Nurse Manager notifying MD. Review of the facility's grievance binder on 3/02/23, at 8:40 A.M., failed to indicate any grievances had been filed by or on behalf of Resident #50's concern. During an interview on 3/02/23, at 10:35 A.M., with the Social Worker (SW) said she had met with Resident #50 on 12/19/22, and Resident #50 complained that a Certified Nursing Assistant (CNA #2) had sprayed water directly in his/her face because he/she complained that CNA #2 had dumped the contents of his/her urinary catheter bag on the shower floor and that it smelled. The SW provided the surveyor with a copy of the facility's investigation to review. Review of the investigation file indicated the following: * A statement from accused CNA #2 indicted that while showering Resident #50 on 12/16/22, Resident #50 repeatedly said you are burning my face. After the shower, according to CNA #2's statement, then he/she (Resident #50) got mad and told me in the presence of my partner (Another CNA) you did try to burn my face. * Review of the investigation file indicated that the incident was reported in HCFRS on 12/19/22, 3 days after Resident #50 made the allegation to CNA #2, in the presence of another CNA. * A statement from the SW indicated that she interviewed Resident #50 on 12/19/22, and Resident #50 told her that CNA #2 emptied his/her catheter bag onto the floor of the shower room, where there is a drain. Resident #50 complained about the smell of urine and that CNA #2 sprayed water in his/her face each time he/she complained. Resident #50 further stated that each time CNA #2 sprayed water in his/her face, she said oops. During an interview on 3/03/23, at 10:21 A.M., Resident #50 recounted to the surveyor what had occurred on 12/19/22. Resident #50 said that at the start of the shower CNA #2 dumped urine from his/her catheter bag on the floor of shower rather than in the little toilette that the other girls dump into. Resident #50 said CNA #2 did not like that he/she told her it smelled, so she sprayed him/her several time in the face. Resident #50 describes it was awful because each time she did it I felt like I was drowning and I didn't know when I should breathe because of the water going in my face. Resident #50 added I told everyone that day what happened, the nurse, the other staff because it was the worst shower I have ever had here and I have been here for 6 years. On 3/03/23, at 10:25 A.M., the surveyor called and left a voicemail for CNA #2. As of 3/6/23, CNA #2 failed to return the call. During an interview on 3/3/23, at 10:40 A.M., the Director of Nursing (DON) said that all staff are mandatory reporters, even on themselves, and when Resident #50 alleged CNA #2 was burning his/her face, CNA #2 should have reported the allegation immediately. The DON said the allegation should have been reported to HCFRS when Resident #50 made the allegation on 12/16/22.

Based on observation, record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 Resident's (#27 and #48) out of a total sample of 20 Residents. Findings include: 1. For Resident #27, the facility failed to accurately code a stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure injury on the MDS assessment. Resident #27 was admitted to to the facility in May 2016 with diagnosis including multiple sclerosis and dysphagia. Review of Resident #27's annual MDS assessment, dated 12/9/22, indicated that he/she had one stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) pressure ulcer. Further review of the MDS indicated that there was no documentation to support that nursing had coded that Resident #27 had a stage 4 pressure ulcer. Review of the Treatment Administration Record, dated December 2022, indicated an active physician's order dated 11/23/22, which required for nursing to complete a dressing for a stage 4 pressure ulcer. Review of the Wound Evaluation and Management Summary, dated 12/7/22, indicated Resident #27 had a stage 4 pressure ulcer of the sacrum for at least 230 days duration. During an interview on 3/3/23, at 7:51 A.M., the MDS nurse said that she coded the MDS incorrectly. 36876 2. Resident #48 was admitted to the facility in May 2012 with diagnoses including Multiple Sclerosis and gastroesophageal reflux disease. Review of Resident #48's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #48 scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating that Resident #48 is cognitively intact. Further review indicated that Resident #48 requires assistance with bathing, dressing and transfers. Additional review of the MDS indicated that at the time of the MDS, (reference date 1/13/23), Resident #48 had 2 Stage III pressure ulcers. Review of Resident #48's wound physician note dated 1/11/23, indicated that Resident #48 had 2 Stage IV pressure ulcers. During an interview on 3/3/23, at 8:36 A.M., the MDS Coordinator said that at the time of the MDS submission, there was a consultant who was working on the MDS. The MDS Coordinator acknowledged the wound physician's documentation indicating that on 1/11/23, Resident #48 had documented Stage IV pressure ulcers and one had deteriorated.

Based on observation, record review and interview the facility failed to implement the plan of care for 3 Residents (#46, #60 and #71) out of a total sample of 20 residents. 1). For Resident #46 the facility failed to implement a custom wedge cushion between his/her legs, failed to elevate her/his heels above the mattress, failed to ensure blue booties were on his/her feet and failed to ensure the mattress setting was set at the prescribed setting. 2). For Resident #60 the facility failed to ensure that nursing implemented a physician's order for air mattress settings. 3). For Resident #71, the facility failed to apply hand splints per his/her plan of care. Findings include: 1. Resident #46 was admitted to the facility in March 2014 with diagnoses including multiple sclerosis and neurogenic bladder. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #46 is totally dependant on staff for all activities of daily living. Further review indicated Resident #46 is cognitively impaired and is rarely/never understood. Review of the doctors orders dated March 2023 indicated to use customized wedge for bilateral lower extremities (BLE) when in bed/supine- to elevate BLE for reduce swelling, to off load heels and keep BLE joints in neutral alignment. Further review indicated an order for soft booties when in bed and wheelchair to off load bilateral heels and promote neutral alignment. Review of the current care plans indicated that Resident #46 had an intervention to use a customized wedge cushion for bilateral lower extremities (BLE) when in bed/supine- to elevate BLE for reduce swelling, to off load heels and keep BLE joints in neutral alignment. Further review indicated to have the air mattress setting at 120 pounds (lbs), rotation every 10 minutes. Further review failed to indicate Resident #46 refuses the above interventions. Review of the nurse's notes failed to indicate Resident #46 refuses care plan interventions. On 3/1/23, at 8:34 A.M., the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. On 3/1/23, at 4:58 P.M., the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. On 3/2/23, at 7:49 A.M. the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. During an interview on 3/2/23, at 9:03 A.M., the Physical Therapist said that the custom wedge cushion that was supposed to be between Residents #46's legs and the booties that were supposed to be on Resident #46's feet, were in the rehab room because the rehab aide had put them in there and not returned them to the resident. During an interview on 3/2/23, at 10:52 A.M., Unit Manager #2 said that Resident #46 was supposed to have a wedge cushion between her/his legs, blue booties on and her/his heels elevated off of the mattress. Unit Manager also acknowledged the incorrect mattress setting. Unit Manager #2 said that the nurses were supposed to check the mattress settings to ensure the proper setting was in place. 44095 2.) Resident #60 was admitted to the facility in November 2021 with diagnosis including multiple sclerosis and chronic pain. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #60 is at risk of developing pressure ulcers/injuries. Review of the physician's order, dated 12/22/21, indicated for nursing to check inflation of mattress setting to 200 pounds. Review of Resident #60's most recent weight record, dated 2/14/23, indicated he/she weighed 194.40 pounds Review of the Treatment Administration Record (TAR), dated March 2023, indicated that nursing had implemented the physician's order and set to 200 pounds. On 3/1/23 at 8:06 AM and on 3/2/23 6:53 A.M., the surveyor observed Resident #60 in his/her bed and the air mattress was set to 280 pounds. During an interview on 3/2/23 12:19 P.M., Nurse #1 said that the Unit Manager will check the mattress settings. During an interview on 3/2/23 at 12:39 P.M., Unit Manager #2 said that nurses are required to verify the correct settings for air mattresses. The Unit Manager said she corrected several Resident's air mattress settings this morning. 36876 3. Resident #71 was admitted to the facility in February 2021 with diagnoses including Guillian-Barre syndrome and legally blind. Review of Resident #71's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact and is totally dependent on staff for dressing, bathing and eating. During an interview with Resident #71 on 3/1/23 at 9:57 A.M., the surveyor observed his/her hands were contracted. Resident #71 said he/she does wear splints, but he/she forgot to ask staff to put them on. Review of Resident #71's physician's orders indicated the following: *Hand splints to be donned during the day when seated in wheelchair, stockinette donned under splints for purposes of tone management, every day at 7:00 A.M. - 3:00 P.M., initiated 4/22/21 On 3/1/23 at 1:45 P.M., and 3/2/23 at 9:24 A.M., Resident #71 was observed not wearing hand splints. Review of the clinical record failed to indicate that Resident #71 refused to wear his/her hand splints. Review of the Treatment Administration Record on 3/3/23 at 8:00 A.M., failed to indicated Resident #71 refused to wear his/her hand splints. Review of Resident #71's care plans failed to indicate any care plans of refusals of care, including the use of hand splints. On 3/3/23 at 9:55 A.M., the surveyor observed Resident #71 in his/her wheel chair not wearing hand splints. The surveyor then met with Unit Manager #1. Unit Manager #1 said that the expectation is not for Residents to ask for their hand splints and for staff to don them as ordered. The surveyor then informed Unit Manager #1 of the observations of Resident #71 not wearing his/her hand splints. Unit Manager #1 said that Resident #71 can be behavioral and refuse to wear his/her hand splints at times. Unit Manager #1 acknowledged that there was no documentation to indicate Resident #71 refused to wear his/her hand splints.

Based on observation, record review and interview the facility failed to revise the plan of care for 3 Residents (#46, #13, and #27) out of a total sample of 20 residents. 1). For Resident #46 the facility failed to revise the plan of care for the use of a blue water bottle at bedside. 2). For Resident #13 the facility failed to revise a plan of care related to wearing an opened toe shoe after his/her dark callous on his/her right foot resolved on 12/7/22. 3). For Resident #27 the facility failed to revise a plan of care when nursing obtained a new mattress (4/1/22) for Resident #27 and he/she no longer required interventions including, noodles on the mattress to increase safety and a raised edge mattress. Findings include: 1. Resident #46 was admitted to the facility in March 2014 with diagnoses including multiple sclerosis and neurogenic bladder. Review of the Minimum Data Set assessment dated [DATE], Resident #46 is fed by a tube directly into the stomach. Further review indicated that Resident #46 is totally dependant on staff for all activities of daily living and does not take anything by mouth. Further review indicated Resident #46 was cognitively impaired and is rarely/never understood. Review of the current care plan indicated that Resident #46 had an intervention for the use of a blue water bottle at bedside at all times within reach of the Resident. On 3/1/23, at 8:34 A.M., the surveyor observed Resident #46 lying in bed without a blue water bottle in the room. On 3/01/23, at 4:58 P.M., the surveyor observed Resident #46 lying in bed without a blue water bottle in the room. On 3/02/23, at 7:49 A.M. the surveyor observed Resident #46 lying in bed without a blue water bottle in the room. During an interview on 3/2/23, at 10:52 A.M., Unit Manager #2 said that Resident #46 can't have anything by mouth and she should have removed the blue water bottle from the care plan. 44095 2.) Resident #13 was admitted to the the facility in May 2022 with diagnoses including traumatic brain injury and hemiplegia affecting the right side. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 2/17/23, indicated he/she is at risk of developing pressure ulcers/injuries. Review of Resident #13's plan of care related to activities of daily living, dated as 10/28/22, indicated he/she required and open toe shoe on his/her right foot. Review of Resident #13's physical therapy discharge summary, dated 12/7/22, indicated he/she was able to tolerate closed toe shoe. On 3/1/23 at 8:35 A.M., 3/1/23 at 4:32 P.M., 3/2/23 at 8:27 A.M., 3/2/23 at 11:59 A.M. and 3/2/23 at 12:50 P.M., the surveyor observed Resident #13 wearing a closed toe shoe on his/her right foot. During an interview on 3/2/23 at 12:22 P.M., Nurse #1 said that Resident #13 wore a closed toe shoe on his right foot. During an interview on 3/2/23, at 12:50 P.M., the Unit Manager #2 said that it had been almost 4 months since Resident #13 required an opened toe shoe. Unit Manager #2 said that she should have updated Resident #13's plan of care on 12/7/22, when Resident #13 was able to wear a closed toe shoe on his/her right foot. 3.) Resident #27 was admitted to to the facility in May 2016 with diagnoses including multiple sclerosis and dysphagia. Review of Resident #27's plan of care related to activities of daily living, dated 8/26/20, indicated he/she required noodles on his/her mattress to increase safety. Review of Resident #27's plan of care related to activities of daily living, dated 9/18/20, indicated keep raised edge mattress in place for safety. Review of the physician's order, dated 4/1/22, indicated Resident #27 required an air mattress. On 3/1/23, at 8:11 A.M., 3/1/23, at 4:33 P.M., and on 3/2/23, at 6:52 A.M., the surveyor observed Resident #27 in bed sleeping there were no noodles on the mattress and there was no raised edge mattress. During an interview on 3/2/23, at 12:16 P.M., Certified Nurse Aide #1 said she was not aware that Resident #27 required noodles or a raised edge mattress. During an interview on 3/2/23, at 12:19 P.M., Nurse #1 said said she was not aware that Resident #27 required noodles or a raised edge mattress. During an interview on 3/2/23, at 12:41 P.M., Unit Manger #2 said she that said that Resident #27 no longer required noodles or a raised edge mattress. Unit Manager #2 said she should have updated Resident #27's plan of care in April 2022 when he/she received the new air mattress.

Based on observation, record review and interview the facility failed to ensure professional standards of practice were maintained during enteral feeding administration for 1 Resident (#46) out of a total sample of 20 residents. Findings include: Review of the facility policy titled TBH (the Boston home) GT (gastric tube) policies dated as revised 10/1/20, failed to indicate when closed system enteral feeding bottles are to be changed or how long they are to continue to infuse the enteral feeding without changing the bottle. Review of the doctor's orders dated March 2023 indicated an order for Jevity 1.2 cal. (calorie) 30 ml (milliliters) per hour for 20 hours up at 4:00 P.M. down at 12 P.M., for a total of 600 ml. On 3/1/23, at 8:36 A.M., the surveyor observed an enteral feeding bottle of Jevity 1.2 cal. hung and infusing, with a date of 2/26/23, written on the bottle. On 3/2/23, at 7:42 A.M., the surveyor observed a bottle of Jevity 1.2 cal hanging with a date of 3/2/23, and a time of 7:00 A.M. During an interview on 3/2/23, at 9:10 A.M., Unit Manager #2 said that she changed the enteral feeding bottle this morning at 7:00 A.M. (39 hours after the 48 hour limit) because the bottle had run empty. Unit Manager #2 then said that enteral feeding bottles should be changed every 48 hours regardless if there are contents still in the bottle. She then said that she had not noticed the date of when the bottle had been hung when she took it down. During an interview on 3/2/23, at 9:01 A.M., the Director of Nursing said that standard of practice is that enteral feeding bottles are to be changed every 48 hours for a closed system.

Based on observation, record review and interview the facility failed to ensure staff maintained medical records that were accurate for one Resident (#46) out of a total sample of 20 residents. Specifically the facility documented that a wedge cushion was in place, soft booties were in place as ordered, heels were off loaded, mattress settings were accurate and that skin checks were completed as documented. Findings include: Resident #46 was admitted to the facility in March 2014 with diagnoses including multiple sclerosis and neurogenic bladder. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #46 is totally dependant on staff for all activities of daily living. Further review indicated Resident #46 is cognitively impaired and is rarely/never understood. Review of the doctors orders dated February and March 2023 indicated to use customized wedge for bilateral lower extremities (BLE) when in bed/supine- to elevate BLE for reduce swelling, to off load heels and keep BLE joints in neutral alignment. Further review indicated an order for soft booties when in bed and wheelchair to off load bilateral heels and promote neutral alignment. Further review indicated to have the air mattress setting at 120 pounds (lbs), rotation every 10 minutes. Further review indicated to perform a skin check once a week. On 3/1/23, at 8:34 A.M., the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. On 3/1/23, at 4:58 P.M., the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. On 3/2/23, at 7:49 A.M. the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. Review of the Treatment Administration Record (TAR) dated 3/1/23, indicated that the nurse signed the TAR on the 7 A.M.- 3 P.M. shift and the 3 P.M.- 11 P.M. shifts indicating that the wedge cushion, the soft booties, the mattress setting and the heels off loaded doctor's orders were all followed as ordered. Review of the TAR dated January 2023 indicated that a skin check was completed on 1/18/23. Review of the medical record failed to indicate that a skin check was completed on 1/18/23 Review of the TAR dated February 2023 indicated that a skin check was completed on 2/1/23, 2/8/23, 2/15/23 and 2/22/23. Review of the medical record failed to indicate that a skin check was completed on 2/1/23, 2/8/23, 2/15/23 and 2/22/23. Review of the TAR dated March 2023 indicated that on 3/1/23, the nurse signed on the 7 A.M.-3 P.M. shift that a skin check had been completed. Review of the medical record failed to indicate that a skin had been completed on 3/1/23. Review of the medical record failed to indicate that weekly skin checks were completed for 1 week in January 2023, for 4 weeks in February 2023 and 1 week in March 2023 as documented complete on the TARs. During an interview on 3/2/23, at 2:06 P.M. Unit Manager #2 said that the skin checks, if completed, would be found under the assessment tab in the electronic medical record. The Unit Manager also acknowledged that the skin checks had not been completed as documented on the TARs.

Based on observation, policy review and interview, the facility failed to ensure its staff implemented appropriate infection control measures to help prevent transmission of communicable diseases and infections for four Residents during the dining experience. Specifically, the facility failed to ensure two staff members (#A and #B) performed hand hygiene in between assisting 4 residents during their lunch meal. Findings include: Review of the facility policy titled, Hand Hygiene, dated as revised 1/2020, indicated healthcare personnel will decontaminate their hands prior to and after each patient contact using alcohol based hand rub. On the the second floor dining room on 3/2/23, two surveyors observed the following: -At 12:28 P.M., the surveyors observed staff #A picking up crackers and dipping the crackers into humus with her bare hands. Staff #A then placed the food directly into the Resident's mouth. Staff #A did not perform hand hygiene. Staff #A then turned to assist another Resident. Staff #A picked up the utensil using the same hand and she began to assist a totally dependent Resident with his/her meal. Staff #A then returned to assist the first Resident with crackers and humus without performing hand hygiene. On 3/2/23 at 12:38 P.M., Staff #A identified the food she was assisting the first Resident with as crackers and humus. -At 12:30 P.M., the surveyors observed at a different table, Staff #B picking up crackers and dipping the crackers into humus with her bare hands. Staff #B then placed the food directly into the Resident's mouth. Staff #B did not perform hand hygiene. Staff B then wiped her hand off on the Resident's clothing protector and then turned to assist another Resident. Staff #B then picked up the utensil using the same hand and began to assist a totally dependent Resident with his/her meal. Staff #B then returned to the other Resident without performing hand hygiene. Staff #B was observed going between feeding both Residents for approximately 7 minutes without performing hand hygiene. On 3/2/23, at 12:37 P.M., Staff #B identified the food she was assisting the Resident with as crackers and humus. The staff member then started to use a spoon for the crackers and humus, however Staff #B did not perform hand hygiene between the Residents. During an interview on 3/2/23, at 12:47 P.M., Unit Manager #2 said that staff #A and staff #B should perform hand hygiene between Residents. Unit Manager #2 said staff #A and staff #B should have not used their bare hands while assisting Residents with meals. During an interview on 3/2/23, at 1:43 P.M., the Infection Control (IC) nurse said she was made aware of the observations. The IC nurse said staff should perform hand hygiene between feeding residents and not touch food with their bare hands. During an interview on 3/3/23, at 7:05 A.M., the Director of Nursing said hand hygiene should have been preformed between Residents.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was assessed as being at high risk for falls, was totally dependent for care and required two staff members for bed mobility and transfers, the Facility failed to ensure staff implemented interventions from his/her plan of care related to the level of assistance he/she required with care needs. On 01/10/22, Nurse #1 repositioned Resident #1, without another staff member present to assist her. Resident #1, was in bed on an air mattress, with the head of the bed elevated, Nurse #1 attempted to reposition Resident #1 to complete a treatment. Nurse #1 pulled downward on the draw-sheet that was underneath Resident #1, however, after Nurse #1 pulled on the draw sheet, he/she kept sliding down the bed, rolled out of bed, and fell to the floor. Resident #1 was later diagnosed with a left leg fracture. Findings include: The Facility's Policy titled, Safety Plans for Residents, dated 09/2018, indicated a safety plan will be initiated based on the outcome of the safety assessment and will address interventions for the safety of residents. Resident #1 was admitted to the Facility in October 2021, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was totally dependent of two staff persons with bed mobility and transfers. The MDS indicated Resident #1 had a BIMS score of 13. The MDS indicated he/she had impairment on both sides of his/her lower and upper extremities. Review of the Report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 01/17/22, indicated, Nurse #1 used the draw-sheet to pull Resident #1 away from the side rail, and this action caused him/her to slide down in bed. The Report indicated Resident #1 is unable to self-adjust his/her body in bed, he/she kept rolling, his/her right leg was dangling and became caught in the side rail. The Report indicated Nurse #1 lowered the bed to help Resident #1 onto the floor. The Report indicated Resident #1 sustained a scrape to the right knee, he/she denied pain at the time, and was transferred back into bed by three staff members. The Report indicated the Physician was notified of the fall. Review of Resident #1's Plan of Care related to Activities of Daily Living (ADL), dated as reviewed 12/2021, indicated Resident #1 required repositioning with two staff members for his/her comfort and functioning in bed. Review of Resident #1's Incident Report, dated 01/10/22, indicated Nurse #1 placed a second pillow underneath Resident #1, who was positioned on the right side, without the help of a second staff member. The Report indicated Resident #1's right leg got caught in the side rail, before falling to the floor. Review of Resident #1's Nurse Progress Note, dated 01/10/22, at 4:27 P.M. indicated, Resident #1's right leg was caught into the side rail. The Note indicated Nurse #1 lowered him/her to the floor. Review of Resident #1's Progress Notes, dated 01/10/22 at 11:54 P.M., indicated, Resident complained of left knee pain. The Note indicated Resident #1's left knee was swollen. The Note indicated there was a skin tear to Resident #1's right leg. Review of Resident #1's Radiology Report, dated 01/11/22, indicated he/she sustained an acute distal femur fracture (of the left leg) Review of the Facility's Investigation Report, dated 01/14/22, indicated, an X-ray was ordered on 01/11/22, and that the results showed a distal femur fracture to his/her left leg. During an interview on 02/03/22 at 12:20 P.M., Resident #1 said his/her left leg was in a cast because he/she fell out of bed during care. Resident #1 said only one staff member (Nurse #1) was providing care instead of two staff members when he/she fell . During an interview on 02/03/22 at 12:40 P.M., Nurse #1 said on 01/10/22, she went into Resident #1's room to administer a treatment on his/her wound. Nurse #1 said she could not find Certified Nurse Aide #1 when she was ready to complete the treatment. Nurse #1 said when she entered Resident #1's room, the head of his/her bed was elevated, and that she pulled the draw-sheet underneath Resident #1 to reposition him/her without lowering the head of the bed. Nurse #1 said, Resident #1 started sliding downward in bed and rolled off on his/her right side onto the floor. Nurse #1 said pulling on the draw-sheet caused Resident #1 to quickly slide downward because he/she was on an air mattress. Nurse #1 said she was aware it required two staff members to reposition Resident #1 in bed. Nurse #1 said she called for help with Resident #1, and said she (Nurse #1), Nurse #2 and CNA #3 helped to transfer him/her back into bed. Nurse #1 said Resident #1 did not present with any signs and symptoms of injury at the time, and that the Physician was notified of the fall. During an interview on 02/03/22 at 11:50 A.M., Certified Nurse Aide (CNA) #1 said she provided care to Resident #1 that morning with CNA #2. CNA #1 said once she was done with care for Resident #1, she went and informed Nurse #1 that he/she was ready for his/her treatment. CNA #1 said Nurse #1 told her she would do the treatment later. CNA #1 said Resident #1 is totally dependent for care and required two staff members for care and positioning in bed. CNA #1 said Nurse #1 did not call for her to assist with repositioning Resident #1 when it was time for the treatment. During an interview on 02/03/22 at 1:50 P.M., the Director of Nurses (DON) said the Nurse Supervisor called her and explained that Resident #1 fell out of bed while Nurse #1 was trying to reposition him/her in bed. The DON said an X-ray showed Resident #1 had a fracture of his/her left leg. On 02/03/22, the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A) 01/11/22, Resident #1 was assessed by a Physician and new orders were given. B) 01/12/22, the Director of Nurses completed an investigation and reviewed of residents' care plans for accuracy. C) 01/10/22 through 1/29/22, the Associate Director of Operations and Nurse Supervisors completed In-service education for 80% of permanent licensed staff, (including Nurse #1) on requiring two staff members for turning and positioning residents in bed on the unit. D) 01/10/22 through 1/29/22, Nurse Supervisors performed random checks/audits on all units to ensure residents plans of care were followed by staff member during care. E) Results of the audits will be discussed in the quality Assurance Performance Improvement (QAPI) meeting which is also attended by the Medical Director. F) The Director of Nurses and/or Designee are responsible for the overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was assessed as being at high risk for falls, was totally dependent for care and required two staff members for bed mobility and transfers, the Facility failed to ensure Resident #1 was provided with the necessary level of staff assistance during repositioning to maintain his/her safety, to prevent incident resulting in an injury. On 01/10/22, Nurse #1 attempted to reposition Resident #1 in bed by herself, to complete his/her wound care treatment. Nurse #1 did not seek assistance from another staff person for help with Resident #1, who was in bed on an air mattress, with the head of the bed elevated, and was physically unable to participate in the task. Nurse #1 pulled downward on the draw-sheet that was underneath Resident #1, however, after Nurse #1 pulled on the draw sheet, Resident #1 kept sliding down the bed, rolled out of bed, and fell to the floor. Resident #1 was later diagnosed with left leg fracture. Findings include: The Facility's Policy titled, Safety Plans for Residents, dated 09/2018, indicated a safety plan will be initiated based on the outcome of the safety assessment and will address interventions for the safety of residents. Resident #1 was admitted to the Facility in October 2021, diagnosis included [CONDITION(S)]. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was totally dependent on two staff persons with bed mobility and transfers. The MDS indicated Resident #1 had a BIMS score of 13. The MDS indicated Resident #1 had impairment on both sides of his/her lower and upper extremities. Review of the Report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 01/17/22, indicated, Nurse #1 used the draw-sheet to pull Resident #1 away from the side rail, and this action caused him/her to slide down in bed. The Report indicated Resident #1 is unable to self-adjust his/her body in bed, he/she kept rolling, his/her right leg was dangling and became caught in the side rail . The Report indicated Nurse #1 lowered the bed to help Resident #1 onto the floor. The Report indicated Resident #1 sustained a scrape to the right knee, he/she denied pain at the time, and was transferred back into bed by three staff members. The Report indicated the Physician was notified of the fall. Review of Resident #1's Plan of Care related to Activities of Daily Living (ADL), dated as reviewed 12/2021, indicated Resident #1 required repositioning with two staff members for his/her comfort and functioning in bed. Review of Resident #1's Incident Report, dated 01/10/22, indicated Nurse #1 placed a second pillow underneath Resident #1, who was positioned on the right side, without the help of a second staff member. The Report indicated Resident #1's right leg got caught in the side rail, before falling to the floor. Review of Resident #1's Nurse Progress Note, dated 01/10/22, at 4:27 P.M. indicated, Resident #1's right leg was caught into the side rail. The Note indicated Nurse #1 lowered him/her to the floor. Review of Resident #1's Progress Notes, dated 01/10/22 at 11:54 P.M., indicated, Resident complained of left knee pain. The Note indicated Resident #1's left knee was swollen. The Note indicated there was a skin tear to Resident #1's right leg. Review of Resident #1's Radiology Report, dated 01/11/22, indicated he/she sustained an acute distal femur fracture to his/her left leg. Review of the Facility's Investigation Report, dated 01/14/22, indicated, an X-ray was ordered on 01/11/22, and that the results showed a left distal femur fracture. During an interview on 02/03/22 at 12:20 P.M., Resident #1 said his/her left leg was in a cast because he/she fell out of bed during care. Resident #1 said only one staff member (Nurse #1) was providing care instead of two staff members when he/she fell . During an interview on 02/03/22 at 12:40 P.M., Nurse #1 said on 01/10/22, she went into Resident #1's room to administer a treatment to his/her wound. Nurse #1 said she could not find Certified Nurse Aide #1 when she was ready to complete the treatment. Nurse #1 said when she entered Resident #1's room, his/her head was elevated, and that she pulled down on the draw-sheet that was underneath Resident #1, to reposition him/her without lowering the head of the bed. Nurse #1 said, Resident #1 started sliding downwards in bed and rolled off on his/her right side onto the floor. Nurse #1 said pulling the draw-sheet caused Resident #1 to quickly slide downward because Resident #1 had an air mattress. Nurse #1 said she was aware it required two staff members to reposition Resident #1 in bed. Nurse #1 said she called for help with Resident #1, and said she (Nurse #1), Nurse #2 and CNA #3 helped to transfer him/her back into bed. Nurse #1 said Resident #1 did not present with any signs and symptoms of injury at the time, and that the Physician was notified of the fall. During an interview on 02/03/22 at 11:50 A.M., Certified Nurse Aide (CNA) #1 said she provided care to Resident #1 that morning with CNA #2. CNA #1 said once she was done with care for Resident #1, she went and informed Nurse #1 that he/she was ready for his/her treatment. CNA #1 said Nurse #1 told her she would do the treatment later. CNA #1 said Resident #1 is totally dependent on two staff persons for care and positioning in bed. CNA #1 said Nurse #1 did not call for her to assist with repositioning Resident #1 when it was time for the treatment. During an interview on 02/03/22 at 1:50 P.M., the Director of Nurses (DON) said the Nurse Supervisor called her and explained that Resident #1 fell out of bed while Nurse #1 was trying to reposition him/her in bed. The DON said an X-ray showed Resident #1 had a fracture to his/her left leg. On 02/03/22, the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A) 01/11/22, Resident #1 was assessed by a Physician and new orders were given. B) 01/12/22, the Director of Nurses completed an investigation and reviews of residents' care plans. C) 01/10/22 through 1/29/22, the Associate Director of Operations and Nurse Supervisors completed In-service education for 80% of permanent licensed staff, ( including Nurse #1) on requiring two staff members for turning and positioning residents in bed on the unit. D) 01/10/22 through 1/29/22, Nurse Supervisors performed random checks/audits on the units to ensure residents plans of care were followed by staff members during care. E) Results of the audits will be discussed in the quality Assurance Performance Improvement (QAPI) meeting which is also attended by the Medical Director. F) The Director of Nurses and/or Designee are responsible for the overall compliance.

Based on observation, record review and interview the Facility staff failed to promote care in a manner and in a environment that maintains or enhances each resident's dignity and respect for 1 Residents (#67) out a total sample of 19 residents. Findings include: Resident #67 was admitted to the Facility 7/2018 with [DIAGNOSES REDACTED]. During an interview on 4/30/19, at 10:45 A.M., Resident #67 said that she/he had been waiting for over 45 minutes to get out of bed. Resident #67 said that she/he had already put the call light on at 10:15 A.M., Unit secretary (US) #1 had come in and shut it off and then left. She/he said that US#1 had told her/him that someone would come to help when they had a chance. She said that she/he had been told that she/he was the last to get up because she/he required so much care. On 4/30/19, at 10:45 A.M., the Surveyor observed Resident #67 ring call light to ask when she/he was going to be helped to get up out of bed. US #1 replied over the intercom. She told the Resident to stop ringing the call light because I already told you that someone was going to get you up when they had time. US #1 then entered the room [ROOM NUMBER] minutes later, shut off the call light and said like I said before, someone will be in as soon as they can, don't put the light on again because then I have to come all the way down and shut it off. During an interview on 4/30/19, at 10:47 A.M., Resident #67 said that US #1 always speaks to her/him like that, and that is just the way she is. Resident #67 then said that she/he was used to it. During an interview on 4/30/19, at 2:54 P.M., the Director of Nursing said that it was unacceptable for a staff member to tell a resident not to use a call light. She also said that it was unacceptable for a resident to wait for extended lengths of time for assistance.

Based on observation, record review and interview the Facility staff failed to notify the physician of a significant weight loss for 1 sampled Resident, (#28), out of a total of 19 sampled residents. Findings include: Resident #28 was admitted to the Facility in 10/2010 with [DIAGNOSES REDACTED]. Review of Resident #28's clinical record indicated he/she receives his nutrition via [DEVICE], (a tube that goes directly into the stomach to administer liquid food). On 4/30/19, at 7:50 A.M., the Surveyor observed Resident #28 sleeping in bed. He/she appeared thin and frail. Review of Resident #28's clinical record indicated the following: 2/13/19: 175 lbs (pounds) 3/13/19: 164.9 lbs (a significant weight loss of 5.77% of his/her total body weight in one month) 3/13/19: 164.7 lbs (re-weigh per policy confirming Resident #28's weight loss) 4/10/19: 165 lbs There was no evidence in the clinical record that Resident #28's physician was notified of the significant weight loss. Review of the Facility's Weights Policy, dated 8/14/2018, failed to include procedures for notifying the resident's physician. During an interview with the Physician on 5/1/19, at 8:10 A.M., he said that he was not aware that Resident #28 had a significant weight loss of 11 lbs between 2/2019 and 3/2019. Despite having a documented significant weight loss of 5.77% of his/her total body weight in one month, Resident #28 did not have a physician evaluate or address his/her medical or nutritional status.

Based on observation, record review and interview, the Facility staff failed to evaluate and assess significant weight loss for 1 sampled resident, (#28), out of a total of 19 sampled residents. Findings include: Resident #28 was admitted to the facility in 10/2010 with [DIAGNOSES REDACTED]. Review of Resident #28's clinical record indicated he/she receives his/her nutrition via [DEVICE], (a tube that goes directly into the stomach to administer liquid food). On 4/30/19, at 7:50 A.M., the Surveyor observed Resident #28 sleeping in bed. He/she appeared thin and frail. Review of Resident #28's Nutritional Status Care plan, dated 7/19/16, indicated the following: *Goals: Weight will be between 168 lbs (pounds) and 178 lbs. *Interventions: Needs per registered dietitian assessment. Adjust tube feeding based on weight changes, labs etc. Review of the Facility's Weights Policy, dated 8/14/2018, indicated the following: Residents with a weight difference of more than 5 pounds are referred by the nurse to the dietitian for evaluation and recommendations to the attending medical doctor. Review of Resident #28's clinical record indicated the following: 2/13/19: 175 lbs (pounds) 3/13/19: 164.9 lbs (a significant weight loss of 5.77% of his/her total body weight in one month) 3/13/19: 164.7 lbs (re-weigh per policy confirming Resident #28's weight loss) 4/10/19: 165 lbs There was no evidence in the clinical record that Resident #28's physician or Dietitian was notified of the weight loss. During an interview with Nurse #1 on 4/30/19, at 1:39 P.M., she said that she was not sure if Resident #1 had a recent weight loss. During an interview with Unit Manager #1 on 4/30/19, at 1:52 P.M., she said that she was not aware that Resident #28 had had a significant weight loss and she did not contact Resident #28's physician to notify him and she had not been in contact with the Dietitian. During an interview with the Physician on 5/1/19, at 8:10 A.M., he said that he was not aware that Resident #28 had had a significant weight loss of 11 lbs between 2/2019 and 3/2019. On 5/1/19, at 8:33 A.M., the Surveyor and CNA #1 observed the lift scale used to weigh all residents on Resident #28's unit. CNA #1 said that the aides are responsible to weigh residents using the lift scale and the scale is not new. On 5/1/19, at 8:52 A.M., the Dietitian and Nurse Practice Leader were interviewed. The Dietitian said that she was not aware of Resident #28's significant weight loss and therefore, had not completed an assessment regarding his/her significant weight loss.

Based on observation, record review and interview, the Facility staff failed to ensure medications and biologicals that were available for administration were at full potency and effective for the use intended in 1 of 1 medication rooms inspected and failed to ensure medications and biologicals were stored and secured in a manner which is consistent with federal regulations and professional standards of practice for 1 Resident (#67) out of a total sample of 19 residents. Findings include: 1. During inspection of the 2nd floor medication room on 4/30/19, at 3:40 P.M., the Surveyor observed the following: 1 bottle of Serum Tears 20% with an expiration date of 1/18/19. 1 Insulin emergency kit with an expiration date of 1/31/19. 1 bottle liquid [MEDICATION NAME] sodium with an expiration date of 2/2018. 2 bottles of liquid [MEDICATION NAME] with an expiration date of 9/2018. 2 bottles of Vitamin B-12 tablets with an expiration date of 11/2018. 1 bottle of aspirin tablets with an expiration date of 3/2019. 1 bottle of calcium [MEDICATION NAME] tablets with an expiration date of 1/2019. 1 can of whey protein powder with an expiration date of 1/30/19. 1 can of whey protein powder with an expiration date of 3/22/19. During an interview on 4/30/19, at 3:50 P.M., Unit Manager #1 acknowledged the expired medications. 1. For Resident #67 the Facility staff failed to ensure medications were stored securely at the bedside. Resident #67 was admitted to the Facility 7/2018 with [DIAGNOSES REDACTED]. During the initial tour on 4/30/19, at 8:25 A,M., and at 10:25 A.M., 1:45 P.M., and 3 :24 P.M., the Surveyor observed the following medications at bedside; 2 bottles of Nyamyc powder (an anti-fungal) 1 tube of [MEDICATION NAME] cream (used to treat [MEDICAL CONDITION] conditions of the skin) 1 bottle of liquid medical adhesive remover During an interview on 5/01/19, at 7:21 A.M., Nurse #2 said that all prescription medications should be locked up in the treatment cart.

Based on record review and interview the facility failed to provide notices of non-coverage for 3 of 3 residents sampled. Findings include: Facilities are required to issue to Medicare recipients a Notice of Medicare Non-coverage (NOMNC), form CMS- , to a beneficiary which conveys notice to the beneficiary of his or her right to an expedited review of a service termination. Review of facility records failed to provide evidence the facility issued these required notices in 3 of 3 records reviewed. During interview with the Minimum Data Set (MDS) Coordinator on 5/2/19, at 9:43 A.M., she said that the the Facility had not been giving each resident written Notice of Medicare Non-coverage - (Form CMS -NOMNC) upon discharge from their Medicare A benefit as required.

Based on record review, observation and staff interview, the Facility staff failed to ensure that for 11 Residents (#2, #8, #36, #37, #39, #41, #45, #71, #81, #86, #87,) from a total sample of 23 Residents, that a Comprehensive Care Plan was developed to address the Residents' use of medical devices (seatbelts) and feeding assistants. Findings include: 1. For Resident #2 the Facility failed to develop a comprehensive plan of care for the use of a seatbelt. Resident #2 was admitted to the Facility in 10/2010 with [DIAGNOSES REDACTED]. During the duration of the survey when the Surveyor observed Resident up in his/her wheelchair daily, he/she had a seatbelt attached to the wheelchair and belted around his/her waist. Review of the Resident's care plan indicated no interventions for the management of the seatbelt. 2. For Resident #39 the Facility failed to develop a comprehensive plan of care for the use of a seatbelt. Resident #39 was admitted to the Facility in 2/2015 with [DIAGNOSES REDACTED]. During the duration of the survey when the Surveyor observed Resident up in his/her wheelchair daily, he/she had a seatbelt attached to the wheelchair and belted around his/her waist. Review of the Resident's care plan indicated no interventions for the management of the seatbelt. 3. For Resident #45 the Facility failed to develop a comprehensive plan of care for the use of a seatbelt. Resident #45 was admitted to the Facility in 3/2007 with [DIAGNOSES REDACTED]. During the duration of the survey when the Surveyor observed Resident up in his/her wheelchair daily, he/she had a seatbelt attached to the wheelchair and belted around his/her waist. Review of the Resident's care plan indicated no interventions for the management of the seatbelt. 4. For Resident #71 the Facility failed to develop a comprehensive plan of care for the use of a seatbelt. Resident #71 was admitted to the Facility in 6/2014 with [DIAGNOSES REDACTED]. During the duration of the survey when the Surveyor observed Resident up in his/her wheelchair daily, he/she had a seatbelt attached to the wheelchair and belted around his/her waist. Review of the Resident's care plan indicated no interventions for the management of the seatbelt. During an interview on 4/05/18, at 12:00 P.M. Resident #71 said she did not know why they insist she wears a seatbelt. She thinks it is because it comes with the wheelchair. She said that she likes it when she goes outside on the sidewalk but she doesn't understand why she has to wear it inside. 5. For Resident #86 the Facility failed to develop a comprehensive plan of care for the use of a seatbelt. Resident #86 was admitted to the Facility in 8/2008 with [DIAGNOSES REDACTED]. During the duration of the survey when the Surveyor observed Resident up in his/her wheelchair daily, he/she had a seatbelt attached to the wheelchair and belted around his/her waist. Review of the Resident's care plan indicated no interventions for the management of the seatbelt. 6. For Resident #87 the Facility failed to develop a comprehensive plan of care for the use of a seatbelt. Resident #87 was admitted to the Facility in 2/2014 with [DIAGNOSES REDACTED]. During the duration of the survey when the Surveyor observed Resident up in his/her wheelchair daily, he/she had a seatbelt attached to the wheelchair and belted around his/her waist. Review of the Resident's care plan indicated no interventions for the management of the seatbelt. 7. For Resident #81, the facility failed to care plan for the use of paid feeding assistants. Resident #81 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of his/her most recent MDS dated [DATE] indicated that he/she is moderately cognitively impaired and requires assistance with eating. Review of Resident #81's clinical record indicated that he/she is assisted by paid feeding assistants, but no care plan was developed to include this intervention. 8. For Resident #41 the facility failed to care plan for the use of paid feeding assistants. Resident #41 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. Review of his/her most recent MDS dated [DATE] indicated that he/she is cognitively intact and requires assistance with eating. Review of Resident #41's clinical record indicated that he/she is assisted by paid feeding assistants during meals, but no care plan was developed to include this intervention. 9. For Resident #8, the facility failed to care plan for the use of paid feeding assistants. Resident #8 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. Review of his/her most recent MDS dated [DATE] indicated that he/she is moderately cognitively impaired and requires assistance with eating. Review of Resident #8's clinical record indicated that he/she is assisted by paid feeding assistants during meals, but no care plan was developed to include this intervention. 10. For Resident #36 the facility failed to care plan for the use of a seatbelt as a positioning device. Resident #36 was admitted to the facility in 4/2016 with [DIAGNOSES REDACTED]. During interview with Resident #36 on 4/9/18 the Surveyor observed he/she was wearing a seatbelt. Review of Resident #36's clinical record indicated the use of the belt for positioning, but no care plan was developed or included the use of the belt for positioning or how to monitor its use. 11. For Resident #37, the facility failed to care plan for the use of a seatbelt as a positioning device. Resident #37 was admitted to the facility in 2003 with [DIAGNOSES REDACTED]. Review of Resident #37's clinical record indicated the use of a seatbelt to assist in positioning, but no care plan was developed or included the use of the belt for positioning or how to monitor its use.

Based on observation, interview and record review the Facility failed to ensure that the residents were assessed for the potential for entrapment, attempt to use alternatives before the use of side rails, and discuss risks vs. benefits with the Resident/responsible party for 13 residents, (#2, #8, #11, #36, #37, #41, #45, #49, #71, #76, #55, #81, #86) out of a total of 23 Residents. Findings include: 1. For Resident #2 the Facility failed to attempt the use of alternatives before the use of siderails. Resident #2 was admitted to the Facility in 10/2010 with [DIAGNOSES REDACTED]. On 4/2/18, at 10:22 A.M. the Surveyor observed Resident #2 in bed with 1/2 rails up. Review of the Facility document titled IDT-Device Decision Guide and dated 3/19/18, indicated that no alternatives to the use of side rails were attempted. Further review of the document indicated that the answer to the question Do any of the devices enable the resident to do something that they would otherwise not be able to do? is marked as No, indicating no benefit to the Resident for the use of siderails. 2. For Resident #45 the Facility failed to accurately assess for the potential for entrapment and attempt to use alternatives before the use of side rails. Resident #45 was admitted to the Facility in 3/2007 with [DIAGNOSES REDACTED]. Review of the Facility document titled IDT-Device Decision Guide and dated 3/16/18, indicated that the mattress was the correct size for the bed and that there were no mattress extenders in place. Further review of the document indicated that no assessment was made to determine the risk of entrapment between the mattress and the bed frame. On 4/10/18, at 11:30 A.M. the Surveyor observed the mattress on the Resident's bed to be greater than 10 inches from the end of the bed frame without a mattress extender in place. On 4/2/18, at 9:12 A.M. the Surveyor observed the Resident in bed with 1/2 rails up. Review of the Facility document titled IDT-Device Decision Guide and dated 3/16/18, indicated that no alternatives to the use of side rails were attempted. 3. For Resident #71 the Facility failed to attempt the use of alternatives before the use of siderails. Resident #71 was admitted to the Facility in 6/2014 with [DIAGNOSES REDACTED]. On 4/9/18, at 7:15 A.M. the Surveyor observed the Resident in bed with 1/2 rails up. Review of the Facility document titled IDT-Device Decision Guide and dated 2/23/18, indicated that no alternatives to the use of side rails were attempted. Further review of the document indicated that the answer to the question Do any of the devices enable the resident to do something that they would otherwise not be able to do? is marked as No, indicating no benefit to the Resident for the use of siderails. 4. For Resident #86 the Facility failed to attempt the use of alternatives before the use of siderails. Resident #86 was admitted to the Facility in 8/2008 with [DIAGNOSES REDACTED]. On 4/2/18, at 9:29 A.M. the Surveyor observed the Resident in bed with 1/2 rails up. Review of the Facility document titled IDT-Device Decision Guide and dated 4/2/18, indicated that no alternatives to the use of side rails were attempted. 5. For Resident #8, the facility failed to assess him/her for risk of entrapment. Resident #8 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. Review of Resident #8's clinical record indicated that he/she was not assessed for the possible risk of entrapment in regards to the use of siderails or ensuring that an appropriate mattress was in place. Additionally, the Surveyor observed a gap of greater than 10 inches between the mattress and the foot board. 6. For Resident #49, the facility failed to assess him/her for risk of entrapment. Resident #49 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Review of Resident #49's clinical record indicated that he/she was not assessed for the possible risk of entrapment in regards to the use of siderails or ensuring that an appropriate mattress was in place. Additionally, the Surveyor observed a gap of 6 inches between the mattress and the headboard and the foot board. 7. For Resident #55 the facility failed to assess him/her for risk of entrapment. Resident #55 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of Resident #55's clinical record indicated that he/she was not assessed for the possible risk of entrapment in regards or he use of siderails or ensuring that an appropriate mattress was in place. Additionally, the Surveyor observed a gap of 5.5 inches between the mattress and the headboard and the footboard. 8. For Resident #81, the facility failed to assess him/her for risk of entrapment. Resident #81 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of Resident #81's clinical record indicated that he/she was not assessed for the possible risk of entrapment in regards to the use of side rails or ensuring that the appropriate mattress was in place. 9. For Resident #41 the facility failed to asses him/her for risk of entrapment. Resident #41 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. Review of Resident #41's clinical record indicated that he/she was not assessed for the possible risk of entrapment in regards to the use of side rails or ensuring that the appropriate mattress was in place. 10. For Resident #36 the facility failed to assess him/her for risk of entrapment. Resident #36 was admitted to the facilitiy in 4/2016 with [DIAGNOSES REDACTED]. Review of Resident #36's clinical record indicated that he/she was not assessed for the possible risk of entrapment in regards to the use of side rails or ensuring that the appropriate mattress was in place. 11. For Resident #37, the facility failed to assess him/her for risk of entrapment. Resident #37 was admitted to the facility in 2003 with [DIAGNOSES REDACTED]. Review of Resident #37's clinical record indicated that he/she was not assessed for the possible risk of entrapment in regards to the use of siderails or ensuring that an appropriate mattress was in place. 04/10/18 11:47 AM When referring to the document titled IDT-Device Decision Guide, the DNS said there is a disconnect between what the nurses were supposed to do in filling it out and what they did do. She said they need more instruction on how to appropriately assess the residents and complete the document. She also indicated that the form they are using does not incorporate a full assessment and they need to look at changing it to conform to the regulations. 12. For Resident #11 the facility failed to assess him/her for risk of entrapment. Resident #11 was admitted to the facility in 5/2009 with [DIAGNOSES REDACTED]. Resident #11 was observed 4/5/18 at 3:58 P.M. in his/her room sitting in a motorized wheelchair. The resident's bed was tidy and the surveyor observed a large gap between the end of the mattress and the footboard. The mattress did not fit the bed frame properly revealing an entrapment potential. 13. For Resident #76 the facility failed to assess him/her for risk of entrapment. Resident #11 was admitted to the facility in 5/2008 with [DIAGNOSES REDACTED]. Resident #76 was observed 4/9/18 at 8:45 A.M. in his/her room lying in bed. The surveyor observed a large gap between the end of the mattress and the footboard. The mattress did not fit the bed frame properly revealing an entrapment potential. During interview with the Maintenance Director 4/9/18 at 11:30 A.M. he said nursing staff were to complete the mattress assessment. He said the facility had replaced many beds recently and he would look into the beds with mattresses that do not fit properly.

Based on observation and interview and record review, the Facility failed to ensure that its' infection control program was consistently followed. Multiple nursing staff members were observed not following basic principles of Infection Control, by not cleaning shared Resident to Resident equipment and while disposing of soiled briefs. Findings include: 1. On 4/05/18, at 10:38 A.M. the Surveyor observed CNA #1 in the 2nd floor television room clipping and filing a Resident's nails. After clipping the Residents' nails, CNA #1 filed the Resident's nails and then used the nail file to brush the nail clippings off the Resident's shirt onto the floor. She then removed her gloves and without performing hand hygiene, left the room to wheel a resident across the hall carrying her dirty gloves. CNA #1 then walked down the hall with gloves in her hand to dispose of her gloves. When she left the television room she left [MEDICATION NAME], nail polish and nail clippers on a table in the television room with 8 residents in it. CNA #1 re-entered the television room and proceeded to use the same contaminated nail clippers and nail file on another resident without cleaning them first. She then repeated the same actions for all residents in the television room, never cleaning the instruments she was using nor performing hand hygiene between residents. Review of the Facility Policy titled Nail Care and dated 4/1/98, indicated that prior to performing nail care the caregiver is to wash their hands, clean equipment after use and wash hands again after procedure. On 4/08/18, at 9:07 A.M. the Director of Nursing (DON) said that she doubted CNA #1 had had any training on nail care. 2. On 4/10/18, at 4:33 P.M. the Surveyor observed CNA #2 exit room [ROOM NUMBER] carrying a clear plastic bag containing soiled briefs while wearing gloves. She then walked down the hall, opened the trash container with her contaminated glove contaminating the lid of the trash container, disposed of the bag, closed the lid of the trash container, removed her gloves, opened the contaminated trash container with her hand contaminating it and then discarded the gloves into the trash container. CNA #2 then entered room [ROOM NUMBER] without performing hand hygiene.

Based on observations, interviews and record review the facility failed to provide care in a manner and in an environment that maintains or enhances each resident's dignity, by staff speaking a foreign language and talking into headsets during care for 3 Residents (#6, #11 #76) from a total sample of 23 residents, and in resident common areas on both the 1st and 2nd floor units. Findings include: 1. Resident #6 was admitted to the facility in 9/2013 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident had a Brief Interview Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact, and is totally dependent for bed mobility, transfers, dressing, toileting and bathing. During interview 4/5/2018 at 4:05 P.M. he/she said the certified nurse aides (CNAs) and nurses consistently speak in a foreign language among themselves when prividing resident care. It is very upsetting when they are caring for me and I do not know what they are saying about me. They also answer questions into their headsets about other residents when providing my care. There is very little interaction because they are distracted by the headset. 2. Resident #11 was admitted to the facility in 5/2009 with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated the resident had a BIMS score of 15 out of 15 indicating the resident was cognitively intact, and is totally dependent for bed mobility, transfers, dressing, toileting and bathing. During interview 4/9/18 at 2:47 P.M. he/she said the staff does speak a foreign language frequently and it makes me feel uncomfortable sometimes. When they talk into the headsets, I think they are talking to me but they are not. 3. Resident #76 was admitted to the facility in 5/2008 with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated the resident had a BIMS score of 08 indicating the resident had moderate cognitive impairment, and is totally dependent for bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing. During interview 4/5/18 at 11:11 A.M. he/she said the staff always talk to each other in another language. I can never understand what they are saying and I think it is disrespectful. During observations 4/2/18, 4/3/18 and 4/5/18 CNA's were speaking into the headsets in resident rooms throughout the day. They were heard answering call lights, answering questions and giving commands to the system. During interview 4/10/18 at 10:30 A.M. the facility Administrator and the Director of Nursing described the use of Accunurse (headset documentation system used by the nursing staff). All nursing staff are trained how to document resident care through the Accunurse system. Unit Managers and management staff are responsible for observation of the proper use of the system. During the Resident Group Interview held on 4/3/18 at 10:30 A.M., the participants from both the 1st and 2nd floor said it was common for staff to speak in languages other than English during care. Multiple residents said that it made them feel uncomfortable and that it has been an ongoing issue in the facility for years. On 4/3/18 at 8:21 A.M., on the 2nd floor, the Surveyor observed a CNA on her cellphone while assisting a resident in bed with their breakfast. On 4/3/18 at 8:32 A.M., on the 2nd floor, the Surveyor observed 2 staff speaking a language other than English while giving care to a resident in his/her bed. On 4/3/18 at 9:00 A.M., on the 2nd floor the Surveyor observed 2 staff speaking in an language other than English in a resident room, while assisting a resident witht heir breakfast. When the staff saw the Surveyor, they left the room and entered another occupied resident room without knocking and continued their conversation in a language other than English. During an interview on 4/3/18, 10:57 A.M. a Resident on the 2nd floor said CNA's speak (a foreign language) in my room. I am tired of them speaking a language I can't understand. I have had as many as 4 CNA's in my room at the same time speaking (in a foreign language). I have told the management many times but it doesn't stop. I don't know what they are saying, maybe they are talking about me. I don't like it. On 4/5/18 at 2:19 P.M., on the 1st floor, the Surveyor observed a Resident asking 2 nurses to not speak in a language other than English. On 4/6/18 at 10:53 A.M., on the 2nd floor, the Surveyor observed two CNA's laughing and speaking a language other than English while giving a resident care in his/her room.

Based on interview and record review the Facility staff failed to thoroughly investigate an injury of unknown source for 2 Residents (#78 and #87) out of a total sample of 23 residents. Findings include: 1. Resident #78 was admitted to the facility in 8/2010 with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated a (Brief Interview of Mental Status) BIMS score of 9 out of 15, indicating the resident had moderate cognitive impairment, and was totally dependent for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. During observation 4/2/18 at 9:25 AM, Resident #78 was lying in bed dressed. A large blood filled area approximately 5 X 3 cm on the right inner forearm near the wrist was observed. Several small reddened areas on both forearms were also observed. The resident said he/she did not know how the large area happened. Record review indicated no identification of the large blood filled area in the nursing progress notes. A Weekly Skin Check completed 3/23/18 identified ecchymosis to bilateral hands and bilateral arms. A Weekly Skin Check completed 3/30/18 identified old dark bruises to bilateral arms. The resident does take blood thinning medicine daily. During observation 4/3/18 and 4/4/18 the large blood filled area was unchanged. The surveyor requested the completed Incident Report for the investigation of the large blood filled area from the Assistant Director of Nurses. During meal observation in the dining room [ROOM NUMBER]/5/18 the Assistant Director of Nursing (ADON) pointed to the large blood filled area of Resident #78's forearm and asked if that is the area in question for the requested incident report. She stated there is no incident report for that area. We do not consider that needing an incident report. The resident gets these old age spots frequently, she has fragile skin. Review of the Facility policy titled Protecting Residents From Abuse, Neglect and Misappropriation of Property and updated 1/30/2018, did not include a procedure for investigating injuries of unknown source. During interview with the Director of Nursing (DNS) on 4/9/18 at 9:30 A.M., she said that an investigation is not necessary for an occurrence like that. The resident gets those areas because of his/her age and blood thinners. The DNS was asked how then can you determine if such an occurrence is not caused by injury or rough treatment by staff? She answered that she knows her staff very well, most have been here for years and would never harm a resident. 2. For Resident #87 the Facility failed to thoroughly investigate a bruise of unknown source. Resident #87 was admitted to the Facility in 11/2017 with [DIAGNOSES REDACTED]. Review of the clinical record indicated a Facility document titled Resident/Visitor Incident Report Form and dated 2/28/17, indicated that the Resident had sustained a bruise on the right posterior wrist that is described as large on the document. Further review of the document indicated that the Resident said he/she did not bump the area and that the Resident reported the area was causing discomfort. Review of the Facility document titled Skin Injury Investigation and dated 2/28/17, indicated that Staff were not interviewed to assist in determining the cause of the injury. Further review of the document indicated that the Resident was not on a blood thinning medication, did not have fragile skin and was not anemic, all potential factors in sustaining a bruise. Review of the Facility policy titled Protecting Residents From Abuse, Neglect and Misappropriation of Property and updated 1/30/2018, did not include a procedure for investigating injuries of unknown source. During an interview on 4/9/18, at 9:25 A.M. the DNS said that we don't do a formal documented investigation of injuries of unknown source. I don't document who I spoke to or what they said. If I think there was abuse I would do a more formal investigation. I would think I would be suspicious of abuse if a resident had sustained a bruise on the wrist or other place that would give me concern or words to that effect.