Every finding on record at Bostonian Nursing Care & Rehabilitation Center

Based on observations, record review and interviews, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for one Resident (#7) out of a total of 25 sampled residents. Specifically, for Resident #7 who has chronic pressure ulcers, the facility failed to implement the physician order to offload the coccyx wound. Findings include:Resident #7 was admitted to the facility in October 2023 with diagnoses that included paraplegia, quadriplegia, type 2 diabetes with neuropathy, and pressure ulcers. Review of Resident #7's most recent Minimum Data Set (MDS) assessment, dated 4/30/26, indicated he/she scored a 6 out of a possible 15 on the Brief Intervention for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she is dependent on staff for bathing, dressing, turning and transferring. The MDS indicated the Resident had unhealed pressure ulcers and is at risk for developing pressure ulcers. The surveyor observed Resident #7 flat on his/her back in bed on: -6/1/26 at 7:56 A.M.-6/1/26 at 8:23 A.M. -6/1/26 at 12:22 P.M. -6/1/26 at 2:07 P.M.-6/1/26 at 4:07 P.M. -6/2/26 at 6:44 A.M. -6/2/26 at 7:48 A.M. -6/2/26 at 8:10 A.M. -6/2/26 at 9:57 A.M., right after morning Activities of Daily Living (ADLs) care.-6/2/26 at 10:25 A.M. -6/2/26 at 10:54 A.M. -6/2/26 at 11:12 A.M. -6/2/26 at 1:36 P.M. -6/2/26 at 3:46 P.M.-6/4/26 at 7:53 A.M., right after morning ADL care. Review of Resident #7's physician order, dated 10/30/24, indicated Reposition resident frequently side to side to keep pressure off the coccyx wound. Document q (every) shift in nurses note outcome of the repositioning if resident refuse document. Review of Resident #7's June 2026 Treatment Administration Record, indicated on 6/1/26 and 6/2/26 nursing signed off the above order every shift as administered. Review of the nursing progress notes from 5/19/26 to 6/3/26 failed to indicate that the Resident refused repositioning. Review of Resident #7's potential for skin care plan, dated 5/24/26, indicated Follow facility policies/protocols for the prevention/treatment of skin breakdown. Administer treatments as ordered and monitor for effectiveness. Review of Resident #7's wound provider progress note, dated 5/28/26, indicated Patient was seen for a chronic pressure ulcer on the coccyx. History of wound has chronic osteomyelitis. Patient was recently discharged from the hospital wound coccyx has increased in size. Educated patient and nursing on the importance of offloading and treatment plan. Review of Resident #7's Norton Scale (Pressure Ulcer Risk Scale), dated 4/17/26, indicated a score of 7 which indicates he/she is at high risk for developing pressure ulcers. During an interview and observation on 6/4/26 at 7:55 A.M., Nurse #2 said Resident #7 has multiple wounds on his/her coccyx and buttocks. Nurse #2 said he/she is flat on his/her back but should have pillows under him/her to keep his/her wounds offloaded but does not. Nurse #2 said if he/she refuses to be offloaded and repositioned then a nursing note should be written. Nurse #2 said it is important to offload his/her wounds to help with wound healing and has not been told by Certified Nurse Aides that he/she has been refusing to be repositioned to offload his/her coccyx wound. Due to the Resident's cognition he/she was unable to participate in the interview process. During an interview and observation on 6/4/26 at 7:56 A.M., the Regional Nurse said the Resident is flat on his/her back, but he/she was repositioned. During an interview on 6/4/26 at 8:34 A.M., the Director of Nurses (DON) said the Resident does have chronic pressure ulcers and the nursing staff should be offloading the wounds and not left flat on his/her back. The DON said if the Resident refuses to be offloaded off of his/her back then the nurse should write a note and not sign off the order as administered. During an interview on 6/4/26 at 8:06 A.M., Certified Nurse Aide (CNA) #1 said that he/she provided morning care to Resident #7 today and said he/she was left on his/her back after care was given. The CNA said the Resident did not refuse to be repositioned.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Midline Catheter (A midline catheter is a peripheral IV (intravenous) catheter inserted into a large vein in the upper arm, with the tip ending near the axilla, used to deliver medications intravenously) consistent with professional standards of practice for one of one Resident (#49) with an IV catheter. Specifically, for Resident #49 the facility failed to ensure that when the midline dressing was lifting (compromised), it was changed, and that the insertion site was able to be visualized for assessments. Findings include:Resident #49 was admitted to the facility in September 2025 with diagnoses that included peripheral vascular disease, type 2 diabetes, and chronic kidney disease. Review of Resident #49's most recent Minimum Data Set (MDS) assessment, dated 5/11/26, indicated he/she was assessed by nursing staff to have moderate cognitive impairment. Review of Resident #49's physician order, dated 5/21/26, indicated Monitor midline to right antecubital site for intactness and s/s of infections q (every) shift. Review of Resident #49's physician order, dated 5/26/26, indicated Change Midline Catheter dressing weekly and PRN (as needed) with transparent dressing. On 6/1/26 at 7:54 A.M. and 2:01 P.M., the surveyor observed a midline IV in the Resident's right arm, the midline insertion site was covered with gauze unable to be visualized and was dated 5/31/26. The bottom corner of the dressing was observed to be lifting. On 6/2/26 at 6:45 A.M., the surveyor observed a midline IV in the Resident's right arm, the midline insertion site was covered with gauze unable to be visualized and was dated 5/31/26. The bottom corner of the dressing was observed to be lifting. The IV insertion site was unable to be visualized for five shifts. Review of Resident #49's IV care plan, dated 5/20/26, indicated Monitor/document/report PRN s/sx (signs and symptoms) of infection at the site: Drainage, Inflammation, Swelling, Redness, Warmth. Monitor/document/report PRN (as needed) s/sx of leaking at the IV site: Edema at the insertion site, Taut, shiny or stretched skin, whitening/blanching or coolness of the skin, slowing or stopping of the infusion, leaking of I.V. fluid out of the insertion site. Review of Resident #49's nursing progress note, dated 6/1/26, indicated Continues on IV antibiotics via Right brachial midline. No complication noted at IV site. During an interview on 6/2/26 at 7:46 A.M., the Assistant Director of Nurses (ADON) said she observed the Resident's midline and the insertion site was unable to be visualized. The ADON said the Resident has a midline because he/she has an infection and said that it is important for the insertion site to be able to be assessed so the nurses would know if there were an infection at the site. During an interview on 6/2/26 at 7:47 A.M., Nurse #1 said she works at the facility most nights and noticed last night (5/31/26 into 6/1/26) that the insertion site of the midline IV was unable to be seen due to gauze covering the insertion site and that the dressing itself was lifting off the skin. Nurse #1 said gauze should not be put over the insertion site because if it is covered then it is unable to be assessed for signs and symptoms of infection. Nurse #1 said the dressing should have been changed also due to the corner lifting. During an interview on 6/2/26 at 8:24 A.M., Nurse #2 said she changed the midline dressing during the day on 5/31/26 and was not aware that she should not have placed gauze over the insertion site. During an interview on 6/2/26 at 2:00 P.M., the Director of Nurses (DON) said a midline IV insertion site should never be covered unless the Resident is actively bleeding at the site. The DON said there would be no way to assess the IV insertion site if it is covered with gauze. The DON said if the corner of the dressing was lifting then the dressing is compromised and needs to be changed right away as it puts the Resident at risk for infection.

Based on record review, policy review and interview, the facility failed to ensure a comprehensive plan of care was developed for Trauma Informed Care for one Resident (#24) who had a history of trauma out of a total sample of 25 residents. Specifically, for Resident #24, the facility failed to develop a comprehensive trauma care plan, with individualized triggers.Findings Include:Review of the facility policy titled, Trauma Informed Care and PTSD, dated August 2019, indicated the following:Policy Statement-The facility will strive to provide that residents who are trauma survivors receive culturally competent, trauma informed care in accordance with professional standards of proactive and accounting of residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re traumatization of the resident. Goal is establishing an atmosphere of calm and safety and attempt to avoid escalation of PTSD reaction.Procedure:Residents will be assessed upon admission to the facility to identify history trauma/PTSD.If a history of Trauma or PTSD is identified staff will develop care plan that may include potential triggers and how to avoid re traumatization. Care plan will be reviewed at admission, quarterly, and in response to significant change.Staff education will be provided upon hire and annually.Resident #24 was admitted to the facility in December 2024 with diagnoses that included Post-Traumatic Stress Disorder (PTSD), borderline personality, major depressive disorder and hallucinations.Review of the most recent Minimum Data Set (MDS) assessment, dated 3/26/26, indicated the Resident was assessed by staff to have intact cognition. The MDS further indicated Resident #24 requires substantial/maximal to dependent assistance for self-care activities and has an active diagnosis of PTSD.Review of Resident #24's medical record failed to indicate a plan of care for PTSD with identified triggers.During an interview on 6/2/26 at 10:54 A.M., the Assistant Director of Nursing said the social worker completes the trauma assessments and develops the PTSD care plans, and she would expect triggers to be identified to better care for the residents.During an interview on 6/2/26 at 11:12 A.M., Social Worker #1 said we complete the trauma assessment when we meet with the resident and try to identify the source of trauma, identify triggers and develop a comprehensive care plan. Social Worker #1 said the care plan should identify the residents' individual triggers to best meet their needs and indicate if the resident declines to discuss triggers or failed to identify any triggers.During an interview on 6/2/26 at 11:43 A.M., the Director of Nursing said the social worker would initiate the trauma informed assessment, develop the care plan and psych services would be consulted. The Director of Nursing said she would expect a PTSD care plan to be developed with identified triggers.Resident #24 declined to participate in the interview process regarding his/her PTSD diagnosis and/or identification of triggers.

Based on observation, record review and interview, the facility failed to implement the care plan for one Resident (#62) out of a total sample of 23 residents. Specifically, the facility failed to ensure Resident #62 was wearing a Wanderguard (a bracelet around the ankle that locks or alarms facility doors when a resident is near them) as ordered by the physician. Findings include: Review of the facility policy titled Elopement Policy dated February 2025, indicated the following: - Include the following if there is any threat of elopement: Identify residents at risk for wandering/elopement behavior. Resident #62 was admitted to the facility in February 2020 with diagnoses including unspecified psychosis and anxiety disorder. Review of Resident #62's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 4 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident has wandering behaviors. The surveyor made the following observations: - On 5/27/25 at 12:14 P.M., Resident #62 was walking up and down the hallway using a rolling walker. There was no Wanderguard bracelet observed on either one of his/her ankles. - On 5/28/25 at 8:15 A.M., Resident #62 was sitting in the dining room. The surveyor asked if he/she could pull down his/her socks below the ankles. No Wanderguard was observed on either ankle. - On 5/28/25 at 9:42 A.M., Resident #62 was walking up and down the hallway using a rolling walker. There was no Wanderguard bracelet observed on either one of his/her ankles. Review of Resident #62's physician's orders indicated the following: - Dated 10/3/23: May use Wanderguard system. Monitor Wanderguard to left ankle every shift for placement, every shift. - Dated 11/22/24: Wanderguard to right ankle. Check function daily, every shift, replace Wanderguard bracelet per expiration date located on device. Review of Resident #62's Elopement Risk Assessment Form dated 4/14/25 indicated that the Resident scored 16. The Assessment indicated that a score above 10 indicates a high risk to wander. Review of Resident #62's care plan dated 10/5/23 indicated the following: - Problem: Resident #62 is an elopement risk/wanderer and has a Wanderguard in place to left ankle. - Intervention: Wanderguard. During an interview on 5/28/25, Unit Manager #1 said Resident #62 wanders up and down the unit all the time and he/she should have a Wanderguard on his/her ankle. Unit Manager #1 and the surveyor reviewed Resident #62's physician's orders and Unit Manager #1 said she would expect the Wanderguard to be in place. Unit Manager #1 and the surveyor observed Resident #62 sitting in his/her bed, the Resident was barefoot and no Wanderguard was observed on either ankle. Unit Manager #1 asked for permission to look for it in the Resident's room, Unit Manager #1 was unable to locate the Wanderguard. Unit Manager #1 said if staff noticed Resident #62 not wearing a Wanderguard she would expect to be notified. During an interview on 5/28/25 at 2:17 P.M., the Director of Nursing said Resident #62 should have been wearing a Wanderguard per the physician's orders. During an interview on 5/29/25 at 7:54 A.M., Social Worker #1 said Resident #62 wanders up and down the hallway all the time.

Based on observations, record review and interviews, the facility failed to implement a care plan for skin protection for 1 Resident (#18) out of a total sample of 25 residents. Finding include: Resident #18 was admitted to the facility in October 2023 with diagnoses including paraplegia. Review of Resident #18's most recent Minimum Date Set (MDS) indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status, which indicated he/she was cognitively intact. The MDS also indicated Resident #18 was dependent on staff for all bed mobility tasks. Review of Resident #18's medical chart indicated he/she was hospitalized from 6/2/24 to 6/14/24 and upon return to the facility, the Resident had a deep tissue injury to his/her left heel. On 6/25/24 at 8:08 A.M., Resident #18 was observed lying in bed with both heels directly on the bed. There were two pressure relieving heel booties on the chair across from the bed. On 6/26/24 at 7:12 A.M., 7:57 A.M. 12:27 P.M., and 12:47 P.M., Resident #18 was observed lying in bed with both heels directly on the bed. There were two pressure relieving heel booties on the chair across from the bed. During an interview on 6/26/24 at 12:27 A.M., Resident #18 said he/she does not wear the protective booties because nursing has not offered to put them on. Resident #18 said he/she would wear the booties if nursing would put them on. Review of Resident #18's physician orders indicated the following order: -Encourage booties to bilateral heels as resident allows, initiated on 6/17/24. Review of Resident #18's Kardex (a form indicating the level of care required) indicated the following: -Encourage booties to bilateral heels as resident allows. During an interview on 6/26/24 at 12:53 P.M., Nurse #2 said she was unaware if Resident #18 had any skin issues on his/her heels. Nurse #2 said she had not yet offered to assist the Resident with putting on the booties today. During an interview on 6/26/24 at 1:09 P.M., the Director of Nursing said orders should be followed as written.

Based on observations, record review and interviews, the facility failed to implement bilateral hand orthotics for the treatment of contractures for 1 Resident (#79) out of a total sample of 25 residents. Findings include: Resident #79 was admitted to the facility in September 2020 with diagnoses including subdural hematoma (bleeding in the brain) and contractures of both the left and right hands. Review of Resident #79's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #79 was dependent on staff for all functional daily tasks. Review of Resident #79's physician orders indicated the following order: -Bilateral palm rolls on at all times - remove for hygiene and ADLs (Activities of Daily Living), every shift, initiated on 10/8/2020. On 6/25/24 at 8:02 A.M., Resident #79 was observed lying in bed with his/her hands in a fisted position and face cloths in both hands. The face cloths were not rolled and only partially in the Resident's hands. On 6/26/24 at 8:05 A.M., 10:21 A.M., and 11:20 A.M., Resident #79 was observed with his/her hands in a fisted position and face cloths in both hands. The face cloths were not rolled and only partially in the Resident's hands. During an interview on 6/26/24 at 11:20 A.M., Certified Nursing Assistant (CNA) #4 searched Resident #79's room and was unable to find hand rolls. CNA #4 said she had never seen the Resident use hand rolls and that staff place towels in Resident #79's hands daily. During an interview on 6/26/24 at 11:26 A.M., Nurse #1 said Resident #79 has an order to use bilateral hand rolls daily due to his/her hand contractures. Nurse #1 said if the hand rolls are missing and staff need to notify the rehabilitation department so new hand rolls can be ordered. Nurse #1 said she was unaware Resident #79's hand rolls had gone missing. During an interview on 6/26/24 at 11:32 A.M., the Occupational Therapist (OT) said she was unaware Resident #79's hand rolls were missing. The OT said hand rolls are used for individuals with contractures in order for hands to be kept open and prevent contractures from worsening. The OT said wash cloths, especially if not rolled, are an ineffective replacement for hand rolls. During an interview on 6/26/24 at 1:09 P.M., the Director of Nursing said she would expect the nursing staff to make a referral to rehabilitation if equipment such as hand rolls go missing. The Director of Nursing said wash cloths do not meet the purpose of hand rolls.

Based on observation, policy review, and interview, the facility failed to maintain appropriate food sanitation practices in the kitchen. Findings include: Review of the facility policy titled Nutrition and Foodservice- Employee Practices, dated 09/2023, indicated the following: - Gloves worn in food preparation should be changed: * as soon as they become soiled or torn * at least every four hours during continual use and more often when necessary * after handling raw meat and before handling cooked or ready-to-eat food During an observation on 6/27/24 at 7:47 A.M., the cook on the serving line was wearing a pair of disposable gloves and walked away from serving the food on the line and put on oven mitts over the disposable gloves, opened the steamer, and then removed the oven mitts. Without changing the disposable gloves, the cook proceeded to touch and serve a ready to eat english muffin with the potentially contaminated gloves. At 7:49 A.M., the cook, while wearing the same contaminated gloves, opened the refrigerator door, and then proceeded to touch ready to eat pancakes with the contaminated gloves. During an interview on 6/27/24 at 10:00 A.M., the Food Service Director was made aware of the cross contamination and said that cooks should change their gloves before touching ready to eat food.

Based on observations, record review and interviews, the facility failed to maintain an accurate medical record by 1. inaccurately marking a treatment complete when it was not for 1 Resident (#18) and 2. not completing daily documentation for 1 Resident (#12) out of a total sample of 25 residents. Finding include: 1. Resident #18 was admitted to the facility in October 2023 with diagnoses including paraplegia. Review of Resident #18's most recent Minimum Date Set (MDS) indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she was cognitively intact. The MDS also indicated Resident #18 was dependent on staff for all bed mobility tasks. Review of Resident #18's medical chart indicated he/she was hospitalized from 6/2/24 to 6/14/24 and upon return to the facility, the Resident had a deep tissue injury to his/her left heel. Review of Resident #18's physician orders indicated the following order: -Encourage booties to bilateral heels as resident allows, initiated on 6/17/24. On 6/26/24 at 12:27 P.M., Resident #18 was observed lying in bed with both heels directly on the bed. There were two pressure relieving heel booties on the chair across from the bed. During an interview on 6/26/24 at 12:27 A.M., Resident #18 said he/she does not wear the protective booties because nursing has not offered to put them on. Resident #18 said he/she would wear the booties if nursing would put them on. Review of the Treatment Administration Record (TAR) indicated nursing had documented the physician order as complete and Resident #18 was wearing the bilateral heel booties. During an interview on 6/26/24 at 12:53 P.M., the surveyor showed Nurse #2 the TAR. Nurse #2 said she documented the physician order as completed even though she had not completed the order. During an interview on 6/26/24 at 1:09 P.M., the Director of Nursing said nurses should not document orders are complete if they had not completed the treatment. 2. Resident #12 was admitted to the facility in May 2024 with diagnoses including muscle weakness and dementia. Review of Resident #12's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #12 is dependent for bathing tasks. Review of the Activity of Daily Living (ADL) documentation for the month of June 2024, indicated the following: -there were 12 daytime shifts (7:00 A.M. to 3:00 P.M.) with no ADL documentation completed. -there were 9 afternoon shifts (3:00 P.M. to 11:00 P.M.) with no ADL documentation completed. -there were 16 nighttime shifts (11:00 P.M. to 7:00 A.M.) with no ADL documentation completed. During an interview on 6/26/24 at 10:09 A.M., Certified Nursing Assistant (CNA) #3 said all documentation is completed on the computer and the CNAs are expected to document all care on all shifts. During an interview on 6/26/24 at 1:09 P.M., the Director of Nursing said the CNAs are expected to document all care provided throughout the day on all shift and there should be no missing documentation.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had developed areas of skin breakdown, had been admitted to the Hospital, and required treatment by the Hospital wound nurse while admitted , the Facility failed to ensure that upon readmission to the Facility he/she was provided nursing treatment and services that were consistent with professional standards of practice related to his/her care needs and as a result his/her pressure injury worsened. Findings include: The Facility's Policy, titled Wound and Skin Care Protocols/Definitions, dated 09/2022, indicated the following definitions: -A pressure injury was defined as any lesion caused by unrelieved pressure resulting in damage to underlying tissue and were staged to classify the degree of tissue damage. -Stage 1 pressure injury was defined as an observable pressure related alteration of intact skin which may include changes in skin temperature, tissue consistency or sensation, and appeared as intact skin with a defined area of non-blanchable redness. -Stage 2 was defined as partial thickness presenting as shallow open ulceration with a red or pink wound bed without slough. The ulcer would be superficial and could present clinically as an abrasion, blister, or shallow crater. -Unstageable was defined as full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green, or brown and/or eschar (brown or black)) in the wound bed. The true depth of the wound could not be determined due to the slough. The Facility's Policy, titled Skin/Wound Care, dated 09/2022, Documentation Guidelines, indicated a complete wound assessment and documentation would be done weekly on all pressure injuries until they were healed, the criteria would include location, stage, size (measurements) and appearance of the wound. The Facility Protocol titled, Pressure Ulcers/Skin Breakdown, dated 10/2022, indicated the physician would order wound treatments for pressure injuries including pressure reduction surfaces, wound cleansing, debridement approaches, and dressings. Resident #2 was admitted to the Facility in February 2023, diagnoses included encephalopathy, sepsis, stroke, diabetes, and dementia. Review of Resident #2's Medical Record indicated he/she was transferred to the Hospital Emergency Department on 02/10/23, was admitted , and was discharged back to the facility on [DATE]. Review of the Hospital Wound Nurse Note, dated 02/14/23, indicated Resident #2 had a wound on his/her sacrum that was combination friction and shear, and that there was discoloration in the gluteal crease with a linear open area with a small amount of serosanguinous (pink, watery) drainage. The Note indicated Resident #2 also had redness to his/her right heel. The Note indicated recommendations included a dressing to Resident #2's coccyx area using sacral adhesive foam, change every three days and as needed, offloading of pressure, and a pressure ulcer care plan. Review of the Hospital Discharge Summary, dated 02/17/23, indicated Resident #2 had a stage two pressure injury at his/her sacrum, and nursing staff were to follow the recommendations developed by the Wound Nurse on 02/14/23. Review of the Facility's Admissions Assessment (for his/her readmission), dated 02/17/23, indicated nursing documented that Resident #2 did not have any pressure injuries. Review of the Nurse Progress Note, dated 02/27/23, indicated Resident #2 had redness developing on his/her buttocks area, and he/she refused to get out of bed. The Note indicated Nursing staff would follow up with Resident #2's Nurse Practitioner regarding his/her pressure injuries. Review of Resident #2's Weekly Skin Check, dated 03/10/23, indicated Resident #2's sacrum area was red and blanchable. Review of the Nurse Progress Note, dated 03/19/23, indicated a wound dressing to Resident #2's coccyx was completed. However, review of Resident #2's Medical Record indicated there was no documentation to support that nursing had obtained a physician's order for a wound dressing, at that time. Review of Resident #2's Weekly Skin Check, dated 03/24/23, indicated Resident #2 had an open area on his/her coccyx. However, there was no documentation to support that nursing had obtained measurements or documented a description of Resident #2's pressure injury. Further review of Resident #2's Medical Record indicated there were still no physician's orders in place for the treatment of his/her pressure injuries. The Nurse's Progress Note, dated 03/30/23, indicated Resident #2 was lethargic, was not eating, and was transferred to the Hospital Emergency Department. Review of the Hospital Admission History and Physical, dated 03/30/23, indicated Resident #2 was admitted to the Hospital Emergency Department and had a pressure injury on his/her sacrum that had worsened since his/her previous admission on 02/10/23 to 02/17/23. The Hospital Admission History and Physical indicated Resident #2's sacral pressure injury measured 4 centimeters (cm) by 4.5 cm and was unstageable. During interview on 06/13/23 at 12:25 P.M., the Assistant Director of Nurses (ADON) said she would do rounds with the wound Physician's Assistant on Mondays and Tuesdays. The ADON said wounds should be measured weekly and documented in the medical record. The ADON said she was unable to locate any documentation of measurements of Resident #2's pressure injuries. During interview on 06/12/23, the Director of Nurses (DON) said every wound should be measured and documentation (by nursing) including measurement and description of the wounds should have been included in Resident #2's medical record, that treatments should have been initiated, and any dressings should have a physician's order.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who had a diagnosis of dementia, the Facility failed to ensure staff implemented and followed their abuse policy, when on 06/10/23, Nurse #2 witnessed an incident of potential physical abuse of Resident #3 by his/her visitor, but did not report the incident to her immediate supervisor or Director of Nurses, placing Resident #3 at risk for potential continued abuse by the visitor. Findings include: The Facility Policy, titled, Prevention of Resident Abuse and Neglect, Mistreatment, Exploitation and Involuntary Seclusion, Misappropriation of Resident Property, dated 10/2022, indicated: -Residents would have a right to be free from mental, physical, sexual, and verbal abuse, neglect, mistreatment, exploitation, or misappropriation of resident property by any source, including staff, other residents, visitors, or family members. -The Facility had the responsibility to protect residents from real or perceived abuse, neglect, mistreatment, exploitation, or misappropriation. -All employees of the Facility were mandated to report incidents of suspected resident abuse, neglect, mistreatment, exploitation, or misappropriation to their immediate supervisor, Director of Nursing Services, or the Executive Director. -The Facility was required by law to report any alleged violations of abuse, neglect, mistreatment, exploitation, or misappropriation to the State Survey Agency, and where alleged violations also gave rise to a reasonable suspicion of a crime, law enforcement would be notified as well. The Facility Policy, titled Investigation Guidelines for Allegations of Abuse or Neglect, dated 09/2022, indicated: -When an allegation of abuse was made, the Resident would be examined and observed for any evidence of bruising or skin tears where hands may have been placed, or a pattern or ring or belt may have been placed. -The Resident would be interviewed, and statements documented. Resident #3 was admitted to the Facility July 2022, diagnoses included dementia, peripheral vascular disease, traumatic subdural hematoma, and stroke. Review of the Nurse's Note, dated 06/10/23, indicated that on 06/10/23, Nurse #2 witnessed Resident #3's visitor forcefully holding his/her feet while taking pictures and or video of his/her private area while Resident #3 was yelling for her to stop, and there were two other male visitors in the room at the time. During interview on 06/14/23 at 12:11 P.M., Nurse #2 said that on 06/10/23 sometime after the lunch time meal, she was asked to go to Resident #3's room by a Certified Nurses Aide (CNA) (exact name unknown). Nurse #2 said that when she entered Resident #3's room she saw Resident #3's visitor holding his/her feet down with one hand and using her mobile phone to take a video or pictures of Resident #3's private area and buttocks, while two other male visitors were in the room watching and could see Resident #3's naked body. Nurse #2 said Resident #3 was yelling for the visitor to let me the fuck go and leave me the fuck alone over and over, was unable to use his/her arms, was helpless, and seemed angry and upset. Nurse #2 said Resident #3's privacy and dignity were violated, and said she felt as though he/she had been abused by the visitor. Nurse #2 said she asked the visitors to leave, and they did. Nurse #2 said she tried to call the Assistant Director of Nurses (ADON), but said the ADON did not answer the phone, and said she did not leave a voice mail. Nurse #2 said she did not report the incident to anyone else in administration. During interview on 06/13/23 at 11:20 A.M., the Director of Nurses (DON) said that on 06/12/23 at 5:30 P.M., she was made aware of the allegation of visitor to Resident abuse when she received a phone call from one of Resident #3's family members. The DON said Nurse #2 should have reported the allegation of abuse to her or to administration immediately, but had not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who had a diagnosis of dementia, the Facility failed to ensure a that after being made aware of an allegation of potential abuse on 06/12/23, that they reported the allegation to the State Agency within two hours, as required. On 06/12/23, the Director of Nurses was made aware of an allegation of physical abuse involving Resident #3 and one of his/her visitors, however a report was not submitted until the following day (06/13/23) to the Department of Public Health. Findings include: The Facility Policy, titled, Identification and Reporting of alleged violations of Abuse, Neglect, Mistreatment, Exploitation, or misappropriation of Resident Property, dated 10/2022, indicated the Director of Nurses or Administrator would notify the DPH of any allegation of resident abuse, neglect, mistreatment, exploitation, or misappropriation immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involves abuse. Resident #3 was admitted to the Facility July 2022, diagnoses included dementia, peripheral vascular disease, traumatic subdural hematoma, and stroke. Review of the Nurse Progress Note, dated 06/10/23, indicated that on 06/10/23, Nurse #2 witnessed Resident #3's visitor forcefully holding his/her feet while taking pictures and video of his/her private area while Resident #3 was yelling for her to stop, and there were two other male visitors in the room at the time. During interview on 06/14/23 at 12:11 P.M., Nurse #2 said that on 06/10/23 sometime after the lunch time meal, she was asked to go to Resident #3's room by a Certified Nurse's Aide (CNA) (exact name unknown). Nurse #2 said that when she entered Resident #3's room she saw Resident #3's visitor holding his/her feet down with one hand and using her mobile phone to take a video or pictures of Resident #3's private area and buttocks, while two other male visitors were in the room watching and could see Resident #3's naked body. Nurse #2 said Resident #3 was yelling for the visitor to let me the fuck go and leave me the fuck alone over and over, was unable to use his/her arms, was helpless, and seemed angry and upset. Nurse #2 said Resident #3's privacy and dignity were violated, and said she felt as though he/she had been abused by the visitor. Nurse #2 said she did not report the incident to anyone in administration. During interview on 06/13/23 at 11:20 A.M., the Director of Nurses (DON) said that on 06/12/23 at 5:30 P.M., she was made aware of an allegation of visitor to Resident abuse when one of Resident #3's family members called her. The DON said however that she had not submitted a report to the DPH that day. The DON said the allegation of abuse should have been reported to the DPH within two hours, but it was not. Review of the report submitted by the facility via Health Care Facility Reporting System (HCFRS), dated 06/13/23, indicated the incident of alleged abuse was reported to the DPH on 06/13/23, the day after facility Administration became aware of the allegation.

Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), who both were noted to have wounds requiring care and treatment by nursing, the Facility failed to ensure the following; 1) for Resident #2, although nursing identified his/her wounds and documented application of a dressing, a comprehensive Plan of Care was not developed by nursing related to the treatment of his/her wounds, and 2) for Resident #3, interventions indicated in his/her Comprehensive Plan of Care to obtain and document measurements of his/her wounds, were not consistently implemented by nursing. Findings include: The Facility Policy, titled, Comprehensive Person-Centered Care Plan, dated 09/2022, indicated a comprehensive person-centered care plan that included measurable objectives to meet the resident's needs would be developed and implemented for each resident, and the care plan would be reviewed and updated when there had been a significant change in the resident's condition or when the resident was readmitted to the Facility from a Hospital stay. The Facility Policy, titled Skin/Wound Care Documentation Guidelines, dated 09/2022, indicated a complete wound assessment and documentation would be done weekly including measurements. The Facility Protocol titled, Pressure Ulcers/Skin Breakdown, dated 10/2022, indicated the physician would order wound treatments for pressure injuries including pressure reduction surfaces, wound cleansing, debridement approaches, and dressings. 1) Resident #2 was admitted to the Facility in February 2023, diagnoses included encephalopathy, sepsis, stroke, diabetes, and dementia. Review of Resident #2's Skin Care Plan, dated 02/08/23, indicated he/she was at risk for pressure ulcer development, and an air mattress was in place as an intervention. Review of Resident #2's Medical Record indicated he/she was transferred to the Hospital Emergency Department on 02/10/23, was admitted to the Hospital and was discharged back to the facility on [DATE]. Review of the Hospital Wound Nurse Note, dated 02/14/23, indicated Resident #2 had a wound on his/her sacrum that was combination friction and shear and discoloration in the gluteal crease with a linear open area with a small amount of serosanguinous (pink, watery) drainage. The Note indicated Resident #2 also had redness to his/her right heel. The Note indicated recommendations included a dressing to Resident #2's coccyx area using sacral adhesive foam, change every three days and as needed, offloading of pressure, and a pressure ulcer care plan. Review of the Nurse Progress Note, dated 02/27/23, indicated Resident #2 had redness developing on his/her buttocks area, and he/she refused to get out of bed. The Note indicated Nursing staff would follow up with Resident #2's Nurse Practitioner regarding his/her pressure injuries. The Weekly Skin Check, dated 03/10/23, indicated Resident #2's sacrum area was red and blanchable. Review of the Nurse's Progress Note, dated 03/19/23, indicated a wound dressing to Resident #2's coccyx was completed. However further review of Resident #2's Medical Record indicated there was no documentation to support a physician's order was obtained for a wound dressing. Review of the Weekly Skin Check, dated 03/24/23, indicated Resident #2 had an open area on his/her coccyx. However, review of Resident #2's Medical Record indicated there was no documentation to support that nursing staff had obtained measurements or documented a description of Resident #2's pressure injuries. Further review of Resident #2's Comprehensive Plan of Care indicated there after he/she was readmitted from the Hospital and noted to have developed pressure injuries, there was no documentation to support that his/her Plan of Care related to Skin Integrity was updated or that an individualized Plan of Care related to his/her new pressure injuries was developed with interventions identified to promote healing or prevent worsening of his/her wounds. The Nurse's Progress Note, dated 03/30/23, indicated Resident #2 was lethargic, was not eating, and was transferred to the Hospital Emergency Department. The Hospital Admission History and Physical, dated 03/30/23, indicated Resident #2 was admitted to the Hospital Emergency Department and had a pressure injury on his/her sacrum that had worsened since his/her previous admission on 02/10/23 to 02/17/23. The Hospital Admission History and Physical indicated Resident #2's sacral pressure injury measured 4 centimeters (cm) by 4.5 cm and was unstageable. During interview on 06/13/23 at 12:25 P.M., the Assistant Director of Nurses (ADON) said she was unable to locate any documentation to support measurements of Resident #2's wound were obtained. 2) Resident #3 was admitted to the Facility in July 2022, diagnoses included peripheral vascular disease, deep vein thrombosis of the right upper extremity with surgical intervention. Review of Resident #3's Skin Integrity Care Plan, dated 01/13/23, indicated interventions included that nursing would obtain and document weekly his/her treatment, which would include measurements of Resident #3's wounds. Review of Resident #3's Order Recap Report indicated he/she had the following Physician's Orders: - 03/22/23, Wound care descriptive documentation of wound at his/her right forearm, every day shift. - 03/22/23, wound care descriptive documentation of wound at right hand, every day shift. - 04/24/23, monitor open are to penis for infection, every shift. Review of Resident #3's Medical Record indicated there was no documentation to support nursing had obtained any measurements of Resident #3's wounds. During interview on 06/13/23 at 12:25 P.M., the Assistant Director of Nurses (ADON) said she was unable to locate any documentation to support measurements of Resident #3's wounds were obtained prior to 06/12/23. During interview on 06/12/23, the Director of Nurses (DON) said every wound should be measured and that nursing documentation including measurements and descriptions of the wounds should be included in the resident's medical record. The DON said there should be a comprehensive Plan of Care developed for any resident with wounds that included interventions to prevent worsening of the wounds and promote healing. The DON said wound measurements should be done weekly or as indicated in the Plan of Care.

Based on record review and interview the facility failed to A). conduct direct resident interviews for the Minimum Data Set Assessment for 9 residents and B). failed to accurately complete a discharge Minimum Data Set Assessment for 1 out of 3 discharge records reviewed, out of a total sample of 25 residents. Findings include: Review of the Centers for Medicare and Medicaid Services, Long Term Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2019 indicated the following: The purpose of this manual is to offer clear guidance, through instruction and example, for the effective use of the RAI, and thereby help nursing home staff achieve the benefits listed above. In keeping with objectives set forth in the Institute of Medicine (IOM) study completed in 1986 (Committee on Nursing Home Regulation, IOM) that made recommendations to improve the quality of care in nursing homes, the RAI provides each resident with a standardized, comprehensive, and reproducible assessment. This tool assesses a resident's ability to perform daily life functions, identifies significant impairments in a resident's functional capacity, and provides opportunities for direct resident interview. In essence, with an accurate RAI completed periodically, caregivers have a genuine and consistent recorded look at the resident and can attend to that resident's needs with realistic goals in hand The goals of the MDS 3.0 revision are to introduce advances in assessment measures, increase the clinical relevance of items, improve the accuracy and validity of the tool, increase user satisfaction, and increase the resident's voice by introducing more resident interview items. a. During the surveyors screening process on 4/4/2023, the Minimum Data Set Assessment indicators on the Long-Term Care Surveyor Process Screen failed to reveal the Brief Interview for Mental Status Scores for multiple residents. Review of the following sampled residents indicated the following: 1. For Resident #11 the facility failed to conduct interviews for two consecutive Minimum Data Set Assessments. Resident #11 was admitted to the facility in 3/2019. Review of the most recent Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 3/10/23, indicated the Brief Interview for Mental Status interview was not conducted with Resident #11 and was blank. Further review of the MDS indicated the resident interview for pain was not conducted and was blank. Review of the MDS with an ARD of 12/8/22 indicated the Brief Interview for Mental Status interview was not conducted with Resident #11 and was blank. Further review of the MDS indicated the resident interview for pain was not conducted and was blank. 2. For Resident #83 the facility failed to conduct interviews for two consecutive Minimum Data Set Assessments. Resident #83 was admitted to the facility in 4/2022. Review of the most recent MDS with an ARD of 1/25/23, indicated the Brief Interview for Mental Status interview was not conducted with Resident #83 and was blank. Further review of the MDS, indicated the resident interview for pain was not conducted and left blank. Review of the MDS with an ARD of 10/25/22, indicated the Brief Interview for Mental Status interview was not conducted with Resident #83 and was blank. Further review of the MDS, indicated the resident interview for pain was not conducted and left blank. 3. For Resident #63 the facility failed to conduct direct interviews for the most recent MDS. Resident #63 was admitted to the facility in 9/2020. Review of the most recent MDS with an ARD date of 1/5/23, indicated Resident #63 did not participate in the interview for the Brief Interview of Mental Status and it was blank. Further review of the MDS, indicated the resident interview for pain was blank. 4. For Resident #85 the facility failed to conduct interviews for the most recent MDS. Resident #85 was admitted to the facility in 9/2020. Review of the most recent Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 1/4/23, indicated the Brief Interview for Mental Status interview was not conducted with Resident #85 and was left blank. Further review of the MDS indicated that the resident interview for pain was blank, not assessed. 45984 5. Resident #44 was admitted to the facility in 6/2021. Review of the most recent MDS with an ARD date of 3/9/23, indicated Resident #44 did not participate in the interview for the Brief Interview of Mental Status and it was blank. Further review of the MDS, indicated the resident interview for pain was blank. 6. Resident #79 was admitted to the facility in 5/2020. Review of the most recent MDS with an ARD date of 3/3/23, indicated Resident #79 did not participate in the interview for the Brief Interview of Mental Status and it was blank. Further review of the MDS, indicated the resident interview for pain was blank. 7. Resident #65 was admitted to the facility in 7/2020. Review of the most recent MDS with an ARD date of 1/26/23, indicated Resident #65 did not participate in the interview for the Brief Interview of Mental Status and it was blank. Further review of the MDS, indicated the resident interview for pain was blank. 8. Resident #4 was admitted to the facility in 4/2020. Review of the most recent MDS with ARD date of 1/26/23, indicated Resident #4 did not participate in the interview for the Brief Interview of Mental Status and it was blank. Further review of the MDS, indicated the resident interview for pain was blank. 9. Resident #84 was admitted to the facility in 6/2021. Review of the most recent MDS with ARD date of 3/16/23, indicated Resident #84 did not participate in the interview for the Brief Interview of Mental Status and it was blank. Further review of the MDS, indicated the resident interview for pain was blank. During an interview on 4/05/23 at 1:49 P.M., the MDS nurse said she was not able to get to the resident interviews earlier enough and before the ARD. During an interview on 4/5/23 at 2:08 P.M., the Director of Nurses said they recently became aware about 2 to 3 weeks ago that resident interviews with residents for the MDS, were not being conducted prior to the ARD. 43846 B. Resident #112 was admitted to the facility in December 2022 with diagnoses including Hypertension, Depression and Hypothyroidism. Review of Resident #112's Nursing Progress Note dated 1/5/23, indicated Pt (patient) alert and oriented, verbal, very excited to go home today, med compliant, no complaints of pain. Review of Resident #112's Social Services Note dated 1/5/23, indicated Resident #112 was discharged to his/her home on 1/5/23 per his/her request and with physician order. Review of Resident #112's most recent Minimum Data Set (MDS), dated [DATE], indicated Resident #112's discharge status was to an acute hospital. During an interview on 4/5/23 at 1:54 P.M., the MDS Nurse said Resident #112's MDS was coded incorrectly to where he/she discharged to and said it should have been coded that he/she went home.

Based on observation, record review and interview the facility failed to provide care consistent with professional standards of practice for respiratory treatment and equipment for 4 Residents (#11, #45, #61 and #68) out of a total sample of 25 residents. Specifically, for Resident #11 the facility failed to ensure the medical plan of care included the use of humidification for continuous oxygen administration and failed to develop a care plan for the use of humidification, failed to ensure for Resident #45 and #61 that the oxygen tubing was maintained per the medical plan of care and for Resident #68 failed to ensure proper equipment was used to administer oxygen therapy and that proper storage of respiratory equipment to prevent infection was maintained. Findings include: Review of the facility's policy, titled, Infection Control Manual, subject 7- Respiratory Equipment dated as revised with no changes 9/22 indicated the following: Purpose: To prevent the transmission of infection associated with respiratory therapy tasks and equipment. Policy: *If distilled water is used in respiratory therapy, the bottle must be dated and initiated when opened and discarded after 24 hours. *Disposable cannulas, masks and tubing is used. Change every 7 days or as needed. Keep PRN tubing and equipment in plastic when not in use. *O2 concentrators have filters that need weekly cleaning. *Nebulizers should be rinsed and dried after use. Wipe mouthpiece with damp gauze or paper towel. Save the equipment in clean plastic bag between treatments. Discard the administration set every 7 days. * Humidification bottles associated with administration of oxygen should be disposable. 1. For Resident #11 the facility failed to develop a plan of care to include the use of humidification oxygen administration and failed to ensure the sterile water bottle, used for humidification, was changed and maintained to prevent the spread of infection. Resident #11 was admitted to the facility in 3/2019 and has a diagnosis of chronic obstructive pulmonary disease (COPD.) Review of the Minimum Data Set Assessment, with an assessment reference date of 3/10/23 indicated Resident #11 is able to make him/herself understood and can understand, requires limited assistance with hygiene, dressing and used oxygen therapy. On 4/4/23 at 10:09 A.M. Resident #11 was observed sitting on the side of his/her bed, wearing a nasal cannula administering oxygen. A bottle attached to the oxygen tubing labeled sterile water for humidification use dated 3/22 and was on the floor in front of the oxygen concentrator. On 4/4/23 the surveyor made the following observations of Resident #11, who was sitting on the side of his/her bed: *At 1:47 P.M., the bottle of sterile water, attached to the oxygen tubing, was on the floor in front of the oxygen concentrator, dated 3/22. *At 4:07 P.M., the bottle of sterile water, attached to the oxygen tubing was on the floor in front of the oxygen concentrator, dated 3/22. Review of Resident #11's medical record indicated the following: *A physician's order dated 11/2/21 oxygen via nasal cannula continuously. *A care plan, resident has COPD r/t (related to) smoking with the intervention to provide oxygen therapy as ordered by the physician, dated 6/6/19. *A care plan, resident is receiving oxygen therapy r/t (related to) COPD and SOB (shortness of breath) with the intervention Oxygen setting: resident has oxygen via nasal cannula at 2 liters continuously, dated 6/6/19. The medical record failed to indicate a plan of care with the interventions for the use of humidification for the oxygen therapy for Resident #11. On 4/5/23 at 7:09 A.M., Resident #11 was observed sitting on the side of his/her bed, with oxygen being administered via the nasal cannula. The bottle of sterile water, attached to the oxygen tubing, dated 3/22, was on the floor in front of the oxygen concentrator. During an interview on 4/5/23 at 11:27 A.M. Nurse #4 said Resident #11 uses oxygen continuously. Nurse #4 said the humidification bottle should not be stored on the floor and that there should be an order for the humidification. The Staff Development Nurse, who was present, said she observed the bottle on the floor this morning and changed the bottle and oxygen tubing. 43846 2. Resident #45 was readmitted to the facility in November 2022 with diagnoses including Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), Dysphagia and Adult Failure to Thrive. Review of Resident #45's most recent Minimum Data Set, dated dated [DATE], indicated Resident #45 was assessed to be moderately cognitively impaired. During an observation on 4/4/23 from 7:58 A.M. to 9:04 A.M., the surveyor observed oxygen tubing in use by Resident #45 with a labeled date of 3/22/23. Review of Resident #45's April 2023 Physician Orders, indicated an order for oxygen via nasal cannula at 3 Liters continuously. Further review of the orders indicated an order for Change O2 (oxygen) Tubing Weekly on Sunday 11pm-7am. During an interview on 4/4/23 at 8:29 A.M., the Charge Nurse said that the oxygen tubing should be changed weekly as the doctor order reads and said the tubing needs to be labeled with a date. 3. Resident #61 was readmitted to the facility in September 2021 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Volvulos, Cognitive Communication Deficit and Major Depressive Disorder. Review of Resident #61's most recent Minimum Data Set, dated dated dated [DATE], assessed as cognitively intact with no memory issues. Review of Resident #61's April 2023 Physician Orders, indicated Oxygen continuously at 2-3 liters per minute via nasal cannula. Further review of the orders indicated Change oxygen tubing and clean filter weekly. During an observation on 4/4/23 from 8:25 A.M. to 8:29 A.M., the surveyor observed oxygen tubing in use by Resident #61 with a labeled date of 3/22/23. During an interview and observation with the Charge Nurse on 4/4/23 at 8:29 A.M., the Charge Nurse said that the oxygen tubing should be changed weekly as the doctor order reads and said the tubing needs to be labeled with a date. 4. Resident #68 was readmitted to the facility in March 2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Chronic Atrial Fibrillation, Depression, Dyspnea and Dysphagia. Review of Resident #68's most recent Minimum Data Set, dated dated dated [DATE], indicated Resident #68 was assessed to be moderately cognitively impaired. A. Review of Resident #68's April 2023 Physician Orders, indicated an order oxygen via nasal cannula 2L (liters) continuously Check oxygen saturation every shift. During an observation on 4/4/23 from 8:08 A.M. to 9:04 A.M., the surveyor observed Resident #68 lying in bed with a non-rebreather oxygen mask (a specialized oxygen mask for high flow oxygen) on his/her face with the oxygen concentrator running and set to 2 liters. The surveyor further observed the non-rebreather oxygen mask bag was not inflated. Review of Resident #68's Nursing Progress Note dated 4/4/23, indicated I had to intervene and give one treatment and place him/her on the non-rebreather (mask). During an interview on 4/4/23 at 8:11 A.M., Resident #68 said he/she has had the the oxygen mask on for awhile to try it out as the nurse instructed him/her to and said he/she has to take it on and off to eat. During an interview on 4/4/23 at 9:11 A.M., Nurse #1 said she did notice that Resident #68 was wearing a non-rebreather mask and said she was unsure why. Nurse #1 said that the mask is only used under special conditions and said it needs to connected to high flow oxygen to work correctly. During an interview on 4/5/23 at 7:24 A.M., the Charge Nurse said that a non-rebreather mask needs at least 10 liters of 02 or it does not work correctly. During an interview on 4/5/23 at 1:31 P.M., the Director of Nurses (DON) said that a non-rebreather mask is only used with high flow oxygen or it does not work correctly. The DON said she was unsure why Resident #68 had the non-rebreather mask on in the first place. During an interview on 4/6/23 at 7:54 A.M., Nurse #2 said he did place Resident #68 on a non-rebreather mask on his shift. Nurse #2 said he turned the oxygen concentrator to 5 liters and said the oxygen should have been on a higher liter to work appropriately but still applied the mask anyway. B. The facility failed to ensure proper infection control practices for oxygen and nebulizers were maintained. During an observation on 4/4/23 from 8:09 A.M. to 9:04 A.M., the surveyor observed the nebulizer machine and mask in Resident #68's nightstand drawer on top of personal items and was observed to not be in an oxygen bag, dated or labeled. The surveyor further observed Resident #68's oxygen tubing not labeled or dated. During an observation on 4/5/23 from 7:02 A.M. to 7:16 A.M., the surveyor observed the nebulizer machine and nebulizer mask in Resident #68's nightstand drawer on top of personal items, not in a oxygen bag and not dated and labeled. Review of Resident #68's April 2023 Physician Orders, indicated Change O2 (oxygen) Tubing Weekly on Sunday 11pm-7am every night shift every Sun (Sunday) Label Tubing with DATE. During an observation and interview 4/5/23 at 7:40 A.M., the Charge Nurse acknowledged that the nebulizer mask was in the nightstand drawer on top of personal items and not labeled with a date or in an oxygen bag. The Charge Nurse said she expects staff to change tubing weekly and to date and label and said she expects the nebulizer mask to be placed in the oxygen bag after use.

Based on record review, policy review and interview, the facility failed to notify the physician of a change in condition for one Resident (#84) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Change in Resident Condition, reviewed and dated September 2022 indicates the following: *Policy: The facility shall promptly notify the resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition and/or status. *Procedure: The nurse will notify the resident's Attending Physician or physician on call when there has been: significant change in the resident's physician/emotional/mental condition Resident #84 was admitted to the facility in June 2021 with diagnoses that include Type 2 Diabetes Mellitus with hyperglycemia, vascular dementia, depression and anxiety. Review of Resident #84's most recently completed Minimum Data Set (MDS) dated [DATE] indicated that he/she had a Brief Interview for Mental Status score of 9 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated that the Resident requires extensive assistance with all activities of daily living. Review of Resident #84's care plan for Diabetes Mellitus, dated 6/14/21 indicated the following: *Goal: Resident will have no complications related to diabetes through the review date. *Interventions: Monitor for s/sx (signs and symptoms) of hyper or hypoglycemia Review of Resident #84's physician orders indicated the following: *An order, dated 9/17/21, if blood sugar is below 70 follow hypoglycemic protocol and notify MD (Medical Doctor)/NP (Nurse Practitioner). If blood sugar is greater than 400 notify MD/NP. Review of Resident #84's Nursing Progress notes indicated the following note dated 3/30/23 at 6:55 A.M.: *This writer doing rounds at 3:45 A.M. noted Resident with slurred speech cold clammy skin diaphoresis, FS (fasting sugar) checked stat results 37. Glucagon 1 mg (milligram) adm (administered) with an increase after 15 minutes 57, snack tolerated at this time orange juice and crackers. FS checked 102, resident noted more alert stated he/she was not aware of what was taking place. Teaching done with Resident to encourage eating at all times to prevent hypoglycemia. Safely maintained, bed low, call bell at reach, nursing continue to monitor. The progress note failed to indicate that the MD or NP was notified. Review of Resident #84's Weights and Vitals Summary indicated that he/she had a blood sugar reading of 37 mg/dL on 3/30/23 at 3:57 A.M. During an interview on 4/5/23 at 10:52 A.M., Nurse #3 said the MD/NP should be notified and it should be documented when a resident has a change in condition so they can follow up with the resident. Nurse #3 said that change in a blood sugar to 37 mg/dL would be considered a change in condition. Upon reviewing Resident #84's medical record with the surveyor, Nurse #3 could not find any evidence that the MD or NP was notified when Resident #84's blood sugar levels were measured at 37 mg/dL. Nurse #3 said when the MD or NP is notified it should be documented in the medical record. During an interview on 4/5/23 at 11:46 A.M., the Director of Nursing (DON) said it is her expectation that the MD would be notified when a resident has a change in condition. The DON said that a change in blood sugar levels would be considered a change in condition. She further said that the MD should have been notified when Resident #84's blood sugar levels were identified at 37 mg/dL.

Based on observation, record review and interview the facility failed to develop and implement the plan of care for supervision during meals for 1 Resident (#313) out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLs) Supporting, dated 9/2022, indicated Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident #313 was admitted to the facility in January 2023 with diagnoses including Dysphagia, Acute Respiratory Failure with Hypoxia and Heart Failure. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #313 was assessed to have moderately impaired cognition. Review of Resident #313's Activity of Daily Living Care Plan, dated 2/23/23, indicated Eating: The resident requires supervision of staff to eat. Review of Resident #313's April 2023 Physician orders, indicated and order Soft and Bite-Sized texture, Mildly Thick Liquids/Nectar Thick Liquids consistency, for Aspiration Need Assistant with meals, Sips between bites. Review of Resident #313's Kardex, dated 4/5/23, indicated Eating: The resident requires supervision of staff to eat. During an observation on 4/4/23 at 8:20 A.M., the surveyor observed Resident #313 in bed, alone with out any staff present in the room, and was observed to be struggling to open drink containers. During an observation on 4/4/23 at 12:35 P.M., the surveyor observed Resident #313 in his/her wheelchair eating lunch, alone with out any staff present in the room, . During an observation on 4/5/23 from 8:03 A.M. to 8:20 A.M., the surveyor observed Resident #313 in bed, alone, and eating breakfast. The privacy curtain was pulled past the Residents foot board. During an observation on 4/5/23 from 12:37 P.M. to 12:45 P.M., the surveyor observed Resident #313 in his/her wheelchair eating lunch, alone with out any staff present in their room, . During an observation on 4/6/23 at 7:59 A.M., the surveyor observed Resident #313 in bed, alone eating his/her breakfast, and observed that the privacy curtain was pulled past the Residents foot board, . During an interview on 4/5/23 at 12:45 P.M., the Charge Nurse said the expectation is that staff follow the care plan for each resident and said if a Certified Nurse Aide is unsure on how to take care of a newer resident they would ask the nurse what the plan of care is.

Based on observations, record review an interview the facility failed to revise an Activity of Daily Living Care Plan to reflect the Residents current status for 1 Resident (#86) out of a total sample of 25 sampled Residents. Findings Include: Resident #86 was readmitted to the facility in January 2023 with diagnoses including Chronic Kidney Disease, Type 2 Diabetes, Dysphagia, and Cognitive Communication Deficit. Review of Resident #86's most recent Minimum data Set (MDS) dated [DATE], indicated Resident #86 requires set up help and supervision by staff for eating. Further review of the MDS failed to indicate a cognition level for Resident #86. Review of Resident #86's Activity of Daily Living (ADL) Care Plan, dated 2/23/23, indicated Eating: The resident requires assist x1 staff to eat. Review of Resident #86's Speech Therapy Discharge Summary, dated 3/21/23, indicated Resident #86 was discharged on a soft/thin liquids diet texture and requires only set up assist. During an observation on 4/4/23 at 8:17 A.M., Resident #86 was in bed, alone with out any staff present eating his/her breakfast. During an observation on 4/4/23 at 12:35 P.M., Resident #86 was in bed, alone with out any staff present eating his/her lunch. During an observation on 4/5/23 from 8:02 A.M. through 8:20 A.M., Resident #86 was in bed, alone with out any staff present eating their breakfast, the privacy curtain was observed pulled down past the Residents legs making Resident #86 to be visualized from the doorway. During an observation on 4/5/23 from 12:37 P.M. through 12:43 P.M., Resident #86 was in bed, alone with out any staff present eating their lunch. During an interview on 4/6/23 at 8:00 A.M., the Charge Nurse said Resident #86 did need assistance with feeding in the past but said he/she has progressed since then. The Charge Nurse said Resident #86's ADL Care Plan should have been updated with his/her new status for eating and was not updated as of yet.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically providing assistance with showers, for one Resident (#65) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, reviewed and dated September 2022, indicated the following: *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. *Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support assistance with: Hygiene (bathing, dressing, grooming, and oral care). Resident #65 was admitted to the facility in July 2020 with diagnoses that include Parkinson's disease, morbid obesity and weakness. Review of Resident #65's most recent completed Minimum Data Set (MDS) dated [DATE] revealed that the Resident has a Brief Interview for Mental Status score of 12 out of possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated that Resident #65 requires total dependence on all ADLs including bathing and did not exhibit any behaviors. On 4/4/23 at 1:52 P.M., Resident #65 was observed laying in his/her bed, the Resident's hair was visibly greasy. The Resident said it has been such a long time since he/she has received a shower that he/she cannot remember the last time he/she has received one and would like to have one. On 4/5/23 at 11:23 A.M., Resident #65 was observed sitting in his/her wheelchair, his/her was visibly greasy and he/she said he/she would still like a shower. Review of the shower schedule indicated that Resident #65 is scheduled to receive showers weekly on Thursdays. Review of Resident #65's ADL self-care performance deficit care plan dated 7/28/20 indicated the following: *Bathing/showering: Resident is able to bath daily with extensive to total dependent of one. Review of Resident #65's Kardex (a form indicating the level of assistance a resident requires) indicated the following: *Bathing/Showering: Resident #65 is able to bath daily with extensive to total dependent of one. Review of the Nursing Flow Sheets for the months of January, February, March and April of 2023 indicated that Resident #65 received a bed bath with total dependence of 1 staff member for each month. There was no documentation that Resident #65 received a shower or refused a shower for these months. Review of Resident #65 nursing progress notes did not indicate any refusal of ADL care. During an interview on 4/5/23 at 1:29 P.M., Certified Nursing Assistant (CNA) #1 said Resident #65 is dependent on staff and requires 2+ staff assistance for transfers. She said the Resident is scheduled for weekly showers and does not refuse care. During an interview on 4/5/23 at 2:21 P.M., Nurse #3 acknowledged that the Nursing Flow Sheets indicated that Resident #65 did not receive a shower for the months of January, February, March and April of 2023. She continued to say that any resident who wants a shower can get one and should be getting a shower at least once a week. She said if a resident refuses it should be documented and another attempt for a shower would be made on the next shift.

Based on observation, record review, interview and policy review, the facility failed to ensure an air mattress was at the correct setting to help prevent the formation of pressure ulcers for one Resident (#96) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Support Surface Guidelines reviewed and dated September 2022, indicated the following: *Preparation - Review the resident's care plan to assess for any special needs of the resident. *General Guidelines: *Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide relief or reduction. *Support surfaces are modifiable. Individual resident needs differ. *Guidelines for Selecting Appropriate Pressure-Relieving Devices: *Use a pressure ulcer risk scale such as the Norton Scale to help determine the need for and appropriate type of pressure-relieving devices. *Nurses will check placement, function and settings for comfort at least daily. Resident #96 was admitted to the facility in December 2022 with diagnoses that include Type 2 Diabetes, muscle weakness and heart failure. Review of Resident #96's annual Minimum Data Set (MDS) assessment dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 12 out of a possible score of 15 indicating that he/she has moderate cognitive impairment. Review of Resident #96's most recent MDS dated [DATE] indicated the Resident requires extensive assistance with all activities of daily living and does not display any behaviors. Further review of the MDS revealed that Resident #96 is at risk for developing pressure ulcers. The surveyor made the following observations: *On 4/4/23 at 1:47 P.M., Resident #96 was observed lying in bed, his/her air mattress was set to 200 lbs. (pounds). *On 4/5/23 at 7:58 A.M., Resident #96 was sitting in his/her wheelchair, the air mattress was set to 200 lbs. *On 4/6/23 at 6:58 A.M., Resident #96 was observed sleeping in bed, his/her air mattress was set to 200 lbs. Review of Resident #96's weight summary report indicated that his/her last reported weight for the week of 4/6/23 was 126.2 lbs. Review of Resident #96's physician order with a start date of 3/30/23 indicated the following: *Air Mattress check placement and function every shift set for comfort prefers 150 lbs. every shift Review of Resident #96's care plan initiated 4/3/23 indicated the following: *Problem: Resident #96 has potential for pressure ulcer development r/t (related to) immobility *Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of Resident #96's assessment titled Norton Plus Pressure Ulcer Risk Scale (an assessment used to assess the risk of developing pressure ulcers) dated 3/29/23 revealed that the Resident was at a high risk for developing pressure ulcers. During an interview on 4/6/23 at 8:00 A.M., the surveyor and the Assistant Director of Nursing (ADON) went into Resident #96's room and observed him/her sleeping in bed with the air mattress set to 200 lbs. The ADON said the air mattress should be set to 150 lbs. and she changed the setting. The ADON continued to say that Resident #96 had pressure ulcers and we have him/her on an air mattress as a preventive intervention, so they do not come back. She further said the air mattress settings should be set as ordered by the physician. During an interview on 4/6/23 at 8:31 A.M., the Director of Nursing (DON) said her expectations are that an air mattress should be set to what the physician's orders indicate.

Based on observation, record review and interview the facility A). Failed to adhere to professional standards of practice by failing to develop a person-centered care plan with individualized interventions for the use of bilateral prostheses and B). Failed to provide physical therapy services following the delivery of a new left prosthesis for 1 Resident (#83), out of a total sample of 25 residents Findings include: Resident #83 was admitted to the facility in 4/2022 and has diagnoses that include cerebral atherosclerosis, peripheral vascular disease, chronic systolic (congested) heart failure, type 2 diabetes mellitus with diabetic neuropathy, acquired absence of left leg below the knee, and acquired absence of the right leg below the knee. Review of the most recent Minimum Data Set (MDS) with an ARD of 1/25/23, indicated Resident #83 can be understood and can understand others. Further, the MDS indicated Resident #83 required extensive assistance for bathing, dressing, bed mobility, transfers, and had functional limited range of motion impairment in both lower extremities. The MDS indicated Resident #83 was on physical therapy services 9/8/22 through 10/27/22. On 4/04/23 at 10:45 A.M. Resident #83 was observed sitting in a wheelchair with prostheses on both his/her right and left legs. Resident #83 pointed to a walker in the corner of the room and said rehabilitation is on halt and he/she was not sure why. Resident #83 said he/she has had the right prosthesis since last year and had the left leg amputated last summer and got the left prosthesis more recently. He/she said he/she puts them on him/herself and that the right one is more difficult to get on. Resident #83 was wearing a shrinker under each of the prosthesis. A). Review of Resident #83's medical record indicated the following active physician orders: *Don (put on) RLE (right lower extremity) shrinker sock while in bed with HOB (head of bed) elevated, dated 9/7/22. *I approve (physician) the interdisciplinary care plan for this resident, dated 4/19/22. The physician's orders failed to indicate orders for the absence of the left leg below the knee and the use of the left leg prosthesis, further the physician orders failed to indicate an order for the use of a prosthesis for acquired right below the knee prosthesis. Review of the Resident #83's care plans indicated the following: *Activities of Daily living performance deficit due to bilateral amputation LBKA (left below the knee amputation) 8/23/22 and RBKA 4/22, impaired balance, limited mobility. Date initiated 4/27/22. *Resident may have acute pain status post RBKA 4/22 and LBKA 8/31/22, date initiated 4/27/22. Review of Resident #83's care plans failed to indicate a care plan with individualized interventions for the use of right and left prostheses was developed to maintain Resident #83's highest level of function with the use of the prostheses. Review of Resident #83's Visual/Bedside Kardex Report, used by nursing and certified nursing aides as a guide for daily care, dated as of 7/14/23 indicated the following: *Off-loading shoe to left foot when bearing weight. *Resident has left heel brace/cushion and requires encouragement to be compliant. Review of the Kardex failed to indicate a plan and interventions related to the use of both left and right leg prostheses. During an interview on 4/5/23 at 3:12 P.M., Physical Therapist #1 (PT#1) said Resident #83 is not safe to ambulate with the prostheses and when last on physical therapy was discharged at an independent level for wheelchair mobility. Physical Therapist #1 said Resident #83 is followed by a prosthetic company. Review of the Physical Therapy Discharge Summary, dated 10/27/22 indicated the following: *Discharge recommendations: 24-hour care. *Functional maintenance program established/trained=Prosthetic Management Program, transfer program. *Prosthetic Management Program established/trained: nursing staff and patient demonstration/verbalize 100 % understanding of don/doff schedule of prosthetic and use of shrinkers and elevation legs to reduce swelling. *Prognosis to maintain CLOF (current level of function) = excellent with consistent staff support. On 4/6/23 at 9:19 A.M., Resident #83 was observed in his/her room wearing both the right and left leg prostheses. When asked by the surveyor how he/she was instructed on how to don the prostheses, he/she said he/she follows the verbal instruction he/she was given by a named person who comes in from the prosthetic company. Review of the medical record failed to indicate any written consultation or information provided by the prosthetic company. During an interview on 4/6/23 at 9:25 A.M., Nurse #5 said nursing staff check Resident #83's skin at the amputation site and assess for pain. Nurse #5 said she was not aware of any interventions for the use of the prostheses and that the Resident puts them on his/her own. Nurse #5 said interventions for the use of prostheses should be on the care plan. Nurse said #5 said she did not know who the person was, or the plan provided by the prosthetic provider. During an interview on 4/6/23 at 10:27 A.M., CNA #3 said she assists Resident #83 with all daily care and was not aware of a specific plan for the use of the prostheses. During an interview on 4/6/23 at 11:18 A.M., PT #1 said one (the left) of Resident #83's prostheses was recent and the other he/she had when he/she was admitted to the facility. PT #1 said the prosthetic management plan on the PT discharge summary was for the right leg prosthesis and that Resident #83 was not seen by Physical Therapy for the Left leg prosthesis. She said she provided training verbally to staff for the right leg prosthetic management. PT #1 said the don/doff schedule depended on the level of inflammation on the right amputation site and that it could vary from 2-4 hours and the Resident should be encouraged to elevate his/her leg. PT #1 acknowledged that a care plan with specific prosthetic management and interventions was not part of Resident #83's care plans for either the right or left prostheses. On 4/6/23 at 12:01 P.M., the Director of Nurses said a care plan for the use of right and left prostheses for the Resident should have been developed. B). Review of the documents provided by the Director of Nursing on 4/6/23 from the Orthotics and Prosthetics Provider indicated the following: *A clinical note dated, 10/25/22, fit shrinkers to (Resident #83's) left BK (below knee.) Clinician spoke to Physical Therapist (#1) on the phone. She states he/she (Resident #83) is being discharged from physical therapy as he/she has plateaued but will pick him/her up again for therapy after he/she receives the prothesis. *A clinical note, dated 11/8/22, Cast for Left BK. Resident #83 is very anxious to receive his/her other prostheses so he/she can continue working with physical therapy. *A clinical note, dated 12/14/22, Fit first BK prosthesis. A new prothesis will allow him/her to easily transfer and ambulate. He/she is hopeful to begin working with physical therapy after he/she receives the new prothesis. *A clinical note, dated 12/29/22, Fit left BK definitive. I am here today to deliver his/her new left definitive prothesis. He/she independently dons the liner and the prosthesis. He/she is hopeful that he/she will begin working with PT shortly. I recommend that PT reach out for a session once he/she becomes comfortable with the prosthesis. Review of Resident #83's physician's orders failed to indicate there was an order for physical therapy, following the receipt of the new left prosthetic. During an interview on 4/6/2023 at 11:18 A.M., PT #1 said Resident #83 was not seen for evaluation or treatment by and should have been after receiving his/her new left leg prosthesis.

Based on record review and interview, the facility failed to identify and address a significant weight loss timely for 1 Resident (#52) out of a total sample of 23 residents. Findings include: Review of the facility policy titled, Resident Weight Monitoring, review date 9/2021 indicated: -Purpose: To determine residents at risk and provide early intervention for weight management and dehydration. -Policy: The nutritional and hydration status of residents will be monitored routinely with weight records. Any changes will be communicated in a timely manner to the interdisciplinary team members. Any significant weight change will be referred to the dietician for recommendations and/or possible reweigh. Review of the facility policy titled, Determining and Addressing Significant Weight Changes, review date 10/2021 indicated: -The nutritional and hydration status of residents will be maximized with appropriate and timely intervention. 1. A resident experiencing weight loss or gain per guidelines: a. 5% in one month b. 7 ½ in three months c. 10% in 6 months should be placed on weekly weight monitoring until the resident attains his or her weight goal and meal/supplement goals. 2. Primary Care Nurse/Nurse Manager will convey the significant weight change to the dietitian via a Diet Request/Change slip, verbally via voice mail or [NAME] e-mail. The resident will then be assessed for possible intervention. 3. The nurse will notify the residents/patients family and physician of the weight change and document such in the Nursing Notes or the resident's Weight Record. Resident #52 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's Minimum Data Set, dated dated dated [DATE], indicated a weight loss of 5% or more in the last month while not on a physician prescribed weight loss regimen. Review of Resident #52's medical record indicated: weight record: 3/25/22- 146.6 lbs. (pounds) 4/01/22- 146.6 lbs. 4/08/22- 146.6 lbs. 4/13/22- 137.0 lbs. (a loss of 6.55% of his/her total body weight) 4/15/22- 137.0 lbs. 4/22/22- 136.8 lbs. *Nutrition Care Plan, initiated 3/18/21: moderate nutritional risk with interventions including, monitor meal intake, weight, and lab data. *Nurse Progress Note: dated 5/17/22 (32 days after initial weight loss), weight loss over the past month noted. Reviewed with MD weights and house supplement added to orders. The clinical record failed to indicate an assessment was by the Dietitian after Resident #52's significant weight loss, or updates to his/her plan of care per the facility's policy. During an interview on 5/20/22 at 8:29 A.M., the Dietitian said, she was not aware of Resident #52's weight loss and did not initiate any interventions to address the weight loss.

Based on records reviewed and interviews, the Facility failed to ensure that staff were trained and competent in emergency first aid or cardiopulmonary resuscitation (CPR) when on [DATE] Resident #1 was discovered bleeding profusely, was unresponsive and there was blood on the floor. - Resident #1 went into [MEDICAL CONDITION], chest compressions were initiated while Resident #1 was sitting in bed at an approximate 45 degree angle, while staff left to find an emergency code cart before full CPR could be started. - Emergency Medical Services (EMS) was not activated until approximately 29 minutes after Resident #1 was first found bleeding and unresponsive. The Emergency Run Report indicated when Paramedics arrived there was approximately 3 liters of blood on the floor and copious amounts of emesis in the suction machine and on Resident #1. - Resident #1 died at 6:42 P.M. on [DATE], following [MEDICAL CONDITION] secondary to hemorrhage shock from profuse bleeding from an AV Fistula (a surgical graft made between an artery and vein used for [MEDICAL TREATMENT]). Findings include: The Red Cross and American Heart Association Updated Guidelines, dated [DATE], indicate that that, the revised guidelines stress the importance of stopping severe bleeding as a critical first aid skill and while pressure is still the first line of defense, the guidelines acknowledge the important role tourniquets and [MEDICATION NAME] agents play in stopping life-threatening bleeding when standard measures fail or are not possible. The guidelines indicate tourniquets can be effective for severe external limb bleeding, and have been found to control bleeding effectively in most cases. The American Heart Association CPR Guidelines 2015 (Updated) indicate: In adult victims of [MEDICAL CONDITION], it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. 2010 (Old): It is reasonable for lay rescuers and HCPs to perform chest compressions at a rate of at least 100/min. Why: The number of chest compressions delivered per minute during CPR is an important determinant of return of spontaneous circulation (ROSC) and survival with good neurological function. 244 CMR: Board of Registration in Nursing 9:03 Standards of conduct for Nurses Clinical Practical Guidelines include: Performance of Techniques and Procedures include that a nurse licensed by the Board shall perform nursing techniques and procedures only after appropriate education and demonstrated clinical competency. Resident #1's [DIAGNOSES REDACTED]. The Plan of Care, titled End Stage [MEDICAL CONDITION], dated as initiated on [DATE], indicated Resident #1 received [MEDICAL TREATMENT] 3 times weekly, staff were to maintain a communication log with the [MEDICAL TREATMENT] center and review for pertinent information, and instructed Do Not Draw Blood or take Blood Pressure on Right Upper Arm with Graft. The Plan of Care, titled Advance Directive Decisions, dated as initiated on [DATE] and updated on [DATE], indicated Resident #1 was a Full Code (in the event of cardiac or respiratory arrest, all attempts of resuscitation will be made). The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 scored 15 on a brief interview for mental status (BIMs) meaning he/she was alert and oriented. A Nurse Progress Note, dated [DATE], indicated at 10:45 A.M. a Certified Nurse Aide (CNA) notified a Nurse that Resident #1 was found bleeding from his/her [MEDICAL TREATMENT] fistula to the right upper arm, and blood was all over the floor and bed. The Note indicated Resident #1 was unresponsive, a code blue (the Facility's emergency activation code) and 911 were called, a tourniquet was applied tightly to Resident #1's upper right arm, and CPR at 30 compressions to 2 artificial breathes by Ambu bag was started. The Note indicated that when Paramedics arrived, Resident #1 was intubated onsite and was transferred to the Hospital for further evaluation. The Surveyor interviewed Nurse #1 at 11:00 A.M. on [DATE] and at 1:30 P.M. on [DATE]. Nurse #1 said that sometime between 10:00 A.M. and 10:30 A.M. on the morning of [DATE], she administered Resident #1 prescribed medication at which time Resident #1 was sitting up in bed and seemed fine or words to that effect. Nurse #1 at that time there was no dressing protecting the AV Fistula on Resident #1's arm but when she checked the Fistula site it seemed intact or words to that effect. Nurse #1 said Resident #1 had a habit of scratching his/her AV Fistula site, and she verbally directed him/her not to do so at that time. Nurse #1 said she did not reapply the dressing, and said her goal was to go back later in the day during treatment rounds to recheck Resident #1's AV Fistula site. Nurse #1 said that a short time later Certifed Nurse Aide (CNA) #1 approached her at the nurses station, and said you need to come quick, there is blood all over the floor and bed, and Resident #1 won't wake up or words to that effect. Nurse #1 said she did not overhead page Code Blue and did not bring the Emergency Code Cart to Resident #1's room at that time. Nurse #1 said that she entered Resident #1's room and saw what at first she thought was a large pool of cranberry juice on the floor. Nurse #1 said when she moved closer to Resident #1 she saw blood coming out, squirting out from Resident #1's AV Fistula site or words to that effect. Nurse #1 said she did not apply pressure to stop the bleeding, but instead went into the hall way and called out help and the words Code Blue, one time or words to that effect. Nurse #1 said she then went back into Resident #1's room, and said she did not apply pressure to stop the bleeding and did not check to see if there was a tourniquet in the room which could be used to assist in stopping the bleeding. Review of Nurse #1's Personnel Record indicated, and Nurse #1 said her CPR certification had expired. Nurse #1 said she had never responded to an emergency situation and did not know what to do. Nurse #1 said she stood back as other staff entered the room and waited for someone to instruct her on what to do The Surveyor interviewed Nurse #2 at 3:00 P.M. on [DATE]. Nurse #2 said she was completing her medication pass when she heard CNA #1 call her by name and asking her to come quickly. Nurse #2 said when she ran into Resident #1's room, no staff, including Nurse #1 where in the room. Nurse #2 said she saw blood all over the floor and saw blood squirting out of Resident #1's upper right arm. Nurse #2 said she saw a towel on the bed which she picked up and pressed down on Resident #1 arm with the towel, pressing his/her arm against the bed. Nurse #2 said she yelled out for someone to call Code Blue On [DATE] the Surveyor received a documented statement from the Facility signed and dated by Nurse #2. The Statement indicated Nurse #2 heard a call for help and she called Code Blue. The Surveyor interviewed Nurse #2 for a second time at 1:05 P.M. on [DATE]. Nurse #2 said she had completed her medication pass and was in another Resident's room when she heard Nurse #1 call out that Resident #1 was bleeding. Nurse #2 said she stopped what she was doing and said went in the hallway where she overhead paged Code Blue, 3 times, on the in-house phone which staff usually utilized to call down to the Kitchen. Nurse #2 said she could not make an outside call from this phone, and said she did not go to the Nurses Station where an outside phone line was available. Nurse #2 said she did not call 911 emergency services. Nurse #2 said Resident #1 was unresponsive and there was blood all over the place or words to that effect. Nurse #2 said she applied pressure to Resident #1's arm by pressing his/her arm against the mattress. Nurse #2 said the Staff Development Coordinator (SDC) handed her a tourniquet which she then applied to Resident #1's right upper arm and someone brought in a back board which they attempted to lay Resident #1 down flat. Nurse #2 said prior to lying Resident #1 on the back board Resident #1 was sitting up in bed at a 45 to 75 degree angle. The Surveyor interviewed the SDC at 3:30 P.M. on [DATE]. The SDC said he was with the DON on the ground floor, when he heard the overhead page for Code Blue. The SDC said that to the best of his recollection this was sometime between 10:30 A.M. and 11:00 A.M. The SDC said that he and the DON rode the elevator to the third floor where the Code Blue location was announced, and said when they got off the elevator someone pointed them in the direction of Resident #1's room. The SDC said when he arrived in the room, there was blood all over the floor and bed, and said Nurse #2 was standing over Resident #1 who was sitting at an approximate 45 degree angle in bed, and was pressing Resident #1's right arm against the bed. The SDC said that at this point things get a little fuzzy or words to that effect. The SDC said he remembers someone staring chest compressions on Resident #1. The SDC said there was no emergency cart in the room so he left to get the emergency cart and the automated emergency defibrillator (AED) which took him about 2 minutes, and he then brought the emergency cart and AED back to Resident #1's room. The SDC said Resident #1 continued to bleed heavily with each chest compression and he left to find a tourniquet. The SDC said he could not get into the medication/supply room were starter Intravenous (IV) kits which continued disposable tourniquets, where kept, and could not find who had keys to the medication/supply room. The SDC said he ran down stairs to the second floor where he removed an IV starter kit from the Pyxis system and said he then returned to the unit and gave the tourniquet from the IV kit to Nurse #2. The SDC said at some point someone called 911 but said he was not sure who this may have been. The Surveyor interviewed the DON at 10:15 A.M. on [DATE] and at 1:40 P.M. on [DATE]. The DON said when she entered the room she did a quick visual inspection and said she saw blood all over the floor and on the bed sheets. The DON said Nurse #2 was applying pressure, with gloved hands and with what appeared to be a face cloth or small hand towel against Resident #1's AV Fistula site on his/her upper right arm. The DON said she reached across and felt a very faint apical pulse on Resident #1's left wrist, which she was able to feel for approximately 2 minutes. The DON said the SDC then left to go get the Emergency Cart, but before he returned she lost the apical pulse and said she could not find a carotid pulse. The DON said Resident #1 was sitting at a 45 degree angle in bed and Nurse #1 was pressing his/her right arm against the bed. The DON said she started to do chest compressions and had completed approximately 30 compressions by the time the SDC arrived with the emergency code cart. The DON said when the SDC returned they placed Resident #1 flat in bed, placed a back board under him/her and started CPR. The Surveyor interviewed the ADON at 11:40 A.M. on [DATE]. The ADON said she heard the overhead Code Blue page at approximately 10:30 A.M. and said by the time she reached Resident #1's room, CPR had already been started by the DON. The Surveyor interviewed the Unit Manager at 11:22 A.M. on [DATE]. The Unit Manager said she was with the ADON when she heard the overhead Code Blue page at approximately 10:30 A.M. The Unit Manager said by the time she reached Resident #1's room, there was blood all over the floor, someone was trying to put a back board under Resident #1, and someone else was trying to apply an AED. The Unit Manager said this was the worse code she had ever responded too, and said it was very traumatic and emotional' or words to that effect. The Emergency Run Report, dated [DATE], indicated Emergency Medical Staff (EMS) were dispatched at 10:59 A.M. ( approximately 29 minutes after CNA #1 said she first saw blood all over the floor in Resident #1's room, and the SDC, ADON and Unit Manager said was the approximate time they heard the overhead page for Code Blue). The Report indicated when Paramedics arrived there was approximately 3 liters of blood on the floor and bed from Resident #1's AV Fistula and copious amounts of emesis. The Report indicated staff said Resident #1 had been found in [MEDICAL CONDITION] at 10:50 A.M. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 died at 6:42 P.M. following [MEDICAL CONDITION] secondary to hemorrhage shock from profuse bleeding from an AV Fistula. On the day of Survey, [DATE], 2 residents (Resident #2 and Resident #3), were identified as residents receiving [MEDICAL TREATMENT] with AV Fistulas. The SDC said the Facility did not have a Policy and/or staff competencies on Emergency First Aid in the event of severe bleeding and/or use of a tourniquet. On the day of Survey, [DATE], 67 of a total resident census of 113 were identified as Full Codes. On [DATE] the Facility provided the Surveyor a copy of the most recent Mock Code Drill Staff in Attendance sign in records: - a Mock Code Drill Staff in Attendance Record, dated [DATE], indicated 9 staff, including Nurse #2, responded to a mock code. The Staff in Attendance Record did not indicate the time of day and/or shift the drill was conducted and/or the title of staff in attendance. - a Mock Code Drill Staff in Attendance Record, dated [DATE], indicated 9, including Nurse #2, staff responded to a mock code. The Staff in Attendance Record did not indicate the time of day and/or shift the drill was conducted. The Facility was unable to provide additional Mock Code Drill Staff in Attendance sign in records. The SDC said he did not have a complete record on file of staff who were CPR certified. A list of Licensed Nursing Personnel provided on [DATE], by the Schedule Coordinator, indicated the Facility had a total of 48 Licensed Nurses on staff. On [DATE] the Facility provided the Surveyor a list of staff which indicated that 15 Nurses had either expired CPR certificates on file or no record of CPR certificate on file.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to demonstrate the skills and competency to perform appropriate and effect immediate first aid interventions when at approximately 10:30 A.M. on [DATE], Certified Nurse Aide (CNA) #1 alerted Nurse #1 that Resident #1 was bleeding, was unresponsive and there was blood all over the floor. - Nurse #1 did not overhead page an emergency code to initiate immediate staff support/response to activate Emergency Medical System and did not bring the emergency code cart to Resident #1's room. Nurse #1 entered the room, saw a pool of blood on the floor and all over Resident #1, she did not assess Resident #1 or initiate basic first aid, but instead walked out of the room and yelled for help. Nurse #1 then returned to the room but did not intervene to stop the bleeding. - When other staff arrived pressure was applied by placing a towel on Resident #1's arm and pushing down on his/her arm against the bed. - Resident #1 continued to bleed profusely and there was a 6 to 7 minute delay before staff were able to locate a tourniquet. - Resident #1 went into [MEDICAL CONDITION], chest compressions were initiated while Resident #1 was sitting in bed at an approximate 45 degree angle, while staff left to find an emergency code cart before full CPR could be started. - Emergency Medical Services (EMS) was not activated until approximately 29 minutes after Resident #1 was first found bleeding. The Emergency Run Report indicated when Paramedics arrived there was approximately 3 liters of blood on the floor and copious amounts of emesis in the suction machine and on Resident #1. - Resident #1 died at 6:42 P.M. on [DATE], following [MEDICAL CONDITION] secondary to hemorrhage shock from profuse bleeding from an AV Fistula (a surgical graft made between an artery and vein used for [MEDICAL TREATMENT]). Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Red Cross and American Heart Association Updated Guidelines, dated [DATE], indicate that that, the revised guidelines stress the importance of stopping severe bleeding as a critical first aid skill and while pressure is still the first line of defense, the guidelines acknowledge the important role tourniquets and [MEDICATION NAME] agents play in stopping life-threatening bleeding when standard measures fail or ore not possible. The guidelines indicate tourniquets can be effective for severe external limb bleeding, and have been found to control bleeding effectively in most cases. The American Heart Association CPR Guidelines 2015 (Updated) indicate: In adult victims of [MEDICAL CONDITION], it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. 2010 (Old): It is reasonable for lay rescuers and HCPs to perform chest compressions at a rate of at least 100/min. Why: The number of chest compressions delivered per minute during CPR is an important determinant of return of spontaneous circulation (ROSC) and survival with good neurological function. The Facility's Policy titled Interdisciplinary Process Code Procedure, dated as revised in [DATE], indicated in the event of a Code Blue the Unit Secretary or other will dial the Intercom/Page and announce Code Blue, Stat for Non-Cardiac events, room number and the floor, 3 times, and immediately call 911. The Policy indicated the employee hearing Code Blue will bring the emergency cart to the resident's room. The Policy indicated the Licensed Nurse will document: date and time condition was observed; vital signs or absence of vital signs; exact time CPR was started; exact time Paramedics were activated and time of arrival; the exact time the Physician was called and reached and document orders; and the exact time the resident was transferred to the hospital, and the time his/her family were notified. The Facility's Policy titled Care Immediately Following [MEDICAL TREATMENT] Treatment , dated as revised in [DATE], indicated: the dressing change will be done in the [MEDICAL TREATMENT] Center post-treatment; if there is major bleeding from the site, apply pressure to the site; contact emergency services and the [MEDICAL TREATMENT] Center; and do not leave the resident alone until emergency services arrive. Resident #1's [DIAGNOSES REDACTED]. The Plan of Care, titled End Stage [MEDICAL CONDITION], dated as initiated on [DATE], indicated Resident #1 received [MEDICAL TREATMENT] 3 times weekly, staff were to maintain a communication log with the [MEDICAL TREATMENT] center and review for pertinent information, and instructed Do Not Draw Blood or take Blood Pressure on Right Upper Arm with Graft. The Plan of Care, titled Advance Directive Decisions, dated as initiated on [DATE] and updated on [DATE], indicated Resident #1 was a Full Code (in the event of cardiac or respiratory arrest, all attempts of resuscitation will be made). The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 scored 15 on a brief interview for mental staus (BIMs) meaning he/she was alert and oriented, and was dependent on staff for personal care. A Nurse Progress Note, dated [DATE], indicated at 10:45 A.M. a Certified Nurse Aide (CNA) notified a Nurse that Resident #1 was found bleeding from his/her [MEDICAL TREATMENT] fistula in the right upper arm, and blood was all over the floor and bed. The Note indicated Resident #1 was unresponsive, code blue (the Facility's emergency activation code) and 911 were called, a tourniquet was applied tightly to Resident #1's upper right arm, and CPR at 30 compressions to 2 artificial breathes by Ambu bag was started. The Note indicated that when Paramedics arrived, Resident #1 was intubated onsite and was transferred to the Hospital for further evaluation. There was no documentation that a thorough clinical assessment, including vital signs or absence of vital signs; time CPR was started; time Paramedics were activated and time of arrival; the exact time the Physician was called and reached and documented orders; and the time the resident was transferred to the hospital, and the time his/her family were notified. This is not consistent with the Facility's Policy titled Interdisciplinary Process Code Procedure. The Facility's Incident Report Form forwarded to the Facility via the electronic Health Care Facility's reporting System (HCFRS), indicated the date and time of the incident involving Resident #1 was [DATE] at 10:30 A.M. However, the incident narrative indicated: Resident #1 was last seen at 10:30 A.M. when medications were administered, blood pressure obtained on left arm; care provided; at 10:45 A.M. the Certified Nurse Aide entered the room and saw fluid on the floor which she identified as blood. The Surveyor interviewed Certified Nurse Aide #1 at 12 noon on [DATE]. CNA #1 said that on the morning of [DATE], she entered Resident #1's room at approximately 10:30 A.M. and as she entered the room she saw a large pool of want looked like cranberry juice on the floor. CNA #1 said as she walked further into the room she saw resident #1 sitting up in bed, said his/her eyes were closed and said there was blood all over his/her belly, or words to the effect. CNA #1 said she called out Resident #1's name but Resident #1 did not respond. CNA #1 said she ran out of the room and called for help, said she saw Nurse #1 and ran towards her and said come quick, there is blood all over the floor and on the bed, and Resident #1 is not answering me, or words to that effect. The Surveyor interviewed Nurse #1 at 11:00 A.M. on [DATE] and at 1:30 P.M. on [DATE]. Nurse #1 said that sometime between 10:00 A.M. and 10:30 A.M. on the morning of [DATE], she gave Resident #1 prescribed medication at which time Resident #1 was sitting up in bed and seemed fine or words to that effect. Nurse #1 said there was no dressing protecting the AV Fistula on Resident #1's arm andwhen she checked the Fistula, it seemed intact or words to that effect. Nurse #1 said Resident #1 had a habit of scratching his/her AV Fistula site, and said she verbally directed him/her not to do so at that time. Nurse #1 said she did not reapply the dressing, and said she did not check Resident #1's blood pressure. Nurse #1 said her goal was to go back later in the day during treatment rounds to recheck Resident #1's AV Fistula site. Nurse #1 said that a short time later CNA #1 approached the nurses station and said you need to come quick, there is blood all over the floor and bed, and Resident #1 won't wake up or words to that effect. Nurse #1 said she followed CNA #1 into Resident #1's room, but did not overhead page Code Blue and did not bring the Emergency Code Cart to Resident #1's room at that time. This is not consistent with the Facility's Policy titled Interdisciplinary Process Code Procedure. Nurse #1 said that when she entered Resident #1's room and saw what at first she thought was a large pool of cranberry juice on the floor. Nurse #1 said when she moved closer to Resident #1 she saw blood coming out, squirting out from Resident #1's AV Fistula site or words to that effect. Nurse #1 said she did not apply pressure to stop the bleeding, but instead went into the hall way and called out help and the words Code Blue, one time or words to that effect. Nurse #1 said she then went back into Resident #1's room, and said she did not apply pressure to stop the bleeding and did not check to see if there was a tourniquet in the room which could be used to assist in stopping the bleeding. Nurse #1 said she stood back as other staff entered the room and waited for someone to instruct her on what to do. The Surveyor interviewed Nurse #2 at 3:00 P.M. on [DATE]. Nurse #2 said she was completing her medication pass when she heard CNA #1 call her by name and asking her to come quickly. Nurse #2 said when she ran into Resident #1's room, no staff, including Nurse #1 where in the room. Nurse #2 said she saw blood all over the floor and saw blood squirting out of Resident #1's upper right arm. Nurse #2 said she saw a towel on the bed which she picked up and pressed down on Resident #1 arm with the towel, pressing his/her arm against the bed. Nurse #1 said she yelled out for someone to call Code Blue On [DATE] the Surveyor received a documented statement from the Facility signed and dated by Nurse #2. The Statement indicated Nurse #2 heard a call for help and she called Code Blue. The Surveyor interviewed Nurse #2 for a second time at 1:05 P.M. on [DATE]. Nurse #2 said she was in another Residents' room when Nurse #1 called out that Resident #1 was bleeding. Nurse #2 said she left what she was doing and said she went in the hallway where she overhead paged Code Blue 3 times on the in-house phone which staff usually utilized to call down to the Kitchen. Nurse #2 said she could not make an outside call from this phone, and said she did not go to the Nurses Station where an outside phone line was available. Nurse #2 said she did not call 911 emergency services. This is not consistent with Nurse #2's initial interview, and is not consistent with the Facility's Policy titled Interdisciplinary Process Code Procedure. Nurse #2 said she continued to apply pressure to Resident #1's arm until other staff arrived at which point in time, unsure of exact sequence, Resident #1 coded and said she traded on and off with the Director of Nurses (DON) continuing to apply pressure, and at one point the DON released pressure and removed the towel to see if Resident #1 was still bleeding. Nurse #2 said Resident #1 was unresponsive and there was blood all over the place or words to that effect. Nurse #2 said the Staff Development Coordinator (SDC) handed her a tourniquet which she then applied to Resident #1's right upper arm and someone brought in a back board which they attempted to lay Resident #1 down flat. Nurse #2 said prior to lying Resident #1 on the back board Resident #1 was sitting up in bed at a 45 to 75 degree angle and she continued to apply pressure to his/her arm by pressing against the mattress. The Surveyor interviewed the SDC at 3:30 P.M. on [DATE]. The SDC said he was with the DON on the ground floor, when he heard the overhead page for Code Blue. The SDC said that to the best of his recollection this was sometime between 10:30 A.M. and 11:00 A.M. The SDC said that he and the DON rode the elevator to the third floor where the Code Blue location was announced, and said when they got off the elevator someone pointed them in the direction of Resident #1's room. The SDC said when he arrived in the room, there was blood all over the floor and bed and said Nurse #2 was standing over Resident #1 who was sitting at an approximate 45 degree angle in bed, and was pressing Resident #1's right arm against the bed. The SDC said that at this point things get a little fuzzy or words to that effect. The SDC said he remembers someone staring chest compressions on Resident #1, and said there was no emergency cart in the room. The SDC said he left to get the emergency cart and the automated emergency defibrillator (AED) which took him about 2 minutes, and then brought the emergency cart and AED back to Resident #1's room. The SDC said Resident #1 continued to bleed heavily with each chest compression and he left to find a tourniquet. The SDC said he could not get into the medication/supply room were starter Intravenous (IV) kits which contained disposable tourniquets, where kept, and could not find who had keys to the medication/supply room. The SDC said he ran down stairs to the second floor where he removed an IV starter kit from the Pyxis system and said he then returned to the unit and gave the tourniquet form the IV kit to Nurse #2. The SDC said at some point someone called 911 but said he was not sure who this may have been. The Surveyor interviewed the DON at 10:15 A.M. on [DATE] and at 1:40 P.M. on [DATE]. The DON said when she entered the room she did a quick visual inspection and said she saw blood all over the floor and on the bed sheets. The DON said Nurse #2 was applying pressure, with gloved hands and what appeared to be a face cloth or small hand towel against Resident #1's AV Fistula site on his/her upper right arm. The DON said she reached across and felt a very faint apical pulse on Resident #1's left wrist, which she was able to feel for approximately 2 minutes. The DON said the SDC then left to go get the Emergency Cart, but before he returned she lost the apical pulse and said she could not find a carotid pulse. The DON said Resident #1 was sitting at a 45 degree angle in bed and Nurse #1 was pressing his/her right arm against the bed. The DON said she started to do chest compressions and had completed approximately 30 compressions by the time the SDC arrived with the emergency code cart. The DON said when the SDC returned they placed Resident #1 flat in bed, placed a back board under him/her and started CPR. The DON said she did not conduct a formal investigation into the surrounding events of this incident, including obtaining written statements from staff and said she assumed Nurse #1 had, or words to that effect. The Surveyor interviewed the ADON at 11:40 A.M. on [DATE]. The ADON said she heard the overhead Code Blue page at approximately 10:30 A.M. and said by the time she reached Resident #1's room, CPR had already been started by the DON. The Surveyor interviewed the Unit Manager at 11:22 A.M. on [DATE]. The Unit Manager said she was with the ADON when she heard the overhead Code Blue page at approximately 10:30 A.M. The Unit Manager said by the time she reached Resident #1's room, there was blood all over the floor, someone was trying to put a back board under Resident #1, and someone else was trying to apply an AED. The Unit Manager said this was the worse code she had ever responded too, it was very traumatic and emotional' or words to that effect. The Emergency Run Report, dated [DATE], indicated Emergency Medical Staff (EMS) were dispatched at 10:59 A.M. (approximately 29 minutes after CNA #1 said she first saw blood all over the floor in Resident #1's room, and the SDC, ADON and Unit Manager said was the approximate time they heard the overhead page for Code Blue). The Report indicated when Paramedics arrived there was approximately 3 liters of blood on the floor and bed from Resident #1's AV Fistula and copious amounts of emesis. The Report indicated staff said Resident #1 had been found in [MEDICAL CONDITION] at 10:50 A.M. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 died at 6:42 P.M. following [MEDICAL CONDITION] secondary to hemorrhage shock from profuse bleeding from an AV Fistula.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to demonstrate the skills and competency to perform appropriate and effect immediate first aid interventions when at approximately 10:30 A.M. on [DATE], Certified Nurse Aide (CNA) #1 alerted Nurse #1 that Resident #1 was bleeding and there was blood all over the floor. - Resident #1 continued to bleed profusely; there was a 6 to 7 minute delay before staff were able to locate a tourniquet; and Resident #1 went into [MEDICAL CONDITION]. - Emergency Medical Services (EMS) was not activated until approximately 29 minutes after Resident #1 was first found bleeding. The Emergency Run Report indicated when Paramedics arrived there was approximately 3 liters of blood on the floor and copious amounts of emesis in the suction machine and on Resident #1. - Resident #1 died at 6:42 P.M. on [DATE], following [MEDICAL CONDITION] secondary to hemorrhage shock from profuse bleeding from an AV Fistula (a surgical graft made between an artery and vein used for [MEDICAL TREATMENT]). Findings Include: Resident #1's [DIAGNOSES REDACTED]. The Plan of Care, titled End Stage [MEDICAL CONDITION], dated as initiated on [DATE], indicated Resident #1 received [MEDICAL TREATMENT] 3 times weekly, staff were to maintain a communication log with the [MEDICAL TREATMENT] center and review for pertinent information, and instructed Do Not Draw Blood or take Blood Pressure on Right Upper Arm with Graft. The Plan of Care, titled Advance Directive Decisions, dated as initiated on [DATE] and updated on [DATE], indicated Resident #1 was a Full Code (in the event of cardiac or respiratory arrest, all attempts of resuscitation will be made). The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 scored 15 on a brief interview for mental status (BIMS) meaning he/she was alert and oriented. A Nurse Progress Note, dated [DATE], indicated at 10:45 A.M. a Certified Nurse Aide (CNA) notified a Nurse that Resident #1 was found bleeding from his/her [MEDICAL TREATMENT] fistula to the right upper arm, and blood was all over the floor and bed. The Note indicated Resident #1 was unresponsive, code blue (the Facility's emergency activation code) and 911 were called, a tourniquet was applied tightly to Resident #1's upper right arm, and CPR at 30 compressions to 2 artificial breathes by Ambu bag was started. The Note indicated that when Paramedics arrived, Resident #1 was intubated onsite and was transferred to the Hospital for further evaluation. The Surveyor interviewed Certified Nurse Aide #1 at 12 noon on [DATE]. CNA #1 said that on the morning of [DATE], she entered Resident #1's room at approximately 10:30 A.M. and as she entered the room she saw a large pool of what looked like cranberry juice on the floor. CNA #1 said as she walked further into the room she saw resident #1 sitting up in bed, said his/her eyes were closed and said there was blood all over his/her belly, or words to the effect. CNA #1 said she called out Resident #1's name but Resident #1 did not respond. CNA #1 said she ran out of the room and called for help, said she saw Nurse #1 and ran towards her, and said come quick, there is blood all over the floor and on the bed, and Resident #1 is not answering me, or words to that effect. The Surveyor interviewed Nurse #1 at 11:00 A.M. on [DATE] and at 1:30 P.M. on [DATE]. Nurse #1 said that sometime between 10:00 A.M. and 10:30 A.M on the morning of [DATE], she gave Resident #1 prescribed medication at which time Resident #1 was sitting up in bed and seemed fine or words to that effect. Nurse #1 said there was no dressing protecting the AV Fistula on Resident #1's arm and said when she checked the Fistula it seemed intact, or words to that effect. Nurse #1 said Resident #1 had a habit of scratching his/her AV Fistula site, and said she verbally directed him/her not to do so at that time. Nurse #1 said she did not reapply the dressing, and said she did not check Resident #1's blood pressure. Nurse #1 said her goal was to go back later in the day during treatment rounds to recheck Resident #1's AV Fistula site. Nurse #1 said that a short time later CNA #1 approached the nurses station, where she (Nurse #1) was completing documentations and said you need to come quick, there is blood all over the floor and bed, and Resident #1 won't wake up or words to that effect. Nurse #1 said she followed CNA #1 into Resident #1's room, but did not overhead page Code Blue and did not bring the Emergency Code Cart to Resident #1's room at that time. Nurse #1 said she entered Resident #1's room and saw what at first she thought was a large pool of cranberry juice on the floor. Nurse #1 said when she moved closer to Resident #1 she saw blood coming out, squirting out from Resident #1's AV Fistula site or words to that effect. Nurse #1 said she did not apply pressure to stop the bleeding, but instead went into the hall way and called out help and the words Code Blue, one time or words to that effect. Nurse #1 said she then went back into Resident #1's room, and said she did not apply pressure to stop the bleeding and did not check to see if there was a tourniquet in the room which could be used to assist in stopping the bleeding. Nurse #1 said she stood back as other staff entered the room and waited for someone to instruct her on what to do. The Surveyor interviewed Nurse #2 at 3:00 P.M. on [DATE]. Nurse #2 said she was completing her medication pass when she heard CNA #1 call her by name and asking her to come quickly. Nurse #2 said when she ran into Resident #1's room, no staff, including Nurse #1 where in the room. Nurse #2 said she saw blood all over the floor and said she saw blood squirting out of Resident #1's upper right arm. Nurse #2 said she saw a towel on the bed which she picked up and pressed down on Resident #1 arm with the towel, pressing his/her arm against the bed. Nurse #2 said she yelled out for someone to call Code Blue On [DATE] the Surveyor received a documented statement from the Facility signed and dated by Nurse #2. The Statement indicated Nurse #2 heard a call for help and she called Code Blue. The Surveyor interviewed Nurse #2 for a second time at 1:05 P.M. on [DATE]. Nurse #2 said she was in another Resident's room when she heard Nurse #1 called out that Resident #1 was bleeding. Nurse #2 said she Nurse #2 said she left what she was doing and said she went in the hallway where she overhead paged Code Blue 3 times on the in-house phone which staff usually utilized to call down to the Kitchen. Nurse #2 said she could not make an outside call from this phone, and said she did not go to the Nurses Station where an outside phone line was available. Nurse #2 said she did not call 911 emergency services. Nurse #2 said she continued to apply pressure to Resident #1'a arm until other staff arrived at which point in time, unsure of exact sequence, Resident #1 coded and said she traded on and off with the Director of Nurses (DON) continuing to apply pressure, and at one point the DON released pressure and removed the towel to see if Resident #1 was still bleeding. Nurse #2 said Resident #1 was unresponsive and there was blood all over the place or words to that effect. Nurse #2 said the Staff Development Coordinator (SDC) handed her a tourniquet which she then applied to Resident #1's right upper arm and someone brought in a back board which they attempted to lay Resident #1 down flat. Nurse #2 said prior to lying Resident #1 on the back board Resident #1 was sitting up in bed at a 45 to 75 degree angle and she continued to apply pressure to his/her arm by pressing against the mattress. The Surveyor interviewed the SDC at 3:30 P.M. on [DATE]. The SDC said he was with the DON on the ground floor, when he heard the overhead page for Code Blue. The SDC said that to the best of his recollection this was sometime between 10:30 A.M. and 11:00 A.M. The SDC said that he and the DON rode the elevator to the third floor where the Code Blue location was announced, and said when they got off the elevator someone pointed them in the direction of Resident #1's room. The SDC said when he arrived in the room, there was blood all over the floor and bed and said Nurse #2 was standing over Resident #1 who was sitting at an approximate 45 degree angle in bed, and was pressing Resident #1's right arm against the bed. The SDC said that at this point things get a little fuzzy or words to that effect. The SDC said he remembers someone staring chest compressions on Resident #1. The SDC said there was no emergency cart in the room, said he left to get the emergency cart and the automated emergency defibrillator (AED) which took him about 2 minutes, and said he then brought the emergency cart and AED back to Resident #1's room. The SDC said Resident #1 continued to bleed heavily with each chest compression and he left to find a tourniquet. The SDC said he could not get into the medication/supply room were starter Intravenous (IV) kits which continued disposable tourniquets, where kept, and could not find who had keys to the medication/supply room. The SDC said he ran down stairs to the second floor where he removed an IV starter kit from the Pyxis system and said he then returned to the unit and gave the tourniquet form the IV kit to Nurse #2. The SDC said at some point someone called 911 but said he was not sure who this may have been. The Surveyor interviewed the DON at 10:15 A.M. on [DATE] and at 1:40 P.M. on [DATE]. The DON said when she entered the room she did a quick visual inspection and said she saw blood all over the floor and on the bed sheets. The DON said Nurse #2 was applying pressure, with gloved hands and with what appeared to be a face cloth or small hand towel against Resident #1's AV Fistula site on his/her upper right arm. The DON said she reached across and felt a very faint apical pulse on Resident #1's left wrist, which she was able to feel for approximately 2 minutes. The DON said the SDC then left to go get the Emergency Cart, but before he returned she lost the apical pulse and said she could not find a carotid pulse. The DON said Resident #1 was sitting at a 45 degree angle in bed and Nurse #1 was pressing his/her right arm against the bed. The DON said she started to do chest compressions on Resident #1 and said she had completed approximately 30 compressions by the time the SDC returned with the emergency code cart. The DON said when the SDC returned they placed Resident #1 flat in bed, placed a back board under him/her and started CPR. The Surveyor interviewed the ADON at 11:40 A.M. on [DATE]. The ADON said she heard the overhead Code Blue page at approximately 10:30 A.M. and said by the time she reached Resident #1's room, CPR had already been started by the DON. The Surveyor interviewed the Unit Manager at 11:22 A.M. on [DATE]. The Unit Manager said she was with the ADON when she heard the overhead Code Blue page at approximately 10:30 A.M. The Unit Manager said by the time she reached Resident #1's room, there was blood all over the floor, someone was trying to put a back board under Resident #1, and someone else was trying to apply an AED. The Unit Manager said this was the worse code she had ever responded too, it was very traumatic and emotional, or words to that effect. The Emergency Run Report, dated [DATE], indicated Emergency Medical Staff (EMS) were dispatched at 10:59 A.M. ( approximately 29 minutes after CNA #1 said she first saw blood all over the floor in Resident #1's room, and the SDC, ADON and Unit Manager said was the approximate time they heard the overhead page for Code Blue). The Report indicated when Paramedics arrived there was approximately 3 liters of blood on the floor and bed from Resident #1's AV Fistula and copious amounts of emesis. The Report indicated staff said Resident #1 had been found in [MEDICAL CONDITION] at 10:50 A.M. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 died at 6:42 P.M. following [MEDICAL CONDITION] secondary to hemorrhage shock from profuse bleeding from an AV Fistula.

Based on records reviewed and interviews, the Facility failed to conduct a thorough investigation and root cause analysis when on [DATE], at approximately 10:30 A.M. Certified Nurse Aide (CNA) #1 alerted Nurse #1 that Resident #1 was bleeding and there was blood all over the floor. Resident #1 continued to bleed profusely; there was a 6 to 7 minute delay before staff were able to locate a tourniquet; and Resident #1 went into [MEDICAL CONDITION]. Emergency Medical Services (EMS) was not activated until approximately 29 minutes after Resident #1 was first found bleeding. The Emergency Run Report indicated when Paramedics arrived there was 3 liters of blood on the floor and copious amounts of emesis in the suction machine and on Resident #1. Resident #1 died at 6:42 P.M. on [DATE], following [MEDICAL CONDITION] secondary to hemorrhage shock from profuse bleeding from an AV Fistula (a surgical graft made between an artery and vein used for [MEDICAL TREATMENT]). Findings include: The Facility's Policy titled Administration Sentinel Event Policy, not dated, indicated: - The purpose of this Policy is to develop a procedure for investigating causes of serious incidents and identifying a system that will prevent the incident form reoccurring. - A sentinel event is described as an event which signals the need for immediate investigation and response, for example, unexpected death, and will be documented and reviewed by the Director of Nurses, the Medical Director. - A root cause analysis will focus primarily on systems and processes leading up to the event, subsequent attempt to uncover cause, and identify what needs to be done to reduce the risk of another sentinel event. A Nurse Progress Note, dated [DATE], indicated at 10:45 A.M. a Certified Nurse Aide (CNA) notified a Nurse that Resident #1 was found bleeding from his/her [MEDICAL TREATMENT] fistula to the right upper arm, and blood was all over the floor and bed. The Note indicated Resident #1 was unresponsive, code blue (the Facility's emergency activation code) and 911 were called, a tourniquet was applied tightly to Resident #1's upper right arm, and CPR at 30 compressions to 2 artificial breathes by Ambu bag was started. The Note indicated that when Paramedics arrived, Resident #1 was intubated onsite and was transferred to the Hospital for further evaluation. The Emergency Run Report, dated [DATE], indicated Emergency Medical Staff (EMS) were dispatched at 10:59 A.M. ( approximately 29 minutes after CNA #1 said she first saw blood all over the floor in Resident #1's room, and the SDC, ADON and Unit Manager said was the approximate time they heard the overhead page for Code Blue). The Report indicated when Paramedics arrived there was approximately 3 liters of blood on the floor and bed from Resident #1's AV Fistula and copious amounts of emesis. The Report indicated staff said Resident #1 had been found in [MEDICAL CONDITION] at 10:50 A.M. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 died at 6:42 P.M. following [MEDICAL CONDITION] secondary to hemorrhage shock from profuse bleeding from an AV Fistula. On the day of survey, [DATE], the Facility was unable to provide the Surveyor with a copy of an Investigation with root cause analysis, including written statements from staff, related to the surrounding events of how Resident #1 bleed out from his/her AV Fistula leading to his/her subsequent death following [MEDICAL CONDITION] secondary to hemorrhage shock from profuse bleeding. The Surveyor interviewed the Administrator at 2:20 P.M. on [DATE]. The Administrator said it was his assumption that the DON investigated and documented the events leading up to the event on [DATE] when Resident #1 was found bleeding and subsequently went in to [MEDICAL CONDITION] causing transfer to the Hospital where Resident #1 died later that day. The Administrator said this event was not discussed with the Medical Director and was not reviewed for performance improvement at the Facility's Quality Assurance and Performance Improvement (QAPI) meeting which was held on [DATE] with the Medical Director in attendance. The Surveyor interviewed the DON 10:15 A.M. on [DATE]. The DON said she met with staff on the afternoon of [DATE] to offer moral support and to discuss the traumatic event which involved Resident #1. The DON said she responded to the code blue and was present when Resident #1 went into [MEDICAL CONDITION], which she said to her mind was sufficient and said she felt she did not need to investigate further at that time, or words to that effect.

Based on record review and interviews, for one of five sampled residents, (Resident #1) the Facility failed to ensure that Resident #1 was provided with an alternate safety intervention when Resident #1's plan of care for supervision on the commode was discontinued (no date known). On 7/23/12 at approximately 7:00 P.M., Resident #1, who was at high risk to fall, was transferred to the commode by two staff persons, and left alone with the curtain drawn. Certified Nurse Aide (CNA) #1 said she stood by the doorway to the room while Resident #1 used the commode. Nurse #1 said approximately 10 minutes after Resident #1 was put on the commode, Nurse #1 responded to a call for help, and observed Resident #1 face down on the ground. Nurse #1 said that Resident #1 had a large laceration on his/her forehead, 911 was called, and Resident #1 was transferred to the Hospital for evaluation. The Facility's internal investigation indicated Resident #1's forehead laceration required 11 sutures to close the wound. Findings include: Resident #1 was admitted to the Facility June of 2012, and [DIAGNOSES REDACTED]. The plan of care for falls, initiated 6/25/12, indicated that Resident #1 was at risk for falls due to dementia, variable functional status, impaired balance, decline in function, and medication side effects. The plan of care interventions included: call light within reach, dycem mat (used to prevent slipping in a chair) in the wheelchair, bed in the low position, and floor mats next to the bed,. The plan of care interventions also included: supervision while on the commode which was yellowed out (discontinued), with no date and no intervention added to ensure Resident #1's safety while on the commode. The Surveyor interviewed the Director of Nurses (DON) on 9/13/12 at 9:50 A.M. The DON said that the original notation in Resident #1's plan of care for supervision on the commode was yellowed out because it was not an effective intervention. The DON said she did not know the date the intervention was yellowed out or why the intervention was not effective. The DON said the staff did not anticipate that Resident #1 would fall off the commode. The Surveyor interviewed Family Member #1 on 9/13/12 at 9:50 A.M. Family Member #1 said Resident #1 had Parkinson's disease and leaned to his/her side, so he/she was not safe to leave alone on a commode. Family Member #1 said he/she requested a safety plan on several occasions from the DON and he/she was not provided Resident #1's safety plan to prevent a fall off the commode. Family Member #1 said CNA #1 left Resident #1's room completely after transferring Resident #1 onto the commode. Family Member #1 said Resident #1 sustained significant injuries, his/her head was split open and there was a lot of blood. The Surveyor interviewed Nurse #1 on 9/13/12 at 10:30 A.M. Nurse #1 said that when a resident required supervision on a commode, the resident should not be left alone on the commode. Nurse #1 said words to the effect of we don't leave them (residents) alone other than outside the curtain if they (residents) need assistance. The Surveyor interviewed the Physical Therapist on 9/13/12 at 1:30 P.M. The Physical Therapist said Resident #1 had several falls in the past and he/she had weak trunk stability. The Physical Therapist said supervision on a commode meant that staff did not leave the resident alone on a commode. The nurse's note, dated 7/12/12, indicated that Resident #1 was readmitted to the Facility after treatment at the Hospital for acute change in mental status. The nurse's note indicated that Resident #1 had Parkinson's disease with dementia, neuropathy, and retinopathy. The physician's progress note, dated 7/23/12, indicated that the Nurse Practitioner assessed Resident #1, who was unable to participate in the interview. The progress note indicated that Resident #1 was sluggish, and had a resting tremor of the upper extremities. The progress note indicated that Resident #1 had a pulse of 88 beats a minute with a regular rhythm and a blood pressure of 144/64. The progress note indicated that an x-ray at the Facility showed a chronic left shoulder fracture. The incident report, dated 7/23/12, indicated that at approximately 7:00 P.M., Resident #1 was found on the floor, 10 minutes after being put on a commode by Nurse #1 and CNA #1. The incident report indicated that Nurse #1 responded to the room, observed Resident #1 lying on his/her right side with his/her face down and bleeding. The incident report indicated Nurse #1 provided first aid, 911 was called, and Resident #1 was transferred to the Hospital. The Surveyor interviewed CNA #1 on 9/13/12 at 12:30 P.M. CNA #1 said she and Nurse #1 put Resident #1 on the commode at approximately 7:00 P.M. CNA #1 said she pulled the privacy curtain around Resident #1, gave him/her the call light to use, and stood outside Resident #1's room, in the doorway. CNA #1 said Resident #1 did not request privacy but she still pulled the privacy curtain and left Resident #1 alone. CNA #1 said less than 5 minutes later, she heard Resident #1 scream, and then he/she fell . CNA #1 said she yelled for Nurse #1 to come into the room. The Surveyor interviewed CNA #2 on 10/3/12 at 11:30 A.M. CNA #2 said she provided care to Resident #1 on several occasions. CNA #2 said Resident #1 did not always use the call light when he/she was given the call light because he/she was confused. CNA #2 said Resident #1 was at risk to fall but she still gave Resident #1 privacy on the commode by standing in the doorway of the room. CNA #2 said sometimes Resident #1 yelled out when he/she was done on the commode. The Surveyor interviewed Nurse #1 on 9/13/12 at 2:00 P.M. Nurse #1 said on 7/23/12, he and CNA #1 put Resident #1 on the commode after dinner. Nurse #1 said approximately 10 minutes later, he heard screams from CNA #1 coming from Resident #1's room. Nurse #1 said he immediately went to Resident #1's room, and observed a large amount of blood on the floor near Resident #1, who was lying on the floor. Nurse #1 said he told staff to call 911, he put pressure on Resident #1's forehead laceration, and waited for 911. Nurse #1 said after Resident #1 was stabilized he asked CNA #1 what happened. Nurse #1 said CNA #1 said she stood outside Resident #1's privacy curtain while Resident #1 used the commode. The Hospital History and Physical, dated 7/24/12, indicated that Resident #1 was admitted to the Hospital for treatment of [REDACTED]. The Hospital History and Physical indicated that it was unclear whether Resident #1 fell off the toilet because of balance or that he/she had a syncopal episode because this was "unwitnessed". The Hospital discharge summary, dated 7/25/12, indicated that Resident #1 was transferred back to the Facility with instructions for the nursing staff to provide Resident #1 with supervision when using the bathroom.