Every finding on record at Brentwood Rehabilitation and Healthcare CTR (The)

Based on observations, record reviews, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when three out of four nurses observed made four errors out of 26 opportunities, resulting in a medication error rate of 15.38%. Those errors impacted three Residents (#66, #106, and #122), out of five residents observed. Specifically, 1. For Resident #66, Nurse #1 administered the wrong dose of Vitamin D3. 2. For Resident #106, Nurse #6 administered the incorrect medication (Banatrol Plus instead of Juven) and Nurse #6 administered the incorrect dose of a medication (Psyllium). 3. For Resident #122, Nurse #7 administered a medication (Sevelamer Carbonate) after a meal, not according to the manufacturer's recommendations. Findings Include: Review of facility policy titled Administering Medications, dated as revised April 2019, indicated the following: -Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. -4. Medications are administered in accordance with prescriber orders, including any required time frame. -7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before or after meals). -10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. Resident #66 was admitted to the facility in June 2019 with diagnoses that included Alzheimer's disease and bipolar disorder. Review of Resident #66's most recent Minimum Data Set (MDS) Assessment, dated 2/6/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident is cognitively intact. Review of Resident #66's physician's orders included the following: -Vitamin D3 1000 units, give 1000 units one time daily for Vitamin D deficiency, dated, 11/7/19. On 3/12/25 at 9:30 A.M. Nurse #1 prepared and administered the following medication: -Vitamin D3 5000 units, two tablets. During an interview on 3/13/25 at 9:20 A.M., the Director of Nurses said she would expect that nurses would administer the correct dosage of medication to the residents. 44095 2. Resident #106 was admitted to the facility in February 2025 with diagnoses including anxiety and osteoporosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated that Resident #106 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #106 physician's order, dated 2/27/25, indicated: - Juven Oral Packet (Nutritional Supplements, used for wound healing containing arginine, glutamine, collagen protein, and micronutrients), give 27.5 gram by mouth two times a day for supplement. Mix with 8 to 10 ounces of water or fluid. - Psyllium Oral Packet (Psyllium), give 3.4 gram by mouth two times a day for constipation, mix with at least 8 ounces of juice, water or other beverage. Stir briskly for 3-5 seconds. Drink Promptly. On 3/12/25 at 5:22 P.M., the surveyor observed Nurse #6 prepare and administer the following medications to Resident #106: - one packet of Banatrol Plus (medication used for diarrhea and loose stools, containing banana flakes and a prebiotic), not Juven as ordered by the physician. - Psyllium Oral Powder, one heaping teaspoon, unmeasured and therefore unable to verify the correct dose. During an interview on 3/12/25 at 6:09 P.M., Nurse #6 said she was taught 3.4 grams is a heaping teaspoon. Nurse #6 then said she wasn't sure how else to measure 3.4 grams. During an interview on 3/12/25 at 6:12 P.M., Nurse #6 and the surveyor reviewed the medication cart, and she said she didn't realize she gave the Banatrol Plus packet instead of the Juven packet. Nurse #6 showed the surveyor that the Banatrol Plus packes and the Juven packets were both stored in a box labeled as Juven. During an interview on 3/13/25 at 10:54 A.M., Unit Manager #1 said that Nurse #6 should have measured the Psyllium Oral Powder to ensure the correct dose. Unit Manager #1 said that Banatrol Plus and Juven are not the same medication and Nurse #6 should have administered the correct medication. During an interview on 3/13/25 at 11:55 A.M., the Director of Nursing (DON) said that Nurse #6 should have measured the Psyllium Oral Powder to ensure the correct dose. Unit Manager #1 said that Banatrol Plus and Juven are not the same medication and Nurse #6 should have administered the correct medication. 3. Resident #122 was admitted to the facility in January 2025 with diagnoses including end stage renal disease (ESRD), acute kidney failure, and edema. Review of the Minimum Data Set (MDS) assessment, dated 2/6/25, indicated that Resident #122 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #122's physician's order, dated 3/5/25, indicated: - Sevelamer Carbonate Oral Tablet 800 milligrams (Sevelamer Carbonate), give 2 tablets by mouth with meals for ESRD (1,600 mg total). Scheduled three times daily at 8:00 A.M., 12:00 P.M., and 5:00 P.M. On 3/12/25 at 6:20 P.M., the surveyor observed Nurse #7 prepare and administer medications to Resident #122 including: - Sevelamer Carbonate 800 mg, 2 tablets, 1 hour and 20 minutes after the scheduled time. Further review of the medication card indicated for the medication to be administered with meals. During an interview on 3/12/25 at 6:21 P.M., Resident #122 said he/she had already finished dinner and there was no dinner tray in front of him/her. Resident #122 said he/she returned from dialysis around 5:15 P.M. During an interview on 3/12/25 at 6:23 P.M., Nurse #7 said she should have given Resident #122's his/her medication during his/her dinner but did not. Nurse #7 said she was aware Resident #122 was back in the Unit around 5:15 P.M., but she did not give him/her his medications on time, but she should have. During an interview on 3/13/25 at 10:58 A.M., Unit Manager #1 said Resident #122 medications should be given with meals, Unit Manager #1 said she was aware that Nurse #7 did not administer the medications with the meal. During an interview on 3/13/25 at 11:58 A.M., the Director of Nursing (DON) said Nurse #7 should have administered Resident #122's medication with the meals as ordered by the physician.

Based on observations, interviews, and record review, the facility failed to maintain accurate medical records for four Residents (#44 ,#80, #106 and #115), out of a total sample of 30 residents. Specifically, 1. For Resident #44, the facility failed to accurately document they completed a physician ordered treatment when they did not. 2. For Resident #80, the facility failed to accurately document his/her cast care when the cast was no longer there. 3. For Resident #106 the facility failed to ensure nursing maintained a complete record of blood pressures for midodrine administration. 4. For Resident #115, the facility failed to accurately document the location of blood pressure readings. Findings include: 1. Resident #44 was admitted to the facility in June 2023 with diagnoses that included anxiety, anemia, depression, and osteoarthritis. Review of Resident #44's most recent Minimum Data Set (MDS) assessment, dated 12/31/24, indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has intact cognition. On 3/11/25 at 8:04 A.M., the surveyor observed Resident #44 in bed with out a dressing on his/her left great toe. On 3/12/25 at 8:15 A.M., the surveyor observed Resident #44 in bed with out a dressing on his/her left great toe. During an interview on 3/12/25 at 8:16 A.M., Resident #44 said staff only change the dressing on his/her left great toe maybe once a week and it was not changed the last few days. Review of Resident #44's physician order, dated 2/14/25, indicated Left great toe: NSW (Normal Saline Wash), pat dry, apply bacitracin (antibiotic ointment) and cover with DPD (dry protective dressing) or band aid every evening shift. Review of Resident #44's March 2025 Treatment Administration Record (TAR), indicated nursing staff administered the treatment to the left great toe on 3/10/25 and 3/11/25. Review of Resident #44's impaired skin integrity care plan, dated 9/19/24, Administer treatments as ordered and monitor effectiveness. On 3/12/25 at 12:04 P.M., Nurse #1 with the surveyor observed Resident #44 in bed without a dressing on his/her left great toe. Nurse #1 said the treatment is not done on his shift and said the evening shift should be following the doctor's order. Nurse #1 said nurses should not sign off a treatment order that was not completed. During an interview on 3/12/25 at 3:50 P.M., the Director of Nursing said orders should only be signed off by nursing staff if they actually completed the physician order. 2. Resident #80 was admitted to the facility in January 2025 with diagnoses that included non-displaced fracture of the right fibula, post-traumatic stress disorder, major depressive disorder, and lack of coordination. Review of Resident #80's most recent Minimum Data Set (MDS) assessment, dated 1/21/25, indicated he/she scored a 13 out of a possible 15 on the Brief Interview for Mental Status indicating moderate cognitive impairments. Further review of the MDS indicated he/she needs partial/moderate assistance from staff members for lower body dressing and for putting on/taking off footwear. On 3/11/25 at 12:09 P.M., the surveyor observed Resident #80 in his/her wheelchair with a boot immobilizer on his/her right foot. On 3/12/25 at 8:00 A.M., the surveyor observed Resident #80 in bed with a boot immobilizer on. Review of Resident #80's active physician orders, dated 1/15/25, indicated Cast/ splint care: Keep cast/splint dry at all times. No dressing changes necessary. Review of Resident #80's March 2025 Treatment Administration Record (TAR), indicated nursing staff signed off the cast care every shift for the month of March from 3/5/25 to 3/11/25. During an interview on 3/12/25 at 11:56 A.M., Nurse #1 said the Resident was admitted with a hard cast on his/her leg but it was removed at the last ortho appointment a few weeks ago. Nurse #1 said nursing staff should not being signing off cast care was in place because the cast was removed weeks ago. During an interview on 3/12/25 at 12:11 P.M., Unit Manager #1 said the Resident had had a real cast and the order should have been changed but it wasn't. Unit Manager #1 said nurses shouldn't sign off something that wasn't done. 44095 3.) Resident #106 was admitted to the facility in February 2025 with diagnoses including anxiety and osteoporosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated that Resident #106 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #106's physician's order, dated 3/2/25, indicated: - Midodrine HCl Oral Tablet 5 milligrams (mg) (Midodrine HCl), give 3 tablets by mouth three times a day for hypotension (low blood pressure), hold for a systolic blood pressure for over 120. Review of Resident #106's Medication Administration Record (MAR), dated 3/4/25 through 3/12/25, indicated nursing documented the midodrine as administered three times daily at 8:00 A.M., 1:00 P.M., and 5:00 P.M. Review of Resident #106's weights and vitals tab titled, Blood Pressure Summary, in the electronic health record included the following values: 3/1/25 at 12:46 P.M., 132/68 3/1/25 at 10:02 P.M., 132/68 3/3/25 at 6:26 P.M., 126/79 3/4/25 at 9:48 A.M., 138/75 3/4/25 at 6:17 P.M., 127/79 3/5/25 at 9:16 A.M., 114/62 3/5/25 at 8:36 P.M., 121/69 3/6/25 at 3:35 P.M., 128/70 3/6/25 at 5:27 P.M., 123/69 3/7/25 at 10:26 A.M., 139/69 3/7/25 at 6:51 P.M., 128/64 3/8/25 at 9:59 A.M., 133/68 3/9/25 at 10:44 A.M., 129/66 3/10/25 at 2:38 P.M., 114/68 3/10/25 at 9:28 P.M., 119/67 3/11/25 at 1:55 P.M., 116/69 3/11/25 at 7:20 P.M., 120/78 3/12/25 at 3:18 A.M., 122/70 Comparative review of Resident #106's MAR, weights and vitals tab, and nursing notes, failed to include documentation to support that nursing consistently obtained and documented blood pressure for each administration of Resident #106's midodrine in accordance with the physician's order at the scheduled times. During an interview on 3/11/25 at 8:52 A.M., Resident #106 said that staff do not always check his/her blood pressure prior to administering his/her midodrine. During an interview on 3/13/25 at 10:08 A.M., Nurse #8 said that Resident #106 receives midodrine for hypotension. Nurse #8 said that nursing should check Resident #106's blood pressure prior to the medication administration. Nurse #8 said that whoever put in the midodrine order did not put in the order correctly. Nurse #8 said that supplemental documentation should have been added to document the blood pressure. During an interview on 3/13/25 at 10:26 A.M., Unit Manager #1 said that Resident #106's midodrine is used for low blood pressure. Unit Manger #1 said that there should be associated blood pressure documented in the medical record for the administration of each midodrine dose. Unit Manager #1 and the surveyor reviewed the MAR and blood pressure summary tab, and Unit Manager #1 said that she was not sure what the documented blood pressures were for because many of them were above 120, and the midodrine should have been held however nursing documented midodrine as administered. During an interview on 3/13/25 at 11:28 A.M., the Director of Nursing (DON) said that the midodrine order should have supplemental documentation for nursing to document the blood pressures. The DON said at minimum there should be blood pressure added to the vital signs tab for each administration, if the blood pressure is not documented on the MAR. The DON reviewed the blood pressure documented in Resident #106's medical record and said the midodrine should be held for blood pressures greater than 120. 49880 4. Review of facility policy titled Hemodialysis Catheters- Access and Care of, dated as revised February 2023, indicated the following: -Care of AVFs (arteriovenous fistulas) -Do not use the access arm to take blood pressure (BP). Resident #115 was admitted to the facility in September 2024 with diagnoses that included end stage renal disease and dependence on renal dialysis (a process to remove extra fluid and waste products from the blood when the kidneys are not able to function properly). Review of Resident #115's Minimum Data Set (MDS) assessment, dated 12/26/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #115 is cognitively intact. The MDS further indicated that Resident #115 receives dialysis. Review of Resident #115's physician's orders indicated the following: -NO Blood Draws, IVs, BPs on right arm, dated 9/18/24. -Check Right arm AV Fistula or AV Graft for bleeding, drainage, signs of infection, and the presence of bruit and thrill. Document abnormal findings in the nurses' notes and report to physician, dated 9/18/24. -Check AV fistula site thrill/bruit, dated 9/19/24. Review of the vital sign portal in the electronic medical record indicated that on 52 occasions since 9/18/24 nursing documented the blood pressure as being taken on the right arm. During an interview on 3/12/25 at 2:13 P.M. Nurse #6 said that she takes care of Resident #115 regularly. She said that the Resident has a fistula to their right arm and blood pressures are only checked on the left arm. She said that if it is documented on the right arm then it is an error. She said the Resident knows that he/she cannot have blood pressure done on the right arm and would not let staff obtain it there. During an interview on 3/13/25 at 9:06 A.M., the Director of Nurses said that medical records should contain accurate information including the correct side that a blood pressure was obtained.

Based on observation, record review and interview, the facility failed to ensure physician orders were implemented for three Residents (#44, #80, and #102) out of a total sample of 30 residents. Specifically, 1. For Resident #44, the facility failed to complete a treatment to his/her left great toe per physician order. 2. For Resident #80, the facility failed to obtain a physician order for the use of his/her boot immobilizer. 3. For (a) Resident #80 and (b) Resident #102, the facility failed to obtain weekly weights per physician order. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #44 was admitted to the facility in June 2023 with diagnoses that included anxiety, anemia, depression, and osteoarthritis. Review of Resident #44's most recent Minimum Data Set (MDS) assessment, dated 12/31/24, indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has intact cognition. During an observation on 3/11/25 at 8:04 A.M., the surveyor observed Resident #44 in bed without a dressing on his/her left great toe. During an observation on 3/12/25 at 8:15 A.M., the surveyor observed Resident #44 in bed without a dressing on his/her left great toe. During an interview on 3/12/25 at 8:16 A.M., Resident #44 said nursing staff only change the dressing on his/her left great toe maybe once a week and it was not changed the last few days. Review of Resident #44's physician order, dated 2/14/25, indicated Left great toe: NSW (Normal Saline Wash), pat dry, apply bacitracin (antibiotic ointment) and cover with DPD (dry protective dressing) or band aid every evening shift. Review of Resident #44's impaired skin integrity care plan, dated 9/19/24, indicated the following: Administer treatments as ordered and monitor effectiveness. On 3/12/25 at 12:04 P.M., Nurse #1 with the surveyor observed Resident #44 in bed without a dressing on his/her great left toe. Nurse #1 said the treatment is not done on his shift and said the evening shift should be following the doctor's order. During an interview on 3/12/25 at 12:20 P.M., the Director of Nurses (DON) said staff should be completing physician's orders. 2. Resident #80 was admitted to the facility in January 2025 with diagnoses that included non-displaced fracture of the right fibula, post-traumatic stress disorder, major depressive disorder, and lack of coordination. Review of Resident #80's most recent Minimum Data Set (MDS) assessment, dated 1/21/25, indicated he/she scored a 13 out of a possible 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairments. Further review of the MDS indicated he/she needs partial/moderate assistance from staff members for lower body dressing and for putting on/taking off footwear. On 3/11/25 at 8:32 A.M., the surveyor observed Resident #80 in bed without a boot immobilizer on. On 3/11/25 at 12:09 P.M., the surveyor observed Resident #80 in his/her wheelchair with a boot immobilizer on his/her right foot. On 3/12/25 at 8:00 A.M., the surveyor observed Resident #80 in bed with a boot immobilizer on. Review of Resident #80's orthopedic consult appointment note, dated 2/21/25, indicated boot immobilizer on at all times expect with hygiene and exercises. Review of Resident #80's active physician orders failed to indicate an order for use of the boot immobilizer. During an interview on 3/12/25 at 11:56 A.M., Nurse #1 said the Resident was admitted with a hard cast on his/her leg, but it was removed at the last ortho appointment a few weeks ago. Nurse #1 said he is not sure when the boot immobilizer should be on the Resident because there is not a physician's order in place for the boot. During an interview on 3/12/25 at 12:00 P.M., the Assistant Director of Nurses said there should be an order in place for a resident wearing a boot immobilizer. During an interview on 3/12/25 at 12:11 P.M., Unit Manager #1 said there should be an order in place for the use of the Resident's boot immobilizer but there is not. 3. (a) Resident #80 was admitted to the facility in January 2025 with diagnoses that included non-displaced fracture of the right fibula, post-traumatic stress disorder, major depressive disorder, and lack of coordination. Review of Resident #80's most recent Minimum Data Set (MDS) assessment, dated 1/21/25, indicated he/she scored a 13 out of a possible 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairments. Review of Resident #80's physician order, dated 1/15/25, indicated Weights Weekly one time a day every Wed (Wednesday). Review of Resident #80's weights indicated the last weight that was taken was on 2/19/25 and was 199.0 Lbs (pounds). Review of Resident #80's February and March 2025 Medication Administration Record (MAR), indicated on 2/12/25, 2/26/25, 3/6/25 and 3/12/25 the weight weekly on Wednesday order was left blank by nursing staff. Review of Resident #80's nutrition care plan, dated 1/17/25, indicated Obtain weights at ordered intervals. Review of Resident #80's nursing progress notes from 2/19/25 to 3/12/25 failed to indicate the resident refused weights. During an interview on 3/12/25 at 3:15 P.M., Nurse #2 said weekly weights are obtained weekly early in the day shift and the weights should be documented under the weights tab in the electronic medical record (EMR). During an interview on 3/12/25 at 3:51 P.M., the Director of Nurses said nursing staff should be following physician orders, obtaining the weekly weights weekly and documenting them in the weights tab in the EMR. (b) Resident #102 was admitted to the facility in January 2023 with diagnoses that included major depressive disorder, asthma, and muscle weakness. Review of Resident #102's most recent Minimum Data Set (MDS) assessment, dated 12/13/24, indicated he/she scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating severe cognitive impairments. Review of Resident #102's physician order, dated 2/24/25, indicated Weights weekly one time a day every Wed (Wednesday). Review of Resident #102's weights indicated the last weight that was taken was on 2/19/25 and was 158.6 Lbs (pounds). Review of Resident #102's February and March 2025 Medication Administration Record (MAR), indicated nursing staff signed off the weekly weight order as administered on 2/26/25 and 3/5/25. Review of Resident #102's nutrition care plan, dated 6/17/24, indicated Obtain weights at ordered intervals. Review of Resident #102's Nurse Practitioner (NP) progress note, dated 2/26/25, indicated Now he/she is losing weight-lost 13 pounds over the 6 weeks. Review of Resident #102's nursing progress notes from 2/19/25 to 3/12/25 failed to indicate the resident refused weights. During an interview on 3/12/25 at 3:15 P.M., Nurse #2 said weekly weights are obtained weekly early in the day shift and the weights should be documented under the weights tab in the electronic medical record (EMR). During an interview on 3/12/25 at 3:51 P.M., the Director of Nurses said nursing staff should be following physician orders, obtaining the weekly weights weekly and documenting them in the weights tab in the EMR.

Based on record review and interview, the facility failed to file a grievance for one Resident (#111), out of a total sample of 30 residents. Specifically, the facility staff failed to ensure the Administrator filed a grievance on behalf of Resident #111's who expressed a complaint of staff sleeping on the night shift. Findings include: Review of the facility policy titled, Grievances/ Complaints, Filing, undated, indicated that Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/ or representative. 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. 4. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board. 5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. 6. The contact information for the individuals) with whom a grievance may be filed is provided to the resident and/or representative upon admission. 7. The administrator is the facility grievance officer. 8. Upon receipt of a grievance and/or complaint, the grievance officer or designee will review and investigate the allegations and submit a written report of such findings within five (5) working days of receiving the grievance and/or complaint. 9. The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. 10. The grievance officer and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. 11. The grievance officer and associated department director will review the findings to determine what corrective actions, if any, need to be taken. 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. 13. If the grievance was filed anonymously, the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance(s) and report the findings. The grievance officer will reiterate to the resident that it is against facility policy and federal regulations to discriminate or sanction a resident who has filed or verbalized a complaint against the facility, and that his or her rights to be free of discrimination or reprisal will be protected. 14. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. 15. This policy will be provided to the resident or the resident's representative upon request. Resident #111 was admitted to the facility in January 2025 with diagnoses including diabetes, anxiety, and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment, dated 1/21/25, indicated that Resident #111 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. Review of Resident #111's plan of care related to post-traumatic stress disorder, dated 1/15/25, indicated: - Patient reports his/her triggers are as follows: Being woken up in the middle of the night abruptly, flipping the lights on (I panic). Further review of Resident #111's active plan of care failed to include accusatory behaviors. During an interview on 3/11/25 at 8:08 A.M., Resident #111 said that staff during the evening and night shift are 'horrendous' and it takes upwards of 30 minutes for staff to answer call bells. Resident #111 said that there are several staff who sleep during the night shift and despite speaking with the facility staff there are still staff members who sleep during the night shift, and he/she has photos of staff members sleeping. Review of the facility grievance log dated January 2025 through March 13, 2025, failed to include documentation to support facility staff filed a grievance on behalf of Resident #111's complaints of staff sleeping on the night shift. During an initial interview on 3/12/25 at 8:02 A.M., the Administrator said she was aware of Resident #111's complaint of staff sleeping on the night shift, but she did not complete a grievance. During an interview on 3/13/25 at 10:10 A.M., Nurse #8 said she was aware of Resident #111's complaints of staff sleeping during the night shift. During an interview on 3/13/25 at 10:23 A.M., Unit Manager #1 said that she was aware of Resident #111's complaint about staff sleeping during the night shift. During an interview on 3/12/25 at 5:58 P.M., the Social Worker said she was aware of Resident #111's complaint of staff sleeping during the night shift. The Social Worker said she told the Administrator and the Director of Nursing of these complaints and said a grievance should have been completed. During an interview on 3/13/25 at 11:15 A.M., the Director of Nursing (DON) said she was aware of Resident #111's complaint of staff sleeping during the night shift and the DON said the Social Worker or Administrator are responsible to file grievances. The DON said that there should be a grievance for Resident #111's concerns with staff sleeping. During a follow up interview on 3/13/25 at 12:22 P.M., the Administrator said she was unable to provide the surveyor with a grievance related to staff sleeping on the night shift.

Based on observations, record reviews, and interviews, the facility failed to ensure nursing implemented interventions for pressure ulcer care for one Resident (#119) out of a total sample of 30 Residents. Specifically for Resident #119 who had an actual pressure injury the facility failed to ensure that nursing implemented interventions including an air mattress and Prevalon boots (heel booties, a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure). Findings include: Review of the facility policy titled, Prevention of Pressure Injuries, dated as revised April 2020, indicated the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. -Preparation Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. - Support Surfaces and Pressure Redistribution 1. Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice. Resident #119 was admitted to the facility in February 2025 with diagnoses including dementia, severe protein malnutrition, and failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/28/25, indicated that Resident #119 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This MDS indicated Resident #119 was totally dependent on staff for putting on and taking off footwear. The MDS indicated that Resident #119 was assessed by nursing as at risk for skin breakdown and he/she had two unstageable pressure ulcers. Review of Resident #119's physician's order, dated 2/28/25, indicated: - Left heel: Apply skin prep, one time a day. Review of Resident #119's physician's order, dated 3/7/25, indicated: - Wound Description for Site: Unstageable (due to necrosis) wound of the left heel, one time a day. Review of Resident #119's plan of care related to actual skin breakdown unstageable (due to necrosis) of the left heel, dated as revised on 3/6/25, indicated: - air mattress to bed, initiated on 2/18/25. - heel booties while in bed as tolerated, initiated on 2/18/25. Review of Resident #119's specialty physician wound evaluation and management summary, dated 3/10/25, indicated: - unstageable full thickness pressure ulcer on left heel, float heels in bed; Prevalon boot when not floating heels. On 3/11/25 at 7:54 A.M., 10:15 A.M., 11:07 A.M. and on 3/11/25 at 4:14 P.M., the surveyor observed Resident #119 in his/her bed on a standard mattress and not an air mattress. Resident #119's feet were directly touching the mattress. There were no Prevalon boots in the room. On 3/12/25 at 8:30 A.M., 12:08 P.M., 4:34 P.M., and on 3/12/25 at 7:03 P.M., the surveyor observed Resident #119 in his/her bed on a standard mattress and not an air mattress. Resident #119's feet were directly touching the mattress. There were no Prevalon boots in the room. On 3/13/25 at 6:47 A.M., and on 3/13/25 at 11:00 A.M., the surveyor observed Resident #119 in his/her bed on a standard mattress and not an air mattress. Resident #119's feet were directly touching the mattress. There were no Prevalon boots in the room. During an interview on 3/13/25 at 7:44 A.M., Certified Nurse Assistant (CNA) #4 said that Resident #119 has an area on his/her heel and is dependent for care. CNA #4 said that Resident #119 accepts care, and he/she does not refuse care. CNA #4 said she was assigned to Resident #119 on 3/12/25 and 3/13/25 during the day shift, and CNA #4 said she was not aware the Resident #119 required an air mattress or Prevalon boots. CNA #4 and the surveyor searched Resident #119's room and were unable to locate Prevalon boots. During an interview on 3/13/25 at 7:50 A.M., Nurse #4 said that he is assigned to Resident #119 five days a week and is familiar with his/her care. Nurse #4 said that Resident #119 has pressure ulcers on his/her feet and Nurse #4 said that Resident #119 does not use an air mattress and does not have Prevalon boots. Nurse #4 said that Resident #119 would tolerate Prevalon booties if he/she was provided Prevalon boots. During an interview on 3/13/25 at 10:33 A.M., Unit Manager #1 said that Resident #119 has a left heel pressure ulcer. Unit Manager #1 reviewed Resident #119's care plan with the surveyor and she said that Resident #119's care plan indicates the use of an air mattress and the use of heel booties, and these interventions should have been provided. On 3/13/25 at 11:00 A.M., the surveyor along with Unit Manager #1 observed Resident #119 in his/her bed on a standard mattress and not on an air mattress. Resident #119's feet were directly touching the mattress. There were no Prevalon boots in the room. During an interview on 3/13/25 at 11:31 A.M., the Director of Nursing (DON) said that Resident #119 has a pressure ulcer and nursing should implement interventions that are in Resident #119's care plan for wound healing.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for two Residents (#232 and #381), out of a total sample of 30 residents. Specifically, 1. For Resident #232, the facility failed to ensure nursing changed the PICC line dressing with a transparent dressing as ordered. 2. For Resident #381, the facility failed to ensure that when a PICC line dressing was lifting (compromised), it was changed or reinforced and failed to change the PICC line dressing as indicated in the physician's orders on 3/8/25. Findings include: Review of the facility policy titled, Central Venous Catheter Care and Dressing Changes, dated as revised March 2022, indicated the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). 2. Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing or sterile gauze) for all central vascular access devices. The type of dressing is based on the condition of the resident and his or her preference. 3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM dressing; b. at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured); or c. immediately if the dressing or site appear compromised. 1. Resident #232 was admitted to the facility in February 2025 with diagnoses including enterocolitis due to clostridium difficile, pulmonary emboli, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 2/13/25, indicated that Resident #232 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #232's plan of care related to intravenous therapy, dated as revised 2/19/25, indicated: - Monitor dressing at IV insertion site daily and change as ordered and as needed (PRN). Review of Resident #232's physician's order, dated 3/6/25, indicated: - IV: (Midline, PICC, CVAD) Change Transparent Dressing on Admission and then every 7 days; Caps to be changed during dressing change, one time a day every Thursday and document. Review of Resident #232's Medication Administration Record, dated 3/7/25, indicated nursing changed Resident #232's PICC line dressing as ordered. On 3/11/25 at 12:09 P.M. and on 3/12/25 at 12:13 P.M., the surveyor observed a PICC line in Resident #232's right arm. The surveyor was unable to view the insertion site as it was obscured by gauze. The dressing was dated 3/7/25. During an interview on 3/12/25 at 12:14 P.M., Nurse #4 said he last changed Resident #232's PICC line dressing on 3/7/25, and said he did not obtain measurements when the PICC line dressing was changed. Nurse #4 said that he applied gauze under the transparent dressing to ensure that the line doesn't migrate when he does the dressing change. Nurse #4 said he is not able to visualize the insertion site with this type of dressing. During an interview on 3/13/25 at 10:45 A.M., Unit Manager #1 said that PICC line dressings should not have gauze under the dressing and if the insertion site is obscured by gauze the dressing needs to be changed more frequently. On 3/13/25 at 11:02 A.M., the surveyor and Unit Manager #1 observed Resident #232's PICC line dressing. Unit Manager #1 said that the insertion site was obscured by gauze and the insertion site could not be visualized. During an interview on 3/13/25 at 11:38 A.M., the Director of Nursing (DON) said nursing should use a transparent dressing without gauze so nursing can visualize the insertion site. 49880 2. Resident #381 was admitted to the facility in March 2025 with diagnoses that include chronic kidney disease and edema. Review of the Nursing Progress note, dated 3/12/25, indicated that the Resident is alert and oriented x 3, able to make needs known.[sic] Review of Resident #381's physician's orders indicated the following: -IV: (Midline, PICC, CVAD) Change Transparent Dressing on Admission and then every 7 days; Caps to be changed during dressing change, dated as 3/7/25. -IV: Assess that the IV catheter is secured well and does not slide around in the vein or become dislodged, the dressing is adhered with no moisture accumulation underneath it, dated 3/7/25. Review of the Patient Care Referral Form from the acute care hospital indicated that a PICC line was placed on 3/7/25. On 3/11/25 at 8:43 A.M. and 2:37 P.M., the surveyor observed a right arm PICC line dressing dated 3/7/25, one side of the dressing was lifting at the edge. The insertion site was not visible due to a disk (medicated patch). On 3/12/25 at 7:36 A.M. and 2:16 P.M., the surveyor observed a right arm PICC line dressing dated 3/7/25. One side of the dressing was lifting at the edge. The insertion site was not visible due to a disk. On 3/13/25 at 7:55 A.M., the surveyor observed a right arm PICC line dressing dated 3/7/25, one side of the dressing was lifting at the edge. The insertion site was not visible due to a disk. Review of the March 2025 Medication Administration Record indicated the PICC line dressing was changed by Nurse #9 on 3/8/25. However, based on the surveyor's observation the dressing was dated 3/7/25. During an interview on 3/13/25 at 8:08 A.M., Nurse #9 said that if a resident has a PICC line dressing that is lifting, then it should be changed. He said he would let a Registered Nurse know because in this facility, as an LPN (Licensed Practical Nurse) he does not change the PICC line dressings. On 3/13/25 at 8:24 A.M., Nurse #9 and the surveyor observed the PICC line dressing on Resident #381. Nurse #9 said that the dressing was lifting on the side, and that he had not noticed it yesterday when he worked. When asked he said that he has not changed the PICC line dressing since the Resident has been here. During an interview on 3/13/25 at 9:13 A.M., the Director of Nurses said that if a PICC line dressing is lifting then it should be changed or reinforced. She said the policy is to change the PICC line dressing weekly. She further said that a nurse should not sign off in the medical record that a PICC line dressing was changed when it was not.

Based on record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#381), out of a total sample of 30 residents. Specifically, the facility failed to follow physician orders to obtain daily weights and failed to notify a physician or nurse practitioner of a potential significant weight gain as indicated in the physician's orders for a resident with a diagnosis of liver cirrhosis (late stage liver disease, in which healthy liver tissue has been gradually replaced with scar tissue, causing symptoms such as swelling in the legs, feet, or ankles). Findings include: Review of facility policy titled Weight Assessment and Intervention, dated as revised March 2022, indicated the following: -Resident weights are monitored for undesirable or unintended weight loss or gain. -Residents are weighed upon admission and at intervals established by the interdisciplinary team. -Any weight change of 5% or more since the last weight assessment is retaken for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Resident #381 was admitted to the facility in March 2025 with diagnoses that include chronic kidney disease, cirrhosis and edema. Review of the Nursing Progress note, dated 3/12/25, indicated that the Resident is alert and oriented x 3, able to make needs known. Review of Resident #381's physician's orders indicated: -Weights Daily on day shift in the morning Contact MD/NP (medical doctor or nurse practitioner) if weight gain greater than 3 lbs. (pounds) in one day or 5 lbs. in 1 week, dated 3/8/25. Review of Resident #381's documented weights in the weight portal of the electronic medical record indicated the following: 3/7/25: 217.0 lbs. 3/11/25: 229.2 lbs. On 3/7/25, the Resident weighed 217 lbs and on 3/11/25, the Resident weighed 229.2 lbs., which is a 5.62% gain or 12.2 lb. difference in 4 days. Review of the Patient Care Referral form from the referring hospital indicated Resident #381 weighted 217 pounds on 3/7/25 at the hospital. Review of the weight portal failed to indicate weights were obtained on 3/8, 3/9 or 3/10. Review of the March 2025 Treatment Administration Record (TAR) indicated that the Resident refused to be weighed on 3/8, 3/9 and 3/12. Review of the medical record failed to indicate that a practitioner had been made aware of the potential significant weight gain. During an interview on 3/12/25 at 1:47 P.M., Nurse Practitioner #1 said that he had seen and examined Resident #381 earlier today. He said that the Resident has an order from the referring hospital for daily weights due to anasarca and liver cirrhosis. He also said that changes had been made to the Resident's diuretic therapy (medication that pulls extra fluid out of the body) due to his/her kidney function so monitoring the weights were important. He said that he was not made aware of the potential significant weight gain or that the Resident had been refusing weights. He said that he would have expected staff to confirm the potential weight gain and report it to him. Review of the medical record at the time of the surveyor's interview with the Nurse Practitioner failed to indicate that the staff had attempted to re-weigh the resident and confirm the potential significant weight gain. Further review of the medical record failed to indicate any refusals by the Resident for a re-weight as well as Physician or Nurse Practitioner notification of the potential significant weight gain. Further review of the medical record indicated that on 3/12/25 at 3:07 P.M., the facility re-weighed the Resident and obtained a weight of 234 lbs., an additional 4.8 lb. weight gain in one day. Another weight was obtained on 3/13/24 at 5:28 A.M., indicating a weight of 234.6 lbs. Review of Resident #381's physician's orders following the confirmation of the weight gain indicated the following: -Fluid Restriction 1.5 Liters every day for edema, with a start date of 3/13/25. During an interview on 3/13/25 at 8:06 A.M., Nurse #9 said that nursing should have confirmed and then reported the significant weight gain to the Nurse Practitioner or Physician when the weight was obtained as indicated in the physician's orders. During an interview on 3/13/25 at 9:08 A.M., the Director of Nurses said that the weight should have been confirmed and if confirmed, reported to the practitioner as indicated in the physician's orders.

Based on observations, record review and interviews, the facility failed to provide a dignified existence for one Resident (#68) out of a total sample of 30 residents. Findings include: Review of the facility policy titled Dignity, revised and dated February 2021, indicated the following: - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. - Residents are treated with dignity and respect at all times. Resident #68 was admitted to the facility with diagnoses including Bipolar disorder and personality disorder. Review of Resident #68's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. The surveyor made the following observations: - On 3/11/25 at 7:59 A.M., Resident #68 was sleeping in his/her bed and was visible in the hallway with his/her bedroom door open. Resident #68 was only wearing briefs, his/her entire buttocks were visible from the hallway. Numerous staff members were observed walking past his/her room with the Resident exposed. There was no privacy curtain in his/her room. - On 3/12/25 at 7:12 A.M., Resident #68 was sleeping in his/her bed and was visible in the hallway with his/her bedroom door open. Resident #68 was completely naked, and his/her entire buttocks and genitals were visible from the hallway. Numerous staff members were observed walking past his/her room with the Resident exposed. There was no privacy curtain in his/her room. On 3/12/25 at 8:16 A.M., the surveyor attempted to interview Resident #68 but he/she declined to be interviewed. Shortly after, Resident #68 was discharged out of the facility to the hospital, he/she was unavailable for the remainder of the survey. During an interview on 3/13/25 at 8:36 A.M., Nurse #10 all residents are entitled to privacy and dignity. Nurse #10 said if a resident is exposed and visible we would offer to cover them with a sheet or close their door so they cannot be seen from the hallway. Nurse #10 said staff should have attempted to cover up Resident #68. During an interview on 3/13/25 at 8:40 A.M., the Director of Nursing said all residents should be treated with dignity and privacy, she said staff should have intervened if Resident #68 was exposed and visible from the hallway.

Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, 1. The facility failed to ensure Nurse #6 disinfected shared resident equipment between resident use. 2. The facility failed to ensure Nurse #9 disinfected shared resident equipment between resident use. Findings include: Review of the facility policy titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, dated as revised June 2011, indicated the purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items. d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Review of the CDC (Centers for Disease Control and Prevention) Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated June 2024, indicated the following: 4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices b. Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. 1. On 3/12/25 between 5:05 P.M. through 5:22 P.M., the surveyor made a continuous observation of Nurse #6 during the evening medication pass. For three different residents Nurse #6 placed the blood pressure cuff directly onto each resident's arm, directly touching his/her skin. Nurse #6 also placed each resident's fingertip into the fingertip pulse oximeter for all three residents. Nurse #6 did not disinfect the multiuse shared equipment between each resident. During an interview on 3/12/25 at 6:08 P.M., Nurse #6 said that she is supposed to clean the vital signs machine at the end of the shift. During an interview on 3/13/25 at 10:52 A.M., Unit Manager #1 said Nurse #6 should have cleaned the vital sign machine in between each resident. 2. During the medication pass, on 3/12/25 at 9:11 A.M., the surveyor observed Nurse #9 check the blood pressure of a resident with a portable blood pressure cuff. Nurse #9 did not sanitize the blood pressure cuff before or after obtaining the resident's blood pressure. During an interview on 3/13/25 at 11:59 A.M., the Director of Nursing (DON) said nursing should clean the vital sign machine between each resident. 49880

Based on observation and interview, the facility failed to properly adhere to food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene, dated from 2021, indicated the following: - Applying and Removing Gloves: Perform hand hygiene before applying non-sterile gloves The surveyor made the following observations during the lunch tray line service on 3/12/25: - At 11:41 A.M., the Foodservice Director (FSD) was wearing gloves and making a peanut butter and jelly sandwich on the tray line. The FSD removed her gloves and touched the lid of the garbage can that was on top of the garbage can with her bare hands contaminating them. The FSD then went back to the tray line and touched five resident meal trays, where food would be on, with contaminated hands. The FSD then left the tray line to sort meal tickets on the milk refrigerator. The FSD then came back to the tray line and touched four more resident meal trays where food will be on with contaminated hands. At 11:46 A.M., the FSD grabbed the handle to the walk-in refrigerator and then proceeded to grab a cup with contaminated hands and put it on a resident's tray. At 11:48 A.M., the FSD then went into her office and then grabbed oven mitts to get food from the oven. At 11:49 A.M., the FSD washed her hands. During an interview on 3/13/25 at 9:06 A.M., the FSD said staff need to wash their hands when they leave their stations in the kitchen and when changing gloves and when their hands become contaminated. The surveyor then shared his observations with the FSD and the FSD said she thought she washed her hands, and she should have after changing her gloves and touching the garbage lid.

Based on record reviews and interviews, the facility failed to ensure one Resident (#232) was free from significant medication errors, out of a total sample of 30 residents. Specifically, for Resident #232 nursing failed to discontinue an order for Vancomycin HCl Oral Suspension (medication used to treat infections) when this brand was no longer covered by the insurance company, subsequently nursing obtained a different order under a different brand name of Vancomycin (Firvanq Oral Solution Reconstituted), which resulted in nursing administering both orders of Vancomycin (four times daily instead of twice daily). Findings included: Review of facility policy titled Administering Medications, dated as revised April 2019, indicated the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Resident #232 was admitted to the facility in February 2025 with diagnoses including enterocolitis due to clostridium difficile, pulmonary emboli, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 2/13/25, indicated that Resident #232 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #232's nurse practitioner note, dated 3/7/25, indicated: - 3/7/25: Patient finished Vancomycin three times daily, has 1-2 soft bowel movements daily, abdomen is soft and mildly tender at left lower quadrant. Vancomycin decreased to 150 milligrams (mg) twice a day for 7 days and after 150 mg once a day for 7 days and discontinue. Review of Resident #232's physician's order, dated 3/7/25, indicated: - Vancomycin HCl Oral Suspension 50 milligrams/ milliliter (Vancomycin HCl), give 3 ml by mouth two times a day for C. Diff for 7 Days and then give 3 ml by mouth one time a day for C. Diff for 7 Days. Further review of the order indicated the medication was scheduled to be given at 8:00 A.M., and 8:00 P.M. Review of Resident #232's Medication Administration Record (MAR), dated March 2025, indicated nursing administered the Vancomycin on 3/10/25, 3/11/25, 3/12/25, and on 3/13/25, as ordered. Review of Resident #232's physician's order, dated 3/9/25, indicated: - Firvanq Oral Solution Reconstituted 50 mg/ml (Vancomycin HCl), give 3 ml by mouth two times a day related to enterocolitis due to clostridium difficile for 7 Days. Further review of the order indicated the medication was scheduled to be given at 9:00 A.M., and 5:00 P.M. Review of Resident #232's Medication Administration Record (MAR), dated March 2025, indicated nursing administered the Firvanq mediation on 3/10/25, 3/11/25, 3/12/25, and on 3/13/25, as ordered. Review of Resident #232's health status note, dated 3/10/25 at 12:02 A.M., indicated: - pharmacy said the Vancomycin 50 mg/ml is not covered by insurance. The brand name Firvanq is covered by insurance. Medication was delivered later today. [sic] During an interview on 3/12/25 at 12:14 P.M., Nurse #4 said that he works Monday through Friday and on 3/10/25 and 3/11/25 he administered Resident #232 Vancomycin twice during his shift around 8:00 A.M., and 2:00 P.M. During an interview on 3/12/25 at 2:17 P.M., Nurse #3 said that on 3/11/25 she administered Resident #232 Vancomycin twice on the evening shift around 4:00 P.M., and again around 10:00 P.M. During an interview on 3/12/25 at 1:53 P.M., the Nurse Practitioner (NP) said that Resident #232 was prescribed Vancomycin for colitis. The NP said that on 3/7/25 he wanted the Resident to be administered Vancomycin twice a day for 7 days followed by daily for 7 days after that. During an interview on 3/13/25 at 10:44 A.M., Unit Manager #1 reviewed the duplicate orders in Resident #232's medical record with the surveyor. Unit Manager #1 said that the nurse should have discontinued the other dose of Vancomycin when she put in the new order for Firvanq. Unit Manager #1 said that if Resident #232 received Vancomycin four times daily it would be a medication error. During an interview on 3/13/25 at 11:41 A.M., the Director of Nursing (DON) said Resident #232 should receive Vancomycin twice a day. The DON said that if Resident #232 received Vancomycin four times a day it would be a medication error.

Based on record review and interviews, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#102) out of a total sample of 30 residents. Specifically, for Resident #102, who had a recent significant weight loss, the facility failed to have the Resident assessed by the dietitian for further interventions. Findings include: Review of facility policy titled Weight Assessment and Intervention, dated March 2022, indicated the following: -Resident weights are monitored for undesirable or unintended weight loss or gain. -Any weight change of 5% or more since the last weight assessment is retaken for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. -Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. Resident #102 was admitted to the facility in January 2023 with diagnoses that included major depressive disorder, asthma, and muscle weakness. Review of Resident #102's most recent Minimum Data Set (MDS) assessment, dated 12/13/24, indicated he/she scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Review of Resident #102's weight indicated on 1/2/25, the Resident weighed 171 lbs (pounds) and on 2/19/25, the Resident weighed 158.6 lbs which is a -7.25 % loss in one month. Review of Resident #102's Nurse Practitioner (NP) progress note, dated 2/17/25, indicated He/she has lost 13 pounds since the first of the year. Continues with significant weight loss. Review of Resident #102's Health Status Note, dated 2/18/25, indicated Note Text: Pt HCP (Health Care Proxy) notified of weight loss. Writer asked dietician to see pt.(patient) NP notified. Review of Resident #102's Nurse Practitioner (NP) progress note, dated 2/21/25, indicated Now he/she is losing weight-lost 13 pounds over the 6 weeks. He/she is under dietician supervision in the nursing home. Weight:158.6 Lbs - 2/19/25. Review of Resident #102's medical record indicated the last time the Resident had a Dietitian assessment was on 12/10/24 and the last progress note written by the Dietitian was on 4/11/24. During an interview and medical record review on 3/12/25 at 3:09 P.M., the Dietitian said when a resident is identified as a significant weight loss she would be told by nursing staff. Then she would write a progress note that would include interventions and update the care plan. The Dietitian said she is not sure if nursing staff told her about Resident #102's significant weight loss from February because she was new to the facility then. The Dietitian said she does know there is a weight pending for Resident #102 to be obtained by nursing. During an interview on 3/12/25 at 3:15 P.M., Nurse #2 said Resident #102 has lost a lot of weight recently. During an interview on 3/13/25 at 3:51 P.M., the Director of Nursing said she was not aware of Resident #102 losing so much weight recently because she thought he/she was gaining weight. The Director of Nursing said a Resident who has lost a significant amount of weight should be assessed by the Dietitian for interventions and to document that in the medical record.

Based on observation, interview and facility policy review, the facility failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness. Findings include: Review of the facility policy titled, Food Preparation and Service, dated November 2022, indicated the following: -Food and nutrition service employees prepare, distribute and serve food in a manner that complies with safe food handling practices. -Proper hot and cold temperatures are maintained during food distribution and service. -Food and nutrition service staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. -Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. Review of the facility policy titled, Handwashing/Hand Hygiene, dated October 2023, indicated staff members must perform hand hygiene before and after wearing gloves. On 3/27/24 at 7:07 A.M., the following was observed in the kitchen during the breakfast meal preparation: *The kitchen assistant was making toast and was wearing gloves. He touched the toaster knob and the packaging of the bread potentially contaminating his gloves. He then touched 10 pieces of bread with the contaminated gloves. Wearing the same gloves, the kitchen assistant then lifted the cover of the trash can to throw out the empty bread package, returned to the toaster and touched 2 pieces of toast. The kitchen aid then removed his gloves and put on a new pair of gloves without washing his hands. He then continued to make toast and touch every piece of toast made. *The cook washed her hands and then put on a new pair of gloves. The cook then touched utensils, the plate covers, and the oven door, contaminating the gloves. The cook then made 12 breakfast sandwiches, placing the cheese on the sandwiches with her contaminated gloves. The cook then opened the steamer door with her gloved hands and with her hands picked up two pancakes and placed them on a plate. The cook then made 12 more breakfast sandwiches touching all 12 pieces of cheese. The cook then touched oven door to remove a plate, and then made 5 more breakfast sandwiches, touching all 5 pieces of cheese. The cook again opened the steamer door and used her gloved hands to pick up 2 pieces of French toast. She then made 5 more breakfast sandwiches, touching 5 more pieces of cheese. During an interview on 3/27/24 at 7:37 A.M., the Food Service Director (FSD) said she is new to the facility and is unsure of the last time the kitchen staff had food handling education. The FSD said gloves would be contaminated if touching anything other than food and food should not be handled with contaminated gloves. The FSD said employees must wash hands when changing gloves.

Based on observation, interview and test tray results, the facility failed to serve food that is palatable, and at a safe and appetizing temperature, on three out of three units tested . Findings include: A group meeting was held on 3/27/24 at 11:00 A.M. During this meeting, 16 out of 16 participants said the food was not hot when it was served to them. A test tray was completed on 3/27/24 on the 2 East Unit at 7:58 A.M. with the following findings using the facility thermometer: *The pureed eggs were 115 degrees Fahrenheit and tasted cool, not hot. The eggs had a sour taste. *The pureed sausage was 111.4 degrees Fahrenheit and tasted warm, not hot. *The cream of wheat was 125.6 degrees Fahrenheit and tasted warm, not hot and was flavorless. *The pureed French toast was 113 degrees Fahrenheit and tasted cool, not hot. There was a very strong cinnamon flavor. *The yogurt was 61 degrees Fahrenheit and tasted warm, not cold. *The milk was 51.6 degrees Fahrenheit and tasted lukewarm, not cold and was not refreshing. *The orange juice was 53.4 degrees Fahrenheit and tasted lukewarm, not cold and was not refreshing. A test tray was completed on 3/27/24 on the 2 East Unit at 8:13 A.M. with the following findings using the facility thermometer: *The eggs were 97.5 degrees Fahrenheit and tasted cool not hot. The eggs tasted salty and had a rubbery texture. *The bagel was 93.4 degrees Fahrenheit and tasted cool. *The orange juice was 56.1 degrees Fahrenheit and did not taste cold. *The milk was 57.2 degrees Fahrenheit and tasted warm not cold. *The cream cheese cup was 67.1 degrees Fahrenheit. A test tray was completed on 3/27/24 on the 1 East Unit at 8:28 A.M. with the following findings using the facility thermometer: *The sausage links were 95 degrees Fahrenheit and tasted cool, not hot. *The egg on the egg sandwich was 110 degrees Fahrenheit and tasted warm, not hot. The bagel was soggy. *The milk was 48 degrees Fahrenheit and tasted cool. *The orange juice was 40 degrees Fahrenheit and tasted cold. *The yogurt was 50 degrees Fahrenheit and tasted luke warm not cold. * The oatmeal was 120 degrees Fahrenheit and tasted warm, not hot. The oatmeal had no flavor. A test tray was completed on 3/27/24 at 8:42 A.M. on the 2 [NAME] unit with the following findings: *The milk was 56 degrees Fahrenheit and tasted warm, not cold. *The orange juice was 56 degrees Fahrenheit and tasted warm, not cold. *The yogurt was 62 degrees Fahrenheit and tasted warm, not cold. * The oatmeal was 130 degrees Fahrenheit and tasted warm, not hot and was flavorless. *The eggs on the egg sandwich were 111 degrees Fahrenheit and tasted cold, not hot and had a rubbery consistency. The bagel was very hard and difficult to bite. *The sausage 101 degrees Fahrenheit and tasted cold, not hot. On 3/2/7/24 at approximately 9:00 A.M., the Food Service Director was told of the temperatures on the test trays. The Food Service Director said the temperatures did not meet the required temperatures for food served.

Based on observation, record reviews and interviews the facility failed to ensure sufficient staffing levels were maintained to provide the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) staffing levels were not provided in accordance with the facility's PPD (per patient day) level and facility assessment, and 2) failed to ensure Activities of Daily Living were provided in accordance to one Resident's (#53) plan of care out of a total sample of 29 residents. Review of the facility assessment, not dated, indicated the following: 'Staffing Guidelines' Our facility has created a staffing pattern to ensure that our residents' needs are met on a consistent basis. Our staffing pattern provides a base to ensure that the facility has a sufficient number of qualified staff to meet the needs of the residents. We incorporate the State of Massachusetts' regulatory requirement for minimum number of hours of care per resident day (PPD) of 3.580 hours (of which at least 0.508 hours must be care provided by a registered nurse) into staffing baseline. We further develop our staffing to provide sufficient nursing care based on the residents' acuity, needs and census to ensure that we meet the needs of each of our residents, which may result in staffing that exceeds the minimum required PPD. Review of the document entitled Centers for Medicare and Medicaid Services, Payroll Based Journal staffing Report, CASPER (Certification and Survey Enhanced Reporting) FY (Fiscal Year) Quarter 1 2024, (October 1-December 31), indicated the facility triggered: Submitted Weekend Staffing data is excessively low. During an interview on 3/26/24 at 8:26 A.M., a resident said staffing is low here, he/she continued to say he/she sits in the shower for 20 minutes waiting for help to get dried off. During an interview on 3/26/24 at 8:41 A.M., a resident said the building is not 100% staffed. During an interview on 3/26/24 at 8:46 A.M., a resident said there are not enough staff here to help him/her get out of bed. During an interview on 3/26/24 at 12:33 P.M., a Resident's family member said today is the most staff I have ever seen here, it is never like this. Normally we wait a long time for care and normally it takes a really long time for meal trays to be passed out. During an interview on 3/27/24 at 7:53 A.M., Nurse #1 said we could use more help with resident care during meal times with feeding residents. We do the best we can with what we have. The DON is on the floor often providing CNA care and medications. Nurse #1 continued to say she thinks staffing is low in the building. During the Resident Group Meeting conducted on 3/27/24 at 11:15 A.M., with the surveyors, 16 out of 16 residents actively participating in the meeting said the facility has low staffing on all shifts, and that low staffing is worse on weekends. The residents said as a result of the low staffing the meals are served cold, showers are not offered, and some residents may not be able to get out of bed when they want to. During an interview on 3/27/24 at 11:14 A.M., the Administrator said the facility is budgeted for a daily PPD (per patient day), 7 days a week at 3.29. Review of the documents provided by the facility and titled, Nursing HPPD (Hours Per Patient Day) dated 1/1/24 through 3/23/24 indicated the following: -January week ending in 1/6/24 indicated the following: *1/1/24 had a PPD of 2.359, total residents 135. *1/2/24 had a PPD of 3.124, total residents 133. *1/5/24 had a PPD of 2.769, total residents 133. *1/6/24 had a PPD of 2.257, total residents 134. Four of six days had a PPD below 3.29, one of which was a weekend day. -January week ending in 1/13/23 indicated the following: *1/7/24 had a PPD of 2.715, total residents 135. *1/13/24 had a PPD of 3.034, total residents 139. Two of the seven days had a PPD below 3.29 and both days were weekend days. -January week ending 1/20/24 indicated the following: *1/14/24 had a PPD of 3.130, total residents 140. *1/20/24 had a PPD of 3.028, total residents 143. Two of the seven days had a PPD below 3.29 and both days were weekend days. -January week ending 1/27/24 indicated the following: *1/21/24 had a PPD of 2.802, total residents 143. *1/27/24 had a PPD of 3.037, total residents 142. Two of the seven days had a PPD below 3.29 and both days were weekend days. -January/February week ending 2/3/24 indicated the following: *1/28/24 had a PPD of 3.285, total residents 141. *2/3/24 had a PPD of 3.246, total residents 135. Two of the seven days had a PPD below 3.29 and both days were weekend days. -February week ending 2/17/24 indicated the following: *2/11/24 had a PPD of 3.036, total residents 139. *2/17/24 had a PPD of 3.209, total residents 134. Two of the seven days had a PPD below 3.29 and both days were weekend days. February week ending 2/24/24 indicated the following: *2/18/24 with a PPD of 2.927, total residents 134. One of the seven days had a PPD below 3.29, which was on a weekend day. -March week ending 3/2/24 indicated the following: *3/2/24 had a PPD of 3.265, total residents 132. One of the seven days had a PPD below 3.29, which was a weekend day. -March week ending 3/9/24 indicated the following: *3/3/24 had a PPD of 3.208, total residents 130. One of the seven days had a PPD below 3.29, which was a weekend day. -March week ending 3/16/24 indicated the following: *3/10/24 had a PPD of 3.104, total residents 130 *3/16/24 had a PPD of 2.896, total residents 140 Two of the seven days had a PPD below 3.29 and both days were weekend days. -March week ending 3/23/24 indicated the following: *3/17/24 had a PPD of 3.104, total residents 132 *3/21/24 had a PPD of 3.200, total residents 144 *3/23/24 had a PPD of 3.012, total residents 141 During an interview on 3/27/24 at 2:29 P.M., the Administrator said the facility is working on staffing ongoing. The Administrator said the facility does not have a scheduler currently and that both she and the Director of Nursing have the responsibility for the staffing schedule and review the schedule in advance daily and fill any holes in the schedule. On 3/28/24 at 9:30 A.M. The Director of Nursing (DON) said the facility scheduler left a few weeks back and that she and the Administrator work on the schedule together and have a cooperate scheduler who also helps to secure staff. The DON said the 1 East Unit has a 34 bed capacity and is not always occupied and the census varies day to day and is staffed with two nurses and four CNAs on the 7:00 A.M. -3:00 p.m., Two nurses and three CNAs on the 3:00 P.M.-11:00 P.M. shift and one nurse and two CNAs on the 11:00 P.M.- 7:00 A.M. shift. The DON said 1 [NAME] unit has a 37-bed capacity and they would like to have four CNAs on the day shift (7:00 A.M.-3:00 P.M.) but only have three today, the 3:00 P.M.-11:00 P.M., has two nurses and three CNAs and 11:00 P.M.-7:00 A.M. is scheduled for one nurse and two CNAs. The DON said the 2 East Unit has a 44-bed resident capacity and is scheduled to have two nurses and five CNAs on the 7:00 A.M.-3:00 P.M. shift, two nurses and three CNAs on the 3:00 P.M -11:00 P.M. shift and one nurse and two CNAs on the 11:00 P.M. -7:00 A.M. shift. The DON said the 2 [NAME] Unit has a 37-bed resident capacity and is scheduled to have two nurses and four CNAs on the 7:00 A.M.-3:00 P.M. shift, two nurses and three CNAs on the 3:00 P.M -11:00 P.M. shift and one nurse and two CNAs on the 11:00 P.M.-7:00 A.M. shift. The DON said the PPD is 3.29. The DON said she has worked as a CNA and as a floor nurse when staff do not show up to assist with resident care. Review of the actual working schedule dated from 3/1/24 through 3/26/24 indicated the following: -A facility census of 139 on 3/1/24 through 3/25/24. -A facility census of 143 on 3/26/24. The 2-West Unit on the 7:00 A.M.-3:00 P.M. had an actual working schedule of three CNAs on 3/1/24 through 3/8/24, an actual working scheduled three CNAs on 3/11/24 through 3/13/24, an actual working schedule of three CNAs on 3/16/24 through 3/24/24, and an actual working schedule of three CNAs on 3/26/24. Out of a total of 26, 7:00 A.M.-3:00 P.M., shifts a total of 21 shifts on the 2 [NAME] unit worked with three CNAs. During an interview on the 2 [NAME] unit on 3/28/24 at 8:08 A.M., Certified Nursing Assistant (CNA) #4 said the unit she works on has about 44 residents. She said the day shift is scheduled for four CNAs but often there will only be three CNAs. CNA #4 said they work together to get the care done and that it is difficult at times. During an interview on the 2 [NAME] unit on 3/28/24 at 8:30 A.M. Nurse #5 said the unit is staffed with three CNAs and two nurses. Nurse #5 said it's hard for the two nurses and three CNAs to manage because many of the residents require a lot of care. Nurse #5 said there are times we get four CNA's but that does not occur very often and most of the time it is three. Nurse #5 said they will work together to get it all done. Nurse #5 said the nurses will help as much as they can. 48990 2) Resident #53 was admitted to the facility in March 2023 with diagnoses including right knee osteoarthritis and muscle wasting. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/28/23, indicated that Resident #53 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. This MDS also indicated Resident #53 required partial/moderate assistance with showering/bathing. Review of the plan of care related to activities of daily living, dated 1/3/24, indicated Resident #53 required assist with bathing. During an interview on 3/26/24 at 9:08 A.M., Resident #53 said he/she was told he/she could not have a shower the last two days because there was not enough staff. Resident #53 said there are often only two certified nurse assistants (CNA) on the floor. During an interview on 3/26/24 at 1:59 P.M., CNA #3 said Resident #53 was scheduled for a shower yesterday (3/25/24), but did not have a shower today or yesterday because there was not enough staff. CNA #3 said there were only two CNA's on the floor 3/26/24. During an interview on 3/27/24 at 8:29 A.M., Nurse #5 said scheduled showers are not given if there are only two CNA's on the floor because there is not enough staff to assist with the showers. During an interview on 3/28/24 at 9:30 A.M., the Director of Nursing (DON) said she is often called in to assist with care, including showers, when there is not enough staff. 45984 41456

Based on observations and interviews, the facility failed to provide a dignified dining experience to the residents of the 2 [NAME] unit. Review of the facility policy titled Assistance with Meals undated, indicated the following: * Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them meals. Findings include: On 3/26/23 at 8:00 A.M., the surveyor observed following on the 2 [NAME] unit: *There were five residents sitting at a table. The first resident was served his/her meal at 8:12 A.M. The last resident was served his/her meal at 8:40 A.M., 28 minutes later. *There were four residents sitting at a table. The first resident was served his/her meal at 8:08 A.M. The last resident was served his/her meal at 8:18 A.M., 10 minutes later. *Two different staff members assisting residents in their room were standing as the resident was eating in bed. The bed was not raised, and the staff members were not at eye level with the resident. On 3/27/24 at 8:02 A.M., the following was observed on the 2 [NAME] unit: *There were six residents sitting at a table. The first resident was served his/her meal at 8:06 A.M. The last resident was served his/her meal at 8:19 A.M., 13 minutes later. *There were four residents sitting at a table. The first resident was served his/her meal at 8:05 A.M. The last resident was served his/her meal at 8:15 A.M., 10 minutes later. *A staff member was assisting a resident with his/her meal. The staff member was standing, not at eye level with the resident. During an interview on 3/27/24 at 2:42 P.M., the Administrator said all residents who are seated together should receive their meals at the same time. The Administrator also said staff should be at eye level with residents when assisting with their meals and not standing above them.

Based on observations, record review and interviews, the facility failed to 1) ensure medications were stored as required for one Resident (#2), out of a total sample of 29 residents and 2) ensure medication carts were locked and medications were properly stored when the medication carts were unattended on two of four units. Findings include: Review of the facility policy titled Medication Storage, dated August 2021 indicated the following: *The assisted living facility will ensure that medications are safely and appropriately stored. *The administrator will provide an appropriate and safe medication storage area, either in a common area or in the resident's unit, for the storage of medications that are not self-administered by the resident. *The storage area requirement may be satisfied through the use of a locked medication cart. *The storage area will be kept locked when not in use. Review of the facility policy titled Administering Medications, dated April 2019, indicated the following: *During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. *Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do safely. 1) Resident #2 was admitted to the facility in October 2020 with diagnoses including chronic obstructive pulmonary disease (COPD), lack of coordination, unspecified asthma and schizoaffective disorder. Review of Resident #2's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 of 15 indicating that he/she is cognitively intact. Further review of the MDS indicated that Resident #2 requires substantial/maximum assistance with activities of daily living. The surveyor made the following observation: *On 3/26/24 at 8:56 A.M., Resident #2 was laying in his/her bed with his/her bedside table next to the bed within reach of the Resident. On the bedside table was an Advair inhaler out of the box, within reach of the Resident. Review of Resident #2's physician's order dated 7/7/23 indicated the following: *Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT (an inhaler that helps the lungs breathe better) - 1 puff inhale orally two times a day related to COPD, after use rinse mouth with water, spit do not swallow. Review of Resident #2's medical record and electronic medical record failed to indicate that the Resident was assessed by the facility to safely self-administer medications. During an interview on 3/27/24 at 10:56 A.M., Unit Manager (UM) #1 said no residents on the unit are able to self-administer medications since they have not been assessed. UM #1 said Resident #2 is not able to self-administer medications and he/she should not have them at his/her bedside. The surveyor showed UM #1 a photo of the inhaler on Resident #2's bedside table and she said it should not be there. UM #1 continued to say we cannot monitor if he/she administers correctly or rinses his/her mouth after use. During an interview on 3/27/24 at 1:31 P.M., the Director of Nursing (DON) said residents need to be assessed to self-administer medications. The DON continued to say Resident #2 should not have an inhaler at his/her bedside without staff present. 48990 2a) The surveyor made the following observation: *On 3/27/24 at 6:01 A.M., the medication cart on the 2 [NAME] unit was unlocked and a medication cup filled with two pills was on top. Nurse #1 was inside a resident room and not able to see the medication cart. On 3/27/24 at 6:05 A.M., Nurse #1 said the medication cart should always be locked when she is not nearby. During an interview on 3/27/24 at 8:35 A.M., the Director of Nursing (DON) said medication carts must be locked when it's not within a nurse's line of vision. The DON said medications should not be left unattended on top of the medication cart. 2b) The surveyor made the following observation: On 3/27/24 at 7:47 A.M., the surveyor observed the 2 East unit medication cart unlocked. Nurse #3 was inside a resident room and not able to see the medication cart. During an interview on 3/27/24 at 7:50 A.M., Nurse #3 came back to the 2 East medication cart and said it was unlocked and locked it. During an interview on 3/27/24 at 12:03 P.M., Nurse #3 said she should not have left the 2 East medication cart unlocked. During an interview on 3/27/24 at 8:35 A.M., the Director of Nursing (DON) said medication carts must be locked when it's not within a nurse's line of vision. The DON said medications should not be left unattended on top of the medication cart.

Based on observation, record review and interview the facility failed to identify and investigate bruises of unknown origin for one Resident (#62) out of a total sample of 29 residents. Findings include: Review of the facility policy titled Assessment of Skin Condition and Integrity dated March 2021, indicated the following: *Conduct a comprehensive head-to-toe skin assessment upon admission, weekly, and as needed. During the skin assessment, inspect for: *Presence of skin impairment(s), type of skin impairment(s) and location of skin impairment(s) *Inspect the skin daily when performing or assisting with personal care or activities of daily living (ADLs). *The following information should be recorded in the resident's medical record: *The type of skin assessment conducted *The condition of the resident's skin *Any new change(s) in the resident's skin condition, if identified. If a new skin alteration is noted, initiate a weekly wound progress report. *Develop, review and/or update the resident-centered care plan and interventions, as needed. Resident #62 was admitted to the facility in September 2021 with diagnoses including lack of coordination, dementia and frontotemporal neurocognitive disorder. Review of Resident #62's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 5 out of a possible 15 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident required partial/moderate assistance with ADLs. On 3/26/24 at 9:14 A.M., the surveyor observed Resident #62 lying in bed. He/she had multiple purple and green discoloration marks roughly one inch wide on his/her left wrist and left arm. Review of Resident #62's care plan dated 8/12/22 indicated the following: *Focus: I am at risk to sustain bruises d/t (due to) poor safety awareness and fragile skin. *Interventions/Tasks: Monitor resident for intrusive behavior and redirect. Review of Resident #62's weekly skin checks and evaluations dated from 2/15/24 through 3/21/24 failed to indicate any skin impairments or markings on Resident #62's left wrist/arm. Review of Resident #62's nursing progress notes failed to indicate any mention of skin impairments or concerns. During an interview on 3/27/24 at 11:08 A.M., Certified Nursing Assistant (CNA) #2 said if we see any type of skin markings like a bruise or cut while caring for a resident we tell nursing and they will investigate it. During an interview on 3/27/24 at 11:13 A.M., Nurse #1 said if we see a new skin mark or impairment, we investigate it and document it on the resident's weekly skin checks. Nurse #1 and the surveyor observed Resident #62's left wrist and arm and Nurse #1 said they are bruises, and she did not know where they are from. Nurse #1 looked into Resident #62's medical record and confirmed he/she did not get blood drawn or that the bruises were documented. She continued to say even if Resident #62 had blood drawn, any new bruise needs to be documented. During an interview on 3/27/24 at 11:42 A.M., Unit Manager (UM) #1 said if a resident has a bruise or mark on their skin the CNA would report it to nursing and we would investigate it. UM #1 said even if the resident has a care plan for bruising it still needs to be documented on weekly skin checks and be investigated. During an interview on 3/27/24 at 1:31 P.M., the Director of Nursing (DON) said if a resident has a new skin impairment such as a bruise it should be documented on their weekly skin checks and investigated to determine how it happened.

Based on observations, interviews and record review for one Resident (#115) out of 29 sampled residents, the facility failed to provide the necessary services to ensure Resident #115 was able to effectively communicate his/her needs. Findings include: Resident #115 was admitted to the facility in May 2023 with diagnoses including cerebral infarction, aphasia, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 1/30/24, indicated Resident #115 did not have a Brief Interview of Mental Status (BIMS) assessment completed as Resident #115 is rarely/never understood. The MDS also indicated Resident #115 is dependent on staff for functional tasks. On 3/26/24 at 9:19 A.M., the surveyor observed Resident #115 sitting up in his/her bed, awake, with the television on. Resident #115 attempted to communicate with the surveyor but could not formulate words. Resident #115 held the surveyor's hand and was able to communicate with yes or no questions by nodding or shaking his/her head. There was no communication board, writing pad, signs, or pictures in the Resident's room for staff to communicate with the Resident. On 3/27/24 at 7:31 A.M., the surveyor observed Resident #115 sitting up in his/her bed, awake, with the television on. Resident #115 attempted to communicate with the surveyor but could not formulate words. There was no communication board, writing pad, signs, or pictures in the Resident's room for staff to communicate with the Resident. On 3/27/24 at 8:28 A.M., the surveyor observed Resident #115 sitting up in his/her bed, awake, attempting to communicate with staff during breakfast when a staff member delivered a breakfast tray. The staff member set up the breakfast tray and did not attempt to communicate with the Resident and exited the room. Review of Resident #115's care plan, last revised 5/3/2023, indicated the Resident had a communication deficit related to global aphasia with profound deficits across language domains. Care plan interventions included: - Nonverbal, aphasic, nods and regards but not always consistently or accurately. -Monitor and document resident's ability to communicate and makes need known. If resident presents with difficulties communicating interdisciplinary team to develop alternative communication methods such as - communication boards, sign language, pointing - that are appropriate to residents level of cognitive and physical functional level. During an interview on 3/27/24 at 11:00 A.M., Certified Nursing Assistant (CNA) #4 said Resident #115 has issues with communicating and staff will ask yes or no questions to help with his/her needs. CNA #4 said the Resident can grunt and attempt to communicate but is not always understood. During an interview on 3/27/24 at 11:12 A.M., Activities Assistant #1 said Resident #115 uses an ipad to communicate during activities because he/she is non-verbal and needs communication devices to make his/her needs known. During an interview on 3/27/24 at 11:25 A.M., Unit Manager #1 said Resident #115 is nonverbal and he/she should have communication devices available in his/her room as the plan of care indicates the use of them. The Unit Manager said staff should use the communication devices when interacting and providing care to Resident #115 to make his/her needs known. During an interview on 3/28/24 at 9:56 A.M., the Director of Nursing (DON) said Resident #115 has communication signs and an ipad that can be used for communicating his/her needs and she expects staff to use them when providing care. The DON said the care plan should be followed and communication devices should be available for staff to use. The DON said all staff should be aware of what communication devices are used and where they are located.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MSD) assessments were accurately completed to reflect the status of two Residents (#36 and #547), out of a total sample of 29 residents. Specifically, 1.) For Resident #36, the facility failed to accurately document that the Resident was determined to meet the criteria for a serious mental illness on a level II Preadmission Screening and Resident Review (PASRR), which is an evaluation to confirm that a Resident has a mental illness or intellectual disability in the MDS assessment. 2.) For Resident #547, the facility failed to accurately document the presence of IV (intravenous) access (a tube that is inserted into the vein to deliver fluids or medications) and administration of IV medications in the MDS assessment. Findings include: 1.) According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, which is the manual used to facilitate accurate and effective resident assessment practices in long-term care facilities, it is indicated: -Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or intellectual disability or a related condition. Resident #36 was admitted to the facility in November 2020 with diagnoses including schizoaffective disorder. Review of the most recent comprehensive MDS assessment, dated 9/16/23, indicated no to question A1500 which asks is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Review of PASRR Level II evaluation, dated 10/26/22, indicated Resident #36 met serious mental illness criteria for PASRR involvement. Review of Resident #36's plan of care related to PASRR, dated 2/16/24, indicated: -Resident meets PASRR Level II determination secondary to diagnosis of serious mental illness. During an interview on 3/28/24 at 9:06 A.M., MDS Nurse #1 said the social worker was responsible to code all the PASRR questions on the MDS assessment and it was coded incorrectly on the MDS assessment, dated 9/16/23. During an interview on 3/27/24 at 12:44 P.M., the Social Worker #1 and the Regional Director of Operations said the MDS assessment, dated 9/16/23, was coded incorrectly and it should have been coded as yes for question A1500 because the level II PASRR determined Resident #36 met serious mental illness criteria for PASRR involvement. 49880 2. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11, October 2023 indicated the following: -When coding IV medications in section O of the MDS assessment, code any drug or biological given by intravenous push, epidural pump, or drip through a central or peripheral port in this item. -When coding IV access in section O of the MDS assessment, code IV access, which refers to a catheter inserted into a vein for a variety of clinical reasons, including long-term medication administration, large volumes of blood or fluid, frequent access for blood samples, intravenous fluid administration, total parenteral nutrition (TPN), or, in some instances, the measurement of central venous pressure. Check central line access when IV access was centrally located (e.g., PICC, tunneled, port). Resident #547 was admitted to the facility in March 2024 with diagnoses that include staphylococcal arthritis and periapical abscess (a pocket or infection around the tooth root). Review of Resident #547's most recent MDS assessment, dated 3/17/24, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating that Resident #547 was cognitively intact. Review of the MDS assessment failed to indicate that Resident #547 was receiving IV medications or had IV access. Review of Resident #547's physician's orders indicated the following: -IV: change transparent dressing on admission and then every 7 days; caps to be changed during dressing change, dated 3/14/24. -One time order for Oxacillin Sodium (an antibiotic medication) 2 grams for one administration, dated 3/14/24. -Oxacillin Sodium 2 grams intravenously every four hours for 13 days, dated 3/15/24. Review of Resident #547's March 2024 Medication Administration Record indicated that IV medication had been administered once on 3/14/24 and six times daily from 3/15/24 through 3/27/24. During an interview on 3/28/24 at 10:25 A.M., the MDS Nurse said that coding no for IV medications and IV access on the 3/17/24 MDS assessment was an error and should have been coded as a yes on the assessment. During an interview on 3/28/24 at 10:44 A.M., the Director of Nursing (DON) said that she would have expected accurate MDS coding for a resident with IV access who was receiving IV medications.

Based on interviews and records reviewed, for three of three sampled residents (Resident #1, #2, and #3), the Facility failed to ensure the residents were free from sexual abuse by a staff member. During the overnight shift beginning on 06/24/22, Resident #1, who was alert and oriented, called 911 (from the Facility) to report he/she had been sexually assaulted by a male staff member (later identified as Nurse Aide (NA) #1). During the course of the Facility and local law enforcement investigations, Resident #2 and Resident #3, also alert and oriented residents, reported they had been sexually assaulted by a male staff member (later identified as NA #1), during the same overnight shift beginning on 06/24/22. Resident #1, #2, and #3's accountings of the alleged sexual abuse remained consistent, with all three residents reporting they were touched by NA #1, in sexually inappropriate manner. Findings include: The Facility's Policy titled, Abuse, Neglect, Exploitation or Misappropriation Prevention Program, undated, indicated the Facility would conduct background checks and not knowingly employ or otherwise engage any individual who has been found guilty of abuse, had findings entered in the state nurse aide registry concerning abuse, and/or any disciplinary actions in effect against his/her professional license by a state licensure body as a result of a finding of abuse. The Facility's Policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, undated, indicated the Facility would provide staff orientation and training/orientation programs that included topics such as resident abuse. Review of the Facility's Contact titled, Agreement, dated 03/14/22, between the Facility and the Staffing Agency, indicated that: - the Staffing Agency would provide specific requested, qualified, screened, and competent caregivers to assist the Facility with meeting residents care needs, and; - all personnel provided to the Facility by the Staffing Agency would meet all the requirements and applicable federal, state, and local regulations. Review of the Facility's Contract titled, Addendum to Agency Service Agreement, undated, indicated the Staffing Agency would provide the Facility with any and all local, federal, and state certifications and licenses for each staff member that the Staffing Agency sent to work at the Facility prior to such individual commencing work at the Facility. 1. The Facility's Internal Investigation, dated 06/25/22, indicated that on 06/25/22, at approximately 4:00 A.M., Resident #1 called 911, and alleged that NA #1 came into his/her bedroom and sexually assaulted him/her. The Investigation indicated Resident #1 was interviewed by local law enforcement and transferred to the Hospital Emergency Department (ED) for evaluation. The Investigation indicated that on 06/25/22, the Staffing Agency told the Facility there was a late call out, so NA #1 was sent to work at the Facility as a replacement, without notifying the Facility and without providing them with pre-employment checks, as indicated in their Contract. Review of Resident #1's Five-Day Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was cognitively intact, and he/she was able to independently make his/her health care decisions. Review of Resident #1's Physician's Note, dated 06/25/22, at 06:52 A.M., indicated that Resident #1 was transferred to the Hospital ED following a complaint of sexual assault at 4:00 A.M. Review of the Facility's Full Quality Assurance (QA) Report, dated 6/25/22, indicated that around 4:00 A.M., Resident #1 called 911 from his/her cell phone and police arrived around 4:05 A.M., and informed staff that Resident #1 alleged that a black male sexually assaulted him/her. The Report indicated that Nurse Aide #1 said he answered Resident #1's call light twice but did not provide care to him/her. Review of the Hospital's ED Provider Note, dated 06/25/22, at 4:27 A.M., indicated Resident #1 said a male staff member (later identified as NA #1) inserted his gloved fingers in his/her genital area. The Note indicated Resident #1 was alert and oriented, without confusion. The Note indicated Resident #1 became agitated and acutely psychotic, with hallucinations while in the ED, and he/she was involuntarily admitted to the Hospital. Review of the Hospital's Admission Note, dated 06/25/22 at 05:00 A.M., indicated Resident #1 said that around 3:00 A.M., a male (later identified as NA #1) came into his/her room and Resident #1 told NA #1 he/she had pain. The Note indicated Resident #1 said NA #1 had on two pairs of gloves and placed his hands inside his/her genital area, and that NA #1 asked Resident #1 if it felt good, or words to that effect. The Note indicated Resident #1 said he/she asked NA #1 to stop, and he did, but that NA #1 did not return with pain medication. The Note indicated Resident #1 stated he/she needed to tell someone, therefore, he/she called 911. 2. The Facility's Internal Investigation, dated 06/26/22, indicated it was alleged that on Thursday or Friday night (later determined to be Friday night, on 6/24/22) Resident #2 heard a male NA (later identified as NA #1), say to his/her roommate (Resident #3) words to the effect of, Why don't you like it like that? The Investigation indicated Resident #2 then said he/she woke up around 2:30 A.M., to a black male (later identified as NA #1) sitting on the side of his/her bed, touching his/her breasts, and that NA #1 put his fingers in his/her genital area. The Investigation indicated Resident #2 yelled words to the effect of, Stop. Don't touch me and that NA #1 left Resident #2's room. Review of the Facility's Full QA Report, dated 6/26/22, indicated that Resident #2 reported being awoken in the middle of the night to a male NA (later identified as NA #1) touching his/her breasts and attempting to put his hands down his/her pants. Resident #2 was admitted to the Facility in June 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Five-Day MDS, dated [DATE], indicated that Resident #2 was cognitively intact, and he/she was able to independently make his/her health care decisions. Review of Resident #2's Physician's Progress Note, dated 06/24/22, indicated that Resident #2 had deconditioning, muscle weakness, and walking difficulties and ongoing physical and occupational therapy would help to improve gait and ADL strength. Review of Resident #2's Behavioral Health Group's Nurse Practitioner's Progress Note, dated 06/27/22 at 1:00 P.M., indicated that Nurse Practitioner #1 met with Resident #2 for an initial evaluation for depression and anxiety. The Note indicated Resident #2 said that very early Saturday Morning (on 06/25/22), a male Nurse Aide (later identified as NA #1) came into his/her room while he/she was asleep, and touched his/her left breast and put his/her hands into his/her genital area. The Note indicated Resident #2 asked NA #1 to stop, and NA #1 left the room. The Note indicated Resident #2 called 911 and informed his/her Family Member about the incident. The Note indicated Resident #2 was anxious about an incident that happened with his/her roommate, Resident #3. The Note indicated Resident #2 may benefit from therapy services. Review of Resident #2's Nurse Practitioner's Progress Note, dated 06/27/22, indicated that NP #2 met with Resident #2 following an allegation of sexual assault. The Note indicated that around 2:30 A.M., after being sexually assaulted by NA #1, he/she could not sleep at all the remainder of the night. The Note indicated that the next day, Resident #2 spoke with his/her Family Member about what happened. The Note indicated Resident #2 said he/she asked his/her roommate, Resident #3, about what happened during that evening (later identified as the overnight shift beginning on 06/24/22) and Resident #3 said he (later identified as NA #1) put his fingers into his/her genital area, touched his/her breasts, and NA #1 began to jerk off in front of him/her. The Note indicated Resident #2 did not report the incident to anyone because he/she did not want to get kicked out of the Facility. 3. The Facility's Internal Investigation, dated 06/26/22, indicated that Resident #3 alleged that during an overnight shift beginning on 06/25/22, a male NA (later identified as NA #1) was, playing with himself while touching his/her breasts; and had his fingers way up in his/her genital area. Resident #3 was admitted in June 2022, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Admission MDS, dated [DATE], indicated that Resident #3 was cognitively intact, and he/she was able to independently make his/her health care decisions. Review of Resident #3's Nurse Practitioner's Progress Note, dated 06/27/22, indicated that NP #2 met with Resident #3 following an allegation that on 06/25/22, a male NA (later identified as NA #1) sexually assaulted him/her while assisting him/her with a bed pan. The Note indicated Resident #3 said NA #1 put his fingers up into his/her genitals and started to go back and forth . The Note indicated Resident #3 said NA #1 asked Resident #3, how he/she felt about it, or words to the effect of. The Note indicated Resident #3 said NA #1 also touched his/her breasts. The Note indicated Resident #3 said that after NA #1 finished what he was doing, he went to Resident #2, (his/her roommate) and assisted Resident #2 briefly, and then left their room. The Note indicated Resident #3 was shaking, crying, and looked very traumatized, and Resident #3 said he/she did not report the incident right away because he/she did not want to get kicked out of the Facility for reporting the incident. The Note indicated Resident #3 spoke with his/her roommate, Resident #2, who also reported being sexually assaulted by NA #1, so they decided to report to the sexual abuse to management. During an interview on 07/20/22 at 4:10 P.M., Nurse Practitioner (NP) #2 said that she met with Resident #1, #2, and #3, during their Admission to the Facility. NP #2 said the residents were reliable and credible, and said she believed their reports of sexual abuse by NA #1, given the consistent detail in the reports of the resident sexual abuse. Review of NA #1's Written Statement, undated, indicated that at approximately 3:51 A.M., he responded to a resident's (later identified as Resident #1) call bell, and saw Resident #1 crying, sitting at the edge of his/her bed and almost falling, so he reached out to Resident #1 to help balance him/her in bed. The Statement indicated Resident #1 said his/her back hurt and he/she needed pain medication. The Statement indicated the nurse (later identified as Nurse #1) was on break and a few minutes later, Resident #1 rang the call bell and reported pain again to NA #1. The Statement indicated NA #1 told Resident #1 that Nurse #1 would give his/her medication soon. The Note indicated Resident #1 said strange things to the effect of someone sexually assaulted me, and it was you. The Note indicated NA #1 did not take Resident #1's statement seriously and said once he walked out of Resident #1's room he saw local law enforcement. During an interview on 07/18/22 at 08:25 A.M., Nurse Aide #1 said he had not completed a nurse aide training program and said he was not a state certified nurse aide. NA #1 said that on 06/24/22, the Staffing Agency Owner contacted him to work at the Facility during the overnight shift beginning on 06/24/22, because there was a call out from another one of her employees. NA #1 said he was answering resident call lights by himself throughout the night and said he independently assisted Resident #3 on and off a bed pan. NA #1 said the other two staff members that he worked with during that shift took a break at the same time, so he was on the unit for about an hour by himself, before law enforcement arrived at the Facility, which was when he was sent home due to the sexual abuse allegations. During an interview on 07/13/22, at 3:35 P.M., the Staffing Agency Owner said a staff member schedule to work the overnight shift called out; therefore, she contacted NA #1 to work the overnight shift beginning on 06/24/22. The Staffing Agency Owner said she did not complete a nurse aide registry check or licensure check prior to sending NA #1 to work at the Facility because NA #1 had not taken a nurse aide training course within the past [AGE] years. The Staffing Agency Owner said she sent NA #1 to work at the Facility as a non-certified nurse aide. During an interview on 07/14/22 at 10:27 A.M., and throughout the Survey, the Administrator said that on 06/25/22, the Facility Staffing Scheduler called the Staffing Agency's Owner to report the allegation of abuse made by their residents involving NA #1 during the prior overnight shift. The Administrator said that was when the Facility became aware that the Staffing Agency Owner had a last minute call out, and sent NA #1 to work at the Facility during the overnight shift on 06/24/22. The Administrator said because they were not aware there had been a change in who the Staffing Agency was sending to work in the Facility that night, they did not ensure NA #1 completed the required Nursing Staff Orientation prior to working at the Facility, and providing care and services to residents.

Based on records reviewed, interviews and observations, for one of three sampled residents (Resident #1), who was dependent on staff for all care needs, the Facility failed to ensure Resident #1 was provided with the necessary care and services to meet his/her care needs, when based on review of the video footage obtained from the facility for 10/23/19, Resident #1 was left seated in his/her Broda chair near the nursing station during the day shift (for a total of approximately six hours), the only time Resident #1 was attended to by staff was when he/she was taken to the dining room for breakfast and lunch. Although staff can be seen in the video footage walking past or standing near Resident #1 while he/she was seated by the nursing station, and Resident #1 can be seen becoming increasingly restless, fidgeting, uncomfortable, and in need of assistance, no-one stops to provide assistance or care to Resident #1 during that time. Findings include: On 10/23/19, at approximately 2:45 P.M., a family member arrived at the facility to visit Resident #1 and upon arrival observed that Resident #1, who was seated near the nursing station, in clear view of several staff members, was disheveled looking and appeared distressed. The family member could see that Resident #1's shirt was partially pulled off exposing a shoulder, he/she had part of the shirt in his/her mouth, his/her hands were in his/her pants and on the floor in front of Resident #1 there was a white popcorn type material all over the floor. During an interview on 12/19/19 at 11:30 [NAME]M., with Family Member #2 (Resident #1's Health Care Agent), Family Member #2 said she has found Resident #1 on several other occasions, prior to the incident on 10/23/19, in the same condition, that Resident #1 would be seated in his/her Broda chair near the nursing station, disheveled, had been incontinent, was clearly uncomfortable, and said it was like the staff had no idea Resident #1 was even sitting there, that staff just walk past him/her without engaging with, speaking to or offering Resident #1 any assistance. Family Member #1 said she has complained to the facility about this because she is concerned Resident #1's care needs are not consistently addressed by staff. The Surveyor reviewed the video surveillance footage, provided by the Facility's Administrator, which was date and time stamped, 10/23/19 from 7:00 [NAME]M. to 4:00 P.M., shift, and depicted multiple staff members, walking near, walking past, sitting near or across from Resident #1 for a total of approximately six hours, as he/she fidgeted about in the Broda chair, pulled at his/her clothing, dug into his/her brief, pulled out and threw brief material on to the floor, and staff failed to provide any assistance. The Administrator and Director of Nursing identified the staff members seen in the video. - On 10/23/19, after a Hospice Certified Nurse Aide (CNA) and one of the facility's CNAs provided Resident #1 with routine morning care, including hygiene and incontinence care, Resident #1 was dressed for the day in street clothes, transferred into his/her Broda chair then transported and left in the dining room for breakfast. The video depicted the following: -07:59:13 Resident #1 was transported in his/her Broda chair out of the dining room and left seated near the nurses' station by a staff member (identified as CNA #4). -8:01:40 - 10:28:00 (approximately 2.5 hours) Resident #1, still seated near the nursing station, another resident seated near him/her, a staff member (identified as CNA #3) stops to speak with the other resident, however CNA #3 does not engage with Resident #1. -During this 2.5 hour period of time, no other staff members are seen interacting with Resident #1. -10:28:49 Resident #1 still seated in his/her Broda chair at the nursing station, is restless and fidgeting. Resident #1 observed using his/her right arm trying to and pushing up on the Broda chair arm rest, tries to lift his/her upper body and continues to move around in the Broda chair. -10:30:55 Resident #1, continues to be fidgety, can be seen moving around in his/her Broda chair and seen leaning his/her trunk forward towards another resident sitting near him/her. -10:32:46 A staff member(identified as Nurse #1) can be seen standing in front of a medication cart, with her back to Resident #1, and two other staff members (identified as CNA #2 and CNA #3) were seated at the nurses' desk. -However, none of these staff members engaged with or address Resident #1. -10:32:49 A resident seated in front of Resident #1 tries to get the attention of staff members (identified as Nurse #1, CNA #2 and CNA #3). The resident calls out to staff, motions to staff by raising and moving his/her hand in the air, until CNA #3 walks towards the resident, who then points to Resident #1. CNA #3 is seen speaking briefly to Resident #1. CNA #2, who can be seen standing behind CNA #3, does not engage with Resident #1 at all. -10:34:38 CNA #3 places a blanket on Resident #1, covering Resident #1's lower body, places Resident #1 legs back onto the leg rests of the Broda chair and then walks away. -10:55:58 CNA #2 transported Resident #1 from the nursing station to the dining room for lunch. -11:26:16 CNA #4 transported Resident #1 from the dining room back to the nurses' station. -Review of the video footage, showed that although Resident #1's room and a hallway bathroom were accessible to staff prior to transporting Resident #1 to the dining room for lunch and then back to the nursing station after lunch, Resident #1 was not toileted or provided with incontinence care, before or after lunch. There is no bathroom in the dining room. -11:39:32 Resident #1 picks up his/her head, rubs and scratches his/her neck and shoulder then proceeds to rub his/her eyes and face. -11:50:22 Resident #1 seen with head looking down. Nurse #1 can be seen going over to Resident #1, lifted Resident #1's head in an upright position by placing her hand on Resident #1's forehead, took Resident #1's temperature and walked away. Resident #1 was awake and continued using his/her left hand to rub at his/her neck, back, and chest area. -11:53:14 Resident #1 leaning forward in Broda chair with his/her head down. Resident #1 fidgeting, with his/her left hand, Resident #1 tries to reach behind him/herself, towards his/her left lower back/buttocks area. -11:54:25 Resident #1 continued to lean forward in the Broda chair, his/her left arm continues to move in an up and down motion reaching towards the left lower back/buttocks area. Resident #1's blanket is at his/her waist line. -11:55:21 Resident #1 continues fidgeting about in the Broda chair, his/her trunk is now pitched forward touching his/her knees and Resident #1 continues moving his/her left hand, behind him/herself, to his/her lower back area. -11:57:16 Resident #1 was approached by Nurse #1, who twice attempts to place medications in Resident #1's mouth. Resident #1 seen moving his/her head away from Nurse #1. Nurse #1 proceeded to give the medications to Resident #1, despite Resident #1 turning his/her head and walks away. -12:08:19 Resident #1's trunk area leaning forward, face was in his/her blanket which was at his/her knees, Resident #1 reaching left hand behind him/herself, toward back/buttocks area, his/her hand can be seen moving in an up and down motion. CNA #2 passes by Resident #1 and does not interact or assist Resident #1. -12:11:04 Resident #1 looking at his/her hands and leaning back in Broda chair, moving his/her legs apart, places hands in brief, blanket at Resident #1's waist side. Resident #1 continues to have his/her hands down his/her brief. -Although, Nurse #1, who is standing at the medication cart, another staff member (unidentified) along with CNA #2, and CNA #3 are at the nurses' station, none of the staff members interact with or addresses Resident #1, who can be seen fidgeting and restless. -12:12:43 Resident #1 leaning forward in his/her Broda chair, body is tilted to the left side of the Broda chair with his/her head down. -Nurse #1 walks by Resident #1, she does not offer any assistance, reposition or interact with Resident #1. -12:21:46 Resident #1 continues sitting at the nursing station without any staff interaction. CNA #2, CNA #3, and CNA #4 can be seen at the nursing station and Nurse #1 joins them. -12:35:00 Resident #1 continues to move about in his/her Broda chair, seen rubbing his/her face and hair. Resident #1's left hand can be seen moving in a downward position, between his/her legs under the blanket. -12:41:23 Resident #1 with his/her right hand on his/her face and hair, left hand moving up and down with his/her legs spread apart and he/she is looking downward. Resident #1 leaning forward, then backwards in Broda chair and his/her blanket is sliding off. -CNA #4 walks towards Resident #1, takes a stool to sit behind Resident #1 to work on the computer mounted on the wall and can bee seen looking at Resident #1, who continues to fidget and move about in his/her Broda chair. -CNA #4 then walks, away without providing or offering assist to Resident #1. -1:28:07 Resident #1's blanket is falling off his/her leg that are restless and moving around, his/her shoulders are moving in an upward and downward motion, his/her body is rocking back and forth, and as Resident #1 lifts his/her right leg and knee, the blanket falls off past his/her waist. -CNA #1, CNA #2 and CNA #4, who are still seen seated at the nurses' station talking, do not get up to see what is going on with Resident #1. -1:35:07 Resident #1 can be seen with his/her hands in his/her pants, and the blanket slips off him/her even more. -Nurse #1, Nurse #3, CNA #1, and CNA #2 along with another staff member (unidentified) are at the nurses' station, none of whom interact with or offered assistance to Resident #1. -CNA #4 can be seen walking past Resident #1, and does not stop to offer or provide any assistance. -1:40:08 Resident #1 reaches down inside his/her pants and can be seen playing with a white substance (later identified as absorbent material from the incontinent brief) he/she pulled out from his/her brief. Resident #1's left hand can be seen pulling down on the waist band of his/her pants, and he/she continues to play with the white material from the brief, as he/she fidgets about in the Broda chair. -Nurse #1 speaks with CNA #4, who is standing behind Resident #1's Broda chair, Nurse #1 then walks by Resident #1 without addressing him/her or providing any assistance. -1:44:47 Resident #1 can be seen pulling at his/her brief in an upward motion, he/she is picking at the brief and throwing the white material from it behind his/her left and right shoulder, Resident #1 then places his/her left hand back in his/her pants and continues to throw white material over his/her shoulder. -Staff (unidentified) and other residents can be seen passing by Resident #1 in the hallway, staff does not stop to intervene, offer or provide any assistance to Resident #1. -1:45:59 Resident #1 continues picking at his/her brief, throwing white material over his/her shoulder. -CNA #1 and CNA #2 can be seen on their personal cell phones, with another staff member (unidentified) at the nurses' station. -Nurse #1 goes to the medication cart which is located near Resident #1 and does not engage with or assist Resident #1. -2:02:59 A Delivery man walks onto the unit, goes to the Nurses' station, and can be seen looking at Resident #1. Resident #1's hands are in his/her pants, he/she continued picking at his/her brief, pulling the white material out of the brief and throwing it over his/her shoulder. -2:09:31 Staff members (identified as Nurse #2 and CNA #5) walk onto the unit, can be seen walking by Resident #1 and CNA #5 can be seen looking down at the floor near Resident #1's Broda chair at the white material on the floor. -2:15:47 Resident #1 places his/her hands back down his/her pants. -Nurse #1 walks by Resident #1 and stands by the medication cart, again without assessing him/her or providing assistance. -2:20:57 Resident #1 can be seen lifting up his/her shirt, scratching self, and his/her hand continue to be down his/her pants. - CNA #4 walks by Resident #1, walks past the white material on the floor, and goes into the nurses' station area without interacting with or addressing Resident #1. -2:26:16 Nurse #2 can be seen looking at the white material on the floor near Resident #1, points to it and speaks with Nurse #1. Nurse #2 then speaks with CNA #4 and points to the floor. CNA #4 can be seen walking away, Nurse #1 and Nurse #2 continue to speak with one another, but none of them go over and interact with, offer or provide assistance to Resident #1. -2:27:44 Resident #1 hands are in his/her pants, Nurse #1 and Nurse #2 can be seen at the medication cart (doing change of shift medication count) which is located near Resident #1. -2:44:22 Resident #1, who is no longer covered by the blanket at all, can be seen scratching his/her right shoulder; his/her shirt is pulled off of his/her right shoulder, his/her head is facing downward, and Resident #1's hands are in his/her pants. -2:47:01 A visitor (identified as Resident #1's family member) can be seen approaching Resident #1 in the hallway, Resident #1 had his/her shirt in his/her mouth, his/her hands were still in his/her pants and his/her right shoulder was exposed. Resident #1's family member can be seen looking at the white material on the floor, and then speaks with Nurse #1 and Nurse #2. - After the family member speaks to Nurse #1 and Nurse #2, Resident #1 is then transported to his/her room by CNA #5, where his/her care needs were met by staff. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, completed 9/27/19, indicated that his/her cognitive patterns were severely impaired. The MDS indicated he/she required total dependence of two staff members for transfers, toileting, hygiene and personal care needs. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder, and was at increased risk for skin breakdown. Resident #1's Plan of Care problems, goals and interventions was reviewed in (MONTH) 2019, and new target dates were set for (MONTH) 2019, and interventions included: - totally dependent on staff for mobility in his/her recliner (Broda chair) - dependent on staff for hygiene care and dressing - totally dependent on two staff members for toileting and incontinent care needs - use of incontinent briefs, with routine incontinent care and monitored skin integrity - routinely re-position him/her and for staff to offer him/her a nap after lunch to rest his/her back - encourage him/her to participate in activities that promote exercise and physical activity for strengthening and improving mobility - when seated in his/her Broda wheelchair, it is to be slighted reclined The Facility's Abuse and Neglect Policy, dated as last revised (MONTH) (YEAR), indicated that neglect means the failure of the facility or it's employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. During an interview on 11/07/19 at 1:01 P.M., Nurse #1 (who works the day shift) said she checks to ensure CNA's are providing toileting and incontinence care for dependent residents during the shift. Nurse #1 said Resident #1 would exhibit body movements that included looking around, leaning his/her body forward, trying to move his/her legs and that his/her facial expression would also indicate if he/she was anxious or worried and needed to be brought to his/her room for personal care. Nurse #1 said she was unaware that Resident #1 was shredding his/her briefs until Resident #1's family member came into visit. Although Nurse #1 said she ensured residents were provide care, checked for incontinence, and was unaware Resident #1 had shredded his/her brief and had thrown the material on the floor, this statement conflicts with video footage reviewed by the Surveyor. Although Resident #1's impaired cognition limited his/her ability to understand and recall the experience of being left seated in his/her Broda chair at the nursing station for more than six hours without his/her personal care needs, including but not limited to incontinence care and repositioning being met, and that despite him/her exhibiting behaviors of increased restlessness, fidgeting and discomfort, that could be seen by multiple staff members who during the course of the shift were only several feet away from him/her, an unimpaired individual would experience physical and emotional distress when left in this condition and deprived of assistance.

Based on observation, record review and interview the facility staff failed to address an unplanned weight loss, until 34 days after the weight was recorded, for 1 sampled Resident (#111) out of a total 27 sampled residents. Findings include: Review of the facility policy titled Weighing and Measuring the Resident, dated (MONTH) (YEAR), indicated the following: * Report significant weight loss/weight gain to the nurse supervisor. * The threshold for significant unplanned weight loss/gain will be based on the following criteria: 1 month - 5% weight loss is significant, 3 months- 7.5% weight loss is significant, and 6 months- 10% weight loss is significant. * Notify the nurse supervisor if the resident refuses the procedure. * If a resident refused to be weighed the staff are to document in the medical record the reason(s) why and the interventions taken. Resident #111 was admitted to the facility in 10/2014, and had [DIAGNOSES REDACTED]. On the most recent Minimum Data Set (MDS) assessment, dated 5/14/19, the Resident scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating moderately impaired cognition. The MDS further indicated that the Resident required the assist of one for eating. During the initial tour of the facility on 6/05/19, at 12:39 P.M., Resident #111 was observed alone in her/his room in bed with an untouched lunch tray in front of her/him. Resident #111 appeared frail, and made no attempts to self feed and when asked how the lunch was he/she said it is cold. Review of the clinical record on 6/10/19 indicated the following weights were taken: *12/5/18: 104 lbs (pounds) *4/5/19: 93.3 lbs - this is a significant weight loss of 10.29% in 4 months. Records do not indicate a re-weigh was completed. *5/6/19: 88.1 lbs - this is a further significant weight loss of an additional 5.57% in 1 month, and a cumulative loss of 15.2% in 5 months. Records do not indicate a re-weigh was completed. Review of the physician progress notes [REDACTED]. A weight had not been recorded for the 3 months between 12/5/18 and 4/5/19. On 6/10/19 the facility dietician's progress note for Resident #111 were reviewed and revealed: 1.) On 11/29/2018, the facility dietitian evaluated Resident #111 and indicated that she/he was stable. 2.) There was no further documentation in the medical record for Resident #111 from the facility dietitian until 5/9/19, 34 days after the significant weight loss was recorded. 3.) On 5/9/19 the facility dietician completed a late entry nutrition progress note for 4/22/19, and addressed the Resident's significant weight loss of 10.7lbs which calculated out to a 10.29% between 12/5/18 and 4/5/19. 4.) Since the late entry note of 4/22/19 (written 5/9/19), an additional weight had been recorded on 5/6/19. The Resident had lost another 5.2 lbs between 4/5/19 and 5/6/19 bringing the total percentage of weight lost between 12/5/19 and 5/9/19 to 15.29%. The Dietitian then recommended a high calorie, high protein supplement. Review of the Medication Administration Record [REDACTED]. There is no evidence in the clinical record as to why there was a delay in providing the supplement or why it was discontinued on 5/22/19. Nor was there evidence that the physician had been notified of the delay or that the supplement was discontinued. Review of the MAR for (MONTH) 2019 through (MONTH) 2019, indicated each month that the Resident, who was on an air mattress, was to have weights taken in order to determine the air mattress settings. Review of the physician progress notes [REDACTED]. Nor was there indication that the MD was notified of the weight loss. During an interview on 6/10/19, at 1:43 P.M., the Dietitian indicated the following: 1.) She was aware that the Resident had gone from (MONTH) (YEAR) to (MONTH) 2019 with no weights recorded and that she was not sure why this had occurred. She stated that she thought that she had requested weekly weights but that often times the physician dismissed her requests. 2.) As well, she elaborated the facility Director of Nursing did not prefer the staff to take weights weekly because if a resident continued to lose weight they would need to come up with more interventions. 3.) She stated that she became aware of the significant weight loss in (MONTH) of 2019 and that at that time she should have made recommendations or assessed the plan of care for potential recommendations but that it had slipped her mind. 4.) The dietitian stated that she was not sure why the monthly weights for Resident #111 had stopped after (MONTH) (YEAR) weight until (MONTH) 2019 and stated that when she discovered that the nursing staff were not making sure that the weights were being done that she alerted nursing management. 5.) Further, she stated, the nurses are responsible to enter the Resident's weights into the medical record, however it wasn't until she reviewed the weekly weight reports that a significant change would be identified. In the case of Resident #111 she was not sure how she overlooked the missing weights. During an interview with the facility's corporate nurse supervisor on 6/11/19 at 10:20 [NAME]M., she provided all of the weights that the facility had for Resident #111 since (MONTH) (YEAR), and stated that she was not certain why there were no weights taken for 3 months. There was no evidence in the medical record that the Resident refused to be weighed for three months. When a weight was obtained after 121 days, and demonstrated a 10.29% weight loss, the facility staff failed to address the significant weight loss until 34 days later, resulting in an additional significant weithg loss of 5.5% for a total of 15.2%.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was free from an accident resulting in an injury when Certified Nurse Aide (CNA) #1 did not follow Resident #1's Plan of Care (Kardex) by repositioning and turning Resident #1 without the assistance of a second staff member in bed, Resident #1 rolled off the bed to the floor and sustained a laceration to the forehead and a fracture to the left humerus (upper arm). Findings include: The Facility's Policy titled Using the Care Plan, revised in (MONTH) 2006, indicated the care plan shall be used in developing the resident's daily care routines and available to staff personnel who have responsibility for providing care or services. Resident #1's Admission Record indicated he/she had [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set assessment, dated 02/15/19, indicated the following: he/she required extensive assistance with two people for bed mobility; and had limited range of motion with impairment to both upper extremities and both lower extremities. Resident #1's Care Plan, dated 09/18/18, indicated he/she was totally dependant on staff for repositioning and turning him/her in bed. The DON provided a copy of Resident #1's Kardex (not dated) that was in effect on 03/23/19 (date of accident). Resident #1's Kardex (not dated) indicated he/she was totally dependent on two staff members for repositioning and turning in bed. Resident #1's Progress Note, dated 03/23/19 at 6:12 P.M., indicated he/she fell out of bed when turned to be cleaned. Resident #1's Progress Note, dated 03/23/19 at 9:48 P.M., indicated he/she returned from the Hospital with four sutures to the laceration on the right forehead and was diagnosed with [REDACTED]. Resident #1's Hospital After Visit Summary, dated 03/23/19, indicated he/she was diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 3:30 P.M. on 04/24/19 and at 12:50 P.M. on 05/06/19. CNA #1 said that, on 03/23/19, CNA #2 assisted her to transfer Resident #1 into bed and then CNA #2 left the room. CNA #1 said she did not review Resident #1's Kardex prior to providing care for Resident #1 to know many staff members were required to reposition and turn Resident #1 safely. CNA #1 said she did not obtain assistance from another staff member and she proceeded to reposition and turn Resident #1 in bed by herself. CNA #1 said she rolled Resident #1 from one side of his/her body (toward her) to the other side of his/her body (away from her) while in bed to provide care. CNA #1 said when she rolled Resident #1 away from her, Resident #1 kept rolling and fell off the bed to the floor. CNA #1 said she immediately reported Resident #1's fall to a nurse. The Surveyor interviewed CNA #2 at 2:25 P.M. on 04/24/19. CNA #2 said she thought Resident #1 required a one person assist for repositioning and turning him/her in bed. CNA #2 said she always repositioned and turned Resident #1 in bed without assistance. CNA #2 said Resident #1 was dependent on others and was not able to move his/her own body. CNA #2 said if Resident #1 was rolled too far, he/she could fall off the bed. CNA #2 said she was aware CNAs were required to review each resident's Kardex for information on how to provide care for them. The Surveyor interviewed Nurse #1 at 4:10 P.M. on 04/11/19. Nurse #1 said Resident #1 was unable to reposition and turn himself/herself in bed. Nurse #1 said she immediately went to Resident #1's bedroom after being notified of the fall. Nurse #1 said Resident #1 was on the floor, had a laceration to the forehead and went sent to the Hospital for evaluation. Nurse #1 said CNA #1 told her she turned Resident #1 onto his/her side positioned away from CNA #1, Resident #1 continued to roll and fell off the bed to the floor. Nurse #1 said CNA #1 told her she did not have a second staff member assisting her with Resident #1. The Surveyor interviewed the Director of Nurses (DON) at 4:35 P.M. on 04/11/19. The DON said CNAs were required to follow the Kardex which documents the Plan of Care requirements related to activities of daily living, such as repositioning and turning in bed.

Based on records reviewed and interviews for one of five residents (Resident #3) the Facility failed to ensure that Resident #3 was free from involuntary seclusion when, at 2:15 A.M. on 7/24/18, Certified Nurse Aide #4 brought Resident #3 into a small dayroom, closed the door, and left Resident #3 in the room alone. Findings include: The Facility Policy titled Abuse Prevention Program, dated 11/2017, indicated that Facility residents had the right to be free from involuntary seclusion. A Minimum Data Set (MDS) Assessement indicated that Resident #3 he/she was admitted to the Facility in (MONTH) of (YEAR) and his/her medical [DIAGNOSES REDACTED]. A Behavior Care Plan, initiated 8/30/18, indicated that Resident #3's behaviors included pacing, chanting, rocking, and word salad. The Care Plan included interventions that directed staff to anticipate Resident #3's needs, assist with developing more appropriate methods of coping, encourage expression of feelings, provide the opportunity for positive interactions and attention, approach in a calm manner, divert attention, remove from situations and take to alternative location as needed. An Incident Report, dated 7/26/18, submitted to the Department of Public Health (DPH) via the Health Care Facility Reporting System (HCFRS), indicated that the Facility had been made aware by Resident #3's Family that when they visited Resident #3 at 6:30 A.M. on 7/23/18 and again on 7/24/18, Resident #3 was in the dayroom (also known as the sensory room), unattended, with the door shut and that an investigation was pending. A Follow-up Report, dated 7/31/18, submitted by the Facility to DPH via HCFRS, indicated that the Facility reviewed video surveillance located in the hallway and determined that Certified Nurse Aide (CNA) #4 abused Resident #3 when CNA #4, who was observed on video, handled Resident #3 in a rough manner while she directed Resident #3 to the sensory room and the Police were notified of the findings. The Surveyor reviewed three pictures that the Facility had printed from video surveillance footage. One picture revealed CNA #4 walking in the hall beside Resident #3 with her left arm wrapped around Resident #3's right arm. Resident #3's right arm appeared to be lifted up and away from his/her body by several inches which appeared to the Surveyor that CNA #4 was leading Resident #3 toward an opened door. The Facility did not secure and could not provide the video surveillance footage to the Surveyor at the time of the Survey. The second picture revealed CNA #4 and Resident #3 in the hall closer to the opened door with CNA #4 standing behind Resident #3 with her arms around the front and wrapped underneath Resident #3's arms. Resident #3's left arm appeared to be pulled slightly back towards CNA #4 and Resident #3's right arm appeared to be up and away from his/her body and Resident #3's body was bent slightly forward. The third picture revealed CNA #4 alone, facing a closed door with her hand on the door knob. The Surveyor interviewed the former Director of Nursing (DON) at 3:02 P.M. on 11/27/18. The former DON said when Resident #3's family told her about the incidents, she reviewed video camera footage and observed Resident #3 walking on the Unit and slamming the wall with his/her hand. The former DON said that the video camera footage revealed that Resident #3 walked into another resident's room, CNA #4 went into the room, then came out holding Resident #3's hand and Resident #3 stopped walking so CNA #4 dragged Resident #3 into the sensory room and closed the door. The DON said the incident was reported to the Police. The Surveyor interviewed CNA #4 at 3:50 P.M. on 12/18/18. CNA #4 said that near the end of her 11:00 P.M. to 7:00 P.M. shift she put Resident #3 in the sensory room, closed the door and left him/her alone in the room because Resident #3 walked non-stop and banged on things and she did not want Resident #3 to wake the other residents up. CNA #4 said that while Resident #3 was inside the room with the door closed Resident #3 continued to walk around banging everything in the room. CNA #4 said that she felt she had to handle Resident #3's behavior in some way and she did not go to the Nurse to ask the Nurse for assistance with Resident #3. The Surveyor interviewed Family Member #4 at 8:50 A.M. on 12/26/18. Family Member #4 said that, on 7/23/18 when his/her spouse arrived at the Facility, at approximately 6:30 A.M., he/she observed Resident #3 inside the sensory room and he/she appeared agitated while he/she walked around inside the room with the door closed and no staff with him/her. Family Member #4 said that the following day his/her spouse arrived at approximately the same time, again saw Resident #3 inside the sensory room with the door closed, no staff in the area, and Resident #3 was seated in a chair holding his/her head and neck.

Based on records reviewed and interviews for one of five sampled residents (Resident #1), the Facility failed to ensure adequate supervision was provided to prevent accidents, when on 6/5/18, Resident #1, who was dependent on Staff for care and transfers, was observed to have multiple bruises on his/her chest and upon further assessment, had additional bruising to his/her left upper arm and axilla. Findings Include: The Facility Report, dated 6/7/18, submitted to the Department of Public Health (DPH) via the Health Care Facility Reporting System (HCFRS) indicated that on the evening of 6/7/18, Resident #1 was found to have a left axial (underarm) bruise with swelling. The Surveyor interviewed Family Member #2 at 10:41 A.M. on 11/28/18. Family Member #2 said that when he/she visited Resident #1 on 6/7/18, he/she observed dark purple bruising on Resident #1's left arm as well as purple and yellow bruises on Resident #1's chest. Family Member #1 said the Facility did not notifiy him/her about Resident #1's bruises and said when he/she questioned nursing staff about Resident #1's bruises, they were unable to explain when and how the bruises occurred. Resident #1's Face Sheet indicated that his/her medical [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 6/7/18, indicated that Resident #1 had severe cognitive impairment and he/she was totally dependent on staff for assistance with bathing, dressing, toileting, bed mobility, and transferring from bed to chair and back. Resident #1's Care Plan, titled Self Care Performance Deficit, included a current plan of care with an intervention initiated, 8/1/14, which directed staff to inspect Resident #1's skin for redness, open areas, scratches, cuts, and bruises daily. The Care Plan included a current plan of care with an intervention initiated, 5/15/17, that directed staff to transfer Resident #1 with the assistance of two staff members and the use of a mechanical lift. A Facility Occurrence Report, dated 6/5/18, indicated that Resident #1 was observed to have multiple fading bruises on his/her sternal area (chest). The Report indicated that the bruises measured eight centimeters by two and a half centimeters and that they were acquired at the Facility. The Report included an entry written by the Director of Nursing (DON), dated 6/5/18, that included an intervention for the use of a pillow between Resident #1's hand and sternum (chest). A Police Report, dated 6/7/18, indicated that Resident #1's Family Member, while visiting Resident #1, discovered fresh bruising on Resident #1's left bicep (upper arm), axilla (armpit), between his/her breasts, as well as swelling, and further bruising to Resident #1's upper chest area. The Police Report indicated that the DON discovered bruising on Resident #1's chest four days prior, on 6/3/18, but did not discuss it with Resident #1's family because she was waiting for an explanation. The Police Report indicated that the bruises to Resident #1's chest were yellow in color as they were almost four days old and the bruises on Resident #1's biceps and axilla were purple and red in color. The Police Report indicated that the DON told the Police she checked Resident #1's skin earlier that morning, it was the first time she heard of the newer bruises to Resident #1's bicep and axilla. A follow-up Report, submitted to DPH via the HCFRS on 6/15/18, indicated that, on the evening of 6/7/18, Resident #1 was observed to have superficial chest bruisies and a deep purple axial bruise which was swollen. The follow-up report indicated that, at 6:30 A.M. on 6/7/18, the DON, during rounds, checked on Resident #1 and did not observe any bruises on his/her chest. The follow-up report indicated that Resident #1 had a history of [REDACTED].#1's bruises, but determined that the bruises were likely the result of Resident #1's medical diagnoses, medications, or contact during care that was unknown to staff. Although the follow-up Report, submitted to DPH by the Director of Nursing, indicated they thought the etiology of Resident #1's extensive bruises was likely due to his/her medical diagnoses, history of bruising easily, and medications, Resident #1's Care Plan interventions which included that Resident #1 was dependent upon staff for transfers, bed mobility, dressing, bathing and grooming, were in place for several months to years. There were no changes in his/her medication orders and Resident #1's Skin Observation Records, from 30 days prior, did not reflect extensive bruising as noted in the Police Report. An Emergency Department Report, dated 6/7/18, indicated that Resident #1 had a large hematoma (a solid swelling of clotted blood within the tissues) on the left side of his/her chest. The Report indicated that Resident #1's laboratory studies were obtained and were unremarkable. A Chest Computed Tomography Scan (CT Scan), dated 6/7/18, indicated that Resident #1 had an intramuscular hematoma involving the left pectoral muscle that measured 7.6 centimeters by 3.5 centimeters and inflammation within the subcutaneous tissues extending into the left axilla likely representing extension of the hematoma into the axillary area. The Emergency Department Report indicated that Resident #1 was admitted to the Hospital for further evaluation. The Surveyor interviewed Nurse #1 at 12:55 P.M. on 11/21/18. Nurse #1 said he did not know how Resident #1's bruises occurred when he first observed them on 6/5/18. The follow-up Report submitted to DPH by the Director of Nursing indicated that, after Facility investigation, the etiology of Resident #1's bruises were unknown The Surveyor interviewed the DON at 11:25 on 11/21/18. The DON said Resident #1 was non-verbal secondary to dementia. The DON said she first heard about Resident #1's bruises on 6/5/18 but did not see them until 6/7/18. The DON said she should have done an investigation and should have obtained statements from staff when the bruises were discovered on 6/5/18. The DON said statements should have been obtained from staff going back to 6/4/18 but said she did not obtain statements or conduct an investigation when she first heard about Resident #1's bruises.

Based on observation, interview and record review the facility staff failed to provide adequate pain management for one sampled Resident (#99) out of a total sample of 27 residents. Findings include: Resident #99 was admitted to the Facility in 6/2018 with [DIAGNOSES REDACTED]. Review of the minimum data set assessment ((MDS) dated [DATE], indicated that Resident #99 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated the resident is cognitively intact. On 7/18/18, at 10:00 A.M. the Surveyor observed Resident #99 sitting on the edge of the seat of her/his wheelchair with an open wound on the back of her/his right thigh,dripping blood and without a dressing covering the wound at that time. The Surveyor also observed blood puddled on the floor underneath the wheelchair and drops of blood from the wheelchair to the bathroom approximately 10 feet away. During an interview on 7/18/18, at 10:00 A.M. Resident #99 said that this is what happens after the wound doctor comes and cleans the wound. She/he also said that she/he was in pain most of the time because of the wound. She/he said that she/he took pills for pain but that they did not work very well. When asked why she/he was sitting on the edge of the seat of the wheelchair, she/he said that it was too painful to sit back in the chair. The Surveyor then observed Resident #99 use a walker to stand up from the wheelchair and sit back down very slowly, grunting and moaning during the process. Resident #99 said she/he was moaning because of the pain. Review of a doctor's order dated 6/6/18, indicated pain levels were to be monitored each shift. Further review of the order indicated that 16 of the first 18 days in 7/2018 the Resident had pain at a level of 5 to 9 (moderate to severe) on a pain scale of 1 - 10 with 10 being the worst level of pain, 11 of those days the Resident's pain level was severe (7-10). Review of the clinical record did not indicate that the Resident was asked what an acceptable level of pain was for her/him. Review of the doctor's orders dated 6/6/18, indicated an order for [REDACTED]., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Also available was an order for [REDACTED]. Review of a wound consult dated 7/18/18, indicated the wound was (Length x Width x Depth ) 12 x 10 x 0.1 centimeters (cm) with a surface area of 120.0 cm squared, which includes thick adherent devitalized necrotic tissue of 25%. The wound doctor removed 30.0 cm squared of necrotic muscle and surrounding tissue at a depth of 0.3 cm. Review of the Medication Administration Record [REDACTED].M. and before 12:00 P.M., including an as needed order for [MEDICATION NAME]. During this time frame, the resident experienced the removal of 30.0 cm squared of necrotic muscle and surrounding tissue, at a depth of 0.3 cm The resident, at 10:00 A.M., had complained to the surveyor he/she was in pain due to the wound. The Surveyor informed nursing at 10:15 A.M A Nurse's aide informed the surveyor that they were aware of the blood on the floor and that housekeeping had been notified. At 10:25 A.M., housekeeping came in the room and cleaned up the blood on the floor. At 10:40 A.M. Nurse #1 came into the room and informed the Resident that she was going to apply a dressing to the wound. On 7/18/18, at 10:55 A.M. the Surveyor observed the application of a dressing to the wound on the right posterior thigh, during which the Resident moaned and grunted, stating it hurts several times. Nurse #1 said to the Resident several times I know, it will be done in a second.The surveyor observed the Resident moaning throughout the dressing application. During an interview with the DON, ADON and Nurse #1 on 7/18/18, at 11:25 A.M., the DON said that she could see that the pain medication regime for the Resident was not effective. On 7/19/18, review of the nurse's progress notes dated 7/18/18, indicated no administration of a [MEDICATION NAME] as needed for pain and no indication of the pain the Resident had expressed to nursing during the dressing application. During an interview with Nurse #1 on 7/19/18, at 1:20 P.M. she said that the current pain medications the Resident was receiving were not effective for the Resident and that she didn't know why the Resident had not been given the as needed [MEDICATION NAME] for pain after nursing was made aware of the Resident's pain on 7/18/18, at 10:40 A.M

Based on records review and interviews for one of four sampled residents (Resident #1), the Facility failed to inform Resident #1's Primary Health Care Agent, when on 11/3/17, Resident #1, who was a full code (a choice to be treated with resuscitation methods to prolong life in the event of a life threatening emergency), presented with right sided weakness, and Resident #1 was not transferred to the Emergency Department until four days later with progressive right sided weakness, and was diagnosed with [REDACTED]. A Massachusetts Health Care Proxy form, dated 3/1/16 and signed by Resident #1, indicated that Resident #1 appointed a Primary Health Care Agent (a representative with legal authority to make all health care decisions, including decisions about life-sustaining treatment when a person lacks the capacity to make decisions themselves) and an Alternate Agent in the event that the Primary Health Care Agent was unwilling or unable to serve. A Policy titled Resident Rights, dated 4/2016, indicated that all residents have the right to appoint a legal representative of his or her choice, be notified of his or her medical condition and any changes in his or her condition, and be informed of and participate in his or her care planning and treatment. A physician's orders [REDACTED].#1 was full code status. There was no indication in Resident #1's Medical Record that indicated that he/she was not to be transferred to the Hospital in the event of an emergency. The Resident Incapacity Form, dated 6/8/17, indicated that Resident #1 lacked the capacity to make or to communicate health care decisions due to end stage dementia and that his/her Health Care Proxy was invoked. A Nurse's Progress Note, timed at 11:30 A.M. and dated 11/3/17, indicated that Resident #1 presented with right sided weakness during morning care, the Nurse Practitioner (NP) was notified, orders were obtained for Aspirin 81 milligrams by mouth daily and laboratory blood work. The Note indicated that Resident #1's Alternate Agent was updated. There was no documentation in Resident #1's Medical Record to indicated that his/her Primary Health Care Agent was notified of his/her change in medical status. A Nurse's Progress Note, timed at 10:15 A.M. and dated 11/7/17, indicated that Resident #1's right sided weakness was progressing, there was a question of [MEDICAL CONDITIONS] (also known as TIA, a [MEDICAL CONDITION] attack that typically resolves within hours and requires immediate medical attention to distinguish from actual [MEDICAL CONDITION]). The Note indicated that an NP Order was obtained to transfer Resident #1 to the Emergency Department (ED) and that Resident #1's Alternate Agent was contacted and in agreement. The Surveyor interviewed the NP at 3:40 P.M. on 1/2/18. The NP said that when the Unit Manager called her and informed her of Resident #1's right sided weakness, she questioned a possible stroke. The NP said she gave the Unit Manager an order to transfer Resident #1 to the hospital for an evaluation. The NP said the Unit Manager told her that Resident #1's Alternate Agent did not want Resident #1 transferred. The Surveyor interviewed the Unit Manager at 4:55 P.M. on 1/8/18. The Unit Manager said that when Resident #1 presented with right sided weakness on 11/3/17, she called the NP first and informed her about Resident #1's symptoms. The Unit Manager said the NP gave her orders for Aspirin and laboratory blood work, but did not give orders to transfer Resident #1 to the hospital. The Unit Manager said she called Resident #1's Alternate Agent after she spoke with the NP and said he was in agreement with the NP orders. The Unit Manager said she did not attempt to contact Resident #1's Primary Health Care Agent to notify her of Resident #1's change of status. The Surveyor interviewed Resident #1's Primary Health Care Agent at 4:20 P.M. on 1/2/18. Resident #1's Primary Health Care Agent said that he/she was not informed of Resident #1's right sided weakness on 11/3/17, was not informed of Resident #1's transfer to the hospital on [DATE], and was not notified by anyone at the Facility that Resident #1 had a [MEDICAL CONDITION]. Resident #1's Primary Health Care Agent said that he/she wanted to be informed when Resident #1's status changed.

Based on records reviewed and interviews for one of four sampled residents (Resident #1), the Facility failed to ensure that professional standards of practice were followed when, on 11/3/17, Resident #1, who was a full code status, presented with right sided weakness, was not transferred to the Emergency Department or evaluated by a Physician or Nurse Practitioner (NP) until four days later when, on 11/7/17, Resident #1 continued to present with progressive right sided weakness, was transferred to the Emergency Department and diagnosed with [REDACTED]. The National Stroke Association Fact Sheet, dated 11/17/16, indicated that symptoms of a [MEDICAL CONDITION] (also known as TIA, occurs when a blood clot blocks an artery for a short time) and symptoms of a [MEDICAL CONDITION] require emergency medical attention. The National Stroke Association Fact Sheet indicated that evaluation and potential treatment for [REDACTED]. A physician's orders [REDACTED].#1 was full code status. There was no indication in Resident #1's Medical Record that indicated that he/she was not to be transferred to the Hospital in the event of an emergency. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was cognitively impaired with a Brief Interview for Mental Status Score (BIMS) of four (a BIMS score of seven or below indicates severely impaired cognition). The MDS indicated that Resident #1 had the ability to ambulate in his/her room with staff assistance, utilized a walker and a wheelchair for mobility, was able to feed his/herself with staff supervision, required extensive assistance of one for personal hygiene, and had no range of motion impairment. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 had a BIMS score of zero, could not ambulate in his/her room, utilized a wheelchair for mobility, required extensive assistance to eat, required extensive assistance of two for personal hygiene, and had upper extremity range of motion impairment. A Nurse's Progress Note, timed at 11:30 A.M. and dated 11/3/17, indicated that Resident #1 presented with right sided weakness during morning care, the Nurse Practitioner (NP) was notified, orders were obtained for Aspirin 81 milligrams by mouth daily and laboratory blood work. A Nurse's Progress Note, timed at 10:15 A.M. and dated 11/7/17, indicated that Resident #1's right sided weakness was progressing, there was a question of [MEDICAL CONDITIONS] (also known as TIA, a [MEDICAL CONDITION] attack that typically resolves within hours and requires immediate medical attention to distinguish from actual [MEDICAL CONDITION]). The Note indicated that NP orders were obtained to transfer Resident #1 to the Emergency Department (ED). An Occupational Therapy (OT) Note, timed at 4:41 P.M. and dated 12/6/17, indicated that Resident #1 was referred for OT due to new onset of decrease in strength, functional mobility, decrease in transfer ability, decrease in range of motion, and reduced ability to safely ambulate. The OT Note indicated that Resident #1's right sided weakness had persisted and he/she presented far below his/her functional baseline prior to the stroke. The Surveyor interviewed Resident #1's NP at 3:40 P.M. on 1/2/18. The NP said when the Unit Manager called her on 11/3/17 and informed her of Resident #1's right sided weakness, she questioned a possible stroke. The NP said she gave the Unit Manager an order to transfer Resident #1 to the ED. The NP said she was informed by the Unit Manager that Resident #1's Alternate Agent did not want Resident #1 transferred to the ED therefore, she ordered daily Aspirin and laboratory blood work for Resident #1. The NP said that the second time she was contacted about Resident #1 was on 11/7/17 and was informed by a nurse that the nursing staff suspected Resident #1 had a bleed. The NP said she told the Nurse Resident #1 may have had a stroke and gave orders to transfer him/her to the ED. The Surveyor interviewed the Unit Manager at 4:55 P.M. on 1/8/18. The Unit Manager said that when Resident #1 presented with right sided weakness on 11/3/17, she called the NP first and informed her about Resident #1's symptoms. The Unit Manager said the NP gave her orders for Aspirin and laboratory blood work, but did not give orders to transfer Resident #1 to the hospital. The Surveyor interviewed Resident #1's Physician at 1:32 P.M. on 1/9/18. Resident #1's Physician said he was not informed of Resident #1's symptoms of right sided weakness on or between 11/3/17 and 11/7/17. The Physician said Resident #1 should have been transferred to the ED when he/she presented with right sided weakness on 11/3/17.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to perform and document a thorough clinical assessment after Resident #1 fell and failed to obtain treatment orders for Resident #1's left distal femur fracture (lower part of thigh bone just above knee). 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. The Facility Policy titled Assessing Falls and Their Causes, (dated April 2016), indicated the residents must be assessed in a timely manner for potential causes of falls and the nursing staff will; record vital signs, evaluate for injuries, notify the resident's physician and family, observe for delayed complications, and document findings in the medical record. The Facility Policy titled Pain-Clinical Protocol, (dated April 2016), indicated the nursing staff will assess each individual for pain when there is onset of new pain or worsening of existing pain, staff will identify any situation or interventions where an increase in a resident's pain may be anticipated, and staff will reassess the individual's pain at regular intervals. The Facility Policy titled Change in a Resident's Condition or Status, (dated April 2016), indicated prior to notifying the Physician the nurse will make detailed observations, gather relevant information and complete an SBAR (documentation within the electronic medical record what includes the change of status, background information about a resident, the nurse's assessment findings, response to medications, and recommendations). An X-ray Report, dated 9/5/16 and electronically signed at 11:34 P.M., indicated Resident #1 had a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg. Nurse #1 was interviewed on 9/28/16 at 10:18 A.M. Nurse #1 said that on 9/5/16, she went into Resident #1's room, sometime mid-morning, after hearing him/her yelling and observed Resident #1 on the floor beside his/her bed. Nurse #1 said she and Nurse #2 assisted Resident #1 off the floor and into bed. Nurse #1 said she assessed Resident #1 and he/she had no pain or signs of injury, however approximately 1 hour later Resident #1 complained of pain, but was unable to specify the location of the pain because of his/her impaired cognition. Nurse #1 said she medicated Resident #1 with Tylenol (an [MEDICATION NAME] medication) which seemed to be effective. Nurse #1 said she called the Physician to inform him that Resident #1 fell and had no injuries, but she didn't remember who she spoke with or the time she placed the call. There was no documentation to indicate Nurse #1 assessed Resident #1. Resident #1's Medication Administration Record [REDACTED]. There was no documentation to indicate Nurse #1 called Resident #1's Physician. This was not consistent with the Facility's Policy or with Nurse #1's statement. Nurse #2 was interviewed on 9/28/16 at 10:45 A.M. Nurse #2 said on 9/5/16, some time mid-morning, Nurse #1 called her into Resident #1's room to help get Resident #1 off the floor because he/she fell . Nurse #2 said when they assisted Resident #1 off the floor and into bed Resident #1 was yelling that his/her stomach hurt. Nurse #2 said, later in the shift, she was on the phone with the Nurse Practitioner and asked Nurse #1 if she wanted to notify the Nurse Practitioner about Resident #1's fall and Nurse #1 said she didn't want to speak with the Nurse Practitioner and would call her later. The Nurse Practitioner who was on call on 9/5/16 was interviewed on 10/5/16 at 3:08 P.M. The Nurse Practitioner said she did not recall whether or not she was notified of Resident #1's fall by Nurse #1. The Director of Nursing (DON) was interviewed at 2:05 P.M. on 10/24/16. The DON said that during the course of the Facility's Internal Investigation Nurse #1 and Nurse #2 said they did not notify the Physician when Resident #1 fell and admitted they lifted Resident #1 off the floor and into bed. An Incident Report, dated 9/7/16 and timed at 10:44 P.M., indicated Resident #1 fell on [DATE]. The report indicated Resident #1 fell and there was no bed alarm in use as a preventative measure at the time of the fall. Resident #1's Treatment Administration Record, dated 9/5/16 and documented as signed by Nurse #1, indicated Nurse #1 checked Resident #1's bed alarm for placement and function during the shift. However, when interviewed by the Surveyor on 9/28/16, Nurse #1 said Resident #1 did not have a bed alarm in use when she found Resident #1 on the floor on 9/5/16. Nurse #3 was interviewed on 10/5/16 at 9:18 A.M. Nurse #3 said on 9/5/16 he obtained shift report from Nurse #1 at the beginning of his 3-11 shift and Nurse #1 did not mention that Resident #1 complained of pain or that he/she fell during the 7-3 shift. Nurse #3 said he heard Resident #1 call for help and when he went into Resident #1's room, he/she complained of leg pain and Resident #1 expressed fear of never being able to walk again, or words to that effect. Nurse #3 said when he moved Resident #1's left leg he/she was in extreme pain. Nurse #3 said he called the Nurse Practitioner to obtain orders for an x-ray of Resident #1's leg. There was no pain assessment or SBAR documented by Nurse #3 which was not consistent with Facility's Policy. Certified Nursing Assistant (CNA) #1 was interviewed on 10/11/16 at 4:20 P.M. CNA #1 said she worked during the evening shift on 9/5/16 and when she went into Resident #1's room she observed him/her holding his/her thigh saying, I'm in pain, I'm in pain. or words to that effect. CNA #1 said Resident #1 was incontinent of urine at the time and because of his/her level of pain, CNA #1 didn't want to touch him/her so she asked Nurse #3 for assistance. CNA #1 said resident #1 was complaining of pain and moaning while they changed and cleaned him/her. CNA #1 avoided moving Resident #1 for the remainder of the shift because he/she was in too much pain. Nurse #4 was interviewed on 10/7/16 at 11:25 A.M. Nurse #4 said when she arrived on the Unit on 9/5/16 for her 11-7 shift, the x-ray technician was still at the Facility and had just finished taking Resident #1's x-ray and Nurse #3 told her Resident #1 was in a lot of pain. Nurse #4 said when she went into Resident #1's room, Resident #1 was yelling out, the pain, the pain, the pain, or words to that effect, and she medicated Resident #1 with Tylenol. Nurse #4 said she knew Resident #1 was in a lot of pain because he/she took the Tylenol right away and Resident #1 didn't typically like to take medications. There was no pain assessment or SBAR documented by Nurse #4 which was not consistent with the Facility's Policy. Nurse #4 said although the x-rays were obtained at the beginning of her shift she did not call to request Resident #1's x-ray results because she didn't know how long the process took. The Director of Clinical Services for the imagining company (company that performed the x-rays) was interviewed on 10/6/16 at 4:00 P.M. The Director of Clinical Services said Resident #1's x-ray results were electronically faxed to the Unit, where Resident #1 resided, at 11:38 P.M. on 9/5/16. The Director of Nurses (DON) was interviewed on 10/7/16 at 10:45 A.M. The DON said the Facility is typically notified of x-ray results by electronic fax and/or phone call and results are ready within 4 hours after the Facility first calls to schedule the x-ray. The DON said if Nurse #4 did not receive Resident #1's x-ray results by faxed she should have called to obtain Resident #1's x-ray results and notified the Physician of Resident #1's of the fracture to obtain treatment orders. The DON said she called the imagining company the following morning, on 9/6/16, to request Resident #1's x-ray results which indicated Resident #1 fractured his/her left leg. The Unit Manager was interviewed on 10/7/16 at 9:58 A.M. The Unit Manager said she told the Nurse Practitioner about Resident #1's fracture at approximately 12:00 P.M. on 9/6/16, approximately 24 hours from time of fall. The Unit Manager said Resident #1 was transferred to the hospital at approximately 2:30 P.M. on 9/6/16, approximately 26 hours from the time of fall and and 14 hours from the time his/her X-ray results were found positive for a distal femur [MEDICAL CONDITION] leg. A Nurse Progress Note, dated 9/6/16 and timed at 8:51 P.M., indicated Resident #1 returned to the Facility at 6:00 P.M. with his/her left leg immobilized due to a distal femur fracture of his/her left leg.

Based on records review and interviews, for 1 of 3 sampled Residents (Resident #1), the facility failed to immediately notify the Physician and his/her Health Care Proxy (HCP) of increased complaints of pain and an x-ray result, which indicated Resident #1 had a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg, following a fall on 9/5/16. Findings include: The Facility Policy titled Change in a Resident's Condition or Status (Dated April 2016) indicated the Facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the Resident's medical/mental condition and/or status and the Nurse Supervisor/Charge Nurse will notify the resident's attending Physician or on-call Physician when there has been an accident or incident involving the resident. The Facility Policy titled Assessing Falls and Their Causes (Dated April 2016) indicated when a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone. Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 5/10/16, indicated Resident #1 was cognitively impaired, dependent on staff for assistance with transfers and mobility and he/she recieved Hospice services for care and comfort related to end stage demementia. An X-ray Report, dated 9/5/16 and electronically signed at 11:34 P.M., indicated Resident #1 had a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg. The Director of Nursing (DON) was interviewed on 9/27/16 at 8:42 A.M. The DON said on 9/7/16, during the course of the Facility's internal investigation, Nurse #1 and Nurse #2 admitted Resident #1 fell on [DATE], they put him/her back into bed and Nurse #1, who was assigned to care for Resident #1, did not notify Resident #1's Physician or Health Care Proxy about Resident #1's fall at that time. This was not consistent with the Facility's Policy titled Assessing Falls and Their Causes. Nurse #4 was interviewed on 10/7/16 at 11:25 A.M. Nurse #4 said when she arrived on the Unit on 9/5/16 for her 11-7 shift, the x-ray technician was still at the Facility and had just finished taking Resident #1's x-ray. Nurse #4 said although the x-rays were obtained at the beginning of her shift, she did not call to request Resident #1's x-ray results because she didn't know how long the process took. The DON said the Facility is typically notified of x-ray results by electronic fax and/or phone call and results are ready within 4 hours after the Facility first calls to schedule the x-ray. The Director of Clinical Services for the imagining company (company that performed the x-ray) was interviewed on 10/6/16 at 4:00 P.M. The Director of Clinical Services said Resident #1's x-ray results were electronically faxed to the Unit that Resident #1 resided on at 11:38 P.M. on 9/5/16. The DON said if Nurse #4 did not receive Resident #1's x-ray results by fax, she should have called to obtain the x-ray results. The DON said she called the imaging company the following morning to request the x-ray results which indicated Resident #1 had a fracture of his/her left leg. The Unit Manager was interviewed on 10/7/16 at 9:58 A.M. The Unit Manager said on 9/6/16 at approximately 12:00 P.M. (approximately 24 hours since the time of fall), she informed Resident #1's Nurse Practitioner that Resident #1 had a fracture of his/her left leg. The Unit Manager said Resident #1 was transferred to the hospital on [DATE] at approximately 2:30 P.M. (approximately 26 hours from the time of fall and 14 hours from the time his/her X-ray results were found positive for a distal femur [MEDICAL CONDITION] leg).

Based on records review and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure Resident #1's bed alarm was in place and functioning correctly, as ordered by the Physician and Resident #1 fell on [DATE] and sustained a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg. Findings include: Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 5/10/16, indicated Resident #1 was cognitively impaired, was dependent on staff for assistance with transfers and mobility, and he/she received Hospice services for care and comfort related to end stage dementia. A Fall Risk assessment dated [DATE] indicated Resident #1 was a high risk for falls. A Plan of Care, dated as revised on 6/13/16, indicated Resident #1 was at risk for falls related to deconditioning and he/she required 2 person physical assistance with bed mobility and transfers. The Director of Nursing (DON) was interviewed on 9/27/16 at 8:42 A.M. The DON said Resident #1 fell on [DATE], without injury, and the plan was to place an alarm on his/her bed to alert staff in the event he/she tried to get out of bed without assistance, or words to that effect. A physician's orders [REDACTED].#1 was to have a bed alarm with checks for placement and function on every shift. There was no documentation to indicated Resident #1's Care Plan was updated to include the physician's orders [REDACTED]. An Incident Report, dated 9/7/16 and timed at 10:44 P.M., indicated Resident #1 fell on [DATE]. The report indicated Resident #1 fell and there was no bed alarm in place as a preventative measure at the time of Resident #1's fall. Nurse #1 was interviewed on 9/28/16 at 10:18 A.M. Although documentation shows Resident #1's Treatment Administration Record was documented as signed by Nurse #1 indicating Resident #1's bed alarm was checked for placement and function during the 7:00 A.M. to 3:00 P.M. shift on 9/5/16, Nurse #1 said she went into Resident #1's room, on 9/5/16, in response to hearing Resident #1 yelling and said Resident #1 did not have a bed alarm on his/her bed when she found Resident #1 on the floor. An X-ray Report, dated 9/5/16, indicated Resident #1 had a distal femur fracture (lower part of thigh bone just above knee) of his/her left leg. The Unit Manager was interviewed on 10/7/16 at 9:58 A.M. The Unit Manager said Resident #1 was transferred to the hospital on [DATE] at approximately 2:30 P.M.

Based on record review and interviews for 1 of 3 sampled resident (Resident #1), the Facility failed to ensure Resident #1 was permitted to remain in the Facility. Resident #1 had an altercation with Resident #2 and was hosptalized on [DATE]. On 6/29/15, the Facility informed Resident #1's legal Guardian they discharged Resident #1 on the date of transfer to the Hospital. Although the Administrator told the Surveyor that Resident #1 was discharged because the safety of individuals in the facility was endangered, this was not consistent with the hospital's treating physician's evaluation of 6/25/15. The Administrator said Resident #1 was readmitted on [DATE], only after the Administrator's boss told him to readmit Resident #1. Resident #1 said he/she missed his/her son's graduation due to being hospitalized . Findings include: Resident #1's Face Sheet indicated he/she was admitted to the Facility in October 2014. The Guardianship for an Incapacitated Person Form indicated that, on 7/16/14, Resident #1 was appointed a legal and permanent Guardian. The Nurse's Progress Note, dated 6/25/15, indicated Resident #1 was observed ramming his/her electric wheelchair into Resident #2's wheelchair, twice, yelling at staff members and making threatening remarks. The Nurse's Note indicated Resident #1 placed on a 1:1 watch, and a physician's orders [REDACTED].#1 was transferred out to the hospital's emergency department. The Application for an Authorization of Temporary Involuntary hospitalization (Section 12, Emergency Transfer) Form, dated 6/25/15, indicated the Physician authorized transport of Resident #1 to the hospital as to avoid the likelihood of serious harm by reason of Mental Illness. The Section 12 form indicated the evidence was that Resident #1 purposely rammed his/her electric wheelchair into Resident #2's wheelchair and threatened to do it again, and Resident #1 stated to Resident #2 that you are glad I don't have a knife. The Facility's Internal Investigation, dated 6/25/15, indicated Resident #1 and Resident #2 had an altercation, the police were called, Resident #2 wanted to press charges against Resident #1, and Resident #1 was transferred to the hospital, via a Section 12. The Social Service Progress Note, dated 6/26/15, indicated Resident #1 was now discharged from the Facility due to his/her behaviors, and Resident #1 would be transferred to a different Facility after his/her hospital stay. The Notice of Intent to Not to Readmit Resident Following a hospitalization or Other Medical Leave of Absence from the Facility with Less than 30 Days' Notice Form (Expedited Appeal), was dated and mailed to Resident #1's legal Guardian on 6/29/15, four days after Resident #1 was discharged from the Facility. The notice indicated Resident #1 was being discharged from the Facility because the safety of individuals in the nursing home was endangered. The Hospital's History and Physical Exam, dated 6/26/15, indicated that Resident #1 had been medically cleared for discharge but the Facility did not accept Resident #1 back. The Surveyor interviewed the Hospital Social Worker at 10:40 A.M. on 8/25/15. The Hospital Social Worker said Resident #1 was evaluated and determined by the Emergency Department to be safe to return to the facility on [DATE]. The Hospital Social Worker said the Administrator told her that the Facility refused to readmit Resident #1 on 6/25/15 because of his/her physical aggression, so Resident #1 remained in the hospital until 7/24/15. The Hospital Social Worker said Resident #1 had no outbursts and no behavioral issues during his/her hospital stay from 6/25/15 through 7/24/15. The Hospital Social Worker said Resident #1 did not meet the requirements of acute care provided in a hospital setting during his/her hospitalization . The Surveyor interviewed the Director of Social Services, at 3:50 P.M. on 8/24/15. The Director of Social Services said there was a discharge planning meeting held on 6/29/15, and Resident #1's legal Guardian was verbally informed that Resident #1 was discharged to the hospital. The Director of Social Services said the Notice of Intent Not to Readmit Resident #1 following hospitalization with less than 30 Days Notice, was dated and mailed 6/29/15, to the Guardian. The Director of Social Services said she spoke with the Hospital Social Worker about placement and other Facilities accepted Resident #1, but the Guardian refused those other Facilities. The Hospital Discharge Summary, dated 7/24/15, indicated Resident #1 was admitted on [DATE] due to assaulting another resident and the Facility did not accept Resident #1 back. The Hospital Discharge Summary indicated Resident #1's stay was prolonged due to Resident #1 and his/her Guardian's refusal for placement at other Facilities that were offered to him/her and, on 7/24/15, Resident #1 was readmitted back to the Facility. The Surveyor interviewed the Administrator, at 1:50 P.M. on 8/24/15. The Administrator said initially she did not re-admit Resident #1 back to the Facility because Resident #2 wanted to press criminal charges on Resident #1. The Administrator said although she initially told the Hospital Social Worker #1, on 6/26/15, that the Facility would not readmit Resident #1 because of his/her behavior, the Administrator said she was instructed by her boss to readmit Resident #1 to the Facility, on 7/24/15. The Surveyor interviewed Resident #1's legal Guardian at 1:15 P.M. on 8/21/15. The Guardian said that, on 6/29/15, the Administrator told her that the Facility did not plan to re-admit Resident #1 to the Facility, following Resident #1's hospitalization on [DATE], because of Resident #1's behaviors. The Guardian said Resident #1 was cleared by the Hospital to return to the facility on [DATE], but the Facility would not let Resident #1 return. The Surveyor interviewed Resident #1 at 10:00 A.M. on 8/24/15. Resident #1 said the Hospital told him/her that the Hospital tried to get Resident #1 back to the Facility but the Facility would not readmit him/her, and he/she was in the hospital for almost a month. Resident #1 said he/she missed his/her son's graduation from junior High School because he/she was in the hospital, and this upset Resident #1.

Based on record review and interview for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 received only the medications ordered by the Physician. On 8/2/14, at 8:30 A.M., Nurse #1 administered [MEDICATION NAME] ([MEDICAL CONDITION] medication), [MEDICATION NAME] (diuretic medication), [MEDICATION NAME] (Ace inhibitor medication), Labetolol (Beta blocker medication), and [MEDICATION NAME] (antiplatelet medication) to Resident #1 which were ordered for Resident #2. Resident #1 experienced a drop in blood pressure and was transferred to the Hospital for intravenous fluids and medications. Findings include: The Resident Admission record for Resident #1 indicated Resident #1 was admitted to the Facility in June, 2013. The Significant Change Minimum Data Set (MDS) assessment, dated 8/26/14, indicated Resident #1 exhibited moderate cognitive deficits. The Facility Policy relative to Safe Medication Administration indicated that licensed staff should use the following methods of resident identification: checking the resident nameband, checking the resident picture in the Medication Administration Record [REDACTED]. The August 2014 MAR for Resident #1, indicated that at 8:00 A.M. on 8/2/14, Resident #1 was to receive [MEDICATION NAME] 5 milligrams (mg). The August 2014 MAR for Resident #2 indicated that at 8:00 A.M. on 8/2/14, Resident #2 was to receive [MEDICATION NAME] extended -release[MEDICATION]) 60 milligrams (mg), [MEDICATION NAME] (diuretic medication) 20 mg, [MEDICATION NAME] (Ace inhibitor medication) 20 mg, Labetolol (Beta blocker medication) 200 mg, and [MEDICATION NAME] (antiplatelet medication) 100 mg. The Incident Report, dated 8/2/14, indicated that Nurse #1 reported that at 8:30 A.M., he administered Resident #2's medications to Resident #1 in error. The Nurse's Note, dated 8/2/14, indicated that beginning at approximately 8:30 A.M., Resident #1 experienced a decrease in blood pressure after ingestion of the wrong medications. The note indicated that Resident #1's blood pressure was documented as 89/49 and he/she exhibited no change in mental status. The note indicated that he/she was given fluids by mouth, the Physician and the Director of Nurses were notified. The Nurse's Note, dated 8/2/14, indicated Resident #1's blood pressure was monitored every fifteen minutes and additional fluids were given by mouth. The note indicated Resident #1's blood pressure went from 89/49 to 97/52 following the administration of oral fluids. The note indicated that Resident #1's blood pressure began to drop again; the Physician was informed and ordered for Resident #1 to be transferred to the Hospital for evaluation if staff were not able to increase the blood pressure. The note indicated that Resident #1 was transferred to the Hospital at 10:00 A.M. on 8/2/14. The Surveyor interviewed Nurse #1 at 3:20 P.M. on 8/27/14. Nurse #1 said he worked per diem at the Facility. He said he was assigned to Resident #2's care and not Resident #1. Nurse #1 initially said he did not recall if he checked the picture provided in the MAR for medication administration identification or if he checked for a name band before giving Resident #1 the medications meant for Resident #2, but later in the interview told the Surveyor he checked the photograph and called Resident #2's name. Nurse #1 said when he entered the room, he said "hi (Resident #2's name), and the resident in the bed (later determined to be Resident #1) responded and sat up. Nurse #1 said he gave the medications to Resident #1 and when he returned to the medication cart, he realized he made an error and reported it immediately to Nurse #2. The Surveyor interviewed the Director of Nurses (DON) at 3:00 P.M. on 8/27/14. The DON said that Nurse #1 did not follow the Facility Policy relative to safe medication administration. The Hospital discharge summary, dated 8/2/14, indicated Resident #1's systolic blood pressure was initially normal on arrival, but then dropped in the 70s and 80s while in the emergency department. The report indicated Resident #1 required calcium [MEDICATION NAME], D50 (high [MEDICATION NAME] intravenous solution), and insulin to stabilize Resident #1's blood pressure.

Based on record review and interview for one of three sampled residents (Resident #1), the Facility failed to ensure that Nurse #1 followed acceptable standards of practice when administering medications, resulting in a significant medication error. On 8/2/14, at 8:30 A.M., Nurse #1 administered [MEDICATION NAME] ([MEDICAL CONDITION] medication), [MEDICATION NAME] (diuretic medication), [MEDICATION NAME] (Ace inhibitor medication), Labetolol (Beta blocker medication), and [MEDICATION NAME] (antiplatelet medication) to Resident #1 which were ordered for Resident #2. Nurse #1 failed to ensure the identity of Resident #1 before administering the medications and Resident #1 experienced a drop in blood pressure, and was transferred to the Hospital for intravenous fluids and monitoring. Findings include: The 1997 National Institute for Health Guidelines for Safe Medication Administration and the 2010 Facility Policy relative to Safe Medication Administration indicated that the Five Rights of Medication Administration, which include the right medication, the right patient, the right dosage, the right time, and the right route, should be followed for all medication administrations. The Resident Admission record for Resident #1 indicated Resident #1 was admitted to the Facility in June, 2013 with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment, dated 8/26/14, indicated Resident #1 exhibited moderate cognitive deficits. The Facility Policy relative to Safe Medication Administration indicated that licensed staff should use the following methods of resident identification: checking the resident name band, checking the resident picture in the Medication Administration Record [REDACTED]. The August 2014 MAR for Resident #1, indicated that at 8:00 A.M. on 8/2/14, Resident #1 was to receive [MEDICATION NAME] 5 milligrams (mg). The August 2014 MAR for Resident #2, indicated that at 8:00 A.M. on 8/2/14, Resident #2 was to receive [MEDICATION NAME] extended-release ([MEDICAL CONDITION] medication) 60 milligrams (mg), [MEDICATION NAME] (diuretic medication) 20 mg, [MEDICATION NAME] (Ace inhibitor medication) 20 mg, Labetolol (Beta blocker medication) 200 mg, and [MEDICATION NAME] (antiplatelet medication) 100 mg. The Incident Report, dated 8/2/14, indicated that Nurse #1 reported that at 8:30 A.M., he administered Resident #2's medications to Resident #1 in error. The Nurse's Note, dated 8/2/14, indicated that beginning at approximately 8:30 A.M., Resident #1 experienced a decrease in blood pressure after ingestion of the wrong medications. The note indicated that Resident #1's blood pressure was documented as 89/49 and he/she exhibited no change in mental status. The note indicated that he/she was given fluids by mouth, the Physician and the Director of Nurses were notified. The Nurse's Note, dated 8/2/14, indicated Resident #1's blood pressure was monitored every fifteen minutes and additional fluids were given by mouth. The note indicated Resident #1's blood pressure went from 89/49 to 97/52 following the administration of oral fluids. The note indicated that Resident #1's blood pressure began to drop again (blood pressure not recorded in note); the Physician was informed and ordered that Resident #1 be transferred to the Hospital for evaluation if staff were not able to increase the blood pressure. The note indicated that Resident #1 was transferred to the Hospital at 10:00 A.M. for more aggressive treatment. The Surveyor interviewed Nurse #1 at 3:20 P.M. on 8/27/14. Nurse #1 said he worked per diem at the Facility. He said he was assigned to Resident #2's care and not Resident #1. Nurse #1 initially said he did not recall if he checked the picture provided in the MAR for medication administration identification or if he checked for a name band before giving Resident #1 the medications meant for Resident #2, but later in the interview told the Surveyor he checked the photograph and called Resident #2's name. Nurse #1 said when he entered the room, he said "hi (Resident #2's name), and the resident in the bed (later determined to be Resident #1) responded and sat up. Nurse #1 said he gave the medications to Resident #1 and when he returned to the medication cart, he realized he made an error and reported it immediately to Nurse #2. The Surveyor interviewed the Director of Nurses (DON) at 3:00 P.M. on 8/27/14. The DON said that Nurse #1 did not follow the Facility Policy relative to safe medication administration. The Hospital discharge summary, dated 8/2/14, indicated Resident #1's systolic blood pressure was initially normal on arrival, but then dropped in the 70s and 80s while in the emergency department. The report indicated Resident #1 required calcium [MEDICATION NAME], D50 (high [MEDICATION NAME] intravenous solution), and insulin to stabilize Resident #1's blood pressure.

Based on record review, observation and staff interview, the facility failed to ensure that 1 of 2 residents (#9) in a total sample of 14, received proper care and treatment to prevent the development of a pressure sore. Findings include: For Resident #9, the facility failed to provide pressure relief, and subsequently, the resident developed a new pressure area secondary to the use of a full leg knee immobilizer which was worn both day and night. Review of the resident's medical record on 1/10/12 at 9:30 A.M., indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/29/11, this resident was sent out to the hospital and diagnosed with [REDACTED]. Review of the Weekly Skin Assessments on 1/10/12, indicated that on 11/14/11, the resident had no new skin issues. Four days later on 11/18/11, the Pressure Ulcer Record and Weekly Skin Assessments indicated that a pressure ulcer was identified on the left heel indicating the "left heel with dark purple area measuring 3.0 x 3.5 centimeters." The Pressure Ulcer Record indicated that there was no drainage. On 11/18/11, the resident's Norton scale (an assessment that indicates skin pressure risk) was a (7). High risk ranges between (5 and 10). The nurse practitioner was asked to look at the resident's left heel on 11/21/11 and documented, "Leg is in immobilizer, so more pressure is on heel when in bed. Heel also rests on footrest of the wheelchair if she slides down in her chair." The resident's most current significant change Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired and coded as a (03) out of a possible score of (15). The resident required extensive assistance with Activities of Daily Living (ADLs). The resident was coded as being totally incontinent of bladder and bowel. The facility identified the resident as having had one recent fall with major injury. The resident was coded as having one unstageable pressure ulcer on the left heel. The most recent skin care plan in place prior to and during the use of the knee immobilizer, was dated 5/27/11 through 11/2011. The goal was: "Resident's skin will remain intact, free from [DIAGNOSES REDACTED], breakdown, excoriation for 90 days." The 5/27/11 interventions included: * Assess skin every shift and report abnormalities. * Provide pressure relieving device on bed. * Turn and position every 2 hours and as needed (prn). * Instruct/assist resident in methods of reducing friction and shearing. * Skilled PT and OT as ordered. * Dietary consult. * Provide foot care per protocol. Podiatry follow-up. * Monitor lab values. * Utilize lift sheet in bed to prevent friction during repositioning. * Position with appropriate support to prevent shearing. The podiatrist saw the resident on 8/11/11 and documents that there was absent dorsal pedal pulse, absent posterior tibial pulse. The resident is also documented as having poor skin turgor and decreased skin temperature. On 8/16/11 the care plan was reviewed. However, there were no interventions added to address the increased risk of skin breakdown due to the lack of pedal pulses and poor circulation to the bilateral feet. At this time, the only modification to the care plan was the added intervention of "A&D to bony prominences to prevent decubiti." This intervention failed to address the added risk of skin breakdown to the feet. There was no further documentation in the clinical record to address this issue. The knee immobilizer was implemented on 10/29/11. There was no evidence that the care plan had been amended to include any interventions to address the 24 hour immobilizer use. On 1/10/12, review of the physician's orders [REDACTED]. -left heel treatment -wash left heel with normal saline, pat dry and apply Allevyn. Change every 3 days. Further review of the care plans on 1/10/12 at 11:00 A.M., indicated that there was no evidence of any additional skin care plan interventions developed until the pressure ulcer was identified on 11/18/11. At this time, a foam boot to the left foot, was added, which could be removed for ambulation and ADLs. Interview with Unit Manager #1, on 1/10/12 at 11:10 A.M., said that he/she was worried about the weight of the immobilizer and the potential effect on this resident's skin. Unit Manager #1 said that preventative measures should have been in place to address this and "we didn't." Unit Manager #1 also said that there were no interventions in place that addressed supporting the weight of the immobilizer in bed or in the wheelchair, nor were there interventions that addressed off-loading the resident's heels to prevent pressure on the heel. On 1/10/12, at the noon meal, Resident #9 was observed being fed by staff, but was able to drink a beverage on his/her own. A foam boot was observed on the residents left foot. At 3:00 P.M., the resident was observed sitting in a wheelchair with a left foam boot applied to the left foot. When approached, the resident did not respond when Surveyor #3 spoke to the resident. Observation of the left heel, on 1/11/12 at 11:00 A.M., by Surveyor #1, during the treatment observation revealed the following: The inner aspect of the left heel had a 3 centimeter by 3 centimeter unstageable area of black eschar, the edges of which were lifting and a scant dark brown drainage was noted on the old dressing. The surrounding skin of the left foot was extremely dry and flaking. The left heel dressing covered most of this resident's foot, once it was wrapped. The facility failed to develop and ensure that the resident received effective, preventive interventions that would relieve pressure to the resident's left heel while wearing the full leg knee immobilizer, in order to prevent the development of a new pressure area.

Based on observation, documentation review and staff interview, the facility failed to provide adequate supervision for 1 of 2 sampled residents (Resident #9) who fell resulting in injury and 1 (Resident #3) of 6 residents with falls without injury in a total sample of 24. Findings include: 1. For Resident #9, the facility failed to provide adequate supervision to prevent a fall resulting in injury. Review of the resident's medical record on 11/7/11 at 9:30 A.M., indicated the resident was admitted to the facility on [DATE] [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident required extensive assistance with Activities of Daily Living, and was independent with eating. The resident was coded as being totally incontinent of bladder and bowel. The facility identified the resident as being a high risk for falls. The most recent care plan dated 8/26/11, for falls/safety had approaches for staff to assist the resident out of bed (with one assist) using a rolling walker. Further record review on 11/7/11 at 10:00 A.M., indicated that a nursing note dated 11/1/11, late entry for 10/28/11 at 6:55 A.M., indicated, "Resident went into bathroom with assist by Certified Nursing Assistant (CNA) and the walker. While in the bathroom, the resident became confused and tripped over his/her feet, when the resident went to sit on the toilet. The resident fell forward, hit his/her head on the walker or the walker fell down. The CNA became distracted (prior to the incident) and did not see the resident to intervene in the fall. The resident was found lying on the floor in the bathroom on the left side. The resident had a laceration over the left eye." Further record review indicated the resident was transferred to the hospital for an evaluation and returned to the facility. The resident did not receive sutures for the laceration above the left eye, but had new orders for a treatment to the area. The resident complained of knee pain and the nurse practitioner was contacted. The nurse practitioner ordered an X-ray which revealed "a non-displaced transverse fracture of the proximal shaft of the tibia." The nurse practitioner ordered the resident be sent to the hospital for further evaluation and treatment. The resident returned to the facility with a knee immobilizer in place. On 11/7/11 at 3:00 P.M., the resident was observed sitting in a wheelchair with a knee immobilizer on the left knee in the day room. Surveyor #4 approached the resident and said hello. The resident did not respond or speak to the surveyor. On 11/8/11 at 11:00 A.M., review of the facility's investigation dated 11/4/11, indicated the the Director of Nurses interviewed the CNA (CNA #2) involved with the resident's fall. According to the investigation, CNA #2 was walking the resident with a gait belt and a walker into the resident's bathroom. CNA #2 heard someone calling her name in the hallway. CNA #2 turned toward the voice and let go of the gait belt for a moment. When CNA #2 turned back around toward the resident, the resident stumbled against the walker and began falling to the floor. CNA #2 indicated she could not stop the resident. The resident hit her/his head on the bottom of the walker. On 11/8/11 at 11:22 A.M., Surveyor #3 and Surveyor #4 interviewed CNA #2 who was caring for the resident on 10/28/11. CNA #2 said that she was taking the resident (with a gait belt around the resident's waist) to the bathroom with the resident's walker. Another CNA called CNA #2 from the hallway and CNA #2 looked left to the direction of the other CNA's voice. The resident kept walking, maybe one or two steps toward the toilet. CNA #2 said she stopped walking with the resident for only a second. CNA #2 said that she did not let go of the gait belt, but loosened up on the grip that she had on the gait belt. CNA #2 further said that the resident tripped over the resident's own feet. The resident hit his/ her head and left knee on the floor. CNA #2 said that "If I could do things differently, I would never take my sight off the resident." CNA #2 said she has cared for this resident, and the resident required one assist to the bathroom with a rolling walker. After the incident, CNA #2 immediately notified the nurse. CNA #2 said she received education and was counseled regarding the incident. On 11/8/2011 at 11:32 A.M., the Director of Nurses (DON) said that CNA #2 said that the resident was alert, but was confused at the time of the fall. The DON said the resident was diagnosed with [REDACTED]. The facility failed to ensure the resident received effective and adequate supervision while being transferred to the bathroom. 2. For Resident #3, the facility failed to provide adequate supervision to prevent accidents. Resident #3 was admitted to this facility in January, 2011 with [DIAGNOSES REDACTED]. This resident developed bilateral heel blisters on 3/19/11, which developed into unstageable decubiti on both heels. On 11/7/11 at 1:00 P.M., a review of the medical record revealed that this resident had 3 falls in the previous 6 months, all of them occurring in Dayroom A with staff present. On 11/7/11 at 1:00 P.M., a review was conducted of the significant change Minimum Data Set Assessment (MDS), dated [DATE], which identified this resident as having both long and short term memory loss and moderate impairment in decision making. This resident was also identified as needing extensive assistance of one person for walking. The Fall Risk Assessment, dated 4/8/11, identified this resident as scoring a 12, which is high risk for falls (greater than 10 is high risk). The first fall occurred on 5/13/11 at 10:00 A.M., in Dayroom A, with 2 CNAs present, 1 who witnessed the fall. This resident was observed to stand up from the chair with slipper socks and foam booties on, slide down and land on buttocks. The CNA who said that she/he had witnessed the fall, did not say that any attempts were made to stop the resident from falling. The other CNA said that she/he was occupied with another resident at the time of the fall and did not see anything. The Falls Care Plan, on 5/13/11, included that following intervention, "staff to ensure to redirect resident to sit down when stand up with booties for safety." Another Fall Risk Assessment, dated 7/6/11, identified this resident as scoring a 17, which is high risk for falls. The second fall occurred on 8/2/11 at 4:15 P.M., in Dayroom A, with 3 staff members present, but none observed this resident's fall. Although this fall was unwitnessed, the facility concluded that this resident fell while attempting to walk after sitting on a chair. The Falls Care Plan, on 8/2/11, included that following intervention, "non skid socks and closer supervision." The third fall occurred on 9/18/11 at 5:55 P.M., in Dayroom A, with 5 staff members present, but none observed this resident's fall. Review of the Accident/Incident Report, dated 9/18/11, indicated that this resident had been served his/her meal at the time of this fall. However, there was not an identified staff person seated with him/her to provide assistance. Further review of the nurses notes, dated 9/18/11, indicated that this resident had removed his/her pressure relieving sandals and had removed both geri sleeves (protective hand and arm coverings) prior to the accident. There was no indication that any of the 5 staff members that were in the dayroom, at the time of the fall, were aware that this resident had removed either geri sleeves or his/her pressure relieving sandals. As a result of this fall and the geri sleeves not being in place, this resident sustained [REDACTED]. Review on 11/7/11 at 1:00 P.M. of the 9/18/11 Falls Care Plan indicated that this resident needs to be supervised at all times when in the dayroom. The most recent, dated 10/7/11, quarterly Minimum Data Set identified this resident as needing a one person physical assist for both transfers and ambulation. Observations were made on the following dates, 11/2/11, 11/3/11, 11/7/11, 11/8/11 and 11/9/11, indicating that this resident was frequently standing and walking without assistance by the staff present in Dayroom A. Observations are as follows: On 11/2/11 at 4:00 P.M., this resident was observed repeatedly standing and walking short distances in the dayroom without any hands on assistance by the CNA present in Dayroom A. This resident was wearing a pair of pressure relieving sandals held together with adhesive tape at this time. On 11/03/11 at 11:45 A.M., Resident #3 was observed in Dayroom A getting up from a stationary chair and taking a few steps around the space by the table where she/he was seated and then returned to the stationary chair after a staff member redirected this resident to sit back down from across the room. This resident was wearing a pair of pressure relieving sandals held together with adhesive tape. This was repeated several times, but no staff member approached this resident to provide any hands on assistance. Observations were made on 11/7/11 from 1:00 P.M. until 1:45 P.M., Resident #3 was in Dayroom A with 17 residents and 3 CNAs. At this time, Resident #3 was restless, standing and walking about in dayroom and being redirected to sit back down. The back of this resident's sweatpants were noted to be stained dark from the buttocks to the back of the knees. The 3 CNAs positioned in the room continued to verbally redirect this resident back to a chair from a distance, without anyone approaching this resident to provide any direct assistance, despite his escalating restlessness. At 1:45 A.M., Resident #3 walked out of the dayroom without any staff assistance and began to walk down the corridor. At this time, a CNA was directed by Unit Manager #3 to assist this resident in getting into some clean clothing. However, 45 minutes had passed, during which this resident was presenting as distressed and restless without the dayroom staff intervening. Interview with the DON on 11/9/11 at 11:15 A.M., she stated that this resident was in Dayroom A for all three falls and that although staff was present, the 2 most recent falls were not observed.

Based on record review, interview and observation, for 2 of 2 sampled residents (Resident #1 and Resident #2), the Facility failed to implement the plans of care for Resident #2, who required supervision due to cognitive impairment, and for Resident #1, who was care planned to not sit next to female residents due to Resident #1's sexually inappropriate behaviors, when on 8/31/10, at approximately 1:00 P.M., Resident #1 sat next to Resident #2 in the dining room and Resident #1 was observed to have placed Resident #1's hand in Resident #2's pants and touched Resident #2's genital area. Though the Speech Language Pathologist (SLP) and CNA #1 were in the room at the time of the incident, neither staff person was supervising Resident #1 or Resident #2. Findings include: Review of the Facility's internal investigation report, dated 9/17/10, indicated that it was alleged that on 8/31/10 at approximately 1:00 P.M., the Accused Certified Nurse Aide (CNA) entered the dining room and observed Resident #1 with Resident #1's hand down the front of Resident #2's pants and touching Resident #2's genital area. Review of Resident #1's patient care referral report, dated 2/24/09, indicated that Resident #1 had a [DIAGNOSES REDACTED]. The report indicated that these behaviors included grabbing and touching. The report indicated that, while at the Hospital, Resident #1's behaviors were managed by enforcing strict boundaries and limiting contact with female patients. Review of Resident #1's social service note, dated 5/11/10, indicated that Resident #1 continued to exhibit sexually inappropriate behaviors, which included touching female residents and staff. Review of Resident #1's psychiatry consultant note, dated 5/11/10, indicated that staff were advised to quickly redirect Resident #1 if Resident #1 attempted to either sit next to or hold the hands of the female residents. Review of Resident #1's nurse's note, dated 6/25/10, indicated that Resident #1 ambulated on the unit, and in the dining room, and was trying to sit next to female residents and watching for staff's reactions. The note indicated that if staff were not watching Resident #1, Resident #1 would try to grab a female residents and touch the female residents genital area. The note indicated that Resident #1 also pulled down the zipper to Resident #1's pants. The note indicated that Resident #1 was observed looking around the room and trying to take advantage of a moment when staff were not watching in order to touch the female residents. Review of Resident #1's behavior monitoring log, dated July, 2010, indicated that Resident #1 exhibited sexually and/or socially inappropriate behaviors on a daily basis. Review of Resident #1's social service note, dated 7/27/10, indicated that staff continued to monitor Resident #1' when around female residents and that Resident #1 continued to exhibit sexually inappropriate behavior toward female residents and staff, which included comments and attempts to touch. The note indicated that the plan was for staff to continue to monitor Resident #1. Review of Resident #1's plan of care, last reviewed on 7/27/10, indicated that Resident #1 had a history of [REDACTED]. Interventions included: Resident #1 will sit at the all-male table for meals; Resident #1 will stand alongside staff in the elevator. The care plan indicated that Resident #1 continued to exhibit inappropriate behaviors on a daily basis. Review of Resident #1's quarterly Minimum Data Set assessment, dated 7/30/10, indicated Resident #1: had poor short and long-term memory; was moderately impaired cognitive skills for daily decision-making (decisions poor; cues/supervision required); had multiple indicators of disordered thinking; had socially inappropriate behaviors exhibited on a daily basis; and ambulated with staff supervision. Review of Resident #1's medical record indicated that there was no documentation of the 8/31/10 incident. Review of Resident #2's quarterly Minimum Data Set assessment, dated 8/20/10, indicated Resident #2: had short and long-term memory impairment; had moderately impaired cognitive skills for daily decision-making (decision poor; cues/supervision required); exhibited multiple indicators of disordered thinking or awareness; and required extensive staff assistance with walking. Review of Resident #2's medical record indicated that there was no documentation of the 8/31/10 incident. Review of Resident #2's skin assessment, dated 9/06/10, indicated that there was no sign of injury. The SLP was interviewed on 9/09/10 at 12:30 P.M. The SLP said that on 8/31/10 at approximately 1:00 P.M., the SLP was in the unit dining room and providing a therapeutic feeding to a resident. The SLP said that at this time, the Accused CNA entered the dining room and yelled out "Hey, cut that out (Resident #1) or I'll snap your hands off at the [***] ing wrists", or words to that effect. Resident #1 stood up from where Resident #1 was sitting and walked to the men's table. The SLP said that, at the time of the incident, CNA #1 was also in the dining room and sitting, slumped in a chair located near the center of the room. The SLP said that CNA #1's arms were folded, and CNA #1 appeared to be resting. The SLP said that CNA #1's head was not visible because of CNA #1's posture. The SLP said that CNA#1 did not appear to be supervising the residents in the dining room. The SLP said that, despite that the Accused CNA yelled at and threatened Resident #1, CNA #1 did not move from the chair, or say anything. The SLP said the SLP was not a member of the nursing staff and was not responsible for supervising the residents in the dining room. The SLP said that the SLP did not know what Resident #1 was doing at the time of the incident, or where Resident #1 was seated. CNA #1 was interviewed on 9/09/10 at 1:00 P.M. CNA #1 said that on 8/31/10, during the afternoon, CNA #1 was either sitting in the center of the dining room, or standing to the side of the room, and supervising the residents in the room. CNA #1 said that it was CNA #1's scheduled time to supervise the room. CNA #1 said that CNA #1 was facing the women's table, and that, despite facing the women's table, CNA #1 did not notice that Resident #1 was sitting next to Resident #2. CNA #1 said that the Accused CNA entered the dining room and yelled, and then CNA #1 noticed that Resident #1 was sitting next to and to the left of Resident #2, and it appeared that Resident #1 may have been pulling up the zipper to Resident #1's pants. CNA #1 said that the Accused CNA then repeatedly told Resident #1 to take Resident #1's seat at the men's table. CNA #1 said that, eventually, Resident #1 stood up from the seat at the women's table and walked to the men's table and sat down. Nurse #1 was interviewed on 10/06/10 at 2:05 P.M. Nurse #1 said that on 8/31/10, at approximately 1:00 P.M., Nurse #1 was passing medications from a cart placed in the hallway directly outside the entryway to the dining room. Nurse #1 said that Nurse #1 was not assigned to monitor or supervise residents in the dining room at this time, but that the Accused CNA was given this assignment. Nurse #1 said that at different points in time the Accused CNA was in the dining room, and at other times Nurse #1 did not see the Accused CNA in the room, but that there was another, unidentified, staff person in the room. Nurse #1 said that sometime between 1:00 P.M. and 1:30 P.M. Nurse #1 noticed that Resident #1 walked over to the men's table and sat down. Nurse #1 said that some minutes later the Accused CNA told Nurse #1 that Resident #1 grabbed at Resident #2. Nurse #1 said that Resident #1 frequently tried to touch, or grab, female residents in a sexual manner, and that Resident #1 was care planned for this behavior. Nurse #1 said that Resident #1's plan of care included keeping Resident #1 physically apart from the female residents, including in the dining room where Resident #1 was assigned to an all-male table. Nurse #1 said that Resident #1 required staff supervision in common areas where Resident #1 would have the opportunity to have physical contact with female residents. Nurse #1 said that it was important for nursing staff to supervise Resident #1 while in the dining room to ensure that Resident #1 did not sit next to a female resident. The Accused CNA was interviewed on 9/09/10 at 1:40 P.M. The Accused CNA said that the Accused CNA entered the dining room at approximately 1:00 P.M., and the Accused CNA observed that Resident #1 was seated next to and to the left of Resident #2, at the women's residents table, and that Resident #1 had Resident #1's hand down Resident #2's pants. The Accused CNA said that the Accused CNA told Resident #1 "(Resident #1), I will break your hands if you don't get them out of there", or words to that effect. The Accused CNA said that Resident #1 then jerked Resident #1's hand out of Resident #2's pants, and that the Accused CNA could see Resident #1's hand pull up from under Resident #2's incontinence brief. The Accused CNA said that the Accused CNA told Resident #1 to sit at the men's table, which Resident #1 did. The Accused CNA said that the Accused CNA then noticed that the SLP was seated at another table and faced Resident #1 and Resident #2. The Accused CNA said that CNA #1 was also seated in a chair in the dining room, but was not facing Resident #1 or Resident #2. The Accused CNA said CNA #1's eyes were half-shut and CNA #1 was not watching the residents. The Accused CNA said that it was well known among nursing staff that Resident #1 targeted female residents and frequently tried to touch female residents on the breasts, buttocks and genital areas. The Accused CNA said that all nursing staff were aware that Resident #1 was not allowed to sit next to female residents, and that while in the dining room Resident #1 was required to sit at the men's table due to Resident #1's behavior toward females. The Accused CNA said that Resident #1 frequently tried to touch Resident #2 and that staff regularly intervened to prevent contact. The Accused CNA said that the Accused CNA was very angry at the time of the incident because neither CNA #1 or the SLP were supervising Resident #1. The Accused CNA said that it was CNA #1's responsibility to supervise the residents who were in the dining room at the time of the incident. The Accused CNA said that, beginning at 1:00 P.M., it was the Accused CNA's responsibility to supervise residents in the dining room. The Director of Nursing (DON) was interviewed on 9/09/10 at 2:30 P.M. The DON said that both Resident #1 and Resident #2 required staff supervision due their poor judgement, secondary to dementia. The DON said that Resident #1 needed additional staff supervision because of a history of sexually inappropriate behavior directed toward females. The DON said that Resident #1's care plan interventions included seating Resident #1 at the all-male dining room table, and not allowing Resident #1 to sit next to female residents. On 9/9/10, the Surveyor observed the dining room where the incident occurred. The Surveyor did not interview Resident #1, or Resident #2, due to their impaired cognition. On 9/910, the Surveyor observed Resident #1 and Resident #2 on the day of the field visit, and neither resident appeared to be in any distress.

Based on record review, interview and observation, for 2 of 2 sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that Resident #1, who had a history of [REDACTED].#2, who was a female resident with cognitive impairment. On 8/31/10, at approximately 1:00 P.M., Resident #1 sat next to Resident #2 and placed Resident #1's hand in Resident #2's pants and touched Resident #2's genital area. Though the Speech Language Pathologist (SLP) and CNA #1 were in the room at the time of the incident, neither staff person was supervising Resident #1 or Resident #2. Findings include: Review of the Facility's internal investigation report, dated 9/17/10, indicated that it was alleged that on 8/31/10 at approximately 1:00 P.M., the Accused Certified Nurse Aide (CNA) entered the dining room and observed Resident #1 with Resident #1's hand down the front of Resident #2's pants and touching Resident #2's genital area. Review of Resident #1's patient care referral report, dated 2/24/09, indicated that Resident #1 had a [DIAGNOSES REDACTED]. The report indicated that these behaviors included grabbing and touching. The report indicated that, while at the Hospital, Resident #1's behaviors were managed by enforcing strict boundaries and limiting contact with female patients. Review of Resident #1's social service note, dated 5/11/10, indicated that Resident #1 continued to exhibit sexually inappropriate behaviors, which included touching female residents and staff. Review of Resident #1's psychiatry consultant note, dated 5/11/10, indicated that staff were advised to quickly redirect Resident #1 if Resident #1 attempted to either sit next to or hold the hands of the female residents. Review of Resident #1's nurse's note, dated 6/25/10, indicated that Resident #1 ambulated on the unit, and in the dining room, and was trying to sit next to female residents and watching for staff's reactions. The note indicated that if staff were not watching Resident #1, Resident #1 would try to grab a female residents and touch the female residents genital area. The note indicated that Resident #1 also pulled down the zipper to Resident #1's pants. The note indicated that Resident #1 was observed looking around the room and trying to take advantage of a moment when staff were not watching in order to touch the female residents. Review of Resident #1's behavior monitoring log, dated July 2010, indicated that Resident #1 exhibited sexually and/or socially inappropriate behaviors on a daily basis. Review of Resident #1's social service note, dated 7/27/10, indicated that staff continued to monitor Resident #1 when around female residents and that Resident #1 continued to exhibit sexually inappropriate behavior toward female residents and staff, which included comments and attempts to touch. The note indicated that the plan was for staff to continue to monitor Resident #1. Review of Resident #1's plan of care, last reviewed on 7/27/10, indicated that Resident #1 had a history of [REDACTED]. Interventions included: Resident #1 will sit at the all-male table for meals; Resident #1 will stand alongside staff in the elevator. The care plan indicated that Resident #1 continued to exhibit inappropriate behaviors on a daily basis. Review of Resident #1's quarterly Minimum Data Set assessment, dated 7/30/10, indicated Resident #1: had poor short and long-term memory; was moderately impaired cognitive skills for daily decision-making (decisions poor; cues/supervision required); had multiple indicators of disordered thinking; had socially inappropriate behaviors exhibited on a daily basis; and ambulated with staff supervision. Review of Resident #1's medical record indicated that there was no documentation of the 8/31/10 incident. Review of Resident #2's quarterly Minimum Data Set assessment, dated 8/20/10, indicated Resident #2: had short and long-term memory impairment; was moderately impaired cognitive skills for daily decision-making (decision poor; cues/supervision required); exhibited multiple indicators of disordered thinking or awareness; and required extensive staff assistance with walking. Review of Resident #2's medical record indicated that there was no documentation of the 8/31/10 incident. Review of Resident #2's skin assessment, dated 9/06/10, indicated that there was no sign of injury. The SLP was interviewed on 9/09/10 at 12:30 P.M. The SLP said that on approximately 8/31/10, at 1:00 P.M., the SLP was in the unit dining room and providing a therapeutic feeding to a resident. The SLP said that at this time the Accused Certified Nursing Assistant (CNA) entered the dining room and yelled out "Hey, cut that out (Resident #1) or I'll snap your hands off at the [***] ing wrists", or words to that effect. Resident #1 stood up from where Resident #1 was sitting and walked to the men's table. The SLP said that, at the time of the incident, CNA #1 was also in the dining room and sitting, slumped, in a chair located near the center of the room. The SLP said that CNA #1's arms were folded, and CNA #1 appeared to be resting. The SLP said that CNA #1's head was not visible because of CNA #1's posture. The SLP said that CNA#1 did not appear to be supervising the residents in the dining room. The SLP said that, despite that the Accused CNA yelled at and threatened Resident #1, CNA #1 did not move from the chair, or say anything. The SLP said that the SLP was not a member of the nursing staff and was not responsible for supervising the residents in the dining room. The SLP said that the SLP did not know what Resident #1 was doing at the time of the incident, or where Resident #1 was seated. CNA #1 was interviewed on 9/09/10 at 1:00 P.M. CNA #1 said that on 8/31/10 during the afternoon, CNA #1 was either sitting in the center of the dining room or standing to the side of the room, and supervising the residents in the room. CNA #1 said that it was CNA #1's scheduled time to supervise the room. CNA #1 said that CNA #1 was facing the women's table, and that, despite facing the women's table, CNA #1 did not notice that Resident #1 was sitting next to Resident #2. CNA #1 said that the Accused CNA entered the dining room and yelled, and then CNA #1 noticed that Resident #1 was sitting next to and to the left of Resident #2, and it appeared that Resident #1 may have been pulling up the zipper to Resident #1's pants. CNA #1 said that the Accused CNA then repeatedly told Resident #1 to take Resident #1's seat at the men's table. CNA #1 said that, eventually, Resident #1 stood up from the seat at the women's table and walked to the men's table and sat down. Nurse #1 was interviewed on 10/06/10 at 2:05 P.M. Nurse #1 said that on 8/31/10, at approximately 1:00 P.M., Nurse #1 was passing medications from a cart placed in the hallway directly outside the entryway to the dining room. Nurse #1 said that Nurse #1 was not assigned to monitor or supervise residents in the dining room at this time, but that the Accused CNA was given this assignment. Nurse #1 said that at different points in time the Accused CNA was in the dining room, and at other times Nurse #1 did not see the Accused CNA in the room, but that there was another, unidentified, staff person in the room. Nurse #1 said that sometime between 1:00 P.M. and 1:30 P.M., Nurse #1 noticed that Resident #1 walked over to the men's table and sat down. Nurse #1 said that some minutes later the Accused CNA told Nurse #1 that Resident #1 grabbed at Resident #2. Nurse #1 said that Resident #1 frequently tried to touch, or grab, female residents in a sexual manner, and that Resident #1 was care planned for this behavior. Nurse #1 said that Resident #1's plan of care included keeping Resident #1 physically apart from the female residents, including in the dining room where Resident #1 was assigned to an all-male table. Nurse #1 said that Resident #1 required staff supervision in common areas where Resident #1 would have the opportunity to have physical contact with female residents. Nurse #1 said that it was important for nursing staff to supervise Resident #1 while in the dining room to ensure that Resident #1 did not sit next to a female resident. Review of Nurse #1's written statement, dated 9/03/10, indicated that on 8/31/10 at approximately 1:00 P.M., Nurse #1 heard the Accused CNA "yelling" at Resident #1, and the Accused CNA told Nurse #1 that Resident #1 "grabbed" Resident #2's crotch. Nurse #1 indicated that though Resident #2 was grabbed, Resident #2 did not appear to be in any distress. The Accused CNA was interviewed on 9/09/10 at 1:40 P.M. The Accused CNA said that the Accused CNA entered the dining room at approximately 1:00 P.M., and the Accused CNA observed that Resident #1 was seated next to and to the left of Resident #2, at the women's residents table, and that Resident #1 had Resident #1's hand down Resident #2's pants. The Accused CNA said that the Accused CNA told Resident #1 "(Resident #1), I will break your hands if you don't get them out of there", or words to that effect. The Accused CNA said that Resident #1 then jerked Resident #1's hand out of Resident #2's pants, and that the Accused CNA could see Resident #1's hand pull up from under Resident #2's incontinence brief. The Accused CNA said that the Accused CNA told Resident #1 to sit at the men's table, which Resident #1 did. The Accused CNA said that the Accused CNA then noticed that the SLP was seated at another table and faced Resident #1 and Resident #2. The Accused CNA said that CNA #1 was also seated in a chair in the dining room, but was not facing Resident #1 or Resident #2. The Accused CNA said CNA #1's eyes were half-shut and CNA #1 was not watching the residents. The Accused CNA said that it was well known among nursing staff that Resident #1 targeted female residents and frequently tried to touch female residents on the breasts, buttocks and genital areas. The Accused CNA said that all nursing staff were aware that Resident #1 was not allowed to sit next to female residents, and that while in the dining room Resident #1 was required to sit at the men's table due to Resident #1's behavior toward females. The Accused CNA said that Resident #1 frequently tried to touch Resident #2 and that staff regularly intervened to prevent contact. The Accused CNA said that the Accused CNA was very angry at the time of the incident because neither CNA #1 or Staff Person #1 were supervising Resident #1. The Accused CNA said that it was CNA #1's responsibility to supervise the residents who were in the dining room at the time of the incident. The Accused CNA said that, beginning at 1:00 P.M., it was the Accused CNA's responsibility to supervise residents in the dining room. The Director of Nursing (DON) was interviewed on 9/09/10 at 2:30 P.M. The DON said that both Resident #1 and Resident #2 required staff supervision due their poor judgement, secondary to dementia. The DON said that Resident #1 needed additional staff supervision because of a history of sexually inappropriate behavior directed toward females. The DON said that Resident #1's care plan interventions included seating Resident #1 at the all-male dining room table, and not allowing Resident #1 to sit next to female residents. On 9/9/10, the Surveyor observed the dining room where the incident occurred. The Surveyor did not interview Resident #1, or Resident #2, due to their impaired cognition. On 9/9/10, the Surveyor observed Resident #1 and Resident #2 and neither resident appeared to be in any distress.