Every finding on record at Brookhaven at Lexington

Based on observation, record review, and interview, the facility failed for one Resident (#5) to follow the physician's order to obtain an apical pulse prior to administering the heart medication Digoxin, out of a total sample of ten residents. Findings include: Resident #5 was admitted to the facility in March 2018 and has active diagnoses which include heart failure, atrial fibrillation, seizures, and stroke. Review of Resident #5's most recent Minimum Data Set assessment, dated 9/3/24, indicated a Brief Interview for Mental Status exam score of 5 out of a possible 15, indicating severe cognitive impairment. Review of Resident #5's current physician orders indicated the following order: - Digoxin, 125 mcg (0.125 mg) tablet. Give 1 tablet by oral route once daily. Hold if AP [apical pulse] less than 60. Monitoring: pulse (apical). Digoxin is a medication used to treat heart failure and atrial fibrillation. On 10/22/24 at 10:05 A.M., during a medication pass with Nurse #1, the surveyor observed Nurse #1 place a pulse oximeter over one of Resident #5's fingers. The pulse oximeter read 93 heart beats per minute. Nurse #1 then administered the tablet of Digoxin to Resident #5. A pulse oximeter is a device placed over a finger used to measure the body's heart rate and oxygen levels. During an interview on 10/22/24 at 10:11 A.M., Nurse #1 said she normally obtains Resident #5's pulse through the pulse oximeter, prior to administering Resident #5's Digoxin. Nurse #5 said she would only obtain an apical pulse from a resident if the physician order required it to be done. During an interview with the Director of Nurses (DON) on 10/22/24 at 11:00 A.M., she said that obtaining an apical pulse prior to administering Digoxin is only required if the physician orders it to be done. The DON said that if the physician does not include a requirement to obtain an apical pulse, then the use of a pulse oximeter or heart rate obtained from the wrist is acceptable.

Based on observation, record review and interview, the facility failed for one Resident (#5), to follow the professional standard for monitoring heart rate by apical pulse prior to administering the heart medication Digoxin, out of a total sample of ten residents. Findings include: Review of the [NAME] Drug Guide, 19th edition, 2024, indicated: - Monitor apical pulse for one full minute before administering oral Digoxin. Hold dose and notify health care professional if pulse rate is less than 60 beats per minute in an adult. The apical pulse is a pulse point located on the chest at the bottom tip (apex) of the heart. A stethoscope is used to hear the arterial pulse rate as the heart contracts and pumps out blood. Resident #5 was admitted to the facility in March 2018 and has active diagnoses which include heart failure, atrial fibrillation, seizures, and stroke. Review of Resident #5's most recent Minimum Data Set assessment, dated 9/3/24, indicated a Brief Interview for Mental Status exam score of 5 out of a 15, indicating severe cognitive impairment. Review of Resident #5's current physician orders indicated: - Digoxin, 125 mcg (0.125 mg) tablet. Give 1 tablet by oral route once daily. Hold if AP [apical pulse] less than 60. Monitoring: pulse (apical). Digoxin is a medication used to treat heart failure and atrial fibrillation. On 10/22/24 at 10:05 A.M., during a medication pass with Nurse #1, the surveyor observed Nurse #1 place a pulse oximeter over one of Resident #5's fingers. The pulse oximeter read 93 heart beats per minute. Nurse #1 then administered the tablet of Digoxin to Resident #5. A pulse oximeter is a device placed over a finger used to measure the body's heart rate and oxygen levels. During an interview on 10/22/24 at 10:11 A.M., Nurse #1 said she normally obtains Resident #5's pulse through the pulse oximeter, prior to administering Resident #5's Digoxin. Nurse #5 said she would only obtain an apical pulse from a resident if the physician order required it to be done. Nurse #5 did not think it was a nursing standard of practice to obtain an apical pulse prior to administering Digoxin. During an interview with the Director of Nurses (DON) on 10/22/24 at 11:00 A.M., she said that obtaining an apical pulse prior to administering Digoxin is only required if the physician orders it to be done. The DON said that if the physician does not include a requirement to obtain an apical pulse, then the use of a pulse oximeter or heart rate obtained from the wrist is acceptable.

Based on observation and interview, the facility failed to secure medications left on top of the medication cart during the medication pass. Findings include: On 10/22/24 at 9:51 A.M., during a medication pass with Nurse #1, the surveyor observed a small pink pill in a medication cup, located on top of the medication cart. Between 9:51 A.M. and 10:11 A.M., Nurse #1 left this medication unattended at various times, including while she was in a resident's bedroom administering medications. On 10/22/24 at 10:01 A.M., during a medication pass with Nurse #1, the surveyor observed Nurse #1 pour medications for a resident and place one tablet of Carbamazepine (an anticonvulsant) into a medication cup, located on top of the medication cart. Nurse #1 gathered the other medications and entered a resident's bedroom, leaving the Carbamazepine unsecured on top of the cart. At approximately 10:09 A.M., eight minutes after entering the resident's bedroom, Nurse #1 re-entered the hallway, closed the bedroom door, and stood by the medication cart. During an interview with Nurse #1 on 10/22/24 at 10:11 A.M., she said the small pink pill was Lisinopril (a blood pressure medication) and that she had intended to administer it earlier in the morning to a resident but forgot to do this. Nurse #1 said the large pink pill was chewable Carbamazepine, and that she had forgotten to administer it to the resident. Nurse #1 said that medications are not allowed to be left unsecured on top of the medication cart when she is not present to supervise them. During an interview with the Director of Nurses on 10/22/24 at 11:00 A.M., she said it was her expectation that nursing staff be present to supervise any medications left unlocked on top of the medication cart.

Based on observation, record review and interview the facility failed to ensure that it is free of medication error rates of five percent or greater. Specifically the medication error rate was 7.69%. Findings include: Review of the facility policy titled Mobile Med Pass and dated March, 10 2017, failed to indicate the nurse is to follow doctor's orders in dispensing medications to a resident. Further review indicated that the nurse is to follow the 5 rights for medication pass. The right patient, the right drug, the right dose, the right route and the right time. Resident #163 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, fractures and dementia. During medication pass on 10/11/23, at 8:58 A.M. the surveyor observed Nurse #1 pour and administer the following medications: Donepezil 10 mg (milligrams) 1 tablet Carbidopa ER (extended release) 25 mg-levodopa 100 mg 1 tablet Comtan 200 mg 1 tablet Nuplazid 34 mg 1 tablet Myrbetriq 50 mg 1 tablet Vitamin B1 100 mg 1 tablet Multivitamin 1 tablet Vitamin D3 25 mcg (micrograms) Review of the doctor's orders indicated the following: Carbidopa 25 mg-levodopa 100 mg give one tablet by mouth once daily take in the morning together with the slow-release levodopa. (This medication was not given by the nurse) Donepezil 10 mg tablet give one tablet by mouth daily at bedtime. (This medication was given by the nurse at 8:58 A.M.) During an interview on 10/11/23, at 12:28 P.M., Nurse #1 said that she thought she had given the Carbidopa 25 mg-levodopa 100 mg and did not realize she had given the Donepezil 10 mg.

Based on observation, interviews and record review, the facility failed to ensure that 1 Resident (#14) received services to prevent a decline in range of motion (range of motion refers to degree of movement of a specific joint) when the resident developed symptoms of increased rigidity/[DIAGNOSES REDACTED] or to determine the decline was unavoidable, out of a total of 13 sampled residents. Findings include: On 11/27/19 at 8:00 [NAME]M., Resident #14 was observed sitting in his/her wheelchair in the dining room. Resident #14's shoulders were curled in and he/she slouched forward with his/her left arm bent at the elbow across his/her body. Resident #14's left wrist was flexed (bent) and all his/her fingers were closed into a fist. Resident #14's right elbow and wrist were bent, and his/her thumb, pointer finger and pinky finger were flexed into a fist, while his/her middle and ring fingers were hyperextended, pointing up towards the ceiling. Resident #14 was unable to be interviewed about his/her positioning due to his/her cognitive impairment. Resident #14 was admitted to the facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. Review of Resident #14's most recent Minimum Data Set assessment dated [DATE], revealed that Resident #14 had severe cognitive impairment and was unable to complete the Brief Interview for Mental Status. The Minimum Data Set also indicated that Resident #14 was dependent on staff for all activities of daily living. Review of Resident #14's medical record on 11/27/19 indicated the following: *A nursing note dated 4/15/19 indicated that Resident #14 required a new intervention of adaptive clothing secondary to increased bilateral arm rigidity during care. *A social services note dated 4/18/19, which indicated that per staff reports, Resident #14 rarely demonstrated verbal or physical resistance to care and that adaptive clothing that could stretch was being ordered because Resident #14 had become more rigid with his/her movements. *A document titled, Nursing - Licensed Nursing Summary, dated 7/14/19, indicated that Resident #14 now required extensive assistance of two staff members and the reason indicated on the document was severe [DIAGNOSES REDACTED] or rigidity. *Review of Resident #14's skin integrity care plan was updated on 9/20/19 to indicate it was noted that Resident #14's arms were stiff during dressing, resulting in a skin tear. Further review of Resident #14's care plan failed to indicate a care plan to specifically address decreased range of motion. During an interview on 11/27/19 at 9:36 [NAME]M., Certified Nursing Assistant (CNA) #1 said that she typically takes care of Resident #14. CNA #1 said that Resident #14 has not been able to move his/her bilateral arms within the last few months because his/her muscles are tighter. When asked if Resident #14 is able to straighten his/her arms fully, CNA #1 said, no. CNA #1 said that Resident #14 is able to relax and loosen a little, but that she can never assist Resident #14 to open his/her elbows and wrists to full range of motion and that neither shoulders can be moved at all. During an interview on 11/27/19 at 9:43 [NAME]M., Nurse #1 said that Resident #14's bilateral arm muscles have become very tight within the last couple of months. On 11/27/19 at 9:49 [NAME]M., Resident #14 was again observed sitting in his/her wheelchair with bilateral shoulders rounded and slouched, his/her left arm bent across his/her body with the left hand in a closed fist position and his/her right elbow bent with his/her hand in a closed fist position with the exception of the third and fourth fingers which were hyperextended. During an interview on 11/27/19 at 10:10 [NAME]M., the Director of Therapy (DOR) said that nursing makes referrals to therapy department when a resident on the unit has a change in function. The DOR said this change could be a new onset contracture. The DOR said that Resident #14 had not been seen by physical or occupational therapy since (YEAR), and that she had not received a referral to assess or screen Resident #14 for decreased range of motion. The DOR also said that she had not received a referral to assess Resident #14 regarding the increased difficulty with dressing tasks caused by the decreased in range of motion, as noted in the (MONTH) 2019 nursing and social services notes. The DOR said that she often sees Resident #14 on the unit and acknowledged that she had observed a decrease in Resident #14's bilateral arm range of motion by observing his/her posture in his/her chair. The DOR said that this posture of bent arms and closed fists has been for a couple of months. During an interview on 11/27/19 at 10:13 [NAME]M., the Unit Manager said that the nursing staff has noticed the increased rigidity of Resident #14's bilateral arms for at least a couple of months. The Unit Manager said it was first noticed during care when the nursing assistants were assisting Resident #14 during bathing and dressing tasks and that Resident #14 did not have full range of motion of both arms. When asked what the facility policy is when a decrease in range of motion is found, the Unit Manager said that the nursing staff will typically make a referral to the therapy department for an assessment, add a second person to assist with dressing and mobility, and if needed, obtain adaptive clothing if the contracture inhibits easy dressing. The Unit Manager said that she did not refer Resident #14 to therapy for the decreased range of motion because Resident #14 had previously refused therapy in (YEAR). During a second interview with the Unit Manager on 11/27/19 at 11:55 [NAME]M., she said that staff first noticed the decline and the increased rigidity in Resident #14's arms in (MONTH) 2019. The Unit Manager said that Resident #14 can be resistive to care so nursing did not give a referral to therapy and just got clothes to manage the decreased range of motion rather than have therapy assess and possibly treat the condition. The Unit Manager said she really did not believe there was a contracture, but rather just a decrease in range of motion and believed that if tried, staff would be able to range Resident #14's arms fully. When asked if it would be possible to do that with the surveyor present, the Unit Manager said yes, and then transported Resident #14 to his/her room and attempted to range his/her arms. The surveyor observed the Unit Manager attempt to provide passive range of motion to Resident #14 but she was unsuccessful in being able to range Resident #14's left shoulder, elbow or wrist. Unit Manager then requested Certified Nursing Assistant (CNA) #1 provide passive range of motion to Resident #14's bilateral arms. CNA #1 began to provide passive range of motion, however, was unsuccessful and stopped when Resident #14 called out ouch. The Unit Manager said that passive range was unable to be completed.

Based on record review, interview and observation, the facility failed to identify and assess the use of a bed side rail and bedroom wall as physical restraints for 1 (Resident #6) of 13 sampled residents. Findings include: Resident #6 was admitted to the facility in (MONTH) (YEAR), and had [DIAGNOSES REDACTED]. Resident #6's most recent annual Minimum Data Set (MDS) assessment, dated 9/3/19, indicated he/she had severely impaired cognition (never/rarely made decisions) and was unable to complete the Brief Interview for Mental Status. The MDS indicated that Resident #6 did not use a bed rail or physical restraints. On 11/26/19 at 9:46 [NAME]M., the surveyor observed Resident #6 lying supine in bed, asleep. The entire right side of the bed was placed against a wall and a left quarter length bed rail was in the raised position. There were no staff in the bedroom at this time. On 11/27/19 at 10:35 [NAME]M., the surveyor re-observed Resident #6 lying supine in bed, asleep. The complete right side of the bed was placed against a wall and a left quarter length bed rail was in the raised position. A staff member was present in the bedroom at this time. Review of Resident #6's medical record indicated there was no assessment for restraint use. A bed rail assessment, dated 8/27/17, indicated that Resident #6 did not require the use of a bed rail and a responsible party did not consent to the use of one. Review of Resident #6's medical record indicated there was no physician's order for a restraint, or a bed rail, or the use of a wall against his/her bed. Resident #6's plan of care did not reference the use of a restraint. During an interview with the Unit Manager on 11/27/19 at 10:35 [NAME]M., she said that staff had not conducted a restraint assessment for Resident #6's bed rail or wall. The Unit Manager said that Resident #6's bed rail assessment indicated a bed rail was not required, and there was no consent for its use. During an interview with the Director of Nurses (DON) on 11/27/19 at 10:45 [NAME]M., she said that a restraint assessment for Resident #6's bed rail and wall had not occurred.

Based on record review, interview and observation the facility failed to 1). assess for the risks of a bed rail, including the risk of entrapment, 2). to review the risks and benefits of bed rail use with the resident or representative, or 3). obtain a consent for the use of a bed rail for 1 resident (Resident #6) of 13 sampled residents. Findings include: On 11/26/19 at 9:46 [NAME]M., the surveyor observed Resident #6 lying supine in bed, asleep. A quarter length bed rail was attached to the left side of the bed and in the raised position. There were no staff in the bedroom at this time. On 11/27/19 at 10:35 [NAME]M., the surveyor re-observed Resident #6 lying supine in bed, asleep. A quarter length bed rail was still attached to the left side of the bed and in the raised position. A staff member was present in the bedroom at this time. Resident #6 was admitted to the facility in (MONTH) (YEAR), and had [DIAGNOSES REDACTED]. Resident #6's most recent annual Minimum Data Set (MDS) assessment, dated 9/3/19, indicated he/she had severely impaired cognition (never/rarely made decisions) and was unable to complete the Brief Interview for Mental Status. The MDS indicated that Resident #6 did not use a bed rail. Review of Resident #6's medical record indicated a bed rail assessment was completed on 8/27/17, and it determined he/she did not require a bed rail. The bed rail assessment did not include an entrapment risk assessment. The medical record did not include a review of the risks and benefits of side rail use with Resident #6 or his/her representative, or a consent for use. Review of Resident #6's medical record indicated there was no physician's order for a bed rail, and there was no care plan intervention referencing the use of a bed rail as either a restraint device or position enabler. During an interview with the Unit Manager on 11/27/19 at 10:35 [NAME]M., she said that staff had completed a bed rail assessment for Resident #6, dated 8/27/17. The Unit Manager said that the assessment indicated a bed rail was not required, and there was no consent for its use. The Unit Manager said that there was a quarter length bed rail attached to Resident #6's bed and that a bed rail assessment needed to occur. During an interview with the Director of Nurses (DON) on 11/27/19 at 10:45 [NAME]M., she said that because staff had been keeping Resident #6's bed rails in the raised position while he/she was in bed, nursing staff would conduct a bed rail assessment. The facility's Bed Side Rail Assessment policy and procedure, dated (MONTH) (YEAR), indicated an assessment should occur on admission, readmission, and when the resident experienced a significant change in functioning. The Policy indicated that informed consent is required for the use of bed rails. The facility policy failed to include a resident centered risk assessment for entrapment.

Based on observation, interview and record review, the facility staff failed to ensure that professional standards of infection control were followed during the wound dressing change for 1 of 1 applicable residents (#16) out of a total sample of 12 Residents. Findings include: According to the Lippincott Manual of Nursing Practice, 10th Edition, page 1084, box 31-1: Gloves - perform hand hygiene before putting on gloves. Change gloves after contact with infectious materials such as feces and wound drainage. Gloves must also be changed between procedures on the same patient. Wearing gloves does not replace the need for hand hygiene. Resident #16 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. The resident is currently being treated for [REDACTED]. On 1/25/19 at 7:41 A.M., during a treatment observation to Resident #16's right foot, revealed Registered Nurse (RN) #1 as she brought the treatment cart into the resident's room. A pair of scissors were lying on top of the treatment cart. RN #1 prepared the overbed table and placed all supplies on a clean barrier. RN #1 left the scissors on the treatment cart. RN #1 proceeded to use the scissors (without disinfecting them) to cut the old dressing off Resident #16's right foot. Once RN #1 was finished with the scissors, she placed the scissors in her pocket. RN #1 did not disinfect the scissors prior to use or after use. RN #1 performed hand hygiene and donned clean gloves. With a normal saline soaked gauze pad, she cleansed the wound of serous drainage and any loose slough (dead tissue). RN #1 discarded the contaminated gauze pad into the trash and without changing her now contaminated gloves, RN #1 applied Santyl (a [MEDICATION NAME] agent) with a sterile Q tip and picked up a clean normal saline soaked gauze pad and applied it against the resident's wound. RN #1 then applied dry gauze and wrapped the resident's foot with a gauze wrap. On 1/25/19 at 7:55 A.M., during interview, RN #1 said she should not have put the scissors in her pocket. She said she should have disinfected them. RN #1 said she wasn't aware that she should have changed her gloves after she cleansed the resident's wound. RN #1 said it makes sense though.

Based on record reviews and staff interview, for timely issuance of the Skilled Nursing Facility Advance Beneficiary Notice and Notice of Medicare Non-Coverage to residents, the Facility failed to provide 1 Resident out of a total of 3 residents reviewed, a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and a Notice of Medicare Non-Coverage. On 12/1/17 at 11:25 A.M., during an interview with the Director of Nurses she said, she could not provide the necessary forms as they were not completed.

Based on observations and interviews, the Facility failed to maintain an Infection Control program designed to prevent the development and transmission of disease and infection during a dressing change for one resident, Resident #20, out of a total sample of 14 residents. Findings include: Review of the Facility policy titled: Dressing Change, Clean dated 2006 indicated there was no guidance to staff on when to perform hand hygiene prior to donning gloves per accepted standards of nursing practice. According to the Lippincott Manual of Nursing Practice, 10th Edition, page 1083, Hand Hygiene should be performed .before donning and after removing gloves. Page 1084, box 31-1: Gloves - perform hand hygiene before putting on gloves. Change gloves after contact with infectious materials such as feces and wound drainage. Gloves must also be changed between procedures on the same patient. Wearing gloves does not replace the need for hand hygiene. For Resident #20 , the Staff failed to ensure that hand hygiene was performed according to professional nursing standards of practice and ensure that infection control standards were maintained during the dressing change. Resident #20 was admitted to the Facility in 7/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] indicated the Resident required total assistance with care and had moderate cognitive impairment. On 11/28/17 at 09:29 A.M., review of the Resident's medical record indicated the presence of 2 small open areas (O. 50cm) on the buttocks. The wounds were Facility acquired. The Resident was on Comfort Care measures. Since the summer, the Resident's weight decreased from 119 to 107 pounds and the physician indicated this was expected weight loss. 1) During an observation made on 11/30/17 at 1:24 P.M. for the dressing change on the Resident's coccyx/buttock area, Staff Nurse #1 did not perform hand hygiene before donning gloves. Staff Nurse #1 changed her gloves two more times during the dressing change without performing hand hygiene before donning new pairs of gloves. After Staff Nurse #1applied the Xeroform occlusive gauze strip covered by a square adhesive cover, she had difficulty removing the last protective adhesive strip. Nurse #1 then removed her gloves and used her bare hands to remove the strip and press down on all the adhesive strip sides of the square to seal them. Nurse #1 had contact with the Resident's buttock area with her bare hands as she did this. Nurse #1 then reached in clean supply cart with her bare hands for additional tape, without performing hand hygiene, touching clean items in drawers, thereby contaminating clean items in the drawer. Nurse #1 was interviewed on 11/30/17 at 1:35 P.M. after the dressing was completed and feedback was provided. The Nurse acknowledged that she should have performed hand hygiene before donning a new pair of gloves. The Nurse said she did not realize she went into the drawer of clean supplies in the cart with dirty hands from touching the resident's buttocks and agreed this was not appropriate infection control practice.

Base on observation, record review and interview, the facility failed to ensure professional standards were met resulting in the administration of an out dated eye medication for 1 Non-sampled Resident (NS#1) in a total sample of 10 residents. Findings include: Resident record review indicated that Resident NS#1 was admitted to the facility in 10/16 from an acute hospital with [DIAGNOSES REDACTED]. Resident NS #1 had a physician order [REDACTED]. During medication administration observation 11/30/16 at 9:20 A.M., Nurse(#1) had administered [MEDICATION NAME] Mealeate 0.5% eye drops that had been opened 10/20/16. During interview with Nurse #1 11/30/16 at 9:40 A.M. she said she observed the [MEDICATION NAME] Mealeate 0.5% bottle labeled, opened 10/20/16 and should have been discarded 30 days after opening. Resident NS #1 had received 12 daily doses of an out dated eye medication.

Based on record review and staff interview, the facility failed to provide a prescribed medication and nutritional supplements ordered by a physician for 3 sampled residents(Resident #1, Resident #5, and Resident #6) and 1 non-sampled resident (Non-sampled resident #2) in a total sample of 10 residents resulting in 44 doses not given due to not being available. Findings include: 1. Review of the medication record for Resident #1 indicated that 16 doses of ProSource 10 gram-100 kcal/30 ml oral liquid a nutritional supplement were not available in the month of November. 2. Review of the medication record for Resident #5 indicated that 17 doses of ProSource 10 gram-100 kcal/30 ml oral liquid a nutritional supplement were not available in the month of November. 3. Review of the medication record for Resident #6 indicated that 1 dose of Latanoprost 0.005% eye drops a medication to treat glaucoma was not available in the month of November. 4. Review of the medication record for Resident NS #2 indicated that 10 doses of Pro-Stat (advanced wound care) AWC 17 gram-100 kcal/30 ml oral liquid a nutritional supplement were not available in the month of November. The Unit Manager said during interview 11/30/16 at 3:00 P.M. that the eye drops and the nutritional supplements had been ordered per protocol but did not arrive in the facility timely.

Based on record review and staff interview, the facility failed to investigate an injury of unknown etiology as required by the facility's Resident Abuse Prohibition Policy for 1 resident (#2) in a sample of 10 residents. Findings include: 1. Review of the facility's current Abuse Prohibition Policy included the following information under the section of Identification: *All residents will be carefully supervised by delegated nursing personnel to ensure prompt identification of events, such as suspicious bruising of residents, occurrences, patterns and trends that may contribute to abuse. *Identification is done continuously: Further review included information regarding Investigations. Specifically, it stated: Any allegations of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property will be reported immediately to one of the following individuals: Charge Nurse, Unit Manager, Nursing Supervisor, Director of Nurses (DON), Assistant Director of Nurses (ADON), or Administrator. A thorough investigation of all incidents, allegations, accidents will be done and carefully reviewed by the Unit Manager, Nursing Supervisor, ADON and DON to determine validity of findings and causative factors. A full report will be submitted to the Administrator. The Administrator will immediately advise other officials in accordance with the Department of Public Health's regulations. For Resident #2, the facility failed to investigate a skin tear located on the Resident's right upper wrist. Review of Resident #2's clinical record indicated that the Resident was admitted to the facility in 8/2014. The Resident's [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 1/4/15, indicated that the Resident was dependent for transfers, personal hygiene, and bathing. The brief inventory of mental status (BIMS) score was 10 indicating moderate mental impairment. Review of the incident report indicated that on 12/30/15 at 3:15 A.M., the Resident was observed to have a skin tear above the right wrist. The Resident was observed to be in bed sleeping prior to the discovery. The report indicated that the Resident was last re-positioned in bed at midnight. The report indicated that the area was washed with normal saline and a steri strip was applied. Review of the staff interviews indicated that the Nurse was informed of the skin tear by the Certified Nurse Aide (CNA). The Nurse documented that she noted the skin tear was fresh and about 0.5 cms. The Nurse documented that the Resident was not able to recall how it happened. The Administrator and DON were interviewed on 1/27/16 at 12:10 P.M. They said that they did not extend the investigation back 24 hours as required per policy because they felt the injury occurred on the night shift based on the presence of fresh blood noted at the sight of injury. The Facility failed to provide any documentation regarding their conclusion in regards to if abuse occurred or not based on their own investigation.

Based on record review and staff interviews, the facility failed to provide appropriate supervision, monitor for effectiveness and modify interventions when necessary to prevent falls and injury for 2 of 10 applicable residents (Resident #1 and #2) with falls, in a total sample of 10 residents. Findings include: A) For Resident #2, the facility failed to utilize effective interventions that would protect the resident from 3 of 5 falls between 3/29/15 and 8/3/15. Resident #2 was admitted to the facility in 8/2014. [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] identified the resident as having a Brief Interview for Mental Status (BIMS) coded as 9 equal to a moderate cognitive impairment. The most recent Quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as having a Brief Interview for Mental Status (BIMS) coded as 10 equal to moderate cognitive impairment. After the fall in 8/15, the Resident was diagnosed with [REDACTED]. The Resident required extensive assist of 1 for transfer and ambulation and activities of daily life. The resident was incontinent of bowel and bladder. Review of the Falls Care Plan dated 8/20/14, in place from admission to record review, indicated that the primary concern for falls was based on new medications used for pain and continued use of ritalin. The medications were of concern based on the fact they may cause dizziness. The Resident also had impaired mobility related to a history of a fall with bilateral shoulder fractures during a prior hospitalization . There are no goals documented for the falls care plan dated with the start date of 8/20/14 until 11/4/15, over 16 months later and these include the following: *Resident will not experience episodes of dizziness resulting in a fall. *Resident will be maintained on the lowest therapeutic medication doses. *Resident will be free from adverse medication side effects. *Resident will continue to be free from fall related injuries. The Falls care plan dated 8/20/14 Interventions included: *Use gait belt with all transfers as recommended by Physical Therapy for safety. Start date 8/20/14 *Provide reality orientation. Start date 8/20/14. *Provide education on safety techniques. Start date 8/20/14 * Medication regimen review as it related to pain and fall. Start date 8/20/14 *Notify MD for any behavioral changes that may contribute to falls. Start date 8/20/14 *Reminders to call for help prior to attempting self transfers. Start date 9/30/14. * Interdisciplinary team fall prevention meetings every week post falls. Start date 11/5/14. *Continue to encourage resident to use call light. Start date12/13/14. *Place phone next to the resident when resting in bed during the day time hours and place the phone on the tray table in front of the resident when seated up in the wheelchair. Start date 12/19/14. *Sign posted in the room to remind staff to place the phone appropriately (as mentioned above). Start date 12/19/14. *Anticipate resident's needs in relation to present Activities of Daily Living function. Start date 1/30/15. *Quarterly fall risk assessment and/or as needed. Start date 1/30/15. *Do not leave unattended in room. Start date 8/2/15. Documented falls on the Incident Report forms included the following: Fall #1 - 3/29/15 at 4:45 P.M. Unwitnessed fall - Resident attempted to get out of bed to answer the phone. The Resident fell to his/her knees and was holding on to the bed. There was no injury documented. The Supervisors incident follow up form dated 3/30/15 recommended that the resident's Daughter will now call the nurse's station and the call will be transferred rather than calling room directly. However, the recommendation was not added to the active careplan. Interventions in the fall care plan dated with a start date of 12/19/14, indicated that; 1) Staff were to place the phone next to the resident when resting in bed during the day time hours and place the phone on the tray table in front of the resident when seated up in the wheel chair. 2) Sign to be posted in the room to remind staff to place the phone appropriately. The investigation failed to include if those interventions were in place at the time of the fall. Fall #2 -5/26/15 at 3 P.M. Unwitnessed fall - Resident attempted to get out of bed and to the wheelchair to water plants on windowsill. Missed wheelchair and landed on back on the floor. Resident complained of neck pain. X-Ray was negative for fracture. Skin tear to left elbow 3 cm in length. 3 Steri-strips applied to the skin tear and ice to neck. The Supervisors incident follow up form dated 5/27/15 recommended to remind the Resident to use the call bell, the wheelchair to be removed out of Resident's sight while in bed and to add a low bed to the care plan. However, removal of the wheel chair out of residents sight while in bed and a low bed were not added to the care plan. Fall #3 - 6/2/15 Unwitnessed fall - Resident reported coming out of bathroom and getting into bed when she/he fell . The Supervisors incident follow up form dated 6/2/15 recommends a low bed to avoid injuries in the future. However, once again, this previously recommended intervention did not get added to the care plan. B) For Resident #1, the facility failed to utilize effective interventions that would protect the resident from 2 falls with staff in attendance while the Resident was in the bathroom between 9/18/15 and 12/28/15 Resident #1 was admitted to the facility in 6/2015. [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as having a Brief Interview for Mental Status (BIMS) coded as 12 equal to moderate cognitive impairment. The Resident required extensive assistance for activities of daily living. For ambulation in the room, the Resident required the extensive assistance of one staff utilizing a rolling walker with gait belt. Fall #1 - 9/17/15 at 12:35 P.M. Incident Report noted: While the Certified Nurse Assistant (CNA) was in the bathroom with the Resident, the Resident fell while standing in front of the sink, washing his/her hands. The Resident fell backwards into the shower area and landed on his/her buttocks. No injury was recorded. There was no indication in the incident report or the Supervisor incident follow up form that a gait belt was in use per care plan dated 6/26/15. The Supervisor incident follow up form indicated that the recommendations to prevent similar occurance were to watch the Resident closely while in bathroom and to use a gait belt when walking (a previously implemented intervention on 6/26/15 stated to use a gait belt for all transfers). However, the recommendation for the use of a gait belt when walking was not added to the care plan as an intervention until 1/5/16 nearly 4 months later and after a second fall occurred while the resident was walking as documented below. Fall #2 - 12/25/15 at 1 A.M. Incident report noted: While a CNA was with the Resident as he/she was ambulating to the bathroom with a walker, the Resident lost his/her balance and fell on his/her buttocks onto the floor. Despite the Resident not being observed to hit his/her head, there was a small amount of bleeding noted from the nose for which a cool compress was applied. No injury noted. The incident report did not indicate if a gait belt was used at the time of the fall. The Supervisors Incident Follow up form recommendation for preventing a similar occurrence, again recommended using a gait belt when helping Resident to the toilet. On 1/26/16 at 1:45 P.M. Surveyor #1 observed Resident #1 sitting on the toilet. Nurse #1 assissted the Resident to a standing position from the toilet without the use of a gait belt, not following the care plan interventions in place at the time. On 1/27/16 at 12:10 P.M. Surveyors #1 and #2 interviewed the Administrator and Director of Nurses. After Surveyor #1 presented the Resident's care plan for review, the DON said that she understood that the gait belt intervention was on the care plan for Resident #1 with a start date of 6/26/15.

Based on record review and staff interview, the facility failed to ensure a bruise of unknown etiology was thoroughly investigated and reported, as required, for 1 non sampled resident (NS #3) out of 3 nonsampled residents, and a total sample of 10 residents. Findings include: Review of a facility Incident Report, dated 3/15/13, indicated "a bruise was noted on the inner right buttock during incontinent care. Area tender to touch, intact." There was no documentation of size, color or shape. Further review of the Incident Report indicated the following questions: * Describe exactly what happened, why it happened, what the causes were... This question was not answered. * Patient's condition before incident...This question was not answered. * Was it necessary to notify physician...This question was not answered. * Date and time of incident...This question was not answered. * Was equipment involved...This question was not answered. Review of the facility policy and procedure titled "Resident Abuse, Mistreatment, Neglect and Misappropriation of Property", dated, 9/1/11, indicated the following: * Conditions of possible abuse: Bruises (bilateral, in several areas, various stages of healing, in the shape of an object) * Any observation or relating of a crime, alleged abuse, neglect, or misappropriation of funds of a resident is immediately told to the supervisor and/or charge nurse. * Massachusetts Department of Public Health is notified within 24 hours if there is no serious bodily injury involved. During interview on 11/14/13 at 4:00 P.M., while referring to the Incident Report involving NS#3, the DON (Director of Nursing) said that she had not seen that incident report. She said that the Nurse Manager completed it. The DON confirmed that the incident report was incomplete and at quick glance, the investigation was not complete. She said she thought that the bruise could have possibly been caused by a cushion NS#3 was using at the time, but confirmed that there was no information within the investigation to support her thought process. She also said that the facility incident report isn't specific to bruises or skin tears of unknown etiology and that the facility was working on the incident reporting process. Because it had been several months since the incident occurred, she said she would have to review the incident again. She said if she found any further information, she would give it to the survey team. At the time of the exit conference, on 11/18/13, the DON offered no further information in regard to the bruise of unknown etiology for NS#3. The facility failed to complete a thorough written investigation to determine the cause of the resident's bruise and failed to report this finding to the Department of Public Health.

Based on observation, record review and interview, the facility failed to provide adequate supervision and effective interventions to prevent falls and/or accidents, for 1 Resident (#5) out of 3 Residents who sustained fractures in a total sample of 10 Residents. Resident #5 sustained 9 falls between 6/20/11 and 12/8/11. One fall resulted in a hip fracture requiring surgery and another fall resulted in a contusion to the back of the head. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan initiated on 6/29/11 identified the Resident as being at risk for injury due to falls and history of falls. Interventions included: - Quarterly falls risk assessment - Provide walker for ambulation - Provide eyeglasses every day - Supervise ambulation - Redirect Resident prn, and as allowed by the Resident - Personal alarm when in bed and/or chair. Check for placement and effectiveness every shift. An initial MDS (minimum data set) completed on 6/22/11 assessed the resident as having severe cognitive impairment, being independent in transfers, and requiring supervision with ambulation. The MDS also indicated that the resident had a fall with injury prior to admission. Review of the resident's medical record on 1/24/12 indicated the resident had 9 falls within six months after admission to the facility. The first fall occurred on 6/16/11 at 4:00 P.M. According to the incident report, the Resident was found lying on his/her left side. Review of incident report and care plan indicated that there was no intervention initiated after this fall. The second fall occurred on 6/20/11 at 3:45 P.M. According to the incident report, the Resident was walking without his/her walker, and lost his/her balance and fell . Review of incident report and care plan indicated that there was no intervention initiated after this fall. The third fall occurred on 8/29/11 at 6:15 A.M. According to the incident report, the resident was found on the floor on his/her back after the personal alarm sounded. The Resident stated that "he/she lost balance when getting up to go use the bathroom." The nursing notes of 8/29/11 indicate that the Resident was sent out to the emergency room (ER) for further evaluation due to complaints of severe back pain. The Resident returned and the X-ray was negative for a fracture. The Resident was screened by the Rehabilitation (rehab) therapist, and there was no need for skilled therapy. Review of incident report and care plan indicated that there was no intervention initiated after this fall. On 9/13/11 at at 7:20 A.M., the resident had a (unwitnessed) fall for the fourth time. According to the incident report, the Resident was found lying on his/her back on the floor. The Resident said "I just fell ." The incident report indicated a skin tear on the left forearm and the right thumb. The nurse's note, dated 9/13/11, indicated that the right thumb had a large skin flap, with a large amount of bleeding, and had a pressure dressing in place. The Physician ordered the Resident to go to the ER for an evaluation to see if sutures were needed. No sutures were required. The Resident was screened by the rehab therapist and there was no need for skilled therapy. The recommendations were to continue to keep the environment free from clutter and pathways clear. Review of the care plan indicated that there was no intervention initiated after this fall. The Quarterly MDS completed on 9/13/11 assessed the resident as continuing to having severe cognitive impairment, being independent in transfers, and requiring supervision with ambulation. The Quarterly MDS indicated that the resident had falls and a fall with injury (not major). The fifth fall occurred on 10/19/11 at 6:30 A.M. The incident report stated that the Resident was found on the floor next to his/her bed. The Resident stated that he/she was trying to get to the bathroom, slipped and fell . A skin tear to the right calf was observed to be 0.5 centimeters (cm) by 0.5 cm. The Resident was screened by the rehab therapist and there was no need for skilled therapy, The recommendation was to continue with the rolling walker and supervision. Review of the care plan indicated that there was no intervention initiated after this fall. The sixth fall occurred on 11/24/11 at 7:30 A.M. The incident report indicated the Resident was walking in the room without the walker, lost balance and fell backwards hitting his/her head. The resident sustained [REDACTED]. The Resident said that he/she was just walking around. The rehab screen indicated that no skilled services were needed. A personal alarm was recommended, but the family declined it. Review of the care plan indicated that there was no intervention initiated after this fall. The seventh fall occurred on 11/30/11 at 9:30 P.M. The Resident was found lying on the floor on supine position. The walker was by the bed. The rehab screen indicated that no skilled services were needed. A personal alarm was recommended, but the family declined it, again. Review of the care plan indicated that there was no intervention initiated after this fall. The eighth fall occurred on 12/4/11 at 3:25 P.M. The Resident came out of the room and just let go of the walker and fell on his/her buttocks. The rehab screen indicated that no skilled services were needed. A personal alarm was discussed with the family and they agreed. The nursing notes of 12/7/11 at 2:00 P.M., indicated that the facility discontinued the personal alarm due to non-compliance, and the fact the resident threw the alarm away twice. Review of the care plan indicated that there was no other intervention initiated after this one was discontinued. The ninth fall occurred on 12/8/11 at 6:45 A. M. Resident was found lying on right side in front of his/her bed. Decreased ability to move and pain when moving right leg was noted. Resident stated that he/she was putting a shirt on, lost balance and fell on right side. The Resident was admitted to the hospital with [REDACTED]. The Resident had surgery to repair the right hip fracture. An interview with the Unit Manager (UM) regarding fall interventions for Resident #5 was conducted on 1/25/12 at 1:45 P.M. The UM said that the following interventions were discussed and/or tried: - could not use a mat due to the resident being unsteady on his/her feet - safety checks - supervision - UM stated that the family refused personal alarm - UM stated that later the family agreed to the alarm and it was initiated - The alarm was discontinued because the Resident did not comply with the use of the alarm and he/she lost alarms The UM stated that she did not remember the time frames for the interventions, nor was there any evidence of the inventions being implemented. The UM stated that she could not find any other inventions which were tried to ensure the Resident's safety. On 1/25/12 at 5:00 P.M., an interview was conducted with the Administer, Director of Nurses, UM, and the rest of the interdisciplinary team. They did not have any additional information to add concerning the interventions implemented to prevent Resident #5 from falling. The facility failed to provide adequate interventions and supervision to keep the Resident safe from accidents and injury.