Every finding on record at Brush Hill Care Center

Based on record review and interview, it was determined the facility failed for one Resident (#10), out of a total sample of 25 residents, to refer to the state-designated authority for further evaluation of the diagnosis of a serious mental illness (SMI). This deficient practice has the potential to impact residents who are diagnosed with major mental illness, intellectual disability or related conditions if a state-designated authority did not evaluate a resident's mental health needs. Findings include: Review of the MassHealth Nursing Facility Bulletin 186, dated June 2024 indicated the following: Definition: Level I Screening- A preliminary screening of all nursing facility applicants, regardless of payer source, conducted prior to their admission to a nursing facility, as required by federal PASRR regulations at 42 CFR 483.100 et seq. using the Level 1 Screening Form. A level 1 Screening identifies whether an applicant has, or is suspected of having, ID (intellectual Disability), DD (Developmental Disability), and/or SMI (Serious Mental Illness). Specific Requirements for Individuals with SMI: C. Post-admission Level II Evaluations for Individuals with SMI. 1. A nursing facility must ensure an individual who has or is suspected of having an SMI is referred to DMH (Department of Mental Health) PASRR, in accordance with Section 3. A for a post-admission Level II Evaluation (i.e. Resident Review) in the following instances: b. When an individual who resides in a nursing facility has experienced a significant change or the individual is newly identified as having a condition that may impact the individual's PASRR disability status, the appropriateness of the individual's nursing facility placement, or the individual's need for specialized services and/or Behavioral Health Services. Resident #10 was admitted to the facility in May 2021 with diagnoses that include but are not limited to adult failure to thrive, unspecified dementia, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 9/26/25, indicated staff assessed Resident #10 as having moderately impaired cognition. Review of the Preadmission Screening and Resident Review (PASRR) Level 1 dated 5/14/21 documented Resident #10 as not having a serious mental health illness. Review of Resident #10's admission Record Face Sheet documented the diagnosis of schizoaffective disorder, unspecified with an onset date of 2/8/25, and present on admission. Review of the Psychiatric Evaluation and Consultation document, dated 2/8/25, indicated:Plan: will recommend changing Seroquel (an antipsychotic medication) indication to schizoaffective disorder, unspecified, as this is a diagnosis the patient has carried since before admission. During an interview on 11/20/25 at 12:19 P.M., the Social Worker said the diagnosis of schizoaffective disorder was not on Resident #10's PASRR Level 1 because it was not on the diagnoses list from the referring hospital. The Social Worker said the PASRR level I was not updated when the diagnosis of schizoaffective disorder was identified, nor was a referral made to the state-designated authority and should have been.

Based on observations, record review, and interview, the facility failed to ensure the resident environment remained free of unattended and unsecured medications for one Resident (#51), out of a total sample of 25 residents and for residents residing on the second-floor unit. Specifically, the facility failed:1. For Resident #51, to ensure medications were not kept at the bedside while staff were not present in a unit with known wandering residents; and2. For residents on the second-floor unit, to ensure medications were kept in a locked medication cart while staff were not present in the hallway.Findings include:1. Review of the facility's policy titled Self-Administration of Medication, dated and revised February 2021, indicated the following: -Any medications that are found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Resident #51 was admitted to the facility in September 2022 with diagnoses including metabolic encephalopathy and vascular dementia. Review of Resident #51's Minimum Data Set Assessments (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for all tasks. On 11/18/25 at 7:46 A.M., the surveyor observed Resident #51 sleeping in his/her bed. On his/her bedside table was a medicine cup with five different medications consisting of pills and capsules. Next to the medicine cup, was a full cup of water. There were no staff members in the room. Prior to entering the room, the surveyor observed a Resident wandering the hallway on the unit. During an interview on 11/18/25 at 7:53 A.M., Nurse #2 said that no residents on the unit are able to self-administer medications as all the residents have dementia. Nurse #2 and the surveyor entered Resident #51's room, and the nurse said the cup of pills should not have been left there and they are from yesterday. Nurse #2 said a nurse should stay with residents to ensure they take their medication. When asked, what are the implications of Resident #51 not taking his/her medication, she said it is bad since he/she is behavioral. Nurse #2 said if a staff member observed the cup of medication at Resident #51's bedside they should notify a nurse. Nurse #2 said residents wander in this unit and a wandering resident could have taken the medication if they entered Resident #51's room. Review of Resident #51's Physician's Orders indicated the following that Nurse #2 was able to identify in the medicine cup: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125MG (milligram) - Give 4 tablet by mouth at bedtime for d/t breakthrough moods and aggressive behaviors -bupropion HCL ER (extended release) Oral Tablet 12 hour 200 MG - give 1 tablet by mouth one time a day related to major depressive disorder -hydralazine HCL tablet 25MG - give 12.5 mg by mouth two times a day for high bp (blood pressure) Review of Resident #51's Medication Administration Record (MAR) indicated that the Resident received his/her medications the night prior. Review of Resident #51's medical record failed to indicate any documentation that he/she is able to self-administer medication. During an interview on 11/19/25 at 9:02 A.M., the Director of Nursing (DON) said there should be a physician's order for residents to self-administer medications as well as a care plan. The DON said no residents on that unit are able to self-administer medications, including Resident #51, and medication should not be left at the bedside unattended by a nurse. The DON said if staff were to observe medication left unattended at the bedside, they should tell a nurse since the unit has wandering residents and they would be at risk of taking the medication. 2. Review of the facility's policy titled Medication Labeling and Storage, dated and revised February 2023, indicated the following: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The surveyor made the following observations: On 11/20/25 at 8:51 A.M., the surveyor observed on the second-floor unit an unlocked and unattended medication cart. The medication cart had a cup of pills on the top of the cart. There was a Resident sitting in his/her wheelchair in the hallway nearby and there were no staff present in the hallway. On 11/20/25 at 8:54 A.M., the surveyor and the Director of Nursing (DON) observed the second-floor unit medication cart unlocked and unattended with a cup of pills on the top of cart. There was a Resident sitting in his/her wheelchair in front of the medication cart. The DON said that Nurse #3 should not have left an unlocked and unattended medication cart and Nurse #3 should not have left pills on top of the medication cart as there is risk of other residents accessing these medications. On 11/20/25 at 8:57 A.M., the surveyor observed Nurse #3 exit a room at the opposite end of the second-floor hallway. Nurse #3 returned to the medication cart and said that she should not have left the medication cart unlocked and unattended as it posed a risk to other residents.

Based on records reviewed and interviews, for one Resident (#1), out of a total sample of 25 residents, the facility failed to ensure that his/her drug regime was free from unnecessary drugs. Specifically, for Resident #1, the facility failed to implement the ophthalmologist's (eye physician) recommendations resulting in Resident #1 receiving an excessive duration of eye drops. Findings include: Review of the facility's policy titled Medications and Treatment Orders, dated July 2016, indicated: 12. Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders.a. Drugs not specifically limited to duration of use and number of doses when ordered will be controlled by automatic stop orders. Resident #1 was admitted to the facility in April 2023 with diagnoses including diabetes, chronic diastolic heart failure, and cataracts (cloudy area in the eye's lens that causes blurry vision, faded colors, and difficulty seeing at night). Review of the Minimum Data Set (MDS) assessment, dated 9/29/25, indicated Resident #1 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. This MDS indicated Resident #1's vision was highly impaired. Review of Resident #1's consultant eye care after visit summary, dated 10/20/25, indicated:1. Ofloxacin (antibiotic) 0.3%, one drop to right eye four times a day.2. Prednisolone (steroid) Acetate 1%, one drop to right eye four times a day.3. Ketorolac (non-steroidal anti-inflammatory) 0.5%, one drop to right eye four times a day.4. Follow up appointment on 10/28/25. Review of Resident #1's Physician's Orders, dated 10/20/25, indicated:-Ofloxacin Otic Solution 0.3% (Ofloxacin (Otic), instill 1 drop in right ear [sic] four times a day for cataract.-Prednisolone Acetate Ophthalmic Suspension 1% (Prednisolone Acetate (Ophth), instill 1 drop in right eye four times a day for cataract.-Ketorolac Tromethamine Ophthalmic Solution 0.5% (Ketorolac Tromethamine (Ophth), instill 1 drop in right eye four times a day for cataracts. Review of Resident #1's nursing progress note, dated 10/28/25 at 9:43 P.M., indicated:-Resident was picked up for his/her scheduled appointment by agent of the transportation agency and wheeled out of the facility escorted by a staff. Resident return from his/her appointment, no new order, new appointment for [DATE]th at 10:20 A.M., ride booked with transportation for a 9:15 A.M. pick-up Review of Resident #1's consultant eye care after visit summary, located in the medical record at the nursing station, dated 10/28/25, indicated:1. Moxifloxacin (tan top): 1 drop into the right eye, 4 times every day for 1 more week, then stop.2. Prednisolone (pink top) and ketorolac (gray top): For both of these drops, use them 4 times every day for 1 week (10/28 - 11/3), then 3 times every day for 1 week (11/4 - 11/10), then 2 times every day for 1 week (11/11 - 11/17), then 1 time every day for 1 week (11/18 - 11/24), then stop. Review of Resident #1's Physician's Orders and Medication Administration Record on 11/20/25 failed to indicate that nursing implemented the ophthalmologist's recommendations, and Resident #1 continued to receive moxifloxacin, prednisolone, and ketorolac four times a day. During an interview on 11/20/25 at 8:31 A.M., Nurse #1 said Resident #1 is receiving eye drops four times day after his/her cataract surgery. Nurse #1 said that the duration of the eye drops is based on the recommendations from the ophthalmologist. Nurse #1 reviewed the note he wrote on 10/28/25 and he said he was not aware that Resident #1 returned with new orders to decrease his/her eye drops. Nurse #1 said that he would have to call the physician to obtain new orders. During an interview on 11/20/25 at 9:16 A.M., the Unit Manager said he wasn't aware of the recommendations from 10/28/25 and he said that the nurse working should have notified the physician and obtained new orders to decrease the frequency of the eye drops. During an interview on 11/20/25 at 9:45 A.M., the Director of Nursing said that Nurse #1 and the Unit Manager should have reviewed the ophthalmologist's recommendations and decreased the frequency of Resident #1's eye drops. During an interview on 11/20/25 at 10:13 A.M., the Physician said that nursing should have notified him of the ophthalmologist's recommendations and that nursing should have implemented the recommendations from the ophthalmologist and decreased the eye drop frequency.

Based on observation and interview, the facility failed to store food from outside sources safely to prevent potential foodborne illness for one Resident (#121), out of a total sample of 22 residents. Findings include:Review of the facility's policy titled Food Brought by Family/Visitors, revised March 2022, indicated the following: - Family/visitors are asked to prepare and transport food using safe food handling practices, including: a. safe cooling and reheating processes;b. holding temperatures - Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. - Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours are discarded. Resident #121 was admitted in October 2025 with diagnoses including cancer and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 10/29/25, indicated Resident #121 scored 14 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. On 11/18/25 at 12:08 P.M., the surveyor observed Resident #121 lying in bed with a bedside table next to him/her that contained old food in a container that appeared to be from family/ a visitor. There were two other containers containing food on his/her nightstand. During an observation with interview on 11/19/25 at 8:31 A.M., the surveyor observed Resident #121 lying in bed with two containers of food on his/her nightstand and an open container of ramen soup with a chicken thigh inside. Resident #121 told the surveyor that the food had been there since last night and that he/she orders food out. During an interview on 11/19/25 at 12:15 P.M., Unit Manager #1 said that Resident #121 sometimes gets food from outside of the building and keeps it in his/her room. Unit Manager #1 said that Resident #121 does not like putting his/her food in the unit refrigerator because he/she is afraid someone will take his/her food, even if it is labeled/dated. During an interview on 11/20/25 at 9:02 A.M., the Food Service Director said that if a family member brings in food from the outside to a Resident, then the leftovers should be labeled and dated and put into the unit refrigerator. The Food Service Director said that she was not aware Resident #121 had been keeping food in his/her room and if the Resident was refusing to put the food in the unit refrigerator, then the facility would try to get him/her a refrigerator for his/her room to use. During an interview on 11/21/25 at 7:20 A.M., the Food Service Director said that Resident #121's family has been bringing in containers of food, and the facility is going to reach out to the family to get Resident #121 a refrigerator for his/her room to store the food closer to Resident #121.

Based on observations and interviews, the facility failed to ensure it was administered in a manner that enabled it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to effectively manage and utilize their administrative team and stay up to date with current Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and Massachusetts Department of Public Health (MDPH) guidance. Findings include: During the recertification survey on 9/17/24 through 9/20/24 and 9/23/24 through 9/25/24 the survey team determined: -the activity department was not meeting the needs of all residents and the activity calendar was not being reviewed and monitored as evidenced by lack of meaningful and engaging activities on all units -the business office was located out of state, and activity related to residents' personal needs accounts and residents access to their funds was managed by the Activity Director -the human resources department was located out of state, and 5/5 employee records were incomplete or out of date -the role of the Infection Preventionist was vacant and was not effectively being covered by current facility staff as evidenced by no antibiotic stewardship program, no infection surveillance and failure to implement enhanced barrier precautions (EBP, an infection control measure for residents with chronic wounds and/or indwelling devices putting them at increased risk for infection) During an interview on 9/24/24 at 11:14 A.M., the Activity Director said she was the liaison between the business office in New York and the facility and was responsible for managing and accessing the residents' funds from their Personal Needs Accounts (PNA). The Activity Director said the responsibility of managing the PNA has interfered with her ability to be hands-on in the activity department and the residents could only access their funds when she was working. During an interview on 9/24/24 at 2:23 P.M., the Administrator said the monthly activity calendar was not reviewed by the leadership team but she was aware the activities department could use some enhancements. During an interview on 9/25/24 at 11:19 A.M., the Administrator said the Human Resources department was off-site but the scheduler was taking care of some new-hire credential verification in house. The Administrator said she was aware employee files were missing some things and could be better. During an interview on 9/24/24 at 9:48 A.M., the Director of Clinical Operations said the Staff Development Coordinator (SDC) was also the Infection Control Nurse. The Director of Clinical Operations said the Infection Control Nurse position had been vacant and the SDC had been covering that role since March. He said a job description had not been signed indicating her understanding of this expectation. The Director of Clinical Operations said a monthly infection control report with infection surveillance was not provided by the SDC but a listing of residents on antibiotics was discussed weekly at the risk meeting. During an interview on 9/24/24 at 9:48 A.M., the Director of Nurses said there had not been an actual designated Infection Control Nurse since last year, but the SDC was supposed to be covering the role. During an on 9/24/24 at 9:48 A.M., the Administrator said the SDC was learning and that she and the Director of Clinical Operations had provided the SDC with guidance. The Administrator said the facility was working to find someone who was qualified to be the Infection Control Nurse. During an interview on 9/24/24 at 9:48 A.M., the Director of Operations said the Infection Preventionist job had been posted off and on in 14-30 day increments, and that it was taken down every so often so the same job was not posted for an extended period of time. Review of the facility provided job postings indicated the Infection Control Nurse position had been posted on 7/26/23, 4/2/24, 5/20/24, and 7/12/24. During an interview on 9/24/24 at 10:26 A.M., the SDC said she was hired as the SDC and not an Infection Control Nurse. The SDC said, in March of this year, she told the leadership team she could help with the infection control program until an Infection Control Nurse was hired. The SDC said her job description was never adjusted and her understanding was that she would be responsible for education and helping with the vaccinations. The SDC said she did not complete a line listing or perform an analysis of antibiotics/infections and had never done that for the facility. The SDC said she was not involved in an antibiotic stewardship program. During an interview on 9/24/24 at 2:23 P.M., the Administrator and the DON said they were unaware of how to find new CDC, CMS, and MDPH guidance and how to stay up to date with changes in facility expectations. The Administrator and DON said they were unaware of regulations related to some of the concerns the surveyors had. The DON said she did not receive any memos from CMS of DPH and did not know when guidelines changed. Refer to 882

Based on document review and interview, the facility failed to develop and implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to: 1. Ensure active involvement of all required members when conducting the facility assessment; and 2. Implement the identified competency-based training as indicated. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance, dated 6/18/24, indicated but was not limited to: -In conducting the facility assessment, the facility must ensure active involvement of the following participants in the process: a. Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and b. Direct care staff, including but not limited to, Registered Nurses, Licensed Practical Nurses/Licensed Vocational Nurses, Nursing Assistants, and representatives of the direct care staff, if applicable c. The facility must also solicit and consider input received from residents, resident representatives, and family members. Review of the facility's policy titled Facility Assessment, dated as revised October 2018, indicated but was not limited to: -The team responsible for conducting, reviewing and updating the facility assessment includes the following: a. the administrator; b. a representative of the governing body; c. the medical director; d. the director of nursing services; e. the infection preventionist; and f. the director (or designee) from the following departments: environmental services, physical operations, dietary services, social services, activity services, and rehabilitative services 1. Review of the Facility Assessment, dated July 2024, indicated but was not limited to: -Names/Titles of individuals involved in completing the assessment: Administrator, Director of Nurses, Medical Director, Director of Social Services, Director of Clinical Operations and Food Service During an interview on 9/25/24 at 3:32 P.M., the Administrator said the facility assessment was last updated July 2024. The Administrator said the process for updating the facility assessment was to review the previous assessment page by page and make sure no changes had occurred in staffing or resident care needs. The Administrator said the leadership team/department heads were involved in updating and formulating the facility assessment. 2. Review of the Facility Assessment, dated July 2024, indicated but was not limited to: -Competency Based Training: All staff are required to complete a comprehensive orientation upon hire and annually thereafter including but not limited to the following requirements: a. Dementia training: original eight hours and four hours annually Review of the staff education records for Nurses #14, #15, #16, and #18 failed to include mandatory dementia training. During an interview on 9/25/24 at 12:54 P.M. and 1:11 P.M., the Staff Development Coordinator said there are approximately 80 relevant employees at the facility, and she could not find any evidence that the annual four-hour dementia training was completed as required in 2023. She said when she began working at the facility, four months ago, there was no staff education program in place. During an interview on 9/25/24 at 11:35 A.M., the Administrator and the facility Scheduler said there was no formal dementia training in the facility at that time. The Administrator and Scheduler said the dementia training should be conducted prior to the completion of orientation and then annually. Refer to F949

Based on record review and interview, the facility failed to ensure the designated Infection Control Nurse (ICN) adequately assessed, developed, implemented, monitored, and managed the infection prevention and control program. Specifically, the ICN failed to: 1. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were implemented; and 2. Implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: 1. On multiple days of survey, the surveyors observed several residents, who met criteria for EBP, but did not have EBP in place. During an interview on 9/24/24 at 10:26 A.M., the Staff Development Coordinator said she has not implemented EBP in the facility. During an interview on 9/24/24 at 1:35 P.M., the Director of Nurses (DON) said the EBP program had not been implemented. 2. During survey, the facility was unable to provide evidence of infection surveillance and of an Antibiotic Stewardship Program. During an interview on 9/24/24 at 9:48 A.M., the surveyor met with the Administrator, the Director of Nurses (DON), the Director of Clinical Services, and the Director of Operations. The Director of Clinical Services said the Staff Development Coordinator was responsible for the Infection Control Program and was the ICN. The Director of Clinical Services said the SDC was responsible for the infection surveillance and antibiotic stewardship program. He said what was provided to the surveyor is what the facility was able to provide. During an interview on 9/24/24 at 10:26 A.M., the SDC said she was not the ICN and had never formally agreed to be responsible for the antibiotic stewardship program or infection surveillance. The SDC said the only aspect of infection control she was responsible for was education and helping with the vaccination effort in the facility. The SDC said since she has been employed by the facility, since February of this year, there has never been an ICN and there has never been an antibiotic line listing/surveillance.

Based on interviews and staff education records reviewed for five direct care staff employees (Nurse #14, Nurse #15, Nurse #16, Nurse #17 and Nurse #18) of five employees reviewed, the facility failed to ensure that training on behavioral health was included as mandatory training for direct care staff. Findings include: Review of the facility's policy titled Behavioral Health Services, last revised July 2022, indicated but was not limited to: -Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress; -Staff training regarding behavioral health services includes, but is not limited to: a. recognizing changes in behavior that indicate psychological distress; b. implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his/her needs; c. monitoring care plan interventions and reporting changes in condition; and d. protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties, history of trauma and post-traumatic stress disorder. Review of the staff education records for Nurse #14, Nurse #15, Nurse #16, Nurse #17 and Nurse #18 failed to include mandatory training on care specific to the individual needs of residents that are diagnosed with a mental, psychosocial, or substance use disorder, a history of trauma and/or post-traumatic stress disorder, or other behavioral health condition; and care specific to the individual needs of residents that are diagnosed with dementia. During an interview on 9/25/24 at 12:54 P.M. and 1:11 P.M., the Staff Development Coordinator said she could not find any evidence that Nurse #14, Nurse #15, Nurse #16, Nurse #17, Nurse #18 or any other staff had received required behavioral health training. She said there are approximately 80 relevant employees at the facility, and she could not find any evidence that behavioral health training was completed as required in 2023. She said when she began working at the facility four months ago, there was no staff education program in place. The facility failed to provide the survey team with any additional documentation by the time of the exit conference on 9/25/24.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for four Residents (#5, #112, #14, and #2), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #5, a comprehensive care plan was developed and implemented to address the Resident's constipation; 2. For Resident #112, a comprehensive care plan was developed to address the use of antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment; 3. For Resident #14, a comprehensive care plan was a. implemented to monitor for adverse consequence (side effects) of antidepressant medications; and b. developed for an antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment; and 4. For Resident #2, a comprehensive care plan was developed for an antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised July 2022, indicated but was not limited to: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The IDT includes, but is not limited to the resident's attending physician. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -The comprehensive, person-centered care plan: -includes measurable objectives and timeframes; -describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -includes the resident's stated goals upon admission and desired outcomes; -builds on the resident's strengths; -reflects currently recognized standards of practice for problem areas and conditions -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. Resident #5 was admitted to the facility in May 2021 with diagnoses including gastroesophageal reflux disease (GERD-chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach). Review of the medical record indicated Resident #5 was sent to the hospital on three occasions within eight months and was treated for conditions including a new diagnosis of constipation: -On 1/10/24, Resident #5 was admitted to the hospital with nausea, coffee ground emesis (vomit that appears like coffee grounds due to presence of old, coagulated blood in the gastrointestinal tract) and abdominal pain. Review of hospital documentation, including the patient visit information and discharge summary, indicated Resident #5 had an abdominal computed tomography scan (CT scan-a medical imaging procedure that uses a combination of X-rays and computer technology to produce detailed images of the inside of your body) that revealed a moderate to large amount of solid colonic stool. The Resident was treated for constipation and discharged back to the facility on [DATE] with a new order for Polyethylene glycol (laxative used to treat constipation by softening hard stools or stimulating the bowels) 17 grams (gm) daily. Review of the Minimum Data Set (MDS) assessment, dated 1/10/24, indicated Resident #5 had a new diagnosis of constipation. Review of the medical record failed to indicate a comprehensive care plan that included a plan of care with measurable objectives and timeframes was developed and implemented for the Resident's new diagnosis of constipation. -On 7/1/24, Resident #5 was admitted to the hospital with vomiting dark colored vomit. An endoscopy (involves passing a tiny lighted camera down the throat, through the esophagus and into the stomach) was performed and revealed a food bezoar (large ball of undigested food in the stomach). The food bezoar was removed, the Resident was treated for constipation and discharged back to the facility on [DATE]. Discharge medications included but were not limited to the following laxatives: bisacodyl 10 milligram (mg) suppository daily as needed; lactulose 10 gm packet, one packet three times a day as needed (if no bowel movement (BM) for greater than 1 day); Senna 8.6 mg take two tablets two times a day, and Polyethylene glycol 17 gm, take 17 gm daily. Instructions listed on the discharge paperwork indicated the Resident should have at least one soft bowel movement every day. Review of the medical record failed to indicate a comprehensive care plan that included interventions, measurable objectives and timeframes was developed and implemented for the Resident's ongoing diagnosis of constipation. -On 8/20/24, Resident #5 was transferred to the hospital with nausea and vomiting. Review of the hospital patient visit information indicated a CT scan was performed and showed the Resident had constipation and was treated. The Resident returned to the facility the same day with discharge instructions for Resident #5 to increase the frequency of administration of Polyethylene glycol 17 gm to twice daily. Review of comprehensive care plans failed to indicate a person-centered comprehensive care plan that included a plan of care with measurable objectives and timeframes was developed and implemented for the Resident's ongoing diagnosis of constipation. During an interview on 9/24/24 at 1:28 P.M., Unit Supervisor #6 reviewed Resident #5's medical record including comprehensive care plans and said there was no care plan in place to address the Resident's diagnosis of constipation. He said a care plan should have been developed and include the plan of care to treat the Resident's constipation. 2. Resident #112 was admitted to the facility in January 2024 and had diagnoses including dementia with agitation, depression, and anxiety. Review of the most recent MDS assessment, dated 7/3/24, indicated Resident #112 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15, and received antipsychotic medication daily. Review of Resident #112's medical record indicated Physician's Orders for the following antipsychotic medication: Zyprexa 2.5 mg, give 2.5 mg three times a day (1/9/24); and Zyprexa 5.0 mg, give 5.0 mg at bedtime (1/9/24) Review of January 2024 through September 2024 Medication Administration Records (MAR) indicated Zyprexa 2.5 mg and 5.0 mg were administered as ordered by the physician. Review of comprehensive care plans failed to indicate Resident #112 was prescribed antipsychotic medication and failed to identify specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 9/25/24 at 10:10 A.M., Social Worker #1 said nursing is responsible for developing care plans for psychotropic medication. She said she develops care plans for mood, behaviors, advanced directives, discharge planning and psychosocial needs. During an interview on 9/25/24 at 3:32 P.M., the Director of Nursing (DON) reviewed Resident #112's care plan and said a care plan had not been developed for his/her use of antipsychotic medication. She said a care plan should have been developed for his/her use of antipsychotic medication that included resident specific targeted behaviors, resident specific interventions, non-pharmacological approaches, and measurable goals. 48695 3. Resident #14 was admitted to the facility in May 2023 with diagnoses including major depressive disorder, anxiety, and psychosis. Review of Resident #14's MDS assessment, dated 8/1/24, indicated Resident #14 had a moderate cognitive impairment as evidenced by staff assessment for mental status. Further review of the MDS indicated Resident #14 had received antidepressant and antipsychotic medications daily. a. Review of Resident #14's current Physician's Orders indicated but was not limited to: - Duloxetine (antidepressant) 30 mg capsule, give 1 capsule by mouth two times a day (dated 5/30/23) - Remeron (antidepressant) 15 mg, give 15 mg by mouth at bedtime (6/3/24) Review of Resident #14's August and September MARs indicated he/she received Duloxetine and Remeron as ordered. Review of Resident #14's care plan included but was not limited to: - Focus: Resident #14 uses antidepressant medication r/t (related to) depression (date initiated 8/22/23) - Goal: Resident #14 will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (date initiated 8/22/23) - Interventions: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift (date initiated 8/22/23) Further review of Resident #14's medical record indicated the facility failed to implement Resident #14's care plan to monitor potential side effects of antidepressant medications. During an interview on 9/24/24 at 12:43 P.M., Nurse #2 said Resident #14 was receiving antidepressant medication but was not being monitored for side effects of antidepressant medication. b. Review of Resident #14's current Physician's Orders indicated but was not limited to: - Olanzapine (antipsychotic medication) 2.5 mg, Give 1 tablet at bedtime (date 10/20/23) Review of Resident #14's August and September MARs indicated he/she received Olanzapine as ordered. Review of comprehensive care plans failed to indicate Resident #14 was prescribed antipsychotic medication and failed to identify specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 9/25/24 at 10:10 A.M., Social Worker #1 said nursing is responsible for developing care plans for psychotropic medication. She said she develops care plans for mood, behaviors, advanced directives, discharge planning and psychosocial needs. During an interview on 9/25/24 at 3:32 P.M., the DON said any resident on an antipsychotic medication should have a care plan for the medication. The DON reviewed Resident #14's care plans and said he/she did not have a care plan for an antipsychotic medication. 4. Resident #2 was admitted to the facility in October 2021 with diagnoses including major depressive disorder. Review of Resident #2's MDS assessment, dated 9/9/24, indicated he/she was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated Resident #2 had received antipsychotic medications. Review of Resident #2's current Physician's Orders indicated but was not limited to: - Vraylar (antipsychotic) 1.5 mg, Give 1 capsule one time a day (date 6/10/2024) Review of comprehensive care plans failed to indicate Resident #2 was prescribed antipsychotic medication and failed to identify specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 9/25/24 at 3:32 P.M., the DON said any resident on an antipsychotic medication should have a care plan for the medication. The DON reviewed Resident #2's care plans and said he/she did not have a care plan for an antipsychotic medication but should have one.

Based on observation, interview, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for seven Residents (#5, #68, #19, #73, #85, #76 and #92), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Residents #5, medication reconciliation process was conducted thoroughly and included all medications approved by the physician upon readmission to the facility, and as needed (PRN) interventions implemented according to physician's orders to potentially prevent hospital intervention to treat constipation, and failed to consistently monitor the Resident's response to interventions to prevent constipation; 2. For Resident #68, all components of wound recommendations were implemented; 3. For Resident #19, implement recommendations from the Wound Consultant; 4. For Resident #73, implement recommendations from the Wound Consultant; 5. For Resident #85, obtain a physician's order for transfer to the hospital; 6. For Resident #76, to notify the Physician when the Resident's blood sugar reading was greater than 400 or 451; and 7. For Resident #92, to notify the Physician when the Resident's gastric residual (a volume of fluid remaining in the stomach at a point in time during enteral feeding) reading was greater than or equal to 100. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber 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. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. 1. Review of the facility's policy titled Bowel (lower gastrointestinal tract) disorders-clinical protocol, last revised September 2017, indicated but was not limited to: -Treatment/Management: The physician will identify and order pertinent cause-specific and symptomatic interventions; for example, institute a regimen to prevent constipation. -Monitoring and Follow-Up: the staff and physician will monitor the individual's response to interventions and overall progress for example, overall degree of comfort or distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc. Review of the facility's policy titled Reconciliation of Medications on Admission, dated 2001, indicated but was not limited to: -The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. -Preparation: Gather the information needed to reconcile the medication list: a. Approved medication reconciliation form b. Discharge summary from referring facility. c. Admission order sheet d. All prescription and supplement information obtained from the resident/family during the medication history; and e. Most recent medication administration record (MAR), if this is a readmission. General Guidelines: -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. -Medication reconciliation helps to ensure that all medications, routes, and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. -Medication reconciliation helps to ensure that medications, routes, and dosages have been accurately communicated to the Attending Physician and care team. Resident #5 was admitted to the facility in May 2021 with diagnoses including gastroesophageal reflux disease (GERD- chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach). Review of the medical record indicated Resident #5 was sent to the hospital on three occasions within an eight-month period of time and was treated for constipation in the hospital: -On 1/10/24, Resident #5 was admitted to the hospital with nausea, coffee ground emesis (vomit that appears like coffee grounds due to presence of old, coagulated blood in the gastrointestinal tract), and abdominal pain. Review of the hospital documentation including the patient visit information and discharge summary indicated Resident #5 had an abdominal and pelvic computed tomography scan (CT scan-a medical imaging procedure that uses a combination of X-rays and computer technology to produce detailed images of the inside of your body) for evaluation of abdominal pain and vomiting. The results revealed a mild distal esophageal wall thickening, and likely a small epiphrenic esophageal diverticulum (an outpouching or pocket that develops on the inside of your esophagus) as well as moderate to large amount of solid colonic stool without gastrointestinal obstruction. The Resident was treated for constipation and discharged back to the facility on [DATE] with new orders including, but not limited to Polyethylene glycol (laxative used to treat constipation by softening hard stools or stimulating the bowels) 17 grams (gm) daily. Review of January 2024 Physician's Orders indicated but was not limited to: -Polyethylene glycol 17 gm/scoop daily, give one scoop one time a day for constipation (1/12/24) Review of the January 2024 Medication Administration Record (MAR) indicated the Polyethylene glycol was administered as ordered by the physician. Review of January 2024 bowel and bladder documentation (every shift) failed to indicate staff documented the Resident's bowel movements in monitoring his/her response to laxative treatment for 38 out of 93 shifts. -On 7/1/24, Resident #5 was admitted to the hospital with vomiting dark colored vomit. The hospital after visit summary indicated an endoscopy (involves passing a tiny lighted camera down the throat, through the esophagus and into the stomach) was performed and found no signs of bleeding in the esophagus or stomach. The imaging revealed a food bezoar (large ball of undigested food in the stomach), and it was removed. The summary indicated a concern that the Resident's bowels may not be moving very well, causing constipation. The Resident was given medication to help him/her have a bowel movement and was discharged back to the facility on [DATE]. Discharge medications included but were not limited to the following laxatives: bisacodyl 10 milligram (mg) suppository daily as needed; lactulose 10 gm packet, one packet three times a day as needed (if no bowel movement (BM) for greater than 1 day); Senna 8.6 mg take two tablets two times a day, and Polyethylene glycol 17 gm, take 17 gm daily. Instructions listed on the discharge paperwork indicated the Resident should have at least one soft bowel movement every day. Review of a Nursing Progress Note, dated 7/5/24 and written by Unit Supervisor #6, indicated Resident #5 returned from the hospital, medications were reviewed, confirmed, and approved with Nurse Practitioner #1 who was on-call for the Resident's attending Physician. Review of July 2024 Physician's Orders indicated but was not limited to: -Polyethylene glycol 17 gm/scoop daily, give one scoop one time a day for constipation (1/12/24) -Bisacodyl Rectal Suppository 10 mg, insert 10 mg rectally as needed for constipation daily (7/5/24) -Lactulose Oral Solution 10 gm/15 milliliters (ml), give 15 ml by mouth every 8 hours as needed for constipation, no BM >1 a day (7/5/24) The physician's orders failed to include Senna 8.6 mg, two tablets two times a day and failed to include the correct dosage identified on the hospital's discharge medication list: lactulose 10 gm packet, one packet three times a day as needed. Review of the July 2024 MAR indicated the Polyethylene glycol was administered as ordered by the physician. Review of July 2024 bowel and bladder documentation and July 2024 MAR indicated Resident #5: -had no BM for six consecutive days (from 7/6/24 to 1/12/24) and was not administered PRN laxative medication according to physician's orders -had no BM for three consecutive days (from 7/12/24 to 1/15/24) and was not administered PRN laxative medication according to physician's orders -had no BM for three consecutive days (from 7/28/24 to 7/30/24) and was not administered PRN laxative medication according to physician's orders Further review of the July 2024 bowel and bladder documentation failed to indicate staff documented the Resident's bowel movements in monitoring his/her response to laxative treatment for 26 out of 78 shifts. On 8/13/24, a new order was initiated for Bisacodyl (stool softener) Oral Tablet Delayed Release 5 mg, give one tablet by mouth at bedtime every other day for constipation. Review of the August MAR indicated the Polyethylene glycol and Bisacodyl every other day was administered as ordered by the physician. Review of August 2024 bowel and bladder documentation and August 2024 MAR indicated Resident #5: -had no BM for two consecutive days (from 8/15/24 and 8/16/24) and was not administered PRN laxative medication according to physician's orders -had no BM on 8/18/24 and was administered PRN lactulose on 8/19/24 -On 8/20/24, Resident #5 was transferred to emergency department for evaluation of nausea and vomiting. Review of the hospital patient visit information indicated a CT scan was performed and the Resident was found to be constipated and was treated. The Resident returned to the facility the same day with discharge instructions for Resident #5 to increase the frequency of administration of Polyethylene glycol 17 gm to twice daily. Review of August 2024 physician's orders indicated, but was not limited to: -Polyethylene glycol 17 gm/scoop daily, give one scoop two times a day for constipation (8/6/24) -Bisacodyl Rectal Suppository 10 mg, insert 10 mg rectally as needed for constipation daily (7/5/24) -Lactulose Oral Solution 10 gm/15 ml, give 15 ml by mouth every 8 hours as needed for constipation, no BM >1 a day (7/5/24) Review of the August 2024 MAR indicated Polyethylene glycol 17 gm twice daily was administered as orderd by the physician. Review of August 2024 bowel and bladder documentation indicated Resident #5: -had no BM for two consecutive days (from 8/21/24 and 8/22/24) and was not administered PRN laxative medication according to physician's orders On 8/23/24, the physician order for Bisacodyl Delayed Release 5 MG was changed to be administered daily. Further review of the August 2024 bowel and bladder documentation indicated Resident #5: -had no BM for four consecutive days (from 8/27/24 and 8/30/24) and was not administered PRN laxative medication according to physician's orders. Further review of the August 2024 bowel and bladder documentation failed to indicate staff documented the Resident's bowel movements in monitoring his/her response to laxative treatment for 28 out of 93 shifts. During interviews on 9/19/24 at 1:04 P.M. and 9/24/24 at 1:28 P.M., Unit Supervisor #6 said the process for medication reconciliation is that the receiving nurse calls the on-call Nurse Practitioner (NP) and reviews all medications listed on the discharge paperwork. He reviewed Resident #5's medical record and said he was the nurse that did the medication reconciliation when he/she was readmitted from the hospital. He said he reviewed all of the medications and instructions on the discharge paperwork with the NP over the phone and she approved it. He said he entered the orders into the computer. However, he said he entered the lactulose order inaccurately, missed entering the order for Senna and did not enter instructions that Resident #5 should have at least one soft bowel movement every day. Unit Supervisor #6 said that Resident #5 should have received the PRN laxative medication every time he/she did not have a BM for greater than one day. 46562 2. Resident #68 was admitted to the facility in March 2020 with the following diagnoses: dementia, venous insufficiency, and chronic wounds to lower extremities. Review of the Minimum Data Set (MDS) assessment, dated 7/29/24, indicated Resident #68 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Review of Resident #68's Physician's Orders indicated but were not limited to: -Left lower extremity vascular wound: wash with normal saline, pat dry, apply xeroform (sterile wound dressing that is non-adherent), cover with ABD pad (an absorbent pad) and wrap with kerlix (bandage roll), every day shift, dated 9/17/24 and discontinued 9/19/24 -Lymphademic (sic) wound (wound related to chronic lymphedema, also known as lymphoedema and lymphatic edema, a condition of localized swelling caused by a compromised lymphatic system) of the right shin: wash with normal saline, apply xeroform, cover with ABD pad and wrap with kerlix, every day shift, dated 9/20/24 -Lymphademic wound of the left shin: wash with normal saline, apply xeroform, cover with ABD pad and wrap with kerlix, every day shift, dated 9/20/24 Review of Resident #68's September Treatment Administration Record (TAR) indicated his/her lower extremity treatments had been completed per physician orders. Review of Resident #68's Wound Evaluation and Management Summary Report, dated 9/16/24, indicated the recommended treatment included but were not limited to: -Lymphademic wound of the left shin: skin prep (liquid that when applied to the skin forms a protective film or barrier) apply every shift -Lymphademic wound of the right shin: xeroform gauze apply once daily, followed by an ABD pad apply once daily, gauze roll (kerlix) daily and an ACE bandage once daily. Treatment to the periwound (skin surrounding the wound): skin prep apply once daily. Review of Resident #68's Wound Evaluation and Management Summary Report, dated 9/18/24, indicated the recommended treatment included but were not limited to: -Lymphademic wound of the left shin: xeroform gauze apply once daily, followed by an ABD pad apply once daily, gauze roll (kerlix) daily and an ACE bandage once daily. Treatment to the periwound: skin prep apply once daily. During an interview on 9/23/24 at 3:38 P.M., Nurse #5 said the Wound Consultant saw residents weekly on Wednesdays and the Director of Nurses (DON) or another facility nurse completed wound visits with him. Nurse #5 said if there were new recommendations they were verbalized during wound rounds and documented on the wound evaluation and management summary report. Nurse #5 said the nurse conducting wound rounds followed up with Wound Consultant recommendations. During an interview on 9/24/24 at 1:00 P.M., Unit Manager #2 said Resident #68 was followed by the Wound Consultant due to his/her chronic lower extremity wounds. Unit Manager #2 said the DON or another nurse conducted wound rounds with the Wound Consultant and followed through with his/her wound recommendations. Unit Manager #2 reviewed Resident #68's Wound Evaluation and Management Summary Reports, dated 9/16/24 and 9/18/24, and compared them to the current physician's orders. Unit Manager #2 said not all the recommended components had been implemented. During an interview on 9/24/24 at 1:35 P.M., the DON said wound rounds were conducted weekly with the Wound Consultant. The DON said the Wound Consultant verbally makes recommendations but also provides a Wound Evaluation and Management Summary Report which included his assessment and recommendations. The DON reviewed the 9/16/24 and 9/18/24 Wound Evaluation and Management a Summary Reports and the DON said she was not sure why all the recommended components were not implemented when the new orders were transcribed and she must have missed parts of it. 48695 3. Resident #19 was admitted to the facility in January 2024 with diagnoses including peripheral vascular disease, end stage renal disease (ESRD) and diabetes mellitus. Review of the MDS assessment, dated 7/3/24, indicated Resident #19 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of Resident #19's current Physician's Orders indicated but was not limited to: - Arterial wound of the left shin Wash W (with) NS (normal saline) pat dry, apply calcium alginate (a dressing used to treat wounds because it absorbs drainage and forms a gel that helps promote healing), cover w (with) gauze island. Apply skin to periwound area. Every evening shift AND as needed (dated 8/30/2024) Review of Resident #19's September TAR indicated his/her lower extremity treatments had been completed per physician's orders. Review of Resident #19's Wound Evaluation Management and Summary Report, dated 9/11/24, indicated the recommended treatment included but were not limited to: -Arterial wound of the left shin: xeroform gauze, followed by gauze island dressing once daily. Treatment to the peri wound: skin prep once daily. Review of Resident #19's Wound Evaluation Management and Summary Report, dated 9/18/24, indicated the recommended treatment included but were not limited to: -Arterial wound of the left shin: xeroform gauze, followed by gauze island dressing once daily. Treatment to the periwound: skin prep once daily. During an interview on 9/24/24 at 8:58 A.M., Nursing Supervisor #6 said the Wound Consultant would come in on Wednesdays and would complete wound rounds with the DON or designee. Nursing Supervisor #6 said the DON would then receive the recommendations from the Wound consultant and would follow-up with the physician. During an interview with record review on 9/24/24 at 3:32 P.M., the DON and surveyor reviewed Resident #19's current physician orders and recommendations form the Wound Consultant date 9/11/24 and 9/18/24. The DON said the recommendations from the Wound Consultant should have been reviewed with the Physician and been implemented. During a telephonic interview on 9/25/24 at 3:18 P.M., Wound Consultant #1 said his expectation was for his recommendations to be implemented. 4. Resident #73 was admitted to the facility in May 2021 with diagnoses including cellulitis of the left lower limb and peripheral venous insufficiency. Review of the MDS assessment, dated 9/19/24, indicated Resident #73 had moderate cognitive impairment as evidenced by staff assessment for mental status. Review of Resident #73's current Physician's Orders indicated but was not limited to: -Non-Pressure wound of the left, dorsal (back of), first toe: wash with NS (normal saline) pat dry, apply skin prep three times daily, (dated 8/9/24, discontinued on 8/15/24) Review of Resident #73's Wound Evaluation Management and Summary Report, dated 8/4/24, indicated the recommended treatment included but was not limited to: -Skin prep apply Q-shift (every shift) Review of Resident #73's Wound Evaluation Management and Summary Report, dated 8/7/24, indicated the recommended treatment included but was not limited to: -Skin prep apply Q-shift During an interview on 09/24/24 at 12:43 P.M., Nurse #2 said the Wound Consultant would come in weekly on Wednesdays and could be available accessible via phone in between visits if needed. Nurse #2 said the Wound Consultant would do rounds with the DON and me. Nurse #2 said the wound doctor would give a verbal recommendation and then would send the written consultation into the resident's electronic medical record. Nurse #2 said the DON or nurse supervisor will follow up with the doctor and put the order into the resident's medical record. During an interview on 9/24/24 at 3:32 P.M., the DON and surveyor reviewed Resident #73's August physician's orders and recommendations from the Wound Consultant dated 8/4/24 and 8/7/24. The DON said the recommendations from the Wound Consultant should have been reviewed with the Physician and been implemented. During a telephonic interview on 9/25/24 at 3:18 P.M., Wound Consultant #1 said his expectation was for his recommendations to be implemented. 5. Resident #85 was admitted to the facility in July 2022 with the following diagnoses ESRD, dependence on renal dialysis, and diabetes mellitus. Review of Resident #85's MDS assessments, dated 4/18/24 and 6/28/24, indicated he/she was discharged to the hospital with return anticipated. Review of Resident #85's Nursing Progress Note, dated 4/18/24, indicated he/she was transferred to the emergency department. Review of Resident #85's Nursing Progress Note, dated 6/28/24, indicated he/she was transferred to the hospital. Review of Resident #85's Order Listing Report for 4/1/24 through 9/25/24 failed to indicate an order to transfer him/her to the hospital on 4/18/24 or 6/28/24. During an interview on 9/25/24 at 11:48 A.M., Nurse #1 said when a resident is sent out to the hospital, the nurse would call the Physician/NP and obtain an order to send the resident to the hospital and then put the order into the resident's medical record. During an interview on 9/25/24 at 3:32 P.M., the DON reviewed Resident # 85's medical record and physician's orders and said there was no order to transfer Resident #85 to the hospital on 4/18/24 or 6/28/24. The DON said a physician's order should be obtained when a Resident is transferred to the hospital. [NAME], [NAME] R. 6. Review of the facility's policy titled Change in a Resident's Condition or Status, dated as revised February 2021, indicated but was not limited to the following: -Policy Statement: our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (for example, changes in level of care, billing/payments, resident rights, etc.). -The nurse will notify the resident's attending physician or physician on call when there has been a: i. specific instruction to notify the physician of changes in the resident's condition. Resident #76 was admitted to the facility in April 2023 with diagnoses that included Type 2 Diabetes Mellitus (a condition in which the body does not produce enough insulin and has trouble controlling blood sugar levels) with unspecified diabetic retinopathy, diabetic neuropathy, End Stage Renal Disease, and dependence on renal dialysis. Review of Resident #76's MDS assessment, dated 6/18/24, indicated Resident #76 received insulin injections. Review of Resident #76's active Physician's Orders included but were not limited to the following: -Insulin Glargine Subcutaneous Solution Pen-injector 100 units/milliliter (mL). Inject 7 units subcutaneously every 12 hours related to Type 2 diabetes mellitus (T2DM) with unspecified diabetic retinopathy without macular edema; Active 9/9/24. -Insulin Lispro Injection Solution 100 units/mL. Inject 3 units subcutaneously two times a day every Monday, Wednesday, Friday related to T2DM with unspecified diabetic retinopathy without macular edema; Active 9/16/24. Insulin Lispro Injection Solution 100 units/mL. Inject as per sliding scale if: 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451 - 999 = 12 units Call Medical Doctor (MD) if blood sugar (BS) is greater than 450, subcutaneously two times a day every Monday, Wednesday, Friday related to T2DM with unspecified diabetic retinopathy without macular edema and Inject 3 units subcutaneously two times a day every Monday, Wednesday, Friday related to T2DM with unspecified diabetic retinopathy without macular edema; Active 9/16/24. Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/mL - Inject 3 units subcutaneously with meals every Tuesday, Thursday, Saturday, Sunday related to T2DM with unspecified diabetic retinopathy without macular edema and Inject as per sliding scale if: 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451+ = 12 units; 451 and higher administer 12 units and call MD; subcutaneously with meals every Tuesday, Thursday, Saturday, Sunday related to T2DM with unspecified diabetic retinopathy without macular edema; Active 9/17/24. Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 units/mL. Inject as per sliding scale if: 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451+ = 12 units; 451 and higher administer 12 units and call MD; subcutaneously with meals every Tuesday, Thursday, Saturday, Sunday related to T2DM with unspecified diabetic retinopathy without macular edema; Active 9/17/24. May perform finger stick to obtain blood for blood sugar before meals and at bedtime; Active 9/16/24. Insulin Lispro Injection Solution. Inject 6 units subcutaneously every 6 hours as needed for hyperglycemia 400 and above. Notify MD; Active 10/9/23. Insulin Lispro Injection Solution. Inject 6 units subcutaneously one time only related to T2DM with unspecified diabetic retinopathy without macular edema until 9/23/24 23:59. Administer 6 units subcutaneously one time only for elevated blood sugar; Active 9/23/24. Further review of Resident #76's past Physician's orders included but were not limited to the following: -Active 8/25/24-9/16/24: Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/mL Inject as per sliding scale if: 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451+ = 12 units; 451 and higher administer 12 units and call MD, subcutaneously with meals related to T2DM with unspecified diabetic retinopathy without macular edema. Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/mL. Inject 3 units subcutaneously with meals related to T2DM with unspecified diabetic retinopathy without macular edema. -Active 8/25/24-9/8/24: Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/mL. Inject 5 units subcutaneously every 12 hours related to T2DM with unspecified diabetic retinopathy without macular edema. -Active 7/13/24-8/25/24: Insulin Lispro Injection Solution 100 UNIT/mL. Inject as per sliding scale if: 150 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; call MD if BS is greater than 400; Subcutaneously with meals related to T2DM without complications. Insulin Lispro Injection Solution 100 UNIT/mL. Inject 3 units subcutaneously with meals related to Type 1 Diabetes Mellitus with hypoglycemia without coma. -Active 7/12/24-8/25/24: Insulin Glargine Subcutaneous Solution 100 UNIT/mL. Inject 5 units subcutaneously every 12 hours related to T2DM without complications. Insulin Lispro Injection Solution 100 UNIT/mL. Inject as per sliding scale if: 200 - 250 = 1 unit; 251 - 300 = 2 units; 301 - 350 = 3 units; 351 - 400 = 4 units; call MD if blood sugar (BS) is greater than 400; Subcutaneously at bedtime related to T2DM without complications. -Active 4/8/23-9/16/24: May perform finger stick to obtain blood for blood sugar before meals and at bedtime. Review of Resident #76's Medication Administration Record (MAR) for July 2024, August 2024, and September 2024 indicated the following blood sugar values: 9/16/24 at 6:00 A.M., BS = 460; 8/29/24 at 4:30 P.M., BS = 451; 8/25/24 at 12:00 P.M., BS = 500; 8/5/24 at 11:30 A.M., BS = 450; 7/1/24 at 9:00 P.M., BS = 594; 7/1/24 at 4:30 P.M., BS = 445. Further review of Resident #76's medical record did not indicate there was documentation that the Physician was notified of the elevated BS value. During an interview on 9/24/24 at 10:30 A.M., Nurse #3 and Nurse #10 said when a resident's blood sugar values are above the threshold indicated in the physician's order, they notify the Physician and document the notification in the Nursing Progress notes. During an interview on 9/25/24 at 2:57 P.M., the DON said she could not find documentation in Resident #76's medical record that the Physician was notified of elevated blood sugars for the dates above, but she expects nurses to document that the Physician was notified. 7. Resident #92 was admitted to the facility in April 2023 with diagnoses that included cerebral infarction, dysphagia (difficulty swallowing), and gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach for feeding or drainage) status. Review of Resident #92's MDS assessment, dated 9/2/24, indicated Resident #92 had a feeding tube. Review of Resident #92's active Physician's Orders included but were not limited to the following: -Enteral Feed, every shift, Jevity 1.5 calorie formula to run at 50 milliliters (mL) per hour continuous; Active 5/12/24. -Enteral: Check Residual every 4 hours, if residual is greater than or equal to 100 hold feed and call MD; Active 4/16/2024. Review of Resident #92's MAR indicated but was not limited to the following: 9/14/24 at 4:00 P.M., gastric residuals (GR) = 100; 9/05/24 at 4:00 P.M., GR = 100; 9/02/24 at 4:00 P.M., GR = 240; 8/31/24 at 8:00 P.M., GR = 100; 8/25/24 at 8:00 P.M., GR = 100; 8/14/24 at 4:00 P.M., GR = 100; 8/13/24 at 4:00 P.M., GR = 240; 7/29/24 at 8:00 P.M., GR = 100; 7/14/24 at 8:00 P.M., GR = 100. Review of Resident #92's medical record failed to indicate there was documentation that the Physician was notified of gastric residuals at or above 100. During an interview on 9/24/24 at 9:40 A.M., Nurse #9 said if Resident #92's gastric residuals were over 100, then the tube feeding is held and the Physician is notified. Nurse #9 said a Nursing Progress note is then written to document the Physician notification. During an interview on 9/25/24 at 4:30 P.M., the DON said she reviewed Resident #92's medical record and did not see Nursing Progress notes or documentation indicating the Physician was notified of gastric residuals at or above 100 from July 2024 through September 2024. The DON said she expects nursing to document they notified t[TRUNCATED]

Based on observation and interviews, the facility failed to ensure its staff provided a meaningful and engaging activity program for residents residing on one Unit (3A), out of four units in the facility. Specifically, the facility failed to ensure residents were involved in activities. Findings include: Review of the facility's policy titled Activity Programs, last revised June 2018, indicated but was not limited to: -The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities -Activities are considered any endeavor, other than routine activities of daily living, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance, physical, cognitive or emotional health -Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting cleanup and critique of the programs -Activities are not necessarily limited to formal activities being provided only by activities staff On the following days of survey, the surveyor made the following observations of the 3A Unit Resident Lounge (activity/dining room): -9/17/24 at 10:20 A.M., 15 residents with one staff member present who was sitting in the corner of the room not engaging with the residents, the television was on but none of the residents were looking in the direction of the television, with no evidence of meaningful activity -9/17/24 at 11:12 A.M., 16 residents with one staff member present who was sitting in the corner of the room not engaging with the residents, the television was on but none of the residents were looking in the direction of the television, with no evidence of meaningful activity -9/17/24 at 2:46 P.M., 10 residents with two staff members present in the room not engaging with the residents, the television was on, with no evidence of meaningful activity -9/17/24 at 4:46 P.M., nine residents with two staff members present in the room not engaging with the residents, the television was on with no evidence of meaningful activity -9/18/24 at 11:23 A.M.,16 residents with two staff members in room, 4 of 16 residents were eating/drinking cookies and coffee, the television was on, staff not engaging with the residents, with no evidence of meaningful activity -9/18/24 at 3:29 P.M.,12 residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television, with no evidence of meaningful activity -9/19/24 at 8:20 A.M., six residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television, with no evidence of meaningful activity -9/19/24 at 1:55 P.M., seven residents with two staff members present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television with no staff engagement and no evidence of meaningful activity -9/23/24 at 10:06 A.M.,11 residents with one staff member present in the room not engaging with the residents, the television was on, 2 of 11 residents were independently completing their weekly menu, 9 of 11 residents with no evidence of meaningful activity -9/23/24 at 3:36 P.M., 11 residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television; 1 of 11 residents was repeatedly banging on the table in front of him/her, with no evidence of meaningful activity -9/23/24 at 4:25 P.M., 14 residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television, with no evidence of meaningful activity -9/24/24 at 12:33 P.M., seven residents with one staff member present in the room not engaging with the residents, the television was on, no residents were looking in the direction of the television; and 1 of 7 residents repeatedly rubbing circles on the table in front of him/her, with no evidence of meaningful activity On the following days of survey, the surveyor made the following observations of the 3A Nurses' Station Hallway/Corridor, not in the Resident Lounge: -9/17/24 at 4:46 P.M., eight residents some of whom were talking amongst themselves with no staff engagement and no evidence of meaningful activity -9/19/24 at 1:55 P.M., six residents with no staff engagement, with no evidence of meaningful activity During an interview on 9/17/24 at 10:14 A.M., Resident #68 said there was not much to do as far as activities go and he/she stayed in bed most of the time. During an interview on 9/17/24 at 10:28 A.M., Resident #273 said he/she did not do much during the day; he/she said the facility had not provided him/her with activities. During an interview on 9/17/24 at 10:37 A.M., Resident #75 said he/she was not offered activities. During an interview on 9/17/24 at 11:07 A.M., Resident #117 said the facility had an activity department but never do what was scheduled. Resident #117 said he/she was not invited to attend activities off the unit. During an interview on 9/17/24 at 3:34 P.M., Resident Representative #1 said Resident #90 was always observed in his/her bed and never in the activity room. Resident Representative #1 said when she visits the facility the residents in the activity room are just sitting and were never involved in an activity. During an interview on 9/23/24 at 10:50 A.M., Certified Nursing Assistant (CNA) #3 said the CNAs rotate in the activity room every 30 minutes to make sure the residents are safe. During an interview on 9/23/24 at 10:53 A.M., CNA #4 said the staff take turns watching the residents in the activity/dining room to make sure they are safe. During an interview on 9/23/24 at 11:06 A.M., Nurse #4 said the 3A Residents receive activities during the coffee social and there will sometimes be music in the room. Nurse #4 said some of the residents leave the unit for activities. Nurse #4 said there was always a CNA in the room to make sure they were safe. During an interview on 9/24/24 at 1:15 P.M., Unit Manager #2 said the 3A unit activities consist of a coffee social in the morning. Unit Manager #2 said the staff tried to encourage residents to attend activities on the 2BC Unit. Unit Manager #2 said the facility could be doing more activities with the residents. During an interview on 9/24/24 at 11:14 A.M., the Activity Director said the activity department consisted of herself, one activity assistant and 2 activity aides. The Activity Director said the role of the activity assistant was mostly paperwork and administrative and the activity aide conducted the activities. The Activity Director said for residents who do not attend activities on other units she tried to visit them at least monthly to offer books or other activities. The Activity Director said the 3A Unit has a monthly game of Shaboom (a musical version of bingo), the coffee social daily, and there is always an activity on Saturdays at 11 A.M. During an interview on 9/24/24 at 2:23 P.M., the Administrator said the Activity Department needed some enhancements and the facility should be offering more than they were.

Based on observations, interviews, and record review, the facility failed to implement nutritional interventions as ordered to maintain acceptable parameters of nutritional status for one Resident (#90), with an unplanned gradual weight loss, in a total sample of 24 residents. Specifically, the facility failed to provide as needed nutritional supplements when his/her meal intake was less than 50% as ordered. Findings include: Resident #90 was admitted to the facility in February 2022 with the following diagnoses: dementia, adult failure to thrive, and moderate protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 7/26/24, indicated Resident #90 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS indicated Resident #90 was 63 inches, weighted 95 pounds, had experienced weight loss and was not on a prescribed weight loss regimen. Review of Resident #90's medical record indicated he/she had progressive weight loss as evidenced by the following weights: -1/08/24 = 110.4 pounds (sitting) -2/08/24 = 108.4 pounds (sitting) -3/04/24 = 105.2 pounds (sitting) -4/05/24 = 101.6 pounds (sitting) -5/05/24 = 100.4 pounds (sitting) -5/07/24 = 101.2 pounds (sitting) -6/03/24 = 100.1 pounds (sitting) -7/05/24 = 95.9 pounds (sitting) -7/19/24 = 95.2 pounds (sitting) -7/26/24 = 95.0 pounds (sitting) -8/06/24 = 96.6 pounds (sitting) -9/09/24 = 93.6 pounds (both sitting and standing) -9/24/24 = 94.0 pounds (wheelchair) Review of Resident #90's dietary note, dated 8/31/24, indicated but was not limited to: -Resident with varied oral intake consumes 0 to 75% of meals per staff records. Receives a no added salt diet, soft and bite size texture thin liquids, red lip plate, super cereal at breakfast, house shakes offered with poor oral intake. House nutrition supplement eight ounces three times per day. Review of Resident #90's Physician's Orders indicated but were not limited to: -House Supplement every eight hours as needed for poor meal percentage, 120 milliliters (ml) to be provided for meal intake of less than 50% as needed three times per day, dated 2/25/22 Review of the August 2024 Documentation Survey Report indicated Resident #90 consumed 0-25% of his/her meal on 38 occasions. Review of the August 2024 Medication Administration Record (MAR) failed to indicate evidence that the as needed house supplement was provided to Resident #90 on all 38 occasions. Review of the September 2024 Documentation Survey Report indicated Resident #90 consumed 0-25% of his/her meal on 25 occasions. Review of the September 2024 MAR failed to indicate evidence that the as needed house supplement was provided to Resident #90 on all 25 occasions. During an interview on 9/24/24 at 12:21 P.M., Nurse #7 said Resident #90 had a poor appetite and eats his/her meals in the unit dining room so that cueing could be provided. Nurse #7 said Resident #90 gets a house supplement three times per day as ordered and receives additional supplements if he/she asks for them. Nurse #7 said she was not sure about the as needed house supplement order. During an interview on 9/24/24 at 1:06 P.M., Unit Manager #2 said Resident #90 was currently 94 pounds and has been followed by the dietitian due to continued weight loss. Unit Manager #2 reviewed Resident #90's medical record and said he/she has current orders for a house supplement three times per day and an as needed order. Unit Manager #2 said when Resident #90 consumed less than 50% of his/her meal the facility should be offering house supplement and documenting it in the MAR. During an interview on 9/24/24 at 11:52 A.M., the Dietitian said she has been following Resident #90 due to gradual weight loss. The Dietitian said Resident #90 had orders for house supplement eight ounces three times per day and an additional order for house supplement if he/she consumed less than 50% of his/her meal. The dietitian said she would expect the supplements to be provided as ordered but did not monitor the documentation and administration of the as needed supplements. During an interview on 9/25/24 at 9:29 A.M., Physician Assistant (PA) #2 said Resident #90 had documented weight loss despite orders for pharmaceutical aids and nutritional supplements being in place. PA #2 said the expectation was for all nutritional interventions to be implemented as ordered and the facility should follow the current treatment plan. During an interview on 9/24/24 at 1:35 P.M., the Director of Nurses (DON) said the resident has been followed for his/her weight loss for a while. The DON reviewed Resident # 90's medical record and said the Resident has scheduled and as needed orders for a nutritional supplement. The DON said the administration of the as needed house supplement should be provided as ordered and documented in the medical record.

Based on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for two Residents (#19 and #76), out of 24 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Review of the facility's policy titled Care of a Resident with End-Stage Renal Disease, last revised September 2010, indicated but was not limited to: -Policy Statement with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of practice. -Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: b) how information will be exchanged between the facilities. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber 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. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. 1. Resident #19 was admitted to the facility in January 2024 with diagnoses including end stage renal disease (ESRD) and diabetes mellitus. Review of Minimum Data Set (MDS) assessment, dated 7/3/24, indicated Resident #19 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Further review of the MDS indicated Resident #19 had received dialysis. Review of Resident #19's current Physician's Orders indicated but was not limited to: - Dialysis Center T (Tuesday)/TH (Thursday)/SAT (Saturday) one time a day every Tue, Thu, Sat for Dialysis Center- dated 1/30/24 - Sevelamer Carbonate (medication used to lower phosphorus levels in the blood) 800 milligrams (mg), Give 3 tablets with meals- dated 5/10/2024 Review of Resident #19's Dialysis Communication Book indicated a recommendation from the dialysis center Dietitian dated 9/12/24 but was not limited to: - Please hold phosphorus binder Sevelamer due to low phos (phosphorus) 2.3 per MD (medical doctor) Further review of Resident #19's Dialysis Communication Book indicated on 9/10/24 he/she had a phosphorus level of 2.3 mg (milligrams)/dL(deciliter). Review of Resident #19's nurses note, dated 9/12/24 indicated but was not limited to: - Resident returned from dialysis with a request from the MD to hold Sevelamer due to low phos (2.3). No stop date noted. Further Review of Resident #19's medical record failed to indicate the Physician or Physician Extender was notified of the recommendation and review of the Medication Administration Record (MAR) indicated Sevelamer had been administered for 18 extra doses. During an interview on 9/19/24 at 3:05 P.M., Nurse #19 said when a resident returns from dialysis the nurse is responsible for checking his/her dialysis communication book and communicating the recommendations to the Physician/Nurse Practitioner (NP). During an interview on 9/19/24 at 3:06 P.M., Unit Supervisor #6 reviewed Resident #19's dialysis communication book and medical record and said the dialysis recommendations were not reported to the Physician/NP and were not followed-up on. During an interview on 9/19/24 at 3:19 P.M., the Director of Nursing (DON) reviewed Resident #19's dialysis recommendations from 9/12/24 and his/her medical record. The DON said the Physician/NP should have been notified of the recommendations and implemented if ordered by the Physician/NP. During an interview on 9/25/24 at 8:58 A.M., NP #1 said she was not notified of the recommendation from the dialysis center and if she had been then she would have implemented it. During a telephonic interview on 9/25/24 at 12:42 P.M., NP #3 said she was not notified of the recommendations from the dialysis center. 49428 2. Resident #76 was admitted to the facility in April 2023 with diagnoses including ESRD and dependence on renal dialysis. Review of Resident #76's MDS assessment, dated 6/18/24, indicated Resident #76 received dialysis services. Review of the Nursing Home Dialysis Transfer Agreement, dated as revised April 2016, indicated but was not limited to the following: -Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to the Center. This information shall include, but is not limited to, where appropriate, the following: e) treatment presently being provided to the Designated Resident, including medications and any changes in a patient's condition (physical or mental), change of medication, diet or fluid intake. h) any other information that will facilitate the adequate coordination of care as reasonably determined by Center. Resident #76's Dialysis Communication Book contained several Dialysis Communication Records, which are forms filled out by both the facility and the dialysis center as a means to relay clinical information and coordinate care for the Resident. During an interview on 9/24/24 at 9:23 A.M., Nurse #3 and the surveyor reviewed Resident #76's Dialysis Communication Record, dated 9/23/24, together. Nurse #3 said the section titled Facility to Complete Prior to Dialysis was incomplete as 3 out of 14 fields were blank. Nurse #3 said nursing should be completing Facility to Complete Prior to Dialysis or Day of Dialysis (Pre-Dialysis) sections, depending on the communication sheet that was used, and the section should be completed in its entirety. Nurse #3 said this included checking any applicable boxes, the nurse's signature, and the time the Resident left for dialysis. Nurse #3 also said one Dialysis Communication Records sheet was to be completed each time Resident #76 left the facility for dialysis. Review of a sample of the Resident's Dialysis Communication Record sheets, specifically the sections titled Complete Prior to Dialysis or Day of Dialysis (Pre-Dialysis), dated from 8/2/24 through 9/23/24, indicated but was not limited to the following: 8/2/24- 4 of 10 fields not completed; 8/5/24- 14 of 14 fields not completed; 8/7/24- 8 of 14 fields not completed; 8/9/24- 5 of 14 fields not completed; 8/10/24- 14 of 14 fields not completed; 8/12/24- 14 of 14 fields not completed; 8/14/24- Review of two Medication Administration notes, both dated 8/14/24, stated Resident #76 was at dialysis. No Dialysis Communication Record sheet for this date was observed in the Resident's medical record; 8/16/24- 5 of 14 fields not completed; 8/19/24- 14 of 14 fields not completed; 8/21/24- 4 of 14 fields not completed; 8/23/24- 4 of 14 fields not completed; 8/26/24- Review of a Nursing Progress note, dated 8/26/24, stated Resident #76 returned from dialysis that day at 10:30 A.M. No Dialysis Communication Record sheet for this date was observed in the Resident's medical record; 8/28/24- 7 of 10 fields not completed; 8/30/24- 5 of 14 fields not completed; 9/2/24- 10 of 14 fields not completed; 9/4/24- 1 of 10 fields not completed; 9/6/24- 2 of 10 fields not completed; 9/9/24- Review of four Medication Administration notes, all dated 9/9/24, stated Resident #76 was at dialysis; no Dialysis Communication Record sheet for this date was observed in the Resident's medical record; 9/13/24- 1 of 14 fields not completed; 9/16/24- 14 of 14 fields not completed; 9/17/24- 9/21/24- Resident was on Medical Leave of Absence (MLOA) from the facility; 9/23/24- 3 of 14 sections not completed. During an interview on 9/25/24 at 10:36 A.M., the DON and the surveyor reviewed several of Resident #76's Dialysis Communication Records sheets from the month of August. The DON said the section titled Facility to Complete Prior to Dialysis or Day of Dialysis (Pre-Dialysis), depending on which communication form was used, should be entirely completed including all applicable boxes checked, a nurse's signature, and the time the Resident left for dialysis. The DON said the weight field was the only acceptable field to remain empty. The DON said the reviewed Dialysis Communication Record sheets from the month of August were incomplete. The DON also said she expected a communication sheet to be completed fully (minus the weight section) each time Resident #76 left the facility for dialysis.

Based on record review and interview, the facility failed to ensure that as needed (prn) orders for psychotropic medications were limited to 14 days, unless otherwise documented by the attending physician or prescribing practitioner that it was appropriate to extend beyond 14 days for three Residents (#31, #112, and #173), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #31, that the prn order for Ativan (antianxiety) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; 2. For Resident #112, that the prn order for Valium (hypnotic) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; and 3. For Resident #173, that the prn order for Valium was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use. Findings include: Review of the facility's policies titled Psychotropic Medication Use and Antipsychotic Medication Use, last revised July 2022, indicated but were not limited to: -Residents will not receive prn doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. -The need to continue prn orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the prn order will be indicated in the order. 1. Resident #31 was admitted to the facility in April 2022 with diagnoses including anxiety. Review of the Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15, and received psychotropic medication daily. Review of Physician's Orders indicated but was not limited to: -Ativan 0.5 milligrams (mg) every four hours as needed for anxiety (9/3/24) During an interview on 9/25/24 at 8:58 A.M., Nurse Practitioner #1 said she is aware that prn orders for psychotropic medications must be limited to 14 days but had not been notified by the facility yet that the order was open-ended. She said she would follow up with nursing. 2. Resident #112 was admitted to the facility in January 2024 with diagnoses including dementia with agitation, depression, and anxiety disorder. Review of the MDS assessment, dated 7/3/24, indicated Resident #112 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15, and received psychotropic medication daily. Review of Physician's Orders indicated, but was not limited to: -Valium 5 mg every six hours as needed (6/6/24) Review of the June 2024 through September 2024 MARs indicated Valium was administered: -June 2024: Five times -July 2024: Five times -August 2024: Seven times -September 2024: Eight times Review of the entire medical record failed to indicate the prn orders for Valium from June 2024 through September 2024 were re-evaluated and a clinical rationale for its continued use was documented in the medical record by either the Physician (MD) or Nurse Practitioner (NP). During an interview on 9/23/24 at 2:22 P.M., Unit Supervisor #6 said the prn order for Valium should have a stop date, but it was missed. During an interview on 9/25/24 at 8:58 A.M., Physician Assistant #2 said he is aware of the requirement for prn orders to have a stop date and documented clinical rationale for continued use and Resident #112's order should have a stop date. 3. Resident # 173 was admitted to the facility in July 2024 with diagnoses including anxiety. Review of the MDS assessment, dated 7/17/24, indicated Resident #173 had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15, and received psychotropic medication daily. Review of Physician's Orders indicated but was not limited to: -Diazepam (Valium) 2 mg as needed daily for anxiety (8/9/24) Review of August 2024 and September 2024 MAR indicated Valium was administered: -August: three times -September: four times Review of the entire medical record failed to indicate the prn orders for Valium from August 2024 through September 2024 were re-evaluated and a clinical rationale for its continued use was documented in the medical record by either the Physician (MD) or Nurse Practitioner (NP). During a telephonic interview on 9/27/24 at 12:51 P.M., Physician #2 said he was not aware that prn orders for psychotropic medication are limited to 14 days and a clinical rationale must be documented in the medical record to extend the prn order.

Based on observation, test tray results, and interview, the facility failed to ensure staff served food that was palatable and at an appetizing temperature for 1 out of 2 test trays conducted. Findings include: During the initial resident screening on 9/17/24, the residents expressed the following concerns about the food at the facility: - Food usually comes up cool - Food is always cold - Food usually comes up cool, even the hot foods - The food is cold sometimes. - Food is often cold; the facility has a tough time controlling that - Food is often cold Review of Food Committee Meeting Minutes, dated 8/27/24, indicated but was not limited to: - French fries are cold Review of Food Committee Meeting Minutes, dated 7/31/24, indicated but was not limited to: - Hard boiled eggs are sometimes undercooked Review of Food Committee Meeting Minutes, dated 4/23/24, indicated but was not limited to: - Food Temps (temperatures) inconsistent On 9/19/24 at 11:53 A.M., the surveyor requested a lunch test tray to the 2A Unit. The food truck left the kitchen at 11:55 A.M., and arrived at the unit at 11:57 A.M. The test tray was conducted with the Food Service Director (FSD) at 12:12 P.M. with the following results in degrees Fahrenheit (F): - Pasta [NAME]: 134 F lukewarm to taste - Broccoli: 132.6 F cold to taste - Garlic Bread: 113 F cold to taste - Cranberry Juice: 53 F cold to taste/touch During an interview on 9/19/24 at 12:20 P.M., the FSD said the temperatures were not within the appropriate ranges, and the hot items should have been hotter for the residents. The FSD said that they have been having a hard time keeping hot foods hot. The FSD said he conducts a test tray maybe monthly.

Based on observations, interviews, and policy review, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain the ice machine in a clean and sanitary manner in three out of four kitchenettes. Findings include: Review of the facility's policy titled Ice Machines and Ice Storage Chests, undated, indicated but was not limited to: - Policy Statement: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. - Policy Interpretation and Implementation: - Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to manufacturer's instructions. The infection preventionist (or designee) maintains a copy of these procedures. On 9/17/24 at 10:37 A.M., the surveyor observed the following in the 2A Unit kitchenette: - Inside the ice machine there was yellowish residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. - Ice Maker Cleaning Schedule posted indicated the months of January, February, March, April, May, June, July, August, and September were blank. On 9/17/24 at 10:57 A.M., the surveyor observed the following in the 2BC Unit kitchenette: - Inside the ice machine there was yellowish and black residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. - Ice Maker Cleaning Schedule was not posted. On 9/17/24 at 12:26 P.M., the surveyor observed the following in the 2BC Unit kitchenette: - Inside the ice machine there was yellowish and black residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. On 9/17/24 at 12:36 P.M., the surveyor observed the following in the 2A Unit kitchenette: - Inside the ice machine there was yellowish residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. On 9/17/24 at 12:39 P.M., the surveyor observed the following in the 1A Unit kitchenette: - Inside the ice machine there was yellowish residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. - Ice Maker Cleaning Schedule posted last signed off January 2024. The months of February, March, April, May, June, July, August, and September were blank. On 9/17/24 at 3:14 P.M., the surveyor observed the following in the 2BC Unit kitchenette: - Inside the ice machine there was yellowish and black residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. On 9/18/24 at 7:13 A.M., the surveyor observed the following in the 2A Unit kitchenette: - Inside the ice machine there was yellowish residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. On 9/18/24 at 7:15 A.M., the surveyor observed the following in the 2BC Unit kitchenette: - Inside the ice machine there was yellowish and black residue/discoloration on one of the plastic components. The discolored component had water dripping down into the ice cubes. During an interview on 9/17/24 at 12:40 P.M., Certified Nursing Assistant (CNA) #1 said the ice machine is used for the residents. CNA #1 said the ice was given to the residents in their water or as ice chips. During an interview on 9/17/24 at 3:35 P.M., Nurse #19 said the ice from the ice machine was used for the residents, to give them a cup of ice water, ice chips, or to fill the water pitcher used for medication pass. During an interview with observation on 9/17/24 at 12:45 P.M., the Food Service Director (FSD) said the ice machines were checked monthly but were not cleaned monthly. The FSD said the ice machines on the 1A, 2A, and 2BC units were dirty and not as clean as they should have been. The FSD director said he did not know how to clean the ice machines or who was responsible for cleaning them. During an interview on 9/17/24 at 1:41 P.M., the Director of Operations said the expectation is for the ice machines to have been checked monthly and the Ice Maker Cleaning Schedule log to have been filled out. The Director of Operations said he was not sure who was responsible for cleaning the ice machines, either housekeeping or dietary was responsible. During an interview on 9/24/24 at 3:35 P.M., the Administrator said the facility did not have a procedure for cleaning the ice machines but there should have been one.

Based on observation, interview, and policy review, for five Residents (#68, #173, #112, #31, and #19), of 24 sampled residents, 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, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for the following Residents: A. For Resident #68, who has chronic wounds, putting him/her at increased risk for infection; B. For Resident #173, who has wounds and a gastrostomy tube; C. For Resident #112, who has a gastrostomy tube and a tracheostomy; D. For Resident #31, who has an indwelling urinary catheter; and E. For Resident #19, who has a wound, putting him/her at increased risk for infection. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated but was not limited to: -Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. -EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing -EBP are indicated for residents with any of the following: a. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO -EBP should be used for any residents who meet the above criteria, wherever they reside in the Facility Review of the facility's policy titled Enhanced Barrier Precautions, dated August 2022, indicated but was not limited to: -EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply a. gloves and gown are applied prior to performing the high contact resident care activity -Examples of high contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care -EBP are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization -Signs are posted in the door or wall outside the resident room indicating the type of precaution and PPE required -PPE is available outside of the residents' rooms A.Resident #68 was admitted to the facility in March 2020 with the following diagnoses: venous insufficiency and chronic wounds to lower extremities. Review of Resident #68's medical record indicated he/she had chronic wounds to his/her lower extremities and was followed by the wound consultant. On the following dates of survey, the surveyor did not observe an EBP sign on the Resident's bedroom door, or anywhere in the immediate vicinity of the Resident's room, and no PPE was available outside or inside the room for staff to use in the event the Resident should require assistance: -9/17/24 at 10:14 A.M. -9/17/14 at 2:56 P.M. -9/18/24 at 8:22 A.M. -9/18/24 at 11:22 A.M. -9/19/24 at 1:56 P.M. -9/23/24 at 10:26 A.M. -9/23/24 at 4:08 P.M. -9/24/24 at 8:05 A.M., the surveyor observed Certified Nursing Assistant (CNA) #5 positioning Resident #68 in bed. CNA #5 was wearing only gloves as PPE. -9/24/24 at 12:32 P.M. -9/24/24 at 12:55 P.M., the surveyor observed two facility staff members transferring Resident #68 from his/her bed to chair. The staff members were wearing only gloves as PPE. Review of Resident #68's Physician's Orders failed to indicate he/she was on EBP. During an interview on 9/24/24 at 12:21 P.M., Nurse #7 and Nurse #4 said there were no residents on that unit requiring any precautions in addition to standard precautions. Nurse #7 and Nurse # 4 said they did not know what EBP was and did not know when or why they would be required. During an interview on 9/24/24 at 12:57 P.M., Unit Manager #2 said Resident #68 did have chronic wounds but was not on any precautions. Unit Manager #2 said she was not aware of EBP. During an interview on 9/24/24 at 1:35 P.M., the Director of Nurses (DON) said Resident #68 had chronic wounds to his/her bilateral lower extremities and was followed by the wound consultant weekly. The DON said Resident #68 did not require any precautions in addition to standard precautions because he/she was not infected with a MDRO. The DON said the EBP program had not been implemented. 34145 B. Resident #173 was admitted to the facility in July 2024 with diagnoses including multiple third degree burns on his/her body, and a gastrostomy tube (feeding tube). Review of the Minimum Data Set (MDS) assessment, dated 7/17/24, indicated Resident #173 had multiple unhealed pressure ulcers, surgical wounds and burns. Review of the medical record indicated Resident #173 was receiving treatment for multiple pressure ulcers, wounds, and gastrostomy tube. Review of the entire medical record failed to indicate an order for EBP for high contact resident care activities. C. Resident #112 was admitted to the facility in January 2024 and had diagnoses including presence of a gastrostomy and a tracheostomy. Review of the MDS assessment, dated 7/3/24, indicated Resident #112 had a gastrostomy and tracheostomy. Review of the medical record indicated Resident #112 was receiving care and treatment for a gastrostomy tube and tracheostomy. Review of the entire medical record failed to indicate an order for EBP for high contact resident care activities. D. Resident #31 was admitted to the facility in August 2017 and had diagnoses including a history of urinary tract infections and urinary retention. Review of the MDS assessment, dated 7/2/24, indicated Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had an indwelling urinary catheter. Review of the medical record indicated Resident #31 was receiving care and treatment for a urinary catheter. Review of the entire medical record failed to indicate an order for EBP for high contact resident care activities. On 9/20/24 at 10:13 A.M., the surveyor observed CNA #6 standing at Resident #31's bedside, the privacy curtain was drawn halfway alongside the bed exposing the Resident's legs. The CNA was observed providing a sponge bath to the Resident's legs while wearing gloves and no gown. The surveyor did not observe an EBP sign on the Residents #173, #112 and #31's bedroom doors, or anywhere in the vicinity of the Residents' rooms, no personal protective equipment was available outside or inside the Residents' rooms for staff to use for high contact resident care activities on the following occasions: -9/18/24 at 9:00 A.M. and 12:00 P.M. -9/19/24 at 1:06 P.M. -9/20/24 at 10:00 A.M. -9/23/24 at 2:10 P.M. -9/24/24 at 7:30 A.M. and 2:00 P.M. -9/25/24 at 10:30 A.M. During an interview on 9/24/24 at 1:57 P.M., Nurse #13 said residents with wounds or indwelling medical devices should be on EBP. She said she doesn't know why Residents #173, #112 and #31 were not placed on EBP. During an interview on 9/24/24 at 10:26 A.M., the Staff Development Coordinator said she is helping with the facility's infection control program until they hire someone to take that role. She said she has not implemented EBP in the facility yet and residents with gastrostomy tubes, catheters and wounds should be on EBP. 48695 E. Resident #19 was admitted to the facility in January 2024 with diagnoses including peripheral vascular disease, end stage renal disease (ESRD), and diabetes mellitus. Review of Resident #19's medical record indicated he/she had an arterial wound to his/her left shin and was followed by the wound consultant. On the following dates of survey, the surveyor did not observe an EBP sign on the Resident 19's bedroom door, or anywhere in the immediate vicinity of the Resident's room, and no PPE was available outside or inside the room for staff to use in the event the Resident should require assistance: - 9/17/24 10:22 A.M. - 9/18/24 12:04 P.M. - 9/19/24 12:54 P.M. - 9/19/24 2:47 P.M. - 9/23/24 11:13 A.M. - 9/24/24 8:42 A.M. - 9/24/24 9:14 A.M. Review of Resident #19's entire medical record failed to indicate an order for EBP for high contact resident care activities. During an interview on 9/24/24 at 9:14 A.M., Nurse #13 said any resident with an open wound should be on EBP but was not. During an interview on 9/25/24 at 3:32 P.M., the DON said she could not speak to EBP because the facility had not implemented them yet in the facility. Refer to 882

Based on document review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. The facility failed to provide the surveyor with their Antibiotic Stewardship Policy for review. The facility failed to provide the surveyor with evidence of antibiotic use protocols and a system to monitor antibiotic use (i.e., infection surveillance and/or a line listing). The facility provided the surveyor with a 3-inch binder labeled Antibiotic Stewardship which contained no information for the past year and contained information dated 2018. During an interview on 9/24/24 at 9:48 A.M., the surveyor met with the Administrator, the Director of Nurses (DON), the Director of Clinical Services, and the Director of Operations. The Director of Clinical Services said the Staff Development Coordinator was responsible for the Infection Control Program and was the Infection Control Nurse. The Director of Clinical Services said the SDC was responsible for the infection surveillance and antibiotic stewardship program. He said what was provided to the surveyor is what the facility was able to provide. During the above noted interview, on 9/24/24 at 9:48 A.M., the Administrator said the facility discussed antibiotics weekly at the risk meeting and kept track of them in an ongoing spreadsheet, but the SDC would be the one to complete the actual surveillance report. During an interview on 9/24/24 at 10:26 A.M., the SDC said she was not the Infection Control Nurse and had never formally agreed to be responsible for the antibiotic stewardship program or infection surveillance. The SDC said the only aspect of infection control she was responsible for was education and helping with the vaccination effort in the facility. The SDC said since she has been employed by the facility, since February of this year, there has never been an infection control nurse and there has never been an antibiotic line listing/surveillance. The facility failed to have a system of monitoring and tracking in place to improve the use of antibiotics within the facility, to protect residents and reduce the threat of antibiotic resistance. As of the end of survey, on 9/25/24, the survey team did not receive any additional information regarding the antibiotic stewardship or infection surveillance. Refer to 882

Based on observations, interviews, and record review, the facility failed to ensure a reasonable accommodation was made for one Resident (#68), of 24 sampled residents. Specifically, the facility failed to ensure the call system was accessible to the Resident to call for staff assistance. Findings include: Review of the facility's policy titled Call System, dated as revised September 2022, indicated but was not limited to: -each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Resident #68 was admitted to the facility in March 2020 with the following diagnoses: dementia, venous insufficiency, and chronic wounds to lower extremities. Review of the Minimum Data Set (MDS) assessment, dated 7/29/24, indicated Resident #68 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS indicated Resident #68 had impaired mobility to both lower extremities. On 9/17/24 at 10:14 A.M., the surveyor observed Resident #68 lying in bed, on his/her right side positioned at an angle with the pillow only partially under his/her head, the call light was hanging against the wall and was not within reach. During an interview on 9/17/24 at 10:15 A.M., Resident #68 said he/she did not have any way of notifying the facility staff that he/she needed help. On 9/17/24 at 2:56 P.M., the surveyor observed Resident #68 lying in bed, the call light was hanging against the wall and was not within reach. On 9/18/24 at 8:22 A.M., the surveyor observed Resident #68 lying in bed, on his/her back with the head of bed elevated, the Resident was closer to the foot of the bed than the head of the bed and the call light was hanging against the wall and was not within reach. On 9/18/24 at 11:22 A.M., the surveyor observed Resident #68 sitting in his/her wheelchair on the right side of the bed, the call light was hanging against the wall (on the left side of the bed) and was not within reach. On 9/19/24 at 1:56 P.M., the surveyor observed Resident #68 lying in bed on his/her right side, the call light was hanging against the wall and was not within reach. On 9/23/24 at 10:26 A.M., the surveyor observed Resident #68 lying in bed on his/her back positioned at an angle closer to the foot of the bed than the head of the bed, the call light was hanging against the wall and was not within reach. During an interview on 9/23/24 at 10:26 A.M., Resident #68 said he/she did not have any way to get help and that he/she would probably just holler. During an interview on 9/23/24 at 10:28 A.M., Rehab Staff #1 said Resident #68 could not reach his/her call light and whoever was with Resident #68 last should have made sure his/her call light was within reach and could have secured it to the railing. During an interview on 9/23/24 at 10:53 A.M., Certified Nursing Assistant (CNA) #4 said residents should always have a call light within reach. During an interview on 9/23/24 at 10:56 A.M., Unit Manager #2 said call lights should always be within reach. During an interview on 9/23/24 at 11:06 A.M., Nurse #4 said call lights should be within reach at all times. On 9/24/24 at 12:32 P.M., the surveyor observed Resident #68 lying in bed on his/her back positioned at an angle, with the pillow only partially under his/her head, the call light was hanging against the wall and was not within reach. During an interview on 9/24/24 at 12:35 P.M., the surveyor and Unit Manager #2 observed Resident #68 without access to his/her call light. Unit Manager #2 said Resident #68 should have his/her call light within reach at all times and maybe he/she should have a hand bell as an alternative. During an interview on 9/24/24 at 1:35 P.M., the Director of Nurses (DON) said call lights should be within reach at all times.

Based on observation, interview, record review, and policy review, the facility failed to review and revise the care plan for one Resident (#31), out of a total sample of 24 residents. Specifically, the facility failed to ensure the care plan was updated to reflect the discontinuation of anticoagulant therapy (medication to break down existing clots or prevent clots from forming). Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised July 2022, indicated but was not limited to: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #31 was admitted to the facility in August 2017 and had diagnoses including a history of traumatic fracture and presence of right artificial knee joint. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and did not receive anticoagulant therapy. Review of the medical record indicated Resident #31 had surgery to his/her right knee in June 2023 and had physician's ordered for Eliquis (anticoagulant) 2.5 milligrams (mg), give one tablet by mouth every 12 hours for prophylaxis for deep vein thrombosis (DVT-a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs) for 14 days (initiated 6/26/23). Review of Resident #31's comprehensive care plans indicated but was not limited to: -Focus: Resident is on anticoagulation therapy related to post-surgical right knee replacement (initiated 6/27/23) -Interventions: Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness every shift; Monitor bleeding every shift (initiated 6/27/23) -Goal: Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date (initiated 6/27/23; target date: 10/8/24) Further review of the medical record indicated on 6/27/23, Resident #31 had bleeding from the surgical site and was sent out to hospital for evaluation. The order for Eliquis was discontinued on 6/27/23 and a new order for aspirin enteric coated 81 mg twice daily was initiated for 30 days, from 6/28/23 to 7/26/23. Review of interdisciplinary care plan meeting documentation indicated care plan meetings were held on 11/22/23, 3/6/24, 4/10/24 and 7/24/24 without a revision to the care plan to reflect the discontinuation of Eliquis on 6/27/23. During an interview on 9/23/24 at 2:22 P.M., Unit Supervisor #6 reviewed Resident #31's care plan for anticoagulant therapy. He said 81 mg of aspirin is not considered anticoagulant therapy and the care plan should have been revised to reflect the discontinuation of anticoagulant therapy when the Eliquis was discontinued on 6/27/23.

Based on observations, interviews, and record review, the facility failed to develop a care plan for one Resident (#141), and implement care plans for 6 Residents (#118, #23, #13, #142, #19 and #62), out of a sample of 40 residents. Specifically, the facility failed: 1. For Resident #141, to develop a care plan to address wandering behavior resulting in a resident-to-resident altercation where the Resident sustained a laceration and skin tears; 2. For Resident #118, to provide supervision with meals per the care plan; 3. For Resident #23, to ensure he/she wore a boot per the physician's orders; 4. For Resident #13, to implement a suicidal ideation care plan; 5. For Resident #142, to apply Geri Sleeves (protect the upper extremities from abrasions, bruises, snags and tears throughout the day. Geri Sleeves use slight compression to aid in relieving the discomfort associated with swelling) as ordered; 6. For Resident #19, to implement a mood care plan; and 7. For Resident #62, the facility failed to provide a communication book per the care plan. Findings include: 1. Resident #141 was admitted to the facility in March 2023 with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 6/23/23, indicated that Resident #141 was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated Resident #141 requires 1 person physical assist with locomotion on the unit. Review of an incident report, dated 7/5/23, indicated Resident #141 has a history of wandering around the unit and that the Resident had wandered into another resident's room leading to an altercation. Resident #141 was pushed, fell , and sustained a skin tear and bruising to bilateral extremities as well as his/her forehead; the Resident was sent to the emergency room for further evaluation. The incident report also indicated the event was not witnessed; staff became aware of the incident when responding to yelling coming from the room. Review of the hospital paperwork indicated Resident #141 presented with upper extremity skin tears, and a laceration over the left brow requiring steri-strips (strips of tape placed across a wound to keep the edges together). Review of a Physician's note, dated 7/5/23, indicated the following: Patient experienced another serious fall today. The circumstances are a bit cloudy though it appears (the Resident) wandered into another resident's room prompting an argument resulting in the fall. The laceration of the eyebrow, nose, and arms are quite large. Review of an Occupational Therapy evaluation, dated 3/23/23, indicated Resident #141 has wandering behaviors. Review of Resident #141's progress notes indicated the Resident has had a reoccurring behavior of wandering first documented by both physician and nursing services within 24 hours of admission in March 2023. Resident #141's wandering behavior was again documented in physician and nursing progress notes on 4/13/23, 5/4/23, 5/12/23, 6/8/23, 6/9/23, 6/12/23, 6/13/23, and the Resident was noted by two different nurses to be wandering into other resident's rooms on 7/14/23. Review of Resident #141's care plans failed to indicate a care plan was developed to address Resident #141's wandering behaviors. Further review of Resident #141's care plans indicated a care plan for potential verbal and physical aggression behavior towards staff and other residents was implemented on 7/12/23, 1 week after the incident. On 7/13/23 at 10:00 A.M., the surveyor observed Resident #141 wandering around the unit. On 7/13/23 at 10:03 A.M., the surveyor observed Resident #141 wandering into the kitchenette unsupervised. The Resident turned the water on and wandered out of the kitchenette. On 7/13/23 at 10:04 A.M., the surveyor observed Resident #141 wandering into another resident's room. Resident #141 closed the door behind him/her. The surveyor entered the room and observed the Resident in the bathroom. The resident who resides in the room was present but staff were not. On 7/13/23 at 10:06 A.M., the surveyor observed Resident #141 wander into a second resident's room; this was unwitnessed by the staff. On 7/13/23 at 10:09 A.M., the surveyor observed Resident #141 wander back into the kitchenette unsupervised and began digging in the trash can. On 7/13/23 at 11:14 A.M., the surveyor observed Resident #141 attempt to wander into an empty shower room. On 7/17/23 at 9:55 A.M., the surveyor observed Resident #141 wandering in the dining room unsupervised. On 7/13/23 at 11:09 A.M., Certified Nursing Assistant (CNA) #9 said Resident #141 frequently wanders, and this is not a new behavior. During an interview on 7/13/23 at 11:10 A.M., CNA #1 said Resident #141 is always wandering so the CNAs need to watch him/her constantly. CNA #1 said the Resident is occasionally found in other resident's rooms. During an interview on 7/17/23 at 9:23 A.M., Nurse #10 said Resident #141 has a known wandering behavior, and that if the Resident enters another resident's room the Resident must be supervised. Nurse #10 said she would have expected a wandering care plan to be developed for any resident exhibiting wandering behaviors. During an interview on 7/17/23 at 2:08 P.M., the Director of Nursing (DON) said she would expect a care plan to be developed if a resident exhibited unsafe wandering behaviors, and that wandering into other resident rooms would be considered unsafe. The DON said Resident #141 must be supervised while ambulating, and that staff should have intervened to prevent Resident #141 from entering the other residents' rooms. The DON said the incident was unwitnessed, and that it happened around dinner time so the staff may have been too busy to supervise the Resident. The DON also said that following the incident, a care plan should have been developed immediately upon return from the hospital to keep the Resident safe. 38141 2. Resident #118 was admitted to the facility in May 2021, and had diagnoses that included hemiplegia (paralysis of one side of the body) following cerebral infarction affecting right dominant side. Review of the most recent MDS assessment, dated 5/26/23, indicated that on the BIMS exam Resident #118 scored a 14 out of 15, indicating intact cognition. The MDS further indicated Resident #118 required extensive assistance from staff for eating. On 7/11/23 at 9:05 A.M., the surveyor observed Resident #118 in bed with a breakfast tray at the overbed table. The surveyor observed thickened liquids and puree consistency food on the breakfast tray. Review of Resident #118's medical record indicated the following: * A current physician's order for aspiration precautions for every shift and puree texture and nectar fluids thickened consistency. Review of Resident #118's current care plan indicated Resident #118 requires a mechanically altered diet and thickened liquids consistency due to dysphagia (difficulty swallowing). The care plan included the following interventions: * Monitor and document/report signs of pocketing food, choking, coughing, holding food in mouth. * Requires assistance from staff to eat, dependent at times. On 7/12/23 at 12:49 P.M., the surveyor observed Resident #118 having lunch in bed. No staff were present to supervise or assist Resident #118. During an observation with an interivew with Resident #118 and their roommate on 7/13/23 at 8:55 A.M., the surveyor observed Resident #118 having breakfast in bed. No staff were present to supervise or assist Resident #118. Resident #118 told the surveyor that staff delivers his/her trays, sets it up and that he/she usually eats by himself/herself; no staff are present to assist him/her. Resident #118's roommate also told the surveyor that Resident #118 eats by himself/herself with no staff assistance or supervision. During an interview on 7/13/23 at 9:00 A.M., Unit Manager #1 said that Resident #118 required supervision and assistance with meals. She told the surveyor that the staff should not have given Resident #118 his/her tray if they are not ready or available to assist him/her. 41105 3. Resident #23 was admitted to the facility in December 2014 and had diagnoses that included epilepsy and fracture of upper and lower end of right fibula. Review of the most recent MDS assessment, dated 6/9/23, indicated that on the BIMS exam Resident #23 scored a 9 out of 15, indicating moderately impaired cognition. The MDS further indicated Resident #23 had no behaviors and required one person physical assistance with dressing. Review of the current Physician's Orders indicated the following order: * WBAT (weight bear as tolerated) in cast boot to right lower extremity (RLE). * May remove ortho boot at bedtime, every night shift, with a start date 4/29/23. Review of the July 2023 Treatment Administration Record (TAR) indicated Nursing signed off, all days in July till present, that Resident #23 wore the boot. Review of the current care plan for Resident #23's fractured right ankle indicated the following intervention: * Check CSM to RLE every shift * WBAT to RLE with cast boot. Next ortho follow up appointment is 5/10/23. On 7/11/23 at 8:42 A.M., the surveyor observed Resident #23 in bed. He/she was not wearing a boot as ordered by the physician. During an observation and interview on 7/11/23 at 10:09 A.M., the surveyor observed Resident #23 in his/her bed not wearing a boot as ordered by the physician. Resident #23 said that he/she is supposed to have a boot on, but that he/she doesn't know where it went. On 7/14/23 at 8:01 A.M., the surveyor observed Resident #23 dressed and in bed. He/she was not wearing a boot as ordered by the physician. On 7/14/23 at 9:00 A.M., the surveyor observed Resident #23 seated in a wheelchair in the hallway with his/her nurse. Resident #23 was not wearing a boot. On 7/14/23 at 11:26 A.M., the surveyor observed Resident #23 using his/her feet to peddle his/her wheelchair forward. Resident #23 was not wearing a boot. During an interview on 7/14/23 at 9:10 A.M., Resident #23's CNA (#7) said that Resident #23 requires full assistance with care, does not have any behavior of refusing care, and that she was not aware that Resident #23 is supposed to wear a boot. During an interview on 7/17/23 at 7:29 A.M., Resident #23's Nurse (#8) said that she called that morning to get an order to discontinue the boot when she could not find the boot in Resident #23's room. During an interview on 7/17/23 at 7:52 A.M., the Rehabilitation Director said that she thinks Resident #23 came back from an ortho appointment recently with a recommendation to discontinue the boot, but that she did not have a hard copy of the recommendation in the facility. As well, she was unaware that the physician had not discontinued the order. During an interview on 7/17/23 at 8:46 A.M., the DON said the expectation was that Resident #23 wear the boot as ordered. She said if Resident #23 had a recommendation to discontinue the ortho boot, Nursing or Rehab would have called the Physician to have the order discontinued. 4. Resident #13 was admitted to the facility in April 2018 and had diagnoses that included bipolar disorder, major depressive disorder, and personal history of suicidal ideation (SI). Review of the most recent MDS assessment, dated 5/19/23, indicated Resident #13 had a BIMS exam score of 8 out of 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 reported feeling depressed and having little energy 7-11 of the past 14 days and has active diagnoses of depression, anxiety, and bipolar disorder. Review of the record indicated Resident #13 was psychiatrically hospitalized at [local area hospital] in April 2018 and had attempted suicide in 2017. Review of the current care plans for Resident #13 failed to indicate a care plan had been developed to address Resident #13's SI and history of suicide attempts. Review of the most recent Psychiatric Evaluation & Consultation, dated 6/7/23, indicated Resident #13 has a history of SI. During an interview on 7/13/23 at 9:55 A.M., Resident #13 said that he/she has a history of SI, that he/she has tried to hang him/herself in the past and take pills to kill him/herself. Resident #13 said he/she presently thinks about killing him/herself and is depressed but we aren't near the woods so I can't hang myself and I'm not good at taking pills. Resident #13 said that he/she would like to speak to a therapist and became tearful during the conversation stating, I just feel so ashamed. During an interview on 7/13/23 at 10:01 A.M., Resident #13's Nurse (#2) said that she was not aware that the Resident had a history of SI. The surveyor informed Nurse #4 of exactly what Resident #13 had said, including that he/she presently is thinking about SI. Nurse #4 thanked the Surveyor, wrote in her notes to have psych see Resident #13 then continued working at her medication cart. She did not assess Resident #13 or notify any staff. * At 10:03 A.M., Nurse #4 walked away from the medication cart, in another direction to pass medication to another resident. * At 10:06 A.M., the surveyor remained across from Resident #13's room and requested staff call the Social Worker (SW). During an interview on 7/13/23 at 10:08 A.M., the facility's Social Worker (SW) #1 said that Resident #13's mood fluctuates up and down. SW #1 said that she had worked at the facility for three years and was unaware that Resident #13 had a history of SI. SW #1 said that there should be a care plan in place for any resident with a history or with active SI. She said, I will have psych see Resident #13 and put a care plan in place. SW #1 then went to speak with Resident #13. * At 10:17 A.M., SW #1 updated the surveyor that Resident #13 doesn't have a plan to kill him/herself today, but I'll put a call out to psych. During an interview on 7/13/23 at 10:29 A.M., Resident #13's CNA (#2) said that she was unaware that the Resident had a history of SI but that Resident #13 wouldn't respond to her that day and his/her roommate told her Resident #13 wasn't in a good mood. During an interview on 7/13/23 at 1:50 P.M., with the DON and Nursing Home Administrator (NHA) the DON said that if a resident has a history of SI there should be a care plan in place to monitor for SI, changes in mood, and safety. 44095 5. Resident #142 was admitted to the facility in March 2023 with diagnoses including dementia, urinary retention, hearing loss, and sepsis. Review of the MDS assessment, dated 6/2/23, indicated Resident #142 had no behaviors and did not refuse care. The MDS indicated he/she required extensive assistance of two for dressing. Review of the Physician's Order indicated: -4/5/23 Geri Sleeves to BUE (bilateral upper extremities) every shift for protection. Remove during care to assess skin. -6/2/23 Geri Sleeves to bilateral upper extremities. Put on in AM (morning) and remove at bedtime, every morning and at bedtime for skin integrity. Review of the plan of care related to skin integrity, dated 4/5/23, indicated for Geri-Sleeves to BUE/ Or long sleeve shirts. Review of the Treatment Administration Record, dated July 2023, indicated nursing implemented the physician's ordered Geri Sleeves each shift on 7/11/23, 7/12/23, 7/13/23, and 7/14/23. On 7/11/23 at 7:59 A.M., 7/11/23 at 9:46 A.M., 7/11/23 at 2:20 P.M., 7/12/23 at 6:44 A.M., 7/12/23 at 10:00 A.M., 7/12/23 at 11:51 A.M., 7/13/23 at 6:39 A.M., 7/13/23 at 8:44 A.M., 7/14/23 at 7:02 A.M., and 7/14/23 at 9:13 A.M., the surveyor did not observe Resident #142 wearing his/her Geri Sleeves or wearing a long sleeve shirt. During an interview on 7/13/23 at 10:00 A.M., CNA #5 said Resident #142 bruises easily and gets skin tears and said was not aware that Resident #142 required Geri Sleeves. During an interview on 7/13/23 at 1:47 P.M., Nurse #4 said Resident #142 bruises and gets skin tears easily. Nurse #4 said that she was not aware that Resident #142 required Geri Sleeves. On 7/14/23 at 7:02 A.M., the surveyor, accompanied by Nurse #5, observed Resident #142 in bed; there were no Geri Sleeves on his/her arms and Resident #142 was wearing a short sleeved johnny (hospital gown). On 7/14/23 at 9:13 A.M., the surveyor, accompanied by the Assistant Director of Nursing (ADON), observed Resident #142 out of bed in a common dining room. Resident #142 was not wearing his/her Geri Sleeves or a long sleeve shirt. The ADON said Resident #142 should be wearing Geri Sleeves. During an interview on 7/14/23 at 11:38 A.M., the DON said nursing should have implemented the physician's ordered Geri Sleeves. 43807 6. Review of the care plan policy titled 'Behavior management/Trauma informed Care' with no revision date indicated the following: *It is the policy of this facility to provide an interdisciplinary approach for the care of residents who have a diagnosis of a mental disorder. Residents demonstrating changes in behavior and mood shall be evaluated to ensure appropriate interventions. *Diagnoses with resulting behavioral symptoms and approaches shall be placed in the resident specific plan of care and communicated to the care staff and other departments as appropriate. Resident #19 was admitted to the facility in October 2022 with diagnoses including bipolar disorder. Review of the most recent MDS assessment, dated 6/2/23, indicated a BIMS score of 3 out of 15 indicating severe impairment. Review of a Psychiatric Note, dated 4/5/23, indicated that Resident #19 has a diagnosis of bipolar disorder defining the Resident's mood as irritable, easily agitated and labile. The progress note further indicated that the Resident had recently been engaged with a physical altercation with another resident. During an interview on 7/13/23 at 7:16 A.M., the Social Worker said a mood disorder care plan should be implemented with personalized interventions. During an interview on 7/13/23 at 7:17 A.M., the ADON said Resident #19 should have a mood disorder care plan with individualized interventions. 7. Review of the facility's policy titled 'Foreign Language', with no revision date, indicated the following: *Facility to maintain an up to date language manual for use of staff. *Facility will maintain and make available company's language manual to staff. *Staff to utilize manual to assist in communicating with Resident in their dominate language of understanding Resident #62 was admitted to the facility in March 2023 with diagnoses including dementia. Review of the most recent MDS assessment, dated 6/16/23, indicated a BIMS score of 99 which indicates the Resident is rarely understood/rarely interviewable. On 7/11/23 at 1:24 PM, the surveyor observed Resident #62 eating while propped up in bed. He/she tried to communicate with the surveyor in Cantonese; no communication book was observed in the room. On 7/12/23 at 9:11 A.M., the surveyor observed Resident #62 waiting for breakfast in bed. He/she tried to communicate with the surveyor in Cantonese; no communication book was observed in the room. Review of Resident #62's communication care plan, initiated 10/5/22, indicated the following: *I am Cantonese speaking. I have a communication book in my room that staff can use to communicate with me. During an interview on 7/13/23 at 7:24 A.M., CNA #1 said she speaks English; she has never seen a communication book in the room. She said she makes up ways to communicate with the Resident and hopes the Resident understands. She said it is difficult to provide care for the Resident with the language barrier, and it would be very helpful if there was a communication book in the room with basic tasks in Cantonese. During an interview on 7/13/23 at 7:35 A.M., the Social Worker said residents who speak a second language should have a communication book in their rooms so staff are able to communicate with them as per the care plan. During an interview on 7/13/23 at 8:19 A.M., the Director of Nurses said per the communication care plan, there should be a communication book in the Resident's room so staff can communicate with the Resident.

Based on observation, record review, and staff interviews, the facility failed to: 1. Ensure that the wound physician's recommendations were addressed and transcribed timely and accurately resulting in a delay of treatment for a skin injury on left foot/heel. Subsequently, the wound deteriorated to a Stage IV pressure injury and required an Intravenous (IV) antibiotics for treatment for one Resident (#124); and 2. Follow the physician's orders for prevention of a pressure ulcer for one Resident (#24), out of a total sample of 40 residents. Findings include: 1. Resident #124 was admitted to the facility in April 2023, with diagnoses including type 2 diabetes mellitus and hemiplegia (paralysis of one side of the body) following cerebral infarction affecting the left non-dominant side. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/23/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #124 scored 5 out of 15, indicating moderately impaired cognition. The MDS further indicated that Resident #124 is dependent on the staff with daily care. On 7/11/23 at 10:01 A.M., the surveyor observed Resident #124 sleeping on an air mattress bed in his/her room. The surveyor also observed Resident #124 wearing heel protectors to his/her bilateral feet. Review of Resident #124's admission skin assessment, dated 4/18/23, indicated a pressure area to the left and right heels. The skin assessment did not indicate the stage of the skin injury. The admission skin assessment further failed to indicate the size or description of the wound. Review of Resident #124's admission Norton Scale assessment (a scale used to predict the likelihood the patient will develop a pressure ulcer), dated 4/18/23, indicated a score of 6 indicating he/she was at risk for developing a pressure ulcer. Review of the Wound Physician's Progress Note, dated 4/27/23, (nine days since the wound was identified) indicated the following: Initial evaluation, Unstageable due to necrosis (dead tissue) of the left heel. Etiology: pressure, wound size: 3 centimeters (cm) length x 4 cm width, depth is immeasurable due to necrosis. Treatment/plan: apply skin prep (a protective film or barrier) to left heel each shift (3x day) for 30 days. Review of Resident #124's Electronic Treatment Administration Record (ETAR) for April 2023 and May 2023 indicated the wound physician's recommendation on 4/27/23 for skin prep to left heel three times a day was transcribed inaccurately as once a day resulting in the Resident receiving skin prep to the pressure ulcer inaccurately for a total of five days. Review of the Wound Physician's Progress Note, dated 5/4/23, indicated the following: Stage 4 (full thickness ulcer with the involvement of the muscle or bone) post debridement of dead tissues of the left heel. Wound size: 3 cm x 4 cm x 0.1 cm depth. Treatment/plan: discontinue skin prep and start xeroform gauze (non-adherent dressing that helps maintains a moist wound environment) apply once daily for 30 days, and ABD pad (used to help absorb heavily draining wounds), apply once daily for 30 days. Review of Resident #124's Electronic Treatment Administration Record (ETAR) for May 2023 indicated the wound physician's recommendation on 5/4/23 for xeroform, and ABD pad once daily to left heel wound was not implemented until 5/10/23, seven days after the recommendations resulting in the Resident not receiving the new treatment order for a total of six days. Review of the Wound Physician's Progress Note, dated 5/11/23, indicated the following: Stage 4 wound of the left heel. Wound size: 4 cm x 3 cm x 0.1cm. Treatment/plan: continue with xeroform gauze, once daily for 23 days, and ABD pad, once daily for 23 days. Review of the Wound Physician's Progress Note, dated 5/17/23, indicated the following: Stage 4 wound of the left heel. Wound size: 4 cm x 3 cm x 0.1 cm. Treatment/plan: continue with xeroform gauze, once daily for 23 days, and ABD pad, once daily for 17 days. Review of the Wound Physician's Progress Note, dated 5/24/23, indicated the following: Stage 4 wound of the left heel. Wound size: 5 cm x 4 cm x 0.1 cm. Treatment/plan: discontinue xeroform gauze and start Santyl (helps to removed damaged tissue from chronic skin injury), once daily for 30 days. Alginate calcium (designed for moderately to heavily exudating wounds, helps reduce bacterial infections), apply once daily for 30 days. Continue ABD pad, once daily for 10 days. Review of Resident #124's ETAR for May 2023 and June 2023 indicated the wound physician's recommendation on 5/24/23 for Santyl, and alginate calcium once daily to left heel wound was transcribed inaccurately. Santyl was not started until 5/26/23, two days after the recommendations were made, and the calcium alginate once daily was not transcribed and implemented at all, resulting in a total of 20 missed doses. Review of the Wound Physician's Progress Note, dated 5/31/23, indicated the following: Stage 4 wound of the left heel. Wound size: 5 cm x 4 cm x 0.3 cm. Treatment/plan: continue Santyl once daily for 23 days. Alginate calcium, apply once daily for 23 days. Continue ABD pad, once daily for 30 days. Review of the Wound Physician's Progress Note, dated 6/7/23, indicated the following: Stage 4 wound of the left heel. Wound size: 5 cm x 6 cm x 0.3 cm. Treatment/plan: continue Santyl once daily for 16 days. Alginate calcium, apply once daily for 16 days. Continue ABD pad, once daily for 23 days. Review of the the Physician's order note, dated 6/9/23, indicated an order for Doxycline (used to treat/prevent infection) 100 milligrams twice a day for left heel infection for 6 weeks. Review of the Wound Physician's Progress Note, dated 6/14/23, indicated the following: Stage 4 wound of the left heel. Wound size: 5 cm x 7 cm x 0.3 cm. Treatment/plan: discontinue Santyl, and alginate calcium. Start sodium hypochlorite solutions (an antiseptic used to clean infected wounds), apply once daily for 30 days: 1/4 strength, and pack with gauze. Continue with ABD pad, once daily for 16 days. Review of Resident #124's ETAR for June 2023 indicated the wound physician's recommendations on 6/14/23 for sodium hypochlorite solution, once daily to left heel wound was not implemented until 6/17/23, three days after the recommendations were made. Review of the Wound Physician's Progress Note, dated 6/21/23, indicated the following: Stage 4 wound of the left heel. Wound size 5 cm x 7 cm x 0.3 cm Treatment/plan: continue with sodium hypochlorite solution, apply once daily, 1/4 strength, and pack with gauze for 23 days. Continue with ABD pad, once daily for 9 days. Review of Resident #124's medical record indicated failed PO (by mouth) antibiotics and started on IV Vancomycin (a medication used to treat infection caused by bacteria) 750 milligrams twice a day on 6/25/23 for osteomyelitis (an infection in a bone) on his/her left heel wound. Resident #124 was not seen by the wound physician on 6/28/23. Resident #124 was at the hospital for Intravenous line (IV) access replacement. During an interview on 7/12/23 at 11:00 A.M., the Attending Physician said that he agrees with the Wound Physician's recommendations unless it's an extreme measure like a surgical procedure. He said that he reviewed and agreed with the Wound Physician's recommendations, but he was not aware that it was not transcribed accurately and implemented in a timely manner. During an interview on 7/12/23 at 11:25 A.M., the Assistant Director of Nursing (ADON) and Nurse Supervisor both reviewed Resident #124's medical record, including physician's orders and treatments for the wound on the left heel. Both the ADON and Nurse Supervisor said that recommendations by the wound physician were not transcribed accurately and transcribed in a timely manner. During an interview on 7/12/23 at 1:58 P.M., the Wound Physician said that on his initial visit on 4/27/23, Resident #124's heels were not open and that he ordered skin prep three times a day. He said that on 5/4/23, with permission from Resident 124's health surrogate, he performed skin debridement to remove necrotic tissue on the left heel and ordered xeroform daily as treatment. He said that on his visit on 5/24/23, he noted increased drainage on the left heel wound and ordered to start Santyl and calcium alginate. He said he was not aware that his recommendations for wound treatment were not done accurately and in a timely manner. 44095 2. Resident #24 was admitted to the facility in March 2023 with diagnoses including metabolic encephalopathy, diabetes, heart failure, dysphagia, end stage renal disease, and convulsions. Review of the facility's policy titled Alternation Pressure Air Mattress, dated August 2016, indicated the policy of this facility is to use an alternating air mattress to: b. relieve pressure and aid in healing and/or prevention of pressure ulcers. 5. set to resident's weight. Review of the MDS assessment, dated 7/3/23, indicated Resident #24 can make self understood and he/she can understand others. The MDS indicated Resident #24 had no behaviors and indicated Resident #24 had one stage 4 pressure ulcer (deep wounds that may impact muscle, tendons, ligaments, and bone) pressure ulcer and one stage 2 pressure ulcer (skin has broken through the top layer of skin (epidermis) and some of the layer below (dermis). The break typically creates a shallow, open wound pressure ulcer. Review of the Physician's Orders indicated: - 3/23/23 Air Mattress: Check for padding and correct air pressure 150 alternating every shift. - 6/29/23 STAGE 2 PRESSURE WOUND OF THE LEFT BUTTOCK, Wash w NS (with normal saline) pat dry, apply Santyl (prescription ointment used to remove dead tissue), followed by calcium alginate (highly absorbent, biodegradable alginate dressing derived from seaweed), cover with foam silicone every evening shift - 6/29/23 STAGE 4 PRESSURE WOUND SACRUM, Wash w NS pat dry, apply Santyl, followed by calcium alginate, cover with foam silicone, every evening shift Review of the [NAME] assessment, dated 6/25/23, indicated Resident #24's risk for pressure ulcer development score of 6 which indicated high risk. Review of the weight record, dated 7/7/23, indicated Resident #24 weighed 139 pounds. Review of the Resident's skin assessment, dated 7/9/23 at 22:00, indicated wound in coccyx, still open, no drainage, no odor, clean dressing apply on the surface. Review of the plan of care related to potential/actual skin impairment, dated 3/23/23, indicated: - low loss air mattress. On 7/11/23 at 8:19 A.M., 7/11/23 at 10:30 A.M., 7/11/23 at 2:15 P.M., 7/12/23 at 6:45 A.M., 7/12/23 at 12:59 P.M., 7/13/23 at 6:40 A.M., 7/13/23 at 7:57 A.M., 7/14/23 at 6:57 A.M., and on 7/14/23 at 9:44 A.M., the surveyor observed Resident #142 in bed and the air mattress was set to 400 pounds. During an interview on 7/13/23 at 10:09 A.M., Certified Nurse Assistant (CNA) #5 said the nurses adjust air mattress settings. During an interview on 07/13/23 at 11:50 A.M., CNA #6 said the nurses adjust air mattress settings. During an interview on 07/13/23 at 1:36 P.M., Nurse #4 said air mattresses are checked during rounds and set to the resident's weight. Nurse #4 said the CNAs do not touch air mattress settings. During an interview on 7/14/23 at 8:36 A.M., Nurse #5 said air mattresses are checked during rounds and set to the resident's weight. Nurse #4 said the CNAs do not touch air mattress settings. On 7/14/23 at 9:44 A.M., the surveyor and the ADON went to Resident #24's room and observed the air mattress set to 400 pounds. The ADON said that Resident #24's air mattress is for his/her pressure ulcers and nursing should have implemented the physician's order and set the air mattress to the correct settings. During an interview on 7/14/23 at 11:47 A.M., the DON said Resident #24's air mattress is for his/her pressure ulcers and nursing should have implemented the physician's order and set the air mattress to the correct settings.

Based on observations, record review, and interview, the facility failed to ensure that the resident environment remained free of accident hazards. Specifically, the facility failed: 1. For Resident #141, to provide adequate supervision and assistance with ambulation resulting in a fall with skin tears and a laceration following a resident-to-resident altercation; 2. For Resident #13, to ensure fall mats were in place, as ordered by the Physician and indicated in his/her plan of care; 3. For Resident #23, to ensure seizure pads were placed on the bed's interior side rail to protect Resident #23 during a seizure; 4. For Resident #46, to ensure the facility policy for supervised smokers was adhered to and that interventions were put in place, following Resident #46's violating the smoking policy; 5. For Resident #82, to ensure the smoking policy was adhered to, resulting in Resident #82 smoking in bed and continuing to obtain cigarettes from Resident #46 following the initial incident on 7/11/23; and 6. For Resident #73, to follow the plan of care for ensuring safe access to smoking materials. 1. Resident #141 was admitted to the facility in March 2023 with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 6/23/23, indicated that Resident #141 was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated Resident #141 requires 1 person physical assist with locomotion on unit. Review of an Incident Report, dated 7/5/23, indicated Resident #141 has a history of wandering around the unit and that the Resident had wandered into another resident's room leading to an altercation. Resident #141 was pushed, fell , and sustained a skin tear and bruising to bilateral extremities as well as his/her forehead; the Resident was sent to the emergency room for further evaluation. The incident report also indicated the event was not witnessed, as staff became aware of the incident when responding to yelling coming from the room. Review of the hospital paperwork indicated Resident #141 presented with upper extremity skin tears, and a laceration over the left brow requiring steri-strips (strips of tape placed across a wound to keep the edges together). Review of a Physician's Note, dated 7/5/23, indicated the following: Patient experienced another serious fall today. The circumstances are a bit cloudy though it appears (the Resident) wandered into another resident's room prompting an argument resulting in the fall. The laceration of the eyebrow, nose, and arms are quite large. Review of Resident #141's care plans indicated the following: *The resident has an Activities of Daily Living (ADL) self-care performance deficit related to confusion, Dementia -ambulates with supervision on unit, assist as needed, initiated 7/3/23 Review of the Physical Therapy Discharge Summary indicated Resident #141 requires supervision - stand by assistance with all ambulation to promote safety. On 7/13/23 at 10:00 A.M., the surveyor observed Resident #141 wandering around the unit. On 7/13/23 at 10:03 A.M., the surveyor observed Resident #141 wandering into the kitchenette unsupervised. The Resident turned the water on, and wandered out of the kitchenette. On 7/13/23 at 10:04 A.M., the surveyor observed Resident #141 wandering into another resident's room. Resident #141 closed the door behind him/her, the surveyor entered the room and observed the Resident in the bathroom, the resident who resides in the room was present but staff were not. On 7/13/23 at 10:06 A.M., the surveyor observed Resident #141 wander into a second resident's room, this was unwitnessed by the staff. On 7/13/23 at 10:09 A.M., the surveyor observed Resident #141 wander back into the kitchenette unsupervised and began digging in the trash can. On 7/13/23 at 11:14 A.M., the surveyor observed Resident #141 attempt to wander into an empty shower room. On 7/17/23 at 9:55 A.M., the surveyor observed Resident #141 wandering in the dining room unsupervised. During an interview on 7/13/23 at 11:09 A.M., Certified Nursing Assistant (CNA) #9 said Resident #141 frequently wanders, and this is not a new behavior. During an interview on 7/13/23 at 11:10 A.M., CNA #1 said Resident #141 is always wandering so the CNAs need to watch him/her constantly. CNA #1 said the Resident is occasionally found in other residents' rooms. During an interview on 7/17/23 at 9:23 A.M., Nurse #10 said Resident #141 has a known wandering behavior, and that if the Resident enters another resident's room the Resident must be supervised. Nurse #10 said she would have expected a wandering care plan to be developed for any resident exhibiting wandering behaviors. During an interview on 7/17/23 at 2:08 P.M., the Director of Nursing (DON) said she would expect a care plan to be developed if a resident exhibited unsafe wandering behaviors. The DON said Resident #141 must be supervised while ambulating, and that staff should have intervened to prevent Resident #141 from entering the other residents room. The DON said the incident was unwitnessed, and that the details of the incident were obtained from the other resident involved in the altercation (Resident #89) as no staff were present. The DON said the incident happened around dinner time so the staff may have been too busy to supervise the Resident. During an interview on 7/17/23 at 2:49 P.M., Resident #89 said that Resident #141 had wandered into his/her room, and that staff were not present in the room at the time of the incident. 41105 2. For Resident #13 the facility failed to ensure fall mats were in place, as ordered by the Physician, and indicated in his/her plan of care. Resident #13 was admitted to the facility in April 2018 and had diagnoses that included dementia and spinal stenosis. Review of the most recent MDS assessment, dated 5/19/23, indicated Resident #13 had a BIMS exam score of 8 out of 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 requires extensive two person assist with bed mobility and transfers. On 7/11/23 at 8:18 A.M., the surveyor observed Resident #13 lying in bed, with the head of the bed nearly flat. The Resident was attempting to bend forward in bed and appeared, based on his/her position, to be a fall risk. There were no fall mats in place. During a record review on 7/11/23 at 9:44 A.M., the following was indicated: * A care plan with a focus: Resident #13 is at risk for falls r/t Gait/balance problems. The care plan interventions include: -Floor matt (sic) on the left side of bed. * The Kardex (resident specific care instructions) under the section titled Safety indicated an intervention Floor matt (sic) on the left side of bed. * Current MD order : May have floor mats L side of the bed, start 9/9/22 Review of Fall incident reports indicated Resident #13 fell : * On 8/19/22 from bed; * On 8/25/22 from bed; * On 10/14/22 in the bathroom; and * On 1/6/23 from bed. On 7/12/23 at 8:02 A.M., the surveyor observed Resident #13 in bed. There was no fall mat in place. A CNA was in the room and failed to put the fall mat in place on the left side of the bed. On 7/12/23 at 12:02 P.M., the surveyor observed Resident #13 in bed. There was no fall mat in place. A CNA was in the room and failed to put the fall mat in place on the left side of the bed. On 7/13/23 at 7:54 A.M., the surveyor observed Resident #13 in bed. There was no fall mat in place. A CNA was in the room and failed to put the fall mat in place on the left side of the bed. During an interview on 7/13/23 at 10:29 A.M., Resident #13's CNA (#2) said it is only her second day working on the floor and that she knows she can read the Kardex for instructions on Resident #13's care needs, but to be honest I never looked at his/hers. CNA #2 said that she was unsure if Resident #13 had ever had any falls or if he/she was supposed to have a fall mat in place. During an interview on 7/13/23 at 11:08 A.M., Resident #13's Nurse (#2) said she did not know if Resident #13 had ever fallen and did not know what the Kardex is. Nurse #4 said that she thinks CNAs should put floor mats in place but isn't sure. During an interview on 7/17/23 at 1:11 P.M., the DON said a fall mat should be in place for Resident #13. 3. For Resident #23, the facility failed to ensure seizure pads were placed on the bed's interior side rail to protect Resident #23 during a seizure. Review of the facility's policy titled Emergency Procedure-Seizure Management, revised March 2011, indicated: * Obtain and have on hand equipment and supplies, including suction equipment and artificial airway, to help manage an active seizure. Resident #23 was admitted to the facility in December 2014 and had diagnoses that included epilepsy and fracture of upper and lower end of right fibula. Review of the most recent MDS assessment, dated 6/9/23, indicated that on the BIMS exam Resident #23 scored a 9 out of 15, indicating moderately impaired cognition. The MDS further indicated Resident #23 had no behaviors and required extensive one person physical assist with bed mobility, dressing and eating. The MDS indicated Resident #23's active diagnoses to include: seizure disorder or epilepsy. On 7/11/23 at 8:42 A.M., the surveyor observed Resident #23 in bed. He/she was wearing a helmet. The right side rail was padded, however the padding on the left side rail was on the outside of the rail, exposing Resident #23 to the rail should he/she have a seizure. Review of the current Physician's Orders indicated an order seizure precautions, every shift. Review of the most recent Licensed Nursing Summary, dated 6/23/23, indicated Resident #23 was dependent for bed mobility, had no behaviors and had seizure precautions q-shift (each shift). On 7/11/23 at 10:09 A.M., the surveyor observed Resident #23 in bed. He/she was wearing helmet. The right side rail was padded, however the padding on the left side rail was on the outside of the rail, exposing Resident #23 to the rail should he/she have a seizure. On 7/12/23 at 6:50 A.M., the surveyor observed Resident #23 in bed. He/she was wearing helmet. The right side rail was padded, however the padding on the left side rail was on the outside of the rail, exposing Resident #23 to the rail should he/she have a seizure. On 7/13/23 at 7:25 A.M., the surveyor observed Resident #23 in bed. He/she was wearing helmet. The right side rail was padded, however the padding on the left side rail was on the outside of the rail, exposing Resident #23 to the rail should he/she have a seizure. On 7/13/23 at 9:42 A.M., the surveyor observed Resident #23 in bed. He/she was wearing helmet. The right side rail was padded, however the padding on the left side rail was on the outside of the rail, exposing Resident #23 to the rail should he/she have a seizure. During an interview on 7/14/23 at 9:10 A.M., Resident #23's CNA (#7) said that she thinks Resident #23's last seizure was last week. CNA #7 said Resident #23 needs pads on the bed side-rails to protect his/her head when he/she has seizures. During an interview on 7/17/23 at 7:29 A.M., Resident #23's Nurse (#8 ) said that seizure precautions mean that the Resident should have padded side rails to both rails while in bed. During an interview on 7/17/23 at 8:46 A.M., the DON said that Resident #23 requires padded side rails for seizure precautions. She said that the padding should be affixed to the interior of the bed rail, not the exterior. 4. For Resident #46 the facility failed to ensure the facility policy for supervised smokers was adhered to and that interventions were put in place, following Resident #46's violating the smoking policy. Review of the facility's policy titled Smoking Policy and Procedure, undated indicated the following: * Upon admission, request to smoke, annually and as needed residents will have a Smoking Assessment completed. Smokers will be determined to be either Supervised or Independent. Brush Hill Center will offer two separate programs to accommodate all smokers. Supervised smokers will have direct and continual supervision during all smoking periods. * No lighters or matches will be retained in the possession of the residents. * Supervised smokers will also keep their cigarettes in a locked cart. * Residents may not share, borrow, purchase smoking material from one another. * Brush Hill Care Center reserves the right to periodically check a resident's belongings if they are known to violate the smoking program. Staff will ensure smoking materials are stored safely and smoking assessment will be completed, re-education on smoking policy and procedures will be provided. Resident #46 was admitted to the facility in March 2022 and has diagnoses that include chronic obstructive pulmonary disease and dementia. Review of the most recent MDS assessment, dated 4/21/23, indicated that on the BIMS exam Resident #46 scored an 11 out of possible 15, indicating moderately impaired cognition. On 7/11/23 at 8:37 A.M., the surveyor observed Resident #46 in his/her room. On his/her dresser were multiple cases and packs of cigarettes and straight razors. Resident #46 said he/she keeps them in his/her room. Review of the most recent Smoking Assessment for Resident #46, dated 2/6/23, indicated Resident #46 is a supervised smoker. Resident #46 signed the facility Smoking Policy on 2/15/23. On 7/11/23 at 10:41 A.M., the surveyor observed Resident #46 in his/her room. Resident #82 briefly entered the room and moments later walked out with two cigarettes. On 7/11/23 at 10:53 A.M., the surveyor observed a hospice nurse report to the Nurse Unit Manager (#2) that Resident #46 provided cigarettes to Resident #82. On 7/11/23 at 2:16 P.M., the surveyor observed Resident #46 in bed asleep. Cartons and cases of cigarettes remained in the room both on the dresser and the bedside table, which is visible from the hall. On 7/12/23 at 6:47 A.M., the surveyor observed Resident #46 in bed asleep. Cartons and cases of cigarettes remained in the room both on the dresser and the bedside table, which is visible from the hall. During an interview on 7/12/23 at 7:14 A.M., CNAs #4 and #3 both said residents cannot keep cigarettes or lighters in their rooms, that the items are locked up with reception and that if they noticed the items in the room they would notify the nurse. During an interview on 7/12/23 at 8:08 A.M., Resident #46 told the surveyor that he/she gives Resident #82 cigarettes every day. On 7/17/23 at 8:04 A.M., the surveyor observed that Resident #46 was not in his/her room and there were cartons and cases of cigarettes both on the dresser and the bedside table, which was visible from the hall. During an interview on 7/17/23 at 9:08 A.M., the DON and Nursing Home Administrator said that as soon as the Nurse Unit Manager learned that Resident #46 provided cigarettes to a peer on 7/11/23 the following should have occurred: * Resident #46 would have the cigarettes removed from his/her room, a progress note written, a new smoking assessment completed. The DON could not say why Resident #46 was assessed to be a supervised smoker and the policy was not being adhered to. 5. For Resident #82 the facility failed to ensure the smoking policy was adhered to, resulting in Resident #82 smoking in bed and continuing to obtain cigarettes from Resident #46 following the initial incident on 7/11/23. Review of the facility's policy titled Smoking Policy and Procedure, undated indicated the following: * Upon admission, request to smoke, annually and as needed residents will have a Smoking Assessment completed. Smokers will be determined to be either Supervised or Independent. Brush Hill Center will offer two separate programs to accommodate all smokers. Supervised smokers will have direct and continual supervision during all smoking periods. * No lighters or matches will be retained in the possession of the residents. * Supervised smokers will also keep their cigarettes in a locked cart. * Residents may not share, borrow, purchase smoking material from one another. * Brush Hill Care Center reserves the right to periodically check a resident's belongings if they are known to violate the smoking program. Staff will ensure smoking materials are stored safely and smoking assessment will be completed, re-education on smoking policy and procedures will be provided. Resident #82 was admitted to the facility on [DATE] and had diagnoses that included dementia, schizoaffective disorder, and alcohol abuse. Review of the most recent MDS assessment, dated 6/30/23, indicated that on the BIMS exam Resident #82 scored a 7 out of 15, indicating severe cognitive impairment. The MDS further indicated Resident #82 had no behaviors. Review of the Hospital Discharge Summary when Resident #82 was initially admitted to the facility indicated Current every day smoker (smokes about 5-6 cigarettes per day) and that he/she refused NRT (Nicotine Replacement Therapy). The problem list in the discharge paperwork indicated Resident #82 refuses nicotine cessation and gets very annoyed when he/she cannot go outside to smoke. Review of the medical record failed to indicate Resident #82 had ever had a Smoking Assessment. Review of the care plan failed to indicate Resident #82 was ever care planned for smoking. On 7/11/23 at 10:41 A.M., the surveyor and a Hospice Nurse observed Resident #82 briefly enter Resident #46's room and moments later walk out with two cigarettes. As Resident #82 walked back toward his/her room the Hospice Nurse said to Resident #82, You aren't going to smoke those in your room are you?. Resident #82 responded that he/she was saving them for later. The Hospice Nurse resumed working at the nurses' station. On 7/11/23 at 10:45 A.M., the surveyor observed Resident #82 from the hallway. Resident #82 was seated on the side of his/her bed, facing toward the hallway. Resident #82 took a lighter out of his/her bedside table, lit a cigarette, and began smoking. When Resident #82 saw the surveyor he/she stood up and said he/she was going to go into the bathroom to have a smoke. On 7/11/23 at 10:53 A.M., the surveyor observed the Hospice Nurse report to Resident #82's nurse that Resident #82 obtained cigarettes from Resident #46. The surveyor then observed the nurse briefly walk toward Resident #82's room then return down the hall and begin interacting with a different resident. During an interview on 7/12/23 at 7:14 A.M., CNAs #4 and #3 both said residents cannot keep cigarettes or lighters in their rooms; that the items are locked up with reception and that if they noticed the items in the room they would notify the nurse. During a record review on 7/12/23 at 7:25 A.M., the record failed to indicate: * A clinical progress note regarding Resident #82 obtaining cigarettes the day prior from a peer. * A care plan regarding smoking. * That the MD, Guardian or Administration were made aware that Resident #82 received cigarettes from a peer and returned to his/her room with the cigarettes, as reported to the Nurse by the Hospice Nurse on 7/11/23 at 10:53 A.M. Review of the CNA task documentation in the past 14 days indicated no behaviors. On 7/13/23 at 7:25 A.M., the surveyor observed Resident #82 in bed with the bedside table ajar. Inside two cigarettes were visible as well as pieces of tobacco. During an interview on 7/14/23 at 9:29 A.M., Resident #82's Nurse (#13) said that she has worked at the facility for two years. Nurse #13 said that Resident #82 used to smoke but now he/she wears a wanderguard so he/she can't leave the unit. During an interview on 7/14/23 at 9:47 A.M., Nurse Unit Manager #2 said the following: * On 7/11/23 the hospice nurse told her that Resident #82 had cigarettes and that Resident #82 denied having cigarettes; * Nurse Unit Manager #2 said that she searched Resident #82's room and took the two cigarettes and the lighter from Resident #82, contrary to the surveyor's observation that Resident #82 had already smoked one of the cigarettes; * She assessed and monitored Resident #82 for smoking, but failed to complete a smoking assessment; * Resident #82 told her that he/she used to smoke and felt like smoking today; * That she searched Resident #46's room the next day but found nothing; * That she failed to write a progress note regarding the room searches; * That she did not update the behavior care plan or initiate a smoking care plan after the incident. During an interview on 7/17/23 at 8:47 A.M., the surveyor updated the DON of their observations of Resident #82. The DON said, He/she could blow up the building. The DON said that she first learned of the situation on 7/14/23 and that the Nurse Unit Manager had not reported the incident when it occurred on 7/11/23. During an interview with the DON and Nursing Home Administrator on 7/17/23 at 9:08 A.M., they said that as soon as the Nurse Unit Manager learned that Resident obtained cigarettes from a peer on 7/11/23 the following should have occurred: * Resident #46 should have the cigarettes removed from his/her room, a progress note written, a new smoking assessment completed and a care plan developed to monitor for further unsafe smoking behavior. 38141 6. For Resident #73, the facility failed to follow the plan of care for ensuring safe access to smoking materials. Resident #73 was admitted to the facility in January 2021, and had diagnoses including dementia, depression, and diabetes mellitus. Review of the most recent MDS assessment, dated 6/30/23, indicated that on the BIMS exam Resident #73 scored a 14 out of 15, indicating intact cognition. During an interview on 7/11/23 at 7:50 A.M., the surveyor observed a pack of cigarettes and a lighter on the overbed table. Resident #73 said that he/she smokes, and that the cigarettes and lighter belong to him/her. Resident #73 said that they are allowed to keep smoking materials with them. Review of Resident #73's smoking care plan indicated the following: -keep all smoking materials and hand them to him/her only at designated smoke breaks. -he/she will return smoking materials to the nurse upon return. On 7/12/23 at 11:50 A.M., the surveyor observed Resident #73 in his/her room with a pack of cigarettes on the overbed table next to him/her. During conversations with Resident #73 about smoking, the Resident showed the surveyor the lighter in his/her pocket. On 7/13/23 at 7:51 A.M., the surveyor observed Resident #73 in bed and a pack of cigarettes on the overbed table next to him/her. During an interview on 7/13/23 at 9:11 A.M., the Unit Manager #1 said that Resident #73 is an independent smoker and is allowed to keep cigarettes with him/her but not a lighter. She said that during smoking times, he/she has to get the lighter from the reception desk and then return it once he/she is done smoking.

Based on observations, interviews and records reviewed, for four of 22 sampled residents (Resident #2, Resident #5, Resident #6, and Resident #12), the Facility failed to ensure that residents were permitted to exercise their rights, which resulted in one resident suffering emotional harm, when: -the Facility's Smoking Program Policy violated the resident's rights for preference and choice for smoking and social leaves; -the Facility failed to allow residents, who wished to smoke outside of the Facility and had no identified safety concerns, to do so as they chose; -the Facility revoked the residents right to smoke and right to go on social leave from the Facility when the residents exercised their right to do so; -the Facility failed to allow residents to enjoy social leave from the Facility; -the Facility failed to provide a private space for residents to have a private conversation on the telephone. Findings include: 1. The Facility policy titled Resident Rights, dated (MONTH) (YEAR), indicated a resident's right to: -be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat resident's symptoms; -self-determination; -exercise his/her rights without interference, coercion, discrimination or reprisal from the facility; -access to a telephone, mail and email; -communicate in person and by mail, email and telephone with privacy. The Facility's policy titled Smoking Program, dated 03/16/18, indicated that residents were required to provide signed consent to the Smoking Program Policy which indicated: -the Facility's smoking program allows residents to smoke in a designated area at designated times, residents will agree to the four designated smoking times each day and will be supervised by a staff member to ensure residents are safe, initial non-compliance with the smoking agreement will result in a 14 day suspension of smoking privileges, continued non-compliance with the smoking agreement and program can result in loss of smoking privileges and a possible 30 day notice of discharge for safety concerns. The Facility Smoking Program Policy and Smoking Program Consent Form, indicated the Facility had four designated smoking times at 9:00 A.M., 1:00 P.M., 4:00 P.M., and 7:00 P.M. Review of the Facility Smoking break schedule indicated residents could go outside to smoke during these times (accompanied by staff). Resident #5: Resident #5's Face Sheet indicated he/she was admitted in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident #5's record indicated he/she was his/her own responsible person and signed all admission paperwork, including consent for treatment when admitted to the Facility. Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact and able to make his/her own health care decisions. There was no documentation to indicate Resident #5 was not safe to leave the Facility grounds or to smoke independently at the Facility. A Resident Smoking Suspension Notification Form, dated 3/5/19, indicated the Facility notified Resident #5 that he/she had lost his/her smoking privileges for 30 days due to continued non-compliance. The Notification Form indicated the Facility conducted a search of Resident #5's room and found a pack of cigarettes with three cigarettes and a lighter. A Smoking Assessment, dated 3/6/19, indicated Resident #5 had no cognitive loss, no visual deficits, no dexterity problems, smoked 5-10 cigarettes per day and was able to light his/her own cigarette. Although there was no documentation to indicate Resident #5 was unsafe to smoke independently, supervision with smoking was checked off on the Assessment. The Assessment also indicated no plan of care was needed to assure Resident #5 was safe while smoking. An Order Summary Report, dated 3/7/19, indicated Resident #5 was suspended, on 3/5/19, from the Facility's smoking program every shift for 30 days. Resident #6: Resident #6's Face Sheet indicated he/she was admitted in (MONTH) (YEAR), [DIAGNOSES REDACTED]. A Contract of Behavior, dated 08/24/18, indicated Resident #6 will adhere to listed behavioral conditions, if Resident #6 wishes to remain at the Facility; the contract of behaviors included: -I will not purchase/borrow or accept cigarettes from other individuals, -I will not smoke on the Facility property, -I will accept the path to help successfully quit smoking, -I will schedule alternate behavior to distract from smoking desire, -I will feel free to reach out to management if I feel vulnerable or frustrated. Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact and able to make his/her own health care decisions. Resident #6's record indicated he/she was alert and oriented x 3 (to person, place and time) his/her own responsible person and signed all admission paperwork, including consent for treatment when admitted to the Facility. There was no documentation to indicate Resident #6 was not safe to leave the Facility grounds or to smoke independently at the Facility. A Clinical Psychologist's Progress Note, dated 08/09/19, indicated that Resident #6 said he/she was so angry that he/she got caught smoking. The Note indicated Resident #6 seemed desperately to want to leave the Facility for freedom. A Social Services Progress Note, dated 08/14/19, indicated that Resident #6 violated the Facility's Smoking Policy. The Note indicated that Resident #6 said he/she would continue to smoke; therefore, a 30 day Notice of Intent to Discharge was issued to Resident #6. The Note indicated Resident #6 would like a less restrictive environment where he/she could have more control over his/her smoking. A Clinical Psychologist's Progress Note, dated 08/19/19, indicated that Resident # 6 said he/she was going to be sent to another facility because of noncompliance. Resident #6 said he/she was afraid of his/her future and wished he/she could stay at the Facility. A Clinical Psychologist's Progress Note, dated 08/26/19, indicated that Resident #6, felt so relieved to know that he/she could stay at the facility. An Activities Note, dated 8/21/19, indicated Resident #6 was independent and chooses his/her own activities. The Note also indicated Resident #6 was suspended from smoking this quarter for smoking out front unsupervised and his/her smoking privileges were suspended permanently. A Social Service Progress Note, dated 8/27/18, indicated Resident #6 remained stable and was his/her own responsible party. The Note indicated Resident #6's smoking privileges were suspended due to unsupervised smoking and a behavior plan will be put into place. An Activities Note, dated 2/19/19 indicated Resident #6 had a stable quarter, continued to be independent in picking activities of choice and he/she no longer smokes. Resident #2: Resident #2's Face Sheet indicated he/she was admitted in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she was cognitively intact. A Review of Resident #2's record indicated that he/she was not allowed to leave the Facility on his/her own for approximately five months (September (YEAR) to (MONTH) 2019); however, there was no documentation to indicate Resident #2 had been assessed in the community to determine if he/she was unsafe to independently leave the Facility and there was conflicting opinions by practitioners regarding Resident #2's ability to make his/her own decisions. Resident #2's Neuropsychological Evaluation, dated 06/23/18, indicated Resident #2 was being seen to determine decision making and competence. The Evaluation indicated Resident #2 said he/she wanted to go to the Library via The Ride. The Evaluation indicated the results did not support a primary [DIAGNOSES REDACTED].#2 passed most neuro tests, early memory good, life long memory good and the Evaluation indicated it was determined Resident #2 should be able to visit the library via The Ride and return to the Facility. Resident #2's Social Service Progress Noted, dated 7/17/18, indicated Resident #2 informed the Social Worker and the DON that he/she was heading out to the library and The Ride was scheduled to pick him/her up at 10:10 A.M. The Note indicated the Social Worker and DON called the library to confirm. The Note indicated the DON told Resident #2 that he/she needed to give the DON two weeks notice before he/she scheduled anything outside the Facility and that Staff was open to Resident #2 going to the library as long as he/she had a companion for him/her to go with. Resident #2's Physician Order, dated 07/31/18, indicated that Resident #2's Health Care Proxy was deactivated indicating he/she was able to make his/her own health care decisions and the Order indicated Resident #2 may go to the library via The Ride. Resident #2's Physician Order, dated 09/25/18, indicated that Resident #2 had an active order that all social leave of absences from the Facility had been revoked and Resident #2 may not leave the premises. There was no documentation to indicate Resident #2's HCP had been revoked or deactivated and no documentation to indicate Resident #2 was no longer his/her own decision maker. Resident #2's record indicated NP #1 and NP #2 had conflicting opinions regarding Resident #2's decision making. Resident #2's Physician Order, dated 01/17/2019, indicated Resident #2's Health Care Proxy was activated by NP #2, due to Major Cognitive Disorder with Behavioral Disturbances. The Surveyor interviewed Psychiatric Nurse Practitioner (NP) #1 at 3:13 P.M. on 03/06/19. NP #1 said the Director of Nurses and Assistant Director (ADON) of Nurses requested Resident #2 stop his/her trips to the library via The Ride because he/she had an activated HCP. NP#1 said Resident #2 never had any issues going to the library and the Facility's psychiatric services had been working with the Facility to find ways to support Resident #2's desire to go the library independently, but the Facility would not allow Resident #2 to leave the premises. NP#1 said the Facility's psychiatric services began to question why Resident #2's HCP was activated, which was why they initiated the Neuropsychological Evaluation, dated 06/23/18. NP #1 said once Resident #2's HCP was deactivated (on 07/13/18), following the Neuropsychiatric Evaluation, there was still conflicting opinions, particularly from the Director of Nursing, who had expressed concerns after the HCP was deactivated. Resident #12: Resident #12's Face Sheet indicated he/she was admitted in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident #12's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact and able to make his/her own health care decisions. There was no documentation to indicate Resident #12 was not safe to leave the Facility grounds or to smoke independently at the Facility. Resident #12's Physician Order, dated 12/13/18, indicated that he/she may go out with a responsible party for three hours, every 72 hours. Resident #12's Physician Order, dated 07/21/18, indicated he/she may leave the Facility with a responsible party. The Surveyor interviewed the Director of Nurses (DON) at 4:00 P.M. on 03/06/19. The DON said Resident #12 was his/her own responsible person, without safety concerns, but had a therapeutic order to leave the Facility with a responsible party. The DON said the Physician wrote this order because Resident #12 had a family member who requested that Resident #12 only go out of the Facility with a responsible party. The Surveyor interviewed Resident #2, Resident #5, Resident #6 and Resident #12 throughout the dates of survey: The Surveyor interviewed one of the Residents during the morning on 02/28/19 and throughout the Survey. This Resident said the smoke breaks at the Facility were lousy, or words to that effect, and residents should be able to smoke when they want. This Resident said he/she would prefer to smoke at other times outside of the Facility's four scheduled smoking times. This Resident said he/she was only allowed to leave the facility grounds if he/she was supervised and he/she didn't understand why. This Resident said he/she independently attended medical appointments out of the Facility, but was not allowed to go out socially independently. This Resident said he/she would enjoy going to the store up the road if he/she could leave the Facility. The Surveyor interviewed the second Resident during the afternoon on 02/28/19 and throughout the Survey. This Resident said his/her nicotine addiction drove him/her to sneak outside to smoke, at times other than the Facility's four scheduled smoking times. This Resident said staff had searched his/her room and person for smoking materials for no reason, or words to that effect. This Resident said that after getting caught smoking outside of the Facility's four smoking times, he/she was punished by the DON and ADON and restricted to his/her room and dining room for two weeks and then given a Wanderguard (tracking device designed to prevent residents at risk from leaving a facility), which made him/her feel confined, kind of like a caged animal, or words to that effect. This Resident said that he/she would avoid walking next to the elevator because the Wanderguard would make a sound, which made him/her feel different from the other residents on the unit. This Resident said he/she would not want anyone else to go through the same sort of things at the Facility that he/she did, or words to that effect. The Surveyor interviewed the third Resident during the afternoon on 02/28/19 and throughout the Survey. This Resident said the Facility had activated/deactivated his/her Health Care Proxy several times and he/she was not allowed to leave the Facility. This Resident said he/she did not have any rights at the Facility. This Resident said the DON did not like him/her and wanted to make him/her miserable. The Surveyor interviewed the fourth Resident during the morning on 03/06/19. This Resident said he/she was not allowed to leave the Facility premises without supervision. This Resident said he/she would like to leave the Facility independently and walk to the store. This Resident said he/she had a friend that visited and would take him/her outside of the Facility at times, but that he/she would like to independently go off facility grounds in nicer weather. The Surveyor interviewed the Director of Nurses (DON) at 1:20 P.M. on 02/28/19. The DON said that residents who chose to smoke were allowed four smoking times each day with staff supervision. The DON said residents, who were alert and oriented and had been assessed to safely smoke a cigarette independently, were still restricted and only allowed to smoke during the four designated smoking times, supervised by staff, per the Facility Smoking Policy. The DON said residents were only allowed to leave the Facility if their physician wrote an order for [REDACTED]. leave order and decided to leave the Facility, the resident would be discharged against medical advice from the Facility. The Surveyor interviewed the Medical Director at 4:10 P.M. on 02/28/19. The Medical Director said he was aware of the Facility's Smoking Policy. The Medical Director said the Facility could not allow residents to go outside and smoke whenever they want because the residents need supervision. The Medical Director said residents who were alert and oriented and had been assessed to safely smoke a cigarette independently were restricted and only allowed to smoke within the four designated smoking times per day because, If residents were that independent, they would not need to be at the Facility, or words to that effect. The Medical Director said he was aware of the Facility's practice of determining if a resident could leave the Facility, based on a physician's therapeutic leave order, even if a resident was alert and oriented and responsible for making their own health care decisions. The Medical Director said if a resident was admitted to the Facility, then the resident needed supervision; otherwise, the Facility could become like a hotel, or words to that effect. The Surveyor interviewed Activities Aide #2 at 4:20 P.M. on 02/28/19. Activities Aide #2 said that resident smoking was allowed out in back of the building and the Activities Department supervised the smoking activity four times a day. Activities Aide #2 said residents were not allowed to smoke independently and not allowed to smoke at times other than the Facility's four scheduled smoking breaks. Activities Aide #2 said words to the effect of, Of course residents who smoke want to go outside to smoke more often than the Facility's four schedule smoking times each day. The Surveyor interviewed Nurse #1 at 1:15 P.M. on 3/7/19, Nurse #4 at 10:40 A.M. on 3/7/19, and Unit Manager #2 at 2:30 P.M. on 3/6/19. Nurse #1, Nurse #4 and Unit Manager #2 said that residents at the Facility required a physician's orders [REDACTED]. 2. The Surveyors toured the Facility at 9:02 A.M. on 2/28/19 and throughout the dates of survey. The Surveyors observed resident rooms did not have telephones. The Surveyor interviewed Nurse #1 at 1:15 P.M. on 3/7/19, CNA #2 at 1:08 P.M. on 3/7/19, CNA #3 at 1:33 P.M. on 3/7/19. Nurse #1, CNA #2 and CNA #3 said residents at the Facility did not have telephones in their rooms, but telephones were available for use at the nurse's station or in the hallway on the resident care unit. The Surveyor interviewed the Administrator at 4:00 P.M. on 03/07/19. The Administrator said the Residents did not have access to an area to have a private conversation on the telephone. The Administrator said the residents had access to use the phone at the nurse's station or in the hallway on the care unit; however, if they wanted to have a private conversation, they would have to ask to use a staff member's office.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to immediately notify the Physician that Resident #2 sustained a fall which resulted in injury. As a result of the fall, Resident #2 developed pain, increased swelling and tenderness to his/her left wrist, the Physician was not notified of the accident/incident until the next day and Resident #2 was transferred to the hospital, over 24 hours after the fall incident, with an avulsion (when a tendon or ligament pulls off a piece of the bone) [MEDICAL CONDITION] ulnar styloid process (a [MEDICAL CONDITION] joint). Findings include: The Facility's Policy titled, Acute Condition Changes-Clinical Protocol, dated 12/2015, indicated the nurse will make detailed observations, collect pertinent information to report to the Physician and notify the Physician whenever there is someone with an acute change of condition. The Facility's Policy titled, Falls-Clinical Protocol, dated 09/2012, indicated the nurse shall assess, document and report a change in condition and the details on how the fall occurred. Resident #2 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. A Fall Assessment, dated 4/2/18, indicated Resident #2 was at high risk for falls. The Care Plan, dated 5/2018, indicated, Resident #2 was at moderate risk for falls related to shuffled gait and balance problems and interventions included to educate Resident #2 about safety reminders, what to do if a fall occurs, encourage Resident #2 to request assistance for all transfers and remind Resident #2 to use call light for assistance. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #2 had moderate cognitive impairment, required limited assist of one staff for transfers and required supervision with ambulation. A Health Care Facility Reporting System (HCFRS) Report, dated 6/9/18, indicated that on 6/8/18 at approximately 4:30 P.M. - 4:45 P.M., Resident #2 complained of pain in his/her left wrist, Nurse #1 assessed the area and obtained orders for [MEDICATION NAME], ice and to follow up in the morning. The Report indicated that on 6/9/18, Resident #2 continued with pain, an x-ray was obtained and was positive for an avulsion [MEDICAL CONDITION] ulnar styloid process, Resident #2 was transferred to the hospital and an investigation of an injury of unknown origin was begun. The HCFRS Report indicated Resident #2 stated that he/she attempted to self transfer from bed to wheelchair, grasped the wheelchair with his/her right hand, wheelchair began to tip and Resident #2 fell landing on his/her left hand and wrist. The report indicated a staff member came into the room and assisted Resident #2 up. The HCFRS Report indicated that during the interview process, Nurse #2 stated that Resident #2 had a fall and Certified Nurse Aide (CNA) #2 and Nurse #2 assisted Resident #2 into the wheelchair. The HCFRS Report indicated that Nurse #2 said that she did not complete an assessment, failed to report the incident and told staff not to report the incident. The HCRS Report indicated Nurse #2 failed to perform an appropriate assessment, failed to report the incident which resulted in delay of treatment, hindered an investigation and failed to follow facility policy and procedure. The physician's orders [REDACTED].#2's left hand/wrist to rule out any fracture. The x-ray report, dated 6/9/18, indicated Resident #2 had an avulsion (when a tendon or ligament pulls off a piece of the bone) [MEDICAL CONDITION] ulnar styloid process (a [MEDICAL CONDITION] joint). The Nursing Home to Hospital Transfer Form, dated 6/9/18, indicated Resident #2 had poor safety awareness, required assist of one with transfers, indicated he/she fell and was transferred to the hospital for a broken left wrist. The Hospital Discharge Summary, dated 6/9/18, indicated Resident #2 was treated at the hospital for a non-displaced [MEDICAL CONDITION] colles (break of the forearm bone where it attaches to the wrist) and a splint was required. Certified Nurse Aide (CNA) #2's written witness statement, dated 6/10/18, indicated that on 6/8/18 at approximately 2:50 PM., CNA #2 noticed Resident #2 on the floor, went to the nurse's station and asked Nurse #2 to come into Resident #2's room. The statement indicated that Nurse #2 and CNA #2 went into Resident #2's room and that Nurse #2 said that Resident #2 was fine and assisted CNA #2 with transferring Resident #2 back into the chair. The statement indicated that Nurse #2 told CNA #2 not to report the incident. Nurse #2's written witness statement, undated, indicated that CNA #2 asked Nurse #2 to help her get Resident #2 up from the floor and that Nurse #2 was rushing and forgot to report this to Resident #2's nurse. The Facility was unable to provide supporting documentation to indicate that Resident #2's Physician was notified on 6/8/18 of the fall. The Surveyor interviewed CNA #2 at 1:06 P.M. on 6/25/18. CNA #2 said that on 6/8/18 at approximately 2:45 P.M., she walked into Resident #2's room, saw Resident #2 on the floor, and said she told Nurse #2. CNA #2 said Nurse #2 told her that Resident #2 was ok and they both transferred Resident #2 into the chair. The Surveyor interviewed Nurse #2 at 11:30 A.M. on 6/26/18. Nurse #2 said that on 6/8/18 close to the end of her shift, CNA #2 asked her to go into Resident #2's room. Nurse #2 said when she got to Resident #2's room, he/she was sitting on the floor. Nurse #2 said she asked Resident #2 if he/she was in any pain, but said Resident #2 did not respond to her question. Nurse #2 said she assisted CNA #2 with transferring Resident #2 into the chair. Nurse #2 said she forgot to write a nurse's note, forgot to complete an incident report, did not notify the Physician, or anybody else of Resident #2's fall and did not follow the Facility's policy. The Surveyor interviewed the Director of Nurses (DON) at 3:40 P.M. on 6/25/18. The DON said whenever an incident/accident occurs, nursing staff are expected to assess the resident for any injury, begin an investigation as to the cause of the incident, complete an incident/accident report and notify the Physician. The DON said Nurse #2 did not follow the Facility's policy.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure acceptable standards of practice were followed when Nurse #2 failed to assess Resident #2 for injuries after he/she fell , failed to monitor his/her condition, failed to document, investigate or report the incident per facility policy and failed to notify the physician of fall. It was later determined that Resident #2 sustained a left wrist fracture as a result of the fall. Findings include: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Facility's Policy titled, Falls-Clinical Protocol, dated 09/2012, indicated the nurse shall assess, document and report a change in condition and the details on how the fall occurred. The policy indicated that based on assessment, staff will document risk factors for falling in the resident's record, discuss the resident's fall risk, identify pertinent interventions to try to prevent subsequent falls, monitor and document response to interventions and if resident continues to fall, re-evaluate the situation and consider possible reasons for the resident's fall and re-evaluate the relevance of current interventions. The Facility's Policy titled, Acute Condition Changes-Clinical Protocol, dated 12/2015, indicated the nurse will make detailed observations, collect pertinent information to report to the Physician and notify the Physician whenever there is someone with an acute change of condition. The Facility's Policy titled, Accidents and Incidents-Investigating and Reporting, dated 7/2017, indicated that all accidents or incidents involving residents shall be investigated and reported to the Administrator. The Policy indicated that the charge nurse shall promptly initiate and document investigation of the accident and include the following data on the incident/accident report: -The date and time accident took place; -The nature of the injury (e.g., fall); -The circumstances surrounding the accident; -Where the accident took place; -The time the injured person's attending Physician was notified as well as the time the Physician responded and his/her instructions; -The date and time the injured person's family was notified and by whom; -The condition of the injured person, including vital signs; -The disposition of the injured; Resident #2 was admitted to the Facility in (MONTH) (YEAR) and [DIAGNOSES REDACTED]. A Fall Assessment, dated 4/2/18, indicated Resident #2 was at high risk for falls. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #2 had moderate cognitive impairment, required limited assist of one staff for transfers and required supervision with ambulation. The Care Plan, dated 5/2018, indicated, Resident #2 was at moderate risk for falls related to shuffled gait and balance problems and interventions included to educate Resident #2 about safety reminders, what to do if a fall occurs, encourage Resident #2 to request assistance for all transfers and remind Resident #2 to use call light for assistance. A Health Care Facility Reporting System (HCFRS) Report, dated 6/9/18, indicated that on 6/8/18 at approximately 4:30 P.M. - 4:45 P.M., Resident #2 complained of pain in his/her left wrist, Nurse #1 assessed the area and obtained orders for [MEDICATION NAME], ice and to follow up in the morning. The Report indicated that on 6/9/18, Resident #2 continued with pain, an x-ray was obtained and was positive for an avulsion [MEDICAL CONDITION] ulnar styloid process, Resident #2 was transferred to the hospital and an investigation of an injury of unknown origin was begun. The HCFRS Report indicated Resident #2 stated that he/she attempted to self transfer from bed to wheelchair, grasped the wheelchair with his/her right hand, wheelchair began to tip and Resident #2 fell landing on his/her left hand and wrist. The report indicated a staff member came into the room and assisted Resident #2 up. The HCFRS Report indicated that during the interview process, Nurse #2 stated that Resident #2 had a fall and Certified Nurse Aide (CNA) #2 and Nurse #2 assisted Resident #2 into the wheelchair. The HCFRS Report indicated that Nurse #2 said that she did not complete an assessment, failed to report the incident and told staff not to report the incident. The HCRS Report indicated Nurse #2 failed to perform an appropriate assessment, failed to report the incident which resulted in delay of treatment, hindered an investigation and failed to follow facility policy and procedure. The physician's orders [REDACTED].#2's left hand/wrist to rule out any fracture. The x-ray report, dated 6/9/18, indicated Resident #2 had an avulsion (when a tendon or ligament pulls off a piece of the bone) [MEDICAL CONDITION] ulnar styloid process (a [MEDICAL CONDITION] joint). The Nursing Home to Hospital Transfer Form, dated 6/9/18, indicated Resident #2 had poor safety awareness, required assist of one with transfers, indicated he/she fell and was transferred to the hospital for a broken left wrist. The Hospital Discharge Summary, dated 6/9/18, indicated Resident #2 was treated at the hospital for a non-displaced [MEDICAL CONDITION] colles (break of the forearm bone where it attaches to the wrist) and a splint was required. Certified Nurse Aide (CNA) #2's written witness statement, dated 6/10/18, indicated that on 6/8/18 at approximately 2:50 PM., CNA #2 noticed Resident #2 on the floor, went to the nurse's station and asked Nurse #2 to come into Resident #2's room. The statement indicated that Nurse #2 and CNA #2 went into Resident #2's room and that Nurse #2 said that Resident #2 was fine and assisted CNA #2 with transferring Resident #2 back into the chair. The statement indicated that Nurse #2 told CNA #2 not to report the incident. Nurse #2's written witness statement, undated, indicated that CNA #2 asked her (Nurse #2) to help CNA #2 get Resident #2 up from the floor and that Nurse #2 was rushing and forgot to report this to Resident #2's nurse. The Facility was unable to provide supporting documentation indicating Resident #2 was assessed for injury following the accident/incident on 6/8/18. There was no documentation to indicate the Physician was notified on 6/8/18, or if preventative measures were implemented to prevent the incident from re-occurring. There was no documentation to indicate that an investigation occurred promptly following the accident/incident. The Surveyor interviewed CNA #2 at 1:06 P.M. on 6/25/18. CNA #2 said that on 6/8/18 at approximately 2:45 P.M., she walked into Resident #2's room and saw Resident #2 on the floor, told Nurse #2 that Resident #2 was on the floor and that Nurse #2 went with her into Resident #2's room, asked Resident #2 if he/she was ok, Nurse #2 told CNA #2 that Resident #2 was ok and they both transferred Resident #2 into the chair. CNA #2 said that Nurse #2 told her that if the Director of Nurses (DON) asked her (CNA #2) what happened to Resident #2, that she should tell the DON that she (CNA #2) was taking Resident #2 to the bathroom and that Resident #2 almost fell . The Surveyor interviewed Nurse #2 at 11:30 A.M. on 6/26/18. Nurse #2 said that on 6/8/18 close to the end of her shift, CNA #2 asked her to go into Resident #2's room. Nurse #2 said when she got to Resident #2's room, he/she was sitting on the floor, Nurse #2 said she asked Resident #2 if he/she was in any pain and said she assisted CNA #2 with transferring Resident #2 into the chair. Nurse #2 said she forgot to write a nurse's note, forgot to complete an incident report, did not notify the Physician or anybody else of Resident #2's fall and said she did not follow the Facility's policy. The Surveyor interviewed the Director of Nurses (DON) at 3:40 P.M. on 6/25/18. The DON said whenever an incident/accident occurs, nursing staff are expected to assess the resident for any injury, begin an investigation as to the cause of the incident, complete an incident/accident report and notify the Physician. The DON said Nurse #2 did not follow the standard of practice or the Facility's policy.

Based on records reviewed and interviews, for two of three residents (Resident #1 and Resident #2), who both had the [DIAGNOSES REDACTED].#1 and Resident #2 from sustaining falls which resulted in injuries. Findings include: The Facility's Policy titled, Falls-Clinical Protocol, dated ,[DATE], indicated that based on assessment, staff will document risk factors for falling in the resident's record, discuss the resident's fall risk, identify pertinent interventions to try to prevent subsequent falls, monitor and document response to interventions and if resident continues to fall, re-evaluate the situation and consider possible reasons for the resident's fall and re-evaluate the relevance of current interventions. 1 ) Resident #1 was admitted to the Facility (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Fall Assessment, dated [DATE], indicated Resident #1 was at high risk for falls. The Care Plan related to falls, dated [DATE], indicated Resident #1 was at risk for falls related to poor balance, unsteady gait and [MEDICAL CONDITION] and interventions included to ensure that the call light is within reach, staff offer frequent verbal/visual reminders to use the call light for assistance, room close to nurse's station, use of appropriate non-skid footwear and Physical Therapy Consult for strength and mobility. The Care Plan related to [DIAGNOSES REDACTED], dated [DATE], indicated Resident #1's interventions included to cue, reorient and supervise as needed. The Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had severe cognitive impairment and required extensive assist of one staff for transfers. The Nurse Tech Kardex, undated, indicated Resident #1 required 2 assists with transfers and was dependent on staff with ambulation. The CNA Flow Sheet, dated ,[DATE], indicated Resident #1 required extensive assist of 1 staff for transfers and toileting and did not ambulate. An Occupational Therapy (OT) Evaluation, dated [DATE], indicated Resident #1 required moderate assist with toileting and was at risk for falls due to physical impairments and associated functional deficits. The Physical Therapy (PT) Evaluation, dated [DATE], indicated Resident #1 required moderate assist with transfers and that Resident #1's gait analysis exhibited excessive postural sway, delayed anticipatory reaction, inadequate postural control with transitional movements, reduced proactive and reactive balance and due to physical impairments and functional deficits was at risk for falls. Physical Therapist #1's written witness statement, dated [DATE], indicated that at approximately 10:15 AM., she heard a loud crash, went into Resident #1's room and observed Resident #1 lying supine on the floor in front of his/her bed, notified the nurse, Resident #1 was assessed and 911 was called. Nurse #3's written witness statement, dated [DATE], indicated that at approximately 10:20 A.M., she was notified that Resident #1 fell . The statement indicated she found Resident #1 lying on the floor flat on his/her back and bleeding from the back of his/her head, 911 was called and Resident #1 was transferred to the hospital. The Nurse Progress Note, dated [DATE], indicated that at 10:20 A.M., Resident #1 was found on the floor, unable to verbalize why he/she fell , bleeding noted from the back of his/her head, 911 was called and Resident #1 was transferred to the hospital. An Incident/Accident Report, dated [DATE], indicated that at 10:20 A.M., Resident #1 was found lying flat on his/her back with a bleeding laceration in the back of his/her head, 911 (Emergency Medical Services) was called and Resident #1 was transferred to the hospital. The Nursing Home to Hospital Transfer Form, dated [DATE], indicated Resident #1 was at risk for falls, sustained a fall with a laceration to the back of his/her head and was transferred to the hospital. The Health Care Facility Reporting System (HCFRS) Report, dated [DATE], indicated that at 10:20 A.M., Resident #1, who was assessed at high risk for falls, was found lying supine in his/her room with the walker at his/her feet. The Report indicated 911 was called, Resident #1 was transferred to the hospital where he/she expired at 4:00 A.M. on [DATE]. The HCFRS report indicated Resident #1 had an unwitnessed fall while ambulating in his/her room with the rolling walker. The Surveyor interviewed Physical Therapist (PT) #1 at 11:40 A.M. on [DATE]. PT #1 said Resident #1 required at least 1 staff assist and a walker for ambulation and transfers due to his/her retropulsion gait and would go backwards during transfers and ambulation. The Surveyor interviewed Nurse #3 at 11:18 A.M. on [DATE]. Nurse #3 said that on [DATE] at approximately 10:20 A.M., she heard a boom and PT #1 notified her that Resident #1 fell and was on the floor. Nurse #3 said she found Resident #1 lying on his/her back on the floor bleeding from the back of his/her head, assessed Resident #1, called 911 and Resident #1 was transferred to the hospital. Nurse #3 said Resident #1 required 1 staff assist and a walker for ambulation and transfers and was at high risk for falls. The Surveyor interviewed the Director of Nurses (DON) at 3:40 P.M. on [DATE]. The DON said Resident #1 had a significant loss of balance, had no safety awareness, was at high risk for falls and that he/she required 1 staff assist and a walker for ambulation and transfers. The DON said Resident #1 transferred himself/herself out of bed unassisted when he/she fell . 2 ) Resident #2 was admitted to the Facility in ,[DATE] and [DIAGNOSES REDACTED]. A Fall Assessment, dated [DATE], indicated Resident #2 was at high risk for falls. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #2 had moderate cognitive impairment, required limited assist of one staff for transfers and required supervision with ambulation. The Care Plan, dated ,[DATE], indicated, Resident #2 was at moderate risk for falls related to shuffled gait and balance problems and interventions included to educate Resident #2 about safety reminders, what to do if a fall occurs, encourage Resident #2 to request assistance for all transfers and remind Resident #2 to use call light for assistance. The CNA Flow Sheet, dated ,[DATE], indicated Resident #2 required continual supervision with transfers. The physician's orders [REDACTED].#2's left hand/wrist to rule out any fracture. An x-ray report, dated [DATE], indicated Resident #2 had an avulsion (when a tendon or ligament pulls off a piece of the bone) [MEDICAL CONDITION] ulnar styloid process (a [MEDICAL CONDITION] joint). The Nursing Home to Hospital Transfer Form, dated [DATE], indicated Resident #2 had poor safety awareness, required assist of one with transfers, indicated that Resident #2 said he/she fell and that the wheelchair landed on top of him/her. The Transfer Form indicated Resident #2 was transferred to the hospital for evaluation and treatment of [REDACTED]. The Health Care Facility Reporting System (HCFRS) Report, dated [DATE], indicated that on [DATE] at approximately 4:30 P.M. - 4:45 P.M., Resident #2 complained of pain in his/her left wrist, Nurse #1 assessed the area and obtained orders for [MEDICATION NAME], ice and to follow up in the morning. The Report indicated that on [DATE], Resident #2 continued with pain, an x-ray was obtained and was positive for an avulsion [MEDICAL CONDITION] ulnar styloid process, Resident #2 was transferred to the hospital and an investigation of an injury of unknown origin was begun. The HCFRS Report indicated Resident #2 stated that he/she attempted to self transfer from bed to wheelchair, grasped the wheelchair with his/her right hand, wheelchair began to tip and Resident #2 fell landing on his/her left hand and wrist. The report indicated a staff member came into the room and assisted Resident #2 up. A Hospital Discharge Summary, dated [DATE], indicated Resident #2 was treated at the hospital for a non-displaced [MEDICAL CONDITION] colles (break of the forearm bone where it attaches to the wrist) and a splint was required. Certified Nurse Aide #2's written witness statement, dated [DATE], indicated that on [DATE] at approximately 2:50 PM., she noticed Resident #2 on the floor, and asked Nurse #2 to come into Resident #2's room. Nurse #2 written witness statement, undated, indicated that CNA #2 asked her to help get Resident #2 up from the floor. The Surveyor interviewed CNA #2 at 1:06 P.M. on [DATE]. CNA #2 said that on [DATE] at approximately 2:45 P.M., she walked into Resident #2's room and saw Resident #2 on the floor, told Nurse #2. The Surveyor interviewed Nurse #2 at 11:30 A.M. on [DATE]. Nurse #2 said that on [DATE] close to the end of her shift, CNA #2 asked her to go into Resident #2's room. Nurse #2 said when she got to Resident #2's room, he/she was sitting on the floor. The Surveyor interviewed the Director of Nurses (DON) at 3:40 P.M. on [DATE]. The DON said Resident #2 was at high risk for falls, had frequent falls, must have transferred himself/herself alone and that Resident #2 required assist with transfers and was supervised during ambulation. The DON said Resident #2 was not assisted or supervised when he/she fell .

Based on records reviewed and interviews for one of six sampled residents, (Resident #2) whose advanced directives indicated he/she was a Full Code, (in the event of cardiac or respiratory arrest all attempts at resuscitation will be initiated), the Facility failed to ensure that staff followed acceptable standards of practice, and were prepared with the necessary equipment and training to respond to an emergency situation, when on [DATE], Resident #2 was found unresponsive, without pulse or respirations, Code Blue was not called, there was a delay in starting cardiopulmonary resuscitation (CPR) and activiating 911, and as a result Resident #2 died at the Hospital later that same day. Surveyor #2 interviewed Certified Nurse Aide (CNA) #1 at 3:55 P.M. on [DATE], Nurse #4 at 3.08 P.M. on [DATE] and Nurse #7 and at 3:38 P.M. on [DATE]. Based on information provided by CNA #1, Nurse #4 and Nurse #7 during their interviews, and review of supporting documentation, the following is the timeline of events which occurred on [DATE]: - At 4:55 A.M. CNA #1 discovered Resident #2 who was unresponsive with difficulty breathing. CNA #1 called Nurse #7 to the room. - Nurse #7 responded, checked Resident #2's blood sugar, heart rate and blood pressure, which were abnormal. Nurse #7 instructed CNA #1 to stay with Resident #2 while she placed a call to the covering Physician. - Nurse #7 then went to get Nurse #4 (who was working on a different unit) to help her with the hospital transfer paperwork for Resident #2, after which Nurse #4 returned to her own unit. - Approximately 5 to 10 minutes later Nurse #7 returned to Resident #2's room at which time Resident #2 had no pulse and was not breathing. - Nurse #7 left Resident #2's room, instructed CNA #1 to stay with Resident #2, and goes back to Nurse #4's unit to ask her to come help. - CNA #1 said he waited approximately 20 minutes, and when Nurse #7 had not returned with Nurse #4, said that he left Resident #2's room to continue with his regular assignment. - Nurse #7 said that at approximately 5:20 A.M. or 5:30 A.M. (she was unable to recall the exact time), she and Nurse #4 initiated cardiopulmonary resuscitation (CPR) on Resident #2. - Nurse #7 and Nurse #4 said emergency equipment was not readily available nor in working order, including the Automated External Defibrillator (AED) that was also not working. - Nurse #7 and Nurse #4 said they did not call a Code Blue because they did not know how to use the Facility's overhead paging system to announce the Code Blue in order to get other staff to respond and help with the code - Nurse #4 said although she activated 911 emergency services, she was unsure of the exact time and said there was a delay in calling 911. - Review of an Ambulance Run Report, dated [DATE], indicated the Facility did not activate 911 Emergency services until 5:47 A.M. - Paramedic #1 said when he arrived at the Facility the main entrance door was open, however, there was no staff present to direct him to the scene. Paramedic #1 said it took approximately five more minutes before he reached Resident #2's room. - At 5:57 A.M. Emergency Personnel arrived at the Facility and took over the care of Resident #2. - At 6:10 A.M. Resident #2 left the Facility in the care of 911 Emergency Personnel with CPR ongoing. - The Hospital Discharge Summary, dated [DATE], indicated Resident #2 had greater than 30 minutes of CPR before return of spontaneous circulation was achieved; was comatose with a score of three on a Glasgow Coma scale (GCS of eight or less indicates severe [MEDICAL CONDITION]); and had multiple rib fractures secondary to prolonged CPR. The Discharge Summary indicated Resident #2 died later that day. In addition; - On [DATE], observations by Surveyor #2 found that three of six emergency code carts were not fully equipped with emergency equipment in the event a resident experienced a sudden change in condition requiring emergency intervention. Of a total census of 130 residents, 70 were identified as being Full Code. - Between [DATE] and [DATE], the Surveyors asked the Facility to provide supporting documentation to support that staff were CPR certified. Out of a total of 85 nursing staff members employed by the Facility (comprised of 7 RN's, 22 LPN's, 47 CNA's and 9 Nursing Administrative staff), the Staff Developing Coordinator (SDC) was able to provide only five CPR cards for Basic Life Support, one of which belonged to the Food Service Director. - Between [DATE] and [DATE], twelve of fourteen staff interviewed could not verbalize an understanding of the Facility's CPR/Code Blue Policy and/or were inconsistent in their assigned responsibility on how to respond to a Code Blue Emergency Situation. Findings include: The Massachusetts Board of Registration in Nursing (BORN) issues this Advisory Ruling on nursing practice pursuant to Massachusetts General Laws (M.G.L.), chapter 30A, section 8, and chapter 112, section 80B, dated [DATE], indicated it is practice in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty, the initiation of CPR when a patient or resident has experienced a [MEDICAL CONDITION] except when the patient or resident has a current, valid Do Not Resuscitate (DNR) order OR Signs of irreversible death. According to the American Heart Association Chain of Survival, dated (YEAR), survival chances decline with every minute that passes by ,[DATE]%, within ,[DATE] minutes brain damage and permanent death start to occur, and after 10 minutes few attempts at resuscitation succeed. Chain of survival includes calling 911, giving immediate and effective CPR, defibrillating, and providing basic life support until advanced life support and delivering post-arrest care, to minimize brain damage. The Facility's Policy titled Code Blue, dated [DATE], indicated the first responder to the emergency situation will call for help an/or will call Code Blue over the intercom, three times, identifying the floor or unit, and the room number or location where the resident is located. The Policy indicated a person will be assigned to document the ongoing code. The Facility's Code Blue Documentation Form, dated as revised in (MONTH) 2007, indicated: - Code witnessed - Yes/No and by whom; - Time Code called and by whom; - Time CPR started; - Time Automated External Defibrillation (AED) started; - Code Team present and name of recorder. Resident #2's [DIAGNOSES REDACTED]. Resident #2's Advance Directive, documented on a Massachusetts Medical Orders of Life Sustaining Treatment (MOLST) Record, dated [DATE], indicated Resident #2 was a Full Code. Although the Nurse Progress Note, dated [DATE], indicated that Resident #2 was discovered unresponsive at 5:15 A.M., this is not consistent with information provided by CNA #1 and Nurse #7 during interview when they said Resident #2 was discovered unresponsive, sweating profusely and had difficulty breathing at 4:55 A.M. - The Nurse Progress Note, dated [DATE], indicated at 5:15 A.M. Resident #1 was found diaphoretic (sweating profusely), was gasping for breathe, his/her heart rate was irregular at 88 beats per minute, blood pressure low ,[DATE], and his/her finger stick blood sugar was elevated to 349 (normal range 72 to 108 when fasting, and 140 two hours after eating). The Note indicated, the Physician was notified and an order was obtained to transfer Resident #2 to the Hospital, an ambulance was called and when the nurse went back to check on Resident #2, he/she was unresponsive, had no respirations and was pulseless, Resident #2 was a Full Code, CPR was initiated, and when Paramedics arrived they took over care, Resident #2 left the Facility at 6:10 A.M. with CPR ongoing. CNA #1 said at approximately 4:55 A.M. he entered Resident #2's room to provide routine early morning care, and said Resident #2 was breathing funny or words to that effect. CNA #1 said he went to look for Nurse #7, and said Nurse #7 asked him to stay with Resident #2 while she went to get Nurse #4. Nurse #7 said that shortly before 5:00 A.M. on [DATE], (not 5:15 A.M as documented in her progress note) Certified Nurse Aide #1 approached her and asked her to check on Resident #2. Nurse #7 said Resident #2 was unresponsive, was sweating profusely, had difficulty breathing, his/her temperature was elevated, and he/she had a finger stick blood sugar of close to 400. Nurse #7 said she called the Physician's answering service and said her call was placed directly through to the on call physician who gave an order to transfer Resident #2 to the Hospital Emergency Department (ED) for evaluation. Nurse #7 said she called the ambulance provider but said she told them this was not an emergency. Nurse #7 said she did not go back to assess Resident #2 but said she did ask Nurse #4 who was assigned to another unit to help her with Resident #2's hospital transfer paperwork. Nurse #4 said that on [DATE], she had gone to Resident #2's unit several times during her shift to help Nurse #7. Nurse #4 she helped Nurse #7 with Resident #2's Hospital transfer paperwork, and said she checked Resident #2's code status, and identified he/she was a Full Code. Nurse #4 said she asked Nurse #7 to go back and complete a full assessment on Resident #2 before transferring him/her to the Hospital and said she then returned to her assigned unit, she did not wait for Nurse #7 to come back after she had reassessed Resident #2. Nurse #7 said she went back into Resident #2's room at approximately 5:00 A.M., approximately 5 to 10 minutes after she had first found Resident #2 unresponsive with difficulty breathing. Nurse #7 said Resident #2 was still unresponsive and said that on closer assessment Resident #2 had no pulse and was not breathing. Nurse #7 said she left Resident #2's room, told CNA #1 to stay, and goes to back to Nurse #4's unit, located on another floor, for help. CNA #1 said he stayed in Resident #2's room for what seemed like a long time, maybe 20 minutes, and said that Nurse #7 and Nurse #4 did not come back. CNA #1 said that by that time he was running late and said he left Resident #2 alone in his/her room. CNA #1 said he did not know if Resident #2 was breathing when he left his/her room. Nurse #4 said she returned to Resident #2's unit with Nurse #7 and said they went into Resident #2's room to assess him/her. Nurse #4 said Resident #2 was sitting up in bed, was unresponsive and had no pulse or respirations. Nurse #4 said she lowered the head of Resident #2's bed and said she asked Nurse #7 to get the code cart and to call a Code Blue. Nurse #4 said she did not start CPR on Resident #2 as she had no emergency equipment in the room and said Resident #2 was heavy and she was unable to transfer him/her to the floor. Nurse #4 said Nurse #7 did not return and after approximately 3 minutes she left Resident #2 alone in his/her room and went to look for Nurse #7. Nurse #4 said she saw Nurse #7 and CNA #1 standing at the Nurses Station and said they were both staring at the phone. Nurse #4 said she approached Nurse #7 and CNA #1 who said they did not know how to use the overhead intercom system to call a Code Blue. Nurse #7 said she did not know the Facility's Code Blue Policy or how to call a Code Blue and said when she asked CNA #1 for help he also did not know how to call a Code Blue. CNA #1 said he did not know what Code Blue meant and said he did not know how to use the overhead paging intercom system. Nurse #4 said she was not familiar with the Facility's Emergency CPR Policy, or how to use the overhead paging intercom system to call a Code Blue. Nurse #4 said she told Nurse #7 and CNA #1 to forget it or words to that effect, and to get the code cart. Nurse #4 and Nurse #7 said when they returned to Resident #2's room with the code cart and the AED, they realized there was no back board with the code cart. Nurse #7 said she started to perform chest compressions on Resident #2, who was lying on top of the bed, and said Nurse #4 left to get a back board. Nurse #7 said she continued performing chest compressions on Resident #2 and said she did not provide rescue breaths on Resident #2 or administer oxygen to him/her because she was alone in the room without help. Nurse #4 said she left Nurse #7 performing chest compressions on Resident #2 while she returned to her assigned unit to get a back board. Nurse #4 said to the best of her knowledge she called 911 on her way back to Resident #2's unit. Nurse #7 said when Nurse #4 returned with the back board they placed it under Resident #2 and started CPR. Nurse #7 said to the best of her knowledge, CPR was initiated on Resident #2 sometime between 5:20 and 5:30 A.M. (approximately 25 to 30 minutes after Nurse #7 said Resident #2 was first found unresponsive). Nurse #7 said they continued chest compressions and rescue breaths on Resident #2 for approximately 10 to 12 minutes and then attempted to apply the AED. Nurse #7 said when they applied the AED, the AED was not working. Nurse #7 said the Paramedics arrived shortly after this and took over the care of Resident #2. Nurse #4 said from the time Resident #2 was discovered unresponsive, to the time CPR was started, and to the time 911 was called, a lot of time had gone by. Nurse #4 said the whole thing was very confusing, or words to that effect. CNA #1 said as he came out of another Resident's room (exact time unknown), he saw the paramedics arrive and he directed them to Resident #2's room. Surveyor #2 interviewed Paramedic #1 at 2:03 P.M. on [DATE]. Paramedic #1 said that on the morning of [DATE], he and his crew member were on route to the Facility for a non-emergency transfer to the Hospital, when he heard over the radio a 911 call come in. Paramedic #1 said he arrived at the Facility at the same time as Police, and said the Fire Department was already there. Paramedic #1 said although the main entrance door was open, there were no staff present to direct them to the scene. Paramedic #1 said he was familiar with the Facility and said he made a judgment call to get in the elevator and press the elevator buttons until he found the right floor. Paramedic #1 said when he stepped off the elevator on the second floor, a staff member directed him to Resident #2's room. Paramedic #1 said there was an approximate five minute delay from the time he arrived on site at the Facility until the time he made contact with Resident #2 and took over emergency care. An Ambulance Run Report indicated Emergency Services were activated by phone at 5:47 A.M. (approximately 52 minutes after the time Nurse #7 said Resident #2 was first found unresponsive). The Run Report indicated when Emergency Personnel arrived on scene at 5:57 A.M., Resident #2 was in [MEDICAL CONDITION], without pulse or respirations and his/her airway was partially blocked with emesis (vomit). The Run Report indicated CPR was continued by Emergency Medical Personnel and Resident #2 was transferred to the closest Hospital Emergency Department. The Hospital Discharge Summary, dated [DATE], indicated Resident #2 was intubated (artificial airway placement) in the field, and had greater than 30 minutes of CPR with shock and injections of [MEDICATION NAME] before return of spontaneous circulation was achieved. Resident #2 was med-flighted to Hospital #2 where he/she was admitted to the medical intensive care unit. The Discharge Summary, dated [DATE], indicated Resident #2 was comatose, scored three on a Glasgow Coma scale (GCS) with no response to pain and no posturing (a GCS of eight or less indicates severe [MEDICAL CONDITION]), and he/she had multiple rib fractures secondary to prolonged CPR. The Discharge Summary indicated that after a discussion with his/her family members, Resident #2 was extubated (artificial airway removed), the breathing machine was turned off, and he/she passed away shortly thereafter, on the same day he/she coded. In addition: On [DATE], Surveyor #2 observed that three of six emergency code carts were not fully equipped with emergency equipment, including artificial airways, oxygen tubing, oxygen masks, and suction equipment, in the event a resident experienced a sudden change in condition requiring emergency intervention. Review of the Facility census report, dated [DATE], indicated a total census of 130 residents. A list of residents advance directives provided by the Assistant Director of Nurses (ADON) on [DATE], indicated 70 were identified as Full Code. Between [DATE] and [DATE], the Surveyors asked the Facility to provide supporting documentation to support staff were CPR certified. Out of a total of 85 nursing staff memebrs employed by the Facility ( comprised of 7 RN's, 22 LPN's, 47 CNA's and 9 Nursing Administrative staff), the Staff Developing Coordinator (SDC) was able to provide only five CPR cards for Basic Life Support, one of which belonged to the Food Service Director. The SDC was unable to provide any documentation to support that for the four Nurses and the six Certified Nurse Aides (CNAs) assigned to cover the four units of the Facility on the day of Resident #2's [MEDICAL CONDITION], were CPR certified. The Director of Nurses (DON) was interviewed at 8:00 AM. on [DATE] and throughout the days of Survey. The DON was unable to provide supporting documentation indicating that a Code Blue Documentation Form was completed for Resident #2's [MEDICAL CONDITION] on [DATE], in accordance with the Facility's Code Blue Policy. The DON said that since the date of Resident #2's [MEDICAL CONDITION], the Facility has conducted only one Mock Code drill (simulation of an actual arrest). A Mock Code Drill Documentation Form indicated a Mock Code was called at 11:30 A.M. on [DATE]. Surveyor #2 interviewed the following staff regarding the Fcaility's CPR/Code Blue Policy; Nurse #8 at 2:25 P.M. on [DATE], CNA #10 at 3:30 P.M. on [DATE], Nurse #26 at 2:00 P.M. on [DATE], Nurse #24 at 2:07 P.M. on [DATE], CNA # 17 at 2:20 P.M. on [DATE], Nurse #27 at 3:55 P.M. on [DATE], CNA 9 at 12:55 P.M. on [DATE], the Food Service Director (FSD) at 12:00 Noon on [DATE] and the Certified Occupational Therapy Assistant (COTA) at 9:35 A.M. on [DATE]. Nurse #8, #24, #26 and #27, and CNA #9, #10 and #17, the FSD and the COTA were inconsistent in their response to understanding the Facility's CPR/ Code Blue Policy an/or their assigned responsibilities on how to respond to a Code Blue situation.

Based on records reviewed and interviews for one of six sampled residents (Resident #2), the Facility failed to ensure that staff responded appropriately when on [DATE], Resident #2, who was a Full Code (in the event of cardiac or respiratory arrest all attempts at resuscitation will be initiated) experienced a sudden and significant change in condition, and failed to ensure that emergency care was provided consistent with his/her advance directives, and Resident #2 died at the Hospital later that day. - At approximately 5:00 A.M. Resident #2 was found unresponsive, had no pulse and was not breathing. CPR was not initiated until sometime between 5:20 A.M. and 5:30 A.M., and emergency services were not activated until 5:47 A.M. Emergency Personnel arrived on scene at 5:57 A.M., however, there was a 5 minute delay until Paramedics reached Resident #2 as no staff were available to direct them upon arrival at the Facility. Resident #2 was transferred to the closest Hospital Emergency Department (ED), at 6:10 A.M. with continued Cardiopulmonary Resuscitation (CPR). - A Hospital Discharge Summary, dated [DATE], indicated Resident #2 had greater than 30 minutes of CPR with shock and injections of [MEDICATION NAME] before return of spontaneous circulation was achieved, was comatose, scored 3 on a Glasgow Coma scale (a GCS of eight or less indicates severe [MEDICAL CONDITION]), and he/she had multiple rib fractures secondary to prolonged CPR. The Discharge Summary indicated Resident #2 died shortly after admission to the medical intensive care unit, on [DATE]. In addition; - Between [DATE] and [DATE], 12 of 14 staff interviewed could not verbalize an understanding of the Facility's CPR/Code Blue Emergency Response Policy and/or were not consistent in their assigned responsibility on how to respond to a Code Blue Emergency Situation. Findings include: Resident #2's [DIAGNOSES REDACTED]. Resident #2's Advance Directive, documented on a Massachusetts Medical Orders of Life Sustaining Treatment (MOLST) Record, dated [DATE], indicated Resident #2 was a Full Code. Although a Nurse Progress Note, dated [DATE], indicated that Resident #2 was discovered unresponsive at 5:15 A.M., this is not consistent with information provided by CNA #1 and Nurse #7 during interview when they said Resident #2 was discovered unresponsive, sweating profusely and had difficulty breathing at 4:55 A.M. The Progress Note, signed as documented by Nurse #7, indicated that at 5:15 A.M. Resident #2 was found diaphoretic (sweating profusely), was gasping for breath, heart rate was irregular at 88 beats per minute, blood pressure low ,[DATE], and finger stick blood sugar was elevated to 349 (normal range 72 to 108 when fasting, and 140 two hours after eating). The Progress Note indicated the on call Physician was notified and an order was obtained to transfer Resident #2 to the Hospital. The Progress Note indicated an ambulance was called and when Nurse #7 went back to check on Resident #2, he/she was unresponsive, had no respirations and had no pulse. Surveyor #2 interviewed CNA #1 at 3:55 P.M. on [DATE]. CNA #1 said that shortly before 5:00 A.M. on [DATE], he entered Resident 2's room to provide early morning care and said Resident #2 was in bed and breathing funny' or words to that effect. CNA #1 said he reported this to Nurse #7. CNA #1 said Nurse #7 asked him to stay with Resident #2 while she went to get Nurse #4. CNA #1 said he remained in Resident #2's room for what seemed like a long time, maybe 20 minutes, and when Nurse #7 and Nurse #4 did not return, he left to complete his assignment. CNA #1 said he did not know if Resident #2 was breathing when he left his/her room. Surveyor #2 interviewed Nurse #7 at 3:38 P.M. on [DATE] and at 2:43 P.M. on [DATE]. Nurse #7 said that shortly before 5 A.M. on [DATE], (not 5:15 A.M. as documented in the Progress note) Certified Nurse Aide #1 approached her and asked her to check on Resident #2. Nurse #7 said Resident #2 was unresponsive and was sweating profusely. Nurse #7 said she called the Physician's answering service and obtained an order from the on call covering Physician to transfer Resident #2 to the Hospital Emergency Department (ED) for evaluation. Nurse #7 said she called the ambulance provider but said she told them this was not an emergency. Nurse #7 said she asked Nurse #4 to help her with Resident #2's Hospital transfer paperwork and said she did not go back to assess Resident #2. Surveyor #2 interviewed Nurse #4 at 3:08 P.M. on [DATE]. Nurse #4, who had come from another unit on another floor, said she went to help Nurse #7 with Hospital transfer paperwork, and said she when she was checking the paperwork she realized that Nurse #7 had not checked Resident #2's oxygen saturation level (blood oxygenation level normal 95 to 100 percent on room air). Nurse #4 said she asked Nurse #7 to go back and reassess Resident #2. Nurse #4 said she did not wait for Nurse #7 to return and said she went back to her assigned unit. Nurse #7 said she went back into Resident #2's room at approximately 5:00 A.M., maybe 5 to 10 minutes after she had originally found Resident #2 unresponsive. Nurse #2 said Resident #2 was still unresponsive but on further assessment Resident #2 had no pulse and was not breathing. Nurse #7 said she left Resident #2's room and went back to Nurse #4's unit to get her. Nurse #4 said that at approximately 5:05 A.M. Nurse #7 came back to her unit and told her that Resident #2 had no pulse and was not breathing. Nurse #4 said she returned to Resident #2's unit with Nurse #7 and said they went into Resident #2's room to assess him/her. Nurse #4 said Resident #2 was sitting up in bed, was unresponsive and had no pulse or respirations. Nurse #4 said she lowered the head of Resident #2's bed, lying him/her flat on the bed, and said she asked Nurse #7 to get the code cart and to call a Code Blue. Nurse #4 said she did not start CPR on Resident #2 and said that after approximately 3 minutes, she left Resident #2 alone in his/her room and went to look for Nurse #7 who had not returned with the code cart. Nurse #4 said she approached Nurse #7 and CNA #1 who where at the Nurses Station, who told her they did not know how to use the overhead intercom system to call a Code Blue. Nurse #4 said she told Nurse #7 and CNA #1 to forget it or words to that effect, and to get the code cart. Nurse #4 and Nurse #7 said when they returned to Resident #2's room with the code cart and the AED, they realized there was no back board with the code cart. Nurse #4 said she returned to her unit, got the back board from her code cart, and said to the best of her recollection, she called 911 on her way back to Resident #2's unit. Nurse #7 said when Nurse #4 returned with the back board, they placed the backboard under Resident #2, and started CPR. Nurse #7 said to the best of her recollection this was sometime between 5:20 and 5:30 A.M. (approximately 25 to 30 minutes after Resident #2 was first found unresponsive). Nurse #4 and Nurse #7 said they continued CPR on Resident #2 until the Paramedics arrived and took over. An Ambulance Run Report, dated [DATE], indicated Emergency Services were activated at 5:47 A.M. and when Emergency Personnel arrived on scene at 5:57 A.M. Resident #2 was in [MEDICAL CONDITION], and he/she left the Facility at 6:10 A.M. with CPR still in progress. Surveyor #2 interviewed Paramedic #1 at 2:03 P.M. on [DATE]. Paramedic #1 said that on the morning of [DATE], he and his crew member were on route to the Facility for a non-emergency transfer to the Hospital, when he heard over the radio a 911 call come in. Paramedic #1 said he arrived at the Facility at the same time as Police, and said the Fire Department was already there. Paramedic #1 said although the main entrance door was open, there were no staff present to direct them to the scene. Paramedic #1 said he was familiar with the Facility and said he made a judgment call to get in the elevator and press the elevator buttons until he found the right floor. Paramedic #1 said when he stepped off the elevator on the second floor, a staff member directed him to Resident #2's room. Paramedic #1 said there was an approximate five minute delay from the time he arrived on site at the Facility until the time he made contact with Resident #2 and took over emergency care. A Hospital Discharge Summary indicated Resident #2 died shortly after admission to the Hospital Medical Intensive Care unit on [DATE]. In addition; The Facility's Policy titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS), dated as revised in (MONTH) 2006, indicated a CPR Team in this Facility shall include a Registered Nurse(RN) , a Licensed Practical Nurse (LPN), and CNAs, all of who have received training and certification in CPR/BLS. Between [DATE] and [DATE], the Surveyors asked the Facility to provide supporting documention to support that staff were CPR certified. Out of a total of 85 nursing staff memebers employed by the Facility ( comprised of 7 RN's, 22 LPN's, 47 CAN's and 9 Nursing Administrative staff), the Staff Developing Coordinator (SDC) was able to provide only five CPR cards for Basic Life Support, one of which belonged to the Food Service Director. The SDC was unable to provide any documentation to support that staff assigned on the 11:00 P.M. to 7:00 A.M. shift on [DATE], the day of Resident #2's [MEDICAL CONDITION], were CPR certified. The SDC did provide an additional 17 CPR certifications. When the Surveyors compared these against the list of employees provided by the Facility, the names on the CPR certifications did not match any current employee. Surveyor #2 interviewed the following staff members regarding the Facility's CPR Policy, Nurse #8 at 2:25 P.M. on [DATE], CNA #10 at 3:30 P.M. on [DATE], Nurse #26 at 2:00 P.M. on [DATE], Nurse #24 at 2:07 P.M. on [DATE], CNA # 17 at 2:20 P.M. on [DATE], Nurse #27 at 3:55 P.M. on [DATE], CNA 9 at 12:55 P.M. on [DATE], the Food Service Director (FSD) at 12:00 Noon on [DATE] and the Certified Occupational Therapy Assistant (COTA) at 9:35 A.M. on [DATE]. Nurse #8, #24, #26 and #27, and CNA #9, #10 and #17, the FSD and the COTA were inconsistent in their response to understanding the Facility's CPR/Code Blue Policy and/or their assigned responsibilities on how to respond to a Code Blue situation.

Based on records reviewed and interviews, for one of six sampled (Resident #2), whose advanced directives included Full Code, (in the event of cardiac or respiratory arrest, all attempts at resuscitation will be initiated), the Facility failed to ensure that assigned staff were trained in the Facility's Emergency Code Blue Policy when on [DATE], Resident #2 was found unresponsive, without pulse or respirations, and Code Blue was not initiated by staff, and there was a delay in activiating 911 emergency services. Resident #2 died at the Hospital later that day. Between [DATE] and [DATE], 12 of 14 staff members interviewed, including Certified Nurse Aide (CNA)#1, Nurse #4 and Nurse #7 who responded to Resident #2's [MEDICAL CONDITION], could not verbalize an understanding of the Facility's CPR/Code Blue Emergency Response Policy and/or were inconsistent in their assigned responsibility on how to respond to a Code Blue Emergency Situation. Findings include: The Facility's Policy titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS), revised (MONTH) 2006, indicated the Facility: - will provide periodic Mock Codes for training purposes; - select and identify a CPR Team for each shift , and to the extent possible, designate a team leader on each shift who is responsible for for coordinating the rescue effort and directing other team members during the rescue effort; - the CPR Team in this Facility shall include a Registered Nurse (RN) , a Licensed Practical Nurse (LPN), and CNA's, all of who have received training and certification in CPR/BLS. The Facility's Policy titled Code Blue, dated [DATE], indicated the the first responder to the emergency situation will call for help and/or will call Code Blue over the intercom, three times, identifying the floor or unit, and the room number or location where the resident is located. Resident #2's [DIAGNOSES REDACTED]. Resident #2's Advance Directive, documented on a Massachusetts Medical Orders of Life Sustaining Treatment (MOLST) Record, dated [DATE], indicated Resident #2 was a Full Code. A Nurse Progress Note, dated [DATE], indicated Resident #2 was discovered unresponsive, had no respirations or pulse, CPR was initiated, and when Paramedics arrived they took over care. The Progress Note indicated Resident #2 left the Facility at 6:10 A.M. with CPR ongoing. Surveyor #2 interviewed Nurse #7 at 3:38 P.M. on [DATE] and at 2:43 P.M. on [DATE]. Nurse # 7 said she was employed by a staffing agency and said ,[DATE] /17 was only her second time working in the Facility. Nurse #7 said although she was CPR certified, she had not received an orientation on the Facility policies and procedures and said she was not familiar with the Facility's Emergency CPR or Code Blue Policies. Nurse #7 said she did not know how to use the overhead intercom system to call a Code Blue. Nurse #7 said that shortly before 5:00 A.M. on [DATE], Certified Nurse Aide (CNA) #1 approached her and asked her to check on Resident #2 and said that Resident #2 was unresponsive. Nurse #7 said she started to complete Hospital transfer paperwork for Resident #2 with the help of Nurse #4 and said approximately 5 to 10 minutes later, she went back to Resident #2's room at which time Resident #2 was was noted to have no pulse and was not breathing. Nurse #7 said she did not call a Code Blue but went to look for Nurse #4, who had returned to her assigned to a unit on another floor, to ask for help. Surveyor #2 interviewed Nurse #4 at 3:08 P.M. on [DATE]. Nurse #4 said she had gone over to help Nurse #7 with Hospital transfer paperwork for Resident #2 and had then gone back to her unit. Nurse #4 said Nurse #7 then came back unit and said Nurse #7 told her that Resident #2 had no pulse and was not breathing. Nurse #4 said she returned to Resident #2's unit with Nurse #7 and said they went into Resident #2's room to assess him/her. Nurse #4 said Resident #2 was sitting up in bed, was unresponsive and had no pulse or respirations. Nurse #4 said she lowered the head of Resident #2's bed, lying him/her flat on the bed, and said asked Nurse #7 to get the code cart and to call a Code Blue. Nurse #4 said she did not start CPR on Resident #2 as she waited for Nurse #7 to return with the code cart. Nurse #7 said that after approximately 3 minutes Nurse #4 had not returned and said she left Resident #2 alone in his/her room and went to look for Nurse #7. Nurse #4 said she had not received an orientation on the Facility policies and procedure and said she was not familiar with the Facility's Emergency CPR or Code Blue Policies. Nurse #4 said she did not know how to use the overhead paging intercom system to call a Code Blue. CNA #1 said that although he was employed by the Facility, he did not know what Code Blue meant and did not know how to use the overhead paging intercom system. Nurse #4 said she told Nurse #7 and CNA #1 to forget it or words to that effect, about calling the Code Blue, and said she asked Nurse #7 to get the code cart. Nurse #4 said a lot of time went by from the time Resident #2 was discovered unresponsive, to the time CPR was started and to the time 911 was called. Nurse #4 said the whole thing was very confusing, or words to that effect. Nurse #7 said to the best of her recollection she and Nurse #4 started CPR on Resident #2 at sometime between 5:20 and 5:30 A.M. on [DATE],( approximately 25 to 30 minutes after the time Nurse #7 said he/she was first discovered unresponsive, without pulse or respirations). An Ambulance Run Report indicated Emergency Services were activated at 5:47 A.M. and when Emergency Personnel arrived on scene at 5:57 A.M. Resident #2 was in [MEDICAL CONDITION], and he/she left the Facility at 6:10 A.M. with CPR still in progress. A Hospital Discharge Summary indicated Resident #2 died shortly after admission to the Hospital Medical Intensive Care unit on [DATE]. In addition: The Director of Nurses (DON) was interviewed at 8:00 AM. on [DATE] and throughout the days of Survey. The DON said that since the date of Resident #2's [MEDICAL CONDITION], the Facility has conducted only one Mock Code drill (simulation of an actual arrest). A Mock Code Drill Documentation Form indicated a Mock Code was called at 11:30 A.M. on [DATE]. Between [DATE] and [DATE], the Surveyors asked the Facility to provide support documentation that staff were CPR certified. Out of a total of 85 nursing staff members employed by the Facility ( comprised of 7 RN's, 22 LPN's, 47 CAN's and 9 Nursing Administrative staff), the Staff Developing Coordinator (SDC) was able to provide only five CPR cards for Basic Life Support, one of which belonged to the Food Service Director. The SDC was unable to provide any documentation to support that staff assigned on the 11:00 P.M. to 7:00 A.M. shift on [DATE], the day of Resident #2's [MEDICAL CONDITION], were CPR certified. The SDC did provide an additional 17 CPR certifications. When the Surveyors compared these against the list of employees provided by the Facility, the names on the CPR certifications did not match any current employee. Surveyor #2 interviewed the following staff members regarding the Facility's CPR and Code Blue Policies; Nurse #8 at 2:25 P.M. on [DATE], CNA #10 at 3:30 P.M. on [DATE], Nurse #26 at 2:00 P.M. on [DATE], Nurse #24 at 2:07 P.M. on [DATE], CNA # 17 at 2:20 P.M. on [DATE], Nurse #27 at 3:55 P.M. on [DATE], CNA 9 at 12:55 P.M. on [DATE], the Food Service Director (FSD) at 12:00 Noon on [DATE] and the Certified Occupational Therapy Assistant (COTA) at 9:35 A.M. on [DATE]. Nurse #8 said she had not received any training on the Facility's CPR/BLS Policy and said she was not familiar with the Facility's Code Blue Policy. Nurse #26 was unable to verbalize where she could identify a resident's Code Status in the event a resident was found unresponsive. Nurse #24 said she had not received any training on the Facility's CPR/BLS Policy and said she was not familiar with the Facility's Code Blue Policy. Nurse #24 said if she found a resident unresponsive she would look for another nurse to assess the resident, and said that together they would then make the decision to call 911 and whether or not start CPR. Nurse #27 said he often worked on the off hour shifts as the only Nurse assigned to a unit. Nurse #27 was unable to verbalize where he could identify a resident's Code Status in the event a resident was found unresponsive. Nurse #27 said it was the SDC's practice to float nurses throughout the Facility units so they would not get to comfortable with one assignment' or words to that effect, and said this made it very difficult in getting know resident's individual care needs. Nurse #27 said he doubted very much if a resident coded and he was the only Nurse assigned to the unit, that he would be able to respond in a timely manner. CNA #9 said he did not know anything about code drills and said if he found someone unresponsive he would do something like lift their arm or words to that effect and try to find out what happened. CNA #10 said if she found anyone unresponsive she would look for another CNA to come and check before going to a find a nurse. CNA #17 said if she found a resident unresponsive she would look for a nurse and said she would then go back to her assignment as she had a lot of other residents to take care of. The FSD said if he discovered someone unresponsive in the main dining room he would first step out into the hallway, take a deep breath and calm himself. The FSD said he would then step back into the dining room and return to the kitchen, located at the back of the dining room behind a closed door, and ask for someone to call a Code Blue. The FSD said residents were not always supervised by nursing staff in the main dining room and said he did not have access to a list of residents code status. The FSD said he would assume that all residents are a full code. The FDS said he would initiate CPR and continue until nursing staff arrived and said he would stop CPR if he was told by nursing staff that the resident was a Do Not Resuscitate (DNR). The COTA said if someone became unresponsive in the gym, she would assess the situation and call Code Blue over the intercom system. The COTA said she did not have access to a list of residents code status and said she would assume that all residents are a full code. The COTA said she would initiate CPR, and continue until nursing staff arrived. The COTA said she would stop CPR if a nurse told her the resident was a DNR.

Based on interviews and records review, the Facility failed to prevent Resident #3 from hitting Resident #5 on the right upper arm on 11/14/17. Findings include: Resident #3's most recent Minimum Data Set (MDS) Assessment, dated 8/23/17, indicated that he/she was cognitively intact. Resident #5's MDS Assessment, dated 11/15/17, indicated his/her cognition was severely impaired. Surveyor #1 interviewed Resident #5 at 10:00 A.M. on 1/22/18. Resident #5 said that Resident #3 smacked him/her. Resident #5 said that he/she did not know why Resident #3 hit him/her. Surveyor #1 interviewed the Human Resource Manager at 10:40 A.M. on 1/24/18. Surveyor #1 interviewed the Receptionist at 12:10 P.M. on 1/24/18. The Human Resource Manager and the Receptionist said that on 11/14/17 they were speaking at the front desk in the lobby. The Human Resource Manager and the Receptionist said that Resident #3 and Resident #5 were seated next to each other in the lobby talking. The Receptionist characterized the conversation between Resident #3 and Resident #5 as a disagreement over what take-out food to order, but said that Resident #3 and Resident #5 never had normal conversations. The Receptionist said she heard the sound of a slap and the Human Resource Manager said she heard Resident #3 yell. The Human Resource Manager and the Receptionist said they looked toward Resident #3 and Resident #5 and saw Resident #5 slap Resident #3's right arm. The Receptionist said that the slap was hard enough to cause Resident #3's wheelchair to move a quarter of a turn. The Human Resource Manager and the Receptionist said the Director of Social Service was nearby and intervened to separate Resident #3 and Resident #5. The Facility internal investigation, dated 11/14/17, indicated that at 8:40 A.M. on 11/14/17, Resident #5 slapped Resident #3's upper right arm. Surveyor #1 interviewed the Director of Social Service at 9:00 A.M. on 1/25/18. The Director of Social Service said that she was in the lobby on 11/14/17 at the time Resident #3 slapped Resident #5. The Director of Social Service said that she intervened and separated Resident #3 and Resident #5. The Director of Social Service said that she interviewed Resident #3 and said Resident #3 told her that Resident #5 slapped him/her. The Director of Social Service said that she interviewed Resident #5 and said he/she told her that he/she slapped Resident #3 on the arm because he/she yelled.

Based on interviews and records reviewed, for one of six sampled Residents (Resident #3) the Facility failed to allow Resident #3 to return to the Facility after evaluation in the emergency department on 11/15/17 determined him/her to be safe and appropriate to return to the Facility. Findings include: The Facility's Internal Investigation Report, dated 11/14/17, indicated that at 8:40 A.M. on 11/14/17, Resident #5 slapped Resident #3's upper right arm. Resident #3's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that he/she was cognitively intact. Resident #5's MDS Assessment, dated 11/15/17, indicated his/her cognition was severely impaired. The Facility Incident Report, dated 11/14/17, indicated that after Resident #3 slapped Resident #5's arm, the Local Police Department was called, the Police arrested Resident #5 and Facility staff told Resident #5 that he/she was being given a No Trespass Order by the Facility. The Administrator was interviewed multiple times between 1/22/18 and 1/30/18. The Administrator stated that he gave Resident #5 a verbal No Trespass order when he/she was arrested on 11/14/17 and subsequently provided him/her with a letter to document the No Trespass order. Despite repeated requests by Surveyor #1, the Administrator did not provide Surveyor #1 with a copy of the No Trespass Order given to Resident #5 on 11/14/17. Surveyor #1 asked the Administrator if the No Trespass Order was a court ordered document and the Administrator said that it was not. The Administrator said that the No Trespass Order was a letter he and the former Director of Nurses wrote on a computer and gave to Resident #5. The Administrator said that he used a similar letter when prohibiting visitors from the Facility although he had not previously used one with a resident. The Police Report dated 11/14/17 indicated that Resident #5 told police he/she did not slap Resident #3, but grabbed Resident #3's arm to pull Resident #3 closer to him/her. The Police Report indicated the police charged Resident #5 with Assault and Battery on a Disable Person. Surveyor #1 interviewed the Hospital Emergency Department Case Manager (CM) on at 10:15 A.M. 1/24/18. The CM said that on 11/14/17, Resident #5 was sent to the Emergency Department from a shelter. The CM said that Resident #5 was released by the court after having been arrested at the Facility and transported to a shelter. The CM said that Resident #5 was an insulin dependent diabetic, had an pressure ulcer on his/her foot and was sent to the shelter without any medications, prescriptions or discharge paperwork. The CM said that because Resident #5 was ill and without medications or prescriptions, the shelter sent him/her to the Emergency Department. The CM said that she contacted the Facility about Resident #5's bed hold and the former Director of Nurses told her that Resident #5 did not have a bed hold and could not return to the Facility. The CM said she contacted the Facility several times about Resident #5 being appropriate to return and said the former Director of Nurses told her that Resident #5 could not return. The CM said that she arranged for a shelter to take Resident #5 with an accommodation for him/her to stay inside the shelter during the day time. The CM said that Resident #5 unnecessarily sat in the emergency department for three days while she made these arrangements which could have been arranged by the Facility. The CM said that she obtained prescriptions for all of Resident #5's medications and provided him/her with two taxi vouchers in order to pick up his medications at a pharmacy and get to the shelter. The CM said that she thought the Facility could have made Resident #5's discharge arrangements and it was not acceptable for the Facility to have issued a No Trespass order without assisting Resident #5 with his/her medications and housing post discharge. Surveyor #1 interviewed the Attorney at 3:30 P.M. on 1/24/18. The Attorney said that after Resident #5 was arrested, the Facility's former Director of Nurses said that Resident #5 was not going to be admitted back to the Facility. The Attorney said Resident #5 had a right to be in the Facility and the Facility refused to take Resident #5 back. The Attorney said that Resident #5 had only the clothes on his/her back and when he/she was sent to the shelter, he/she could not stay because of his/her medical needs. The Attorney said the Facility would not assist Resident #5 to find placement and would not provide his/her personal belongings or medications. The Attorney said that Resident #5 stayed in the hospital emergency department for three days until the CM arranged for him/her to go to a shelter with accommodations and with his/her medications and prescriptions. Surveyor #1 called the Facility's former Director of Nurses for an interview on 2/7/18 and 2/9/18, without a return response. Surveyor #1 interviewed the Director of Social Service at 9:30 A.M. on 1/25/18. The Director of Social Service said that after the police arrested Resident #5, Facility administration decided that he/she could not return to the Facility. The Director of Social Service said the day after Resident #5's arrest she learned that the police let him/her go and he/she was in the emergency department. The Director of Social Service said that the former Director of Nurses communicated with the hospital about Resident #5 and said she was not involved. The Director of Social Service said the former Director of Nurses told her that the hospital wanted to send Resident #5 back to the Facility and said the former Director of Nurses told the hospital that they could not. The Director of Social Services said that prior to Resident #5's arrest she had been arranging for his/her discharge. The Director of Social Service said that although Resident #5 previously resided in a shelter and was comfortable with being discharged to a shelter, she was trying to arrange placement in a rest home or boarding house. Surveyor #1 asked the Director of Social Services if she could have arranged for Resident #5's discharge to a shelter. The Director of Social Service said that the Facility provided care to residents with a history of homelessness and the social service department was capable of arranging for resident discharges to a shelter including arranging taxi vouchers, prescriptions and medications. Surveyor #1 asked the Director of Social Services if the Facility could separate residents with a history of conflict. The Director of Social Service said that the Facility had four units and had implemented one to one supervision many times for residents who posed a risk to other residents.

Based on interviews and records reviewed, for one of six sampled residents (Resident #6) the Facility failed to ensure the accuracy of Resident #6's assessment when areas of extensive bruising in multiple stages of healing were identified during a Hospital emergency department visit on 1/7/18 and 1/8/18 and were not documented in his/her clinical record. Findings include: Surveyor #1 interviewed the Hospital Nurse at 2:30 P.M. on 2/7/18. The Hospital Nurse said Resident #6 arrived at the Hospital during the Evening shift on 1/7/18 with extensive bruising on his/her upper and lower extremities, left hip and left side of his/her back. The Hospital Nurse said Resident #6 had serious bruising and swelling on his/her left wrist. Resident #6's Emergency Department Record dated 1/7/18 indicated that Resident #6 presented with multiple areas of ecchymosis with bruising of different ages present on the lower legs bilaterally and the left forearm. Review of the Facility's Nurse Progress Notes in Resident #6's medical record, from 1/3/18 through 1/23/18, indicated there was no documentation to indicate any bruising on Resident #6's body. Resident #6's Physician order [REDACTED]. Resident #6's Skin Check Schedule indicated that staff checked his/her skin on 1/3/18 and 1/10/18 but there was no documentation of the findings of the skin check. Surveyor #1 interviewed the Assistant Director of Nurses (ADON) at 9:33 P.M. on 1/23/18. The ADON said that he was responsible for the Skin Program since summer (YEAR). The ADON said that staff checked residents' skin weekly, initialed the treatment record and wrote a progress note. The ADON said that if the nurses did not write a progress note, the Facility had no evidence that the skin check was conducted. Surveyor #1 interviewed Nurse #12 at 7:30 P.M. on 1/2/18. Nurse #12 said that she was the supervisor on 1/7/18 during the Day shift and said she was also working administering resident medications on a unit. Nurse #12 said that around lunch time Nurse #24 and Nurse #26, who worked on another unit, called her and reported that Resident #6 was agitated, hit staff and threw glasses. Nurse #12 said she assisted Nurse #24 and Nurse #26 with efforts to arrange for Resident #6's transfer to the hospital emergency department for evaluation. Nurse #12 said that while on Resident #6's unit she noticed bruising on Resident #6's knees and shin. Nurse #12 said Resident #6 pointed to a red area on his/her leg and a red, swollen area on his/her hand and said it hurt. Surveyor #1 asked Nurse #12 whether the areas of redness, swelling and bruising were documented and she said she had not documented her observations but hoped that the nurses assigned to care for Resident #6 during the Day and Evening shift had documented the bruises.

Based on interviews and records reviewed, for one of six sampled residents (Resident #6), the Facility failed to ensure that Nurse #6, #26 and #24 understood the nature of and the method to obtain a Section 12 (a Form used in compliance with a section of Massachusetts General Law that allows an authorized professional to order transport of a patient to the Hospital for psychiatric evaluation when failure to do so creates a likelihood of serious harm despite the patient's or resident's refusal to go to the hospital). Although Resident #6 exhibited behavioral symptoms which included throwing items at staff and residents and ramming his/her wheelchair into things around 1:00 P.M. on 1/7/18, the Facility did not call an ambulance to transport him/her to the hospital until 8:11 P.M., (approximately seven hours later) because Nurse #6, Nurse #26 and Nurse #24 had not obtained the Section 12 Form necessary to transport Resident #6 to the hospital despite his/her refusal. The Emergency Medical Technicians (EMTs) who responded to the Facility at 8:43 P.M. obtained the Section 12 Form from their medical control physician and at 9:00 P.M. the EMTs transported Resident #6 to the hospital. The Facility's failure resulted in Resident #6's hospital evaluation being delayed for 8 hours during which Resident #6 exhibited multiple episodes of out of control behavior and sustained bruises to his/her arms and legs from ramming his/her wheelchair. Findings included: A Report to the Department of Public Health from the Disabled Persons Protections Commission (DPPC), dated 1/8/18, indicated that while in the Emergency Department, Resident #6 was found to have multiple bruises over his/her left side. Resident #6's Minimum Data Set (MDS) Assessment, completed 12/20/17, indicated that Resident #6's cognition was severely impaired and he/she moved his/her wheelchair independently. The Nurse Progress Note, dated 1/7/18 at 4:39 P.M., indicated that Resident #6 was very agitated during the 7:00 A.M. to 3:00 P.M. (Day) shift. The Note indicated that Resident #6 went into other resident's rooms, took their belongings and tried to hurt staff. The Note indicated that Resident #6 disturbed his/her roommate, threw his/her roommate's lunch on the floor and broke a plate. The Note indicated that Resident #6 was combative, could not control him/herself and verbally abused staff. The Note indicated that the Medical Director was notified to get a Section 12 Form to send Resident #6 to the hospital for evaluation. The Note indicated that the Psychiatric Service was aware of the situation. Surveyor #1 interviewed Nurse #26 at 1:00 P.M. on 1/30/18. Surveyor #1 interviewed Nurse #24 at 12:30 P.M. on 1/30/18. Nurse #26 said she was assigned to be Resident #6's nurse during the Day shift on 1/7/18. Nurse #24 and Nurse #26 said that during the Day shift, Resident #6 hit and followed staff members, used foul language, threw items including hot cups of coffee and his/her roommates lunch onto the floor, took items from other resident's rooms, stripped another resident's bed of its' linen, threw it on the floor and rammed his/her wheelchair into walls. Nurse #24 and Nurse #26 said that they called Nurse #12, a supervisor who was working on another unit, and asked what they should do about Resident #6. Nurse #24 and Nurse #26 said that Nurse #12 told them that they had to do a Section 12. Nurse #26 said she had never been involved with obtaining a Section 12 and knew that it had to do with situations when residents were dangerous to themselves or others. Nurse #24 said that a Section 12 was a form that needed to be filled out so that a resident could be sent to the hospital for evaluation. Nurse #26 said that Nurse #12 told her that she needed to contact the Psychiatric Service to have them send a paper regarding the Section 12. Nurse #24 and Nurse #26 said that Nurse #12 told them that she did not know how the Psychiatric Service would send the Section 12 Form to the Facility as the fax machines on all four Facility Units did not work. Nurse #26 said that she left a message with the Psychiatric Service, but said she had not spoken to them before the end of the Day shift. Surveyor #1 interviewed Nurse #12 at 7:30 P.M. on 1/2/18. Nurse #12 said that she was the supervisor on 1/7/18 during the Day shift and also was assigned to care for residents on a unit. Nurse #12 said that around lunch, Nurse #24 and Nurse #26 called her and reported that Resident #6 was agitated, hit staff and threw glasses. Nurse #12 said that she reported the situation to Facility leadership, notified the Medical Director and told Nurse #24 and Nurse #26 that they needed to obtain a Section 12 Form for Resident #6. Nurse #12 said that at 3:00 P.M., Nurse #24 and Nurse #26 told her they had not received the Section 12 Form. Nurse #12 said that the Facility's fax machines were not working. Nurse #12 said that it was a long delay and she thought Nurse #24 and Nurse #26 called the Psychiatric Service several times to try and arrange a way to receive the Section 12 Form. Surveyor #1 interviewed the Psychiatric Nurse Practitioner at 10:20 A.M. on 1/26/18. The Psychiatric Nurse Practitioner said that she received two messages from the Facility on 1/7/18 and around 4:30 P.M. or 5:00 P.M. and said she called the Facility. The Psychiatric Nurse Practitioner said that she spoke with a nurse who reported that Resident #6 exhibited suicidal ideation and the nurse wanted a Section 12 Form sent to the Facility. The Psychiatric Nurse Practitioner said that the nurse told her that the Facility fax machines were not working and they did not have an email where the Section 12 Form could be sent. The Psychiatric Nurse Practitioner said that she asked the nurse whether Resident #6 was willing to go to the hospital and the nurse said that she did not know. The Psychiatric Nurse Practitioner said that she told the nurse to ask Resident #6 whether he/she was willing to go to the hospital and if Resident #6 was unwilling, the nurse should call her back. The Psychiatric Nurse Practitioner said that the phone call was the only contact that she had with Facility staff on 1/7/18 and staff did not call her back to report that Resident #6 was not willing to go to the hospital and that they needed the Section 12 Form. The Nurse Progress Note for the 3:00 P.M. to 11:00 P.M. (Evening) shift on 1/7/18 indicated that Resident #6 was agitated and staff were unable to redirect him/her. The Note indicated Resident #6 yelled, threw things and tried to pull a resident out of bed. The Note indicated that Resident #6 had an order from the Day shift to be sent to the hospital for evaluation and left the Facility at 9:00 P.M. by ambulance. Surveyor #1 interviewed Nurse #6 at 10:00 A.M. on 1/24/18. Nurse #6 said she was assigned to care for Resident #6 during the Evening shift on 1/7/18. Nurse #6 said that when she arrived at 3:00 P.M. staff reported that they were waiting for a Section 12 Form to be faxed to the Facility. Nurse #6 said that during the Evening shift she was not able to receive the Section 12 Form because the Facility fax machines were not working. Nurse #6 said that Day shift staff told her that when the Psychiatric Service called she should tell them to fax the Section 12 paperwork to the hospital. Surveyor #1 asked Nurse #6 whether she was aware that EMTs could not transport a resident to the hospital for evaluation against their wishes without the Section 12 Form in hand and Nurse #12 said that she was not. Nurse #6 said that at some point during the shift, she spoke to the Assistant Administrator who told her to send Resident #6 to the Hospital without the Section 12 Form and Nurse #6 said she scheduled an ambulance. Nurse #6 stated words to the effect of, when the ambulance arrived, Resident #6 went off on the EMTs and put him/herself on the floor. Nurse #6 said that Resident #6 kicked and fought staff and it took 3 staff and 2 EMTs to secure Resident #6 on a stretcher. The Patient Care Report, dated 1/7/18, indicated that the request for an ambulance was received on 1/7/18 at 8:11 P.M. for a verbally aggressive resident and at 8:43 P.M. the EMTs arrived to Resident #6's location within the Facility. The Report indicated that staff told the EMTs Resident #6 did not have a Section 12 Form and that he/she had been physically and verbally aggressive since the morning. The Report indicated that when the EMTs informed Resident #6 that he/she was going to the hospital, Resident #6 refused to go, became verbally abusive and wheeled him/herself down the hallway. The Report indicated that the EMTs contacted the EMS Service Medical Control Physician who completed a Section 12 Form. The Report indicated Resident #6 entered another resident room and put him/herself onto the floor. The Report indicated Resident #6 was combative on the floor and was lifted by the EMTs to a stretcher and secured with two rails and five seat belts. The Report indicated that at 9:00 P.M. Resident #6 was transported to the hospital. Surveyor #1 interviewed the Hospital Nurse at 2:30 P.M. on 2/7/18. The Hospital Nurse said Resident #6 arrived at the Hospital during the Evening shift on 1/7/18 with extensive bruising of various stages of healing on his/her upper and lower extremities and left hip and left side of his/her back. The Hospital Nurse said Resident #6 had serious bruising and swelling on his/her left wrist. Nurses #24, #26 and #6 said that Resident #6 had not accepted care during the Day and Evening shift and said they were unable to get close enough to him/her to assess him/her. Nurses #24, #26 and #6 said that did not know about bruises on Resident #6's body. Nurse #12 said she noticed bruising on Resident #6's knees and shin. Nurse #12 said Resident #6 pointed to a red area on his/her leg and an area on his/her hand which was red and swollen and said words to the effect of hurt. Surveyor asked Nurse #12 whether the areas of redness, swelling and bruising were documented and she said she had not documented her observations but hoped that the nurses assigned to care for Resident #6 during the Day and Evening shift had documented the bruises.

Based on records reviewed, interviews and observations for Non Sampled (NS) Resident L, the Facility failed to ensure interventions in his/her nutritional plan of care were implemented for the prevention of weight loss. NS Resident L had an unplanned weight loss of 10.6 lbs between 10/27/17 and 1/22/17. Findings include: NS Resident L's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated 10/27/17, indicated NS Resident L required supervision and set up help with eating, that is; verbal cues, opening cartons, and/or touching or steadying assistance as needed. The MDS indicated NS Resident L weighed 124 lbs which indicated he/she experienced a greater than a 5% weight loss in the last 6 months. The MDS indicated NS Resident L was not on a prescribed weight loss program. A Nutritional Plan of Care, dated 10/27/17, indicated NS Resident L's ideal weight was 136 lbs, however he/she had a recent weight loss related to difficulty swallowing and a variable oral intake. The Plan of Care indicated staff were to supervise and provide strong encouragement to NS Resident L with meals, monitor for chewing/swallowing difficulties and adjust menu preferences as needed. Review of NS Resident L's most recent electronic Weight and Vitals Summary Record, dated 1/22/18, indicated NS Resident L weighed 114.6 lbs, which was a 10.6 lb weight loss, which was greater than a 7.5 % weight loss in three months, since the MDS was completed on 10/27/17. The Facility was unable to provide an electronic or hard copy of a Nutritional Assessment or Nutritional Progress Notes, for non-sampled Resident L . Surveyor #2 interviewed the Dietitian at 2:29 P.M. on 2/9/18. The Dietitian said prior to her date of hire in November, (YEAR), a staffing agency had been covering the dietary department, and said there was a severe lack of documentation to support nutritional assessments, evaluations and weight records that were completed on residents. The Dietitian said she based her initial evaluations on residents whom staff had identified with nutritional problems, and from the MDS schedule. The Dietitian said she was unaware of NS Resident L's weight loss, and said staff had not informed her about concerns related to NS Resident L's meal percentage intake. The Dietitian said she had not completed a nutritional assessment or evaluation on NS Resident #L and said she was unaware of his/her nutritional needs. On 1/23/18, at approximately 8:40 A.M. Surveyor #2 entered NS Resident L's room and observed NS Resident L sitting up in bed with his/her meal tray on the over-bed tabled in front of him/her. There was no staff members present in Resident #L's room at that time. NS Resident L was trying to feed him/herself. NS Resident L's right hand trembled as he/she tried to raise a fork, with pancake, to his/her mouth, however, the pancake fell off the fork and back on to a plate before NS Resident L was able to get the fork to his/her mouth. On 1/28/18, at approximately 5:17 P.M. Surveyor #4 entered NS Resident L's room and observed NS Resident L seated in front of his/her meal tray. There was no staff members present in Resident #L's room at that time. NS Resident L asked Surveyor #4 to open his/her container of ice cream. Surveyor #4 explained to NS Resident #L that she was not a staff member but would go look for help. Surveyor #4 was unable to find a staff member to assist her and when Surveyor #4 returned to the room, NS Resident L's meal tray had been removed from in front of him/her and was placed on the top of the dresser out of NS Resident L's reach. At 5:24 P.M. Surveyor #4 observed NS Resident L seated in a wheelchair near the nurses' station. Surveyor #4 asked NS Resident L whether someone helped him/her with the ice cream and NS Resident L said no and said he/she was hungry. At 5:26 P.M. Surveyor #4 observed NS Resident L's dinner tray which was still at his/her bedside. Surveyor #4 observed that NS Resident L's ice cream container was still unopened. NS Resident L's tray contained his/her soup and sandwich which were uneaten. At 5:28 P.M. Surveyor #4 observed NS Resident L in a wheelchair at the nurses' station and he/she stated words to the effect, I want my dinner now. Surveyor #4 observed four staff, (two nurse's and two Certified Nurse Aides) in the vicinity of NS Resident L. Surveyor #4 heard one staff member state words to the effect of (NS Resident L) already ate and another staff member said words to the effect of (he/she) only ate (his/her) quiche. At 5:40 P.M. Surveyor observed NS Resident L was still seated at the nurses' station and he/she stated words to the effect, I want my dinner now, and staff present at the nurses' station, did not did not acknowledge NS Resident L, did not retrieve his/her meal tray from his/her room, and did not offer him/her an alternate meal. Review of NS Resident L's Medication Administration Record [REDACTED]. Surveyor #2 interviewed the Director of Nurses (DON) at 4:12 P.M. on 1/25/18. The DON said that although she had identified there was an issue with staff accurately documenting resident meal percentage intake, she had not addressed this issue with staff. The DON said NS Resident L's documented meal percentage intake was not accurate.

Based on record review, observation, and staff interview, the facility failed to provide medically related social services for 2 of 24 sampled residents (#8 and #14) to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: 1. For Resident #8, the facility failed to provide medically related social service interventions to the Resident, who had a medical history of [REDACTED]. The Resident was sent to the emergency room (ER) three times in July, 2014; twice (7/3/14 and 7/4/14) for alcohol screening for significant alcohol consumption and once on 7/18/14 as a Section 12 admission (a danger to self and others) after consumption of alcohol. Resident #8 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. The resident is an independent smoker. Record review on 8/13/14 indicated the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], identified the resident as alert and oriented to person, place and time with a Brief Interview for Mental Status (BIMS) code of 15 out of 15. According to the MDS, the resident exhibited no behaviors and received anti-depressant medication. On 8/13/14, the surveyor reviewed physician orders since admission. There was no physician order at anytime that stated that the Resident "may have alcohol". On 8/13/14, the surveyor reviewed physician orders since admission in 12/2013. Review of the physician orders since admission indicated that the Resident had an order for [REDACTED]. The orders also included Morphine Sulfate 60 milligrams (mg) (a narcotic) every 12 hours for pain management which the Resident received every day and an order for [REDACTED]. Review of the Facility Admission Agreement on 8/19/14 indicated that the admission agreement contained Rules regarding alcoholic beverages. The facility Admission Agreement Rules and Regulations regarding alcohol stated: "Alcoholic Beverages": "Alcoholic Beverages are prohibited unless prescribed by a physician and dispensed by a Facility staff member". During interview with the Administrator on 8/19/14 at 11:00 A.M., the surveyor asked how the residents are informed about the facility rules and regulations concerning alcohol. The surveyor was told that all residents are given the Rules and Regulations involving Alcoholic Beverages in the Admission Packet and the rules are reviewed with residents during the admission process. The Administrator told the surveyor that Resident #8 signed the Alcoholic Beverage agreement on admission. During the same interview the surveyor was told that all residents admitted to the facility are assessed for SLOA by the physician. an order for [REDACTED]. Resident #8 had care plans in place from Social Services for: a. "Problematic Mood" dated 6/7/14 and b. "Hx of ETOH/substance abuse" dated 6/7/14. a. Review of the Social Service Care Plan for "Problematic Mood" interventions include: "Monitor mood and mental status, document any signs of problematic mood". "Supportive visits, provide reassurance during periods of alterations in mood". "Consider referral to Psych service if staff interventions ineffective". "Assist resident in problem-solving as needed". Review of nursing progress note dated 7/3/14 indicates: "Pt (patient) appeared to be under the influence of ETOH and has a minor ETOH odor; pt sent out to ER (emergency room ) for eval (evaluation) of ETOH use; ETOH was found in the pt's room inside of a ginger ale bottle; pt's narcotics are on hold for 48 hours." Review of the MD order dated 7/3/14 indicted "May send pt out to ER for ETOH screen. Hold narcotics for 48 hours + (positive) ETOH". Review of the nursing progress note dated 7/4/14 indicates "Pt was very argumentative with other pts. Argumentative with staff throwing belongings. Pt went out of building @ 6:30/pm (sic) returned @ 8:30/pm (sic). Refused meds earlier. Pt appeared to be under the influence of alcohol. Alcohol was on (his/her) breath. (He/she) was flushed, pupils dilated. Pt conts (continues) to be argumentative and yelling. MD called. NO (new order) sent pt to ER for eval. Ambulance called. Pt left @ 10 pm to hospital." Review of the nursing progress note dated 7/18/14 written at 10:00 A.M. indicated "Resident was found outside being verbally abusive towards others, not easily redirected, s/sx (signs/symptoms) of intoxication noted, MD, (Name), notified, NO, may section (Section 12) resident to ER (Name of Hospital), hold narcotics or 48 hours, living area assessment to be performed. Resident had difficulty complying with meds, refused all upon knowledge of narcotic hold, transferred (Hospital) via Section 8 (sic), to ER at 10:30 A.M." There were four Social Service progress notes documented in the record after the ER screening for intoxication on 7/3/14 and 7/4/14. Review of the first Social Service note dated 7/7/14 indicated that "sent out on 7/3/14 to the ER after he/she appeared to be intoxicated". There was no documentation of any reassessment of the SLOA, no documentation of consulting with geri-psych, and no documentation of any reassurance provided during periods of alterations of mood and no documentation of any interventions by social service. There was no documentation that the Resident had been sent out to the ER a second time on 7/4/14 due to alcohol intoxication. There was no documentation of any assessment of the Resident's behavior or mood in the note and no documentation of any interventions by social service. Review of the second Social Service note dated 7/7/14 indicated that the resident was transferred to another unit "due to a conflict with another PT on the unit 1A". Again, there was no documentation that the Resident had been sent out to the ER a second time on 7/4/14 due to alcohol intoxication. There was no documentation of any assessment of the Resident's mood or behavior in the note that led to the room change. Review of the third Social Service note dated 7/8/14 indicated "this writer tried to speak w/Pt regarding the ETOH allegation, his/her outbursts towards the nursing staff and allegations made by the other resident on Unit 1A. (Patient) became very agitated, yelling and refused to engage in conversation". There was no documentation of any assessment of the Resident's behavior or mood in the note. Review of the fourth Social Service note dated 7/9/14 indicated "SW (social worker) attempted to re-approach Pt to address the above allegations. (Patient) once again refused to speak with me". There was no documentation of any assessment of the Resident's behavior or mood in the note. There was no documentation that any other member of the Social Service staff had attempted to provide supportive visits or reassurance during this time. Record review on 8/13/14 indicated two Social Service notes dated 7/18/14 and 7/19/14 after the Resident was sent "Section 12" to theER on [DATE]. The Social Service note dated 7/18/14 indicated "Pt was send (sic) out to the ER for evaluation. (Patient) was presenting with behavior which warrants him being send (sic) out for Eval". There was no documentation of any assessment of the behavior in the note or any documentation of SLOA in light of the hospitalization for intoxication. The Social Service note dated 7/19/14 indicated "Pt returned from 7/18/14 after his/her evaluation". There was no documentation of any assessment of the behavior in the note. There was no documentation of any assessment of the behavior in the note or any documentation of SLOA in light of the hospitalization for intoxication. On 8/13/14 during record review, the surveyor found no documentation in the social service notes or on the care plans of any monitoring of mood and mental status. There was no documentation of how to identify signs of problematic mood, or referral to psych, per the care plan, when staff interventions were ineffective. There was no documentation of any interventions for alcohol consumption which the Resident did not have an order for [REDACTED]. On 8/18/14, the surveyor found changes to the above care plans that had been written by the Resident's social worker detailing the occurrences of the hospitalization s as if they had been written on the dates the events occurred. The surveyor asked the Director of Social Service on 8/18/14 at 10:30 A.M. when the additions had been written and was told that the information had been added to the record on the morning of 8/18/14. The surveyor asked why the notes were not dated as of 8/18/14 when they were added. The Director of Social Service had no reply except to say that after it was brought to her attention she told the Resident's social worker to add the information. b. On 8/13/14, the surveyor reviewed the Resident's Social Service Care Plan for "HX of ETOH/Substance Abuse" dated 6/7/14. The care plan described the problem as "Resident has a history of recent alcohol abuse/substance abuse". The Social Service interventions include: "Supportive visits" "Consult with geri-psych (geriatric psychiatric) services as needed" "Offer opportunities for choices, self determination within nursing home environment. "Offer AA/AAA (sic) services upon discharge There was no Social Service documentation found in the record regarding any interventions for alcohol use per the Care Plan after any of the three ER visits as documented in the nursing progress notes dated 7/3/14, 7/4/14. and 7/18/14. Review of three nursing progress note dated 7/3/14 at 1:00 P.M., 7/4/14 and 7/18/14 (see above) indicated that on three occasions the Resident had obtained and consumed alcohol to the extent that required the Resident to be transferred to the ER for alcohol intoxication. The 7/3/14 note also indicated that alcohol had been found in the Resident's room. the nursing progress notes also indicated behaviors that required the facility to take action to ensure the safety of both Resident #8 and the other residents. According to Social Service notes dated 7/7/14, 7/8/14, 7/9/14, social service indicated that the Resident was sent out on 7/3/14 to the ER after he/she appeared to be intoxicated, failed to document the emergency transfer on 7/4/14 for alcohol intoxication, and failed to document any interventions per the "Social Service Care Plan for "HX of ETOH/Substance Abuse" dated 6/7/14. Review of the Social Service note dated 7/8/14 indicated "this writer tried to speak w/Pt regarding the ETOH allegation, his/her outbursts towards the nursing staff and allegations made by the other resident on Unit 1A. (Patient) became very agitated, yelling and refused to engage in conversation". There was no documentation of any assessment of the behavior in the note and no documentation of any interventions by social service per the "Social Service Care Plan for "HX of ETOH/Substance Abuse". Review of the Social Service note dated 7/9/14 indicated "SW (social worker) attempted to re-approach Pt to address the above allegations. (Patient) once again refused to speak with me". There was no documentation of any assessment of the behavior in the note and no documentation of any interventions by social service per the "Social Service Care Plan for "HX of ETOH/Substance Abuse". Review of the Social Service note dated 7/18/14 indicated "Pt was send (sic) out to the ER for evaluation. (Patient) was presenting with behavior which warrants him being send (sic) out for Eval". There was no documentation of any assessment of the behavior in the note and no documentation of any interventions by social service per the "Social Service Care Plan for "HX of ETOH/Substance Abuse". The facility failed to ensure that Social Service implemented existing care plans and provided interventions for the Resident after a consistent pattern of going out on SLOA, obtaining and drinking alcohol to the point of transfer to theER on three separate occasions for screening for alcohol intoxication including the 7/18/14 Section 12 (danger to self/others) transfer. There was no documentation of any consult with geri psych or request of the facility psychiatric services for assistance with substance use for this Resident. . There was no documentation of any attempts at revisiting the status of the SLOA with the physician after any of the hospitalization s. On 8/19/14 the surveyor called the consultant psychiatric service at 11:00 A.M. and spoke with the consulting social worker providing one to one therapy for the Resident. The surveyor asked the consultant if she had ever been informed of the three alcohol related ER visits the Resident had on 7/3/14, 7/4/14, and 7/18/14. The consultant told the surveyor that she had met with the resident on 7/2/14, 7/9/14, 7/17/14, 7/23/14, 7/24/14, and 7/30/14. Review of the consultant notes on 8/19/14 indicated that the consultant was concerned that the Resident had been drinking alcohol. She told the surveyor she had not been given information about the ER visits. The consultant told the surveyor that she had been called by the facility social service department on the morning of 8/19/14 and told of the admissions. The surveyor asked the Director of Social Service on 8/18/14 at 10:30 A.M. if the facility hosted AA meetings and was told that meetings were available in the community but not at the facility. The Director of Nurses and the Administrator were interviewed on 8/19/14 regarding the above incident. Neither were aware that social services had not notified the facility psychiatric service social worker assigned to the Resident regarding the Resident's behavior problems. The Medical Director was interviewed on 8/19/14 at 11:30 A.M. regarding the incidents. According to the Medical Director, the facility did not provide substance abuse interventions at the facility, but conceded that the geri psych consultants could have provided guidance for the staff if staff had requested assistance in dealing with the Resident's behaviors. The Medical Director told the surveyor that to his knowledge, the facility had not requested any assistance from the facility psychiatric consultants to provide suggestions for the professional staff for either "HX of ETOH/Substance Abuse" or "Problematic Mood interventions" care plans. Please see F 280 2. The facility failed to provide medically related social service interventions for Resident #14, who had a history of [REDACTED]. Resident #14 was admitted with [DIAGNOSES REDACTED]. Resident #14 is an independent smoker. Review of the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], identified the Resident as alert and oriented with a Brief Interview for Mental Status (BIMS) code of 15 out of 15. According to the MDS, the Resident exhibited no behaviors and had not indicators of depression. Review of the facilities Admission Agreement (this is paperwork that is presented to either the Resident or the Responsible person upon Admission to the facility) indicated the following Rules and Regulations: "Alcoholic Beverages are prohibited unless prescribed by a physician and dispensed by a Facility staff member". "This is a smoke-free facility, unless other wise noted. If smoking is allowed, it is permitted only in designated smoking areas. Facility staff may evaluate your ability to safely smoke independently. Please contact us for further information. Resident #14 was alert and oriented and participated in the admission process. Resident #14 was aware of the facility rules in regards to the smoking rules, and that alcoholic beverages were prohibited unless prescribed by a physician and dispensed by a Facility staff member". The Resident had a Care Plan in place from Social Services for "Hx of ETOH/substance abuse" dated 6/24/14. The Care Plan described the problem as "Resident has a history of recent alcohol abuse/substance abuse". Interventions include: * supportive visits * consult with geri-psych services as needed * encourage family in maintaining contracts with resident * offer opportunities for choices, self determination within nursing home environment. * Offer AA/ALA services upon discharge Review of the clinical record on 8/19/14 revealed the following: The Resident did not have an order that stated "may have alcohol". Review of the Social Service notes dated 5/14 (no day of the month on note) and 6/4/14, did not address the issue of the Resident being transferred to the emergency room for ETOH intoxication or speaking to the Residents family/or Resident when the Resident returned to the facility. There were no interim Social Service notes addressing any of the Residents transfers to the hospital on [DATE], 6/9/14 and 7/3/14 for the consumption of alcohol. The clinical record revealed the Resident had physician order for [REDACTED]. This allowed the Resident to independently smoke at the soccer field, off the facility grounds since the facility was considered " Smoke Free". The Residents SLOA privileges had been put on hold after the first episode of ETOH intoxication on 4/21/14, and again on 6/6/14. At this time because the SLOA had been revoked the Resident signed out from the facility against medical advise on 6/14/14 and went to a family members house. The Resident subsequently ended up in the emergency room for ETOH intoxication and and then returned to the facility. The Care Plan had not been developed after the first episode of intoxication which was 4/21/14, nor had it been reviewed and revised after each subsequent episode of intoxication. The Resident had not been evaluated by geri-psych until 8/1/14. There was no documentation in the Social Service progress notes that addressed the Residents ETOH usage. Social Service failed to address the ETOH episodes and transfers/returns to the facility in the progress notes and no supportive visits were completed as per the Care Plan.

Based on observation, record review and interview, the facility failed to review and revise a Behavior Care Plan for two residents, (#8 and #14) in a total sample of 24 residents. Findings include: 1. For Resident #8 the facility failed to review and revise a comprehensive plan of care to address the current, consistent behavior of the Resident associated with his/her SLOA during which alcohol was obtained and consumed resulting in the Resident being transferred to the emergency roiagnom on three separate occasions, 7/3/14, 7/14/14 and 7/18/14 for [MEDICAL CONDITION]. The ER screening also resulted in the primary care physician holding narcotic pain medication for 48 hours after readmission to the facility. The clinical record was reviewed on 8/13/14 and 8/18/14. Resident #8 was admitted in 3/2014 with [DIAGNOSES REDACTED]. The resident is an independent smoker. Review of the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], identified the resident as alert and oriented to person, place and time with a Brief Interview for Mental Status (BIMS) code of 15 out of 15. According to the MDS. the resident exhibited no behaviors and received anti-depressant medication. Review of Physician order [REDACTED]. Review of the Physician order [REDACTED]. Review of the Physician order [REDACTED]. Review of recent nursing progress note dated 7/3/14 indicates: "Pt (patient) appeared to be under the influence of ETOH and has a minor ETOH odor; pt sent out to ER (emergency room ) for eval (evaluation) of ETOH use; ETOH was found in the pt's room inside of a ginger ale bottle; pt's narcotics are on hold for 48 hours." Review of the MD order dated 7/3/14 indicted "May send pt out to ER for ETOH screen. Hold narcotics for 48 hours + (positive) ETOH". Review of the nursing progress note dated 7/4/14 indicates "Pt was very argumentative with other pts. Argumentative with staff throwing belongings. Pt went out of building @ 6:30/pm returned @ 8:30/pm. Refused meds earlier. Pt appeared to be under the influence of alcohol. Alcohol was on (his/her) breath. (He/she) was flushed, pupils dilated. Pt conts (continues) to be argumentative and yelling. MD called. NO (new order) sent pt to ER for eval. Ambulance called. Pt left @ 10 pm to hospital." Review of the MD order dated 7/4/14 indicated "Send PT to ER for eval". Review of the nursing progress note dated 7/18/14 indicates "Resident found outside being verbally abusive towards others, not easily redirected, s/sx (signs and symptoms) of intoxication noted, MD notified, NO (new order). section (Section 12--emergency transfer to the hospital as an imminent danger to him/herself or others) to hospital. Hold narcotics for 48 hours...transferred at 10:30 AM...MD aware of all non-compliance issues." Review of the MD order dated 7/18/14 indicated "Section resident to ER, hold narcotics X 48 hrs (hours)." On on 8/14/14 the surveyor reviewed the mental health notes, from the facility consultant psychiatric service dated 7/2/14 that indicated "pt appeared red and flushed in the face. Stated he/she was tired. Easily agitated and annoyed. Questioned if pt had anything to drink (alcohol)." Review of the mental health notes from the facility consultant psychiatric service dated 7/30/14 indicated "grandiose, defiant, refused to reason. Pt difficult to talk w/ (with) appeared w/flushed face and glassy eyes. Alcohol?? (sic) Change in behavior." There was a Behavior Care Plan for HX (History of) ETOH/substance abuse dated 6/7/14. There was no documentation of any revision after any of the events documented in the nursing notes regarding the ingestion of alcohol with subsequent emergency hospitalization s for [MEDICAL CONDITION] on 7/3/14, 7/4/14, and 7/18/14. At no time was a Behavior Care Plan developed to address this resident's frequent drinking as documented by the nursing notes, consultant notes, and hospitalization s for [MEDICAL CONDITION]. At no time was there any care plan update of the SLOA which allowed the resident to buy and drink alcohol during these LOA's as well as at the nursing facility. Interview with the Director of Nurses (DON) on 8/18/14 at 1:00 P.M. was held regarding the facility's failure to address these behaviors and failure to develop an effective Behavior Care Plan. The DON had no response to the inquiry regarding the review, revision or development of an effective Behavior Care Plan. Please refer to F319. For Resident #14 the facility failed to develop a comprehensive plan of care to address the acquisition and consumption of alcohol that resulted in the Resident being transferred to the emergency roiagnom on four separate occasions. Resident #14 was admitted with [DIAGNOSES REDACTED]. Resident #14 is an independent smoker. Review of the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], identified the Resident as alert and oriented with a Brief Interview for Mental Status (BIMS) code of 15 out of 15. According to the MDS, the Resident exhibited no behaviors and had not indicators of depression. Further review of the clinical record revealed the Resident had physician order [REDACTED]. The Resident did not have and order for the consumption of alcohol. On 4/21/14 the Resident was observed to have blood shot eyes and slurred speech. The Resident admitted to drinking alcohol. States that the ETOH was acquired at a family members house. The Resident was sent to the emergency room (ER). On 6/6/14 the Resident was found on the floor in his/her room. Resident had stated he/she was trying to go to the bathroom. Upon further investigation of the situation, a gallon of ETOH was found in the Residents room. The Resident was sent to the emergency room (ER). On 6/9/14 the Resident was noted to be intoxicated. ETOH was found to be in a soda bottle. The Resident did not deny drinking ETOH, stated a friend brought the ETOH in. The Resident was sent to the emergency room (ER). On 7/3/14 the Resident was suspected of ETOH intoxication. The Resident was sent to the emergency room (ER). At no time was a Behavior Care Plan developed to address this Resident's frequent drinking and continued independent SLOA's. There was no documentation regarding follow-up for this on-going ETOH use, nor was there any internal investigations as to where and how the Resident obtained the ETOH. There were no incident reports regarding the above incident available to review. On 8/19/14 at 5:45 P.M. Director of Nursing said the facility failed to develop a comprehensive plan of care to address the acquisition and consumption of alcohol.

Based on observation, record review and staff interview, the facility failed to ensure that one resident (#8) in a total sample of 24, who displayed mental or psychosocial adjustment difficult received appropriate treatment and services to correct the assessed problem. Findings include: For Resident #8 the facility failed to provide appropriate treatment and services to address the known problem of alcohol consumption resulting three hospitalization s 7/3/14, 7/4/14, and 7/18/14. Record review on 8/13/14 indicated that Resident #8 was admitted in 3/2014 with [DIAGNOSES REDACTED]. The resident is an independent smoker. Review of the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], identified the resident as alert and oriented to person, place and time with a Brief Interview for Mental Status (BIMS) code of 15 out of 15. According to the MDS, the resident exhibited no behaviors and received anti-depressant medication. The resident received [MEDICATION NAME] 60 mg every 12 hours for pain and had a PRN order for [MEDICATION NAME] 10 mg every 4 hours. A review of the medical record indicated that on admission the physician ordered a psychiatric consult as needed. Review of the Social Service notes dated 7/7/14 indicated that the resident was sent out on 7/3/14 to the ER after he/she appeared to be intoxicated. There was no mention of any reassessment of the SLOA, no mention of consulting with geri-psych, and no documentation of any signs of problematic mood. Review of the Social Service note dated 7/7/14 indicated that the resident was transferred to another unit "due to a conflict with another PT on the unit 1A". Review of the Social Service note dated 7/8/14 indicated "this writer tried to speak w/Pt regarding the ETOH allegation, his/her outbursts towards the nursing staff and allegations made by the other resident on Unit 1A. (Patient) became very agitated, yelling and refused to engage in conversation". Review of the Social Service note dated 7/9/14 indicated "SW (social worker) attempted to re approach Pt to address the above allegations. (Patient) once again refused to speak with me". Review of the Social Service note dated 7/18/14 indicated "Pt was send (sic) out to the ER for evaluation. (Patient) was presenting with behavior which warrants him being send (sic) out for Eval". On on 8/14/14 the surveyor reviewed the psychiatric consultant notes, from the consultant psychiatric service dated 7/2/14 that indicated "pt appeared red and flushed in the face. Stated he/she was tired. Easily agitated and annoyed. Questioned if pt had anything to drink (alcohol)." Review of the mental psychiatric consultant notes from the consultant psychiatric service dated 7/30/14 indicated "grandiose, defiant, refused to reason. Pt difficult to talk w/ (with) appeared w/flushed face and glassy eyes. Alcohol?? (sic) Change in behavior." On 7/19/14, the surveyor asked the consultant if she had ever been informed of the three alcohol related hospitalization s the Resident had on 7/3/14, 7/4/14, and 7/18/14. The consultant told the surveyor she had not been given that information. The consultant told the surveyor that she had met with the resident on 7/2/14, 7/9/14, 7/17/14, 7/23/14, 7/24/14, and 7/30/14. There was a Behavior Care Plan for HX (History of) ETOH/substance abuse dated 6/7/14 but no documentation or care plan update after any of the events documented in the nursing notes regarding the ingestion of alcohol with subsequent emergency hospitalization for alcohol on 7/3/14, 7/4/14, and 7/18/14. The Medical Director was interviewed on 8/19/14 at 11:30 A.M. regarding the incidents. According to the Medical Director, the facility did not provide substance abuse interventions at the facility, but conceded that the geri psych consultants could have provided guidance for the staff if staff had requested assistance in dealing with the Resident's behaviors. The Medical Director told the surveyor that to his knowledge, the facility had not requested any assistance from the facility psychiatric consultants to provide suggestions for the professional staff for either "HX of ETOH/Substance Abuse" or "Problematic Mood interventions" care plans. The surveyor asked the Director of Social Service on 8/18/14 at 10:30 A.M. if the facility hosted AA meetings and was told that meetings were available in the community but not at the facility. At no time were Care Plans developed to address this resident's refusal to talk with the facility social worker, frequent drinking as documented in nursing notes, and continued SLOA which allowed the resident to obtain and drink alcohol during these LOA's as well as at the nursing facility. The social service department did not seek information or assistance from the facility geri psych consultant nor was the psychiatric consultant informed of the Resident's active alcohol consumption.

2. For Resident #5, the facility failed to ensure that the resident did not have unplanned significant weight loss. The facility failed to ensure that interdisciplinary assessments and interventions were consistently implemented in an attempt to prevent an unplanned significant weight loss of 22 pounds (13.4%) occurring between the date of admission, 11/15/11, and 2/15/12 when a "Change in Condition Evaluation" was conducted by nursing staff. Review of the medical record on 2/22/12 and 2/28/12 indicated: Resident #5 was admitted [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), signed as complete 12/2/11, coded the resident under section B Hearing, Speech, and Vision section B0200 (Hearing) as moderately impaired for hearing, and under section B0300 as no use of hearing aid. Under section B1000 (Vision) the resident was coded as highly impaired. Under section C "cognitive patterns" the resident was assessed by staff as "3" severely impaired - never/rarely made decisions. Under section G "Functional Status" H. "eating" the resident was assessed as a "limited assist with meals - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance". The progress note written by the nurse practitioner, dated 11/15/11, noted that the resident was neurologically impaired and non-verbal, "does not follow commands". The Dietician's "Nutrition Data Collection Tool", dated 11/17/11, described the resident's weight upon admission to the facility from the hospital as "d/c (discharge) wt (weight) 163 (pounds)." The physician orders [REDACTED]. Review of the weights documented by staff indicated that between 11/15/11 and 2/15/12 the resident's weight went from the admission weight of 163 pounds to 141 pounds, a loss of 22 pounds or 13.4% since admission, as recorded 2/20/12 by the Dietician. Between 11/16/11 and 12/7/11, only one weight was documented: a weight of 156 pounds was recorded on 12/7/11, a loss of more than 4.6%, with three "refusals to be weighed" on 11/16/11, 11/23/11, 11/30/11. The weight recorded on 12/24/11 was 154 pounds, a weight loss of more than 5% since admission. There were no other weights recorded between 12/7/11 and 12/24/11. On 1/7/12, the weight recorded was 147.4 pounds, which represented an additional weight loss of 4.6% in the two weeks since 12/24/11. Weights were recorded in January, 2012 as follows: 1/7/12, 147.2 pounds; 1/14/12, 148 pounds; 1/21/12, 152 pounds; 1/28/12, 137 pounds. The weight loss between 1/21/12 and 1/28/12 was 15 pounds (or 10%) in one week. During interview on 2/22/12, Unit Manager #2 indicated that the resident had refused to be weighed or was "too agitated" to be weighed weekly in November and December as ordered. Unit Manager #2 had no information on whether the MD had been notified of the weight loss. There was no mention of weight loss found in the review of all nurses notes, MD progress notes and nurse practitioner notes between 11/15/11 and 2/15/12. On 2/15/12 the facility documented a weight loss on the "Change in Condition Evaluation" form. The form documented that the nurse practitioner and the guardian were notified of the weight loss and the times of notification. There is no written remark on the document. The resident was referred to physical therapy, occupational therapy and speech therapy on 2/20/12. The written response from speech therapy on 2/21/12 was that "skilled rehab intervention not indicated at this time". "Suggest staff A (assist) with meals to insure increase (sic) intake". Review of the meal percentage intake recorded for the resident since admission indicated that the meal consumption was routinely documented as "good" defined by the facility as 85-100% consumption. During interview with the Dietician on 2/22/12, the surveyor was told that supplements had been added to the resident's meal trays at lunch and dinner since admission. The Dietician told the surveyor that the resident was being helped with meals and that the recordings of meal percentages indicated that the resident was consuming the meals. The Dietician told the surveyor that no information had been given by nursing regarding the weight loss or the refusals to be weighed during November and December 2011. The Dietician's "Nutrition Progress Note", dated 12/5/11, document a weight of 156 pounds and a diet upgrade to puree with thin liquids. The note dated 1/5/12 documented a weight of 146 pounds with the comment: "? accuracy, recheck pending, p.o. (by mouth) intake noted as good, fed by staff, Mighty Shake lunch and dinner." The Dietician's "Nutrition Progress Note" dated 1/12/12 document a weight of 147, with the comment: "p.o. continues to be good." The Dietician's "Nutrition Progress Note" dated 2/6/12 document a weight of 137, with the comment: "recheck pending" In spite of the documentation of meal consumption, the resident continued to lose weight. Weight loss is the indication that the resident was not consuming sufficient calories on a daily basis. The Resident lost between 22 and 32 pounds (13.6% and 17%) of body weight from admission on 11/15/11 to 2/15/12 (12 weeks) with no intervention by the facility, no MD notification of the weight loss, and no change in the dietary recommendations. The first documentation of significant weight loss was recorded by the facility on 2/15/12. Following surveyor inquiry, the facility provided a copy of a nurse practitioner visit dated 2/25/12. The facility obtained orders for supplements to be provided by nursing during the medication administration times for the resident. Based on record review, observation and interview, the facility failed to ensure two residents (#3 and # 5), in a total sample of 24 residents, did not have unplanned significant weight loss. The facility failed to ensure that interdisciplinary assessments and interventions were consistently implemented in an attempt to prevent weight loss. Findings include: 1. For Resident #3, the facility failed to prevent a significant weight loss of 10 pounds in a three month period. The resident's weight decreased from 85.0 pounds to 74.6 pounds between 11/12/11 and 2/22/12. The facility failed to implement their own Weight Policy for accurate monitoring of weights which delayed recognition of the loss and revision of nutritional interventions. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) of 8/26/2011, and Quarterly MDS of 11/25/11, assessed the resident's eating ability as "requiring limited assistance/resident highly involved in activity". The Annual MDS also indicated a height of 59 inches and weight of 89 lbs. Ideal body weight (IBW) was indicated as 101-134 lbs. The Dietary Care Plan of 8/27/11 listed the following problems as "potential for altered nutritional status": dementia, marginal by mouth (po) intake, poor dentition/trouble chewing and weight less than ideal body weight. The Dietary Care Plan listed the following goals: "promote weight gain, by mouth (po) intake greater than 50% and weight goal of 90-95 lbs." The Dietary Care Plan listed the following interventions: "encourage po greater than 50%, monitor weight (no frequency noted), offer snacks between meals, feed whenever necessary, muffin and sandwiches allowed." The Dietary Care Plan of 11/26/2011 indicates the following: "current wt. 85.2 lbs/ wt. stable, po fair, resident encouraged by staff and continues to receive supplements for increased calories." Review of the Resident's Care Plan indicated the resident was weighed monthly. The monthly weight log documented the following weights: 8/11/2011: 128.2 lbs. 9/6/11: 81.8 lbs. 10/10/11: 84.2 lbs. 11/12/11: 85 lbs. (last three months below) 12/7/11: 85 lbs. 1/12/12: 80 lbs. 2/8/12: 79.2 lbs. 2/22/12 85.2 lbs. 2/22/12 re-weigh via Hoyer Lift of 74.6 lbs. The Facility Nursing Procedure Manual for Weight, dated 6/2008, indicated to record accurate weight change by the following procedures: verify any adaptive equipment (splints, braces, etc.) be removed prior to weighing; same scale be utilized and calibrated to zero prior to use; if a weight change is noted, re-weigh the resident to verify accuracy before reporting; report weight changes to nursing supervisor. If a weight loss of 5% in 1 month/ 10% in 6 months or weight loss in last 2-3 times weighed, notify nursing supervisor, MD, dietician and family and treat as ordered. On the afternoon of 2/22/12 the Surveyor observed a Certified Nursing Assistant (CNA) weigh Resident #3 on the Unit's chair scale. The CNA did not remove the leg rests or the chair cushion. The CNA said the weight should be recorded at 83.8 lbs. based on a weight of 128.8 minus 45 lbs. (the recorded chair weight), factoring in adaptive equipment weight. On 2/22/12 in the afternoon, Unit Manager (UM) #1 said that the Certified Nursing Assistants (CNAs) sometimes weighed Resident #3 on the chair scale without removing adaptive equipment (e.g., splints, braces, seat cushion etc.) prior to weighing and calculated adaptive equipment accordingly. UM#1 decided to weigh the Resident via Hoyer lift for a more accurate reading. The Hoyer lift weight was 74.6 lbs. which indicated a 3 month weight loss of 10 lbs., an approximate 12% weight loss. On 2/22/12 in the afternoon, the Dietician told the surveyor that he/she agreed that the inaccurate weights most likely impeded identification of Resident #3's weight loss. The Nurse Practitioner's (NP) note of 2/23/12 indicated new orders for an increase in MedPass supplements to 120 milliliters (mls) four times per day, lab work: Complete Blood Count indicates a Red Blood Cell level of 3.03 (range= 4.0-5.10), Hemaglobin level of 9.4 (range=12.1-15.7) and Hematocrit level of 28.8 (range=35.0-45.0), Complete Metabolic Panel (pending) HgbA1C =5.6 (range= 4.8-5.9), [MEDICATION NAME]= 3.9 (range= 3.2-5.2), Total Protein= 6.0 (range= 6.4-8.3) and monthly weights increased to weekly weights for 4 weeks and to re-evaluate. On 2/24/12 the NP added [MEDICATION NAME] (a protein supplement) 1 packet PO two times per day for 14 days to the new orders for the total protein lab result of 6.0 (6.4-8.3). On 2/23/12, the Dietary Care Plan indicated a significant weight change and added weekly weights via Hoyer lift for 4 weeks. On 2/27/12, the Dietary Care Plan indicated the following new interventions: encourage Resident PO intake greater than 85%, encourage independent eating, but feed as needed, [MEDICATION NAME], monitor labs, vitamins/minerals as ordered, avoid milk products, and [MEDICATION NAME] milk/ice cream upon request. The facility failed to accurately weigh and monitor changes in nutritional status resulting in a significant weight loss for Resident #3.