Every finding on record at Cape Cod Post Acute Care

Based on observation and interview, 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 ensure food was properly stored in the walk-in refrigerator in the main kitchen.Findings include:Review of the facility's policy titled Food Receiving and Storage, undated, indicated but was not limited to:- Foods shall be received and stored in a manner that complies with safe food handling practices.- Critical Control Point means a specific point, procedure, or step in food preparation and serving process at which control can be exercised to reduce, eliminate, or prevent the possibility of a food safety hazard. Some operational steps that are critical to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices.- All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date).- Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.- Uncooked and raw animal products and fish are stored separately in drip proof containers and below fruits, vegetables, and other ready to eat foods to prevent meat juices from dripping onto these foods. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to:3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. On 6/4/26 at 7:27 A.M., the surveyor, accompanied by the Administrator, observed in the main kitchen walk-in refrigerator:-Cubed white blocks of cheese wrapped in clear plastic wrap, labeled Tuesday Cheese Hard; Prep/Opened on 5/12/26 7:09 P.M., Use By 6/1/26 7:09 P.M.-One clear pitcher covered with plastic wrap, containing a red liquid substance unlabeled and undated-One open cardboard box with an open blue plastic bag containing raw exposed chicken-One clear plastic container containing a thick orange colored substance, labeled waffles 5/26-One clear plastic container with a green clear gelatin-like substance with white puffed marshmallow like objects, unlabeled and undated-One opaque colored plastic container with a thick off-white substance, labeled 2/26 Pudding-One opaque colored plastic container with a thick red gelatin-like substance, labeled Monday Gelatin-Homemade; Prep/Opened on 5/11/26 2:01 P.M., Use By 5/13/26 2:01 P.M.-One clear plastic container, labeled Friday Rice; Cooked Prep/Opened On 5/29/26 1:52 P.M., Use By 5/31/26 1:52 P.M.-One metal plastic covered container containing black bean like objects, labeled Monday Non-Meat leftovers; Prep/Opened on 6/1/26 7:14 P.M., Use By 6/3/26 7:14 P.M.-One clear plastic covered container containing French fries, labeled Sunday Left Over; Prep/Opened on 5/31/26 6:32 P.M., Use By 6/2/26 6:32 P.M.-One clear plastic container covered with plastic wrap, labeled Sunday Tuna Salad; Prep/Opened on 5/31/26 1:20 P.M., Use By 6/2/26 1:20 P.M.-One clear plastic container covered with plastic wrap, labeled Monday Egg Salad Sandwich; Prep/Opened on 6/1/26 9:20 A.M., Use By 6/3/26 9:20 A.M.-One cut cucumber wrapped with plastic, unlabeled and undated-One-gallon plastic bag, dated 5/29/26, containing but not limited to: -Two Carrots -One end of romaine lettuce end with pink discoloration -One half of a cucumber wrapped in plastic, soft and squishy to touch-Two covered clear plastic containers, labeled Artichokes 5/10-One covered clear plastic container with the lid slightly ajar containing a thick white substance, unlabeled and undated-One covered clear plastic container containing a thick red colored substance, undated and unlabeled During an interview on 6/10/26 at 11:02 A.M., the Food Service Manager said food in the walk-in refrigerator must be labeled and dated correctly and discarded by the use by date. She said all raw meat must be stored in a sealed, leak-proof container to prevent contamination.

Based on observation, interview, and record review, the facility failed to ensure two Residents (#4 and #82), out of a total sample of 24 residents, had their call bell devices accessible and within reach to call for staff assistance while in their rooms.Findings include:Review of the facility's policy titled Answering Call Lights, adopted April 2016, indicated but was not limited to the following:- The purpose of this procedure is to respond to the resident's requests and needs.- Be sure that the call light is plugged in at all times.- When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of the Facility Assessment, reviewed 4/29/26, indicated but was not limited to:- Physical Environment:- Physical environment, services, and other physical plant characteristics are considered when caring for our resident population. The facility is outfitted with necessary furniture and equipment to ensure a safe, comfortable, and homelike environment.- Equipment utilized to care for resident population includes but is not limited to: - General Facility Equipment: Nurse Call System A. Resident #4 was admitted to the facility in February 2026 with diagnoses including cognitive communication deficit and need for assistance with personal care.Review of the Minimum Data Set (MDS) assessment, dated 2/26/26, indicated Resident #4 had a moderate cognitive deficit as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 and he/she required assistance with activities of daily living.During an interview with observation on 6/4/26 at 9:45 A.M., the surveyor observed Resident #4 sitting in his/her wheelchair on the left side of his/her bed, with his/her call light button wrapped around the right siderail of his/her bed with the button of the call light button resting on the floor out of his/her reach. Resident #4 said there are times he/she cannot reach their call light button to call for help. Resident #4 said he/she had told nursing staff multiple times that he/she was unable to reach his/her call light button.On 6/4/26 at 12:32 P.M., the surveyor observed Resident #4 sitting in his/her wheelchair on the left side of his/her bed, with his/her call light button wrapped around the right siderail of his/her bed with the button of the call light button resting on the floor out of his/her reach.On 6/4/26 at 2:40 P.M., the surveyor observed Resident #4 sitting in his/her wheelchair on the left side of his/her bed, with his/her call light button wrapped around the right siderail of his/her bed with the button of the call light button resting on the floor out of his/her reach.On 6/5/26 at 7:49 A.M., the surveyor observed Resident #4 sitting in his/her wheelchair on the left side of his/her bed, with his/her call light button wrapped around the right siderail of his/her bed with the button of the call light button resting on the floor out of his/her reach.During an interview on 6/9/26 at 12:17 P.M., Certified Nursing Assistant (CNA) #3 said all residents must have their call lights within their reach at all times. CNA #3 said if a resident is seated in their wheelchair next to their bed, then their call light button should be either laying on his/her bed within their reach or on their lap.During an interview on 6/9/26 at 12:22 P.M., Nurse #5 said residents' call light button must be within their reach at all times when in their room.B. Resident #82 was admitted to the facility in November 2022 with diagnoses including hemiplegia (form of paralysis that affects only one side of the body) and anxiety disorder.Review of the MDS assessment, dated 5/26/26, indicated Resident #82 was cognitively intact as evidenced by a BIMS score of 15 out of 15 and he/she required assistance with activities of daily living.During an interview with observation on 6/4/26 at 9:51 A.M., the surveyor observed Resident #82 sitting in his/her wheelchair on the right side of his/her bed, with his/her call light button laying on the floor under the left side of his/her bed out of Resident #82's reach. Resident #82 said there are times he/she cannot reach their call light button to call for help. Resident #82 said he/she was unable to use their call light button because he/she could not reach it from where he/she was sitting. Resident #82 said he/she couldn't even see their call light button.On 6/4/26 at 12:33 P.M., the surveyor observed Resident #82 sitting in his/her wheelchair on the right side of his/her bed, with his/her call light button resting on the floor on the left side his/her bed out of his/her reach.On 6/4/26 at 2:40 P.M., the surveyor observed Resident #82 sitting in his/her wheelchair on the right side of his/her bed, with his/her call light button resting on the floor on the left side his/her bed out of his/her reach.On 6/5/26 at 7:49 A.M., the surveyor observed Resident #82 sitting in his/her wheelchair on the right side of his/her bed, with his/her call light button resting on the floor on the left side of his/her bed out of his/her reach.On 6/5/26 at 12:55 P.M., the surveyor observed Resident #82 sitting in his/her wheelchair on the right side of his/her bed, with his/her call light button resting on the floor on the left side of his/her bed out of his/her reach.During an interview with observation on 6/9/26 at 12:13 P.M., the surveyor observed Resident #82 sitting in his/her wheelchair on the right side of his/her bed, with his/her call light button resting on the top of his/her bed behind Resident #82's wheelchair. The surveyor asked Resident #82 if he/she could reach his/her call light button. Resident #82 turned to his/her left and said he/she was not able to reach the call light button.During an interview on 6/9/26 at 12:17 P.M., CNA #3 said Resident #82's call light button should be positioned next to Resident #82's wheelchair so he/she could reach it.During an interview with observation on 6/9/26 at 12:22 P.M., the surveyor observed Nurse #5 pick up Resident #82's call light button from the bed and position it next to him/her. Nurse #5 said Resident #82 could not reach his/her call light button when it was positioned behind his/her wheelchair.During an interview on 9/9/26 at 12:55 P.M., the Director of Nursing and the Assistant Director of Nursing said all residents should have their call light buttons left within their reach.

Based on observation, interview, and record review, the facility failed to develop a person-centered care plan, including measurable goals and individualized interventions for one Resident (#7), out of a total sample of 24 residents, who suffered from symptoms of depression and was prescribed antidepressant medications. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated but was not limited to the following: -a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident-the comprehensive, person-centered care plan: includes measurable objectives, describes services to be furnished to attain the resident's highest practicable psychosocial well-being, includes which professional services are responsible for each element of care, builds on the resident's strengths, and reflects currently recognized standards of practice for problem areas and conditions-assessments of residents are ongoing and care plans are revised as information about the residents and their condition changesResident #7 was admitted to the facility in April 2026 with diagnoses including: protein-calorie malnutrition, malignant neoplasm (cancer) of the breast; and secondary malignant neoplasm of the bone.Review of the Minimum Data Set (MDS) assessment, dated 5/1/26, indicated the Resident was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15 and a PHQ-9 score (Mood interview questionnaire for depression interpretation) of 12 out of 27 which indicated moderate depression. During an interview on 6/4/26 at 9:10 A.M., Resident #7 began to cry while discussing his/her time at the facility and said he/she had suffered a lot of losses. The Resident said he/she had seen their therapist on this day and felt that he was beneficial for him/her and said this is the person who recommended he/she start on antidepressants. The Resident said he/she had never in their life experienced sadness like this before and it was a lot to handle. The Resident said the staff at the facility are very nice, but he/she still feels helpless and hopeless at times. During an interview on 6/5/26 at 8:36 A.M., Nurse #3 said Resident #7 receives services from the Psychiatric Nurse Practitioner (PNP) who was last in the facility and visited with the Resident the day prior (6/4/26). She said the Resident's mood fluctuates because he/she had a lot going on medically. During an interview on 6/5/26 at 11:21 A.M., Certified Nurse Assistant (CNA) #1 said the Resident occasionally declined to get out of bed. She said she doesn't know if there is a plan or anything specific the staff should do if the Resident expresses any sadness or anxiousness to them, but she would notify the nurse and sit with the Resident to allow him/her to speak to them. Review of the Psychiatric evaluation and consultation notes for Resident #7, indicated but were not limited to the following: 4/8/26: Initial comprehensive psychiatric evaluation Review of symptoms (ROS): Depression Collaboration: Nursing and PNP discussed resident's current level of depressive symptoms and overall emotional functioning with a focus on situational contributors to low activity participationCurrent assessment/Plan: No signs of acute neurocognitive decline; PHQ-9 score of 15, indicating moderate depressive symptoms. Initiate Trazodone (an antidepressant) 50 milligrams (mg) every 12 hours for depression and insomnia. Recommend supportive talk therapy, monitoring for mood changes or behavior particularly in the context of complex medical comorbidities, encourage participation in structured social activities to promote reduced social isolation. Maintain non-pharmacological interventions. 4/29/26: Comprehensive evaluation in the context of recent medical decompensation, with concerns for mood changes, decreased engagement in activities and adjustment to medical illness. ROS: Depression Resident reports improved clarity of thought, but low energy, decreased motivation, intermittent sadness, and reduced participation in activities likely multifactorial due to medical burden and psychosocial stressors related to loss of independence. Sleep is improving.Collaboration: Nursing and PNP discussed refused care, declining participation in certain therapies and medications. Nursing staff were advised on supportive communication strategies to enhance cooperation and reduce care resistance. Current assessment/Plan: Resident exhibits moderate depressive symptoms (PHQ-9 score of 12). Initiate Sertraline 50mg daily for management of depressive symptoms. Provide supportive psychotherapy focused on coping with chronic illness, loss of independence, and emotional adjustment. Encourage gradual participation in rehab and social activities. Staff are advised to monitor for acute changes in mood, cognition, behavior and notify psych services if concerns arise. 6/4/26: Follow up psychiatric evaluation in context of recent medical decompensation with mood changes, decreased engagement in activities, reduced motivation and psychological adjustment to complex medical illness and loss of functional independence. ROS: DepressionPhysical exam: Mood is described as ok, resident acknowledged periods of sadness and discouragement related to medical conditions.Collaboration: Nursing and PNP discussed resident preference to receive medications at the same time whenever possible, staff acknowledged request and will attempt to maintain administration consistency within operational and clinical limitations. Current assessment/Plan: Continue Sertraline 50mg daily for depressive symptoms, monitor for effectiveness. Continue Trazodone 25mg twice daily as prescribed. Encourage expression of emotions and reinforce adaptive coping strategies. Encourage social engagement and structured activities. Maintain non-pharmacological interventions. Review of the Psychosocial Evaluation for Resident #7, dated 5/4/26, indicated but was not limited to the following: Diagnosis: Major Depressive disorder, single episode, moderateSummary: Clinician met with Resident due to symptoms of depression including persistent sadness. Resident became tearful during conversation and expressed fear and feeling overwhelmed by the uncertainty of their condition, feeling lost in the process. Encouraged increased socialization and reframing of negative and intrusive thoughts. Resident remained tearful but engaged in session. Ongoing sessions 1-5 times a month for 30 minutes. The record did not include any follow up interactions of visits between the Resident and person performing one to one talk therapy at the time of the survey. Review of the June 2026 Physician's Orders, indicated but were not limited to the following:Consult psychiatric and/or psychological services as needed (4/7/26)Trazodone 25mg twice a day for anxiety (4/23/26)Sertraline 50mg daily at bedtime for depression (5/1/26) During an interview on 6/9/26 at 8:18 A.M., CNA #2 said he knows the Resident and provides assistance typically for transfers and answering call lights. He said in general the Resident's mood is sad and they are reluctant to get out of bed sometimes and requires encouragement. He said he isn't aware of any Resident specific interventions that staff would provide to help alleviate the Resident's mood or provide extra support. Review of the current care plans for Resident #7 failed to indicate a care plan for management and treatment of Resident #7's ongoing depressed mood which included psychiatric consultation, use of antidepressant medications and their non-pharmacological interventions that could be utilized by staff and measured for effectiveness of mood improvement. During an interview on 6/9/26 at 9:20 A.M., Nurse #4 said Resident #7 is very down and has a lot going on so a flat affect and depressed tearful mood is common for him/her related to his/her ongoing medical issues. She said she finds the Resident can have his/her attention diverted by talking about dogs since he/she was a dog trainer in the past. She said the Resident did see psych services for medication management but wasn't sure of any other specific interventions for management of the Resident's mood and would expect there would be at least a mood care plan to direct that but couldn't locate one. During an interview on 6/9/26 at 9:23 A.M., Nurse #6 said Resident #7 had some significant medical situations occurring and displayed a down mood most of the time and has been more tearful recently. She said they just recently increased the Resident's Sertraline on 6/7/26 for this reason. She said she doesn't believe the Resident attends activities, but the staff try to spend some one-to-one time with the Resident when they can and the family visits weekly. She said she wasn't sure of any non-pharmacological interventions to help regulate or monitor for the Resident's mood, but there should be a care plan to provide more detail. On review of the medical record and care plans for the Resident, she said there should have been a care plan put in place when the depression symptoms were identified or the antidepressant was started to indicate a goal, monitoring towards that goal, and any other resident-specific interventions but there was not one in place at this time. During an interview on 6/9/26 at 12:46 P.M., the Regional Social Worker said every resident is evaluated by psych services at the time of admission. She said if any resident triggers with a PHQ-9 score of 12 or more they would request further psych follow up. She said she would expect that this Resident would have a care plan in place to direct the staff in monitoring the Resident's mood, response to their antidepressant medications and any non-pharmacological recommendations and interventions that the staff could use to help alleviate depressive symptoms. During an interview on 6/10/26 at 9:07 A.M., MDS Nurse #2 said the MDS completed for the Resident on 5/1/26 was an interim payment MDS for the use of intravenous fluids at the end of April. She said any other changes including the PHQ-9 change for mood which indicated a moderate depressive mood would likely not be noticed and have a care plan triggered to be created since it was not the reason the MDS was being completed. During an interview on 6/10/26 at 10:18 A.M., the Director of Nurses and Regional Clinical Nurse consultant said that when Resident #7 was identified as exhibiting sadness or depression a resident-centered individualized mood care plan should have been developed to determine a goal, monitoring of the psychotropic medications and indicate non-pharmacological interventions that could potentially or actually assist the staff in managing the Resident's depression. She said any one of the staff should have identified this issue and developed and implemented a care plan for it and in this instance that did not occur. During a telephone interview on 6/10/26 at 12:17 P.M., the PNP said Resident #7 demonstrated a fluctuation in mood routinely related to dealing with multiple difficult medical situations. He said he had recommended Sertraline for the Resident back in April and activity involvement. He said he would have discussions with nursing staff about approaches including socialization as to prevent self-isolation and felt organized activities would have been beneficial. He said he was willing to further collaborate with the facility to help determine alternative non-pharmacological interventions, but in his opinion, the facility did not seem interested in having him involved in the care plan process.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC-a flexible tube inserted through a vein in one's arm and passed through to larger veins near the heart, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#126), out of a total sample of 24 residents. Specifically, the facility failed to measure and document the external catheter length to ensure the PICC line had not migrated (moved from the heart to another area, which could have significant impact on treatment, or cause serious harm) and measure and document arm circumference.Findings include:Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, revised April 2022, indicated but was not limited to the following:Purpose:-The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings.General Guidelines:-Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion.-For PICCs, measure arm circumference and compare to baseline when clinically indicated to assess for edema and possible deep vein thrombosis. Resident #126 was admitted to the facility in May 2026 with diagnoses including malignant neoplasm of corpus uteri (cancer that originates in the body of the uterus). Review of the Minimum Data Set (MDS) assessment, dated 5/25/26, indicated Resident #126 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had been receiving antibiotics intravenously. During an interview with observation on 6/4/26 at 8:42 A.M., the surveyor observed a single lumen PICC line covered with a transparent dressing, dated 6/3/26, in Resident #126's left upper arm. Resident #126 said he/she had just completed their prescribed intravenous antibiotics a few days ago. On 6/9/26 at 7:54 A.M., the surveyor observed a single lumen PICC line covered with a transparent dressing, dated 6/4/26, in Resident #126's left upper arm. Review of Resident #126's Physician's Orders indicated but was not limited to:-Change PICC dressing every 7 days and as needed. Measure and record external length of catheter from insertion site to hub every Thursday. Notify the Physician for any difference in measurement, dated (5/24/2026)-Change PICC dressing every 7 days and as needed. Measure and record external length of catheter from insertion site to hub every Saturday. Notify the Physician for any difference in measurement. (5/22/2026) -Discontinued 5/24/2026 Review of Resident #126's hospital PICC Line properties, dated 5/19/26, indicated but was not limited to:-PICC Single Lumen Power Left Basilic (a large superficial blood vessel that runs along the inner side of the arm and forearm),-Initial Exposed Catheter Length: 0 centimeters (cm) Review of Resident #126's June Treatment Administration Record (TAR) indicated Resident #126's PICC line dressing was changed on 6/4/26.Further review of the June TAR failed to indicate the external length of Resident #126's PICC line. Review of Resident #126's Admission/readmission Screener assessment, dated 5/21/26, indicated but was not limited to:- IV (Intravenous) Access: -Does the Resident have an IV access? Yes -Type(s) of IV Access Present: PICC -Location of PICC Line: Left Antecubital -Number of Ports: 1 -Total Catheter Length (in cm): Left Blank -External Catheter Length (in cm): Left Blank -Arm Circumference at insertion site (in cm): Left Blank Further review of Resident #126's medical record indicated but was not limited to:-Effective Date: 5/21/26 11:07 P.M. admission Summary: Resident has a PICC to his/her left arm. Flushes with good blood return.-Effective Date: 5/28/26 12:00 A.M. Type: Health Status Note: Left upper extremity PICC dressing changed. External catheter length 1.5 cm-Effective Date: 6/3/26 4:00 P.M. Type: Health Status Note: PICC line dressing changed. During an interview on 6/9/26 at 11:56 A.M., Nurse #1 said the external length of a PICC line needs to be measured on admission and with every dressing change to see if it came out. Nurse #1 reviewed Resident #126's medical record and said the only measurements of Resident #126's external catheter length he could find were from 5/28/26. He said the external catheter measurements for Resident #126's PICC line should have been completed on his/her admission assessment and with every dressing change, but he could not find any other measurements. During an interview on 6/9/26 at 12:43 P.M., the Director of Nursing, the Assistant Director of Nursing, and the Regional Nurse Consultant reviewed Resident #126's medical record. They said Resident #126 had a PICC line in his/her left upper arm. They said the external measurements of the PICC line needed to be done on admission and with every dressing change. They said the measurement could be documented on Resident #126's admission/readmission screener assessment, care plan, treatment administration record, or in a nursing note. They said they were only able to find measurements for the eternal length of Resident #126's PICC line on 5/28/26 and were unable to see any other measurements.

Based on observation, interview, and document review, the facility failed to ensure staff followed Contact enteric precautions and donned (put on/wore) the correct personal protective equipment (PPE) to prevent a potential spread of Clostridioides difficile (C. diff - bacterium that causes diarrhea and colitis), for one Resident (#143), out of a total sample of 24 residents. Findings include: Review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions, dated as revised September 2022, indicated but was not limited to the following: -Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection, or has a laboratory confirmed infection, and is at risk for transmitting the infection to othersCONTACT PRECAUTIONS:-contact precautions are implemented for residents with known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces and resident care items in the resident's environment-staff and visitors wear gloves when entering the room, gloves are removed and hand hygiene is performed before leaving the room; wear disposable gown upon entering the room and remove disposable gown before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown removedReview of the Centers for Disease Control and Prevention (CDC) Clostridium difficile (C. diff) fact sheet for healthcare professionals, dated 2024, indicated but was not limited to the following: -C. diff can spread by touching contaminated surfaces or residents, and not following hand hygiene and infection control practices-for Prevention: healthcare professionals can adhere to recommended hand hygiene practices and contact precautions Review of the Contact Enteric Precautions sign in use by the facility, undated, indicated but was not limited to the following: STOP: Contact enteric precautions. Families and visitors follow instructions from information sheetEveryone must: clean hands with sanitizer when entering the room and wash with soap and water upon leaving the roomDoctors and staff must: gown and glove at the door & use patient dedicated or disposable equipmentResident #143 was admitted to the facility in June 2026 with diagnoses including enterocolitis (inflammation of the small intestine and colon) due to C. diff. Review of the current orders for Resident #143, dated 6/10/26, indicated but were not limited to the following: Contact precautions for C. diff every shiftReview of the current care plans for Resident #143 indicated but were not limited to the following: I have C. diff (6/4/26); Interventions: contact enteric precautionsDuring an observation with interview on 6/8/26 at 9:13 A.M., the surveyor observed Activity Assistant #1 enter Resident #143's room without performing any form of hand hygiene or donning a gown or gloves. The contact enteric precautions sign was posted outside of the room, and PPE was available directly outside the room. Activity Assistant #1 placed a paper on the overbed table and left the room without performing hand hygiene. During an interview at this time she said she only went into the room to deliver a day in history sheet and perform a one on one check in. On 6/8/26 at 11:52 A.M., the surveyor observed Resident #143 holding their coffee mug in a slight tilt. The surveyor observed Nurse #2 perform hand hygiene using alcohol-based hand sanitizer and enter the room to place the coffee cup on the Resident's tray. The surveyor did not observe Nurse #2 don a gown or gloves prior to entering the room. Once Nurse #2 adjusted the Resident's cup she reached into the PPE bin outside of the room door and pulled out a gown and gloves without performing any hand hygiene prior to touching the clean items in the PPE storage bins. Nurse #2 remained in the room with the Resident until 12:12 P.M. During an interview on 6/8/26 at 12:12 P.M., Nurse #2 said Resident #143 was on enteric contact precautions. She said she was aware she needed to sanitize her hands prior to entering the room and believed she only needed to wear gown and gloves if she were to do any care. She said the Resident was on precautions for C. diff and she hadn't had a resident with these precautions in a while. She reviewed the posted Enteric contact precautions sign with the surveyor and said she should have put the gown and gloves on prior to entering the room but did not. During an interview on 6/9/26 at 2:00 P.M., the Infection Preventionist said Resident #143 is on contact precautions for C. diff. She said the expectation is for all staff to follow the sign posted outside of the door and sanitize their hands and put on gloves and a gown prior to entering the room and remove the PPE and wash their hands prior to leaving the room. She was made aware of the surveyor's observations and said the staff did not follow the posted sign providing them guidance on hand hygiene and PPE use as they should have. She said the staff should not be using dirty hands to retrieve clean PPE from the PPE storage bin. She said the surveyor's observations did not meet the facility expectations or guidelines for caring for a resident with contact precautions for C. diff.

Based on interview and record review, the facility failed to ensure professional standards of practice were followed for two Residents (#39 and #24), out of a total sample of 23 residents. Specifically, the facility failed to ensure: 1. For Resident #39, a. The diagnosis of schizophrenia added after admission had supporting documentation in the medical record; and b. Eye ointment was administered per physician's orders and the physician was notified timely of the medication being unavailable for administration; and 2. For Resident #24, to follow Pharmacy/MD recommendation to do an Abnormal Involuntary Movement Scale (AIMS) test assessing for tardive dyskinesia (an involuntary neurological movement disorder that is usually a side effect of certain dopamine receptor blocking drugs). Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers 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. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. 1. Review of the facility's policy titled Schizophrenia Documentation Review, dated July 23, 2024, indicated but was not limited to the following: - Completed signed forms and associated supporting documentation are to be uploaded into PCC (the electronic medical record). -To ensure appropriate assessment and coding of a diagnosis of schizophrenia for residents, the following worksheet must be completed in its entirety and signed by the attending physician. Review of the facility's policy titled Unavailable Medications, dated June 2021, indicated but was not limited to the following: -In conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. -Upon receipt of information from pharmacy regarding a medication that is unavailable, nursing staff shall notify the physician of the unavailable medication, explain the circumstance, obtain a new order and discontinue prior order, or obtain a hold order for the unavailable medication. Resident #39 was admitted to the facility in June 2020 with diagnoses which include atrial fibrillation, low back pain, and a chronic foot ulcer. Review of the Minimum Data Set (MDS) assessment, dated 3/1/25, indicated Resident #39 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact, and he/she had a diagnosis of schizophrenia. a. Review of the Diagnosis List in the electronic medical record indicated the diagnosis of Schizophrenia was added to Resident #39's profile on 12/7/22 with an effective date of 6/17/20 and ranked history of diagnosis. Review of the medical record failed to indicate why the diagnosis was added to his/her profile two and a half years after admission. Review of the medical record failed to indicate Resident #39 had this diagnosis on admission and failed to indicate supporting documentation of the diagnosis had been provided to the facility to facilitate adding the diagnosis to his/her profile. Review of the comprehensive care plan failed to indicate a care plan for Schizophrenia had been developed. Further review of the medical record failed to indicate any supporting documentation of the diagnosis from any historical medical provider. During an interview on 5/6/25 at 10:35 A.M., Social Worker #2 said she did not know where the diagnosis came from. During an interview on 5/6/25 at 11:00 A.M., the Administrator said she thought all historical documents had been scanned into the electronic medical record. During an interview on 5/6/25 at 11:20 A.M., Medical Records Staff #1 said there were no documents waiting to be scanned in, everything should be uploaded, and she was unable to locate any supporting documentation related to the diagnosis. During an interview on 5/6/25 at 4:45 P.M., Consulting Staff/Regional MDS Nurse #3 said she was unable to validate the diagnosis, and they were working on it. She said she did not know where it came from and could not find any documentation of where it came from in the medical record. She said the MDS Nurse that added it to the profile is no longer employed at the facility and she was going to remove the diagnosis from the MDS pending confirmation/supporting documentation. During an interview on 5/6/25 at 4:45 P.M., Consulting Staff #1 said they had a care plan meeting today and they asked his/her sister about the diagnosis, and she told them Resident #39 was behavioral as a child but was unsure if the diagnosis was a true diagnosis because lots of things were tossed around. She said they had the sister sign a medical records release to attempt to get prior records from out of state. She said she was unable to obtain historical psych notes from the previous provider to see if they had acknowledged where the diagnosis came from. During an interview on 5/8/25 at 8:37 A.M., the Director of Nurses (DON) said she did not know where the diagnosis came from, and the corporate team was still looking into it. b. Review of the Physician's Orders indicated but were not limited to the following: -Sodium Chloride 5% Ophthalmic Ointment, instill 0.25 inch in right eye at bedtime for eye health (start 10/19/24 end 4/16/25) - Sodium Chloride 5% Ophthalmic Ointment, instill 0.25 inch in right eye at bedtime for eye health (4/16/25) Review of the Medication Administration Record (MAR) indicated but was not limited to the following: -January 2025 the medication was not administered 4 times out of 31 opportunities. -February 2025 the medication was not administered 3 times out of 28 opportunities. -March 2025 the medication was not administered 6 times out of 31 opportunities. -April 2025 the medication was not administered 12 times out of 30 opportunities. Further review of the MAR indicated the code (22) was documented on the MAR indicating Drug/Treatment not administered. Review of the nursing progress notes failed to indicate why the medication was not administered and failed to indicate the physician was notified the medication was not administered. Further review of the physician orders indicated but were not limited to the following: -Sodium Chloride 5% Ophthalmic Ointment, instill 0.25 inch in right eye at bedtime for eye health; Pharmacy Alert dated 11/30/24 indicated the order will not be filled because it has been rejected. Over the Counter (OTC). The alert was cleared by staff on 2/20/25. - Sodium Chloride 5% Ophthalmic Ointment, instill 0.25 inch in right eye at bedtime for eye health; Pharmacy Alert, dated 4/16/25, indicated the order will not be filled because it has been rejected. This item is ordered through Central Supply NOT FROM THE PHARMACY. The alert was cleared by staff on 4/16/25 and the order was rewritten. During an interview on 5/6/25 at 9:52 A.M., Unit Manager #2 said they have some difficulty getting this medication from the new pharmacy. She said they were arguing that it was OTC/house stock, but the old pharmacy used to supply it. She said they don't usually have trouble getting meds delivered and sometimes they just need to rewrite the order and then they send it. She said if it was not available and not administered the nurses should have checked the emergency supply, notified the physician to put it on hold or get a new order, and it should have been documented in a nurse's note. She said it should not continue for days being unavailable/not administered without notifying the physician to see what they want to do. During an interview on 5/6/25 at 10:00 A.M, Nurse #6 said she noticed it was not available when working the evening shift. She said the pharmacy was arguing with her that it was OTC, but the previous pharmacy used to deliver it, so she didn't know what the issue was. She said there were a lot of agency and travel nurses working that shift, and she was not sure how long it had been unavailable before they got it discontinued last week. During an interview on 5/8/25 at 8:05 A.M., Central Supply Staff #1 said she did not stock that item as routine house stock and did not recall ever being asked to order it for a specific resident. She said anything that is not on the routine stock list she needs to get approval for, or it comes from the pharmacy. During an interview on 5/8/25 at 8:37 A.M., the DON said if a medication is unavailable the nurse should be notifying the physician to put it on hold until it is available, obtain a new order for something else, or discontinue the medication. She said if something is OTC and it is not in the medication room; the nurse should be checking with Central Supply to order it. Additionally, she said if the pharmacy sends an alert, they will not fill it because it is OTC, the nurses should not be clearing the alert without reaching out to Central Supply to obtain the medication. 46862 2. Review of the facility's policy titled Abnormal Involuntary Movement Scale (AIMS), undated, indicated, but was not limited to: 1. The Abnormal Involuntary Movement Scale (AIMS) is a standardized evaluation. 2. Conduct the AIMS examination procedure as ordered by the physician or as per state guidance. 3. The AIMS should be conducted by a licensed nurse, physician or other licensed practitioner. 4. The results of the AIMS should be used in conjunction with clinical data ant the primary physician to guide treatment decisions. Review of Cureus. 2023 May 25;15(5):e39486. doi: 10.7759/cureus.39486 titled Increasing Abnormal Involuntary Movement Scale (AIMS) Screening for Tardive Dyskinesia in an Outpatient Psychiatry Clinic: A Resident-Led Outpatient Lean Six Sigma Initiative indicated the AIMS is used not only to detect tardive dyskinesia (TD) but also to follow the severity of a patient's TD over time [3]. It is a valuable tool for clinicians who are monitoring the effects of long-term treatment with neuroleptic medications and for researchers studying the effects of these drugs. The AIMS is administered every three to six months to monitor the patient for the development of TD. For most patients, TD develops three months after the initiation of neuroleptic therapy. In elderly patients, however, TD can develop after as little as one month. https://pmc.ncbi.nlm.nih.gov/articles/PMC1029217 Resident #24 was admitted to the facility in September 2024 with diagnoses which included atrial fibrillation, depression, and dementia with behavioral disturbance. Review of the MDS assessment, dated 3/26/25, indicated Resident #24 had moderate cognitive impairment as evidenced by a BIMS score of 13 out of 15. The MDS also indicated Resident #24 was receiving antipsychotic medication. Review of the Physician's Orders indicated the following: -Seroquel oral tablet 25 milligram (mg) (Quetiapine Fumarate), give 2 tablets by mouth at bedtime, dated 1/2/2025 -Seroquel oral tablet 12.5 mg (Quetiapine Fumarate), give 2 times by mouth a day, dated 9/25/2024 and discontinued 11/8/24 Review of the MAR for September 2024 through May 2025 indicated Resident #24 received Seroquel as ordered by the Physician. Review of the Consultant Pharmacist Recommendations to Prescriber dated 11/8/2024 indicated: -Resident is receiving the following antipsychotic medication: Seroquel -AIMS assessment is required every 6 months. -Physician response agree assess AIMS. Further review of the medical record did not indicate the AIMS had been completed. During an interview on 05/06/25 at 9:00 A.M., Nurse #1 said the DON receives the pharmacy recommendations. Nurse #1 said the DON will give them to the Unit Managers (UM) or Nurse on the unit when we don't have a UM. Nurse #1 said she could not see that an AIMS had been completed per the pharmacy recommendation. During an interview on 05/08/25 at 12:46 P.M., the DON said she receives the pharmacy recommendations. The DON said she and/or the UM would give the recommendations to the physician to review and sign. The DON said if recommendations are agreed by the physician, she or the UM would make the order changes. The pharmacy recommendation would be signed by the DON or UM and dated to signify the change was completed. The recommendation would then be given to the medical records staff to scan into the computer. The DON and surveyor reviewed the pharmacy consultant recommendation dated 11/8/24. The DON said the recommendation was not carried out as agreed upon by the physician. The AIMS was not done.

Based on observation, interview, and document review, the facility failed to ensure staff stored drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure open drinks were not stored in the medication freezer, in one of two medication rooms observed; and 2. Ensure medications are not left unsecured and unattended in the Resident room and on top of the medication cart, during a medication pass. Findings include: Review of the facility's policy titled Administering Medications, dated as revised April 2019, indicated but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. -The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. -During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. -No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications. Review of the facility's policy titled Medication Labeling and Storage, dated as last revised February 2023, indicated but was not limited to the following: -Compartments containing medications are locked when not in use, and carts used to transport such items are not left unattended if open or otherwise potentially available to others. -Medications are stored separately from food. -Multi-dose vials that have been opened are dated and discarded within 28 days unless manufacturer specifies a shorter or longer date for the open vial. -If the facility has discontinued, outdated medications the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 1. On 5/5/25 at 1:48 P.M., the surveyor observed the medication storage room on the North 1 Unit with Nurse #3, and made the following observations: -Inside the medication freezer was an extra-large plastic cup with blue slush drink labeled Coolata, opened, with a straw placed inside. During an interview on 5/5/25 at 1:49 P.M., Nurse #3 said food and drinks are not supposed to be stored in the medication refrigerator or freezer. He said someone must have placed it inside the freezer for him. Nurse #3 said the drink belongs to him and it should have been stored in the employee break room. 2. On 5/6/25 at 9:33 A.M., the surveyor observed Nurse #4 prepare Resident #24's 8:00 A.M. medications which included the following: -Aspirin 81 milligrams (mg) -Breyna Inhaler (used to treat asthma) -Diltiazem 60 mg (used for high blood pressure) -Fluoxetine 20 mg (used for depression) -Metoprolol 25 mg (used for high blood pressure) -Spironolactone 25 mg (used to treat heart failure) -Toresimide 20 mg (used to treat fluid overload) -Plavix 75 mg (used to prevent blood clots) -Praxdia 150 mg (used to prevent blood clots) -Voltaren ointment (used to treat pain) Nurse #4 popped six pills into one plastic medication cup and the two blood pressure medications into another plastic medication cup. She took the tube of Voltaren ointment and Breyna inhaler and placed them on top of the medication cart. Nurse #4 took the two plastic medication cups and entered Resident #24's room, leaving the ointment and inhaler on top of the medication cart, within her view. She placed the two medication cups down on the Resident's overbed table and attempted to take the Resident's blood pressure. Nurse #4 said she needed to get a larger blood pressure cuff and exited the room. The two medication cups remained on the Resident's overbed table, unsecured and unattended. At 9:42 A.M., Nurse #4 locked the medication cart and proceeded down the hallway to obtain a larger blood pressure cuff. The two medications remained on top of the medication cart, unsecured and unattended. At 9:47 A.M., Nurse #4 returned to the medication cart, took the inhaler from the top of the cart, leaving the Voltaren ointment on top of the cart and entered the Resident's room. Nurse #4 took Resident #24's blood pressure, administered both plastic cups of medications and the inhaler to Resident #24. During an interview on 5/6/25 at 9:54 A.M., Nurse #5 said she should not have left the medications at the bedside or on top of the cart, it is not safe. She said she was focused on getting a larger blood pressure cuff, and did not remember to secure the medications. During an interview on 5/7/25 at 12:10 P.M., the Director of Nursing (DON) said no food or drink should ever be stored in the medication refrigerator or freezer for risk of cross contamination of the medications. The DON said medication should never be left unsecured at the resident's bedside, or on top of a medication cart. The DON said all medications must be secured when unattended.

Based on observations, record review, and interviews, 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 ensure contact tracing and outbreak testing were completed on two occurrences in February 2025. Findings include: Review of the facility's policy titled Infection Prevention and Control Program, dated December 2023, indicated but was not limited to the following: -Outbreak Management is a process that consists of determining the presence of an outbreak, managing affected residents, preventing the spread, and documenting information about the outbreak. Review of the facility's policy titled Contact Tracing-Residents, dated July 2023, indicated but was not limited to the following: -Contact tracing is a method of identifying those who may have been exposed to COVID-19, to help track and prevent the transmission of COVID-19. -Close contact (exposure) is defined by the Centers for Disease Control (CDC) as being within 6 feet of an infected person for a cumulative total of 15 minutes over a 24-hour period. -Identify the infectious period (2 days prior to the onset of symptoms, if symptomatic). -For each day of the infectious period, identify all locations the resident visited. -For each location, make notes about each person that could have been in contact with the resident. -Identify contacts at each location for each day. -A person in close contact with the case-patient during the symptomatic period would be considered exposed. -Notify all exposed persons and the required monitoring and quarantine restrictions. Review of the facility's policy titled COVID-19 Testing Requirements-MA, dated as last revised May 11, 2023, indicated but was not limited to the following: Outbreak testing: -If a new case of COVID-19 is identified the facility will test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a Department of Public Health epidemiologist directs otherwise. -Testing should take place as soon as possible. If the facility identifies that the resident or staff members first exposure occurred less than 24 hours ago, then they should wait to test until 24 hours after exposure. Review of the Infection Surveillance Monthly Report for February 2025 indicated Resident #307 tested positive for COVID-19 on 2/15/25 and Resident #1 tested positive for COVID-19 on 2/17/25. a. Resident #307 was admitted to the facility in January 2024 with diagnoses which include chronic obstructive pulmonary disease (COPD), Parkinson's disease, respiratory failure, heart failure, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 3/5/25, indicated Resident #307 scored 1 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive impairment. Review of the medical record including progress notes indicated he/she was symptomatic and had tested positive for COVID-19. b. Resident #1 was admitted to the facility in January 2023 with diagnoses which include cognitive impairment, malnutrition, and history of COVID-19. Review of the MDS assessment, dated 3/25/25, indicated Resident #1 scored 6 out of 15 on the BIMS, indicating he/she had severe cognitive impairment. Review of the medical record including progress notes indicated he/she was symptomatic and had tested positive for COVID-19. The surveyor requested contact tracing and outbreak testing for the two cases. The facility failed to provide the surveyor with a list of who had been exposed to Resident #307 or Resident #1 and when they were tested . Review of the COVID Testing Log in the Testing Room indicated six staff COVID-19 tests had been logged for the month of February. The six tests that were logged were done between 2/20/25 and 2/28/25. The surveyor reviewed the COVID Testing Log with the Director of Nurses (DON)/Infection Preventionist (IP), Consulting Staff #2, and Consulting Staff #1. They were unable to identify if the staff members that tested had been exposed to either of the residents or if they were testing as a precaution. During an interview on 5/8/25 at 11:25 A.M., the DON/IP and Consulting Staff #2 said they use contact tracing for positive COVID-19 cases. They said outbreak testing for everyone exposed would be done every 48 hours until they go seven days without a new case. They were unable to provide the surveyor with contact tracing and outbreak testing information for these two cases. They said the previous IP should have ensured everyone exposed was tested every 48 hours, but the log was incomplete, and they were unable to provide the surveyor with any other testing log or documentation. During an interview on 5/8/25 at 2:06 P.M., Consulting Staff #1 said they use contact tracing and those exposed would test every 48 hours. She said unless they did not work, she would expect to see a test logged every day they worked or at least every 48 hours starting when the positive case was identified. She said she was unable to locate any contact tracing or outbreak testing information for either case.

Based on record review and interview, the facility failed to provide education, assess for eligibility, offer and administer Pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for four Residents (#19, #60, #61, #78), out of a total sample of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled Vaccination of Residents, dated as last revised October 2019, indicated but was not limited to the following: -All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated. -Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. (See current vaccine information statements at Centers for Disease Control and Prevention (CDC) website for educational materials.) Review of the facility's policy titled Pneumococcal Vaccine, dated as last revised October 2023, indicated but was not limited to the following: -All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. -Administration of pneumococcal vaccines are made in accordance with current CDC recommendations. Review of the CDC guidance Pneumococcal Vaccine Timing for Adults, dated 10/2024, indicated but was not limited to the following: For Adults [AGE] years old or older, vaccine recommendations are as follows: -Unvaccinated adults should receive: a) PCV20 (Prevnar 20, a pneumococcal conjugate vaccine) or PCV21 vaccine (Capvaxive, a pneumococcal conjugate vaccine) or b) PCV15 followed by PPSV23 at least one year later -Adults who have received PPSV23 vaccine only (at any age): a) PCV20 or PCV21 vaccine administered at least one year after PPSV23 was received -Adults who have received PCV13 vaccine at any age: a) PCV20 or PCV21 vaccine administered at least one year after PCV13 was received -Adults who have received PCV13 at any age and PPSV23 when younger than age 65: a) PCV20 or PCV21 at least 5 years after PCV13 or PPSV20 vaccine was received a. Resident #19 was admitted to the facility in December 2023 with diagnoses which included respiratory failure, diabetes, hypertension, and cerebral infarct (stroke). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had moderate cognitive impairment. Review of the medical record indicated he/she had consented to receive the Pneumococcal vaccine on 1/8/24. Review of the electronic Immunization Record indicated he/she had consented on admission and refused the Pneumococcal (PCV13) vaccine on 4/22/24. Based on CDC guidance he/she would be eligible to receive the current pneumococcal vaccine (PCV20 or PCV21). Further review of the medical record failed to indicate the facility had reapproached the Resident and offered the current Pneumococcal vaccine (PCV20 or PCV21). b. Resident #60 was admitted to the facility in March 2023 with diagnoses which included hypertension, COVID-19, and Atrial Fibrillation. Review of the MDS assessment, dated 4/22/25, indicated Resident #60 scored 15 out of 15 on the BIMS, indicating he/she was cognitively intact. Review of the electronic Immunization Record failed to indicate he/she had been offered, accepted, or refused the pneumococcal vaccine. c. Resident #61 was admitted to the facility in May 2021 with diagnoses which included diabetes, pneumonia, and respiratory failure. Review of the MDS assessment, dated 3/15/25, indicated Resident #61 scored 5 out of 15 on the BIMS, indicating he/she had severe cognitive impairment. Review of the electronic Immunization Record indicated that he/she had refused the Pneumococcal (PPSV23) vaccine. Based on CDC guidance he/she would be eligible to receive the current pneumococcal vaccine (PCV20 or PCV21). Further review of the medical record failed to indicate the facility had reapproached the Resident/Resident Representative and offered the current Pneumococcal vaccine (PCV20 or PCV21). d. Resident #78 was admitted to the facility in June 2022 with diagnoses which included hypertension, emphysema, and malnutrition. Review of the MDS assessment, dated 4/19/25, indicated Resident #78 scored 3 out of 15 on the BIMS, indicating he/she had severe cognitive impairment. Review of the Consent for Immunizations, dated 6/22/22, indicated he/she had already received a pneumococcal vaccine. The form failed to indicate which vaccine he/she had previously received and when. Based on CDC guidance he/she would be eligible to receive the current pneumococcal vaccine (PCV20 or PCV21). Review of the electronic Immunization Record failed to indicate the Resident/Resident Representative had been offered, accepted, or refused the current pneumococcal vaccine (PCV20 or PCV21). During an interview on 5/6/25 at 9:31 A.M., Nurse #5 said everything was scanned into the electronic medical record and there were no paper charts. She said she did not know who coordinated the consents and administration of vaccines. During an interview on 5/6/25 at 9:52 A.M., Unit Manager #2 said all consents and administration records should be in the electronic medical record. She said she thought everything had been administered for the year but was unsure who oversaw it now because the Infection Preventionist (IP) Nurse had left. During an interview on 5/6/25 at 4:39 P.M, Consulting Staff #2 said she was working with the Director of Nurses in assuming the IP role. She said they have been doing it together because the previous IP had left abruptly. She said she was unable to locate any additional consents or administration records but was going to continue to look. During an interview on 5/7/25 at 11:00 A.M., Consulting Staff #2 said they recently started to offer the current pneumococcal vaccine (PCV20) but was unsure if it had been offered to the other residents because she was unable to locate any additional consents or administration records.

Based on record review and interview, the facility failed to provide education, assess for eligibility, offer and administer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for five Residents (#54, #19, #60, #61, #78), out of a total sample of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled Vaccination of Residents, dated as last revised October 2019, indicated but was not limited to the following: -All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated. -Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. (See current vaccine information statements at Centers for Disease Control and Prevention (CDC) website for educational materials.) Review of the facility's policy titled COVID-19 Vaccinations, dated as last revised March 20,2024, indicated but was not limited to the following: -Residents who meet eligibility criteria will be offered the COVID-19 vaccine. -Each resident who has not already been immunized and does not have medical contraindication will be offered the vaccine dose(s) for which they are eligible as recommended by the CDC. -When COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member will be provided with current information regarding those additional doses, including any change in the benefits to risks and potential side effects associated with the COVID-19 vaccine. -The facility will document in the medical record education provided, including the date the education took place, that the resident (or representative) either accepted and received or did not receive the vaccine. Review of CDC guidance titled Stay Up to Date with COVID-19 Vaccines, revised 1/7/25, indicated but was not limited to the following: -Everyone ages 6 months and older should get the 2024-2025 COVID-19 vaccine. This includes people who have received a COVID-19 vaccine, people who have had COVID-19, and people with long COVID. -People ages [AGE] years and older: You are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. a. Resident #54 was admitted to the facility in April 2025 with diagnoses which include malnutrition, heart failure, kidney disease, diabetes, and respiratory failure. Review of the Minimum Data Set (MDS) assessment, dated 4/4/25, indicated Resident #54 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the COVID-19 Consent form indicated refused-already had. The form was signed and undated. The form failed to indicate what COVID-19 vaccine he/she previously had, when it was administered, if he/she was to up to date, or if he/she should be offered the current vaccine. Review of the electronic Immunization Record failed to indicate any vaccination records had been documented (the record was blank). b. Resident #19 was admitted to the facility in December 2023 with diagnoses which include respiratory failure, diabetes, hypertension, and cerebral infarct (stroke). Review of the MDS assessment, dated 3/26/25, indicated Resident #19 scored 11 out of 15 on the BIMS, indicating he/she had moderate cognitive impairment. Review of the medical record failed to indicate the facility offered the current (2024-2025) COVID-19 vaccine to the Resident. Review of the electronic Immunization Record indicated he/she had received the 2023-2024 COVID-19 vaccination but failed to indicate he/was offered and accepted or declined the current vaccine. c. Resident #60 was admitted to the facility in March 2023 with diagnoses which include hypertension, COVID-19, and atrial fibrillation. Review of the MDS assessment, dated 4/22/25, indicated Resident #60 scored 15 out of 15 on the BIMS, indicating he/she was cognitively intact. Review of the medical record indicated the facility offered the current (2024-2025) COVID-19 vaccine to the Resident and he/she wished to accept the vaccination. The form was signed and dated 12/19/24. The Internal Use only section for documentation of the administration was left blank. Review of the electronic Immunization Record indicated he/she had received the 2023-2024 COVID-19 vaccination but failed to indicate he/she had received the current vaccination as requested. d. Resident #61 was admitted to the facility in May 2021 with diagnoses which include diabetes, pneumonia, and respiratory failure. Review of the MDS assessment, dated 3/15/25, indicated Resident #61 scored 5 out of 15 on the BIMS, indicating he/she had severe cognitive impairment. Review of the medical record indicated the facility offered the current (2024-2025) COVID-19 vaccine to the resident/resident representative and they wished to accept the vaccination. The form was signed and dated 12/10/24. The Internal Use only section for documentation of the administration was left blank. Review of the electronic Immunization Record indicated he/she had received the 2023-2024 COVID-19 vaccination but failed to indicate he/she had received the current vaccination as requested. e. Resident #78 was admitted to the facility in June 2022 with diagnoses which include hypertension, emphysema, and malnutrition. Review of the MDS assessment, dated 4/19/25, indicated Resident #78 scored 3 out of 15 on the BIMS, indicating he/she had severe cognitive impairment. Review of the medical record indicated the facility failed to offer the current (2024-2025) COVID-19 vaccine to the resident/resident representative. Review of the electronic Immunization Record indicated he/she had received an unspecified COVID-19 vaccination on 1/4/24 but failed to indicate he/she was offered, received, or declined the current vaccination. During an interview on 5/6/25 at 9:31 A.M., Nurse #5 said everything was scanned into the electronic medical record and there were no paper charts. She said she did not know who coordinated the consents and administration of vaccines. During an interview on 5/6/25 at 9:52 A.M., Unit Manager #2 said all consents and administration records should be in the electronic medical record. She said she thought everything had been administered for the year but was unsure who oversaw it now because the Infection Preventionist (IP) Nurse had left. During an interview on 5/6/25 at 4:39 P.M, Consulting Staff #2 said she was working with the Director of Nurses in assuming the IP role. She said they have been doing it together because the previous IP had left abruptly. She said the newer consent form offers the current (2024-2025) vaccine but could not locate any administration records for those that had signed it and was unsure if it had been offered to the others.

Based on observation, interview, and record review, the facility failed to ensure quality of care based on professional standards of practice for one Resident (#20), out of a sample of 23 residents. Specifically, the facility failed to ensure staff fully assessed Resident #20 who was observed to be in respiratory distress, resulting in a delay in treatment. Findings include: Review of the facility's policy titled Change in a Resident's Condition or Status, dated as last revised February 2021, indicated but was not limited to the following: -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. -The nurse will notify the resident's attending physician when there has been: a significant change in the resident's physical/emotional/mental condition. -The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's policy titled Resident Examination and Assessment, dated as last revised February 2014, indicated but was not limited to the following: -The purpose of this procedure is to examine and assess the resident for any abnormalities in health status. -Respiratory: Lung sounds (upper and lower lobes) for wheezing, rales, rhonchi, or crackles, irregular or labored respirations -Documentation: All assessment data obtained during the procedure; How the resident tolerated the procedure; and If the resident refused, the reason(s) why and the intervention taken. - Reporting: Notify the physician of any abnormalities such as labored breathing, change in cognitive status. Review of the facility's policy titled Hospice Program, dated as revised July 2017, indicated, but was not limited to the following: -The responsibility of the facility to meet the resident's nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include notifying the hospice about the following: -A significant change in the resident's physical, mental, social, or emotional status; -Clinical complications that suggest a need to alter the plan of care; and -Communicating with the hospice provider and documenting such communication to ensure the needs of the residents are addressed and met. Resident #20 was admitted to the facility in December 2024 with diagnoses including Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) (a progressive lung disease that causes persistent airflow obstruction characterized by respiratory symptoms), and respiratory failure. Review of the Minimum Data Set (MDS) assessment, dated 3/21/25, indicated Resident #20 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the medical record indicated Resident #20 was placed on hospice services in May 2025 for a diagnosis of COPD, after a recent re-hospitalization for shortness of breath. Review of the comprehensive care plans for Resident #20 included: Focus: I have altered respiratory status related to CHF Goal: I will be free from signs or symptoms of respiratory infection by the review date Interventions: -Administer medications as ordered, monitor effectiveness and for side effects, report abnormal findings to practitioner, document findings and interventions. -Administer oxygen as ordered -Administer respiratory treatments and inhalants as ordered, monitor effectiveness and for side effects, report abnormal findings to practitioner, document findings and interventions. -Apply continuous positive airway pressure (CPAP) (non-invasive ventilation that uses a steady stream of pressurized air into the airways, through a mask that fits over the nose or nose and mouth). Focus: I am oxygen dependent related to COPD, chronic respiratory failure and CHF. CPAP at bedside. Goal: I will remain free of symptoms and complications of low oxygen levels, such as shortness of breath, dizziness, tachycardia (increased heart rate), headache through review date. Interventions: -Duo nebs (combination of medications that relax muscles in airways and increase air flow to the lungs) as ordered -Dependent on oxygen at 1-2 liters per minute continuously via nasal cannula (NC) -Monitor and document breath sounds, breathing patterns, and dyspnea (shortness of breath). Report abnormal findings to physician or designee. -Monitor vital signs, including pulse oximeter, as ordered and clinically indicated. On 5/7/25 at 9:18 A.M., the surveyor observed Certified Nursing Assistant (CNA) #3 approach Nurse #3 and tell him Resident #20 wanted his/her CPAP mask put on. At this time, another resident approached Nurse #3 and said Resident #20 does not feel well, and requested Nurse #3 check on him/her. Nurse #3 and the surveyor entered Resident #20's room. The surveyor observed Resident #20 sitting on the edge of the bed holding a CPAP mask in his/her hands. The CPAP machine was on, and the surveyor could hear the pressurized air coming out of the mask. Resident #20 was wearing a NC delivering oxygen at 3 liters per minute. The Resident's skin color appeared bluish/gray and breathing appeared labored, he/she was taking very quick short breaths and making grunting sounds. Nurse #3 approached the Resident and asked what they needed. Resident #20 was unable to speak and responded with a mumble. Nurse #3 exited the room and told the surveyor he was going to notify the Director of Nursing (DON) about the Resident's distress. The surveyor observed Nurse #3 return to the medication cart and start preparing medications. On 5/7/25 at 9:20 A.M., the surveyor observed Nurse #3 enter a different resident's room with medications. Nurse #3 did not return to Resident #20's room. On 5/7/25 at 9:24 A.M., the surveyor was approaching the nursing station to alert Unit Manager #3 to check on Resident #20 when the surveyor observed Hospice Nurse #1 enter Resident #20's room. On 5/7/25 at 9:28 A.M., the surveyor observed Nurse #3 speaking with a co-worker, next to his medication cart, having a casual conversation. The surveyor walked past Nurse #3 and entered Resident #20's room. Hospice Nurse #1 said Resident #20 is struggling to breathe and asked the surveyor if the nurse checked the oxygen saturation and the last time the Resident had been medicated to make him/her comfortable. At this time, Nurse #3 entered the room, holding a pair of surgical gloves in his hand. Nurse #3 said he was just about to put on Resident #20's CPAP mask. Nurse #3 then applied Resident #20's CPAP mask without difficulty. The surveyor exited the room and remained in the hallway outside of the room to allow nursing staff to provide care. On 5/7/25 at 9:38 A.M., the surveyor overheard from the doorway to Resident #20's room, Hospice Nurse #1 request Nurse #3 to increase the liter flow of oxygen because the Resident's oxygen saturation was 85%. She also asked Nurse #3 when the Resident had his/her Morphine (a medication used to manage pain and shortness of breath in terminally ill patients) administered to improve his/her shortness of breath. Nurse #3 responded that the Resident was medicated with Morphine at 6:00 A.M, prior to his shift. Hospice Nurse #1 said she was going to recommend a medication for anxiety, and a medication to reduce secretions to help improve the Resident's comfort level. During an interview on 5/7/25 at 9:47 A.M., Nurse #3 said when a resident appears to be in distress, he completes a nursing assessment. He said he takes their oxygen saturation, respiratory rates and blood pressure. He said when he entered Resident #20's room this morning and asked him/her what he/she needed, he was unable to understand him/her, so he notified the DON. He said he counted his/her respirations in his head, and they were 16 which is normal. He said the DON was going to come assist Resident #20, so he continued to complete his medication pass. Nurse #3 said he could have done more to help the Resident and not taking a complete set of vital signs with the oxygen level is not his normal practice. He said having a surveyor with him made him nervous. Nurse #3 said he just offered the Resident Morphine to assist his breathing, however the Resident refused. He said he just increased the Resident's oxygen flow to five liters, put on the CPAP mask, and his/her breathing has improved. He said hospice is aware of the change of condition because they are here now. Review of a Hospice Nurse #1's progress note, dated 5/7/25, time blank, indicated Resident #20 had significant dyspnea (shortness of breath), lung sounds severely diminished with crackles throughout. Vital signs 93% on 3 liters of oxygen, respirations 18, Blood pressure 131/84, heart rate 75. New recommendations for Hyoscine 0.125 milligrams (mg) (used to reduce saliva) every four hours as needed for secretions, and Lorazepam 0.5-1mg (used to treat anxiety) every four hours as needed for anxiety. Physician was made aware of recommendations and is in agreement. Review of the nursing progress note, dated 5/7/25 at 10:11 A.M., written by Nurse #3, indicated Resident #20 was asked if he/she wanted Morphine for shortness of breath, and declined. The progress note failed to include any respiratory assessment. Review of the nursing progress note, dated 5/7/25 at 1:05 P.M., indicated at approximately 9:15 A.M., Resident #20 wanted to apply his/her own CPAP, and respirations were noted to be 16, and Resident #20 was agitated, and not in distress. The progress note failed to include documentation if the CPAP was in place, any further respiratory assessment or intervention taken for the documented agitation. During an interview on 5/7/25 at 11:35 A.M. with the DON, Consulting Staff #1 and Consulting Staff #2, the DON said she expects nurses to complete a full head to toe assessment of a resident when there is a suspected change of condition. She said the assessment must include a complete set of vital signs, including oxygen saturation, lung sounds, pain level and review of the resident's medication list. The surveyor reviewed her observations with the DON and Consulting staff #1 and #2, and the DON said the nurse must ensure the resident is stable, prior to resuming their medication pass. The DON said she feels the Resident becomes overwhelmed when there are too many people in the room. Consulting staff #2 said Nurse #3 did not follow the proper procedure.

Based on record review and interview, the facility failed for one Resident (#89), with a history of trauma, out of a total sample of 23 residents, to assess the history of trauma and failed to develop a plan of care accounting for the Resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization. Findings include: Review of the facility's policy titled Trauma Informed Care and Culturally Competent Care, dated as last revised August 2022, indicated but was not limited to the following: -To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. -Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care and delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporated knowledge about the trauma into care plans, policies, procedures, and practices to avoid re-traumatization. -Trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. -Triggers are highly individualized. Common triggers may include lack of privacy, confinement in a crowd or small space, loud noises, bright/flashing lights, certain sights, objects, sounds, smells, or physical touch. -Evaluate the need for trauma-informed care as part of the facility assessment. -Perform universal screening of residents. -Screening may include trauma history, including type, severity, and duration. -Utilize initial screening to help identify the need for further assessment and care. -Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identified triggers. -Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. -Identify and decrease exposure to triggers that may re-traumatize the resident. Resident #89 was admitted to the facility in September 2024 with diagnoses which include Post-Traumatic Stress Disorder (PTSD), insomnia, REM Sleep behavior disorder, depression, Psychotic disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 3/20/25, indicated Resident #89 scored 7 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had moderate cognitive impairment, and he/she had PTSD. Review of the medical record including Assessments and Evaluations failed to indicate a Trauma Assessment to identify potential triggers had been completed on admission. Review of the comprehensive care plan indicated but was not limited to the following: FOCUS: I have a history of PTSD related to surviving a traumatic event (1/9/25) GOAL: I will be able to identify the triggers that cause me to experience anxiety, trauma, and flashbacks, and learn coping mechanisms to mitigate their impact on my well-being. INTERVENTIONS: -Accept my current level of function. Be consistent, positive, honest, and non-judgmental while working with me. -Assist me with identifying coping/calming mechanisms to manage anxiety or correct misunderstandings conditioned at the time of trauma/stress, such as relaxation techniques, deep breathing, visualization, and removing myself from the situation. -Avoid situations that may cause flashbacks. Ask me about my triggers and incorporate them into my plan of care. -Consult psychiatry/psychology as needed. -Monitor and document resident feelings, such as insecurities, anxiety, anger mistrust emotional detachment, unwanted/intrusive thoughts, insomnia, etc. Report observations to physician or designee as clinically indicated. -Provide spiritual/religious support as needed. The comprehensive care plan failed to identify potential triggers related to the diagnosis of PTSD. During an interview on 5/6/25 at 9:52 A.M., Unit Manager #2 said the Social Workers do the trauma assessment and update the care plans. During an interview on 5/8/25 at 8:20 A.M., Social Worker #2 said every resident should have a trauma evaluation regardless of the diagnosis of PTSD and a resident with the diagnosis should not only have one done on admission, but it should also be re-addressed quarterly. She said Resident #89 did not have one done on admission and he/she should have. Additionally, she said there is a separate Trauma Evaluation, and one built into the Social Worker Evaluation, but neither were done in this case. She said he/she was on a different unit at the time of admission, but it still should have been done and was unsure why it was not. She said the subsequent quarterly evaluations she did also did not address the PTSD/trauma. She said Resident #89 has dementia and is unreliable. She said in this situation the questions should have been deferred to the Health Care Proxy (HCP), but she did not address it with the HCP and should have. During an interview on 5/8/25 at 8:37 A.M., the Director of Nurses said every resident should have a trauma evaluation and those with PTSD should have potential triggers on the care plan. She said the Social Worker does them and was unsure why this one had not been completed.

Based on observation and interview, 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 ensure food was properly stored in the walk-in refrigerator in the main kitchen. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. Review of the facility's policy titled Food Receiving and Storage, undated, indicated but was not limited to: - Critical Control Point means a specific point, procedure, or step in food preparation and serving process at which control can be exercised to reduce, eliminate, or prevent the possibility of a food safety hazard. Some operational steps that are critical to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices. - Foods shall be received and stored in a manner that complies with safe food handling practices. - All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). - Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. On 5/4/25 at 7:49 A.M., the surveyor observed in the main kitchen walk-in refrigerator: - One pouch of whipped cream, undated, tip uncovered and exposed and resting on refrigerator shelf; - One plastic food storage container containing coleslaw covered with plastic wrap, dated 5/2/25 use by manufacturers date, not stored in manufacturer's container and no manufacturer's date listed; - One metal container of chopped spinach covered with plastic wrap, prepped on 4/29/25 use by 5/2/25, large amount of condensation on the plastic wrap and spinach with brown discoloration; - One plastic container labeled turkey sandwich, prepped on 5/1/25 use by 5/3/25; - Two containers of soup, prepped on 5/1/25 use by 5/3/25; - One plastic food storage container containing a roasted red pepper, dated 5/2/25 use by manufacturer's date, not stored in manufacturer's container and no manufacturer's date listed; - One container of chopped lettuce, prepped on 4/29/25 use by 5/1/25, with reddish brown discoloration; - One container of sliced tomatoes, prepped on 4/29/25 use by 5/1/25, soggy and limp; - One open bag of cilantro, with brown and white discoloration, dried out; - Three bags of shredded carrots, best by 4/27/25, soggy with brown discoloration; - One box of frozen meat, undated, opened and meat exposed; - One metal bowl of shredded lettuce, undated; - One bag of defrosted cinnamon rolls, dated pulled on 4/26/25 use by 4/27/25; - One box of bacon, undated, opened and bacon exposed; - One box of frozen sausage, undated, sausage open and exposed; On 5/4/25 at 12:39 P.M., the surveyor observed in the main kitchen walk-in refrigerator: - One plastic container labeled turkey sandwich, prepped on 5/1/25 use by 5/3/25; - One metal container of chopped spinach covered with plastic wrap, prepped on 4/29/25 use by 5/2/25, large amount of condensation on the plastic wrap and spinach with brown discoloration; - One open bag of cilantro, with brown and white discoloration, dried out; - One container of sliced tomatoes, prepped on 4/29/25 use by 5/1/25, soggy and limp; - One pouch of whipped cream, undated, uncovered and exposed resting on another pouch of whipped cream in a box; - Two containers soup, prepped on 5/1/25 use by 5/3/25; - Three bags of shredded carrots, best by 4/27/25, soggy with brown discoloration; On 5/5/25 at 12:40 P.M., the Food Service Manager (FSM) and the surveyor observed in the main kitchen walk-in refrigerator: - Three bags of shredded carrots, best by 4/27/25, soggy with brown discoloration; - One open bag of cilantro, with brown and white discoloration, dried out; - One box of frozen sausage, undated, sausage open and exposed; - One pouch of whipped cream, undated, tip exposed and resting on another pouch of whipped cream in a box; During an interview on 5/5/25 at 12:45 P.M. the FSM said prepared foods should be stored in the manufacturers' containers and labeled with an open date. The FSM said the nozzle on the pouch of whipped cream should not have been exposed and should have been covered to prevent contamination and dated with an open date. The FSM said all foods in the walk-in refrigerator must be rotated and either used by or discarded by the expiration date or use by date. The FSM said frozen foods should be defrosted and used by the use by date and meats should not be exposed to the elements but kept covered to prevent cross contamination.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required physical assistance of staff with Activities of Daily Living (ADL), the Facility failed to ensure they maintained a complete and accurate medical record, related to Certified Nurse Aide (CNA) ADL Flow Sheets, when daily documentation by CNA's (for all three shifts) were not consistently completed, with flow sheets left blank. Findings include: Review of the Facility Policy titled, Point of Care (POC) Documentation, dated 10/08/24, indicated the following: -Certified Nurse Aides (CNA) will document resident care in the electronic health record module POC; -CNA's will provide resident care in accordance with each resident's individualized plan of care which can be accessed from within POC; -CNA's will document the resident's self-performance, and the support provided for activities of daily living, including: bed mobility, transferring, toileting, dressing, bathing, eating, personal hygiene and locomotion. Resident #1 was admitted to the Facility in December 2024, diagnoses included: acute and chronic respiratory failure, myotonic muscular dystrophy, dysphagia, anxiety disorder, attention-deficit hyperactivity disorder, atrial fibrillation, artificial openings of gastrointestinal tract, and nutritional deficiency. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/03/25, indicated that Resident #1 required physical assistance of staff for bathing, dressing, personal hygiene, transfers and ambulation. Review of Resident #1's Care Plan, titled ADL Self Care Performance Deficit related to disease process, renewed and revised with his/her Quarterly MDS, dated [DATE], indicated he/she required the physical assistance of staff for transfers and toileting, and staff supervision for hygiene, dressing, bathing, and ambulation. Review of Resident #1's CNA Documentation Record (ADL Flow Sheets), dated 12/05/24 through 12/31/24, indicated that for the following shifts, documentation on the flow sheets was incomplete: -7:00 A.M. to 3:00 P.M. - 11 days (out of 26) ADL care areas were left blank -3:00 P.M. to 11:00 P.M. - 10 days (out of 26) ADL care areas were left blank -11:00 P.M. to 7:00 A.M. - 6 days (out of 26) ADL care areas were left blank Review of Resident #1's CNA Documentation Record (ADL Flow Sheets), dated 01/01/25 through 01/31/25, indicated that for the following shifts, documentation on the flow sheets was incomplete: -7:00 A.M. to 3:00 P.M. - 5 days (out of 31) ADL care areas were left blank -3:00 P.M. to 11:00 P.M. - 14 days (out of 31) ADL care areas were left blank -11:00 P.M. to 7:00 A.M. - 3 days (out of 31) ADL care areas were left blank Review of Resident #1's CNA Documentation Record (ADL Flow Sheets), dated 02/01/25 through 02/28/25, indicated that for the following shifts, documentation on the flow sheets was incomplete: -7:00 A.M. to 3:00 P.M. - 3 days (out of 28) ADL care areas were left blank -3:00 P.M. to 11:00 P.M. - 3 days (out of 28) ADL care areas were left blank -11:00 P.M. to 7:00 A.M. - 2 days (out of 28) ADL care areas were left blank During an interview on 04/29/25 at 1:15 P.M., Certified Nurse Aide (CNA) #1 said that the documentation of ADL's is done in POC in the Electronic Medical Record (EMR) and has to be completed by the end of the shift. During an interview on 04/29/25 at 4:41 P.M., Certified Nurse Aide (CNA) #2 said that the documentation of ADL's is done in POC in the EMR and has to be completed by the end of the shift. During an interview on 04/29/25 at 5:15 P.M., the Director of Nurses (DON) said CNA's document the ADL's they provided to the residents in POC in the EMR and it should not be incomplete. The DON said it was her expectation that the CNA's should be documenting all care provided to residents by the end of every shift and should not be left blank.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was experiencing a decline in condition, was on comfort measures at end of life and receiving Hospice Services, the Facility failed to ensure that nursing followed acceptable standards of practice related to complete and accurate documentation in clinical records regarding documentation of his/her decline in condition up to and including his/her death, and that an RN pronouncement had been done. Findings include: Review of the Facility Policy titled, Charting and Documentation, dated revised [DATE], indicated the following: -all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record; -all observations, medications administered, services performed, etc., must be documented in the resident's medical record; -all incidents, accidents, or changes in the resident's condition must be recorded. Review of the Facility Policies titled, Change in Condition and Change in Condition Notification, dated as revised [DATE], indicated the following: -a significant change in condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff, is not self-limiting, impacts more that one area of the resident's health status and requires revision to the care plan; -the facility will monitor residents for changes in their condition, and respond appropriately to those changes; -the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the Facility Policy titled, Registered Nurse Pronouncement, dated as revised [DATE], indicated the following: -the registered nurse may conclude that death has occurred and pronounce the death of a resident when the patient has been receiving hospice services under the physician's plan of care, the death was a result of a terminal illness, there is a Do Not Resuscitate order in place, the death was anticipated according to the prognosis documented in the record, and the nurse has made a reasonable effort to contact the physician at the time of death and the effort should be documented in the medical record; -the nurse will document in the medical record: the time of the pronouncement, findings from the assessment of the patient that substantiated the conclusion that death has occurred, notification of the physician, family and funeral home, removal of the body; -nurses documentation of pronouncement should include: absence of pulses, absence of pupillary response, absence of breath sounds, attempts to reach the physician, notification of family/Next of Kin (NOK) /Health Care Proxy (HCP), and what funeral home was notified. 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. Resident #1 was admitted to the Facility in [DATE], diagnoses included: displaced unspecified condyle fracture of lower end of left femur, bilateral hearing loss, moderate protein-calorie malnutrition, cerebral palsy, essential hypertension and unstageable pressure ulcer of right and left hip. Review of Resident #1's Advance Directives, documented on a Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) Record, dated [DATE], indicated Resident #1 was a Do Not Resuscitate. Review of a Physician Progress Note, dated [DATE], indicated that Resident #1's clinical status was declining, new lower extremity ulcer noted and is likely a [NAME] (terminal ulcer that develops when a person is at the end of life) ulcer due to his/her general decline, as well as decreasing nutrition and quick onset. The Note indicated that Resident #1 was declining overall, and Hospice should be considered, he/she presented with failure to thrive, was functionally declining, and had cerebral palsy, most appropriate for Hospice but HCP has not been open to this in the past. Review of a Nurse Progress Note, dated [DATE] at 7:00 P.M., indicated Resident #1 continues to decline throughout the shift, exhibiting signs and symptoms of pain and shortness of breath requiring (PRN) as needed Roxanol (highly concentrated solution of the narcotic analgesic morphine sulfate for oral administration used for the treatment of severe chronic pain) throughout the day, all PRN doses had good effect but would wear off as the 2 hour mark approached. The Note indicated that Resident #1 was noted with increased oral secretions, and hyoscyamine (used for excessive salivation) was ineffective, the physician was notified and Scopolamine (used for excessive oral secretions) patches were ordered. Review of a Physician Progress Note, dated [DATE], indicated that Resident #1 was on Hospice and was declining for some time, family was present and comfort care medications were discussed. The Note indicated end of life care continues, comfort care with Ativan (anti-anxiety), morphine as needed and scopolamine and Zofran (anti-emetic) as needed and to continue with Hospice care. Review of an RN Pronouncement of Death Certificate, dated [DATE] at 07:12 A.M., indicated that Resident #1 was pronounced dead at the Facility by Nurse #3. However, further review of Resident #1's Nurse Progress Notes indicated there was no documentation after [DATE] to support nursing had assessed and monitored Resident #1's decline in condition up to and including his/her death on [DATE], or that an RN Pronouncement had been completed. This was not consistent with the Facility's Change in Condition, Change in Condition Notification and Registered Nurse Pronouncement Policies. During a telephone interview on [DATE] at 5:29 P.M., Nurse #3 said that he was assigned to care for Resident #1 on [DATE], [DATE], and [DATE] during the 11:00 P.M. to 7:00 A.M. shift and he also worked the [DATE], 3:00 P.M. to 11:00 P.M. shift. Nurse #3 said he could not explain why there were no nurse progress notes in Resident #1's medical record during his shifts. Nurse #3 said that he was assigned to Resident #1 on [DATE] on the 11:00 P.M. to 7:00 A.M. (into [DATE]) shift and said he was the nurse who pronounced Resident #1 dead on [DATE] at 7:12 A.M. Nurse #3 said that he was aware of the Facility's RN pronouncement policy and said he thought he wrote a nurse progress note with his assessment of Resident #1 and said he could not explain why there was no nurse progress note in Resident #1's following the pronouncement of his/her death. During a telephone interview on [DATE] at 10:38 A.M., Nurse #4 said that she was assigned to Resident #1 on [DATE] and [DATE] during the 7:00 A.M. to 7:00 P.M. shift and [DATE] during the 7:00 A.M. to 3:00 P.M. shift. Nurse #4 said that Resident #1 was actively dying and required pain medication around the clock. Nurse #4 said that on [DATE], Resident #1 had excessive secretions and she called the physician to obtain an order for scopolamine to dry up his/her secretions. Nurse #4 said that was the last nurse progress note she wrote and said there was no need to write any further nurse progress notes for someone who was dying. During a telephone interview on [DATE] at 1:00 P.M., Nurse #5 said that he was assigned to Resident #1 on [DATE] during the 7:00 A.M. to 3:00 P.M. shift. Nurse #5 said that he was still in training and that he was expected to administer all the medications and perform all of the treatments to his assigned residents. Nurse #5 said that he was never told to write nurse progress notes for the residents assigned to him. During a telephone interview on [DATE] at 2:00 P.M., Nurse #6 said she was assigned to Resident #1 on [DATE] during the 3:00 P.M. to 11:00 P.M. shift. Nurse #6 said that Resident #1 was actively dying and that was a change in condition for him/her. Nurse #6 said that she should have written a nurse progress note about her assessment of Resident #1 and said she did not have enough time during her shift to write a nurse progress note about Resident #1's condition. During an in-person interview on [DATE] at 4:05 P.M. and a subsequent telephone interview on [DATE] at 12:03 P.M., the Director of Nurses (DON) said that it was her expectation that nurses write a nurse progress note every shift with detailed assessment of a resident's change in condition. The DON said that when a resident is actively dying that is a change in condition and there should be nurse progress notes in the medical record every shift. The DON said she could not explain why there were no nurse progress notes after [DATE] in Resident #1's medical record. The DON said that it was her expectation that there be detailed nurse progress note with assessment data as indicated in the Facility's RN pronouncement policy in the medical record whenever an RN pronouncement is completed. The DON said that Resident #1's medical record did not have any nurse progress notes about an RN pronouncement and said that Nurse #3 did not follow the Facility's policy.

Based on record reviews and interviews, for one of three sampled residents (Resident #1) who had physician orders for wound dressing changes, the facility failed to ensure they maintained complete and accurate resident Treatment Administration Records (TAR) in the Electronic Medical Record (EMR) when Resident #1's TAR's, related to documentation of dressing changes, were not consistently completed during the months of May 2024 and June 2024. Findings include: Review of the Facility Policy, Charting and Documentation, dated as revised January 2023, indicated that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Observations, medications administered, services performed, etc., must be documented in the resident's clinical records. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: - Date and time the procedure/treatment was provided; - Name and title of the individual(s) who provided the care; - The assessment data and/or any unusual findings obtained during the procedure/treatment; - How the resident tolerated the procedure/treatment; - Whether the resident refused the procedure/treatment; - Notification of family, physician, or other staff if indicated; - The signature and title of the individual documenting. Review of the Facility Policy, Wound Care, dated as revised January 2023, indicated the following in reference to documentation: -the type of wound care given; -the date and time the wound care was given; -the position in which the resident was placed; -the name and title of the individual performing the wound care; -any change in the resident's condition; -all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; -how the resident tolerated the procedure; -any problems or complaints made by the resident related to the procedure; -if the resident refused the treatment and the reason(s) why; -the signature and title of the person recording the data. Resident #1 was admitted to the Facility in May 2024, diagnoses included: displaced unspecified condyle fracture of lower end of left femur, bilateral hearing loss, moderate protein-calorie malnutrition, cerebral palsy, essential hypertension and unstageable pressure ulcer of right and left hip. Review of Resident #1's Physician Orders for May 2024, indicated he/she had an order, dated 5/13/24, for a dressing to his/her left hip pressure injury, for nursing to cleanse area with normal saline, pack wound with Dakins (diluted bleach solution used to cleanse wounds to prevent and treat infections) fluffed gauze, cover with dry protective dressing daily every day and evening shift. Review of Resident #1's TAR (EMR), for May 2024, indicated the treatment to the left hip pressure injury was not documented as administered by nursing on 5/18/24 during the day shift, on 5/19/24 during the day and evening shift and on 5/20/24 during the day shift, per physician orders. Review of Resident #1's Physician Orders for June 2024, indicated he/she had an order, dated 6/23/24, for a dressing to his/her left lateral distal calf, for nursing to cleanse with Dakins for 15 minutes, remove and apply alginate (a biodegradable dressing made from seaweed that absorbs exudate and forms a gel), cover with a 4 x 4 dressing, wrap with gauze daily during the day shift. Review of Resident #1's TAR (EMR) for June 2024, indicated the treatment to the left distal calf was not documented as administered by nursing on 6/29/24 during the day shift per physician orders. Review of Resident #1's Physician Orders indicated he/she had an order, dated 5/31/24, for a dressing to his/her left hip, for nursing to irrigate with normal saline, pack with alginate, apply Santyl topically, skin prep peri-wound and cover with border gauze daily during the day shift. Review of Resident #1's TAR EMR, for June 2024, indicated the treatment to the left hip was not documented as administered by nursing on 6/28/24 and 6/29/24 during the day shift per physician orders. Review of Resident #1's Physician Orders indicated he/she had an order, dated 5/31/24, for a dressing to his/her right hip, for nursing to irrigate with normal saline, pack with alginate, apply Santyl topically, skin prep peri-wound and cover with border gauze daily during the day shift. Review of Resident #1's TAR EMR, for June 2024, indicated the treatment to the right hip was not documented as administered by nursing on 6/29/24 during the day shift per physician orders. During a telephone interview on 07/29/24 at 10:38 A.M., Nurse #4 said she was familiar with Resident #1 and was assigned to care for Resident #1 on 6/29/24 during the day shift. Nurse #4 said she provides treatments to the residents on her assignment. Nurse #4 said if the TAR EMR was left blank she probably did not provide a treatment to Resident #1's right hip on 6/29/24, as ordered by the physician. During a telephone interview on 7/29/24 at 2:00 P.M., Nurse #6 said she was familiar with Resident #1 and works on all the units in the facility. Nurse #6 said she provides treatments to the residents on her assignment. Nurse #6 said she would follow the physician orders and sign off the treatment as completed on the TAR EMR. Nurse #6 said when a treatment is not signed off as completed in the TAR, the treatment is considered not done. During an interview on 07/24/24 at 3:00 P.M., the Unit Manager said that it was her expectation that all treatments be provided and signed off in the TAR EMR as being provided. The Unit Manager said that if a treatment is not signed off and left blank on the TAR EMR, then the treatment is considered as not done. During an interview on 07/24/24 at 4:05 P.M., the Director of Nursing (DON) said all nurses must document treatments provided on the TAR EMR. The DON said when a treatment is provided by nursing and the corresponding documentation is not signed off as completed, then the treatment is considered as not done.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that after an administrative staff member (Director of Nurses #1) was made aware on 4/08/24 that Resident #1 was found with an injury of unknown origin (facial bruising), that it was reported to the Department of Public Health (DPH) within two hours, as required, when it was not reported to the DPH until 4/09/24, the following day. Findings include: Review of the Facility Policy titled Abuse, with a revision date of October 2022, indicated the Facility prohibits the mistreatment, neglect, and abuse of residents by anyone. The Policy indicated the following: -all alleged violations involving abuse, neglect, exploitation, and/or misappropriation of resident property will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law; -the facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown source to determine if abuse or neglect was involved; -an injury will be classified as an Injury of Unknown Source when both of the following conditions are met: source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. -the shift supervisor/charge nurse is identified as responsible for immediate initiation of the reporting process upon receipt of the allegation; -the supervisor who initially received the report must inform the Administrator/Director of Nursing immediately and initiate gathering requested information; -once an allegation of abuse has been made, the Administrator/Director of Nurses must be informed immediately; -an investigation must be directed by the Administrator or designee immediately; -notify the appropriate State Agency immediately (no later than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident. Resident #1 was admitted to the Facility in August 2022, diagnoses included unspecified dementia, major depressive disorder, anxiety, hypertension, and unspecified psychosis. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 04/09/24, indicated that on 4/08/24, Resident #1 was found to have a bruise [injury to facial area with swelling], the bruise was reported to a supervisor today [4/08/24] and an investigation was initiated. The Report indicated that on 4/09/24, it was reported to the Administrator that the resident had a mark on his/her face, and it was unclear if it was a bruise or rash. The Report indicated that Resident #1's swelling went away, however, the mark remained, and it was unclear as to the etiology of the redness on Resident #1's face. The Report indicated that the Physician documented that Resident #1's face appeared to be swollen, with a rash or petechia (small red or purple spot that can appear on the skin which is caused by hemorrhage of capillaries) present. The Report indicated that the facility was unable to substantiate abuse at the time, as it was unclear if the marks on Resident #1's face were in fact bruises, a rash or part of the dying process. Review of a Nurse Progress Note, dated 04/08/24 at 3:53 P.M., written by the Unit Manager, indicated that Resident #1's daughter was very upset regarding the discoloration to Resident #1's face and lips. The Note indicated that Director of Nurses (DON) #1 was notified. During an interview on 5/21/24 at 12:20 P.M., the Unit Manager said that on 04/08/24 during the day shift Resident #1 was found with red and purple discoloration to his/her face and lips, and that his/her lips were swollen. The Unit Manager said that Resident #1's daughter was present at the time when the discoloration was found and was distraught about what Resident #1's face looked like. The Unit Manager said she notified Director of Nurses #1 on 4/08/24 during the day shift. The Surveyor was unable to interview Director of Nurses #1, as she did not respond to the Departments telephone and letter requests for an interview. During an interview on 05/21/24 at 4:00 P.M., the Administrator said that he was off on Monday, 04/08/24 and said the incident was not reported to him until 04/09/24. The Administrator said that he reported the alleged incident to the DPH on 04/09/24, after he was notified. The Administrator said it was his expectation that an injury of unknown origin be reported to the DPH within 2 hours of the allegation being made according to facility policy.

Based on observations, interviews, record reviews, and policy review, the facility failed to notify the physician about a change in condition in order to re-evaluate the potential need to alter the treatment plan for two Residents (#2, #61), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #2, to notify the physician regarding a 12.66% severe significant weight loss in three months (11/21/23 to 2/3/24) and 5.39% in one month (2/3/24 to 3/8/24); and 2. For Resident #61, to notify the physician regarding a 6.95% (10/21/23 to 11/21/23) severe significant weight loss in one month, as well as a 10.54% (10/21/23 to 1/25/24) severe significant weight loss in three months and an additional 10.74% severe significant weight loss in three months (11/30/23 to 3/18/24). Findings include: Review of the facility's policy titled Weight Assessment and Interventions, revised May 2019, included but was not limited to: - The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. - Monthly weights will be obtained each month or as ordered by physician. - Weights will be recorded in the medical record (electronic health record where available) for each resident. - Any weight change of five pounds (lbs.) in a month or three pounds in a week since their last weight assessment should be retaken within 72 hours for confirmation and verified by Nursing. - Re-weigh should be reviewed by the Licensed Nurse. - Licensed Nurses should notify Dietician of identified weight change once reviewed. - Dietician notification should be documented within Resident's medical record. - Dietician or diet technician should respond within 72 hours of receipt of notification. - The threshold for significant unplanned and undesired weight change will be based on the following criteria: (a) one month: 5% weight change is significant, greater than 5% is severe; (b) three months: 7.5% weight change is significant; greater than 7.5% is severe; (c) six months: 10% weight change is significant; greater than 10% is severe. 1. Resident #2 was admitted to the facility in February 2021 with diagnoses including schizoaffective disorder and type II diabetes. Review of the Minimum Data Set (MDS) assessment, dated 1/24/24, indicated Resident #2 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Further review of Section K of the MDS assessment indicated Resident #2 had a weight loss of 5% or more in the last month or 10% or more in the last six months. Section K of the MDS assessment indicated Resident #2 was not on a prescribed weight loss regimen. Review of Resident #2's active Physician's Orders included but were not limited to: - 2/26/24: Weekly Weight - weekly weight secondary to weight loss every day shift every seven days Review of Resident #2's weights in the electronic medical record indicated the following weights: - 11/21/23: 191.2 lbs. - 12/2023: not obtained - 01/23/24: 172.2 lbs. - 02/03/24: 167.0 lbs. - 03/08/24: 160.0 lbs. Review of Resident #2's weights indicated he/she had a 12.66% severe significant weight loss in three months. Further review of Resident #2's weights indicated a 5.39% significant weight loss in one month (2/3/24 and 3/8/24). Review of Resident #2's nutritional care plan indicate interventions included but were not limited to: - Obtain weight per physician (MD) order on same scale. Notify MD/Nurse Practitioner (NP)/Registered Dietician (RD) of significant weight changes (revised 11/14/23). Review of a dietary progress note, dated 2/12/24, indicated Resident #2 had a 12.7% significant weight loss over the past three months. The RD recommended the facility obtain a reweight of Resident #2 prior to any further intervention changes. Further review indicated the RD recommended Resident #2 to have weekly weights, sugar free house supplement (four ounces twice daily) and change to regular size portions (versus the previously recommended large portions). Documentation failed to indicate MD/NP notification of continued significant weight loss was completed. Review of MD/NP notes failed to indicate MD/NP documentation related to Resident #2's significant weight loss. During an interview on 3/18/24 at 1:58 P.M., Nurse #4 said when weights are input into the electronic medical record they populate red for a significant change. Nurse #4 said the Dietitian would notify the MD directly of any new recommendations or changes. During an interview on 3/18/24 at 3:13 P.M., Unit Manager (UM) #1 said she and the RD should be reviewing weights of all residents on the unit. UM #1 said she was uncertain if Resident #2's MD was aware of their significant weight loss. UM #1 said she would be responsible for notifying the MD of changes in weight. UM #1 said staff should be notifying the MD of changes in weight to ensure the interdisciplinary team are aware. During an interview on 3/18/24 at 4:09 P.M., the RD said she reviews weights for significant weight loss when they are obtained by staff at the facility. The RD said she then determines an individualized plan for each resident to address the weight loss. The RD said the goal is to review each resident in the facility quarterly, or more often if a significant weight loss is identified. The RD said Resident #2 has had a continued significant weight loss. The RD said she notifies nursing staff of recommendations to notify the MD. The RD said she does not notify the MD of significant weight loss or recommendations herself. During an interview on 3/18/24 at 4:27 P.M., the Director of Nurses (DON) said her expectation would be for the RD to identify a significant weight loss for any residents in the building. The DON said she would expect the nursing staff and/or the RD to notify the MD regarding the changes identified. The DON said the UM should be looking at changes to identify risk factors for residents on each unit. 2. Resident #61 was admitted to the facility in December 2021 with diagnoses including hypertension, atrial fibrillation (abnormal heart rhythm), and cerebral infarction (stroke). Review of the MDS assessment, dated 2/21/24, specified a BIMS score of 14 out of 15, indicating he/she had intact cognition. Further review of Section K of the MDS assessment indicated Resident #61 had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Section K of the MDS assessment indicated Resident #61 was not on a prescribed weight loss regimen. Review of Resident #61's weights in the electronic documentation system indicated the following weights: - 9/2023: not obtained - 10/21/23: 178.4 lbs. - 11/21/23: 166.0 lbs. - 11/30/23: 169.4 lbs. - 12/2023: not obtained - 1/25/24: 159.6 lbs. - 2/2024: not obtained - 3/18/24: 151.2 lbs. Review of Resident #61's weight indicated that Resident #61 had a 6.95% severe significant weight loss between 10/21/23 and 11/21/23. Further review indicated Resident #61 had a 10.54% severe significant weight loss in three months (10/21/23 to 1/25/24). Additionally, a second severe significant weight loss of 10.74% was identified in three months (11/30/23 to 3/18/24). Review of Resident #61's nutritional care plan indicated interventions included but were not limited to: - Obtain weight per physician (MD) order on same scale. Notify MD/Nurse Practitioner (NP)/Registered Dietician (RD) of significant weight changes (revised 10/5/23). Review of MD/NP progress note documentation, dated 3/5/24, indicated the Resident was seen for family concerns related to weight loss and poor appetite. Further review of the documentation indicated Resident #61's weight was down but failed to address the significant weight loss. Documentation indicated Resident #61 may benefit from house supplement shakes three times per day. Further review of the medical record failed to indicate the MD was notified of the Resident's severe significant weight loss between 10/21/23 to 11/21/23 (6.95%), 10/21/23 to 1/25/24 (10.54%) and 11/30/23 to 3/18/24 (10.74%). During an interview on 3/18/24 at 1:58 P.M., Nurse #4 said when weights are input into the electronic medical record they populate red for a significant change. Nurse #4 said the Dietitian would notify the MD directly of any new recommendations or changes. During an interview on 3/18/24 at 3:25 P.M., UM #1 said she and the RD should be reviewing weights of all residents on the unit. UM #1 said she was uncertain if Resident #61's MD was aware of their significant weight loss. UM #1 said she would be responsible for notifying the MD of changes in weight. UM #1 said staff should be notifying the MD of changes in weight to ensure the interdisciplinary team are aware. During an interview on 3/18/24 at 4:09 P.M., the RD said she reviews weights for significant weight loss when they are obtained by staff at the facility. The RD said she then determines an individualized plan for each resident to address the weight loss. The RD said she pulls a weight report for each resident when reviewing their documentation. The RD said the goal is to review each resident in the facility quarterly, or more often if a significant weight loss is identified. The RD said Resident #61 has had a continued significant weight loss and it needed to be addressed. The RD said she notifies nursing staff of recommendations to notify the MD. The RD said she does not notify the MD of significant weight loss or recommendations herself. During an interview on 3/18/24 at 4:27 P.M., the DON said her expectation would be for the RD to identify a significant weight loss for any residents in the building. The DON said she would expect the nursing staff and/or the RD to notify the MD regarding the changes identified. Refer to F692

Based on observation, record review, policy review, and interview, the facility failed to ensure that four Residents (#24, #70, #226, and #2), out of a total sample of 24 residents, were provided an environment free from accident hazards. Specifically, the facility failed to ensure staff: Provided adequate supervision and/or followed their Falls Prevention and Management policy of investigating falls and initiating fall prevention interventions for: 1. Resident #24, who had six total falls, all related to toileting, one of which consisted of an acute left-sided 7th rib fracture, healing 5th and 6th rib fractures, and a closed head injury; 2. Resident #70, who had two falls, less than 12 hours apart, one resulting in a fracture of the left femoral neck (left hip fracture) requiring inpatient hospital stay and surgical repair; and the other resulting in a hematoma to the right side of the head and a skin tear to the right arm; 3. Resident #226, to ensure adequate supervision and the appropriate level of staff assistance after the Resident was observed by staff to be ambulating independently with his/her walker into the facility's main lobby from a transit bus upon his/her return from dialysis; and 4. Resident #2, to ensure that falls were thoroughly investigated, and interventions were implemented to prevent further falls. Findings include: Review of the facility Fall Prevention and Management Policy, dated as last revised January 2023, indicated but was not limited to the following: -Fall Risk Evaluation will determine fall risk factors. The interdisciplinary team (IDT) identifies and implements appropriate interventions to reduce the risk of falls or injury while maximizing dignity and independence. ASSESSMENT AND PREVENTION -Fall risk assessments will be completed for all residents; initially on admission / readmission, quarterly, significant change and after an identified fall. -As part of the assessment, the nurse will help identify individuals with a history of falls and risk factors for subsequent falling. a. History of falling. b. History of one or more recent falls. c. Root cause for fall history will be identified. -The staff will implement goals and interventions based on the resident's individual needs. -Communicate interventions to care givers. -Review and revise IDT care plan when a change is identified, after an event. -If the resident continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. POST FALL -The nurse will complete an incident report. -Resident fall will be evaluated for 72 hours post fall, including full vital signs every shift. -Resident will be referred to therapy for a screen. CAUSE IDENTIFICATION -For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall -IDT should review resident's gait, balance, dizziness, and current medications to assess possible contributors to fall -The IDT and physician should continue to collect and evaluate information until causes for falls can be identified. MONITORING AND FOLLOW UP -IDT should monitor and document on residents' response / success with fall reduction interventions -Residents who continue to fall with interventions in place will be assessed for changes in or additions to interventions. Review of the facility's policy titled Incident Reports, dated as last revised October 2022, indicated but was not limited to the following: -It shall be the responsibility of the person in charge to ensure that all incidents involving resident injury are followed by the completion of an incident report. -Incident reports shall be completed and submitted within eight hours of the incident. -Incident reports shall be filled out for any unusual or dangerous occurrence. Example: Resident Fall. -All sections of the incident report must be completed -The incident report and statements shall be completed as soon as possible after the incident has occurred by the licensed person and/or certified nursing assistant (CNA) involved, and then forwarded to the Nurse Manager. Review of the Falls Packet, undated, indicated but was not limited to the following: -Incident Procedure: a. In electronic medical record under risk management create a new incident and save. b. Fill out all sections as appropriate. c. Complete fall evaluation. d. Care plan needs to be updated, under problem add date of the fall, under interventions add the intervention put in place to keep the resident safe/prevent a repeat fall. e. Fall packet with witness statements and neurological check go to the Director of Nurses (DON), along with a copy of the rehab screen. f. Rehab screen goes to rehab department. -All incident reports must have a note written by the risk manager/DON stating the incident was investigated and the results of said investigation. -If it was a fall there must be an accompanying intervention The Falls packet included the following documents: -Blank Witness Statements with the following questions: a. When was the last time you saw the resident? b. What was the resident doing? c. When was the last time you toileted/changed the resident? d. Was the resident incontinent at the time of the incident? e. Did the resident have any behaviors not normal to the resident? f. What did the resident say he/she was doing at the time of the fall? g. Any other information that would help get to the cause of the incident? -Blank Neurological Assessment -Blank Referral/Screen to Rehab Services 1. Resident #24 was admitted to the facility in December 2023 with diagnoses including encephalopathy (any brain disease that alters brain function or structure), diabetes mellitus type 2, bipolar disorder, anxiety, seizures, cognitive communication deficit, unsteadiness on feet, and lack of coordination. Medications included antipsychotic, antidepressant, narcotic, diuretic, and anti-seizure medications. Review of the Minimum Data Set (MDS) assessment, dated 12/28/23, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was a substantial/maximum assist for toileting, showering, and bathing, dependent on staff for putting on and taking off footwear, and a partial/moderate assist for walking 10 feet. The MDS also indicated Resident #24 was frequently incontinent of urine, always incontinent of stool, and was not on a urinary or bowel toileting program. The MDS failed to indicate an admission fall history was able to be determined. Review of the clinical record indicated Resident #24 sustained six falls between 1/10/24 and 2/25/24, one of which (2/25/24) resulted in an acute left-sided 7th rib fracture, healing 5th and 6th rib fractures, and a closed head injury. Six out of six falls were unwitnessed, and all were related to toileting. During an interview on 3/12/24 at 9:17 A.M., Resident #24 said he/she had a history of strokes with a left-sided deficit and decreased range of motion. During an interview on 3/14/24 at 10:42 A.M., Resident #24 said he/she had had three falls in the last month and a half and said, I get dizzy when I stand up. The Resident said his/her legs were weak and unsteady. The Resident said he/she gets up on his/her own to go to the bathroom and loses his/her balance and does hit the call bell, but they don't come in time. Resident #24 said he/she currently had a broken rib with a 3 out of 10 (10 being the worst) pain every time I breathe and was taking Oxycodone for pain. Review of the Falls Incident Reports (IR) for Resident #24 indicated but was not limited to the following: Fall #1 (1/10/24 at 11:15 P.M.): -Review of the medical record indicated Resident #24 had an unwitnessed fall and was found sitting on the floor in the bathroom with his/her walker at his/her back. The Resident stated he/she went into the bathroom to urinate, was washing his/her hands and lost balance and stumbled to the floor. The Resident complained of left arm pain and right rib pain and requested to be transferred to the emergency department (ED) for evaluation. Predisposing factors included weakness, decreased safety awareness, impaired memory, and decreased strength/endurance. No injuries were observed by staff. Review of the ED report, dated 1/11/24 at 12:00 A.M., indicated Resident #24 presented from the rehab facility after a fall in the bathroom which was unwitnessed. The Resident stated he/she hit the right side of his/her head, back, and right arm and reported right-sided neck pain and chest wall pain. There were no acute findings, and the Resident was discharged back to the facility. Review of the medical record indicated an Admission Fall Risk Evaluation was not completed until 1/12/24, 19 days after the admitted and two days after the first fall was sustained, which indicated Resident #24 was at high risk for potential falls. The evaluation indicated prevention protocol should be initiated immediately and documented on the care plan. Review of the medical record indicated a Moderate Risk for Falls care plan was initiated 1/12/24, 19 days after admission and two days after the first fall was sustained, indicated Resident #24 was at risk due to deconditioning, incontinence, and psychoactive drug use. The goal was that the Resident will not sustain serious injury through the review date. Interventions included the call light within reach and encourage to use it for assistance as needed, appropriate footwear when ambulating, safe environment, and physical therapy (PT) eval and treat as ordered and as needed (prn). Further review of the medical record indicated an Activities of Daily Living (ADLs) Functional/Rehabilitation Potential care plan was initiated 1/12/24, 19 days after admission and two days after the first fall was sustained, indicated Resident #24 had a self-care deficit due to pain and decreased range of motion to the left shoulder. The goal was that the Resident will maintain the highest level of functioning through the target date. Interventions included answering the call light promptly and have within reach at all times, transfer assist x 1, toilet transfer assist x 1, bed mobility assist x 1, mobility ambulate with assist x 1, toileting hygiene max assist x 1. Review of the medical record failed to include a falls packet and one was not provided to the surveyor upon request. Fall #2 (1/13/24 at 11:27 A.M.): -Review of the medical record indicated Resident #24 had a second unwitnessed fall and was found sitting on his/her bottom with his/her back to the bathroom wall. The Resident stated he/she was toileted by an aide and when finished, he/she got up to get back into bed and lost his/her balance and fell . No injuries were observed pre- or post-incident. Predisposing factors included confusion and gait imbalance. Review of the medical record failed to include a falls packet, post fall risk evaluation, or new interventions implemented to help keep the Resident safe and prevent a repeat fall. Fall #3 (1/21/24 at 1:00 P.M.): -Review of the medical record indicated Resident #24 had a third unwitnessed fall and was found sitting on the floor next to the room door and bathroom door. The call light was placed by the roommate. The Resident had complaints of arm pain and said he/she had tendonitis. Weakness was noted to the bilateral lower extremities (HX of CVA). No injuries were observed. The Resident was noted to have some confusion stating he/she was going to the bathroom. The Resident is a total assist at baseline. Predisposing factors included confusion, weakness, decreased safety awareness, and decreased strength. Review of the medical record failed to include a falls packet and one was not provided to the surveyor upon request. A new Risk for Falls care plan was initiated on 1/21/24 and included interventions such as to assist the resident with ambulation and transfers utilizing therapy recommendations, educate the resident on maintaining a safe environment, ensure call light is available, and if a fall occurs alert the provider and initiate frequent neuros and bleeding eval per facility protocol. There were no goals listed. Fall #4 (2/19/24 at 5:00 A.M.): -Review of the medical record indicated Resident #24 had a fourth unwitnessed fall and was found sitting on his/her bottom on the floor at the bedside. The Resident stated he/she had just finished using the urinal and his/her feet slid out from under him/her. The Resident complained of a sore left arm and bottom after landing on them. No injuries were observed. Predisposing factors included poor lighting, gait imbalance, and decreased strength. Review of the medical record failed to include a falls packet, referral to therapy for a screen to determine the need for therapy interventions, post fall risk evaluation, or new interventions implemented to help keep the Resident safe and prevent a repeat fall. Fall #5 (2/19/24 at 10:23 P.M.): -Review of the medical record indicated Resident #24 had another unwitnessed fall, same day, and was found sitting on the floor in the bathroom. The resident stated he/she was toileting self with walker and lost his/her foot grip with non-skid slipper socks on and fell to the floor. The Resident complained of left rib cage and left arm/elbow pain with limited range of motion to the left upper extremity. The Resident refused ED transport. A stat x-ray was ordered for the left rib cage and left upper extremity. No injuries were observed at the time of the incident. Predisposing factors included trip hazard, impulsiveness, and ambulating without assist. Review of a Nurse Practitioner's Note, dated 2/20/24 at 4:14 P.M., indicated positive pain with pressure to the Resident's left ribs. Left arm with no obvious abnormalities. X-rays reviewed, no fractures. Review of the medical record failed to include a referral to therapy for a screen to determine the need for therapy interventions, post fall risk evaluation, or new interventions implemented to help keep the Resident safe and prevent a repeat fall. Fall #6 (2/25/24 at 11:51 P.M.): -Review of the medical record indicated Resident #24 had a sixth unwitnessed fall and was found on the floor in the room next to his/her bed. The Resident stated, I fell and hit my head really hard and it's hurting. No injuries were observed at the time of the incident. The Resident was transported to the ED for evaluation. Predisposing factors included gait imbalance and decreased strength and that the incident occurred during unassisted self-transfer from the bed and ambulating independently. Review of the ED report, dated 2/26/24 at 12:18 A.M., indicated but was not limited to the following: -The Resident has a history of prior strokes with left-sided weakness and was status post an unwitnessed fall at the rehab center going to the bathroom, lost his/her balance and fell back. Resident reported striking his/her head and brief loss of consciousness. He/she stated he/she was unable to get up off the ground and was found approximately 10 minutes later. Complaints of right shoulder pain, headache, and neck pain. ED diagnoses included healing fractures of the left 5th and 6th ribs, an acute fracture in the left 7th rib, and a closed head injury. The Resident was discharged back to the facility at 3:17 A.M. Review of the medical record failed to include a referral to therapy for a screen to determine the need for therapy interventions, post fall risk evaluation, or new interventions implemented to help keep the Resident safe and prevent a repeat fall. Review of a Physician's Progress Note, dated 2/26/24 at 9:06 P.M., indicated the Resident had a recent fall with healing rib fractures and an acute rib fracture and continued to be unsteady. Continue PT, use walker, fall precautions. Review of a Physical Therapy Treatment Encounter Note, dated 3/8/24, indicated the patient and nurse were educated to discharge from PT services at this time. Patient does remain a fall risk due to impaired cognition. Perhaps considering a toileting schedule may decrease patient's attempts at self-toileting. During an interview on 3/14/24 at 11:00 A.M., Certified Nursing Assistant (CNA) #11 said Resident #24 was at risk of falls and was incontinent at times. She said they had to watch him/her because he/she sits at the side of the bed and puts his/her feet on the ground including when sleeping. CNA #11 said the Resident was steady with a walker and could get up on his/her own but was encouraged to use the call light. She said the Resident did not always do that though so needed to be supervised. CNA #11 said the Resident had not had any falls in a while. During an interview on 3/14/24 at 3:18 P.M., Nurse #9 said Resident #24 gets out of the bed to the chair but was not safe to do it on his/her own. She said he/she was very unsteady and had fallen a bunch of times. Nurse #9 said the Resident had a history of a stroke and lost part of his/her eyesight so was unsteady on his/her feet and had no safety awareness. Nurse #9 said she was not aware of any falls that resulted in major injury, but said the Resident required supervision and shouldn't be getting up on his/her own. On 3/18/24 at 7:00 A.M., the surveyor observed Resident #24 sleeping in bed. Both feet were hanging off the side of the bed. During an interview on 3/18/24 at 7:05 A.M., Nurse #11 said the Resident was at risk for falls and had one a month ago but was not injured. He said the Resident could take him/herself to the bathroom but overestimates him/herself a lot. Nurse #11 said the Resident could stand by his/herself to use the urinal but required supervision to the bathroom saying, he/she'll let us know. He said interventions were to have the call light within reach, non-skid socks, and the bed in a low position. On 3/18/24 at 8:00 A.M., the surveyor observed Resident #24 awake and lying sideways in the bed with both feet on the ground. The Resident's feet were partially wrapped with Ace bandages. The Resident was not wearing non-skid socks or footwear. During an interview on 3/18/24 at 2:11 P.M., the Rehab Director (RD) said Resident #24 was under therapy services from 12/22/23 through 2/7/24, then from 2/27/24 through 3/8/24. She said the Resident was always an assist while working with therapy and was non-compliant with calling for assistance. The RD said Resident #24 was not under therapy services at the time of the 2/19/24 and 2/25/24 falls and was not aware of them. She said nursing did not alert the Rehab Department of the falls or send referral requests for post-fall evaluations but should have. The RD said if a resident falls, nursing is supposed to send a referral for a falls screen, typically physical therapy (PT), and they would see the resident within 48 hours to determine the circumstances, what did they do, did they get hurt, and do they need services at that time. The RD further said the therapy department was not integrated with the facility's electronic record system so could not be alerted to orders or falls in that manner. On 3/19/24 at 7:50 A.M., the surveyor observed Resident #24 awake and lying sideways in the bed, with both feet on the ground. The Resident was not wearing non-skid socks or footwear. During an interview on 3/19/24 at 11:25 A.M., Nurse #13 said Resident #24 was at risk for falls and had had multiple falls since admission. She said there was no significant pattern of falls that she knew of, but the Resident did a lot of self-transferring, had poor safety awareness, and had a rib fracture. She said the Resident had some confusion and was taking high risk medications that could increase the risk of falls. She said a fall risk care plan was not initiated until 1/12/24 and new interventions were not identified or implemented after each fall to help reduce the Resident's fall risk. Post fall, Nurse #13 said the physician, patient's family/health care proxy, and DON should be notified and a rehab screen and falls packet completed after each fall. Nurse #13 said if interventions are unsuccessful and a resident continues to fall, they should be assessed for changes and additional interventions put in place. Nurse #13 said she had not received training or education for use of the fall risk tool, techniques to prevent falls, or transfer protocols regarding Resident #24 to help prevent further falls. She said it was just based off her own knowledge. During an interview on 3/19/24 at 1:09 P.M., with the DON and Consulting Staff #1, Consulting Staff #1 said there was no falls care plan in place, or a fall risk assessment completed prior to the Resident's first fall on 1/10/24 but should have been as that would have potentially identified the Resident as being a fall risk with the appropriate interventions in place. She said she could not locate any of the other fall's packets, but after each fall there should have been a fall risk evaluation completed that shift, the physician notified, rehab referral, and an investigation completed to determine what happened with the appropriate new interventions put into place immediately. Consulting Staff #1 said a care plan for falls and ADLs was not initiated until two days after the first fall and did not indicate an actual fall had occurred. She said new interventions were not added after each of the subsequent falls and, the interventions that were in place, were not effective to help prevent future falls and avoid injury. She said she wasn't aware there was a pattern to the falls in that all the falls were related to toileting. 48084 2. Resident #70 was admitted to the facility in April 2023 with diagnoses which included Alzheimer's disease, anemia, orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down), difficulty walking, syncope (fainting or sudden temporary loss of consciousness) and collapse, and a history of falls. Review of the MDS assessment, dated 12/19/23, indicated Resident #70 had a score of 3 out of 15 on the BIMS, indicating severe cognitive impairment, needed supervision/assistance with ADLs, was occasionally incontinent of urine, and had a history of falls. Review of Resident #70's medical record indicated he/she had sustained four falls between October 2023 and March 2024 (10/26/23, 10/27/23, 12/10/23, and 3/1/24). FALL #1 on 10/26/23: Review of the progress note, dated 10/26/23 at 6:41 P.M., indicated Resident #70 was alert and confused at baseline, Resident was noted on the floor with a small area to left side of temple. Additionally, the note indicated the Resident had received new glasses yesterday after not having them for a while. Nurse will monitor to ensure he/she is adjusting to having the glasses on again. Review of Incident Report, dated 10/26/23, indicated the nurse heard Resident #70 call out and upon entering the room, Resident was noted to be on the floor on his/her left side with a 1x1x0.1 centimeter (cm) cut to the left temple from his/her glasses. Additionally, a 3x3 cm bruise was noted to the left elbow. The Resident did not know how he/she fell , however stated he/she hit his/her back on the footboard of the roommate's bed. The Mental Status section indicated he/she had memory impairment. The notes section indicated Resident complained of discomfort related to the fall, no visible injuries, ice applied, MD notified, leg equal in length will continue to monitor. The Predisposing Environmental Factors section and the Predisposing Physiological Factors section were not completed. The Predisposing Situation Factors section had other checked off and the comment noted the Resident had new glasses. Review of the care plans for Resident #70 indicated but were not limited to the following: Review of the Fall Risk Care Plan for Resident #70 indicated: FOCUS: Resident #70 is at risk for falls related to deconditioning, history of fall secondary to syncope and collapse (4/11/23). GOAL: He/she will be free of falls through review date (4/11/23). INTERVENTIONS: -Be sure Resident #70's call light is within reach and encourage him/her to use it for assistance as needed. He/she needs prompt response to all requests for assistance (4/11/23) -Ensure Resident #70 is wearing appropriate footwear when ambulating or mobilizing in wheelchair (4/11/23). -Follow facility fall protocol. (4/11/23) -Physical Therapy evaluate and treat as ordered or as needed (4/11/23) The facility failed to update the Fall Risk care plan or initiate a new intervention to keep the Resident safe/prevent a repeat fall per facility policy and Fall Packet procedure guide. Review of the Activities of Daily Living (ADL) Care Plan prior to the fall on 10/26/23, indicated Resident #70 needed supervision with transfers, ambulation, and toileting. Review of the Vision Care plan for Resident #70, indicated the following: FOCUS: Resident #70 has impaired visual function related to age (8/12/23) GOAL: Resident #70 will show no decline in visual function through the review date (8/23/23) INTERVENTIONS: -Ensure appropriate visual aids (eyeglasses) are available to support his/her participation in activities (8/12/23) -Remind him/her to wear glasses when up. Ensure resident is wearing glasses which are clean, free from scratches, and in good repair. Report any damage to nurse/family. (8/12/23) There were no additional interventions on the vision care plan, current or historical. The facility failed to note the Resident had been without glasses for a while, had new glasses, or needed additional monitoring for adjustment to the new glasses status post fall. Review of the most recent Fall Risk Evaluation indicated an evaluation was done on 10/17/23 as part of the quarterly MDS schedule, and the total score was 9. The Fall Risk Evaluation determines the level of fall risk based on questions pertaining to current health status, recent fall history, ambulation status, blood pressure, vision, diagnosis/predisposing conditions, recent change in condition, and recent hospitalization . A score of 10 of greater would indicate HIGH risk for potential falls and prevention protocol should be initiated immediately and documented on the care plan. The facility failed to complete a Fall Risk Evaluation after the fall on 10/26/23 per policy. Further review of Resident #70's medical record, including progress notes, medication administration records (MAR), treatment administration records (TAR), and physician's orders failed to indicate any new intervention had been implemented to prevent additional falls/injury. FALL #2 on 10/27/23: Review of the progress note, dated 10/27/24 at 6:24 A.M., indicated at 4:15 A.M., staff heard a loud noise down the hall and found Resident #70 lying on the floor on his/her right side. Resident said he/she was coming out of the bathroom. The Resident was assisted back to bed and complained left hip was sore. Review of the Incident Report, dated 10/27/23, indicated staff heard a loud noise down the hall, and found Resident #70 lying on the floor in his/her room. The Resident said he/she was coming back from the bathroom. Resident #70 was wearing regular socks, not slipper socks and complained left hip was sore. The Mental Status section indicated he/she was memory impaired and decision making impaired. The notes section indicated the Resident had his/her walker with them. Predisposing Environmental Factor included poor lighting and adaptive equipment. Predisposing Physiological Factors included confusion, decreased safety awareness, impaired memory, and decreased strength and endurance. Predisposing Situation Factors included using a walker, side rails up, and improper footwear. Further review of the Complete Incident Report, dated 10/27/23, failed to include witness statements. Review of the Reportable Incident Folder indicated but was not limited to the following: -Date of Incident: 10/27/23 at 4:15 A.M. -There were three witness statements dated 10/26/23, all three staff members indicated they saw the resident ambulating prior to the fall the evening of 10/26/23. None of the statements indicated the staff had intervened or provided assistance/supervision. None of the statements indicated when the resident was last toileted. (One response was not sure and the other two were N/A (not applicable) to the question regarding when the resident was last toileted. The resident required supervision/assistance with toileting. -There were not any witness statements related to the fall on 10/27/23. The facility failed to provide supervision with transfers and ambulation on 10/26/23, resulting in the Resident falling in his/her room striking head, elbow, and back and failed ensure a new intervention had been implemented to prevent additional falls/injury, resulting in Resident #70 falling again, less than 12 hours later while ambulating in room and toileting self. The facility failed to update the Fall Risk care plan or initiate a new intervention to keep the resident safe/prevent a repeat fall per facility policy and Fall Packet procedure guide. Further review of Resident #70's medical record, including progress notes, and physician's orders failed to indicate any new intervention had been implemented to prevent additional falls. Review of the progress note, dated 10/27/23 at 11:51 A.M., indicated Resident #70 complained of increased pain to the left hip, had compromised circulation, sensation, and motion (CSM) to left lower extremity, had a bruise to left hip, and was grimacing in pain. An order was obtained to transfer Resident #70 to the emergency room for evaluation. Review of the Discharge Summary from the hospital, dated 10/30/23, indicated but was not limited to the following: -Resident #70 had a left displaced (the bones are not in alignment) femoral neck (hip) fracture. -Resident #70 underwent a left hip hemiarthroplasty (surgery to replace half of the hip joint with an artificial one). The facility failed to provide supervision with transfers, ambulation, and toileting, and failed to ensure Resident #70 had proper footwear on while ambulating, resulting in the Resident falling in his/her room and fracturing his/her hip. The facility failed to complete a Fall Risk Evaluation after the fall on 10/27/23 per policy. FALL #3 on 12/10/23: Review of the progress note, dated 12/10/23 at 3:59 A.M., indicated a loud noise was heard coming from the room. The Resident was observed on the bathroom floor with a hematoma to the right side of his/her head and a skin tear to the right arm. The resident was assisted from the floor and into the wheelchair and then transferred to the emergency room for further evaluation. There was no incident report completed for this fall on 12/10/23 per policy. Review of the most recent Fall Risk Evaluation indicated an evaluation was done on 10/30/23 as part of the Admission/Re-Admission MDS schedule, the total score was 12, indicating the Resident was a HIGH RISK for potential falls and prevention protocol should be initiated immediately and documented on the care plan. The facility failed to complete a Fall Risk Evaluation after the fall on 12/10/23 per policy. Review of the ADL Care Plan prior to the fall 12/10/23, indicated Resident #70 needed assistance with transfers, ambulation, toileting, and dressing. Review of the Fall Risk care plan failed to indicate it had been updated with a new intervention to prevent further falls/injury and an actual Fall care plan had not been initiated, per policy. Further review of Resident #70's medical record, including progress notes, and physician's orders failed to indicate any intervention had been implemented to prevent additional falls. The Resident was sent to the hospital on 12/10/23 for further evaluation after the fall with head strike, he/she was treated at the hospital and subseque[TRUNCATED]

Based on observations, interviews, record review, and policy review, the facility failed to monitor the nutritional status for two Residents (#2, #61) with an unplanned significant weight loss, out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #2, to continue to monitor the Resident's nutritional status after they experienced a severe significant weight loss of 12.66% in three months (11/21/23 to 2/3/24), resulting in a continued significant weight loss of 5.39% in one month (2/3/24 to 3/8/24) which the facility did not identify or address; and 2. For Resident #61, to continue to monitor the Resident's nutritional status after they experienced a severe significant weight loss of 6.95% in one month (10/21/23 to 11/21/23), resulting in a 10.54% severe significant weight loss in three months (10/21/23 to 1/25/24) and a 10.74% severe significant weight loss in three months (11/30/23 to 3/18/23) which the facility did not identify or address. Findings include: Review of the facility's policy titled Weight Assessment and Interventions, revised May 2019, included but was not limited to: - The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. - Monthly weights will be obtained each month or as ordered by physician. - Weights will be recorded in the medical record (electronic health record where available) for each resident. - Any weight change of five pounds (lbs) in a month or three pounds in a week since their last weight assessment should be retaken within 72 hours for confirmation and verified by Nursing. - Re-weigh should be reviewed by the Licensed Nurse. - Licensed Nurses should notify Dietician of identified weight change once reviewed. - Dietician notification should be documented within Resident's medical record. - Dietician or diet technician should respond within 72 hours of receipt of notification. - The threshold for significant unplanned and undesired weight change will be based on the following criteria: (a) one month: 5% weight change is significant, greater than 5% is severe; (b) three months: 7.5% weight change is significant; greater than 7.5% is severe; (c) six months: 10% weight change is significant; greater than 10% is severe. 1. Resident #2 was admitted to the facility in February 2021 with diagnoses including schizoaffective disorder and type II diabetes. Review of the Minimum Data Set (MDS) assessment, dated 1/24/24, indicated Resident #2 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Further review of Section K of the MDS assessment indicated Resident #2 had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Section K of the MDS assessment indicated Resident #2 was not on a prescribed weight loss regimen. Further review of the MDS assessment indicated Resident #2 required set-up assistance for meals. On 3/12/24 at 12:05 P.M., the surveyor observed Resident #2 eating his/her lunch meal in the dining room on the North Two Unit. Resident #2 was seated at a table with other residents and his/her meal was set-up by staff. Staff were observed to assist by cutting Resident #2's meal and opening drinks. Staff were not observed to provide any additional assistance with feeding to the Resident. The surveyor observed Resident #2 leaning to the right side in their wheelchair and gripping onto the table with both hands throughout the meal. The surveyor observed Resident #2 consume a few bites of his/her meal before fluctuating between sleeping and calling out to staff. On 3/13/24 at 12:12 P.M., the surveyor observed Resident #2 brought into the North Two Unit dining room for lunch. Resident #2 was positioned at a table with other residents and set up by staff members for the meal. Staff were observed to assist by cutting Resident #2's meal and opening drinks. Staff were not observed to provide any additional assistance with feeding to the Resident. The surveyor observed Resident #2 asleep throughout the meal. Staff members were observed to encourage the Resident to initiate eating by tapping him/her on the shoulder and saying, it is time to eat. Resident #2 was observed to be asleep without initiating feeding throughout the mealtime. The surveyor did not observe Resident #2 consume any food during the lunch meal. Review of Resident #2's active Physician's Orders included but were not limited to: - 11/20/23: DIET - Regular Texture, Thin Liquid Consistency, Consistent/Controlled Carbohydrate (CCHO) Diet - 2/21/24: House Diabetic Supplement - two four-ounce supplements per day - 2/26/24: Weekly Weight - weekly weight secondary to weight loss every day shift every seven days Review of Resident #2's Medication Administration Record (MAR) indicated a House Diabetic Supplement was provided to him/her twice daily from 2/21/24 through 3/17/24. Further review of the MAR indicated failed to indicate a percentage value of amount consumed on 15 out of 51 opportunities. Furthermore, the MAR indicated the Resident drank less than or equal to 50% of the house supplement provided on 23 of 51 opportunities. Review of Resident #2's weights in the electronic medical record indicated the following weights: - 09/2023: not obtained - 10/2023: not obtained - 11/21/23: 191.2 lbs. - 12/2023: not obtained - 01/23/24: 172.2 lbs. - 02/03/24: 167.0 lbs. - 02/26/24: not obtained - 03/04/24: not obtained - 03/08/24: 160.0 lbs. Review of Resident #2's weights indicated he/she had a 12.66% severe weight loss in three months. Further review of Resident #2's weights indicated a 5.39% significant weight loss in one month (2/3/24 and 3/8/24). A significant and/or severe weight loss value for six months was unable to be calculated due to failure of the facility to obtain a monthly weight value in 9/2023. Review of Resident #2's nutritional care plan failed to indicate he/she was at risk for nutritional decline. Interventions for Resident #2's nutritional care plan included but were not limited to: - Obtain weight per physician (MD) order on same scale. Notify MD/Nurse Practitioner (NP)/Registered Dietician (RD) of significant weight changes (revised 11/14/23). Review of Resident #2's Comprehensive Nutrition Assessment, dated 11/9/23, indicated his/her weight history was not stable. The RD recommended continued monthly weights and diet as ordered. No new interventions were recommended. Review of RD documentation failed to indicate any further assessment of Resident #2's weights until 2/12/24, three months after the Comprehensive Nutrition Assessment. Dietary progress note documentation, dated 2/12/24, indicated Resident #2 had a 12.7% significant weight loss over the past three months. The RD recommended the facility obtain a reweigh of Resident #2 prior to any further intervention changes. Further review of RD documentation on 2/21/24 indicated Resident #2 had triggered for significant weight loss of 12.7% over the past three months. The RD recommended Resident #2 to have weekly weights, sugar free house supplement (four ounces twice daily) and change to regular size portions (versus the previously recommended large portions). Further review of the RD documentation failed to indicate the RD identified the significant weight loss of 5.39% in one month (2/3/24 to 3/8/24). Review of nursing notes failed to indicate documentation related to Resident #2's weight loss. Nursing documentation failed to indicate refusal or inability to obtain weekly weights on 3/4/24 and 2/26/24, as well for monthly weights in 12/2023, 10/2023, and 9/2023. Nursing documentation failed to indicate the RD or MD were notified of weight loss. Review of MD/NP notes failed to indicate documentation related to Resident #2's significant weight loss. During an interview on 3/18/24 at 9:42 A.M., Nurse #4 said staff try to obtain weights for all residents on the unit on the first Monday of each new month. Nurse #4 said staff go down the list until each resident's weight is obtained. Nurse #4 said sometimes it takes a while for weights to be obtained. Nurse #4 said some residents have orders to be weighed weekly and those orders come over on a specific day. Nurse #4 said residents with monthly weights do not necessarily have orders to be weighed on a specific day. Nurse #4 said monthly weights do not come up on the Medication Administration Record (MAR) for a specific date to obtain. During an interview on 3/18/24 at 10:20 A.M., Unit Manager (UM) #1 said weights are obtained monthly for most residents on the unit. UM #1 said weights should have a standard order to be obtained and the order would generate a date and shift to be inputted. UM #1 said refusal of weights should be documented in the medical record. During an interview on 3/18/24 at 1:58 P.M., Nurse #4 said when weights are input into the electronic medical record they populate red for a significant change. Nurse #4 said Resident #2 did populate on her MAR to obtain a weekly weight. Nurse #4 said she was unsure of weekly weights being obtained by other nursing staff. Nurse #4 said the Dietitian would notify the MD directly of any new recommendations or changes. During an interview on 3/18/24 at 3:13 P.M., UM #1 said she and the RD should be reviewing weights of all residents on the unit. UM #1 said she was uncertain if Resident #2's MD was aware of their significant weight loss. UM #1 said she would be responsible for notifying the MD of changes in weight. UM #1 said staff should be notifying the MD of changes in weight to ensure the interdisciplinary team are aware. UM #1 said Resident #2 should not have any missing weekly or monthly weights. During an interview on 3/18/24 at 4:09 P.M., the RD said she reviews weights for significant weight loss when they are obtained by staff at the facility. The RD said she then determines an individualized plan for each resident to address the weight loss. The RD said she pulls a weight report for each resident when reviewing their documentation. The RD said she typically pulls a weight report to review resident trends in weight loss. The RD said if weights are not obtained in greater than or equal to 30 days, the resident would not populate on the weight report. The RD said she does her best to compare weight reports monthly to not miss any resident weights. The RD said because weights are missing, she is patching together assessments. The RD said the goal is to review each resident in the facility quarterly, or more often if a significant weight loss is identified. The RD said she was behind on quarterly assessments. The RD said Resident #2 has had a continued significant weight loss. The RD said she notifies nursing staff of recommendations to notify the MD. The RD said she does not notify the MD of significant weight loss or recommendations herself. During an interview on 3/18/24 at 4:27 P.M., the Director of Nurses (DON) said her expectation would be for the RD to identify a significant weight loss for any residents in the building. The DON said she would then expect the RD to make any recommendations to address the significant weight loss. The DON said she would expect the nursing staff and/or the RD to notify the MD regarding the changes identified. The DON said the UM should be looking at changes to identify risk factors for residents on each unit. 2. Resident #61 was admitted to the facility in December 2021 with diagnoses including hypertension, atrial fibrillation (abnormal heart rhythm), and cerebral infarction (stroke). Review of the MDS assessment, dated 2/21/24, specified a BIMS score of 14 out of 15, indicating he/she had intact cognition. Further review of Section K of the MDS assessment indicated Resident #61 had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Section K of the MDS assessment indicated Resident #61 was not on a prescribed weight loss regimen. The MDS assessment indicated Resident #61 had a mechanically altered diet and he/she required set-up feeding assistance. On 3/13/24 at 12:15 P.M., the surveyor observed Resident #61 in their room. Resident #61 said he/she did not want their lunch meal today. The surveyor did not observe as meal tray in Resident #61's room. Review of Resident #61's active Physician's Orders included but were not limited to: - 11/20/23: DIET - Regular Diet; Mechanical Soft Chopped Meat Texture; Thin Liquid Consistency - 6/6/23: REC - Aspiration Precautions; seated upright with head of bed (HOB) Raised for meals and for at least 45-60 minutes after meals; slow rate of intake; small bolus size; alternate solids and liquids - 3/5/24: House Supplement - three times per day for nutritional supplementation; eight ounces; prefers chocolate Ensure or clear supplement Further review of Resident #61's active Physician's Orders failed to include an order for monthly weights to be obtained. Review of Resident #61's Medication Administration Record (MAR) indicated a House Supplement was provided to him/her three times per day from 3/6/24 through 3/17/24. Further review of the MAR indicated the facility failed to document the percentage value consumed by Resident #61 as follows: - 3/6/24: 8:00 A.M. - 10:00 A.M. - 3/6/24: 12:00 P.M. - 2:00 P.M. - 3/6/24: 4:00 P.M. - 8:00 P.M. - 3/7/24: 8:00 A.M. - 10:00 A.M. - 3/7/24: 12:00 P.M. - 2:00 P.M. - 3/14/24: 12:00 P.M. - 2:00 P.M. Further review of the MAR indicated the Resident drank less than or equal to 50% of the house supplement provided on 10 of 36 opportunities. Review of Resident #61's weights in the electronic documentation system indicated the following weights: - 9/2023: not obtained - 10/21/23: 178.4 lbs. - 11/21/23: 166.0 lbs. - 11/30/23: 169.4 lbs. - 12/2023: not obtained - 1/25/24: 159.6 lbs. - 2/2024: not obtained - 3/18/24: 151.2 lbs. Review showed Resident #61 had a 6.95% severe significant weight loss in one month (10/21/23 to 11/21/23). Further review showed two additional severe significant weight losses in a three-month period between 10/21/23 through 1/25/24 (10.54%) and 11/30/23 through 3/18/24 (10.74%). Review of Resident #61's nutritional care plan indicated he/she was presenting with an undesired weight loss and further weight loss is not desired. Interventions for Resident #61's nutritional care plan included but were not limited to: - Obtain weight per physician (MD) order on same scale. Notify MD/Nurse Practitioner (NP)/Registered Dietician (RD) of significant weight changes (revised 10/5/23). Review of Resident #61's Comprehensive Nutrition Assessment, dated 11/30/23, indicated his/her weight history was not stable, and a significant weight loss was identified. The assessment indicated to continue with current diet as ordered, use of house supplements, and monitoring of intakes and weights. Review of a Dietary progress note, dated 1/26/24, indicated review of the Speech Therapy diet texture to meet house formulary diets. No indication of continued weight loss was addressed in the documentation. Further review of the Dietary progress notes failed to indicate the RD identified the Resident's 10.54% (10/21/23 to 1/25/24) and 10.74% (11/30/23 to 3/18/24) severe significant weight loss over three months and considered interventions to curb further weight loss. Review of nursing progress notes failed to indicate documentation related to Resident #61's weight loss. Nursing progress note documentation failed to indicate refusal or inability to obtain monthly weights in 2/2024, 12/2023, and 9/2023. Furthermore, nursing progress note documentation failed to indicate the RD or MD were notified of the severe significant weight loss. Review of MD/NP progress note documentation, dated 3/5/24, indicated the Resident was seen for family concerns related to weight loss and poor appetite. Further review of the documentation indicated Resident #61's weight was down. Documentation indicated Resident #61 may benefit from house supplement shakes three times per day. Further review of MD/NP progress note documentation indicated no weight changes addressed in reports dated 2/8/24, 2/6/24, 1/18/24, 1/2/24, and 11/30/23. During an interview on 3/12/24 at 11:11 A.M., Resident #61 said they prefer to eat their meals in their room. Resident #61 said they do not require assistance with meals. Resident #61 said they did not want breakfast this morning and did not eat. During an interview on 3/18/24 at 9:42 A.M., Nurse #4 said staff try to obtain weights for all residents on the unit on the first Monday of each new month. Nurse #4 said staff go down the list until each resident's weight is obtained. Nurse #4 said sometimes it takes a while for weights to be obtained. Nurse #4 said some residents have orders to be weighed weekly and those orders come over on a specific day. Nurse #4 said residents with monthly weights do not necessarily have orders to be weighed on a specific day. Nurse #4 said monthly weights do not come up on the Medication Administration Record (MAR) for a specific date to obtain. Nurse #4 said Resident #61 was on the list to obtain a weight today. Nurse #4 and the surveyor reviewed the most recent weights for Resident #61. Nurse #4 said she thought Resident #61 had been weighed in February but could not find the documentation. During an interview on 3/18/24 at 10:20 A.M., Unit Manager (UM) #1 said weights are obtained monthly for most residents on the unit. UM #1 said weights should have a standard order to be obtained and the order would generate a date and shift to be inputted. UM #1 said refusal of weights should be documented in the medical record. During an interview on 3/18/24 at 1:58 P.M., Nurse #4 said when weights are input into the electronic medical record they populate red for a significant change. Nurse #4 said the Dietitian would notify the MD directly of any new recommendations or changes. During an interview on 3/18/24 at 3:25 P.M., UM #1 said she and the RD should be reviewing weights of all residents on the unit. UM #1 said she was uncertain if Resident #61's MD was aware of their significant weight loss. UM #1 said she would be responsible for notifying the MD of changes in weight. UM #1 said staff should be notifying the MD of changes in weight to ensure the interdisciplinary team are on the same page. UM #1 and the surveyor reviewed the active physician orders for Resident #61. UM #1 said she could not see any weight orders for the Resident. UM #1 said Resident #61 should not have had any missing monthly weights. During an interview on 3/18/24 at 4:09 P.M., the RD said she reviews weights for significant weight loss when they are obtained by staff at the facility. The RD said she then determines an individualized plan for each resident to address the weight loss. The RD said she pulls a weight report for each resident when reviewing their documentation. The RD said she typically pulls a weight report to review resident trends in weight loss. The RD said if weights are not obtained in greater than or equal to 30 days, the resident would not populate on the weight report. The RD said she does her best to compare weight reports monthly to not miss any resident weights. The RD said because weights are missing, she is patching together assessments. The RD said the goal is to review each resident in the facility quarterly, or more often if a significant weight loss is identified. The RD said she was behind on quarterly assessments. The RD said Resident #61 has had a continued significant weight loss and it needed to be addressed. The RD said she notifies nursing staff of recommendations to notify the MD. The RD said she does not notify the MD of significant weight loss or recommendations herself. During an interview on 3/18/24 at 4:27 P.M., the Director of Nurses (DON) said her expectation would be for the RD to identify a significant weight loss for any residents in the building. The DON said she would then expect the RD to make any recommendations to address the significant weight loss. The DON said she would expect the nursing staff and/or the RD to notify the MD regarding the changes identified. The DON said the UM should be looking at changes to identify risk factors for residents on each unit.

Based on observations, interview, policy review, and record review, the facility failed for nine Residents (#24, #226, #49, #14, #26, #58, #94, #44, and #114), out of a total sample of 24 residents, to develop and implement individualized person-centered care plans to meet the resident's physical, psychosocial and functional needs. Specifically, the facility failed: 1a. For Resident #24, to develop and implement a care plan that identified risk factors as well as interventions designed to reduce or prevent the development of pressure related ulcers/injuries upon which the Resident developed a facility acquired full thickness unstageable (actual depth of ulcer is completely obscured by slough and/or eschar in the wound bed) left heel ulcer; and b. to develop and implement a care plan that identified risk factors as well as interventions designed to help prevent incidents/accidents upon which the Resident who had six total falls, one of which resulted in an acute left-sided 7th rib fracture, healing 5th and 6th rib fractures, and a closed head injury; 2a. For Resident #226, to develop and implement a care plan to help prevent incidents/accidents; and b. to develop and implement a care plan to address the Resident's physical, psychosocial, and functional needs while receiving dialysis services; 3. For Resident #49, to develop a care plan for activities; 4. For Resident #14, to implement a care plan intervention of continual supervision during meals for the Resident's high risk for aspiration (the drawing of food or fluid into the lungs while eating); 5. For Resident #26, to develop a person-centered care plan for the use and care of a splint device to help prevent the worsening of a left hand contracture; 6a. For Resident #58, to develop and implement a person-centered care plan to ensure the use of physician ordered Geri-sleeves to help protect the Resident from skin tears on his/her bilateral arms, and b. to ensure the Resident was engaged in leisurely activities to help enhance his/her quality of life and had an individualized care plan indicating what types of leisurely pursuits the Resident may enjoy within their cognitive abilities; 7. For Resident #94, to implement the activities person-centered care plan; 8. For Resident #44, to develop and implement an individualized care plan for this Resident who would take their bedroom furniture apart; and 9. For Resident #114, to develop a care plan for activities. Findings include: Review of the facility's policy titled Care Plans Comprehensive, dated as revised 10/2022, indicated but was not limited to the following: -a comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -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 will: describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; include resident preferences and goals; incorporate identified problem areas and risk factors; reflect the resident's expressed wishes regarding care and treatment; aid in preventing or reducing the decline in the resident's functional status; enhance the optimal function of the resident; reflect currently recognized standards of practice for problem areas and conditions -identify problem areas and their causes and develop interventions that are targeted and meaningful 1. Resident #24 was admitted to the facility in December 2023 with diagnoses including encephalopathy (any brain disease that alters brain function or structure), diabetes mellitus type 2, seizures, unsteadiness on feet, and lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 12/28/23, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was at risk for developing pressure ulcers, and had no unhealed pressure ulcers. The MDS also indicated the Resident was frequently incontinent of urine, was a substantial/maximum assist for toileting. The MDS failed to indicate an admission fall history was determined. a. Review of the medical record for Resident #24 failed to indicate a comprehensive care plan was developed on admission for the prevention of skin breakdown and pressure injuries despite the MDS indicating the Resident was at risk for developing pressure injuries. Review of the Admission Physician's Progress Note, dated 12/23/23, indicated the Resident's skin was warm and dry and had chronic lower extremity edema versus lymphedema. There was no mention of an alteration in skin integrity. Review of a nursing Skilled Evaluation note, dated 1/5/24, indicated the Resident's skin was warm and dry, skin color within normal limits and turgor was normal. There was no mention of an alteration in skin integrity to the Resident's left heel. Review of a Physician's Progress Note, dated 1/8/24, indicated Resident #24 reported left heel pain. His/Her extremities were edematous and swollen and a left heel blister was noted with some darkened fluid as if there was mild bleeding within; no erythema or induration to suggest infection. Review of the medical record indicated a Norton Scale for Predicting Risk of Pressure Ulcer assessment was completed on 1/12/24, three days after the identification of a left heel blister and three weeks after admission, indicating Resident #24 was at high risk for developing pressure injuries. Review of the medical record indicated a care plan was developed on 1/12/24 for an alteration in skin integrity, three days after the left heel blister was identified. Interventions included but were not limited to weekly skin checks, follow MD orders for skin care and treatments, heels off-loaded when in bed, inspect feet daily with care and moisturizer, and pressure ulcer risk assessment weekly x 4 upon admission then quarterly and with change in condition. Review of the medical record indicated a Clinical Admission note was completed as a late entry on 1/24/24, 33 days after admission. The progress note indicated Resident #24 had a left heel diabetic foot ulcer with slough present in the wound bed, purulent wound exudate, fragile skin peri wound, minimal dressing saturation, boggy skin, pain, and was receiving daily wound treatments. Resident #24 was referred to the Wound Physician for evaluation. Review of the Initial Wound Evaluation and Management Summary for Resident #24, dated 1/25/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound was a new injury, >11 days in duration, measured 4.3 x 2.5 x 0.1 centimeters (cm) and was a pressure wound. Recommendations included: Primary Dressing - normal saline wash apply once daily for 30 days, Iodosorb gel, apply once daily for 30 days Secondary Dressing - abdominal pad apply once daily for 30 days, gauze roll (stretch) 4 apply once daily for 30 days, tape (waterproof adhesive) apply once daily for 30 days -Peri-wound Treatment - skin prep apply once daily for 30 days Plan of Care Recommendations - elevate legs, float heels in bed, off-load wound, reposition per facility protocol, pillows, booties Review of Resident #24's care plan indicated the recommended intervention for booties was not implemented until 2/6/24, 12 days after the wound doctor assessed the Resident. During an interview on 3/14/24 at 10:42 A.M., the surveyor observed Resident #24 lying in bed. The Resident did not have a foam bootie on his/her left foot as recommended by the wound doctor. He/she said the last time it was applied was maybe last week, but lately never. The Resident said he/she started with a blister on his/her left heel which had gotten worse since then, hurt more, and felt like it was infected. During an interview on 3/14/24 at 3:18 P.M., Nurse #9 said Resident #24 was at risk for developing pressures and had a stage 2 pressure ulcer on his/her left heel. On 3/18/24 at 11:20 A.M., the surveyor observed Resident #24 lying in bed. The Resident's heels were not elevated off the mattress and a foam bootie was not observed on the Resident's left heel in accordance with the Resident's plan of care. During an interview on 3/19/24 at 10:26 A.M., Nurse #13 said Resident #24 was at risk for developing pressures, had pressure sites on his/her feet, and had basic bootie and heel protection orders. She said the 1/25/24 wound note indicated an unstageable pressure wound of the left heel that was new and > 11 days old. She said a new treatment was recommended on that visit and subsequent visits for a normal saline wash and Iodosorb dressing daily along with to float the Resident's heels while in bed, elevate the legs, and use pillows and booties, but the order was not entered until 3/14/24. She said there was no admission skin evaluation, no Braden risk assessment (Norton Scale) completed until 1/12/24, and a care plan for skin integrity was not developed or implemented until 1/12/24. She said interventions and treatments should have been implemented consistently to improve skin and to prevent/avoid any pressure related injuries. During an interview on 3/19/24 at 1:35 P.M., the surveyor reviewed the medical record with the Director of Nurses (DON) and Consulting Staff #1. Consulting Staff #1 said the Resident was not admitted with a left heel wound. She said physician's notes dated 12/23/23 (admission note) did not mention anything about the Resident's heels until the 1/9/24 note. She said the first skin evaluation was not conducted until 1/24/24 but should have been done upon admission and weekly. Consulting Staff #1 said the initial wound note on 1/25/24 indicated the left heel was a new pressure wound. Consulting Staff #1 said there was no care plan in place for skin integrity until 1/12/24 and care planned interventions should be reviewed and revised quarterly and with any changes. b. During an interview on 3/14/24 at 10:42 A.M., Resident #24 said he/she had had three falls in the last month and a half and said, I get dizzy when I stand up. The Resident said his/her legs were weak and unsteady. The Resident said he/she gets up on his/her own to go to the bathroom and loses his/her balance and does hit the call bell, but they don't come in time. Resident #24 said he/she currently had a broken rib with a 3 out of 10 (10 being the worst) pain every time I breathe and was taking Oxycodone for pain. Review of the medical record failed to indicate a comprehensive fall care plan was developed on admission to the facility and implemented for the prevention of falls and injury. Review of the medical record indicated Resident #24 had an unwitnessed fall on 1/10/24 at 11:15 P.M. and was found sitting on the floor in the bathroom with his/her walker at his/her back. The Resident stated he/she went into the bathroom to urinate, was washing his/her hands and lost balance and stumbled to the floor. The Resident complained of left arm pain and right rib pain and requested to be transferred to the emergency department (ED) for evaluation (no acute findings). Review of the fall incident reported indicated predisposing factors included weakness, decreased safety awareness, impaired memory, and decreased strength/endurance. No injuries were observed by staff. Review of the medical record indicated an Admission Fall Risk Evaluation was not completed until 1/12/24, three weeks after the admitted and two days after the first fall was sustained, which indicated Resident #24 was at high risk for potential falls. The evaluation indicated prevention protocol should be initiated immediately and documented on the care plan. Further review of the medical record failed to indicate the interdisciplinary team (IDT) had identified and implemented appropriate interventions to help reduce the risk of falls or injuries upon admission until 1/12/24, two days after the first fall. Resident #24's comprehensive care plan initiated on 1/12/24 indicated he/she was at moderate risk for falls related to deconditioning, incontinence and medication use. A goal was developed to not sustain serious injury and included (but not limited to) interventions to be sure the call light is within reach and prompt response to all requests, ensuring appropriate footwear is in place when ambulating, physical therapy as needed and ensuring a safe environment with floors free from spills and/or clutter; adequate light and a working call light within reach. Further review of the medical record indicated Resident #24 had an unwitnessed fall on 1/13/24 at 11:27 A.M., and was found sitting on his/her bottom with his/her back to the bathroom wall. The Resident stated he/she was toileted by an aide and when finished, he/she got up to get back into bed and lost his/her balance and fell . No injuries were observed pre- or post-incident. Predisposing factors included confusion and gait imbalance. Review of the care plans failed to indicate new interventions were implemented to help keep the Resident safe and prevent a repeat fall. Review of the medical record indicated Resident #24 had a third unwitnessed fall on 1/21/24 at 1:00 P.M. and was found sitting on the floor next to the room door and bathroom door. The call light was placed by the roommate. The Resident had complaints of arm pain and said he/she had tendonitis. Weakness was noted to the bilateral lower extremities (HX of CVA). No injuries were observed. The Resident was noted to have some confusion stating he/she was going to the bathroom. The Resident is a total assist at baseline. Predisposing factors identified included confusion, weakness, decreased safety awareness, and decreased strength. A new Risk for Falls care plan was initiated on 1/21/24 and included interventions such as to assist the resident with ambulation and transfers utilizing therapy recommendations, educate the resident on maintaining a safe environment, ensure call light is available, and if a fall occurs alert the provider and initiate frequent neuros and bleeding eval per facility protocol. There were no goals listed. Further review of the medical record indicated Resident #24 had another unwitnessed fall on 2/19/24 at 5:00 A.M. and was found sitting on his/her bottom on the floor at the bedside. The Resident stated he/she had just finished using the urinal and his/her feet slid out from under him/her. The Resident complained of a sore left arm and bottom after landing on them. No injuries were observed. Predisposing factors included poor lighting, gait imbalance, and decreased strength. Review of the care plans failed to indicate new interventions were implemented to help keep the Resident safe and prevent a repeat fall. The medical record further indicated Resident #24 had a second unwitnessed fall on 2/19/24 at 10:23 P.M. and was found sitting on the floor in the bathroom. The Resident stated he/she was toileting self with walker and lost his/her foot grip with non-skid slipper socks on and fell to the floor. The Resident complained of left rib cage and left arm/elbow pain with limited range of motion to the left upper extremity. The Resident refused ED transport. A stat x-ray was ordered for the left rib cage and left upper extremity. No injuries were observed at the time of the incident. Predisposing factors included trip hazard, impulsiveness, and ambulating without assist. Review of the care plans failed to indicate new interventions were implemented to help keep the Resident safe and prevent a repeat fall. Review of the medical record indicated Resident #24 had an unwitnessed fall on 2/25/24 at 11:51 P.M and was found on the floor in the room next to his/her bed. The Resident stated, I fell and hit my head really hard and it's hurting. No injuries were observed at the time of the incident. The Resident was transported to the ED for evaluation. Predisposing factors included gait imbalance and decreased strength and that the incident occurred during unassisted self-transfer from the bed and ambulating independently. Review of the ED report, dated 2/26/24 at 12:18 A.M., indicated but was not limited to the following: -The Resident has a history of prior strokes with left-sided weakness and was status post an unwitnessed fall at the rehab center going to the bathroom, lost his/her balance and fell back. Resident reported striking his/her head and brief loss of consciousness. He/she stated he/she was unable to get up off the ground and was found approximately 10 minutes later. Complaints of right shoulder pain, headache, and neck pain. ED diagnoses included healing fractures of the left 5th and 6th ribs, an acute fracture in the left 7th rib, and a closed head injury. The Resident was discharged back to the facility at 3:17 A.M. Review of the care plans failed to indicate new interventions were implemented to help keep the Resident safe and prevent a repeat fall. On 3/19/24 at 7:50 A.M., the surveyor observed Resident #24 awake and lying sideways in the bed, with both feet on the ground. The Resident was not wearing non-skid socks or footwear. During an interview on 3/19/24 at 11:25 A.M., Nurse #13 said Resident #24 was at risk for falls and had had multiple falls since admission. She said a fall risk care plan was not initiated until 1/12/24 and new interventions were not identified or implemented after each fall to help reduce the Resident's fall risk. Nurse #13 said if interventions are unsuccessful and a resident continues to fall, they should be assessed for changes and additional interventions put in place. During an interview on 3/19/24 at 1:09 P.M., with the DON and Consulting Staff #1, the DON said she was new to the facility with a start date of 3/4/24 and referred questions to Consulting Staff #1. Consulting Staff #1 said there was no falls care plan in place, or a fall risk assessment completed prior to the Resident's first fall on 1/10/24 but should have been as that would have potentially identified the Resident as being a fall risk with the appropriate interventions in place. Consulting Staff #1 said a care plan for falls and ADLs was not initiated until two days after the first fall and did not indicate an actual fall had occurred. She said new interventions were not added after each of the subsequent falls and, the interventions that were in place, were not effective to help prevent future falls and avoid injury. 2. Resident #226 was admitted to the facility in February 2024 with diagnoses including fracture of right neck of femur, reduced mobility, dependence on renal dialysis, symptoms and signs involving cognitive functions and awareness, difficulty in walking, muscle wasting and atrophy, and end stage renal disease. Review of the MDS assessment, dated 2/24/24, indicated Resident #226 had moderate cognitive impairment as evidence by a BIMS score of 11 out of 15, required dialysis, used a walker, car transfer in/out of car or van was not attempted due to safety or medical concerns, walking 10 feet and 50 feet required supervision or touch assist, and walking 150 feet was not attempted. a. Review of the Patient Care Referral Form, dated 2/18/24, indicated Resident #226 presented to the ED on 1/26/24 after a mechanical fall at home. The Resident sustained a right femoral subcapital fracture (occurs in the neck of the thighbone) and underwent hemiarthroplasty (partial hip replacement) on 1/27/24. He/she was transferred to a short-term rehab facility on 2/2/24 through 2/18/24. The Resident's family was unable to provide the level of assistance needed for safe discharge home and ongoing rehab was recommended. The Resident was then transferred to the current nursing facility to continue to receive therapy services. Review of the medical record failed to indicate an Admission Fall Risk Evaluation had been completed to determine the Resident's history of falls and risk factors to help prevent subsequent falls. Further review of the medical record failed to indicate the interdisciplinary team (IDT) had identified and implemented appropriate care planned interventions to help reduce the risk of falls or injuries and the level of assistance required for activities of daily living (ADLs) per facility policy. During an interview on 3/14/24 at 8:17 A.M., Nurse #6 said Resident #226 was arranged to take a bus to and from dialysis, but the bus driver yesterday just dropped him/her off and did not wheel him/her in like they usually do. Nurse #6 and Nurse #10 said they both saw the resident just walking in to the facility's main lobby. During an interview on 3/19/24 at 9:10 A.M., the surveyor reviewed the medical record with Nurse #6 who said the Resident did not have a comprehensive, person-centered care plan that included risk factors for identified problem areas such as PT/rehab status post hip surgery, ADLs, and fall risk interventions to ensure the Resident's safety and maintain hip precautions. Nurse #6 said an admission Fall Risk Evaluation was not done. She said last week the Resident went to dialysis then she saw him/her in the lobby walking independently with a walker, I guess the driver just dropped him/her off, there was no one with him/her. During an interview on 3/19/24 at 12:44 P.M., with the DON and Consulting Staff #1, Consulting Staff #1 said the Resident should not have been ambulating independently and nursing staff should be aware of any precautions in place and the Resident's ambulatory status. She further said the Resident's care plan was not comprehensive for ADLs, PT/OT/rehab, and fall risk, and there was no fall risk evaluation completed upon admission but should have been. b. Review of current Physician's Orders indicated the following: -Resident to attend dialysis 3 times a week on Monday, Wednesday, and Friday. Pick up time at 10:30 A.M., by Cape Cod Regional Transit Authority (CCRTA) bus for a chair time of 12:00 P.M. - 5:00 P.M. for dialysis, 2/19/24 During an interview on 3/12/24 at 10:53 A.M., Resident #226 said he/she goes to dialysis on Mondays, Wednesdays, and Fridays and had a left arteriovenous (AV) fistula (irregular connection between an artery and a vein used for dialysis). Review of the medical record failed to indicate a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented with problem areas such as dialysis identified with targeted interventions added. During an interview on 3/19/24 at 9:16 A.M., the surveyor reviewed the medical record with Nurse #6 who said the Resident was receiving dialysis services but did not have a care plan in place for it or targeted interventions. During an interview on 3/19/24 at 12:44 P.M., Consulting Staff #1 said the Resident did not have a comprehensive care plan that included dialysis but should have. 3. Resident #49 was admitted to the facility in November 2023 with diagnoses including schizoaffective disorder, bipolar type, dementia, and anxiety disorder. Review of the MDS assessment, dated 1/1/24, indicated Resident #49 had moderate cognitive impairment as evidenced by a BIMS score of 12 out of 15. Review of current Physician's Orders indicated the following: -May participate in activities (as tolerated) not in conflict with medical care plan, 1/17/23 During an interview on 3/18/24 at 8:01 A.M., the surveyor observed Resident #49 sitting alone in the main lobby listening to music. The Resident said he/she liked to participate in activities but no one from the activities staff had met with him/her about it to discuss his/her preferences. The Resident said he/she wished there was more art as he/she liked to do that. Review of the Resident's medical record for Resident #49 failed to indicate an activities care plan had been developed for the Resident who liked to listen to music and participate in art activities. During an interview on 3/19/24 at 12:35 P.M., Consulting Staff #1 said Resident #49 had not had an activities assessment completed since admission and there was no care plan for it. 43935 4. Resident #14 was admitted to the facility in September 2018 and has the following diagnoses: Parkinson's disease, Diabetes mellitus type 2 and gastro-esophageal reflux disease (a condition in which stomach contents move up into the esophagus). Review of the most recent BIMS for Resident #14 indicated he/she was moderately cognitively impaired with a score of 11 out of 15 and his/her healthcare proxy (HCP) was invoked. During a telephone interview on 3/12/24 at 12:38 P.M., Family Member #3 said he doesn't get to come by much but there are issues with the Resident eating meals and another family member comes to the facility weekly to make sure the Resident gets the help he/she needs since the facility does not help him. During a telephone interview on 3/21/24 at 2:31 P.M., Family Member #4 said he specifically comes to visit Resident #14 at least weekly at meal time to help the Resident consume his/her meal. He said most of the time the Resident struggles to get the food from the spoon to his/her mouth and more than half the meal usually ends up on the Resident's lap or table and causes the Resident frustration. He said he doesn't know if the facility staff don't have the time or if the Resident is ineligible for assistance at meals, but the Resident grew up with his/her entire family running a restaurant business and food brings him/her lots of joy. He said he would be grateful if the facility would provide the Resident with more assistance during meals because he/she loves to eat and the entire experience of having a meal. He said he comes in to assist the Resident, who needs to be reminded not to rush because he/she is a choking risk and gets pneumonia. He said the Resident is not always capable of completing the task of eating independently and they leave the Resident alone to do so and that is his only concern. Review of the current care plans for Resident #14 indicated, but were not limited to the following: Focus: Resident has a self care deficit secondary to limited physical mobility related to Parkinson's disease and impaired vision (revised: 5/31/22) Goal: Resident will safely perform to maximum ability with self care activities through target date (revised: 3/12/4) Interventions: Eating: Continual supervision; aspiration risk (revised: 1/22/24) The surveyor made the following observations and had the following interactions with Resident #14: - 3/12/24 at 8:39 A.M., Resident in bed with breakfast in front of him/her. Resident was using a weighted spoon and attempting to eat his/her puree pancakes. The spoon was half empty or empty once the Resident got the food to his/her mouth landing on the Resident's shirt and overbed table. Resident #14 said, I'm doing poorly, I can't get this, and continued to attempt to scoop a spoon of scrambled egg into his/her mouth, but the food was dropping off the spoon and the Resident placed an empty spoon into their mouth. There was no staff in the room providing supervision or assistance to the Resident. - 3/12/24 at 8:49 A.M., Resident attempting to eat breakfast with the weighted spoon. Resident got approximately a half spoon full of egg into his/her mouth and said, Got some. Egg and pancake were observed on the Resident's clothing and table. There was no staff in the room providing continual supervision or assisting the Resident. - 3/12/24 at 8:53 A.M., Resident eating egg and pancake mixture with weighted spoon, but the Resident's hands were shaking hands as he/she attempted to scoop them into his/her mouth. There were no staff in the room providing supervision or assistance, Resident #14 said: I need help, I can't get it all. - 3/12/24 at 12:23 P.M., Sitting in high back wheelchair in his/her room leaning slightly forward to the right. Lunch was in front of the Resident and he/she appeared to be struggling while attempting to scoop ground meat with tomato sauce on it into his/her mouth with the weighted spoon. The Resident said, It's a bit hard. There were no staff members providing supervision or assistance to the Resident. The surveyor observed three Certified nurse assistants (CNA) standing at the opposite end of the hall socializing. - 3/12/24 at 12:36 P.M., CNA #8 entered Resident #14's room and asked the Resident if he/she was done eating lunch. The Resident replied, I'm hungry still and the CNA replied, Ok, well go ahead and eat then and left the room without providing the Resident any assistance or supervision. Only about 25% of the lunch meal was observed to be missing from the lunch tray at this time. - 3/12/24 at 12:47 P.M., CNA #8 re-entered Resident #14's room and asked if the Resident was still eating or if she could take the lunch tray. The Resident replied: ok can I just have a little something and the CNA offered the Resident a pudding dessert and milk. CNA #8 said the Resident ate about 50% of his/her meal. Food was observed on the Resident's lap. She did not remain with the Resident while he/she consumed their pudding and milk. - 3/13/24 at 8:03 A.M., CNA #7 repositioned Resident #14 in his/her bed and provided him/her their breakfast tray. The tray consisted of scrambled eggs and moist puree appearing pancakes and the Resident was left alone to consume it. CNA #7 did not stay in the room to provide the Resident with supervision or assistance if needed. - 3/13/24 at 8:20 A.M., Resident was struggling to use the weighted spoon to bring a scoop of eggs to his/her mouth. Food was falling off the spoon as it made its way to the Resident's mouth. There were no staff in the room providing supervision to the Resident. - 3/13/24 at 8:49 A.M., Resident observed to have eggs on their lap/clothing. There was no staff in the room to supervise or assist the Resident. Resident #14 said, I'm trying to get more and thank you for checking on me. - 3/13/24 at 12:23 P.M., Sitting up in the bed with lunch meal in front of him/her and the weighted spoon in his/her right hand. The Resident was attempting to scoop a spoonful of ground meat with tomato sauce into his/her mouth and some food was falling off the spoon as he/she reached their mouth landing on his/her lap. The Resident said, I'm having a problem and was observed to be having difficulty consuming their meal. There were no staff in the room providing supervision. -3/14/23 at 8:30 A.M., Sitting in bed, using the weighted spoon to bring scrambled egg to his/her mouth with shaking hands. The Resident was observed to cough following a full spoon of eggs making it into his/her mouth. A second attempt of bringing a scoop of egg to his/her mouth resulted in egg being spilled on the Resident's chest. There was no staff in the room to supervise the Resident. 3/14/24 at 12:24 P.M., Sitting in high back wheelchair in his/her room consuming his/her lunch. There were no staff in the room providing supervision to the Resident. 3/15/24 at 8:39 A.M., Sitting in bed attempting to eat scrambled eggs with a weighted spoon, there is egg observed on the Resident's chest, there are no staff in the room supervising the Resident. Review of the medical record for Resident #14 indicated a Speech Language Pathology (SLP) skilled therapy discharge summary dated: 9/6/23, that indicated, but was limited to the following information: - Resident is at elevated risk for aspiration with all by mouth (PO); Resident is receptive to cues for small bites, slow rate of intake. - Resident requires supervision or assistance at meal time due to safe swallowing 76 - 90% of the time During an interview on 3/13/24 at 1:52 P.M., the SLP said she knew Resident #14 and had treated him/her. She said Resident #14 is very high risk for aspiration and should be supervised for meals to ensure he/she is safe from aspiration. During an

Based on observation, interview, record review, and policy review, the facility failed to ensure one Resident (#24), out of a total sample of 24 residents, received care and treatment per professional standards of practice to promote optimal wound healing and to prevent the development of a facility acquired unstageable (actual depth of ulcer is completely obscured by slough and/or eschar in the wound bed) left heel ulcer, full thickness. Specifically, the facility failed to conduct a timely Braden risk assessment upon admission to predict the Resident's level of risk for pressure ulcer development, complete an admission comprehensive skin assessment documented in the Resident's electronic health record (EHR), develop and implement a care plan that identified risk factors as well as interventions designed to reduce or prevent the development of pressure related ulcers/injuries, obtain orders and provide wound care treatments per wound consultant recommendations, and consistently off-load the Resident's heels and ensure weekly skin checks were completed per physician's orders. Findings include: Review of the facility's policy titled Pressure Wound Prevention, revised February 2022, indicated but was not limited to the following: -Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. -Assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the Braden risk assessment weekly for 4 weeks then quarterly, annually or any significant change in resident condition. -Conduct a comprehensive skin assessment upon admission including: a. skin integrity - any evidence of existing or developing pressure ulcers or injuries; b. tissue tolerance; and c. areas of impaired circulation due to pressure from positioning or medical devices. -Identify any signs of developing pressure injuries and inspect pressure points. -Evaluate, report, and document potential changes in the skin. -Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Protocol - Wound Care and Rounds, revised January 2023, indicated but was not limited to the following: New Wound Identified in House: -Licensed nurse should complete an assessment of the wound including shape, size, depth, staging (if applicable) and condition of wound. -Licensed nurse/manager/supervisor will notify the physician and obtain a treatment order and an order for pain medication 30 minutes prior to treatment. -An Incident Report and Facility Acquired Pressure Ulcer Investigative Tool will be initiated. -Interdisciplinary team should review and revise the care plan for new interventions, during morning meeting the following day as applicable. -A comprehensive nurse's note will be completed identifying the wound as unavoidable/ avoidable with documentation including co-morbidities, risk factors and interventions. -Weekly rounds should take place on the same day each week Review of the facility's policy titled Wound - Ulcer, dated January 2023, indicated but was not limited to the following: -Nurses may not diagnose, just describe -Staff will institute a plan for any resident who has potential for skin breakdown or whose condition is deteriorating. This may include: d. floating areas of concern such as heels when appropriate f. use of elbow or heel protectors when appropriate Resident #24 was admitted to the facility in December 2023 with diagnoses including encephalopathy (any brain disease that alters brain function or structure), diabetes mellitus type 2, cognitive communication deficit, unsteadiness on feet, and lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 12/28/23, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was at risk for developing pressure ulcers, and had no unhealed pressure ulcers. The MDS also indicated skin and ulcer treatments of ointments/medications were being applied other than to the feet. During an interview on 3/12/24 at 9:17 A.M., Resident #24 said he/she had a hematoma (pool of clotted blood) on his/her left heel from three to four weeks ago, was not sure how he/she got it, but it was very painful. The Resident said he/she was being followed by the wound doctor. December 2023 Review of the Admission Physician's Progress Note, dated 12/23/23, indicated the Resident's skin was warm and dry and had chronic lower extremity edema versus lymphedema. There was no mention of an alteration in skin integrity. Review of the medical record for Resident #24 failed to indicate a comprehensive care plan was developed on admission for the prevention of skin breakdown and pressure injuries despite the MDS indicating the Resident was at risk for developing pressure injuries. Review of Physician's Orders indicated the following: -Weekly skin assessment by a licensed nurse (documented in Point Click Care (PCC), electronic health record) every evening shift every Monday, 12/25/23 January 2024 Review of a Physician's Progress Note, dated 1/1/24, indicated Resident #24's skin was warm and dry with an erythematous patch on very low back and upper buttock and had a shingles rash. There was no mention of an alteration in skin integrity to the Resident's left heel. Review of a nursing Skilled Evaluation, dated 1/5/24, indicated the Resident's skin was warm and dry, skin color within normal limits and turgor was normal. There was no mention of an alteration in skin integrity to the Resident's left heel. Review of a Physician's Progress Note, dated 1/8/24, indicated Resident #24 reported left heel pain. His/her extremities were edematous and swollen and a left heel blister was noted with some darkened fluid as if there was mild bleeding within; no erythema or induration to suggest infection. Review of Physician's Orders indicated the following: -Mupirocin External Ointment 2%, apply to left heel topically two times a day for blister, wash with normal saline, pat dry, apply Mupirocin two times daily, start 1/9/24, stop 1/11/24 -Mupirocin External Ointment 2%, apply to left heel topically every day and evening shift for wound care, wash with normal saline, pat dry, apply Mupirocin two times daily, start 1/12/24, stop 3/14/24 Review of the medical record indicated a Norton Scale for Predicting Risk of Pressure Ulcer assessment was completed on 1/12/24, three days after the identification of a left heel blister and three weeks after admission, indicating Resident #24 was at high risk for developing pressure injuries. Review of the medical record indicated a care plan was developed on 1/12/24 for an Alteration in Skin Integrity related to diabetes, edema, urinary incontinence, and a left heel unstageable wound and was as follows: -Goal: Resident's skin would show improved healing through the next review date -Interventions: complete skin condition check weekly, dietary intervention/evaluation, follow MD orders for skin care and treatment, seen by wound MD, heels off-loaded when in bed, inspect feet daily and report changes to nurse, pressure ulcer risk assessment weekly x 4 weeks upon admission then quarterly and with change in condition, and to protect the skin with incontinent care, 1/12/24. Further review of the medical record indicated a care plan was developed on 1/12/24 for Diabetes Mellitus and was as follows: -Goal: Resident will have no complications related to diabetes through the review date -Interventions: Check all of the body for breaks in skin and treat promptly as ordered by doctor, inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, and monitor/document/report to MD as needed for signs and symptoms of infection to any open areas: redness, pain, heat, swelling or pus formation, 1/12/24 Review of the January 2024 Treatment Administration Record (TAR) failed to indicate a weekly skin assessment was conducted on 1/24/24 and failed to indicate the Mupirocin external ointment 2% was documented as being applied topically to the Resident's left heel every day and evening shift for wound care for 8 out of 26 shifts from 1/12/24-1/24/24. Review of a nurse's Clinical Admission Note, dated as a late entry on 1/24/24, 33 days after admission, indicated Resident #24 had a left heel diabetic foot ulcer with slough present in the wound bed, purulent wound exudate, fragile skin peri wound, minimal dressing saturation, boggy skin, pain, and was receiving daily wound treatments. Review of the Initial Wound Evaluation and Management Summary for Resident #24, dated 1/25/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicted the wound was a new injury, greater than 11 days in duration, measured 4.3 x 2.5 x 0.1 centimeters (cm) and was a pressure wound. Recommendations included: Primary Dressing - normal saline wash apply once daily for 30 days, Iodosorb gel, apply once daily for 30 days Secondary Dressing - abdominal pad apply once daily for 30 days, gauze roll (stretch) 4 apply once daily for 30 days, tape (waterproof adhesive) apply once daily for 30 days -Peri-wound Treatment - skin prep apply once daily for 30 days Plan of Care Recommendations - elevate legs, float heels in bed, off-load wound, reposition per facility protocol, pillows, booties Review of Resident #24's care plan indicated the recommended intervention for booties was not implemented until 2/6/24, 12 days after the wound doctor assessed the Resident. Review of a Nurse's Progress Note, dated 1/25/24, indicated the Resident presented with a wound on the left lower extremity (heel) at the time of bilateral leg wrapping treatment. The patient complained of having lots of pain coming from the heel. The wound was 4 x 6, red color around it with a small amount of slug (Sic). The patient was seen that day by the wound doctor. New orders in place and started today on the 3-11 shift. Review of the January 2024 TAR and Medication Administration Record (MAR) failed to indicate a treatment order was obtained for the Iodosorb gel, abdominal dressing, gauze roll stretch, and skin prep dressing to the left heel per the Wound Physician's recommendations. Further review of the January 2024 TAR indicated the Mupirocin external ointment 2% continued to be applied topically to the Resident's left heel every day and evening shift for wound care for 8 out of 12 shifts from 1/26/24-1/31/24. February 2024 Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/1/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.3 x 2.6 x 0.1 cm and was not at goal. Surgical excisional debridement (dead or unhealthy tissue removed) was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24 visit. The Resident's Alteration in Skin Integrity care plan was revised to include a left heel bootie on while in bed as tolerated, initiated 2/6/24. Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/8/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.7 x 2.8 x 0.1 cm and was not at goal. Surgical excisional debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24 and 2/1/24 visits. Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/15/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.7 x 3.2 x 0.1 cm and was not at goal. Surgical excisional debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24, 2/1/24, and 2/8/24 visits. Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/22/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.7 x 3.3 x 0.1 cm and was not at goal. Sharp selective debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24, 2/1/24, 2/8/24, and 2/15/24 visits. Review of the Wound Evaluation and Management Summary for Resident #24, dated 2/29/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 4.4 x 3.5 x 0.1 cm and was not at goal. Surgical excisional debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24, 2/1/24, 2/8/24, 2/15/24, and 2/22/24 visits. Review of the February 2024 TAR and MAR failed to indicate a treatment order was obtained for the Iodosorb gel, abdominal dressing, gauze roll stretch, and skin prep dressing to the left heel per the Wound Physician's recommendations and no documentation was found in nurse progress notes to suggest the specific wound treatment recommendations were being followed. Further review of the February 2024 TAR indicated the following: -weekly skin assessments not conducted on 2/12/24 and 2/19/24 -left foot bootie/heel protector not documented as being applied for 21 out of 87 shifts -Mupirocin external ointment 2% continued to be applied topically to the Resident's left heel every day and evening shift for wound care for 29 out of 58 shifts March 2024 Review of the Wound Evaluation and Management Summary for Resident #24, dated 3/7/24, indicated an unstageable (due to necrosis) full thickness wound was located on the left heel. The visit note indicated the wound size was 3.7 x 2.8 x 0.1 cm and improved. Surgical excisional debridement was performed. The Wound Physician recommended the same treatment as indicated in the previous 1/25/24, 2/1/24, 2/8/24, 2/15/24, 2/22/24, and 2/29/24 visits. Review of Physical Therapy Treatment Encounter Notes, dated 1/24/24, 1/30/24, 2/1/24, 2/6/24, and 2/7/24, indicated the patient denied gait training and/or transferring due to pain in the left heel, increased sensitivity, and/or due to wound. Review of the Resident's Alteration in Skin Integrity care plan indicated it was revised to include a consultation with the vascular surgeon, initiated 3/14/24. Review of the March 2024 TAR and MAR failed to indicate a treatment order was obtained for the Iodosorb gel, abdominal dressing, gauze roll stretch, and skin prep dressing to the left heel per the Wound Physician's recommendations until 3/14/24. Further review of the March 2024 TAR indicated the following: -weekly skin assessments not conducted on 3/11/24 -Mupirocin external ointment 2% continued to be applied topically to the Resident's left heel every day and evening shift for wound care for 24 out of 26 shifts During an interview on 3/14/24 at 10:42 A.M., the surveyor observed Resident #24 lying in bed. The Resident did not have a foam bootie on his/her left foot as recommended by the wound doctor. He/she said the last time it was applied was maybe last week, but lately never. The Resident said he/she started with a blister on his/her left heel which had gotten worse since then, hurt more, and felt like it was infected. During an interview on 3/14/24 at 11:00 A.M., Certified Nursing Assistant (CNA) #11 said she was assigned to the Resident that day and was familiar with him/her. She said the Resident had no pressure areas she was aware of or skin issues but should have a pillow under his/her heels. She said she didn't know if he/she was supposed to have a foam bootie on. During an interview on 3/14/24 at 3:18 P.M., Nurse #9 said Resident #24 was at risk for developing pressures and had a stage 2 pressure ulcer on his/her left heel. During an observation with interview on 3/14/24 at 4:05 P.M., the surveyor observed the Resident's left heel wound with the Wound Physician and Nurse #9. The Wound Physician said the left heel was an unstageable necrosis pressure injury and the Resident came in with it. He said it was much better this day and getting a lot smaller. The wound, per surveyor observation, was approximately 2 cm x 2 cm x unstageable. The wound had a dark center and small area of detached necrotic tissue from the wound bed which was removed by the physician. Once removed, the wound bed was red in color with scant sero-sanguinous drainage. The surrounding skin was pink. The Wound Physician said they were originally using betadine (used to treat or prevent skin infection) products but the Resident was still in pain, so the new treatment was to use Iodosorb gel (gel that's applied to the skin to treat wet ulcers and wounds). The surveyor informed the Wound Physician that there was no order for the Iodosorb gel dressing treatment since the initial visit recommendation on 1/25/24 and that staff had been documenting on the TARs the mupirocin ointment application to the left heel since early January. The Wound Physician said the mupirocin treatment shouldn't have been continued as it was an antibiotic and would have needed to be monitored. He said there had been a lot of turnover with the Director of Nurses (DON) position and there was no designated wound nurse, but wound recommendations should be followed. The Wound Physician further said because the Resident crossed his/her left leg over his/her right, staff needed to off-load both. He said the Resident had bilateral lower extremity circulation issues so that may be a factor in his/her wound healing. During an interview on 3/18/24 at 11:17 A.M., Unit Manager (UM) #1 said she was not the designated wound nurse. She said sometimes the Infection Preventionist would round but whoever was available to help would help. On 3/18/24 at 11:20 A.M., the surveyor observed Resident #24 lying in bed. The Resident's heels were not elevated off the mattress and a foam bootie was not observed on the Resident's left heel in accordance with the Resident's plan of care. On 3/19/24 at 7:50 A.M., the surveyor observed Resident #24 lying sideways in bed awake with his/her feet on the ground. No foam bootie was observed in the Resident's room. During an interview on 3/19/24 at 10:26 A.M., Nurse #13 said Resident #24 was at risk for developing pressures, had pressure sites on his/her feet, and had basic bootie and heel protection orders. She said the 1/25/24 wound note indicated an unstageable pressure wound of the left heel that was new and greater than 11 days old. She said a new treatment was recommended on that visit and subsequent visits for a normal saline wash and Iodosorb dressing daily along with to float the Resident's heels while in bed, elevate the legs, and use pillows and booties, but the order was not entered until 3/14/24. She said there was no designated wound nurse but if recommendations are made by the wound physician, she wasn't sure who would take and implement them. She said there was no admission skin evaluation, no Braden risk assessment (Norton Scale) completed until 1/12/24, and a care plan for skin integrity was not developed or implemented until 1/12/24. She said interventions and treatments should have been implemented consistently to improve skin and to prevent/avoid any pressure related injuries. During an interview on 3/19/24 at 1:35 P.M., the surveyor reviewed the medical record with the DON and Consulting Staff #1. Consulting Staff #1 said the Resident was not admitted with a left heel wound. She said physician's notes, dated 12/23/23 (admission note) and 1/1/24, did not mention anything about the Resident's heels until the 1/9/24 note. She said the first skin evaluation was not conducted until 1/24/24 but should have been done upon admission and weekly. Consulting Staff #1 said the initial wound note on 1/25/24 indicated the left heel was a new pressure wound. She said if there's a wound physician recommendation, it gets printed and placed in the physician's book. If there's a change, then the nurse should call the physician to get orders and any interventions completed consistently without blank holes to prevent a pressure ulcer from forming or worsening. Consulting Staff #1 said there was no care plan in place for skin integrity until 1/12/24 and care planned interventions should be reviewed and revised quarterly and with any changes.

Based on observations, interviews, record review, and policy review, the facility failed to ensure 11 Residents (#56, #82, #301, #81, #63, #79, #65, #26, #37, #71, #70), out of a total sample of 27 residents, were provided adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to: A. Follow their Falls Management and Prevention Policy of investigating falls and initiating fall prevention interventions for: 1.) Resident #56, resulting in nine falls, two falls resulting in major injury (hip fractures) 2.) Resident #82, resulting in 24 falls with one fall resulting in a cut/bruise between the resident's eyes, one fall resulting in a cut on the upper lip, and a third fall resulting in a skin tear. 3.) Resident #301, resulting in one fall with major injury (fractured femur) 4.) Resident #81, resulting in one fall with no injury 5.) Resident #63, resulting in one fall with no injury 6.) Resident #79, resulting in one fall with a laceration to temple resulting in two sutures 7.) Resident #65, resulting in four falls and was sent to emergency room for a head strike (bump to head) and two 2 skin tears 8.) Resident #26, resulting in four falls with no injury 9.) Resident #37, resulting in one fall with no injury 10.) Resident #71, resulting in three falls, one fall resulting in complaints of pain, bruising and swelling of the right elbow and hand requiring a ring removal to the right fourth finger. B. For Resident #70, follow their smoking policy and Centers for Medicare & Medicaid Services (CMS) guidance for a safe smoking area. Findings include: A. Review of the facility's policy titled Fall Management Program, revised 1/28/2022, indicated the following: The Fall Response steps are a comprehensive approach that forms the backbone of the Falls Management Program (FMP). It includes the following eight steps: 1. Evaluate and monitor resident for 72 hours after the fall. 2. Investigate fall circumstances. 3. Record circumstances, resident outcomes, along with resident and staff response. 4. Notify primary care provider. 5. Implement immediate intervention within first 24 hours. 6. Complete falls assessment. 7. Develop plan of care. 8. Educate and monitor staff compliance. Review of the Falls Packet indicated the following must be completed for every fall including: 1. Point Click Care incident report 2. Care plan update with new immediate interventions implemented following falls 3. Write new interventions on ADL (activity of daily living) status sheet in CNA (Certified Nursing Assistant) ADL documentation binder 4. Obtain CNA statements 5. Complete rehab screen for every fall 1. Resident #56 was admitted to the facility in September 2021 with diagnoses that included Alzheimer's disease and hypertension. Review of the medical record indicated that Resident #56 would wander the halls independently. Review of the medical record indicated Resident #56 had nine falls in six months, two resulting in major injury. Review of the Resident's falls failed to include a fall investigation, completed falls assessment after each fall, CNA/nursing statements, request for rehab screen, and immediate interventions to prevent further falls. -2/2/22 at 7:30 A.M., Resident #56 had an unwitnessed fall and was found sitting on his/her bottom beside another resident and an empty bed. The nurse documented that the Resident was assessed and assisted back to standing position. Review of documentation indicated no documented evidence of an investigation, falls assessment, rehab screen, or interview statements from CNA/nursing, and immediate interventions to prevent further falls -2/17/22 at 8:30 A.M., Resident #56 had an unwitnessed fall in the hallway. The Resident was observed lying in the hallway and noted to have facial grimacing. The physician was contacted and ordered was obtained to have the Resident sent to the hospital for evaluation. The Resident returned to the facility in March 2022 with a diagnosis of a right hip repair. Review of the documentation indicated there was no documented evidence of an investigation of the fall, a falls assessment, interview statements from CNA/nursing staff, and immediate interventions to prevent further falls -3/1/22 at 9:00 P.M., Resident #56 was lowered to the floor by the CNA after the Resident's roommate attempted to assist Resident #56. There was no documented evidence of an investigation of the fall, a falls assessment, or interview statements from CNA/nursing staff. Review of the medical record indicated a new care plan was developed, dated 3/3/22, for an actual fall with surgical intervention (ORIF right femoral shaft), poor balance, unsteady gait. -The interventions included: -1:1 attention and supervision when possible -fat mat on both sides of the bed -low bed -PT consult for strength and mobility -3/3/22 at 3:45 P.M., Resident #56 had an unwitnessed fall and was found kneeling next to his/her bed in a praying position. Resident was assisted to a Broda chair (positioning chair) with 1:1 CNA in attendance. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from CNA/nursing staff or changes to the care plan to prevent further falls. -3/5/22 at 9:20 P.M., Resident #56 was rocking in the Broda chair when it fell backwards, the CNA caught it and lowered it to the floor and the Resident fell out. The CNA remained with the resident. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from CNA/nursing staff, or changes to the care plan to prevent further falls. Review of the Minimum Data Set (MDS) for Resident #56, dated 3/7/22, indicated that the Resident required extensive assistance, with one person assist, for bed mobility, transfers, walking in the room or corridor, dressing, toileting, and personal hygiene. The MDS did not reflect the Resident's history of falls. -4/2/22 at 9:09 A.M., Resident #56 had an unwitnessed fall, and the CNA found the Resident on the floor between the two beds while holding on to the bed rail. The Resident was transferred to a wheelchair. There was no documented evidence of an investigation of the fall, completed falls assessment, and interview statements from CNA/nursing staff. A new care plan was developed, dated 4/4/22, that identified the application of an external device for prevention of injury to self, characterized by high risk for injury/falls, impaired mobility, physical aggression related to anxiety and cognitive impairment. The intervention was a lap buddy while in the wheelchair. -4/16/22 at 12:54 A.M., Resident #56 had an unwitnessed fall and was found on the floor mat next to the bed. The resident's head was against the wall. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from CNA/nursing staff, or changes to the care plan to prevent further falls. On 6/16/22 the lap buddy was removed and replaced with an alarming seat belt to wheelchair, remove and adjust to stand and reposition every two hours and as needed. -7/27/22 at 6:45 A.M., Resident #56 had an unwitnessed fall and was found on blue mats on the floor in a prone position. The Resident was assisted back to bed. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from nursing staff, or changes to the care plan to prevent further falls. -7/29/22 at 6:34 A.M., Resident #56 had an unwitnessed fall and was found sitting upright on the floor. The Resident was inspected for wounds, and none were found. There was no documented evidence of an investigation of the fall, falls assessment, interview statements from CNA/nursing staff, or changes to the care plan to prevent further falls. Review of the Nursing Progress Notes, dated 8/8/22, indicated the Resident was grimacing when repositioned. The nurse assessed the Resident and found to have lower back and left leg pain. NP was notified and ordered an X-ray. Seven hours later the nurse documented that the X-ray was positive, and an order was obtained to send Resident #56 to the hospital for evaluation. The Resident was admitted and treated for a left hip fracture. There was no documented evidence of an investigation of the fall, a falls assessment, interview statements from CNA/nursing staff, or changes to the care plan to prevent further falls. During an interview on 8/18/22 at 3:14 P.M., the Director of Nursing said there are no completed fall assessments, and the falls policy has not been followed, including post fall documentation which included the falls investigation, falls assessment, obtaining CNA/nursing statements, rehab screens requests, and interventions to prevent the resident from further falls. During an interview on 8/22/22 at 12:50 P.M., the Rehab Director said she only had rehab screens for Resident #56 after the two hip fractures, but not for the other falls. 2. Resident #82 was admitted to the facility in October 2021 with diagnoses that included dementia with behavioral disturbances and depression. Review of the medical record indicated a care plan was developed, dated 10/14/21, identifying that the resident was at high risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor communication, comprehension, and unaware of safety needs. -Goals: to be free from falls -Interventions included: *provide frequently used items within reach at bedside *ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair Review of the MDS assessment, dated 10/19/21, indicated Resident #82 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (indicating severe cognitive impairment), and had falls prior to admission. The MDS also indicated the Resident required extensive assist, with physical assist of one person, for bed mobility, bed transfer, dressing, toileting, and personal hygiene, and limited assist, with physical assist of one person, for walking in the room, corridor and on the unit. The MDS indicated the Resident was unsteady and only able to stabilize with staff assistance when moving from the seat, walking, turning around, moving on and off the toilet, and surface to surface transfer. Review of the medical record indicated Resident #82 had 24 falls in nine months, including three falls resulting in injury. Review of the 24 falls failed to include fall investigation, falls assessment after each fall, CNA/nursing statements, request for rehab screen, neurological checks when appropriate, and immediate interventions to prevent further falls: -11/8/21 at 3:15 A.M., Resident #82 had an unwitnessed fall and was found sitting on the floor next to their bed. -11/21/21 at 4:00 A.M., Resident #82 had a witnessed fall. A CNA was in the Resident's room and observed the Resident ambulating to the bathroom, lost his/her balance, and fell . -11/29/21 at 12:04 A.M., Resident #82 was observed ambulating and the Resident's legs gave out and he/she fell to the floor. The was no documented evidence that the facility conducted a falls investigation, falls assessment, CNA/nursing statements, and implement immediate interventions after each fall to prevent further falls. Review of the MDS assessment, dated 1/18/22, indicated the Resident's BIMS score was 5 out of 15 (indicating severe cognitive impairment). The MDS also indicated that the Resident was independent for bed mobility and eating, required supervision for transfer, walking in the room and unit, and extensive assist, with physical assist of one person, for dressing, toileting, and personal hygiene. The MDS indicated the Resident was unsteady and only able to stabilize with staff assistance when moving from the seat, walking, turning around, moving on and off the toilet, and surface to surface transfer. -3/24/22 at 5:15 P.M., Resident #82 had an unwitnessed fall and was found on the floor next to the bed. -4/7/22 at 11:48 P.M., Resident #82 had an unwitnessed fall and was found on the floor by the nursing station. -4/8/22 at 7:00 P.M. Resident #82 had a witnessed fall and had slid off the side of the bed while attempting to stand. The was no documented evidence that the facility conducted a falls investigation, completed a falls assessment, obtained CNA/nursing statements, submitted a request for rehab screen, and implement immediate interventions after each fall to prevent further falls. Review of the MDS assessment, dated 4/19/22, indicated the Resident's BIMS score was 3 out of 15 (indicating severe cognitive impairment). The MDS also indicated that the Resident was independent for bed mobility, transfer and eating, required supervision for walking in the room, limited assist for walking in the corridor and unit, and extensive assist, with physical assist of one person, for dressing, toileting, and personal hygiene. The MDS indicated that the Resident was unsteady and only able to stabilize with staff assistance when moving from the seat, walking, turning around, moving on and off the toilet and surface to surface transfer. This MDS indicated the Resident had two or more falls since the last assessment. -5/13/22 at 6:16 A.M., Resident #82 had an unwitnessed fall and was found in the hallway, on the floor. The Resident sustained an injury (cut/bruise) to the bridge of the nose. -5/16/22 at 3:07 A.M., Resident #82 was ambulating to the bathroom with staff and had to be lowered to the floor. There was no documented evidence that the facility conducted a falls investigation, completed a falls assessment, obtained CNA/nursing statements, submit a request for rehab screen, and implement immediate interventions after each fall to prevent further falls. Review of the documentation indicated Resident #82's care plan for falls was revised on 5/16/22 to include the following: -psych evaluation as ordered -toilet before and after all meals -5/18/22 at 11:30 A.M., Resident #82 had an unwitnessed fall and was found in their room on the floor. The Resident sustained a cut to the upper lip. Review of the documentation indicated a falls investigation, falls assessment, rehab screen request, and immediate interventions to prevent falls had not occurred. -5/22/22 at 5:15 A.M., Resident #82 had an unwitnessed fall, and the Resident was found on the floor, across the hall, in room 312. Review of the documentation indicated no evidence that the facility conducted a falls investigation, falls assessment, obtained CNA/nursing statements, and implement immediate interventions after each fall to prevent further falls. -5/24/22 at 1:00 P.M., Resident #82 was found on the floor (location not identified) and the nurse documented a question if the resident had struck his/her head. -5/31/22 at 5:10 A.M., Resident #82 had an unwitnessed fall and was found outside his/her room. -6/13/22 at 11:39 P.M., Resident #82 had an unwitnessed fall and was found on the floor in his/her room. -6/20/22 at 8:29 A.M., Resident #82 had an unwitnessed fall and was found on the floor in the unit lounge. Review of the documentation indicated a falls investigation, rehab screen request, staff statements, and immediate interventions to prevent falls had not occurred after each fall. -7/5/22 at 4:26 A.M., Resident #82 had an unwitnessed fall and was found on the floor between two beds. -7/16/22 at 7:30 A.M., Resident #82 had an unwitnessed fall and was found on the floor in the common area. The Resident sustained a skin tear to the left forearm. There was no documented evidence that the facility conducted a falls investigation, completed a falls assessment, obtained CNA/nursing statements, requested for rehab screen, and implement immediate interventions after each fall to prevent further falls. Review of the MDS assessment, dated 7/19/22, indicated the Resident's BIMS score was 2 out of 15 (indicating severe cognitive decline). The MDS also indicated the Resident was independent for bed mobility, required supervision for transfer, walking in the room and, eating, and limited assist, with the physical assist of one person, for walking in the corridor and on the unit, and extensive assist, with physical assist of one person, for dressing, toileting, and personal hygiene. The MDS indicated the Resident was unsteady and only able to stabilize with staff assistance when moving from the seat, walking, turning around, moving on and off the toilet and surface to surface transfer. The MDS indicated the Resident had two or more falls with injury. -7/20/22 at 6:00 A.M., Resident #82 had a witnessed fall and landed on the floor. The Resident was sent to the hospital and returned to the facility with documentation that indicated the Resident was slightly dehydrated. -7/24/22 at 10:28 P.M., Resident #82 had an unwitnessed fall and was found on his/her knees next to his/her bed. -7/26/22 at 12:55 A.M., Resident #82 had an unwitnessed fall and was found on the floor (location not identified) and was sent to the hospital for evaluation. The Resident returned to the facility the same day with no identified injuries. Review of the documentation indicated a falls investigation, fall assessment, rehab screen request, staff statements, and immediate interventions to prevent further falls had not been completed after each fall. -8/8/22 at 11:30 A.M., Resident #82 had an unwitnessed fall and was found on the floor, between two beds, in his/her room. -8/11/22 at 2:00 A.M., Resident #82 had an unwitnessed fall, and was found on the floor, between two beds, in his/her room. -8/11/22 at 9:00 A.M., Resident #82 had a witnessed fall and during morning care the Resident placed himself/herself on the floor. -8/11/22 at 9:10 A.M., Resident #82 had an unwitnessed fall. The CNA left the Resident after providing morning care and upon reentry to the Resident's room the CNA found the Resident on the floor. -8/11/22 at 3:15 P.M., Resident #82 had a witnessed fall. The Resident got up and ambulated to another resident's room. The staff member was unable to redirect the Resident. The Resident picked up another resident's walker which caused him/her to lose balance and fall to the floor, landing on his/her bottom. The was no documented evidence that the facility conducted a falls investigation, completed a falls assessment, obtained CNA/nursing statements, requested for rehab screen, and implement immediate interventions after each fall to prevent further falls. During an interview on 8/24/22 at 2:30 P.M., the Director of Nursing said there are no completed falls assessments, and the falls policy has not been followed by nursing, including post fall documentation which included completion of the falls investigation, falls assessment, obtaining CNA/nursing statements, rehab screens requests, and immediate interventions to prevent the resident from further falls. During an interview on 8/24/22 at 3:00 P.M., the Rehab Manager said Resident #82 was only seen by Physical Therapy on 11/30/22, and 5/24/22. The Rehab Manager said she had not received rehab screens requests for the other falls that Resident #82 had. 3.) Resident #301 was admitted to the facility in June 2022 with diagnoses that included [CONDITION(S)], Chronic Obstructive Pulmonary Disorder ([CONDITION(S)]), and difficulty walking. Review of the MDS assessment, dated 7/12/22, indicated the Resident had a BIMS of 13 out of 15 indicating Resident #301 is cognitively intact. Further review of the MDS indicated the Resident is totally dependent for transfers and requires extensive assist with ambulation. During an interview on 8/18/22 at 10:49 A.M., Resident #301 said he/she broke his/her leg after falling in the bathroom. The Resident said he/she tried to get up off the toilet and fell to the floor. Review of the Nurse's Progress Notes indicated the following: -7/23/22 at 7:12 P.M.: the Resident was found on the floor in the bathroom with his/her back against the wall. The note indicated the Resident was assisted to the wheelchair with the assist of two staff. -7/24/22 at 6:00 P.M.: the Resident had no apparent injuries and denied pain. -7/25/22 at 7:35 P.M.: the Resident complained of leg pain and could not participate with therapy. The physician was notified and an order for an x-ray was obtained. Results of the x-ray showed a left tibia fracture. Resident #301 was transferred to the hospital for treatment. Further review of the nurse progress notes indicated Resident #301 returned to the facility on [DATE] with a knee immobilizer in place to the left leg. Review of the Nursing Assessments indicated no documented evidence that a fall assessment was completed after the fall. Review of the Falls Care Plan, initiated 6/29/22, indicated Resident #301 was at risk for falls characterized by a history of falls/injury. The goal was Resident #301 would have no falls with injury. The interventions to achieve this goal were as follows but not limited to: - Have commonly used articles within reach (6/29/22) - Reinforce need to call for assistance (6/29/22) - Resident to wear proper and non-slip footwear (6/29/22) Further review of the Falls Care Plan indicated the care plan was revised on 7/26/22, three days after the fall occurred, to include: - Analyze previous Resident falls to determine whether pattern/trend can be addressed - Assist Resident with regular toileting and remind Resident to call for toileting assistance when required - PT/OT to assess and treat as needed Review of the medical record indicated the facility failed to assess and implement appropriate interventions to reduce falls. 4.) Resident #81 was admitted to the facility in May 2020 with diagnoses that included hypertension and dementia. Review of the MDS assessment, dated 7/12/22, indicated the Resident had a BIMS of 6 out of 15 indicating the Resident has severe cognitive impairment. Further review of the MDS indicated the Resident is totally dependent on staff for transfers and does not ambulate. Review of the Nurse's Progress Notes indicated the following: -7/27/22 at 5:07 P.M.: the Resident had a fall in the morning and should continue to be monitored for injuries. Resident had no pain. Review of the Nurse Practitioner's note, dated 8/7/22, indicated that floor mats had been implemented after the fall. Review of the Falls Care Plan, initiated 5/27/20, indicated the Resident was at risk for injury related to fall history. The goal was the Resident would not sustain a fall related to injury by utilizing fall precautions. The interventions to achieve this goal were as follows but not limited to: - Fall assessment quarterly (10/25/21) - Offer Resident to rest after breakfast and lunch (1/3/21) (revised 4/26/21) - Bed in lowest position (5/21/20) (revised 10/6/20) Further review of the Falls Care Plan indicated no documented evidence the care plan was revised or reviewed to reflect the use of floor mats. Review of the nursing assessments indicated no documented evidence that a fall assessment was completed after the fall on 7/27/22. 5.) Resident #63 was admitted to the facility in July 2022 with diagnoses that included stroke, [CONDITION(S)], and coronary artery disease. Review of the MDS assessment, dated 7/12/22, indicated a BIMS of 13 out of 15 indicating the Resident is cognitively intact. Further review of the MDS indicated the Resident was dependent on staff for transfers and required extensive assist with ambulation. Review of the medical record indicated Resident #63 had an unwitnessed fall on 8/14/22 while the CNA stepped out of the bathroom to gather supplies. The Resident was assessed for injury and was observed to have swelling of his/her right hand. The physician was notified and an order for an x-ray was obtained. The results of the x-ray were negative. Review of the nursing assessments indicated no documented evidence that a fall assessment was completed after the fall. Review of the Falls Care Plan, initiated on 7/7/22, indicated the Resident was at risk for falls related to reduced strength and endurance. The goal was the Resident will be free of falls through the next review date. Interventions to achieve this goal is as follows but not limited to: - PT evaluate and treat as ordered (7/7/22) - Follow facility policy (7/7/22) - Ensure the Resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair (7/7/22) Further review of the Falls Care Plan indicated no documented evidence that the care plan was reviewed or revised for the fall on 8/14/22. 6.) Resident #79 was admitted to the facility in April 2022 with diagnoses that include hernia repair, dementia with behavioral disturbances, and anxiety. Review of the MDS assessment, dated 7/12/22, indicted a BIMS of 10 out of 15 indicating the Resident has moderate cognitive impairment. Further review of the MDS indicated the Resident required supervision with transfer and limited assist with walking. Review of the Nurse's Note, dated 7/10/22 at 1:08 P.M., indicated the Resident had a fall in the hallway and sustained a laceration to his/her left temple. The Resident was transferred to the hospital for treatment and returned the same day to the facility with two sutures to the left forehead. Review of the nursing assessment indicated no fall assessment was completed after the Resident's fall. 7.) Resident #65 was admitted to the facility in July 2022 with diagnoses that included pneumonia, hypertension, and diabetes. Review of the MDS assessment, dated 7/14/22, indicated the Resident had a BIMS of 14 out of 15 indicating the Resident was cognitively intact. Further review of the MDS indicated the Resident required assist with transfers and ambulation. Review of the medical record indicated the Resident had the following falls: - 8/1/22- Resident was found on the floor next to the bed - 8/8/22- Resident was found on floor next to the bed - 8/14/22- Resident was found on his/her right side with two skin tears on right elbow and left hand - 8/16/22- Resident found on floor next to bed Review of nursing assessments indicated no documented evidence that fall assessments were completed for any of the four falls. Review of the Falls Care Plan, initiated on 7/8/22 and revised on 8/1/22, indicated the Resident was at risk for falls related to deconditioning, history of falls, and recent falls. The goal was the Resident will be free of minor injury through the review day by utilizing fall precautions. Interventions to achieve this goal is as follows but is not limited to: - Follow facility protocol (7/8/22) - Lock brakes on bed, chair, etc. before transferring (8/1/22) - Appropriate footwear (8/1/22) - Provide/monitor use of adaptive devices (8/1/22) Further review of the falls care plan indicated no documented evidence that the care plan was reviewed or revised after the falls sustained on 8/8/22, 8/14/22, or 8/16/22. Review of the medical record indicated the facility failed to review and revise the care plan timely for appropriate interventions to reduce future falls. 8.) Resident #26 was admitted to the facility in May 2022 with the following diagnoses: Alzheimer's disease, hypertension, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #26, dated 5/25/22, indicated a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating the Resident has severe cognitive impairment. Further review of the MDS indicated Resident #26 was independent for bed mobility, transfer out of bed, and ambulation with use of a rolling walker. On 8/18/22 at 12:06 P.M. the surveyor observed Resident #26 ambulating from his/her room to hallway four times. Resident #26 was observed to not be using his/her walker. Review of the Care Plan for Resident #26, dated 5/19/22, indicated the Resident was a fall risk and interventions for fall prevention included the following: - Be sure call light is within reach and encourage the resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance. (6/2/22) - Ensure that Resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. (6/2/22) - Follow facility fall protocol (5/19/22) - PT evaluate and treat as ordered or PRN (5/19/22) Resident #26's Care Plans further indicated the Resident required assist with Activities of Daily Living, using a rolling walker and requires distance supervision with ambulation (5/19/22). Review of the Nursing Progress Notes indicated Resident #26 had four falls from May 2022 through August 2022 as follows: - 5/28/22 at 1:30 A.M.: Resident #26 had a witnessed fall while ambulating in the hallway and tripped over a chair. There was no indication in the medical record that Resident #26 was utilizing his/her rolling walker at the time of the fall. Review of the medical record failed to include a falls packet, referral/screen to rehab services, CNA statements, falls assessments, or interventions implemented to reduce the risk of falls. - 5/29/22 at 3:23 P.M.: Resident #26 had a witnessed fall. The Resident stumbled and fell backwards on to his/her bottom. There was no indication in the medical record that Resident #26 was utilizing his/her rolling walker at the time of the fall. Review of documentation failed to include a falls packet, referral/screen to rehab services, CNA statements, or falls assessments. Review of the medical record indicated the Falls Care Plan was revised on 6/2/22 to include: -Be sure call light is within reach and encourage the resident to use it for assistance as needed. -Resident needs prompt response to all requests for assistance. -Ensure that Resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. - 7/17/2022 at 12:48 P.M.: Resident #26 had an unwitnessed fall. The Resident was found lying on floor in front of nurses' station, leaning towards his/her left side. There was no indication in the medical record that Resident #26 was utilizing his/her rolling walker at the time of the fall. Review of the medical record failed to include a falls packet, referral/screen to rehab services, CNA statements, falls assessments, or interventions implemented to reduce the risk of falls. - 8/15/22 at 5:45 P.M.: Resident #26 had an unwitnessed fall. The Resident was found lying on his/her back on the floor at nurses' station, behind the closed gate with his/her feet up resting against counter and his/her head against the wall. (The gate is affixed to the nurses' station and acts as a barrier to deter wandering residents from entering the nurses' station). There was no indication in the medical record that Resident #26 was utilizing his/her rolling walker at the time of the fall. Review of the medical record failed to include a falls packet, referral/screen to rehab services, CNA statements, falls assessments, or interventions implemented to reduce the risk of falls. During an interview on 8/18/22 at 2:20 P.M., the Director of Nursing said, I do not have completed investigations for Resident #26's falls. The investigations were not completed because management and I have been working on med carts. During an interview on 8/23/22 at 09:30 A.M., the Rehab Manager said, no rehab screens were conducted for the four falls Resident #26 had on 5/28/22, 5/29/22, 7/17/22 and 8/15/22. 9.) Resident #37 was admitted to the facility in December 2020 with diagnoses that included: [CONDITION(S)]/[CONDITION(S)], bilateral lower extremity [CONDITION(S)], and vascular wounds. Review of the Minimum Data Set (MDS) assessment, dated 6/7/22, indicated Resident #37 had a Brief Interview [TRUNCATED]

Based on observation, interviews, record review, and policy review, the facility failed to ensure staff identified, addressed, and monitored significant weight changes for six Residents (#56, #71, #78, #79, #49, and #87) with unplanned, insidious (gradual), and/or significant weight changes, out of a total sample of 27 residents. In addition, the facility failed to weigh residents upon admission and not use hospital weights to conduct nutrition assessments, weigh residents according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, the facility failed to: 1. Resident #56, reweigh the resident to ensure accurate weights, and failed to provide nutrition interventions when there was a significant weight loss; 2. Resident #71, weigh the resident upon admission and not use the hospital weight to conduct an initial assessment, weigh the resident weekly per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Resident #78, weigh the resident upon admission and not use the hospital weight to conduct the initial assessment, weigh the resident weekly per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Resident #79, weigh resident weekly per recommendation of the dietitian, and provide nutrition interventions to prevent further weight loss when the resident experienced significant weight loss; 5. Resident #49, implement nutrition recommendations to prevent further weight loss and; 6. Resident #87, weigh the resident upon admission and not use the hospital weight to conduct an initial assessment, weigh the resident weekly per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's policy titled Weight Policy, reviewed on 2/15/22, indicated the following: POLICY: Weight can be a useful indicator of nutritional status, when evaluated within the context of the individual's personal history and overall condition. When weighing a resident, adjustment for amputation or prostheses may be indicated. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. PROCEDURE: -Each resident shall be weighed on admission or readmission (to establish a baseline weight), weekly for the first four (4) weeks after admission and a least monthly thereafter to help identify and document trends such as insidious weight loss. -Monthly weights should be obtained by the 10th day of the month, or a date set by the Director of Nursing service. -The last weight in the hospital may differ markedly from the initial weight upon admission to the facility and is not to be used in lieu of actually weighing the resident. -Weights may be ordered more frequently if there is a significant change in condition, food intake has declined and persists (more than one week), or there is other evidence of alternated nutritional status or fluid and electrolyte imbalance. -The type of scale used for the initial weight should be noted (wheelchair or bed scale), it also should be noted if the resident is wearing or not wearing orthotics or prostheses. -Any significant change in weight compared to the previous weight should be rechecked and visually verified for accuracy by the nurse on duty before being documented in the medical record. -The dietitian, physician and responsible party should be notified of the significant weight change. 1. Resident #56 was admitted to the facility in September 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #56, dated 3/7/22, indicated the Resident required limited assistance, with one person physical assist for eating, and the Resident was 65 inches tall and weighed 134 pounds. The surveyor made the following observations of Resident #56. - On 8/18/22 at 11:59 A.M., the Resident was observed being fed by staff and ate 100% of the meal. -On 8/22/22 at 12:25 P.M., the CNA brought the Resident into his/her room and fed the Resident. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident's weights indicated the following: *1/3/22-125.2 pounds *2/2/22 132.4 pounds *3/3/22 134.0 pounds *3/9/22 128 pounds *4/13/22 and 4/20/22 130 pounds *5/2022 no weight documented *6/6/22 126 pounds *6/15/22 125 pounds *7/4/22 131 pounds *7/20/22 122.2 pounds (crossed out) *7/28/22 128 pounds *8/19/22 121.6 pounds *8/22/22 125.8 pounds Review of the Resident's Nutrition Assessment, dated 6/29/22, indicated the Resident was 65 inches tall and weighed 125 pounds (indicating minor weight change of 2.2% in 6 months). The Dietitian documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nutrition Progress Note, dated 7/27/22, indicated the Resident weighed 122.2 pounds, reflecting a 6.7% significant weight loss. The Dietitian requested that the Resident be reweighed. Review of the Nutrition Progress Note, dated 8/9/22, indicated the Dietitian documented that the 122.2 pounds was determined to be inaccurate and was crossed out on the Resident's weight log. Review of the medical record indicated the Resident was hospitalized for repair of left [CONDITION(S)] and was readmitted to the facility in August 2022. The Dietitian completed the assessment with a weight of 128 pounds which was obtained on 7/28/22. The Dietitian documented that she was waiting for a readmission weight. Review of the Resident's weight log, dated 8/19/22, indicated the Resident's readmission weight was 121.6 pounds, and reflected a significant weight loss of 6.4 pounds (5%) within 30 days. Further review of the weight log indicated the Resident was weighed on 8/22/22 and weighed 125.8 pounds. There was a delay in obtaining the readmission weight by 7 days and the Dietitian failed to reassess the Resident's nutritional needs based on the most current weight of 121.6 pounds and provide a change in the Resident's plan to prevent further weight loss. During an interview on 8/22/22 at 2:00 P.M., the Dietitian said she was not aware of the Resident's weights that were obtained on 8/19/22 and 8/22/22. The Dietitian said she did not know if the Resident was wearing the leg brace when the staff weighed him/her. The Dietitian said she was having difficulties obtaining weights including admission, readmission, and reweighs. During a subsequent interview on 8/23/22 at 10:00 A.M., the Dietitian said the Resident was weighed while wearing the left leg brace, but it was not documented on the weight log per facility policy. The dietitian said she was not sure of the Resident's true weight, or if the Resident had a weight change greater than first identified. 2. Resident #71 was admitted in April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 4/9/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The MDS also indicated the Resident was independent for eating and weighed 126 pounds. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - 4/2/22, prescribed a house diet. - 4/6/22, a new order for the Resident to receive a one time a day snacks per patient request. - 5/3/22, a new order for weekly weights. Review of the Resident's weights indicated the following: admission weight 126.0 pounds (obtained from Hospital discharge summary) 4/26/22- 134.8 pounds 6/15/22- 126.2 pounds 6/30/22- 119.4 pounds (5% weight loss in 30 days and 10% weight loss since 4/26/22) 7/6/22- 119.4 pounds 7/19/22- 119.4 pounds 7/20/22- 119.4 pounds 8/3/22- 118.2 pounds 8/19/22- 119.8 pounds The facility failed to weigh the Resident weekly per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Nutrition Assessment, dated 4/8/22 (completed on 4/11/22), indicated the Resident was able to feed him/herself, but required encouragement and cues for self-feeding. The Dietitian documented the Resident was 65 inches tall, weighed 126 pounds (hospital acquired weight), and required 1716-2020 calories, 56-69 grams protein to meet their nutritional needs. The Dietitian further documented the Resident's family had requested Ensure Plus and was waiting for staff to obtain an admission weight on the Resident. The Dietitian documented the goal was to prevent weight loss, and recommended a change in supplements to Ensure Plus, once a day, and may benefit from appetite stimulant. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Dietitian's Progress Note, dated 5/2/22, indicated the Resident required increased calorie and protein due to compromised skin integrity and poor appetite/intake. The Dietitian reviewed the Resident's weights indicating an increase in weight with the most recent weight of 134 pounds on 4/26/22. The plan was to increase Ensure Plus to two times a day and continue weekly weights for assessment of weight trends. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nutrition Progress notes, dated 6/30/22, indicated the Resident's most recent weight was 119.4 pounds, representing an 11.4% significant weight loss. The Dietitian documented that she had requested the Resident be reweighed. Review of the Nutrition Progress Note, dated 7/12/22, indicated that a reweigh was obtained with similar results, however she questioned the accuracy related to the staff's weighing methods. The plan was to continue with current plan of care and follow at risk. Review of the Quarterly Nutrition Assessment, dated 7/5/22 (completed on 7/12/22), indicated the Resident weighed 119 pounds, representing an 11.4% weight loss since 4/26/22. The Dietitian documented that she questioned the weight change with the Resident's improved intake, however questioned accuracy with weighing method and unable to ascertain previous weighing methods. The documented plan was to continue with current plan of care. Review of the Dietitian's Progress Note, dated 8/19/22, indicated the Resident continues to trigger for significant weight loss, however observed stable times two months. The Dietitian documented to continue with current plan of care. Review of Resident #71's meal percentage intake indicated the following: May 2022- 26 of 31 days were left blank June 2022- 14 of 30 days were left blank July 2022 - August 2022 completed and reflected the Resident ate fair to good (50-100%) The Dietitian failed to address the Resident's continue significant weight loss and provide interventions to prevent further weight change. 3. Resident #78 was admitted in September 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had hospitalization s for [CONDITION(S)] in March 2022 and July 2022, and aspiration pneumonia in March 2022. On 8/18/22 at 7:55 A.M., the Resident was observed sitting in bed, with the head of the bed elevated. The Resident was alone and not supervised or assisted for meals as per the plan of care. On 8/18/22 at 11:45 A.M., Resident #78 was observed eating while the CNA was setting up the resident's lunch tray. The tray consisted of double portion entree, mashed potato, puree vegetable and ground meat with gravy. Resident attempted to feed self with a few bites. CNA assisted resident with the rest of the meal. Resident consumed 100% of meal. Review of the Nutrition Care Plan, dated 9/19/21, with revisions on 4/4/22, indicated the Resident was at actual/potential nutrition risk with a history of aspiration pneumonia, [CONDITION(S)] affecting left side, diabetes and oropharyngeal phase dysphagia requiring altered mechanical textures, GI bleed, [CONDITION(S)] with delusions, long term use of insulin, ?obese with variable weight trends indicating significant loss. Increased needs related to skin integrity with wounds. -Interventions include: -Continue to encourage and promote selection of high protein foods to improve/protect skin integrity -Continue to update preferences for increased acceptability meals -HCC (house consistent carbohydrate), moist ground texture with extra moist, thin liquids, large portions -Monitored labs as ordered -Monitor PO intake -Monitor skin assessment -Monitor weight per facility policy -Provide medication as ordered Review of the MDS assessment, dated 3/19/22, indicated the Resident had a loss of liquids/solids when eating, difficulty holding food in mouth, cough/choking during meals or when swallowing. The MDS also indicated the Resident was 73 inches tall and weighed 244 pounds. Review of the clinical record, dated 3/23/22, indicated that there was a new order for the Resident to be weighed weekly. Review of the weight history indicated the following: -3/14/22-(readmission weight) 243.6 pounds -3/24/22-238 pounds -4/26/22-236.4 pounds -6/30/22-225 pounds -7/24/22-223 pounds -7/28/22-218 pounds -8/3/22-214 pounds The facility failed to weigh the Resident weekly per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS assessment, dated 6/14/22, indicated the Resident had a loss of liquids/solids when eating, difficulty holding food in mouth, cough/choking during meals or when swallowing. The MDS also indicated the Resident was 73 inches tall, but the weight section was left blank. Review of the Nutrition Assessment, dated 6/16/22 (completed on 6/23/22), indicated the Resident was 75 inches tall and weighed 236.4 pounds (last known weight 4/26/22). The Dietitian recalculated the Resident's calorie and protein needs as follows: 2325-2790 calories and 140-186 grams protein. The Dietitian documented the Resident had a downward weight trend on the past quarter, triggered for significant change (-13.1%) since 10/18/21. The Dietitian documented some weight loss likely accurate but question the extent of the weight loss and documented awaiting weight for assessment of weight trends. The Dietitian indicated that as of 6/20/22 the Resident had a stage three (3) pressure ulcer to the right heel, with improved venous ulcer of left lower leg. The Dietitian recommended to increase Glucerna (sugar free supplement) to three times a day to support stable weight and wound healing. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nutrition Care Plan, dated 6/23/22, indicated an addition of nursing staff/CNA to assist with feeding and monitoring aspiration-requires extensive assistance. Review of the Nutrition Progress Note, dated 7/22/22, indicated the Resident had been discharged from the facility with anticipated return (hospitalization ,d+[DATE]-[DATE]). The Dietitian documented that the most recent weight (6/30/22) 225# was a trigger for significant weight loss (-10.7% since 1/5/22). The Dietitian documented that the Resident received Glucerna, three times a day, and large portions with usually good acceptance. The Dietitian documented that the Resident did appear visibly thinner extremities. There was no documented plan to address the Resident's additional weight loss. Review of the Readmission Nutrition Assessment, dated 7/26/22, indicated the Resident weighed 223 pounds, which continued to trigger for significant weight loss in 6 months. The Dietitian documented the current weight confirmed the significant weight loss was accurate despite interventions. The Registered Dietitian documented that although the Resident was overweight the goal is for stable trends, desirable weight loss acceptable however focus on gradual vs rapid should occur, would benefit the Resident's diabetic status. The Resident still had a stage three (3) pressure ulcer on the right heel and open wound on the sacrum. Despite the ongoing significant weight loss, there were no new interventions to prevent the weight loss from continuing. During an interview on 8/24/22 at 11:30 A.M., the Dietitian said she was not aware of the Resident's weights obtained on 7/28/22 and 8/3/22, representing an additional nine pound weight loss. She said she does have problems obtaining weekly weights and requests for the resident to be reweighed, if the weight does not appear accurate. The Dietitian said the Resident's weight loss was not planned. 4. Resident #79 was admitted to the facility in April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record indicated the following weights were obtained for Resident #79: -4/13/22- 105 lbs. (pounds) - 4/19/22- 102.8 lbs. - 4/20/22- 102.8 lbs. - 5/2/22- 103.2 lbs. - 5/18/22- 102 lbs. - 6/15/22- 101.6 lbs. - 7/8/22- 103.2 lbs. - 7/20/22- 97.6 lbs. (flagged in electronic medical record as a -5% change in weight) - 7/27/22- 95.4 lbs. (flagged in electronic medical record as -7.6% change in weight) - 8/19/22-96.8 lbs. - 8/24/22- 97.2 lbs. Review of the Dietitian's Recommendations, dated 7/18/22, indicated the Resident be started on the nutritional supplement Ensure Plus daily at 2:00 P.M. for additional protein. The Dietitian recommendation indicated a slight/gradual decrease in weight was observed since admission. The goal was to prevent further loss and to maintain stable weights. The recommendation was approved by the physician and documented as filed by the nurse. Review of the Dietitian's Note, dated 7/17/22, indicated Resident #79 had a 7.6% weight loss. The note indicated to continue the nutritional supplement Ensure Plus daily at 2:00 P.M. that was recommended on 7/18/22. Further review of the documentation in the medical record by the dietitian, dated 7/21/22, indicated the Resident triggered for significant weight loss and required close monitoring. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/22, the Dietitian recommended Resident #79 be weighed weekly due to a downward trend triggering significant weight loss at this time. The Resident per the dietitian note required close monitoring. Review of the meal percentage sheets (sheets that indicate how much the Resident eats at mealtime) indicated no documented evidence for meal intake for the following: - May 2022- 25/31 days with no documented evidence of meal intake - June 2022- 15/30 days with no documented evidence of meal intake - July 2022- 6/31 days with no documented evidence of meal intake Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5.) Resident #49 was admitted to the facility in September 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 6/21/22, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating the Resident had moderately impaired cognition, required supervision and set up with eating, and was 63 inches tall. The resident's weight section was left blank. Review of Resident #49's weights indicated the following: 1/26/22- 111 pounds 2/2/22- 110 pounds 2/28/22- 106.8 pounds 4/13/22- 105 pounds 4/20/22- 104.8 pounds 5/18/22- 105.4 pounds Review of the Medical Nutrition Therapy assessment dated , 6/27/22, completed by Dietitian #1 indicated Resident #49's weights had been trending down without significant loss. The Dietitian used the most recent weight of 105.4 pounds to conduct the assessment. The Dietitian indicated Resident #49 was receiving Mighty Shakes twice per day. The Dietitian made recommendations to increase the Mighty Shakes to three times per day and left the recommendation form in the MD binder. Record review indicated the Dietitian's recommendations had been signed by the Nurse Practitioner and then signed by Nurse #5 on 6/30/22. Review of the current August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order to increase Mighty Shakes to three times per day had not been implemented. During an interview on 08/23/22 at 12:47 P.M., Nurse #1 said that every provider has their own binder for facility staff to leave requests and/or recommendations. When a provider comes to the facility, they check the binder and approve or deny any requests or recommendations. Then, a facility nurse will transcribe orders as indicated and file the recommendations in the resident record. During an interview on 8/23/22 at 1:00 P.M., Nurse # 5 said I signed that recommendation after the Nurse Practitioner approved it, I should have transcribed it into his/her orders. Nurse #1 indicated that she would follow up with the Dietitian. During an interview on 08/23/22 at 12:15 P.M., the Dietitian said she is aware that Resident #49's weight is trending down, but it has not been significant. She left a recommendation to increase nutritional supplements in the MD book. The Dietitian said she does not follow up on her recommendations to ensure that they have been approved and implemented. Further review of Resident #49's weights indicated that he/she continued to have weight loss as follows: 6/29/22- 102.8 pounds 7/27/22- 103 pounds 8/3/22- 101.8 pounds 6. Resident #87 was admitted in April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 7/28/22 indicated Resident #87 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the clinical record, dated 6/22/22, indicated new orders for weight every week for four weeks initiated 6/22/22, and a second order written 7/27/22 for continued weekly weight due to nutritional risk/poor intake. Review of Resident #87's weight history indicated the following: 4/19/22 148.8 pounds (lbs.) (Hospital record) 5/5/22 133.0 lbs. 5/19/22 127.4 lbs. 5/31/22 123.6 lbs. 5/31/22 123.6 lbs. 6/10/22 126.8 lbs. 6/21/22 125.6 lbs. 7/28/22 114.0 lbs. (9.2% weight loss past 30 days since 6/21/22 loss of 11.6 lbs.) 8/17/22 108.6 lbs. 8/19/22 108.6 lbs. (14.6% weight loss past two months since 6/21/22 loss of 17 lbs.) Review of Resident #87's current care plan indicated but was not limited to the following: Nutrition: -Resident presents with actual or potential nutrition risk related to past medical history severe protein, hypertension, [CONDITION(S)] [CONDITION(S)], difficulty walking and lack of coordination (reduce mobility), stage three pressure ulcer of the right heel, history of [CONDITION(S)], [CONDITION(S)], GERD, low body mass index indicating underweight status and multiple wounds with compromised skin integrity -Presenting with questionable weight trends exhibiting significant losses in the past quarter, continues with losses despite interventions in place. -Presents with increased protein and calorie needs to protect and promote wound healing date initiated 6/27/22 Goal: 1. Will continue to tolerate diet 2. Will consume 50% or more of offered foods, beverages, and supplements with adequate hydration with focus on protein rich foods and snacks 3. Improve skin integrity and wound healing 4. Will maintain labs/body mass as able 5. Will maintain stable weight trends, prevent losses as able with true gains acceptable should they occur Plan: 1. Provide diet as ordered house diet with regular textures thin liquid consistencies for max choice/intakes 2. Provide vitamins as ordered 3. Honor food preferences as able to promote acceptance/good intakes: yogurt with all meals 4. Provide supplements as ordered: Pro-stat 30 mL (milliliters) twice a day, Magic cup twice a day, Ensure Clear Liquid once a day 5. Monitor skin /labs /BMI /weight/ intake as ordered 6. Provide medications as ordered 7. Continue to promote/encourage selection of protein-rich food /snacks. Review of the Nutrition Intake Record binder (record of resident meal intake for breakfast, lunch, and dinner) from April through August 2022 indicated no meal intake was recorded for Resident #87 for 57 days and only partially filled out for seven days. Reviewed the Nursing Flow Sheets for June, July, and August 2022 which also recorded meal intake for breakfast, lunch, and dinner indicated there was no meal intake for 47 days and only partial meal intakes for eight days. In addition, the days that overlapped recording meal intake with the Nutrition Intake Record binder, the recording did not consistently match for percent meal consumed. Review of the Medical Nutrition Therapy Assessment, dated 4/28/22, indicated but was not limited to: -Height 69.0 inches, weight 148.8 lbs. (Hospital record) -Diet to include 2 grams no salt added with regular texture and thin liquid -Denies chewing and swallowing at his time -Resident reports good appetite 75-100%, enjoys meals -Most recent weight 148.8 lbs. (Hospital) used for this assessment. Recommend to provide. -Continue to encourage adequate hydration and protein rich meals/snacks -Magic cup twice a day with lunch and dinner for additional protein and calories Review of the Medical Nutrition Therapy Assessment, dated 6/23/22, indicated but was not limited to: -Average food beverage intake is averaging more than 50% in the last 7 days. -Height 69.0 inches, weight 125.6 lbs. recorded 6/21/22 -Diet to include house regular texture and thin liquids, approbate for max choice/intake. -Denies chewing and swallowing at his time -Documented intake of 75% at this time -Resident reports improved oral intake, previously poor however close monitoring required due to history of false reporting. -[MEDICATION(S)] ([MEDICATION(S)]), appetite stimulant. -Pro-stat twice daily for wound healing. Yogurt provided with all meals; kitchen updated. -Most recent weight 6/21/22 was 125.6 lbs. and continues to trigger for significant weight loss 15.6%, 23.2 lbs. since 4/19/22 148.8 lbs. (hospital weight) -Continued diet, vitamins and supplements as ordered. Recommend to also provide Magic cup twice daily for increased protein and kcal, encourage adequate hydration and protein-rich meals/snacks. Review of Medical Nutrition Therapy Assessment, dated 7/26/22, indicated but was not limited to: -Average food beverage intake is averaging more than 50% in the last 7 days. -Weight loss of 9.2% for 1 month and weight loss of 23.4 % for 6 months. -Resident presenting with questionable weight trends triggering for significant losses however unable to determine accuracy of the trends. -House regular texture and thin liquids, appropriate for max choice/intake. -Staff interview presenting with poor oral intake, however Resident continues to report good oral intake- previously variable between poor/good, however close monitoring required to related to history of false reporting. -[MEDICATION(S)], appetite stimulant -Potential decline in appetite recently related to active urinary tract infection, oral intake encouraged and resident states he/she will try their best. -Continues multiple supplements for wounds/support of stable weight trends -Pro-stat 30 mL twice daily, Ensure Clear Liquid once daily and Magic cup twice daily. Yogurt also with all meals for included protein and calories -Most recent weight 7/28/22 was 114 lbs. and at this time continues to trigger for significant losses from hospital weight and now in the past one month -Nursing recent downward trend related to unit change and in different scales used -Dietitian awaits further weights. -Resident did accurately present with some losses initially upon admission however unable to determine verify extent of triggered losses. -Continue to encourage oral intake and hydration will monitor. Review of history of nutritional supplements Resident has received: -Magic Cup two times a day for additional kcals and protein for improved skin/wound healing initiated 04/29/22 -Ensure Plus one time a day for diet initiated 06/04/22 and changed to Ensure Clear Liquid Ensure Clear Liquid 07/27/22 -Promod (liquid protein fruit punch) 30 ML one time a day initiated 06/02/22, discontinued 06/15/22 -[MEDICATION(S)] Tablet ([MEDICATION(S)]) Give 7.5 mg by mouth at bedtime for appetite stimulant initiated 06/03/22, increased [MEDICATION(S)] Tablet to 15 MG 07/17/22 -Pro-Stat Liquid (liquid protein drink) Give 30 ml by mouth two times a day initiated 6/21/22 During an interview with Resident #87 and Family Member #2 on 8/23/22 at 12:30 P.M., Resident #87 said, The food is not that good; like today he/she was having trouble cutting the ham and chewing it. The Resident said he/she often has a hard time eating the meat because it is tough. The Resident continued to say he/she has been asking to make meal selections, and they finally gave him/her a menu to fill out. Family Member #2 added the Resident needs help filling out the menu or it won't get done. The Resident said sometimes he/she gets a yogurt to eat, but not always and said if the Magic Cup is not open, he/she can't get it open because of the arthritis in their hands. A Certified Nursing Assistant came in to take the tray away and the Magic Cup which remained unopened. Family Member #2 stopped the tray from being removed and took off the cover and the Resident started eating it. Resident #87 said if he/she had their choice of a meal it would be a turkey dinner with all the fixings, fresh fish, or pizza. Resident #87 said the food is not that good here. During an interview on 8/24/22 at 2:00 P.M., the Dietitian said she is aware Resident #87 continues to show significant weight loss despite dietary supplement in place, including Magic cup twice daily, Pro-stat liquid protein twice daily, Ensure Clear liquid once daily and yogurt provided at every meal. The Dietitian said she was also aware the Resident was not being weighed weekly as ordered by the physician and she has repeatedly asked for the weights but is not getting them. In addition, she said the meal percentages are not being consistently filled out and she relies on asking the staff or the Resident for information on how much f

Based on observation, record review, and interviews, the facility failed to follow their policy and implement an individualized comprehensive plan of care to promote optimal healing and the prevention of a facility acquired unstageable left heel ulcer for one Resident (#87), out of a total sample of 27 residents. Specifically, the facility failed to: 1) Reposition the Resident every two hours, correctly off-load the Resident's heels, and ensure the Resident wore bilateral Prevalon boots per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2) Ensure the air mattress is set to the Resident's correct weight; and 3) Perform weekly skin assessments. Findings include: Review of the facility's policy titled Pressure Ulcer Injury Prevention Program, dated 2/18/22, indicated but was not limited to the following: Policy: Point Group care shall have a system in place that assures observations are timely and appropriate interventions are implemented and monitored and revised as appropriate and changes in condition are recognized evaluated reported to the resident's attending practitioner and other health care professionals as appropriate. -The facility shall provide care and treatment and services to: -Promote the prevention of pressure ulcer development -Promote the healthy healing of pressure ulcers that are present including prevention of infection to the extent possible -Prevent development of additional pressure areas The facility's pressure ulcer injury prevention treatment program shall include: -Implementing individualized comprehensive plan of care interventions to help stabilize/ reduce underlining risk factors with each dressing change or at least weekly the pressure ulcer injury wound shall be assessed and documented: -Date, location of ulcer and staging, size, depth of the pressure ulcer injury wound, presence location, and extent of any undermining or tunneling sinus /tract and the presence of extradites the type, color, odor, amount, pain. -Description of the wound and edges and surrounding tissue rolled edges, redness, hardness, maceration, and description of healing pressure ulcer. Residents who are dependent on staff for repositioning: -Reposition the resident every two hours and as needed depending on the resident's condition -A turning schedule shall be followed and documented on the 24-hour flow sheet -Use pressure redistributing devices i.e., gels, air fluidized mattresses, low air mattresses, four-inch convoluted foam, when appropriate -To reduce pressure effectively always follow manufacturer's instructions for these devices. -Sheepskin heel and elbow protectors are not effective at redistributing pressure; they provide comfort and reduce friction and shearing forces; they may be used to prevent bony prominence's from rubbing together. -Place a pillow under the resident's lower leg suspending the heels to decrease the pressure placed on the resident's heels Resident #87 was admitted in April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 7/28/22, indicated Resident #87 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. In addition, it indicated the Resident's height to be 69 inches and weight to be 114 pounds. Review of Resident #87's current Skin Care Plan indicated but was not limited to the following: Actual alteration in skin integrity related to unstageable wound right heel, excoriated coccyx (bottom), wounds bilateral lower extremities, and wound top of the left foot. -Resident will have improved skin integrity as evidenced by signs and symptoms of healing within the next 90 days. Interventions: -Assess for pain/comfort level as needed prior to dressing change and medicate per physician order -Consult and treatment by certified wound physician or nurse as needed -Dietary intervention -Follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Monitor for signs of infection and report to physician and obtain treatment. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 5/23/22, indicated a new unstageable deep tissue injury was located on the left heel. The visit note further indicated the wound size was 2.9 cm length x 3.2 cm width with no depth measured. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 6/01/22, indicated an unstageable deep tissue injury was located on the left heel. The visit note further indicated the wound size was 4.0 cm length x 3.2 cm width with no depth measured. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 6/06/22, indicated an unstageable deep tissue injury was located on the left heel. The visit note further indicated the wound size was 4.0 cm length x 3.2 cm width with no depth measured. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 6/27/22, indicated an unstageable deep tissue injury was located on the left heel. The visit note further indicated the wound size was 4.4 cm length x 3.2 cm x 0.1 cm depth. Small amounts of serous exudate present. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 7/6/22, indicated a now unstageable necrotic pressure ulcer was located on the left heel. The visit note further indicated the wound size was 4.0 cm length x 3.0 cm width with no depth measured. Small amounts of serous exudate present. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 7/18/22, indicated an unstageable necrotic pressure ulcer was located on the left heel. The visit note further indicated the wound size was 3.0 cm length x 2.5 cm width with no depth measured. Small amounts of serous exudate present. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 8/1/22 indicated an unstageable necrotic pressure ulcer was located on the left heel. The visit note further indicated the wound size was 4.5 cm length x 2.5 cm width with no depth measured. Small amounts of serous exudate present. The wound was not improved. Review of the Wound Care Specialist's Follow-Up Visit note for Resident #87, dated 8/15/22, indicated an unstageable necrotic pressure ulcer was located on the left heel. The visit note further indicated the wound size was 3.4 cm length x 2.4 cm width with no depth measured. Small amounts of serous exudate present. The surveyor observed throughout the entire survey (8/16/22 through 8/24/22), Resident #87 was positioned in bed lying on his/her back with a neck roll behind his/her neck. The left foot had a Prevalon boot that was observed to be twisted on left foot on multiple days. The Resident's air mattress was observed to be set on 325 throughout the survey and his/her current weight is 108.6 lbs (recorded on 8/19/22). 1) Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Prevalon boots to bilateral lower extremities for improved off-loading During an interview on 08/16/22 at 12:48 P.M., Resident #87 said he/she has a big sore on the left foot, and he/she has to wear this big boot. The surveyor observed the left foot had a Prevalon boot that was twisted, not properly positioned, with his/her foot up on a pillow. During an interview on 08/17/22 at 03:05 P.M., the surveyor observed Resident #87 wearing a Prevalon boot on their left foot. The Prevalon boot was twisted and not properly positioned on the foot. During an interview on 08/18/22 at 10:40 A.M., Resident #87 said no one has come in to wash him/her up today, he/she said they have been lying in bed all morning. Resident #87 said no one has repositioned him/her this morning. The surveyor observed the left Prevalon boot to be in a poor position on the left foot. During an interview on 08/18/22 at 12:20 P.M., Certified Nursing Assistant (CNA) #9 said she just finished providing morning care for Resident #87 which included washing and changing him/her. On 08/22/22 at 10:45 A.M., Resident #87 was observed lying flat on his/her back. On 08/22/22 at 12:29 P.M., Resident #87 was observed lying flat on his/her back with neck roll behind his/her neck. On 08/22/22 at 05:35 P.M., Resident #87 was observed lying flat on his/her back with the neck pillow behind his/her neck. The Resident was not wearing the Prevalon boot, it was on the chair across the room. The surveyor observed the left heel resting directly on the air mattress and not off-loaded. During an interview on 08/23/22 at 09:35 A.M., Resident #87 said Unit Manager #1 took the boot off yesterday and never put it back on. The surveyor observed the left heel weight bearing directly on the air mattress. The Resident was lying directly on his/her back with the neck roll behind his/her neck. The surveyor asked Resident #87 if he/she could off weight the left heel off the mattress. Resident was observed making multiple attempts, but said he/she was unable with the blankets covering his/her legs. On 08/23/22 at 11:15 A.M., the surveyor observed Resident #87 lying flat on his/her back and the Prevalon boot on the chair. The surveyor observed the Resident's left heel lying directly on the air mattress. During an interview on 08/23/22 at 10:50 P.M., Nurse #3 said the Certified Nursing Assistants are supposed to reposition all residents every two hours and document it in the CNA flow book. 2) Review of the facility's policy titled Low Air Loss Mattress Guidelines, dated 2/3/22, indicated but was not limited to the following: Low air loss mattress uses indicated as follows: -To assist in the prevention of pressure ulcers as part of a holistic program of pressure ulcer management Settings: -The patient weight indication is a close approximation of correct setting if the mattress is too soft or firm simply press up or down arrow to adjust as necessary for patient comfort wait between set points for mattress stabilization. Linens: -Should be used as minimally as possible, fitted sheet is preferable, and breathable under pads. On 08/16/22 at 12:48 P.M., the surveyor observed Resident #87 lying on his/her back in bed. The air mattress had bolster sides and the pressure was set on 325. During an interview on 08/17/22 at 03:05 P.M., Resident #87 said I have this air mattress with these things on the sides and I can't roll at all. Resident #87 was observed lying on his/her back in bed. The air mattress had bolster sides and the pressure was set on 325. On 08/18/22 at 10:40 A.M., the surveyor observed Resident #87 on his/her back in bed. The air mattress had bolster sides and the pressure was set on 325. On 08/22/22 at 10:45 A.M., the surveyor observed Resident #87 lying flat on his/her back and the air mattress was set on 325. During an interview on 08/22/22 at 12:29 P.M., the Resident said the air mattress was okay, he/she didn't like the side panels because it made it difficult to move him/herself in bed. The surveyor observed Resident #87 lying on his/her back and the air mattress setting to be on 325. On 08/22/22 at 05:35 P.M., the surveyor observed Resident #87 lying flat on his/her back with the neck roll behind his/her neck. The air mattress was set at 325. On 08/23/22 at 11:15 A.M., the surveyor observed Resident #87 lying flat on his/her back. The air mattress was set at 325. During an interview on 08/23/22 at 01:30 P.M., the Maintenance Director said the contracted company comes in and sets up the air mattress and sets the setting at 325 for max inflate to fill the bed quickly, the nurses need to set it to the resident's weight. During an interview on 08/23/22 at 1:00 P.M., the Staff Development Coordinator (SDC) said there should be physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Maintenance sets up the mattress. The nurses monitor the mattress and document on the treatment record the air mattress is on the right setting and working properly every shift. The surveyor informed the SDC Nurse that Resident #87's air mattress has been set on 325 throughout the survey and the Resident's current weight is 108 lbs. Review of Resident #87's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) Review of weekly skin checks for Resident #87 indicated that since admission the Resident only had weekly skin checks on the following dates: - 4/29/22, 5/6/22, 5/13/22, 5/20/22, and 5/27/22 There were no weekly skin assessments performed after 5/27/22 to check for impaired skin and monitor current open areas and skin concerns, a total of 12 weeks of missing assessments. During an interview on 08/23/22 at 01:05 P.M., the surveyor informed the Director of Nurses of observations made throughout the survey relative to Resident #87 positioning in bed, the left heel not being off-loaded and the Prevalon boots being worn incorrectly, the incorrect setting on the air mattress and the missing weekly skin assessments for the past 12 weeks. The Director of Nurses said the air mattress is a pressure relieving device and the nursing staff should adjust the settings and should be monitoring the function of the mattress. She said she is aware there has been a problem with assessments being completed.