Every finding on record at Care One at Lowell

Based on record review and interview, the facility failed to ensure that one Resident (#81) was free from significant medication errors out of a total sample of 31 residents. Specifically, the facility failed to ensure insulin was not administered when Resident #81's blood sugar was not within the parameters prescribed by the physician.Findings include:Resident #81 was admitted to the facility in March 2025 with diagnoses that included type 2 diabetes mellitus, cerebral infarction, major depressive disorder and insomnia. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 8 out of 15, indicating moderate cognitive impairment. The MDS further indicated the use of insulin injections. Review of Resident #81's active care plan indicated the following-Endocrine system related to Insulin Dependent Diabetes, hypothyroidism, dated as revised 3/7/25, with interventions that included administer medications per physician orders and to obtain glucometer readings and report abnormalities as ordered. Review of active physician's orders indicated the following:-Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine), Inject 5 unit subcutaneously at bedtime for DM2 (diabetes) hold if fsbs (fasting blood sugar) is less than 120 related to diabetes, dated 4/8/26. Review of the May 2026 Medication Administration Record MAR) indicated the following:-On 5/11/26 the Resident's blood sugar was documented as 111, and Lantus insulin was signed off as administered. Review of blood sugar results in the electronic medical record indicated the following:-A blood sugar of 111 on 5/11/26 at 9:07 P.M. Review of Resident #81's progress notes indicated the following:-An Orders - Administration Note, dated, 5/12/26 at 12:00 A.M., which indicated BS [blood sugar] 78 at 12:00A, glucose given, will continue to monitor. [sic]-An Orders- Administration Note, dated 5/12/26 at 5:30 A.M., which indicated BS 72 at 5:30A, glucose given. [sic] Resident #81 was unable to participate in an interview. During an interview on 5/13/26 at 1:22 P.M., Nurse #8 said that Resident #81 is a brittle diabetic and has a tendency to have his/her blood sugars drop. Nurse #8 said that if Resident #81's blood sugar is below 120 then the insulin should not be given as indicated in the physician's orders. She said that if insulin is given outside of the parameters there is the potential for the blood sugar to drop too low causing symptoms of hypoglycemia (low blood sugar) for the Resident. During an interview on 5/14/26 at 7:52 A.M., Nurse #5 said that on 5/11/26 he worked and took care of Resident #81. He said that he administered 5 units of Lantus insulin at bedtime. He said that the Resident's blood sugar was 111. Nurse #5 said at the time of the insulin administration, the Resident was having a snack of cookies and juice. During an interview on 5/14/26 at 8:04 A.M., the Director of Nurses said that the insulin should not have been given below the indicated parameter in the physician's order. She said administering the insulin outside of the parameter has the potential to cause the Resident's blood sugar to drop. She said that Resident #81 is sensitive to the medications and has the potential to have his/her blood sugars drop. During an interview on 5/14/26 at 8:35 A.M., Nurse #7 said that she worked overnight into the morning of 5/12/26. She said that Resident #81 asked a staff member to get the nurse because he/she felt like their blood sugar was low. Nurse #7 said that Resident #81's blood sugar has dropped before, so she went in and checked the blood sugar immediately. Nurse #7 said that Resident #81's blood sugar was 78 and because the Resident felt like they were low she gave him/her a snack of pudding and apple juice. Nurse #7 said she monitored the Resident throughout the night, and again at 5:30 A.M., the reading was low, and she gave the Resident another snack of juice and pudding. Nurse #7 said it is possible that the Resident had low blood sugars that night because the bedtime insulin was administered outside of the parameters indicated in the physician's order. During a follow up interview on 5/14/26 at 8:44 A.M., the Director of Nurses said that administering Resident #81's insulin on 5/11/26 would be considered a medication error. During an interview on 5/14/26 at 8:53 A.M., Nurse Practitioner #1 said that she would expect the nursing staff to follow the physician's order and hold the insulin based on the parameters indicated in the order. She said that this would be a medication error. The Nurse Practitioner said that she was not aware of the need for nursing to administer snacks overnight on 5/12/26 to manage low blood sugars, but she said that receiving the Lantus outside of the parameters that evening could have potentially led to the low blood sugars overnight.

Based on observations, interviews, and record review, the facility failed to ensure staff maintained accurate medical records for one Resident (#47) out of a total sample of 31 residents. Specifically, for Resident #47, the facility failed to:a. Ensure the Resident's active physician orders accurately documented the correct site of a pressure injury.b. Ensure nursing staff accurately documented treatments being administered, when they were not.c. Ensure skin assessments accurately documented the correct site of a pressure injury. Findings include:Review of the facility policy titled 'Charting and Documentation', revised July 2017, indicated, but was not limited to, the following:-The following information is to be documented in the resident medical record:>Treatments or services performed.-Documentation in the medical record will be objective (not opinioned or speculative), complete, and accurate. Resident #47 was admitted to the facility in February 2019 with diagnoses including dementia, traumatic brain injury, and chronic pain. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/10/26, indicated that Resident #47 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, and required assistance with activities of daily living. The MDS further indicated the Resident was at risk for pressure ulcers/injuries.On 5/12/26 at 8:27 A.M., the surveyor observed Resident #47 lying in bed with a reddened area to his/her right heel, and a pressure-redistributing boot at the foot of the bed that was not attached to the Resident. The Resident said he/she was unsure of the etiology of the reddened area to his/her right heel, but staff had not been applying any treatments to it.On 5/12/26 at 2:54 P.M., two surveyors observed Resident #47 lying in bed with a pressure-redistributing boot on his/her right foot. The surveyors observed the Resident's right heel with the Regional Nurse and Nurse #1, who assessed the wound as moist, red, fragile, approximately 3x3 centimeters in size, and either pressure or shearing-related. The Regional Nurse and Nurse #1 assessed the Resident's left heel which was intact without any concerns.a. Review of Resident #47's active physician orders indicated the following:-Left heel: Paint with Betadine (an antiseptic), every shift, start date 4/22/26.-Pressure-redistributing bootie: Apply to left lower extremity at all times as tolerated by resident, every shift, start date 4/14/26. Review of Resident #47's wound practitioner assessment reports indicated the following:-4/21/26: Location: Right heel, Etiology: Pressure, Stage/Severity: Unstageable.>Treatment: Betadine, leave open to air, daily, PRN (as needed) for soiling, saturation, or accidental removal.-5/5/26: Location: Right heel, Etiology: Pressure, Stage/Severity: Unstageable.>Treatment: Betadine, leave open to air, daily, PRN (as needed) for soiling, saturation, or accidental removal. During an interview on 5/12/26 at 3:03 P.M., Nurse #1 said Resident #47 has a pressure injury on his/her right heel and no skin issues on his/her left heel. Nurse #1 said the Resident's physician orders for Betadine and the pressure-redistributing boot were inaccurately written for the left heel and should have been written for the right heel, and she has been applying the treatments to the right heel.During an interview on 5/13/26 at 11:03 A.M., Nurse #2 said Resident #47 has a pressure injury to his/her right heel and no skin issues on his/her left heel. Nurse #2 said she noticed the physician orders for Betadine and the pressure-redistributing boot were inaccurately written for the left heel and should have been written for the right heel, but she forgot to correct it. During an interview on 5/13/26 at 11:39 A.M., the Assistant Director of Nursing (ADON) said she attends wound rounds weekly with the wound practitioner and is responsible for transcribing treatment recommendations into orders and ensuring they are accurate. The ADON said Resident #47 has an unstageable pressure injury to his/her right heel and no skin issues on his/her left heel. The ADON said she mistakenly transcribed Resident #47's wound practitioner's treatment and pressure-redistributing boot recommendations for the incorrect heel which would be considered inaccurate documentation.During an interview on 5/12/26 at 2:54 P.M., the Regional Nurse said her expectation is that wound practitioner treatment recommendations should be transcribed into orders accurately, including the correct location of a wound. b. Review of Resident #47's active physician orders indicated the following:-Left heel: Paint with Betadine (an antiseptic), every shift, start date 4/22/26, discontinue date 5/12/26.-Right heel: Paint with Betadine, every shift, start date 5/12/26. On 5/12/26 at 8:27 A.M., the surveyor observed Resident #47 lying in bed with a reddened area to his/her right heel, and a pressure-redistributing boot at the foot of the bed that was not attached to the Resident. The Resident said he/she was unsure of the etiology of the reddened area to his/her right heel, but staff had not been applying any treatments to it; the heels did not appear to have yellow staining consistent with Betadine application.On 5/12/26 at 2:54 P.M., two surveyors observed Resident #47 lying in bed with a pressure-redistributing boot on his/her right foot. The surveyors observed the Resident's right heel with the Regional Nurse and Nurse #1, who assessed the wound as moist, red, fragile, approximately 3x3 centimeters in size, and either pressure or shearing related. The Regional Nurse and Nurse #1 assessed the Resident's left heel which was intact without any concerns. The heels did not appear to have yellow staining consistent with Betadine application.Review of the Treatment Administration Record (TAR) for May 2026 indicated that on 5/12/26 and 5/13/26, nurses documented that they applied the Betadine as ordered.During an interview on 5/12/26 at 2:54 P.M., Nurse #1 said Resident #47 has a physician's order for Betadine to the left heel every shift and had not yet applied the treatment for her shift because she had to get more from central supply. Nurse #1 said she checked off the order as being completed in the Treatment Administration Record (TAR) when it was not; she said she should not have checked off the order as being completed in the TAR because it is inaccurate documentation.During an interview on 5/13/26 at 11:03 A.M., Nurse #2 said Resident #47 has a physician's order for Betadine to the right heel every shift and had not yet applied the treatment for her shift because she was waiting to complete the medication pass. Nurse #2 said she checked off the order as being completed in the Treatment Administration Record (TAR) when it was not; she said she should not have checked off the order as being completed in the TAR because it is inaccurate documentation.During an interview on 5/13/26 at 11:39 A.M., the Assistant Director of Nursing (ADON) said her expectation is that nurses should be documenting in residents' chart accurately. The ADON said nurses should not be documenting treatments as done when they are not because it would be considered inaccurate documentation. c. Review of skin checks completed on 4/19/26, 4/26/26, 5/3/26, and 5/10/26 indicated nursing documented that Resident #47 had an in-house acquired blister to his/her left heel.During an interview on 5/13/26 at 11:03 A.M., Nurse #2 said Resident #47 has a pressure injury to his/her right heel and no skin issues on his/her left heel. Nurse #2 said the skin assessments were documented inaccurately and should have been documented with the correct wound location.During an interview on 5/13/26 at 11:39 A.M., the Assistant Director of Nursing (ADON) said she was responsible for completing some of the skin assessments for Resident #47. The ADON said Resident #47 initially had a blister that developed into an unstageable pressure injury to his/her right heel, not his/her left heel; she said the skin assessments were documented inaccurately and should have been documented with the correct wound location.

Based on observations, interviews, and record review, the facility to ensure that services provided met professional standards for two Residents (#43, #8), out of 31 total sampled residents. Specifically,1.For Resident #43, the facility failed to implement his/her physician's order to complete weekly skin checks since 3/16/26.2.For Resident #8, the facility failed to ensure bilateral pressure-redistributing boots were in place as indicated in the physician's order. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized 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. 1. Resident #43 was admitted to the facility in November 2025 with diagnoses that included mood disorder, dysphagia, hemiparesis and hemiplegia, and aphasia. Review of Resident #43's most recent Minimum Data Set (MDS) assessment, dated 2/10/26, indicated he/she scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairments. Further review of the MDS indicated the Resident did not reject care. Review of Resident #43's physician order, dated 11/10/25, indicated Weekly Skin Check. Complete Skin check under Forms Tab. Every day shift every Mon (Monday). Review of Resident #43's forms tab in the electronic medical record indicated the last documented skin check was completed on 3/16/26. Review of Resident #43's nursing progress notes from 3/23/26 to present indicated the Resident did not refuse skin checks. Review of Resident #43's March, April, May 2026 Medication Administration Record indicated the Weekly Skin Check. Complete Skin check under Forms Tab on 3/23/26, 3/20/26, 4/6/26, 4/13/26, 4/20/26, 4/27/26, 5/4/26, 5/11/26 were signed off by nursing as administered. During an interview on 5/13/26 at 1:19 P.M., Resident #43 says he/she does not mind having his skin checks done. During an interview and observation on 5/13/26 at 1:20 P.M., Nurse #6 said she works Monday through Thursday every week and is assigned to Resident #43. Nurse #6 said the Resident does not refuse skin checks and they should be completed on Monday's which is his/her shower day. Nurse #6 said he/she never refuses the shower and only refuses to be shaved. Nurse #6 said she did not complete the weekly skin checks because the form did not populate when she signed off the weekly skin check order. Nurse #6 reviewed the forms tab in the Resident's electronic medical record and confirmed to the surveyor the last skin check completed was on 3/16/26. During an interview on 5/13/26 at 1:29 P.M., the Assistant Director of Nurses (ADON) said nurses are expected to follow doctor's orders. The ADON said if the weekly skin check order is signed off as completed it should be documented under forms tab and if the resident did refuse a skin check it should be written in a nursing progress and not signed off as completed. During an interview and observation on 5/13/2026 at 1:31 P.M., the Regional Nurse reviewed the forms tab in the Resident's electronic medical record and confirmed to the surveyor the last skin check completed was on 3/16/26. The Regional Nurse said if the weekly skin check order is signed off as completed it should be documented under forms tab. 2. Resident #8 was admitted to the facility in September 2025 with diagnoses including functional quadriplegia, chronic pain syndrome, and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/31/26, indicated that Resident #8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, and required assistance with activities of daily living, including bed mobility. The MDS further indicated that Resident #8 was at risk of developing pressure ulcers/injuries. On 5/12/26 at 9:30 A.M., the surveyor observed Resident #8 lying in bed without pressure-redistributing boots on his/her feet. On 5/13/26 at 9:08 A.M., the surveyor observed Resident #8 lying in bed without pressure-redistributing boots on his/her feet. On 5/13/26 at 12:38 P.M., the surveyor observed Resident #8 lying in bed without pressure-redistributing boots on his/her feet. Resident #8 said he/she wears the boots to make him/her more comfortable and for pressure relief due to a history of wounds to his/her heels at a previous facility. The Resident said staff are responsible for applying the boots, but they haven't put them for at least a month because they are in the laundry. Resident #8 said he/she has never refused to wear the boots. Review of the Norton Assessment (a tool to assess the risk of pressure ulcer development), completed on 3/2/26, indicated Resident #8 had a score of 10, indicating he/she is at high risk of skin breakdown. Review of Resident #8's active physician orders indicated the following: -Apply pressure redistributing booties (heel boots that are designed to reduce the risk of bedsores by keeping the heels floated and relieving pressure) at all times, every shift, start date 3/30/26. Review of Resident #8's alteration in skin integrity care plan, revised 10/10/25, indicated the following intervention: -Apply pressure redistributing booties at all times, initiated 3/30/26. During an interview on 5/13/26 at 12:35 P.M., Certified Nursing Assistant (CNA) #1 said Resident #8 should be wearing boots at all times due to risk of pressure injuries; she said the Resident does not refuse to wear them. CNA #1 said she put the Resident's boots in the laundry yesterday, 5/12/26, and should get them back later today. CNA #1 said she sends Resident #8's boots to the laundry regularly and the Resident does not have an extra pair of boots he/she could wear until they are cleaned and returned. During an interview on 5/13/26 at 12:58 P.M., Nurse #2 said Resident #8 should be wearing boots at all times due to risk of pressure injuries; she said the purpose of the boots is to alleviate pressure on the Resident's heels to prevent skin breakdown. Nurse #2 said the CNAs are responsible for applying the boots and nursing is responsible for ensuring they are in place per the physician's order. Nurse #2 said Resident #8 currently does not have boots on because they are in the laundry and should get them back today or tomorrow. Nurse #2 said the Resident does not have an extra pair of boots he/she could wear until they are cleaned and returned. During a further interview on 5/13/26 at 2:18 P.M., Nurse #2 said physician orders should be followed as written. During an interview on 5/13/26 at 1:51 P.M., the Director of Nursing (DON) said the purpose of the boots is for pressure relief for pressure injuries or risk of pressure injuries. The DON said if a resident's boots are soiled, there is an extra supply of boots available in the facility until they are cleaned and returned. During a further interview on 5/13/26 at 2:22 P.M., the DON said her expectation is that physician orders should be followed as written.

Based on observation, record review and interview, the facility failed to ensure physician visits were completed timely, completed as required for new admissions, and were alternated between the physician and the nurse practitioner for seven Residents (#26, #27, #144, #8, #129, #120 and #89) out of a total of 34 sampled residents. Specifically: 1. For Residents #26, #27 and #144, the facility failed to ensure they were seen by the physician as required after admission to the facility. 2. For Residents #8, #89, #120 and #129, the facility failed to ensure they were seen by the physician as required. Findings include: Review of Physician Visits policy, dated 2001 indicated: Policy Statement: The attending physician must make visits in accordance with applicable state and federal regulations. 1. The attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history and the presence of medical conditions or problems that cannot be handled readily by phone. 2. The attending physician must visit his/her patients at least once every thirty days for the first ninety days following the resident's admission and then at least every sixty days thereafter. 3. Non-physician practitioners may perform required visits, sign orders and sign certifications/re-certifications as permitted by state and federal law. 4. After the first 90 days, if the attending physician determines that a resident need not be seen by him/her every thirty days, an alternate schedule of visits may be established, but not to exceed every sixty days. A physician assistant or nurse practitioner may make alternate visits after the initial ninety days following admission, unless restricted by law or regulation. 5. The attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. 1a. Resident #26 was admitted to the facility in February 2025 with diagnoses including vascular dementia and epilepsy. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she was moderately cognitively impaired as evidenced by a score of nine out of a possible 15 on the Brief Interview for Mental Status Exam. Review of the physician's progress notes indicated Resident #26 had been seen once by the physician upon admission, on 2/28/25, and had no other visits by the physician or the nurse practitioner, every 30 days, as required. 1b. Resident #27 was admitted to the facility in February 2025 with diagnoses including diffuse traumatic brain injury and epilepsy. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #27 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status score of 9 out of 15, and required assistance with bathing, dressing and toileting. Review of Resident #27's physician progress notes indicated he/she was seen once upon admission by the physician on 2/28/25, and had no other visits, every 30 days, as required. 1c. Resident #144 was admitted to the facility in October 2024 with diagnoses including osteomyelitis and blindness. Review of the Minimum Data Set Assessment, dated 4/29/25, indicated Resident #144 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. Review of Resident #144's physician progress notes indicated he/she was not seen by the physician until 1/15/25 (approximately three months after his/her admission) and then by the nurse practitioner on 4/28/25. 2a. Resident #8 was admitted to the facility in June 1999 with diagnoses including schizophrenia and intracranial injury. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #8 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 3 out of a possible 15, and required assistance with bathing. Review of Resident #8's physician progress notes from July 2024 through May 2025 indicated he/she had been seen by the nurse practitioner on 10/15/24 and 1/15/25 and only had one visit from the physician on 1/15/25. 2b. Resident #89 was admitted to the facility in July 2022 with diagnoses including chronic obstructive pulmonary disease and chronic kidney disease. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #89 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. Review of Resident #89's physician progress notes July 2024 and May 2025 indicated Resident #89 was seen by the Nurse Practitioner on 8/28/24, 9/24/24, 10/1/24, 10/8/24, 11/11/24, 11/12/24, 12/13/24, 1/15/24 and 2/19/25, and Resident #89 was seen once by the physician on 1/15/25. 2c. Resident #120 was admitted to the facility in January 2024 with diagnoses including traumatic subdural hemorrhage immobility syndrome (paraplegic). Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #120 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam (BIMS). During an interview on 5/19/25 at 8:06 A.M., Resident #120 said that he/she had not been seen by the nurse practitioner or physician in a while. Review of Resident #120's physician progress notes between June 2024 and May 2025 indicated he/she had been seen by the nurse practitioner on 6/11/24, 8/13/24, 8/28/24, and 1/15/25 and by the physician on 6/14/24 and 1/15/25. 2d. Resident #129 was admitted to the facility in January 2024 with diagnoses including paraplegia and communicating hydrocephalus. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #129 is cognitively intact evidenced by a score of 15 out of a possible 15 in the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #129 is totally dependent on staff for eating, bathing and mobility. During an interview on 5/19/25 at 10:15 A.M., Resident #129 said he/she had not seen the nurse practitioner or physician in a while. Review of Resident #129's progress notes from June 2024 through May 2025 indicated he/she was seen by the physician on 1/15/25, 2/13/25, 3/10/25, and 4/18/25, and had visits from the Nurse Practitioner on 2/19/25 and 3/28/25. During an interview on 5/19/25 at 10:18 A.M., Unit Manager #1 said that each unit has their own nurse practitioner, and they come in weekly. Unit Manager #1 said that physician and nurse practitioner notes are located in the electronic record. During an interview on 5/19/25 at 2:25 P.M., the Assistant Director of Nursing (DON) said that the physician notes had been pulled directly from the physician's office and then should be uploaded by Medical Records. The ADON said that Residents should be seen every three months by the physician or nurse practitioner. During an interview on 5/20/25 at 10:21 A.M., Nurse Practitioner #1 said that residents are visited by the attending physician upon admission and that nurse practitioners alternate visits after. Nurse Practitioner #1 said notes are written after residents are seen and are accessible to staff electronically from their office. Nurse Practitioner #1 said resident visit frequencies are based on the regulation and that she did not think new admissions were being seen as required every 30 days for the first 90 days. During an interview on 5/21/25 at 9:34 A.M., Physician #1 said that residents are seen within 48 hours of admission by the physician and then visits are alternated with the nurse practitioners as required. Physician #1 said notes are written after each visit and then uploaded by staff into the record. Physician #1 said that there might be some residents who were missed for visits as an oversight.

Based on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for one Resident (#11) out of 34 total sampled residents. Specifically, for Resident #11, the nurses inaccurately documented insulin was administered when it was not. Findings include: Review of the facility policy titled 'Charting and Documentation', revised July 2017, indicated: - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #11 was admitted to the facility in July 2018 with diagnoses including diabetes, stage four chronic kidney disease, and congestive heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/18/25, indicated Resident #11 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #11 received insulin daily. During an interview on 5/21/25 at 8:41 A.M., Resident #11 said his/her blood sugars are unstable and his/her insulin needs to be held if his/her blood sugar is below 200. Resident #11 said he/she is very involved in his/her insulin management and is happy because nursing always holds his/her insulin when needed. Review of Resident #11's active physician orders indicated: - All insulin to be held if fasting blood sugars are 200 and below, every shift, initiated 5/17/24. - Novolin 70/30 relion (a type of insulin) subcutaneous (under the skin) suspension 100 unit/ml (milliliter), inject 25 unit subcutaneously in the morning, hold insulin if fasting glucose is 200 or below, initiated 12/5/24. - Novolin n relion (a type of insulin) subcutaneous suspension, inject 18 units subcutaneously in the evening, insulin to be held if fasting blood sugar 200 and below, initiated 12/4/24. - Novolog (a type of insulin) solution 100 unit/ml, inject 8 unit subcutaneously in the evening, insulin to be held if fasting blood sugar 200 and below, initiated 3/5/25. Review of Resident #11's Medication Administration Record (MAR), dated April 2025, indicated: - On 4/1/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 90. - On 4/4/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 77. - On 4/6/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 114. - On 4/8/25 at 9:00 A.M., a nurse administered 25 units of novolin 70/30 insulin, when blood sugar was 198. - On 4/11/25 at 9:00 A.M., a nurse administered 25 units of novolin 70/30 insulin, when blood sugar was 133. - On 4/11/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 134. - On 4/14/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 194. - On 4/21/25 at 5:00 P.M., Nurse #4 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 160. - On 4/27/25 at 5:00 P.M., a nurse administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 163. Review of Resident #11's Medication Administration Record (MAR), dated May 2025, indicated: - On 5/1/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 97. - On 5/2/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 191. - On 5/6/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 90. - On 5/8/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin, when blood sugar was 177. - On 5/13/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 177. - On 5/16/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin, when blood sugar was 90. - On 5/17/25 at 5:00 P.M., Nurse #6 administered 18 units of novolin n insulin, when blood sugar was 194. - On 5/19/25 at 5:00 P.M., a nurse administered 18 units of novolin n insulin and 8 units of novolog insulin, when blood sugar was 152. Review of Resident #11's nursing progress notes, dated 4/1/25 to 5/19/25, failed to indicate any clarifying information on insulin being administered or held on the above noted dates in the April 2025 and May 2025 MARs. During an interview on 5/21/25 at 7:59 A.M., Nurse #4 said Resident #11's insulin should always be held if his/her blood sugar reading was below 200. Nurse #4 said she had always held Resident #11's insulin when his/her blood sugar was below 200. Nurse #4 said insulin should not be documented as administered if it was not. During an interview on 5/21/25 at 8:25 A.M., Unit Manager #2 said Resident #11's insulin should always be held if his/her blood sugar reading was below 200. Unit Manager #2 said she was surprised that Resident #11's insulins were documented as administered when his/her blood sugars were below 200 because Resident #11 is very involved and aware of his/her insulin orders. Unit Manager #2 said she believed it was documented inaccurately. Unit Manager #2 said insulin should not be documented as administered if it was not. During a telephone interview on 5/21/25 at 8:50 A.M., Nurse #6 said he was aware that Resident #11's insulin needed to be held if his/her blood sugars were below 200. Nurse #6 said during April 2025 and May 2025 he always held his/her insulin if Resident #11's blood sugars were below 200. Nurse #6 further said that Resident #11 was very involved in his/her insulin management and always wanted to see the blood sugar reading. Nurse #6 said Resident #11 got excited if it was under 200 and would never allow any nurse to administer insulin if it were below 200. Nurse #6 said he must have documented Resident #11's insulin inaccurately. Nurse #6 said insulin should not be documented as administered if it was not. During an interview on 5/21/25 at 9:44 A.M., the Director of Nursing (DON) said Resident #11 would not allow insulin to be administered if his/her blood sugar was below 200 and felt the documentation was inaccurate. The DON said insulin should not be documented as administered if it was not.

Based on observations, interviews, and record review, the facility failed to ensure a safe and homelike environment for one Resident (#133), out of 34 total sampled residents. Specifically, the facility failed to ensure Resident #133's sink was not leaking and good repair. Findings include: Review of the facility policy titled 'Homelike Environment', revised February 2021, indicated: - Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. Resident #133 was admitted to the facility in February 2024 with diagnoses including epilepsy (seizure disorder) and a history of a heart attack. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/4/25, indicated Resident #133 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 5/20/25 at 7:05 A.M., Resident #133 said his/her sink had been leaking for approximately two months. The surveyor and Resident #133 observed his/her bathroom sink which was actively dripping water into a plastic basin on the floor directly below. This plastic basin contained approximately an inch of discolored water. Resident #133 said staff were aware because he/she had asked for it to be repaired multiple times since it began leaking. Resident #133 said he/she must empty this basin by him/herself because staff has not done anything to help empty it or to repair the sink. Resident #133 said it's gross and it attracts bugs which he/she hates. During an interview on 5/20/25 at 7:08 A.M., Certified Nurse Assistant (CNA) #3 said she knew Resident #133's sink had been leaking for over a month. CNA #3 said if a sink was broken and in need of repair, it should have been written in the maintenance log so maintenance could follow-up. CNA #3 showed the surveyor the maintenance log, which had maintenance requests that began on 4/21/25. This maintenance log failed to indicate any concerns regarding Resident #133's leaking sink. CNA #3 said it should have been written here but it was not. During an interview on 5/20/25 at 7:10 A.M., Unit Manager #2 said if a sink needed to be repaired then a request should have been written in the maintenance log or Unit Manager #2 should have sent an email to maintenance. Unit Manager #2 said she was unaware of any maintenance requests or emails sent regarding Resident #133's concern about leaking sink. During an interview on 5/20/25 at 7:15 A.M., the Maintenance Director said he was not notified about Resident #133's concern about a leaking sink until this morning after the surveyor brought it to Unit Manager #2's attention. The Maintenance Director said he should have been notified by it being put in the maintenance log, but it was not. During an interview on 5/21/25 at 9:44 A.M., the Director of Nursing (DON) said staff should have notified maintenance immediately when the sink began leaking. The DON said over a month is too long to wait to notify maintenance of the need to repair.

Based on interviews and record review, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#115), when he/she was discharged from hospice services, out of a total sample of 34 residents. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2024, indicated a SCSA comprehensive assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. Resident #115 was admitted to the facility in January 2024 with diagnoses including Huntington's disease (an inherited condition that affects movement, thinking, and mood) and hypertension (high blood pressure). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/25/25, indicated Resident #115 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. This MDS also indicated Resident #115 was receiving hospice services. Review of Resident #115's nursing progress notes, dated 4/30/25, indicated: - Per hospice team - pending dc (discharge) from hospice services. - Per DON (Director of Nursing) - Administrator informed nursing team of client will be off hospice services either today or tomorrow. Review of Resident #115 census summary indicated Resident was discharged from hospice services beginning 4/30/25. Review of Resident #115 nursing progress notes, dated 5/17/25 and 5/18/25, indicated Resident was receiving hospice services, when he/she was not. Review of Resident #115 plan of care related to nutritional status, revised on 10/31/24, indicated: - On hospice with goal of comfort and care. This care plan had not been updated since before the Resident was discharged from hospice services on 4/30/25. Review of Resident #115's medical record on 5/19/25 at 2:15 P.M. failed to indicate a SCSA assessment had been completed, which was 19 days after Resident was discharged from hospice services. During an interview on 5/19/25 at 2:17 P.M., Unit Manager #2 said Resident #115 was discharged from hospice services on 4/30/25. During an interview on 5/19/25 at 2:19 P.M., the MDS Nurse said a SCSA needs to be completed after any resident is discharged from hospice services as required by the RAI guidelines. During a follow-up interview on 5/19/25 at 2:35 P.M., the MDS Nurse said Resident #115 should have had a SCSA completed since he/she was discharged from hospice services on 4/30/25, but one was not completed. During an interview on 5/19/25 at 2:38 P.M., the Director of Nursing (DON) said she expects the MDS Nurse to follow RAI guidelines. The DON said a SCSA should have been completed for Resident #115 because he/she was discharged from hospice services.

Based on observations, interviews and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#140) with a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 34 sampled residents. Specifically, the facility failed to ensure nursing changed the water flush bag (a bag containing water that is connected to and delivers water for hydration through a gastrostomy tube) every 24 hours as necessary to prevent infection and maintain the integrity of the feeding system. Findings include: Review of the facility policy titled 'Enteral Nutrition Feedings (tube feeding), revised 7/26/13, indicated: - An open system (bag and tubing) may hang up to 24 hours unless compromised. Resident #140 was admitted to the facility in June 2024 with diagnoses including diabetes and sepsis. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/11/25, indicated Resident #140 was rarely/never understood and had severe cognitive impairment as evidenced by a Staff Assessment for Mental Status. This MDS also indicated Resident #140 received 501 ml (milliliters) or more of average fluid intake per day by tube feeding. On 5/19/25 at 12:22 P.M., the surveyor observed Resident #140 in bed receiving his/her tube feeding and water flush through an enteral feeding pump with the water flush settings at flush 220 ml every 6 hours. The water flush bag was dated 5/17/25 at 4:20 A.M., which was 56 hours and 2 minutes before this observation. Review of Resident #140's physician's orders indicated: - Enteral feed order, flush enteral tube q (every) 6 hours with 220 ml of water, initiated 3/17/25. Further review of Resident #140's physician's orders failed to indicate any instructions regarding the frequency of water flush bag changes. Review of Resident #140's nursing progress notes, dated 5/17/25 to 5/19/25, failed to indicate any rationale for the water flush bag not being changed since 5/17/25. During an interview on 5/20/25 at 6:55 A.M., Nurse #2 and the surveyor observed Resident #140's water flush bag, which was now dated 5/19/25 at 6:30 P.M. (indicating the water flush bag was not changed for 62 hours and 10 minutes). Nurse #2 said water flush bags must be changed every 24 hours. Nurse #2 said she was assigned Resident #140 on night shift on 5/18/25 and 5/19/25. Nurse #2 said she did not change the water flush bag on 5/18/25 because it was the evening shift nurses responsibility to change it when she connected a new tube feeding container to the enteral feeding pump. During an interview on 5/20/25 at 12:43 P.M., Nurse #3 said she was assigned Resident #140 on the evening shift for 5/17/25 and 5/18/25. Nurse #3 said water flush bags must be changed every 24 hours. Nurse #3 said she poured more water into the water flush bag to make sure there was enough water in the bag for the scheduled flushes and connected a new tube feeding container to the enteral feeding pump, but she did not change the water flush bag on 5/17/25 or 5/18/25 because it was the night shift nurses responsibility. During an interview on 5/20/25 at 2:18 P.M., the Assistant Director of Nursing said there were no additional facility policies that specifically addressed water flush bags, but water flush bags should be changed every 24 hours. During an interview on 5/21/25 at 8:25 A.M., Unit Manager #2 said Resident #140's water flush bag should have been changed every 24 hours when a new tube feeding container was connected to the enteral feeding pump. During an interview on 5/21/25 at 9:44 A.M., the Director of Nursing (DON) said Resident #140's water flush bag should have been changed every 24 hours when a new tube feeding container was connected to the enteral feeding pump.

Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#125) out of sample of 34 residents. Specifically, for Resident #125, the facility failed to provide oxygen to the Resident as indicated in the physician's orders. Findings include: Review of facility policy, titled Oxygen Administration, dated as revised October 2010, indicated the following: -Verify that there is a physician's order for this procedure. Review the physician's orders for facility protocol for oxygen administration. -Steps in the procedure: 9. Place appropriate oxygen device on the resident (i.e. mask, nasal cannula and/or nasal catheter). Resident #125 was admitted to the facility in July 2023 with diagnoses that included Chronic Diastolic Heart Failure, primary pulmonary hypertension and sleep apnea. Review of Resident #125's most recent Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15, indicating that the resident was cognitively intact. Further review of the MDS failed to indicate the use of oxygen therapy. Review of Resident #25's physician's orders indicated the following: -O2 (oxygen) at 2L (liters) continuously via Nasal Cannula, dated 4/16/24. Review of Resident #125's active care plan indicated the following: -Cardiac disease related to CAD (coronary artery disease), Hypertension (high blood pressure), CHF (congestive heart failure), with interventions that included to administer oxygen as ordered, dated as revised 8/2/23. On 5/19/25 at 8:24 A.M., Resident #125 was observed sleeping in bed. The Resident was receiving oxygen at 3 liters per minute via a face mask. On 5/19/25 at 1:29 P.M., Resident #125 was observed awake in bed. The Resident was receiving oxygen at 3 liters per minute via a face mask. On 5/20/25 at 7:00 A.M., Resident #125 was observed sleeping in bed. The Resident was receiving oxygen at 3 liters per minute via a face mask. On 5/21/25 at 7:56 A.M., Resident #125 was observed lying in bed. The Resident was receiving oxygen at 3 liters per minute via a face mask. Resident #125 declined to be interviewed by the surveyor, or speak to his/her oxygen use. During an interview on 5/21/25 at 8:30 A.M., Nurse #1 said that oxygen should be delivered as indicated in the physician's orders. She said if the order is to receive oxygen via nasal cannula, then the resident should not be using a mask. During an interview on 5/21/25 at 9:06 A.M., the Director of Nurses said that oxygen should be administered based on the physician's order, including both the flow rate and means of which it is delivered to the resident.

Based on observations, interviews, and record reviews for two Residents (#62 and #126) out of five residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of three nurses observed made two errors out of 26 opportunities resulting in a medication error rate of 7.69%. Specifically, 1.) For Resident #62, the nurse administered the incorrect dose of atorvastatin calcium (a medicine used to treat high cholesterol). 2.) For Resident #126, the nurse failed to ensure an order for aspirin included a dosage prior to administration. Findings include: Review of the facility policy titled 'Administering Medications', revised April 2019, indicated: - Medications are administered in accordance with prescriber orders. - The individual administering medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1.) Resident #62 was admitted to the facility in April 2019 with diagnoses including hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Review of the most recent Minimum Data Set (MDS) assessment, dated 3/25/25, indicated Resident #62 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. On 5/20/25 at 8:23 A.M., the surveyor observed Nurse #4 prepare and administer the following medication to Resident #62: - One atorvastatin calcium 10 mg (milligram) tablet. Review of Resident #62's active physician order, initiated 5/15/25, indicated: - Atorvastatin calcium oral tablet 20 mg, give 1 tablet by mouth one time a day. During an interview on 5/20/25 at 11:31 A.M., Nurse #4 said she administered one atorvastatin calcium 10 mg tablet to Resident #62 but should have administered two tablets because the dose was recently increased to 20 mg. During an interview on 5/20/25 at 2:08 P.M., the Director of Nursing (DON) said Nurse #4 should not have administered atorvastatin calcium 10 mg because the physician's order is for 20 mg. 2.) Resident #126 was admitted to the facility in April 2024 with diagnoses including hyperlipidemia and atrial fibrillation (irregular heart rhythm). Review of the most recent Minimum Data Set (MDS) assessment, dated 4/29/25, indicated Resident #126 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. On 5/20/25 at 9:00 A.M., the surveyor observed Nurse #7 prepare and administer the following medication to Resident #126: - One chewable aspirin 81 mg tablet. Review of Resident #126's active physician order, initiated 4/26/24, indicated: - Aspirin oral tablet chewable, give 1 tablet by mouth in the morning. This order failed to indicate a dosage. During an interview on 5/20/25 at 11:39 A.M., Nurse #7 said all medications require a dosage to be included in the physician order. Nurse #7 said the aspirin should not have been administered without clarifying the physician order to include a dosage because the correct dosage could not be verified. During an interview on 5/20/25 at 2:08 P.M., the Director of Nursing (DON) said all medications require a dosage to be included in the physician order. The DON said there should have been a dosage included in Resident #126's physician's order for aspirin but there was not.

Based on record review and interview, the facility failed to ensure diagnostic test results were maintained in the clinical record for one Resident (#120) out of a total of 34 sampled residents. Specifically, the facility failed to ensure the results of an ultrasound were reviewed and reported to the attending physician and filed in his/her clinical record. Findings include: Review of the Lab and Diagnostic Test Results Clinical Protocol policy dated November 2018 indicated: - When test results are reported to the facility, a nurse will first review the results. -A physician can be notified by phone, fax, voicemail, e-mail, pager or a telephone message. -Facility staff should document information about when, how and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report. Resident #120 was admitted to the facility in January 2024 with diagnoses including traumatic subdural hemorrhage immobility syndrome (paraplegic). Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #120 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam (BIMS). During an interview on 5/19/25 at 8:05 A.M., Resident #120 said he/she was having pain in his/her genitals and staff were aware. Review of the physicians' orders indicated an order, dated 5/13/25, for an ultrasound on his/her genitals. Review of the medical record indicated the ultrasound was obtained on 5/13/25. Review of the clinical record failed to include the results of Resident #120's ultrasound. During an interview on 5/20/25 at 8:11 A.M., seven days after the ultrasound was ordered, Unit Manager #1 was unable to locate Resident #120's test results in the clinical record and accessed the results electronically from the diagnostic center and printed out a copy. Unit Manager #1 said that she had not reviewed the results of the ultrasound or notified the attending physician of the ultrasound results. Unit Manager #1 said Resident #120 had the ultrasound done after he/she had reported pain in his/her genitals. During an interview on 5/20/25 at 9:39 A.M., Nurse #8 said that Resident #120 had reported gential pain yesterday. Nurse #8 said she thought Resident #8 had an ultrasound to his/her genitals because he/she was reporting pain. During an interview on 5/21/25 at 9:53 A.M., the Director of Nursing (DON) said that ultrasound results should be reviewed by staff and reported to the attending physician the day the results are in. The DON said that nurses can access the results on the computer if they're not automatically uploaded into the electronic health record. The DON was not aware that Resident #120's ultrasound results were not in his/her clinical record or reviewed until the surveyor inquiry on 5/20/25.

Based on record review and interview, the facility failed to provide written documentation related to transfer discharge notices and bed hold upon hospitalizations for three Residents (#129, #144 and #93) out of a total of 34 sampled residents. Findings include: 1. Resident #129 was admitted to the facility in January 2024 with diagnoses including paraplegia and communicating hydrocephalus. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #129 is cognitively intact evidenced by a score of 15 out of a possible 15 in the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #129 is totally dependent on staff for eating, bathing and mobility. Review of the clinical record indicated Resident #129 was transferred to the hospital on 1/18/25, 2/8/25, 3/4/25, 3/18/25 and 4/16/25. The clinical record failed to indicate if a transfer notice or bed hold notice was provided. During an interview on 5/20/25 at 1:37 P.M., the Social Worker said that the notices were not completed. The Social Worker said that the notices will not get done if she is not here. 2. Resident #144 was admitted to the facility in October 2024 with diagnoses including osteomyelitis and blindness. Review of the Minimum Data Set Assessment, dated 4/29/25, indicated Resident #144 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. Review of Resident #144's clinical record indicated he/she was transferred to the hospital on 2/12/25. The clinical record failed to indicate if a transfer notice or bed hold notice was provided. During an interview on 5/20/25 at 1:37 P.M., the Social Worker said that the notices were not completed. The Social Worker said that the notices will not get done if she is not here. 3. For Resident #93, the facility failed to provide a transfer discharge notice for 3 hospitalizations. Resident #93 was admitted in January 2021 with diagnoses including anxiety and major depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #93 could not participate in the Brief Interview for Mental Status exam due to severe cognitive impairment. Review of the Minimum Data Set indicated Resident #93 had hospitalizations on 12/13/24, 1/15/25, and 3/7/25. Review of the medical record failed to indicate that a transfer/discharge notice had been provided to Resident #93 and/or his/her representative. During an interview on 5/20/25 at 1:37 P.M., the Social Worker said that the notices were not completed. The Social Worker said that the notices will not get done if she is not in the building.

Based on records reviewed and interviews, for one of three sampled Employee Personnel Records (Certified Nurse Aide #1), the Facility failed to ensure they conducted a Massachusetts Nurse Aide Registry background check before hire, in accordance with the Facility Policy. Findings include: Review of the Facility's Policy titled Background Screening Investigations, dated March 2019, indicated background checks are completed prior to employment. The Policy indicated that any employee applying for a position as a Certified Nurse Assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. Review of Certified Nurse Aide (CNA) #1's Personnel File indicated he was hired on 06/07/22. Further review of the file indicated there was no documentation to support that CNA #1 had a Massachusetts Nurse Aide Registry background check conducted by the Facility before hire. During an interview on 07/09/24 at 3:30 P.M., the Administrator, Director of Nurses (DON) and Assistant Director of Nurses said a Massachusetts Nurse Aide Registry could not be located for CNA #1 to support it had been conducted prior to hire. During a telephone interview on 07/10/24 at 12:35 P.M., the DON said that although ongoing attempts were made by their offsite Human Resource department to locate CNA #1's Massachusetts Nurse Aide Registry check, it was not located.

Based on observations, record review and interview, the facility failed to provide dental services for one Resident (#132) out of a total sample of 31 residents. Specifically: For Resident #132, the facility failed to ensure dental services were provided after it was reported that Resident #132 had dental pain. Findings include: Review of the facility policy titled Dental Services, revised and dated December 2016, indicated the following: - Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. - Routine and 24-emergency dental services are provided to our residents through a contract agreement with a licensed dentist comes to the facility monthly. - Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. Resident #132 was admitted to the facility in January 2024 with diagnoses including focal traumatic brain injury, major depressive disorder and epilepsy. Review of Resident #132's Minimum Data Set (MDS) assessment, dated 1/10/24, indicated the following under Section L - Oral Dental Status: - Obvious or likely cavity or broken natural teeth Review of Resident #132's most recent MDS assessment, dated 4/2/24, indicated that the Resident had a Brief Interview of Mental Status score of 15 out of a possible 15 indicating that he/she is cognitively intact. During an observation and interview on 6/25/24 at 8:35 A.M., the surveyor observed a tube of Orajel (an over-the-counter medication used to temporarily treat dental pain) on Resident #132's bed side table. Resident #132 said his/her teeth hurt and it hurts to chew food and that his/her family member brought in the Orajel for his/her dental pain. Resident #132 was observed to have many black, dark spots on the visible teeth. Review of Resident #132's Care Conference Notes, dated 1/3/24, indicated the following: - He/she needs to see a dentist, he/she has some rotting teeth in the back of his/her mouth that is causing him/her discomfort. Review of Resident #132's physician's order dated 1/4/24 indicated the following: - Consults: Dental care as needed During an interview on 6/26/24 at 12:41 P.M., Resident #132's Health Care Representative's family member said Resident #132 really needs to see a dentist as his/her teeth are in bad shape and if a dentist could come into the facility that would be great as Resident #132 does not always want to get out of bed. The Health Care Representatives continued to say that Resident #132 has not been seen by a dentist since his/her admission and they would like one to see him/her. They continued to say that they brought in the Orajel for Resident #132's teeth pain. During an interview on 6/27/24 at 7:56 A.M., Unit Manager #1 said if it is known that a resident has dental pain then the facility would have a dentist see the resident as soon as possible. Unit Manager #1 said a dentist should have seen Resident #132 months ago since it was documented in January 2024 of his/her dental discomfort. During an interview on 6/27/24 at 7:33 A.M., the Director of Nurses (DON) said all residents have care conferences which is for their individualized care plans and if something appropriate is discussed then interventions will be implemented. The DON said if dental pain was discussed in a care conference, then the facility would have the resident see a dentist as soon as possible. The DON said she was not aware that Resident #132 was having dental pain since January, had dental issues or that the Resident's Health Care Representatives brought in Orajel for his/his teeth pain. The DON continued to say that a dentist and dental hygienist comes to the building every few months and they have been in the building since January. She continued to say if she knew about Resident #132's dental pain she would have made sure the dentist or dental hygienist saw the resident as Resident #132's representatives consented for dental care to be provided while in the facility.

Based on record review and interview the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to conduct an assessment for trauma per the facility policy, and develop an individualized comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization for two Residents (#146 and #123) who had an active diagnosis of PTSD out of a total sample of 31 Residents. Findings include: 1. For Resident #146 the facility failed to conduct an assessment for trauma per the facility policy, and develop a comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization. Resident #146 was admitted to the facility in March 2024 with diagnoses including PTSD, traumatic brain injury and depression. Review of the Minimum Data Set (MDS) assessment, dated 3/21/24, indicated Resident #146 had a diagnosis of PTSD. Further review indicated Resident #146 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Review of the doctor's orders, dated June 2024, indicated Resident #146 had a diagnosis of PTSD. Review of Resident #146's care plan, with a focus of PTSD, indicated a goal to avoid re-traumatization triggers, however, the care plan failed to indicate what the triggers for re-traumatization are, how Resident #146 exhibits an activation of PTSD when it occurs and what interventions are needed to help reduce the impact to the Resident during the triggered event. 43807 2. Resident #123 was admitted to the facility in November 2022 with diagnoses including Post Traumatic Stress Disorder (PTSD). A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated a PTSD diagnosis. A review of the social services admission assessment, dated 11/4/22, indicated the following: -Primary care PTSD screen with a list of traumatic events, a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone killed or seriously injured, and having a loved one die through homicide and suicide. -Resident #123 answered yes to experiencing one of the traumatic events. A review of the social services admission notes, dated 11/4/22, indicated the following: -Daughter reported that the Resident has a history of childhood trauma as well as a history of physical and verbal abuse by male partners. A review of Resident #123's trauma care plan, initiated 11/4/22, indicated the following: -Resident has had a previous traumatic event in his/her past that put him/her at risk for mood lability including depression and anxiety related to his/her trauma. During an interview on 6/27/24 at 7:37 A.M., the Social Worker said trauma is only assessed at admission for all residents, she said trauma is assessed again if a traumatic event occurs in the facility during the Resident's stay. The Social Worker said Resident #123 answered yes to experiencing one of the traumatic events listed in the trauma assessments, she said Resident #123's family member provided more specific details of the trauma the Resident experienced as indicated in the social service admission note. She said a personalized care plan should have been developed with the specific traumatic events Resident #123 experienced. The Social Worker said triggers should also have been identified and personalized in the care plan to prevent re-traumatization. During an interview on 6/27/24 at 9:50 A.M., the Director of Nurses said all trauma care plans should be personalized with the specific traumatic event, she said triggers should be identified and care planned as well.

Based on observation, record review and interview, the facility failed to monitor and assess the use of equipment being used as a potential restraint for one Resident (#57) out of a total sample of 31 residents. Specifically, the facility staff failed to: For Resident #57, conduct individualized monitoring and ongoing assessments for the use of thigh bands (used to secure the body in a wheelchair to prevent sliding down in the chair and designed to relieve pressure on certain body areas) while lying flat. Findings include: Review of the facility policy titled Restraints: Physical, dated revised 10/13/2017, indicated that the purpose of the policy is to ensure that if a restraint is indicated to treat medical symptoms that it is the least restrictive device possible, used for the least amount of time possible in order to treat the medical symptoms. Resident #57 was admitted to the facility in October 2018 with diagnoses including Huntington's disease, psychosis and depression. Review of the Minimum Data Set assessment, dated 4/9/24, indicated that Resident #57 was not able to complete the Brief Interview for Mental Status exam and is severely cognitively impaired. Further review indicated that Resident #57 is totally dependent for all activities of daily living. Further review failed to indicate that Resident #57 used a restraint. On 6/25/24 at 9:49 A.M., the surveyor observed Resident #57 lying flat in a Broda chair (a type of wheelchair that allows a resident to lay flat) in the Residents room with bilateral padded straps originating from the center of the seat, going up and over each thigh, across the hips and ending in a buckle behind the back of the chair, preventing the Resident from exiting the chair. On 6/25/24 at 1:27 P.M., the surveyor observed Resident #57 sitting in a Broda chair in the hallway with bilateral padded straps originating from the center of the seat, up going up and over each thigh, across the hips and ending in a buckle behind the back of the chair, preventing the Resident from exiting the chair. On 6/25/24 at 3:42 P.M., the surveyor observed Resident #57 sitting in a Broda chair in the hallway with bilateral padded straps originating from the center of the seat, up going up and over each thigh, across the hips and ending in a buckle behind the back of the chair, preventing the Resident from exiting the chair. On 6/26/24 at 7:40 A.M., the surveyor and Unit Manager #1 observed Resident #57 lying in a Broda chair in the Residents room with bilateral padded straps originating from the center of the seat, going up and over each thigh, across the hips and ending in a buckle behind the back of the chair, preventing the Resident from exiting the chair. Review of the medical record failed to indicate that Resident #57 used a restraint. Review of the doctor's orders failed to indicate an order for the use of a restraint or the use of thigh bands. Review of the care plan, dated and reviewed 3/25/24, failed to indicate a care plan for the use of a restraint. Further review failed to indicate the use of thigh bands. Further review indicated a behavior care plan related to Resident #57's behavior of purposefully sitting/placing self on the floor as a means of resistance to redirection when having behaviors. Review of the facility document titled Occupational Therapy Discharge Summary, dated 12/01/22, indicated that thigh bands are used to prevent forward sacral sliding, to promote skin integrity when in the Broda chair. Further review indicated that the thigh bands were placed to promote optimal positioning to promote safe swallowing and intake of high calorie nutritional beverage to help Resident maintain weight. Further review failed to indicate that the Broda chair with thigh bands was to be used while the Resident was lying flat. Review of the facility document titled Pre-Restraining Evaluation, dated 3/1/21, indicated that use of both thigh bands and a chest band in Broda chair provides positional support to maximize proper sitting without preventing any volitional movements. Further review indicated that the facility did not consider the thigh bands a restraint however, the document failed to indicate if the use of the thigh bands were appropriate while the Resident is lying flat in the Broda chair and whether their use while lying flat would act as a restraint. Review of the facility document titled Physical Restraint Elimination Review, dated as reviewed quarterly on 4/11/23, 7/11/23, 10/10/23 and 1/9/24 and 4/9/24, failed to indicate that the Resident was evaluated for the use of the thigh bands (a potential restraint) for purposes other than those recommended by Occupational Therapy. During an interview on 6/26/24 at 7:40 A.M. Unit Manager #1 said that the straps are used to prevent Resident #57 from exiting the chair. Unit Manager #1 said that Resident #57 sleeps in the Broda chair with the straps in place because he/she has a history of getting out of bed and then falls to the floor. Unit Manager #1 said that Resident #57 has been sleeping in the Broda chair with the straps in place for a long time. During an interview on 6/27/24 at 11:12 A.M., the Director of Nursing said that the use of the thigh bands while the Resident is lying flat in the Broda chair should have been evaluated, care planned and a doctor's order written.

Based on observation, record review and interview, the facility failed to develop a comprehensive plan of care for one Resident (#132) out of a total sample of 31 residents. Specifically, the facility failed to develop an individualized plan of care for Resident #132 related to migraine headaches. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated and revised 4/25/22, indicated 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 Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Resident #132 was admitted to the facility in January 2024 with diagnoses including focal traumatic brain injury, major depressive disorder and epilepsy. Review of Resident #132's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview of Mental Status score of 15 out of a possible 15 indicating that he/she is cognitively intact. During an interview on 6/25/24 at 8:35 A.M., Resident #132 said he/she gets migraines daily and he/she wears his/her sunglasses all the time as it helps. Review of Resident #132's pre-admission paperwork, dated 11/7/23, prior to entering the facility indicated the following written by a Nurse Practitioner: - During interview with this writer patient reports that he/she suffers migraine headaches. Review of Resident #132's physician's order, dated 1/3/24, indicated the following: - Excedrin Migraine Oral Tablet (a medication used to temporarily treat migraine headache pain) 250-250-65 MG (milligrams): Give 1 tablet by mouth every 12 hours as needed for pain related to unspecified focal traumatic brain injury. Review of Resident #132's medical diagnoses, care plans, and progress notes failed to mention that the Resident has migraine headaches. During an interview on 6/26/24 at 12:41 P.M., Resident #132's Family member said he/she has migraine headaches, and he/she says wearing the sunglasses helps them. During an interview on 6/27/24 at 7:25 A.M., Certified Nursing Assistant #1 said she is familiar with Resident #132 and said she was not sure why he/she wears sunglasses and did not know that the Resident gets migraine headaches. During an interview on 6/27/24 at 7:56 A.M., Unit Manager #1 said she was not sure why Resident #132 always wears sunglasses. She continued to say that she did not know Resident #132 has a history of migraine headaches and still has them. Unit Manager #1 said if a resident has migraine headaches, then a care plan should be developed so interventions can be implemented. During an interview on 6/27/24 at 8:41 A.M., the Director of Nurses (DON) said she did know Resident #132 has migraine headaches or has a history of them. She said if it was mentioned in the pre-admission paperwork then a care plan should have been implemented. The DON and surveyor reviewed Resident #132's preadmission paperwork and she said a care plan and medical diagnosis should have been developed for Resident #132's migraine headaches.

Based on record review and interview, the facility failed to follow professional standards of practice for two Residents (#150 and #151) out of two closed records reviewed. Specifically, 1. For Resident #150, the facility failed to obtain a doctor's order for a transfer to the hospital and 2. For Resident #151, the facility failed to obtain a doctor's order for a transfer home. Findings include: The facility policy titled Transfer or Discharge, Facility-Initiated, dated 2001, failed to indicate that a doctor's order would be obtained for resident discharges. 1. For Resident #150 the facility failed to obtain a doctor's order for a transfer to the hospital. Resident #150 was admitted to the facility in June 2023 with diagnoses including Huntington's disease, schizophrenia and depression. Review of the progress note, dated 4/4/24, indicated that Resident #150 was transferred to the hospital on 4/4/24 via ambulance. Review of the doctor's orders, dated April 2024, failed to indicate an order to transfer Resident #150 to the hospital. During an interview on 6/25/24 at 4:05 P.M., the Director of Nursing said that a doctor's order should be obtained for a transfer to the hospital. 2. For Resident #151 the facility failed to obtain a doctor's order for a transfer home. Resident #151 was admitted to the facility in January 2024 with diagnoses including alcohol dependence, alcoholic cirrhosis of the liver and psychosis. Review of the progress note, dated 5/11/24, indicated that Resident #151 was discharged home. Review of the doctor's orders dated May 2024 failed to indicate an order to discharge Resident #151 home. During an interview on 6/25/24 at 4:05 P.M., the Director of Nursing said she would expect a doctor's order would be obtained for a transfer home.

Based on observations, interviews and policy review, the facility failed to ensure that housekeeping staff maintained proper hand hygiene practices on one of four nursing units. Findings include: Review of facility policy titled Handwashing/Hand Hygiene, dated as revised 3/18/24, indicated the following: - The facility considers hand hygiene the primary means to prevent the spread of healthcare- associated infections. - 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors. - Indications for Hand Hygiene. 1. Hand hygiene is indicated. c. after contact with blood, body fluids or contaminated surfaces. e. after touching a resident's environment. g. immediately after glove removal. 5. The use of gloves does not replace hand hygiene/ hand washing. Review of facility policy titled Personal Protective Equipment- Gloves, dated July 2009, indicated the following: 2. Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. 8. Wash your hands after removing gloves. On 6/26/24 at 7:01 A.M., the surveyor observed Housekeeper #2, wearing gloves, emptying trash from a resident room on the [NAME] Park Unit. Housekeeper #2 exited the resident room, put the trash into a larger bag, and without doffing (removing) her gloves or performing any hand hygiene, she entered a second resident room with the same contaminated gloves on her hands. Housekeeper #2 continued this routine through five resident rooms, entering and exiting the rooms to empty trash wearing the same pair of contaminated gloves and without any hand hygiene in between rooms. During an interview on 6/26/24 at 11:22 A.M., the Housekeeping Manager said that staff should be removing gloves before exiting a room and sanitizing hands in between tasks or between moving on to another resident's room. During an interview on 6/26/24 at 2:32 P.M., the Infection Control Nurse said staff should not be wearing gloves in the hallway. He said gloves should be removed before exiting a room and hands should be sanitized upon exiting and before entering another resident room. During an interview on 6/27/24 at 6:55 A.M., the Director of Nurses said staff should not exit a resident room and go into the hallway with gloves on. The expectation is that no staff wear gloves in the hallway and gloves are changed and hand hygiene is performed between tasks or between resident rooms.

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one Resident (#71) out of a total sample of 31 residents. Specifically, the facility coded Resident #71 as using a trunk restraint when he/she did not use one. Findings include: Resident #71 was admitted to the facility in January 2019 with diagnoses including traumatic subarachnoid hemorrhage and unspecified dementia. Review of Resident #71's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 13 out of 15 indicating that he/she is cognitively intact. Further review of section P of Resident #71's MDS indicated that the Resident used a trunk restraint less than daily. Review of section GG of Resident #71's MDS indicated he/she does not use any mobility devices and can ambulate independently. On 6/25/24, 6/26/24 and 6/27/24, the surveyor observed Resident #71 walking around the second-floor unit without assistance, no restraint was present. Review of Resident #71's medical record failed to indicate physician's orders, care plans or a restraint assessment were present to indicate the usage of a restraint. During an interview on 6/26/24 at 9:13 A.M., Unit Manager #1 said she has no memory of Resident #71 using a restraint and it was likely coded as an error. During an interview on 6/26/24 at 10:03 A.M., the MDS Nurse said she checks residents' charts, progress notes, discharge notes and speaks with the interdisciplinary team when inputting MDS information. She further said that no residents in the facility use restraints and Resident #71 was coded in error as using a restraint.

Based on observations, record reviews and interviews, the facility failed to prevent a decline in range of motion for 1 Resident (#63) out of a total sample of 37 residents. Findings include: Resident #63 was admitted to the facility in January 2017 with diagnoses including dementia and Human Immunodeficiency Virus disease. Review of Resident #63's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident was unable to complete the Brief Interview for Mental Status exam and staff has assessed him/her to have severe cognitive impairment. The MDS also indicates Resident #63 is dependent on staff for all activities of daily living. On 4/4/23 at 10:10 A.M., Resident #63 was observed lying in bed. His/her right knee was fully flexed (bent), with the Resident's heel touching his/her left upper, inner thigh. Resident #63 was unable to follow commands to straighten his/her leg and is not able to be interviewed. During an interview on 4/05/23 at 9:07 A.M., Nurse #1 said Resident #63's right knee has been progressively flexing for the past two months. Nurse #1 said the Resident used to be able to straighten his/her knee but has not been able to lately. Nurse #1 and the surveyor then entered Resident #63's room and Nurse #1 attempted to passively straighten the Resident's right knee. As she was doing this, Resident #63 began to make grunting noises and moving his/her arms as if in pain. When asked if the Resident was having increased pain, Nurse #1 said yes. Nurse #1 said physical therapy is sometimes involved with providing range of motion exercises to residents in the facility but could not say specifically when physical therapy had been last involved with Resident #63. Review of Resident #63's medical chart indicated the following: *Section G of the MDS dated [DATE] indicated there was no range of motion impairment to Resident #63's lower extremities. *A nurse practitioner note, dated 2/24/23, which indicated the following: extremities: left lower extremity with both hip and knee contracture, unable to straighten the patients leg out, increased tone in (the Resident's) right leg and upper extremities. Plan: contractures with significant pain/ (the Resident) is on scheduled Tylenol. *A nurse practitioner note, dated 3/31/23, which indicated the following: The patient is exhibiting signs of pain. Per nursing staff, (the Resident) is frequently moaning and seems uncomfortable with position changes. (The Resident) presently only has scheduled Tylenol three times a day. Plan: chronic pain. The patient is exhibiting nonverbal symptoms of discomfort likely related to immobility and contractures as well as increased tone. We will initiate baclofen twice daily and continue extra strength Tylenol. Would add Cymbalta if (the Resident) is tolerating baclofen if he/she continues to appear uncomfortable. During an interview on 4/6/23 at 8:08 A.M., Nurse #2 said she has noticed Resident #63's right knee flexing more over the past few months. Nurse #2 said Resident #63 needed to have an increase in medication due to the pain associated with the tightening of the muscle behind the right knee that is causing the decrease in range of motion. Nurse #2 said she had told the Unit manager about the decrease in range of motion/increased bending of the knee a couple of months ago. Nurse #2 said she believed the Unit Manager would relay the information to the rehabilitation department so the therapy staff could begin working with the Resident. Nurse #2 said the nursing staff places a pillow under the Resident's right knee to prevent it from bending but it is ineffective. During an interview on 4/5/23 at 10:24 A.M., the Director of Rehabilitation (DOR) said the therapy staff complete screens on an as needed basis as well as yearly for all residents. The DOR said the therapy department also receives referrals from the nursing staff when a resident has a change in status. The DOR said she had not received a referral from the nursing staff regarding a change in range of motion of Resident #63's right knee. The DOR said Resident #63 had last been on therapy a year ago and his/her range of motions was limited but she wasn't sure if it had gotten worse. During an interview on 4/5/23 at approximately 11:50 A.M., the DOR was completing an evaluation on Resident #63. The Resident was sitting up in a wheelchair and his/her right knee was flexed to a degree that the Resident's foot was under the seat of the chair. The DOR said there was a definite increase in the tightness of the muscle behind the right knee causing it to bend more. The Occupational Therapy Evaluation dated 4/6/23 indicated Resident #63 was evaluated and placed on therapy services to treat a decline in range of motion to the right knee. During an interview on 4/06/23 at 8:15 A.M., Unit Manager #1 said Resident #63's right knee has been progressively decreasing in range of motion and all staff are aware of it. Unit Manager #1 said he remembers speaking with Nurse #2 about it but never made a direct referral to the therapy department for treatment.

Based on record review and staff interview, the facility staff failed to maintain acceptable parameters of nutritional status by providing adequate interventions to maintain body weight and prevent weight loss for 6 Residents (#71, #86, #121, #21, #12 and #84) in a total sample of 38 residents. Findings include: Review of the facility policy titled, Weight Assessment and Intervention, dated September 2008, indicated the following: *The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. *A weight change of 5 lbs (pounds) or more in a patient weighing more than 100 lbs or 2 lbs in a patient weighing less than 100 lbs since the weight assessment will be retaken for validation. If the weight is verified, nursing will notify the dietitian. *The dietitian will respond within 72 hours *Weights will be reviewed by the 10th of the month to follow individual weight trends overtime. Negative trends will be evaluated to determine significant weight changes 1. Resident #71 was admitted to the facility in June 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)] and dysphagia. Review of Resident #71's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief interview of Mental Status (BIMS) score of 1 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated that Resident #71 was dependent on staff for all functional tasks. Review of Resident #71's physician orders indicated an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #71's weight record indicated the following: *Weights were not taken weekly as ordered, with only 9 out of a possible 20 opportunities for weights completed. *On 4/29/21 Resident #71 weighed 210.2 lbs. (pounds) *On 6/21/21 Resident #71 weighed 183.5 lbs. - a 12.7% weight loss in 2 months *On 9/1/21 Resident #71 weighed 169.2 lbs. - a 7.79% weight loss in 3 months *On 10/6/21 Resident #71 weighed 162.9 lbs. *On 11/12/21 Resident #71 weighed 161.8 lbs. *On 12/23/21 Resident #71 weighed 148.1 lbs. - an additional 9.09% weight loss in 2 months *On 1/6/22, Resident #71 weighed 141.6 lbs.- an additional 4.39% weight loss in 1 month *Resident #71 lost a total of 41.9 lbs. resulting in a significant weight loss of 22.83% in 9 months. Further review of Resident #71's physician orders indicated the following: *Super cereal (cereal with extra calories to provide extra nourishment) at breakfast, initiated on 7/1/21 (10 days after the 12.7% weight loss was identified) *Super mashed potatoes (potatoes with extra calories to provide extra nourishment). lunch and dinner, initiated on 7/1/21(10 days after the 12.7% weight loss was identified) *Special house smoothie with all meals, initiated 12/1/6/21 (after 3 months of continued weight loss without intervention). On 1/4/22 at 8:45 A.M., on 1/5/22 at 8:51 A.M., and 1/6/22 at 8:39 A.M., Resident #71's breakfast trays were observed. There was no super cereal or smoothie with any of the breakfast trays. Resident #71's meal tickets on the tray did not indicate super cereal was to be served. On 1/5/22 at 12:41 P.M. and on 1/6/22 at 12:39 P.M., Resident #71's lunch trays were observed. There was no smoothie on either tray. The Resident did have mashed potatoes on his/her tray; Resident #71's meal ticket did not indicate the need for super mashed potatoes. During an interview on 1/5/22 at 12:36 P.M., the kitchen aid who prepared Resident #71's lunch meal said that the potatoes were regular, not super potatoes. Review of the Document titled, Nutritional Evaluation, dated 6/24/21, indicated Resident #71 had a 9.5% weight loss. The recommendation section of the evaluation indicated to continue to monitor as the recommendation, and no interventions were initiated to prevent further weight loss. Review of the Document titled, Nutritional Evaluation, dated 9/22/21, indicated a 6.7% weight loss since the last assessment on 6/24/21. The recommendation section of the evaluation indicated to encourage nutritional drink TID (3x/day) as the recommendation. Additional review of Resident #71's physician orders indicated the nutritional drink was discontinued on 6/24/21. Review of the Document titled, Nutritional Evaluation, dated 12/22/21, indicated further weight loss but did not indicate the percentage of loss. The recommendation section of the evaluation indicated to encourage smoothies 5x/daily and recommend SF active liquid protein. Review of Resident #71's nutritional care plan initiated on 5/2/2020 and last revised on 12/16/21 indicted the following: *Provide nutrient dense food with meals, initiated 5/4/2020 *Provide supplements as ordered, initiated 10/8/2020 and revised 12/22/21 *Weights as ordered, initiated 5/4/2020 Resident #71's nutritional care plan failed to indicate any nutritional interventions were added to address the significant weight loss that occurred from June to November 2021. During an interview on 1/06/22 at 8:53 A.M., Nurse #4 said that Resident #71 received a shake for a supplement 3 times a day. Nurse #4 was unaware of all other nutritional interventions put in place by the Dietitian and was also unaware of Resident #71's order to be weighed weekly. During an interview on 1/6/22 at 10:41 A.M., the Registered Dietitian (RD) said she works in the building 3 days a week. She said that when in the building, she monitors all residents' weights. The RD said that Certified Nursing Assistants are responsible for taking each resident's weight and she enters all weights into the computer. The RD said that all weights are taken per the physician orders but was unable to say the process that the facility uses to ensure weights are taken. The RD also said that the scales are calibrated each month to ensure accuracy of weights. The RD said that the facility has a weekly risk meeting where weight loss is discussed, but that this meeting has not been held within the last month. In addition, the RD said that notes are not taken at the meeting. When asked specifically about Resident #71, the RD said he/she has had a significant weight loss since 2020. The RD was unaware of the order for the Resident to be weighed weekly. The RD said Resident #21 is lactose intolerant, so she has recently started him/her on a juice smoothie as well as the nutritional drink. The RD was also unaware that the order for the nutrition drink was discontinued in June 2021. The RD further said that she had started the Resident on fortified foods in July but had not initiated any other interventions until she recommended the smoothie in December. The RD said that she does not have a process for ensuring her recommendations are followed and does not always observe the Residents during mealtime. The RD was unaware that Resident #71 was not receiving fortified foods and the smoothies during the meals observed during survey. During a follow-up interview on 1/6/22 at 11:30 A.M., the Dietitian provided the surveyor with Resident #71's updated meal tickets. When doing so, the Dietician said that Resident #71's nutritional interventions had not been listed on the meal ticket and the kitchen was unaware of the interventions that were to be added to Resident #71's meals. The Dietician said that because these had been missing on the meal ticket, Resident #71 had not been receiving the interventions recommended. 2. For Resident #86, the facility failed to initiate interventions after a significant weight loss. Resident #86 had a 7.01% weight loss in one month. Resident #86 was admitted to the facility in June 2000 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most current Minimum Data Set, dated dated dated [DATE] indicated Resident #86 scored a 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. In addition, Resident #86 eats independently and it was unknown if Resident #86 had a significant weight loss. Review of Resident #86's weight record indicated the following weights: 8/3/21 202.5 pounds 10/7/21 - 187.2 pounds ( 7.01% weight loss) 11/7/21 - 188.3 pounds No further weights were recorded. A Nutrition Evaluation dated 11/8/21 indicated Weight Status/Nutritional Needs: Noted to have a weight loss; percentage of weight loss equals 8. Weight loss is unplanned. Nutritional Problems/Interventions: Unintended weight loss. Nutritional interventions include the following: Routine snacks. Therapeutic diet. (These were not new interventions). Review of Resident #86's care plan for Nutritional Status included the following interventions: - Administer vitamin/mineral supplements as ordered. - Notify physician and responsible party of significant weight changes. - Provide diet/HS (hour of sleep) snack as per order. - Weights as ordered. There were no interventions to address Resident #86's weight loss. On 1/5/21 at 9:10 A.M., Resident #86 was observed eating breakfast in his/her room independently. Resident #86 was observed to eat about 75% of breakfast. During an interview with the Dietician 1/6/22 a 11:11 A.M., she stated she was not sure if the weights for Resident #86 were accurate and Resident #86 often refuses weights. The staff should be attempting to get a re-weigh. The Dietician also stated she was not aware that Resident #86 had a weight loss and no interventions were implemented to prevent further weight loss. The Dietician stated she would talk to the Nurse Practitioner about Resident #86's weight loss. 3. For Resident #121, the facility failed to initiate interventions after a significant weight loss. Resident #121 had a 6.12% in one month. Resident #121 was admitted to the facility in February 2010 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set, dated dated dated [DATE], indicated Resident #121 scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, Resident #121 eats independently. Review of Resident #121 weight record indicated the following weights: 5/6/21 - 140.6 6/10/21 - 132 (6.12 % weigh loss) 7/6/21 - 132.1 8/2/21 - 138.2 9/7/21 - 135.6 10/7/21 - 135.7 11/14/21 - 132.4 There were no further recorded weights recorded. Review of the Nutritional Status care plan included the following interventions: - Cut up food (initiated 1/15/15). - Adaptive equipment Lip plate (initiated 11/12/14). - Administer vitamin/mineral supplements as ordered. Pudding as a night snack (initiated 11/12/14). - Honor food preferences (initiated 11/12/14). - Weights as ordered (initiated 11/12/14). There were no interventions implemented to address Resident #121's significant weight loss in 6/2021. During an interview with the Dietician on 1/6/21 at 11:00 A.M., she stated Resident #121 has a lot of behaviors and often refuses weights, so there is not much you can do. Resident #121 is not discussed at the Risk meeting which is held every Tuesday. The Dietician acknowledged Resident #121's weight loss was not addressed. 4. For Resident #84, the facility failed to address a significant weight loss. Resident #84 was admitted to the facility in October 2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 84's most recent Minimum Data Set assessment dated [DATE] indicated he/she is moderately cognitively impaired and requires assistance with personal bathing. Review of Resident #84's physicians orders indicated the following: [MEDICATION(S)] (a medication used to treat [CONDITION(S)] than can cause some water weight loss) 40 MG twice a day, initiated 6/3/21. Review of Resident #84's weights indicated the following: 6/1/21 202.4 lbs (pounds) 7/20/21 190.2 a loss of 5.84% of his/her total body weight. Review of the Dietitian's note dated 7/15/21 indicated: Resident triggers for 5.0% significant weight loss. Resident on planned weight loss due to increased [MEDICATION(S)] 6/3/21. Plan: continue to monitor. Review of Resident #84's August 2021 weights indicated: 8/5/21: 176.8 lbs 8/10/21: 173 lbs a loss of 14.52% of his/her total body weight since 6/1/21 Review of the Dietitian assessment dated [DATE] indicated: 8/10/21: Weight as of 8/5/21: 176.8 Partial weight loss may be due to increased [MEDICATION(S)] 6/3/21. Average meal intake: 76-100% Nutrition Problems: Increase energy expenditure, increased nutrient needs, unintended weight loss. Recommendations: Suspect fair nutritional status. Resident has intact skin, good intake and adequate weight. Continue to monitor. Despite the assessment identifying Resident #84 having an increased nutrient need, no new interventions were implemented to address Resident #84's weight loss. Review of Resident #84's physicians orders indicated that there had been no changes in Resident #84's orders for [MEDICATION(S)] since 6/3/2021. Additional review of Resident #84's weights indicated: 9/7/21: 175.7 lbs 10/19/21: 170.6 lbs a loss of 15.71% of his/her total body weight since 6/1/21. 11/2/21: 172.3 lbs 11/9/21: 166.9 lbs a loss of 17.54 % of his/her total body weight. Review of the Dietitian's notes dated 10/28/21 and 11/23/21, indicated Resident #84's intake remained at 76%-100%, attributed his/her continued weight loss on the use of [MEDICATION(S)] and indicated the plan was to monitor Resident #84's status without implementing new interventions. Review of Resident #84's physicians orders indicated that there had been no changes in Resident #84's orders for [MEDICATION(S)] since 6/3/2021. Review of Resident #84's December 2021 weights indicated: 12/7/21 167.2 lbs 17.39% since 6/3/21 12/21/21 172.9 lbs Review of Resident #84's clinical record failed to indicate the Dietitian assessed him/her during December 2021. Review of Resident #84's clinical notes also failed to indicate that his/her weight loss had been evaluated in 2021 by the physician or the nurse practitioner. During an interview with Nurse #6 on 1/6/22 at 12:27 P.M., he said that no one on the Unit has had any weight loss. During an interview with the Dietitian on 1/6/22 at 11:30 A.M., she said that Resident #84 had lost weight because he/she takes [MEDICATION(S)]. The Dietitian said she was not aware that Resident #84's [MEDICATION(S)] dosage had not changed since June 2021 and said she would have to look into his/her weights. During interviews with the Nurse Practitioner on 1/5/22 at 2:25 P.M., and 1/10/22 at 2:12 P.M., she said that the Dietitian follows all residents in the facility for weight loss and alerts her for monitoring and review for residents weight. The Nurse Practitioner said she was not made aware of any weight losses for Resident #84. The Nurse Practitioner said that initial weight loss could be expected when [MEDICATION(S)] was first initiated, but if ongoing weight loss occurred without changes in the dosage, she would expect to be notified to assess the resident's medical status for possible causes. 5. For Resident #12, the facility failed to timely address and implement interventions in response to a severe weight loss. Resident #12 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Minimum Data Set assessment dated [DATE] indicated he/she is moderately cognitively impaired and requires assistance with bathing and dressing. Review of Resident #12's weights indicated the following: 3/18/21 140.4 lbs (pounds) 4/14/21 140.4 lbs 5/11/21 142 lbs 6/1/21 137.2 lbs No weights documented for July 2021 8/4/21: 127.8 (Disputed value by Dietitian) 8/10/21 129.2 lbs a total loss of 9.1% of his/her body weight since 5/11/21 9/1/21: 129.8 lbs 9/28/21: 128 lbs Review of the Dietitian's notes indicated the following: 8/4/21: Resident triggers for significant weight loss. Weight had been stable. Not deemed valid until re-weigh completed. Plan: Re-weigh requested. A re-weigh validating Resident #12's weight loss was not completed until 8/10/21; 6 days after the first documented weight loss. Additional review of the clinical record indicated that the Dietitian failed to re-assess Resident #12 after his/her weight loss was verified for the remainder of August 2021 and all of September 2021. Review of Resident #12's physicians orders indicated the following: Mighty shake (nutritional supplement) three times a day for weight loss; give sandwiches with lunch and dinner, initiated 9/22/21, 44 days after Resident #12's weight loss was verified on 8/10/21. Review of Resident #12's October 2021 weights indicated; 10/4/21: 122.1 lbs a loss of 14 % of his/her total body weight since 5/11/21 10/18/21: 122.8 lbs Review of the Dietitians note dated 10/28/21, (80 days after Resident #12's verified weight loss documented on 8/10/21) indicated: Resident triggers for significant weight loss. Intake reported at 83%. Does consume supplements per observation. Suspect fair/good nutritional status. Continue to monitor. No additional interventions were implemented after Resident #21's continued weight loss. During an interview with 1/6/22 at 12:33 P.M., Unit Manager #1 said no residents on the unit had had a significant weight loss. During an interview with the Dietitian on 1/6/22 at 11:00 A.M., she said that Resident #12 had lost weight in the past couple months and was receiving sandwiches with meals in response to the weight loss. During interviews with the Nurse Practitioner on 1/5/22 at 2:25 P.M., and 1/10/22 at 2:12 P.M., she said that the Dietitian follows all residents in the facility for weight loss and alerts her for monitoring and review for residents weight issues. The Nurse Practitioner said she was not made aware that Resident #12's weight loss began in August 2021. 6. For Resident #21 the facility failed to timely address a significant weight loss. Resident #21 was admitted to the facility in January 1995 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's most recent Minimum Data Set assessment dated [DATE], indicated Resident #21 was cognitively intact and independent with activities of daily living. On 1/4/22 at 10:21 A.M. the surveyor observed Resident #21 in the hallway. Resident #21 was thin and wearing large, baggy clothing. Review of Resident #21's care plans indicated: Resident has altered Nutritional Status, 12/3/14 Interventions: Provide supplements as per orders, Mighty shakes three times daily, (3/31/21), weights as ordered. Review of Resident #21's weights indicated the following: 1/6/21 172 lbs (pounds) 2/2/21 168. 8 lbs 3/2/21 165 lbs 4/19/21: 168.2 lbs 5/4/21: 167.8 lbs 6/1/21: 162.5 lbs 6/30/21: 158.6 lbs 7/8/21: 152.8 lbs a of loss 9.47% of his/her total body weight since since 2/2/21. 7/26/21: 155.8 lbs 8/4/21: 153.8 lbs 9/9/21: 149.6 lbs a loss of 11.05% of his/her total body weight since 4/19/21 9/16/21: 151.8 lbs 10/4/21: 149.8 lbs 11/4/21: 151 lbs 12/6/21: 152.1 lbs 1/1/22: 152.1 lbs Review of the Dietitian's notes indicated that she evaluated Resident #21 for weight loss on 7/10/21 and attributed the weight loss discrepancy to his/her clothing possibly being baggy. No intervention was implemented to address Resident #21's weight loss. The Dietitian's notes also indicated she evaluated Resident #21 for weight loss on 9/16/21, 9/29/21, and 11/4/21, but did not identify potential causation or implement interventions to address Resident #21's initial and sustained weight loss. Review of the Nurse Practitioner Note dated 12/17/21 indicated: Weight loss; Resident is on [MEDICATION(S)] twice a day. We will discontinue the [MEDICATION(S)] and initiate [MEDICATION(S)] which does not have the side effect of weight loss; so as to prevent him/her from becoming underweight. We will continue the shakes as ordered. During interviews with the Nurse Practitioner on 1/5/22 at 2:25 P.M., and 1/10/22 at 2:12 P.M., she said that the Dietitian follows all residents in the facility for weight loss and alerts her for monitoring and review for residents weight issues. The Nurse Practitioner said that Resident #21 had begun taking [MEDICATION(S)] in January 2021. The Nurse Practitioner said that she changed the medication because a side-effect can be weight loss. The Nurse Practitioner said that she was not made aware that Resident #21's weight loss had begun in July 2021. During an interview with the Dietitian on 1/6/22 at 11:00 A.M., she said that she was aware of Resident #21's weight loss and said that he/she often wears baggy clothing which can impact the efficacy of the scale. The Dietitian said that Resident #21 is a very picky eater and he/she is supposed to be getting peanut butter and jelly sandwich with his/her meals along with supplements to help maintain his/her weights. During an interview with Nurse #6 on 1/6/22 at 12:27 P.M. he said that Resident #21 has had a weight loss because he/she is a very picky eater. Resident #21's care plan failed to include Resident #21's foods that he/she dislikes, or interventions implemented to address Resident #21's eating habits. Review of Resident #21's meal tickets for breakfast, lunch and dinner failed to indicate he/she was receiving sandwiches with meals, and failed to indicate his/her food likes and dislikes. During a follow up interview with the Food Service Director on 1/10/22 at approximately 11:10 A.M., she said that Resident #21 was not receiving sandwiches with his/her meals.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was in a wheelchair and being transported by Facility staff in a Facility owned transport van, the Facility failed to ensure his/her safety was maintained to prevent incident or accidents resulting in an injury. On 11/12/21, during the return trip to the Facility from an outside appointment, although Resident #1's wheelchair had been secured in the van by staff, Resident #1 him/herself had not been secured with a seatbelt by staff, the van driver suddenly decelerated the vehicle, and he/she slid out of the wheelchair. Resident #1 landed on the floor of the van, his/her right leg was twisted underneath him/her, and he/she was transferred to the Hospital Emergency Department for evaluation. Resident #1 was diagnosed with a right leg fracture and was admitted for surgical repair for the fracture. Findings include: The Facility's Policy, titled, Vehicle Safety, dated 10/03/19, indicated: -Seat belts were to be used in all vehicles at all times. -Prior to each trip, the driver would conduct an inspection using the pre-tip inspection checklist. -Wheelchairs and passengers would be secured at all times when the vehicle was in motion. -If an accident or incident occurred, staff would safely stop the vehicle and turn off the engine, check the condition of the passenger(s) and call 911 if necessary. Resident #1 was admitted to the Facility in October 2009, diagnoses included [CONDITION(S)]. Review of the Nurse Progress Note, dated 11/12/21, indicated Resident #1 had been a passenger in the Facility's transport van, and when the driver stopped quickly, he/she slid out of his/her wheelchair, was complaining of pain in his/her right leg, and was transferred to the Hospital Emergency Department for evaluation. Review of the Hospital History and Physical Report, dated 11/12/21, indicated Resident #1 was admitted to the Hospital after he/she was a passenger in a wheelchair van, staff did not strap him/her in, and he/she was thrust forward, landed on the floor with his/her right thigh bent underneath him/her. The Report indicated Resident #1 required traction and surgical intervention to correct the right femur fracture. Review of the Facility's Investigation Summary, dated, 11/18/21, indicated that on 11/12/21, at 2:00 P.M., Transport Driver #1 and Therapeutic Aide (TA) #1 brought Resident #1, in his/her wheelchair onto the Facility's van to be transported back to the Facility from an appointment. The Summary indicated TA #1 secured Resident #1's wheelchair to the van, however did not secure him/her in the wheelchair using a seat belt, and Transport Driver #1 failed to check if Resident #1 was secured with a seat belt. The Summary indicated that, due to traffic, Transport Driver #1 had to decelerate the van quickly, and the motion caused Resident #1 to slide out of his/her wheelchair onto the floor of the van, and he/she landed with his/her right leg twisted underneath his/her body. The Summary indicated Resident #1 was transferred to the Hospital Emergency Department, diagnosed with a fractured right femur, which required surgical intervention. During an interview on 12/07/21 at 3:01 P.M., Transport Driver #1 said that on 11/12/21 at 2:00 P.M., he picked Resident #1 and Therapeutic Assistant (TA) #1 from Resident #1's doctor's appointment. Transport Driver #1 said he operated the wheelchair lift with Resident #1, who was seated in his/her wheelchair, and TA #1 who was standing on the lift. Transport Driver #1 said he closed the lift door and went around the van to the driver's seat to start the van while TA #1 strapped the wheelchair to the van. Transport Driver #1 said said he thought TA #1 had also applied the seat belt to Resident #1. Transport Driver #1 said he did not check to see if Resident #1 was properly secured with a seat belt before driving the van. Transport Driver #1 said that on the way back to the Facility, a car in front of him stopped quickly, and he had to decelerate the van quickly. Transport Driver #1 said he heard a noise that sounded like something fell , heard Resident #1 screaming that his/her leg was broken. Transport Driver #1 said he should have checked to see that Resident #1 was properly secured using a seat belt, and said Therapeutic Assistants are not trained to apply seat belts in the van. During an interview on 12/07/21 at 12:26 P.M., Therapeutic Aide (TA) #1 said that on 11/12/21, he accompanied Resident #1 to a doctor's appointment, and they were picked up by Transport Driver #1 at 2:00 P.M., to return to the Facility. TA #1 said he rode up on the wheelchair lift with Resident #1 while Transport Driver #1 operated the lift, and said Transport Driver #1 then closed the door of the lift and went around the outside of the van to the driver's seat. TA #1 said he secured Resident #1's wheelchair to the van, but did not secure Resident #1's seatbelt. TA #1 said he had never been trained on how to use the seatbelt or wheelchair securing system in the van. Therapeutic Assistant (TA) #1 said that on their way back to the Facility, he was riding in the back of the van with Resident #1, and the van came to an abrupt stop. TA #1 said Resident #1, who was not secured with the seat belt, then slid out of his/her wheelchair and onto the floor of the van, landed on his/her buttocks, and one of his/her legs was bent behind him/her. TA #1 said Resident #1 was screaming and complained of pain in the leg. TA #1 said he picked Resident #1 up off the floor and sat him/her on a seat next to him. Transport Driver #1 and TA #1 said they contacted the Facility to notify them of the accident and to obtain further instruction, and said since they were only a block away from the Facility they were instructed to return there. During an interview on 12/07/21 at 1:13 P.M., the Assistant Director of Therapeutic Services said that on 11/12/21 at 3:30 P.M., Therapeutic Assistant (TA) #1 called and said Resident #1 had fallen in the van, and that they were almost at the Facility. The Assistant Director of Therapeutic Services said he went out to the parking lot to meet them and Resident #1 was seated in his/her wheelchair when he got to the van and said he/she was complaining of pain in his/her leg. During an interview on 12/07/21 at 9:15 A.M., the Administrator said the Transport Driver should have applied the seat belt to Resident #1 before the van was in motion. On 12/07/21, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) Resident #1 was transferred to the Hospital and required surgical intervention to correct his/her fractured femur. B) The Facility's Ad-Hoc QAPI meeting minutes, dated 11/12/21, indicated that any resident transported by the Facility staff had the potential to be affected, the Facility identified the need to re-educate staff regarding safe transportation practices and restraint systems in the transport vehicles, and the Facility's vehicle was inspected for any issues concerning the restraint devices. C) The Facility's Performance Improvement Plan (PIP), dated 11/12/21, indicated the following: 1) Facility developed and implemented a plan of correction to address the concerns related to the deficient practice, including: 2) The Director of Nurses/designee would audit falls for compliance with nursing assessment prior to moving the resident weekly for three weeks, then randomly for two months. 3) The Administrator/designee would audit the daily Transportation Logs for compliance with passenger securement weekly for three weeks, then monthly for two months. 4) Results from the audits will be brought to QAPI monthly for review and further recommendations. D) The Basic Life Support (BLS) education record, dated 11/17/21, indicated transportation staff's BLS were renewed. E) The Employee Education Attendance Record, dated 11/18/21, indicated transportation staff were educated that a resident who has fallen or who has suspected trauma must be assessed by a nurse before being moved. F) The Employee Education Attendance Records, dated 11/18/21, indicated transportation staff were educated on the Facility's Policy titled, Vehicle Safety. G) The Education Certificated of Completion, dated 11/17/21, 11/18/21, and 11/19/21, indicated transportation staff completed online course education on the Facility's vehicle's restraint system, and each transportation staff member passed a test regarding this education. H) The Competency Driving Safety Exams, dated 11/19/21, indicated transportation staff passed competency training for transportation safety. I) The Employee Education Attendance Records, last dated 12/01/21, indicated nursing, therapeutic behavior staff, activities staff, and social services staff, were educated that a resident who has fallen or who has suspected trauma must be assessed by a nurse before being moved. J) The Employee Education Attendance Records, last dated 12/01/21, indicated nursing, therapeutic behavior staff, activities staff, and social services staff were educated on the Facility's Policy titled, Vehicle Safety. K) The Administrator and/or designee is responsible for compliance.

Based on records review and interviews for 2 of 5 sampled residents (Resident #1 and Resident #2) the Facility failed to perform thorough assessments, accurately notify the Physician in order to seek further medical care for an initial post assault examination, and obtain appropriate orders for laboratory testing for potential exposure to [MEDICAL CONDITION], when on 2/10/17 Resident #1, who's [DIAGNOSES REDACTED].#2 forced him/her to perform oral and anal sex. Resident #2 has a [DIAGNOSES REDACTED].#1. Findings Include: The Centers for Disease Control and Prevention recommends in Sexual Assault and Abuse and STD's ([MEDICAL CONDITION]), that examinations of survivors of sexual assault be conducted by an experienced clinician in a way that minimizes further trauma and that collections of specimens and serum (blood) samples at initial examination for laboratory STD [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision making were moderately impaired and Resident #1 was able to ambulate independently in and out of his/her room. A Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Brief Interview for Mental Status (BIMS) score was 15 out of 15 and Resident #2 was able to ambulate independently with a walker in and out of his/her room. Surveyor #1 interviewed Companion #1 on 3/24/17 at 1:43 P.M. Companion #1 said, because Resident #1's primary language was not English, he/she often translated for Resident #1 at the Facility. Companion #1 said that, on 2/10/17, while he/she and Resident #1 were out for the day, Resident #1 appeared to be upset, anxious, and repeatedly told him/her that Resident #2 was not a good person and Resident #2 woke Resident #1 up and forced Resident #1 to perform oral sex on him/her. Surveyor #1 interviewed the Rehabilitation Program Director (Program Director) on 3/24/17. The Program Director said he was present when the Police questioned Resident #1 on 2/10/17. The Program Director said Resident #1 used gestures to describe the allegations he/she made about Resident #2. The Program Director demonstrated the gestures he observed Resident #1 make to Police to Surveyor #1 by cupping his hand and putting it in front of his mouth making a forward and backward motions in front of his mouth. The Program Director, with his hand remaining cupped put his hand around his back in front of his buttocks and made the same forward and backward motion behind his buttocks. He said that according to the gestures he observed Resident #1 make, Resident #1 was also alleging that Resident #2 had forced him/her to have anal sex in addition to oral sex. The Program Director said he informed the Director of Nursing. Surveyor #1 interviewed the Unit Manager on 3/24/17 at 3:37 P.M. The Unit Manager said although she notified Resident #1's Physician about his/her allegation that Resident #2 forced him/her to perform oral sex, she did not notify the Physician about the allegation of anal sex. Surveyor #1 interviewed the Unit Manager on 4/13/17 at 2:20 P.M. The Unit Manager said that although she looked at Resident #1's skin while he/she was in the bathroom on 2/10/17, the day he/she made the allegation, she just looked at Resident #1's skin to check for any marks or bruising but was not told about his/her allegation that Resident #2 forced him/her to have anal sex and didn't know to further assess Resident #1. The Unit Manager said that although they obtained a physician's orders [REDACTED].#1 to determine the presence of the same type of blood borne pathogen that Resident #2 was positive for, they did not obtain physician's orders [REDACTED]. The Unit Manager said she could not recall if Resident #1 received trauma counseling, however if he/she had received counseling, either Clinical Counselor #1 or Clinical Counselor #2 would have counseled Resident #1. However, Clinician #1 and Clinician #2 did not speak Resident #1's native language and Resident #1's primary language was not English. The Unit Manager said Resident #2 said he/she had no injuries, therefore so she did not complete an assessment on him/her. The Unit Manager said that Physician orders [REDACTED].#2 had the presence of the same type of blood borne pathogen that Resident #1 was positive for. Surveyor #1 interviewed Clinical Specialist #1 on 3/24/17 at 1:27 P.M. Clinical Specialist #1 said she did not counsel Resident #1. Surveyor #1 interviewed Clinical Specialist #2 on 4/13/17 at 2:45 P.M. Clinical Specialist #2 said she did not counsel Resident #1. Surveyor #1 interviewed the Director of Nursing (DON) on 3/24/17 at 2:43 P.M. The DON said although she was told about Resident #1's gesture alleging Resident #2 forced him/her to have anal sex, the Facility did not notify Resident #1's Physician and did not transfer Resident #1 to the Hospital for further evaluation because they weren't sure what Resident #1 meant by the gesture. Surveyor #1 interviewed Resident #1's and Resident #2's Physician on 3/27/17 at 12:00 P.M. Resident #1 and Resident #2's Physician said the Facility did not notify him about Resident #1's allegation of being anally raped by Resident #2 and he would have provided further orders and expected that the Facility send Resident #1 to the Hospital for further evaluation.

Based on records review and interviews, the Facility failed for 1 of 5 sampled residents (Resident #2) to develop a comprehensive Care Plan that addressed Resident #2's frequent display of masturbating in public view, watching pornography in public view, and sleeping naked without bed covers in public view. A Care Plan was not updated to include goals, interventions, and evaluations to include that 3 residents alleged Resident #2 sexually assaulted them. Findings include: The Facility Policy, titled Care Plans-Comprehensive, 9/2010, included that Care Plans are designed to: Incorporate identified problem areas, Incorporate risk factors associated with identified problems, and Care Plan interventions are designed after careful consideration of the relationship between the resident's problem areas with targeted, meaningful interventions and Care Plans are revised as information about the resident and resident's condition changes. A Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Brief Interview for Mental Status (BIMS) score was 15 out of 15 and Resident #2 was able to ambulate independently with a walker in and out of his/her room. A Pre-Admission Status Report, dated 5/9/14, indicated Resident #2, had a history of [REDACTED]. The report further indicated that Resident #2 had been observed 2 months prior to be having unprotected sex with his/her roommate and neurobehavioral goals upon admission to the Facility would include goals to address behaviors which included poor sexual boundaries. Surveyor #1 interviewed the Director of Social Services on 4/13/17 at 11:55 A.M. The Director of Social Services said she did not recall why the Pre-Admission Status Report mentioned goals to address Resident #2's poor sexual boundaries and she did not know what type of poor sexual boundaries were of concern at the time of Resident #2's admission, but interventions should have been in a care plan. The Director of Social Services said that she was not surprised that Resident #2's admission paperwork did not include specifics as to what his/her poor sexual boundaries referred to and she would attempt to locate additional information. The Director of Social Services did not provide any further documentation that related to Resident #2's poor sexual boundaries or any interventions established to address such behaviors as referred to in Resident #2's Pre-Admission Status Report. Upon review of Resident #2's record, there was no Care Plan established on admission that addressed specific targeted interventions for Resident #2's poor sexual boundaries. A Progress Note, dated 3/8/16, indicated Resident #2 allegedly put his/her hand up another Resident's pant leg and touched his/her private area while they were outside the activity room. An Incident Report Form, dated 3/8/16, indicated that staff who was present in the area where the alleged incident occurred did not witness the alleged incident. A Progress Note, dated 10/14/16, indicated Resident #2 allegedly touched another Resident's breast while in the activity room the previous day. An Incident Report Form, dated 10/14/16, indicated that staff in the activity room did not observe Resident #2 touching the Resident's breast An Incident Report, dated 2/10/17, submitted to the Department of Public Health by the Director of Nursing indicated that Resident #2's Roommate (Resident #1) alleged that Resident #2 forced him/her to perform oral sex. Surveyor #1 interviewed Therapeutic Assistant #1 on 3/29/17 at 9:16 A.M. Therapeutic Assistant #1 said he has observed Resident #2 masturbating without using his/her privacy curtain at various times throughout the day. Surveyor #1 interviewed Nurse #1 on 3/27/17 at 10:12 A.M. Nurse #1 said Resident #2 masturbated every night and he frequently observed Resident #2 watching pornography on the TV while masturbating in his/her room. Surveyor #2 interviewed Resident #4 on 4/13/17 at 2:40 P.M. Resident #4 said that for the past few months, Resident #2 masturbated in bed with the privacy curtain and bedroom door open to the hallway. Resident #4 said he/she had to walk past Resident #4's bedroom to get to his/her bedroom, so he/she often saw Resident #2 masturbating. Resident #4 said he/she told the nursing staff a number of times that it bothered him/her and he/she did not want to see Resident #2 masturbating. Resident #4 said that staff, did nothing. They told me I did the same thing. During the Survey on 3/24/17, Resident #2 was not being supervised at all times. During the Survey, on 3/24/17 and 4/13/17, Resident #1's care plan was not updatd to include follow-up support or counseling services related to his/her allegation of rape. The Care Plan did not include post exposure [MEDICATION NAME] or follow up laboratory tests following possible sexual assault. Resident #2's Care Plan, initiated on 12/1/14, included that Resident #2 was at risk for inappropriate sexual behavior, with a goal that indicated Resident #2 will be free from sexually inappropriate behaviors, however, the Care Plan did not include interventions specific to Resident #2 sleeping naked in bed without covers, watching pornography, and masturbating in public view. The Care Plan was not updated to address sexual allegations made on 3/8/16, 10/14/16, and 2/10/17 and did not include interventions specific to the prevention of a similar allegations. This was not consistent with the Facility Policy titled Care Plans-Comprehensive.

Based on record review and interviews for 2 of 14 sampled residents (Resident #1 and Resident #2), who had known histories of aggressive and violent behaviors, the Facility failed to supervise the facility's lobby, as required by its Therapeutic (supervision) Schedule, when on [DATE] an altercation occurred which resulted in Resident #1 pushing Resident #2, who fell and struck his/her head on the floor. Resident #2 complained of dizziness and a headache, he/she vomited and experienced left-sided body weakness. Resident #2 was diagnosed at the Hospital with a subdural hematoma (a collection of fluid within the brain), and he/she died later that day. Findings include: Resident #1's [DIAGNOSES REDACTED]. Resident #1's Plan of Care for Behavior, initiated on [DATE] and most recently reviewed on [DATE], indicated he/she exhibited verbal and physical aggression, with a tendency to push other residents out of his/her way. Interventions included removing him/her from a public area if he/she demonstrated disruptive or inappropriate behaviors. Resident #2's [DIAGNOSES REDACTED]. Resident #2's Plan of Care for Behavior, initiated on [DATE] and most recently reviewed on [DATE], indicated he/she required supervision related to verbal and physical aggression and impulsivity. Interventions included removing Resident #2 from a public area if he/she demonstrated disruptive or inappropriate behaviors. The Nurse's Progress Note, dated [DATE], indicated Resident #2 was allegedly pushed by another resident and fell to the floor, hitting his/her head. Resident #2 complained of headache and dizziness, he/she vomited and suffered left-sided body weakness. Staff transferred Resident #2 to the Hospital, where he/she was diagnosed with [REDACTED]. The Facility's Internal Investigation Report, dated [DATE], indicated Resident #2 suffered a subdural hematoma, following an unwitnessed fall at 7:35 A.M., and he/she died at the Hospital that afternoon. The Investigation File indicated statements were obtained from 8 residents who were in the area at the time of the incident involving Resident #1 and Resident #2, and at which time no staff were present. The Surveyor interviewed the Nursing Supervisor at 12:00 P.M. on [DATE]. The Nursing Supervisor said that at approximately 7:35 A.M. on [DATE], she was walking to the main dining room on the ground floor when Resident #3 approached her and asked her to come to the lobby quickly because Resident #1 had pushed Resident #2 to the floor and struck his/her head. The Nursing Supervisor said she immediately ran to the lobby where she saw Resident #2 lying on the floor wiggling around and trying to get up. The Surveyor interviewed Resident #3 at 1:55 P.M. on [DATE], Resident #4 at 2:10 P.M. on [DATE], and Resident #5 at 2:25 P.M. Resident #3, Resident #4 and Resident #5 said Resident #1 and Resident #2 had a verbal altercation, which Resident #5 said was over a chair. Resident #3, Resident #4 and Resident #5 said that Resident #1 then stood up and pushed Resident #2 backwards and Resident #2 fell to the floor and hit the back of his/her head on the floor. Review of the Therapeutic Schedule, dated [DATE], and utilized by the Facility's behavioral staff, indicated Therapeutic Aide #1 was assigned to supervise the Lobby area between 7:00 A.M. and 8:00 A.M., and he/she was to report directly to the lobby at 7:00 A.M. The Surveyor interviewed Therapeutic Aide #1 at 2:45 P.M. on [DATE] and at 11:30 A.M. on [DATE]. Therapeutic Aide #1 said the elevator was unlocked each morning at 7:30 A.M. to allow residents access to the ground floor lobby, where they wound gather until nursing staff were available to supervise the dining room. Therapeutic Aide #1 said it was the role of behavioral staff assigned to the lobby area to supervise residents and intervene to defuse inappropriate behaviors. Therapeutic Aide #1 said that on the morning of [DATE], there were 4 sick calls from behavioral staff, including the Schedule Manager. Therapeutic Aide #1 said that although she sent out text messages to other staff, she was unable to find replacements to cover assignments. Therapeutic Aide #1 said although it was practice on the weekends to inform the Nursing Supervisor of all sick calls, she did not do that at the start of her shift but instead removed herself from the schedule to perform supervisor tasks and did not reassign another staff person to supervise residents in the lobby area between 7:00 A.M. to 8:00 A.M. Therapeutic Aide #1 said at the time of the incident involving Resident #1 and Resident #2 the lobby area was unsupervised. Therapeutic Aide #1 said call-outs were a common problem on weekends, which resulted in reassigning scheduled assignments, including 1:1 supervision, 15 minute safety checks and supervision of common areas.

Based on record review and interviews, the Facility failed to ensure staff performed a post-fall neurological or physical assessment for 1 of 14 sampled residents (Resident #2) who struck his/her head on the floor following an unwitnessed fall. On [DATE], at approximately 7.35 A.M., Resident #1 intentionally pushed and knocked Resident #2 to the floor and he/she hit his/her head. After staff arrived, Resident #2 told staff he/she felt dizzy and had a headache, but these symptoms were not immediately reported to a physician. - Over the course of approximately 85 minutes following the incident, Resident #2's condition continued to decline to the point he/she was unable to ambulate, he/she vomited and experienced left-sided body weakness (abnormal assessment findings indicative of possible closed-head injury). - The Facility failed to immediately obtain emergency medical services via 911. Staff later transferred Resident #2 to the Hospital and he/she was diagnosed with [REDACTED]. Resident #2 died that same day. Findings include: The Facility's policy titled Neurological Assessment, dated [DATE], indicated: a neurological assessment will be completed on any resident who sustains an injury to the head and/or has an unwitnessed fall. The procedures included neurological assessments to be completed every 15 minutes for 1 hour, every 30 minutes for the next 4 hours, every hour for the next 2 hours, and every shift for 72 hours following the fall. Resident #2's [DIAGNOSES REDACTED]. Resident #2's activated Health Care Proxy named a Health Care Agent, who was responsible for making decisions related to his/her medical and nursing care. The Facility's Internal Investigation Report, dated [DATE], indicated Resident #2 suffered a subdural hematoma, following an unwitnessed fall at 7:35 A.M., and he/she and died at the Hospital later that afternoon. The Nurse's Progress Note, dated [DATE], indicated Resident #2 was allegedly pushed by another resident and fell to the floor, hitting his/her head. Resident #2 complained of headache and dizziness, he/she vomited and suffered left-sided weakness. The Nurse's Progress Note indicated staff transferred Resident #2 to the Hospital at approximately 9:00 A.M., at which time he/she was unable to move his/her left side. There was no documentation to indicate staff performed a neurological assessment, including level of consciousness, pupil reaction and motor function, as required by the Neurological Assessment policy. The Surveyor interviewed the Nursing Supervisor at 12:00 P.M. on [DATE]. The Nursing Supervisor said that at approximately 7:35 A.M. on [DATE], she was walking to the main dining room on the ground floor when she was approached by Resident #3. The Nursing Supervisor said that Resident #3 asked her to come to the lobby quickly because Resident #1 had pushed Resident #2 to the floor. The Nursing Supervisor said she immediately ran to the lobby where she saw Resident #2 lying on the floor and wiggling around and trying to get up. The Nursing Supervisor said she called out to kitchen staff, who had responded to the noise in the lobby, and asked for someone to go upstairs to Resident #2's unit and ask a nurse to come help her. The Nursing Supervisor said she did not see any marks or redness on Resident #2's head and Resident #2 pulled himself/herself up from the floor, while holding on to a chair, and sat down on the chair. The Nursing Supervisor said Resident #2 told her that he/she was fine and asked to go to the bathroom. The Nursing Supervisor said that Nurse #1 arrived on the scene and she asked Nurse #1 to take over Resident #2's care while she escorted the other residents away from the area and into the dining room. The Nursing Supervisor said she did not do a formal assessment, including a neurological assessment, on Resident #2, and she did not call a physician to report that Resident #2 had fallen and struck his/her head on the floor. The Surveyor interviewed Nurse #1 at 10:00 A.M. and at 2:40 P.M. on [DATE]. Nurse #1 said she entered the lobby area and Resident #2 was sitting in a chair. Nurse #1 said she asked Resident #2 how he/she was feeling and Resident #2 said that he/she felt dizzy and had a headache. Nurse #1 said she asked Resident #2 on a scale of 0 to 10 (0 meaning no pain and 10 the worst pain imaginable) to describe his/her pain, and Resident #2 replied 5. Nurse #1 said she checked Resident #2's blood pressure, which was elevated at ,[DATE]. Nurse #1 said she asked Resident #2 if he/.she would allow her to bring him/her back upstairs to his/her unit for further evaluation. Nurse #1 said Resident #2 refused and was insistent on going to the bathroom. Nurse #1 said she walked with Resident #2 to the bathroom and after Resident #2 had finished in the bathroom she walked with Resident #2 to the dining room, where he/she sat down at a table to wait for breakfast. Nurse #1 said she told Nurse #2, who was supervising the dining room, that Resident #1 had fallen and hit his/her head and asked Nurse #2 to, keep an eye on Resident #2. Nurse #1 said she went back upstairs and did not complete a formal assessment, including a Neurological Assessment, on Resident #2. Nurse #1 said she did not call a physician to report that Resident #2 had fallen and struck his/her head on the floor and that he/she was dizzy and complained of a headache. The Surveyor interviewed Nurse #2 at 3:15 P.M. on [DATE]. Nurse #2 said that after breakfast was finished a Dietary Aide approached her and said that Resident #2 was dizzy. Nurse #2 said she walked over to Resident 2 and asked him/her what was wrong and Resident #2 replied that he/she was dizzy. Nurse #2 said she telephoned Resident #2's unit and asked staff to bring a wheelchair to the dining room to transport Resident #2 back to his/her unit. Nurse #2 said she did not complete a formal assessment, including a neurological assessment, on Resident #2 and she did not call a physician to report Resident #2's change in condition. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 4:00 P.M. on [DATE]. CNA #1 said that following the incident, Resident #2 had left-sided weakness and was very unsteady. CNA #1 said Nurse #2 helped her to transfer Resident #2 into a wheelchair and she brought Resident #2 upstairs to his/her Unit in the elevator. CNA #1 said when they exited the elevator Resident #2 started to vomit. Nurse #1 said Resident #1 was vomiting and he/she reported that his/her left hand and arm hurt. Nurse #1 said she checked Resident #1's blood pressure, which was now ,[DATE]. Nurse #1 said she did not perform a further neurological assessment on Resident #2 and instead asked staff to wash Resident #2 while she placed a call to the the Medical Director, who was the on-call covering Physician that day. Nurse #1 said the Medical Director called back and gave an order to transfer Resident #1 to the Hospital, at which time she activated 911 emergency services. The Ambulance Run Report, dated [DATE], indicated Resident #2 complained of pain at a scale of 10 and was unable to move his/her left side, and he/she left the Facility at 9:18 A.M. The Surveyor interviewed the Medical Director at 12:45 P.M. on [DATE]. The Medical Director said regardless of Resident #2's past diagnoses, staff should have called him immediately when staff discovered Resident #2 struck his/her head on the floor and complained of dizziness and a headache, at which time he would have ordered Resident #2's transfer to the Hospital for further evaluation.

Based on record review and interview for 5 of 13 sampled residents (Residents #6, #7, #8, #10, #12 and #14) acceptable standards of practice were not followed when: - On 5/23/15, Resident #10 had an unwitnessed fall and told staff that he/she struck his/her head on the floor. Resident #10 sustained a 2 centimeter (cm) by 10 cm laceration on his/her forehead. Staff did not notify the Physician until approximately 2 hours after Resident #10 informed staff of the incident. On 5/24/15 and 5/25/15, staff did not consistently perform a neurological assessment on Resident #10, in accordance with the Facility's Neurological Assessment Policy. A thorough investigation into the surrounding events of Resident #10's fall was not conducted. - On 5/25/15 through 5/31/15, Resident #12 had 4 unwitnessed falls, one of which included a fall in the bathroom, where he/she struck his/her head on the floor and sustained a laceration to the back of his/her head (requiring 4 surgical staples). Staff did not consistently perform a neurological assessment, in accordance with the Facility's Neurological Assessment policy. - On 7/26/15, Nurse #1 did not sign-off on the Medication Administration Record [REDACTED]. - On 7/27/15, staff failed to place a smoking apron on Resident #6, as required by his/her Plan of Care for Smoking. At approximately 9:35 A.M., during the scheduled supervised smoking break, the Surveyor observed Resident #6 smoking a cigarette and his/her safety apron was lying on the ground located at the opposite end of the patio. - The Facility failed to review and revise Resident #14's Plans of Care. Most significantly, from approximately 1/3/15 to 6/21/15, Resident #14 either initiated or participated in 8 documented incidents of aggression or violence toward staff or other residents, and the Facility failed to review or revise the Plan of Care to attempt to improve management of these behaviors. Findings include: 1. The Facility's policy titled, Acute Condition Changes, dated December 2012, indicated nursing staff will contact the Physician based on the urgency of a resident's change in condition and request a response within approximately one-half hour or less. The Facility's policy titled, Neurological Assessment, dated 6/22/15, indicated a neurological assessment will be completed on any resident who sustains an injury to the head and/or has an unwitnessed fall. The procedures included neurological assessments to be completed every 15 minutes for 1 hour, every 30 minutes for the next 4 hours, every hour for the next 2 hours, and every shift for 72 hours following the fall. The Policy indicated level of consciousness, pupil response, motor function, pain response, vital signs and observations for changes in condition would be documented for each shift. The Facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated February 2014, indicated a prompt investigation will be initiated following all accidents or incidents involving residents and will include documentation regarding the circumstances surrounding the incident, accounts from witnesses, and the time the Physician was notified. 2. The Fall Risk Assessment, dated 4/17/15, indicated Resident #10 was identified as being at a high-risk for falls related to poor judgement and lack of safety awareness and his/her history of prior falls. The Care Plan for Falls Risk (undated), indicated Resident #10 will attempt to self transfer without staff assistance and interventions included the use of a chair alarm. The Rehabilitation Screen, dated 5/16/15, indicated Resident #10 had impaired cognition, he/she could propel his/her wheelchair independently, required limited assistance with transfers, and assistive devices included the use of a chair alarm. The quarterly Minimum Data Set (MDS) assessment, dated 5/19/15, indicated Resident #10 was non-ambulatory and required extensive assistance from 1 person for transfers in and out of his/her wheelchair. The Nurse's Progress Note, dated 5/23/15, indicated at 7:00 P.M. Resident #10 approached the Nurses' Station where he/she told staff he/she had fallen in the day room and picked himself/herself up. On assessment, Resident #10 had a 2 centimeter (cm) by 10 cm laceration on his/her head. Staff applied a dry protective dressing and performed a neurological assessment. The Incident Report, dated 5/23/15, indicated staff notified the Physician at 9:00 P.M., 2 hours after Resident #10 told staff that he/she fell and struck his/her head on the floor. The Incident Report indicated at this time the Physician gave the order to apply a dry protective dressing to the laceration on Resident #10's head. Review of the Incident Report indicated there were no attached statements from staff who worked on the evening of 5/23/15 and no documentation to indicate if Resident #10's chair alarm sounded at the time of his/her fall, or documentation which indicated how Resident #10 got up from the floor and back into his/her wheelchair. The Surveyor interviewed Nurse #3 at 11:15 A.M. on 8/4/15. Nurse #3 said that on the evening of 5/23/15, Resident #10 approached her at the Nurses' Station, shortly after supper time, and told her that he/she had fallen in the day room and hit his/her head on the floor. Nurse #3 said Resident #10 had a laceration on his/her forehead, which she cleaned and covered with a dry protective dressing. Nurse #3 said there was an alarm on Resident #10's wheelchair, which she did not hear sound and which she did not check to see if it was functioning properly. Nurse #3 said she initiated a neurological assessment on Resident #10, but she did not call the Physician until later that evening to inform him that Resident #10 had fallen and struck his/her head on the floor. Nurse #3 said she did not interview staff to determine if anyone had seen Resident #10 fall, or had helped him/her to get up from the floor and back into his/her wheelchair. Resident #10's Neurological Assessment Flow Sheet, dated 5/24/15, indicated that staff on the 7:00 A.M. to 3:00 P.M. shift and the 3:00 P.M. to 11:00 P.M. shift failed to document Resident #10's level of consciousness, pupil response, motor function, pain response, vital signs or observations for changes in condition, contrary to the Neurological Assessment policy. 3. The quarterly MDS assessment, dated 3/24/15, indicated Resident #12 had moderate cognitive impairment, he/she was non-ambulatory and required extensive assistance from 1 person with transfers. The Fall Risk Assessment, dated 6/22/15, indicated Resident #12 was identified as being at a high-risk for falls related to poor judgement and lack of safety awareness, problems with gait and balance, and a high number of prescribed medications. The Facility Incident Reports and Nurse Progress Notes, dated 5/25/15, 5/27/15 and 5/28/15, indicated Resident #12 had 4 unwitnessed falls. This included a fall in the bathroom at 6:00 P.M. on 5/27/15 resulting in a laceration to the back of Resident #12's head. Staff transferred Resident #12 to the Hospital, where he/she received 4 surgical staples to close the laceration on his/her head. Resident #12's Neurological Assessment Flow Sheets, and Nurse Progress Notes (5/25/15, 5/27/15 and 5/28/15) indicated: - On 5/25/15, staff did not wake Resident #12 out of his/her sleep between 3:35 A.M. and 5:20 A.M. to check his/her level of consciousness, pupil response, motor function, pain response, vital signs or make observations for changes in condition. The Neurological Assessment Flow Sheet indicated that on the 7.00 A.M. to 3:00 P.M. shift, Resident #12 refused to let staff perform a neurological assessment on him/her. There was no documentation indicating staff informed the Physician that Resident #12's neurological assessments were not completed, as required by the Facility's Neurological Assessment policy. - On 5/26/15, the assessing nurse did not perform a neurological assessment on the 3:00 P.M. to 11:00 P.M. shift. There was no documentation indicating staff informed the Physician that Resident #12's neurological assessments were not completed, per the Facility's Neurological Assessment Policy, following an unwitnessed fall. - On 5/27/15 Resident #12 refused to let staff perform a neurological assessment on him/her on him/her between 7:00 A.M. and 6:00 PM. Resident #12 had unwitnessed falls at 10:00 A.M. and at 6:00 P.M. There was no documentation indicating staff informed the Physician that Resident #12's neurological assessments were not completed, per the Facility's Neurological Assessment Policy, following an unwitnessed fall. - On 5/28/15, Resident #12 refused to let staff perform a neurological assessment on him/her on him/her on the 7:00 A.M. to 3:00 shift and the 3:00 P.M. to 11:00 P.M. shift. Resident #12 had an unwitnessed fall at 9:50 A.M. There was no documentation indicating staff informed the Physician that Resident #12's neurological assessments were not completed, per the Facility's Neurological Assessment Policy, following an unwitnessed fall. - On 5/29/15, Resident #12 refused to let staff perform a neurological assessment on him/her during the 11:00 P.M. to 7:00 A.M. shift, and staff did not perform a neurological assessment on the 7:00 A.M. to 3:00 P.M. shift or the 3:00 P.M. to 11:00 P.M. shift. There was no documentation indicating staff informed the Physician that Resident #12's neurological assessments were not completed, as required by the Facility's Neurological Assessment policy. - On 5/30/15, Resident #12 refused to let staff perform a neurological assessment on him/her during the 11:00 P.M. to 7:00 A.M. shift. Staff did not perform a neurological assessment on the 7:00 A.M. to 3:00 P.M. shift. There was no documentation indicating staff informed the Physician that Resident #12's neurological assessments were not completed, as required by the Facility's Neurological Assessment policy. - On 5/31/15, the staff did not wake Resident #12 out of his/her sleep during the 11:00 P.M. to 7:00 A.M. shift to perform a neurological assessment. There was no documentation indicating staff informed the Physician that Resident #12's neurological assessments were not completed, as required by the Facility's Neurological Assessment policy. The Surveyor interviewed the Medical Director at 12:45 P.M. on 7/28/15 and at 11:45 A.M. on 8/10/15. The Medical Director said it was his expectation that whenever a resident had 1) a witnessed fall were he/she struck his her head, 2) an unwitnessed fall or 3) told staff that he/she had a headache or felt dizzy, staff were to follow the Facility's Neurological Assessment policy and procedure to determine if any sign of head injury exists. The Medical Director said staff were to waken residents out of sleep when a neurological assessment was required and were to inform the covering Physician if a resident refused to let staff perform a neurological assessment. The Medical Director said staff had not informed him that staff were not consistently performing neurological assessments on residents post-fall and potential head injury or that residents were refusing to let staff perform a neurological assessment on them post-fall and potential head injury. 4. On 7/27/15, the Surveyor reviewed Resident #6, Resident #7 and Resident #8's medication administration records (MARs) and determined that medications scheduled for the evening of 7/26/15 were not signed off as administered. The Surveyor interviewed Nurse #1 at 3:00 P.M. on 7/27/15. Nurse #1 said that while she did administer the evening medications prescribed to Resident #6, Resident #7 and Resident #8 on 7/26/15, she did not document on the MARs that these were given. 5. The quarterly MDS assessment, dated 7/14/15, indicated Resident #6 was cognitively impaired with limited range of motion and functional mobility. A Smoking Safety Evaluation record, dated 7/15/15, indicated Resident #6 was unable to light a cigarette with a lighter or smoke safely, and he/she was unable to extinguish a cigarette safely and completely when finished smoking. The Smoking Plan of Care, dated 7/15/15, indicated Resident #6 required supervision during designated smoking times, and he/she required a robotic smoking system and to wear a smoking apron for his/her safety. On 7/27/15, at approximately 9:35 A.M., during the designated supervised smoking break, the Surveyor observed Resident #6 smoking a cigarette while utilizing the robotic system, however, his/her safety apron was lying on the ground located at the opposite end of the patio. 6. Review of Resident #14's quarterly MDS assessment, dated 5/26/15, indicated he/she was diagnosed with [REDACTED]. - Resident #14's Plan of Care for Disruptive and Aggressive Behavior, initiated on 12/9/14, indicated he/she was at risk for these behaviors due to impulsivity related to his/her [DIAGNOSES REDACTED]. Goals of care included being free of episodes of aggression for the next 90 days and to decrease the frequency of intrusive and disruptive behavior less than 2 times per week. Interventions included: be aware of his/her personal space, if behavioral interventions are not working, leave (if safe to do so) and reapproach later, encourage him/her to write down what is making him/her upset. Listen and offer suggestions to help solve his/her problem. The Plan of Care for Disruptive and Aggressive Behavior did not include physical restraint as an intervention. Resident #14's Nurses' Progress Notes, dated 1/3/15, 1/19/15, 1/27/15, 2/13/15, 3/7/15, 3/14/15, 6/5/15 and 6/21/15, indicated he/she exhibited combative, aggressive and/or violent behavior toward residents and staff. Resident #14's Nurse's Progress Note and Incident Report, dated 1/3/15, indicated he/she attacked staff, and staff subsequently physically restrained and placed Resident #14 on 1:1 supervision. Resident #14's Nurse's Progress Note and Incident Report, dated 1/19/15, indicated he/she threw a chair at staff and hit a staff member on the arm, and then staff physically restrained Resident #14. Resident #14's Nurse's Progress Note and Incident Report, dated 1/27/15, indicated he/she attacked staff and struck staff multiple times, and then staff physically restrained Resident #14. Resident #14's Nurse's Progress Note, dated 2/13/15, indicated he/she tried to hit staff, and staff then physically restrained Resident #14. Resident #14's Nurse's Progress Note and Incident Report, dated 3/7/15, indicated he/she threw water at staff, hit and pushed staff, and staff then physically restrained Resident #14. Resident #14's Nurse's Progress Note and Incident Report, dated 3/14/15, indicated he/she grabbed a staff member by the hair, hit and punched staff on the head, and staff then physically restrained Resident #14. Resident #14's Nurse's Progress Note, dated 6/8/15, indicated he/she and his/her roommate were involved in a violent confrontation and Resident #14 was hit in the mouth and sustained bruising near the right eye and a small cut. Resident #14's Nurse's Progress Note and Incident Report, dated 6/21/15, indicated staff observed him/her, beating another resident in the hallway. Throwing punches on his left face. Staff physically restrained Resident #14 and placed him/her under 1:1 supervision. Resident #14's Plan of Care for Disruptive and Aggressive Behavior indicated it was not reviewed, or revised, since its initiation date on 12/9/14 and did not reflect any of the significant behaviors documented in the above reference Nurses Progress Notes and Incident Reports. Resident #14's Care Plan did not include new goals or interventions or reference the regular use of physical restraints. Resident #14's Behavior Department's Neurobehavioral Plan of Care, dated 6/15/15, indicated he/she could be physically and sexually inappropriate. The Care Plan included multiple staff interventions to address, manage and de-escalate these behaviors. Interventions did not include the regular use of physical restraints. Review of the medical record indicated Resident #14 did not have a Behavior Department's Neurobehavioral Plan of Care initiated at the onset of his/her violent behaviors, which began in January 2015. The Behavior Department's Neurobehavioral Plan of Care was not updated or revised to reflect the significant incident which occurred on 6/21/15. 7. Review of all of Resident #14's nursing Plans of Care indicated these had not been reviewed, or updated regularly, since being developed by staff, in approximately December 2014. Examples include, but are not limited to: - Review of Resident #14's Plan of Care for Elopement, dated 2/4/15, had not been reviewed since its initiation date, including the scheduled 90-day reassessment date. - Review of Resident #14's Plan of Care for Antipsychotic Medications, dated 12/4/14, had not been reviewed since its initiation date, including the scheduled 90-day or 180-day reassessment dates. - Review of Resident #14's Plan of Care for Mood, dated 12/8/14, had not been reviewed since its initiation date, including the scheduled 90-day or 180-day reassessment dates. - Review of Resident #14's Plan of Care for Sexually Inappropriate Behavior, dated 12/9/14, had not been reviewed since its initiation date, including the scheduled 90-day or 180-day reassessment dates. - Review of Resident #14's Plan of Care for Full Code Status, dated 12/8/14, had not been reviewed since its initiation date, including the scheduled 90-day or 180-day reassessment dates. - Review of Resident #14's Plan of Care for Neurological Deficiencies, dated 12/4/14, had not been reviewed since 12/29/14, including the scheduled 90-day or 180-day reassessment dates. - Review of Resident #14's Plan of Care for Communication Deficits, dated 12/4/14, had not been reviewed since its initiation, including the scheduled 90-day or 180-day reassessment dates.

Based on interview and record review, the Facility failed to provide ongoing American Sign Language (ASL) interpreter services to Resident #14, despite that this was his/her primary means of communication and that other means (such as writing) were insufficient due to his/her cognitive ability. Resident #14 was deaf and non-speaking and used written communication for only basic needs. Findings include: Review of Resident #1's Speech Language Evaluation/Plan of Care and Discharge Summary, dated 11/7/14, indicated he/she required prompts for the use of 2-word written communication, and was able to use writing for only basic needs. The Summary indicated Resident #14's limitations in written communication remained a barrier in a setting without other ASL speakers. Resident #14's Plan of Care for Communication Deficits, dated 12/4/14, indicated [DIAGNOSES REDACTED]. Care Plan interventions included using yes/no questions and responses when able; use paper and pen to write his/her needs/wants when unable to effectively understand each other; provide reassurance and patience when communicating with patient. Repeat information as needed; when talking to patient use gestures and simple sentences while maintaining eye contact. Resident #14's Plan of Care for Communication Deficits did not include the use of an ASL interpreter. Review of Resident #14's quarterly Minimum Data Set assessment, dated 5/26/15, indicated he/she was diagnosed with [REDACTED]. The Surveyor interviewed Resident #14, with the assistance of an ASL interpreter, at 10:30 A.M. on 7/31/15. Resident #14 signed he/she grew up attending a school for the deaf and ASL was his/her primary means of communication. Resident #14 signed that the Facility used ASL interpreters very infrequently and he/she did not read lips well, and he/she wanted more ASL services. Resident #14 said Facility staff had not provided an ASL interpreter to orient him/her to the Facility, explain the admission packet, review his/her resident rights as a nursing home resident, or explain how to contact the local ombudsman. The Surveyor interviewed ASL Interpreter #1 at 11:55 A.M. on 7/27/15. ASL Interpreter #1 said she provided services to Resident #14 from the Fall of 2014 until the Spring of 2015. ASL Interpreter #1 said the Facility did not request interpreter services to explain to Resident #14 the Facility's admission process, to orient him/her to the Facility, resident rights, or how to access the local ombudsman or nursing/rehabilitation assessments. ASL Interpreter #1 said services were provide for 1 physician examination and 1 care plan meeting. The Surveyor interviewed the Speech Therapist at 11:30 A.M. on 7/27/15. The Speech Therapist said she provided treatment to Resident #14 from 9/10/14 to 3/27/15. The Speech Therapist said ASL was Resident #1's primary means of communication, but the Facility did not have an ASL interpreter on staff. The Speech Therapist said that, due to this constraint, it became a goal of treatment to help Resident #14 learn how to use a writing board to communicate. The Speech Therapist said formal testing, however, showed Resident #14 had significant difficulty using written communication. The Speech Therapist said Resident #14 was highly variable in his/her ability to follow written directions, or to understand writing. The Surveyor interviewed the Case Manager from the Massachusetts Commission for the Deaf and Hard of Hearing at 4:00 P.M. on 7/30/15. The Case Manager said it was the expectation of the Commission that the Facility provide ASL interpreter services to orient Resident #14 to the Facility, for all healthcare-related meetings, and to explain his/her legal rights as a nursing home resident. The Surveyor interviewed the Director of Social Services at 3:15 P.M. on 7/27/15. The Director of Social Services said that Resident #14 was admitted to the Facility in September 2014 and the Facility began to provide ASL interpreter services in December 2014. The Director of Social Services said the Facility had a goal of arranging ASL interpreter services for Resident #14 weekly or biweekly. Review of the Facility's invoices for ASL interpreter services indicated these weekly or biweekly goals were not met. Only 9 of the approximately 46 weeks of his/her current admission period (12/8/14, 1/7/15, 1/15/15, 2/4/15, 3/4/15, 3/21/15, 3/27/15, 6/15/15 and 7/3/15) were services actually provided.

Based on record review and interview, for 3 of 13 sampled residents (Resident #2, Resident #10 and Resident #14), the Facility failed to notify the Physician in a timely manner of significant injuries and/or emergent restraints. - On [DATE], at approximately 7.35 A.M., Resident #1 intentionally pushed Resident #2 and he/she fell and struck his/her head. After staff arrived, Resident #2 told staff he/she felt dizzy and had a headache, but these symptoms were not immediately reported to a physician. Approximately 85 minutes later, Resident #2 vomited and experienced left-sided body weakness. Resident #2 was unable to walk and required the assistance of 2 people to transfer into a wheelchair. Staff later transferred Resident #2 to the Hospital, where he/she was diagnosed with [REDACTED]. - On [DATE], Resident #10 had an unwitnessed fall and told staff he/she struck his/her head on the floor. Resident #10 sustained a 2 centimeter (cm) x 10 cm laceration to his/her forehead but this was not reported to the Physician until approximately 2 hours later, at 9:00 P.M. - On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], the Facility emergently restrained Resident #14. The Facility did not attempt to notify the Physician of these significant incidents or of the restraints, and did not obtain orders for these restraints. Findings include: 1. The Facility's policy titled, Acute Condition Changes, dated [DATE], indicated nursing staff will contact a physician based on the urgency of a resident's change in condition and request a response within approximately one-half hour or less. 2. Resident #2's [DIAGNOSES REDACTED]. The Facility Internal Investigation Report, dated [DATE], indicated Resident #2 suffered a subdural hematoma, following an unwitnessed fall at 7:35 A.M., and he/she died at the Hospital later that afternoon. The Nurse's Progress Note, dated [DATE], indicated Resident #2 was allegedly pushed by another resident and fell to the floor, hitting his/her head. Resident #2 complained of headache and dizziness, he/she vomited and suffered left-sided body weakness. The Nurse's Progress Note indicated staff called the Physician at approximately 9:00 A.M., and the Physician gave an order to transfer Resident #2 to the Hospital. The Surveyor interviewed the Nursing Supervisor at 12:00 P.M. on [DATE]. The Nursing Supervisor said that at approximately 7:35 A.M. on [DATE], while on her way to the dining room, Resident #3 approached her and told her that Resident #2 had been in an altercation with Resident #1 and that Resident #2 had fallen and struck his/her head onto the floor. The Nursing Supervisor said she ran to the lobby area where she saw Resident #2 lying on the floor. The Nursing Supervisor said she called out to dietary staff, who had already responded to the noise in the lobby, and asked for someone to go upstairs and ask a nurse to come help her. The Nursing Supervisor said she remained with Resident #2 until she was relieved by Nurse #1. The Nursing Supervisor said she did not notify the Physician that Resident #2 had fallen and struck his/her head on the floor, and did not assess Resident #2, per Facility policy. The Surveyor interviewed Nurse #1 at 10:00 A.M. and 2:40 P.M. on [DATE] and at 3:00 P.M. on [DATE]. Nurse #1 said Resident #2 told her that he/she felt dizzy and his/her head hurt. Nurse #1 said Resident #2 refused to go back to his/her unit and insisted on going to the bathroom and then to the dining room for breakfast. Nurse #1 said she did not notify the Physician that Resident #2 had fallen and struck his/her head on the floor, and did not assess Resident #2, per Facility policy. Nurse #1 said she then began her assigned medication pass. Nurse #1 said at approximately 9:00 A.M., a Certified Nurse Aide escorted Resident #2 upstairs in a wheelchair and that he/she was vomiting and complained of left-sided body weakness. Nurse #1 said she called the Medical Director, who was the on-call covering physician that day, and the Medical Director gave the order to transfer Resident #2 to the Hospital for further evaluation. The Surveyor interviewed the Medical Director at 12:45 P.M. on [DATE] and at 11:45 A.M. on [DATE]. The Medical Director said nursing staff should have called him immediately when it was discovered that Resident #2 had struck his/her head on the floor and complained of dizziness and a headache, at which time he would have given the order to immediately transfer Resident #2 to the Hospital for further evaluation. 3. A Fall Risk Assessment, dated [DATE], indicated Resident #10 was identified as being at a high-risk for falls related to poor judgement, lack of safety awareness and his/her history of prior falls. The Plan of Care for Falls (undated), indicated Resident #10 will attempt to self-transfer (without first requesting staff assistance) and interventions included the use of a chair alarm. The Rehabilitation Screening, dated [DATE], indicated Resident #10 had impaired cognition, could propel his/her wheelchair independently, required limited assistance with transfers, and assistive devices included the use of a chair alarm. The Nurse's Progress Note, dated [DATE], indicated at 7:00 P.M. Resident #10 approached the Nurses Station where he/she told staff he/she had fallen in the day room and had picked himself/herself up. On assessment, Resident #10 had a 2 centimeter (cm) by 10 cm laceration on his/her head. Staff applied a dry protective dressing and a neurological assessment was performed. The Facility Incident Report, dated [DATE], indicated staff notified the Physician at 9:00 P.M. and an order was given to apply a dry protective dressing to the laceration on Resident #10's head. The Surveyor interviewed Nurse #3 at 11:15 A.M. on [DATE]. Nurse #3 said that on the evening of [DATE], Resident #10 approached her at the nurses station, shortly after supper time, and told her that he/she had fallen in the day room and hit his/her head on the floor. Nurse #3 said Resident #10 had a laceration on his/her forehead, which she cleaned and covered with a dry protective dressing. Nurse #3 said she did not call the Physician until later that evening to inform him that Resident #10 had fallen and struck his/her head on the floor. 4. Review of Resident #14's Physicians' orders, dated [DATE] to [DATE], indicated there was no physician notification of his/her significant violent behavior or order for the associated restraints, despite that staff physically restrained Resident #14 on 7 documented occasions on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Resident #14's Nurse's Progress Note and Incident Report, dated [DATE], indicated he/she attacked staff, and staff subsequently physically restrained and placed Resident #14 on 1:1 supervision. Resident #14's Nurse's Progress Note and Incident Report, dated [DATE], indicated he/she threw a chair at staff and hit a staff member on the arm, and then staff physically restrained Resident #14. Resident #14's Nurse's Progress Note and Incident Report, dated [DATE], indicated he/she attacked staff and struck staff multiple times, and then staff physically restrained Resident #14. Resident #14's Nurse's Progress Note, dated [DATE], indicated he/she tried to hit staff, and staff then physically restrained Resident #14. Resident #14's Nurse's Progress Note and Incident Report, dated [DATE], indicated he/she threw water at staff, hit and pushed staff, and staff then physically restrained Resident #14. Resident #14's Nurse's Progress Note and Incident Report, dated [DATE], indicated he/she grabbed a staff member by the hair, hit and punched staff on the head, and staff then physically restrained Resident #14. Resident #14's Nurse's Progress Note and Incident Report, dated [DATE], indicated staff observed him/her, beating another resident in the hallway. Throwing punches on his left face. Staff physically restrained Resident #14 and placed him/her under 1:1 supervision. The Surveyor interviewed the Director of Neurobehavior at 1:00 P.M. on [DATE]. The Director of Neurobehavior said the Facility used Crisis Prevention Intervention (CPI) technique to manage residents violent behavior and the technique included manual holds by staff on residents. The Director of Neurobehavior said that incidents involving CPI were documented on incident reports, but not reported to a physician. The Director of Neurobehavior said that the Facility did not consider CPI to be a restraint and as such did not seek a physician's orders [REDACTED].#14 on any of the above referenced dates.