Every finding on record at Care One at Northampton

Based on observation, interviews and record reviews, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and reflective of the resident's status at the time of the assessment, for five Residents (#51, #11, #10, #3 and #4), out of a total sample of 21 residents. Specifically, the facility failed to:For Resident #51, accurately code that insulin injections were administered in the MDS assessment dated [DATE].For Resident #11, accurately code that insulin injections and hypoglycemic (used to treat high blood sugar) medication were administered on the MDS assessment dated [DATE], and accurately code hospice services on the MDS assessment dated [DATE].For Resident #10, accurately code that the Resident utilized tobacco and had sustained two falls during the reference period for the MDS assessment dated [DATE].For Resident #3, accurately code urinary continence status as not rated due to his/her indwelling catheter and that he/she receives nutrition/hydration interventions to manage skin problems on the MDS assessment dated [DATE]. For Resident #4, accurately code the use of hypoglycemic medication and antipsychotic (used to treat mental illness) medication on the MDS assessment dated [DATE]. Findings include: 1. Resident #51 was admitted to the facility in April 2021 with diagnoses including Dementia and Type 2 Diabetes. Review of Resident #51's MDS Assessment, dated 4/8/25, indicated the following: -Seven day look back period captured Resident data from 4/2/25 through 4/8/25 -use of hypoglycemics, including insulin (a specific type of hypoglycemic), was not indicated. Review of Resident #51's April 2025 Medication Administration Record (MAR) indicated the following: -Lantus (a type of insulin) was received daily from 4/2/25 through 4/8/25 During an interview on 12/18/25 at 12:08 P.M., MDS Nurse #1 said the MDS assessment dated [DATE] was coded inaccurately and should have indicated that Resident #51 was administered insulin on seven days during the assessment reference period. 2. Resident #11 was admitted to the facility in November 2022 with diagnoses including cerebral infarction (stroke), Diabetes and frontotemporal neurocognitive disorder. a. Review of Resident #11's MDS assessment dated [DATE], indicated the following: -Seven day look back period captured Resident data from 8/6/25 through 8/12/25 -use of hypoglycemics, including insulin (a specific type of hypoglycemic), was not indicated. Review of Resident #11's August 2025 MAR indicated the following: -Lantus was received daily 8/6/25 through 8/12/25 b. Review of the MDS assessment dated [DATE], indicated Resident #11 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of seven out of 15 and was not receiving hospice services. Review of the December 2025 Physician's orders indicated the Resident was admitted to hospice services on 10/23/25. Review of the Hospice/Palliative Care Plan, initiated 10/23/25, indicated the Resident signed on to hospice services related to his/her terminal/end stage disease. During an interview on 12/18/25 at 12:07 P.M., MDS Nurse #1 said the MDS assessment dated [DATE] was inaccurately coded and should have indicated Resident #11 received seven days of insulin injections and was on hypoglycemic medication. MDS Nurse #1 said the MDS assessment dated [DATE] was also inaccurately coded and should have indicated the Resident was receiving hospice services. 3. Resident #10 was admitted to the facility in September 2019 with diagnoses including abnormal gait and mobility and hemiplegia following a cerebrovascular disease affecting the left side. Review of the list of current residents who smoked, provided by the facility upon entrance on 12/16/25, indicated Resident #10 was an active smoker. Review of the Smoking Care Plan, initiated 11/6/19 and revised 6/25/21, indicated Resident #10 was a current smoker. Review of the Quarterly Nurse assessment dated [DATE] indicated relative to Resident #10 was an active smoker. Review of the December 2025 Physicians orders included the following: -Supervised smoking at designated times . 10:00 A.M., 2:00 P.M., 6:00 P.M. (max. of 2 cigarettes at each time). All smoking materials are to be locked in med cart/med room, initiated 10/30/23 Review of Resident #10's progress notes indicated the following Situation Background Appearance and Review/Notify (SBAR) Notes: -9/3/25: Resident had an unwitnessed fall -11/16/25: Resident had an unwitnessed fall Review of the MDS assessment dated [DATE], indicated Resident #10: -was not a current tobacco user. -had not sustained any falls since the last assessment. On 12/18/25 at 9:59 A.M., the surveyor observed Resident #10 smoking outside of the facility in the designated smoking area with a facility staff present. During an interview on 12/18/25 at 12:09 P.M., MDS Nurse #1 said the MDS assessment dated [DATE] was inaccurately coded and should have indicated Resident #10 used tobacco as he/she was an active smoker and should have indicated that the Resident sustained two falls during the assessment reference period. 4. Resident #3 was admitted to the facility in August 2025 with diagnoses including protein-calorie malnutrition, obstructive and reflux uropathy, and urinary retention. Review of MDS assessment dated [DATE] indicated the following for Resident #3: -Seven day look back period captured Resident data from 11/19/25 through 11/25/25 -had an indwelling catheter in place -was always incontinent of urine -had a pressure ulcer which was not present on admission -did not receive nutrition/hydration interventions to manage skin problems Review of the November 2025 MAR indicated the following from 11/18/25 through 11/25/25: -Med Pass Reduced Sugar (nutritional supplement) 120 ml was administered at least daily Review of the December 2025 Physician's orders included the following: -Med Pass Reduced Sugar 120 ml three times daily, initiated 9/9/25 -Foley Catheter (type of indwelling urinary catheter) every night shift, secure and change and flush with 10 cubic centimeters (cc) sterile saline . document urinary output 16 French 10 cc balloon, initiated 8/21/25 On 12/17/25 at 8:35 A.M., the surveyor observed Resident #3 reclining upright in bed eating breakfast. A urinary drainage bag was observed within a privacy bag and anchored on the lower section of the bed. During an interview on 12/18/25 at 12:03 P.M., MDS Nurse #1 said the MDS assessment dated [DATE] was inaccurately coded for Resident #3 and should have indicated 9 - not rated under urinary continence because the Resident had a urinary catheter. MDS Nurse #1 further said the nutritional supplement should have been coded under the nutrition and hydration interventions to manage skin problems, but it was not accurately coded. 5. Resident #4 was admitted to the facility in January 2023 with diagnoses including Diabetes, Post Traumatic Stress Disorder (PTSD), Adjustment Disorder, and Vascular Dementia. Review of Resident #4's MDS assessment dated [DATE], indicated the following: -Seven day look back period captured Resident data from 9/26/25 through 10/2/25 -use of hypoglycemics, including insulin, was not indicated -the second use of antipsychotics under section N, (question N0450), was not indicated Review of Resident #4's September 2025 MAR indicated the following: -Lantus was received daily 9/26/25 through 9/30/25 -Seroquel (a type of antipsychotic) was received daily 9/26/25 through 9/30/25 Review of Resident #4's October 2025 MAR indicated the following: -Lantus was received daily 10/1/25 through 10/2/25 -Seroquel was received daily 10/1/25 through 10/2/25 During an interview on 12/19/25 at 9:50 A.M., MDS Nurse #1 said Resident #4 had received seven days of insulin and the use of hypoglycemic box should have been checked on the 10/2/25 MDS assessment but was not. MDS Nurse #1 further said Resident #4 had received seven days of an antipsychotic and the second antipsychotic use section (N0450) should have been checked but was not. MDS Nurse #1 said that it is important to accurately code the MDS so that the Resident's care plan is accurate.

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#8) of three applicable residents reviewed for incontinence, out of a total sample of 21 residents, was fully assessed and interventions implemented to assist in improving the Resident's episodes of incontinence. Specifically for Resident #8, the facility failed to: -accurately assess for bladder incontinence, and -complete a bladder retraining program Findings include: Review of the facility policy titled Urinary Continence and Incontinence- Assessment and Management, revised August 2022, indicated the following: -the staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence -the physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible -as part of the ongoing assessments, the nursing staff and physician will screen for information related to urinary incontinence. Examples of sources of such information may include the resident. -relevant information related to urinary continence includes: >history of urinary incontinence; factors precipitating incontinence; and associated symptoms >previous treatment/management attempts and response to interventions >pertinent diagnoses. >observations. >functional and/or cognitive capabilities or limitations that could affect continence. >environmental factors and assistive devices that may restrict or facilitate a resident's ability to access the toilet. -as part of its assessment, nursing staff will seek, and document results related to continence. Relevant details include: >voiding patterns. >associated pain or discomfort >types of incontinence: stress, urge, mixed, overflow, transient, functional -the evaluation will include a review for medications that might affect continence. -the staff and physician will summarize an individual's continence status. For residents deemed incontinent, this includes categorizing incontinence as urge, stress, overflow, mixed, or functional, and relevant causes, risk factors, and complications -the physician and staff will address treatable causes or contributing factors related to urinary incontinence. -as indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan -the staff will document the results of the toileting trial in the resident's medical record. -the staff and physician will evaluate the effectiveness of interventions and implement additional pertinent interventions as indicated Resident #8 was admitted to the facility in June 2025 with diagnoses including Congestive Heart Failure (CHF), abnormal gait and mobility, and overactive bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #8:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15.-required substantial/maximum assistance from staff with toileting.-was frequently incontinent. On 12/16/25 at 9:27 A.M., Resident #8 was observed dressed and seated in a wheelchair in his/her room. During an interview at the time, Resident #8 said he/she would ring his/her call bell and have to wait up to 30 minutes for staff to respond so that he/she could be assisted to the bathroom. Resident #8 said this occurred frequently during all shifts, that he/she wore an incontinence brief, but sometimes could not wait for staff to assist him/her and would become incontinent in the brief. Review of the Urinary Incontinence Care Plan initiated 6/29/25, indicated Resident #8 had impaired mobility, overactive bladder, physical limitations and medications that contributed to his/her incontinence. The plan of care included the following interventions: -provide assistance with toileting or incontinence care as needed. -use absorbent products as needed (briefs). Review of the Quarterly Nursing Assessments dated 9/17/25 and 12/17/25 indicated Resident #8: -was incontinent of bladder -the facility was unable to determine the type of incontinence-did not present with transient, reversible or potentially treatable condition related to incontinence-was cognitively intact and that bladder retraining program should be initiated Review of Resident #8's clinical record failed to indicate that any bladder retraining program was initiated for the Resident. Review of the Occupational Therapy (OT) Discharge summary dated [DATE], indicated Resident #8:-required assistance of one staff for all activities of daily living (ADL) tasks including toileting. -required supervision for all transfers and mobility using a rolling walker. Review of the Certified Nurse Aide (CNA) Care Card on 12/18/25 at 7:27 A.M., indicated Resident #8 required assistance of one staff with toileting. During an interview on 12/18/25 at 10:19 A.M., Resident #8 said that toileting had improved during the night with staff assisting him/her to the bathroom, but he/she continued to have incontinent episodes when he/she rings the call bell, and staff cannot assist him/her on time. Resident #8 further said he/she would like to be more independent with toileting and had a difficult time managing the adult incontinence briefs that were utilized. Resident #8 also said that one facility staff member uses adult pull-up style incontinence brief which was easier for him/her to manage because the adult pull-up style incontinence briefs were thinner and work like underwear. Resident #8 said he/she was not incontinent prior to coming to the facility and that he/she would like to have fewer to no episodes of incontinence. Resident #8 said he/she was not aware of any plan to decrease his/her incontinence, would like to have this looked into by the facility, and would like to be more independent with toileting. During an interview on 12/18/25 at 10:23 A.M., CNA #2, who is a regular staff and worked all shifts, said Resident #8 required assistance of one staff with toileting and wears an adult brief. CNA #2 said the Resident was able to indicate when he/she needed to use the bathroom and will ring the call bell for staff assistance. CNA #2 said Resident #8 was continent of both bowel and bladder and has had no episodes of incontinence when CNA #2 has worked with him/her. During an interview on 12/18/25 at10:27 A.M., Unit Manager (UM) #1 said residents were assessed on admission for bowel and bladder status and a determination is made relative to a plan for toileting. UM #1 said Resident #8 will ring his/her call bell for staff assistance with toileting due to his/her Oxygen use and diuretic medication (medication to assist with removing fluid accumulation in the body) and was currently not on a toileting plan. UM #1 said Resident #8 has not had bladder patterning completed to assess when there were episodes of incontinence and there has been no discussion with the facility staff/Resident #8 to see if interventions could be implemented that may decrease the Resident's episodes of incontinence. During an interview on 12/18/25 at 12:30 P.M., with the Director of Nursing (DON) and Consulting Staff #1, the DON said Resident #8 was assessed and determined to be frequently incontinent since admission and that this had not changed. The DON said the Resident was also on diuretic medication and that the facility staff were not aware that he/she had expressed concerns about his/her incontinence. Consulting Staff #1 said that bladder and bowel status was assessed on admission, quarterly and when there was a condition change. Consulting Staff #1 reviewed the most recent Quarterly Nursing assessment dated [DATE] and said she could understand why there were questions about the assessment. Consulting Staff #1 said upon completing the Quarterly Nursing Assessment, the Nurses should review the relevant documentation but also involve the Resident in the completion of the assessment. Consulting Staff #1 said the most recent Nursing Assessment (12/17/25) was incomplete and did not indicate that a bladder retraining program should be initiated when the Resident was determined to be cognitively intact and incontinent.

Based on interviews, and record reviews, the facility failed to implement a system of infection control surveillance relative to COVID-19 testing for four Residents (#23, #96, #31, #41) out of a total sample of 21 residents and on two (Federal and Elm) Units out of three Units. Specifically, the facility failed to test four Residents #23, #96, #31, #41 on the Federal Unit and Elm Unit, who were experiencing respiratory symptoms to rule out COVID-19 infection, placing other residents and staff at potential risk for infection. Findings include:Review of the CDC Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 12/11/25 at <https://www.cdc.gov/long-term-care-facilities/hcp/respiratory-virus-toolkit/index.html> indicated the following:-Test residents and Health Care Provider (HCP) with new respiratory illness signs or symptoms.-Selection of diagnostic tests will depend on the suspected cause of the infection (e.g., which respiratory viruses are circulating in the community or the facility, recent contact with someone confirmed to have a specific respiratory infection) and if the results will inform clinical management (e.g., treatment, duration of isolation). -At a minimum, testing should include SARS-CoV-2 and influenza viruses with consideration for other causes (e.g., RSV). Review of the CDC Guidance for Symptoms of COVID-19, dated 3/10/25 at <https://www.cdc.gov/covid/signs-symptoms/index.html>, indicated the following:-Signs and Symptoms:-The following list does not include all possible symptoms. Symptoms may change with new COVID-19 variants and can vary depending on vaccination status. Possible symptoms include:<Fever or chills<Cough<Shortness of breath or difficulty breathing<Sore throat<Congestion or runny nose<New loss of taste or smell<Fatigue<Muscle or body aches<Headache<Nausea or vomiting<Diarrhea Review of the facility policy titled Coronavirus Disease (COVID-19) - Testing Residents, revised June 2023, indicated the following:-Testing Residents with signs or symptoms of COVID-19:1. Any resident (regardless of vaccination status) with even mild symptoms of COVID-19 receives a viral test as soon as possible.a. Because it may be difficult to tell the difference between influenza, COVID-19, and other acute respiratory infections based on symptoms alone, testing for pathogens other than SARS-CoV-2 may be conducted based on recommendations from the Infection Preventionist (IP) and Providers. During the initial pool screening on 12/16/25 from 7:40 A.M. through 8:50 A.M., the surveyor observed residents coughing on the Elm unit. During an interview on 12/17/25 at 3:47 P.M., the Infection Preventionist (IP) said there had been residents on the Elm and Federal Units with upper respiratory symptoms such as cough and congestion. The IP said that she tracked and monitored facility infections via a line listing process which monitored resident symptoms, date of onset, testing including diagnostic criteria used to determine infection, and prescription medication use. At this time, the surveyor requested a copy of the facility line listing for survey team to review. Review of the infection control line listing for November 2025 and December 2025 provided by the facility indicated the following:-Resident #23 developed signs and symptoms of cough, difficulty breathing, and shortness of breath on 11/29/25.-Resident #96 developed signs and symptoms of cough and shortness of breath on 12/8/25.-Resident #31 developed signs and symptoms of cough and chest congestion on 12/12/25.-Resident #41 developed signs and symptoms of cough, chest congestion, and fever on 12/17/25. Review of Resident #23's medical record failed to indicate a COVID-19 test was performed once respiratory symptoms were identified on 11/29/25.Review of Resident #96's medical record failed to indicate a COVID-19 test was performed once respiratory symptoms were identified on 12/8/25.Review of Resident #31's medical record failed to indicate a COVID-19 test was performed once respiratory symptoms were identified on 12/12/25.Review of Resident #41's medical record indicated the following:-Active Physician's Order for COVID-19 Antigen testing as needed for regulatory compliance or symptoms as needed, started 9/25/23Further review of Resident #41's medical record failed to indicate that a COVID-19 test was performed once respiratory symptoms were identified on 12/17/25. During interviews on 12/18/25 at 10:33 A.M. and 2:24 P.M., the IP and Consulting Nurse #1 reviewed the facility line listing with the survey team. The IP said that respiratory symptoms of cough and shortness of breath could be considered COVID-19 symptoms. The Consulting Nurse #1 reviewed the following with the survey team:-Resident #23 developed respiratory symptoms on 11/29/25 and no COVID test was performed.-Resident #96 developed respiratory symptoms on 12/2/25 per the nursing notes, had continued symptoms of cold and cough symptoms on 12/6/25, and no COVID test was performed.-Resident #31 developed respiratory symptoms on 12/12/25 and no COVID test was performed.-Resident #41 developed respiratory symptoms on 12/17/25, the Resident was just added to the line listing, and there was no evidence at time of interview that a COVID-19 test was performed. During an interview on 12/19/25 at 9:33 A.M., the Director of Nursing (DON) said when residents develop respiratory symptoms, the facility would perform a chest x-ray to rule out pneumonia or atelectasis (collapsed lung), if the chest x-ray came back negative, then the facility would test for influenza and COVID-19. The DON further said the facility had performed COVID-19 testing the night of 12/18/25 for any residents with respiratory symptoms and there were no positive cases of COVID-19 identified. The DON said Residents #23, #96, #31, and #41 should have been tested for COVID-19 sooner, but they had not been tested.

Based on interviews, and record review, the facility failed to ensure that an antibiotic stewardship program was implemented for one Resident (#51), of two applicable residents reviewed for antibiotics, out of a total sample of 21 residents.Specifically, for Resident #51, the facility failed to obtain culture and sensitivity results timely to evaluate the appropriateness of the prescribed and administered antibiotic to treat a urinary tract infection (UTI) to ensure it would be effective in treating the specific bacteria identified from laboratory results. Findings include: Review of the facility policy titled Antibiotic Stewardship, revised December 2016, indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The policy also included the following: -the purpose of the antibiotic stewardship program is to monitor the use of antibiotics -when a culture and sensitivity is ordered, lab results and the current clinical situation will be communicated with the Prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of the facility policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, indicated the following: -antibiotic usage and outcome data will be collected and documented using the facility approved antibiotic surveillance tracking form. -the data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. -all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP). -the IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. -therapy may require further review and possible changes if: >the organism is not susceptible to antibiotic chosen >the organism is susceptible to narrower spectrum antibiotic -at the conclusion of the review, the Provider will be notified of the review findings Resident #51 was admitted to the facility in April 2021 with diagnoses including Dementia and Chronic Kidney Disease. Review of the Minimum Data Set (MDS) Assessment, dated 9/30/25, indicated Resident #51:-had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of four out of 15-had no behaviors -was incontinent of urine Review of Resident #51's clinical record indicated the following: -Nursing Notes dated 12/11/25: <Resident #51 noted to be increasingly confused and more difficult to redirect, consistent with symptoms typically observed during previous UTIs. <The Resident was incontinent of urine, denied pain or burning with urination and was without a fever. <The Provider was updated and gave a new order for a urine specimen to rule out a UTI. Urine obtained via straight catheterization. Urine analysis results show 3+Leukocytes and negative for Nitrates. Provider was updated and wanted to wait for culture results to come back. -Provider Note on 12/12/25: <preliminary urine was >100,000 streptococci, awaiting final culture, <start Macrobid (antibiotic) 100 milligrams (mg) twice daily for five days and Culturelle (probiotic) daily for seven days. <Will review the culture and sensitivity once resulted. Review of the December 2025 Medication Administration Record (MAR) indicated Macrobid 100 mg was administered once on 12/11/25, twice daily from 12/12/25 through 12/15/25, and once on 12/16/25. Review of Resident #51's clinical record on 12/16/25 at 3:00 P.M. failed to indicate any urine culture and sensitivity results from the urine specimen obtained on 12/11/25. During an interview on 12/16/25 at 3:18 P.M., the surveyor and Nurse #1 reviewed Resident #51's clinical record. Nurse #1 said laboratory results should be in the Resident's record but was unable to find them and would have to ask the Unit Manager (UM #1). Nurse #1 said Resident #51 was started on an antibiotic for a UTI on 12/11/25 and that it usually takes about 48 hours to receive the urine culture and sensitivity results. During an interview on 12/16/25 at 3:27 P.M. and 4:00 P.M., UM #1 said she contacted the lab and requested the Resident's urine culture and sensitivity results. UM #1 said the urine culture and sensitivity results should have been requested on 12/15/25, but they were not requested until 12/16/25 after the surveyor had inquired. UM #1 said the Provider was updated today (12/16/25) of the Resident's urine culture and sensitivity results and changed the Resident's antibiotic to Rocephin 1 gram (gm) to be given intramuscularly daily for five days. UM #1 said it was the nursing staff's responsibility to follow up with the Resident's laboratory results. Review of the Urine Culture and Sensitivity result, printed on 12/16/25, indicated the specimen was collected on 12/11/25 and had verified results on 12/13/25 (48 hours later). During interviews on 12/18/25 at 2:36 P.M. through 2:50 P.M., with the IP and Consulting Staff #1, the IP said resident infections were monitored and tracked, and if antibiotics were administered, they would usually not be started until the culture and sensitivity was obtained. Consulting Staff #1 said an Antibiotic Time Out Assessment would be completed by the Unit Managers when an antibiotic was started and that this form assists with assessing if an antibiotic was appropriate to be administered. The IP said she reviewed the infection control dashboard daily for type of resident infection and if an antibiotic was started, did it meet the specific criteria to be started, and the overall facility picture to assess for patterns. Consulting Staff #1 said relative to Resident #51, the Antibiotic Time Out assessment was not completed which could have potentially caught that the antibiotic prescribed/administered (Macrobid) was not the correct antibiotic based on the Resident's urine culture and sensitivity results. When the surveyor asked about the facility's infection surveillance process involving the IP and resident antibiotic use, the IP said she missed that Resident #51 had been placed on an antibiotic.

Based on interviews and records reviewed for one of three sampled residents (Resident #1) who had a Nurse Practitioner's (NP) order, dated 01/14/25, to obtain a urine specimen for suspected urinary tract infection, the Facility failed to ensure that nursing notified the NP when they were unable to obtain the specimen as ordered, to determine next steps or obtain new orders. Resident #1 was transferred and admitted to the Hospital on 01/18/25 and was diagnosed with Urosepsis (a serious complication when the body has a life threatening response to an infection which can lead to organ failure, tissue damage, or death). Findings include: Review of the Facility's Policy titled, Change in Resident's Condition or Status, revised February 2021 indicated but was not limited to the following: - Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). - The nurse will notify the resident's attending physician or physician on call when there has been a (an) need to alter the resident's medical treatment significantly, and refusal of treatment or medication two or more consecutive times. Resident #1 was admitted to the Facility in December 2024, diagnoses included, Urinary Retention (a condition where a person is unable to empty their bladder completely), Stiff Person Syndrome (SPS, a rare autoimmune neurological disorder characterized by muscle stiffness, spasms, and other neurological symptoms), Acute Focal Neurological Deficit (a problem with nerve, spinal cord, or brain function that can affect movement and sensation), and Functional Neurological System Disorder with abnormal movement (FND, a condition that affects how the brain and body communicate). Review of Resident #1's Physician's Orders for January 2025, indicated he/she had an order, dated 01/14/25, for nursing to obtain a urine specimen and send to the laboratory for urinalysis (U/A, a laboratory test that examines a person's urine to detect and evaluate various health conditions) with culture and sensitivity (C&S, a laboratory test that identifies the cause of an infection and determine the best treatment) every shift and discontinue the order once the urine specimen was obtained. Review of Resident #1's Treatment Administration Record (TAR) related to the Physician's Order, dated 01/14/25, to obtain a urine specimen indicated nursing documentation and coding (per the code key provided on the last page of the TAR) was as follows: - 01/14/25, Evening Shift, a checkmark (per nursing means the order was acknowledged, but does not indicate the specimen was obtained) - 01/14/25, Night Shift, 9 (the code indicates, other, see nursing note) with no corresponding nursing note - 01/15/25, Day Shift, a checkmark - 01/15/25, Evening Shift, 2 (the code indicates resident refusal) - 01/15/25, Night Shift, 7 (the code indicates resident was asleep) - 01/16/25, Day, Evening and Night shift, a checkmark - 01/17/25, Day Shift, a checkmark - 01/17/25, Evening Shift 13 (the code indicates absence of condition, not applicable) - 01/17/25, Night Shift 9 (with a corresponding nursing note that it was attempted, but the Nurse was unsuccessful) Review of Resident #1's Medical Record, which included diagnostic testing results and Progress Notes indicated there was no documentation to support his/her urine sample was ever obtained, and no documentation to support Nursing staff notified the Nurse Practitioner (NP) that the urine specimen had not been obtained. During an interview on 02/19/25 at 3:10 P.M., (which included a review of Resident #1's January 2025 TAR with the surveyor), Nurse #4 said that it did not appear nursing ever obtained a urine specimen from Resident #1. Nurse #4 said that if a nurse was unable to obtain a specimen, the expectation was to communicate that information to the nurse on the next shift and document why they were unable to obtain the specimen either on the TAR or in a Nursing Progress Note. Nurse #4 said after two unsuccessful attempts, it was expected the nurse notify the Provider (Physician or NP) and document that notification in a Nursing Progress Note. During an interview on 02/20/25 at 9:15 A.M., Unit Manager #1 said it did not appear that nursing staff ever obtained a urine specimen from Resident #1 and that the NP or Physician should have been notified. Unit Manager #1 said there was no documentation in Resident #1's record to indicate that Nursing staff notified the NP or Physician that the specimen was not obtained, as ordered. During an interview on 02/20/25 at 10:15 A.M., the Nurse Practitioner said she wrote an order to obtain a urine specimen from Resident #1, and said she was aware on 01/15/25 during the day shift that the specimen had not yet been obtained because she accessed the computerized laboratory system and did not see that the lab work was pending. The NP said she spoke with Unit Manager #1 on 01/15/25 and told her that she needed to ensure Resident #1's urine specimen was obtained soon. The NP said if she had known the nurses were unable to obtain a urine specimen, she could have altered her treatment to include an order for an antibiotic based on Resident #1's symptoms. On 01/18/25, Resident #1 experienced a significant decline in status, was transferred and admitted to the hospital and was diagnosed with Urosepsis and pneumonia. During an interview on 02/20/25 at 11:05 A.M., the Director of Nursing (DON) said it did not appear that nursing staff obtained a urine specimen from Resident #1, as ordered. The DON said if the nurse on one shift was unable to obtain the specimen, it was the expectation the nurse would communicate that information at shift change to the oncoming nurse to attempt, and if after the second time the nurse was unable to obtain the specimen, the NP or Physician should have been notified to allow them the opportunity to alter the treatment plan (such as order an antibiotic based on symptoms).

Based on interviews and records reviewed for one of three sampled residents (Resident #1), who on 1/14/25, had a physician's order for nursing to obtain a urine specimen for a suspected urinary tract infection, the Facility failed to ensure they maintained a complete and accurate medical record, when nursing documentation related to obtaining the urine specimen was incomplete, including but limited to no documentation to support nurses communicated from shift to shift that the urine specimen still needed to obtained. Findings include: Resident #1 was admitted to the Facility in December 2024, diagnoses included, Urinary Retention (a condition where a person is unable to empty their bladder completely), Stiff Person Syndrome (SPS, a rare autoimmune neurological disorder characterized by muscle stiffness, spasms, and other neurological symptoms), Acute Focal Neurological Deficit (a problem with nerve, spinal cord, or brain function that can affect movement and sensation), and Functional Neurological System Disorder with abnormal movement (FND, a condition that affects how the brain and body communicate). Review of Resident #1's Physician's Orders for January 2025, indicated he/she had an order, dated 01/14/25, (written by the Nurse Practitioner), for nursing to collect a urine specimen and send it to the lab for urinalysis (U/A, a laboratory test that examines a person's urine to detect and evaluate various health conditions) with culture and sensitivity (C&S, a laboratory test that identifies the cause of an infection and determine the best treatment) every shift and to discontinue the order once the specimen was obtained. Review of Resident #1's Treatment Administration Record (TAR) for January 2025, related to the Physician's Order, dated 01/14/25, to obtain a urine specimen indicated the following: - 01/14/25, Evening Shift, a checkmark (per nursing means the order was acknowledged, but does not indicate the specimen was obtained) - 01/14/25, Night Shift, 9 (the code indicates, other, see nursing note) with no corresponding nursing note - 01/15/25, Day Shift, a checkmark - 01/15/25, Evening Shift, 2 (the code indicates resident refusal) - 01/15/25, Night Shift, 7 (the code indicates resident was asleep) - 01/16/25, Day, Evening and Night shift, a checkmark - 01/17/25, Day Shift, a checkmark - 01/17/25, Evening Shift 13 (the code indicates absence of condition, not applicable) - 01/17/25, Night Shift 9 (with a corresponding nursing note that it was attempted, but the Nurse was unsuccessful) Review of Resident #1's Medical Record, which included laboratory results and Nursing Progress Notes, indicated there was no documentation to support that nursing staff obtained the urine specimen except for one Nursing Progress Note, dated 01/18/25, that indicated a nurse attempted to obtain the specimen but was unsuccessful in doing so. During an interview on 02/19/25 at 3:10 P.M., (which included a review of Resident #1's January 2025 TAR with the surveyor), Nurse #4 said that upon reviewing the TAR, it did not appear nursing ever obtained a urine specimen for Resident #1. Nurse #4 said a checkmark on the TAR did not mean the specimen was obtained, and there are certain codes nursing staff could use when documenting in the TAR. Nurse #2 said a nurse would use code 2 to indicate if a resident refused. Nurse #4 said there were other codes a nurse could enter such as 5 for held, and 9 for other, but said if those codes were used, the nurse was required to indicate a reason why the specimen could not be obtained. During a telephone interview on 02/20/25 at 2:00 P.M., Nurse #2 said she did not obtain a urine specimen from Resident #1 during the evening shift of 01/14/25 and said she could not remember if she reported this to the oncoming night shift nurse. During a telephone interview on 02/21/25 at 2:50 P.M., Unit Manager #1 said nursing staff never obtained a urine specimen from Resident #1, and if they were unable to obtain the specimen, they should have documented the reason as to why on either the TAR or in a Nursing Progress Note. Unit Manager #1 said the only documentation related to the nursing staff's reason why they did not obtain a urine specimen was in a Nursing Progress Note on 01/18/25, and the TAR on 01/15/25 for both the evening and overnight shift (refused and asleep). Unit Manager #1 said there was no additional nursing documentation on 01/14/25 (evening shift), 01/15/25 (day shift), 01/16/25 (any shift), or on 01/17/25 (any shift), to indicate why Resident #1's urine specimen had not been obtained. During an interview on 02/20/25 at 11:05 A.M., the Director of Nursing (DON) said nursing staff never obtained a urine specimen from Resident #1, as ordered. The DON said if the nurse on one shift was unable to obtain the specimen, it was the expectation the nurse would communicate that information at shift change to the oncoming nurse, so they knew to attempt to do so during their shift. The DON said the checkmarks on Resident #1's January TAR indicated that nursing staff acknowledged the order, however it did not mean the specimen was obtained. The DON said if nursing was unable to obtain the specimen, nursing was expected to select a code on the TAR (i.e., refused, asleep) and if there was not a specific code to indicate a reason, she said nursing should have documented a reason in a Nursing Progress Note.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) whose comprehensive care plan interventions included that he/she required assistance of two staff members and a mechanical lift for transfer due to non-weight bearing status, the Facility failed to ensure staff consistently implemented and followed interventions in his/her care plan, when on 01/12/25, during the evening shift, Certified Nurse Aide (CNA #1) without the assistance of another staff member and a mechanical lift, transferred Resident #1 using a stand/pivot transfer technique, Resident #1 screamed during the transfer and while care was being provided immediately after the transfer. Resident #1 was later diagnosed with a fracture involving the left distal femur (thigh bone) and was transferred to the Hospital Emergency Department (ED) for treatment. Findings include: Review of the Facility's policy, titled Care Plan, Comprehensive Person-Centered, dated as revised December 2016, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and /or items included in the plan of care. Resident #1 was admitted to the Facility in December 2020, diagnoses included unspecified dementia, osteopenia (a condition of diminished bone thickness), anemia (low red blood cells), and Macular Degeneration (eye disease that causes vision loss). Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated he/she was severely cognitively impaired with a score of 3 out 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS also indicated that Resident #1 was dependent on staff for bathing, dressing, hygiene, transfers, incontinent care and was non-ambulatory. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her 12/19/24 MDS, indicated he/she required assistance of two persons with a [mechanical lift] due to non-weight bearing status with ADL's. Review of Resident #1's Care Card (used by the CNAs to determine individual resident care needs) indicated he/she required assistance of two staff members with a [mechanical lift] for transfers due to non-weight bearing status with ADL's. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/16/25, indicated that Resident #1 sustained a fracture to his/her left distal femur. Review of the Facility's Investigation Summary, dated 01/20/25, indicated that on 01/12/25 during the evening shift Resident #1 was transferred from wheelchair to bed [by CNA #1] as an assist of one, via stand/pivot, and not according to his/her care plan status which indicated he/she required an assist of two staff members utilizing a mechanical lift. The Investigation Summary indicated that the Facility's conclusion was that it was more likely than not the fracture occurred during the transfer on 01/12/25 at 4:00 P.M. Review of the Mobile X-ray Report, dated 01/14/25 at 10:07 A.M., indicated Resident #1 had a fracture involving the left distal femur supracondylar region (complex lesions that are usually difficult to treat) with impaction. Review of Resident #1's Hospital Discharge Summary, dated 01/14/25, indicated Resident #1 sustained a distal left femur fracture, was placed in a knee immobilizer for comfort and to help facilitate healing. Review of the Director of Nurses (DON) Written Summary of her interview with CNA #1, undated, indicated CNA #1 told her that on 01/12/25 at 4:00 P.M, she stood Resident #1 up and pivot transferred him/her into bed without assistance from a second staff member, and without a mechanical lift. The Summary indicated CNA #1 told the DON that once she began to roll Resident #1 over in bed to perform care, he/she started yelling out. During an interview on 02/4/25 at 2:12 P.M., Certified Nurse Aide (CNA) #1 said that she had worked at the Facility since April of 2024 and had been assigned to care for Resident #1 on 01/12/25, during the 3:00 P.M. through 11:00 P.M. shift. CNA #1 said that she had not provided care for Resident #1 in the past. CNA #1 said that despite never having care for or having transferred Resident #1 before, said she did not check Resident #1's Care Card or Care Plan prior to transferring him/her. CNA #1 said that on 01/12/25 at about 4:00 P.M., she transferred Resident #1 from his/her wheelchair to his/her bed by herself using a stand/pivot transfer instead of a mechanical lift. CNA #1 said she performed the transfer by placing Resident #1's arms on her shoulders, reaching her arms around Resident #1's body, like she was hugging him/her, stood Resident #1 up, and pivoted him/her to a sitting position on the bed. CNA #1 said that Resident #1 was screaming during the entire transfer. CNA #1 further said that once Resident #1 was lying in bed, she rolled him/her back and forth to provide incontinent care and that Resident #1 was screaming when he/she was moved. During an interview on 02/4/25 at 4:10 P.M., the Director of Nurses (DON) said the Facility began an investigation after Resident #1's knee X-ray report on 01/14/25 indicated he/she had a fracture. The DON said that during her investigation she became aware that CNA #1, CNA #2 and CNA #3, during different times of the day, had transferred Resident #1 on 01/12/25 without using a mechanical lift as indicated in his/her care plan. The DON said during the investigation she discovered that CNA #1 had transferred Resident #1 by herself using a stand/pivot transfer, and that CNA #2 and CNA #3 had transferred Resident #1 together by manually lifting him/her up to transfer him/her, and that none of them had used a mechanical lift. During an interview on 02/4/25 at 10:55 A.M., Certified Nurse Aide (CNA) #2 said she worked at the facility for two years, was familiar with Resident #1's care and had him/her on her assignment on 01/12/25 on the day shift. CNA #2 said that she and CNA #3 had transferred Resident #1 from his/her bed to his/her wheelchair on 01/12/25 around 11:00 A.M. without using the mechanical lift. CNA #2 said that the Care Card and the Therapy Binder are supposed to be used by the CNA's to learn how to provide resident care which included how they transferred, but said that she only checks them hit or miss. CNA #2 said she did not check Resident #1's Care Card prior to transferring him/her on 01/12/25. During an interview on 02/4/25 at 9:20 A.M., Certified Nurse Aide (CNA) #3 said that she had worked at the Facility for three years, mostly on the night shift but was now working the day shift. CNA #3 said that on 01/12/25 she assisted CNA #2 with transferring Resident #1 without using a mechanical lift. CNA #3 said that she had never transferred Resident #1 before, and said she did not check his/her Care Card to determine his/her transfer status prior to the transfer. The DON said that at the conclusion of the Facility's Internal Investigation, they determined it was more likely than not that Resident #1's fracture occurred during the transfer on 01/12/25 at 4:00 P.M., when CNA #1 said she transferred Resident #1 [who was non-weight bearing] unassisted using a stand/pivot transfer and that Resident #1 had yelled out during the transfer. On 02/4/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A . Resident #1 was transferred to the Hospital Emergency Department for evaluation and treatment on 01/14/25 and returned to the facility later the same day with a knee immobilizer. A pain management plan was put in place. B . CNA #1, CNA #2, and CNA #3 received disciplinary actions specifically for not following Resident #1 plan of care. C. On 01/16/25 Unit Managers and/or designee completed audits of current residents requiring assistance from two staff members with a mechanical lift, for compliance with care plans, CNA Care Card, and observation that transfers were conducted per the plan of care. D. On 1/22/25 Unit Managers conducted staff interviews with questionnaires completed by CNAs to ensure knowledge and competence of requirement to review Care Cards and appropriate transfer of residents. E. On 01/14/25 the Facility Staff Educator initiated re-education for Nurses and CNAs on following Resident Care Plans and safe lifting and movement of residents. The education was completed 01/22/25. F. On 1/16/25 the DON and/or designee initiated random weekly observations of staff to ensure compliance with Resident transfers according to Care Plan. Audits will continue weekly for three weeks and monthly for two months. G. The care area concern was discussed by the Quality Assurance Performance Improvement (QAPI) Committee on 01/15/25 and on-going audit results will continue to be reviewed at the QAPI Committee meetings monthly for three months. H. The DON and/or designee is responsible for compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1),who was non-weight bearing, required the assistance of two staff members and a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and assistive device (mechanical lift) in a effort to maintain Resident #'1's safety during transfers to prevent incident/accidents resulting in an injury. On 01/12/25, Certified Nurse Aide (CNA) #1, without another staff member or use of the mechanical lift, transferred Resident #1 by herself from his/her wheelchair to bed using stand/pivot transfer, Resident #1 screamed out during the transfer and during care provided by CNA #1 immediately after the transfer, and was later diagnosed with a fracture to his/he left distal femur (thigh bone). Findings include: Review of the Facility's policy, titled Safe Lifting and Movement of Residents, dated as revised July 2017, indicated that in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. Staff will document resident transferring and lifting needs in the care plan. Review of the Facility's policy, titled Activities of Daily Living (ADL) Supporting, dated as revised March 2018, indicated Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: mobility (transfer and ambulation). Resident #1 was admitted to the Facility in December 2020, diagnoses included unspecified dementia, osteopenia (a condition of diminished bone thickness), anemia (low red blood cells), and macular degeneration (eye disease that causes vision loss.) Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated he/she was severely cognitively impaired with a score of 3 out 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS also indicated that he/she was dependent on staff for bathing, dressing, hygiene, transfer, incontinent care and was non-ambulatory. Review of Resident #1's Activities of Daily Living (ADL) Care Plan reviewed and renewed with his/her 12/19/24 MDS, indicated he/she required assistance of two persons with a [mechanical lift] due to non-weight bearing status with ADL's. Review of Resident #1's Care Card (used by the CNA's to determine individual care needs) indicated he/she required assistance of two staff members with a [mechanical lift] for transfer due to non-weight bearing status with ADL's. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/16/25, indicated that Resident #1 sustained a fracture to his/her left distal femur. Review of the Facility's Investigation Summary, dated 01/20/25, indicated that [on 01/12/25 during the evening shift]Resident #1 was transferred from wheelchair to bed as an assist of one via stand/pivot, and not according to his/her care plan status which indicated he/she required an assist of two utilizing a mechanical lift. The Report indicated that the Facility's Investigation conclusion was that it was more likely than not the fracture occurred during the transfer on 01/12/25 at 4:00 P.M. [completed by CNA #1]. Review of the mobile X-ray report, dated 01/14/25 at 10:07 A.M., indicated Resident #1 sustained a fracture involving the left distal femur supracondylar region (complex lesions that are usually difficult to treat) with impaction. Review of Resident #1's Hospital Discharge Summary, dated 01/14/25, indicated Resident #1 sustained a distal left femur fracture and was placed in a knee immobilizer for comfort and to help facilitate healing. Review of the Director of Nurses' (DON) written summary of her interview with CNA #1, undated, indicated that CNA #1 transferred Resident #1 into bed on 01/12/25 at 4:00 P.M utilizing a one person assist stand/pivot transfer and without a mechanical lift. The Interview Summary indicated CNA #1 said that once Resident #1 was in bed and she (CNA #1) began to roll him/her to perform care, Resident #1 started yelling out. During an interview on 02/4/25 at 2:12 P.M., Certified Nurse Aide (CNA) #1 said that she had worked at the Facility since April of 2024 and had been assigned to care for Resident #1 on 01/12/25 during the 3:00 P.M. through 11:00 P.M. shift. CNA #1 said that she had not provided care for Resident #1 in the past. CNA #1 said that despite never having cared for or having transferred Resident #1 before, said she did not check his/her Care Card or Care Plan prior to transferring him/her. CNA #1 said that on 01/12/25 at about 4:00 P.M., she transferred Resident #1 from his/her wheelchair to his/her bed alone, using a stand/pivot transfer instead of the mechanical lift. CNA #1 said she performed the transfer by placing Resident #1's arms on her shoulders, reaching her arms around Resident #1's body, like she was hugging him/her, stood him/her up and pivoted Resident #1 to a sitting position on the bed. CNA #1 said that Resident #1 was screaming during the entire transfer. CNA #1 further said that once Resident #1 was sitting on the edge of the bed, she wrapped one of her arms around his/her shoulders and put her other arm under his/her legs to position him/her from sitting to lying in the bed. CNA #1 said that once Resident#1 was lying in bed, she rolled him/her back and forth to provide incontinent care and that Resident #1 was screaming whenever he/she was moved. CNA #1 said that she did not report Resident #1's screaming during the transfer and/or during care to the nurse. During an interview on 02/4/25 at 4:10 P.M., the Director of Nurses (DON) said that the facility began an investigation after Resident's #1's knee X-ray report on 01/14/25 indicated he/she had a fracture. The DON said that during her investigation into the injury she became aware that CNA #1 had transferred Resident #1 by herself on 01/12/25, without getting another staff person or using a mechanical lift, as indicated in his/her care plan. The DON said they determined that Resident #1's [who was non-weight bearing] fracture more likely than not, occurred during the stand/pivot transfer by CNA #1 on 01/12/25. On 02/4/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A . Resident #1 was transferred to the Hospital Emergency Department for evaluation and treatment on 01/14/25 and returned to the facility later the same day with a knee immobilizer. A pain management plan was put in place. B . CNA #1 received disciplinary actions specifically for not following Resident #1 plan of care. C. On 01/16/25 Unit Managers and/or designee completed audits of current residents requiring assistance from two staff members with a mechanical lift, for compliance with care plans, CNA Care Card, and observation that transfers were conducted per the plan of care. D. On 1/22/25 Unit Managers conducted staff interviews with questionnaires completed by CNAs to ensure knowledge and competence of requirement to review Care Cards and appropriate transfer of residents. E. On 01/14/25 the Facility Staff Educator initiated re-education for Nurses and CNAs on following Resident Care Plan and safe lifting and movement of residents. The education was completed 01/22/25. F. On 1/16/25 the DON and/or designee initiated random weekly observations of staff to ensure compliance with Resident transfers according to Care Plan. Audits will continue weekly for three weeks and monthly for two months. G. The care area concern was discussed by the Quality Assurance Performance Improvement (QAPI) Committee on 01/15/25 and on-going audit results will continue to be reviewed at the QAPI Committee meetings monthly for three months. H. The DON and/or designee is responsible for compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who complained of pain that was new and for whom the Facility had initiated an investigation into an injury of unknown origin. the Facility failed to ensure that it was reported to the Department of Public Health (DPH) within two hours as required, and reported it to the DPH 48 hours later. Findings include: Review of the Facility Policy, titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated as revised September 2022, indicated the following: - All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. - If resident abuse, neglect, exploitation, misappropriation of resident property or an injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. - Immediately is defined as within two hours of an allegation involving abuse or resulting in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/16/25 at 11:44 A.M., indicated Resident #1's injury of an unknown source was reported to DPH. However, this was 48 hours after the facility administration had been made aware of the injury. Resident #1 was admitted to the Facility in December 2020, diagnoses included dementia, macular degeneration (eye disease that causes vision loss), osteopenia (a condition of diminished bone thickness) and iron deficiency anemia (low red blood cells). Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident #1 was severely cognitively impaired with a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 was dependent on staff for Activities of Daily Living (ADLs) and transfers. Review of a Facility Incident Report, titled Injury of Unknown Source, dated 01/14/25, indicated Resident #1 had been complaining of left lower extremity pain, since 01/13/25. The Report indicated that an X-ray of Resident #1's left hip was performed on 01/13/25 and the results were negative for fracture. The Report indicated that Resident #1's pelvis and left knee were X-rayed on 01/14/25 and that the results, received at approximately 10:45 A.M., indicated an acute impacted distal femur supracondylar fracture. The Report further indicated that Resident #1 could not give a description of how the injury occurred, and there were no witnesses. During an interview on 02/04/25 at 5:00 P.M., the Director of Nurses (DON) said that on 01/14/25 at approximately 10:45 A.M., she was made aware that Resident #1's X-ray results indicated he/she had a fracture of the distal femur. The DON said that Resident #1 had no recent falls and no recent incidents, and that due to his/her impaired cognitive status he/she was unable to say how the injury may have occurred. The DON said that on 01/14/25 she determined the fracture to be an injury of an unknown source and initiated an investigation per the Facility Abuse Policy. The DON further said that she intended to report the injury to DPH immediately, but did not actually submit the report via HCFRS until 01/16/25. On 02/04/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A. On 01/16/25, the former Director of Nurses recognized that Resident # 1's injury of an unknown source had not been reported to DPH, and she alerted the DON, who then submitted the report in HCFRS. B. On 01/16/25, the Clinical Services Coordinator or designee educated the Facility Director of Nurses on ensuring allegations of abuse, neglect, mistreatment reports and injuries of an unknown source are correctly submitted through HCFRS within the two-hour reporting requirement. C. On 01/16/25, the DON audited the previous reportable incidents, to ensure they were submitted properly and timely to DPH through HCFRS. D. The Administrator or designee will audit abuse allegations for two-hour reporting and submission compliance, weekly for three weeks then monthly for two months. E. The Facility Plan of Correction, including audits, will be reviewed by the Quality Assurance Committee for three months for follow up and resolution. F. The Administrator and/or designee are responsible for overall compliance.

Based on observation, interview, record and policy review, the facility failed to implement infection control practices relative to the use of Personal Protective Equipment (PPE) for one Resident (#96), out of a total sample 19 residents, and provide a sanitary smoking environment for four resident smokers, to prevent the transmission and development of infections. Specifically, the facility staff failed to: 1. Adhere to Enhanced Barrier Precautions (EBP: protective barrier gowns and gloves used as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] during high contact resident care) for Resident #96 with a peripheral inserted central catheter (PICC-a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein in the chest used to administer fluids and medication), increasing the Resident's risk for infection. 2. Provide smoking assistance to residents in a sanitary manner, when the individual cigarettes for four residents were lit by Nurse #4 placing each cigarette in her mouth, lighting the cigarette, and then handing to each resident, increasing the risk for the transmission of germs to four residents. Findings include: Review of the facility's policy titled Infection Prevention and Control Program dated December 2023, indicated the following: -An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -The program is based on accepted national infection prevention and control standards. 1. Review of the facility's policy titled Enhanced Barrier Precautions dated August 2022, indicated the following: -EBP's are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDRO's) to residents. -EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. -Gloves and gown are applied prior to performing the high contact resident care activity. -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: >device care or use-central line . -Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. Resident #96 was admitted to the facility in August 2024, with diagnoses including Septic Thrombophlebitis (an infection of a vein with a subsequent systemic response when an infection triggers the body's immune system to damage its own organs and tissues), and Methicillin Susceptible Staphylococcus Aureus (MSSA: a bacterial infection that develops when bacteria enter the body through a cut or wound on the skin and can cause infections in the skin, blood, bones, organs and joints, often treated with antibiotics) infection. Review of the August 2024 Physician's orders, indicated the following: -Enhanced Barrier Precautions (EBP) for all high contact/direct patient care and all PICC care management provided, every shift. -Cefazolin Sodium (an antibiotic used to treat Staphylococcus infections) Injection Solution, reconstituted, two grams (gm) intravenously (into the blood stream through a vein) every eight hours for Sepsis, initiated 8/6/24. -Sodium Chloride 0.9% intravenous 10 milliliters (ml) three times a day for PICC flush (manual injection with normal saline to clean or clear the catheter) prior to antibiotic use, initiated 8/7/24. On 8/30/24 at 1:40 P.M., the surveyor observed Nurse #3 enter Resident #96's room wearing a mask. The surveyor observed Nurse #3 sanitize her hands and don (put on) gloves, but did not don a gown. The surveyor further observed Nurse #3 cleanse and flush the Resident's PICC with normal saline, prepare the intravenous tubing, set the infusion pump and start the Cefazolin Sodium Injection infusion. On 8/30/24 at 1:45 P.M., the surveyor observed an orange circle sticker on the name plate of Resident #96 posted outside of the Resident's room. The surveyor further observed an orange sign indicating Enhanced Barrier Precautions on the closet door inside of Resident #96's room which indicated the following: -STOP-ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: >Clean their hands, including before entering and when leaving the room. -PROVIDERS AND STAFF MUST ALSO wear gloves and a gown for the following High Contact Resident Care Activities .Device Care or use: central lines . During an interview on 8/30/24 at 1:49 P.M., the surveyor and Nurse #3 reviewed the EBP sign on the Resident's closet door. Nurse #3 said she should have worn a gown prior to using the PICC for the normal saline flush and antibiotic infusion. Nurse #3 said that she did not see the sign on the Resident's closet door and that she was not aware that the facility was using an orange circle sticker on the name plate to identify Residents on EBP. During an interview on 8/30/24 at 2:55 P.M., the Director of Nursing (DON) said the facility had a system of placing an orange circle sticker on the name plate of the residents who are on EBP and placing an EBP sign inside the room on the resident's closet door. The DON said there was a posting at the nurses station instructing the Nurses about this system. The DON further said that Nurse #3 should have worn a gown prior to accessing Resident #96's PICC to reduce the risk of the spread of infection. 47901 2. During a smoking observation on 9/3/24 at 10:02 A.M., the surveyor observed Nurse #4 in the smoking area with four residents. The surveyor observed Nurse #4 place a cigarette in her mouth, light the cigarette with a lighter and then hand the cigarette to the resident to continue smoking. The surveyor further observed Nurse #4 perform this process for each of the four residents by placing a cigarette in her mouth, lighting the cigarette and handing the lit cigarette to each resident. During an interview on 9/3/24 at 10:05 A.M., Nurse #4 said she lit each resident's cigarette with a lighter by placing the cigarette in her mouth and then handed the cigarette to the (four) residents to continue smoking. Nurse #4 said that this was a bad infection control practice. During an interview on 9/3/24 at 11:15 A.M., the Director of Nursing (DON) said Nurse #4 should not have lit the resident's cigarettes by placing the cigarettes in her mouth prior to distributing the cigarettes to the (four) residents.

Based on observation, interview, policy and record review, the facility failed to meet professional standards of practice for one Resident (#98), for three closed records, out of a total sample of 19 residents. Specifically, the facility failed to obtain Physician's orders for the use, management and care of a Thoracic Lumbar Sacral Orthosis (TLSO: brace used to limit movement in the spine) brace for Resident #98, after the Resident suffered a fall with fracture of the spine, and the TLSO brace was being applied by facility staff, placing the Resident at risk for inappropriate use of the TLSO brace and further spinal injury. Findings include: Review of the facility policy titled Medication and Treatment Orders, revised July 2016, indicated: -Orders for medications and treatments will be consistent with principles of safe and effective order writing. -Only authorized, licensed practitioners, or individuals authorized to take verbal orders from Practitioners, shall be allowed to write orders in the medical record. -Orders for medications must include: a. name and strength of the drug; b. number of doses, start and stop date, and/or specific duration of therapy; c. dosage and frequency of administration; d. route of administration; e. clinical condition or symptoms for which the medication is prescribed; and f. any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.). -Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders. a. Drugs not specifically limited to duration of use and number of doses when ordered will be controlled by automatic stop orders. b. One (1) day prior to the date the stop order is to become effective, the nurse supervisor/charge nurse on duty must contact the prescriber or attending physician to determine if the medication is to be continued. Resident #98 was admitted to the facility in May 2024, with diagnosis including wedge compression fracture of the third lumbar vertebrae (broken bone in the spine at the L3 location). Review of the Emergency Medicine Note dated 5/29/24 indicated: -X-ray of the lumbar spine was obtained while the Resident was wearing a TLSO brace. -Resident had an L3 Fracture. -Recommendation that Resident wear the TLSO brace when the [Resident] was not lying flat. Review of the Initial Physician's Encounter Note dated 5/31/24, indicated: -Resident #98 was found to have an L3 compression fracture. -Seen by Neurosurgery who recommended TLSO brace, no surgical intervention. -Continue TLSO brace at all times, except when lying flat. Review of Resident #98's medical record failed to indicate any Physician's orders for the application, frequency of use, duration of therapy, care of, and any pertinent limitations of the TLSO brace. Review of the Physical Therapy Evaluation and Plan of Treatment dated 5/31/24, indicated: -Resident was status post fall with L3 Compression Fracture. -Resident had TLSO brace when out of bed (to be donned/doffed [put on/taken off] in bed). Review of the Plan of Care for musculoskeletal problems relative to L3 fracture initiated 5/31/24, indicated the following interventions: -Refer to the Therapy Plan of Treatment in the medical record for more detail. -TLSO brace per [Physician] order. Review of Skilled Nursing Notes dated 6/1/24 and 6/3/24, indicated that a body brace to upper torso was in use by the Resident. During an interview on 9/3/24 at 8:40 A.M., the Director of Nursing (DON) said that evidence of Resident #98's TSLO brace would be documented as a Physician's order but there was no Physician's order in place for Resident #98's TSLO brace. During a follow-up interview on 9/3/24 at 9:34 A.M., the DON said there was no Physician's order in place for the TSLO brace. The DON said there should have been a Physician's order so staff could document the use of the TSLO brace and monitor for potential skin issues.

Based on observation, interview, record and policy review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for two Residents (#13 and #52), out of a total sample of 19 residents. Specifically, the facility staff failed to: 1. For Resident #13, ensure that humidified Oxygen was administered as ordered by the Physician. 2. For Resident #52, ensure that the Oxygen liter flow being administered to the Resident and the range for oxygen saturation (SPO2: measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) levels were not higher than the parameters ordered by the Physician, and putting the Resident at risk of hypercapnia [high carbon dioxide levels in the blood). Findings include: Review of the facility policy titled Oxygen Administration, dated 2001, indicated the following: -Verify that there is a Physician's Order for this procedure. -Review the Physician's Orders or facility protocol for oxygen administration. -The following equipment and supplies will be necessary when performing this procedure . humidifier bottle. Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014, https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf, indicated the following: -All Oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with Physician's orders or inadequate instruction for Oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia [high carbon dioxide levels in the blood) and chronic obstructive pulmonary disease that oxygen administration may lead to an increase in PaCO2. -Equipment maintenance and supervision: >All oxygen delivery equipment should be checked at least once daily . >Facets to be assessed include proper function of the equipment, prescribed flow rates, remaining liquid or compressed gas content, and backup supply. 1. Resident #13 was admitted to the facility in July 2024, with diagnoses including Chronic Respiratory Failure (CRF - a long term condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue) and Shortness of Breath (difficult or labored breathing). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #13 utilized Oxygen and was always understood. Review of the August 2024 Physician's Order Summary Report indicated: -Humidified Oxygen at 2.5 liters per minute (LPM: flow rate that supplemental Oxygen is set for delivery), via nasal cannula (thin, flexible tube that provides supplemental Oxygen through the nose via nasal prongs) to maintain oxygen saturation greater than 90 percent (%), dated 4/19/24. On 8/29/24 at 3:55 P.M., the surveyor observed Resident #13 seated in bed with Oxygen being administered via nasal cannula. The surveyor observed that the liter flow on the oxygen concentrator (medical device that uses air in the atmosphere, filters it, and delivers air that is 90 - 95% oxygen concentrated) was set to 2.5 LPM and had no humidifier bottle attached. Resident #13 said that he/she does not touch the oxygen concentrator and that he/she had never had a humidifier bottle attached to his/her oxygen concentrator. On 8/30/24 at 8:26 A.M., the surveyor observed Resident #13 seated in bed with Oxygen being administered via nasal cannula and the liter flow was set at 2.5 LPM with no humidifier bottle attached. During an interview at the time, Resident #13 said that there had not been a humidifier bottle attached to his/her oxygen concentrator. On 8/30/24 at 8:36 A.M., the surveyor and Unit Manager (UM) #2 observed Resident #13's oxygen concentrator and observed that there was no humidifier bottle attached to the oxygen concentrator and providing humidity to the Resident's Oxygen as ordered. UM #2 said that it was the Nurses responsibility to ensure that the humidifier bottle was attached to the Resident's oxygen concentrator. 2. Resident #52 was admitted to the facility in February 2023, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - a chronic lung disease that causes obstructed airflow from the lungs and difficulty breathing) and Chronic Respiratory Failure. Review of the most recent MDS assessment dated [DATE], indicated Resident #52 utilized Oxygen and was usually able to make him/herself understood. Review of the August 2024 Physician's Order Summary Report indicated the following order: -supplemental Oxygen via nasal cannula continuous (delivered around the clock) one liter (LPM) every shift for shortness of breath to maintain blood oxygen saturation between 88% - 92% every shift, dated 4/19/24. Further review of the August 2024 Physician's Order Summary Report indicated no orders to titrate (increase or decrease) the Resident's Oxygen liter flow from the ordered 1 LPM. Review of Resident #52's August 2024 blood oxygen saturation documentation indicated that the Resident's blood oxygen saturation levels had been in the range of 94% to 98% which was above the parameters (88% - 92%) ordered by the Physician. On 8/29/24 at 2:13 P.M., the surveyor observed Resident #52 seated in a wheelchair at his/her bedside with Oxygen administered via nasal cannula. The surveyor observed that the liter flow on the oxygen concentrator was set to 2 LPM. Resident #52 said that he/she does not touch the oxygen concentrator and that his/her liter flow had been set at 2 LPM. On 8/30/24 at 7:51 A.M., the surveyor observed the Resident seated in a wheelchair next to his/her bed with Oxygen administered via nasal cannula and the liter flow on the oxygen concentrator was set at 2 LPM. During an interview at the time, Resident #52 said that the oxygen concentrator had always been set at 2 LPM. On 8/30/24 at 8:38 A.M., the surveyor and UM #2 observed Resident #52's oxygen concentrator and observed that the flow rate was set at 2 LPM. The surveyor and UM #2 reviewed the Physician's orders, and UM #2 said that Resident #52 had been administered the wrong dose of Oxygen and should have been on 1 LPM of Oxygen per the Physician's order. On 8/30/24 at 11:05 A.M., the surveyor and the Assistant Director of Nursing (ADON) reviewed Resident #52's blood oxygen saturation level documentation. The ADON said the facility staff should have followed the Physician's order and notified the Physician when Resident #52's blood oxygen saturation levels were above the (ordered) parameters, but they had not.

Based on observation, interview, policy and record review, the facility failed to maintain complete and accurate medical records for one Resident (#48), for three closed records,out of a total sample of 19 residents. Specifically, the facility failed to maintain accurate documentation of meal intake percentage by Certified Nurses Aides (CNAs) when Resident #48 was identified as being at risk for weight loss. Findings include: Review of the Facility Policy titled, Charting and Documentation, dated 2001, indicated: -All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. -The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the Facility Policy titled, Nutrition and Hydration to Maintain Skin Integrity, dated 2001, indicated: -to document food consumption and changes in the resident's nutritional status. Resident #48 was admitted to the facility in June 2024, with diagnoses of Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), Dysphagia (difficulty swallowing foods or liquids) and Altered Mental Status (AMS - a general term for a change in mental function that can affect a person's awareness, movement, and behavior). Review of Resident #48's Skilled Nursing Progress Note indicated the following: -7/27/24 Resident refuses to eat. -8/8/24 indicated Resident #48 lacked motivation and needed much encouragement to eat, take medications and to get out of bed. The note further stated if not encouraged, the Resident would stay in bed all day. Review of Resident #48's Nutrition Notes indicated the following: -4/1/24: Family concerned about Resident's poor oral intake. -6/17/24: Weight warning - [Resident] weight 220 pounds. -6/27/24: Weight 207.8 indicating significant weight decline in weight in one month. -7/22/24: Weight warning with [Resident] weight 193.6 pounds. -8/14/24: Weight warning with [Resident] weight 186.7 pounds. -8/20/24: Weight warning with [Resident] weight 182.0 pounds, poor oral intake due to poor appetite. Remeron (antidepressant medication used to stimulate appetite) was already in place as well as nutritional supplements (increased calorie/protein items). During an observation on 8/29/24, the surveyor observed the following: -At 8:24 A.M., a staff member entered Resident #48's room and placed a breakfast tray in front of the Resident while he/she laid in bed with the head of bed elevated. Resident #48's eyes were closed. -At 9:09 A.M., Resident #48's breakfast remained untouched. -At 9:16 A.M., a staff member entered the Resident's room and removed the breakfast tray. During an observation on 8/29/24, the surveyor observed the following: -At 12:15 P.M., a staff member entered Resident #48's room with a lunch tray, elevated the Resident's head of bed up, mentioned the Resident's name and walked out of the room. -At 12:27 P.M., Resident #48's eyes remained closed and the Resident had not touched his/her lunch tray. -At 1:07 P.M., Certified Nurses Aide (CNA) #4 entered the Resident's room and assisted with the lunch meal. During an interview on 8/29/24 at 1:17 P.M., CNA #4 said Resident #48 needed to be encouraged to eat, that the Resident did not eat anything for breakfast and had 25% of the meal at lunch. Review of the CNA Documentation indicated CNA #4 documented the following for 8/29/24: -Resident #48 ate 75% to 100% for breakfast. -Resident #48 ate 75% to 100% for lunch. During a telephone interview on 8/29/24 at 4:14 P.M., CNA #4 said she had to leave in a rush at the change of shift, and had documented the Resident's meal intake in error. CNA #4 said that Resident #48 did not eat 75% to 100% for breakfast or lunch. On 8/30/24 at 8:22 A.M., the surveyor observed CNA #5 (in training) assisting Resident #48 with the breakfast meal. At 9:02 A.M., CNA #5 said Resident #48 had finished eating and only ate 18% of the meal and consumed 476 milliliters (ml) of fluid. CNA #5 said she was being trained by CNA #6. CNA #6 said she was working closely with CNA #5. Review of the CNA documentation for 8/30/24, showed Resident #48 had 51% to 75% of meal intake for breakfast. During an interview on 9/3/24 at 8:28 A.M., CNA #6 said the breakfast documentation on 8/30/24 was an error for Resident #48. During an interview on 9/3/24 at 11:32 A.M., the Registered Dietician (RD) said Resident #48 had lost a lot of weight in a short period of time. The RD said she had noted that the Resident had poor appetite and would only eat less than 25% of any meal. The RD said that the documentation of the CNAs did not accurately reflect the Resident's meal intake.

Based on interview and record review, the facility failed to conduct regular inspections of all resident bed frames, mattresses, and bed rails as part of a routine maintenance program to identify areas of possible entrapment risks and damaged equipment. Findings include: Review of the facility policy, titled Bed Safety and Bed Rails, revised August 2022, included: Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. During an interview on 5/30/23 at 8:20 A.M., the Maintenance Director said all resident beds and related equipment were to be inspected annually. At this time, the Maintenance Director provided a log of the most recent bed inspections completed, which was April 2022. The Maintenance Director said to be considered as completed annually, all resident beds and related equipment were to be inspected within the same time frame (month of April) the following year (2023), but that this had not yet been completed as required.

Based on record review and interview, the facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR- screen to determine if a resident has intellectual or developmental disabilities and/or serious mental illness and is in need of further evaluation) for one Resident (#29) out of a total sample of 23 residents, who exceeded the initial 30 days expected facility stay. Findings include: Resident #29 was admitted to the facility in December 2019 with a diagnosis of Schizophrenia. Review of the PASRR dated 12/4/19 indicated the following: -The Resident screened positive for a serious mental illness (SMI) -Expected to stay in nursing facility for less than 30 days Review of the PASRR completed on 11/15/21 (668 days after the 30 calendar days had passed since the Resident's admission to the facility) indicated that the nursing facility determined the Resident would not be discharged before the expiration of the exempted hospital discharge (EHD) date. During an interview on 5/30/23 at 8:27 A.M., Social Worker (SW) #1 said that she had been employed by the facility for less than one year and could not speak to why a new Level I had not been completed after the 30 calendar days had passed. She additionally said that something should have been completed in between the first PASRR that was completed upon admission and the second PASRR that had been completed on 11/15/21. She further said that there had been a high turnover of Social Workers in the last few years and felt that things were likely missed because of this. She said that they had a social service consulting company coming in two to three times per week to help cover the social work department but only had enough time to complete some tasks, not everything that was required of the department. During a follow-up interview on 5/30/23 at 9:52 A.M., SW #1 said that she called the PASRR office and was told that a SW who no longer worked at the facility had completed and submitted a PASRR Level One on 11/15/21 and that it was not completed timely.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#407 and #49) out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. Assess Resident #407 for constipation (a condition in which one may have fewer than three bowel movements (BMs) a week; stools that are hard, dry, or lumpy; stools that are difficult or painful to pass; or a feeling that not all stool has passed), implement the facility's bowel protocol, and implement the Physician's orders for treatment of constipation, increasing the risk for fecal impaction (lodgement of dry, hard stool that cannot pass out of the colon or rectum). 2. Implement the Physician directed plan of care for properly applying elastic bandages to Resident #49's lower extremities when the Resident had a diagnosis of congestive heart failure (CHF- chronic condition in which the heart does not pump blood as well as it should and can result in symptoms including, but not limited to swollen legs) and had bilateral lower extremity edema (swelling caused by excess fluid in body tissues), resulting in indentations to the back of Resident #49's left lower extremity and top of the left foot, increasing the Resident's risk for reducing blood circulation and skin impairment. Findings include: 1. Resident # 407 was admitted to the facility in May 2023 with a diagnosis of Diverticulosis (a condition in which small, bulging pouches develop in the digestive tract, and may result in constipation). Review of the Bowel Protocol Log Form provided by the facility, undated, indicated the following: -After six consecutive shifts (48 hours) without or with small to smearing BM, the following protocol will be initiated, and the Resident's name will be logged onto the Bowel Protocol Log. Every nurse needs to document what med was given and any results. Step 1-initiate bowel protocol by giving 120 milliliters (ML) of prune juice. Step 2-give Senna per MD order-if prune juice ineffective. Step 3-give suppository per MD orders-if Senna ineffective Step 4-give enema per MD orders-if suppository ineffective Step 5-if no results from enema notify MD/PA/NP During an interview on 5/24/23 at 9:34 A.M., Resident #407 said he/she had not had a bowel movement in nine days, since the day he/she was admitted to the facility. Review of the Minimum Data Set assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points, indicating the Resident was cognitively intact. Review of the facility Bowel Movements and Continence/Toilet Use report dated 5/15/23-5/24/23, indicated Resident #407's last BM was 5/15/23. Review of the Nurse's Progress notes dated 5/15/23-5/23/23, showed no evidence Resident #407 had moved his/her bowels. Review of Resident #407's Physician's orders, dated 5/26/23, indicated the following: -Senna tablet 8.6 milligrams (MG) give 1 tablet by mouth every 24 hours as needed for constipation, date initiated 5/15/23. -Fleets Enema 7-19 grams/118 ML (sodium phosphates) insert 1 unit rectally every 24 hours as needed for constipation-use only if bisacodyl suppository is ineffective, date initiated 5/15/23. Review of the Medication Administration Record (MAR) dated 5/1/23-5/31/23, indicated the resident had not received Senna 8.6 MG tablet, and Fleets Enema as ordered by the Physician. During an interview on 5/26/23 at 9:41 A.M., Nurse #2 said that the 11:00 P.M. to 7:00 A.M. (night shift) nurse generates a report every night that indicates residents that have not had a BM in three days. The night shift nurse gives the report to the 7:00 A.M. to 3:00 P.M. (day shift) nurse, and it is the day shift nurse's responsibility to initiate the bowel protocol. Nurse #2 said the bowel protocol is to give prune juice and Senna, and if this is not effective, to give a suppository. Nurse #2 said if the suppository is not effective, give a Fleets Enema. Nurse #2 said that Resident #407 should have had the bowel protocol initiated on 5/19/23 but this was not done as required. During an interview on 5/25/23 at 10:28 A.M., the surveyor and the Director of Nurses (DON) reviewed the Bowel Movements and Continence/Toilet Use report and MAR. The DON said that she did not see any documented BM after 5/15/23 and did not see Senna or Fleets Enema administered as ordered by the Physician. 42761 2. Resident #49 was admitted to the facility in January 2020 with diagnoses including Congestive Heart Failure (CHF) and Pulmonary Hypertension (type of high blood pressure that affects arteries in the lungs and heart). Review of Resident #49's MDS assessment, dated 4/25/23, included the following: - The Resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15 possible points, indicating he/she was cognitively intact. - The Resident had an active diagnosis of Heart Failure. - The Resident was being treated with a diuretic (used to excrete water from the body) medication daily during the assessment's observation period. - The Resident was at risk for developing pressure ulcers. Review of Resident #49's May 2023 Physician's orders included: ACE (elastic bandage) wraps on in A.M. (morning), wrap feet to top of calf, off at HS (hours of sleep) for edema. On 5/24/23 at 9:21 A.M., the surveyor observed Resident #49, seated in his/her room, in a wheelchair beside the bed with his/her feet resting on the floor. The Resident had elastic bandage wraps on both lower extremities and slipper socks on his/her feet. The elastic bandage on the Resident's right lower extremity was wrapped approximately 3/4 of the way up his/her lower leg. The back of the elastic bandage was rolled down slightly and there was an area of indentation on the back of the Resident's right calf. The Resident's left lower extremity was also wrapped with an elastic bandage, which was approximately 3/4 of the way up his/her front left lower leg. The back of the elastic bandage was rolled down to approximately mid-calf, and the surveyor observed an area of indentation, across the back of the Resident's left calf, where the bandage was rolled down, and the exposed portion of the Resident's left calf overlapped the top part of the bandage that was rolled down. During an interview at this time, Resident #49 said he/she had problems with swelling in both legs, he/she took Lasix (a diuretic medication) daily to help reduce the swelling, and that staff wrapped his/her lower legs in bandages daily. Resident #49 then said he/she felt the bandages were too tight and that he/she had pain when staff removed them. On 5/25/23 at 9:52 A.M., the surveyor observed Resident #49 seated in his/her room, in a wheelchair beside the bed, with his/her feet resting on the floor. The Resident was observed with elastic bandage wraps on both lower extremities and slipper socks on his/her feet. The elastic bandage on the Resident's right lower extremity was wrapped approximately 3/4 of the way up his/her lower leg. The back of the elastic bandage was slightly rolled down. The Resident's left lower extremity elastic bandage was wrapped approximately 3/4 of the way up his/her front left lower leg. The back of the elastic bandage was rolled down to approximately mid-calf, and the surveyor observed an area of indentation, across the back of the Resident's left calf, where the bandage was rolled down, and the exposed portion of the Resident's left calf overlapped the top part of the bandage that was rolled down. The surveyor also observed that the top of the Resident's left foot had a large bump/ swelling under the slipper sock from approximately the middle of the foot toward the toes. On 5/25/23 at 1:30 P.M., the surveyor observed Resident #49 seated in his/her room, in a wheelchair beside the bed. The surveyor's observation of the Resident's lower extremities was unchanged from the previous observation at 9:52 A.M. During an interview at this time, Resident #49 said the elastic bandages felt too tight and when staff removed the bandages in the evening, the back of his/her left leg always hurt. Resident #49 then said once the bandages had been off for a while, his/her leg no longer hurt. During an interview on 5/25/23 at 1:45 P.M., Nurse #5 said applying elastic bandages to the resident's lower extremities for edema management was a basic nursing practice. When the surveyor asked Nurse #5 to observe Resident #49's lower extremities and elastic bandages, Nurse #5 asked, are they too tight?. The surveyor then asked Nurse #5 to observe the Resident. At this time, the surveyor and Nurse #5 observed the Resident together and Nurse #5 said the elastic bandages were too tight and needed to be re-wrapped. He also said that there had been other times when the bandages were applied too tightly, and he had to re-wrap them for the Resident. Nurse #5 then removed the elastic bandages from Resident #49's lower extremities. When Nurse #5 removed the elastic bandage from the Resident's left lower extremity, the Resident gasped, used both hands to grab securely onto the wheelchair arm rests, and then held his/her breath. The surveyor observed a large area of indentation on the back of Resident #49's calf, where the elastic bandage had been rolled down, and several other small linear areas of indentation across the Resident's calf below the large indentation. The top of Resident #49's left foot also had an area of indentation that extended across the top of the mid-foot, from side to side, where the elastic bandage was wrapped, and there was a large, raised area from where the elastic bandage had ended mid-foot, which extended through the forefoot (front of the foot), to the base of the toes. Nurse #5 asked the Resident if he/she had pain and the Resident nodded his/her head. Resident #49 said every time staff removed the elastic bandage from his/her left lower leg there was pain and discomfort. Nurse #5 then inspected the Resident's skin, offered to re-apply the elastic bandages, and the Resident agreed. Nurse #5 then applied the elastic bandages to Resident #49's bilateral lower legs, wrapping from the forefoot to the top of the calf. Resident #49 said the bandages felt much better. During a follow-up interview on 5/25/23 at 2:00 P.M., Nurse #5 said it was important to apply elastic bandages properly for residents with lower extremity edema. He said bandages should be applied according to the instructions provided by the Physician and that when being applied from the foot to the top of the calf, staff were supposed to start at the forefoot area, not mid-foot and stop just below the knee. Nurse #5 said when elastic bandages for edema were applied at the mid-foot, they could result in edema pocketing below the bandage, and when not applied to the top of the calf, they could result in edema pocketing above the bandage. Nurse #5 said Resident #49's elastic bandages should have been applied from the forefoot to the top of the calf, but they were not. Nurse #5 further said this was important because improper application of elastic bandages for edema could result in decreased circulation, pockets of edema, and pressure areas on the skin.

Based on observation, record review and interview, the facility failed to maintain an environment that was free of accidental hazards for one Resident (#40) out of a total sample of 23 residents, relative to medication storage and administration. Specifically, for Resident #40, facility staff left unattended medications at the bedside without determining all medications had been ingested safely and appropriately. Findings include: Review of the facility policy titled Storage of Medications, revised 11/2020 indicated the following: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administered medications have access to locked medications. Resident #40 was admitted to the facility in June 2018. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating that Resident #40 was cognitively intact. Review of the medical record indicated no documented evidence of self-administration education, signed consent or a Physician's order that allowed the Resident to self-administer medication. During an interview and observation on 5/24/23 at 9:11 A.M., the surveyor noted two plastic medicine cups containing medications (multiple pills) in both on the Resident's overbed table. Resident #40 said that the nurse brought the medication in about a half an hour ago while he/she was eating breakfast. The Resident said that the nurse knows that he/she will take them so the nurse will just leave them until he/she is ready. Resident #40 said sometimes he/she had a hard time getting the blood pressure medication down because of the size of it. During an interview on 5/25/23 at 9:27 A.M., Nurse #4 said that when administering medications, it was required that you stay with the resident to ensure they had taken all the medications. She said that yesterday she did leave Resident #40's room prior to him/ her consuming all his/her pills. She said that she would typically check back with the Resident shortly after to ensure that he/she had taken all the medications. She also said that she was outside of the Resident's room, however she should have ensured the Resident took the medications prior to leaving the room and did not. During an interview on 5/25/23 at 11:51 A.M., the Director of Nursing (DON) said that it was expected that the nurse administering medications would stay with the resident until all medications had been ingested and the resident was comfortable and safe.

Based on record review and interview, the facility failed to maintain complete and accurate medical records for one Resident (#59) out of a total sample of 23 residents. Specifically for Resident #59 the facility failed to: 1. Ensure the Resident's most recent Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST- form that indicates a resident's wishes regarding treatments to sustain life) was signed by the Resident. 2. That the Resident's Care Plan accurately reflected the current active MOLST. Findings include: Resident #59 was admitted to the facility in January 2023. 1. Review of the Resident's medical record indicated a completed MOLST dated 2/25/23 that indicated the Resident wished to be a Do Not Resuscitate (DNR), Do Not Intubate (DNI), would like non-invasive ventilation (NIV), and would like to be transferred to the hospital. The MOLST did not indicate a decision relative to the use of artificial nutrition. Review of the Advanced Directives care plan indicated the Resident had advanced directives in place which included no artificial nutrition initiated on 3/21/23. During an interview on 5/25/23 at 11:36 A.M., UM #1 said the care plan should match the current active MOLST which did not indicate whether the Resident wanted artificial nutrition. She further said this information matched the unsigned MOLST that was in the chart and that unsigned MOLST would not have been considered active until the Resident signed it, so the care plan should not have been updated with that information until it was signed by the Resident. 2. Review of the Resident's medical record indicated an updated MOLST that was signed by the Physician on 3/21/23 but was incomplete as the Resident signature portion was left blank. Review of the Physician's progress note, dated 3/21/23, indicated the Physician had reviewed the MOLST with the Resident and per the Resident's request, updated the Resident's MOLST. During an interview on 5/25/23 at 10:03 A.M., Unit Manager (UM) #1 said the MOLST was incomplete because the Resident had not signed the form, as required. She further said staff should have ensured the form was signed after the Physician had reviewed the form with the Resident.

Based on observation, interview, and policy review, the facility failed to ensure its staff cleaned and disinfected a blood glucose meter/ glucometer (a device that measures blood sugar levels), per device and disinfectant manufacturer's instructions, increasing the risk for transmission of blood borne pathogens on one unit(Nonotuck) out of three units. Review of the Centers for Disease Control and Prevention (CDC) article titled, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, dated 3/2/11, indicated: whenever possible, blood glucose meter should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. Review of the Evencare G3 blood glucose meter manufacturer's cleaning and disinfecting procedure indicated the meter should be cleaned and disinfected between each patient. The following products have been approved for cleaning and disinfecting the Evencare G3 Meter: - Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8) - Medline Micro-Kill Plus Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10) - Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12) - Micro-Kill Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1) Review of the facility policy titled, Blood Glucose Monitoring, dated 7/2/12 indicated the following: - Disinfect the meter before and after each use, or when the monitor is visibly soiled as follows: - Use Super Sani-Cloth Germicidal Disposable Wipe (or other commercially prepared pre-moistened wipe which meets CDC guidelines) to wipe down the meter . On 5/25/23 at 3:53 P.M., and at 4:04 P.M., on the Nonotuck unit, the surveyor observed Nurse # 1 wipe an Evencare G3 blood glucose meter with an alcohol prep pad (a disposable pad soaked with 70% isopropyl alcohol) after obtaining blood sugar readings. During an interview on 5/25/23 at 4:04 P.M., Nurse #1 said the facility policy was to wipe the glucose meter with alcohol and wait four minutes. During an interview on 5/25/23 at 4:28 P.M., the Director of Nurses (DON) said the blood glucose monitor had not been cleaned and disinfected properly. She said Nurse #1 should have used Micro Kill, or Micro Kill Bleach cloth after each time she used the meter.

Based on interview and record review, the facility failed to ensure staff documented if residents had been offered, received, or declined recommended Pneumococcal immunizations for three Residents (#10, #53, and #87), out of a total sample of five residents. Findings include: Review of the facility policy titled Pneumococcal Vaccine, Revised October 2019, indicated the following: -Administration of the Pneumococcal Vaccines or re-vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. CDC guidelines found at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html indicated: >For those who have not previously received any pneumococcal vaccine +, CDC recommends you: -Give 1 dose of PCV15 or PCV20. -If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. -If PCV20 is used, a dose of PPSV23 is NOT indicated. >For those who have only received PPSV23, CDC recommends you: -Give 1 dose of PCV15 or PCV20. -The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. >For those who have only received PCV13, CDC recommends you either: -Give 1 dose of PCV20 at least 1 year after PCV13, or -Give 1 dose of PPSV23; the minimum interval between the PCV13 and PPSV23 doses will vary based on their specific risk factor. >For those who have received PCV13 and 1 dose of PPSV23, CDC recommends you either: -Give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine, or -Give a second dose of PPSV23 at least 8 weeks after PCV13 and 5 years after PPSV23 if they have an immunocompromising condition. 1. Resident #10 was admitted to the facility in July 2022. Review of the Resident's medical record indicated the Resident received the Pneumococcal Polysaccharide Vaccine (PPSV23-type of pneumococcal vaccination) on 2/10/11 and the Pneumococcal Conjugate Vaccine (PCV13-type of pneumococcal vaccination) on 8/18/15. Further review of the Resident's medical record indicated no documentation the Resident had been offered, received, or declined any further recommended Pneumococcal immunizations. 2. Resident #53 was admitted to the facility in February 2023. Review of the Resident's medical record indicated no documentation that the Resident had been offered, received, or declined any recommended Pneumococcal immunizations. 3. Resident #87 was admitted to the facility in December 2022. Review of the Resident's medical record indicated the Resident received the PCV13 on 2/13/15 and on 2/6/16. Further review of the Resident's medical record indicated no documentation the Resident had been offered, received, or declined any further recommended Pneumococcal immunizations. During an interview on 5/30/23 at 9:00 A.M., the Director of Nursing (DON) said when a resident is admitted to the facility the admitting nurse should complete the Influenza and Pneumococcal Consent and Tracking Form with the resident and/or resident's representative. This form should then be reconciled with the Massachusetts Immunization Information System (MIIS), updated as needed with the dates of vaccinations, or the decision should be made to offer the vaccinations to the resident if they were not up to date. The DON said at this time the facility did not have a process for tracking which residents in the facility needed any additional recommended Pneumococcal Vaccination doses. She further said for Residents #10, #53, and #87, there was no documentation to indicate if the Residents had been offered, received, or declined any recommended Pneumococcal Vaccinations at the time of their admission, and this should have been done as required.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff notified the Physician regarding an injury of unknown injury, when on 4/29/18 Resident #1 was found to have a large bruise, showed signs and symptoms of left shoulder discomfort, followed by decreased range of motion in the same shoulder and it was not reported to the Physician until 4/30/18. Findings include: The Facility Policy, titled Change in a Resident's Condition or Status, dated 5/2017, indicated that the Facility will; - Promptly notify the Attending Physician of changes in the resident's medical/mental and/or status; -Discovery of injuries involving the resident, accident or incident involving the resident, need to alter the Resident's medical treatment significantly, - A significant change in condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing disease related interventions, - Prior to notifying the Physician or healthcare provider, the Nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact Situation, Background, Assessment, Recommendations (SBAR) Communication form. The Facility Investigation Report, with a revision date of 5/21/18, indicated on 4/29/18 at 8:00 P.M., Resident #1 had new left wrist tenderness treated with Tylenol at 6:00 P.M. and a new bruise was found that extended from the left flank around the rib cage to below the left breast. CNA #3's written witness statement, dated 4/30/18, indicated on 4/29/18 at 8:00 P.M., when Resident #1's shirt was lifted over his/her head during personal care, a new dark bruise was noticed, and Resident #1 said the bruise hurt. CNA #2's written witness statement, dated 4/30/18, indicated on 4/30/18, while this CNA was performing morning care for Resident #1, and washed under his/her left arm, Resident #1 started yelling and saying that his/her shoulder hurt, so this CNA stopped and told the Nurse. The Surveyor interviewed Physician #1 at 12:20 P.M. on 5/31/18. Physician #1 said neither herself nor covering Physician Assistant #2 were notified on 4/29/18 of Resident #1's new chest bruise and left wrist swelling. Physician #1 said she was not notified that Resident #1 had complained of left shoulder pain on 4/30/18. Physician #1 said she was not notified of Resident #1's left shoulder pain until 5/5/18, when she ordered a shoulder X-ray and Resident #1 was found to have a dislocated left shoulder. The Surveyor interviewed Physician Assistant #1 at 12:04 P.M. on 5/31/18. Physician Assistant #1 said that on 4/30/18, she only examined Resident #1 for left wrist pain, because that was only what had been reported to her. Physician Assistant #1 said that the new chest bruise found on 4/29/18 and Resident #1's new left shoulder pain with decreased range of motion on 4/30/18, had not been reported to her. The Surveyor interviewed Nurse #1 at 12:40 P.M. on 6/1/18 and reviewed the Facility's investigation report she (Nurse #1) signed, during this interview, for Resident #1's wrist swelling and the new chest bruise. Nurse #1 said although it was documented in the investigation report that the Physician was notified on 4/29/18 at 8:19 P.M., Nurse #1 said she did not notify the Physician of Resident #1's new left chest bruise or left wrist swelling. The Nurses Progress Note, dated 4/30/18, indicated at 6:00 P.M., Resident #1 had mild swelling above the left wrist and at 8:00 P.M., a Certified Nurse Aide (CNA) found a new bruise of unknown origin, extending from the left lateral flank (side of the body between the ribs and the hip) to just under the resident's left breast. (There were no measurements, of the bruise documented in Resident #1's medical record). The Surveyor interviewed CNA #1 at 2:40 P.M. on 5/30/18. CNA #1 said that on 4/30/18, during morning care, she asked Resident #1 to lift his/her left arm so she could wash him/her, but Resident #1 would not lift his/her left arm up, which was unusual. CNA #1 said words to the effect, so I lifted Resident #1's left arm up a little and he/she started screaming, so I stopped, got closer to Resident #1 and asked him/her if the left shoulder was hurting and he/she said, yes. CNA #1 said she immediately reported Resident #1's left shoulder pain and inability to move his/her arm to the Nurse. The Surveyor interviewed CNA #2 at 3:05 P.M. on 5/30/18. CNA #2 said she told the Nurses all week about Resident #1 not having any control of his/her left arm, about him/her not being able to move his/her left arm, and that it would flap back down. CNA #2 said Resident #1 had complained of left shoulder pain and had been difficult to care for all week. The Nurses Progress Note, dated 5/5/18 at 3:46 P.M., indicated Resident #1's Family Member requested a left shoulder X-Ray, he/she had limited range of motion of the left arm and the Physician was notified. The Nurses Progress Note, dated 5/5/18 at 5:00 P.M., indicated a call was placed to the Physician to inform of X-ray report findings of Resident #1's shoulder dislocation. The Mobile X-ray Company Report, dated 5/5/18 at 1:52 P.M., indicated Resident #1 had left shoulder pain, the results indicated the humerus (upper arm bone) was anteriorly and inferiorly dislocated, an anterior shoulder dislocation. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 3:30 P.M. on 5/30/18. The ADON said there was not documentation in the Nurses Notes that the Physician was notified of Resident #1's new chest bruise on 4/29/18. The ADON said there was not documentation to support that the Physician examined Resident #1 for new left shoulder pain with decreased range of motion on 4/30/18, not until 5/5/18, approximately 5 days later, when the Resident #1's pain and decreased range of motion were reported to the Physician a left shoulder X-Ray indicated a dislocated shoulder.

Based on observation, clinical record review and interview, the Facility failed to maintain the optimal nutritional status of a resident (resulting in a weight loss of 9.7 pounds in a 16 day period) for 1 of 22 residents sampled, ( Resident # 75 ). Findings include: Resident # 75 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission minimum data set, (MDS) assessment with an assessment reference date (ARD) of 11/14/17 indicated that Resident # 75 was cognitively intact, with a Brief Interview for Mental Status, (BIMS) assessment score of 15/15, had no memory issues and no behavioral issues. Resident # 75 received >51% of his/her calories from artificial nutrition via a feeding tube, received a mechanically altered diet by mouth, and required extensive assistance with eating. Body weight was noted as 145 pounds. Review of the admission Physician's orders indicated that Resident #75 was to receive [MEDICATION NAME] 1.2 ( a liquid nutritional formula) 55 milliliters (ml.) per hour for 12 hours a night equal to 660 ml. of formula via his/her feeding tube, as well as a puree diet with nectar thickened liquids by mouth. Review of the clinical record indicated that on 11/8/17 Resident #75 weighed 144.9 pounds. Review of laboratory results obtained on 11/8/17 indicated; -[MEDICATION NAME] (a protein found in blood, a low level may indicate poor nutritional staus or kidney or liver dysfunction) level was 2.5 (Normal range 3.9-4.8). -Total Protein (a low level may indicate a liver disorder, a kidney disorder or malnutrition) level was 5.4 (Normal range 6.5-8.0). Review of a Nurse's note dated 11/8/17 indicated that Resident #75 received [MEDICATION NAME] for nausea. Review of meal consumption records indicate that on 11/8/17 Resident #75 refused breakfast and lunch, and ate 75% of the evening meal. Review of a Dietician note dated 11/9/17 indicated; Weight 144.9. Receives enteral feedings due to dysphagia. Feedings administered via gastrostomy tube, via continuous pump. No indication of intolerance to feedings or flushes. No medications evident that have the potential to impact nutritional status. No recent lab values noted with a nutritional impact. Average meal intake is 76%-100%. Identified nutritional problems: Overweight/obesity. Nutritional interventions include enteral nutrition and modified diet. Recommendations; if po's (meals by mouth) improve will d/c (discontinue) tube feeding. Will continue to follow. Review of a Physician's progress note dated 11/9/17 indicated that Resident #75 complained of nausea and vomiting. Review of meal consumption records dated 11/9/17 -11/12/17 indicated that the resident was refusing two meals each date and ate 25-75% of the third meal. Review of meal consumption records indicate that on 11/13/17 Resident #75 ate 50% of breakfast and lunch, and the evening meal was noted as not applicable. Review of a Dietician's note dated 11/13/17 indicated; Resident prefers mechanically altered ground texture over regular texture, likes fresh fruit, canned peaches and thickened soup. Tolerates nectar thick liquids. Recommend decreasing feed rate to 44 ml/hr due to poor tolerance. Change formula from [MEDICATION NAME] 1.2 to [MEDICATION NAME] 1.5, infuse @ 44 ml/hr start at 8:00 P.M., for 12 hours or until 530 ml is infused. Flush 100 ml water every 8 hours. Monitor HOB, (head of bed) must be greater than 30 degrees. Will continue to follow. Review of a physician's order dated 11/13/17 indicated orders to change diet to regular puree with nectar thickened liquids, half portions, and change tube feeding to [MEDICATION NAME] 1.5 44 ml. per hour, begin at 8:00 P.M., run for 12 hours until 530 ml. of formula is infused. Review of a Physician's progress note dated 11/14/17 indicated that Resident # 75 had difficulty eating due to nausea and feeling full. Review of meal consumption records indicate that on 11/14/17 Resident #75 refused breakfast, ate 50 % of lunch, and the evening meal was noted as not applicable. Review of meal consumption records indicate that on 11/15/17 Resident #75 refused breakfast, ate 50% of lunch, and refused the evening meal. On 11/16/17 Resident #75's weight was noted to be 141.8, indicating a loss of 3.1 pounds since 11/8/17. There was no indication that the Physician or the Dietician was notified regarding this weight loss. Review of a Physician's order dated 11/16/17 indicated an order to change the texture of Resident #75's meals to ground with cut up meats, half portions with nectar thick liquids. Review of meal consumption records indicate that on 11/16/17 Resident #75 ate 50% of breakfast and lunch and refused the evening meal. Review of a Nurse's note dated 11/17/17 indicated that Resident #75 vomited once, and that the tube feeding was not administered. Review of meal consumption records indicate that on 11/17/17 Resident #75 ate 75% of breakfast and lunch, and 50% of the evening meal. Review of a Nurse's note dated 11/18/17 indicated that Resident #75 requested [MEDICATION NAME] for nausea, and tolerated small amounts of food and fluids. two additional Nurse's notes dated 11/18/17 indicate that Resident #75 requested [MEDICATION NAME] for nausea. Review of meal consumption records indicate that on 11/18/17 Resident #75 refused breakfast and lunch, and ate 50% of the evening meal. Review of meal consumption records indicate that on 11/19/17 Resident #75 ate 75% of all meals. Review of a Nurse's note dated 11/20/17 indicated that Resident #75 complained of being nauseous for the past 2 days. Review of a Dietician's note dated 11/20/17 indicated; Recommend hold nocturnal tube feed for 2 days due to nausea and vomiting and feelings of fullness discouraging po intake. Monitor po's, n/v (nausea and vomiting) if po's are improved and n/v subside, will recommend continued d/c of enteral nutrition. Review of a Physician's order dated 11/20/17 indicated a recommendation to hold the tube feeding for 2 days due to nausea and vomiting and a full feeling. Review of meal consumption records indicated that Resident #75 ate 75% of all meals on 11/20/17 and 11/21/17. Review of a Physician's progress note dated 11/21/17 indicated that Resident # 75 was vomiting, and had a poor appetite. Review of a Nurse's note dated 11/21/17 indicated that Resident #75's appetite was fair. Review of meal consumption records for 11/22/17 indicate that Resident #75 ate 25% of breakfast, 50% of lunch and 75% of the evening meal. Review of a Dietician's note dated 11/22/17 indicated; Since discontinuation of enteral nutrition, resident's nausea has become less frequent, no episodes of vomiting. PO's are improving Resident was encouraged by Dietician to consume plenty of fluids and try to eat more than half of each meal, will continue to monitor. Review of a Physician's order dated 11/22/17 indicated an order to stop the tube feedings due to poor tolerance, nausea and vomiting. Po intake has improved. Review of a Nurse's note dated 11/23/17 indicated that Resident #75 requested [MEDICATION NAME] for nausea. Review of meal consumption records for 11/23/17 indicated that Resident #75 ate 25% of breakfast, refused lunch and ate 50% of the evening meal. On 11/24/17 Resident #75's weight was noted to be 135.2, reflecting a weight loss of 9.7 ponds since 11/8/17. Review of the Facility policy Weight assessment and intervention, dated 6/23/15 indicated; -Any weight change of 5 pounds or greater since the last weight assessment will be retaken the next day for confirmation. -If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. -The Dietician will respond within 24 hours of receipt of written notification. Review of the clinical record did not indicate that a weight was re-checked, and did not indicate notification of the Dietician. During interview on 1/16/18, at 12:45 P.M., the Dietician said that Resident # 75 was not a great eater, and that the weight loss was not a big surprise, given that Resident # 75 was not keeping down the food/fluids that he/she was given. When asked if he had been notified of Resident # 75's 9.7 pound weight loss, the Dietician said that the electronic medical record would have alerted him, and that residents with weight loss are discussed in weekly risk meetings. Review of Dietician's notes and review of meeting notes submitted by the Dietician did not include mention of the weight loss. The Dietician said that Resident #75's weight loss was implied, and that was why he was following the Resident. He said that he did not know what other interventions could have been done to prevent the weight loss. During interview on 1/18/18 at 2:30 P.M., the Dietician said that he was aware of the weight loss, but had missed documenting it. He said that a weight should have been re-checked, and that it was very evident that the Resident had lost weight. Review of meal consumption records for 11/24/17 indicated that Resident #75 refused breakfast and lunch, and ate 75% of the evening meal. Review of meal consumption records for 11/25/17 indicated that Resident #75 refused all meals. Review of meal consumption records for 11/26/17 indicated that Resident #75 ate 75% of all meals. Review of a Nurse's note dated 11/26/17 indicated that Resident #75 had a urinary tract infection, and would be put on an antibiotic, and no other acute issues were noted. Review of meal consumption records for 11/27/17 indicate that Resident #75 refused breakfast and lunch. On 11/27/17 Resident was admitted to the hospital. Review of the Hospital records indicate that Resident #75 was admitted for treatment, and diagnosed with [REDACTED]. During interview on 1/18/18 at 2:30 P.M., the Dietician said that he did not agree with the Hospital's [DIAGNOSES REDACTED].

Based on records reviewed and interviews for 2 of 3 sampled residents (Resident #2 and #3), the Facility failed to prevent financial exploitation by Certified Nurse Aide (CNA) #1. CNA #1 stole two bank checks from Resident #2's pocketbook, wrote the checks out to herself in amounts totaling $800.00 and forged Resident #2's signature on the checks. CNA #1 stole Resident #3's credit card from his/her wallet and made purchases at five different stores totaling $453.39. Findings include: The Policy titled, 10/11/17, indicated abuse includes misappropriation of resident property. It is the deliberate misplacement, exploitation, or wrongful, temporary,or permanent use of resident's belongings or money without the resident's consent. 1. Resident #2 was admitted to the Facility in 4/2017 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE] indicated that Resident #2 was cognitively intact and was able to make his/her own decisions. The Surveyor interviewed Resident #2 at 11:40 A.M. on 12/30/17. Resident #2 said that on 9/13/17 when he/she paid the Hairdresser, he/she recognized that two checks were missing from his/her checkbook, and said he/she called the Bank. Resident #2 said the bank informed him/her that the two checks were written out to CNA #1's name and that the signature endorsing the two checks was not Resident #2's signature. Resident #2 said that he/she did not write the two checks, that one check was in the amount of $300.00 and the other for $500.00. Resident #2 said that his/her signature was forged, and that the Bank said it was a theft. Resident #2 said the theft has made him/her feel insecure because it happened while he/she was sleeping. Resident #2's bank check #1007, dated 9/5/17 (post dated after CNA #1 worked on 9/6/17) , indicated CNA #1 wrote this check out to herself for $500.00 and forged Resident #2's signature on the authorization line. Resident #2's bank check #1008, dated 9/7/17, indicated CNA #1 wrote this check to herself and for $300.00 and forged Resident #2's signature on the authorization line. The Facility's Internal investigation, dated 9/13/17, indicated Resident #2 had two checks missing from his/her check book, the two checks were written out to CNA #1, the alleged suspect, and they were cashed at the Bank. The alleged suspect, CNA #1 only worked one 11:00 P.M. to 7:00 A.M. shift at the Facility on 9/6/17. The Police Report, dated 9/13/17, indicated Resident #2 had called his/her bank on 9/13/17 to check on the account balance because two checks were missing from the numbered sequence in his/her checkbook. The Police Report indicated that the Bank reported the two missing checks were made out to CNA #1 name. The Report indicated that Resident #2 had advised the Bank that he/she does not know that person (CNA #!) and that he/she had not written the two checks. The Psychiatric Consultation, dated 9/29/17, indicated that Resident #2 was seen due to complaints of ongoing anxiety, that he/she recently had his/her checkbook stolen by a staff member. The Consult indicated Resident #2 was now suspicious of caregivers. The Surveyor interviewed the Administrator at 9:15 A.M. on 11/29/17. The Administrator said that their investigation findings were that CNA #1 stole Resident #2's checks and financially exploited him/her. 2. Resident #3 was admitted to the Facility in 7/2016 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE] indicated that Resident #3 is cognitively intact and able to make his/her own decisions. The Surveyor interviewed the Business Office Manager at 11:15 on 11/30/17. The Business Office Manager said Resident #3 could not verbally communicate to the Bank over the telephone because he/she is deaf, and he/she was driven to the Bank. The Bank checked the credit card purchases and found that there were five different store purchases made in Springfield Massachusetts (MA), totaling $453.39. The Surveyor interviewed Resident #3 at 2:05 P.M. on 11/30/17. Resident #3 said that his/her credit card was stolen from his/her bedside table. Resident #3 said that unauthorized purchases were made at out of town stores and said that he/she only buys at the local stores. Resident #3 said he/she was angry that someone had stolen and used his/her credit card, and he/she said, How dare they, I don't feel safe or comfortable now, because it is always in the back of my head what happened, or words to that effect. The Bank letter to Resident #3, dated 12/7/17 indicated there were five fraudulent charges made to Resident #3's credit card totaling $ 453.39. The Facility's internal investigation, dated 9/15/17 indicated that Resident #3 noticed his/her credit card was missing 9/15/17. A Bank Affidavit for Unauthorized Credit card usage, dated 9/15/17 and signed by Resident #3 indicated purchased from 5 different stores in Springfield MA were made on: 9/8/17 for $30.15 9//8/17 for $182.20 9/8/17 for $183.07 9/11/17 for $25.98 9/11/17 for $31.99 The Surveyor interviewed the Administrator at 9:15 A.M. on 11/29/17. The Administrator said that their investigation findings were that CNA #1 stole Resident #3's credit card and financially exploited him/her. The Surveyor interviewed Detective #1 at 2:38 P.M. on 11/30/17. Detective #1 said that their preliminary investigation indicated the theft of Resident #2's checks and Resident #3's credit card were done by CNA #1. On the day of the Survey 11/30/17, the Facility provided documentation to support concerns identified during this survey, were addressed. In response to the misappropriation incidents the Facility took the following corrective action: A. Facility wide Resident audit was performed on 9/13/17, with how the Residents secure their belongings with discussion of the Resident drawer key, keeping the drawer locked and placing the key in a safe location preferably on their person. B. Nursing Staff were educated from 9/13/17 through 9/17/17, on Abuse the signs and symptoms of non-verbal abuse. The content included staff recognition of the signs and symptoms of non-verbal abuse, protection of residents and the reporting abuse procedure. C. Additional Staff education was conducted from 9/13/17 through 9/17/17, on Abuse neglect and the Elder Justice Act; Understanding this Act and the different types of abuse and how to care plan to prevent and address abuse. D. Education for 9/13/17 through 9/17/17, included the Essential Resident Rights; Understanding the resident rights which included their right to have money and belongings in their room and on their person and the Facility's expectation and policies on residents rights; Resident rights to be free from abuse and feel safe with their personal belongings. E. The Facility meet with the Resident Council on 9/14/17, to address and discuss the recent reported thefts. F. A Quality Assurance and Performance Improvement Committee Meeting was held on 9/11/17. Administration discussed and developed action plans and follow-up on the security of the night stands and keys. One hundred percent of the nightstands were checked for workable locks. The plan was to provide to all admissions with education with using the locked drawer. G. The Administration discussed with the contracted staffing agency accurate employee references prior to hire. H. The Director of Nursing is responsible for the implementation of the plan for complying with the methods identified for preventing and recognizing abuse especially misappropriation.

Based on records reviewed and interviews for 1 of 3 residents (Resident #1), the Facility failed to protect Resident #1 from the verbal abuse on 6/10/17 when Certified Nursing Assistant (CNA) #1 said to Resident #1, words to the effect, [***] , I only have 2 days left, what makes you think I won't hit you back. Findings include: The Policy titled, Abuse Investigations, dated 1/16/17, indicated the Facility is committed to protecting the residents from abuse, neglect, misappropriation of resident property by anyone including, but not necessarily limited to Facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents. The Admission Minimum Data Set (MDS), dated [DATE] indicated Resident #1 was severely cognitively impaired, had verbal behavioral symptoms directed at others and intrudes on the privacy of others. The Facility Investigation, dated 6/10/17 indicated at 1:45 A.M., Resident #1 was intrusively wandering about the Unit and when CNA #1 attempted to redirect Resident #1, he/she became combative attempting to scratch and hit CNA #1 with a cane. CNA #1 said words to the effect, [***] , I only have 2 days left, what makes you think I won't hit you back. The investigation findings determined that CNA #1 was verbally abusive towards Resident #1. The Surveyor interviewed Nurse #1 at 3:32 P.M. on 7/21/17. Nurse #1 said that on 6/10/17 during the 11:00 P.M. to 7:00 A.M. shift, she witnessed CNA #1 say to Resident #1, words to the effect, [***] , I only have 2 days left, what makes you think I won't hit you back. Nurse #1 said she immediately separated Resident #1 and CNA #1 and asked CNA #1 to leave the Unit and started an abuse investigation. The Surveyor interviewed CNA #2 at 1:06 P.M. on 7/21/17. CNA #2 said on 6/10/17 during the 11:00 P.M. to 7:00 A.M. shift, she heard CNA #1 call Resident #1 a [***] and said CNA #1 also said to Resident #1 what makes you think I won't hit you back, or words to that effect. The Surveyor interviewed the Director of Nurses (DON) at 8:25 A.M. on 7/21/17. The DON said the investigation findings indicated CNA #1 was verbally abusive towards Resident #1. Although Resident #1 was unable to be interviewed by the Surveyor due to Resident #1's cognitive deficits, the Reasonable Person Concepts presumes that an unimpaired person would experience mental anguish from being sworn at and threatened by a caregiver.

Based on observations, staff interviews and record reviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 4 of 12 applicable residents (#3, #7, #13 and #20), in a total sample of 22 residents. Findings include: 1. For Resident #20, the facility failed to provide adequate supervision and effective interventions to prevent falls. The resident had 4 falls from 3/24/16 through 6/21/16. One fall resulted in a laceration requiring 11 sutures, to the left occipital region of the resident's scalp, to close the wound. Resident #20, was admitted to the facility in 12/2015, with [DIAGNOSES REDACTED]. Review of the falls care plan, initiated on 1/4/16 identified the resident as exhibiting: impaired balance; wandering; being in an unfamiliar environment; and having an impaired activity tolerance. The falls care plan indicated the following interventions: bed alarm, chair alarm, and supervision when the resident was out of his/her room due to wandering. Review of the quarterly Minimum Data Set (MDS) Assessment, with the Assessment Reference Date (ARD) of 3/22/16, indicated that the resident had severe cognitive impairment; required assistance during transfers and supervision with ambulation. Review of the Progress Note, of 3/24/16 at 1:30 P.M., indicated that the resident experienced an unwitnessed fall (in another resident's room), with no injury. Review of the Incident/Accident Report, dated 3/24/16, indicated that the resident tripped over a floor mat that jutted out beyond the foot board of the bed. The following intervention was added: move the floor mat (in the other resident's room) to prevent a tripping hazard. Review of the Progress Note, of 3/26/16, indicated that the resident experienced a second unwitnessed fall, in her/his room, with no injury at 7:20 A.M. The falls care plan was updated to include: a low bed. Review of the Incident/Accident Report, dated 3/26/16, indicated that the resident was found sitting on the floor on a sheet. Review of the Physical Therapy Evaluation, dated 3/28/16, indicated that Resident #20 had poor safety awareness, poor balance and cognitive impairments. Review of the falls care plan indicated that the chair alarm was discontinued on 3/29/16. Review of the Physical Therapy Progress Notes, dated 4/1/16, indicated that Resident #20 was not aware of things in front of him/her making him/her a high fall risk. The notes further indicated that verbal cues on path navigation were given to the resident for safety. Review of the Progress Note, dated 4/2/16, indicated that the resident experienced a third unwitnessed fall at 2:15 P.M., sustaining a laceration to the top frontal portion of the head. The resident was transferred to the emergency room and returned to the facility with 11 sutures to the forehead. Review of the Investigation Report indicated that the resident sustained [REDACTED]. The falls care plan was updated to include the following interventions: put black mat in front of the other resident's room to prevent Resident #20 from entering and conduct a house wide audit to replace thick fall mats with low-profile fall mats with beveled edges. Review of the Physical Therapy Progress Notes/Discharge Summary, dated 4/8/16, indicated that due to Resident #20's impaired cognition, unawareness of the environment/items in front of him/her, Resident #20 required supervision for out of bed mobility at all times. Review of the Progress Note, dated 6/21/16, indicated that the resident fell in the hallway and sustained a superficial laceration over his/her left temple. Review of the Incident/Accident Report, dated 6/21/16, indicated that Resident #20 tripped on the laces of his/her untied shoes while ambulating in the hallway at 5:30 P.M. Further review indicated that steri-strips were applied to the laceration over his/her left temple. The falls care plan was updated to include: Slip on shoes with non-skid socks, tab alarm in bed and a bed alarm (already in place as of 1/4/16). During an interview, on 10/18/16 at 12:45 P.M., with the Director of Nursing (DON), she said that Resident #20 always went into the other resident's room to visit. She said that at the time of the (4/2/16) fall, Resident #20, had declined and was exhibiting a shuffling gait and low steps. During an interview on 10/18/16 at 1:55 P.M., the DON said that the interventions put in place for Resident #20 were not effective and that he/she was not supervised at the time of the falls on (3/24/16 and 4/2/16). The DON said that the activity department was working to keep Resident #20 occupied during the day with the goal of keeping him/her out of other residents rooms. 2. For Resident #13, the facility failed to provide adequate supervision and effective interventions to prevent continued falls. Resident #13, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment of 12/2/15 indicated that the resident was severely cognitively impaired; required extensive assistance with transfers and ambulation and exhibited an unsteady balance. The falls care plan of 12/11/15 indicated the following interventions: bed and chair alarm, commonly used items within reach, bed in low position and assist with transfers and ambulation, as needed. Review of the Progress Note of 12/14/15 indicated the resident experienced an unwitnessed fall, with no injury. During an interview with UM (Unit Manager) #1(on 10/13/16 at 10:25 A.M.), she said the Nursing Progress Note and the falls investigation indicated that to prevent recurrence that 1:1 supervision would be provided when the resident was agitated. Review of the Progress Note of 12/15/15 indicated the resident experienced a second unwitnessed fall, with no injury. The falls care plan was updated to include: fall mats to both sides of bed, every 2 hours offer to toilet, right side of bed against wall and recliner when agitated, with TABS alarm on. Review of the Progress Note of 1/5/16 indicated the resident experienced a third unwitnessed fall, with no injury. During review of the investigation with UM #1 (on 10/13/16 at 10:25 A.M.), she said the resident was agitated prior to the fall and that supervision was not being provided, as planned. She further said that after the fall, staff education was to be provided regarding the staff continuing to provide the resident with close supervision, however, she said the facility had no evidence that staff education had been conducted, as planned. The investigation indicated to prevent recurrence the staff would continue with close supervision (defined by UM #1 as the resident should be within the staff's visual field in order to monitor the resident.) Review of the Progress Note of 1/16/16 indicated the resident experienced a fourth unwitnessed fall, sustaining a laceration to the right flank area. During review of the investigation with UM #1 (on 10/13/16 at 10:25 A.M.), she said the resident was agitated prior to the fall and that supervision was not being provided, as planned. Review of the Progress Note of 1/16/16 indicated the resident experienced a second fall on that day, with no injury. The falls care plan was updated to include: alarming velcro seatbelt in wheelchair. Review of the quarterly MDS of 3/2/16 indicated that the resident remained essentially unchanged except to indicate that the resident now experienced falls. The falls care plan was reviewed by the staff on 3/23/16 and remained essentially unchanged. Review of the Progress Note of 4/4/16 indicated the resident experienced a fifth unwitnessed fall, with no injury. During review of the investigation with UM #1 (on 10/13/16 at 10:25 A.M.), she said the resident's bed locks were disengaged and not in the locked position, per facility protocol. She further said that she was unaware of the last time the resident had been checked on, prior to the fall, and that the resident was not being assisted out of bed, as planned. To prevent recurrence it was indicated that the resident would be out of bed prior to breakfast. Review of the Progress Note of 4/11/16 indicated the resident experienced a sixth unwitnessed fall, with no injury. The falls care plan was updated to include: adjustment of wheelchair to low height. Review of the Progress Note of 5/7/16 indicated the resident experienced a fall, with no injury. The investigation indicated to prevent recurrence the auto locking brakes, on the wheelchair, would be adjusted. Review of the Progress Note of 5/17/16 indicated the resident experienced a seventh unwitnessed fall, with no injury. During review of the investigation with UM #1 (on 10/13/16 at 10:25 A.M.), she said the facility was unaware of the details surrounding the fall (i.e.: if bed alarm sounded/if fall mats were in place) and that a referral to therapy for a rehabilitation (rehab.) screen was requested, by Nursing. UM#1 said the rehab. screen was not conducted, as planned. During interview with the DON (Director of Nursing) (on 10/17/16 at 2:45 P.M.), she said that per the facility policy, that after every resident fall, a referral to therapy would be made for a rehab. screen to be conducted. The investigation indicated that the plan, after the fall, was to utilize an alarming floor mat. The falls care plan was updated to include: scoop/perimeter defining mattress. The resident's bed against the wall was discontinued on 5/27/16. Review of the quarterly MDS of 5/31/16 indicated that the resident remained essentially unchanged. The falls care plan was reviewed by the staff on 6/21/16 and remained essentially unchanged. Review of the quarterly MDS of 8/24/16 indicated that the resident remained essentially unchanged except to note that the resident had not fallen since the prior assessment. Review of the Progress Note of 9/6/16 indicated the resident experienced a fall, sustaining a bump on the head with an abrasion/bruise 7 cm. (centimeters) by 4 cm. The falls care plan was reviewed by the staff on 9/13/16 and remained essentially unchanged. Review of the Progress Note of 9/29/16 indicated the resident experienced a fall, sustaining a skin tear to the forearm. During review of the investigation with UM #1 (on 10/13/16 at 10:25 A.M.), she said that a referral to therapy for a rehab. screen was requested. During interview with the Director of Rehab. (on 10/18/16 at 10:50 A.M.), she said the rehab. screen was not conducted, as per facility policy. The care plan was updated to include: encourage resident to call out for help. During the Initial tour on 10/11/16 at 9:15 A.M., with UM #1, the surveyor observed the resident sitting in a wheelchair, in the hall, and a yellowish /gray fading black and blue was observed on his/her left outer eye/temple area. UM #1 told the surveyor that the resident had a history of [REDACTED]. On 10/12/16 between 7:55 A.M. and 9:50 A.M., the surveyor observed the resident lying in bed, on a regular mattress (not a scoop mattress, as planned) and the resident's call light was observed dangling off the bed and was on the floor (not within the resident's reach, as planned). At 2:45 P.M., the surveyor observed a CNA (Certified Nursing Assistant) changing the resident's sheets on the regular bed mattress. During an interview with UM #1, on 10/13/16 at 10:25 A.M., she said that the resident is confused, has had a history of [REDACTED]. She further said that the facility needs to be creative with additional (falls) interventions, to keep the resident safe. At 11:25 A.M., the surveyor and UM #1 observed that the resident did have a regular bed mattress in place and not a scoop mattress, as planned. A discussion was held with UM #1 that the facility failed to provide effective interventions and adequate supervision to prevent continued falls (11 falls in total). 3. For Resident #3, the facility failed to provide adequate supervision and effective interventions to prevent continued falls. Resident #3, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) Assessment of 7/12/16 indicated that the resident exhibited short and long-term memory deficits, severely impaired decision making ability; required extensive assistance with transfers and ambulation, exhibited an unsteady balance and had a history of [REDACTED]. Review of the Progress Note of 7/20/16 indicated the resident experienced an unwitnessed fall, with no injury. During an interview with UM #1 (on 10/13/16 at 11:40 A.M.), she said that at the time of the fall, (according to the MDS Assessment), the resident required assistance with transfers and ambulation. UM #1 said at the time of the fall, assistance was not being provided. The falls care plan of 7/29/16 indicated the following intervention: supervision at times when ambulating out of room (during interview on 10/13/16 at 11:40 A.M. with UM #1), she said the care plan was unclear, however, said based on the facility assessment, the resident required assistance when ambulating out of her/his room. Review of the Progress Note of 8/6/16 indicated the resident experienced a second unwitnessed fall, sustaining a lump on the back of the head. Review of the Progress Note of 8/15/16 indicated the resident experienced a fall, with no injury. During review of the investigation with UM #1 (on 10/13/16 at 11:40 A.M.), she said the plan after the fall, to prevent recurrence, was to ensure that the resident in a well lit area. Review of the Progress Note of 8/19/16 indicated the resident experienced a fall, with no injury. Review of the Progress Note of 8/19/16 indicated the resident experienced a third unwitnessed fall (second fall on the same date), sustaining an open area to the left eyebrow, requiring steri-strips to close the wound. During an interview with UM #1 (on 10/13/16 at 11:40 A.M.), she said that at the time of the fall, the resident was not being assisted with ambulation, as planned. Review of the Progress Note of 8/27/16 indicated the resident experienced a fall, with no injury. The falls care plan was updated to include: utilize TABS alarm, at all times, when in bed. Review of the Progress Note of 9/13/16 indicated the resident experienced a fall, with no injury. The falls investigation indicated that a referral to rehab. (rehabilitation) was made. During interview with the Director of Rehab. (on 10/17/16 at 10:45 A.M.), she said that the rehab. screen had not been conducted, as planned. The falls care plan was updated (on 9/23/16) to include: non-skid socks when not wearing shoes. Review of the Progress Note of 9/28/16 indicated the resident experienced a fourth unwitnessed fall, with no injury. During an interview with UM #1 (on 10/13/16 at 11:40 A.M.), she said that at the time of the fall, the resident's TABS alarm did not activate, as planned, and that poor lighting contributed to the fall, as the area was not well lit, as planned. The falls care plan was updated to include: 15 minute safety checks (between 9/28/16 and 10/3/16). UM #1 further said the facility had no evidence that the 15 minute safety checks had been conducted, as planned. Review of the Progress Note of 10/3/16 indicated the resident experienced a fifth unwitnessed fall, sustaining a hematoma and temple laceration. requiring 4 steri-strips to close the wound. During an interview with UM #1 (on 10/13/16 at 11:40 A.M.), she said that at the time of the fall, the resident's TABS alarm was not on in bed, as planned, and that poor lighting contributed to the fall, as the area was not well lit, as planned. The care plan was updated to include: bed alarm under shoulders, 2 assist for ambulation and TABS alarm in wheelchair. On 10/11/16 at 1:35 P.M., the surveyor observed the resident sitting in her/his wheelchair, across from the Nurse's station. The resident had a tan colored bruise on the temple/forehead area, with a small laceration in the center of the area. The resident was observed standing up, out of the wheelchair, and the TABS alarm string was observed to be excessively long. UM #1 approached the resident and requested she/he sit back down in the wheelchair. On 10/12/16 at 7:35 A.M., the surveyor observed the resident lying in bed, asleep, and the wall vent night light was not lit, as planned. During an interview on 10/12/16 at 4:40 P.M., with CNA (Certified Nursing Assistant) #2, she said the resident requires 2 assist with transfers and ambulation, is unsteady on her/his feet as her/his legs buckle and that the resident's bed alarm should be under the resident's bottom (CNA was unaware that the bed pad alarm was to be placed under the resident's shoulders, per care plan). She further said the resident's room vent night lights, in the wall, were supposed to be on 24 hours a day. During an interview with the Director of Maintenance on 10/13/16 at 12:30 P.M., he said that the vent night lights stay on in the resident's room, at all times (24 hours/7 days a week). During an environmental tour, of the third floor unit, the surveyor and Director of Maintenance observed the vent night lights in the Resident's room were not on/light bulb burnt out. At the end of the tour, the Director of Maintenance said to the surveyor that he would replace the light bulbs within 5 minutes and make sure all the night lights were working. During an interview with UM #1, on 10/13/16 (at 11:40 A.M.), she said the resident was confused, exhibited poor safety awareness, is unsteady on her/his feet, needs assist with ambulation and tires when ambulating. Further discussion was held with UM #1 that the facility failed to provide effective interventions and adequate supervision to prevent continued falls (9 falls in total). 4. For Resident #7, the facility failed to provide effective interventions and adequate supervision in order to provide an effective falls intervention program, for this resident with a history of impaired balance/poor coordination, and unsteady gait. Resident #7, was admitted to the facility in 5/2014, with [DIAGNOSES REDACTED]. Further review of the clinical record indicated that the Resident had [DIAGNOSES REDACTED]. Review of Quarterly MDS (Minimum Data Set) Assessment of 2/4/16 identified the resident as having moderately impaired cognition; moderate difficulty with hearing; had trouble sleeping and was restless; required extensive assistance for transfers and toilet use; required supervision for ambulation with a walker in the room and the corridor; was occasionally incontinent of bowel and bladder; received antipsychotic and antidepressant medications each day during the past 7 days; and had no falls since the last assessment. Review of the current plan of care for falls, originally initiated on (11/21/14), indicated, I am at risk for falls due to impaired balance/poor coordination, unsteady gait and medication side effects. The goal was to minimize risk for injury related to falls. Interventions included: - Administer medications per physicians order, monitor and report adverse effects. - Leave my walker open and at my bedside. - Please make sure I have proper footwear or non-slip socks on at all times. - Provide me with oversite to assistance of one to transfer and ambulate. - Reinforce the need to call for assistance. - Remind me to use my call bell. Review of a Nursing Note and investigation of 2/13/16 indicated that the resident was found sitting on the floor next to the bed at 3:20 P.M. The resident was trying to reach for something low, and fell . The care plan was updated to provide the resident with a reacher. A Fall Risk Assessment completed on 2/13/16 indicated the Resident scored 12, High Risk. (A score of 10 or above is High Risk for Falls per facility policy). Review of a Nursing Note dated 4/2/16 indicated that on 4/1/16 at 9:15 P.M. the resident had an unwitnessed fall at the bedside. The resident was reaching for tissues that dropped on the floor and slid out of the bed onto the floor. Review of the investigation did not mention the reacher given to the resident following the fall of 2/13/16. During discussion with the DON (Director of Nursing) and Unit Manager (UM) #2 on 10/18/16 at 9:00 A.M., they said the resident was not always compliant with using the reacher, but could not indicate if the reacher was available to the resident prior to 4/1/16 fall. On 4/4/16 the plan of care was updated to remind the resident not to pick up items off the floor and call for assist. Review of a Fall Risk Assessment completed on 4/2/16 indicated the resident scored 14, High Risk, an increased risk for falling, compared to the assessment completed on 2/13/16 of (12). Review of a Quarterly MDS Assessment of 5/5/16 identified the resident as having intact cognition; depressed, trouble concentrating; required limited assistance for walking in the corridor, locomotion on the unit, and toilet use; was frequently incontinent of bladder and continent of bowel; received antipsychotic and antidepressant medications each day during the past 7 days; and had two falls since the prior assessment. A Fall Risk Assessment completed on 5/5/16 indicated the Resident scored 16, High Risk. (A score of 10 or above is High Risk for Falls). Review of the Progress Notes indicated the resident had two falls on 6/26/16. The first fall was at 12:00 P.M. The resident's roommate notified the nurse that the resident had fallen. The resident was found on the floor next to the bed. Review of the investigation indicated that the resident stood up to go to the bathroom and fell . The care plan was updated to include a bed alarm. The second fall occurred at 6:00 P.M. Review of the investigation indicated that the resident was confused and went to use the hallway bathroom. The alarm did not sound. CNA (Certified Nursing Assistant) #5, who was in the hallway redirected the resident back to his/her room, (despite needing oversight to assistance of one to transfer and ambulate, and limited assistance for toilet use.) CNA #5, then went into the supply closet, and came out and heard the resident say, I fell . Review of the Nursing Note and the investigation indicated, Resident must be checked on every hour for the next 24 hours and check alarm for no further malfunctions. The surveyor asked to review the hourly checks for the 24 hours on 10/18/16 at 9:00 A.M. On 10/18/16 at 11:20 A.M., the DON indicated that the hourly checks had not been completed. The care plan was updated on 6/27/16 to also include a tabs alarm. Review of a Nursing Note of 6/27/16 indicated the resident was sitting in the Day Room at 5:20 P.M. when the chair alarm sounded and the resident was found on the floor lying on his/her right side. Review of the investigation indicated the resident sustained [REDACTED]. The resident was sent to the hospital for evaluation and returned on 6/28/16 with a pressure dressing and steri strips to close the laceration. A Fall Risk Assessment completed on 6/28/16 indicated the Resident scored 20, High Risk. an increased risk for falling, compared to the assessment completed on 5/5/16 of (16). (A score of 10 or above is High Risk for Falls). Review of a Nursing Note of 7/2/16 indicated that the resident had experienced vomiting after the evening meal. At 8:40 P.M. the resident was found sitting on the floor at the bedside unresponsive. The resident said I feel lousy, when aroused. The tabs and bed alarm were sounding, as planned. The resident was sent to the hospital for an evaluation. The plan of care was updated to include to check the resident every hour, and ensure the tabs and bed alarm are functioning. The resident returned to the facility on [DATE]. During interview (on 10/18/16 at 11:20 A.M.), the DON indicated that the hourly checks had not been completed. Review of a Nursing Note of 7/7/16 indicated that the resident was found sitting on the floor of the bathroom at 1:30 P.M A new intervention for a fall mat to the side of the bed and 15 minute checks. A Fall Risk Assessment completed on 7/7/16 indicated the Resident scored 24, High Risk. an increased risk for falling, compared to the assessment completed on 6/28/16 of (20). (A score of 10 or above is High Risk for Falls). Review of a Quarterly MDS Assessment of 8/5/16 identified the resident as having severely impaired cognition; feeling tired and having little energy; requiring extensive assistance for bed mobility, transfers, ambulation with the walker, and toilet use; utilized a wheelchair for long distances; was occasionally incontinent of bladder; received antipsychotic and antidepressant medications each day during the past 7 days; and had two or more falls since the prior assessment. Review of a Nursing Note of 10/6/16 indicated that the resident was lowered to the floor in the bathroom by a CNA at 10:00 A.M. during care and the resident hit his/her head on the wall. The resident sustained [REDACTED]. Neurological Checks were initiated and were within normal limits. The surveyor observed the resident lying in the bed on 10/13/16 at 2:30 P.M., awake, had fall mats on both sides of the bed, had a bed alarm, however, the tab alarm string and clip were disconnected from the resident and lying on the floor, on the left side of the bed. The reacher was on a high dresser, to the right side of the resident's bed, and not conveniently within the resident's reach as planned. During discussion with the UM #2 on 10/13/16 at 2:50 P.M., in Resident #7's room, UM #2 said that the tab alarm should be on the resident at all times when the resident is in the bed, however, the resident takes it off. UM #2 then reconnected the tabs alarm and left the room. The surveyor observed Resident #7 on 10/18/16 at 8:00 A.M. lying in the bed, receiving medications from Nurse #1, with the tab alarm disconnected. When Nurse #1 completed administering the medications, the surveyor asked the nurse if the tab alarm was on. Nurse #1 checked, and indicated to the surveyor it was not, and that it should always be on when the resident is in the bed, and reconnected the tab alarm. When walking out of the room Nurse #1 stated to the surveyor that the resident frequently takes off the tab alarm. At 8:04 A.M., the surveyor told Nurse #2 a medication pass was going to be conducted with her. Nurse #2 indicated she would be right back and went behind the nursing station. The surveyor stood beside the medication cart to the left of the Nursing Station. Resident #7's room was approximately 8 to 9 feet from the medication cart. The surveyor observed Resident #7 walking with the walker into the bathroom unassisted, despite requiring oversight to assistance of one to transfer and ambulate, and assistance of one for toilet use. The surveyor could not hear any alarm sounding. Nurse #2 returned to the medication cart and the surveyor asked her if she heard an alarm sounding and she indicated no. The surveyor then indicated to the Nurse that Resident #7 had just ambulated with the walker into the bathroom and the Nurse went into the bathroom to assist the resident. Upon entering the resident's room the sound of the bed alarm was audible, however, it was not from the hallway with the call lights sounding (ineffective intervention). When Nurse #2 finished assisting the resident, she indicated the resident must have removed the tab alarm again. (ineffective intervention). During an interview on 10/18/16 at 2:35 P.M., with CNA #3, she said that Resident #7 was a fall risk. We have to watch (him/her). (He/she) has mats by the bed, a bed alarm, and a tabs alarm. (He/she) gets up alone all the time and does not ring the call bell. (He/she) stays in bed all of the time. He/she has fallen in the past and takes the tabs alarm off. During an interview on 10/18/16 at 2:40 P.M., with CNA #4, she said, Have to keep an eye on that one. Keeps television on sometimes and does not like alarms. Gets wiggly and tips over. Surveyor clarified last statement and asked if CNA meant unsteady on his/her feet and CNA indicated yes. Takes tabs alarm off, just got upset with me again today because I kept putting it back on. He/she was yelling at me. If you put it on in a place that's comfortable for (him/her) it's better. During interview with the DON on 10/18/16 at 9:00 A.M. the surveyor indicated the concern for the resident's 8 falls in the past 8 months, including the surveyor observations during the survey duration. The DON nodded her head, Yes when the surveyor indicated the concern for the ineffective fall plan and interventions provided to Resident #7.