Every finding on record at Carleton-Willard Village Retirement & Nursing CTR

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required two staff members assistance with the mechanical sling lift for all transfers, the Facility failed to ensure he/she was free from neglect, when on 06/03/25 Certified Nurse Aide (CNA) #1, although she was aware of facility policy and that Resident #1 required an assist of two staff persons for transfers with a mechanical sling lift, CNA #1 transferred Resident #1 by herself, and he/she fell from lift on to the floor. CNA #1 also did not immediately report the fall to nursing so Resident #1 could be assessed for potential injury prior to being moved, but instead physically picked Resident #1 up off the floor by herself and put him/her back into bed. Once Resident #1 was back in bed, she still did not report the incident to nursing. Over two and a half hours later, Resident #1 was found to be bleeding from a cut on back of his/her head, had bruising on his/her back and left hip area, was complaining of severe back and left shoulder pain, was transferred to the Hospital Emergency Department (ED) and was diagnosed with several fractured ribs, fractured left scapula, several spinal fractures, bilateral subdural bleeds, a head laceration, and other internal injuries. Findings include: The Facility Policy, titled Resident Abuse Prevention Program, dated as revised 10/14/22, indicated: - The Facility would ensure that every resident was free from all forms of abuse, including neglect. -Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services. The term willful meant the individual must have acted deliberately. -Neglect was defined as the failure of the Facility, its employees or service providers to provide services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. This included cases of indifference or disregard for resident care, comfort, or safety that resulted in or could have resulted in physical harm, mental anguish, or emotional distress. Review of the Facility's Incident Investigation Summary, undated, indicated the following: -On the morning of 06/03/25, some time between 07:05 A.M., and 07:20 A.M., Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 from his/her bed to his/her reclining wheelchair via the mechanical sling lift, and during the transfer Resident #1 fell from the sling onto the floor. -CNA #1 did not notify anyone that Resident #1 had fallen, and instead manually picked Resident #1 up from the floor, then placed him/her back in bed. -CNA #1 noticed blood on the back of Resident #1's head but did not report it to any other staff member. Resident #1 was admitted to the Facility in July 2023, diagnoses included Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy. Review of Resident #1's Activities of Daily Living Care Plan, dated as reviewed on 05/14/25, indicated Resident #1 required assistance of two staff members using the mechanical sling lift for all transfers. Review of Resident #1's Nurse Progress Note, dated 06/03/25, indicated that at 07:30 A.M., Nurse #1 heard Resident #1 groaning, he/she said he/she had pain in his/her back, and Nurse #1 administered his/her scheduled pain medication. The Note indicated that when Nurse #1 reassessed Resident #1, around 20 minutes later at 07:50 A.M., he/she was still complaining of back pain, so Nurse #1 applied a hot pack to his/her back. The Note indicated Resident #1 was fed breakfast in bed [by CNA #1], and Nurse #1 returned to his/her room twice during the breakfast meal to assess his/her pain. The Note indicated that at 10:00 A.M., Unit Secretary #1 alerted Nurse #1 that Resident #1 had blood on his/her pillow, and that Unit Manager #1, the Director of Nurses (DON) and Nurse Practitioner (NP #1) were all notified, responded, and NP #1 ordered for Resident #1 to be transferred to the Hospital ED. Review of Resident #1's Emergency Department After Visit Summary, dated 06/03/25, indicated he/she had a witnessed fall from the mechanical sling lift at the Facility, and he/she was diagnosed with the following: -Bilateral subdural fluid collections (a collection of blood between the dura mater (the tough outer layer of the meninges) and the surface of the brain. This condition typically occurs after a head injury and can be life-threatening due to the pressure it exerts on the brain) that measured 3 millimeters (mm) on the right and 5 mm on the left. -Left first and second nondisplaced (bones were broken, but remained in their original position) rib fractures. -Left second, third, fourth, and fifth acute rib fractures including significant displacement and flail segments (a condition that occurs when three or more adjacent ribs are fractured in two or more places, allowing that segment of the thoracic wall to displace and move independently of the rest of the chest wall. In flail chest, a segment of the chest wall separates from the rest and moves in the opposite direction from the rest of the chest wall when a person breathes. This condition can result in damage to the lungs or other organs.) -Left small to moderate pneumothorax (a condition where air or gas accumulates in the pleural space, the area between the lungs and the chest wall. This can cause partial or complete lung collapse, leading to chest pain and shortness of breath.) -Left trace hemothorax (a collection of blood in the pleural cavity, which is the space between the chest wall and the lung. It can be caused by an injury.) -Left scapula (shoulder blade) markedly comminuted (broken into more than two pieces), displaced (out of alignment) fracture, extending to the glenoid (socket part of the shoulder.) -Thoracic (middle spine) second and third transverse process (bony protrusion that extends sideways from each vertebra in the spine) acute nondisplaced fractures. -Lumbar (lower spine) second superior endplate mild to moderate height loss (occurs when the bone in the front (anterior) part of a vertebral body collapses and forms a wedge shape) and 3 millimeter (mm) retropulsion (a retropulsed fragment refers to a piece of the vertebra or intervertebral disc material that has been displaced from the vertebral body backward into the spinal canal.) Review of Resident #1's Nurse Practitioner Note, dated 06/04/25, indicated he/she returned to the Facility the evening of 06/03/25, and his/her skin observation revealed the following: -A superficial open area on the back of his/her head measuring 0.5 centimeters (cm.) -Reddish bruising to the left back, buttock, and left upper back along the lateral edge of the scapula. Review of Certified Nurse Aide (CNA) #1's Written Statement, dated 06/03/25, indicated that on 06/03/25 at 07:30 A.M., she attempted to transfer Resident #1 without assistance from another staff member, using the mechanical sling lift. The Statement indicated that during the transfer, the upper left hook of the sling released from the lift, and Resident #1 fell to the floor. The Statement indicated CNA #1 noticed blood on the back of Resident #1's head, manually lifted him/her up from the floor by herself, put him/her back to bed, and did not notify anyone that Resident #1 had fallen. The Statement indicated CNA #1 then left Resident #1's room, went and provided care for another resident, assisted with passing breakfast trays on the unit, and then went back to Resident #1's room to assist with feeding him/her breakfast. Further review of CNA #1's Written Statement indicated that when Unit Manager #1 later questioned her about the blood found on Resident #1's pillow, she initially denied knowing anything had happened, but later admitted that Resident #1 had fallen. During a telephone interview on 06/10/25 at 08:55 A.M., Certified Nurse Aide (CNA) #1 said she normally worked full time the 03:00 P.M., to 11:00 P.M., shift on the Resident #1's unit, and had picked up the 07:00 A.M. to 03:00 P.M., shift on 06/03/25. CNA #1 said that on 06/03/25 around 7:30 A.M., she attempted to transfer Resident #1 using the mechanical sling lift without assistance from another staff member, and during the transfer the sling released from the lift, and Resident #1 fell around four feet straight down to the floor. CNA #1 said she physically lifted Resident #1 up from the floor by herself and placed him/her back in bed. CNA #1 said she did not think his/her injuries were serious, that she did not report the fall to anyone, and left Resident #1's room, and went to provide care for another resident. CNA #1 said she was aware that it was the facility's policy for two staff members to assist with mechanical sling lift transfers and knew that Resident #1 required two assists for transfers. CNA #1 also said she knew it was important to immediately notify a nurse when a resident fell and before moving the resident, but she did neither of them because she knew she was in trouble. CNA #1 said she was not aware that Resident #1 was bleeding from the back of his/her head, and said she only wrote that in her Written Statement because the Director of Nurses told her to. During an interview on 06/10/25 at 02:58 P.M., CNA #2 said she was the lead CNA for the unit, and on 06/03/25 at 06:40 A.M., she conducted her usual walking rounds on the unit and saw that Resident #1, who was usually washed and dressed by the 11:00 P.M., to 07:00 A.M., shift was in bed and fully dressed. CNA #2 said that between 07:15 A.M., and 07:20 A.M., she noticed Resident #1's bedroom door was slightly open and the mechanical sling lift was in the room. CNA #2 said when she entered the room to offer to help transfer Resident #1, he/she was no longer wearing a shirt, the mechanical lift sling pad was not positioned under him/her and was instead hanging from lift by the two top clips. CNA #2 said CNA #1 was in the bathroom washing something in the sink but she did not see what it was, and said CNA #1 told her that Resident #1's shirt had gotten dirty. CNA #2 said she noticed a few drops of blood on Resident #1's top sheet but thought maybe he/she had a nosebleed, and then left the room, because she thought CNA #1 was not ready to get Resident #1 up out of bed at that time. During an interview on 06/10/25 at 01:06 P.M., Nurse #1 said that on 06/03/25 at 07:00 A.M., she gave CNA #1 report, told her to start her assignment with Resident #1, and to get her when she was ready to transfer him/her, since Resident #1 required two staff members for transfers via the mechanical sling lift. Nurse #1 said she went to Resident #1's room at 07:30 A.M. and could hear Resident #1 groaning even with the door closed. Nurse #1 said she went into Resident #1's room, saw CNA #1 standing next to his/her bed, and Resident #1 was complaining of back pain. Nurse #1 said she told CNA #1 to feed Resident #1 in bed that morning, medicated him/her with his/her scheduled pain medication and applied a warm pack to his/her back. Nurse #1 said she returned to Resident #1's room twice while CNA #1 was feeding him/her breakfast to assess his/her pain. Nurse #1 said CNA #1 did not report that there was any sort of incident or fall that had occurred at all. Nurse #1 said she did not know something had happened to Resident #1 until 10:00 A.M., when Unit Secretary #1 told her there was blood on his/her pillow. Nurse #1 said when she went to check on what Unit Secretary #1 reported, she said there were two pillows with blood on them, that one pillow had an area of blood located on the corner of it that was around five inches wide and four inches long, and the second pillow had an area of blood in the center of it that was around six inches long and four inches wide, surrounded by smaller spots of blood. Nurse #1 described the blood as bright red and fresh. Although Nurse #1 went into Resident #1's room to assess him/her at least three different times (07:30 A.M., at the start of the breakfast meal sometime between 8:00 A.M. -8:30 A.M., and, again at 08:50 A.M.), while CNA #1 was in the room, and despite Nurse #1 assessing Resident #1 for pain, and specifically asking CNA #1 how he/she was doing, CNA #1 never told Nurse #1 about Resident #1's fall out of the mechanical sling lift. CNA #1 never told Nurse #1 that she picked Resident #1 up off the floor and put him/back bed, or reported to Nurse #1 that he/she was bleeding from the back of his/her head. During an interview on 06/10/25 at 12:07 P.M., Family Member #1 said that on 06/03/25 at 09:30 A.M., he was on a video call with Resident #1 when he noticed what appeared to be blood behind his/her head on his/her pillow, and he/she complained of left shoulder pain, which was unusual. Family Member #1 said he called the unit desk and asked Unit Secretary #1 to check on Resident #1. Family Member #1 said Resident #1 had advanced dementia and could not speak up for him/herself. Family Member #1 said he was most disturbed by the fact that CNA #1 had left Resident #1 in bed for well over two hours, in pain, without any care and without letting anyone know what had happened to him/her. During an interview on 06/10/25 at 03:22 P.M., Unit Manager #1 said that on 06/03/25 at 10:00 A.M., Nurse #1 told her that Resident #1 was bleeding, and said she immediately went to assess Resident #1. Unit Manager #1 said there was blood on two pillows, and she and Nurse #1 tried to roll Resident #1 over to assess him/her, but could not because he/she moaned in pain and said, that hurts. Unit Manager #1 said she was able to briefly see the back of Resident #1's head, said it was raw and there was fresh blood in his/her hair. Unit Manager #1 said while she and Nurse #1 were assessing Resident #1, CNA #1 came to the room. Unit Manager #1 said she asked CNA #1 if anything had happened to Resident #1 and said CNA #1 said no, and also denied knowing that Resident #1 had blood on his/her pillow. Unit Manager #1 said there was also blood observed on the floor in Resident #1's room, that CNA #1 was asked if she knew about the blood on the floor, that CNA #1 said she knew about the blood on the floor but had not reported it, and said why would I? Unit Manager #1 said later that day she reviewed CNA #2's written statement that indicated she had seen some blood spots on Resident #1's sheet and of CNA #1 washing something in Resident #1's bathroom sink. Unit Manager #1 said she went to Resident #1's personal laundry hamper and found his/her shirt, which was sopping wet with water and it had a faint blood stain around the upper back and collar areas. During an interview on 06/10/25 at 08:04 A.M., The Director of Nurses (DON) said it was Facility policy that two staff members were required for all mechanical sling lift transfers, and that all resident falls were to be reported to the nurse immediately and before the resident was moved. The DON said CNA #1 did not follow Facility policies, which resulted in Resident #1's injuries and a significant delay in care. The DON said CNA #1 initially denied that anything had happened to Resident #1, but later admitted to the incident, admitted that she knew Resident #1 was bleeding, and that she had not reported it to anyone. The DON said as a result Resident #1 went over two hours without being assessed by nursing, therefore necessary care and treatment was delayed. On 06/10/25, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 06/03/25, The Facility conducted an Ad-Hoc Quality Assurance Performance Improvement meeting, which indicated the Facility Leadership developed an action plan to correct the deficient practice, ensure that residents were free from falls involving the mechanical sling lift devices, and that all resident falls are reported to the nurse immediately. B) 06/03/25, The Assistant Director of Nurses (ADON)/designee educated all licensed staff and CNAs of the Facility policy and the requirement to always have two staff members present for all mechanical sling lift transfers. C) 06/03/25, The ADON/designee educated all licensed staff and CNAs of Facility policy and the requirement not to move a resident following a fall until a nurse has assessed them. D) 06/03/25, The ADON/designee educated all licensed staff and CNAs of Facility policy and the requirement to report all incidents involving residents immediately so a nurse can assess the resident and prevent further injuries. E) 06/05/25, The Inspection Report indicated the mechanical sling lift manufacturing company inspected all the Facility's mechanical sling lift devices and determined they were all in good working order. F) 06/06/25, The Mechanical Lift Sling Inspection attestations, signed by the Unit Managers, indicated the Facility's lift slings were inspected by and found to be intact without tears or fraying straps, and the fasteners were intact without cracks. G) The Staff Educator/designee conducted an audit to determine that all licensed staff and CNAs had a competency completed within the last year on mechanical sling lift transfers. H) 06/09/25, The Service Report indicated the mechanical sling lift manufacturing company conducted annual maintenance on the Facility's mechanical sling lift devices. I) 06/09/25, Department Managers educated all Facility staff that all staff in all departments were required to immediately report any noticed change in a resident condition, falls, anything out of the ordinary such as blood, to the nurse on duty or Unit Manager. J) 06/09/25, The Point of Care Audit Tool indicated Unit Managers conducted observations of staff performance of mechanical sling lift transfers. K) The DON/designee will conduct follow up audits consisting of visual observations of all licensed and CNA staff performances using the mechanical sling lift for transfers, and immediate re-education will be conducted as needed. L) The Unit Managers/designee will conduct weekly observations on all shifts of staff performance of five mechanical sling lift transfers for four weeks, and immediate re-education will be conducted as needed. M) The Facility will continue to monitor compliance at monthly and quarterly Quality Assurance Meetings. N) The Director of Nurses and/or designee are responsible for ongoing compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required two staff member assistance using the mechanical sling lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in significant injuries. On the morning of 06/03/25, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without another staff member present to assist her, and during the transfer the upper left clip of the sling unattached from the lift, and Resident #1 fell around four feet onto the floor. Resident #1 was transferred to the Hospital Emergency Department (ED) and was diagnosed with several fractured ribs, fractured left scapula, several spinal fractures, bilateral subdural bleeds, a head laceration, and other internal injuries. Findings include: The Facility Policy, titled, Transfer Utilizing a Mechanical Lift, dated as revised September 2023, indicated two licensed or certified staff were needed to do a Mechanical Lift transfer, and one of the staff members would have their hands on the resident during the transfer. A mechanical sling lift (often referred to as a Patient Lift or Hoyer Lift) is a device that allows caregivers to safely transfer an individual between a bed, wheelchair, shower chair, or another surface. A sling lift is comprised of a base on casters, a boom, and a cradle that supports the sling. Resident #1 was admitted to the Facility in July 2023, diagnoses included Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy. Review of Resident #1's Activities of Daily Living Care Plan, dated as reviewed on 05/14/25, indicated Resident #1 required assistance of two staff members using the mechanical sling lift for all transfers. The Facility's Incident Investigation Summary, undated, indicated that on the morning of 06/03/25, some time between 07:05 A.M., and 07:20 A.M., Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 from his/her bed to his/her reclining wheelchair via the mechanical sling lift, and during the transfer Resident #1 fell from the sling and onto the floor. Review of Resident #1's Nurse Progress Note, dated 06/03/25, indicated that at 07:30 A.M., Nurse #1 heard Resident #1 groaning, he/she said he/she had pain in his/her back, and Nurse #1 administered his/her scheduled pain medication. The Note indicated that when Nurse #1 reassessed Resident #1, around 20 minutes later at 07:50 A.M., he/she was still complaining of back pain, so Nurse #1 applied a hot pack to his/her back. The Note indicated Resident #1 was fed breakfast in bed [by CNA #1], and Nurse #1 returned to his/her room twice during the breakfast meal to assess his/her pain. The Note indicated that at 10:00 A.M., Unit Secretary #1 alerted Nurse #1 that Resident #1 had blood on his/her pillow, and that Unit Manager #1, the Director of Nurses (DON) and Nurse Practitioner (NP #1) were all notified, responded, and NP #1 ordered for Resident #1 to be transferred to the Hospital ED. Review of Resident #1's Emergency Department After Visit Summary, dated 06/03/25, indicated he/she had a witnessed fall from the mechanical sling lift at the Facility, and he/she was diagnosed with the following: -Bilateral subdural fluid collections (a collection of blood between the dura mater (the tough outer layer of the meninges) and the surface of the brain. This condition typically occurs after a head injury and can be life-threatening due to the pressure it exerts on the brain) that measured 3 millimeters (mm) on the right and 5 mm on the left. -Left first and second nondisplaced (bones were broken, but remained in their original position) rib fractures. -Left second, third, fourth, and fifth acute rib fractures including significant displacement and flail segments (a condition that occurs when three or more adjacent ribs are fractured in two or more places, allowing that segment of the thoracic wall to displace and move independently of the rest of the chest wall. In flail chest, a segment of the chest wall separates from the rest and moves in the opposite direction from the rest of the chest wall when a person breathes. This condition can result in damage to the lungs or other organs.) -Left small to moderate pneumothorax (a condition where air or gas accumulates in the pleural space, the area between the lungs and the chest wall. This can cause partial or complete lung collapse, leading to chest pain and shortness of breath.) -Left trace hemothorax (a collection of blood in the pleural cavity, which is the space between the chest wall and the lung. It can be caused by an injury.) -Left scapula (shoulder blade) markedly comminuted (broken into more than two pieces), displaced (out of alignment) fracture, extending to the glenoid (socket part of the shoulder.) -Thoracic (middle spine) second and third transverse process (bony protrusion that extends sideways from each vertebra in the spine) acute nondisplaced fractures. -Lumbar (lower spine) second superior endplate mild to moderate height loss (occurs when the bone in the front (anterior) part of a vertebral body collapses and forms a wedge shape) and 3 millimeter (mm) retropulsion (a retropulsed fragment refers to a piece of the vertebra or intervertebral disc material that has been displaced from the vertebral body backward into the spinal canal.) Review of Resident #1's Nurse Practitioner Note, dated 06/04/25, indicated he/she returned to the Facility the evening of 06/03/25, and his/her skin observation revealed the following: -A superficial open area on the back of his/her head measuring 0.5 centimeters (cm.) -reddish bruising to the left back, buttock, and left upper back along the lateral edge of the scapula. During a telephone interview on 06/10/25 at 08:55 A.M., (which included a review of her written statement, dated 06/03/25), Certified Nurse Aide (CNA) #1 said she normally worked full time on the 03:00 P.M., to 11:00 P.M., shift on the Resident #1's unit, and had picked up the day (07:00 A.M. to 03:00 P.M.) shift on 06/03/25. CNA #1 said at the time of the incident, she had been working at the facility for around two years, and had received education and training on mechanical sling lift transfers. CNA #1 said that she was familiar with Resident #1, and knew Resident #1 required two staff members assistance for transfers with the mechanical sling lift. CNA #1 also said she knew it was Facility policy that two staff members were required to assist with all mechanical sling lift transfers. CNA #1 said that on 06/03/25 around 07:30 A.M., she attempted to transfer Resident #1 out of bed using the mechanical sling lift without getting assistance from another staff member. CNA #1 said during the transfer the upper left hook on the sling released from the lift and Resident #1, who was still suspended up in the sling around four feet off the floor, fell straight down to the floor. CNA #1 said she never asked another staff member to help her transfer Resident #1, because they were short staffed. However, review of the facility staffing schedule for Resident #1's unit for 6/03/25 during the day shift, indicated there were 33 residents on the unit, nursing staff consisted of the Unit Manager, two licensed nurses, five CNA's and one additional CNA that was on orientation. During an interview on 06/10/25 at 01:06 P.M., Nurse #1 said that on 06/03/25 at 07:00 A.M., she gave CNA #1 report, told her to start her assignment with Resident #1, and to get her when she was ready to transfer him/her. Nurse #1 said she reminded CNA #1 that Resident #1 required two staff members for transfers via the mechanical sling lift. Nurse #1 said CNA #1 never came to get her to assist with Resident #1's transfer out of bed, so she had no idea CNA #1 had tried to transfer Resident #1 by herself and that he/she fallen out of the lift sling. During an interview on 06/10/25 at 02:58 P.M., CNA #2 said she was the lead CNA for Resident #1's unit. CNA #2 said that between 07:15 A.M., and 07:20 A.M., she noticed Resident #1's bedroom door was slightly open and the mechanical sling lift was in the room. CNA #2 said when she entered the room to offer to help CNA #1 with transferring Resident #1, noticed that the mechanical lift sling pad was not positioned under him/her and was instead hanging from lift by the two top clips. CNA #2 said she left the room, because she thought CNA #1 was not ready to get Resident #1 up out of bed at that time. During an interview on 06/10/25 at 03:22 P.M., Unit Manager #1 said that on 06/03/25 at 10:00 A.M., Nurse #1 told her that Resident #1 was bleeding, and said she immediately went to assess Resident #1. Unit Manager #1 said there was blood on two pillows, and she and Nurse #1 tried to roll Resident #1 over to assess him/her, but could not because he/she moaned in pain and said, that hurts. Unit Manager #1 said she was able to briefly see the back of Resident #1's head, said it was raw and there was fresh blood in his/her hair. Unit Manager #1 said while she and Nurse #1 were assessing Resident #1, CNA #1 came to the room. Unit Manager #1 said she asked CNA #1 if anything had happened to Resident #1 and said CNA #1 said No. Unit Manager #1 said CNA #1 was asked if she knew about the blood on Resident #1's floor, that CNA #1 said she knew about the blood on the floor but had not reported it, and said why would I? During an interview on 06/10/25 at 08:04 A.M., The Director of Nurses (DON) said CNA #1 had been working at the facility for two years, and that per her employee file, all of CNA #1's mandatory trainings which included but was not limited to facility policy's, abuse, neglect, provision of ADL care, safety, and mechanical lifts transfers had been completed and were up to date. The DON said CNA #1 should have had another staff member with her for Resident #1's transfer on 06/03/25, but did not, and as a result Resident #1 fell and sustained serious injuries. On 06/10/25, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 06/03/25, The Facility conducted an Ad-Hoc Quality Assurance Performance Improvement meeting, which indicated the Facility Leadership developed an action plan to correct the deficient practice, ensure that residents were free from falls involving the mechanical sling lift devices, and that all resident falls are reported to the nurse immediately. B) 06/03/25, The Assistant Director of Nurses (ADON)/designee educated all licensed staff and CNAs of the Facility policy and the requirement to always have two staff members present for all mechanical sling lift transfers. C) 06/03/25, The ADON/designee educated all licensed staff and CNAs of the Facility policy and the requirement not to move a resident following a fall until a nurse has assessed them. D) 06/03/25, The ADON/designee educated all licensed staff and CNAs of the Facility policy and the requirement to report all incidents involving residents immediately so a nurse can assess the resident and prevent further injuries. E) 06/05/25, The Inspection Report indicated the mechanical sling lift manufacturing company inspected all the Facility's mechanical sling lift devices and determined they were all in good working order. F) 06/06/25, The Mechanical Lift Sling Inspection attestations, signed by the Unit Managers, indicated the Facility's lift slings were inspected by and found to be intact without tears or fraying straps, and the fasteners were intact without cracks. G) The Staff Educator/designee conducted an audit to determine that all licensed staff and CNAs had a competency completed within the last year on mechanical sling lift transfers. H) 06/09/25, The Service Report indicated the mechanical sling lift manufacturing company conducted annual maintenance on the Facility's mechanical sling lift devices. I) 06/09/25, Department Managers educated all Facility staff that all staff in all departments were required to immediately report any noticed change in a resident condition, falls, anything out of the ordinary such as blood, to the nurse on duty or Unit Manager. J) 06/09/25, The Point of Care Audit Tool indicated Unit Managers conducted observations of staff performance of mechanical sling lift transfers. K) The DON/designee will conduct follow up audits consisting of visual observations of all licensed and CNA staff performances using the mechanical sling lift for transfers, and immediate re-education will be conducted as needed. L) The Unit Managers/designee will conduct weekly observations on all shifts of staff performance of five mechanical sling lift transfers for four weeks, and immediate re-education will be conducted as needed. M) The Facility will continue to monitor compliance at monthly and quarterly Quality Assurance Meetings. N) The Director of Nurses and/or designee are responsible for ongoing compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive plan of care interventions indicated that he/she required the assistance of two staff members with the mechanical sling lift for all transfers, the Facility failed to ensure that staff consistently implemented and followed interventions related to transfers per his/her plan of care. On 06/03/25, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without the assistance from any other staff member, during the transfer the left upper clip on the mechanical sling lift became disconnected and Resident #1 fell to the floor. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with several fractured ribs, fractured left scapula, several spinal fractures, bilateral subdural bleeds, a head laceration, and other internal injuries. Findings include: The Facility Policy, titled Baseline and Comprehensive Person-Centered Care, dated as revised 06/01/24, indicated the Facility would develop and implement a comprehensive person-centered plan of care for each resident that included services to maintain or attain their highest practicable, physical, mental, and psychosocial well-being. The Facility Policy, titled, Transfer Utilizing a Mechanical Lift, dated as revised September 2023, indicated two licensed or certified staff were needed to do a Mechanical Lift transfer, and one of the staff members would have their hands on the resident during the transfer. A mechanical sling lift (often referred to as a Patient Lift or Hoyer Lift) is a device that allows caregivers to safely transfer an individual between a bed, wheelchair, shower chair, or another surface. A sling lift is comprised of a base on casters, a boom, and a cradle that supports the sling. Resident #1 was admitted to the Facility in July 2023, diagnoses included Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy. Review of Resident #1's Activities of Daily Living Care Plan, dated as reviewed on 05/14/25, indicated Resident #1 required assistance of two staff members with the use of the mechanical sling lift for all transfers. The Facility's Incident Investigation Summary, undated, indicated that on the morning of 06/03/25, some time between 07:05 A.M., and 07:20 A.M., Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 from his/her bed to his/her reclining wheelchair via the mechanical sling lift, and during the transfer Resident #1 fell from the sling and onto the floor. Review of Resident #1's Nurse Progress Note, dated 06/03/25, indicated Resident #1 was noted to be groaning, said he/she had pain in his/her back, and Nurse Practitioner (NP) #1 ordered for Resident #1 to be transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Emergency Department After Visit Summary, dated 06/03/25, indicated he/she had a witnessed fall from the mechanical sling lift at the Facility, and was diagnosed with the following: -Bilateral subdural fluid collections (a collection of blood between the dura mater (the tough outer layer of the meninges) and the surface of the brain. This condition typically occurs after a head injury and can be life-threatening due to the pressure it exerts on the brain) that measured 3 millimeters (mm) on the right and 5 mm on the left. -Left first and second nondisplaced (bones were broken, but remained in their original position) rib fractures. -Left second, third, fourth, and fifth acute rib fractures including significant displacement and flail segments (a condition that occurs when three or more adjacent ribs are fractured in two or more places, allowing that segment of the thoracic wall to displace and move independently of the rest of the chest wall. In flail chest, a segment of the chest wall separates from the rest and moves in the opposite direction from the rest of the chest wall when a person breathes. This condition can result in damage to the lungs or other organs.) -Left small to moderate pneumothorax (a condition where air or gas accumulates in the pleural space, the area between the lungs and the chest wall. This can cause partial or complete lung collapse, leading to chest pain and shortness of breath.) -Left trace hemothorax (a collection of blood in the pleural cavity, which is the space between the chest wall and the lung. It can be caused by an injury.) -Left scapula (shoulder blade) markedly comminuted (broken into more than two pieces), displaced (out of alignment) fracture, extending to the glenoid (socket part of the shoulder.) -Thoracic (middle spine) second and third transverse process (bony protrusion that extends sideways from each vertebra in the spine) acute nondisplaced fractures. -Lumbar (lower spine) second superior endplate mild to moderate height loss (occurs when the bone in the front (anterior) part of a vertebral body collapses and forms a wedge shape) and 3 millimeter (mm) retropulsion (a retropulsed fragment refers to a piece of the vertebra or intervertebral disc material that has been displaced from the vertebral body backward into the spinal canal.) Review of Resident #1's Nurse Practitioner Note, dated 06/04/25, indicated he/she returned to the Facility the evening of 06/03/25, and his/her skin observation revealed the following: -A superficial open area on the back of his/her head measuring 0.5 centimeters (cm.) -reddish bruising to the left back, buttock, and left upper back along the lateral edge of the scapula. During a telephone interview on 06/10/25 at 08:55 A.M., (which included a review of her written statement, dated 06/03/25), Certified Nurse Aide (CNA) #1 said she normally worked full time on the 03:00 P.M., to 11:00 P.M., shift on the Resident #1's unit, and had picked up the day (07:00 A.M. to 03:00 P.M.) shift on 06/03/25. CNA #1 said at the time of the incident, she had been working at the facility for around two years, and had received education and training on mechanical sling lift transfers, and the need to review resident care plans before providing care. CNA #1 said that she was familiar with Resident #1, and his/her plan of care, and that she knew Resident #1 required two staff members assistance for transfers with the mechanical sling lift. CNA #1 also said she knew it was Facility policy that two staff members were required to assist with all mechanical sling lift transfers. CNA #1 said she never asked another staff member to help her transfer Resident #1. CNA #1 said that on 06/03/25 around 07:30 A.M., she attempted to transfer Resident #1 out of bed using the mechanical sling lift without getting assistance from another staff member. CNA #1 said during the transfer the upper left hook on the sling released from the lift and Resident #1, who was still suspended up in the sling around four feet off the floor, fell straight down to the floor. During an interview on 06/10/25 at 01:06 P.M., Nurse #1 said that on 06/03/25 at 07:00 A.M., she gave CNA #1 report, told her to start her assignment with Resident #1, and to get her when she was ready to transfer him/her. Nurse #1 said she reminded CNA #1 that Resident #1 required two staff members for transfers via the mechanical sling lift. Nurse #1 said CNA #1 never came to get her to assist with Resident #1's transfer out of bed, so she had no idea CNA #1 had tried to transfer Resident #1 by herself and that he/she fallen out of the lift sling. During an interview on 06/10/25 at 02:58 P.M., CNA #2 said she was the lead CNA for the unit, and on 06/03/25 at 06:40 A.M., she conducted her usual walking rounds on the unit and saw that Resident #1, who was usually washed and dressed by the 11:00 P.M., to 07:00 A.M., shift was in bed and fully dressed. CNA #2 said that between 07:15 A.M., and 07:20 A.M., she noticed Resident #1's bedroom door was slightly open and the mechanical sling lift was in the room. CNA #2 said when she entered the room to offer to help CNA #1 with transferring Resident #1, noticed that the mechanical lift sling pad was not positioned under him/her and was instead hanging from lift by the two top clips. CNA #2 said she left the room, because she thought CNA #1 was not ready to get Resident #1 up out of bed at that time. Review of the facility staffing schedule for Resident #1's unit for 6/03/25 during the day shift, indicated there were 33 residents on the unit, nursing staff consisted of the Unit Manager, two licensed nurses, five CNA's and one additional CNA that was on orientation. During an interview on 06/10/25 at 08:04 A.M., The Director of Nurses (DON) said CNA #1 had been working at the facility for two years, and that per her employee file, all of CNA #1's mandatory trainings which included but was not limited to facility policy's, abuse, neglect, provision of ADL care, safety, and mechanical lifts had been completed and were up to date. The DON said CNA #1 should have had another staff member with her for Resident #1's transfer on 06/03/25, but did not, and as a result Resident #1 fell and sustained serious injuries. The Director of Nurses (DON) said all mechanical lift transfers must be conducted with two staff members. On 06/10/25, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 06/03/25, The Facility conducted an Ad-Hoc Quality Assurance Performance Improvement meeting, which indicated the Facility Leadership developed an action plan to correct the deficient practice, ensure that residents were free from falls involving the mechanical sling lift devices, and that all resident falls are reported to the nurse immediately. B) 06/03/25, The Assistant Director of Nurses (ADON)/designee educated all licensed staff and CNAs of the Facility policy and the requirement to always have two staff members present for all mechanical sling lift transfers. C) 06/03/25, The ADON/designee educated all licensed staff and CNAs of the Facility policy and the requirement not to move a resident following a fall until a nurse has assessed them. D) 06/03/25, The ADON/designee educated all licensed staff and CNAs of the Facility policy and the requirement to report all incidents involving residents immediately so a nurse can assess the resident and prevent further injuries. E) 06/05/25, The Inspection Report indicated the mechanical sling lift manufacturing company inspected all the Facility's mechanical sling lift devices and determined they were all in good working order. F) 06/06/25, The Mechanical Lift Sling Inspection attestations, signed by the Unit Managers, indicated the Facility's lift slings were inspected by and found to be intact without tears or fraying straps, and the fasteners were intact without cracks. G) The Staff Educator/designee conducted an audit to determine that all licensed staff and CNAs had a competency completed within the last year on mechanical sling lift transfers. H) 06/09/25, The Service Report indicated the mechanical sling lift manufacturing company conducted annual maintenance on the Facility's mechanical sling lift devices. I) 06/09/25, Department Managers educated all Facility staff that all staff in all departments were required to immediately report any noticed change in a resident condition, falls, anything out of the ordinary such as blood, to the nurse on duty or Unit Manager. J) 06/09/25, The Point of Care Audit Tool indicated Unit Managers conducted observations of staff performance of mechanical sling lift transfers. K) The DON/designee will conduct follow up audits consisting of visual observations of all licensed and CNA staff performances using the mechanical sling lift for transfers, and immediate re-education will be conducted as needed. L) The Unit Managers/designee will conduct weekly observations on all shifts of staff performance of five mechanical sling lift transfers for four weeks, and immediate re-education will be conducted as needed. M) The Facility will continue to monitor compliance at monthly and quarterly Quality Assurance Meetings. N) The Director of Nurses and/or designee are responsible for ongoing compliance.

Based on observations, and interviews, the facility failed to ensure medications were labeled and dated once opened, according to manufacturer's guidelines, in three out of three medication carts. Findings include: Review of the facility policy titled Storage of Medications, dated 4/26/21, indicated the following: It is the policy of [NAME]-[NAME] Village that medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy, of a current order exists. During an observation on 2/6/25 at 8:47 A.M., the following medications were observed in the Ross-[NAME] medication cart low side: -One 887mL (milliliter) bottle of (Pro-Stat) Liquid Protein opened and undated, therefore unable to determine an expiration date. Manufacturer instructions indicate to discard the bottle after 90 days of opening. During an interview on 2/6/25 at 8:55 A.M., Nurse #1 said medications must be dated when opened and should be discarded if undated as unable to determine the expiry date. During an observation on 2/6/25 at 9:05 A.M., the following medications were observed on the Ross-[NAME] medication cart high side: -One bottle of fluticasone nasal spray (nasal spray contain steroid used to treat allergies) 50 mcg (micrograms) open and undated, therefore unable to determine the expiration date. Manufacturer instructions indicate to discard after using 120 sprays. -One bottle of atropine 1% ophthalmic eye drops (used orally for increased secretions) opened and undated, therefore unable to determine an expiration date. Manufacturer instructions indicate to discard 28 days after opening. During an interview on 2/6/25 at 9:20 A.M., Nurse # 2 said medications should have been dated when opened and undated medications need to be removed from medication cart. During an observation on 2/6/25 at 9:22 A.M., the following medications were observed in the [NAME] medication cart low side: -One bottle of brinzolamide suspension 1% (used to treat increased pressure in the eye) opened and undated, therefore unable to determine an expiration date. Manufacturer instructions indicate to discard 28 days after opening. During an interview on 2/6/25 at 9:30 A.M., Nurse #3 said medications should have been dated when opened and undated medications need to be removed from medication cart. During an interview on 2/6/25 at 1:30 P.M., the Director of Nursing (DON) said medications must be dated and labeled appropriately when opened according to the manufacturer's instructions and said expired medications must be removed.

Based on observations, interviews and record review, the facility failed to implement a comprehensive person-centered care plan for one Resident (#72) out of a total sample of 20 residents. Specifically, for Resident #72: a.) the facility failed to ensure covered cups for hot beverages were implemented as directed by the plan of care. b.) the facility failed to ensure staff cut up food as directed by the plan of care. Findings include: Review of the facility policy titled 'Baseline and Comprehensive Person-Centered Care', revised 6/1/24, indicated, but was not limited to the following: - The comprehensive care plan must describe the following: services to attain or maintain the Resident's highest practicable, physical, mental and psychosocial well-being, and any services that would otherwise be required by are not provided due to the Resident's exercise of rights. - The Residents have the right to refuse treatment and the rationale to be stated in the medical records. - Services provided will be in consultation with the Resident and the Resident's representative. Resident #72 was admitted to the facility in January 2025 with diagnoses including glaucoma and macular degeneration, which are both chronic eye diseases that cause vision loss. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #72 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. This MDS also indicated Resident #72's vision was highly impaired wearing glasses and required substantial/maximal assistance with eating. a.) Review of Resident #72's plan of care related to nutrition, dated 1/10/25, indicated: - Resident #72 has an alteration in nutrition due to a significant unplanned weight loss due to poor PO (by mouth) intake. - Resident #72 has impaired vision. - Identify placement of foods entree and long [sic] plate. - Provide lip plate, soup in mugs, covered cup for hot beverage. Review of Resident #72's occupational therapy evaluation, dated 1/3/25, indicated: - Patient is legally blind. Review of Resident #72's Dietitian progress note, dated 1/10/25, indicated: - [Resident] reported tea was too hot -- milk added. - Provide covered cup for hot beverage. Review of Resident #72's occupational therapy progress note, dated 1/21/25, indicated: - Resident was noted to be wearing 'bib' to cover his/her clothes and protect his/her skin from spillage. On 2/5/25 at 9:20 A.M., the surveyor observed Resident #72 eating alone in his/her room with the door closed. There was an uncovered mug of tea next to his/her breakfast tray. The meal slip on the breakfast tray failed to indicate need for covered cup for hot beverages. On 2/5/25 12:22 P.M., the surveyor observed Resident #72 eating alone in his/her room. There was an uncovered mug of tea on his/her lunch tray. The meal slip on the lunch tray failed to indicate need for covered cup for hot beverages. There was tea spilled on the surface of the lunch tray. On 2/6/25 at 9:36 A.M., the surveyor observed Resident #72 eating alone in his/her room. There was an uncovered mug of tea on his/her breakfast tray. The meal slip on the breakfast tray failed to indicate need for covered cup for hot beverages. On 2/6/7 at 12:28 P.M., the surveyor observed Resident #72 eating alone in his/her room with the door closed. There was an uncovered mug of tea on his/her lunch tray. The meal slip on the lunch tray failed to indicate need for covered cup for hot beverages. There was tea spilled on to the surface of the lunch tray. Resident #72 said sometimes he/she spills hot drinks and staff never put covers on the mugs. During an interview on 2/7/25 at 8:32 A.M., the Dietitian said Resident #72 always drinks his/her tea from an uncovered mug. The Dietitian said Resident #72 often spills because of his/her significant visual deficits, but that staff always makes sure the beverages aren't too hot that they would cause burns. The Dietitian was unaware the Resident's care plan indicated provide covered cups for hot beverages but said it should have been implemented if it was in the care plan. During an interview on 2/7/25 at 9:03 A.M., Certified Nurse Assistant (CNA) #2 and CNA #3 said special instructions, such as covered mugs, would be indicated on the meal slip on the tray or communicated to the CNAs by nurse report or on the assignment list. CNA #2 and CNA #3 said they were unaware Resident #72 required covered cups for hot beverages. During an interview on 2/7/25 at 9:08 A.M., Nurse Unit Manager #2 said any interventions on Resident #72's active care plan should be implemented. Nurse Unit Manager #2 was unaware Resident #72 required covered mugs for hot beverages. Nurse Unit Manager #2 observed the uncovered mug on Resident #72's tray and said that it was not a covered cup such as was indicated in his/her care plan. During an interview on 2/7/25 at 10:11 A.M., the Director of Nursing (DON) said any interventions on Resident #72's active care plan should be implemented, including providing a covered cup for hot beverages. b.) Review of Resident #72's plan of care related to nutrition, dated 1/10/25, indicated: - Resident #72 has an alteration in nutrition due to a significant unplanned weight loss due to poor PO (by mouth) intake. - Resident #72 has impaired vision, needs food cut up for him/her. - Identify placement of foods entree and long [sic] plate. - Diet as ordered. - Assess for finger foods as needed. Review of Resident #72's active physician's order, dated 1/3/25, indicated: - Diet Type: Regular; Diet Consistency: Cut-Up. Review of Resident #72's occupational therapy evaluation, dated 1/3/25, indicated: - Patient is legally blind. Review of Resident #72's Dietitian progress note, dated 1/10/25, indicated: - Food cut up because resident cannot see to do it himself/herself. Review of Resident #72's Dietitian progress note, dated 1/23/25, indicated: - Resident #72 is tolerating a regular cut up diet which he/she needs because he/she is not able to see to do it himself/herself. Review of Resident #72's occupational therapy progress note, dated 1/19/25, indicated: - noted mild difficulty with cutting egg. On 2/5/25 at 9:20 A.M., the surveyor observed Resident #72 eating alone in his/her room with the door closed. Resident #72 was using a red built up fork to attempt to eat a runny fried egg. There also were other finger foods on the plate, including an english muffin and bacon. Resident #72 repeatedly attempted to load the fork with the egg and bring the fork to his/her mouth unsuccessfully. The meal slip on the breakfast tray indicated the need for a regular, cut up diet and that a cut-up egg-fried should be on this meal tray. On 2/6/25 at 9:36 A.M., the surveyor observed Resident #72 eating alone in his/her room. There was an uncut over-easy fried egg, with the yolk appearing to be runny. There also were other finger foods on the plate, including an english muffin and bacon. The meal slip on the breakfast tray indicated the need for a regular, cut up diet and that a cut-up egg-fried should be on this meal tray. On 2/6/7 at 12:28 P.M., the surveyor observed Resident #72 eating alone in his/her room with the door closed. There was a sandwich cut in half filled with a filling that appeared to be tuna fish. There was also two large leaves of lettuce and two slices of tomatoes. Resident #72 was holding one triangle slice of bread containing a large mound of tuna fish filling. Resident #72 was mouthing the bread and unsuccessfully attempting to eat the tuna fish filling by licking it. Resident #72 said he/she has trouble eating things when it isn't cut up into smaller pieces. During an interview on 2/7/25 at 8:32 A.M., the Dietitian said Resident #72 had difficulty with his/her meals because of significant visual impairment and requires staff to identify the location of food on the meal tray and cut up food that is not finger foods. The Dietitian said Resident #72 needed his/her food cut up because he/she cannot see the food. The Dietitian said Resident #72's fried egg should have been cut-up, as indicated on the meal-slip. The Dietitian said Resident #72 usually did well with finger foods, but a runny fried egg was not a finger food. During an interview on 2/7/25 at 9:03 A.M., Certified Nurse Assistant (CNA) #2 and CNA #3 said Resident #72 had significant visual deficit and requires staff to identify the location of food on the meal tray. CNA #2 and CNA #3 said runny, fried eggs should be cut up as indicated on the meal slip on the tray. During an interview on 2/7/25 at 9:08 A.M., Nurse Unit Manager #2 said Resident #72 had significant visual deficit and required staff to identify the location of food on the meal tray and to cut up food that was not finger foods. Nurse Unit Manager #2 said runny, fried eggs should be cut up as indicated on the meal slip on the tray. During an interview on 2/7/25 at 10:11 A.M., the Director of Nursing (DON) said the fried egg should have been cut up if indicated on the meal slip and all interventions, such as a cut up diet, should be implemented following the Resident's active plan of care.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated he/she required the use of monitoring devices (bed and chair alarms) to alert staff when he/she attempted to stand or transfer alone, the Facility failed to ensure staff implemented and followed interventions identified in his/her plan of care, when alarms were not consistently used by staff, and he/she experienced two falls less than 24 hours apart, both of which resulted in an injury. After fall on 5/08/24, Resident #1 sustained a head laceration that required six staples to close, and on 5/09/24, Resident #1 fell again, fractured his/her nose and had a large hematoma (bruise) on his/her forehead. Findings include: The Facility Policy, titled Baseline and Comprehensive Person-Centered Care, dated as revised on 06/15/21, indicated nursing staff would implement a plan of care for each resident to provide effective person-centered care. Resident #1 was admitted to the Facility in May 2024, diagnoses included orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down and can cause dizziness, lightheadedness, fainting, and other problems), chronic atrial fibrillation, stroke, macular degeneration, and was legally blind. Review of Resident #1's Fall Risk Assessment, dated 05/02/24, indicated he/she was assessed by nursing as being at high risk for falls. Review of Resident #1's Fall Risk Care Plan, dated 05/02/24, (which was provided by the facility in the Report they submitted to the Department of Public Health via the Health Care Facility Reporting System (HCFRS), dated 05/13/24), indicated that his/her interventions included for staff to equip Resident #1 with a device that monitored rising (clarified during the survey by the Director of Nursing to mean bed and chair alarms). However, despite the Fall Risk Care Plan indicating Resident #1 required alarms, review of Resident #1's medical record, dated 5/02/4 through 5/08/24, indicated there was no nursing or CNA documentation to support any type of monitoring device was in place and being monitored by staff, in an effort to maintain Resident #1's safety. Review of Resident #1's Nurse Progress Note, dated 05/08/24, indicated that at 05:00 P.M., Resident #1 was found on the floor in his/her room, was bleeding from a laceration on the left side of his/her head, and was transferred to the Hospital Emergency Department. Review of Resident #1's Hospital Emergency Department Discharge Summary, dated 05/08/24, indicated he/she was assessed and treated for a 4 centimeter (cm) laceration to the left side of his/her head as a result of a fall at the Facility, and required 6 staples to close the wound. During an interview on 05/29/24 at 12:39 P.M., Certified Nurse Aide (CNA) #1 said that on 05/08/24 at 5:00 P.M., she saw Resident #1 standing alone in his/her room, and witnessed Resident #1 fall. CNA #1 said Resident #1 did not have any alarms in place or sounding at the time. During an interview on 05/29/24 at 03:09 P.M., CNA #4 said that on 05/08/24 she was the CNA assigned to care for Resident #1 on 05/08/24, and at 05:00 P.M., she was called over by CNA #1 because Resident #1 had fallen, and was bleeding. CNA #1 said Resident #1 did not have any alarms in place at that time. During an interview on 05/29/24 at 02:57 P.M., Nurse #1 said that on 05/08/24 at 05:00 P.M., he was told by CNA #4 that Resident #1 had fallen. Nurse #1 said Resident #1 was bleeding from a laceration on the left side of his/her head and was transferred to the Hospital Emergency Department. Nurse#1 said prior to this incident, Resident #1 did not not have bed or chair alarms in place. Nurse #1 said that when Resident #1 returned to the Facility that night at 9:45 P.M., he implemented bed and chair alarms for Resident #1 as a measure to prevent falls. Review of Resident #1's Nurse Progress Note, dated 05/09/24, indicated that he/she had an unwitnessed fall when CNA #1 left him/her (unattended in the bathroom) on the toilet seat to get linen. The Note indicated CNA #1 said she heard a loud bang, and upon returning to Resident #1's room, found him/her lying on the bathroom floor, was bleeding from his/her nose, had swelling to his/her forehead, and was transferred to the Hospital Emergency Department. Review of Resident #1's Hospital emergency room Discharge Summary, dated 05/09/24, indicated he/she was diagnosed with a closed fracture of the nasal bone as a result of a fall at the Facility. During a telephone interview on 05/29/24 at 11:42 A.M., Certified Nurse Aide (CNA) #2 said that on 05/09/24 at 5:40 A.M., she assisted Resident #1 to the bathroom, and left him/her on the toilet while she went to the linen cart, which was located outside Resident #1's room and a few doors down the hall, to get linen. CNA #2 said when she transferred Resident #1 from his/her bed, there was a bed alarm in place and functioning which she disabled in order to help Resident #1 up from the bed. CNA #2 said she should not have left Resident #1 alone in the bathroom without an alarm in place. CNA #2 said after going to get the linens, she heard a loud bang, and upon returning to the Resident #1's room, found him/her on his/her stomach on the bathroom floor and he/she was bleeding from the laceration on the left side of his/her head he/she had gotten from the fall on 05/08/24. CNA #2 said she could not see if Resident #1 was bleeding from his/her nose. During an interview on 05/29/24 at 03:55 P.M., Nurse #4 said she worked the 11:00 P.M., (05/08/24) to 7:00 A.M., (05/09/24) shift. Nurse #4 said it was reported to her during shift report (from Nurse #1) that Resident #1 had fallen, was transferred to the Hospital Emergency Department where he/she was treated for a laceration to the left side of his/her head. Nurse #4 said Nurse #1 shared in report that he had implemented bed and chair alarms for Resident #1 for safety. Nurse #4 said she checked on Resident #1 throughout her shift and the bed alarm was in place and functioning. Nurse #4 said that on 05/09/24 at 5:40 A.M., CNA #2 informed her that Resident #1 was on the floor in the bathroom. Nurse #4 said Resident #1 was found in the bathroom, lying on the floor on his/her stomach with his/her face on the floor, was bleeding from his/her nose and the laceration at the left side of his/her head, and was transferred to the Hospital emergency room . During an interview on 05/29/24 at 9:03 A.M., The Director of Nurses (DON) said staff should implement alarms when they are identified on a resident's care plan, and said residents who have bed and chair alarms implemented should not be left alone without an alarm in place.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, had a fall on 5/08/24 with an injury, was known to be impulsive and whose fall risk interventions included the use of monitoring devices (bed and chair alarms) to alert staff when he/she rose from a sitting or lying position, the Facility failed to ensure he/she was provided with the necessary safety devices and level of staff supervision to maintain his/her safety, when on 05/09/24 Certified Nurse Aide #1 assisted Resident #1 to the toilet, removed his/her alarm and left him/her unattended in the bathroom to go get supplies. Resident #1 fell in the bathroom, struck his/her face on the floor, and as a result, was transferred to the Hospital Emergency Department where he/she was diagnosed with a nasal bone fracture and large forehead hematoma (bruise). Findings include: The Facility Policy, titled Fall Prevention Protocol, dated 11/13/17, indicated staff would provide an environment of safety, prioritize and assist with the prevention of resident falls, and through the use of assessments tools, all residents would be assessed for risks of falling and programs would be initiated as a result of the assessment. The Policy indicated residents that were assessed as being at risk to fall would have interventions initiated as indicated through the assessment and Interdisciplinary Team Plan of Care. The Facility Policy, titled Bed and Chair Alarms, dated 07/14/08, indicated the Facility would use bed and chair alarms to help assure resident safety from falls. The alarms would not replace clinical judgement, and staff would monitor residents closely to avoid fall situations. The Facility Policy, titled Baseline and Comprehensive Person-Centered Care, dated as revised on 06/15/21, indicated nursing staff would implement a plan of care for each resident to provide effective person-centered care. Resident #1 was admitted to the Facility in May 2024, diagnoses included orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down and can cause dizziness, lightheadedness, fainting, and other problems), chronic atrial fibrillation, stroke, macular degeneration, and was legally blind. Review of Resident #1's Fall Risk Assessment, dated 05/02/24, indicated he/she was assessed by nursing as being at high risk for falls. Review of Resident #1's Fall Risk Care Plan, dated 05/02/24, (which was provided by the facility in the Report they submitted to the Department of Public Health via the Health Care Facility Reporting System (HCFRS), dated 05/13/24), indicated that his/her interventions included for staff to equip Resident #1 with a device that monitored rising (clarified during the survey by the Director of Nursing to mean bed and chair alarms). However, despite the Fall Risk Care Plan indicating Resident #1 required alarms, review of Resident #1's medical record, dated 5/02/4 through 5/08/24, indicated there was no nursing or CNA documentation to support any type of monitoring device was in place and being monitored by staff, in an effort to maintain Resident #1's safety. Review of Resident #1's Nurse Progress Note, dated 05/08/24, indicated that at 05:00 P.M., Resident #1 was found on the floor in his/her room, was bleeding from a laceration on the left side of his/her head, and was transferred to the Hospital Emergency Department. During an interview on 05/29/24 at 02:57 P.M., Nurse #1 said that on 05/08/24 at 05:00 P.M., he was told by CNA #4 that Resident #1 had fallen. Nurse #1 said Resident #1 was bleeding from a laceration on the left side of his/her head and was transferred to the Hospital Emergency Department. Nurse#1 said prior to this incident, Resident #1 did not not have bed or chair alarms in place. Nurse #1 said that when Resident #1 returned to the Facility at 9:45 P.M., he implemented bed and chair alarms for Resident #1 as a measure to prevent falls. Review of Resident #1's Hospital Emergency Department Discharge Summary, dated 05/08/24, indicated he/she was assessed and treated for a 4-centimeter (cm) laceration to the left side of his/her head as a result of a fall at the Facility, and required 6 staples to close the wound. During an interview on 05/29/24 at 12:39 P.M., Certified Nurse Aide (CNA) #1 said that on 05/08/24 at 5:00 P.M., she saw Resident #1 standing alone in his/her room, and witnessed Resident #1 fall. CNA #1 said Resident #1 did not have any alarms in place or sounding at the time. During an interview on 05/29/24 at 03:09 P.M., CNA #4 said she was assigned to care for Resident #1 on 05/08/24 during the evening shift (3:00 P.M to 11:00 P.M.), and said Resident #1 did not have any alarms in place at that time. During an interview on 05/29/24 at 03:55 P.M., Nurse #4 said she worked the 11:00 P.M., (05/08/24) to 7:00 A.M., (05/09/24) shift. Nurse #4 said it was reported to her during change of shift report that Resident #1 had fallen, was transferred to the Hospital Emergency Department where he/she was treated for a laceration to the left side of his/her head. Nurse #4 said Nurse #1 had implemented bed and chair alarms for Resident #1 for safety. Nurse #4 said she checked on Resident #1 throughout her shift and the bed alarm was in place and functioning. Nurse #4 said that on 05/09/24 at 5:40 A.M., CNA #2 informed her that Resident #1 was on the floor. Nurse #4 said Resident #1 was found in the bathroom, lying on the floor on his/her stomach with his/her face on the floor and he/she was bleeding from his/her nose and laceration at the left side of his/her head, and was transferred to the Hospital emergency room . Review of Resident #1's Nurse Progress Note, dated 05/09/24, (written by Nurse #4 during the 11:00 P.M. to 7:00 A.M. shift) indicated that at 5:40 A.M., Resident #1 had an unwitnessed fall when CNA #1 left him/her on the toilet seat [and left the bathroom] to get linens. The Note indicated CNA #1 said she heard a loud bang, and upon returning to Resident #1's room, found him/her lying on the bathroom floor, he/she was bleeding from his/her nose, had swelling to his/her forehead, and was transferred to the Hospital Emergency Department. Review of Resident #1's Hospital emergency room Discharge Summary, dated 05/09/24, indicated he/she was diagnosed with a closed fracture of the nasal bone as a result of a fall at the Facility. During a telephone interview on 05/29/24 at 11:42 A.M., Certified Nurse Aide (CNA) #2 said that on 05/09/24 at 5:40 A.M., she assisted Resident #1 to the bathroom, and left him/her on the toilet while she went to the linen cart, which was located outside Resident #1's room and a few doors down the hall, to get linen. CNA #2 said she heard a loud bang, and upon returning to the Resident #1's room, found him/her on his/her stomach on the bathroom floor and he/she was bleeding from the left head laceration he/she had gotten from the fall on 05/08/24. CNA #2 said she could not see if Resident #1 was bleeding from his/her nose. CNA #2 said when she assisted Resident #1 to transfer from his/her bed, there was a bed alarm in place and functioning which she disabled in order to help Resident #1 up from the bed. CNA #2 said she should not have left Resident #1 alone in the bathroom without an alarm in place. During an interview on 05/29/24 at 9:03 A.M., The Director of Nurses (DON) said staff should implement alarms when they are identified on a resident's care plan, and said residents who have bed and chair alarms implemented should not be left alone without an alarm in place.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had a history of having sustained a subdural hematoma (pool of blood between the brain and it;s outer covering), the Facility failed to ensure staff provided quality of care consistent with professional standards of practice, when on 5/19/24 after finding Resident #2 on the floor after an unwitnessed fall, two Certified Nurse Aides (CNAs) picked him/her up off the floor and put him/her in bed before informing and having nursing assess him/her for the potential for injury, and as a result, his/her neurological signs were not measured or documented per facility policy in the event of an unwitnessed fall, by nursing. Findings include: The Facility Policy, titled Actual Fall Protocol, dated as revised on 05/03/18, indicated a fall was defined as a problem characterized by the failure to maintain an appropriate lying or sitting position, resulting in an individual's abrupt, undesired relocation to the ground. The Policy indicated that all falls were to be assessed and treated immediately to provide comfort and prevent further injury, the resident should never be moved until the licensed nurse assesses him/her, and any neurological changes. The Facility Policy, titled Neurological Signs for Suspected Head Injury, dated as revised 03/16/19, indicated neurological signs would be assessed on a resident who had sustained or was suspected to have sustained a head injury. The Policy indicated neurological signs would be assessed every two hours for the first 24 hours, then every shift for 48 hours. Resident #2 was admitted to the Facility in July 2019, diagnoses included sepsis, hypertension, history of subdural hematoma, cognitive impairment, and anxiety. Review of Resident #2's Nurse Progress Note, dated 05/19/24, indicated he/she had a skin tear on his/her elbow. The Progress Note indicated he/she denied falling, but was unable to explain how he/she got the skin tear. During an interview on 05/29/24 at 12:39 P.M., Certified Nurse Aide (CNA) #1 said that on 05/19/24 at 10:20 P.M., she found Resident #2 lying on the floor in his/her room. CNA #1 said she got CNA #5, who was assigned to Resident #2, and they lifted Resident #2 up off the floor and put him/her in bed. CNA #1 said when they removed his/her shirt they discovered the skin tear on his/her left arm. CNA #1 said she stayed with Resident #2 and that CNA #5 went to tell Nurse #3 about the incident, and that she (CNA #1) left the room when CNA #5 returned. Review of CNA #5's Written Witness Statement, dated 05/19/24, indicated Resident #2 was sitting on his/her bed and she noticed he/she had a skin tear on his/her left arm. Review of CNA #5's additional Witness Statement, emailed by CNA #5 to the facility, dated 05/24/24, indicated that on 05/19/24 at 10:20 P.M., CNA #1 told her that Resident #1 was found on the floor in his/her room. The Statement indicated that she (CNA #5) and CNA #1 picked Resident #2 up from the floor and put him/her onto the bed, and when they removed his/her shirt they discovered the skin tear on his/her left arm. The Statement indicated she (CNA #5) reported to Nurse #3 that Resident #2 had a skin tear. However, there was no documentation in either one of CNA #5's statements that indicated she notified Nurse #3 about Resident #2's being found on the floor (after an unwitnessed fall). During a telephone interview on 06/03/24 at 11:34 A.M., Nurse #3 said that on 05/19/24 at 10:30 P.M., Certified Nurse Aide #5 told him that Resident #2 had a new skin tear on his/her left arm. Nurse #3 said when he went to assess Resident #2, he/she was seated on his/her bed and had a skin tear on his/her left elbow that measured 4 centimeters (cm) by 2 cm. Nurse #3 said he asked Resident #2 if he/she fell , and he/she said no. Nurse #3 said he asked CNA #5 if Resident #2 fell , and she said no. Nurse #3 said he did not ask any other staff if they knew what happened to Resident #2 that caused the skin tear, and said he was informed several days later that Resident #2 told Unit Manager #1 that he/she had fallen. During an interview on 05/29/24 at 1:22 P.M., Unit Manager #1 said that on 05/20/24 she read the skin tear report regarding Resident #2's skin tear, and said she did not understand how he/she got the skin tear. Unit Manager #1 said she tried calling Nurse #3, but was unable to reach him. Unit Manager #1 said that on 05/21/24 (two days after the unwitnessed fall) Resident #2 told her that he/she had fallen, and that was how he/she got the skin tear. Unit Manager #1 said CNA #1 and CNA #5 should have told Nurse #3 that Resident #2 was found on the floor (after an unwitnessed fall). Unit Manager #1 said Nurse #3 should have collected statements from staff other than CNA #5's in an effort to learn what had happened to Resident #2. Unit Manager #1 said that due to the delay in nursing staff knowing that Resident #2 had fallen, nursing staff did not initiate neurological signs for Resident #2 following an unwitnessed fall, but should have. During an interview on 05/29/24 at 4:09 P.M., the Director of Nurses (DON) said the Facility's policy is that with any unwitnessed fall, a licensed nurse assesses the resident before he/she is moved, and neurological signs would be initiated immediately after the fall and monitored. The DON said Resident #2 should have been assessed by the nurse before being moved, and neurological signs should have been initiated and monitored immediately following the fall, but were not.

Based on records reviewed and interviews for one of three sampled residents (Resident #3) the Facility failed to ensure they maintained complete and accurate Medical Records when Medication Administration Record documentation was not consistently completed for Resident #3 related to the administration of a diuretic medication during the month of August 2023. Findings Include: Review of the Facility Medication Pass Observation Tool, dated as revised 2018, indicated documentation of medication administration is completed accurately and charted consistently. Resident #3 was admitted to the Facility in February 2022, diagnoses included dementia, atrial fibrillation, atrioventricular block, depression, syncope, congestive heart failure, and osteoarthritis. Review of Resident #3's Physician's Order, dated 08/14/23, indicated he/she was to be administered Lasix 40 milligrams (mg) one tablet by mouth daily. Review of Resident #3's Medication Administration Record (MAR), for August 2023, indicated on 08/15/23 documentation for his/her Lasix 40 mg tablet by mouth daily at 9:00 A.M. had been left blank and was not initialed by a nurse as having had been administered or documented as having been held. Review of Resident #3's Medical Record indicated there was no documentation in a Nurse Progress Note for 08/15/23 to support if his/her Lasix 40 mg had been administered at 9:00 A.M. or if the medication was not administered and a reason why. There was also no documentation to support that Resident #3's Lasix 40 mg had been administered at 2:00 P.M. or if the dose had not been administered and a reason why. Review of Resident #3's Nurse Progress Note, dated 08/16/23, indicated his/her Physician was in and was made aware of missed Lasix dose on Tuesday (8/15/23). During an interview on 09/18/23 at 3:59 P.M., Nurse #6 said when she wrote the Nurse Progress Note on 08/16/23, she had written that Resident #3 missed his/her Lasix dose on Tuesday (8/15/23) because when she received report on 08/16/23, she was told that his/her Lasix had not been signed off on in the MAR as having been administered so she thought that it had not been administered. During an interview on 09/13/23 at 1:22 P.M., Unit Manager #2 said she had been aware that Resident #3's Lasix 40 mg daily had not been signed off on his/her MAR as having had been administered on 08/15/23. Unit Manager #2 said when she saw that Resident #3's Lasix had not been signed off on 08/15/23, she just thought the medication had not been given and said she did not ask the nurse about it. Review of Resident #3's new Physician Order, dated 08/18/23, indicated he/she was to be administered Lasix 40 mg twice daily for three days, 08/18/23, 08/19/23, and 08/20/23, then resume Lasix 40 mg once daily. Further review of Resident #3's MAR, for August 2023, indicated that on 08/19/23, documentation for his/her Lasix 40 mg tablet by mouth twice daily for three days to be administered at 9:00 A.M. and 2:00 P.M. were both been left blank and had not been initialed and signed off by a nurse as having had been administered or held. Unit Manager #2 said she did not know why Resident #3's Lasix was not signed off on at 9:00 A.M. or 2:00 P.M. on 08/19/23 in the MAR. During an interview on 09/14/23 at 11:28 A.M., Nurse #5 said when she worked on the 7:00 A.M. to 3:00 P.M. shift on 08/19/23, she although she could not be certain, she said she recalled there had been a resident who had a new Lasix order and said she would have had no reason not to administer Resident #3's Lasix as ordered on 08/19/23. Nurse #5 said she thought she administered Resident #3's Lasix on 08/19/23 but forgot to sign it off on the MAR that day. During an interview on 09/13/23 at 3:19 P.M. and on 09/18/23 at 9:46 A.M., the Director of Nursing (DON) said she did not know why the Lasix on Resident #3's MAR was not signed off as being administered by nurses and said she expected for nurses to sign off medications when they administer them. The DON said the Facility did not have a Policy regarding documentation of medications in the MAR and said if a medication was not administered for some reason, the nurses were still expected to sign the MAR but put a circle around their initials and then write on the back of the MAR the reason why the medication had not been administered.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure residents were free from significant medications errors when 1) on 08/28/23 Resident #1 was administered medications that were ordered for and were to be administered to another resident and 2) on 08/16/23 Physician's Orders for a diuretic medication were not transcribed onto Resident #3's Medication Administration Record and were therefore not administered as ordered. Findings Include: Review of the Facility Policy titled Medication Administration, dated as revised 12/01/19, indicated all residents are identified using the photograph in the Medication Administration Book. 1) Resident #1 was admitted to the Facility in March 2022, diagnoses included dementia, depression, gout, Vitamin D deficiency, peripheral vascular disease, edema, and osteoarthritis. Review of the Facility Medication Error Report, dated 08/28/23, indicated that at 8:30 A.M. Resident #1 was administered medications ordered for another resident which included the following medications: Evista (helps prevent osteoporosis) 60 mg Lamictal (anti-convulsant) 400 mg Trazodone (antidepressant) 150 mg Seroquel (anti-psychotic) 25 mg Review of Resident #1's Physician's Orders indicated he/she did not have orders for any of these medications. Review of Resident #1's Nurse Progress Note, dated 08/28/23, indicated that approximately fifteen minutes after being administered medications, he/she became somnolent and was moaning. The Note indicated Resident #1's blood pressure was noted to be low, he/she was assisted to bed and oxygen was administered for comfort. The Note indicated a call was placed to his/her Physician and an order was obtained to transfer him/her to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Emergency Department Encounter Note, dated 08/28/23, indicated he/she presented to the Hospital Emergency Department after an accidental ingestion when he/she received another patient's medications at 8:30 A.M. The Note indicated the peak onset for most of the medications accidentally administered to Resident #1 was one to four hours, he/she was monitored for nine to ten hours and then transferred back to the Facility. During an interview on 09/13/23 at 12:14 P.M. and 09/14/23 at 1:15 P.M., Nurse #1 said that on the 7:00 A.M. to 3:00 P.M. shift on 08/28/23, she oriented Nurse #7, an Agency nurse who had never worked on the unit before, to the unit. Nurse #1 said she went through Nurse #7's resident assignment with her to discuss how each resident took their medications. Nurse #1 said she told Nurse #7 that most residents on the unit could not state their names due to dementia and said she showed her the pictures used to identify each resident that were located in the Medication Administration Record (MAR) binder with each resident's medication sheets. Nurse #1 said she told Nurse #7 that Resident #2 should be medicated first. Nurse #1 said before Nurse #7 went down the hall with the medication cart, Certified Nurse Aide (CNA) #1 walked past them in the hall wheeling a resident (later identified as Resident #1) in his/her wheelchair. Nurse #1 said she heard Nurse #7 ask if the resident was Resident #2. Nurse #1 said she told Nurse #7 that the resident with CNA #1 was Resident #1 and said she told Nurse #7 Resident #1's first and last name. Nurse #1 said Nurse #7 then took the medication cart and went down the hall. Nurse #1 said shortly afterwards, she went to the dining room to assist with breakfast and observed Resident #1 at a table in the dining room seated in his/her wheelchair slumped to the side moaning with his/her eyes closed. Nurse #1 said as she called out Resident #1's name a few times, Nurse #7 came over and asked her Resident #1's name and said she told Nurse #7 Resident #1's name and that Nurse #7 then told her she had administered Resident #2's medications to Resident #1. Nurse #1 said she called his/her Physician to obtain an order to transfer him/her to the Hospital Emergency Department for evaluation. Nurse #1 said pictures of both Resident #1 and Resident #2 were in the Medication Administration Record binder with each resident's medication sheets. During an interview on 09/18/23 4:32 P.M., Nurse #7 said she worked for a Staffing Agency and had been going to the Facility for approximately three weeks. Nurse #7 said when she worked the 7:00 A.M. to 3:00 P.M. shift on 08/28/23, it was the first time she had worked on the Dementia Unit. Nurse #7 said the Facility had pictures located in the Medication Administration Record binders to identify residents for medication passes and said there were pictures in the binders on the Dementia Unit. Nurse #7 said after she listened to change of shift report, Nurse #1 told her who to administer medications to first. Nurse #7 said a CNA #1 walked by wheeling a resident (later identified as Resident #1) in a wheelchair and said she asked CNA #1 the resident's name. Nurse #7 said although she thought CNA #1 told her the resident's name, she later learned that CNA #1 gave her own name which was a similar sounding name to the resident that Nurse #1 had suggested she medicate first. Nurse #7 said that after CNA #1 walked by, she thought the resident in the wheelchair was Resident #2 who she was supposed to administer medications to. Nurse #7 said CNA #1 wheeled the resident (Resident #1) down to the dining room and she remained at her medication cart to finish preparing the medications and said she then went to the dining room and administered the medications (which were supposed to be administered to Resident #2) to Resident #1. Nurse #7 said shortly after, she observed the resident (Resident #1) she had just medicated moaning and that another nurse was obtaining vitals signs on the resident. Nurse #7 said she heard the nurse calling out Resident #1's name and said she asked the nurse who the resident was and said the nurse told her Resident #1's name. Nurse #7 said realized she had accidentally given Resident #2's medications to Resident #1. Nurse #7 said prior to administering Resident #2's medications to Resident #1, she had not used the pictures to identify the right resident because she had asked CNA #1 and thought she was told the correct name. During an interview on 09/13/23 at 3:19 P.M., the Director of Nursing (DON) said when she spoke to Nurse #7 about giving Resident #2's medications to Resident #1, she determined that Nurse #7 did not follow the correct protocol for identifying residents prior to medication administration. The DON said Nurse #7 should have looked at the pictures in the Medication Administration Record binder. 2) Resident #3 was admitted to the Facility in February 2022, diagnoses included dementia, atrial fibrillation, atrioventricular block, depression, syncope, congestive heart failure, and osteoarthritis. Review of Resident #3's Nurse Progress Note, dated 08/16/23, indicated he/she presented with shortness of breath with an oxygen saturation level of 84%-88% (normal range is 90-95%) on room air, his/her respiratory rate was twenty-two (normal range is 12-16), and he/she had a dry cough. The Note indicated that two liters of oxygen was administered to Resident #3 via nasal canula. Review of a subsequent Nurse Progress Note, dated 08/16/23, indicated Resident #3's Physician had been in and ordered for him/her to be administered an extra 40 mg of Lasix (a diuretic, used to treat fluid retention) one time now (at 3:00 P.M.). Review of Resident #3's Laboratory Results, dated 08/16/23, indicated his/her pro b-type naturiuretic peptide laboratory blood test (measures level of a protein in blood to detect heart failure) results were reported 6911.0 (average reference range is 0.0-449.0). Review of Resident #3's Physician's Progress Note, dated 08/16/23, indicated he/she was observed to have 2+ left lower extremity edema (a system based on how deep the pits are and how long they last after you press the swollen area, to identify how much fluid is in the tissues). The Note indicated that Resident #3 was noted to have course bibasilar crackles in his/her lungs (crackles hear at bases of lungs caused by the popping open of small airways collapsed by fluid). The Note indicated for Resident #3 to receive Lasix 40 mg twice daily for three days and then resume Lasix 40 mg daily. Review of Resident #3's Physician's Orders, dated 08/16/23, indicated a Physician's order was written as Give(n) Lasix 40 mg by mouth twice daily for three days starting today then resume Lasix 40 mg by mouth daily. Review of the Facility Medication Error Report, dated 08/18/23, indicated that, on 08/16/23, Resident #3's Physician was in to see him/her and ordered to increase his/her Lasix to 40 mg twice daily for three days but that the order had not been transcribed (onto his/her Medication Administration Record), therefore the medication had not been given according to the Physician's orders. Review of the Facility Medication Administration Incident Report Addendum, undated, indicated Resident #3 had received the wrong dosage of Lasix related to a transcription error. Review of Resident #3's MAR, for August 2023, indicated the Physician's Order from 08/16/23 for Lasix 40 mg by mouth twice daily for three days was not transcribed onto his/her MAR or administered as ordered. The MAR indicated although Resident #3 was administered a second dose of Lasix 40 mg on 08/16/23, which had been transcribed as a one time order for 08/16/23, and that he/she had been administered two doses of Lasix 40 mg on 08/18/23 when the transcription error was discovered, he/she was only administered one dose of Lasix 40 mg on 08/17/23 and had not been administered a second 40 mg dose as ordered. During an interview on 09/13/23 at 1:22 P.M., Unit Manager #2 said that on 08/18/23 she noted that Resident #3's Physician's order for Lasix 40 mg twice daily for three days written on 08/16/23 had not been transcribed as ordered, onto his/her MAR. During an interview on 09/18/23 at 4:05 P.M., the Physician said that on 08/16/23 she ordered Lasix 40 mg twice daily for three days, starting that day and then to resume 40 mg daily after that because Resident #3 had experienced hypoxia (low oxygen in body tissues). The Physician said although Resident #3 was administered Lasix 40 mg twice daily on 08/16 and 08/18, nurses also should have administered his/her Lasix 40 mg twice on 08/17/23, however he/she was not administered Lasix twice that day because the orders she wrote on 08/16/23 had not been transcribed by nurses that day as ordered. During an interview on 09/13/23 at 3:19 P.M. and 09/18/23 at 11:34 A.M., the Director of Nursing (DON) said the Facility did not have a Policy related to Medication Order Transcription. The DON said there was a nurse from a Staffing Agency scheduled on 08/16/23 when Resident #3's Physician wrote the new Lasix order. The DON said the nurse got confused because of the way the Physician's Order had been written which was Given Lasix 40 mg by mouth twice daily for three days, starting today, then resume Lasix 40 mg by mouth daily. The DON said when the Nurse Practitioner came in to see Resident #3 on 08/18/23 it was discovered that the Lasix order from 08/16/23 had not been transcribed. The DON said although Resident #3 got an extra one time dose of Lasix on 08/16/23, the nurse did not follow procedure to clarify the Lasix order, if she did not understand it.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a diagnosis of dementia and was cognitively impaired, the Facility failed to ensure care and treatment provided by nursing met professional standards of practice when on 08/28/23, Nurse #7 did not properly identify Resident #1 prior to administering him/her medications and administered another resident's medications to him/her. Findings Include: Review of the Facility Policy titled Medication Administration, dated as revised 12/01/19, indicated it was the Facility Policy that licensed nurses administer medications from a mobile medication cart and use a system which demonstrates both safety and efficiency when administering medications to residents. The Policy indicated all residents are identified using the photograph in the Medication Administration Book. The Policy further indicated each medication is checked three times prior to administration to the resident and that the first check included checking the order and medication card as well as for the right resident. The Policy indicated that the third check also included checking for the right resident and right medication. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in March 2022, diagnoses included dementia, depression, gout, Vitamin D deficiency, peripheral vascular disease, edema, and osteoarthritis. Review of the Facility Medication Error Report, dated 08/28/23, indicated that at 8:30 A.M. Resident #1 was administered medications ordered for another resident (Resident #2's) which included the following medications: Evista (prevents osteoporosis) 60 mg Lamictal (anti-convulsant) 400 mg Trazodone (antidepressant) 150 mg Seroquel (anti-psychotic) 25 mg Review of Resident #1's Nurse Progress Note, dated 08/28/23, indicated that approximately fifteen minutes after being administered medications, he/she became somnolent and was moaning. The Note indicated Resident #1's blood pressure was noted to be low, he/she was assisted to bed and oxygen was administered for comfort. The Note indicated a call was placed to his/her Physician and an order was obtained to transfer him/her to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Emergency Department Encounter Note, dated 08/28/23, indicated he/she presented to the Hospital Emergency Department after an accidental ingestion when he/she received another patient's medications at 8:30 A.M. During an interview on 09/13/23 at 12:14 P.M. and 09/14/23 at 1:15 P.M., Nurse #1 said that on the 7:00 A.M. to 3:00 P.M. shift on 08/28/23, Nurse #7, who worked for a Staffing Agency, worked on the unit for the first time. Nurse #1 said she oriented Nurse #7 to the unit and listened to change of shift report with her. Nurse #1 said she told Nurse #7 that most residents on the unit could not state their names due to dementia and said she showed her the pictures used to identify residents that were located in the Medication Administration Record Binder and said she told Nurse #7 to administer medications to Resident #2 first. Nurse #1 said before Nurse #7 went down the hall with the medication cart, Certified Nurse Aide (CNA) #1 was walking by the nursing station with Resident #1 and said she heard Nurse #7 asked if the resident was Resident #2. Nurse #1 said she told Nurse #7 that the resident with CNA #1 was Resident #1. Nurse #1 said shortly afterwards, she went to the dining room to assist with breakfast and observed Resident #1 at a table in the dining room seated in his/her wheelchair slumped to the side moaning with his/her eyes closed. Nurse #1 said as she called out Resident #1's name a few times, when Nurse #7 came over and asked her who the resident was and said when she told Nurse #7 it was Resident #1. Nurse #1 said Nurse #7 then told her she had administered Resident #2's medications to him/her (Resident #1). Nurse #1 said after Resident #1 was assisted to his/her room and into bed, she called his/her Physician and obtained orders to transfer him/her to the Hospital Emergency Department for evaluation. Nurse #1 said pictures of both Resident #1 and Resident #2 were in the Medication Administration Record (MAR) binder for the residents that Nurse #7 was assigned to. During an interview on 09/18/23 4:32 P.M., Nurse #7 said she worked for a Staffing Agency and had been going to the Facility for approximately three weeks. Nurse #7 said she had worked on other units at the Facility, but when she worked the 7:00 A.M. to 3:00 P.M. shift on 08/28/23, it was the first time she had worked on the Dementia Unit. Nurse #7 said the Facility had pictures located in the Medication Administration Record binders to identify residents for medication passes and said resident pictures had been in the binders on the other units she had previously worked on as well as on the Dementia Unit. Nurse #7 said Nurse #1 told her the name of a resident who she should medicate first that morning. Nurse #7 said as she was preparing medications for the resident, CNA #1 walked down the hall assisting a resident (later identified as Resident #1) in a wheel chair. Nurse #7 said when she asked CNA #1 the resident's name, said she thought the name CNA #1 told her, was the same name as the name of the resident that Nurse #1 had asked her to medicate first. Nurse #7 said CNA #1 brought the resident (Resident #1) down to the dining room, and said after she finished preparing the medications (that were supposed to be administered to Resident #2) she went to the dining room and administered the medications to Resident #1 who she had seen being wheeled to the dining room by CNA #1. Nurse #7 said shortly afterwards, she observed the resident (Resident #1) she had just medicated was moaning and that another nurse was obtaining vitals signs on the resident. Nurse #7 said she heard the nurse calling out Resident #1's name and said she asked the nurse who the resident was and said the nurse told her Resident #1's name. Nurse #7 said realized she had accidentally given Resident #2's medications to Resident #1. Nurse #7 said when she administered Resident #1 the medications that morning, she did not do any further checks to identify if she was giving the right medications to the right resident. Nurse #7 said she did not check the pictures in the Medication Administration Record binder before she administered medications to Resident #1 (which were actually supposed to be for Resident #2). During an interview on 09/13/23 at 3:19 P.M., the Director of Nursing (DON) said Nurse #7 did not correctly identify Resident #1 prior to medication administration and said Nurse #7 should have looked at the pictures in the Medication Administration Record binder, but had not, to identify the right resident before she administered any medications.

Based on observation, policy review and interviews, the facility failed to 1.) ensure staff wore Personal Protective Equipment (PPE) appropriately and 2.) failed to perform hand hygiene when indicated on 2 of 3 Resident care units during a facility wide COVID-19 outbreak. Findings include: Review of the Massachusetts's Department of Public Health (DPH) policy dated 12/23/21 titled Comprehensive Personal Protective Equipment (PPE) Guidance indicated the following: *At this time, when the risk of community transmission of COVID-19 in Massachusetts continues to be increased, HCP should wear eye protection for all patient encounters. *HCP should perform hand hygiene prior to donning and after doffing gloves. During an interview with the Director of Nursing (DON) on 1/11/22 at 7:09 A.M., she said the that the facility was currently in the middle of a COVID-19 outbreak, there was a resident from 1 of the 3 resident units that had tested positive for COVID-19. During an observation on [NAME] Hall unit on 1/11/22 at 8:43 A.M., Certified Nursing Assistant (CNA#1) was in room [ROOM NUMBER] helping set up breakfast for the Resident. CNA #1 was removing the lid from the coffee, pouring sugar into the coffee, moving the utensils so that the Resident could reach them. CNA #1 was wearing her eye protection on her head. During an interview with CNA #1 on 1/11/22 at 8:46 A.M., she said the expectation of the facility is to wear eye protection appropriately while on the Resident unit. During an interview with the DON on 1/11/22 at 12:03 P.M., she said eye protection should be worn at all times on the unit, especially while the facility is in a COVID-19 outbreak. During an observation on Ross-[NAME] Hall unit housing a Resident positive for COVID-19, Housekeeper (HK #1) finished cleaning room [ROOM NUMBER], removed her gloves and did not perform hand hygiene. HK#1 then wrote a note on her clip board, pushed her cart to room [ROOM NUMBER], knocked on the door, went into the room to restock paper towels and returned to her cart. HK #1 then pushed the cart to room [ROOM NUMBER], restocked paper towels in the bathroom, returned to her cart and put on gloves without performing hand hygiene. During an interview with HK#1 on 1/11/22 at 10:18 A.M., she said she has been educated on performing hand hygiene. HK#1 said the expectation is for her to perform hand hygiene before and after wearing gloves. During an interview with the DON on 1/11/22 at 12:04 P.M., she said hand hygiene is expected before and after glove changes.

Based on record review, policy review and interviews, the facility failed to perform weekly Polymerase Chain Reaction (PCR-detects [CONDITION(S)] ribonucleic acid in a cell) testing on 1 unvaccinated staff out of a total of 7 unvaccinated staff members during moderate community transmission levels. Findings include: CMS guidelines titled Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements revised 9/10/21 indicated the following: *Routine testing of unvaccinated staff should be based on the extent of the virus in the community. *Routine testing intervals by county COVID-19 level of community transmission: moderate(yellow), minimum testing frequency of unvaccinated staff: once a week. *Determining Transmission Risk If the two indicators suggest different transmission levels, the higher level is selected Low Moderate Substantial High New cases per 100,000 persons in the past 7 days* <10 10-49.99 50-99.99 >100 Percentage of positive NAATs tests during the past 7 days** <5% 5-7.99% 8-9.99% >10.0% Review of the community transmission levels in Middlesex County indicated the following percentages, for the week of 12/20/21-4/15 %, week of 12/27/21-5.99% and week of 1/3/22- 12.55%. Review of the testing log indicated Diet Tech (DT#1) did not get a PCR test on the week of 12/23/21 to 12/29/21 and 12/30/21 to 1/5/21. The transmission risk was at a moderate level during these two weeks. Review of the staff schedule indicated that the DT #1 worked on 12/23/21, 12/24/21, 12/26/21,12/27/21, 12/29/21, 12/30/21, 12/31/21, 1/1/22, 1/2/22, 1/3/22, 1/4/22 and 1/5/22. During an interview with the Infection Preventionist (IP#1) on 1/11/22 at 2:03 P.M., she said unvaccinated staff are tested daily with a BinaxNOW rapid test (detects specific proteins on the surface of the coronavirus) prior to their shift, they are also tested weekly with a PCR test. IP#1 said DT#1 missed PCR testing during the weeks of 12/23/21 to 12/29/21 and 12/30/21 to 1/5/21, the expectation is for unvaccinated staff to get tested weekly with a PCR test in addition to a daily BinaxNOW rapid test prior to their shift.

Based on observation, record review, interview and policy review, the facility failed to ensure medications were properly secured for 1 Resident (#17) out of 20 sampled residents. Findings include: Review of the Facility's Storage of Medication Policy, undated, indicated the following: -Bed side medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. 1. Resident #17 was admitted to the facility in January 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #17's quarterly Minimum Data Set (MDS) assessment, dated 2/10/21, indicated that Resident #17 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated a severe cognitive impairment. During an observation on 4/23/21 at 11:18 A.M., Resident #17 was sitting in his/her chair with two bottles of refresh lubricant eye drops (used to temporarily relieve symptoms of eye dryness) on the overbed table in front of him/her. Review of Resident #17's medical record indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's medical record revealed a document titled Assessment for self-administration of medication or assessment to leave medication at bedside dated 2/21/21, which indicated the following: -Unable to self-medicate due to cognitive impairment -Do not leave medication at bed side, nurse to store and prepare medications On 4/26/21 at 9:29 A.M., the surveyor observed Resident #17 sitting in his/her recliner chair with 2 bottles of refresh lubricant eye drops on the overbed table in front of him/her. On 4/26/21 at 10:27 A.M., Nurse #5 was interviewed, she said that Resident #17 does not self-administer medications and that the eye drops should not be left in Resident #17's room. Nurse #5 removed the two bottles of refresh lubricant eye drops from Resident #17's room.

Based on observation, record review and interview, the facility failed to identify and accurately assess the use of bed pillows as a possible restraint for 1 Resident (#18) out of a total of 20 sampled residents. Findings include: Resident #18 was admitted to the facility in June 2012 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/23/21 at 8:19 A.M. Resident #18 was resting in bed with four pillows, two on each side of Resident #18's legs, tucked under the fitted sheet. During an observation on 4/26/21 at 6:55 A.M., Resident #18 was resting in bed with four pillows, two on each side of Resident #18's legs, tucked under the fitted sheet. During an interview on 4/26/21 at 7:02 A.M., Nurse #1 said that the Certified Nursing Assistants (CNA's) put the bed pillows under the fitted bed sheet to stop Resident #18 from moving his/her legs out of the bed for safety. When asked by the surveyor what was the purpose behind placing the pillows by Resident #18's legs, Nurse #1 acknowledged the intent was to prevent the resident from getting out of bed. During an interview on 4/26/21 at 9:28 A.M., CNA #1 said that he is assigned to care for Resident #18. CNA #1 said that Resident #18 is a fall risk and that when he/she is in bed, they put the pillows on each side of him/her to keep him/her safe. CNA #1 said that if the pillows were not under the sheet in his/her bed, then Resident #18's legs would go on the floor. CNA #1 also said they use the pillows to keep him/her from falling. Review of the Resident #18's Falls Care Plan on 4/23/21 at 9:30 A.M., dated 2/11/21 indicated the following: Resident is at risk for falls related to: Poor safety awareness and dementia. Approaches: Bilateral upper side-rails in use for positioning (resident does continues to move a lot in bed), non-ambulatory, assess for comfort/pain, Body pillow in bed for comfort/provides a sense of security. The care plan failed to include the use of pillows as an intervention utilized to prevent falls and there were no care plans implemented that identified the pillows as a possible restraint. Review of the Facility's Restraints Policy, dated 1/30/17, indicated the following: Definitions: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the Resident's body that the individual cannot remove that restricts freedom of movement or normal access to one's body. Review of Resident #18's Pre-Restraining Assessment, dated 3/25/21, indicated that the assessment was completed by Unit Manager #1. The assessment tool indicated that the use of body pillows was not a restraint because Resident #18 was not ambulatory. During an interview on 4/26/21 at 9:53 A.M., the Director of Rehab said she could not recall speaking about Resident #18 at a risk meeting or about the use of pillows as a potential restraint. The Director of Rehab said she was not familiar with Resident #18's mobility status. During an interview on 4/26/21 at 11:19 A.M., Unit Manager #1 said she did not consider the use of the pillows as a restraint because Resident #18 was not ambulatory.

Based on observation and interview, the facility failed to follow resident care plans and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. For Resident #67, the facility failed to provide supervision during meals per his/her plan of care. Resident #67 was admitted to the facility in January 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/26/21 at 8:54 A.M., Resident #67 was eating alone in his/her room. Resident #67 attempted to take bites of his/her breakfast meal using a fork, but then resorted to using his/her hands. Review of Resident #67's alteration in mobility and self-care care plan, dated 1/7/21 indicated that he/she requires supervision during meals. Review of Resident #67's Monthly Nursing Summary, dated 3/15/21, indicated he/she requires continual supervision during meals and he/she will not finish a meal without cueing, is easily distracted and easily fatigued. Resident #67's Monthly Nursing Summary dated 4/20/21 was not complete and the section indicating assistance with meals was left blank. Review of Resident #67's Activities of Daily Living flow sheet for April 2021, indicated that Resident #67 required and received supervision for all meals every day for the entire month, despite the surveyors observation of the breakfast meal on 4/26/21. During an observation on 4/27/21 at 8:41 A.M., Resident #67 was served his/her breakfast tray in his/her room by CNA #2 and then left alone. The surveyor then observed Resident #67 taking bites of his/her breakfast alone while in bed in his/her room. During an interview on 4/27/21 at 9:18 A.M., CNA #2 said that Resident #67 does eat meals at times in his/her room alone. 2. For Resident #72, the facility failed to apply a palm protector to his/her left hand as ordered by a physician. Resident #72 was admitted to the faciliy in March 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #72's Minimum Data Set Assessment 4/7/21, indicated that Resident #72 was severely cognitively impaired and had bilateral contractures of the upper extremities and lower extremities. During an observation on 4/23/21 at 9:17 A.M., the surveyor observed Resident #72's two contracted hands, but he/she was wearing a palm protector on just his/her right hand and none on the left hand. During an observation on 4/23/21 at 11:01 A.M., Resident #72 was in an activity wearing a palm protector on his/her right hand and none on the left hand. Review of Resident #72's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Bilateral Palm protectors. Remove for AM/PM care and hygiene. Assess skin each shift. *Schedule: Every day at 7:00 A.M. - 3:00 P.M.; 3:00 P.M. -11:00 P.M.; 11:00 P.M., - 7:00 P.M. Review of the Treatment Administration Record (TAR), on 4/26/21 at 9:30 A.M., indicated that Resident #72 wore bilateral palm protectors each shift, every day for April 2021, including 4/23/21 despite the surveyors observations that he/she was not wearing the left palm protector on 4/23/21. Additionally, there was no evidence in the clinical record or on the TAR that Resident #72 ever refused or did not tolerate wearing both palm protectors. Review of the daily nursing schedule indicated that Nurse #2 was assigned to care for Resident #2 on 4/23/21 and had signed off that Resident #72 was wearing both left and right palm protectors. During an interview on 4/26/21 at 9:14 A.M., Nurse #2 said that she was not sure if Resident #72 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/26/21 8:15 A.M., Resident #72 was being fed his/her breakfast by Nurse #3. Resident #72 was wearing one palm protector on his/her right hand and none on the left. During an interview with Nurse #3 on 4/26/21 at 9:25 A.M., she said that Resident #72 does wear palm protectors for both the right and left hand. Nurse #3 said that CNA's are responsible for applying the palm protectors and she was unsure of when the order specified for Resident #72 to be wearing them.

Based on observations, interview and facility policy review the facility failed to prevent the possible spread of infection, including COVID-19, as evidenced by the failure of a staff member to wear eye protection while in a resident care area in 1 out of 3 units. Findings include: Review of the Centers for Disease Control guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 23, 2021, indicated the following: Health Care Personnel (HCP) working in areas with minimal to no community transmission, should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other personal protective equipment (PPE). In addition, universal use of a well-fitting facemask for source control is recommended for HCP if not otherwise wearing a respirator. Review of the facility policy titled Coronavirus Personal Protective Equipment with a revision date of 4/26/21, indicated the following: *The following PPE guidelines should be adhered to for Residents on Red precautions (not vaccinated, symptomatic or COVID positive: -Use eye protection for all residents -For red precautions wear a N95 mask, face shield or goggles, and gloves while providing direct resident care and when in resident care areas. On 4/26/21, at 8:00 A.M., the surveyor observed Activities Staff #1, without eye protection on, walking down the hall on the [NAME] unit going in and out of resident rooms handing out newspapers. On 4/26/21, at 8:30 A.M., the surveyor observed Activities staff #1, without eye protection on, sitting in front of the computer in the dining room while residents were eating breakfast. On 4/26/21, at 12:02 P.M., the surveyor observed Activities staff #1 without eye protection on, walking through the [NAME] unit onto the elevator. During an interview on 4/26/21, at 1:15 P.M., The surveyor shared her observations of Activities Staff #1 with the Infection Control Nurse. The Infection Control Nurse said that she has spoken to Activities Staff #1 before about wearing his eye protection and that the facility policy is to wear eye protection in resident care areas. Activities Staff #1 was unable to be interviewed as he had left the building. CMS considers CMS and CDC COVID-19 guidance to be a national standard. The facility failed to abide by the standard and transmission-based precautions identified in its own policies and procedures, thus increasing the potential for transmission of COVID-19 in the facility.

Based on observations, interviews and policy review the facility failed to prevent the possible spread of COVID-19 as evidenced by 1) the failure of a staff member to wear eye protection while in a resident care area and 2) the failure of one Certified Nurse's Aide (CNA) to properly dispose of soiled linen, remove her gloves and perform hand hygiene before exiting a resident room and 3) the failure to ensure that a Restorative Aide was wearing her mask as required while in the facility and 4) the failure of staff on the COVID-19 unit to wear Personal Protective Equipment (PPE) appropriately on 2 out of 3 units. Findings include: 1) Review of the Centers for Disease Control guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Dec. 14, 2020, indicated the following: *Health care personnel (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also: Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Review of the facility policy titled Coronavirus Personal Protective Equipment with a revision date of 12/18/20, indicated the following: *Face shields or goggles (eye protection) must be worn at all times in resident care areas. On 12/23/20, at 9:35 A.M., the surveyor observed Activities Assistant #1 sitting on the Caswell Unit in front of the piano. The surveyor then observed Activities Assistant #1 stand up, pick up a guitar and walk towards the(NAME)unit. During this time, the surveyor observed that Activities Assistant #1 was only wearing prescription glasses and did not have proper eye protection on. During an interview on 12/23/20, at 9:55 A.M., Activities Assistant #1 , now wearing goggles, said that when the surveyor saw him earlier sitting at the piano, he had forgotten to put his goggles on. Activities Aide #1 further said that he was aware that he should of had eye protection on while in the resident care area. 2) Review of the Centers for Disease Control guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Dec. 14, 2020, indicated the following: *Hand Hygiene-HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. *Put on clean, non-sterile gloves upon entry into the patient room or care area. *Change gloves if they become torn or heavily contaminated. *Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. Review of the facility policy titled Infection Control Plan for Managing the Spread of [MEDICAL CONDITION] or other Communicable Disease , with a revision date of 12/22/20, indicated the following: *Remove and dispose of gloves after use on a patient. *Perform hand hygiene after glove removal. *Place soiled linen directly into a laundry bag in the patients room or directly outside the room in a linen bag. On 12/23/20, at 9:50 A.M., the surveyor observed CNA #1 walk out of a resident room with gloves on while carrying unbagged dirty linen, she then walked down the hall and opened the lid to the dirty linen cart and placed the linen in the cart, CNA #1 then took her gloves off. During an interview on 12/23/20, at 9:52 A.M., CNA #1 said that the policy was to bag the linen and perform hand hygiene prior to leaving a resident room. She said that if the cart is close by they just place it in the cart. During an interview on 12/23/20, at 10:35 A.M., The Assistant Director of Nursing said that the facility policy was to bag the linen before leaving the room, unless the cart was directly outside, and then perform hand hygiene. 3) Review of the Centers For Disease Control and Prevention document titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Dec. 14, 2020, indicated the following: *HCP should wear a facemask at all times while they are in the healthcare facility, including in break rooms or other spaces where they might encounter co-workers. *Encourage Physical Distancing-Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent [DIAGNOSES REDACTED]-CoV-2 transmission. Review of the facility policy titled COVID-19 and resident Seating in Upper(NAME)Dining Room and Staff Dining, with a revision date of 12/23/20, indicated the following: *All staff will maintain 6 feet or more from each other and residents with their masks off, while eating or drinking. On 12/23/20, at 1:05 P.M., on the(NAME)unit the surveyor observed Restorative Aide #1 without a mask on, eating her lunch at her desk in the Rehabilitation room within 4 feet of a resident who was exercising on a stationary bike. During an interview on 12/23/20, at 1:06 P.M. Restorative Aide #1 said that she thought it was ok to eat at her desk. She further said that she thought she was far enough away from the resident exercising on the bike. During an interview on 12/23/20, at 1:15 P.M., the Assistant Director of Nursing said that facility policy was to have only 1 staff member in each designated staff break area. She further said that restorative Aide #1 should not have been in the Rehabilitation room eating her lunch. 4) Review of the Centers For Disease Control and Prevention document titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Dec. 14, 2020, indicated the following: *Gowns-Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (i.e., washable or cloth) gowns should be laundered after each use. *In general, HCP caring for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should not wear more than one isolation gown at a time. Review of the facility policy titled Infection Control Plan for Managing the Spread of [MEDICAL CONDITION] or other Communicable Disease ,with a revision date of 12/22/20, indicated the following: *Gowns- Wear an isolation gown, if soiling of personal clothes or uniform with a patient's blood or body fluids, including respiratory secretions, is anticipated. Most patient interactions do not necessitate the use of gowns. However, procedures that involve holding the patient close are examples of when a gown may be needed when caring for [MEDICAL CONDITION] patients. *Disposable or cloth gown may be used. *Gowns should be worn only once and then placed in a waste or laundry receptacle. Review of the facility policy titled Infection Control Procedures During Infection Disease Outbreak , with a revision date of 12/18/20, indicated the following: *Care staff should put on a clean gown with each resident and remove between each resident. Change gowns between all residents. On 12/23/20, at 2:32 P.M., on the dedicated COVID-19 Unit, the surveyor observed Nurse #1 and CNA #2 wearing white PPE suits. A call light went off, and the surveyor observed Nurse #1 and CNA #2 each put a gown on over their white PPE suit prior to entering the resident's room to answer the call light. During an interview on 12/23/20, at 2:35 P.M., Nurse #1 and CNA #2 said that prior to entering a room they always don (put on) the gown over their white suit, then remove the gown prior to exiting the resident's room. During a phone interview on 12/23/20, at 3:30 P.M., the Administrator said that she would have to look into why the staff on the COVID-19 Unit are wearing cloth gowns over their white PPE suits when they enter the resident rooms. CMS considers CMS and CDC COVID-19 guidance to be a national standard. The facility failed to abide by the standard and transmission-based precautions identified in its own policies and procedures, thus increasing the potential for transmission of COVID-19 in the facility.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who was dependent on staff members to be fed, normally consumed 100% of his/her meals, the Facility failed to ensure Resident #1 was free from all forms of abuse, including neglect, when on 10/29/20 Certified Nurse Aide (CNA) #1, who said he would feed Resident #1, decided to not feed Resident #1 his/her breakfast and lunchtime meals that day, and disposed of the food items from both meals trays into the trash in the residents' room without notifying another staff member that the resident had not eaten. Findings include: Review of the Facility Policy titled Resident Abuse Prevention Program, dated 11/01/19, indicated that each resident will be free from Abuse, and Abuse can include Neglect. The Policy indicated no abuse or harm of any type will be tolerated. Review of Resident #1's Face Sheet indicated he/she had [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 08/18/20, indicated he/she was unable to speak, rarely or never was able to make himself/herself understood, rarely or never understood others, had severely impaired cognitive skills for daily decision making, and was totally dependent with the assistance of one person for eating. Review of Resident #1's Alteration in Mobility and Self Care Care Plan, dated 12/26/19, indicated he/she was non-verbal, had expressive and receptive [MEDICAL CONDITION], was unable to feed him/herself requiring staff assistance, and had a good appetite. During an interview on 12/08/20 at 01:10 P.M., CNA #2 said on 10/29/20 CNA #1 told her that he was going to feed Resident #1 his/her breakfast and took his/her meal tray. CNA #2 said during breakfast time, she saw CNA #1 exit Resident #1's bedroom holding the meal tray and an opaque trash bag that CNA #1 placed inside the large trash receptacle on the unit. CNA #2 said there appeared to be a red liquid inside the bag CNA #1 held, which resembled the red cranberry juice Resident #1 drank during meals. CNA #2 said she immediately reported to Nurse #1 the allegation that CNA #1 did not feed Resident #1 breakfast and had thrown his/her meal out into a trash bag and put it in the trash receptacle. CNA #2 said Nurse #1 opened the opaque trash bag that was in the trash receptacle, and saw food inside the trash bag. CNA #2 said Nurse #1 immediately instructed CNA #3 to feed Resident #1 cereal and a drink. During an interview on 12/14/20 at 1:50 P.M., Nurse #1 said Resident #1 was nonverbal, was dependent on staff to feed him/her and was known to eat 100% of his/her meals. Nurse #1 said at approximately 9:15 A.M. on 10/29/20, CNA #2 told her it did not appear that Resident #1 had been fed breakfast. Nurse #1 said she went into Resident #1's room and saw that his/her clothing protector was clean. Nurse #1 said she saw that the dishes on Resident #1's meal tray on the meal cart were empty which would have indicated he/she was fed the entire meal. Nurse #1 said CNA #2 told her she saw CNA #1 put the empty tray on the meal tray cart and throw an opaque trash bag that appeared to have food and drink inside, into the trash receptacle. Nurse #1 said she instructed CNA #2 to feed Resident #1 warm cereal and a drink, and said she gave him/her a meal supplement drink in case Resident #1 did not eat breakfast. Nurse #1 said she had intended to speak with CNA #1, however he was on the other side of the Unit and did not see CNA #1 again until lunchtime. During an interview on 12/10/20 at 12:15 P.M., CNA #3 said on 10/29/20 CNA #1 said he would feed Resident #1. CNA #3 said she saw CNA #1 enter Resident #1's room with his/her breakfast tray and and within a few minutes, CNA #1 exited Resident #1's room holding a meal tray with empty dishes, and an opaque trash bag, and that CNA #1 put the trash bag into the trash receptacle. CNA #3 said it was not possible to feed Resident #1 100% of his/her meal and provide mouth care within just a few minutes. CNA #2 said at lunchtime she saw CNA #1 take Resident #1's food tray from the meal cart and enter his/her room. CNA #2 said she entered Resident #1's bedroom, and saw CNA #1 inside Resident #1's bathroom. CNA #2 said she saw CNA #1 scrape food off the plate and scoop yogurt from the container using a spoon into the trash bag. CNA #2 said she left the room, and then observed CNA #1 exit Resident #1's bedroom with the trash bag and place it inside the large trash receptacle. CNA #2 said she immediately reported to Nurse #1 the allegation that CNA #1 did not feed Resident #1 his/her lunch and that she observed CNA #1 disposing of the meal into the trash bag. CNA #3 said during the lunchtime meal, she observed CNA #1 exiting Resident #1's bedroom with the empty meal tray and a trash bag, which CNA #1 then put into the trash receptacle. CNA #3 said she pulled the trash bag out of the trash receptacle, and saw that the bag contained food. CNA #3 said she reported to Nurse #1 the allegation that CNA #1 did not feed Resident #1 his/her lunch, and showed her the trash bag containing the food. CNA #3 said Nurse #1 told her to feed Resident #1 lunch. Nurse #1 said at approximately 12:10 P.M. on 10/29/20, after getting report from CNA #2 and CNA #3, she checked on Resident #1 who appeared clean, as though he/she had not eaten lunch and said the food appeared to have been scraped off his/her dishes. Nurse #1 said CNA #2 told her she saw CNA #1 throwing Resident #1's yogurt out into the trash bag and that CNA #1 had thrown the trash bag full of food into the trash receptacle. Nurse #1 said she then immediately reported the allegation that CNA #1 neglected to feed Resident #1 breakfast and lunch to the Nurse Manager, the Assistant Director of Nurses and to the Director of Nurses. Nurse #1 said the trash bag allegedly containing Resident #1's lunch meal was retained as evidence. Nurse #1 said after reporting the allegation, she asked CNA #1 to tell her how much Resident #1 had eaten of his/her breakfast and lunch meals. Nurse #1 said CNA #1 told her he fed Resident #1 and he/she had eaten 100% of his/her breakfast and lunch meals. During an interview on 12/10/20 at 04:00 P.M., CNA #1 said Resident #1 was unable to communicate his/her needs or feelings. CNA #1 said Resident #1 was dependent on other to feed him/her. CNA #1 said Resident #1 typically ate 50% to 100% of his/her meals. CNA #1 said he was assigned to care for Resident #1 and it was his responsibility to feed him/her. CNA #1 said on 10/29/20, during the breakfast and lunch time meals, he entered Resident #1's room with his/her meal trays, said he remained in Resident #1's room for approximately 10 minutes each time and scraped all the contents of Resident #1's meals (pureed diet), including the drinks and food from the dishes on the meal trays into the trash can in Resident #1's bathroom. CNA #1 said he placed the empty meal trays after breakfast and lunch onto the meal truck and said he threw out the trash bag into the trash receptacle on the Unit. CNA #1 said he only assisted Resident #1 to drink some fluids at lunch time. CNA #1 said he did not inform any of the other staff members that Resident #1 was not fed his/her breakfast or lunch time meal. CNA #1 said he did not inform anyone that Resident #1 had not been fed and no one questioned him until after lunch time. CNA #1 said he reported to nursing that Resident #1 was fed and ate 100% of his/her breakfast and lunch meals, when in fact he/she did not. CNA #1 said he did not know if Resident #1 ate a snack, was provided another meal or a meal supplement drink. CNA #1 said while he was in Resident #1's room during breakfast and lunch, he contemplated about whether or not he wanted to take the time to feed him/her. CNA #1 said he did not talk to anyone about his feelings, said he was stressed out, and had no other reason or excuse to deny Resident #1 food. Resident #1 was unable to be interviewed by the Surveyor due to severe cognitive impairment. A reasonable person with intact cognitive functioning that was dependent on a staff member for nutritional sustenance, would have experienced emotional harm as a result of CNA #1 delivering the meals into Resident #1's bedroom, intentionally withholding food, and disposing the meals into a trash bag. During an interview on 12/08/20 at 09:15 A.M., the Director of Nurses (DON) said CNA #1 admitted to not feeding Resident #1 breakfast and lunch.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure staff implemented and followed their Abuse Policy, when Nurse #1 did not immediately report an allegation of neglect, as required, when on 10/29/20, it was reported to her that Certified Nurse Aide (CNA) #1 did not feed Resident #1 his/her breakfast meal and had disposed of his/her food in the trash, until a second allegation was reported to her that CNA #1 again, did not feed Resident #1 his/her lunch, and was witnessed by staff disposing the meal into a trash bag. Findings include: Review of the Policy titled Investigation of Complaint of Resident Abuse, Mistreatment, Neglect or Injury of Unknown Origin of Resident, or Misappropriation of Their Property, dated 02/28/20, indicated when neglect of a resident is observed, reported to, or suspected by any employee, immediate action is required. The Policy indicated the employee will notify the immediate nursing supervisor, who will immediately notify the Administrator and Director of Nursing Services. Review of Resident #1's Face Sheet indicated he/she had [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 08/18/20, indicated he/she was unable to speak, rarely or never was able to make himself/herself understood, rarely or never understood others, had severely impaired cognitive skills for daily decision making, and was totally dependent with the assistance of one person for eating. During an interview on 12/08/20 at 01:10 P.M., CNA #2 said on 10/29/20 CNA #1 told her that he was going to feed Resident #1 his/her breakfast and took his/her meal tray. CNA #2 said during breakfast time, she saw CNA #1 exit Resident #1's bedroom holding the meal tray and an opaque trash bag that he then placed inside the large trash receptacle on the unit. CNA #2 said there appeared to be a red liquid inside the bag CNA #1 was holding which resembled the red cranberry juice Resident #1 drank during meals. CNA #2 said she immediately reported to Nurse #1 the allegation that CNA #1 did not feed Resident #1 breakfast and that she believed CNA #1 threw the meal out into a trash bag into the trash receptacle. CNA #2 said Nurse #1 opened the trash bag CNA #1 had thrown into trash receptacle, and saw food inside the trash bag. During an interview on 12/14/20 at 01:50 P.M., Nurse #1 said Resident #1 was nonverbal, was dependent on staff to fed him/her and was known to eat 100% of his/her meals. Nurse #1 said at approximately 9:15 A.M. on 10/29/20, CNA #2 told her it did not appear that Resident #1 was fed breakfast. Nurse #1 said she went into Resident #1's room saw that his/her clothing protector was clean, and it did not look like he/she had eaten. Nurse #1 said she saw that the dishes on Resident #1's meal tray on the meal cart were empty which would have indicated he/she was fed the entire meal. Nurse #1 said CNA #2 told her she saw CNA #1 put the empty tray on the meal tray cart and throw a trash bag, appearing to have food and drink inside, into the trash receptacle. Nurse #1 said she instructed CNA #2 to feed Resident #1 warm cereal and a drink, and said she also gave Resident #1 a meal supplement drink in case Resident #1 did not eat breakfast. CNA #2 said at lunchtime she saw CNA #1 take Resident #1's food tray from the meal cart and enter his/her bedroom. CNA #2 said she entered Resident #1's bedroom, and saw CNA #1 inside his/her bathroom. CNA #2 said she saw CNA #1 scrap food off the plate and scoop yogurt from the container using a spoon into the trash can bag. CNA #2 said she left the bedroom, observed CNA #1 exit Resident #1's bedroom with the trash bag and place it inside the large trash receptacle. CNA #2 said she immediately reported to Nurse #1 the allegation that CNA #1 did not feed Resident #1 his/her lunch and was observed disposing the meal into the trash bag. During an interview on 12/10/20 at 12:15 P.M., CNA #3 said on 10/29/20 CNA #1 told her that he would feed Resident #1. CNA #3 said she saw CNA #1 enter Resident #1's room with the meal tray, and that a few minutes later, she saw CNA #1 exit Resident #1's room holding a meal tray with empty dishes, and a trash bag that CNA #1 then put into the trash receptacle. CNA #3 said it was not possible to feed Resident #1 100% of his/her meal and provide mouth care within the few minutes. CNA #3 said she and CNA #2 reported to Nurse #1 the allegation that CNA #1 did not feed Resident #1 his/her breakfast meal. CNA #3 said Nurse #1 told them she would observe CNA #1's actions at lunchtime. CNA #3 said during the lunchtime meal, she observed CNA #1 exiting Resident #1's bedroom with the meal tray and a trash bag, which he/she put into the trash receptacle. CNA #3 said she pulled out the trash bag out of the trash receptacle, and saw that the bag contained food. CNA #3 said she reported to Nurse #1 the allegation that CNA #1 did not feed Resident #1 his/her lunch, and showed her the trash bag containing the food. CNA #3 said after speaking to Nurse #1, she fed Resident #1 lunch. Nurse #1 said she had intended to speak with CNA #1 after the allegation about not feeding Resident #1 breakfast was reported to her, but said he was on the other side of the Unit and said she did not see CNA #1 until lunchtime. Nurse #1 said she did not look at the trash bag allegedly containing Resident #1's breakfast meal. Nurse #1 said she did not immediately report CNA #2's allegation to the Administrator or Director of Nurses that CNA #1 neglected to feed Resident #1 his/her breakfast meal. Nurse #1 said at approximately 12:10 P.M. on 10/29/20, after getting report from CNA #2 and CNA #3, she checked on Resident #1 who appeared clean, as though he/she had not eaten lunch and said the food appeared to have been scraped off his/her dishes. Nurse #1 said CNA #2 told her she saw CNA #1 throwing Resident #1's yogurt out into the trash bag and that CNA #1 had thrown the trash bag full of food into the trash receptacle. Nurse #1 said she then immediately reported the allegation of neglect to the Unit Manager, the Assistant Director of Nurses and to the Director of Nurses. During an interview on 12/08/20 at 09:15 A.M., the Director of Nurses (DON) said the allegation that CNA #1 neglected to feed Resident #1 breakfast and had disposed of the food on his/her meal tray in the trash, was not reported to her until approximately 12:30 P.M. on 10/29/20, when she was also told of the allegation that CNA #1 had not fed and thrown out Resident #1's lunchtime meal.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members at all times for repositioning, the facility failed to ensure staff followed the plan of care and as a result Resident #1 sustained a fracture to his/her right upper arm on 7/20/17 at 1:10 P.M. while being repositioned by Certified Nurse Aide (CNA) #1 alone. Findings include: The Facility's Policy titled, Positioning a Resident in Bed, dated 9/19/16, indicated the following; Refer to CNA flow sheet for resident's current status and number of staff assistance required. The Policy indicated the staff will maintain residents' proper body alignment to prevent musculoskeletal system deformities. The Plan of Care, dated 12/17/15, indicated two staff members at all times when meeting the needs of Resident #1. The Licensed Nursing Summary, dated 6/30/17, indicated Resident #1 required the assistance of two staff members with positioning secondary to Resident #1 unable to position self, fatigues easily, combative, generalized weakness, unable to follow directions and needing special attention for positioning. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1's Mental Status was severely impaired. The MDS indicated Resident #1 was totally dependent on the physical assistance of two staff members for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). A Nurse's note dated 7/02/17, for the 7:00 A.M. to 3:00 P.M. shift, indicated CNA #1 attempted to roll Resident #1 onto his/her left side, did not realize his/her right hand was positioned in the opening of the bed side rail and heard a noise from Resident #1's arm during the attempted roll. The Nurse's note indicated Resident #1 verbalized It hurts, or words to that effect. The Nurse's note indicated Resident #1 was assessed and noted to have swelling of the right bicep with spasms radiating down his/her hand. The Nurse's note indicated Resident #1 was transferred to the hospital at 2:10 P.M., for evaluation. The hospital History and Physical, dated 7/02/17, indicated Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed Nurse #1 at 5:01 P.M. on 8/18/17. Nurse #1 said CNA #1 said to him Come quick, or words to that effect to Resident #1's room. Nurse #1 said when he entered the room he could see Resident #1's right bicep was swollen with spasms in his/her right arm. Nurse #1 said Resident #1's right arm was not in a proper alignment and Resident #1 said It hurt's, or words to that effect. Nurse #1 said he gave CNA #1 a verbal report at the start of the shift and was made aware that Resident #1 required the assistance of two staff members with positioning and care. The Surveyor interviewed CNA #1 at 4:25 P.M. on 08/21/17. CNA #1 said he was assigned to provide care to Resident #1 on 7/02/17. CNA #1 said Resident #1's Plan of Care indicated he/she required the assistance of two staff members with care and positioning. CNA #1 said he had noticed Resident #1's right arm was in the bed side rail. CNA #1 said he tried to pull his/her hand off the bed side rail and then moved Resident #1. CNA #1 said it happened so quickly and Resident #1 was combative trying to hit him with his/her left hand. CNA #1 said he heard a popping sound after he had moved Resident #1. The Surveyor interviewed the Nurse Manager at 2:19 P.M. on 8/18/17. The Nurse Manager said she has spoken to CNA #1 at least once in the past in regards to following the Plan of Care when Residents' required the assistance of two staff members with care and positioning. The Nurse Manager said CNA #1 was educated on the importance of receiving a verbal report from the the residents' primary Nurse, reviewing the CNA Assignment worksheet (indicates residents' safety and transfer status) and reading the communication book (any new changes) at the start of every shift. On 8/18/17 and 08/22/17, the Facility provided the Surveyor with a plan of correction which addressed the concern as evidence by: A) The Facility terminated CNA #1 on 7/03/17. B) Resident #1 returned to the facility on [DATE]. C) The Facility provided the Surveyor with documentation, dated 7/03/17, 7/04/17 and 7/05/17, that indicated licensed staff were re-educated by the Nursing Supervisor/staff educator on the following topics; Residents' Plan of Care, CNA's must check worksheets daily and the importance of staff to follow Resident 's Plan of Care (ie. eating, care and transfers). The documentation indicated the objective was all Residents' are receiving appropriate care. D) The Facility initiated Quality Improvement and Performance Project (PIP) on 7/05/17. PIP was initiated according to Facility to assure Residents' individual plans of care were being followed and to review if any system change needed to be implemented. E) The Facility provided the Surveyor with Care Observation Sheets, dated 7/05/17 through 8/11/18, which the Facility indicated that observations are being done twice weekly, one during the week, one on the weekend on a different shift and conducted by the Assistant Director of Nursing and/or Supervisory staff. The Director of Nursing (DON) said direct care observations include positioning, transfers, incontinent care, customary routine and nap schedules have been performed twice a week since 7/05/17 and all staff observed this far, were following the Plan of Care which required the assistance of two staff members with care. F) The DON will continue to oversee the direct care observation and it will continue at least until the end of this year, and then the process will be re-assessed. G) The DON conducted a mandatory in service for all licensed nurses on 7/12/17 and 7/13/17, related to Quality Assurance Performance Improvement (QAPI) process and communication of the Plan of Care, following the Plan of Care including assist level for all aspects of care, and explanation of supervisory staff conducting observations on adherence to Plan of Care. H) The Surveyor interviewed CNA #4 at 9:57 A.M. on 8/18/17. CNA #4 said at the start of shift she receives an updated CNA assignment, receives a verbal report from the Nurse and needs to review the communication binder located at the Nurse's desk (CNA #4 was currently reviewing the binder when this Surveyor approached her) which will describe the Residents' Plan of Care. CNA #4 said they need to sign each page after reading the information in the Communication book on all of the Residents' at start of shift. CNA #4 said this is how we know how to safely take care of our Residents'.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members at all times for repositioning, the facility failed to maintain his/her safety, failed to ensure two staff members repositioned Resident #1 and as a result he/she sustained a fractured right upper arm on 7/20/17 at 1:10 P.M. while being repositioned by Certified Nurses Aide (CNA) #1 alone. Findings include: The Facility's Policy titled, Positioning a Resident in Bed, dated 9/19/16, indicated the following; Refer to CNA flow sheet for Resident's current status and number of staff assistance required. The Policy indicated the staff will maintain Residents' proper body alignment to prevent musculoskeletal system deformities. The Plan of Care, dated 12/17/15, indicated two staff members at all times when meeting the needs of Resident #1. The Licensed Nursing Summary, dated 6/30/17, indicated Resident #1 required an assist of two staff members with positioning secondary to Resident #1 unable to position self, fatigues easily, combative, generalized weakness, unable to follow directions and needing special attention for positioning. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1's Mental Status was severely impaired. The MDS indicated Resident #1 was totally dependent on the physical assistance of two staff members for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). A Nurse's note dated 7/02/17, for the 7:00 A.M. to 3:00 P.M. shift, indicated CNA #1 attempted to roll onto Resident #1 to his/her left side, did not realize his/her right hand was positioned in the opening of the bed side rail and heard a noise from Resident #1's arm during the attempted roll. The Nurse's note indicated Resident #1 verbalized It hurts, or words to that effect. The Nurse's note indicated Resident #1 was assessed and noted to have swelling of the right bicep with spasms radiating down his/her hand. The Nurse's note indicated Resident #1 was transferred to the hospital at 2:10 P.M. The hospital History and Physical, dated 7/02/17, indicated Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed CNA #1 at 4:25 P.M. on 8/21/17. CNA #1 said he was assigned to provide care to Resident #1 on 7/02/17. CNA #1 said Resident #1's Plan of Care indicated he/she required the assistance of two staff members with care and positioning. CNA #1 said repositioned Resident #1 by himself, said he heard a popping sound after he had moved Resident #1, and reported it to Nurse #1. The Surveyor interviewed Nurse #1 at 5:01 P.M. on 8/18/17. Nurse #1 said he gave CNA #1 a verbal report at the start of the shift and was made aware that Resident #1 required the assistance of two staff members with positioning and care. Nurse #1 said CNA #1 said to him Come quick, or words to that effect to Resident #1's room. Nurse #1 said when he entered the room he could see Resident #1's right bicep was swollen with spasms in his/her right arm. Nurse #1 said Resident #1's right arm was not in a proper alignment and Resident #1 said It hurt's, or words to that effect. A Risk Management Meeting Report, dated 7/03/17, indicated Resident #1's Care Plan and CNA Assignment indicated he/she required an assist of two staff members with bed mobility. The Report indicated CNA #1 provided care independently when positioning Resident #1. On 8/18/17 and 8/22/17, the Facility provided the Surveyor with a plan of correction which addressed the concern as evidence by: A) The Facility terminated CNA #1 on 7/03/17. B) Resident #1 returned to the facility on [DATE]. C) The Facility provided the Surveyor with documentation, dated 7/03/17, 7/04/17 and 7/05/17, that indicated licensed staff were re-educated by the Nursing Supervisor/staff educator on the following topics; Residents' Plan of Care, CNA's must check worksheets daily and the importance of staff to follow Resident 's Plan of Care (ie. eating, care and transfers). The documentation indicated the objective was all Residents' are receiving appropriate care. D) The Facility initiated Quality Improvement and Performance Project (PIP) on 7/05/17. PIP was initiated according to Facility to assure Residents' individual plans of care were being followed and to review if any system change needed to be implemented. E) The Facility provided the Surveyor with Care Observation Sheets, dated 7/05/17 through 8/11/18, which the Facility indicated that observations are being done twice weekly, one during the week, one on the weekend on a different shift and conducted by the Assistant Director of Nursing and/or Supervisory staff. The Director of Nursing (DON) said direct care observations include positioning, transfers, incontinent care, customary routine and nap schedules have been performed twice a week since 7/05/17 and all staff observed this far, were following the Plan of Care which included residents' observed required the assistance of two staff assistance with care. F) The DON will continue to oversee the direct care observation and it will continue at least until the end of this year, and then the process will be re-assessed. G) The DON conducted a mandatory in service for all licensed nurses on 7/12/17 and 7/13/17, related to Quality Assurance Performance Improvement (QAPI) process and communication of the Plan of Care, following the Plan of Care including assist level for all aspects of care, and explanation of supervisory staff conducting observations on adherence to Plan of Care. H) The Surveyor interviewed CNA #4 at 9:57 A.M. on 8/18/17. CNA #4 said at the start of shift she receives an updated CNA assignment, receives a verbal report from the Nurse and needs to review the communication binder located at the Nurse's desk (CNA #4 was currently reviewing the binder when this Surveyor approached her) which will describe the Residents' Plan of Care. CNA #4 said they need to sign each page after reading the information in the Communication book on all of the Residents' at start of shift. CNA #4 said this is how we know how to safely take care of our Residents'.