Every finding on record at Carlyle House

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), whose comprehensive plan of care indicated he/she required two staff member assistance with use of the Hoyer (mechanical) lift for all transfers, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions, when on 12/30/25 Certified Nurse Aide (CNA) #1 transferred him/her without the assistance of another staff member, and Resident #1 sustained injuries including a right head laceration, and multiple fractures during the transfer.Findings include:The Facility Policy, titled Resident Assessment, dated 09/01/20, indicated an individualized interdisciplinary plan of care, treatment and services would be developed by the interdisciplinary team that identified the plan for care treatment, and services to be provided.The Facility Policy, titled Mechanical Lifts dated 02/26/09, indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift.A Hoyer (mechanical) 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 October 2019, diagnoses included osteoporosis, dementia, and adult failure to thrive.Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her quarterly Minimum Data Set (MDS) Assessment, dated 12/10/25, indicated he/she required full mechanical lift transfers with a two person assist (date initiated 01/04/23).Review of Resident #1's electronic resident care Kardex (reference document used by staff detailing key resident information, including transfer status), indicated he/she required two staff member assistance using the Hoyer Lift for all transfers.Review of the Nurse Progress Note, dated 12/30/25, indicated that at 06:00 P.M., Resident #1 was bleeding from his/her right temple area as a result of the Hoyer lift having struck his/her head during a transfer, and Resident #1 was transferred to the Hospital Emergency Department.Review of the Facility's Unusual Event Report, dated 12/31/25, indicated that on 12/30/25 at 06:00 P.M., Resident #1 sustained a laceration to the right side of his/her head as the result of an improper Hoyer Lift transfer, and was transferred to the Hospital Emergency Department as a result.Review of the Hospital Emergency Department admission History and Physical, dated 12/31/25, indicated Resident #1 was diagnosed with the following:-A hematoma (a localized collection of blood outside of blood vessels, usually caused by injury to the vessel wall, resulting in blood pooling within tissues) and ulceration on his/her right lateral temple area, which was wide and unable to be approximated and sutured.-Minimally displaced proximal and distal left clavicular (slender S-shaped long bone that connects the arm to the body's axial skeleton) fractures.-Acute fracture of the left superior and inferior pubic ramus (part of the pelvis).During a telephone interview on 01/28/26 at 2:02 P.M., Certified Nurse Aide (CNA) #1 said that on 12/30/25 at 6:00 P.M., she transferred Resident #1 using the Hoyer Lift without assistance from another staff member. CNA #1 said she lowered Resident #1 onto the bed, but his/her shoulders were not entirely lowered onto the mattress but instead were still suspended in the lift sling three to four inches from the mattress. CNA #1 said she disconnected the right upper sling strap from the Hoyer Lift, which caused Resident #1's upper body to quickly land on the bed, and the sling bar to swing onto the right side of Resident #1's head. CNA #1 said Resident #1's right temple area started bleeding immediately, and said she called out to CNA #2 and CNA #3 for help.CNA #1 said she knew how to access the Kardex and that she knew Resident #1's plan of care was that all transfers required two staff members, however she said she had attempted to transfer him/her without assistance.During an interview on 01/21/26 at 2:00 P.M., Nurse #1 said that on 12/30/25 around 6:00 P.M., CNA #1 told her she needed help with Resident #1. Nurse #1 said when she got to Resident #1's room, CNA #1, CNA #2, and CNA #3 were in the room, Resident #1 was on his/her bed lying on his/her left side, and CNA #1 was holding a towel to the right side of his/her head near the temple area. Nurse #1 said she removed the towel to assess Resident #1's head and saw blood was flowing from a deep open wound and there was blood on Resident #1's face and in his/her hair. Nurse #1 said she instructed CNA #1 to maintain pressure on the wound with the towel while she got bandage supplies, and by the time she returned two minutes later, the towel was saturated with blood. Nurse #1 said, after meeting Resident #1 emergent care needs, she asked CNA #1 what happened, that she asked CNA #1 if she had transferred Resident #1 by herself, and that CNA #1 responded yes.During an interview on 01/21/26 at 3:09 P.M., the Director of Nurses (DON) said CNA #1 should have followed Resident #1's plan of care and had another staff member assist her to transfer Resident #1, but did not, and as a result, Resident #1 sustained injuries and required transfer to the Hospital Emergency Department.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required two staff member assistance with the use of a Hoyer (mechanical) lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, in accordance with facility policies and assessed level of care needs, to maintain his/her safety to prevent an incident/accident resulting in significant injuries. On 12/30/25, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without another staff member present to assist her, which resulted in an unsafe transfer. Resident #1 sustained a laceration to the right side of his/her head, was transferred to the Hospital Emergency Department (ED) for an evaluation, where he/she was also diagnosed with multiple fractures.Findings include:The Facility Policy, titled Mechanical Lifts dated 02/26/09, indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift.A 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 October 2019, diagnoses included osteoporosis, dementia, and adult failure to thrive.Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated he/she required full mechanical lift transfers with a two person assist (date initiated 01/04/23).Review of Resident #1's electronic resident Kardex (reference document used by staff, with key resident information related to care needs, including transfer status), indicated he/she required two staff member assistance using the Hoyer Lift for all transfers.Review of the Nurse Progress Note, dated 12/30/25, indicated that at 6:00 P.M., Resident #1 was bleeding from his/her right temple area as a result of the Hoyer lift having struck his/her head during a transfer, and Resident #1 was transferred to the Hospital Emergency Department.Review of the Hospital Emergency Department admission History and Physical, dated 12/31/25, indicated Resident #1 was diagnosed with the following:-A hematoma (a localized collection of blood outside of blood vessels, usually caused by injury to the vessel wall, resulting in blood pooling within tissues) and ulceration on his/her right lateral temple area, which was wide and unable to be approximated and sutured.-Minimally displaced proximal and distal left clavicular (slender S-shaped long bone that connects the arm to the body's axial skeleton) fractures.-Acute fracture of the left superior and inferior pubic ramus (part of the pelvis).Review of CNA #1's annual skills competency education record indicated that CNA #1 had been educated and completed facility required competency related to performing mechanical lift transfers.During a telephone interview on 01/28/26 at 2:02 P.M., Certified Nurse Aide (CNA) #1 said she had transferred Resident #1 many times, and said she knew it was Facility policy for at least two staff members to operate the Hoyer lift when completing transfers with a resident. CNA #1 said she knew how to access the care Kardex and knew that Resident #1 required two staff members for all transfers, however said she attempted to transfer him/her without assistance, and could not explain why.CNA #1 said that on 12/30/25 around 6:00 P.M., she transferred Resident #1 using the Hoyer Lift without assistance from another staff member. CNA #1 said she lowered Resident #1 onto the bed, but his/her shoulders were not entirely lowered to the mattress but instead were still suspended in the lift sling three to four inches from the mattress. CNA #1 said when she disconnected the right upper sling strap from the Hoyer Lift, that caused Resident #1's upper body to quickly land on the bed, and the sling bar to swing onto the right side of Resident #1's head. CNA #1 said Resident #1's right temple area started bleeding immediately, and said she called out to CNA #2 and CNA #3 for help.During an interview on 01/21/26 at 2:00 P.M., Nurse #1 said that on 12/30/25 at 6:00 P.M., CNA #1 told her she needed help with Resident #1. Nurse #1 said when she got to Resident #1's room, CNA #1, CNA #2, and CNA #3 were in the room, Resident #1 was on his/her bed lying on his/her left side, and CNA #1 was holding a towel to the right side of his/her head. Nurse #1 said she removed the towel to assess Resident #1's head and saw blood was flowing from a deep open wound and there was blood on Resident #1's face and in his/her hair. Nurse #1 said she instructed CNA #1 to maintain pressure on the wound with the towel while she got bandage supplies, and by the time she returned two minutes later, the towel was saturated with blood.Nurse #1 said, after meeting Resident #1 emergent care needs, she asked CNA #1 what happened, that she asked CNA #1 if she had transferred Resident #1 by herself, and that CNA #1 responded yes.During interviews conducted with CNA #2, CNA #3, CNA #4, CNA #5, and Nurse #1, each of them said it was a well-known Facility policy that all Hoyer Lift transfers required two staff members to be present for the safety of the residents and staff. During an interview on 01/21/26 at 3:09 P.M., the Director of Nurses (DON) said it was Facility policy that two staff assist with all Hoyer Lift transfers, and said CNA #1 should have had another staff member assist her to transfer Resident #1, but did not, and as a result, Resident #1 sustained injuries and required transfer to the Hospital Emergency Department.

Based on interviews, and record review, the facility failed to ensure that the appropriate individual had the authority to make decisions regarding Advance Directives (legal documents that provide instructions for medical care when an individual is incapacitated) for one Resident (#26) out of a total sample of 13 residents. Specifically, for Resident #26, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) Form was completed by a Legal Guardian (person assigned by the court to make decisions for an individual who is incapacitated) who had an expansion for the authority to make decisions about the Resident's Advance Directives relative to his/her wishes for life-sustaining treatments. Findings include: Review of the facility policy for Medical Orders - Life Sustaining Treatment, last revised 6/18/19, indicated:-to ensure that resident/responsible party's wishes concerning life sustaining treatment are documented properly and respected to the extent possible by the facility.-A guardian has the authority to request changes to an existing MOLST, or void the MOLST, provided the guardianship document includes an expansion to allow authorization for medical orders for life sustaining treatment. -Note: Guardianship documents may be specific as to which medical orders can be authorized. Ensure the document permits the changes being requested by the Guardian. Resident #26 was admitted to the facility in September 2020, with diagnoses including Paranoid Schizophrenia and Dementia. Review of Resident #26's clinical record indicated:-a MOLST Form signed on 4/15/21, by Resident #26's Legal Guardian with requests for DNR (Do Not Resuscitate), DNI (Do Not Intubate), DNH (Do Not Hospitalize), no dialysis, no artificial nutrition and no artificial hydration. -letters of Guardianship for an incapacitated person dated 9/16/20, without the expansion for authorization of Advance Directives.-the Legal Guardian did not have the authority to refuse or discontinue life-sustaining treatments on the Resident's behalf. Review of Resident #26's July 2025 Physician's orders indicated an order to follow the MOLST instructions. During an interview on 7/24/25 at 11:49 A.M., Social Worker (SW) #1 said that Resident #26's Legal Guardian was a friend, and not a family member. During an interview on 7/24/25 2:25 P.M., SW #1 said that Resident #26's MOLST Form was not valid because the Legal Guardian did not have the required Guardianship expansion to sign the Resident's MOLST Form for DNR, DNI, DNH, no dialysis, no artificial nutrition and no artificial hydration.

Based on record review, and interview, the facility failed to accurately code Minimum Data Set (MDS) Assessments as the clinical basis for care planning and care delivery for four Residents (#4, #20, #7 and #36) out of a total sample of 13 residents. Specifically: 1.For Resident #4, the facility failed to accurately code an intravenous line (IV) access when the Resident had an IV access in place. 2. For Resident #20, the facility failed to accurately code antidepressant and antipsychotic medications when the Resident was ordered for and being administered an antidepressant medication daily but was coded as receiving an antipsychotic medication when the Resident was not ordered for antipsychotic medication. 3. For Resident #7, the facility failed to accurately code for the administration of anti-anxiety medication when the Resident was ordered for and being administered anti-anxiety medication. 4. For Resident #36, the facility failed to accurately code for dialysis treatment when the Resident was routinely receiving dialysis services. Findings include: 1. Resident #4 was admitted to the facility in April 2025, with diagnoses including Urinary Tract Infection (UTI) and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. Review of the MDS dated [DATE] indicated Resident #4 had no IV access. Review of Resident #4’s July 2025 Physician’s orders indicated: -Bard midline single lumen placed left basilic, Gauge: 4 FR [French - catheter measurement], length int [sic] 15 cm (centimeters), total length 15 cm, arm circumference 27 cm. Start date 6/26/25. -flush IV with 10 cc (cubic centimeters) normal saline for patency, every night shift for patency. Start date 6/26/25. During an interview on 7/29/25 at 2:20 P.M., the MDS Nurse said Resident #4 did have IV access during the 7-day look back period for the MDS dated [DATE], and that the MDS was coded incorrectly. The MDS Nurse said the MDS should have been coded yes, the Resident did have IV access. 2. Resident #20 was admitted to the facility in February 2025, with diagnoses including Liver Disease Unspecified, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbances and Major Depressive Disorder. Review of Resident #20’s MDS assessment dated [DATE], indicated the Resident was being administered an antipsychotic medication and was not being administered an antidepressant medication. Review of the Resident’s May 2025 Physician’s orders indicated: -Trazadone HCL Oral Tablet 50 mg [milligrams] (Trazadone HCL - antidepressant medication), give 0.5 [half] tablet by mouth at bedtime for mood and related symptoms (total dose 25 mg). Review of Resident #20’s May 2025 Medication Administration Record (MAR) indicated the Trazadone medication was administered as ordered by the Physician at bedtime. Further review of the Resident’s May 2025 Physician’s orders and MAR failed to indicate that the Resident had an order for an antipsychotic medication or that he/she was administered an antipsychotic medication. During an interview on 7/29/25 at 2:20 P.M., the MDS Nurse said Resident #20 was receiving an antidepressant medication and was not receiving an antipsychotic medication during the 7-day look back period for the MDS dated [DATE]. The MDS Nurse said the MDS was coded incorrectly. The MDS Nurse said the MDS should have been coded yes for antidepressant medication and no for an antipsychotic medication use. 3. Resident #7 was admitted to the facility in December 2023 with diagnoses of anxiety disorder and Post-Traumatic Stress Disorder (PTSD). Review of Resident #7's July 2025 Physician's orders indicated: -ALPRAZolam Oral Tablet 0.25 mg (Alprazolam/ Xanax - anti-anxiety medication). Give 0.25 mg by mouth every 24 hours as needed (PRN) for anxiety. Start Date 5/25/25. Review of Resident #7's MAR for June 2025 indicated that the Resident was administered the ALPRAZolam medication on June 19th and June 23rd. Review of Resident #7's MDS assessment dated [DATE], failed to indicate any anti-anxiety medication administration for the Resident. During an interview on 7/29/25 at 1:49 P.M., the MDS Nurse said that Resident #7's MDS dated [DATE] was coded incorrectly for anti-anxiety medication. The MDS Nurse said that she had reviewed the Resident's June 2025 MAR, and the Resident did receive anti-anxiety medication twice during the MDS 7-day look back period. The MDS Nurse said that the Resident's MDS dated [DATE] should have indicated anti-anxiety medication use but it did not. 4. Resident #36 was admitted to the facility in October 2024 with diagnoses including Dependence on renal dialysis and Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease (CKD) or End Stage Renal Disease (ESRD). Review of Resident #36's July 2025 Physician's orders indicated: -Dialysis Appointment - Pickup Time 9:15am . every Day Shift Monday, Wednesday, Friday . Start date 1/8/25 Review of Resident #36's April 2025 MAR indicated that the Resident attended dialysis treatments in April 2025 on the following days: 4/2/25, 4/4/25, 4/9/25, 4/11/25, 4/14/25, 4/16/25, 4/18/25, 4/21/25, 4/23/25, 4/25/25, 4/28/25 and 4/30/25. Review of Resident #36's MDS assessment dated [DATE], failed to indicate that the Resident was receiving Dialysis Treatment. During an interview on 7/29/25 at 1:50 P.M., the MDS Nurse said that Resident #36's MDS dated [DATE] was coded incorrectly for Dialysis Treatment. The MDS Nurse said that the Resident had been receiving Dialysis Treatment since being admitted to the facility. The MDS Nurse said the Resident's MDS dated [DATE] should have indicated Dialysis Treatment for the Resident but it did not.

Based on interview, and record review, the facility failed to ensure that the Resident was provided the right to participate in the care plan process for one Resident (#26), out of a total sample of 13 residents. Specifically, the facility failed to ensure that quarterly care plan meetings were conducted as required for Resident #26, and that the Resident and/or Resident Representative were encouraged to participate in the care plan meetings. Findings include:Review of the facility policy titled Resident Assessment, release date 9/1/20, indicated:-to obtain the necessary information to develop and maintain an individualized interdisciplinary plan of care, treatment and services with appropriate education and training about each resident's illness and care needs. -once the comprehensive, interdisciplinary care plan is established, the interdisciplinary team [IDT] reviews the plan of care, treatment, services, and goals collaboratively with the resident and family/responsible party no later than 21 days after admission.-the interdisciplinary team evaluates the resident goals and effectiveness of the plan of care, treatment and services at least every 92 days or more frequently.-the resident goals and plan of care, treatment, and services are reviewed and revised, when necessary, with the interdisciplinary team collaboratively and with the resident, family or responsible party. Resident #26 was admitted to the facility in September 2020, with diagnoses including Paranoid Schizophrenia and Dementia. Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated that Resident #26:-was cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15. -was English speaking.-is usually understood and usually understands others. During an interview on 7/23/25 at 7:52 A.M., Resident #26 said that he/she was unaware of what a care plan meeting was, but that he/she would like to be invited to them. Review of the MDS Schedule for Resident #26 indicated that the Resident had care plan meetings scheduled for 8/7/24, 11/6/24, 2/5/25 and 5/7/25. Review of Resident #26's clinical record failed to indicate documented evidence that the Resident participated in the care planning process with the IDT during quarterly care plan reviews as required, in August 2024, November 2024, February 2025 and May 2025. Further review of Resident #26's clinical record failed to indicate documented evidence as to why the Resident did not or could not participate in any care plan meetings, or refusals to participate in the meetings in 2024 and 2025. During an interview on 7/24/25 at 2:14 P.M., Social Worker (SW) #1 said that Resident #26 had not been invited to attend his/her care plans meetings. SW #1 said that she was unable to provide evidence from the clinical record that the Resident had been invited to or attended the care plan meetings in 2024 and 2025.

Based on observation, and interview, the facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles of practice on one Unit (Front Unit) and one (Medication Cart A) of two medication carts reviewed. Specifically, the facility failed to ensure that multi-dose vials of eye medications were dated once opened according to manufacturer's guidelines in the Front Unit medication storage room, and for Medication Cart A located on the Front Unit. Findings include:Review of the facility policy titled Medication Storage in the Facility, dated January 2024, indicated that .:-When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.-The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration.-Medication in multidose containers may be used until the manufacturer's expiration date, or for the length of time allowed by the state regulation, whichever is less. -The date opened and/or the triggered expiration date should be recorded on a label for such purpose affixed to the vial. Expiration dates triggered by opening should be available either in the manufacturer's labeling or package insert, on a chart provided by the pharmacy, or from the pharmacist.-In the absence of manufacturer guidance for discarding multi-dose vials after opening, the facility will defer to the USP 797 guidelines which recommend discarding multi-dose vials (other than some Insulins) at 28 days after opening. Review of the facility policy titled Timolol Eye Drop Policy, undated, included:-most manufacturers recommend discarding Timolol eye drops 4 weeks after opening the bottle.-Risk of contamination: After opening, eye drops lose their sterile seal, making them susceptible to contamination by bacteria and other germs that can cause serious eye infections and even vision loss.-Loss of effectiveness: Over time, the active ingredients in eye drops can break down and become less potent, reducing their ability to treat the intended condition. Review of the facility policy titled Artificial Tears Policy, undated, included:-Unopened artificial tears generally last for 1 to 2 years from the manufacturing date. Once opened, the duration of use is significantly shorter. Most experts recommend discarding opened bottles of artificial tears, whether they contain preservatives or not, after 30 days. On 7/24/25 at 8:30 A.M., during a medication storage room observation on the Front Unit with the Director of Nursing (DON), the surveyor observed an open multi-dose vial of Timolol Maleate ophthalmic Eye Drop Solution 0.25% (eye medication) in the refrigerator. The surveyor further observed the open vial of ophthalmic solution did not have an open or use by date noted on the vial. During an interview at the time, the DON said that when a multi-dose vial of medication was opened it should be labeled with an open and use by date, but this open vial did not have either. On 7/24/25 at 9:57 A.M., the surveyor and Nurse #1 observed Medication Cart A on the Front Unit, and the surveyor observed an open multi-dose vial of Natural Tears eye drop solution with no open or discard date noted on the vial. When the surveyor asked, Nurse #1 said he did not know when the multi-dose vial of Natural Tears eye drops had been opened. Nurse #1 said that the correct procedure was to date a multi-dose vial of eye drops on the day that the vial was first opened. Nurse #1 said he was not sure how long the eye drops would be good to use once they were opened but there should also be a use by date labeled on the eye drops on the day they are opened. The surveyor also observed a plastic cup containing two open multi-dose vials of Timolol Maleate ophthalmic Eye Drop Solution in Medication Cart A. One opened vial had an open date of 4/3 noted on it, and the second vial had no open date. Neither of the two vials were labeled with a use by date. Nurse #1 further said that both vials should have an open and use by date, but the vials were missing the use by date and the second vial had no open date information. Nurse #1 said that both vials should be discarded because he could not tell when they had been opened. During an interview on 7/28/2025 at 8:15 A.M., the DON said when the nursing staff open any multi-dose vial of medication, they should apply a yellow sticker and write the open date and the discard date on the sticker. The DON said the Timolol Maleate eye drops should have a use by date 4 weeks after opening, and the Natural Tears eye drops should have a discard date that is 30 days after opening. The DON said the Timolol and Natural Tears multi-dose vials that were identified should have been labeled after opening but they had not been, and so the staff could not determine if the medication was still viable. The DON said that the opened and unlabeled eye medication would all have to be discarded.

Based on interview, and record review, the facility failed to administer Pneumococcal Vaccinations for one Resident (#9) out of five applicable residents, out of a total sample of 13 residents. Specifically, for Resident #9, the facility failed to administer Pneumococcal Vaccines when the Resident was eligible to receive, and the Responsible Party consented to the Pneumococcal immunization, putting the Resident at risk of acquiring pneumococcal illnesses.Findings include:Review of the facility's policy titled Resident Pneumococcal Vaccine, last issued January 2023, indicated the following:-Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within ninety days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician approved pneumococcal vaccination protocol. -Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the CDC guidance titled Pneumococcal Vaccine Timing for Adults, dated October 2024, indicated but was not limited to the following:>Adults 50 years or older:-Shared clinical decision-making for those who already completed the series with PCV13 (Pneumococcal Conjugate Vaccine: vaccine used to protect against 13 types of pneumococcal bacteria that commonly cause serious infections) and PPSV23 (Pneumovax 23: vaccine used to help protect against serious infections caused by 23 types of pneumococcal bacteria).-Prior vaccines shared clinical decision-making option for adults [AGE] years old or older.>Complete series: previously received PCV13 at any age & PPSV23 at or older than 65 yrs and it has been more than five years since the series was completed.>Together, with the patient, vaccine providers may choose to administer PCV20 or PCV21 to adults that are [AGE] years old or older who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. Resident #9 was admitted to the facility in December 2022 with diagnoses including hemiplegia and hemiparesis and dysphagia. Review of Resident #9's Immunization Record indicated the Resident received a dose of Prevnar 13 Vaccine (PCV13) on 5/24/17 and the Pneumovax 23 (PPSV23) on 10/1/19 prior to his/her facility admission. Review of Resident #9's clinical record indicated:-The Resident was greater than [AGE] years of age.-No evidence the Resident had received any Pneumococcal Vaccinations since the dose of PPSV23 on 10/1/19.-Consent for administration of Pneumococcal Vaccine signed by the Resident's Responsible Party on 12/16/22, if the vaccine is indicated.-A Physician's order dated 1/9/23, indicating may have Pneumococcal vaccine. Review of the CDC PneumoRecs VaxAdvisor online calculator indicated the following recommendation for Resident #9:-Give one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. During an interview on 7/29/25 at 9:06 A.M., the Director of Nursing (DON) said that Resident #9 should have received the Pneumococcal Vaccine, when he/she became eligible in 2024, but he/she had not received the Pneumococcal Vaccine.

Based on observation, records reviewed and interviews, for one of six sampled residents (Resident #1), who had limited mobility due to a cylinder (plaster type) cast on his/her right leg from his/her mid thigh down to his/her ankle, required physical assistance from staff with rolling and moving in bed, and had requested the use of bed rails for bed mobility, the Facility failed to ensure he/she was adequately supervised for safety and potential hazards related to the use of bed rails as an assistive device, in order to prevent an incident and/or accident resulting in serious injury or death. On [DATE] around 6:00 A.M., Resident #1 was found unresponsive, without a pulse, his/her lower body was hanging off the mattress with his/her feet touching the floor, and his/her head/neck area was hyperextended and caught between the mattress and the bed rail. Resident #1 was pronounced dead at the facility. Findings include: Review of the Facility's Policy titled Bed Rails, dated as released [DATE], indicated the facility will ensure the resident receives assistance as needed for bathroom utilization, transferring in and out of bed, bed mobility and other care needs. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated [DATE], indicated that around 6:00 A.M. on [DATE], staff members observed Resident #1 in bed with his/her head between the mattress and the bed rail and his/her right leg and leg cast off of the mattress with his/her foot touching the floor. The Report indicated that Resident #1 did not have a pulse, CPR was initiated and 911 was called, however, Resident #1 was pronounced dead at the Facility. Resident #1 was admitted to the Facility in [DATE], with diagnoses that included right patella (kneecap) fracture and Parkinson's Disease. Review of Resident #1's Baseline Care Plan, dated [DATE], indicated bed rails per resident request for turning and positioning. During a telephone interview on [DATE] at 2:30 P.M. the MDS Nurse said that she wrote the notation on Resident #1's Baseline Care Plan that bed rails were requested by Resident #1 for turning and positioning after a conversation with Resident #1 during which he/she asked for the bed rails to be put on the bed. Review of Resident #1 medical record indicated there was no documentation to support nursing obtained a physician's order for use of bed rails. During an interview on [DATE] at 12:00 P.M., the Maintenance Director said that, on [DATE], at the request of nursing staff, he installed two half bed rails on Resident #1's bed. The Maintenance Director said he completed an entrapment assessment at that time. Resident #1's Admission Minimum Data Set Assessment, dated as completed [DATE], indicated the following: -his/her cognitive patterns were intact, -he/she was 5'3 tall and weighed 131 pounds, -was always incontinent of bowel and bladder, -had impaired functional mobility in lower extremity on one side, -required partial to moderate assistance for bed mobility, -required substantial to maximum assistance to move from lying to siting on the edge of the bed and vice versa, (staff provided more than half the effort to complete activity). -he/she was dependent for transferring between surfaces (staff member does all the effort to complete the activity). Further review of Resident #1's medical record indicated there was no documentation to support that nursing assessed him/her for the use of bed rails upon admission, if the bed rails potentially posed a safety hazard or that any alternative measures were attempted. During an interview on [DATE] at 1:25 P.M., the Director of Nursing said that it was the Facility practice for all newly admitted residents to be assessed for bed rails on admission. The Director of Nursing said that the nurse who completed Resident #1's admission worked for an Agency and had not completed his/her bed rail assessment, but should have. The Surveyor was unable to interview the Agency Nurse that completed Resident #1's admission as she did not respond to the Department of Publics requests for an interview. During a follow-up interview on [DATE] at 1:13 P.M., the Director of Nursing said that at the time of Resident #1's admission, the Facility did not have a procedure in place for auditing to ensure bed rail assessments for newly admitted residents had been completed within twenty-four hours of admission. Review of Resident #1's physician orders and Treatment Administration Record (TAR), dated [DATE] through [DATE], indicated he/she had a hinge brace on his/her right leg (from mid thigh area down to just above the ankle). However, there was no documentation to support the Facility developed a care plan which addressed Resident #1's bed rail use. Review of Resident #1's physician orders and Treatment Administration Record (TAR), dated [DATE] through [DATE], indicated he/she had a cylinder cast on his/her right leg (from mid thigh area down to just above the ankle). Further review of Resident #1's medical record indicated there was no documentation to support that after Resident #1 had the hinged brace removed and a cylinder cast was placed on his/her right leg (from the upper thigh to ankle) on [DATE], which also limited his/her mobility with an increased need for staff assistance to lift and move his/her right leg, that nursing re-assessed him/her for an appropriate alternative to bed rails, or re-assessed him/her for safety or potential for hazards related to continued use of bed rails. Review of Resident #1's Comprehensive Care Plan related to Focus Area of Activities of Daily Living (ADL) self-care performance deficit due to Parkinson's Disease and patella fracture and incontinence care needs, dated [DATE], indicated interventions included the following: - the resident is totally dependent on two staff for repositioning and turning in bed every 2 hours and as necessary, - the resident requires assistance by one to two staff to move between surfaces, - check every two hours and as required for incontinence During an in-person interview on [DATE] at 12:55 P.M. with the Rehab Manager (RM) and a telephone interview on [DATE] at 1:15 P.M. with the Physical Therapy Assistant (PTA), they said the following: Resident #1 was admitted to the Facility with a right patella fracture following a motor vehicle accident. Resident #1 was admitted to the Facility with a hinge brace on his/her right leg which kept his/her right leg in a fully extended position. That on [DATE], Resident #1 had a surgical procedure (an open reduction and internal fixation of the right patella and soft tissue repair) and returned to the Facility with a cylinder (long leg) cast. The Rehab Manager said the cast extended from Resident #1's mid-thigh to ankle, ended with a large plaster lump in the area of his/her ankle and made the cast heavier. The RM and PTA said that on [DATE], Resident #1 went for a surgical follow up and returned with a different cylinder cast which also extended from his/her mid thigh to ankle, that there was no longer a large lump at the ankle, but that is was still difficult for Resident #1 to move his/her right without assistance due to the weight of the cast. The RM and PTA said Resident #1 was able to stand and bear weight, was non-ambulatory, and required maximum assistance to transfer between surfaces. The RM and PTA said Resident #1 required physical assistance with bed mobility, that he/she had trouble moving his/her right leg on his/her own because of the weight of the cast. The RM and PTA said staff had to pick up and help move Resident #1's right leg (in the cylinder cast) when he/she moved from sitting to lying down and vice versa, as well as during transfers between surfaces. During an interview on [DATE] at 7:07 A.M., CNA #3 said that she was assigned to care for Resident #1 during the overnight shift that started on [DATE] and ended on [DATE]. CNA #3 said that she did not know Resident #1 well and staff members on the 3:00 P.M. to 11:00 P.M. shift told her that Resident #1 would ring his/her call bell for assistance if he/she needed anything. CNA #3 said that she checked on Resident #1 at 11:00 P.M. and 3:00 A.M., and said Resident #1 appeared to be asleep, the head of his/her bed was raised and the bed was in a low position. CNA #1 said she did not check Resident #1 for incontinence, did not provide any personal care and did not reposition him/her during the 11:00 P.M. to 7:00 A.M. shift. CNA #3 said sometime around 5:30 A.M. or 6:00 A.M. (exact time unknown). when she went to check on him/her, she found Resident #1 half off the bed and called for help from the nurse. During an interview on [DATE] at 1:06 P.M., Nurse #1 said that she was the nurse assigned to Resident #1's unit during the 7:00 P.M. to 7:00 A.M. shift starting on [DATE] and ending on [DATE]. Nurse #1 said that had cared for Resident #1 one or two times prior to the shift. Nurse #1 said Resident #1 received medications around 8:00 P.M. or 9:00 P.M. and usually slept through the night. Nurse #1 said that between 5:30 A.M. and 6:00 A.M., she was in and out of Resident #1's room several times because Resident #1's roommate had a problem with his/her blood sugar. Nurse #1 said that she could see Resident #1 in his/her bed asleep while she attended to the roommate. Nurse #1 said that around 6:00 A.M., when she was at his/her medication cart in the hallway, one of the CNAs came running and reported that something was wrong in Resident #1's room. Nurse #1 said when she arrived at Resident #1's room, she saw that Resident #1's legs were dangling off the mattress and hanging over the safety mat that was on the floor beside the bed. Nurse #1 said that it looked like Resident #1 had rolled out of bed. Nurse #1 said that Resident #1's buttock area was neither on the mattress or the floor, was hanging in the air. Nurse #1 said that Resident #1's right (casted) leg was crossed over his/her left leg. Nurse #1 said that the only part of Resident #1's body that was on the floor were his/her feet. Nurse #1 said that Resident #1's head was on the bed rail, with the bed rail under Resident #1's chin, his/her face was pointed up toward the ceiling and the back of his/her head was on the corner edge of the mattress. Nurse #1 said that Resident #1's head was stuck between the bottom corner of the bed rail and the mattress. Nurse #1 said that the head of Resident #1's bed was raised to 45 degrees, that the bed rail was down, and that the lower corner of the bed rail was higher than the mattress. Nurse #1 said that Resident #1 was not alert, was pale, had no pulse and did not appear to be breathing. Nurse #1 said they called a Code Blue, called 911, Nurse #2 came to assist her, the CNAs assisted Nurse #2 with transferring Resident #1 back to bed, and CPR was initiated. During an interview on [DATE] at 6:15 A.M., Nurse #2 said that on [DATE] around 6:00 A.M. she was called to Resident #1's unit to assist with a Code Blue. Nurse #2 said that when she arrived at Resident #1's room, Resident #1 was on the side of the bed with the side rail in front of him/her keeping him/her from falling out of bed. Nurse #2 said that Resident #1's legs were off the mattress and angled toward the floor and his/her chin was resting on top of the bed rail. Nurse #2 said Resident #1's head was hyperextended and his/her face was pointed upward toward the ceiling. Nurse #2 said she released the side rail and Resident #1 fell forward into the arms of CNA #1 and CNA #7 and they lifted him/her into bed. Nurse #2 said Resident #1's body was warm, he/she was not breathing, his/her face color was ashen and his/her left leg was discolored and almost mottled. During an in-person interview on [DATE] at 4:11 P.M. with Certified Nurse Aide (CNA) #1 and a telephone interview on [DATE] at 11:00 A.M. with CNA #7, they said on [DATE], they assisted with putting Resident #1 back to bed around 6:30 A.M. They said that Resident #1's head was stuck between the mattress and the bed rail, his/her chin was caught on the bed rail, his/her lower body was off the bed and his/her legs were extended out in front of him/her. CNA #7 said that when Resident #1 was freed from the bed rail, he saw that the area underneath Resident #1's neck was red and his/her head remained in the same position, with his/her neck extended and face looking upward. Nurse #1 said that while administering CPR she noted bruising under Resident #1's chin. Nurse #1 said Emergency Medical Services (EMS) arrived and pronounced Resident #1 dead. The Police Report, dated [DATE], indicated the police arrived at the Facility at 6:23 A.M. having been dispatched for an unresponsive resident. The Police Report indicated Resident #1 was found by Nurse #1 with his/her body laying half off the bed with his/her body on the ground and his/her head pinned between the mattress and the guardrails [bed rails]. The EMS Patient Care Report for the ambulance service dated [DATE] at 6:30 A.M. indicated EMS arrived at the Facility for an unresponsive patient. The Report indicated staff were unable to provide a certain time Resident #1 was last known to be well. The Report indicated staff reported that they found no pulse or breathing and began CPR. The Report indicated that on exam, Resident #1 was unresponsive to painful stimuli and the paramedic was unable to manipulate his/her neck, jaw, shoulders, hips and knees due to rigor (rigor mortis, stiffening of the joints and muscles of the body a few hours after death). The Report indicated that resuscitative efforts for Resident #1 were ceased due to bodily condition clearly indicating biological death. During an interview on [DATE] at 1:40 P.M., the Administrator said that he was informed of Resident #1's accident/incident at the Facility on [DATE] and responded to the Facility to initiate an investigation and assist the police who were on site and also conducting an investigation.

Based on observation, records reviewed and interviews for one of six sampled residents (Resident #1) who had limited mobility in his/her right leg related the need for a hinge brace which was changed to a long leg cylinder cast (both of which kept his/her right leg fully extended) for treatment of a fractured patella (knee cap), and had requested bed rails to aide in bed mobility, the Facility failed to ensure nursing completed bed rail assessment on Resident #1, attempted the use of an appropriate alternative to bed rails and obtained informed consent prior to installing two quarter bed rails on his/her bed. On [DATE], around 6:00 A.M., Resident #1 was found by staff unresponsive, without a pulse, his/her legs were off the bed, extended over the floor mat next to the bed, his/her head/neck was caught on and hyperextended up over the bed rail, and the back of his/head was against the mattress. Resident #1 was pronounced dead at the facility. Findings include: Review of the Facility's Policy titled Bed Rails, dated as released [DATE], indicated the facility will: - attempt to use appropriate alternatives prior to installing a bed rail, - assess the resident risk for entrapment using established systems, - obtain informed consent, - ensure the care plan reflects bed rail usage, including purpose of the bed rails, - will periodically reassess the resident's needs and bed rail usage to determine ongoing appropriateness, and, - ensure the resident receives assistance as needed for bathroom utilization, transferring in and out of bed, bed mobility and other care needs. Federal regulations related to Bed Rails, include guidance facilities' need to consider when determining whether to use bed rails to meet the needs of a resident, the following components of the resident assessment should be considered including, but not limited to: -Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; -Size and weight; -Sleep habits; -Medication(s); -Acute medical or surgical interventions; -Underlying medical conditions; -Existence of delirium; -Ability to toilet self safely; -Cognition; -Communication; -Mobility (in and out of bed); and -Risk of falling Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated [DATE], indicated that around 6:00 A.M. on [DATE], staff members observed Resident #1 in bed with his/her head between the mattress and the side rail and his/her right leg and leg cast off the mattress with his/her foot touching the floor. The Report indicated that Resident #1 did not have a pulse, CPR was initiated, 911 was called, and was pronounced dead at the Facility. Resident #1 was admitted to the Facility during [DATE] following a hospitalization with diagnoses that included right patella (knee cap) fracture and Parkinson's Disease. During a telephone interview on [DATE] at 2:30 P.M. the MDS Nurse said she had a conversation with Resident #1 right after his/her admission and that he/she requested bed rails be put on his/her to help with turning and positioning. The MDS Nurse said she did not discuss alternatives to bed rails with Resident #1 or discuss the risks and benefits of bed rails with Resident #1 during their conversation. During an interview on [DATE] at 12:00 P.M., the Maintenance Director said that, on [DATE], at the request of nursing staff, he assessed Resident #1's bed for entrapment risk and installed two half bed rails. Review of the Bed System Measurement Device Test Results Worksheet, dated [DATE] and signed by the Maintenance Director, indicated two half rails were installed on Resident #1's bed. Resident #1's Admission Minimum Data Set Assessment, dated as completed [DATE], indicated the following: -his/her cognitive patterns were intact, -he/she was 5'3 tall and weighed 131 pounds, -was always incontinent of bowel and bladder, -had impaired functional mobility in lower extremity on one side, -required partial to moderate assistance for bed mobility, -required substantial to maximum assistance to move from lying to siting on the edge of the bed and vice versa, (staff provided more than half the effort to complete activity). -he/she was dependent for transferring between surfaces (staff member does all the effort to complete the activity). Further review of Resident #1's medical record indicated there was no documentation to support that nursing assessed him/her for the use of bed rails upon admission, if the bed rails potentially posed a safety hazard or that any alternative measures were attempted. During an interview on [DATE] at 1:25 P.M., the Director of Nursing said that every Facility resident has a bed rail assessment completed by nursing as part of their admission assessment, but said however, that Resident #1's bed rail assessment had not been completed. Further review of Resident #1's medical record indicated there was no documentation to support nursing reviewed and documented the risks and benefits of bed rail use with Resident #1 or that they obtained informed consent from Resident #1 prior to installing the two half bed rails on his/her bed. The Surveyor asked the Director of Nursing if the facility had any documentation related to the review of the risks and benefits of the use of bed rails with Resident #1 or of his/her informed consent for the bed rails, prior to the Facility having installed his/her bed rails. The Director of Nursing provided the Surveyor with a blank Side (bed) Rail Consent Form and said the Facility used the Form to document informed consent for bed rails with residents, including documentation of discussions of the risks and benefits of bed rails. The Director of Nursing said that staff had not completed a Side (bed) Rail Consent Form with Resident #1. Review of Resident #1's physician orders and Treatment Administration Record (TAR), dated [DATE] through [DATE], indicated he/she had a hinge brace on his/her right leg (from mid thigh area down to just above the ankle). Review of Resident #1's Comprehensive Care Plan indicated the Facility initiated care plans for the following Focus Areas between [DATE] and [DATE]: - Activities, - ADL self-care performance deficit due to Parkinson's Disease and patella fracture, - Wish to return home when medically cleared for discharge, - Risk for falls due to unaware of safety needs, - Adjustment disorder with mixed anxiety and depressed mood, - Potential Nutritional problem due to self-imposed diet restrictions, - Parkinson's Disease without dyskinesia - Risk for pain due to patella fracture - Potential for pressure ulcer development due to immobility - Bladder and bowel incontinence, and, - Impaired visual function. Although, Resident #1's Baseline Care Plan indicated he/she had requested bed rails, there was no documentation to support the Facility developed an individualized comprehensive care plan which addressed his/her use of bed rails. Review of Resident #1's physician orders and Treatment Administration Record (TAR), dated [DATE] through [DATE], indicated he/she had a cylinder cast on his/her right leg (from mid thigh area down to just above the ankle). Further review of Resident #1's care plan indicated there was no documentation to support that after Resident #1 had the hinged brace removed and a cylinder cast was placed on his/her right leg (from the upper thigh to ankle) on [DATE], which also limited his/her mobility with an increased need for staff assistance to lift and move his/her right leg, that nursing re-assessed him/her for an appropriate alternative to bed rails, or re-assessed him/her for safety related to continued use of bed rails. During an in person interview on [DATE] at 12:55 P.M. with the Rehab Manager (RM) and a telephone interview on [DATE] at 1:15 P.M. with the Physical Therapy Assistant (PTA) they said the following: Resident #1 was admitted to the Facility with a right patella fracture following a motor vehicle accident. Resident #1 was admitted to the Facility with a hinge brace on his/her right leg which kept his/her right leg fully extended. That on [DATE], Resident #1 had a surgical procedure (an open reduction and internal fixation of the right patella and soft tissue repair) and returned to the Facility in a long leg cylinder cast. The Rehab Manager said the cast extended from Resident #1's mid-thigh to ankle, ended with a large plaster lump in the area of his/her ankle, which made the cast heavier. The RM and PTA said that on [DATE], Resident #1 went for a surgical follow up and returned with a different cylinder cast which also extended from his/her mid thigh to ankle, that there was no longer a large lump at the ankle, but that is was still difficult for Resident #1 to move his/her right without assistance. The Rehab Manager and PTA said that during his/her stay at the Facility, Resident #1 was able to stand and bear weight, however, was non-ambulatory and that required maximum assistance to transfer between surfaces. They said Resident #1 required physical assistance with bed mobility, had trouble moving his/her right leg on his/her own because of the weight of the cast, and used the bed rails to shift his/her weight. They said that staff members had to pick up, support and move Resident #1's right leg when he/she moved from sitting to lying down and vice versa and during transfers between surfaces. During a telephone interview on [DATE] at 2:18 P.M., Certified Nurse Aide (CNA) #5 said Resident #1 did not always understand how to use his/her call light and sometimes called out for assistance when staff entered his/her room during rounds. CNA #5 said Resident #1 used the bed rails to help him/herself roll. CNA #5 said that on more than one occasion, when she entered Resident #1's room after having previously left him/her positioned properly in the bed, she observed Resident #1 with his/her legs off the mattress hanging toward the floor. CNA #5 said she had not reported what she had seen to nursing or rehab staff. CNA #5 said that Resident #1 could move his/her legs off the mattress when he/she wanted to get out of bed. During an interview on [DATE] at 7:07 A.M., CNA #3 said that on [DATE] sometime around 5:30 A.M. or 6:00 A.M. (exact time unknown), she found Resident #1 half off the mattress and called for help from the nurse. During an interview on [DATE] at 1:06 P.M., Nurse #1 said that between 5:30 A.M. and 6:00 A.M., she was in and out of Resident #1's room several times because Resident #1's roommate had a problem with his/her blood sugar. Nurse #1 said that around 6:00 A.M., one of the CNAs came running and reported that something was wrong in Resident #1's room. Nurse #1 said when she arrived to Resident #1's room she saw that Resident #1's legs were dangling off of the mattress over the fall mat on the floor beside the bed. Nurse #1 said that it looked like Resident #1 had rolled out of bed. Nurse #1 said that Resident #1's buttocks were neither on the mattress or the floor and were hanging in the air. Nurse #1 said that Resident #1's right (casted) leg was crossed over his/her left leg. Nurse #1 said that the only part of Resident #1's body on the floor were his/her feet. Nurse #1 said that Resident #1's head was on the bed rail with the bed rail under Resident #1's chin, his/her face was pointed up toward the ceiling and the back of his/her head was on the corner edge of the mattress. Nurse #1 said that Resident #1's head was stuck between the bottom corner of the bed rail and the mattress. Nurse #1 said that the head of Resident #1's bed was raised to 45 degrees and although the bed rail was down, said the corner of the bed rail was higher than the mattress. Nurse #1 said that Resident #1 was not alert, was pale, had no pulse and did not appear to be breathing. During an interview on [DATE] at 6:15 A.M., Nurse #2 said that on [DATE] around 6:00 A.M. she was called to Resident #1's unit from another unit to assist. Nurse #2 said that when she arrived to Resident #1's room, Resident #1 was on the side of the bed with the bed rail in front of him/her keeping him/her from falling out of bed. Nurse #2 said that Resident #1's legs were angled down toward the floor and his/her chin was resting on top of the bed rail. Nurse #2 said Resident #1's head was hyperextended and his/her face was pointed up toward the ceiling. Nurse #1 said she and Nurse #2 initiated CPR and 911 was called. Nurse #1 said that while administering CPR she noted bruising under Resident #1's chin. Nurse #1 said Emergency Medical Services (EMS) arrived and pronounced Resident #1 dead. The Police Report, dated [DATE], indicated the police arrived at the Facility at 6:23 A.M. having been dispatched for an unresponsive resident. The Police Report indicated Resident #1 was found by Nurse #1 with his/her body laying half off of her/her bed with his/her body in the ground and his/her head pinned between the mattress and the guardrail [bed rail]. The EMS Patient Care Report for the ambulance service, dated [DATE] at 6:30 A.M., indicated EMS arrived at the Facility for an unresponsive patient. The Report indicated staff were unable to provide a certain time Resident #1 was last known to be well. The Report indicated staff reported that they found no pulse or breathing and began CPR. The Report indicated that on exam, Resident #1 was unresponsive to painful stimuli and the paramedic was unable to manipulate his/her neck, jaw, shoulders, hips and knees due to rigor (rigor mortis, stiffening of the joints and muscles of the body a few hours after death). The Report indicated that resuscitative efforts for Resident #1 were ceased due to bodily condition clearly indicating biological death. During an interview on [DATE] at 1:40 P.M., the Administrator said that he was informed of Resident #1's accident/incident at the Facility on [DATE] and responded to the Facility to initiate an investigation and assist the police who were on site and conducting an investigation.

Based on records reviewed and interviews, for two of six sampled residents (Resident #1 and Resident #5), who both had bed rails on their beds, the Facility failed to ensure they developed and implemented individualized comprehensive plans of cares that included interventions, treatment goals and measurable outcomes, when Resident #1 and Resident #5, Plans of Care did not include or address the installation and use of bed rails. Findings include: Review of the Facility's Policy titled Resident Assessment and Care Plan, dated as revised 10/01/17, indicated the Facility would develop and maintain an individualized interdisciplinary plan of care, treatment and services with appropriate education and training about each resident's care needs. The Policy indicated the care plan identifies the plan for the resident's care, treatment and services and how services will be provided. Review of the Facility's Policy titled Bed Rails, dated as released 11/28/17, indicated the facility will ensure the care plan reflects bed rail usage, including purpose of the bed rails. 1) Resident #1 was admitted to the Facility during December 2024 following a hospitalization with diagnoses that included right patella (kneecap) fracture and Parkinson's Disease. Review of Resident #1's Baseline Care Plan, dated 1/01/25, indicated side rails per resident request for turning and positioning. During an interview on 2/20/25 at 12:00 P.M., the Maintenance Director said that, on 1/02/25, at the request of nursing staff, he installed two half bed rails on Resident #1's bed. Resident #1's Admission Minimum Data Set Assessment, dated as completed 1/07/25, indicated his/her cognitive patterns were intact, he/she required partial or moderate assistance for bed mobility, substantial to maximum assistance to move from lying to siting on the edge of the bed and vice versa and was dependent for transferring between surfaces. Review of Resident #1's Comprehensive Care Plan indicated there was no documentation to support the Facility developed and implemented a care plan to address Resident #1's bed rail use. During a telephone interview on 2/26/25 at 2:30 P.M. the MDS Nurse said that it was an oversight that the use of bed rails were not included and developed as care planned area, and said that there were no interventions, goals or outcomes identified in Resident #1's care plan. 2) Resident #5 was admitted to the Facility during July 2024, with diagnoses that included low back pain and coronary artery disease. Resident #1's most recent Quarterly Minimum Data Set Assessment, completed 1/22/25, indicated his/her cognitive patterns were intact, he/she was independent for rolling side to side in bed and required supervision or physical assistance to move from lying to siting on the edge of the bed and vice versa and for transferring between surfaces. Review of Resident #5's physician orders indicated there was a physician order in place, dated 7/16/24, for two half rails. The Bed System Measurement Device Test Results Worksheet, dated 7/16/24, indicated the Maintenance Director applied a half rail to the right side of Resident #5's bed. Review of Resident #5's Comprehensive Care Plan indicated there was no documentation to support the Facility developed and implemented a care plan to address Resident #1's side rail use, until 2/11/25. During an interview on 3/03/25 at 2:40 P.M. the MDS Nurse said that it was an oversight that the bed rails were not included as an intervention on Resident #5's care plan between July 2024 and 2/11/25.

Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility failed to have an RN working at least eight consecutive hours for 16 days between 10/1/23 and 2/11/24, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Findings include: Review of the Fiscal Year Quarter One (dated 10/1/23 through 12/31/23) Payroll Based Journal (PBJ: reporting system to which nursing facilities report on staffing data) Report indicated that the facility reported No RN in the facility for eight consecutive hours on the following dates: -10/21/23 - 10/22/23 -11/4/23 - 11/5/23 -11/18/23 - 11/19/23 -11/24/23 -12/2/23 - 12/3/23 -12/17/23 -12/30/23 - 12/31/23 During an interview on 4/29/24 at 9:26 A.M., the Administrator said the facility had no Nurse staffing waivers. During an interview on 5/1/24 at 1:02 P.M., with the Administrator and the Director of Nursing (DON), the Administrator said there was no RN in the facility for the required eight consecutive hours on the dates reported on the PBJ Report. The Administrator said that one RN was on a leave of absence and one RN had resigned which impacted the facility's RN coverage between the period of 10/1/23 and 12/31/23. The DON said if no RN was scheduled to work in the facility, she would attempt to work with staffing agencies for RN coverage or ask another RN to cover the shift, or she would have to come in. The DON said RN staffing had improved and she would review payroll records to see whether any additional dates indicated the RN coverage requirement had not been met since 12/31/23. During a follow-up interview on 5/1/24 at 2:30 P.M., the DON said she reviewed Nurse staffing schedules after 12/31/23, and identified four more days (1/27/24, 1/28/24, 2/10/24, and 2/11/24), in addition to the dates reported on the PBJ Report, when the facility had no RN coverage. The DON provided the surveyor with her time card and said she was not in the facility on any of the additional four days identified to provide the required RN coverage.

Based on interview, record and policy review, the facility failed to provide privacy and confidentiality for one Resident (#50) out of a total sample of 13 residents. Specifically, for Resident #50, the facility staff failed to provide privacy while assisting with personal care in the facility shower room, when an unauthorized CNA (Certified Nurses Aide #1) entered the shower room to utilize their personal cell phone, and CNA #2 who was providing personal care did not cover or drape the Resident to prevent exposure of body parts. Findings include: Review of the facility policy for Cell Phone and Recording Devices, dated 9/1/11, indicated: -It is the policy of the facility that the use of cell phones and other recording devices is not permitted in resident care areas. -Resident care area is defined as any area inside or outside of the building designed for resident occupancy or use. This includes but is not limited to resident rooms and bathrooms, common areas and dining rooms, resident patios . -Examples of situations that constitute violation of this policy: using a device in a resident room, resident bathroom, or other resident area. Review of the facility policy for Quality of Life-Dignity, last revised February 2020, indicated: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. -Resident's private space and property are respected at all times -Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Resident #50 was admitted to the facility in November 2023 with diagnoses including: wedge compression fracture of the T5 and T6 vertebrae (the fifth and sixth bones) of the thoracic (part of the body between the neck and the abdomen) spine, non-traumatic subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover and protect the brain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #50 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) exam indicating that he/she was moderately cognitively impaired. Review of the Documentation Survey Report [CNA flow sheets] for April 2024 indicated that Resident #50 was showered by CNA #2 on 4/25/24, during the 3:00 P.M. to 11:00 P.M. evening shift. During an interview on 4/29/24 at 10:35 A.M., Resident #50 said that CNA #1 had been using their personal cell phone while he/she was being assisted with showering by CNA #2 on 4/25/24. Resident #50 further said that he/she felt embarrassed as he/she was naked, and was worried that CNA #1 could have been recording him/her with the personal cell phone. During an interview on 4/29/24 at 2:13 P.M., the Administrator said that CNA #1 should not have been in the resident shower room on their personal cell phone, and he had been using his cell phone in the resident shower area. During an interview on 4/30/24 at 3:37 P.M., CNA #2 said she saw CNA #1 enter the shower room while Resident #50 was being showered on 4/25/24. CNA #2 said that CNA #1 did not announce his presence and was on his personal cell phone. CNA #2 said CNA #1 should not have been using the cell phone in a resident shower area. When the surveyor asked if the Resident was covered while CNA #1 was in the shower room on his personal cell phone, CNA #2 said she continued to shower the Resident and did not cover him/her for privacy.

Based on interview, record and policy review, the facility failed to perform a trauma assessment on admission to the facility for two Residents (#7 and #45) out of a total sample of 13 residents. Specifically, the facility failed to assess whether Resident's #7 and #45 had any history of trauma, and/or any triggers which may cause re-traumatization to the Residents. Findings include: Review of the facility's policy titled Trauma Informed Care, last revised January 2023, indicated: -Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. -Include trauma informed care as part of the QAPI plan, so that needs, and problem areas are identified and addressed. -Implement universal screening of residents for trauma, including but limited to, upon admission and annually. 1. Resident #7 was admitted to the facility in December 2022 with a diagnosis of Bi-Polar Disorder (a serious mental illness characterized by extreme mood swings. They can include extreme excitement episodes or extreme depressive feelings). Review of Resident #7's medical record did not include any documentation that an assessment for trauma and the prevention of potential re-traumatization had been initiated. 2. Resident #45 was admitted to the facility in November 2022 with diagnoses including: Schizophrenia (a severe mental disorder characterized by delusions [false beliefs], hallucinations [perception of sights, sounds, etc. that are not actually present], incoherence and physical agitation) and Major Depressive Disorder. Review of Resident #45's medical record did not include any documentation that an assessment for trauma and the prevention of potential re-traumatization had been initiated. During an interview on 4/30/24 at 4:02 P.M., Social Worker (SW) #1 said that the trauma informed care assessments should be completed for all residents on admission and/or annually. SW #1 also said the trauma assessments had not been completed for Residents #7 and #45 and the assesments should have been completed.

Based on observation, interview, and record review, the facility failed to ensure that its staff adhered to infection control standards for one Resident (#25) out of a total sample of 13 residents. Specifically, the facility staff failed to perform appropriate hand washing/hygiene for four opportunities, during a wound care procedure to prevent contamination and the spread of infection. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene, issued January 2023 indicated the following: -Hand Hygiene is the final step after removing and disposing of personal protective equipment (PPE). -The use of gloves does not replace hand washing/hand hygiene. -Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. Review of the facility policy titled Personal Protective Equipment - Gloves, issued January 2023, indicated the following: -Wash your hands with appropriate alcohol-based hand sanitizer or soap and water after removing gloves. Review of the Centers for Disease Control Guidelines for Core Infection Prevention and Control Practices in All Settings indicated the following: >Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient. -Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. -Before moving from work on a soiled body site to a clean body site on the same patient. -After touching a patient or the patient's immediate environment. -After contact with blood, body fluids or contaminated surfaces. -Immediately after glove removal. Review of the Centers for Disease Control Hand Hygiene in Healthcare Settings Glove Use indicated the following: -Gloves are not a substitute for hand hygiene. -If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. -Perform hand hygiene immediately after removing gloves. -Change gloves and perform hand hygiene during patient care, if gloves become damaged, or visibly soiled with blood or body fluids following a task. -Change gloves and perform Hand hygiene when moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. -Never wear the same pair of gloves in the care of more than one patient. -Carefully remove gloves to prevent hand contamination. Resident #25 was admitted to the facility in November 2018, with diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and sacral pressure ulcer ([PU: localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device], sacral: a wound located above the buttocks). Review of the Minimum Data Set (MDS) Assessment, dated 7/30/23, indicated Resident #25 was severely cognitively impaired and rarely or never participated in daily decision making. Review of Resident #25's Physician's orders dated 5/1/24, indicated the following: -Sacrum: >wash NS (normal saline: sodium chloride and water mixture that can be used to cleanse wounds), >pat dry, >apply Alginate (wound care product used to absorb heavy drainage and promote healing), Skin Prep (skin care product used to form a protective barrier) to peri-wound (fragile skin found around a wound that is prone to injury), >cover with foam dressing, >may use Ostomy Paste (product used to fill uneven skin contours to create a flatter surface) to the lower peri-wound. Initiated 4/19/24. On 5/1/24 at 11:05 A.M., the surveyor observed the Assistant Director of Nurses (ADON) and Nurse #1 providing the following wound care for Resident #25's sacral wound: -Nurse #1 and the ADON performed hand hygiene and donned (put on) disposable gowns and gloves. -Nurse #1 removed the old sacral dressing and placed it in the trash receptacle. -Nurse #1 then removed her gloves and placed them in the trash receptacle. -Nurse #1 then put on clean gloves (without performing hand washing/hygiene first) and cleansed the wound as ordered. -Nurse #1 then removed her gloves and placed them in the trash receptacle. -Nurse#1 then put on clean gloves (without performing hand washing/hygiene first) and applied skin prep to the peri-wound area. -Nurse #1 then removed her gloves and placed them in the trash receptacle. -Nurse #1 then put on clean gloves (without performing hand washing/hygiene first) and applied the Alginate dressing to the wound. -Nurse #1 then removed her gloves and placed them in the trash receptacle. -Nurse #1 then put on clean gloves (without performing hand washing/hygiene first), reached into her pocket and retrieved a marker pen, initialed the outer foam dressing and placed the foam dressing on the Resident's wound. During an interview on 5/1/24 at 11:19 A.M., the ADON said that Nurse #1 did not perform hand hygiene after removing the soiled gloves and before putting on clean gloves because Nurse #1 would have had to leave the wound care supplies and go into the bathroom to wash her hands. During an interview on 5/1/24 at 11:30 A.M., Nurse #1 said that she sometimes brings a bottle of alcohol-based hand sanitizer into the room when she performs wound care. Nurse #1 said should have used an alcohol-based hand sanitizer each time she removed her gloves while providing wound care for Resident #25 but she did not use a hand sanitizer.

Based on interview, record and policy review, the facility failed to ensure that the Pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus that can range from ear and sinus infections to pneumonia and blood stream infections) Vaccination was administered to two Residents (#42 and #36) for five applicable residents, out of a total sample of 13 residents, increasing the Residents' risk for facility acquired Pneumococcal infections. Specifically, the facility staff failed to: -identify whether Residents #42 and #36 were up to date with their Pneumococcal Vaccinations. -administer the Pneumococcal Vaccine to Residents #42 and #36 when the Residents were not up to date with their Pneumococcal Vaccinations and were eligible to receive the Pneumococcal Vaccine. Findings include: Review of the facility's policy, titled Pneumococcal Vaccine, dated January 2023, indicated: -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. -Assessment of pneumococcal vaccination status will be conducted within 30 working days of the resident's admission if not conducted prior to admission. -Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. -Administration of the pneumococcal vaccines or re-vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. Review of CDC guidelines titled Pneumococcal Vaccination Timeline for Adults, dated 3/15/23, indicated the following for adults aged [AGE] years and older: -Make sure your patients are up to date with Pneumococcal Vaccination. -If no Pneumococcal doses have been received, administer either one dose of PCV20 (Pneumococcal Conjugate Vaccine/ Prevnar 20: vaccine used to protect against 20 types of pneumococcal bacteria that commonly cause serious infections) or one dose of PCV15 (Pneumococcal Conjugate Vaccine 15-valent: vaccine used to protect against 15 types of pneumococcal bacteria that commonly cause serious infections in adults) followed by one dose of PPSV23 (Pneumovax 23: vaccine used to help protect against serious infections caused by 23 types of pneumococcal bacteria) no earlier than one year following the administration of the prior PCV15 dose. -If one dose only of PCV13 (Prevnar 13: vaccine used to protect against 13 types of pneumococcal bacteria that commonly cause serious infections) has been received at any age, one dose of PCV20 or PPSV23 should be administered no earlier than one year following the administration of the prior PCV13 dose. 1. Resident #42 was admitted to the facility in December 2022 with diagnoses including: Diabetes Mellitus (disorder in which the body has high sugar levels for prolonged periods of time) and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment, and interferes with daily life activity). Review of Resident #42's medical record indicated the Resident was over [AGE] years of age. Review of Resident #42's May 2024 Physician's orders indicated an order, initiated 1/9/23 with no stop date, as follows: -May have Pneumococcal Vaccine. Review of Resident #42's 2023-2024 Immunization Consent Form, dated and signed by the Resident's Representative on 10/3/23, indicated that Resident #42's Representative consented to the administration of the Pneumococcal Vaccine for Resident #42. Review of Resident #42's Minimum Data Set (MDS) Assessment, dated 3/27/24, indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total points. Review of Resident #42's Immunization Report, printed and provided by the facility on 5/1/24, indicated the Resident received one dose of PCV13 on 3/27/23. Further review of Resident #42's Immunization Report indicated no evidence the Resident had ever received any other dose of the Pneumococcal Vaccine. 2. Resident #36 was admitted to the facility in February 2024 with diagnoses including: Chronic (persisting for a long time) Leukemia (type of cancer which affects the production and function of blood cells) and Diabetes Mellitus (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). Review of Resident #36's medical record indicated the Resident was over [AGE] years of age. Review of Resident #36's Physician's orders dated 2/22/24, with no stop date, indicated: -May have Pneumococcal Vaccine. Review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15 total points. Review of Resident #36's Immunization Consent Form, dated and signed by the Resident on 2/22/24, indicated the Resident wished to receive the Pneumococcal Vaccine if it was indicated. Review of Resident #36's Immunization Report, printed and provided by the facility on 5/1/24, indicated no evidence the Resident had ever received Pneumococcal Vaccination. During an interview on 4/30/24 at 10:27 A.M., the Infection Preventionist (IP) said he began working at the facility about 30 days prior to survey as the IP and that he was responsible for overseeing resident vaccines. The IP said he had not offered Pneumococcal Vaccines to any residents other than new admissions over the previous 30 days and that he would review Residents #42 and #36 medical records regarding their Pneumococcal Vaccination status. The IP further said that the facility was behind on Pneumococcal Vaccinations for residents. During an interview on 5/1/24 at 10:05 A.M., the IP said he located some vaccine information in the Massachusetts Immunization Information System (MIIS) for Residents #42 and #36 and that the immunization records generated for both Residents from the MIIS had been uploaded into the Resident's electronic medical record (EMR). On 5/1/24 at 1:32 P.M., the surveyor and the IP reviewed the facility's Pneumococcal Vaccine Policy and Immunization Records for residents #42 and #36. During an interview at the time, the IP said he realized approximately one week prior to the survey period that the facility was not in compliance with offering and administering Pneumococcal Vaccinations for residents and that he ran a facility-wide audit, but had not had the opportunity to assess each residents' vaccination status. The IP said Resident #36 was recently admitted to the facility, in February 2024, and that the Resident's Pneumococcal Vaccination status had not been assessed until the surveyor's inquiry (more than 30 days following the Resident's admission to the facility). The IP also said he was not aware that Resident #42 and Resident #36 were not up to date and were eligible for Pneumococcal Vaccinations until after the surveyor's inquiry.

Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded for two Residents (#45 and #55), out of a total sample of 13 residents. Specifically, the facility failed to ensure that: 1. Two consecutive MDS Assessments for Resident #45 were accurately coded relative to the use of psychotropic (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medications. 2. One MDS Assessment for Resident #55 was accurately coded relative to the Resident's discharge status. Findings include: 1. Resident #45 was admitted to the facility in November 2022 with diagnoses including Schizophrenia (a severe mental disorder characterized by delusions [false beliefs], hallucinations [perception of sights, sounds, etc. that are not actually present], incoherence and physical agitation) and Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy). Review of Resident #45's care plans, last revised 3/12/24 indicated: -The Resident had Depression related to their disease process. -The Resident was at risk for falls due to psychoactive (medication that affects how the brain works) drug use. Review of Resident #45's MDS assessments dated 2/21/24 and 4/9/24, did not indicate that the Resident was receiving antidepressant medication. Review of Resident #45's Physician's orders for April 2024 indicated the following prescribed medications: -Celexa (antidepressant) 10 milligrams (mg), with a start date of 2/19/24 . -Remeron (antidepressant) 7.5 mg, with a start date of 2/15/24. During an interview on 5/1/24 at 1:24 P.M., the MDS Nurse said that the 2/21/24 and 4/9/24 MDS assessments had been inaccurately coded and that Resident #45's MDS assessments should have been coded as receiving antidepressant medications. 50138 2. Resident #55 was admitted to the facility in December 2023 with diagnoses including: Hypertension (HTN: high blood pressure. When the blood pressure measures consistently above 130/80 millimeters of mercury [mm Hg]). Review of Resident #55's Physician's orders dated 2/7/24, indicated: -May discharge home with meds (medications) and services. Review of Resident 55's Nurse Practitioner (NP) Progress Note dated 2/7/24, indicated that Resident #55 could be discharged home with medications and services. Review of the Nurse Progress Note dated 2/7/24, indicated that Resident #55 was discharged home in the care of family. Review of Resident #55's Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident was discharged to the hospital. During an interview on 5/1/24 at 12:04 P.M., the MDS Nurse said the coding was inaccurate on the MDS assessment dated [DATE], for Resident #55. The MDS Nurse said Resident #55 was discharged home so the discharge location should have been coded as discharge to home/community.

Based on record review and interview the facility failed to ensure that its staff honored the wishes for one Resident (#45) out of 13 total sampled residents for advanced directives (a person's wishes regarding medical treatment). Specifically, the staff failed to accurately document and execute a Medical Orders for Life-Sustaining Treatment (MOLST - a medical order form that converts an individual's wishes regarding life-sustaining treatment into medical orders) form for Resident #45. Findings include: Review of the facility policy titled Medical Orders - Life Sustaining Treatment revised [DATE] included: -purpose .to ensure that resident/responsible party's wishes concerning life sustaining treatment are documented properly and respected to the extent possible by the facility. -MOLST forms should be re-discussed with the resident/responsible party periodically, as necessary, and revised as needed to ensure that it accurately reflects treatment preferences. Resident #45 was admitted to the facility in [DATE]. Review of the Resident's clinical record showed evidence of two MOLST forms filed under the advanced directive section of the record. The MOLST forms were both located in one plastic sleeve with the first MOLST covering up the second more recent MOLST form. The first MOLST form signed by the Resident's Health Care Proxy (HCP - a person that you trust as your proxy, or agent, to express your wishes and make health care decisions for you) on [DATE], was cosigned by the Resident's physician on [DATE], and indicated that the Resident would be considered a Do Not Resuscitate (DNR - do not perform cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating). The second MOLST form was signed by the Resident on [DATE], but was not cosigned by any advanced practitioner, and indicated that the Resident wished for resuscitation to be attempted in the event that he/she stopped breathing or if his/her heart stopped beating. Review of the Care Plan Meeting note dated [DATE] indicated that the Resident's HCP had not been invoked (made active) by the advanced practitioner, indicating that the Resident still made his/her own decisions regarding health care. Review of the Minimum Data Set Assessment, dated [DATE], indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status. Review of the Social Service (SS) progress note dated [DATE] indicated .Discussed current MOLST . with patient individually. Per pt (patient) request, discussed with both pt and spouse .current MOLST directives .DNR .Pt would like to change MOLST after discussing with spouse in person. Review of the Resident's current Physician's orders dated [DATE] indicated that the Resident's status for advanced directives was a DNR, order initiated [DATE]. During an interview on [DATE] at 12:03 P.M., Nurse #1 said that if a resident was unresponsive, she would go and look in the chart to determine if the patient should be resuscitated or not by reviewing the MOLST form. When asked what she would do for Resident #45 if he/she became unresponsive, Nurse #1 reviewed the Resident's record and said that Resident #45 was a DNR per the MOLST, so she would not perform CPR. After the surveyor pointed out that there were actually two MOLST forms in the record, Nurse #1 reviewed the two MOLST forms. The Nurse said that both forms were actually invalid because the first MOLST form dated [DATE] was signed by the HCP which was not invoked and should have been signed by the Resident, and that the second MOLST form was never signed by the Physician. Nurse #1 said that there were actually no valid advanced directives in place. Nurse #1 said that after reviewing the forms she decided that she would perform CPR for Resident #45 if he/she became unresponsive During an interview on [DATE] at 4:40 P.M., the Director of Nursing (DON) said that she spoke with the Resident in [DATE] after she identified that the current MOLST dated [DATE] was signed by the HCP and not the Resident, even though the HCP was not invoked. The DON further said that she met with the Resident in [DATE] and the Resident said that he/she wished to be a full code (wished to be resuscitated if his/her breathing stops or if his/her heart stops beating). The DON said that she assisted the Resident in completing a new MOLST form on [DATE], and the Physician was notified. The DON was not able to provide any documentation that the Physician was notified about the updated MOLST form. The DON said that she thought the MOLST form had been completed and placed in the Resident's clinical record. After reviewing the two MOLST forms located in the Resident's record, the DON acknowledged that both MOLST forms were invalid as the HCP should not have signed for the Resident on [DATE] and the Physician did not sign the MOLST form dated [DATE].

Based on record review and interview, the facility failed to ensure that its staff completed a timely Level One Preadmission Screening and Resident Review (PASRR) for one Resident (#6) before the Resident was admitted to the facility. Specifically, the facility failed to ensure that its staff completed a Level One PASRR for Resident #6 prior to him/her being admitted to the facility when the Resident had documented mental illness and was likely to require more than 30 days of care. Findings include: Resident #6 was admitted to the facility in April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's clinical record included the following: - A Baseline Care Plan, dated 4/1/22, which indicated that the Resident's goal was to reside at the facility. - A Social Service Note, dated 4/8/22, which indicated that the Resident had been admitted to the facility, from another long term care facility, for long term care. - A Level One PASRR which was not completed prior to the Resident's admission to the facility, and was dated 5/31/22. During an interview on 11/2/22 at 9:22 A.M., the Admissions Director said that Level One PASRRs were required to be completed prior to residents being admitted to the facility and that the purpose of completing the Level One PASRR was to determine whether a resident required further evaluation of needs for specialized services related to mental illness or intellectual disability. She said that staff at the facility had been having some difficulty getting Level One PASRRs completed timely within the previous one to one and a half years due to workload. The Admissions Director said that Resident #6 was admitted to the facility for long term care from another long term care facility and that the Level One PASRR should have been completed prior to him/her being admitted , but it was not. The Admissions Director said that she had no further explanation for why the Level One PASRR had not been completed timely, as required.

Based on observation, interview and record review the facility failed to ensure that 1) for Resident #1, the facility followed a Physician's order for a pressure wound to the left heel, and, 2) for Resident #37, failed to implement a care plan intervention for the use of a seat cushion as part of the skin integrity care plan when the Resident had been identified as being at risk, in a total sample of 13 Residents. Findings include: 1. Resident #1 was admitted to the facility in June 2022. Review of a Physician's order, implemented 10/25/22, indicated the following: -Wash left heel wound with normal saline, pat dry. -Apply a thin later of [MEDICATION(S)] (antibacterial ointment) -Cover with gauze -Wrap with Kling wrap (a gauze roll) During an observation on 11/2/22 at 3:00 P.M., the surveyor observed Nurse #3 perform a dressing change to Resident #1's left heel. When Nurse #3 removed the Resident's sock, a 2 X 2 piece of gauze covered with tape was observed covering the wound. No Kling gauze wrap was observed per the Physician's order. During an interview at this time with Nurse #3, she said the previous dressing did not include the use of the Kling gauze wrap. See F880 2. Resident #37 was admitted to the facility in July 2022. Review of the Resident's care plan for skin integrity indicated the Resident had the potential for skin alterations because of a decrease in mobility, a decrease in the ability to position himself/herself, nutritional problems, and incontinence. One intervention to prevent an alteration in skin integrity was the use of a pressure relieving cushion to the Resident's wheelchair. On 11/3/22 at 2:45 P.M., the surveyor observed Resident #37 in a common area seated in a wheelchair. No pressure cushion was observed. During an interview with Nurse #5 at that time, she said the Resident did not have the pressure relieving cushion on his/her wheelchair per the care plan.

Based on observation, interview, and record review, the facility failed to ensure that its staff provided care and services to maintain an indwelling urinary catheter (tube inserted into the body used to drain urine from the bladder) for one Resident (#26), according to the Resident's plan of care. Specifically, facility staff failed to provide documented evidence that Resident #26 was provided with monthly follow-up visits to the Urologist (a doctor who specializes in the study or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #26 was admitted to the facility in January 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Discharge Tracking Minimum Data Set, dated dated [DATE], indicated that Resident #26 had an unplanned discharge to the acute hospital, and he/she was anticipated to return to the facility. Review of the Resident's acute hospital admission History and Physical, dated 6/26/22, included that the Resident presented to the hospital with lethargy, high-grade fever, and decreased appetite. Further review of the document included the following: - The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . - Acute issues included [CONDITION(S)] (body's extreme response to an infection, which can start in the urinary tract, and is considered a medical emergency) and [CONDITION(S)]. - The plan included to consult Urology. Review of a Nurse Progress Note, dated 6/30/22, indicated that Resident #26 had returned to the facility and included that a note was left for the incoming staff to make an appointment with the Urologist who would replace the SP catheter every month. Review of the Resident's active Indwelling Catheter Care Plan included the following: - Resident #26 had an indwelling SP urinary catheter. - Special needs/considerations, updated 6/30/22, included that the Resident had experienced [CONDITION(S)] .and was positive for a [CONDITION(S)]. - An additional entry, dated 7/5/22, included that the Resident's SP tube was to be changed monthly in the office status post [MEDICAL RECORD OR PHYSICIAN ORDER] - An undated intervention that indicated that the Resident's SP tube could be changed at the facility if it became clogged or dislodged. Review of a Nurse Progress Note, dated 7/24/22, included that the Resident presented with lethargy and a high temperature, and required a transfer to the acute hospital. Review of the Resident's acute care hospital Discharge Summary, dated 7/27/22, included that the Resident had been admitted to the hospital due to a catheter associated [CONDITION(S)], Urology was consulted, and the Resident's SP catheter was replaced. Review of a Nurse Progress Note, dated 7/28/22, included that Resident #26 returned to the facility from the hospital on 7/27/22. Review of a Social Service Progress Note, dated 8/5/22, included that a care plan review meeting had been held and that care plan focus areas had been reviewed. There was no evidence that any revisions were made for the Indwelling SP Catheter Care Plan related to the entry for the Resident to have his/her SP tube changed monthly in the office. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the November 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - An order, initiated 4/9/19 with no stop date, which indicated: May have Urology follow-up as needed. - An order, initiated 4/24/19 with no stop date, which indicated: SP tube maintained by Urology as ordered; may be changed in-house as needed. - An order, initiated 6/15/21 with no stop date, which indicated: May change SP catheter in-house as needed if clogged or dislodged, based on clinical indication of infection, or if closed system is compromised. Review of the clinical record included no documented evidence that Resident #26 had his/her SP catheter changed more than one time since his/her return from the acute hospital on 6/30/22, and there was no evidence that the Resident had been to the Urologist monthly, as indicated in the care plan, since 7/5/22. During an interview on 11/3/22 at 11:00 A.M., the Director of Nursing (DON) reviewed Resident #26's clinical record with the surveyor and said that she was unable to locate evidence that the Resident had been to the Urologist to have his/her SP catheter changed, according to the Resident's Care Plan, but that she would contact the Urology office to request notes from the Resident's appointments there. On 11/7/22 at 12:36 P.M., the surveyor made a follow-up request to the DON for evidence of Resident #26's Urology appointments since 7/5/22, but no evidence was provided. During an interview on 11/7/22 at 2:10 P.M., Nurse #5 said that she had worked at the facility for a couple of months and, to her knowledge, Resident #26 had never had an appointment to see the Urologist since she had worked there. No documented evidence that Resident #26 had been to the Urologist to have his/her SP catheter changed monthly, as indicated in the care plan on 7/5/22, was provided to the surveyor before the time of survey completion on 11/7/22.

Based on interviews and records reviewed for one of four sampled residents (Resident #1), whose Health Care Proxy was activated, the Facility failed to permit Resident #1 to return to the Facility following an evaluation in the Hospital Emergency Department (ED) on 4/19/22 due to a change in mental status. As a result of the facility not permitting Resident #1 to return to the facility, he/she remained in the Hospital ED for three weeks, while the Hospital searched for alternative placement for him/her. Findings include: Review of the Admission Agreement, undated, indicated that before the Facility sought to involuntarily discharge a resident, the Facility shall give the resident and their representative written notice of the proposed discharge. The Admission Agreement indicated the written notice provided by the Facility to the resident and the representative would include the reasons for the proposed discharge, the effective date of the proposed discharge, the location to which the resident would be discharged , a notice of the rights of the resident to appeal the discharge and the names and telephone numbers of agencies available to furnish the resident with legal and other assistance. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nursing Progress Note, dated 4/19/22 at 2:42 P.M., indicated that Resident #1 was noted to have increased agitation and confusion and an order was obtained from the physician to transfer Resident #1 to the Hospital Emergency Department (ED) for further evaluation and treatment. Review of the Facility's Internal Investigation, dated 4/19/22, indicated that following an incident in which Resident #1 wandered into Resident #2's room and displayed sexually inappropriate behaviors, Resident #1 was transported to the Hospital Emergency Department (ED) for evaluation and would not be returning to the Facility. During an interview on 5/24/22 at 4:00 P.M., Family Member #1 said that she was Resident #1's Health Care Agent. Family Member #1 said that on 4/19/22 the Facility notified the family that there had been an incident with Resident #1 and another resident (Resident #2), so she went to the Facility to see what happened. Family Member #1 said that she spoke to the Director of Admissions and the Social Worker and they told her that Resident #1 would be transferred to the Hospital ED for a change in his/her mental status Family Member #1 said when she met with the Director of Admissions and the Social Worker on 4/19/22, they never said Resident #1 was not going to be readmitted . Family Member #1 said that the Director of Admissions told her that Resident #1 might not be allowed to return to the Facility, unless the Hospital could identify a specific and remediable cause for Resident #1's change in mental status. Family Member #1 said that while Resident #1 was in the ED, a psychiatric clinician called her and said that Resident #1 had dementia which was the cause of his/her behavior at the Facility on 4/19/22. Family Member #1 said that the psychiatric clinician told her that when she called the Facility about sending Resident #1 back to the Facility, the Facility refused to take Resident #1 back. Family Member #1 said, Resident #1 remained in the ED while the Hospital case management department looked for a bed for Resident #1 in another skilled nursing facility. Family Member #1 said that Resident #1 spent more than a week in the ED and the Manager of Case Management told her that the Hospital sent out over fifty referrals to skilled nursing facilities without securing a bed for Resident #1. Family Member #1 said she contacted the Social Worker at the Facility and the Social Worker told her that Resident #1 still could not be readmitted to the Facility. Review of the Hospital Discharge Summary, dated 6/01/22, indicated that Resident #1 was in the Hospital ED from 4/19/22 until 5/10/22 (twenty-one days) and the hospital case manager was unable to find placement for him/her. The Summary indicated that Resident #1 was admitted to the Hospital from the emergency department on 5/10/22 due to hypothermia and worsening dementia and the hospital subsequently discharged Resident #1 to short-term rehab on 6/01/22, forty-three days after he/she arrived in the emergency department. During an interview on 5/23/22 at 9:00 A.M. the Director of Admissions and on 6/07/22 at 5:11 P.M., the Social Worker said that they met with Family Member #1 together at the facility on 4/19/22 following an incident with Resident #1. The Director of Admissions and the Social Worker said that they talked to Family Member #1 about Resident #1's transfer to the hospital for an evaluation following his/her significant change in mental status. The Director of Admissions and the Social Worker said that during the meeting, they told Family Member #1 that Resident #1 might not be allowed to return to the Facility because of his/her mental status and change in behavior. During an interview on 5/23/22 at 12:50 P.M., the Administrator said that the Hospital called him at about 8:00 P.M. on 4/19/22 and asked to send Resident #1 back to the Facility. The Administrator said that he told the hospital that the Facility could not take Resident #1 back. During an interview on 6/03/22, the Manager of Case Management at the hospital said that the Hospital ED told her that Resident #1 needed referral to skilled nursing facilities because the Facility would not take Resident #1 back. The Manager of Case Management said that Resident #1 was appropriate for long-term care at a skilled nursing facility. The Manager of Case Management said that at one point, after Resident #1 had spent several days in the ED, she checked with the Facility Director of Admissions about whether Resident #1 could return to the Facility. The Manager of Case Management said the Director of Admissions told her that the Facility would not readmit Resident #1 because of the incident that had occurred between Resident #1 and another Facility resident (Resident #2). The Director of Admissions said that several days into Resident #1's hospitalization , the Manager of Case Management at the hospital contacted her and asked her about Resident #1 being able to return to the Facility. The Director of Admissions said that she told the Manager of Case Management that the Facility could not take Resident #1 back. The Social Worker said that several days after Resident #1 was transferred to the hospital, Family Member #1 called her and asked if Resident #1 could return to the Facility. The Social Worker said that although she did not really understand all of the details of Resident #1's transfer and discharge to the hospital, said she knew that the Facility would not allow Resident #1 to return.

Based on record reviews and interviews, for 1 of 3 sampled residents (Resident #1), The Facility failed to provide adequate supervision and effective interventions to prevent a fall with injury. -Resident #1's Care Plan for incontinence had not been revised since 1/17/13 with new interventions to meet his/her current toileting needs. The plan indicated Resident #1 was to be assisted to use the bathroom before meals. Resident #1 was not toileted before or after the dinner meal on 9/22/14 as per the care plan. - Resident #1's plan of care included the use of a personal alarm, but on 9/22/14, Resident #1's alarm did not sound to alert the staff Resident #1 was ambulating without assistance; -The DON said although the staff were not assigned to supervise the dining area, staff were expected to distantly supervise the dining area after dinner when residents were in the dining area. On 9/22/14, Resident #1, who was previously seated in the dining room following the supper meal, ambulated from the dining area to his/her bathroom alone; staff were unaware he/she exited the dining area without assistance, and at 7:45 P.M., Nurse #2 observed Resident #1 on the floor in the bathroom. Resident #1 sustained fractured right humerus (long bone in the arm). Findings include: The Facesheet indicated staff admitted Resident #1 to the Facility in January 2013 with [DIAGNOSES REDACTED]. The Resident Care Plan, dated 1/17/13, related to Resident #1's incontinence, included: prompted toileting upon waking, with morning care, before meals, after activities, with afternoon care, at bed time, and as needed (prn). The Resident Care Plan, related to mobility deficit, dated 1/17/13, included one assist with ambulation and transfer activities. The Resident Care Plan, related to fall risk, dated 1/17/13, included the use of a chair alarm. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 7/11/14, indicated Resident #1 had cognitive impairment. The MDS Assessment indicated one staff was required to assist Resident #1 with transfer activities, toileting, and ambulation. The certified nurse aide (CNA) Kardex, that was not dated, indicated Resident #1 was impulsive, forgetful, and at risk for falls. The Occupational Therapy note, dated 8/15/14, indicated Resident #1 was to be supervised at all times during transfers to the bathroom and mobility with a rolling walker. The Surveyor interviewed Occupational Therapist (OT) #1 at 2:36 P.M., on 10/15/14. OT #1 said Resident #1 required supervision with ambulation and toileting. OT #1 said Resident #1 required a supervised area when not in bed. OT #1 said a supervised area was an area where staff would notice if a resident stood and attempted to leave the area. The Surveyor interviewed the Director of Nurses (DON) at 10:12 A.M., on 10/15/14. The DON said Resident #1 frequently attempted to self ambulate to and from his/her bed and was frequently incontinent of bowel and bladder functions. The Surveyor interviewed Nurse #1 at 10:45 A.M., on 10/15/14. Nurse #1 said he checked Resident #1's chair alarm on 9/22/14 in the dining area prior to the dinner meal being served and there were no issues. Nurse #1 said Resident #1 stayed in the dining area after dinner, which was his/her usual routine. The Surveyor interviewed CNA #5 at 12:32 P.M., on 10/15/14. CNA #5 said on 9/22/14, during the evening shift, she was assigned to Resident #1. CNA #5 said she was not familiar with Resident #1's plan of care. CNA #5 said she observed Resident #1, at 3:30 P.M. on 9/22/14, in bed and did not assist Resident #1 to the bathroom. CNA #5 said when she returned from her break at approximately 4:00 P.M., on 9/22/14, she observed Resident #1 in the dining area, seated in his/her chair, and his/her chair alarm was functioning. CNA #5 said she did not assist Resident #1 to the bathroom, before or after dinner. CNA #5 said Resident #1 remained seated in the dining area after dinner, per his/her usual routine. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 3:30 P.M., on 10/15/14. The Surveyor interviewed CNA #3 at 3:40 P.M., on 10/15/14. The Surveyor interviewed CNA #4 at 3:23 P.M., on 10/15/14. The Surveyor interviewed Nurse #2 at 11:50 A.M., on 10/17/14. Nurse #2, and CNA #2 said Resident #1 did not have a toileting schedule. Nurse #2, CNA #1, CNA #3, and CNA #4 said when Resident #1's alarm sounds, Resident #1 usually has to go to the bathroom. This was not consistent with Resident #1's Care Plan. CNA #3 said Resident #1 occasionally asked to use the bathroom. CNA #1 said the staff checked the dining area every 15 minutes after dinner, while residents remained in the dining area. CNA #1 said the staff were not able to hear alarms from residents who were seated in the dining area when they provided personal care to residents at the end of the hallway. CNA #4 said he observed Resident #1, at approximately 6:00 P.M. on 9/22/14, sitting in the dining area and did not observe Resident #1 again, prior to his/her fall in the bathroom. CNA #1 said she saw Resident #1, at approximately 6:30 P.M. on 9/22/14, sitting in his/her chair in the dining area. CNA #1 said she did not go into the dining area after 6:30 P.M. and did not observe Resident #1 prior to his/her fall in the bathroom. Nurse #1 said his shift usually ended at 7:00 P.M. Nurse #1 said at 7:00 P.M., on 9/22/14, he sat at the nurses' station and completed paperwork. Nurse #1 said he often left the nurses' station while completing his paperwork to perform different tasks on the nursing unit. Nurse #1 said between 7:00 P.M. and 7:40 P.M., on 9/22/12, he was at the nurses' station completing paperwork and giving report to Nurse #2. Nurse #1 said he did not recall if he left the nurses' station between 7:00 P.M. and 7:40 P.M, but he did not hear Resident #1's alarm sound and did not observe Resident #1 walk past the nurses' station to his/her room between 7:00 P.M. and 7:40 P.M. on 9/22/14. The Nurse's note, dated 9/22/14, indicated Resident #1 transferred himself\herself to the bathroom without staff assistance, and the chair alarm did not sound. The Nurse's note indicated Resident #1 was incontinent of a large loose stool in the bathroom, slipped, and sustained a fall. The Nurse's note indicated Resident #1 had right arm swelling and right arm pain. The Nurse's note indicated the staff transferred Resident #1 to the Emergency Department (ED). Nurse #2 said her shift started at 7:00 P.M. on 9/22/14. Nurse #2 said after shift report, she made rounds on Resident #1's unit. Nurse #2 said Resident #1 was not in his/her room and was usually in the dining area. Nurse #2 said she did not go to the dining area between 7:00 P.M. and 7:40 P.M., and therefore, did not observe Resident #1. Nurse #1 said he checked Resident #1's chair alarm on 9/22/14 in the dining area prior to the dinner meal being served and it was functioning. Nurse #1 said Resident #1 stayed in the dining area after dinner, which was his/her usual routine. CNA #4 and CNA #5 said between 7:00 P.M. and 7:40 P.M. on 9/22/14, they provided personal care to residents and did not check the dining area during that time. Nurse #2 said she was passing medications on Resident #1's unit at 7:40 P.M. on 9/22/14, and responded to Resident #1's bathroom light. Nurse #2 said she observed Resident #1 on the bathroom floor and Resident #1 was incontinent of feces. During a tour of nursing unit 2 at 10:30 A.M., on 10/15/14, the Surveyor observed a glass window in the dining area that provided visualization of the dining area from the nurses' station, the nurses' station was between the dining area and Resident #1's room and Resident #1's room was directly across from the nurses' station. The Surveyor observed that Resident #1 would have to walk directly past the nurses' station from the dining area to arrive at his/her room. The Surveyor interviewed the Director of Nurses (DON) at 10:12 A.M., on 10/15/14. The DON said she investigated Resident #1's fall. The DON said Resident #1 sat in the dining area on 9/22/14 after dinner per his/her usual routine. The DON said none of the staff assigned to Resident #1's unit, during the evening shift on 9/22/14, observed Resident #1 leave the dining area. The DON said her investigation indicated Resident #1's chair alarm did not sound on 9/22/14, and no one investigated why the chair alarm did not sound. The DON said staff are not assigned to monitor the dining area after meals. The DON said although the staff were not assigned to supervise the dining area, staff were expected to distantly supervise the dining area after dinner when residents were in the dining area. The DON said supervision was defined as observations made every 15 minutes, not for 15 consecutive minutes. The DON said Resident #1 had a right humeral fracture sustained from a fall on 9/22/14.