Every finding on record at Center For Extended Care at Amherst

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was non-ambulatory and per his/her care plan required the assistance of two staff members with a mechanical lift for all transfers, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions for transfers, when on 03/14/26, Certified Nurse Aide #1 transferred Resident #1 by herself using a stand pivot transfer technique, Resident #1 was later diagnosed with a left ankle fracture. Findings include:Review of the Facility Policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated that care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The Policy indicated that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/16/26, indicated that during care on 03/15/26, staff noted Resident #1's left foot and ankle was bruised and swollen. The Report indicated that Resident #1 had no signs or symptoms of pain at that time. The Report indicated that an X-ray was ordered and completed on 03/16/26 and the results showed a fracture of the left distal fibula. The Report also indicated that CNA #1 told the Nurse Supervisor that she had transferred Resident #1 into bed alone, without the use of a mechanical lift, on the evening of 03/14/26. The Report indicated that Resident #1 was sent to the Emergency Department for evaluation and treatment. Review of Resident #1's Hospital Discharge Note, dated 03/17/26, indicated the following:-bluish bruise to left side of forehead-diffuse osteopenia (reduced bone density) -acute comminuted (when bone shatters into three or more pieces) and minimally displaced [NAME] type B ankle fracture (break at the level of the fibrous joint that connects the fibula and the tibia, often resulting from twisting injuries or falls). -acute nondisplaced medial malleolar (inner ankle) fracture -diffuse soft tissue swelling about the ankle. Resident #1 was admitted to the Facility in October 2019 with diagnoses including dementia with behavioral disturbance, osteoporosis (decreased bone density and quality, making bones weak and brittle), left side hemiplegia (paralysis or weakness) due to unspecified cerebrovascular disease, history of falls, and unsteady on feet. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/10/26, indicated he/she was severely cognitively impaired with a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 was non-ambulatory, and dependent on staff for mobility and Activities of Daily Living (ADL). Review of Resident #1's ADL Care Plan, reviewed and renewed with the Quarterly MDS completed 01/10/26, indicated interventions initiated in August 2025 (and still current) included that he/she required the use of a mechanical lift with assistance from two staff members for all transfers due to cognitive and physical deficits, including hemiplegia and dementia. The ADL Care Plan also indicated that Resident #1 was non-weight bearing with transfers.Review of Unit Manager #1's Written Summary of her interview with Certified Nurse Aide (CNA) #6, dated 03/15/26, indicated that CNA #6 reported that while providing care to Resident #1 with CNA #2, on the morning of 03/15/26, they observed a bruise on Resident #1's ankle and immediately notified the nurse. Review of Unit Manager #1's Written Summary of her interview with Certified Nurse Aide (CNA) #1, dated 03/15/26, indicated that CNA #1 told Unit Manager #1 that on 3/14/26, she had transferred Resident #1 without assistance from a second staff member and had not used any assistive devices. The Summary indicated that upon learning that CNA #1 had not used the mechanical lift and had not provided the required level of assistance when transferring Resident #1, she was immediately suspended.During an interview on 04/07/26, Unit Manager #1 said she worked the day shift as the Nurse Supervisor on 03/15/26, when Resident #1's bruise was reported by CNA #2. Unit Manager #1 said she immediately initiated an investigation and reviewed the schedule to determine who had worked the previous shift(s).Unit Manager #1 said that Resident #1 was on CNA #1's assignment from 3:00 P.M. on 03/14/26 through 7:00 A.M. on 03/15/26. Unit Manager #1 said that CNA #1 told her that she transferred Resident #1 alone, without the mechanical lift, and used a stand pivot transfer technique with him/her. The Unit Manager further said there were no documented falls or incidents involving Resident #1 during the shifts prior to the discovery of the ankle fracture. Unit Manager #1 said that she attributed the injury to CNA #1 transferring Resident #1 alone without the use of the mechanical lift, which was contrary to Resident #1's Plan of Care. Unit Manager #1 further said that Resident #1 was frail, non-ambulatory and non-weight bearing, and that his/her care plan intervention to provide transfers with assistance from two staff and a mechanical lift had been in place for a long time. Review of Certified Nurse Aide #1's schedule indicated she worked on Resident #1's Unit as follows: -03/14/26 from 3:00 P.M. to 03/15/26 until 7:00 A.M. Review of Resident #1's ADL Flow Sheets dated 03/14/26 and 3/15/26, indicated CNA #1 provided Resident #1's care on the evening and overnight shifts. Review of the Director of Nurses (DON) and Assistant Administrator's (AA) Written Summary of their interview with Certified Nurse Aide (CNA) #1, dated 03/18/26, indicated that CNA #1 reported Resident #1 had a good night on 03/14/26 with no behaviors. The Summary indicated that CNA #1 told the DON and the AA that she had transferred Resident #1 to bed without a second staff member for assistance, by performing a stand-pivot transfer as she always does. The Summary indicated that when CNA #1 told the DON that she was unaware of and had not reviewed Resident #1's Care Plan, the DON showed her documentation that indicated she had been educated during orientation on that requirement.The Surveyor was unable to interview Certified Nurse Aide #1 as she did not respond to the Department of Public Health's requests for an interview. During an interview on 04/07/26 at 3:08 P.M., Certified Nurse Aide #3 said she worked the evening shift on 03/14/26, on Resident #1's unit. CNA #3 said that she was familiar with Resident #1's care needs and that he/she required a mechanical lift and two staff members to transfer safely.CNA #3 further said that staff typically ask one another for assistance when transferring residents who require two-person support; however, CNA #1 did not request her assistance when transferring Resident #1 that evening. During an interview on 04/07/26 at 3:18 P.M., Certified Nurse Aide #5 said that he worked the evening shift on 03/14/26, on Resident #1's unit. CNA #5 said that Resident #1 required a mechanical lift and assistance from two staff members to transfer, and that CNA #1 did not request his help with Resident #1's transfers that evening. During an interview on 04/07/26 at 2:17 P.M., the Director of Nurses (DON) said that CNAs were expected to reference the Care Plan to determine the necessary interventions for each resident, and that CNAs were educated on the need to reference the Care Plan for residents on their assignment. The DON said the Care Plan interventions were readily accessible to the CNAs in the section of the EHR where they document. The DON said that CNA #1 told her that she was unaware of the Care Plans, despite having signed off on the training and education she had received during her orientation. The DON further said that CNA #1 should have referenced Resident #1's Care Plan and that it was not her first time caring for him/her. The DON said that CNA #1 should have used a mechanical lift and gotten a second staff member to assist her when she transferred Resident #1 on 03/14/26.On 04/07/26, the Facility presented the Surveyor with a plan of correction with an effective date of 03/20/26, that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) 03/15/26, Nursing immediately assessed Resident #1's injuries, notified the provider, and X-rays were ordered. The X-ray was completed on 03/16/26 and results were positive for left ankle fracture, with a plan for an orthopedic consult on 03/17/26. An ankle wrap provided and Resident #1's pain was managed.B) 03/17/26, The Facility was unable to obtain a same-day orthopedic consult, therefore Resident #1 was sent to the Emergency Department for further evaluation and a splint was applied to his/her left ankle.C) The Director of Nurses (DON) and Staff Development Coordinator (SDC) reviewed CNA #1's education file and confirmed that she had received education on locating and referencing resident care plans, during her orientation to the facility on [DATE]. D) 03/18/26 through 03/20/26, the SDC trained all nursing staff related to the provision of direct care, regarding the requirement to review and follow the residents' plan of care with every encounter. Education was validated with a post test. E) Effective 03/18/26 The Director of Nurses and Unit Manager #1 initiated weekly random observational audits across all shifts to ensure staff were following the care planned interventions for resident transfers. The audits are scheduled to be completed weekly for four weeks and then monthly for three months. F) An Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted, and the audit results will be presented during the Facility's April 2026 QAPI Committee Meeting. The Committee will continue to monitor for 90 days.G) The Administrator, the Director of Nursing and/or their designees are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was non-weight bearing and required two staff members and a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and assistive devices, to maintain his/her safety to prevent an incident/accident resulting in an injury, when on 03/14/26, Certified Nurse Aide #1 transferred Resident #1 alone, without a mechanical lift, using a stand pivot type transfer. Resident #1 was later found with bruising and swelling to his/her left ankle and was diagnosed with a left ankle fracture, (which was consistent with the type of injury that could occur with the twisting motion of a stand-pivot a pivot transfer). Findings include:Review of the Facility Policy titled Safe Lifting and Movement of Residents, dated as revised July 2017, indicated that in order to protect the safety and well-being of staff and residents, and to promote quality care, the Facility uses appropriate techniques and devices to lift and move residents. Further review of the Policy indicated that nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. The Policy indicated that Staff would document resident transferring and lifting needs in the care plan. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/16/26, indicated that during care on 03/15/26, staff noted Resident #1's left foot and ankle was bruised and swollen. The Report indicated that Resident #1 had no signs or symptoms of pain at that time. The Report indicated that an X-ray was ordered and completed on 03/16/26 and the results showed a fracture of the left distal fibula. The Report indicated that Resident #1 was sent to the Emergency Department for evaluation and treatment. Further review of the Report indicated that CNA #1 told the Nurse Supervisor that she transferred Resident #1 into bed alone, without the use of a mechanical lift, on the evening of 03/14/26. Review of Resident #1's Hospital Discharge Note, dated 03/17/26, indicated the following:-bluish bruise to left side of forehead-diffuse osteopenia (reduced bone density) -acute comminuted (when bone shatters into three or more pieces, usually due to severe trauma) and minimally displaced [NAME] type B ankle fracture (break at the level of the fibrous joint that connects the fibula and the tibia, often resulting from twisting injuries or falls). -acute nondisplaced medial malleolar (inner ankle) fracture -diffuse soft tissue swelling about the ankle. Resident #1 was admitted to the Facility in October 2019 with diagnoses including dementia with behavioral disturbance, osteoporosis (decreased bone density and quality, making bones weak and brittle), left side hemiplegia (paralysis or weakness) due to unspecified cerebrovascular disease, history of falls, and unsteady on feet. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/10/26, indicated he/she was severely cognitively impaired with a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 was non-ambulatory, and dependent on staff for mobility and Activities of Daily Living (ADL). Review of Resident #1's ADL Care Plan, reviewed and renewed with the Quarterly MDS completed 01/10/26, included an intervention, dated as initiated August 2025, that he/she required the use of a mechanical lift with assistance from two staff for all transfers due to cognitive and physical deficits, including hemiplegia and dementia. The ADL care plan indicated Resident #1 was non-weight bearing with transfers.Review of Unit Manager #1's Written Summary of her interview with Certified Nurse Aide (CNA) #6, dated 03/15/26, indicated that during the day shift on 03/14/26, CNA #6 transferred Resident #1 using a mechanical lift with assistance from another staff member. The Summary further indicated that CNA #6 reported that Resident #1 had no visible bruising when she completed her shift.The Summary indicated that CNA #6 reported that while providing care to Resident #1 with CNA #2, on the morning of 03/15/26, they observed a bruise on Resident #1's ankle and immediately notified the nurse. Review of Unit Manager #1's Written Summary of her interview with Certified Nurse Aide (CNA) #1, dated 03/15/26, indicated that CNA #1 told her that Resident #1 did not exhibit any unsafe physical behaviors or physical aggression toward staff, and did not inadvertently strike any part of his/her body during care, during the evening or overnight (3/14/26 into 3/15/26) shifts.The Summary indicated that CNA #1 told Unit Manager #1 that she had transferred Resident #1 without a second staff member present to assist her and had not used any assistive devices. The Summary indicated that CNA #1 had not provided the required level of assistance when transferring Resident #1.During an interview on 04/07/26, Unit Manager #1, said she worked the day shift as the Nurse Supervisor on 03/15/26, when Resident #1's bruise was reported by CNA #2. Unit Manager #1 said she started an investigation immediately and reviewed the schedule to see who had worked the previous shift (s).Review of Certified Nurse Aide #1's schedule indicated she worked on Resident #1's unit as follows: -03/14/26 from 3:00 P.M. to 03/15/26 until 7:00 A.M. Review of Resident #1's ADL Flow Sheets, dated 03/14/26, indicated CNA #1 provided Resident #1's care on the evening and overnight shifts. Unit Manager #1 said that Resident #1 had a history of combative and resistant behaviors and a diagnosis of dementia, limiting her ability to report how the injury occurred. However, she said that staff had not reported or documented any combative behavior since 03/11/26. Additionally, Unit Manager #1 said the CNA that documented Resident #1's behavior on 03/11/26 indicated that his/her behavior was limited to grabbing and did not involve his/her lower extremities. Unit Manager #1 said she ruled out combative behavior as a potential cause of Resident #1's injury.Unit Manager #1 said that Resident #1 was on CNA #1's assignment from 3:00 P.M. on 3/14/26 through 7:00 A.M. on 3/15/26. Unit Manager #1 said that on 03/15/26, CNA #1 told her that Resident #1 had not exhibited combative behaviors during care on 03/14/26. Unit Manager #1 said that CNA #1 told her that she transferred Resident #1 alone, without the mechanical lift, using a stand pivot transfer technique.The Unit Manager further said there were no documented falls or incidents involving Resident #1 during the shifts prior to the discovery of the ankle fracture. Unit Manager #1 said that she attributed the injury to CNA #1 transferring Resident #1 alone without the use of the mechanical lift, contrary to Resident #1's Plan of Care. Unit Manager #1 said that Resident #1 was frail, non-ambulatory and non-weightbearing, and his/her intervention to provide transfers with assistance from two staff and a mechanical lift had been in place for a long time. The Surveyor was unable to interview Certified Nurse Aide #1 as she did not respond to the Department of Public Health's requests for an interview. During an interview on 04/07/26 at 1:10 P.M., Certified Nurse Aide #2 said that Resident #1 slept late on 03/15/26 during the day shift and that while she and CNA #6 were providing care to him/her, they noticed bruising on his/her left ankle and the left side of his/her forehead. CNA #2 said she immediately reported Resident #1's bruises to the nurse. During an interview on 04/07/26 at 3:08 P.M., Certified Nurse Aide #3 said she worked the evening shift on 03/14/26, on Resident #1's unit. CNA #3 said that she was familiar with Resident #1's care needs and that he/she required a mechanical lift and two staff members to transfer safely. CNA #3 said CNA #1 had not requested her assistance when transferring Resident #1 that evening. During an interview on 04/07/26 at 3:29 P.M., Certified Nurse Aide #4 said she worked the evening shift on 3/14/26 on Resident #1's unit and was not asked by CNA #1 to assist with Resident #1's transfers that evening. During an interview on 04/07/26 at 3:18 P.M., Certified Nurse Aide #5 said that he worked the evening shift on 03/14/26, on Resident #1's unit. CNA #5 said that Resident #1 required a mechanical lift and assistance from two staff members to transfer, and that CNA #1 had not requested his assistance with Resident #1's transfers that evening. Review of the Director of Nurses (DON) and Assistant Administrator's (AA) Written Summary of their interview with Certified Nurse Aide (CNA) #1, dated 03/18/26, indicated that CNA #1 reported Resident #1 had a good night on 03/14/26 with no behaviors. The Summary indicated that CNA #1 told the DON and the AA that she had transferred Resident #1 to bed without a second staff member present to assist her, by performing a stand-pivot transfer as she always does. During an interview on 04/07/26 at 2:17 P.M., the Director of Nurses said that she was notified on 03/15/26 that staff had discovered a large bruise on Resident #1's ankle, and that an investigation had been initiated. The DON said the Provider ordered an X-ray of Resident #1's left ankle and that the results were positive for an ankle fracture. The DON said that when a same-day orthopedic appointment could not be obtained, Resident #1 was sent to the Emergency Department (ED) for evaluation and returned with an ankle splint. The DON said that there were no documented accidents or incidents involving Resident #1 in the days prior to the injury, other than the transfer performed by CNA #1, that was done without the required assistance and equipment, because CNA #1 told them she had transferred Resident #1 with a stand=pivot transfer; which resulted in him/her bearing weight to transfer. The DON said that CNA #1 was suspended on 03/15/26 pending the results of the Facility's investigation, and that she refused to submit a written statement. The DON said that CNA #1 is no longer employed by the Facility. On 04/07/26, the Facility presented the Surveyor with a plan of correction with an effective date of 03/20/26, that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows:A) 03/15/26, Nursing immediately assessed Resident #1's injuries, notified the provider, and X-rays were ordered. The X-ray was completed on 03/16/26 and results were positive for left ankle fracture, with a plan for an orthopedic consult on 03/17/26. An ankle wrap provided and Resident #1's pain was managed.B) 03/17/26, The Facility was unable to obtain a same-day orthopedic consult, therefore Resident #1 was sent to the Emergency Department for further evaluation and a splint was applied to his/her left ankle.C) The Director of Nurses (DON) and Staff Development Coordinator (SDC) reviewed CNA #1's education file and confirmed that she had received education on locating and referencing resident care plans, during her orientation to the facility on [DATE]. D) 03/18/26 through 03/20/26, the SDC trained all nursing staff related to the provision of direct care, regarding the requirement to review and follow the residents' plan of care with every encounter. Education was validated with a post test. E) Effective 03/18/26 The Director of Nurses and Unit Manager #1 initiated weekly random observational audits across all shifts to ensure staff were following the care planned interventions for resident transfers. The audits are scheduled to be completed weekly for four weeks and then monthly for three months. F) An Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted, and the audit results will be presented during the Facility's April 2026 QAPI Committee Meeting. The Committee will continue to monitor for 90 days.G) The Administrator, the Director of Nursing and/or their designees are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had right sided weakness from a stroke and whose care plan interventions included that he/she required the assistance of two staff members for bed mobility, including turning and repositioning in bed, the Facility failed to ensure that staff consistently implemented and followed interventions from his/her plan of care. When on [DATE] at 1:15 P.M., while attempting to change his/her bed sheets, Certified Nurse Aide (CNA) #1 turned and repositioned Resident #1 on his/her left side in bed, without having another staff member present to assist her, Resident #1 rolled out of the bed and landed on his/her knees on the floor. Resident #1 sustained bilateral (right and left) distal femur (lower part of the thigh bone near the knee joint) fractures and was transferred to the Hospital Emergency Department (ED) where he/she presented with hemorrhagic shock (major blood loss after trauma) and died the next day. Findings include: Review of the Facility Policy titled Care Plans, Comprehensive-Person Centered, dated as revised [DATE], indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the Report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated [DATE], indicated that Resident #1, whose Plan of Care identified that he/she required the assistance of two staff members with bed mobility (which included turning and repositioning), received care in bed at 1:15 P.M. from Certified Nurse Aide #1. The Report indicated that CNA #1 rolled Resident #1 (onto his/her left side) without assistance from another staff member, and was changing the bed sheet under him/her when he/she rolled out of bed and landed on his/her knees [on the floor]. The Report indicated that CNA #1 quickly went around the bed and lowered Resident #1 the rest of the way to the floor. The Report indicated a Nurse assessed Resident #1 who reported knee pain, and that no other injuries were identified. The Report indicated that Resident #1 was assisted back to bed via mechanical lift and once in bed he/she reported increased bilateral knee pain. Further review of the Report indicated that STAT (immediate) X-rays were obtained at 3:15 P.M. which identified bilateral distal femur fractures. The Report indicated that Resident #1 was transferred to the Hospital ED for evaluation and he/she died on [DATE]. Review of Resident #1's Radiology Report, dated [DATE], indicated he/she had acute femoral fractures, on the left and right. Review of Resident #1's Hospital Discharge Note, dated [DATE], indicated he/she presented to the Hospital ED on [DATE], with bilateral femur fractures related to a fall at his/her nursing facility. The Note further indicated that Resident #1 was in traumatic hemorrhagic shock, transitioned to comfort measures, and passed away at 1:57 A.M. [on [DATE]]. Resident #1 was admitted to the Facility in February 2025, diagnoses included cerebral infarction (stroke), dysphagia (difficulty swallowing), long term/current use of anticoagulants (blood thinners), osteoarthritis, lack of coordination, need for assistance with personal care and weakness. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1 was severely cognitively impaired with a score of 1 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 was dependent on staff to roll left and right in bed and that he/she had upper and lower extremity limitations that interfered with daily functions or placed him/her at risk of injury. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with Quarterly MDS completed [DATE], indicated he/she required assistance of two staff members for bed mobility, which included turning and repositioning during care, and required a mechanical lift with assistance of two staff members for transfers. Review of Resident #1's CNA Care Card (Certified Nurse Aide, reference guide, identifies residents specific care needs, including number of staff required to provide assistance during tasks), dated [DATE], indicated he/she required the assistance of two staff members for bed mobility (which included rolling and repositioning in bed). Review of Certified Nurse Aide #1's Personnel Record, indicated it included a CNA Competency Form, signed and dated by CNA #1 on [DATE], that indicated she had demonstrated competency in following the Fall Prevention Program, utilizing fall preventative measures according to the residents care plan, and reviewing the CNA Care Card. Further review of the Record indicated that on [DATE], CNA #1 completed education on safe patient handling for lifting and positioning. During a telephone interview on [DATE] at 4:36 P.M., Certified Nurse Aide (CNA) #1 said she had been a CNA for 15 years, had worked per diem at the Facility since [DATE], and that she had only provided care to Resident #1 on two other occasions prior to [DATE]. CNA #1 said that she was not familiar with the procedure for reviewing the CNA Care Card or the Care Plan to determine the residents' care needs and relied on asking other staff. However CNA #1's statement was inconsistent and contradicted documentation in her personnel record, that was signed and dated by her, which indicated she had been educated and trained on facility procedure and need to review each residents Care Plan and CNA Care Card, prior to providing care. CNA #1 said she did not review Resident #1's Care Plan or CNA Care Card, to determine the level of staff assistance he/she required to provide safe care. CNA #1 said that on [DATE], she was changing Resident #1's bed sheets at 1:15 P.M., while he/she was in bed. CNA #1 said that she rolled Resident #1 onto his/her left side, and he/she held on to the left bedrail while she (CNA #1) went around to the right side of the bed and secured the fitted sheet to the mattress. CNA #1 said the sheet was too small for the mattress, and the mattress curled up on the right side of the bed which then caused Resident #1 to roll out of the left side of the bed. CNA #1 said Resident #1 landed on his/her knees on the floor, with the upper portion of his/her body still on the bed. CNA #1 said that while Resident #1 clung to the bedrail, she reached over the bed, grabbed him/her by the shirt, climbed across the bed, and slowly lowered his/her upper body to the ground. CNA #1 said she supported Resident #1's upper body against her legs while she rang the call light and yelled for help. During a telephone interview on [DATE] at 9:01 A.M., Certified Nurse Aide (CNA) #2 (which also included a review of her written witness statement dated [DATE]) said she reviewed CNA #1's assignment with her at the start of the shift on [DATE] and said she told CNA #1 that Resident #1 required the assistance of two staff members for bed mobility and transfers. CNA #2 said that she offered to assist CNA #1 with Resident #1's care, about 30 minutes before her break, and again at 1:00 P.M., when she was leaving for break. CNA #2 further said that she informed CNA #1 she would be taking her break on the porch nearby and was available to help with Resident #1's care when needed. CNA #2 said CNA #1 never came to get her while she was on break and when she returned to the unit she learned that Resident #1 had fallen out of bed. During an interview on [DATE] at 11:00 A.M., Physical Therapist Assistant (PTA) #1 said that during the day shift on [DATE], she was in the hallway on [NAME] 2 when she heard someone in Resident #1's room yelling for help. PTA #1 said that when she entered the room, Resident #1 was sitting on the floor on the left side of the bed, with both knees bent to one side and his/her upper body resting against CNA #1's legs. PTA #1 said no other staff members were present when she arrived, so she immediately went to find Nurse #1. During a telephone interview on [DATE] at 3:07 P.M., Nurse #1 (which also included a review of her written witness statement dated [DATE]) said at 1:15 P.M. she responded to a call for help and found Resident #1 sitting on the floor on the left side of his/her bed. Nurse #1 said that Resident #1's knees were slightly tucked underneath him/her like someone in a skirt might sit and his/her back was supported by CNA #1's legs. Nurse #1 said there were no other staff members in the room and that CNA #1 admitted that she moved [turned and repositioned] Resident #1 on her own. During an interview on [DATE] at 3:39 P.M., Unit Manager #1 (which also included a review of her written witness statement dated [DATE]) said that she was called at 1:17 P.M. to come to Resident #1's room because he/she had fallen. Unit Manager #1 said that when she entered Resident #1's room, Nurse #1 and CNA #1 were already there, and Resident #1 was lying on the floor, parallel to the bed, on his/her right side with a pillow under his/her head. Unit Manager #1 said that when she asked Resident #1 what happened, he/she pointed at CNA #1 and said, it's her fault. Unit Manager #1 said that CNA #1 told her that she rolled Resident #1 onto his/her left side, without another staff member present to assist her, and to change the fitted sheet on his/her bed. Unit Manager #1 said CNA #1 reported that the sheet was too small, caused the mattress to buckle, and Resident #1 rolled out of bed and landed on his/her knees on the floor. Unit Manager #1 said that CNA #1 told her that she was on the opposite side of the bed from Resident #1 when this happened and that she had to go around the bed to lower Resident #1's upper body to the floor. Unit Manager #1 further said that when she asked CNA #1 if she was aware that Resident #1 required assistance from two staff members with care, which included bed mobility and repositioning, that CNA #1 remained silent, would not answer the question. Unit Manager #1 said that Resident #1 was transferred back to bed with the help of a mechanical lift and assistance from three staff members. Unit Manager #1 said that Resident #1 was alert and communicated that he/she was experiencing pain in both knees. Unit Manager #1 said Resident #1 was administered medication for pain and a STAT X-ray was ordered by the Physician. During an interview on [DATE] at 4:00 P.M., the Director of Nurses (DON) said that Resident #1's X-rays were completed at 3:15 P.M., revealing fractures in both the left and right distal femurs. The DON said Resident #1 was transferred to the Hospital ED and comfort measures were initiated, as he/she was not a surgical candidate. The DON said the Facility was later informed that he/she had died in the early hours of [DATE]. The DON said that although CNA #1 was not typically assigned to the [NAME] 2 unit, she had worked several shifts per week at the Facility for nearly a year. The DON said that during CNA #1's orientation, she received training on how to access the CNA Care Card and Care Plan, prior to caring for a resident, to reference and determine the level of staff assistance each resident needed to be safely cared for. The DON further said the Resident Care Plans were regularly updated in the Electronic Health Record (EHR) and the interventions were automatically reflected on the CNA Care Card to ensure it accurately represented each resident's current care needs. The DON said the expectation was for staff to reference the Care Card before providing care. The DON said that Resident #1 required the assistance of two staff members for turning and repositioning in bed. The DON said that on [DATE], CNA #1 had not checked Resident #1's Care Plan or Care Card prior to moving Resident #1 in bed, without assistance from another staff member. On [DATE], the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A. [DATE], Nursing immediately assessed Resident #1 for injuries, STAT X-rays were ordered, and he/she was transferred to the Hospital Emergency Department for evaluation. B. [DATE], CNA #1 was suspended pending investigation and no longer works at the Facility. C. [DATE] through [DATE], the Director of Nurses (DON) and the Staff Development Coordinator (SDC) provided re-education and re-trained all nursing staff that provide direct resident care, regarding the requirement to follow the resident's plan of care with every encounter. D. [DATE], a Root Cause Analysis was completed by the Quality Assurance Performance Improvement (QAPI) Committee and an Improvement plan was developed. E. [DATE], the DON and the SDC completed additional staff training with a post education quiz, on providing assistance of two as care planned, with bed mobility and transfers. The training included instructions to get a nurse or therapist if another CNA is not available. F. [DATE], the Facility recognized that all residents have the potential to be affected by the same deficient practice, and the DON completed a facility-wide audit for all residents requiring assistance from two staff members for bed mobility and transfers, which included a review of their Comprehensive Care Plans and CNA Care Cards. G. Effective [DATE] through [DATE], daily visual observation audits by the Nursing Administration were conducted on all three shifts to ensure the resident's care plan interventions were being implemented and followed. H. The areas of concern and data collected, will continue to be presented at the Facility's Quality Assurance Performance Improvement (QAPI) Committee Meeting monthly, and the Committee will continue to monitor for 60 to 90 days, to ensure substantial compliance. I. The Administrator, the Director of Nursing and/or their designees are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had right sided weakness from a stroke and required the assistance of two staff members for turning and repositioning in bed, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting serious injury and death. On [DATE] at 1:15 P.M., while attempting to change his/her bed sheets, Certified Nurse Aide (CNA) #1, without another staff member to assist her, positioned Resident #1 on his/her left side away from her, and Resident #1 rolled out of the bed, landing on his/her knees on the floor. Resident #1 sustained bilateral (right and left) distal femur (lower part of the thigh bone near the knee joint) fractures and was transferred to the Hospital Emergency Department (ED) where he/she presented with hemorrhagic shock (major blood loss after trauma) and died the next day. Findings include: Review of the Facility Policy titled Falls and Fall Risk, Managing, dated as revised [DATE], indicated that a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g. a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen if not for another person or if he or she had not caught himself/herself, is considered a fall. Review of the Report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated [DATE], indicated that Resident #1, whose Plan of Care identified that he/she required assistance from two staff members with bed mobility [which included turning and repositioning] received care in bed, at 1:15 P.M. from Certified Nurse Aide #1. The Report indicated that CNA #1 rolled Resident #1, without assistance from another staff member, and was changing the sheet under him/her when he/she rolled out of bed and landed on his/her knees. The Report indicated that CNA #1 quickly went around the bed and lowered Resident #1 the rest of the way to the floor. The Report indicated the Nurse assessed Resident #1 who reported knee pain, that no other injuries were identified, Resident #1 was assisted back to bed via mechanical lift and once in bed he/she reported increased bilateral knee pain. Further review of the Report indicated that STAT (immediate) X-rays were obtained at 3:15 P.M. which identified bilateral distal femur fractures. The Report indicated that Resident #1 was transferred to the ED for evaluation and he/she died on [DATE]. Review of Resident #1's Radiology Report, dated [DATE], indicated he/she had acute femoral fractures, on the left and right. Review of Resident #1's Hospital Discharge Note, dated [DATE], indicated he/she presented to the Hospital ED on [DATE], with bilateral femur fractures related to a fall at his/her nursing facility. The Note further indicated that Resident #1 was in traumatic hemorrhagic shock, transitioned to comfort measures, and passed away at 1:57 A.M. ([DATE]). Resident #1 was admitted to the Facility in February 2025, diagnoses included cerebral infarction (stroke), dysphagia (difficulty swallowing), long term/current use of anticoagulants (blood thinners), osteoarthritis, lack of coordination, need for assistance with personal care and weakness. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1 was severely cognitively impaired with a score of 1 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 was dependent on staff to roll left and right in bed, and that he/she had upper and lower extremity limitations that interfered with daily functions or placed him/her at risk of injury. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with Quarterly MDS completed [DATE], indicated he/she required assistance of two staff members for bed mobility, which included turning and repositioning, and required a mechanical lift with assistance of two staff members for transfers. Review of Resident #1's CNA Care Card (Certified Nurse Aide, reference guide, identifies residents specific care needs, including number of staff required to provide assistance during tasks), dated [DATE], indicated he/she required the assistance of two staff members for bed mobility (rolling and repositioning in bed). Review of Certified Nurse Aide #1's Personnel Record, indicated there was a CNA Competency Form, signed and dated by CNA #1 on [DATE], that indicated she had demonstrated competency in following, the Fall Prevention Program, utilizing fall preventative measures according to the care plan, and reviewing the CNA Care Card. Further review of the Record indicated that on [DATE] CNA #1 completed additional education on safe patient handling for lifting and positioning. During a telephone interview on [DATE] at 4:36 P.M., Certified Nurse Aide (CNA) #1 said she had been a CNA for 15 years, had worked per diem at the Facility since [DATE], and that she had only provided care to Resident #1 on two occasions, prior to [DATE]. Although CNA #1's personnel record contained documenation specific to education and training she received while at the facility, which she dated and signed, CNA #1 said that she was not familiar with the facility procedure for reviewing the CNA Care Card or the Care Plans to determine the residents' care needs and relied on asking the staff. CNA #1 said she did not review Resident #1's Care Plan or CNA Care Card, to determine the level of assistance needed to provide safe care. CNA #1 said on [DATE] she changed Resident #1's bed sheets at 1:15 P.M., while he/she was in bed. CNA #1 said that she rolled Resident #1 onto his/her left side, and he/she held on to the left bedrail while she (CNA #1) went around to the right side of the bed and secured the fitted sheet to the mattress. CNA #1 said the sheet was too small for the mattress, the mattress started curling up on the right side of the bed and caused Resident #1 to roll out of the left side of the bed. CNA #1 said Resident #1 landed on his/her knees on the floor, with the upper portion of his/her body still on the bed. CNA #1 said that while Resident #1 clung to the bedrail, she reached over the bed and grabbed him/her by the shirt, climbed across the bed, and slowly lowered his/her upper body to the ground. CNA #1 said she supported Resident #1's upper body against her legs while she rang the call light and yelled for help. During a telephone interview on [DATE] at 9:01 A.M., Certified Nurse Aide (CNA) #2 (which also included a review of her written witness statement dated [DATE]) said she reviewed CNA #1's assignment with her at the start of the shift and told her that Resident #1 required the assistance of two staff members for bed mobility and transfers. CNA #2 said that she offered to assist CNA #1 with Resident #1's care, about 30 minutes before her break, and again at 1:00 when she was leaving for break. CNA #2 further said that she informed CNA #1 she would be taking her break on the porch nearby and was available to help with Resident #1's care when needed. CNA #2 said CNA #1 never came to get her to assist with Resident #1's care. During an interview on [DATE] at 11:00 A.M., Physical Therapist Assistant (PTA) #1 said that during the day shift on [DATE], she was in the hallway on [NAME] 2 when she heard someone in Resident #1's room yelling for help. PTA #1 said that when she entered the room, Resident #1 was sitting on the floor to the left side of the bed, with both knees bent to one side and his/her upper body resting against CNA #1's legs. PTA #1 said no other staff members were present when she arrived, so she immediately went to find Nurse #1. During a telephone interview on [DATE] at 3:07 P.M., Nurse #1 (which also included a review of her written witness statement dated [DATE]) said at 1:15 P.M. she responded to a call for help and found Resident #1 sitting on the floor on the left side of his/her bed. Nurse #1 said that Resident #1's knees were slightly tucked underneath him/her like someone in a skirt might sit and his/her back was supported by CNA #1's legs. Nurse #1 said there were no other staff members in the room and that CNA #1 admitted that she moved [turned and repositioned] Resident #1 on her own. Nurse #1 said that Resident #1 required the assistance of two staff members with turning in bed and that CNA #1 did not ask anyone for assistance. Nurse #1 said that CNA #1 told her the fitted sheet she used was too small for Resident #1's mattress and that when she tried to make it fit the mattress buckled. Nurse #1 said she observed that the right side of the mattress was curled up because the fitted sheet was too small for the mattress. During an interview on [DATE] at 3:39 P.M., Unit Manager #1 (which also included a review of her written witness statement dated [DATE]) said that she was called at 1:17 P.M. to come to Resident #1's room because he/she had fallen. Unit Manager #1 said that when she entered Resident #1's room, Nurse #1 and CNA #1 were already there, and Resident #1 was lying on the floor, parallel to the bed, on his/her right side with a pillow under his/her head. Unit Manager #1 said that when she asked Resident #1 what happened, he/she pointed at CNA #1 and said it's her fault. Unit Manager #1 said that CNA #1 told her that she rolled Resident #1 onto his/her left side, without another staff member present to assist her, and changed the fitted sheet on his/her bed. Unit Manager #1 said CNA #1 reported that the sheet was too small, caused the mattress to buckle, and Resident #1 rolled out of bed and landed on his/her knees. Unit Manager #1 said that CNA #1 told her that she was on the opposite side of the bed from Resident #1 when this happened and that she had to go around the bed to lower Resident #1's upper body to the floor. Unit Manager #1 further said that when she asked CNA #1 if she was aware that Resident #1 required assistance from two staff members with care, she remained silent, would not answer the question and later blamed the incident on an ill-fitting sheet. Unit Manager #1 said that after the incident, once Resident #1 was in bed, she observed that there were bariatric sheets (the appropriate size for Resident #1's mattress) readily available in both nearby linen closets. Unit Manager #1 said that Resident #1 was transferred back to bed with the help of a mechanical lift and assistance from three staff members. Unit Manager #1 said that Resident #1 was alert and communicated that he/she was experiencing pain in both knees. Unit Manager #1 said Resident #1 was administered medication for pain and STAT X-rays were ordered by the Physician. During an interview on [DATE] at 4:00 P.M., the Director of Nurses (DON) said that Resident #1's X-rays were completed at 3:15 P.M., revealing fractures in both the left and right distal femurs. The DON said Resident #1 was transferred to the Hospital ED and the Facility was later informed that he/she had died in the early hours of [DATE]. The DON said that although CNA #1 was not typically assigned to the [NAME] 2 unit, she had worked several shifts per week at the Facility for nearly a year. The DON said that during CNA #1's orientation, she received training on how to use the CNA Care Card and Care Plan to reference the level of assistance each resident needed to be safely cared for. The DON further said the CNA Care Card and Care Plans were regularly updated to reflect each resident's current care requirements. The DON said that Resident #1 required the assistance of two staff members for turning and repositioning in bed, and that on [DATE], CNA #1 rolled Resident #1 in bed without assistance from another staff member and did not seek help from anyone else while providing his/her care. The DON said that although the bed sheet that CNA #1 used was too small, Resident #1's fall from bed would have been prevented if a second staff member had been present to assist as required. On [DATE], the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A. [DATE], Nursing immediately assessed Resident #1 for injuries, STAT X-rays were ordered, and he/she was transferred to the Hospital Emergency Department for evaluation. B. [DATE], CNA #1 was suspended pending investigation and no longer works at the Facility. C. [DATE] through [DATE], the Director of Nurses (DON) and the Staff Development Coordinator (SDC) provided re-education and re-trained all nursing staff that provide direct resident care, regarding the requirement to follow the resident's plan of care with every encounter. D. [DATE], a Root Cause Analysis was completed by the Quality Assurance Performance Improvement (QAPI) Committee and an Improvement plan was developed. E. [DATE], the DON and the SDC completed additional staff training with a post education quiz, on providing assistance of two as care planned, with bed mobility and transfers. The training included instructions to get a nurse or therapist if another CNA is not available. F. [DATE], the Facility recognized that all residents have the potential to be affected by the same deficient practice, and the DON completed a facility-wide audit for all residents requiring assistance from two staff members for bed mobility and transfers, which included a review of their Comprehensive Care Plans and CNA Care Cards. G. Effective [DATE] through [DATE], daily visual observation audits by the Nursing Administration were conducted on all three shifts to ensure the resident's care plan interventions were being implemented and followed. H. The areas of concern and data collected, will continue to be presented at the Facility's Quality Assurance Performance Improvement (QAPI) Committee Meeting monthly, and the Committee will continue to monitor for 60 to 90 days, to ensure substantial compliance. I. The Administrator, the Director of Nursing and/or their designees are responsible for overall compliance.

Based on observations, interviews, and records reviewed, the facility failed to provide care consistent with professional standards of practice to prevent deterioration of a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one Resident (#41), of five applicable residents reviewed for pressure ulcer care and services, out of a total sample of 26 residents. Specifically, for Resident #41, the facility failed to implement the Physician's order for the use of prophylaxis booties for a Deep Tissue Injury (DTI- pressure induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface may remain intact.) pressure ulcer resulting in the Resident ' s Pressure Ulcer deteriorating with related swelling, redness and severe pain at the Pressure Ulcer location. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, included but was not limited to the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical .functional needs is developed and implemented for each resident. >Each care plan is consistent with resident rights to participate .including the right to: Receive the services and/or items included in the plan of care. Resident #41 was admitted to the facility in February 2023 with diagnoses including Restless Leg Syndrome, Diabetes Mellitus, Difficulty Walking, Dementia and Parkinsons Disease. Review of Resident #41 ' s Minimum Data Set (MDS) Assessment, dated 5/6/25, included but was not limited to the following: -The Resident was severely cognitively impaired as evident by the Brief Interview for Mental Status (BIMS) score of six out of a total possible score of 15 with the ability to recall after cueing (something to wear). -The Resident required substantial/maximum assistance (helper does more than half the effort) to apply and remove footwear. -The Resident was at risk for Pressure Ulcers. -The Resident had an unhealed DTI Pressure Ulcer. On 6/2/25 at 11:43 A.M., the surveyor observed Resident #41 lying in bed, covered by bed linens and a pair of gray booties were observed on a chair positioned at the foot of the Resident ' s bed. During an interview at the time, Resident #41 said those are my boots over there on that chair. Resident #41 said that he/she did not have booties on his/her feet under the bed linens. Resident #41 said he/she had a wound on the left foot and the nurses were treating it. Resident #41 said he/she was unaware if the wound was getting better or not and said his/her left foot had some bad pain. Resident #41 said that he/she should have booties on when in bed, but not all staff remember to put the booties on. During an interview on 6/3/25 at 8:51 A.M., the surveyor observed Resident #41 lying in bed and Resident #41 said his/her left foot was hurting. Resident #41 said he/she was not wearing booties and then pointed to the chair at the foot of his/her bed. The surveyor observed a pair of gray booties on the chair at the foot of the Resident's bed. Resident #41 then lifted the bed linens to expose his/her legs and feet, and the surveyor observed the Resident ' s legs and feet and observed no booties to be in place. The Resident ' s left ankle was observed positioned directly against the mattress. The surveyor further observed eight spots of dried light pink substance on the Resident ' s fitted sheet around the area his/her left foot was located. The Resident said he/she was unaware if the skin was open, but the ankle was hurting more than yesterday. On 6/3/25 at 1:53 P.M., the surveyor observed Resident #41 seated in a wheelchair at his/her bedside and wearing ankle high socks. The Resident ' s bed was unmade, and the fitted sheet on the Resident ' s bed was observed with multiple areas of dried light pink substance present on the Resident ' s fitted sheet where the Resident ' s feet were located in the previous observation at 8:51 A.M. During an observation and interview on 6/4/25 at 7:51 A.M., the surveyor observed Resident #41 lying in bed and a pair of gray booties were located on a chair at the foot of the Resident ' s bed. Resident #41 said that he/she had started the night with the booties on but had used the bathroom and the booties were not put back on. Resident #41 said staff should have at least put a pillow under his/her feet but not everyone does. The Resident then pulled back his/her bed linen and the surveyor observed the Residents' legs and feet. The Residents ' left ankle was observed to be flat against the mattress without booties or a pillow in place. The surveyor then observed a light pink substance on the Residents ' fitted sheet in 12 spots along the foot area. The Surveyor observed Resident #41 from the hallway continuously until 8:42 A.M without evidence of staff entering the room. On 6/4/25 at 8:42 A.M., the surveyor observed Resident #41 transferred out of bed and into a wheelchair by Nurse #1 and Certified Nurses Aide (CNA) #1. During an interview at the time, Nurse #1 said Resident #41 should have had booties on when he/she was in bed but did not. Nurse #1 said Resident #41 was at high risk for skin breakdown because of his/her diagnoses of Parkinsons Disease and Diabetes. Nurse #1 said the booties were ordered by the Physician to prevent Resident #41 ' s DTI from getting worse and without the booties on, the Resident ' s wound could worsen. Nurse #1 said the CNAs should know to apply the Resident ' s booties because the booties would be listed in the CNA care Kardex (resident specific information about delivery of care). The surveyor and Nurse #1 observed the CNA care Kardex for Resident #41, which did not indicate evidence for the application of the Resident ' s booties while in bed as a care needed intervention. Nurse #1 said the booties should also be listed in the Point of Care (POC) documentation for the CNA staff. The surveyor and Nurse #1 observed the POC documentation which did not have evidence present that the Resident required booties while in bed as a care need intervention. The surveyor and Nurse #1 observed the gray booties on the chair at the foot of the Residents' bed and Nurse #1 said the gray booties belonged to Resident #41 and should have been on the Resident when he/she was lying in bed. Nurse #1 said if Resident #41 had been out of bed during the night, the staff should have re-applied the booties when the Resident returned to bed. The surveyor and Nurse #1 then observed the Residents fitted sheet which had the pink substance present on the fitted sheet and Nurse #1 said the pink substance looked like wound drainage. The surveyor and Nurse #1 observed Resident #41 ' s left ankle wound. Nurse #1 said that the Resident ' s left ankle wound had dried drainage and appeared to be opened. Nurse #1 said the Resident ' s wound had deteriorated from DTI to an open wound. Review of Resident #41 ' s medical record included but was not limited to: -A Nursing Progress Note, dated 5/1/25 at 23:20 (11:20 P.M.) indicating Resident #41 had a new DTI pressure area to the left outer ankle. -A Physician's order for Skin Prep to the Resident ' s left outer ankle; DTI every shift for left ankle DTI, effective 5/2/25. -A Rehabilitation Screen request, dated 5/2/25 for new DTI to left ankle with a recommendation response to discontinue previous brace and continue booties to bilateral feet. -A Physicians order to apply booties to bilateral feet when in bed, every shift (11:00 P.M.-7:00A.M., 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M.) for prophylaxis; Pressure Wound, effective 5/3/25. Review of Resident #41's Treatment Administration Record (TAR) for May 2025 and June 2025 indicated: -Ankle brace to the left foot was discontinued, effective 5/2/25. -Booties were applied to bilateral feet as ordered, effective 5/3/25-6/4/25. -Skin Prep was applied to the left outer ankle DTI as ordered, effective 5/1/25- 6/4/25. Review of Resident #41 ' s weekly wound documentation for May 2025 included the following: -On 5/3/25 and 5/10/25 the Resident ' s left ankle DTI was intact, measured 7 mm (millimeters) in length by) 8 mm in width by 0 mm depth. -On 5/17/25 the Resident ' s left ankle DTI was intact, without evidence of measurements present. -On 5/24/25 the Resident ' s DTI was scabbed, improving, and measured 0.5 centimeters (cm). -On 5/31/25 the Resident ' s DTI was scabbed and measured less than 0.5 inch. Further review of Resident #41's medical record failed to indicate any evidence that the scabbed area identified on 5/24/25 and 5/31/25 to the Resident ' s left ankle had reported to the MD and/or the facility ' s wound care nurse and/or assessed as a newly identified skin issue. Review of Resident #41 ' s June 2025 Physician's orders included but was not limited to: -Activated Health Care Proxy (HCP-A person that can make decisions for another when they are unable to do so themselves), effective 4/19/24. -Apply Skin Prep (a liquid applied to the skin that forms a protective film barrier to protect against friction/shearing) to bilateral heels and left outer ankle pink areas to prevent breakdown, every day shift (7:00 A.M.-3:00 P.M.) and evening shift (3:00 P.M.-11:00 P.M) for to [sic] prevent skin breakdown, effective 3/27/24 . -Diabetic Foot Care at bedtime (3:00 P.M.-11:00 P.M.): note any abnormal findings in nurses note, effective 12/4/24. -Document Behavior Symptoms every shift; 4 = Rejection of care (code all that are observed; write a note for any observed behavior, effective 2/27/23. Review of Resident #41's Person-Centered care plan for Activity of Daily Living (ADL) Performance, revised 2/7/25, indicated: -The Resident had self care deficits. -The Resident required substantial/maximum assistance of one person for dressing. -The Resident required substantial/maximum assistance of one person for bed mobility. Review of Resident #41's Person-Centered care plan for Risk of/and Actual Skin Impairment, revised 5/2/25, indicated: -Resident will maintain or develop clean and intact skin through next review date, 8/6/25. -Administer treatment as ordered. -Report abnormalities, failure to heal .to Medical Doctor (MD). Review of Resident #41 ' s Behavior Monitoring documentation for May 2025 and June 2025 included but was not limited to: -No evidence of documented refusal of care. During an interview and observation on 6/4/25 at 9:08 A.M., Unit Manager (UM) #1 said she was the Wound Care Nurse in the facility and was following Resident #41 for the DTI pressure area of the left ankle. UM #1 said the DTI had been identified on 5/1/25 during evening care and had been thought to be caused by the Resident's previous foot brace, therefore the foot brace had been discontinued, and booties were ordered for protection along with a topical treatment of Skin Prep to the area. UM #1 said she first assessed the Resident ' s wound on 5/2/25 following morning report and the left ankle area was intact, maroon in color and non-blanching (an area of redness that does not fade when pressed on, typically due to bleeding under the skin). UM #1 said the Resident ' s left ankle DTI could get worse without the use of booties in place because the booties provided protection against pressure from the bed surface. UM #1 said the Resident ' s booties should be listed on the CNA Kardex and POC, but they were not. UM #1 said it was important to include the booties on the CNA Kardex and POC so that the CNA staff would know what was required for the care of Resident #41. UM #1 said Resident #41 spends most of the day in bed and the booties were important for protection of the DTI. UM #1 said Resident #41 had a history of refusing care but if the booties were refused the staff should use pillows to offload and float the DTI area to prevent skin breakdown. During that same time the surveyor and UM #1 observed Resident #41 ' s left ankle wound, and UM #1 said the Resident ' s wound had deteriorated, was open, was painful to the Resident when touched, and presented with new swelling. UM #1 further said the Resident ' s wound bed was now open and had drainage. UM #1 said that she should have been contacted sooner by the nurses about the change in the Resident ' s DTI area. During an interview on 6/4/25 at 9:40 A.M., the Director of Nursing (DON) said Resident #41 did not have evidence of documented refusal of care for the months of May 2025 and June 2025. The DON said the Resident's booties should have been in place as ordered by the Physician. During an interview on 6/4/25 at 11:13 A.M., CNA #1 said she was the CNA providing care to Resident #41 today. CNA #1 said the nurses give report for anything a resident needed for care and that CNA staff could also read the residents ' care Kardex too. CNA #1 said she was aware that Resident #41 was supposed to have booties on when in the bed but had not checked the Resident until 8:42 A.M. for breakfast delivery. CNA #1 said there have been times in the past when CNA #1 came on duty and the Resident ' s booties were not in place from the night before, so she would have to put the booties on. CNA #1 said when she came to the Resident ' s room today to transfer the Resident for breakfast, the booties were not on the Resident but should have been on, to protect the left ankle wound. During an interview on 6/4/25 at 11:35 A.M., UM #1 said she had cleansed and measured the Resident ' s left ankle wound area to be 1 cm long by (x) 0.8 cm wide x 0.1 cm deep, and that the wound had scant serosanguinous (light pink) drainage, redness to the area, swelling and painful to touch. UM #1 said that Resident #41 reported nine out of 10 pain, and the Provider would be seeing the resident later today for examination. During an interview on 6/4/25 at 1:40 P.M., the DON said Resident #41 ' s intervention for booties were not listed on the CNA Kardex but should have been so that CNA staff would know how care was to be delivered for the Resident.

Based on observation, interview, and record review, the facility failed to ensure that resident meal trays were served timely for three Units (West 1, [NAME] 2 and Dharma), out of three units observed. Specifically, the facility failed to ensure that resident meals were delivered timely and coordinated with medication administration times for residents that required meals in order for medications to be appropriately administered. Findings include: Review of the Food Truck Delivery Schedule, undated, indicated the following meal delivery times: >Breakfast: West 2-A: 7:55 A.M. West 2-B: 8:05 A.M. West 1-A: 8:15 A.M. West 1-CDR: 8:25 A.M. West 1-B: 8:30 A.M. Skole (Dharma Unit): 8:35 A.M. Gluckin (Dharma Unit): 8:40 A.M. [NAME] 1 (Dharma Unit): 8:45 A.M. >Lunch: West 2-A: 11:55 A.M. West 2-B: 12:00 P.M. West 1-A: 12:05 P.M. West 1-CDR: 12:20 P.M. West 1-B: 12:30 P.M. Skole (Dharma Unit): 12:35 P.M. Gluckin (Dharma Unit): 12:45 P.M. [NAME] 1(Dharma Unit): 12:50 P.M. >Dinner: West 2-A: 4:50 P.M. West 2-B: 5:00 P.M. West 1-A: 5:10 P.M. West 1-CDR: 5:20 P.M. West 1-B: 5:30 P.M. Skole (Dharma Unit): 5:40 P.M. Gluckin (Dharma Unit): 5:50 P.M. [NAME] 1 (Dharma Unit): 6:00 P.M. On 6/3/25 from 1:30 P.M. to 2:30 P.M., a Resident Council Meeting was held with the surveyor, and the following concerns were relayed: -Resident #8 said when alternate food items were requested, it took 30 minutes for the food to be received. -Resident #86, who resided on [NAME] 1 Unit, said the meals were not delivered timely. Six other residents who were in the meeting agreed. Resident #86 further said that he/she was Diabetic and received Insulin medication prior to meals, and the timing of his/her meals mattered for the medication administration. Resident #86 said his/her breakfast meal tray delivery could range from 8:00 A.M. until 9:30 A.M., lunch meal tray delivery could range from 12:00 P.M. to 1:30 P.M. and dinner tray meal delivery could range from 4:30 P.M. to 6:30 P.M. During an interview on 6/4/25 at 10:05 A.M., Family Member #1, whose family resided on the Dharma Unit, said the times that the resident meals were delivered varied greatly. Family Member #1 said the dinner meal for his/her family could be served at 5:15 P.M. up until 6:30 P.M., which made a difference with when medications were administered and the effect of the medications. Family Member #1 said his/her family received a medication to assist with sleep and if that medication was administered prior to receiving the dinner meal and the meal was late, his/her loved one would be sleepy and would have difficulty consuming the meal. Family Member #1 said when he/she requested an alternate meal/items, there were times when the kitchen would be contacted and no one would respond to attend to the request. Family Member #1 said this occurred mostly on the weekends when staff in the kitchen were not available for meal/food requests, so he/she had been bringing in food from home on the weekends to give to his/her family. Family Member #1 said he/she requested an early dinner meal for 5:00 P.M. on 5/29/25 so he/she could attend a family support meeting at the facility for 6:00 P.M. and the dinner meal did not arrive until 6:15 P.M., so he/she missed the meeting. Review of the Food Truck Delivery Daily Tracking Logs from 5/2/25 through 5/31/25 indicated that on 25 out of 29 days, resident meals were delivered 20 minutes or more from the scheduled meal delivery time indicated. On the following dates/times, the following was observed by the surveyors: -6/3/25 at 8:17 A.M., the [NAME] 2-B Food Truck arrived on the [NAME] 2 Unit (scheduled to arrive at 8:05 A.M.) -6/4/25 at 12:36 P.M., the [NAME] 2-B Food Truck arrived to the [NAME] 2 Unit (scheduled to arrive at 12:00 P.M.) -6/4/25 at 12:38 P.M., the [NAME] 1-A Food Truck arrived to the [NAME] 1 Unit (scheduled to arrive at 12:05 P.M.) -6/4/25 at 12:45 P.M., the [NAME] 1-B Food Truck arrived to the [NAME] 1 Unit (scheduled to arrive at 12:30 P.M.) -6/4/25 at 12:56 P.M., the [NAME] 1-CDR Food Truck arrived to the [NAME] 1 Unit (scheduled to arrive at 12:20 P.M.) -6/4/25 at 1:03 P.M., the Skole Food Truck arrived to the Dharma Unit (scheduled to arrive at 12:35 P.M.) -6/4/25 at 1:12 P.M., the Gluckin Food Truck arrived to the Dharma Unit (scheduled to arrive at 12:45 P.M.) -6/4/25 at 1:20 P.M., the [NAME] Food Truck arrived to the Dharma Unit (scheduled to arrive at 12:50 P.M.) During an interview on 6/4/25 at 2:32 P.M., the surveyor reviewed the concerns about meal delivery times and observations from survey with the Food Service Director (FSD). The FSD said she was made aware by nursing on occasion when resident meals were late, but was not aware that this was a consistent concern. The FSD said when she reviewed the Food Truck Delivery Logs, she saw that there were issues with when resident meals were delivered to the units compared to when they were scheduled to be delivered. The FSD said unless there was a concern expressed, she did not routinely review the Food Truck Delivery Logs, but should have been. The FSD said she understood the concern relative to the resident meal delivery times and that this process needed to be changed. During an interview on 6/04/25 at 3:22 P.M., the Administrator said he was aware and understood that there was an issue with when resident meals were delivered.

Based on observations, interview and record review, the facility failed to maintain a clean and sanitary kitchen. Specifically, the facility failed to ensure: -storage for resident food/fluids remained clean and free of foul odors -shelves that maintained clean pots/pans/dishware used for resident meals were clean and free from debris -fans in the facility kitchen were free of dust/debris Findings include: Review of the facility policy titled Sanitation, undated, indicated the following: >Equipment and Utensils: -utensils and food-contact surfaces of equipment shall be cleaned and sanitized -tableware shall be washed, rinsed, and sanitized after each use -non-food-contact surfaces of equipment shall be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris On 6/2/25 from 7:25 through 7:41 A.M., during an initial kitchen tour, the surveyor observed the following: -shelf/tray that house containers of spices were dirty and had debris present -large utility fan in the storage area was thickly covered with dirt/dust. -milk cooler had a strong rancid odor and had puddles of water and milk on the bottom of the cooler. -presence of fruit flies/gnats On 6/4/25 from 11:36 A.M. through 1:15 P.M., the surveyor observed the following in the main facility kitchen: -multi-shelve units that housed clean pots/pans located to the left of the walk-in refrigerator had observable dirt, grease present -clear bins with clean utensils had presence of food particles -lower shelves near the preparation areas which had clean pots/pans present, were visibly dirty and had food particles/debris present -large utility fan located in a preparation and clean dishes area was observed on and was dirty and dust laden. -presence of fruit flies/gnats During an observation and interview on 6/4/25 at 11:56 A.M., the Food Service Director (FSD) said the shelving/bins that had clean pots/pans/utensils were dirty and should be cleaned weekly and as needed. The FSD said this was not currently a task delegated on the kitchen's cleaning schedule and would need to be added. The FSD said the utility fans located in the kitchen were dusty, were maintained by the Maintenance Department and were cleaned when the Dietary staff notified them that they needed to be cleaned. The FSD further said that the sanitization concerns identified in the kitchen were an infection control concern. The FSD said the Maintenance Department were aware of the fruit flies/gnats located in the kitchen. During an interview on 6/4/25 at 4:10 P.M., the Director of Maintenance said there had been an issue with fruit flies/gnats in the facility kitchen for approximately a month and was improving with treatment. The Director of Maintenance further said the utility fans were put in the kitchen to draw out the fruit flies/gnats from the facility kitchen. The Director of Maintenance said there was no routine cleaning of the utility fans and that they would typically not be in the kitchen until the weather was warmer, and that they should not have been in the kitchen if they were dirty.

Based on observation, interview, and record review, the facility failed to provide care and services per professional standards of practice related to monitoring the use of Vitamin D (vitamin that helps regulate calcium and phosphorus in the body, crucial for bone health and immune system) medication for one Resident (#116) out of a total sample of 26 residents. Specifically, for Resident #116, the facility failed to obtain Physician orders to monitor serum laboratory results to determine appropriate decrease of the dosage of Vitamin D medication, when the Resident was administered high doses of Vitamin D medication weekly, putting him/her at risk for adverse effects of the medication. Findings include: Review of the National Institutes of Health (NIH) article titled: Vitamin D, Fact Sheet for Health Professionals, last updated 7/26/24, https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ indicated the following in part: -Serum (blood) concentration of 25(OH)D is currently the main indicator of Vitamin D status. -Because Vitamin D is fat soluble, its absorption depends on the gut's ability to absorb dietary fat. Fat malabsorption is associated with medical conditions that include some forms of liver disease . -Excess amounts of Vitamin D are toxic. Because Vitamin D increases calcium absorption in the gastrointestinal tract, Vitamin D toxicity results in marked: >hypercalcemia (total calcium greater than 11.1 mg/dL, beyond the normal range of 8.4 to 10.2 mg/dL), >hypercalciuria, and high serum 25(OH)D levels (typically greater than 375 nmol/l [150 ng/mL]). Hypercalcemia, in turn, can lead to nausea, vomiting, muscle weakness, neuropsychiatric disturbances, pain, loss of appetite, dehydration, polyuria, excessive thirst, and kidney stones. -In extreme cases, Vitamin D toxicity causes renal failure, calcification of soft tissues throughout the body (including in coronary vessels and heart valves), cardiac arrhythmias, and even death. -Vitamin D toxicity has been caused by consumption of dietary supplements that contained excessive Vitamin D amounts because of manufacturing errors, that were taken inappropriately or in excessive amounts, or that were incorrectly prescribed by physicians. Resident #116 was admitted to the facility in August 2024, with diagnoses including metabolic encephalopathy, Vitamin D Deficiency, cirrhosis of liver and Dementia. Review of the Minimum Data Set (MDS) Assessment, dated 5/20/25, indicated Resident #116 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of a total possible score of 15. Review of Resident #116's June 2025 Physician's Order Summary, indicated: -Ergocalciferol (Vitamin D) Oral Capsule 1.25 milligram (mg) (50000 UT), give 50000 IU by mouth one time a day, every Thursday, related to Hypocalcemia (low calcium in the blood), initiated 8/16/24. Further review of the Physician Order Summary failed to indicate any Physician orders to monitor for Vitamin D toxicity or ongoing orders to monitor and obtain serum laboratory values for Vitamin D levels. Review of the Physician's Progress Note dated 8/19/24, indicated the following relative to Resident #116: -Vitamin D deficiency -Continue Ergocalciferol 50,000 IU weekly x 8 weeks -Recheck Vitamin D level -If Vitamin D level was within Normal limit, convert Vitamin D dose to 2000 IU daily. Review of the Physician's Progress Note dated 9/30/24 indicated: -Vitamin D deficiency -Continue Ergocalciferol 50,000 (International Units) IU weekly x 8 weeks -Recheck Vitamin D level -If Vitamin D level was within Normal limit, convert Vitamin D dose to 2000 IU daily. Further review of the Physician's Progress Note dated 9/30/24, indicated that Vitamin D levels had not been ordered from admission, but had been ordered to be drawn on 10/14/24. During an interview on 6/3/25 at 12:20 P.M., the Director of Nursing (DON) said there was no Physician's order for Vitamin D serum laboratory levels to be obtained for Resident #116. The DON further said Vitamin D serum laboratory levels for Resident #116 had not been ordered by the Physician, and had not been drawn. During an interview on 6/3/25 at 12:45 P.M., the Physician Nurse Practitioner (PNP) said Vitamin D serum laboratory levels for Resident #116 had not been ordered and there was no record that a serum Vitamin D level had been obtained. The PNP said a serum Vitamin D level was needed to monitor for the continued need of the Vitamin D 50,000 IU weekly. During an interview on 6/3/25 at 2:27 P.M., the Pharmacy Consultant said he did not realize Resident #116 was being administered Vitamin D 50,000 IU weekly. The Pharmacy Consultant said Vitamin D 50,000 IU was usually prescribed to be administered monthly and was not aware the Resident had been taking the Vitamin D 50,000 IU weekly for the past 10 months without serum Vitamin D laboratory levels. The Pharmacy Consultant further said Vitamin D 50,000 units being administered to Resident #116 for this length could lead to Vitamin D toxicity. During an interview on 6/4/25 at 9:08 A.M., the facility's Medical Director said serum Vitamin D laboratory levels for Resident #116 should have been ordered, and obtained and he was not aware that this had not been done.

Based on records reviewed and interviews, for one of three sampled employee personnel files, Certified Nurse Aide (CNA) #1, the Facility failed to ensure staff implemented and followed their Abuse policies related to background checks when Massachusetts Nurse Aide Registry (NAR) and Criminal Offender Record Information (CORI) checks were not conducted on CNA #1 as required, prior to employment at the facility. Findings include: Review of the Facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, undated, indicated the Facility will conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of CNA #1's personnel file indicated CNA #1 was hired by the Facility on 12/20/20, and was a current employee. Further review of CNA #1's personnel file indicated that NAR and CORI checks had not been performed prior to or upon hire. During an interview on 04/15/25 at 12:15 P.M., the Human Resource Director said that the process for hiring new Facility staff included obtaining NAR and CORI checks prior to the start of employment. The Human Resource Director said that she had no documentation to support that NAR or CORI checks had been done on CNA #1 and that she could not speak to the hiring process that was in place prior to her employment October 2024. During an interview on 04/15/25 at 4:30 P.M., the Director of Nurses (DON) said that NAR and CORI checks should be completed on all new staff prior to employment. The DON said the Facility had no documentation to support that NAR and CORI checks had been done for CNA #1. The DON said an audit of personnel records had not been completed.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was severely cognitively impaired and dependent on staff for care, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 10/13/24 at 9:00 A.M., two staff members witnessed Certified Nurse Aide (CNA) #1 directing profanity at Resident #1 and treating him/her in a demeaning, insulting manner during care. Findings include: Review of the Facility Policy titled Resident Rights, dated as revised 02/20/21, indicated that employees shall treat all residents with kindness, respect and dignity. Resident #1 was admitted to the Facility in September 2016, diagnoses included Alzheimer's disease and cognitive communication deficit. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/09/24, indicated Resident #1 was severely cognitively impaired with a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 was totally dependent on staff for Activities of Daily Living (ADLs) and mobility, and he/she rejected care one to three days per week during the assessment reference period. Review of the Facility's Investigation Summary, undated, indicated CNA #2 said that CNA #1 used fowl language while caring for Resident #1 and accused him/her of being difficult. The Report indicated that CNA #3 said she also witnessed CNA #1 use profanity during Resident #1's care, and that CNA #1 had rolled Resident #1 over during care too fast and was rough. The Report indicated the incident was reported to the Nurse Supervisor, upon completion of Resident #1's care, and CNA #1 was suspended pending investigation. During a telephone interview on 11/08/24 at 12:06 P.M., Certified Nurse Aide (CNA) #1 said that on 10/13/24, while she was providing morning care to Resident #1, CNA #2 was providing care to his/her roommate, and CNA #3 arrived a few moments later to help with Resident #1's mechanical lift transfer. CNA #1 said that she may have used profanity when speaking to CNA #2 when she did not help her with Resident #1's care, and that CNA #2 must have misunderstood and thought her swearing was directed at Resident #1. During an interview on 11/07/24 at 11:40 A.M., Certified Nurse Aide (CNA) #2 (which also included a review of her Written Witness Statement dated 10/13/24) said that while she was providing care to Resident #1's roommate, at 9:00 A.M., CNA #1 was in the room, providing care to Resident #1. CNA #2 said the privacy curtain was drawn and that although she could not see CNA #1, she clearly heard her direct profanity, repeatedly, at Resident #1. CNA #2 said that Resident #1 was calling out during care and that CNA #1 sounded increasingly frustrated. CNA #2 said that Resident #1 had a history of resisting and calling out during care, especially with unfamiliar staff. CNA #2 said that she heard CNA #1 say to Resident #1, [Resident #1] why the fuck are you so difficult?, What the fuck is your problem? and Why won't you fucking roll? CNA #2 said that CNA #1 told her (in the presence of Resident #1) I can't fucking deal with [Resident #1], I don't know why he/she is being so difficult when he/she can fucking help! CNA #2 said that she told CNA #1 that Resident #1 couldn't help his/her behavior. CNA #2 said that she couldn't intervene at that moment because it would have been unsafe to leave the resident she was caring for, so she rang the call light for assistance. CNA #2 said that CNA #3 immediately responded to the call light. Review of Certified Nurse Aide (CNA) #3's Written Witness Statement, dated 10/13/24, indicated that she entered Resident #1's room to assist with his/her care and witnessed CNA #1 roll him/her roughly and too quickly. CNA #3 said that CNA #1 said [Resident #1] is too fucking much! During a telephone interview on 11/07/24 at 1:57 P.M., the Nurse Supervisor (which also included a review of her Written Witness Statement dated 10/13/24) said that when she suspended CNA #1, pending investigation of the incident involving Resident #1, she acted aggressively toward staff and tried to find out who reported her, prior to leaving the facility. During an interview on 11/07/24 at 1:30 P.M., the Director of Nurses (DON) said that based on witness statements and the Nurse Supervisor's interview with CNA #1, she was suspended pending an internal investigation and was terminated.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who required staff assistance with ambulation and was usually continent, the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of abuse to the Administrator and/or designee, when on 03/14/24 at approximately 5:00 A.M., Resident #1 reported to the Nurse Supervisor that a Certified Nurse Aide (later identified as CNA #1) told him/her that he/she was not allowed to get out of bed to use the bathroom until the morning. Although the Nurse Supervisor was made aware of the allegation, Facility Administration was not made aware of the incident until 9:30 A.M. (over four hours later), when the Director of Nurses (DON) discovered a progress note about the allegation, and subsequently CNA #1 also worked through to the end of the shift, for a minimum of two more hours, therefore placing other residents at risk for abuse/neglect. Findings include: Review of the Facility Policy titled Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating, dated as revised September 2022, indicated all reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Further review of the Policy indicated if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator, Director of Nursing and to other officials according to state law. The Policy indicated the administrator ensures that the resident and the person (s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. The Policy indicated any employee who has been accused or resident abuse is placed on leave with no resident contact until the investigation is complete. Review of the Facility Policy titled Abuse, Neglect and Exploitation, dated as revised 01/11/23, indicated abuse includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The Policy indicated that when a suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is is cared for and initial reporting has occurred, an investigation should be conducted. Review of the Facility's Investigation Narrative, undated, indicated that during a review of clinical notes during the Facility's morning meeting on 03/14/24, it was noted that Resident #1 told the Nurse Supervisor during the overnight shift, that he/she had a terrible night because someone told him/her that he/she could not get out of bed and use the bathroom until the morning. The Narrative indicated the Social Worker interviewed Resident #1 who further alleged that the staff member pushed him/her back into bed. Resident #1 was admitted to the Facility in March 2024, diagnoses included left artificial knee and difficulty walking. Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 03/05/24, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 was always continent of urine and required partial/moderate assistance from staff for mobility and activities of daily living (ADLs). Review of Resident #1's Nurse Progress Note (written by the Nurse Supervisor), dated 03/14/24 and time stamped 7:28 A.M., indicated that Resident #1 complained that he/she had a horrible night because someone told him/her that he/she could not get out of bed to use the bathroom until morning. During a telephone interview on 04/24/24 at 12:22 P.M., the Nurse Supervisor said that when he checked Resident #1's vital signs on 03/14/24 at approximately 5:00 A.M., Resident #1 appeared anxious, upset, and slightly confused. The Nurse Supervisor said that Resident #1 told him that a CNA (identified as CNA #1) on the overnight shift told him/her that he/she was not allowed to get out of bed to use the bathroom until morning. The Nurse Supervisor said he documented Resident #1's allegation in his/her medical record, but said he did not report the allegation to Facility Administration. During an interview on 04/24/24 at 1:07 P.M., the Director of Nurses (DON) said that on the morning of 03/14/24, at approximately 9:30 A.M., she discovered a progress note in Resident #1's Medical Record that indicated he/she told the Nurse Supervisor that a staff member refused to assist him/her to the bathroom during the overnight shift and had said he/she had to wait until morning. The DON said that Resident #1 had urine-soaked clothing and bedding that morning, which was unusual because he/she did not have a history of urinary incontinence. The DON said that the Nurse Supervisor had not immediately reported the allegation to Facility Administration as required, therefore, the accused (CNA #1) was allowed to work the remainder of her shift, placing other residents at risk for abuse.

Based on observation, interview and record review, the facility failed to implement infection control practices to prevent contamination and the spread of infection facility wide, and for one Resident (#24) and on one unit (Dharma Unit). Specifically, the facility failed to: 1. perform annual water testing for Legionella according to the facility water management plan. 2. clean and disinfect a vital signs monitoring machine between resident use on the Dharma Unit. 3. change gloves and perform hand hygiene while performing wound care for Resident #24. Findings include: 1. Review of the facility water management plan, last revised 1/23/23, indicated the following: -Legionella Testing: >The facility has a program to annually test the facility water for Legionella growth. >The facility tests the water using OnSite Legionella Testing. >One of the following locations to be selected at random to be tested : Ice Machines, Kitchen Hot Water Holding Tank, Kitchenette Cold Water faucet on [NAME] One Unit, Boiler Hot Water Tank, Resident Sink [NAME] two Unit . During an interview on 4/8/24 at 12:56 P.M., the Maintenance Director said that he performs water temperature checks on Tuesdays in random areas of the building and performs Legionella water testing annually, using an in-house water sampling kit that then gets sent to a lab. During a follow-up interview on 4/8/24 at 1:38 P.M., the Maintenance Director said that he could not provide any evidence that the facility had performed any annual Legionella water testing. The Maintenance Director said he has not performed any water testing for the past two years. The Maintenance Director further said he should have performed the Legionella water testing according to the facility water management plan. 42741 2. Review of the facility policy titled Cleaning and Disinfection of Resident - Care Items and Equipment, revised September 2022, indicated the following: -Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment [DME]). On 4/8/24 at 8:23 A.M., the surveyor observed Nurse #3 using the portable vital signs machine to obtain measurements from a resident. The surveyor observed Nurse #3 apply the blood pressure cuff to the resident's upper arm and the pulse oximeter (device that measures a person's blood oxygen saturation [the amount of oxygen that is in the blood]) to the resident's finger. Nurse #3 proceeded to obtain the resident's vital signs from the machine. The surveyor observed Nurse #3 take the equipment off the resident and return it to her medication cart without cleaning and/or disinfecting the portable vital sign equipment. On 4/8/24 at 9:50 A.M., the surveyor observed Nurse #3 using the portable vital signs machine to obtain vital signs on a second resident. Nurse #3 applied the blood pressure cuff to the resident's upper arm and pulse oximeter to the resident's finger and proceeded to obtain the resident's vital signs. The surveyor observed Nurse #3 take the equipment off the resident after obtaining the vital signs and return the equipment to her medication. The surveyor did not observe Nurse#3 cleaning and/or disinfecting the portable vital signs machine after use on a second resident. On 4/8/24 at 10:09 A.M., the surveyor observed Nurse #3 using the portable vital signs machine to obtain vital signs on a third resident. Nurse #3 applied the blood pressure cuff to a resident's upper arm and pulse oximeter to the resident's finger and proceeded to obtain the resident's vital signs. The surveyor observed Nurse #3 remove the equipment from the resident's body and return the equipment to her medication cart. The surveyor did not observe Nurse #3 cleaning and/or disinfecting the portable vital signs machine after use on a third resident. During an interview on 4/8/24 at 10:13 A.M., Nurse #3 said the portable vital signs machine should be cleaned and disinfected between each resident use. Nurse #3 further said she had not cleaned and/or disinfected the portable vital signs machine between resident use as required. 47901 3. Review of facility policy titled Handwashing/Hand Hygiene revised August 2019, indicated: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Hand washing to be performed before handling clean or soiled dressings, gauze pads, etc. -Handwashing to be performed after handling used dressings, contaminated equipment, etc. -Handwashing is the final step after removing and disposing of personal protective equipment. Resident #24 was admitted to the facility in September 2023 with diagnoses including Unspecified Intellectual Disabilities, Overweight, Cerebral Palsy (a congenital disorder of movement, muscle tone, or posture), Stage 4 Pressure Ulcer of the sacral area (large wound in which the skin is significantly damaged on the buttocks) and Abnormal Posture. Review of Resident #24's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of two out of 15, and that the Resident was at risk of developing pressure ulcers. Review of the Physician's orders dated 3/27/24 indicated: -Pressure injury Stage 4 wound to coccyx - cleanse wound with normal saline (solution of salt and water) -protect peri (area around the wound) wound with skin prep -lightly pack wound with Calcium Alginate (a pad containing calcium used to aid in wound healing) moistened with normal saline -cover with bordered foam dressing every day shift During an observation on 4/8/24 at 11:51 A.M., for a wound dressing change, the surveyor observed the following: -Nurse #1 accompanied by Unit Manager (UM) #1 entered Resident #24's room with gauze, normal saline, Calcium Alginate pad, a pack of cotton swabs and boarded foam pad. -Nurse #1 went to the bathroom, washed hands, and donned (put on) gloves and a gown. -Nurse #1 assisted UM #1 and repositioned Resident #24 to his/her side allowing access to the sacral wound. -Nurse #1 sprayed saline on the wound bed, wiped area off with gauze, and wearing the same gloves, took the scissors, and cut the Calcium Alginate pad to fit the wound bed while being directed by UM #1. -Nurse #1 moistened the Calcium Alginate pad and applied the pad to Resident #24's wound bed. -Nurse #1 applied the protective foam dressing to the wound, then dated the dressing. -Wearing the same gloves that was worn from Nurse #1's entry to the Resident's room, Nurse #1 picked up the remaining clean unused gauze and the pack of opened cotton swabs, exited the room, and placed the items on top of the treatment cart. -Nurse #1 then returned to the room, doffed (removed) the gloves, and washed her hands. During an interview on 4/8/24 at 12:15 P.M., the surveyor asked Nurse #1 if there was any breach (failure to follow established infection control procedures that prevent the transmission of infectious organisms) in infection control during the wound dressing change and Nurse #1 said that she did not have any breach. UM #1 explained to Nurse #1 that she should have removed her gloves after washing the wound bed, and worn new gloves before she applied clean dressings to the wound. UM #1 further explained that after applying the dressing, Nurse #1 should have removed her gloves and washed her hands, but she did not complete handwashing. UM #1 said that Nurse #1 touched the clean gauze and the opened cotton swabs with the same dirty gloves thereby contaminating the clean items.

Based on observation, interview, and record review, the facility failed to maintained a clean and sanitary facility kitchen in accordance with professional standards for food service safety. Specifically, the facility failed to: -ensure that a rinse temperature issue with the facility dish machine was addressed according to professional standards when the minimum temperature and sanitation requirements were not being met as required. -ensure the use of a commercial grade chlorine-based sanitizer and not household bleach was used in the dish machine to sanitize the facility dish ware. Findings include: Review of the facility policies indicated no policy for management of dishware in the event the facility dish machine became compromised. On 4/9/24 at 12:10 P.M., the surveyor observed Dietary Staff #1 loading soiled dishes onto a rack and through the running dish machine. The surveyor observed the temperature gauges on the dish machine with the following readings: -Wash Temperature: 170 degrees -Rinse Temperature: 170 degrees -Final Rinse Temperature: 170 degrees The surveyor further observed signage affixed to the dish machine that read: >Dish Machine Temperature: -Wash Temperature: 160 degrees -Rinse Temperature: 180 degrees - If rinse temperature goes below 180 degrees you must let the Food Service Director (FSD) or the cook supervisor know immediately During an interview at the time of the observation with the FSD, the FSD said that the required rinse temperature for sanitation of the dishes was 180 degrees. The FSD said that the rinse temperature on the dish machine was 170 degrees because the machine had to run for a few cycles before the rinse temperature would reach 180 degrees and staff would re-wash the same dishes repeatedly until the rinse temperature reached 180 degrees. The FSD also said that the dish machine was a high temperature dish machine and that the facility had ordered a booster device to aid the dish machine in reaching the required 180 degrees rinse temperature more easily. On 4/9/24 at 2:07 P.M., the surveyor observed Dietary Staff #1 and Dietary Staff #2 operating the dish machine. The surveyor observed that the temperature gauges on the dish machine reflected a wash temperature of 170 degrees and a rinse temperature of 162 degrees. The surveyor further observed Dietary Staff #2 spray food and debris from soiled dish ware, then placed the dishes onto racks and slide the rack into the dish machine. Dietary Staff #1 then took the rack of dishes from the opposite end of the dish machine, placed the dishes on different racks and removed them from the dish room. When the surveyor asked, Dietary Staff #1 said he took the dishes and put them away for future use. The surveyor asked Dietary Staff #1 to provide the temperature readings on the temperature gauges of the dish machine and Dietary Staff #1 verified that the rinse temperature reading was 162 degrees and not the required 180 degrees. Dietary Staff #1 said the dish machine water temperature had been an issue for the last two months. Dietary Staff #2 then said that the dish machine had been broken for a long time and the facility management had been made aware of the issue. During an interview on 4/9/24 at 2:16 P.M., the FSD said that they were waiting for a booster device to be delivered for the dish machine. The FSD said that the dishes were cleaned and sanitized even though the dish machine was not rinsing at the required temperature of 180 degrees. The FSD further said that dietary staff were using bleach in the dish machine to sanitize the dish ware. During a follow-up observation with the FSD at the time in the dish room, the surveyor noted a strong odor of bleach and observed a gallon bottle of household bleach sitting on the top of the dish machine with a clear plastic hose coming out of the open spout at the top of the bottle. The FSD said that the bottle contained bleach and that the bleach was getting funneled through the wash cycle into the dish machine to sanitize the dish ware. The FSD said that he did not know who recommended the bleach sanitizer. Dietary Staff #1 then said that a dish machine representative had recommended the use of the bleach. During an interview on 4/9/24 at 2:46 P.M., with the Administrator and Consulting Staff #1, the Administrator said that he was unaware that dietary staff were using household bleach in the dish machine to sanitize the dishes and did not know how long the dietary staff had been using the household bleach as a sanitizer. Consulting staff #1 said that the bottle on top of the dish machine was household bleach and that staff should not have been using household bleach to sanitize dish ware. Consulting Staff #1 said that staff were supposed to be using a commercial grade chlorine based sanitizer in the dish machine. Consulting Staff #1 also said that the dish machine vendor was on his way to the facility to install the proper sanitizer solution. Review of an email communication provided by the facility to the Administrator dated 1/23/24, indicated the following: -Vendor representative came and serviced the dish machine and dropped off more test strips. -Staff instructed to use bleach until order arrives. -DO NOT dilute the bleach, use it directly out of the bottle for accurate readings of parts per million (PPM). During a telephone interview on 4/10/24 at 8:42 A.M., Additional Staff #1 said that he worked as a vendor and had been to the facility on the evening of 4/9/24 to install a commercial grade chlorine-based sanitizer to the facility dish machine. Additional Staff #1 said he had been made aware during the visit that the facility staff had been using a gallon bottle of household bleach to sanitize dish ware in the dish machine. Additional Staff #1 also said that he came to the facility on [DATE], to drop off test strips to be used to test the chemical balance in the dish machine water while the dietary staff were using the commercial grade chlorine based sanitizer in the dish machine. Additional Staff #1 said he told the dietary staff to order additional commercial grade chlorine-based sanitizer because they were running low, but he did not tell staff to use household bleach to sanitize the dish ware in the dish machine. Additional Staff #1 said that he would never advise the facility to use household bleach to sanitize dish ware in the dish machine because there was no way of accurately measuring the sanitization level of the dish ware or the safest level of bleach for safe human consumption. Additional Staff #1 also said that the commercial grade chlorine-based sanitizer and household bleach are two different chemicals and that the commercial grade sanitizer contains no household bleach. During an interview on 4/10/24 at 11:30 A.M., the Administrator said that the commercial grade chlorine-based sanitizer had been installed in the dish machine on 4/9/24 by the vendor. The Administrator said that the dietary staff would use the commercial chlorine based sanitizer until the dish machine booster arrived and the machine was able to maintain the proper temperatures for sanitization. The Administrator said that the Maintenance Director had tested the chemical balance of the dish machine water this morning and had found the commercial chlorine-based sanitizer level readings to be within range. The Administrator said that dietary staff should not have been using household bleach to sanitize dish ware in the dish machine.

Based on observation, interview, and policy review the facility failed to ensure a dignified existence for the facility residents in one dining room ([NAME]) out of three dining rooms observed on the Dharma Unit (Dementia Special Care Unit - DSCU). Specifically, the facility failed to ensure that: 1. the staff spoke respectfully of residents. 2. staff were seated while assisting residents with their meals. Findings include: Review of the facility policy titled Dignity, revised February 2021, indicated the following: -Residents are treated with dignity and respect at all times. -Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice, and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. Review of the facility policy titled Assistance with Meals, revised March 2022, indicated the following: -Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals b. keeping interactions with other staff to a minimum while assisting residents with meals c. avoiding the use of labels when referring to residents (e.g. feeders) During the initial dining observation on 4/7/24 from 9:55 A.M. to 10:15 A.M., in the [NAME] dining room the surveyor observed the following: -A staff member asked loudly enough for all in the dining room to hear, Are there anymore feeders? -A staff member responded loudly enough for all in the dining room to hear He/she is also a feed, you can do him/her when you are done. During a dining observation at the breakfast meal on 4/8/24 from 9:06 A.M. to 9:25 A.M., in the [NAME] dining room the surveyor observed the following: -A staff member standing at the side of a resident assisting him/her with his/her meal. -The surveyor further observed that there were multiple empty chairs available for the standing staff member to sit while assisting the resident with his/her meal. During a dining observation at the lunch meal on 4/8/24 from 12:47 P.M. to 1:27 P.M., in the [NAME] dining room the surveyor observed the following: -Certified Nurses Aides (CNA) #1 and CNA #2 were seated at a dining room table with multiple residents present, and having a personal conversation in a language that was not fluent for all the residents seated at the table. During an interview on 4/8/24 at 12:49 P.M., Unit Manager (UM) #2 said not all residents who were seated at the table where CNA #1 and CNA #2 were seated, spoke the language the CNA's were speaking. UM #2 said the CNAs should not be having a personal conversation in the dining room while seated at a table with residents. During a dining observation at the breakfast meal on 4/9/24 from 8:53 A.M. to 9:31 A.M., in the [NAME] dining room the surveyor observed the following: -The Dharma Unit Activities Director said loudly enough for all in the dining room to hear He/she (referring to a resident still in the dining room) is a feed. -The Staff Development Coordinator (SDC) was standing while assisting a resident with his/her meal from 9:05 A.M. to 9:10 A.M. -The surveyor further observed that there were multiple empty chairs available for the SDC to sit in while assisting the resident. During an interview on 4/9/24 at 9:10 A.M., the SDC said she should not have been standing over the resident to assist him/her with his/her meal, that she should have been seated next to the resident. During an interview on 4/9/24 at 9:31 A.M., UM #2 said when staff members are assisting residents with their meals, the staff members should be seated at the residents' level. During an interview on 4/9/24 at 1:45 P.M., the Dharma Unit Activities Director said the residents should not be referred to as feeds and wording such as he/she needs assistance should be used instead. During an interview on 4/9/24 at 1:48 P.M., UM #2 said staff should not refer to residents by their level of care needs such as feeders, that staff should utilize the resident's name which is more dignified.

Based on interview and record review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP/ Nurse Practitioner) of a significant change in condition for two Residents (#54 and #74) out of a total sample of 25 residents. Specifically, the facility staff failed to notify the Physician/NPP: 1. To determine the need to alter medication treatment when Resident #54 had recurrent seizure activities. 2. When Resident #74 experienced an unplanned, significant weight loss in one month. Findings include: 1. Resident #54 was admitted to the facility in November 2017 with diagnoses including: Idiopathic Epilepsy (a type of epilepsy with a strong genetic basis that affects people of all races and sexes), Epileptic Syndromes (a group of signs and symptoms that tend to occur together in seizure activity) with Seizures (a burst of uncontrolled electrical activity in the brain that cause temporary changes in muscle tone, behaviors, sensations or awareness) of localized onset and Conversion Disorder (functional neurologic system disorder that causes physical and sensory problems that are not caused by the person faking them). Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact, as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of total possible 15, and that the Resident was independent with activities of daily living (ADLs). During an interview on 4/10/24 at 8:47 A.M., Resident #54 said that he/she had chronic pain related to his/her uncontrolled seizures. The Resident said that most of the time the seizure activity resulted in a fall or hitting part of his/her body on objects in his/her room. Review of the April 2024 Physician's orders for Resident #54 indicated: -Lamotrigine (medication used to treat seizures) 400 milligram (mg) tablet every morning and at bedtime for Epilepticus (medical emergency of seizures), initiated 1/3/2022. Review of the Nursing Progress Notes indicated the following: -On 5/19/23, Resident #54 had a seizure while ambulating in the hallway and was lowered to the floor. The Nursing Progress Note further indicated that Resident #54's seizure lasted approximately 30 seconds and he/she was assisted back into a wheelchair, then into his/her bed. -On 10/15/23, Resident #54 had a seizure that lasted approximately 10 seconds and that the Resident was assisted into his/her bed. -On 11/12/23, Resident #54 had a seizure that lasted 10 to 15 seconds. -On 12/9/23, Resident #54 mentioned to the Nurse that he/she did not feel right, and the Nurse observed that the Resident had a seizure that lasted for 10 seconds. -On 1/7/24, Resident #54 wheeled him/herself in the hallway, had a seizure and was lowered to the floor. The Nursing Progress Note further indicated that the Resident's seizure lasted approximately 15 seconds and he/she was assisted back to bed. -On 3/3/24, Resident #54 had a seizure that lasted approximately 20 seconds and the Resident was assisted back to his/her bed. Further review of Resident #54's Medical Record failed to indicate that the Physician/NPP was notified of Resident #54's seizure activity on: 5/19/23, 10/15/23, 11/12/23, 12/9/23, 1/7/24, and 3/3/24. During an interview on 4/10/24 at 10:47 A.M., Nurse #4 said if a Resident had a seizure, he would perform vital signs and notify the Physician/NPP for further orders. Nurse #4 further said he had not had Resident #54 on his assignment. During an interview on 4/10/24 at 11:00 A.M., Nurse #1 said she had only worked in the facility for a few months, but if she had a resident with seizures, she would perform a physical assessment and notify the Physician/NPP. During an interview on 4/10/24 at 11:15 A.M., the NPP said the facility staff had never informed her that Resident #54 ever had any seizure activity. The NPP said she should have been notified each time Resident #54 had seizure activity and was not notified. The NPP further said there had been concerns about Physicians/NPP not receiving notification from the facility staff about resident change in condition and this was a task being worked on with the facility. During an interview on 4/10/24 at 12:18 P.M., the Director of Nurses (DON) said the facility had no policy on Physician/NPP notification. When the surveyor asked the DON about the Physician/NPP notification process for Resident #54, the DON said the Resident's seizures were not true and if the staff believed they were true seizures the staff would have notified the Physician. 45429 2. Resident #74 was admitted to the facility in February 2024, with diagnoses including urinary tract infection (UTI: bacterial infection of the urinary tract) and fracture of the upper end of the left humerus (the bone of the upper arm, forming joints at the shoulder and the elbow). During an interview on 4/7/24 at 10:25 A.M., Resident #74 said that he/she had lost weight since their admission to the facility. The Resident also said that he/she had discussed the weight loss concerns with staff. Review of Resident #74's weights documented in the electronic medical record (EMR) indicated: -On 2/19/24, the Resident weighed 111.5 lbs. -On 3/13/24, the Resident weighed 104.5 pounds (a 6.28 % significant weight loss in one month). Review of Resident #74's Minimum Data Set (MDS) Assessment, dated 2/24/24, indicated the following: -The Resident was cognitively intact as exhibited by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15 points. -The Resident was not on a Physician prescribed weight loss regimen. Review of Resident #74's care plan for Nutrition Risk, initiated 3/6/24, indicated the following interventions: -to report to Physician significant weight loss: 3 pounds in 1 week, greater than 5% in one month, greater than 7.5% in three months, greater than 10% in six months. -monitor weights and notify the Physician of any significant change. Review of the facility's Risk Meeting Notes indicated that the facility was aware that Resident #74 had triggered for weight loss on 3/7/24. Review of Resident #74's medical record did not indicate that the Physician/NPP had been notified of the significant weight loss. During an interview on 4/9/24 at 12:55 P.M., the Director of Nurses (DON) said when a resident experiences a significant weight loss, the Physician should be notified immediately. During an interview on 4/9/24 at 2:13 P.M., the Doctor of Nursing Practice (DNP) said that she had not been made aware of Resident #74's weight loss and that she should have been notified by the facility staff.

Based on observation and record review the facility failed to ensure that a homelike environment was maintained for residents in one dining area ([NAME]) out of three dining areas observed on the Dharma Unit (Dementia Special Care Unit). Specifically, the facility and staff failed to ensure that the dining experience for residents was a homelike environment by adding tablecloths to the dining room tables and removing meals from the meal trays prior to serving the residents. Findings include: On the following days and times: -4/7/24 at 10:15 A.M., -4/8/24 at 9:06 A.M., -4/8/24 at 12:47 A.M., -4/9/24 at 9:00 A.M., the surveyor observed in the [NAME] dining area, multiple residents seated at tables with no tablecloths covering the tables and all resident meals were being served on the delivery trays, that no meals had been removed from the delivery trays before being placed in front of the residents. During an interview on 4/9/24 at 9:31 A.M., Unit Manager (UM) #2 said the dining in the [NAME] dining area would be more homelike if tablecloths were added to the tables. UM #2 further said she was unsure why tablecloths were not utilized in the [NAME] dining area as tablecloths were used on the tables in the other two dining areas on the Dharma Unit. UM #2 also said that staff used to take all items off the delivery trays and set them up in front of the residents, but that had not been done in some time. UM #2 said removing the meal items from the delivery trays would make the dining experience more homelike for the residents.

Based on interview and record review the facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded for two Residents (#101 and #122), out of a total sample of 25 residents. Specifically, the facility failed to ensure the MDS Assessment: 1. For Resident #101, was accurately coded relative to receiving hospice services. 2. For Resident #122, was accurately coded relative to the use of antibiotic medications. Findings include: 1. Resident #101 was admitted to the facility in November 2023 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue), Heart Failure (HF: when the heart is unable to pump blood as it should, resulting in fluid buildup in the feet, arms, lungs and other organs) and Multiple Sclerosis (MS: a chronic autoimmune disorder affecting movement, sensation, and bodily functions). Review of Resident #101's care plan, last revised 4/8/24, indicated that the Resident was receiving Hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) services starting on 3/4/24. Review of Resident #101's Significant Change MDS assessment dated [DATE], indicated that the Resident was not receiving Hospice services. Review of April 2024 Physician's orders for Resident #101 indicated the following: -Admit to Hospice, start date 3/4/24 -Continue with Hospice services, start date 3/4/24 -Notify Hospice of any clinically significant changes, start date 3/15/24 During an interview on 4/8/24 at 10:44 A.M., the Director of Nurses (DON) said that the MDS was inaccurately coded and that Resident #101's MDS should have been coded as receiving Hospice services. 44222 2. Resident #122 was admitted to the facility in March 2024 with diagnoses of Retention of Urine (difficulty urinating and completely emptying the bladder), Bacteremia (bacteria in the blood), other specified sepsis (a body's response to infection damaging tissues) and Urinary Tract Infection (UTI: bacterial infection of the urinary tract). Review of the March 2024 Physician's orders for Resident #122 included: -Ampicillin Sodium (an antibiotic medication) Intravenous (IV: administered into a vein) Solution Reconstituted 2 GM (gram), order date 3/1/24. -Ampicillin Sodium, Use 2 gram intravenously every 6 hours for infection until 3/10/2024 [at] 23:59, start date 3/2/24, completed 3/10/24. Review of the Resident's March 2024 Medication Administration Record (MAR) indicated that the Resident received the intravenous Ampicillin Sodium every 6 hours as ordered, from 3/2/24 until 3/10/24. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident had diagnoses of septicemia (bacteria that poisons the blood) and a UTI. The MDS did not indicate that the Resident was receiving antibiotic medication (Ampicillin Sodium). During an interview on 4/10/24 at 9:51 A.M., the MDS Nurse reviewed the Resident's clinical record and said that the MDS dated [DATE] should have indicated that the Resident was receiving antibiotic medication during the MDS look back period but it did not. The MDS Nurse further said that this was a coding error.

Based on observation, record review, and interview, the facility failed to provide care and services to achieve or maintain bladder function for one Resident (#122) out of three applicable residents, out of a total sample of 25 residents. Specifically, for Resident #122, the facility staff failed to obtain Physician's orders for the care and services of an indwelling urinary catheter (a flexible tube inserted into the bladder to allow for urine flow) to prevent complications and urinary tract infections. Findings include: Review of the Facility's Physician's Order Set for the care of Indwelling Urinary Catheters, undated, included: -Foley Catheter (brand name of an indwelling urinary catheter) Care every shift. -Foley Catheter ___F (F/Fr: French - unit of measurement for the size of the diameter of the tubing), ___cc (cubic centimeters a unit of measurement: indicating the capacity of the catheter's balloon/bulb) bulb (Insertion and PRN (as needed) change) Diagnosis: _______ as needed for Occlusion (blockage), Leakage AND one time only for initial insertion or re-insertion for 1 Day. -Flush Foley Catheter with 60 cc (cubic centimeters: indicating the amount of fluid) Normal Saline as needed for Obstruction. -Foley Catheter Privacy Bag every shift. -Change Foley Bag every day shift every 7 day(s). Resident #122 was admitted to the facility in March 2024 with diagnoses of Retention of Urine (difficulty urinating and completely emptying the bladder), Chronic Kidney Disease Stage 2 (CKD - when the kidneys are damaged and cannot filter blood the way that it should) and Urinary Tract Infection (UTI: bacterial infection of the urinary tract). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #122: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15. -had an indwelling urinary catheter. -required staff assistance with toileting tasks. Review of the April 2024 Physician's orders for Resident #122 included: -Ensure catheter privacy leg bag placed higher to avoid pulling. Every day and evening shift for irritation. -Foley Catheter; 18 Fr, 10 ml (balloon/bulb) -Urine output Q (every) shift -every shift for catheter insitu (in the appropriate place) [catheter placement] Further review of the April 2024 Physician's orders did not indicate: -orders for catheter care every shift. -Instructions for irrigation/flushing of the catheter. -Instructions for replacing the catheter. -Instructions for replacing the bedside drainage bag. -Instructions for the application of an anchoring device. During an observation and interview on 4/10/24 at 10:30 A.M., Nurse #3 confirmed that the Resident's indwelling urinary catheter was size 18 Fr 10 ml, that there was an anchoring device in place on the Resident's right thigh, and that the bedside drainage bag was covered with a privacy bag and had been changed on 4/5/24. Nurse #3 reviewed the Resident's current Physician's orders and said that she thought there should be more orders in place for the care of an indwelling urinary catheter. Nurse #3 said she could not find any current Physician's orders for catheter care every shift, replacement of the catheter, or flushing of the catheter. Nurse #3 said there was usually a set of orders that was put in place for any resident with an indwelling urinary catheter, but she could not find any evidence that this had been done for Resident #122. During an interview on 4/10/24 at 12:00 P.M., the Director of Nurses (DON) said that the orders for the care and services of the Resident's indwelling urinary catheter should have been put in place but they were not. The DON said that there was no specific facility policy for the care and services of an indwelling urinary catheter and that the staff just put the Physician's order set in place for residents that have an indwelling urinary catheter. The DON said the Physician's order set was not put in place for Resident #122. The DON said that orders for catheter care each shift, placing a securing device weekly, flushing of the catheter for blockage, and replacment of the drainage bag and catheter were not in place but should have been.

Based on interview and record review, the facility failed to accurately implement a psychotropic medication (medication that affects brain activity) gradual dose reduction (GDR) as recommended by the Psychiatric Certified Nurse Practitioner (CNP) for one Resident (#94) out of a total sample of 25 residents. Specifically, the facility staff failed to: -For Resident #94, ensure that the recommendation made by the Psychiatric CNP for a GDR of Zyprexa (an antipsychotic medication) morning dose from 5 milligrams (mg) to 2.5 mg was accurately implemented, when the morning dose of Zyprexa was increased back to 5 mg without any further recommendations, thereby cancelling the GDR process. Findings include: Review of the facility policy titled, Psychotropic Medication Use, revised July 2022, indicated the following: -Residents on psychotropic medications receive gradual dose reductions . Resident #94 was admitted to the facility in March 2022, and had diagnoses including anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities), Alzheimer's Dementia (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, that is severe enough to interfere with daily life), and a history of psychosis (when someone loses contact with reality). Review of the Psychiatric CNP note dated 1/9/24, indicated the following recommendation: -Patient with a decrease in cognition, suggest trial GDR. -Suggest discontinue (d/c) Zyprexa 5 milligram (mg) daily at 9:00 A.M. -Suggest Zyprexa 2.5 mg daily at 9 A.M. and Zyprexa 5 mg daily at 5:00 P.M. Review of the March 2024 Physician's Order Summary indicated the GDR recommended for the A.M. dose of Zyprexa by the Psychiatric CNP was implemented as ordered: -Zyprexa 2.5 mg, give 2.5 mg by mouth in the morning with a start date of 1/17/24. Further review of the Physician's Order Summary indicated the Resident continued to receive the evening dose of Zyprexa as evidence by the following order: -Zyprexa 2.5 mg, give 5 mg by mouth in the evening .with a start date of 1/17/24. Review of the January 2024, February 2024, and March 2024 Medication Administration Records (MARs) indicated: -from 1/17/24 through 3/9/24: the Resident received the 2.5 mg prescribed dose of Zyprexa in the morning. -from 1/17/24 through 3/10/24: the Resident received the 5 mg prescribed dose of Zyprexa in the evening. Review of the Psychiatric CNP note dated 3/5/24 indicated the following recommendation: -Suggest reducing HS (hour of sleep or bedtime) Zyprexa dose from 5 mg to 2.5 mg due to Resident decline. Review of the March 2024 Physician's Orders indicated the following orders: -Zyprexa Oral Tablet 2.5 mg, give 5 mg by mouth in the morning .with a start date of 3/9/24 and a discontinued date of 3/11/24. -Zyprexa Oral Tablet 2.5 mg, give 5 mg by mouth in the morning .with a start date of 3/11/24. -Zyprexa Oral Tablet 2.5 mg by mouth in the evening .with a start date of 3/11/24 Review of the March 2024 and April 2024 MARs indicated: -from 3/9/24 through 4/8/24: the Resident received the prescribed 5 mg dose of Zyprexa in the morning and the 2.5 mg dose of Zyprexa in the evening. Further review of the Resident's medical record indicated no documentation that any of the Resident's medical providers had made the recommendation for the Resident's morning dose of Zyprexa to be increased back to 5 mg. During an interview on 4/8/24 at 10:40 A.M., the Psychiatric CNP said she was unsure why the Resident's prescribed morning dose of Zyprexa was increased back to 5 mg. The CNP further said that her recommendation was for the Resident to have 2.5 mg Zyprexa in the morning and to have the evening dose of Zyprexa also reduced to 2.5 mg, and this was not done as recommended. During an interview on 4/8/24 at 4:41 A.M., Unit Manager (UM) #2 said she was unsure why Resident #94's morning dose of Zyprexa was increased back to 5 mg. UM #2 further said the morning dose of Zyprexa should have remained at 2.5 mg and the Psychiatric CNP had recently decreased the Resident's evening dose of Zyprexa down to 2.5 mg and it looked like the doses got swapped and the Resident never had the full GDR completed as recommended.

Based on interview and record review, the facility failed to re-evaluate a performance improvement plan (PIP) when the identified interventions were no longer making progress toward the identified goal for improving lunch meal tray arrival times for one unit (Dharma Unit) out of three units observed. Specifically, the facility failed to ensure that an effective system was maintained for implementing changes, monitoring performance, and obtaining feedback from residents and family representatives, related to consistently late lunch time meals. Findings include: Review of the facility Quality Assurance Performance Improvement Plan signed 1/17/24, indicated the following: -Areas of the plan are measures by clinical outcomes, aspects of performance, and resident satisfaction with the goal . -Information gathered is analyzed and compared to set benchmarks. Benchmarks may be adjusted based on the data outcomes. -Current performance improvement projects include Tray arrival time. Review of the PIP titled Dietary Department Improvements dated 1/2/24, indicated the following problem had been identified: Complaints from residents, Ombudsman, and families about food deliveries being late. During an interview on 4/7/24 at 11:44 A.M., Family Member #2 whose family resided on the Dharma Unit said he/she was always at the facility to assist his/her loved one with lunch and the lunch meal is late sometimes, even coming to the unit 30 minutes or more later than the scheduled time on some days. During an interview on 4/9/24 at 1:01 P.M., Family Member #1 whose family resided on the Dharma Unit said he/she was always at the facility to visit with his/her loved one during the lunch meal and that the lunch meal truck is often late and his/her family was always very hungry by the time the meal truck arrived to the unit. During an interview on 4/9/24 at 2:27 P.M., the Food Service Director (FSD) said he was aware of the current problems with the meal trucks getting to the units after the scheduled times. The FSD said the meal trucks should arrive on the unit within 5 minutes of the scheduled meal time. The FSD said the facility was currently completing a PIP for late meal trucks and he felt that the kitchen was short staffed. The FSD further said for the kitchen to run properly and for meals to be delivered on time there needed to be four staff members working in the kitchen. Review of the PIP Plan dated 1/2/24, indicated the following interventions: -Daily recordings of when trays come up and findings brought to QAPI monthly meeting until system improved and tray delivery time gets better. Further review of the PIP Plan dated 1/2/24, indicated no specific parameters for measuring what late meant or that a measurable goal had been set to detemine if interventions were working. Review of the last 14 days of Food Truck Delivery Daily Tracking Log from 3/27/24 through 4/8/24, indicated that on 10 of 15 days the lunch meal was not delivered on the unit per the FSD targeted time frame of five minutes from the scheduled meal time for the Dharma Unit. Further review of the Food Truck Delivery Daily Tracking Log indicated on 3/7/24, 4/3/24, 4/4/24, 4/5/24, 4/6/24, and 4/7/24, the lunch meal was delivered 20 minutes or more late to the Dharma Unit. Review of the Dietary Department QAPI sheet dated 2/1/24, indicated the following: Food Truck Delivery on Units Late: Lunch trays were late two times Review of the Dietary Department QAPI sheet dated 3/13/24, indicated the following: Food Truck Delivery on Units Late: Lunch trays were late six times Further review of the Dietary Department QAPI sheets from February 2024 and March 2024, indicated no documentation: -pertaining to which units the meal trucks were delivered late to. -on which days the meal trucks were late. -as to why the meal trucks were late on those days. -that new interventions were discussed and planned to improve meal truck delivery to the units. During an interview on 4/10/24 at 9:17 A.M., the Administrator said he was unsure why meal trucks continued to be late for the lunch meal on the Dharma Unit. The Administrator further said interventions should have been adjusted when the meal trucks continued to be late to the units over a period of two months and interventions had not been re-assessed at this time. The Administrator said the current intervention was to hire more staff but when he looked at the staffing schedule he was unable to show that there was not enough staff for the kitchen (3/27/24 through 4/8/24 indicated four or more staff members working) to run effectively except for 4/7/24 when there was only three staff members in the kitchen. During a follow-up interview on 4/10/24 at 10:55 A.M., the Administrator said he had no current process implemented to obtain feedback from the Residents and/or Resident Family Members from the Dharma unit to see if meal truck delivery time had improved. The Administrator said the current feedback was obtained only from the facility's other two units (not from the affected Dharma Unit)

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was at risk for choking related difficulty chewing and swallowing, was assessed and care planned as requiring continual supervision at all times while eating, the Facility failed to ensure staff implemented interventions from his/her plan of care regarding the need for continual supervision while eating, when after he/she was given food by a staff member, Resident #1 took the food into his/her room, the staff member did not remain with the resident and continual supervision was not provided. - On 11/15/20, at approximately 11:00 A. M, the Activity Aide passed out morning snacks to residents on the unit, the Activity Aide gave Resident #1 a donut crushed up in milk in a cup with a spoon, and then continued passing out snacks to other residents on the unit. Resident #1 took the snack into his/her room to consume it and was left unsupervised by staff. One minute later Resident #1 came out into the hallway and signaled to staff that he/she was choking, the [MEDICATION NAME] (first aide procedure for dislodging an obstruction from the windpipe) maneuver was performed, 911 was called and Resident #1 was transported to the Hospital where he/she was pronounced dead upon arrival. Findings include: The Facility Policy, titled, Comprehensive Care Plans - Person Centered, dated 8/2019, indicated that the care plan will meet the resident's needs and describe the services that are to be furnished to attain or maintain the resident's highest physical, mental and psychological wellbeing. Incorporate identified problem areas and risk factors associated with the identified problems. The Facility Policy, titled, Safety and Supervision of Residents, dated 8/2019, indicated that resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards. The Policy indicated that an individualized resident centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards including adequate supervision. Implementing and monitoring interventions to reduce accident risks and hazards shall include the following: - Communicating specific interventions to all relevant staff; - Assigning responsibility for carrying out interventions; - Providing training, as necessary; - Ensuring that interventions are implemented. Review of Resident #1's Nurse Progress Note, dated 5/17/20, indicated Resident #1 had a decline in his/her eating skill, needed to be physically fed meals by staff due to pocketing food, and a ground diet was ordered for supper. Review of Resident #1's Physician Order, dated 5/20/20, indicated he/she had an order for [REDACTED]. Review of Resident #1's Speech Language Pathologist (SLP) Evaluation, dated 5/20/20, indicated he/she was referred by the nursing staff because of increased difficulty with oral intake, oral pocketing and increased oral transit time. The SLP Evaluation indicated that bedside swallowing assessment indicated Resident #1 had moderate oropharyngeal (part of the throat just behind the mouth) dysphagia (difficulty swallowing foods and liquids) and required moderate verbal and visual cues while eating. The Evaluation indicated staff were to utilize the following safe swallow strategies with Resident #1 while he/she was eating, resident to be sitting upright, ensure resident attention to the food bolus, slow rate, alternate liquids and solids and appropriately sized bites and sips. The Evaluation indicated Resident #1's diet was downgraded to dysphagia ground diet (food is soft, moist and easily mashed with a fork) with thin liquids via cup sips. The Evaluation indicated that the recommended level of supervision was increased to close (continual) supervision for Resident #1, while eating. Review of the physician's orders [REDACTED].#1's diet was changed to dysphagia ground. Review of the Discharge Speech Language Pathologist (SLP) Evaluation, dated 6/09/20, indicated Resident #1 continued to receive supervision with oral intake with occasional verbal and visual cues, and to utilize the safe swallow strategies. During an interview on 11/20/20 at 11:30 A.M., the Speech Therapist said Resident #1 had difficulty chewing his/her food, pocketed food in his/her mouth and required a dysphagia ground diet with alternating sips of liquids and solids. The Speech Therapist said that in Resident #1's SLP Evaluation, dated 5/20/20, as well as in the Discharge Evaluation, dated 6/09/20, she indicated the type of supervision Resident #1 required when eating was close supervision. The Speech Therapist said close supervision means a staff member must be physically present the entire time with the resident while he/she is eating food. The Speech Therapist said that Resident #1's snack of a crumbled up donut in milk would be considered a solid food and because of that, while eating it, the resident needed to alternate bites of food with sips of liquids, to promote adequate swallowing. Review of Resident #1's the Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was diagnosed with [REDACTED]. Review of Resident #1's Nutrition Plan of Care, dated 7/7/20 and reviewed 9/2020, indicated goals included for resident not to have chewing or swallowing problems. Interventions included, to monitor him/her for signs and symptoms of dysphagia, pocketing, choking, coughing, drooling and holding food in his/her mouth and making several attempts at swallowing. Review of Resident #1's Nutrition Assessment, dated 10/06/20, indicated he/she was alert but confused, had missing and broken teeth, the plan was to continue monitoring him/her due to chewing and swallowing difficulty, and to supervise Resident #1 with eating, per the Plan of Care. Review of Resident #1's Nursing Plan of Care related to Activities of Daily Living, reviewed and renewed 9/2020, indicated for eating, staff to provide him/her with continual supervision and cueing, and for him/her to eat meals in the Dining Room. Review of Resident #1's Certified Nurse Aide (CNA) Plan of Care related to his/her care needs, dated 11/2020, indicated for eating, staff to provide continual supervision and cueing, and for Resident #1 to eat meals in the Dining Room. The Facility Policy, titled, Feeding, dated 8/2019, indicated that the Facility will provide adequate meals and assistance by qualified staff to meet the Resident's needs. The levels of assistance and supervision included: - Continual Supervision and Cueing: Provide assistance with cutting food and opening containers as needed and encouragement as needed, plus verbally cueing the resident to initiate, or to continue to eat. - Continual Supervision and Dysphagia: Assist the resident with cutting food and opening containers as needed. Ensuring textures, appropriately sized bites, and appropriate liquids. Monitoring for difficulty swallowing and provide encouragement. Review of the list of residents, provided by the Director of Nurses, who resided on Resident #1's wing of the unit for November 2020, indicated that 10 out 22 residents on the unit required supervision while eating, which included continual supervision, supervision with cues, and supervision with contact guard assistance. The List also indicated that two residents required physical assistance with eating and three residents were totally dependent on staff to be fed. Review of Staffing schedules, for November 2020, indicated there were only two CNA's and one nurse assigned to Resident #1's unit to meet the care needs, including supervision with eating for the residents. During an interview on 11/20/20 at 7:15 A.M., the Dietitian indicated Resident #1 required a dysphagia ground diet with thin liquids. The Dietician said Resident #1 could feed him/herself but said he/she required continual supervision and cueing during intake. The Dietician said continual supervision with cueing meant that Resident #1 required to be monitored continually while eating, that a staff member needed to be right there, sitting with him/her. Review of Nurse #1's Nurse Progress Note, dated 11/15/20, indicated that CNA #1 called out to her, that Resident #1 was standing in the hallway choking and was unable to cough. The Note indicated Nurse #1 performed the [MEDICATION NAME] maneuver several times with no effect, Resident #1 was lowered to the floor and pieces of a doughnut came out of his/her mouth, and the [MEDICATION NAME] maneuver was performed again with no effect. The Note indicated 911 was called, Emergency Services arrived, and Resident #1 was transferred to the Hospital Emergency Department. Review of the Facility's Internal Investigation, dated, 11/15/20, indicated that on 11/15/20 at approximately 11:00 A.M., the Activity Aide gave Resident #1 a snack in his/her room, a crumbled donut in milk and then left Resident #1's room. The Investigation indicated less than one minute later, Resident #1 walked out of his/her room and into the hallway and was choking. During an interview on 11/20/20 at 5:43 P.M., the Activity Aide said it was her task to pass out morning snacks on the unit, but said it was not her responsibility to provide supervision to residents while eating. The Activity Aide said when she gave Resident #1 his/her snack, a cup with the crumbled donut in milk and a spoon, said she did not give Resident #1 a drink and said she was not aware if he/she had a drink in his/her room. The Activity Aide said she did not know Resident #1 required supervision while eating and did not know Resident #1 had to alternate bites of solid food with liquids. The Activities Aide said she receives a list from the Food Service Director with the specific dietary needs that include the type of diet and meal consistency for each resident, but said the list does not have any information about residents requiring supervision or swallowing strategies. Review of Resident #1's Transfer Form, dated 11/15/20 at 11:20 A.M., indicated he/she had a choking episode, became unresponsive, the [MEDICATION NAME] maneuver was performed multiple times with no effect. Resident #1's diet was dysphagia ground food secondary to having no teeth or dentures. Review of the Hospital Emergency Department Report, dated 11/15/20, indicated after a witnessed choking episode and likely respiratory arrest, Resident #1 presented on arrival with no spontaneous breathing and no cardiac activity. Resident #1 was pronounced dead at 11:28 A.M. due to respiratory arrest and his/her body was accepted by the Medical Examiner. During an interview on 11/19/20 at 3:00 P.M., CNA #1 said Resident #1 usually sat in a chair for meals and snacks in the doorway of his/her room so staff could supervise him/her. CNA #1 said sometimes Resident #1 sat in his/her room in a recliner to eat snack or meals and that nursing staff patrolled the hallway provide supervision. CNA #1 said on the day of the incident, when Resident #1 was given a snack (crushed up donut in milk), Resident #1 took the snack into his/her room to eat it and said nursing staff were not patrolling the hallways. CNA #1 said she and Nurse #1 were at the nurses station (approximately 20 feet away from where Resident #1 was eating in his/her room ) and said that they could not visually supervise Resident #1 from there. During an interview on 11/19/20 at 4:00 P.M., Nurse #1, who was Resident #1's primary nurse on 11/15/20 during the 7:00 A.M. to 3:00 P.M. shift, said Resident #1 required supervision with food including snacks, and that a staff member needed to be with Resident #1 while she/she was eating. Nurse #1 said Resident #1 had a history of [REDACTED]. Nurse #1 said Resident #1 was not supervised by a staff member while eating his/her snack on the day of the choking incident. Nurse #1 and CNA #1 said they could not provide the appropriate level of supervision with eating to all of the residents that required it, that they were not always able to monitor the hallways to check on residents who ate in their rooms, because they also had to had to answer call lights and attend to resident care needs. During an interview on 11/19/20 at 2:20 P.M., and on 11/23/20 at 7:45 A.M., the Director of Nurses (DON) said for residents that require continual supervision with eating, a staff member must be with the resident the entire time while they are eating food. The DON said Resident #1 was not provided with continual supervision while eating as per his/her plan of care due to limitations on the number of residents that could be in the dining room, in order to be compliant with social distancing.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as being at risk for choking, had a history of [REDACTED].#1 was provided with the required level of supervision while eating to prevent incidents and accidents, when he/she was left unsupervised with food, choked and died . - On [DATE], at approximately 11:00 A. M, the Activity Aide passed out morning snacks to residents on the unit, the Activity Aide gave Resident #1 a donut crushed up in milk in a cup with a spoon, and then continued passing out snacks to other residents on the unit. Resident #1 took the snack into his/her room to consume it and was left unsupervised by staff. One minute later Resident #1 came out into the hallway and signaled to staff that he/she was choking, the [MEDICATION NAME] (first aide procedure for dislodging an obstruction from the windpipe) maneuver was performed, 911 was called and Resident #1 was transported to the Hospital where he/she was pronounced dead upon arrival. Findings include: The Facility Policy, titled, Eating, dated ,[DATE], indicated that residents will be assessed by an interdisciplinary team to ascertain the ability of the Resident to safely eat in their room. Residents who have been identified as being able to safely eat in their rooms will be provided with ongoing supervision during meal rounds by a Certified Nurse Aide (CNA) and or assigned staff. The Facility Policy, titled, Feeding, dated ,[DATE], indicated that the Facility will provide adequate meals and assistance by qualified staff to meet the resident's needs. The levels of assistance and supervision included: - Continual Supervision and Cueing: Provide assistance with cutting food and opening containers as needed and encouragement as needed plus verbally cueing the resident to initiate, or to continue to eat. - Continual Supervision and Dysphagia: Assist the resident with cutting food and opening containers as needed. Ensuring textures, appropriately sized bites, and appropriate liquids. Monitoring for difficulty swallowing and provide encouragement. The Facility Policy, titled, Safety and Supervision of Residents, dated ,[DATE], indicated that resident safety and supervision and assistance to prevent accidents are facility wide priorities. The Policy indicated Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards. Review of the list of residents, provided by the Director of Nurses, who resided on Resident #1's wing of the unit for [DATE], indicated that 10 out 22 residents on the unit required supervision while eating, which included continual supervision, supervision with cues, and supervision with contact guard assistance. The List also indicated that two residents required physical assistance with eating and three residents were totally dependent on staff to be fed. Review of Staffing schedules, for [DATE], indicated there were only two CNA's and one nurse assigned to Resident #1's unit to meet the care needs, including supervision with eating for the residents. Review of Resident #1's Nurse Progress Note, dated [DATE], indicated Resident #1 had a decline in his/her eating skills, needed to be physically fed by staff due to pocketing food, and a ground diet was ordered for supper. Review of Resident #1's Nurse Progress Note, dated [DATE], indicated Resident #1 required cueing with eating. Review of Resident #1's Physician Order, dated [DATE], indicated he/she had an order for [REDACTED].>Review of Resident #1's Speech Language Pathologist (SLP) Evaluation, dated [DATE], indicated he/she was referred by the nursing staff because of increased difficulty with oral intake, oral pocketing and increased oral transit time. The SLP Evaluation indicated that bedside swallowing assessment indicated Resident #1 had moderate oropharyngeal (part of the throat just behind the mouth) dysphagia (difficulty swallowing foods and liquids) and required moderate verbal and visual cues while eating. The Evaluation indicated staff were to utilize the following safe swallow strategies with Resident #1 while he/she was eating, resident to be sitting upright, ensure resident attention to the food bolus, slow rate, alternate liquids and solids and appropriately sized bites and sips. The Evaluation indicated Resident #1's diet was downgraded to dysphagia ground diet (food is soft, moist and easily mashed with a fork) with thin liquids via cup sips. The Evaluation indicated that the recommended level of supervision was increased to close (continual) supervision for Resident #1, while eating. Review of the Discharge Speech Language Pathologist Evaluation, dated [DATE], indicated Resident #1 continued to receive supervision with oral intake with occasional verbal and visual cues required, and to utilize the safe swallow strategies. Review of Resident #1's medical record indicated there was no documentation to support that the safe swallow strategies identified and recommended in the Speech Language Pathologist Evaluations, dated [DATE] and [DATE] were transcribed on to the physician's orders [REDACTED]. Review of Resident #1's medical record indicated there was no documentation to support that he/she was assessed by an interdisciplinary team to ascertain the ability to safely eat in his/her room. During an interview on [DATE] at 11:30 A.M., the Speech Therapist said Resident #1 had difficulty chewing his/her food, pocketed food in his/her mouth and required a dysphagia ground diet with alternating sips of liquids and solids. The Speech Therapist said that in Resident #1's SLP Evaluation, dated [DATE], as well as in the Discharge Evaluation, dated [DATE], indicated the type of supervision Resident #1 required when eating was close supervision. The Speech Therapist said close supervision means a staff member must be physically present the entire time with the resident while he/she is eating food. The Speech Therapist said that Resident #1's snack of a crumbled donut in milk would be considered a solid food and because of that, while eating it, the resident needed to alternate bites of food with sips of liquids, to promote adequate swallowing. Review of Resident #1's the Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was diagnosed with [REDACTED]. Review of Resident #1's Nutrition Assessment, dated [DATE], indicated he/she was alert but confused, had missing and broken teeth, the plan was to continue monitoring him/her due to chewing and swallowing difficulty, and to supervise Resident #1 while eating, per the Plan of Care. Review of Resident #1's Nursing Plan of Care related to Activities of Daily Living, dated [DATE], reviewed and revised ,[DATE], indicated for eating, to provide him/her with continual supervision and cueing, and to eat meals in the Dining Room. Review of Resident #1's CNA Plan of Care related to his/her care needs in ,[DATE], indicated for eating provide continual supervision and cueing, and eat meals in the Dining Room. Review of Resident #1's Nutrition Plan of Care, dated [DATE], reviewed and revised ,[DATE], indicated a goal for Resident #1 was not to have chewing or swallowing problems. Interventions included, to monitor him/her for signs and symptoms of dysphagia, pocketing, choking, coughing, drooling and holding food in his/her mouth and several attempts at swallowing. During an interview on [DATE] at 7:15 A.M., the Dietitian indicated Resident #1 required a dysphagia ground diet with thin liquids, that he/she could feed him/herself, but required supervision for meals. The Dietician said Resident #1's Plan of Care for eating was continual supervision with cueing, which meant he/she needed to be monitored continually while eating, that a staff member needed to be right there, sitting with him/her. Review of Resident #1's Nurse Progress Note, dated [DATE], written by Nurse #1 indicated that CNA #1 called out to her, that Resident #1 was standing in the hallway choking and unable to cough. The Note indicated Nurse #1 performed the [MEDICATION NAME] maneuver several times with no effect, Resident #1 was lowered to the floor and pieces of a donut came out, the [MEDICATION NAME] maneuver was performed again, 911 was initiated, and Emergency Medical Services transported Resident #1 to the Hospital Emergency Department. Review of the Facility's Internal Investigation, dated, [DATE], indicated the following: - On [DATE] at approximately 11:00 A.M., the Activities Aide gave Resident #1 a snack in his/her room, a crumbled up donut in milk and then left Resident #1's room. - Less than one minute later, Resident #1 walked out of his/her room and into the hallway and was choking. - Nurse #1 immediately performed the [MEDICATION NAME] maneuver, Resident #1 became unresponsive, and was lowered to the floor, had agonal breathing (an abnormal breathing pattern of inadequate oxygenation). - Resident #1's Advance Directives were for Do Not Resuscitate, Do Not Intubate, may transfer to the hospital. - 911 was called and EMS arrived. Resident #1's Transfer Form, dated [DATE] at 11:20 A.M., indicated he/she had a choking episode, became unresponsive, the [MEDICATION NAME] maneuver was performed multiple times with no effect. Resident #1's diet was dysphagia ground food secondary to having no teeth or dentures. Review of the Ambulance Run Sheet, dated [DATE] at 10:57 A.M., indicated EMS responded to a report of a choking unresponsive Resident, Nursing Staff had a valid DNR/DNI and stated to only transport to the Hospital. On EMS arrival to the Facility, Resident #1 was lying on the floor with small amounts of vomit noted near him/her. Nursing Staff stated Resident #1 was eating a donut when he/she choked and vomited once but was unable to cough. Resident #1 had agonal respirations, pupils were non-reactive (an abnormal neurological sign), skin cool to touch, he/she was suctioned. He/she was placed on a non-rebreather mask with oxygen at 15 liter per minute and a cardiac monitor, with a heart rate of 114 (normal 60 to 100), then the heart rate decreased to 40 (abnormally low). During transport he/she became pulseless and apneic (without respirations) with sustained asystole (a flat line, no electrical activity of the heart) for the duration of the transport. Review of the Hospital Emergency Department Report, dated [DATE], indicated after a witnessed choking episode and likely respiratory arrest, Resident #1 presented on arrival with no spontaneous breathing and no cardiac activity. Resident #1 was pronounced dead at 11:28 A.M. due to respiratory arrest and his/her body was accepted by the Medical Examiner. Review of the Activity Aide's written Witness Statement, dated [DATE], indicated that she was in the hallway providing the residents with snacks, and gave Resident #1 a crumbled up donut in milk, which he/she took into his/her room. The Statement indicated she left Resident #1's room, and a few moments later, Resident #1 came out of the room and was choking. During an interview on [DATE] at 5:43 P.M., the Activity Aide said it was her task to pass out morning snacks on the unit, but said it was not her responsibility to provide supervision to residents while eating. The Activity Aide said when she gave Resident #1 his/her snack, a cup with the crumbled up donut in milk and a spoon, said she did not give Resident #1 a drink and said she was not aware if he/she had a drink in his/her room. The Activity Aide said she did not know Resident #1 required supervision while eating and did not know Resident #1 had to alternate bites of solid food with liquids. Review of CNA #1's written Witness Statement, dated [DATE], indicated that Resident #1 walked out of his/her room and looked very pale, Resident #1 started shaking, and she (CNA #1) called out to Nurse #1 for help. The Statement indicated Nurse #1 performed the [MEDICATION NAME] maneuver several times and nothing came out of Resident #1 mouth. Resident #1 was lowered to the floor and turned on his/her side. CNA #1 performed a finger sweep of Resident #1's mouth and a piece of donut came out, and he/she was barely breathing. During an interview on [DATE] at 3:00 P.M., CNA #1 said Resident #1 usually sat in a chair for meals and snacks in the doorway of his/her room so staff could supervise him/her. CNA #1 said sometimes Resident #1 sat in his/her room in a recliner to eat snack or meals and that nursing staff patrolled the hallway provide supervision. CNA #1 said on the day of the incident, when Resident #1 was given a snack (crushed up donut in milk), Resident #1 took the snack into his/her room to eat it and said nursing staff were not patrolling the hallways. CNA #1 said she and Nurse #1 were at the nurses station (approximately 20 feet away from where Resident #1 was eating in his/her room ) and said that they could not visually supervise Resident #1 from there. CNA #1 said from the Nurses Station, she saw Resident #1 come out of his/her room, stand in the hallway, and that it looked like Resident #1 was choking. CNA #1 said Resident #1 was breathing abnormal, he/she went limp started to fall, she (CNA #1) called out to Nurse #1 to come help. CNA #1 said after Nurse #1 performed the [MEDICATION NAME] maneuver several times, she performed a finger sweep and removed a quarter size piece of food (donut) from Resident #1's mouth During an interview on [DATE] at 9:30 A.M., CNA #2 said when snacks are passed out to the residents, they are not always able to supervise residents that required supervision by patrolling the hallways because they still had to respond to call lights. CNA #2 said that sometimes they were in a residents' room providing assistance with toileting or with other things a resident needs, and said they are unable to do hallway monitoring duties at the same time. CNA #2 said Resident #1 had a history of [REDACTED]. During an interview on [DATE] at 4:00 P.M., Nurse #1, who was Resident #1's primary nurse on [DATE] during the 7:00 A.M. to 3:00 P.M. shift, said Resident #1 required supervision with food including snacks, and that a staff member needed to be with Resident #1 while she/she was eating. Nurse #1 said Resident #1 had a history of [REDACTED]. Nurse #1 said Resident #1 was not supervised by a staff member while eating his/her snack on the day of the choking incident. Nurse #1 and CNA #1 said they could not provide the appropriate level of supervision with eating to all of the residents that required it, that they were not always able to monitor the hallways to check on residents who ate in their rooms, because they also had to had to answer call lights and attend to resident care needs. During an interview on [DATE] at 2:20 P.M., and on [DATE] at 7:45 A.M., the Director of Nurse (DON) said for residents that require continual supervision with eating, a staff member must be with the resident the entire time while they are eating food. The DON said Resident #1 was not provided with continual supervision while eating as per his/her plan of care due to limitations on the number of residents that could be in the dining room, in order to be compliant with social distancing.

Based on observations, record reviews and interviews, the facility staff failed to provide adequate supervision and assistance to prevent falls with major injury for 3 Residents (#94, #71 and #90). Findings include: 1. Resident #94 was readmitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. Review of the 3/30/18 Significant Change in Status Minimum Data Set (MDS) Assessment indicated the Resident had moderate cognitive impairment as evidenced by a score of 9 out of 15 on the Brief Interview for Mental Status Assessment. Further review of the 3/30/18 Significant Change in Status MDS Assessment indicated the Resident was dependent for transfers, personal hygiene and toilet use and required assist of 2 staff members. Review of facility Fall Prevention Policy, revised (6/2017), indicated that any resident who falls will be reviewed by an interdisciplinary team and the care plan reviewed and updated. Review of the medical record indicated the Resident has had 5 falls since initial admission to the facility. The resident sustained [REDACTED].M. and the fall resulted in the Resident having a bump to the back of head. Review of the Fall Investigation Report indicated the Resident was placed on the toilet at 2:30 P.M. by the 7:00 A.M. to 3:00 P.M. staff. The oncoming shift staff were unaware of the resident on the toilet. The Resident's son was in to visit and was looking for a staff member to assist the Resident off of the toilet but could not find anyone. When the son went back into the bathroom, he saw the Resident on the floor and assisted the Resident back onto toilet. The intervention put in place after the fall was to check on resident often, as resident may unsafely rise from wheelchair or bed without notice. The resident sustained [REDACTED].M. with no injury. Review of the Fall Investigation Report indicated the Resident was reaching for the call bell. The intervention put in place after the fall was for resident to wear slipper socks to feet while in bed and shoes when out of bed. The resident sustained [REDACTED].M. with no injury. Review of the Fall Investigation Report indicated the Resident fell forward out of wheelchair reaching for something. The resident was wearing slippers and not shoes or non skid socks as care planned. The intervention was to discuss with physician decreasing dose of an antidepressant the Resident was receiving. The resident sustained [REDACTED].M Review of 3/8/18 21:01 Nurse Notes indicated the Resident was reaching for something on the floor and fell . Resident obtained a left forearm skin tear and a bump on the head. There were no items noted on the floor. Per Fall Investigation Report, there was no injury from the fall. The interventions after the fall was to move the Resident closer to the Nurse' Station and medication changes. The resident sustained [REDACTED].M Per Fall Investigation Report, the Resident was placed on the toilet, left alone and rang for assistance. When a staff member responded, the Resident stated he/she was not ready to be assisted off the toilet. A staff member heard the resident fall in the bathroom. Two staff members went into the bathroom and lifted the Resident off the floor and into a wheelchair and propelled the resident to the Nurse' Station for the charge nurse to assess the Resident. Resident requested to go to the emergency room (ER) and was transferred to the ER. Resident was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During an interview on 4/19/18 at 9:09 A.M., the DON said for the 3/18/18 fall, the Resident should not have been lifted off the bathroom floor by 2 CNAs until assessed by the charge nurse. She said the 2 CNAs involved with transferring resident from the floor into a wheelchair were terminated. The other 2 CNAs that transferred the Resident onto the toilet on 3/18/18 and left resident alone were educated. 2. For Resident #71, the facility staff failed to ensure the Resident was free from falls. The resident sustained [REDACTED]. Resident # 71 was admitted to the facility in 2/2017 with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 8/10/17, included the following interventions: - Bed alarm in bed and laser alarms to both sides of the bed. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 8/28/17, indicated that the resident was severely cognitively impaired as evidenced by a score 6 out of a possible 15 on the Brief Interview for Mental Status (BIMS), required extensive assistance for transfers, minimal assistance for ambulation, and had no falls. Review of the nurse's note, dated 10/29/17, indicated that the resident sustained [REDACTED].M., the resident's alarm sounded and the resident was found on the floor near his/her bed. The resident stated that he/she was going to the bathroom. Review of the facility's internal investigation indicated that on 10/29/17, the resident's alarm sounded and he/she was found on the floor. The nurse assessed the resident's skin and body and no injuries were noted. Further review of the internal investigation indicated that after the nurse assessed the resident, 2 CNAs attempted to assist the resident to stand. The resident was not able to stand and complained of pain in his/her leg. The 2 CNAs lifted the resident into bed using a mechanical lift. There is no documentation that the CNAs reported the resident's inability to stand to the nurse. Further review of the facility's internal investigation indicated that at 7:10 A.M. the CNA called the nurse into the resident's room. The nurse observed the resident was lying supine in the bed. The resident's left leg was externally rotated and flexed. The resident had pain with any movement of the leg. The facility's investigation further indicated that at 7:30 A.M. the physician was called and a STAT (immediate) x-ray was ordered and the x-ray was taken at 11:30 A.M. Review of the investigation further indicated that at 2:00 P.M., the report was made to the facility that the resident sustained [REDACTED].M., the resident was transferred to the hospital. Review of the significant change MDS Assessment, dated 12/16/17, indicated that the resident was cognitively impaired, was dependent for transfers and did not ambulate, and had one fall with no injury. Review of the nurse's note, dated 12/31/17, indicated that the resident was found on the floor. The resident was observed on the floor mat by his bed, on his hands and knees. Fall was unwitnessed. Review of the facility's internal investigation, dated 12/31/17, indicated that the resident's bed alarm did not sound. Review of the nurse's note, dated 1/5/18, indicated that the resident was found on the floor sitting with his back to the wall. Review of the facility's internal investigation, dated 1/5/18, indicated that the bed alarm did not sound. Review of the nurse's note, dated 1/18/18, indicated that the resident was found on the floor, sitting and leaning towards his right side. Review of the facility's internal investigation and witness statements, dated 1/18/18, had contradictory information as to if the bed alarm sounded or not. Review of the nurse's note, dated 2/5/18, indicated that the resident was found half sitting on the floor on the right side of his bed. Review of the facility's internal investigation, dated 2/5/18, indicated that the resident's bed had an alarm but it did not sound. Review of the nurse's note, dated 2/9/18, indicated that the resident was found on the floor, sitting on his buttocks, with his right side leaning on the nightstand. Review of the facility's internal investigation, dated 2/9/19, indicated that the resident had the alarm in his/her hand and the alarm was not sounding. Review of the nurse's note, dated 2/12/18, indicated that the resident was found on the floor, on his hands and knees, next to the bed. Review of the facility's internal investigation, dated 2/12/18, indicated that the resident's bed alarm did not sound. The report indicated only a bed alarm was i. use at the time of the fall. During an interview with Nurse #2 on 4/19/18 at 09:59 AM she said that the resident required 2 assist for getting out of bed and he/she should be supervised at all times. He/she is in a supervised area when he/she is out of bed. Nurse #2 further stated that there are not enough staff to provide supervision to prevent falls. The surveyor, on 4/19/18 at 10:34 A.M., observed the resident sitting in a wheelchair in front of the TV within view of the nurse's station. During an interview with the Director of Nursing (DON) 4/19/18 at 01:02 PM She said that the resident is now in a room where he/she is more visible. The DON further said that the resident sustained [REDACTED]. The DON said that the nurse who originally assessed the resident did not notice the possible fracture. The DON further said that the resident's alarms should consistently sound. 3. For Resident #90, the facility staff failed to ensure that the resident's alarms were functioning and the resident sustained [REDACTED]. Resident #90 was admitted to the facility in 7/2016, with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 2/10/17, included the following interventions: - Quarter side rails to assist with bed positioning. - Bed alarm - Laser alarm to bed - Low bed Review of the Fall Risk Assessment, dated 10/25/17, indicated that the resident was at a high risk for falls. Review of the nurse's note, dated 12/9/17, indicated that the resident was found on the floor next to the bed during rounds for care. The resident's alarms were on but not sounding. The resident was found on his/her knees with the left arm caught in side rail, and no visible trauma or injury noted. Review of the facility's internal investigation, dated 12/9/17, indicated that the resident's arm was caught in the left side rail and the alarms were not sounding. There was no evidence that a new side rail assessment was completed at this time. Review of the nurse's note, dated 12/11/17, indicated that the resident was found on the floor next to his/her bed. Review of the facility's internal investigation, dated 12/11/17, indicated that the alarm did not sound at the time of the fall. Review of the nurse's note, dated 1/22/18, indicated that at 3:05 A.M. the resident was found on the floor, face down on the floor mat between the bed and the wall. Red areas were observed on his/her forehead, left forearm and upper chest. No open areas were observed. He/she had 2 motion alarms and a bed alarm, none of which sounded. Upon inspection of the laser alarm on that side of the bed, it was found that the battery was not working. Review of the facility's internal investigation, dated 1/22/18, indicated that the resident's alarms were not sounding. The surveyor observed Resident #90 on 4/19/18 at 9:19 A.M. The resident was sitting in a Broda (high backed tilted) chair being fed by staff. During an interview with CNA #4 on 04/18/18 at 10:30 AM, CNA #4 said that the resident used a bed alarm, 2 laser alarms, mats on floor,on both sides of the bed, a scoop mattress, a body pillow and half siderails. The alarms are checked when the resident gets out of the bed and when he/she goes into the bed. During an interview with the Director of Nursing (DON) on 4/19/18 at 12:47 P.M. The DON said that the alarms should have sounded and the side rails should have been reevaluated after the fall of 12/9/17. The DON further said that there was no reason why the resident should be falling out of bed. The DON further stated that she did not have any information concerning how the resident's arm became caught in the side rail and a full side rail assessment should have been completed after the fall.

Based on records reviewed, interviews and observations for two of three sampled Residents (Resident #1 and #2), the Facility failed to implement individualized interventions identified in the plan of care for the prevention of falls, which resulted in Resident #1 not being provided the necessary supervision and assistance in the bathroom, and he/she fell and sustained two fractures to the bones in his/her left hand and Resident #2 was not provided one person assistance with ambulation and as a result he/she had three unwitnessed falls in less than two months with bruising and need for hospital transfer for further evaluation. Findings included: The Facility Policy titled, Resident Comprehensive Care Plan, dated 4/1/12, indicated that all residents will have in place, accurate, comprehensive care plans that reflect their medical, social, functional, and rehabilitative needs and goals. The Facility Policy, titled Fall Prevention, dated 5/1/09, indicated that any resident who falls will have an assessment done, be reviewed by an interdisciplinary team, and the care plan reviewed and updated. 1. Resident #1 was admitted to the facility in 11/2017 for short term rehabilitation with [DIAGNOSES REDACTED]. The Certified Nurse Aide (CNA) Care Card for falls, dated 11/17/17, indicated for toileting Resident #1 was an assist of one person for care and staff were to stay with the Resident #1 while in the bathroom due to poor safety awareness. Resident #1 required a bed alarm while in bed and a personal alarm while in the chair. The Admission Minimum Data Set (MDS) assessment, dated 11/23/17, indicated Resident #1 was severely cognitively impaired and required the assistance of one person for transfers, ambulation and toileting. The Nurse's Note, dated 11/26/17, indicated that Resident #1 had a fall in the bathroom at 4:30 P.M., that Resident #1 had asked CNA#1 to give him/her privacy while on the toilet, and CNA #1 left the bathroom. The Note indicated, Resident #1's visitor called Nurse #4 to check on Resident #1 in the bathroom, Resident #1 found sitting on the floor with his/her left hand outstretched on the floor and he/she complained of soreness on the top of the left hand. The Note indicated, Resident #1 said that he/she lost his/her balance and fell while trying to wash his/her hands at the bathroom sink. The Facility's Internal Investigation, dated 11/26/17, indicated after CNA #1 ambulated Resident #1 to the bathroom, she left Resident #1 alone in the bathroom, exited the room and went to answer call bells. The Investigation indicated, Resident #1 had an unwitnessed fall in the bathroom. The Investigation indicated, Resident #1's CNA care card indicated that he/she was a one person assist with ambulation, transfers and toileting. The Investigation indicated, CNA #1 was interviewed and stated that she did not read the CNA care card that indicated Resident #1 was a one person assist. The Physician's Note, dated 11/27/17, indicated Resident #1 had moderate swelling over the entire dorsum (top) of the left hand, with point tenderness at the base of the thumb and mild tenderness throughout the metacarpal bones. Possible fracture, will get an X-Ray. The X-Ray Report of the left hand, dated 11/27/18, indicated there was an acute spiral [MEDICAL CONDITION] and 4th metacarpals. The Surveyor interviewed CNA #1 at 10:30 A.M. on 3/23/18. CNA #1 said that on 11/26/17 at approximately 4:30 P.M., she assisted Resident #1 to the bathroom, and then left to answer call bells. CNA #1 said she did not know that Resident #1 was care planned not to be left alone in the bathroom or that he/she required a one person assist for toileting, transfers and ambulation. CNA #1 said she did not follow the care plan, when she left Resident #1 unsupervised in the bathroom and he/she fell . The Surveyor interviewed the Director of Nurses (DON) at 9:30 A.M. on 3/22/18. The DON said that CNA #1 did not follow Resident #1's care plan for assistance with ambulation, transfers and toileting. The DON said Resident #1 had an unwitnessed fall on 11/27/17 in the bathroom when he/she was left unsupervised and fell and fractured two bones in in his/her left hand. 2. Resident #2 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 10/15/17, indicated Resident #2 was severely cognitively impaired, required corrective lenses for vision, supervision for transfers and ambulation, and had a history of [REDACTED]. The Falls Care Plan, dated 10/16/17, indicated Resident #2 was at risk for falls due to confusion, unaware of safety needs and that he/she was being treated with [MEDICATION NAME] (an anticoagulation medication) which can increase the risk of bleeding with a fall. The Care Plan indicated, that Resident #2 required contact guard with one person assist as tolerated when ambulating, at times he/she may get agitated when someone is touching him/her, so stay next to the Resident when he/she is agitated. Interventions included; encourage Resident #2 to stay in the common area when out of bed, to redirect to common area when ambulating and to stay away from carpeted areas. The Falls Care Plan, updated 11/7/17, indicated additional intervention included to encourage Resident #2 to use his/her walker at all times. The Nurses Note, dated 1/18/18, indicated at 6:45 P.M., Resident #2 fell in the TV Room, landed on his/her left side, sustained a bruise on the left hip and complained of left sided pain. The Physician was notified, and an X-Ray of the left hip was ordered. The Nurses Note, dated (1/19/18), indicated left hip X-Ray was negative for a fracture. The Facility Investigation, dated 1/18/18, indicated Resident #2 had an unwitnessed fall while attempting to walk, he/she complained that his/her hip hurt. The interventions to be implemented by the facility to prevent further occurrences were; Resident #2 was confused and wandered, he/she does not stay in one place, continuous checks to be conducted every 15 minutes, remind the Resident #2 to use the walker and provide assist of one as tolerated. The Surveyor interviewed the DON at 5:10 P.M. on 3/22/18. The DON said that for the fall of 1/18/18, Resident #2's falls care plan was not followed regarding assistance with ambulation and the care plan was not updated with a new intervention. The Nurses Note, dated 2/14/18, indicated at 7:45 P.M., Resident #2 fell while ambulating without his/her walker, he/she was redirected several times but, Resident #2 will only use his/her walker for a few seconds. Resident #2 had no injuries from the fall. The Facility's Investigation, dated 2/14/18, indicated someone yelled out that Resident #2 was on the floor. Resident #2 had fallen and was found lying on the floor on his/her left side. Prior to the fall, Resident #2 had been walking in the hall. The Investigation indicated, that no additional interventions for safety were identified or were implemented by the facility. The Investigation indicated, Resident #2 was taken to bed, and there was no injury noted. The Investigation indicated, Resident #2 stands and walks frequently and refuses or forgets to use his/her walker. The Surveyor interviewed the DON at 5:10 P.M. on 3/22/18. The DON said that on 2/14/18, Resident #2 had an unwitnessed fall, the falls care plan was not followed for staff assistance of one with ambulation and was not updated with any new interventions. The Nurses Note, dated 2/25/18, indicated at 7:25 P.M., Resident #2 was found on the floor in the hallway, and he/she complained of left hip and lower back pain. The Note indicated, Resident #2 had slight external rotation of the left lower leg and Resident #2 was transferred to the Hospital Emergency Department. The Facility's Investigation, dated 2/25/18, indicated at 7:25 P.M., Resident #2 had an unwitnessed fall in the hall. The Investigation indicated, Resident #2 required an assist of one person for ambulation and transfers. Interventions to prevent further falls were; to keep the Resident #2 in common areas for monitoring and continue with the intervention to supervise him/her with ambulation. The DON said that for the fall of 2/25/18, Resident #2's falls care plan was not followed for an assistance of one person with ambulation and said the care plan was not updated with new interventions. The DON said that Resident #2 was care planned for a contact guard (having direct contact with the Resident while ambulating) assistance, not just supervision while ambulating, as documented on the investigation. The Surveyor interviewed Nurse #4 at 3:40 P.M. and at 4:05 P.M. on 3/22/18. Nurse #4 said Resident #2 required constant supervision by staff, an assist of one staff person for ambulation at all times, and should be wearing his/her glasses. The Surveyor observed on 3/22/18 at 7:42 A.M., Resident #2 ambulating approximately 20 feet up and down the carpeted hallway, back and forth without supervision or assistance from staff, and without his/her walker or glasses. The Surveyor observed Resident #2 walk through the low swinging doors, into and then out of the Nurses station, and then Resident #2 continued to pace back and forth on the carpeted area. The Surveyor interviewed the DON at 5:10 P.M. on 3/22/18 and discussed the Surveyors observations of Resident #2 on 3/22/18 at 7:42 A.M. The DON said Resident #2 should have been in the common area with supervision and should not have been ambulating up and down the carpeted areas unassisted, since he/she shuffles his/her feet on uneven surfaces when it changes from carpet to floor.

Based on records reviewed, interviews and observations for two of three sampled residents (Resident #1 and #2 ), the Facility failed to provide adequate supervision and assistance to prevent accidents with injury. - On 11/26/17, Resident #1, who was identified as being at high risk for falls and required the assistance of one person for transfers, ambulation and toileting, was left unattended in the bathroom, fell and fractured two bones in his/her left hand. - On 2/25/18, Resident #2, who was also identified as being at high risk for falls and required contact guard assistance of one person when ambulating, experienced his/her third unwitnessed fall in less than two months, he/she complained of left hip pain, and was transferred to the Hospital Emergency Department for evaluation. Findings include: The Facility's Policy, titled Fall Prevention, dated 5/1/09, indicated that all residents identified as being at risk for falls will have an interdisciplinary care plan addressing fall risk. Any resident who falls, will have an assessment done, be reviewed by an interdisciplinary team, and the care plan reviewed and updated. 1. Resident #1 was admitted to the facility in 11/2017 for short term rehabilitation with [DIAGNOSES REDACTED]. The Fall Risk assessment, dated 11/16/17, indicated Resident #1 was at high risk for falls. The Certified Nurse Aide (CNA) Care Card for falls, dated 11/17/17, indicated for toileting Resident #1 was an assist of one person for care and staff were to stay with Resident #1 while he/she was in the bathroom due to poor safety awareness. The Care Card indicated Resident #1 required a bed alarm while in bed and a personal alarm while in the chair. The Admission Minimum Data Set (MDS) assessment, dated 11/23/17, indicated Resident #1 was severely cognitively impaired and required the assistance of one person for transfers, ambulation and toileting. The Nurses Note, dated 11/26/17, indicated that Resident #1 had a fall in the bathroom at 4:30 P.M., and that he/she was confused. The Note indicated, Resident #1 asked CNA#1 to give him/her privacy while on the toilet, and CNA #1 left the bathroom. The Note indicated, Resident #1's visitor called Nurse #4 to check on Resident #1 in the bathroom, that Resident #1 was found sitting on the floor with his/her left hand outstretched on the floor and he/she complained of soreness on the top of the left hand. The Note indicated, Resident #1 said that he/she lost his/her balance and fell while trying to wash his/her hands at the bathroom sink. The Facility's Internal Investigation, dated 11/26/17, indicated after CNA #1 ambulated Resident #1 to the bathroom, she left Resident #1 alone in the bathroom, exited the room and went to answer call bells. The Investigation indicated, Resident #1 had an unwitnessed fall in the bathroom. The Investigation indicated, Resident #1's CNA care card indicated that he/she was a one person assist with ambulation, transfers and toileting. The Investigation indicated, CNA #1 was interviewed and stated that she did not read the CNA care card that indicated Resident #1 was a one person assist. The Physicians Note, dated 11/27/17, indicated Resident #1 had moderate swelling over the entire dorsum (top) of the left hand, with point tenderness at the base of the thumb and mild tenderness throughout the metacarpal bones. Possible fracture, will get an X-Ray. The X-Ray Report of Resident #1's left hand, dated 11/27/18, indicated there was an acute spiral [MEDICAL CONDITION] and 4th metacarpals. The Surveyor interviewed CNA #1 at 10:30 A.M. on 3/23/18. CNA #1 said that on 11/26/17 at approximately 4:30 P.M., she assisted Resident #1 to the bathroom, and then left to answer call bells. CNA #1 said she did not know that Resident #1 was care planned not to be left alone in the bathroom or that he/she required a one person assist for toileting, transfers and ambulation. CNA #1 said she did not follow the care plan, when she left Resident #1 unsupervised in the bathroom and he/she fell . The Surveyor interviewed the Director of Nurses (DON) at 9:30 A.M. on 3/22/18. The DON said that CNA #1 did not follow Resident #1's care plan for assistance with ambulation, transfers and toileting. The DON said Resident #1 had an unwitnessed fall on 11/27/17 in the bathroom when he/she was left unsupervised and fell and fractured two bones in in his/her left hand. 2. Resident #2 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 10/15/17, indicated Resident #2 was severely cognitively impaired, required corrective lenses for vision, supervision for transfers and ambulation, and had a history of [REDACTED]. The Fall Risk assessment, dated 10/15/17, indicated Resident #2 was at high risk for falls. The Falls Care Plan , dated 10/16/17, indicated Resident #2 was at risk for falls due to confusion, unaware of safety needs and that he/she was being treated with [MEDICATION NAME] (an anticoagulation medication) which can increase the risk of bleeding with a fall. The Care Plan indicated, that Resident #2 required contact guard with one person assist as tolerated when ambulating, at times he/she may get agitated when someone is touching him/her, so stay next to the Resident when he/she is agitated. Interventions included; encourage Resident #2 to stay in the common area when out of bed, to redirect to common area when ambulating and to stay away from carpeted areas. The Falls Care Plan interventions, updated 11/7/17, indicated to encourage Resident #2 to use his/her walker at all times. The Nurses Note, dated 1/18/18, indicated at 6:45 P.M., Resident #2 fell in the TV Room, landed on his/her left side, sustained a bruise on the left hip and complained of left sided pain. The Physician was notified, and an X-Ray of the left hip was ordered. The Facility Investigation, dated 1/18/18, indicated Resident #2 had an unwitnessed fall while attempting to walk, he/she complained that his/her hip hurt. The interventions to be implemented by the facility to prevent further occurrences were; Resident #2 was confused and wandered, he/she does not stay in one place, continuous checks to be conducted every 15 minutes, remind the Resident #2 to use the walker and provide assist of one as tolerated. The Nurses Note, dated 1/19/18, indicated left hip X-Ray was negative for a fracture The Surveyor interviewed the DON at 5:10 P.M. on 3/22/18. The DON said that for the fall of 1/18/18, the falls care plan was not followed for providing assistance of one staff person with ambulation and the care plan was not updated with a new intervention. The Nurses Note, dated 2/14/18, indicated at 7:45 P.M., Resident #2 fell while ambulating without his/her walker, he/she was redirected several times but, Resident #2 would only use his/her walker for a few seconds. Resident #2 had no injuries from the fall. The Facility's Investigation, dated 2/14/18, indicated someone yelled out that Resident #2 was on the floor. Resident #2 had fallen and was found lying on the floor on his/her left side. Prior to the fall, Resident #2 had been walking in the hall. The Investigation indicated, Resident #2 was taken to bed, and there was no injury noted. The Investigation indicated, Resident #2 stands and walks frequently and refuses or forgets to use his/her walker. The Investigation indicated, that no additional interventions for safety were identified or were implemented by the facility. The Surveyor interviewed the DON at 5:10 P.M. on 3/22/18. The DON said that on 2/14/18, Resident #2 had an unwitnessed fall, and said the falls care plan was not updated with any new interventions. The Nurses Note, dated 2/25/18, indicated at 7:25 P.M., Resident #2 was found on the floor in the hallway, and he/she complained of left hip and lower back pain. The Note indicated, Resident #2 had slight external rotation of the left lower leg and Resident #2 was transferred to the Hospital Emergency Department. The Facility's investigation, dated 2/25/18, indicated at 7:25 P.M., Resident #2 had an unwitnessed fall in the hall. The Investigation indicated, Resident #2 required an assist of one person for ambulation and transfers. Interventions to prevent further falls were; to keep the Resident #2 in common areas for monitoring and continue with the intervention to supervise with ambulation. The DON said that for the fall of 2/25/18, Resident #2's falls care plan was not followed for an assistance of one person with ambulation and said the care plan was not updated with new interventions. The DON said that Resident #2 was care planned for a contact guard (having direct contact with the Resident while ambulating) assistance, not just supervision while ambulating, as documented on the investigation. The Surveyor interviewed Nurse #4 at 3:40 P.M. and at 4:05 P.M. on 3/22/18. Nurse #4 said Resident #2 wore glasses for seeing distances, required constant supervision by staff, and an assist of one staff person for ambulation at all times. The Surveyor observed on 3/22/18 at 7:42 A.M., Resident #2 ambulating approximately 20 feet up and down the carpeted hallway, back and forth without supervision or assistance from staff, and without his/her walker or glasses. The Surveyor observed Resident #2 walk through the low swinging doors, into and then out of the Nurses station, and then Resident #2 continued to pace back and forth on the carpeted area. The Surveyor interviewed the DON at 5:10 P.M. on 3/22/18 and discussed the Surveyors observations of Resident #2 on 3/22/18 at 7:42 A.M. The DON said Resident #2 should have been in the common area with supervision and should not have been ambulating up and down the carpeted areas unassisted, since he/she shuffles his/her feet on uneven surfaces when it changes from carpet to floor.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #2), the Facility failed to ensure Resident #2 was free from sexual abuse. The staff failed to follow Resident #1's plan of care for a 1:1 staffing ratio while Resident #1 was awake. On 5/5/17, during the morning shift, Resident #1 who was awake for approximately 30 to 60 minutes was not provided 1:1 supervision and he/she wandered into Resident #2's Room where he/she was found at approximately 7:45 A.M. (Resident #1 was last observed awake in his/her room at 6:30 A.M.). Certified Nursing Assistant #1 witnessed Resident #1 exposing his/her penis and masturbating at the foot of Resident #2's bed. Approximately two to three hours after the incident, Resident #2 complained of burning in the groin area and stated it hurts down there. A physical examination by the Nurses indicated Resident #2 had swollen and pink labia. Although Resident #2's impaired mental status limited his/her ability to recall and understand the alleged incident, the Reasonable Person Concept presumes that an unimpaired individual would experience mental anguish when left alone with a naked Unknown Male Intruder who was exposing his/her penis and masturbating by the foot of his/her bed. Findings include: The Policy titled, Abuse Investigation and Reporting, dated 1/2017, indicated all residents have the right to be free from verbal, sexual, physical, and mental abuse. Resident #2 was admitted to the Facility in 2/2016 with a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #2 was severely cognitively impaired and was an extensive assist of one person with transfers and ambulation. Resident #1 was admitted to the Facility in 4/2017 with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and was independent with transfers and ambulation. The Nursing Care Plan for behavior, dated 4/24/17 indicated while Resident #1 was awake he/she needed 1:1 staff supervision to assure the safety of other Residents. The care plan indicated due to hallucinations Resident #1 sees and touches things, make sure that Resident #1 does not touch other residents inappropriately. The Psychiatric Evaluation, dated 4/26/17, indicated Resident #1 has advanced dementia, he/she wanders and Resident #1 was found, with his/her pants down, with his/her underwear still on, and was touching the brief of another resident. The Evaluation indicated Resident #1's behaviors were disinhibited and unpredictable when staff were not immediately available to redirect him/her. Recommend continuous supervision for safety of peers and discuss family's willingness to pursue another facility that can manage his/her behavior and risk of harm to peers. The Internal Investigation, dated 5/5/17, indicated on 5/5/17 at approximately 7:45 A.M., Certified Nursing Assistant (CNA) #1 found Resident #1 standing at the foot of Resident #2's bed, exposing his/her penis and masturbating in front of Resident #2 and Resident #2 was in bed waving a scarf at Resident #1. The Investigation indicated there was a period of time when Resident #1 was awake, was supposed to be on a 1:1 staffing ratio between the times of 7:15 A.M. and 7:45 A.M. and was not. The Internal Investigation, dated 5/5/17, indicated that at approximately 10:00 A.M. Resident #2 became diaphoretic his/her pulse was 48 (normal 60 to 100), BP 130/95 (normal 120/80), respiratory rate 16 (normal 16 to 20) and oxygen saturation was 96% (the percentage of oxygen in the blood stream, normal is greater than 90%). Resident #2 was pulling at his/her pants, when asked what hurts, Resident #2 stated, down there. A full body assessment was done by Nursing and Resident #2's labia were swollen and pink. After 45 minutes Resident #2 was back to him/herself, pulse increased to 58 (normal 60 to 100). Resident #2 was sent to the Emergency Department for evaluation of possible sexual assault. The Surveyor interviewed Nurse #2 at 9:09 A.M. on 5/17/17. Nurse #2 said that Resident #2's signs and symptoms on 5/5/17, which included diaphoresis, abnormally low heart rate and complaints of burning in the groin area, had not occurred previously. The Supervision While Awake For Resident #1 and Constant Supervision when Resident is Sleeping Form, dated 5/5/17, indicated: - 7:00 A.M. and 7:15 A.M., Resident #1 was awake sitting in the Foyer, - 7:30 A.M. Resident #1 was awake sitting (his/her location was not documented), - 7:45 A.M., Resident #1 was awake and getting dressed in his/her room. The Surveyor interviewed CNA #3 at 11:05 AM. on 5/16/17. CNA #3 said he was not assigned to take care of Resident #1 until 8:00 A.M. on 5/5/17 and said he documented the 15 minutes checks from 7:00 A.M. to 7:45 A.M., even though he did not provide the supervision. CNA #3 said no one was assigned to provide 1:1 supervision for Resident #1 from 7:00 A.M. to 7:59 A.M. The Emergency Department note, dated 5/5/17, indicated Resident #2 was unable to provide a history of the event. The Sexual Assault Nurse Examiner (SANE) did not perform an examination of Resident #2 because he/she did not meet the minimum criteria. Resident #2 was transferred back to the Facility, since Resident #1 would no longer be at the Facility. The Surveyor interviewed the Director of Nurses (DON) at 7:30 A.M. on 5/16/17. The DON said that Resident #1 was care planned to be on 1:1 (staffing ratio) supervision while awake to prevent sexually inappropriate behaviors. The DON said Resident #1 was awake at the start of the 7:00 A.M. to 3:00 P.M. shift on 5/5/17, but was not under 1:1 supervision as indicated by his/her plan of care.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure the staff followed Resident #1's plan of care for a 1:1 staffing ratio while Resident #1 was awake. On 5/5/17, during the morning shift, Resident #1 who was awake for approximately 30 to 60 minutes was not provided 1:1 supervision and he/she wandered into Resident #2's Room where he/she was found at approximately 7:45 A.M. (Resident #1 was last observed awake in his/her room at 6:30 A.M.). Certified Nursing Assistant #1 witnessed Resident #1 exposing his/her penis and masturbating at the foot of Resident #2's bed. Approximately two to three hours after the incident, Resident #2 complained of burning in the groin area and stated it hurts down there. A physical examination by the Nurses indicated Resident #2 had swollen and pink labia. Although Resident #2's impaired mental status limited his/her ability to recall and understand the alleged incident, the Reasonable Person Concept presumes that an unimpaired individual would experience mental anguish when left alone with a naked Unknown Male Intruder who was exposing his/her penis and masturbating by the foot of his/her bed. Findings include: The Policy titled, Resident Comprehensive Care Plan Policy, dated 4/1/12, indicated that all residents will have in place, accurate, comprehensive care plans that reflect their medical, social, functional, and rehabilitative needs and goals. Resident #1 was admitted to the Facility in 4/2017 with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and was independent with transfers and ambulation. The Nursing Care Plan for behavior, dated 4/24/16 indicated when Resident #1 was awake he/she needed 1:1 staff supervision to assure the safety of other residents. The care plan indicated due to hallucinations Resident #1 sees and touches things, make sure that Resident #1 does not touch other residents inappropriately. There was no Nurse Progress Note on 5/5/17, documenting Resident #1's unwelcome sexual advancement towards Resident #2. The Internal Investigation, dated 5/5/17, indicated on 5/5/17 at approximately 7:45 A.M., Certified Nursing Assistant (CNA) #1 found Resident #1 standing at the foot of Resident #2's bed masturbating in front of Resident #2 and Resident #2 was in bed waving a scarf at Resident #1. The Investigation indicated there was a period of time when Resident #1 was supposed to be on a 1:1 staffing ratio between the times of 7:15 A.M. and 7:45 A.M. and was not. The Internal Investigation, dated 5/5/17, indicated that at approximately 10:00 A.M. Resident #2 became diaphoretic his/her pulse was 48 (normal 60 to 100), BP 130/95 (normal 120/80), respiratory rate 16 (normal 16 to 20) and oxygen saturation was 96% (the percentage of oxygen in the blood stream, normal is greater than 90%). Resident #2 was pulling at his/her pants, when asked what hurts, Resident #2 stated, down there. A full body assessment was done by Nursing and Resident #2's labia were swollen and pink. After 45 minutes Resident #2 was back to him/herself, pulse increased to 58 (normal 60 to 100). Resident #2 was sent to the Emergency Department for evaluation of possible sexual assault. The Surveyor interviewed Nurse #2 at 9:09 A.M. on 5/17/17. Nurse #2 said that Resident #2's signs and symptoms on 5/5/17, which included diaphoresis, abnormally low heart rate and complaints of burning in the groin area, had not occurred previously. The Emergency Department note, dated 5/5/17, indicated Resident #2 was unable to provide a history of the event. The Sexual Assault Nurse Examiner (SANE) did not perform an examination of Resident #2 because he/she did not meet the minimum criteria. Resident #2 was transferred back to the Facility, since Resident #1 would no longer be at the Facility. The Surveyor interviewed the Director of Nurses (DON) at 7:30 A.M. on 5/16/17. The DON said that Resident #1 was care planned to be on 1:1 (staffing ratio) supervision while awake and was not at the start of the 7:00 A.M. to 3:00 P.M. shift on 5/5/17 as indicated in their investigation.

Based on observations, records reviewed and interviews, for 1 of 3 sampled residents (Resident #2) the Facility failed to provide adequate supervision of Resident #1, and as a result Resident #2 experienced unwelcome sexual advances. - On 5/5/17 during the start of the 7:00 A.M. to 3:00 P.M. shift, Resident #1 who was awake was not provided with 1:1 staffing ratio for approximately 30 to 60, Resident #1 wandered into Resident #2's Room where he/she was found by Certified Nursing Assistant #1, exposing his/her penis and masturbating at the foot of Resident #2's bed. Approximately 2 hours after the incident, Resident #2 complained of burning in the groin area and stated it hurts down there. A physical examination by the Nurses indicated Resident #2 had swollen and pink labia. Resident #2 was transferred to the Emergency Department. - The Emergency Department Report, dated 5/5/17 indicated Resident #2 was unable to provide a history of the event. The Sexual Assault Nurse Examiner (SANE) did not perform a sexual assault examination of Resident #2 because he/she did not meet the minimum criteria. Resident #2 was transferred back to the Facility since Resident #1 would no longer be at the Facility. -Although Resident #2's impaired mental status limited his/her ability to recall and understand the alleged incident, the Reasonable Person Concept presumes that an unimpaired individual would experience mental anguish when left alone with a naked Unknown Male Intruder who was exposing his penis and masturbating by the foot of his/her bed, while clothed only in a nightgown in Resident #2's bed. Findings include: The Policy titled, Safety Checks 1:1 Supervision, dated 10/16/03, indicated Residents who have been identified as a risk to themselves or others may be placed on safety checks. Behavior includes physical aggression or assault. If the resident is placed on safety checks or 1:1 supervision, the Charge Nurse will be responsible for assigning staff to do the checks 1:1 supervision. When doing 1:1 supervision, the resident must be within sight at all times. The staff person doing 1:1 supervision is not to be assigned other work. The Policy titled, Nursing Unit Rounds, dated 1/28/09, indicated Unit Rounds are done at the beginning of each shift by the oncoming licensed nurses to identify and resolve any problems as they occur. The licensed nurse enters resident rooms and other resident areas to briefly assess each resident's location, and any environmental needs such as warmth, cleanliness, safety and general comfort of the resident. Resident #2 was admitted to the Facility in 2/2016 with a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #2 was severely cognitively impaired and was an extensive assist of one person with transfers and ambulation. Resident #1 was admitted to the Facility in 4/2017 with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and was independent with transfers and ambulation. The Nursing Care Plan for behavior, dated 4/24/16 indicated while Resident #1 was awake he/she needed 1:1 staff supervision to assure the safety of other Residents. The care plan indicated due to hallucinations Resident #1 sees and touches things, make sure that Resident #1 does not touch other residents inappropriately. The Psychiatric Evaluation, dated 4/26/17, indicated Resident #1 has advanced dementia, he/she wanders and Resident #1 was found, with his/her pants down, with his/her underwear still on, and was touching the brief of another resident. The Evaluation indicated Resident #1's behaviors were disinhibited and unpredictable when staff were not immediately available to redirect him/her. Recommend continuous supervision for safety of peers and discuss family's willingness to pursue another facility that can manage his/her behavior and risk of harm to peers. The Internal Investigation, dated 5/5/17, indicated on 5/5/17 at approximately 7:45 A.M., Certified Nursing Assistant (CNA) #1 found Resident #1 standing at the foot of Resident #2's bed masturbating in front of Resident #2. Resident #2 was in bed waving a scarf at Resident #1. The Investigation indicated there was a period of time when Resident #1 was supposed to be on a 1:1 staffing ratio, between the times of 7:15 A.M. and 7:45 A.M. and was not. The Investigation indicated that at approximately 10:00 A.M. on 5/5/17, Resident #2 became diaphoretic his/her pulse was 48 (normal 60 to 100), BP 130/95 (normal 120/80), respiratory rate 16 (normal 16 to 20) and oxygen saturation was 96% (the percentage of oxygen in the blood stream, normal greater than 90%). Resident #2 was pulling at his/her pants and stated it burns, down there. A full body assessment was done by Nursing and Resident #2's labia were swollen and pink. After 45 minutes Resident #2 was back to him/herself, pulse increased to 58 (normal 60 to 100). Resident #2 was sent to the Emergency Department for evaluation of possible sexual assault. The Surveyor interviewed the Director of Nurses (DON) at 7:30 A.M. on 5/16/17. The DON said that Resident #1 was care planned to be on 1:1 (staffing ratio) supervision while awake and was not at the start of the 7:00 A.M. to 3:00 P.M. shift on 5/5/17 as indicated in their investigation,dated 5/5/17. The Surveyor interviewed Nurse #2 at 9:09 A.M. on 5/17/17. Nurse #2 said that Resident #2's signs and symptoms on 5/5/17, which included diaphoresis, abnormally low heart rate and complaints of burning in the groin area, had not occurred previously. The Emergency Department note, dated 5/5/17 indicated Resident #2 was unable to provide a history of the event. The Sexual Assault Nurse Examiner (SANE) did not perform a sexual assault examination of Resident #2 because he/she did not meet the minimum criteria, and Resident #2 was transferred back to the Facility. A Police Report, dated 5/5/17, indicated the Police were dispatched for a report of a sexual offense at the Facility. The Police Officer meet with the Administrator. The Administrator indicated that this morning Resident #1 had allegedly committed a unwanted sexual act towards Resident #2 and that Resident #2 was disturbed by this incident. The Surveyor interviewed Nurse #2 at 9:09 A.M. on 5/17/17. Nurse #2 said she was the assigned to take care of Resident #1 in the morning of 5/5/17 but did not perform the Unit Round checks for the Residents. The Supervision While Awake For Resident #1 and Constant Supervision when Resident is Sleeping Form, dated 5/5/17, indicated: -7:00 A.M. and 7:15 A.M., Resident #1 was awake sitting in the Foyer, -7:30 A.M. Resident #1 was awake sitting (his/her location was not documented), -7:45 A.M., Resident #1 was awake and getting dressed in his/her room. The Surveyor interviewed CNA #3 at 11:05 AM. on 5/16/17. CNA #3 said he was not assigned to take care of Resident #1 until 8:00 A.M. on 5/5/17 and said he documented the 15 minutes checks from 7:00 A.M. to 7:45 A.M., even though he did not provide the supervision. CNA #3 said no one was assigned to provide 1:1 supervision for Resident #1 from 7:00 A.M. to 7:59 A.M. The Surveyor interviewed CNA #2 at 10:30 A.M. on 5/16/17. CNA #2 said that on 5/5/17 she walked by Resident #1's room at 6:30 A.M. and Resident #1 was awake out of bed and walking by his/her bed. CNA #2 said she was not aware Resident #1 needed supervision when he/she was awake. CNA #2 said she found Resident #2 at 7:45 A.M. on 5/5/17 at the foot of Resident #2's bed with his/her penis exposed and masturbating. CNA #2 said Resident #2 was trying to shoo Resident #1 out of the room, was waving scarf and had stated this Man, this Man, or words to that effect. The Surveyor interviewed the Director of Nurses (DON) at 7:30 A.M. on 5/16/17. The DON said that Resident #1 was care planned to be on 1:1 (staffing ratio) supervision while awake and was not at the start of the 7:00 A.M. to 3:00 P.M. shift on 5/5/17.

Based on record review, observations, and staff interviews, the facility failed to follow the resident's plan of care relative to fall prevention, assistive devices, gait belt use and chair cushion use, for 6 residents (#1, #3, #5, #8, #17 and #20), out of a total sample of 24 residents. Findings include: Review of the Facility's Gait/Transfer Belt Policy & Procedure indicated Gait belts will be used to ensure the safe transfer and ambulation of all residents who require physical assistance to stand, transfer and/or ambulate. The policy further indicated, All direct care staff are to have gait belts on their persons at all times. 1. For Resident #1, the Facility failed to follow the Gait/Transfer Belt Policy & Procedure. Resident #1 was admitted to the Facility in 5/2015 with a [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 5/13/15, indicated that the resident was cognitively intact and required extensive assistance with transfers and ambulation. Review of the Falls Care Plan, dated 5/21/15, indicated that the resident required the assistance of 1 staff member for transfers and ambulation, with a walker. Review of the nurse's note, dated 7/14/15, indicated that after Resident #1 was weighed, he/she stepped off of the scale, started walking, tripped on the corner of the floor, and fell . The nurse's note further indicated that the resident complained of pain and was admitted to the hospital with [REDACTED]. During an interview with the Director of Nursing (DON) on 11/19/15 at 10:30 A.M., she said that the CNA, who was with the resident at the time of the fall on 7/14/15, should have utilized a gait belt per the Facility's policy. The Surveyor observed Resident #1 on 11/23/15 at 8:15 A.M. CNA #1 was ambulating Resident #1 with a walker, holding onto Resident #1's waist, and not utilizing a gait belt, which is against facility policy. During an interview with CNA #1 on 11/23/15 at 8:20 A.M., CNA #1 said that Resident #1 was supposed to use a gait belt but refused. The Surveyor observed Resident #1 on 11/23/15 11:15 A.M. Unit Manager (UM) #3 placed the gait belt on Resident #1's waist. UM #3 then ambulated Resident #1 using a walker and a gait belt. The resident did not resist the use of the gait belt. During an interview with UM #3 on 11/23/15 at 2:20 P.M., she said that the CNA who was with the resident when he/she fell on [DATE], should have used a gait belt per the Facility's policy and said that a gait belt should always be used when ambulating the resident per the Facility's policy. Refer to F323. 2. For Resident #5, the facility failed to ensure individualized care planned interventions were provided relative to 2 falls (on 5/23/15 and on 8/23/15 when the resident required 4 staples to a laceration on the head). Resident #5 was admitted to the facility in 3/2010. The resident's [DIAGNOSES REDACTED]. Review of the risk for falls care plan indicated the following interventions to prevent falls: - Bed and chair pad alarms. - Alarming floor mat. - Left side of the bed against the wall. Review of a Progress Note and Fall Report, dated 5/23/15, indicated the resident fell at 10:40 P.M. There were no alarms sounding. The Fall Report indicated that the resident's bed and alarms were not positioned properly, subsequently, the alarms did not sound. In addition, the left side of the bed was not against the wall, as planned. The facility determined this to be a direct result of the fall. A Post Fall Meeting Progress Note, dated 7/27/15, indicated that while reviewing the resident's recent fall history, it was noted that the most vulnerable time is in evening when in bed. The facility's plan was to have a hall monitor (staff member) in place when the resident is in bed, and the care plan was updated to include Hall Monitor when in bed. Review of a Progress Note and Fall Report, dated 8/2/15, indicated that the resident was found on the floor, sitting on a mat beside the bed at 7:45 A.M. with no apparent injuries. The report indicated that supervision would be provided in the hallway. Review of the 8/23/15 Progress Note and Fall Report indicated the resident fell at 1:00 A.M., and sustained a 3 centimeter (cm) laceration to the head, requiring a visit to the emergency room where the Resident received staples to the laceration. The Fall Report indicated a section inquiring if safety measures worked correctly or not. Documentation indicated that the hall monitoring had not been provided, as planned. During interview on 11/23/15 at 8:10 A.M., the Director of Nursing (DON) said that an employee warning was issued after the 8/23/15 fall, as supervision had not been provided for Resident #5. The DON said that the best person to review falls with would be UM #4, who was familiar with Resident #5. During interview and review of the clinical record on 11/23/15 at 4:50 P.M., UM #4 said that care planned interventions had not been implemented for Resident #5, in which 1 fall resulted in a [MEDICAL CONDITION] that required staples to close the wound. Please refer to F323. 3. For Resident #20, the facility failed to ensure care planned interventions were followed relative to 4 falls (12/10/14, 4/29/15, 8/7/15 and 11/8/15). Resident #20 was admitted to the facility in 5/2014. The resident's [DIAGNOSES REDACTED]. Review of the clinical record indicated that as a result of Resident #20 being found by the side of the bed (11/4, 11/20 and 12/2/14), that two mattresses would be placed beside the resident's bed at hour of sleep (HS). Review of a Progress Note and Fall Report, dated 12/10/14 at 8:45 P.M., indicated that the Resident was found crawling on the floor trying to go to the bathroom. The Fall Report indicated that the two mattresses had not been placed beside the resident's bed at HS, as planned. The report indicated that both mattresses were found to be leaning against the roommate's bed, on the other side of the room. Review of the at risk for falls care plan indicated the following interventions: - Chair and bed alarms. - Bed against the wall. - Do not leave unsupervised in wheelchair (w/c). - 2 mattresses left side of bed. - Laser alarm left side of bed. - Place in Foyer after meals. The clinical record indicate that Resident #20 fell on [DATE], and sustained 6 skin tears. Review of the 4/29/15 Fall Report indicated the resident attempted to ambulate to the bathroom from the sitting room at 4:00 P.M., and fell . The fall was not witnessed. The Post Fall Investigation report indicated that the resident had been assisted via a wheelchair (w/c) into the sitting room area. The 4/30/15 Post Fall Meeting Progress Note indicated that Resident #20 would not be left in the Dining Room, and will be placed in the Foyer after meals. Review of a Progress Note and Fall Report, dated 5/30/15 at 11:40 A.M., indicated the resident fell when the w/c tipped forward as the resident attempted to stand. The Fall Report indicated the resident was seated in a w/c in the Dining Room, the fall was witnessed, but staff were not able to get to the resident in time to prevent the fall. The 6/1/15 Post Fall Meeting Progress Note indicated the staff would use the w/c for transport only, and the resident would be placed into a stationary chair. Review of the 8/7/15 Progress Note and Fall Report, indicated the resident fell at 6:30 P.M. in the Dining Room. The alarm was sounding. The Fall Report indicated that there was no supervision provided. The resident was left in the Dining Room after supper, which is not a supervised area, subsequently, the resident attempted to walk independently, and fell . According to the 4/30/15 post fall meeting note, the resident was not supposed to be left in the Dining Room after meals, therefore the care planned intervention had not been followed. Review of the 11/8/15 Progress Note and Fall report indicated that the resident fell from the w/c onto the foot pedals while in the Foyer at 9:25 A.M. The resident was not placed in a stationary chair, as planned. The w/c was only supposed to be used for transport. The Fall Report indicated the plan would be for the staff to place the resident into a stationary chair (plan already in place, and had not been followed to prevent falls). The Surveyor observed Resident #20 sitting in a w/c in the Dining Room on 11/18/15 at 8:20 A.M., 11/19/15 at 12:30 P.M., and again on 11/23/15 at 8:17 A.M. Resident #20 was not placed into a stationary chair, as planned. The w/c was to be used for transport only. During interview and review of the resident's falls and care plans on 11/23/15 at 4:15 P.M., UM #4 said that adequate supervision and care planned interventions had not been provided for Resident #20. Please refer to F323. 4. For Resident #3, the facility failed to ensure care planned interventions were implemented and appropriate for 3 falls (10/18/14, 1/2/15 and 6/13/15. Resident #3 was admitted to the facility in 1/2013. The resident's [DIAGNOSES REDACTED]. Review of the at risk for falls care plan indicated the following interventions: - Ambulate stand by assist with walker. - Bed alarm. - Low bed and a laser alarm. - Non-skid socks. - Cannot be alone in room when out of bed. Review of a 10/18/14 Progress Note and Fall Report indicated the resident was found on the floor in the bathroom, and the resident's walker was in the hallway. The care plan was not followed relative to use of the walker for ambulation. Review of the 1/2/15 Progress Note and Fall Report indicated the resident fell in the bathroom, was wearing socks without treads, and sustained a laceration to the back of the head. The Fall Report, indicated that the resident had to go to the bathroom, got up from the bed, slipped and fell . The report indicated that the resident was not wearing non-skid socks, as planned. Review of a 6/13/15 Progress Note and Fall report indicated at 6:45 P.M., the resident was found on the floor between the resident's room and the bathroom with pants and brief pulled down below the knees. The resident hit his/her face and above the right eye. The area was red and swollen. The fall was not witnessed. The report indicated that the resident ambulated, without the walker, tried to toilet self and fell . The alarms were not sounding, subsequently, laser and bed alarms were not provided, as planned. During interview and review of the clinical record with UM #4 on 11/23/15 at 4:45 P.M., UM #4 said that fall interventions had not been provided relative to an assistive device, walker, for ambulation and alarms, as planned for Resident #3. Please refer to F323. 5. For Resident #8, the facility failed to follow the Physician's plan of care and provide the use of a seat cushion. Resident #8 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. Review of the 11/2015 signed physician's orders [REDACTED]. Review of the 11/2015 Treatment Administration Record (TAR) indicated a treatment order for Waffle Cushion in chair when out of bed (OOB), and check inflation every shift. Further review of the 11/2015 TAR indicated nursing had completed this treatment as ordered on all shifts, and all days through 11/18/15 and on the 11:00 P.M.-7:00 A.M. shift on 11/19/15. On 11/19/15 at 8:25 A.M., 8:55 A.M., and 9:30 A.M., and on 11/20/15 at 8:00 A.M., the Surveyor observed the resident sitting in a chair without a waffle cushion underneath him/her. The Surveyor observed the resident sitting on a chair pad alarm (flat pad with an alarmed device attached) when in a chair. During an interview on 11/20/15 at 12:20 P.M., UM #1 said she did not know why the resident was not using the Waffle Cushion in a chair when OOB, but it should have been used as ordered. 6. For Resident #17, the facility failed to follow the plan of care relative to the use of a bed alarm for 1 of 2 falls. Resident #17 was admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 9/10/15, indicated the resident was cognitively intact, required limited assistance with bed mobility, toileting, hygiene, and required extensive assistance with bathing. Review of the Falls Care Plan, date initiated 9/17/15, included the following interventions: -Seat pad alarm on wheelchair, -Low bed with alarm. Review of the Resident Care Sheet, dated 9/17/15, indicated the resident was a fall risk and was to have pad alarm to the bed and chair. Review of a Nurse's Note, dated 9/12/15, indicated the resident was found sitting on the floor beside the bed. Review of the POS [REDACTED]. On 11/20/15 at 8:00 A.M., the resident was observed sitting in his/her wheelchair in the dining room. He/she was dressed, had on shoes, a left arm brace and sling and a right knee brace. The resident was sitting on a waffle cushion and a chair alarm was in place on the wheelchair. During an interview on 11/20/15 at 2:30 P.M., UM #1 said she was unsure why the bed alarm was unplugged at the time of the fall, but it should not have been. Refer to F323.

Based on observation, record review and interview, the Facility failed to ensure that 4 of 13 applicable residents with falls (#1, #3, #5, and #20) received adequate supervision, assistive devices and interventions to prevent falls, from a total sample of 24 residents. Findings include: 1. For Resident #1, the Facility failed to prevent 1 fall, resulting in a fracture, by ensuring that the Gait/Transfer Belt Policy & Procedure was followed. Resident #1 was admitted to the Facility in 5/2015 with [DIAGNOSES REDACTED]. Review of the Facility's Gait/Transfer Belt Policy & Procedure indicated: Gait belts will be used to ensure the safe transfer and ambulation of all residents who require physical assistance to stand, transfer and/or ambulate. The policy further indicated: All direct care staff are to have gait belts on their persons at all times. Review of the Fall Risk Assessment, dated 5/6/15, indicated that the resident scored an 8 out of a possible 15, with a score of 10 or more indicating a high risk for falls. Review of the Admission Minimum Data Set (MDS) Assessment, dated 5/13/15, indicated that the resident was cognitively intact and required extensive assistance with transfers and ambulation. Review of the Falls Care Plan, dated 5/21/15, indicated that the resident required the assistance of 1 staff member for transfers and ambulation with a walker. Review of the Physical Therapy Treatment Record, dated 6/20/15, indicated that the resident became confused and agitated in the evening and forgot to use the front wheeled walker. The resident required the assistance of 1 staff member for ambulation. Review of the nurse's note, dated 7/14/15, indicated that after the resident was weighed, he/she stepped off of the scale, started walking, tripped on the corner of the floor and fell . The note further indicated that the resident complained of pain and was admitted to the hospital with [REDACTED]. Review of the Facility's internal investigation, dated 7/14/15, indicated that the Certified Nurse Aide (CNA), who was with the resident received disciplinary action for not utilizing a gait belt per the Facility's policy. During an interview with the Director of Nursing (DON), on 11/19/15 at 10:30 A.M., she said that the CNA who was with the resident at the time of the fall on 7/14/15, received disciplinary action for not utilizing a gait belt per the Facility's policy. The Surveyor observed Resident #1 on 11/23/15 at 8:15 A.M. CNA #1 was ambulating Resident #1 with a walker, holding onto Resident #1's waist. CNA #1 did not utilize a gait belt. During an interview with CNA #1 on 11/23/15 at 8:20 A.M., CNA #1 said that Resident #1 was supposed to use a gait belt but often refused. The Surveyor observed Resident #1 on 11/23/15 11:15 A.M. Unit Manager (UM) #3, placed the gait belt around Resident #1's waist. UM #3 then ambulated Resident #1 using a walker and a gait belt. The resident did not resist the use of the gait belt. During an interview with UM #3 on 11/23/15 at 2:20 P.M., she said that the CNA, who was with the resident when he/she fell on [DATE], should have used a gait belt per the Facility's policy. 2. For Resident #5, the facility failed to ensure adequate supervision and appropriate care planned interventions to prevent 3 falls (3/29/15, 5/23/15 and on 8/23/15), 1 with minor injury (3/29/15, red areas hip and shoulder), and one with major injury (8/23/15 laceration requiring 4 staples to the head). Resident #5 was admitted to the facility in 3/2010. The resident's [DIAGNOSES REDACTED]. Review of the 10/2014 Fall Risk Assessment indicated the resident scored a 14, and was a high risk for falling (score 10 or greater indicates high fall risk). Review of the Annual MDS Assessment (10/30/14) and a Quarterly MDS Assessment (1/29/15) indicated that the resident had severe cognitive impairment (Annual BIMS score 0/15, and the Quarterly BIMS score 2/15); required supervision for transfers and ambulation; had balance problems and unsteadiness and had falls with no injury (Quarterly 1/29/15). Review of the 3/29/15 Progress Note indicated that the resident fell from a stationary chair in the Foyer at 8:00 P.M. Review of the 3/29/15 Fall Report indicated that the resident was confused, probably fell asleep while sitting in the chair and fell on to left side. The resident's left hip and shoulder were red. According to the report, staff were present, but did not see what happened. Review of a Witness Statement indicated a Nurse was sitting at the Nursing Station and witnessed only the end of the fall, subsequently, the fall was not prevented. Review of a Progress Note and Fall Report, dated 4/13/15, indicated that the resident turned in the chair slightly and slid from a chair in the Dining Room, with no injury. This fall was witnessed by a staff member who could not reach the resident in time to prevent the fall. Review of the 4/23/15 Quarterly MDS assessment indicated the resident had severe cognitive impairment (BIMS score of 1/15), and now indicated that the resident required limited assist from staff for transfers and mobility. The assessment inaccurately indicated that the resident only had 1 fall with minor injury. Review of the risk for falls care plan indicated the following interventions to prevent falls: - Bed and chair pad alarms. - Alarming floor matt. - Left side of the bed against the wall. - Hall Monitor when in bed. Review of a Progress Note, dated 5/23/15, indicated the resident was found on the floor beside the bed at 10:40 P.M., and there was no alarm sounding. Review of the 5/23/15 Fall Report indicated that the fall was unwitnessed. According to the report, a staff member heard the resident moaning, and walked into the resident's room to find the him/or on the floor. The report indicated that the resident's bed and alarms (bed and laser alarms) were not positioned properly, subsequently, they did not sound, and the resident fell . Review of the Quarterly MDS assessment, dated 7/16/15, indicated the resident had both short and long term memory and cognitive impairments; received limited assist from staff now for transfers, ambulation and toilet use, and had 2 or more falls with no injury. Review of the Progress Notes, dated 7/21/15 at 9:10 P.M. and 7/26/15 at 7:30 P.M., indicated the resident was found on the floor in the resident's room. Alarms were sounding, but the resident was already on the floor by the time staff responded. The Post Fall Meeting Progress Note, dated 7/27/15, indicated that while reviewing the resident's recent fall history, it was noted that the most vulnerable time is in evening when the resident in bed. The facility's plan was to have a hall monitor (staff member) in place when the resident is in bed. Review of a Progress Note and a Fall Report, dated 8/2/15, indicated that the resident was found on the floor, sitting on a mat beside the bed at 7:45 A.M. with no apparent injuries. The report indicated that supervision would be provided in the hallway. Review of the 8/23/15 Progress Note indicated the resident was found on the floor on the 11:00 P.M. to 7:00 A.M. shift, and he/she sustained a 3 centimeter (cm) laceration to the head. Review of the 8/23/15 Fall Report indicated a staff member responded to an alarm at 1:00 A.M., and found the resident on the floor next to the bed. The resident had hit his/her head on the night stand. The resident had a 3 cm laceration to the posterior head, was transferred to the hospital, and received 4 staples to close the laceration to the head. The section of the Fall Report inquiring if safety measures worked correctly or not indicated that the alarms worked. However, the staff member who was supposed to be monitoring the resident had other alarms to check on, therefore adequate supervision had not been provided, the resident fell , and received a head injury requiring staples. During interview on 11/23/15 at 8:10 A.M., the Director of Nursing (DON) said that an employee warning was issued after the 8/23/15 fall, as supervision had not been provided for Resident #5. The DON said that the best person to review falls with would be UM #4, who was familiar with Resident #5. During interview and review of the clinical record on 11/23/15 at 4:50 P.M., UM #4 said that adequate supervision and care planned interventions had not been provided to prevent falls for Resident #5, 1 fall that resulted in a head laceration and required staples to close the wound. 3. For Resident #20, the facility failed to ensure adequate supervision and effective interventions relative to 6 falls (12/10/14, 4/29/15, 5/30/15, 8/7/15, 10/8/15 and 11/8/15), 4 with minor injury (4/29/15, abrasions and bruises; 5/30/15, skin tears; 8/7/15, bumps and 10/8/15, abrasions). Resident #20 was admitted to the facility in 5/2014. The resident's [DIAGNOSES REDACTED]. Review of the clinical record indicated that as a result of Resident #20 being found by the side of the bed (11/4, 11/20 and 12/2/14), that two mattresses would be placed beside the resident's bed at hour of sleep (HS). Review of a progress note, dated 12/10/14 at 8:45 P.M., indicated that the Resident was found crawling on the floor trying to go to the bathroom. Review of the 12/10/14 Fall Report indicated that the fall was not witnessed, and that the two mattresses had not been placed beside the resident's bed, as planned. The report indicated that both mattresses were found to be leaning against the roommate's bed, on the other side of the room. Review of the Quarterly MDS assessment, dated 2/5/15, indicated the resident had moderate cognitive impairment (identified by a score of 12/15 on the BIMS); had balance problems, was unsteady during transitions, walking, and had fallen more than two times, without injuries since the prior assessment (MDS, dated [DATE]). Review of the fall risk assessment, dated 2/5/15, indicated the resident scored an 11, and was at risk for falls (score greater than 10 indicated high fall risk). Review of the at risk for falls care plan (increased fall risk indicated:decreased safety awareness, history of falls, used psychotropic medications, restlessness from urinary retention and the need to go to the bathroom and delusions) indicated the following interventions: - Chair and bed alarms. - Bed against the wall. - Do not leave unsupervised in wheelchair (w/c). - 2 mattresses left side of bed. - Laser alarm left side of bed. - Place in Foyer after meals. The clinical record indicated Resident #20 fell on [DATE], and sustained 6 skin tears. Review of the 4/29/15 Fall Report, indicated the resident attempted to ambulate to the bathroom from the Dining Room at 4:00 P.M. (area located on the Dementia Special Care Unit {DSCU}), and fell . The fall was not witnessed. According to the Post Fall Investigation report, the resident had been assisted via a wheelchair (w/c) into the Dining Room. The resident did not wait for staff to assist him/her to the bathroom, as staff instructed the resident to do (resident with moderate cognitive impairment). The 4/30/15 Post Fall Meeting Progress Note indicated that the resident would not be left in the Dining Room, and will be placed in the Foyer after meals. Review of the Annual MDS assessment, dated 4/30/15, indicated the resident had severe cognitive impairment (with a BIMS score of 7/15); had balance problems transitioning and walking; and had falls, one with injury and one with minor injury. Review of a progress note, dated 5/30/15 at 11:40 A.M., indicated the resident fell when the w/c tipped forward as the resident attempted to stand. The resident sustained [REDACTED]. Review of the 5/30/15 Fall Report indicated that the resident was seated in a w/c in the Dining Room, the fall was witnessed, but staff were not able to get to the resident in time to prevent the fall. The 6/1/15 post fall meeting progress note indicated the resident's dementia was progressing, and that the resident would only use the w/c for transport, and would be placed into a stationary chair. Review of the Quarterly MDS assessment, dated 7/30/15, indicated the resident had severe cognitive impairment (scored a 6/15 on the BIMS), had balance problems transitioning and walking, and had 2 or more falls, with minor injury. Review of the 8/7/15 progress note, indicated the resident fell at 6:30 P.M., due to unsafe standing in the Dining Room. The alarm was sounding. The resident sustained [REDACTED]. Review of the 8/7/15 Fall Report indicated that there was no supervision provided. The resident was left in the Dining Room after supper, which is not a supervised area, subsequently, the resident attempted to walk independently, and fell (adequate supervision and effective interventions had not been provided as the resident fell , despite the use of an alarm). In addition, the resident was not supposed to be left in the Dining Room after meals (The 4/30/15 post fall meeting Progress Note indicated that the resident would not be left in the Dining Room, and will be placed in the Foyer after meals). Review of the 10/8/15 Progress Note, indicated that staff responded to an alarm, and by the time staff arrived, the resident was found in the hallway, outside of his/her room on the floor at 8:10 P.M. Review of the 10/8/15 Fall Report, indicated the fall was unwitnessed, the resident was confused, and the alarm was sounding as the resident crawled out of his/her bed (bed alarm), onto mattresses that were on the floor, then off the mattresses (laser alarm), out of his/her room and out into the hallway. The resident sustained [REDACTED]. The Post Fall Meeting Progress Note, dated 10/9/15, indicated that the 10/8/15 incident was likely not a fall, and indicated that no new care plan interventions were needed (Alarms ineffective intervention to prevent falls, as the resident was able to crawl from the bed, which was alarmed, onto the mattresses, then onto the floor, which had a laser alarm, then crawled out of the room and into the hallway before staff responded). Review of the Quarterly MDS assessment, dated 10/29/15, indicated the resident with severe cognitive impairment (BIMS score of 7/15), had balance problems transitioning and walking, and had 2 or more falls with minor injury. Review of the 11/8/15 Progress Note, indicated that the resident fell from the w/c onto the foot pedals while in the Foyer at 9:25 A.M. (resident was not placed in a stationary chair, as planned. The w/c was only supposed to be used for transport). Review of the 11/8/15 Fall Report indicated that the resident's alarm sounded as a staff member was coming around the corner, and saw the resident slide from the w/c onto the foot pedals, and then assisted the resident to the floor, off of the foot pedals. The plan was for the staff to place the resident into a stationary chair (plan already supposed to be in place, and had not been followed to prevent falls). The Surveyor observed Resident #20 sitting in a w/c in the Dining Room on 11/18/15 at 8:20 A.M., 11/19/15 at 12:30 P.M., and again on 11/23/15 at 8:17 A.M. Resident #20 was not placed into a stationary chair, as planned. The w/c was only supposed to be used for transport. During interview and review of the resident's falls and care plans on 11/23/15 at 4:15 P.M., UM #4 said that adequate supervision, care planned and effective interventions had not been provided for Resident #20. 4. For Resident #3, the facility failed to ensure adequate supervision, assistive devices and effective interventions relative to 3 falls (10/18/14, 1/2/15 and 6/13/15). Resident #3 was admitted to the facility in 1/2013. The resident's [DIAGNOSES REDACTED]. Review of the at risk for falls care plan indicated the following interventions: - Ambulate stand by assist with walker. - Bed alarm. - Low bed and a laser alarm. - Non-skid socks. - Cannot be alone in room when out of bed. Review of a 10/18/14 Progress Note and Fall report indicated the resident was found on the floor in the bathroom, and the resident's walker was in the hallway. The resident did not have the walker for ambulation. In addition, the resident required limited assist from staff for toilet use. The Fall Report indicated reinforcement to use the walker was necessary. Review of the 1/2/15 Progress note and Fall report indicated the resident fell in the bathroom, was wearing socks without treads, and sustained a laceration to the back of the head. The Fall Report indicated that the resident had to go to the bathroom, got up from the bed, slipped and fell . The report indicated that the resident was not wearing non-skid socks. The alarms worked, but the resident was already on the floor by the time staff responded. Review of a Significant Change in Condition MDS assessment, dated 1/23/15, indicated the resident had severe cognitive impairment (BIMS score 3/15); required supervision for bed mobility and transfers, required limited assist from staff for ambulation with a walker, and had 1 fall with minor injury. Review of the Care Area Assessment (CAA) for falls indicated that the resident had previous falls with injury, unsteady gait, and required assist for balance. Review of the Quarterly MDS assessment, dated 4/9/15, was essentially unchanged. This assessment indicated that the resident did not have any falls since the last assessment (1/23/15). Review of a 6/13/15 Progress Note and Fall report indicated at 6:45 P.M., the resident was found on the floor between the resident's room and the bathroom with pants and brief pulled down below the knees. The resident hit his/her face above the right eye. The area was red and swollen. The fall was not witnessed. The report indicated that the resident ambulated, without the walker, tried to toilet self and fell . The alarms were not sounding, subsequently, laser and bed alarms were not provided. During interview and review of the clinical record with UM #4 on 11/23/15 at 4:45 P.M., UM #4 said that fall interventions had not been provided relative to non-skid footwear, an assistive device (walker) for ambulation and alarms for Resident #3. 5. For Resident #17, the facility failed to ensure that a functioning bed alarm was in place, an intervention that the facility indicated would prevent falls. The resident sustained [REDACTED]. In addition, the facility failed to ensure effective interventions were provided when the resident sustained [REDACTED]. Resident #17 was admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. Review of the facility's Fall Prevention Policy (dated 5/1/09) indicated the following: - The Charge Nurse will complete the Fall Risk Assessment on admission for all residents. -All resident at risk for falls will have fall care planning. Possible interventions to be considered for prevention of falls; Bed Alarm. Review of the Fall Risk Assessment (was not dated) indicated a total score of 11. A total score of 10 or above represents a high fall risk. Review of the Admission MDS Assessment, dated 9/10/15, indicated the resident was cognitively intact, required limited assistance with bed mobility and toileting. Review of the Falls Care Plan, date initiated 9/17/15, included the following interventions: - Seat pad alarm on wheelchair, - Low bed with alarm. - Mat to left side of the bed. Review of the Resident Care Sheet, dated 9/17/15, indicated the resident was a fall risk and was to have pad alarm to the bed and chair. Review of a Nurse's Note (dated 9/12/15) indicated the resident was found sitting on the floor beside the bed. Review of the Fall Report (dated 9/12/15) indicated the unwitnessed fall occurred at 3:30 P.M. in the resident's room. The resident was not injured. The Post Fall Investigation (dated 9/12/15) indicated the bed alarm was not sounding and had been unplugged. The report indicated the safety measures or corrections made after the fall included personal body alarm and bed alarm. The Falls Care Plan was updated to include the personal body alarm, and it was then discontinued at a later date (unknown date). Review of a Nurse's Note, dated 11/10/15, indicated the resident sustained [REDACTED]. The Post Fall Investigation, dated 11/10/15, indicated the alarms were in place and sounding at the time of the fall (ineffective intervention, as the alarm did not prevent the resident from falling). On 11/20/15 at 8:00 A.M., the resident was observed sitting in his/her wheelchair in the dining room. He/she was dressed, had on shoes, a left arm brace with sling and a right knee brace. The resident was sitting on a waffle cushion and a chair alarm was in place on the wheelchair. During an interview on 11/20/15 at 2:30 P.M., UM #1 said the nurse added a personal body alarm and a working bed alarm after the fall of 9/12/15. She said the personal body alarm was later discontinued, and the bed alarm was maintained. She said she was unsure why the bed alarm was unplugged but should not have been, as it was in place to help prevent the fall.