Every finding on record at Charlene Manor Extended Care Facility

Based on observations, interviews, and record review, the facility failed to ensure that appropriate services to maintain or improve range of motion were implemented for two Residents (#21 and #93) out of a total sample of 27 residents. Specifically, 1. For Resident #21, the facility failed to ensure the Physician's orders were followed relative to the use of the right wrist/hand and left-hand orthosis (device used externally that aids in body alignment and/or function), resulting in worsening bilateral hand contractures, and physical pain for the Resident. 2. For Resident #93, the facility failed to ensure the right-hand orthosis recommended by the Occupational Therapist (OT) was being applied for use by the Resident as required, placing the Resident at risk of worsening contractures. Findings include: The facility staff failed to implement the consistent use of a left-hand carrot orthosis and apply the right-hand wrist and hand orthosis (splint) for Resident #21 as ordered by the Physician and follow the care plan relative to the application of the ordered orthosis devices when the right-hand and wrist splint was being substituted with the use of a stuffed animal. An Occupational Therapy services re-evaluation indicated Resident #21's bilateral hand contractures worsened since the Resident was discharged from Occupational Therapy Services in November 2025, with the Resident unable to tolerate the right-hand and wrist splint and the left carrot orthosis device and assessed by OT with increased tone and contracture, pain and poor hygiene in both hands. 1.Resident #21 was admitted to the facility in December 2024, with diagnoses including hemiplegia (weakness) affecting the left side, and osteoarthritis of the right hand. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #21: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of 15 total possible points. -was able to understand others. -was able to make him/herself understood. -was dependent on assistance for activities of daily living (ADL) including eating, showering/bathing, dressing, oral care, and toileting. On 2/17/26 at 10:44 A.M., the surveyor observed Resident #21 lying in bed, with the fingers of both hands curled into the palms in a fist position and he/she was holding the call bell cord in his/her right hand. The surveyor did not observe any orthosis device on/in the Resident's left hand. Resident #21 attempted to open his/her hands but was unable to open the fingers of the left hand, and only minimally extend open the fingers of the right hand. During an interview at the time, Resident #21 said he/she had pain in both hands. Review of Resident #21's Orthotic Schedule, signed and dated by the Occupational Therapist (OT) on 10/10/25, indicated: -Device: Carrot (specialized, cone-shaped device used to treat hand contractures) for left hand -Purpose of splint: To reduce the left-hand contracture. -Apply splint to the left palm. Place during morning care, and remove with nighttime care, replacing with a rolled washcloth. Gently open fingers to slide carrot in. Do not force [sic]. -Device: Resting right hand splint -Purpose of splint: To reduce right hand contracture. -Apply splint to right hand and wrist. Place with morning care and remove after six hours (lunch time). Review of Resident #21's Occupational Therapy Discharge Summary, signed and dated by the OT on 11/7/25, indicated: -Contracture management bilaterally: Carrot for the left hand, and resting hand splint for the right hand/wrist. -tolerated splints up to six hours. -Staff education of hand hygiene and splints completed. -Services had been required to decrease painful condition of upper extremity in order to enhance the Resident's quality of life by improving the ability to decrease pain in upper extremities and to allow for Activities of Daily Living (ADL) participation. -Recommendations: Gentle passive range of motion (PROM) and splint use. Review of Resident #21's Splint Care Plan, effective 10/10/25, indicated: -will not have problems associated with the use of splints (for example, skin breakdown, pain). -will not have an increase of contracture. -Interventions: Monitor for pain, stiffness and/or skin breakdown, Physical Therapy/Occupational Therapy evaluation as ordered, Apply splints as ordered. Review of Resident #21's Active Physician Orders Report, undated, indicated: -Left hand carrot roll to reduce contracture, Day and Evening. Gently open fingers in the morning, cleanse hand and dry completely. Place carrot handroll [sic] in palm, remove handroll at hour of sleep (HS), and place rolled washcloth in its place. Check skin integrity. Start date 12/20/25. -Right hand and wrist splint to reduce contracture, Day and Evening. Apply right hand splint gently to wrist and hand in the morning with care and remove after lunch, check skin integrity. Start date 1/29/26. On 2/19/26 at 9:24 A.M., the surveyor observed Resident #21 lying in bed, with his/her right hand under the covers and not visible to the surveyor. The surveyor did not observe a carrot or rolled washcloth in the Resident's left hand. During an interview on 2/19/26 at 11:24 A.M. Certified Nurse Aide (CNA) #4 said (rehabilitation) therapy would place a device in both of Resident #21's hands sometimes, usually the right hand. CNA #4 said therapy applied the devices to Resident #21's hands, but the CNA's could apply the devices as well. CNA #4 said Resident #21 was supposed to have a brace on his/her hand at all times and if the Resident did not have the brace on his/her hand, the hand would become closed, and the fingers would become tight. CNA #4 lifted Resident #21's blanket, and the surveyor observed a small ostrich stuffed animal on the bed next to the Resident's right hand. CNA #4 placed the stuffed animal into the Resident's right hand and said the stuffed animal was provided by therapy to keep the Resident's right hand open. CNA #4 said Resident #21 had a carrot pillow that he/she could use in the right hand as well. Resident #21 at this time said that the carrot was for his/her left hand, not the right hand and that he/she could not find the carrot. The surveyor did not observe any orthosis device placed in the Resident's left hand at this time. On 2/20/26 at 8:13 A.M., surveyor observed Resident #21 lying in bed, and did not observe any orthotic device in either of the Resident's right or left hands. During an interview on 2/20/26 at 12:18 P.M., CNA #5 said Resident #21 had a stuffed animal for the right hand, and a carrot for the left hand that should be used in her/her hands. CNA #5 said Resident #21 usually received medication before the devices were placed in his/her hands because it hurt the Resident when the devices were placed. CNA #5 also said Resident #21 never refused use of the devices (stuffed animal and carrot) for his/her hands. On 2/20/26 at 12:24 P.M., the surveyor observed Resident #21 sitting in his/her wheelchair, with a small ostrich stuffed animal in his/her right hand and a carrot orthosis in his/her left hand. During an interview on 2/20/26 at 12:29 P.M., Nurse #2 said the carrot orthosis was supposed to be placed in Resident #21's left hand, and that there was a brace for Resident #21's right hand but the Resident did not like the brace. Nurse #2 said (rehabilitation) therapy told her that the small stuffed animal could be used in place of the right-hand brace as long as Resident #21's fingers did not overlap. Nurse #2 said the devices (carrot and small stuffed animal) were to be placed in Resident #21's hands in the morning and removed after lunch. Nurse #2 said Resident #21 was having pain, and she had administered pain medication before re-inserting the carrot in the Resident's left hand earlier today. Review of Resident #21's February 2026 Treatment Administration Record (TAR) indicated: -Right hand and wrist hand [sic] splint to reduce contracture, apply right hand splint gently to wrist and hand in the morning with care and remove after lunch. Check skin integrity. One time a day for routine splinting, apply right hand/wrist splint (scheduled for 9:00 A.M.). -Nurse #2 electronically signed off application of the right-hand splint on 2/20/26 (not the stuffed animal observed in use). During interviews on 2/20/26 at 1:08 P.M. and 1:28 P.M., the Director of Rehabilitation Services said if Resident #21 were not able to tolerate an orthosis device that had been recommended by therapy, the process was that nursing staff would notify therapy and therapy would re-evaluate the Resident to determine whether an alternative device was needed. The Director of Rehabilitation Services said that there was no evidence in Resident #21's records that therapy had been notified Resident #21 was unable to tolerate the right wrist and hand orthosis that had been recommended by the Occupational Therapist and ordered by the Provider. During an interview on 2/20/26 at 1:24 P.M., Occupational Therapist (OT) #2 said when Resident #21 was discharged from Occupational Therapy services in November 2025, the Resident was recommended for a carrot to be placed in the left hand and a resting hand splint to be placed on the right hand. OT #2 said the right resting hand splint was to be applied with morning care and removed after lunch. OT #2 said there was to be either a carrot or a washcloth placed in the Resident's left hand at all times. OT #2 said if no devices were placed in Resident #21's left hand, the Resident's hand would tighten up into a fist. OT #2 said she had not received any communication from the nursing staff that Resident #21 no longer tolerated the right-hand brace, and she was not aware of the use of a stuffed animal as an alternative to the ordered right-hand brace. OT #2 said the importance of the orthosis devices were to prevent contractures, decrease risk for skin breakdown, improve hand hygiene, reduce pain, reduce the risk of yeast infection of the hands, and reduce tone. OT #2 said if the orthosis devices were not in place as recommended, concerns included worsening contractures, worsening tone, and increased risk for skin breakdown. Review of Resident #21's Progress Note signed and dated by the Physician Assistant (PA) on 2/20/26, indicated: -had slowly worsening contractures. -historically had bilateral hand pain. -As an alternative to the hand brace, Resident had been using a stuffed animal to grip/protect his/her palms. Review of Resident #21's Occupational Therapy Evaluation, signed and dated by OT #2 on 2/21/26, indicated but was not limited to the following: -was unable to tolerate the right resting hand splint and the left carrot orthosis device. -presented with increased tone, pain and poor hygiene in both hands. -Right hand range of motion: Increased contracture. Unable to utilize resting hand splint. -Left hand range of motion: Increased contracture. Unable to take measurements. -Occupational Therapy services would be required to establish a plan to reduce pain, reduce further contractures, improve hand hygiene, and reduce the risk of hand wounds. During an interview on 2/25/26 at 11:12 A.M., Resident #21 said he/she had pain in his/her hands when someone tried to pry his/her hands open. During an interview on 2/25/26 at 11:55 A.M., CNA #3 said that she had been placing washcloths in Resident #21's hands for about two months because the Resident's hands were so contorted. During an interview on 2/25/26 at 12:39 P.M., OT #2 said she re-evaluated Resident #21 on 2/21/26 and the Resident's bilateral hand contractures worsened since the Resident was discharged from Occupational Therapy Services in November 2025. OT #2 said Resident #21 was in too much pain to open his/her hands and was no longer able to use the carrot in the left hand or the resting hand splint to the right hand. OT #2 said Resident #21 was grimacing in pain during the evaluation on 2/21/26 and had started to guard. OT #2 also said when she touched the tops of Resident #21's fingers on 2/25/26, Resident #21 had anxiety anticipating the thought of OT #2 touching his/her hand. During an interview on 2/25/26 at 2:08 P.M., the PA said when she assessed Resident #21 on 2/20/26, the Resident was holding a stuffed animal in his/her hand and had worsened bilateral hand contractures. The PA said Resident #21 had a history of discomfort related to the contractures and was currently prescribed pain medication. The PA said her expectation was that orthosis devices were utilized as recommended by therapy, and if Resident #21 could not tolerate the devices, nursing should have notified rehabilitation services and herself so that additional interventions could be implemented. The PA said concerns for Resident #21 not using the orthosis devices as recommended included progression of the hand contractures, and poor hand hygiene and nail care. During an interview on 2/25/26 at 4:11 P.M., Resident #21's Representative (RR) said Resident #21 was remarkably stoic (could endure pain without showing their feelings or complaining) and would therefore complain very little relative to any discomfort. During an interview on 2/26/26 at 9:48 A.M., Nurse #6 said that prior to the Occupational Therapy re-evaluation on 2/21/26, Resident #21's plan of care included use of a stuffed animal and a brace to the Resident's right hand, and a carrot for the Resident's left hand. Nurse #6 said that Resident #21 would use the stuffed animal and brace at different times in the right hand. Nurse #6 said he could not provide evidence that the stuffed animal used as an alternative to the right-hand/wrist brace was included in the Resident's plan of care. Nurse #6 said when the stuffed animal was being used as an intervention in the Resident's plan of care and was not part of the Resident's plan of care, therapy and the Unit Manager should have been notified. Nurse #6 said that he did not recall speaking with therapy or the Unit Manager about the stuffed animal being utilized in Resident #21's care as an intervention to treat the Resident's right hand contracture. During an interview on 2/26/26 at 10:31 A.M., the Director of Nursing (DON) said her expectation was that nursing staff followed the Provider's orders regarding use of orthosis devices. The DON said that if orthosis devices were not used as ordered, there was a risk for the Residents' decline. 2. Resident #93 was re-admitted to the facility in May 2023, with diagnoses including osteoarthritis and chronic pain. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #93:-was moderately cognitively impaired as evidenced by a score of 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam.-was able to understand others.-was able to make his/herself understood.-did not receive therapy services (including occupational therapy or physical therapy) in the last seven days.-did not reject care. On 2/17/26 at 10:04 A.M., the surveyor observed that Resident #93's middle finger on his/her right hand was crossed over the pinky finger at rest. During an interview at the time, Resident #93 said the OT had tried to make the Resident's right hand more mobile and had talked to him/her about getting a right-hand brace/splint. Resident #93 said he/she did not have a brace/splint. Review of Resident #93's Comfort Care Plan, effective 9/28/21, indicated:-Potential for alteration in comfort/pain related to arthritis/osteoarthritis.-will experience a decrease in pain after pain reducing measures are implemented. (Effective 7/1/25)-Interventions: Therapy screen and treatment for possible pain reduction modalities as indicated. Review of Resident #93's Occupational Therapy Discharge Summary, signed and dated by OT #3 on 1/20/26, indicated:-Services were provided to establish an orthotic management schedule to prevent worsening contracture and promote good skin integrity.-Recommendations: Splint/brace. Review of Resident #93's Medication and Treatment Administration Records (MAR/TAR) dated January 2026 failed to indicate that a brace/splint had been applied to the Resident's right hand. Review of Resident #93's MAR/TAR dated February 2026 failed to indicate that a brace/splint had been applied to the Resident's right hand. Review of Resident #93's Care Kardex, undated, failed to indicate application of a brace/splint to the Resident's right hand. Review of Resident #93's Occupational Therapy Evaluation, signed and dated by OT #3 on 2/22/26, indicated:-Occupational Therapy services were indicated to assess for custom splint and possible adjustment to the splinting schedule. During an interview on 2/25/26 at 11:44 A.M., CNA #3 said that Physical [sic] therapy would come to apply a device to Resident #93's right hand, which the Resident would wear for two hours as tolerated. CNA #3 said that either the therapist or nursing staff would remove the device. CNA #3 said that she would determine whether a resident required an orthosis device by reviewing the resident's care plan or Kardex. CNA #3 said she recalled last seeing Resident #93 utilizing a device to his/her right hand about three weeks prior. During an interview on 2/25/26 at 12:08 P.M., Unit Manager (UM) #1 said the nursing staff were going to take over the application and removal of the orthosis device to Resident #93's right hand from the rehabilitation staff a few weeks ago, as the Resident was supposed to be discharged from therapy services at that time. UM #1 said that the Resident was not discharged from therapy services at that time, and only the therapy staff was to apply and remove the orthosis device to the Resident's right hand. UM #1 said when the Resident was to be discharged from therapy services, UM #1 would be responsible for updating the Resident's plan of care with the application of the orthosis device to the right hand, including the duration and the frequency of use. UM #1 said the nursing staff would from that time on be responsible for any associated documentation regarding use of the device. During an interview on 2/25/26 at 12:49 P.M., OT #3 said when Resident #93 was discharged from OT services in January 2026, the recommendation was for the Resident to wear a splint overnight to the right hand. OT #3 said that the purpose of the splint was to prevent worsening contracture of the right hand. OT #3 said that she performed a splinting audit on 2/21/26 and did not find evidence of Resident #93's splint in his/her room nor evidence of the Resident's splinting plan. OT #3 said she did not know the last time Resident #93 had worn the splint prior to 2/21/26. OT #3 said that upon evaluation of the Resident's right hand on 2/21/26, it was determined that there was no worsening of the Resident's range of motion or pain level, and the Resident's skin was intact. OT #3 said that the Resident was at risk for increased contracture if she was not able to wear the right-hand splint for an extended period of time. During an interview on 2/25/26 at 2:23 P.M., the PA said that there would be concerns for worsening of the contracture, increased pain, and impaired ability to perform nail care and hand hygiene if the right-hand orthosis device was not utilized by Resident #93 as recommended by therapy.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was admitted to the Facility for a short term stay and had a history of aggression, the Facility failed to ensure Resident #1's Comprehensive Care Plan included interventions, goal and outcomes related to his/her inappropriate and aggressive behaviors directed at and involving other residents, and discharge planning. Findings include: Review of the Facility Policy titled Resident to Resident Altercation, dated as revised 03/20/09, indicated a system to follow-up on all altercations with an emphasis to prevent future altercations will be in place such as, care plans will be updated to incorporate recommendations from the formal incident review process in addition to immediate updates that may have occurred at the time of or proactively prior to the altercation. Review of the Facility Policy titled Care Planning, dated as revised 02/15/25, indicated that Care Planning includes a standardized discharge process to effectively transition a resident to their next level of care, including home, community, or alternate facility. Resident #1 was admitted to the Facility in November 2024, diagnoses included congestive heart failure, diabetes mellitus and bipolar disorder. Review of Resident #1's Admission Social Service Note, dated 12/02/24, indicated that Resident #1's goal was to be discharged to an apartment. Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 12/03/24, indicated Resident #1's goal was to return to the community. Resident #1's Quarterly MDS Assessment, dated 02/05/25, 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). The MDS indicated that Resident #1 was independent with mobility and Activities of Daily Living (ADLs). Further review of the MDS Assessment indicated that Resident #1 exhibited physical behavioral symptoms directed toward others on one to three days, and verbal behavioral symptoms directed toward others on four to six days, during the seven-day assessment period. Review of Resident #1's Nurses Notes, from 01/01/25 through 04/10/25, indicated progress notes included several behavioral incidents in which Resident #1 made inappropriate comments, used derogatory language, and directed insults toward residents and their family members in the resident common area, often disrupting the evening meal. Review of a Facility Incident Report, dated 02/18/25, indicated that at approximately 9:15 P.M., Resident #1 turned off Resident #2's television and said, Time to go to bed. The Report indicated that Resident #2 then turned the television back on with the volume muted, and that Resident #1 returned to Resident #2's side of the room and turned his/her television off again. The Report indicated that Resident #1 struck Resident #2 on the shin with the television remote control and that Resident #2's right shin was noted to be red and swollen. The Report further indicated that Resident #1 was sent to the emergency department to be evaluated by behavioral health. Review of Resident #1's Behavior Care Plan, reviewed on 03/20/25, indicated that although he/she had interventions and goals related to physical altercations and accusatory statements specific to staff member interactions, the care plan did not address goals and/or interventions specific to his/her adverse behaviors with other residents, which included resident to resident physical altercations, frequent episodes of verbal aggressive and inappropriate behaviors directed at residents in common areas. The Surveyor was unable to interview with Resident #1, as he/she no longer resided in the facility and was in Police custody after physically assaulting a resident. Further review of Resident #1's Comprehensive Care Plan indicated there was no documentation to support that it addressed goals and interventions specific to his/her potential, preferences and plans for discharge from the facility. During an interview on 05/06/24 at 3:32 P.M., Nurse #1, who worked regularly on Resident #1's Unit during the evening shift, said that Resident #1 often shared sexually explicit stories from his/her past with other residents while in the common areas and during meals. Nurse #1 said that redirecting Resident #1 often did not go well and resulted in him/her targeting the intervening staff member, making a scene and setting the tone for the evening meal. During a telephone interview on 05/08/25 at 10:16 A.M., Certified Nurse Aide (CNA) #1, who worked full time during the evening shift on Resident 1's unit, said that Resident #1 spent a lot of time in the resident common area. CNA #1 said that Resident #1 frequently disrupted mealtimes by calling other residents names or directing insults at them. CNA #1 said that these behaviors were difficult to redirect, often resulting in other residents choosing to remain in their rooms for the evening meal. During an interview on 05/06/25 at 3:03 P.M., the Social Worker said that there had been no formal discharge care plan for Resident #1, and to her understanding, he/she had declined any discharge placement other than section-eight housing, which typically had a waiting period of three years in the community. The Social Worker said that the Case Manager at Resident #1's insurance provider had been looking for placement at other long term care facilities. During an interview on 05/06/25 at 4:30 P.M., the Administrator said that Resident #1 was given a 30-day notice of a facility-initiated discharge on 03/03/25, based on his/her independent functional status, and that the notice was rescinded on 03/21/25 because a discharge location could not be established. During an interview on 05/06/25 at 4:45 P.M., the Director of Nurses (DON) said that Resident #1's Behavioral Care Plan should have addressed goals and interventions related to his/her verbally aggressive and inappropriate behaviors toward other residents and said that it should have been updated following his/her physical altercation with Resident #2, that occurred on 02/18/25. The DON further said that Resident #1 had been admitted for a short term stay and should have had a care plan in place that included goals and interventions to transition back into the community. The DON said that she was unaware that Resident #1's Comprehensive Care Plan did not address his/her discharge plan

Based on records reviewed and interviews, for one of three sampled Residents (Resident #1), who sustained an unwitnessed fall, the facility failed to ensure they maintained a complete and accurate medical record when nursing did not complete the 72-hour neurological checks following his/her unwitnessed fall, per facility policy. Findings include: Review of the Facility's policy titled Falls Management: Post Fall, with a revision date of 09/30/24, indicated an Incident and Accident Report would be completed after each resident fall. Review of the Facility's Incident Report Checklist indicated for nursing to initiate neurological checks (assessment used to determine head injury) when a resident sustained a head injury or unwitnessed fall by utilizing the Neuro Check Sheet. Review of the Neurological Check Flowsheet indicated to assess the following with each check: - Level of consciousness - Pupil response - Motor response (hand grasps) - Pain response - Vital signs (blood pressure, temperature, pulse and respiration) Further review of the Flowsheet indicated the neurological checks were to be completed every 15 minutes for the first hour post-fall, then every 30 minutes for the next four hours, then every hour for the next two hours, then every shift for the next 72 hours. Resident #1 was admitted to the facility in November 2024, diagnoses included Covid-19, chronic kidney disease - stage 4 (severe) and acute diastolic heart failure. Review of Resident #1's Accident and Incident Report, dated 11/01/24 at 4:45 P.M., indicated Resident #1 sustained an unwitnessed fall in his/her room and was assessed to have a small bump on the back of his/her head after the fall. Review of Resident #1's Neurological Check Flowsheet, dated 11/01/24, indicated his/her neurological checks were initiated on 11/1/24 at 4:45 P.M., and checked again at 5:00 P.M., and 5:15 P.M. However, according to facility policy, his/her neurological checks were to be obtained every 15 minutes for one hour and were not obtained at 5:30 P.M. or 5:45 P.M., by nursing as required. Further review of the Flowsheet indicated Resident #1's neurological checks were not documented as being obtained on the following dates/times: 11/01/24 (per policy every 30 minutes x 4 hours and then every hour x 2 hours), for all of the below listed times, the Flowsheet was blank. - 6:15 P.M. - 6:45 P.M. - 7:15 P.M. - 7:45 P.M. - 8:15 P.M. - 9:15 P.M. - 9:45 P.M. -11:45 P.M. 11/02/24-11/04/24, all shifts (per policy every shift x 72 hours) During an interview on 03/12/25 at 3:50 P.M., Nurse #2 said the Nursing Supervisor heard Resident #1 yelling from the bathroom, said that he/she hit his/her head, and there was a small bump noted to the back of his//her head. Nurse #2 said when a resident either has an unwitnessed fall and/or a fall in which a resident hits their head, the nurse was required to initiate neurological assessments and document the assessments on the Flowsheet. Nurse #2 reviewed Resident #1's Neurological Check Flowsheet, dated 11/1/24, and said she documented neurological assessments on 11/1/24 at 8:45 P.M., 10:45 P.M. and for the 11:00 P.M. - 7:00 A.M. shift, but she did not document any other assessments for the rest of her shift (3:00 P.M. - 11:00 P.M.), and said she unsure why. During an interview on 03/12/25 at 12:40 P.M., Nurse #1 said if a resident sustained an unwitnessed fall or a fall where the resident struck their head, the nurse was required to initiate neurological checks and record the findings on the Flowsheet. Nurse #1 said there are specific intervals of time in which these assessments should be completed which are clearly written on top of the Flowsheet. During the interview, Nurse #1 reviewed Resident #1's Neurological Check Flowsheet, dated 11/1/24 and said there were many blank spaces. During an interview on 03/12/25 at 1:00 P.M., the Admission Nurse said if a resident had an unwitnessed fall or a fall in which the resident hit their head, the nurse was supposed to initiate neurological checks and complete the Neurological Check Flowsheet. The Admission Nurse said the reason neurological assessments are important is because the assessments are designed to identify a potential brain injury. During the interview, the Admission Nurse reviewed Resident #1's Neurological Check Flowsheet, dated 11/1/24, and said that Resident #1's Flowsheet was incomplete. During an interview on 03/12/25 at 5:00 P.M., the Director of Nursing (DON) said the Neurological Check Flowsheet was expected to be completed by nursing staff after a resident had an unwitnessed fall or a fall in which a resident hit their head. During the interview, the DON reviewed Resident #1's Neurological Check Flowsheet, dated 11/1/24, and said the Flowsheet was incomplete.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent and treat pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for two Residents (#26 and #53), of four applicable residents reviewed for pressure ulcers, out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #26: -offload (minimizing or removing any weight or force to help prevent and heal pressure ulcers) pressure on his/her buttocks and provide repositioning and assistance out of bed daily per Resident's plan of care to reduce the risk of developing pressure ulcers per the comprehensive plan of care and Resident preference/request. -assess the Resident's skin when he/she complained of buttocks discomfort. -implement interventions per professional standards of care and practice when a pressure ulcer was identified, including having hoyer pads available to transfer the Resident out of bed daily. -ensure the low loss air mattress was at the appropriate setting per the Resident's weight and comfort. 2. For Resident #53: -complete skin screening and assessment as required for the Resident who was at risk for pressure ulcers. -identify and implement treatment for a pressure ulcer that developed from the use of a nasal cannula (a thin flexible tube that provides supplemental oxygen through the nose via nasal prongs) resulting in a Stage Two pressure ulcer (partial-thickness skin loss with exposed dermis) of the philtrum (the vertical groove between the base of the nose and the border of the upper lip) and the base of the nostrils. Findings include: Review of the facility Policy titled Skin Integrity Management, revised November 15, 2024, indicated the following: -The facility must ensure the resident receives care, consistent with professional standards of practice to prevent pressure ulcer or injury and does not develop pressure ulcer or injury unless the individual's clinical condition demonstrates they were unavoidable. -Any resident with pressure ulcer or injury receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. -Skin assessment can and should be included in the normal workflow such as: >during provision of care, when turning, lifting, or transferring a resident. >each time you apply oxygen, check the resident's ears for any pressure areas. -When a resident has a device [sic], obtain Medical Doctor (MD) order to remove device and monitor skin integrity every shift unless it is medically contraindicated. Secure the device properly and regularly monitor and adjust if needed, the degree of tension to reduce pressure at the skin device interface. -When a skin breakdown is identified, report this timely to the Medical Practitioner. Obtain a wound treatment and document in Physician order and ETAR (electronic treatment administration record). -Use wound care and treatment products consistent with the company's protocol. Document each prescribed wound treatment in the resident's electronic health record 1. Resident #26 was admitted to the facility in April 2013, with diagnoses including Multiple Sclerosis (MS: a chronic autoimmune disorder of the central nervous system marked by numbness, weakness, loss of muscle coordination, and problems with vision, speech, and bladder control), Type 2 Diabetes (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar levels), Cerebral Palsy (a group of conditions that affect movement and posture caused by brain damage to the developing brain before birth), and Morbid Obesity (when the body weight is found to be more than 80 - 100 pounds above the individual's ideal body weight). Review of the High Risk for Skin Breakdown Care Plan, initiated 8/15/17, indicated Resident #26 was at high risk for pressure ulcer development and indicated the following: -Resident should be encouraged to get out of bed daily, initiated 8/15/17 -Encourage activity and mobility, initiated 8/15/17 -Observation of skin condition during care - report pink, red or open areas to Nurse, initiated 8/15/17 -Apply Periguard (barrier cream that helps moisture and protect the skin) with each incontinent episode, initiated 11/24/17 -Gel pressure relieving cushion while in wheelchair, initiated 9/28/23 Review of the Activities of Daily Living Care Plan initiated 8/15/17, with an effective date of 10/11/23 indicated Resident #26 had decreased mobility and should be Out of Bed to wheelchair daily. Review of the Resident's Profile Care Plan effective 8/24/18, indicated the following: -Behaviors exhibited by Resident- none at present, initiated 8/24/18 -Resident prefers to get up later in the morning before lunch and goes to bed before supper, initiated 8/24/18 -Transfers with Hoyer Lift (mechanical device used to transfer individuals with limited mobility) - Large Hoyer pad (GREEN), initiated 7/21/21 -Decubitus Ulcer (bedsores that develop when an individual was unable to change positions for extended periods of time) Prevention- barrier cream to coccyx (tailbone), buttocks each shift, initiated 7/24/21 Review of the Occupational Therapy (OT) Discharge Summary, dated 2/11/24, indicated the following discharge recommendation: -Staff to assist the Resident with Hoyer transfer into the gerichair (specialized wheelchair) daily for at least one meal per day. Review of the Resident#26's MDS Assessment, dated 8/15/24 indicated: -he/she was cognitively intact as evidenced by a BIMS score of 13 out of a total possible 15. -had range of motion impairment affecting bilateral (both) lower extremities. -required total assistance from staff for toileting, showering, dressing, personal hygiene, rolling side to side, and transfers out of bed. -was frequently incontinent of bladder and bowel function. -was at risk for pressure ulcer development with a history of Moisture Associated Skin Damage (MASD - erosion of skin caused by prolonged moisture such as urine, stool or sweat). -utilized a Pressure Reducing Bed -weighed 190 pounds -had no rejections of care, refusals or change in behaviors. Review of Resident #26's October 2024 Physician orders indicated the following: -Alternating pressure mattress overlay. Every shift ensures inflation and correct setting every shift. Setting at 260 [sic] based on weight and manufacturers guidelines. Set at 260 for pain management based on resident assessment and preferences, initiated 6/26/24. -Weekly Skin screening for new areas of concern on Monday day shift, initiated 6/17/22 On 11/3/24 at 9:55 A.M., the surveyor observed Resident #26 lying in bed on his/her back with the head of the bed slightly elevated. The surveyor observed the Resident's legs were elevated on pillows and an air mattress was on the bed and set at 250 pounds. During an interview at the time, Resident #26 said that the air mattress was not always comfortable, and he/she needed to sleep with a pillow under his/her buttocks because if he/she was in the wrong position it hurt because there was a sore on his/her buttocks. Resident #26 said that he/she has not been out of bed in at least a week because the staff had not been able to find a Hoyer pad for the lift that assists with transferring him/her out of the bed and that he/she would like to get out of the bed. On 11/4/24 at 8:11 A.M., 8:43 A.M., 9:58 A.M., and 4:15 P.M., the surveyor observed the Resident lying in bed. At 8:43 A.M., the surveyor observed the Nurse Practitioner (NP) enter Resident #26's room and the Resident reported that he/she had buttocks pain. The NP asked the Resident if he/she was getting out of bed daily, and the Resident said that he/she had not been out of bed because the staff did not have the Hoyer pad and that he/she would like to get out of the bed. On 11/4/24 at 12:55 P.M., the surveyor observed Resident #26 lying on his/her back in bed with the head of the bed elevated. The Resident said that he/she was not getting out of bed today because the CNA said a Hoyer pad was not available. The surveyor observed a sign on the Resident's wall beside the bed, from OT which indicated the following: Resident was to be out of bed three to five (3-5) times per week for two to three (2-3) hours to get stronger and prevent sacral (skin injury near the base of the spine from extended pressure on the area) ulcers. On 11/5/24 at 7:42 A.M., and 2:32 P.M., the surveyor observed the Resident lying in bed. During an interview with CNA #9 at 2:32 P.M., she said the Resident did not get out of bed today because there were not enough Hoyer pads for all the residents and that it was difficult to find the correct size Hoyer pad for Resident #26. CNA #9 said if a Hoyer pad cannot be found, then Resident #26 cannot get out of bed, and she would notify the Nurse or the Unit Manager (UM). CNA #9 further said that if Resident #26 stayed in the bed, this would put him/her at risk for skin breakdown and that the Resident recently had an area that healed on his/her buttocks. CNA #9 said Resident #26 currently had redness and pain on his/her buttocks, and that she applied a cream and repositioned her. CNA #9 said if she noticed a skin issue, she would alert the Nurse. At this time, the surveyor requested to evaluate Resident #26's buttocks redness with CNA #9 and Nurse #9 and observed the following: -the Resident's right and left buttocks were deep red in color. -the left buttocks were painful upon touch and appeared deep red in color and was intact. -the right buttocks had two small round superficial (outer layer of the skin is open and damaged) open areas, each about 1.0 centimeter (cm) in diameter. During an interview at the time, Nurse #9 said the Resident had a Stage Two pressure area on his/her right buttock and a possible Stage Two on his/her left buttock but wanted to have the Wound Nurse evaluate the Resident's skin. Nurse #9 said they would make the NP/MD aware of his/her areas. Review of the medical record failed to indicate interventions were implemented for the two stage 2 pressure injuries observed on 11/5/24 On 11/6/24 at 7:56 A.M., the Resident was observed lying in bed with the air mattress set at 250 pounds. During an interview at the time, the Resident said his/her buttocks was sore this morning. During an interview on 11/6/24 at 8:24 A.M., CNA #9 said Resident #26 had complaints of discomfort in his/her buttocks. CNA #9 said she notified the Resident's Nurse (#5), who gave CNA #9 a cream to apply to the Resident's buttocks area. During an interview on 11/6/24 at 8:30 A.M., Nurse #5 said she had administered the scheduled pain medication to Resident #26 for complaints of buttocks pain and was aware there was an open area on his/her buttocks. During an interview on 11/6/24 at 8:43 A.M., UM #1 said she did not recall being told about missing Hoyer pads for Resident #26, that he/she was supposed to get out of bed every other day but sometimes refused and needed encouragement. UM #1 further said that if the Resident refused care, it would be documented. UM #1 said she was aware that the Resident had not been out of bed for a week and a half and thought it was due to the refusals and did not know it was because there was a lack of Hoyer pads. On 11/6/24 at 12:06 P.M., the surveyor observed Resident #26 dressed and seated in a recliner chair next to his/her bed prior to lunch. During an interview at the time, the Resident said he/she was happy to be up and out of bed but was starting to get a sore on his/her buttocks again. Resident #26 said the facility staff applied a cream to his/her buttocks early that morning and that he/she was scheduled to see the Wound Nurse. During an interview on 11/6/24 at 1:43 P.M., Nurse #5 said she provided CNA #9 Zinc Oxide (medicated cream to treat or prevent skin irritation) ointment, to be applied to Resident #26's painful buttocks. Nurse #5 said she had not assessed the Resident's buttocks yet today. The surveyor and Nurse #5 reviewed the current Physician's orders for Resident #26, and Nurse #5 said there were currently no treatment orders for the Resident's buttock areas. Nurse #5 said the Resident had two open areas on his/her buttocks that were identified on 10/23/24 (14 days prior) and she thought the current areas the Resident had were the same areas that were previously identified. Nurse #5 said when an alteration in a Resident's skin integrity was identified, the Nurse would assess the area, notify UM #1, complete an incident report and notify the Physician by utilizing the Provider Communication Book. The surveyor and Nurse #5 reviewed the Provider Communication Book and were unable to locate where there was notification about the Resident's identified buttocks areas on 11/5/24. Further review of the Provider Communication Book indicated an entry from Nurse #5, dated 10/23/24, notifying the Provider of two open areas to Resident #26's buttocks, that Zinc Oxide ointment had been applied, and a request for a treatment to the areas. An additional notation next to the written communication from Nurse #5 indicated a handwritten ? Triad (cream applied to promote wound healing and protect skin). Nurse #5 said she thought this notation for Triad was a response from the Provider and that she was not aware that this notation was made. Nurse #5 further said that if there was a Provider response in the Provider Communication Book, then the Nurse should have clarified with the Physician about the response and should have transcribed treatment orders if that was what was intended. Nurse #5 said she should not have provided CNA #9 with the Zinc Oxide ointment to apply to Resident #26 because it was not ordered by the Physician for use. Review of the medical record failed to indicate an assessment was completed for the two open areas identified on 10/23/24 or additional interventions were implemented. On 11/6/24 at 2:45 P.M., the surveyor observed Resident #26's buttocks with Nurse #5 and observed the following: -A layer of white cream was covering the Resident's left and right buttocks. -The right buttocks had two small circular superficial (on the surface or shallow) areas about 1.0 cm in diameter, due to the white cream covering the buttocks, the wound beds (open areas) were unable to be thoroughly visualized by the surveyor. -Redness was observed on both the right and left buttocks. During an interview immediately following the observation, Nurse #5 said the Resident's left buttocks was impaired, but it was difficult to assess as the areas were covered in a thick white cream. Nurse #5 further said she thought the Resident's current areas were in the same spots as the areas identified on 10/23/24 but was unable to verify this. The surveyor observed the Resident's air mattress was set at 260 pounds and Nurse #5 also said the Resident's air mattress was set to 260 pounds and that air mattresses were supposed to be set according to the Resident's weight. The surveyor and Nurse #5 reviewed the current weight for Resident #26 which was 174 pounds on 10/15/24. Nurse #5 said that the current setting on the Resident's air mattress did not match what the Resident's current weight was and if the air mattress was set too high (increased pressure/firmness), that would put the Resident at a higher risk for skin breakdown. Nurse #5 said she did not feel comfortable adjusting Resident #26's air mattress because she had never been taught how to do that (adjust the settings). During an interview on 11/6/24 at 3:37 P.M., UM #2, who was identified as the Wound Nurse, said she had not been notified of any new alterations in skin or areas of concerns for Resident #26 over the past month. UM #2 said if an alteration in a Resident's skin is identified, the Nurse completes a notification form which is put in her mailbox. UM #2 said she completes weekly wound rounds on Tuesdays and had not been notified therefore was not following Resident #26. UM #2 said the Nurse who identified the Resident's areas should have followed the facility's wound protocol, completed an assessment of the wound including the measurements and description, and notified the Physician to obtain treatment orders. UM #2 said the Provider should have been contacted immediately to obtain an appropriate treatment order for Resident #26 and the Nurse should not have written the request in the Provider Communication Book. UM #2 said Zinc Oxide ointment was a prescription medication, and only the Licensed Nurses should be applying the medication, and it should only be applied when there was a Physician's order. During an interview on 11/6/24 at 3:58 P.M., UM #1 said Resident #26 had re-occurring moisture associated skin damage on the buttocks and would be followed by the Wound Nurse until resolved. UM #1 said when the Resident's areas were identified, an incident report should have been promptly completed, the Physician called to notify of the areas and obtain treatment orders, and the facility Wound Nurse also notified so that the Resident would be assessed on weekly wound rounds. UM #1 said the Nurses should be checking in the Provider Communication Book to review any new orders. The surveyor and UM #1 reviewed Resident #26's current Physician orders, and UM #1 said there were no current treatments in place for Resident #26's buttocks areas and orders would need to be obtained prior to applying any treatments. UM #1 said that a Licensed Nurse should be assessing the Resident's skin condition when applying Physician ordered treatments, not the CNAs. UM #1 said once a wound was identified, it would be monitored daily on the Resident's treatment record, and the Nurse would complete assessments which include any pain, condition/status of the wound, the skin condition surrounding the wound, the condition of the wound bed, drainage, odor and if the area was worsening to call the Physician. UM #1 said the Resident wounds were to be measured weekly. UM #1 said the Resident's air mattress should be set to the Resident's weight and comfort. UM #1 said the Resident's weight obtained today was about 190 pounds, so the air mattress should be set at about 200 pounds but was set to 260 pounds. UM #1 said if an air mattress was set higher than it should be, it could affect the Resident's skin negatively and cause increased pressure because the air mattress was firmer. UM #1 said the air mattresses were monitored every shift by the Nurses to ensure that they are set appropriately. UM #1 said if a Resident on an air mattress developed a wound or complained of pain, the Nurse should assess the air mattress setting to determine if it was an appropriate setting based on the Resident's weight and comfort. UM #1 said Resident #26 was alert, oriented and able to communicate his/her needs. 2. Resident #53 was admitted to the facility in December 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes obstructed airflow from the lungs that leads to respiratory problems including difficulty breathing, shortness of breath and wheezing), Hypoxemia (low levels of oxygen in the blood), and Non-ST Elevation Myocardial Infarction (NSTEMI: type of heart attack that occurs when an artery is partially blocked, reducing blood flow and oxygen to the heart muscle). Review of the Activities of Daily Living Care Plan, initiated 12/22/22, indicated Resident #53 had an alteration in his/her ability to provide self care and included the following interventions: -Check skin during care and report any abnormalities/issues to nursing/Medical Doctor (MD), initiated 12/22/22 -Assistance of one staff with bathing, dressing, grooming, initiated 1/16/23 Review of the Cardiac Care Plan, initiated 12/22/22, included the following intervention: -Administer oxygen as ordered by the MD . Monitor O2 (oxygen) saturation (SpO2 - measure of oxygen in the blood as a percentage of the maximum oxygen the blood could carry) as ordered and as needed (PRN), initiated 12/22/22 Review of the Minimum Data Set (MDS) Assessment, dated 9/5/24, indicated: -Resident #53 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of a total possible score of 15. -required moderate assistance from staff with bathing, grooming and dressing. -was at risk for pressure ulcers. -utilized oxygen therapy during the reference period. Review of Resident #53's Nursing Progress Notes indicated the Resident was using 2 LPM (LPM: amount of oxygen administered per minute) oxygen via nasal cannula on the following dates: -9/11/24 at 10:37 P.M. -9/12/24 at 2:45 P.M., and 9:18 P.M. -10/2/24 at 10:50 P.M. -10/6/24 at 9:48 P.M. -10/7/24 at 10:58 P.M. -10/8/24 at 1:49 P.M., and 3:27 P.M. -10/13/24 at 2:02 P.M. -10/23/24 at 12:37 A.M. Review of the Resident's clinical record indicated the following: -he/she was transferred to the hospital on 9/7/24 for increased fevers and generalized malaise and returned to the facility on [DATE]. -a skin check completed on 9/11/24 (upon return from the hospital) indicated he/she had bruises on both arms and a scratch on the left arm. -weekly skin checks completed for September 2024, October 2024, and November 2024 indicated no new areas of concern. Review of November 2024 Physician's orders indicated: -Oxygen as needed (PRN) to keep pulse oximetry (amount of oxygen in the blood) above 93 percent (%) as needed for shortness of breath, initiated 11/29/23 -Replace oxygen tubing every 7 days, weekly on Wednesdays, initiated 10/23/24 -Weekly Skin Screening for new areas of concern during the day shift on Tuesdays. Complete incident report for any new areas of concern, initiated 2/16/24 On 11/3/24 at 9:40 A.M., the surveyor observed Resident #53 lying in bed with oxygen being administered via nasal cannula from an oxygen concentrator which was set at 2 LPM and included a humidifier bottle. The surveyor observed a reddened open area at the base of the Resident's nose (below the nostrils) underneath the nasal cannula tubing/prongs. During an interview at the time, Resident #53 said that he/she had been having pain to the open area and he/she did not think the staff were aware of the open area. The surveyor observed Resident #53 utilizing 2 LPM humidified oxygen and visible open area at the base of the nostrils on the following: -11/4/24 at 9:56 A.M., and 12:53 P.M. -11/5/24 at 7:47 A.M. During an interview on 11/4/24 at 2:59 P.M., Certified Nurses Aide (CNA) #8 said she had given Resident #53 a shower earlier in the day. CNA #8 said she had removed the Resident's oxygen/ nasal cannula during the shower, and re-applied the oxygen, and had not noticed anything abnormal about the Resident's skin condition. CNA #8 further said if a new skin condition had been noticed, a Stop and Watch Form would be filled out, in addition to alerting the Nurse. On 11/5/24 at 7:47 A.M., the surveyor observed Resident #53 with humidified oxygen being administered via nasal cannula at 2 LPM. The Resident said his/her nasal area was sore and lifted the nasal cannula from under the nose to show the surveyor a round, open wound, approximately 1 centimeter (cm) which was red/yellow in color. The surveyor observed scabbed tissue surrounding the wound and that the nasal cannula tubing/prongs was in direct contact with the Resident's nasal wound. On 11/5/24 at 7:54 A.M., the surveyor and CNA #8 observed the area where Resident #53 said he/she was experiencing pain when the Resident lifted the nasal cannula from under his/her nostrils to show the area. CNA #8 said she did not see the area prior to now. During an interview on 11/5/24 at 7:56 A.M., Unit Manager (UM) #1 said the open area under Resident #53's nose was not identified from staff prior to today. UM #1 said she assessed the Resident's open area and thought it was irritated and caused from the use of his/her oxygen nasal cannula tubing. The surveyor relayed the previous observations of the Resident's nostril area to UM #1. UM #1 said if a Resident was on oxygen therapy, the nursing staff should be assessing the oxygen flow rate, the tubing, and the condition of the Resident's skin including the ears and nostrils daily. During an interview on 11/5/24 at 9:13 A.M., Nurse #8 said she assessed Resident #53's nose that morning after being alerted by CNA #8, and described the Resident's skin underneath the nostrils to be an open area with a wound yellow/red base and scabbed areas below the open area. Nurse #8 said the area was likely a result of the oxygen nasal cannula tubing rubbing against the Resident's skin. Nurse #8 said she did not see a progress note or treatment orders written relative to the Resident's open area, so she was going to alert the Nurse Practitioner (NP)/MD and the facility Wound Nurse for an evaluation. Nurse #8 said if a Resident utilized oxygen, the Nurse should be assessing the Resident every shift to ensure the oxygen nasal cannula tubing was an appropriate fit in order to avoid rubbing, pressure and skin breakdown. Review of the Incident/ Accident Report Form, dated 11/5/24, and completed by UM #1, indicated that Resident #53 was on continuous oxygen and that his/her nostrils were red, chaffed and have opened. During an interview on 11/5/24 at 9:36 A.M., UM #2 (Wound Nurse) said she assessed the Resident's skin and the nasal wound area was a Stage 2 Pressure Ulcer (open wound with partial thickness skin loss) which resulted from the oxygen nasal cannula tubing.

Based on observation, interview, record and policy review, the facility failed to ensure that an appropriate Hoyer pad (seating device used to assist in transferring a resident using a mechanical lift) was available to assist in transferring one Resident (#26), out of a total sample of 25 residents. Specifically, the facility failed to provide an appropriate sized Hoyer Pad to assist in transferring Resident #26 out of bed based on his/her preferences and Rehabilitation recommendations to get out of bed resulting in the Resident remaining bedbound and increasing the risk for discomfort and skin breakdown. Findings include: Review of the facility Policy titled Activities of Daily Living, effective date 11/14/16, indicated: -Each resident will receive the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing, consistent with resident's comprehensive assessment and plan of care. -The facility will provide care and services for the following activities of daily living: Mobility- Transfer and ambulation. The care and services will be based on the resident's ability as identified in MDS assessment, Rehab evaluation, nursing assessment and person-centered care plan. -Assistive Devices and Adaptive Equipment are provided as needed. -Resident abilities, personal choices and self-image are accounted for during ADLS. Resident # 26 was admitted to the facility in April 2013, and has diagnoses including Multiple Sclerosis (MS: a chronic autoimmune disorder of the central nervous system marked by numbness, weakness, loss of muscle coordination, and problems with vision, speech, and bladder control), Type 2 Diabetes (chronic condition that occurs when your body cannot regulate blood sugar levels), Cerebral Palsy (a group of disorders that affects a person's ability to move, maintain balance and posture caused by brain damage to the developing brain before birth), Chronic Obstructive Pulmonary Disease (a chronic lung disease that blocks airflow and makes it hard to breathe), 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 Morbid Obesity (when the weight is found to be more than 80 - 100 pounds above the individual's ideal body weight). Review of the Comfort Care Plan, effective 8/15/17, indicated the Resident has potential for alteration in comfort and pain and indicated the following interventions initiated on 8/15/17: -Identify, assess and document presence of pain or discomfort. -Identify activities that can exacerbate pain and medicate prior to activity as indicated. -Encourage the Resident to report occurrences of pain at onset and monitor for changes in sign and symptoms of pain. Review of the ADL (Activities of Daily Living) Care plan, effective 8/15/17, indicated the resident has an alteration in ability to provide self-care and had the following interventions: -Encourage resident to make decisions and choices during care if able, initiated 8/15/17 -Follow daily schedule as much as possible, initiated 8/15/17 -Transfers require two staff assist with a Hoyer Lift, initiated 7/4/22 Review of the High Risk for Skin Breakdown Care Plan, initiated 8/15/17, indicated Resident #26 was at high risk for pressure ulcer development and indicated the following: -Resident should be encouraged to get out of bed daily, initiated 8/15/17 -Encourage activity and mobility, initiated 8/15/17 -Observation of skin condition during care- report pink, red or open areas to Nurse, initiated 8/15/17 -Apply Periguard (barrier cream that helps moisture and protect the skin) with each incontinent episode, initiated 11/24/17 -Gel pressure relieving cushion while in wheelchair, initiated 9/28/23 Review of the Resident's Profile Care Plan effective 8/24/18, indicated the following: -Behaviors exhibited by Resident- none at present, initiated 8/24/18 -Resident prefers to get up later in the morning before lunch and goes to bed before supper, initiated 8/24/18 -Transfers with Hoyer Lift (mechanical device used to transfer individuals with limited mobility) - Large Hoyer Sling (GREEN), initiated 7/21/21 -Decubitus Ulcer (bed sore or open area) Prevention- barrier cream to coccyx (tailbone), buttocks each shift, initiated 7/24/21 Review of the Occupational Therapy (OT) Discharge Summary, dated 2/11/24, indicated the following discharge recommendation: -Staff to assist the Resident with Hoyer transfer into the gerichair (specialized wheelchair) daily for at least one meal per day Review of Resident #26's MDS Assessment, dated 8/15/24, indicated: -The Resident was able to make themselves understood and understands others -He/she was cognitively intact as evidenced by a BIMS score of 13 out of a total possible 15. -Had range of motion impairment affecting bilateral (both) lower extremities. -Required total assistance from staff for transfers out of bed, toileting, showering, dressing, personal hygiene, and rolling side to side -Was frequently incontinent of bladder and bowel function. -Was at risk for pressure ulcer development. -Had no rejections of care, refusals or change in behaviors. Review of the Resident's clinical record from 9/6/24 -11/6/24, indicated that he/she did not exhibit any behaviors including refusal of care. During an interview on 11/3/24 at 9:55 A.M., Resident #26 said that he/she has not been out of bed in at least a week because the staff had not been able to find a Hoyer pad that lifts him/her out of the bed and that he/she would like to get out of the bed. The surveyor observed Resident #26 lying in bed on: -11/4/24 at 8:11 A.M. -11/4/24 at 9:58 A.M. -11/4/24 at 4:15 P.M. On 11/4/24 at 8:43 A.M., the surveyor observed Resident #26 lying in bed. The surveyor observed the Nurse Practitioner (NP) entering Resident #26's room, and the Resident said that he/she had buttocks pain. The NP asked the Resident if he/she was getting out of bed daily, and the Resident said that he/she had not been out of bed because the staff did not have the Hoyer pad and that he/she would like to get out of the bed. On 11/4/24 at 12:55 P.M., the surveyor observed Resident #26 lying on his/her back in bed with the head of the bed elevated. During an interview at the time, Resident #26 said that he/she was not getting out of bed today because the CNA said a Hoyer pad was not available. The Resident said the Hoyer pad he/she needed was being used by another resident, and that he/she would like to get out of bed if the facility staff were able to locate a Hoyer pad. Resident #26 said a staff member had taken the Hoyer pad out of his/her room a while ago. Resident #26 described the Hoyer pad as gray with a yellow stripe down the back. Resident #26 further said that Hoyer pad color was the only one that could be used for him/her, and he/she had not been out of bed for about one and a half weeks because there had not been the appropriate Hoyer pad available. The surveyor observed a sign on the Resident's wall, beside the bed, from OT which indicated the following: Resident was to be out of bed three to five times (3-5) per week for two to three (2-3) hours to get stronger and prevent sacral ulcers (skin injury that occurs near base of the spine from extended pressure on the area). On 11/5/24 at 7:42 A.M., the surveyor observed Resident #26 lying in bed. During an interview at the time, the Resident said he/she would like to get out of bed but there was no Hoyer pad in his/her room. On 11/5/24 at 2:32 P.M., the Resident was observed lying in bed. During an interview with CNA #9 at the time, she said the Resident did not get out of bed today because there were not enough Hoyer pads for all the residents and that it was difficult to find the correct size Hoyer pad for Resident #26. CNA #9 said the Resident needed a yellow striped Hoyer pad. CNA #9 said the Resident wanted to get out of bed, but had not been able to get up for about a week and a half because his/her Hoyer pad was not available. CNA #9 said if the appropriate size Hoyer pad was found, it was often taken out of the Resident's room and used for other residents. CNA #9 said she would look in the laundry every day for the Resident's size Hoyer pad, but there were none in the laundry. CNA #9 said if there were not enough Hoyer pads, then a resident might not receive a scheduled shower or in the case of Resident #26, did not get out of bed. CNA #9 said if a Hoyer pad cannot be found, then Resident #26 cannot get out of bed, and she would notify the Nurse or the Unit Manager (UM). On 11/6/24 at 7:56 A.M., the surveyor observed the Resident lying in bed. During an interview at the time, the Resident said his/her buttocks was sore this morning. CNA #9 entered the room at the time and said that they were able to find a yellow striped Hoyer pad and would be able to get Resident #26 out of bed today. During an interview on 11/6/24 at 8:43 A.M., UM #1 said there have been issues with Hoyer pads, that they often go missing and staff need to search laundry and/or other units to find them for the residents. UM #1 said facility management was aware of the issue, had ordered additional Hoyer pads, but there were still not enough. UM #1 said she did not recall being told about missing Hoyer pads for Resident #26, that he/she was supposed to get out of bed every other day but sometimes refused and needed encouragement. UM #1 further said that if the Resident refused care, it would be documented. UM #1 said she was aware that the Resident had not been out of bed for a week and a half and thought it was due to the refusals and did not know it was because there was a lack of Hoyer pads. During an interview on 11/6/24 at 9:42 A.M., CNA #6 said there has been an issue with not having enough Hoyer pads for all the residents that required them. CNA #6 said it was a real problem when the residents have showers and need two Hoyer pads per resident (one wet/one dry). CNA #6 said that the staff must either wait until they have the right size Hoyer pads and leave people in bed, or they use the incorrect size Hoyer pads if it was safe. CNA #6 said this has been a problem for a long time and that the facility administration was aware. During an interview on 11/6/24 at 10:06 A.M., UM #1 said the issue with not having enough Hoyer pads had been a problem for a while and administration was aware. UM #1 said that her unit had 18 residents that required a mechanical lift and many of them used the same size (yellow stripe) Hoyer pad. UM #1 said there were not enough of these sized Hoyer pads, had made administration aware, and they were now looking to order more. On 11/6/24 at 12:06 P.M., the surveyor observed Resident #26 dressed and seated in a recliner chair next to his/her bed prior to lunch. During an interview at the time, the Resident said he/she was happy to be up and out of bed but was starting to feel sore on his/her buttocks again. During an interview on 11/6/24 at 12:14 P.M., CNA #5 said if the staff need a Hoyer pad for a resident, then they needed to go to the laundry room because all the Hoyer pads were shared between the three units, and it was a hit or miss on whether or not they could find the appropriate Hoyer pad. CNA #5 further said that the yellow and white Hoyer pads were the most popular size used by the residents. During an interview on 11/6/24 at 12:34 P.M., CNA #9 said the staff used red and yellow Hoyer pads more frequently than others and the unit had previously received more Hoyer pads, but that they got absorbed into the rest of the building. During an interview on 11/6/24 at 12:48 P.M., Nurse #2 said the CNAs have informed her that Hoyer pads could not be found for residents, and have had the CNAs search the laundry department, call or go from unit to unit to search for the needed Hoyer pads. Nurse #2 said the unavailability of certain sized Hoyer pads occurs on average two days a week and that she had reported this concern to administration in the past. On 11/6/24 at 2:48 P.M., the Environmental Services Director (ESD) said he had just gone out to a sister facility to get more Hoyer pads because they had one that was torn. The ESD said the Hoyer pads are inspected and replaced if torn and that staff will come to laundry and get them, or the staff will call with what they need. The ESD said he had not been made aware of the facility not having enough Hoyer pads for residents and was not aware of a certain amount of Hoyer pads needed on each unit. The ESD said that they complete rounds and audits to determine if a Hoyer pad was torn, and then they will be replaced if needed. During an interview on 11/6/24 at 2:53 P.M., Maintenance Staff Member #1 said that a Hoyer pad audit was completed every three months and that nursing would notify them if they there were not enough Hoyer pads. Maintenance Staff Member #1 was unsure of the amount of Hoyer pads in the building or how many Hoyer pads were needed. Maintenance Staff Member #1 said if a staff member had mentioned more Hoyer pads were needed, they would order them or get some from a sister facility. During an interview on 11/6/24 at 3:20 P.M., Central Supply Staff #1 said she did not routinely order Hoyer pads but if they were needed, she would be able to order them. Central Supply Staff #1 said some Hoyer pads were ordered in June 2024 and September 2024 (one of each size), and they were distributed to each unit. During an interview on 11/6/24 at 3:45 P.M., with the Administrator and Director of Nursing (DON), the Administrator said nursing staff would communicate the need for Hoyer pads to administration. The DON said there was an audit for Hoyer pads that was supposed to be completed quarterly, but the audit has not been completed. Both the Administrator and DON said they had not been made aware of a Hoyer pad shortage until 11/5/24 and had not been notified of any residents having to stay in bed because there were not enough Hoyer pads to assist the residents out of bed. The DON provided the surveyor with a blank audit tool titled Mechanical Lift Clinical Audit- Quarterly and said that the audit tool provided was supposed to be in use for the Hoyer pads but it had not been completed. Please Refer to F686

Based on observation, and interview, the facility failed to ensure unit kitchenette cleanliness and safety was maintained on two units (Meadows Unit and [NAME] Unit) out of three unit kitchenettes observed. Specifically, the facility failed to: 1. For the Meadows Unit, ensure the kitchenette refrigerator and toaster were cleaned as required, and broken and/or missing refrigerator equipment were addressed, repaired and replaced. 2. For the [NAME] Unit, ensure the toaster was cleaned as required to maintain the equipment in a clean and safe manner. Findings include: 1. On 11/3/24 at 9:36 A.M., the surveyor observed the following in the Meadows Unit kitchenette: -Refrigerator had one broken and one missing crisper drawer. -Food debris was noted on the inside shelves of the refrigerator door and on the bottom of the inside refrigerator floor. -A dirty plate discarded on the top of the refrigerator. -Toaster was thickly laden with crumbs inside. On 11/4/24 at 2:10 P.M., the surveyor observed the following in the Meadows Unit kitchenette: -Refrigerator had one broken and one missing crisper drawer. -Food debris was noted on the inside shelves of the refrigerator door and on the bottom of the inside refrigerator floor. -A dirty plate discarded on the top of the refrigerator. -Toaster thickly laden with crumbs inside. On 11/5/24 at 9:49 A.M., the surveyor and House Keeping Staff #2 observed the following in the Meadows Unit kitchenette: -Refrigerator had one broken and one missing crisper drawer. -Food debris was noted on the inside shelves of the refrigerator door and on the bottom of the inside refrigerator floor. -A dirty plate discarded on the top of the refrigerator. -Toaster thickly laden with crumbs inside. During an interview immediately following the observation, House Keeping Staff #2 said it did not appear the toaster had been cleaned recently and it should not be laden with crumbs as it posed a fire risk. House Keeping Staff #2 also said dirty dishes should be removed from the kitchenette every day. House Keeping Staff #2 said it was housekeeping's responsibility to keep surfaces in the kitchenette clean such as the floor and the counter tops, but he was unsure if he was supposed to clean the inside of the refrigerator regularly but would often wipe down if he noticed any spills or debris in the refrigerator. During an interview on 11/5/24 at 12:06 P.M., the Food Services Director (FSD) said it was the Housekeeping Staff's responsibility to keep the kitchenettes clean and this included cleaning the inside of the refrigerators regularly. The FSD said Maintenance Staff should be made aware if refrigerators are broken and in need of repair and any staff member in the facility can report a broken item. On 11/5/24 at 1:07 P.M., the surveyor and the Environmental Services Director observed the following on the Meadows Unit: -Refrigerator had one broken and one missing crisper drawer. -Food debris was noted on the inside shelves of the refrigerator door and on the bottom of the inside refrigerator floor. -A dirty plate discarded on the top of the refrigerator. During an interview directly following the observation, the Environmental Services Director (ESD) said no staff members had made him aware the refrigerator on the Meadows Unit had a broken crisper drawer or that the other crisper drawer was missing. The ESD said it was the responsibility of the Dietary Staff to maintain the cleanliness of the inside of the refrigerator and the refrigerator had debris on the door and the inside bottom of the refrigerator was dirty. The ESD further said dirty dishes should be removed from the kitchenette daily by the Dietary Staff and the dirty plate that was on top of the refrigerator should not have been left there for multiple days. During an interview on 11/6/24 at 11:28 A.M., the Administrator said the facility currently had no written protocol or checklist for who maintains and/or specifically cleans each item in the unit kitchenettes. The Administrator said his expectation is the Dietary Staff maintain the cleanliness of the inside of the unit refrigerator and any time the Dietary Staff come to stock the kitchenette they should be removing any used plates or other utensils. The Administrator further said the toasters are to be cleaned by the Housekeeping Staff and should be cleaned daily. 50563 2. On 11/3/24 at 9:48 A.M., the surveyor observed the toaster in the [NAME] Unit kitchenette to have a buildup of crumbs inside the toaster. On 11/5/24 at 9:35 A.M., the surveyor and Dietary Staff #1observed a buildup of crumbs in the toaster located in the [NAME] Unit kitchenette. During an interview at the time, Dietary Staff #1 said there was concern for cross contamination and a fire hazard due to the buildup of crumbs in the toaster.

Based on observation, interview and record review, the facility failed to ensure that one Unit (Homestead) out of three units observed, had sufficient staff members to meet the needs of the unit residents. Specifically, the facility failed to ensure: -sufficient staff were available to assist with Activity of Daily Living (ADL: basic skills needed in daily life and include eating, bathing, toileting and grooming/personal hygiene) for residents residing on the Homestead Unit. Findings include: During the initial pool process on 11/3/24, the following observations/interviews were obtained on the Homestead Unit: 1. On 11/3/24 at 11:36 A.M., a Resident (who requested to be anonymous) said sometimes when he/she rings the call bell to alert staff that he/she needed help, it could take hours for someone to assist him/her. The Resident said he/she required assistance from staff with toileting needs, that this did not occur on all shifts and the occurances vary. The Resident said it bothered him/her when the staff do not answer his/her request for assistance when ringing the call bell. 2. Resident #88 was admitted to the facility in August 2022 with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Parkinson's Disease (a movement disorder of the nervous system that worsens over time) with Dyskinesia (uncontrolled, involuntary movements of the face, arms or legs). Review of the Activities of Daily Living (ADL: basic skills needed in daily life and include eating, bathing, toileting and grooming/personal hygiene) Care Plan, initiated 8/25/22, indicated Resident #88 had decreased ability to perform ADLs due to decreased cognition and mobility. The care plan included the following intervention: -Assist to dependent of one staff for grooming (includes brushing teeth, shaving/facial hair removal, hair and nail care), initiated 1/1/23 Review of the Minimum Data Set (MDS) Assessment, dated 8/1/24, indicated Resident #88: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 4 out of 15 -was dependent on staff for personal hygiene, including grooming tasks. During an interview on 11/3/24 at 9:29 A.M., Resident #88's Representative said the Resident required total assistance from staff with ADL care. The Resident Representative said he/she liked to be neatly dressed and without facial hair daily and it appeared that today, Resident #88 was not provided assistance with facial hair removal, and did not have his/her face washed because it looked like there was residue remaining on his/her eyes from sleep. The Resident Representative said the family visits often and have voiced concerns about the Resident's dentures not being cleaned regularly, and that face/head washing did not appear to have been completed by the staff. The Resident Representative said the Resident has very dry skin on his/her head and body, and did not think the staff were applying lotion as needed. The Resident Representative also said the Resident had lost weight and required assistance from staff with meals. The surveyor observed Resident #88 was dressed and seated in a specialized wheelchair, with facial hair observed on his/her cheeks, chin and upper lip. The surveyor observed Resident #88 with facial hair remaining on his/her cheeks, upper lip and chin on the following dates/times: -11/4/24 at 8:49 A.M., -11/4/24 at 2:13 P.M., and -11/5/24 at 9:01 A.M. During an interview on 11/5/24 at 9:17 A.M., Resident #88's Representative approached the surveyor and said the facility staff on the day shift (7:00 A.M. to 3:00 P.M.) were really good but there were not enough of the staff to care for the residents on the unit. The Resident Representative further said there did not seem to be enough time for the staff to provide the care that the residents needed. During an interview on 11/5/24 at 9:58 A.M. and 10:15 A.M., Certified Nurses Aide (CNA) #8 said she was familiar with Resident #88's care. CNA #8 said facial hair removal should be offered daily and that Resident #88 preferred to have no facial hair. CNA #8 said the Resident required total assistance from staff with all personal care including grooming/personal hygiene needs and did not refuse care. CNA #8 said she was able to partially remove the Resident's hair from under his/her chin but was unable to finish because the breakfast meal arrived and she had other residents to take care of so she did not have time to finish assisting Resident #88. 3. On 11/3/24 (Sunday) from 8:18 A.M. through 9:02 A.M., the surveyor observed the following during the breakfast meal pass on the Homestead Unit: -8:18 A.M.: Meal cart arrived to the unit and was positioned at the nursing station. Two Nurses were observed at the medication carts and no staff were observed to assist with passing the meal trays. -8:36 A.M.: (18 minutes after the meal cart arrived on the unit) one CNA began passing the breakfast trays in the Unit Dining room where 17 residents were observed seated at various tables. No other staff were observed to be assisting with meal pass at this itme. -8:45 A.M.: (27 minutes later) A second CNA began assisting with the breakfast meal pass. Serveral Residents were without their breakfast meal and one Resident was observed asking for his/her meal. -8:53 A.M.: (35 minutes later) Several other staff members began to assist with meal pass at this time. -9:02 A.M.: (44 minutes later) the Breakfast meal was served to all residents. On 11/4/24 from 8:15 A.M. through 9:17 A.M., the surveyor observed the following during the breakfast meal tray pass on the Homestead Unit: -Corporate Clinical Staff, the Unit Manager (UM), one CNA and Director of Social Services were observed to assist with the meal pass in the Unit Dining room. During the breakfast meal pass, one Resident asked the surveyor who all the new people on the unit were today assisting with the breakfast meal. During an interview on 11/5/24 at 12:14 P.M., Nurse #11, who was a regular facility staff said the Homestead Unit CNAs, the Unit Manager (UM) and the Activities staff typically assist with resident meal pass. Nurse #11 said the UM worked Monday through Friday and was often on-call during the weekends to cover shifts. Nurse #11 said that she had worked on a Dementia Special Care Unit (DSCU) previously, that there were many residents on the Homestead Unit with high acuity (intensity or severity of resident care needs) and thought there was not enough staff to assist with the care the residents needed. Nurse #11 said the Homestead Unit was supposed to have five CNAs on the 7:00 A.M. to 3:00 P.M. shift and several times when she works, they have four CNAs. Nurse #11 said the 3:00 P.M. to 11:00 P.M. shift should have four CNAs and frequently they have three CNAs. Nurse #11 said she recognized the concerns with the residents meal distributation and that there should be enough staff to assist with meal passing so that residents are served/assisted with the meals at the same time. Nurse #11 said the staff observed assisting with meal pass during the survey do not typically assist with the meal pass.

Based on record review and interview, the facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team (IDT), and included the Resident and/or Resident's Representative for three Residents (#17, #92, and #88) out of a total sample of 25 residents. Specifically, facility failed to provide evidence that: 1. Resident #17 and/or his/her Representative were invited and attended/did not attend two separate care plan meetings held for the Resident. 2. Resident #92's care plan was reviewed and revised by the IDT following one Resident Assessment completed. 3. Resident #88's care plan was reviewed and revised by the IDT following two separate Resident Assessments completed. Findings include: Review of the facility's policy titled Care Planning, dated 10/1/10 and revised 10/28/22, indicated the following: -A letter will be sent to each resident or resident representative inviting them to the care plan meeting. -Each discipline reviews the overall plan and any concerns prior to the care plan meeting and completes their section of the Care Plan UDA (user defined assessment). -The Care Plan Coordinator (Social Worker) oversees the meeting. -Unit managers, Activities Staff, Dietary, Certified Nurses Aides (CNAs), Rehabilitation Staff as indicated. -The Care Plan Coordinator will review the Care Plan Meeting UDA for completion and document participation of IDT and resident/resident representative within the UDA. -The Care Plan Coordinator will document a summary of the meeting in the Care Conference Note section of the Care Plan Meeting UDA. 1. Resident #17 was admitted to the facility in December 2023, with diagnoses including Cerebrovascular Accident (CVA: when blood flow to a part of the brain is stopped either by a blockage or a rupture of a blood vessel). Review of Resident #17's clinical record indicated the facility held Care Plan Meetings on the following dates: -1/18/24 -4/16/24 Review of Resident #17's Care Plan Meeting Notes, dated 1/18/24 and 4/16/24, included no information relative to: -Whether the Resident and/or his/her Representative were invited to attend the meetings. -Whether the Resident and/or his/her Representative attended or did not attend the meetings. -Which members of the facility staff attended the meetings. 2. Resident #92 was admitted to the facility in May 2023, with diagnoses including Dementia (group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident #92's clinical record indicated facility staff completed a Minimum Data Set (MDS) Assessment for Resident # 92, dated 4/25/24. Further review of Resident #92's clinical record did not indicate any evidence that the Resident's care plan was reviewed and revised by the IDT following completion of the MDS Assessment. During an interview on 11/5/24 at 1:44 P.M., the Social Worker (SW) said that the Care Plan Meeting Notes for Resident #17 dated 1/18/24 and 4/16/24 were incomplete. The SW said that there was no evidence to indicate whether the Resident and/or his/her Representative were invited to attend the meetings, and whether the Resident and/or his/her Representative did or did not attend the meetings. The SW also said there was no evidence to indicate which facility staff attended the meetings to review the care plan. The SW said that participation of the Resident/Representative and facility staff in the care plan meetings was required to be documented in the Resident's clinical record, but was not documented for Resident #17. The SW also said that the IDT did not meet to review and revise Resident #92's care plan following completion of the MDS assessment dated [DATE]. The SW said that the meeting for Resident #92 did not occur and was missed due to human error. 37400 3. Resident #88 was admitted to the facility in August 2022 with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Chronic Kidney Disease Stage 3 (considered the middle stage kidney disease where there is mild to moderate damage to the kidneys, and the kidneys do not filter waste and fluid as well as they should). Review of the Resident's clinical record indicated MDS Assessments were scheduled on the following dates: -11/16/23 -2/15/24 -5/7/24 -8/1/24 Review of the Resident's Care Plan Meeting Notes indicated no documented evidence of what was discussed and/or who attended the meetings on the following dates: -11/30/23 -3/1/24 Further review of the Resident's clinical record indicated no documented evidence that any care plan meetings were held after the 5/7/24 MDS Assessment. During an interview on 11/5/24 at 1:02 P.M., the SW said once an MDS Assessment is completed, the care plan meeting would be scheduled 1-2 weeks after the completion of the MDS Assessment. The SW said the MDS Nurse would schedule the care plan meetings, the SW would assign the care plan meeting times, and the Receptionist would send the care plan meeting dates/times to the Resident/Resident responsible party. The SW said the care plan meetings are held with the interdisciplinary team regardless of whether the family/Resident attends and that each discipline would discuss changes relative to the Resident over the last quarter and then the meeting would be open discussion about other concerns. The SW said Social Services, Activities, Nursing and Dietary staff are to be present at the Resident care plan meetings. The SW said she would include a synopsis of the meeting in the care plan meeting notes and also indicate who attended the meeting. The SW further said the care plan meeting for Resident #88 was missed after the 5/7/24 MDS Assessment. The surveyor and the SW reviewed Resident #88's Care Plan Meeting Forms and the SW said there did not appear to be any care plan meeting synopsis notes or any indication of who participated in the Resident's meetings on 11/30/23 and 3/1/24.

Based on interview, and record review, the facility failed to ensure recommendations made by the facility Dietitian were followed for one Resident (#104), out of a total sample of 25 residents, who experienced a significant weight loss and was at risk for further decline. Specifically, for Resident #104, the facility failed to ensure that weekly weights were obtained when recommended by the Dietitian after the Resident experienced a significant weight loss of 13.44% in five months. Findings include: Review of the facility policy titled Nutrition Management, revised 9/30/24, indicated the following: -Review dietitian's recommendations. -Obtain orders per recommendations. -If Medical Doctor (MD) does not want to follow recommendations, document explanation in nursing note. Resident #104 was admitted to the facility in January 2024, with diagnoses of Type 2 Diabetes (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar levels), Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), muscle weakness, Dysphagia (difficulty swallowing), Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment, weight loss, decreased appetite or poor nutrition and inactivity), and muscle wasting and atrophy (deterioration of the muscles). Review of Resident #104's weights indicated the following: -4/8/24: weight - 131 pounds (lbs.) -10/1/24: weight - 113.40 lbs. (13.44% weight loss in five months). Review of the Significant Weight Change Report, dated 10/14/24, indicated the following: -Resident #104 had a significant weight loss of 13.44% and the Dietitian requested the Resident be reweighed. Review of the Dietitian's email correspondence with Unit Manager (UM) #2, dated 10/19/24, indicated the following request: -Resident #104's last weight was obtained on 10/1/24 and was 113 lbs. which was a significant weight loss from his/her previous weight of 131 lbs. -Requested a reweigh to clarify current weight. Review of the Significant Weight Change Report, dated 10/21/24, indicated the following: -Resident #104 had a significant weight loss of 13.44% and the Dietitian requested a reweigh. Review of the Dietitian Progress Note, dated 10/24/24, indicated the following: -Resident #104 had a significant loss in weight and met the criteria for malnutrition (lack of nutrients in the body). -Request weekly weights at this time. Review of the Dietitian Recommendation Sheet for Resident #104, dated 10/24/24, indicated the following: -Need current weight and recommend weekly weights at this time. -Dietitian requested a current weight and/or clarification about the significant weight loss. Review of the Dietitian's email correspondence with UM #2 and the Director of Nursing (DON), dated 10/28/24, indicated the following request: -Resident #104 needs to be weighed as he/she had lost a significant amount of weight. -Resident #104 had last been weighed on 10/1/24. -Reweigh was needed to verify weight loss. Review of the November 2024 Physician's orders indicated the following order: -Obtain weight day shift every thirty days with a start date of 10/31/24. Review of the October 2024 Medication Administration Record (MAR) indicated no documentation that a weight had been acquired on 10/31/24 as ordered and no additional documentation to explain why a weight was not acquired. During an interview on 11/5/24 at 1:30 P.M., the Dietitian said she had been asking for Resident #104 to be re-weighed weekly since it was identified Resident #104 had a significant weight loss in October 2024 and reweigh had not been done as she had recommended. The Dietitian said there was no documentation to show why the Resident had not been weighed when requested the Resident be reweighed on 10/14/24, 10/19/24, 10/21/24, 10/24/24, and 10/28/24. The Dietitian said her expectation would be once she makes a recommendation for a reweigh staff would obtain the Resident's weight within a couple of days or provide documentation to her if the Resident refused to be weighted within a couple days of the Dietitian recommendation being made. The Dietitian said she had been waiting on Resident #104's updated, current weight for a couple of weeks. During an interview on 11/5/24 at 2:09 P.M., UM #2 said she had been unable to check her email from the Dietitian for the last couple of weeks because she had to work the medication cart as the facility had Nurses call out. UM #2 said when she is pulled from her Unit Manager position to work on a medication cart there is no one who covers the tasks that need to be completed by the Unit Manager such as reviewing the Dietitian's emails. UM #2 said when the Dietitian makes a recommendation it should be implemented shortly after the Dietitian makes the recommendation. UM #2 said for Resident #104 the recommendation for weekly weights had not been implemented as of 11/5/24.

Based on observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter, for one Resident (#2) out of a total sample of 25 residents, which increased the Resident's risk for indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body). complications and resulted in a delay in treatment. Specifically, facility staff failed to: -Follow hospital discharge instructions for Resident #2 to attend a scheduled appointment with the Urologist. -Consult the Physician when Resident #2 experienced urinary leakage (complication that can occur when a urinary catheter becomes dislodged or obstructed) outside of his/her indwelling urinary catheter system when the Resident's plan of care did not contain specific instructions to manage indwelling urinary catheter leakage. -Provide timely treatment to correct indwelling urinary catheter complications when the Resident's indwelling urinary catheter was leaking and was not replaced timely by facility staff. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidelines for Proper Techniques for Urinary Catheter Maintenance, reviewed at https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html, indicated the following: -Maintain a closed drainage system. -If . leakage occurs, replace the catheter and collecting system . -Maintain unobstructed urine flow. - . it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. -If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction. Review of Resident #2's Hospital Discharge Summary, dated 9/1/24, indicated the following: -The Resident's discharge diagnoses included Dementia and Chronic Indwelling Foley Catheter. -The Resident was to be discharged from the hospital to a skilled nursing facility (SNF). -The Resident was scheduled for a follow-up appointment with the Urologist on 9/4/24 at 1:45 P.M. Resident #2 was admitted to the facility in September 2024, with diagnoses including Urinary Retention (a condition where the bladder does not empty all the way, or at all), Obstructive Uropathy (blockage in the urinary system) and Chronic Foley (type of indwelling urinary catheter) Catheter. Review of Resident #2's clinical record indicated the following active Physician orders: -Provide Foley catheter care, dated 9/1/24. -Foley privacy bag in place for bedside Foley drainage, dated 9/1/24. -Foley catheter output every shift, dated 9/1/24. -May change Foley catheter PRN (as needed) for occlusion or leakage. Change urinary catheter and drainage bag as a complete system. -Foley catheter continuous/site care/privacy bag. Site care QS (every shift). Privacy bag in place for bedside Foley drainage, dated 9/1/24. Further review of the Physician orders indicated a space to enter the Foley catheter size and retention bulb (or retention balloon - a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body) size, but both the Foley catheter size and retention bulb size spaces were left bank. Review of Resident #2's Urinary Catheter Care Plan, initiated 9/2/24, indicated: -Change catheter if closed system is interrupted and as needed to maintain patency (degree of openness to allow flow of urine). -Notify MD (Medical Doctor: Physician) of suspected catheter complications, as needed. -Refer to Urologist as needed . Review of Resident #2's Minimum Data Set (MDS) Assessment, dated 9/4/24, indicated the following: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident had an indwelling urinary catheter. -The Resident was dependent on staff for toilet hygiene. Review of Resident #2's clinical record did not indicate any evidence the Resident attended his/her scheduled Urology appointment on 9/4/24. Review of Resident #2's Nursing Progress Note, completed by Nurse #5 and dated 10/20/24 at 2:20 P.M., indicated the following: -The Resident was observed to have urine in his/her incontinence brief. -Urine in the incontinence brief was abnormal since the Resident had a Foley catheter. -There were no Physician orders for what type of Foley catheter the Resident had or needed if the catheter needed to be replaced. -Will ask supervisor for assistance on what to do next. Review of Resident #2's Nursing Progress Note, completed by Nurse #5 and dated 10/20/24 at 2:45 P.M., indicated the following: -The Weekend Supervisor came to the Unit to observe Resident #2's Foley catheter. -The Weekend Supervisor said the Foley catheter looked fine and to enter a note into the Physician Communication Book about the Resident's catheter leaking for the Physician to review the next day. -There were 200 milliliters (mL) of urine in the Foley catheter drainage bag as well as urine in the Resident's incontinence brief that same day. Review of Resident #2's Nursing Progress Note, written by Nurse #10 and dated 10/21/24 at 6:17 A.M., indicated the following: -A Certified Nurses Aide (CNA) alerted Nurse #10 to lack of urine in the Resident's Foley bag. -The Resident's Foley catheter was still leaking, and the Resident's incontinence brief was full of urine. -A note was left in the Physician Communication Book. -The Resident appeared to have discomfort in his/her genital area. Review of Resident #2's Nursing Progress Note, written by Nurse #2 and dated 10/21/24 at 8:47 A.M., indicated the Resident's Foley catheter was not draining. Further review of the Nursing Progress Note indicated Nurse #2 contacted the Physician and obtained instructions to flush the Foley catheter and to replace the Foley catheter if the catheter continued with no flow after flushing. Specific instructions were indicated in the Nursing Progress Note as follows: -Deflate the catheter balloon, advance the catheter, then reinflate the balloon. -Flush the catheter with 60 mL of normal saline (NS: sterile fluid solution). -Change the catheter with a size 16 French (Fr: unit corresponding to the outer circumference of a catheter) and 30 mL balloon if the catheter continued with no flow after flushing. Review of Resident #2's Nursing Progress Note, written by Nurse #2 and dated 10/21/24 at 12:04 P.M., indicated the following: -The Resident had roughly 200 mL of tea colored urine in his/her Foley catheter bag prior to Nurse #2 flushing the Foley catheter. -There was urine in the Resident's incontinence brief. -Nurse #2 changed the Resident's Foley catheter with a 16 Fr/30 mL balloon. -When the new Foley catheter was advanced, some urine leakage was observed. -Nurse #2 then advanced the Foley catheter further, got yellow urine return through the catheter with some sediment (particles in urine, visible to the naked eye, that can be a sign of various medical conditions including infection, kidney problems, and dehydration) and minor clotting (blood). On 11/6/24 at 8:12 A.M., the surveyor observed Resident #2 lying in bed in his/her room. The surveyor observed clear catheter tubing, extending out from under the bed covers, that connected to a urinary drainage bag. The surveyor observed that the tubing was draining clear light yellow urine. During an interview on 11/6/24 at 11:15 A.M., Nurse #5 said that if a Resident's catheter leaked, the Nurse would need to flush the catheter according to the Physician's order and that if flushing the catheter did not correct the leaking, then the Nurse would need to replace the catheter with the catheter type and size ordered by the Physician. Nurse #5 said when she observed Resident #2's urinary catheter leaking on 10/20/24, she reviewed the Resident's Physician orders, but there were no orders in place to flush the urinary catheter and there were no orders with what size urinary catheter to replace the Resident's catheter with. Nurse #5 said there were no Physicians in the facility on the weekends, so she wrote a note in the Physician Communication Book relative to the Resident's catheter leaking. Nurse #5 said that she could not do anything about the Resident's urinary catheter leaking because there were no orders in place. During an interview on 11/6/24 at 11:20 A.M., Nurse #2 said she observed the Resident with urine leakage around his/her catheter on 10/21/24. Nurse #2 said when she observed the leakage, she reviewed the Resident's Physician orders and there were no orders to flush the catheter and no order for the size of the replacement catheter. Nurse #2 said she then contacted the on-call Physician regarding Resident #2's catheter leaking because 10/21/24 occurred on a weekend. Nurse #2 said there was always a Physician on-call outside of normal weekday hours and on the weekends. Nurse #2 said she obtained orders from the on-call Physician to flush the catheter and to replace the catheter with a size 16 Fr with a 30 mL balloon if flushing the catheter did not correct the problem of urine leakage. Nurse #2 said she flushed Resident #2's Foley catheter and it continued to leak, so she replaced the catheter, per the order she obtained from the Physician. Nurse #2 said that Physician orders should have been obtained for Resident #2 relative to management of indwelling urinary catheter complications when the Resident was admitted to the facility in September 2024 and that the Resident should not have had to wait until 10/21/24 to have his/her indwelling urinary catheter replaced after it began leaking on 10/20/24. Nurse #2 said that she could not answer whether Resident #2 had been seen by a Urologist since being admitted to the facility. During an interview on 11/6/24 at 12:51 P.M., the Director of Nursing (DON) said that the facility has Physician coverage 24-hours per day, every day of the week and that if a Physician is not in the facility, one can always be contacted by phone. The DON said that Residents admitted to the facility with indwelling urinary catheters should have Physician orders with specific instructions to care for catheter associated complications, including urinary leakage, at the time they are admitted to the facility. The DON said that orders to care for urinary catheter complications should have been obtained for Resident #2 when the Resident was admitted to the facility in September 2024. The DON further said Nurse #5 should have contacted the Physician on 10/20/24 when she observed that Resident #2's Foley catheter was leaking and Resident #2's Physician orders did not indicate the process for what to do if the Resident experienced urinary catheter complications, including urinary leakage. The DON said that Nurse #5 should have called the on-call Physician and obtained instructions to replace Resident #2's urinary catheter when she observed urine leaking outside of the Resident's catheter on 10/20/24 and that the Resident should not have had to wait until the following day for orders to be obtained from the Physician by Nurse #5 so that his/her Foley catheter could be changed. The DON said that she was not sure whether Resident #2 attended his/her scheduled appointment with the Urologist on 9/4/24. During a follow-up interview on 11/6/24 at 3:40 P.M., the DON said that she did not locate any evidence in Resident #2's clinical record that the Resident attended his/her scheduled Urology appointment on 9/4/24 and that a facility staff member was in the process of contacting the Urology office to inquire whether the Resident attended the appointment. No evidence was provided to the survey team relative to whether Resident #2 attended his/her scheduled Urology appointment on 9/4/24 prior to the end of the survey period. Please refer to F726 and F880.

Based on observation, interview, record review and policy review, the facility failed to ensure that one Resident (#53) out of a total sample of 25 residents, was free from potential accidental hazards when the Resident was allowed to store an Albuterol Sulfate inhaler (aerosolized bronchodilator medication) on his/her bedside table and use the inhaler without assessment or supervision. Specifically, for Resident #53, the facility failed to ensure: -that a prescribed Albuterol Sulfate inhaler was kept in a secured medication cart and not at the Resident's bedside. -the Resident was assessed to self-administer the medication, and was aware of precautions like an increased heart rate and/or difficulty breathing that could result from the medication use or overuse. -that the inhaler was not easily accessible to the Resident and potentially other residents when it was left on Resident #53's bedside table to be administered without Physician approval and without Licensed Staff supervision. Findings include: Review of the facility policy titled Administration Procedures for All Medications, dated 9/20/13, indicated medications would be administered in a safe and effective manner. The policy also included: -check the Medication Administration Record (MAR) for the order Review of the facility policy titled Self Administration of Medications, revised 6/30/21, indicated a resident would be assessed for cognitive, physical, and visual ability to self-administer medications. The policy also included: -if the resident wishes to self administer, the Nurse, the Interdisciplinary Team (IDT) will determine the resident's ability to safely self-administer -the Self-Administration of Medications Informed Consent and Assessment Tool will be completed -ensure a Physician's order is in place -provide safe, locked storage if keeping medications at bedside -the Medication Nurse will monitor the resident's compliance and record on the MAR Resident #53 was admitted to the facility in December 2022, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD: a chronic lung disease that causes obstructed airflow from the lungs and leads to respiratory problems including difficulty breathing, shortness of breath and wheezing). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #53 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 5 out of 15. On 11/3/24 at 9:40 A.M., the surveyor observed Resident #53 lying in bed and an Albuterol inhaler was observed on a table positioned next to the Resident's bed and was easily accessible to him/her. During an interview at the time, Resident #53 said he/she self administered the Albuterol medication whenever he/she needed it. On 11/4/24 at 12:53 P.M., the surveyor observed Resident #53 seated on the edge of the bed eating lunch. The surveyor observed that the Albuterol inhaler remained on the Resident's bedside table. On 11/5/24 at 7:47 A.M., the surveyor observed the Resident lying in bed and the Albuterol inhaler remained on the his/her bedside table. On 11/5/24 at 7:54 A.M., the surveyor and Certified Nurses Aide (CNA) #8 observed Resident #53 in his/her bedroom. During an interview at the time, CNA #8 said she was unsure if the Resident was able to have the Albuterol inhaler accessible at his/her bedside. Review of Resident #53's November 2024 Physician's orders indicated the following: -Health Care Proxy (HCP: the person chosen as the healthcare decision maker when the individual is unable to do so for themself) was invoked, initiated 1/16/23 -Albuterol Sulfate 0.09 milligram (mg) per 1 actuation, 2 puffs orally as needed every 4 hours for COPD, initiated 5/27/24 Review of the November 2024 MAR indicated no documented evidence that Resident #53 was administered the Albuterol inhaler nor was there documented evidence in the clinical record that the Resident was able to self- administer the Albuterol inhaler. During an interview on 11/5/24 at 7:56 A.M., Unit Manager (UM) #1 said she did not think Resident #53 had been evaluated for self administration of the Albuterol medication. UM #1 further said leaving medication unattended at the Resident's bedside could be dangerous because the Resident could be administering the medication incorrectly or another resident on the unit could wander into the Resident's room and use the inhaler. UM #1 said if the Resident was assessed to be able to self-administer the Albuterol inhaler, it would need to be stored in a secure place where other residents could not have access to it. UM #1 said it was unclear how often Resident #53 had been taking the Albuterol medication and because he/she had memory impairment, it could put the Resident at risk for self-harm. On 11/5/24 at 9:13 A.M., the surveyor and Nurse #8 observed Resident #53 in his/her room. Resident #53 was observed lying in bed and the Albuterol inhaler remained on the bedside table. When the surveyor asked about the inhaler, Nurse #8 removed the Albuterol inhaler from the Resident's bedside table and said Resident #53 should not have the inhaler accessible to him/her because he/she would be unable to self-administer the medication safely.

Based on observation, interview, and record review, the facility failed to offer assistance in scheduling an appointment to ensure good foot health was maintained for one Resident (#78) out of a total sample of 25 residents. Specifically, for Resident #78, the facility failed to offer podiatry services to maintain good foot health when the Resident was at risk for decline in his/her foot health related to a history of Peripheral Vascular Disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and below the knee amputation (surgically cutting off a limb). Findings include: Review of the facility policy titled Consulting services, Podiatry/Dental/Optometry/Audiology, approved date 12/22/16, indicated the following: -Resident/Resident Representative are provided information about consulting services upon admission and at any time when need arrives. Resident #78 was admitted to the facility in September 2024, and had diagnoses of PVD, Sepsis (a life-threatening medical emergency that occurs when an infection triggers the body's immune system to damage its own organs and tissues), Osteomyelitis (inflammation of bone or bone marrow due to infection), and had a recent right below knee amputation. During an observation and interview on 11/3/24, at 9:51 A.M., the surveyor observed Resident #78 lying in bed. Resident #78 said he/she was worried about a reddened area on his/her lower left leg. The surveyor observed the Resident's lower left leg which had a small reddened area. The surveyor also observed the Resident's left foot to be dry on the sole, with large patches of skin flaking off, his/her toenails were very long extending beyond the tip of the toe, hardened, and dirty under the nails. Resident #78 said he/she had not been offered podiatry services since his/her admission to the facility. Resident #78 said he/she was concerned about maintaining good foot health because he/she did not want to have his/her left leg amputated like his/her right leg had been. Review of Resident #78's medical record indicated no documentation the Resident had been offered podiatry services at the time of his/her admission. During an observation and interview on 11/5/24 at 10:02 A.M., the surveyor and Nurse #4 observed Resident #78 was lying in bed. Nurse #4 observed Resident #78's foot and said Resident #78's toenails were long and hardened and needed to be trimmed. Nurse #4 said for Residents with a history of PVD, good foot health was important and Resident #78 should have been offered podiatry services. During an interview on 11/5/24 at 12:46 P.M., the Director of Admissions said Resident #78 should have been offered podiatry services at the time of his/her admission to the facility and she could find no documented evidence that podiatry services had been offered to him/her.

Based on observation, interview, record and policy review, the facility failed to ensure one Resident (#88) out of a total sample of 25 sampled residents, received care and services consistent with professional standards of practice relative to completing a timely assessment and obtaining treatment orders for an identified skin issue. Specifically, the facility identified Resident #88 had a quarter sized fluid filled blister on his/her right lower leg and failed to assess the cause of the blister, notify the Physician and Responsible Party timely and obtain treatment orders to assist in healing, increasing the risk of potential further skin decline and infection. Findings include: Review of the facility policy titled Skin Integrity Management, revised November 2023, indicated based on the comprehensive assessment of the resident, the facility must ensure that the resident receives care, consistent with professional standards of practice to prevent pressure ulcer or injury and does not develop pressure ulcer or injury unless the individual's clinical condition demonstrates that they were unavoidable. The policy also included the following: -Purpose: > maintain the integrity of the resident's skin, the largest organ in the body which plays a significant factor in overall health, >minimize the risks and prevent the occurrence of skin breakdown through initial comprehensive and regular skin assessments >develop and implement a comprehensive, person-centered plan of care aimed at maintaining skin integrity, prompt identification, intervention and management of any skin breakdown on accepted clinical standards of practice -Procedure: >when skin breakdown is identified, report this timely to Medical Practitioner and resident representative as required by policy. Complete an Incident Report for newly developed pressure ulcer/injury. >obtain wound treatment order, document in Physician's Order and ETAR (electronic treatment administration record) >obtain a referral to Wound Consultant who will partner with facility Nurse in conducting weekly wound assessment and treatment review. Resident, if by their choice can be seen by outside wound, vascular, or surgical consultant for treatment >every treatment recommendation will be reviewed timely with the resident's primary Medical Practitioner and an order will be entered in the resident's electronic medical record >referral to Registered Dietician for nutritional interventions to promote wound healing >referral to Rehabilitation Services for treatment modalities that they can provide to aid wound healing >monitor all medical conditions that may affect wound healing . >conduct weekly wound rounds- complete measurements of each wound: L x W x D (length of wound by width of wound by depth of wound), description of wound med, description of wound edges and surrounding skin, type and amount of exudates (wound drainage), type of wound dressing, signs of infection and presence or absence of pain >document findings of the weekly wound assessments in the resident's electronic medical record: Weekly Skin Condition Report >develop a comprehensive plan of care addressing the management and treatment of the resident's wound, towards the goal of healing the wound, managing pain from the presence and treatment of the wound and preventing infection >use wound care and treatment products consistent with the company's protocol. Document each prescribed wound treatment in the resident's electronic health record- ETAR >ensure resident/family participation by providing education related to prevention and treatment while a resident >ensure that resident or resident representative is made aware of the progress or non-progress of wound healing, changes to treatment and management of wound as it occurs Resident #88 was admitted to the facility in August 2022, with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Chronic Kidney Disease Stage 3 (considered the middle stage kidney disease where there is mild to moderate damage to the kidneys, and the kidneys do not filter waste and fluid as well as they should), Anemia (condition that develops when the blood produces a lower than normal amount of red blood cells and/or hemoglobin [protein in red blood cells that carries oxygen from the lungs to other organs/tissues] to carry oxygen to the body's tissues), and abnormal posture. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the following for Resident #88: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 4 out of 15 -had no range of motion deficits -utilized a wheelchair -was dependent on the assistance of staff with toileting, personal hygiene, bathing, dressing, turning, repositioning and transfers -was at risk for pressure ulcers and did not have pressure ulcers Review of the Activities of Daily Living (ADLs: basic skills needed in regular daily life including ambulating, dressing, bathing, eating) Care Plan, initiated 8/25/22, indicated Resident #88 had an alteration in ability to provide self-care due to cognitive deficits, decreased activity tolerance/endurance and decreased mobility. The plan of care included the following interventions: -be alert to non-verbal cues or problems, initiated 8/25/22 -check skin during care and report any abnormalities/issues to nursing/Medical Doctor (MD), initiated 8/25/22 -assistance to dependent of 1 staff with bathing, dressing, grooming, initiated 1/1/23 -assistance to dependent on 2 staff with transfers, initiated 1/1/23 -assistance of 1-2 staff with bed mobility and positioning, initiated 1/1/23 Review of the Nursing Progress Note dated 10/31/24, indicated the Certified Nurses Aide (CNA) notified the Nurse at approximately 9:00 P.M. that Resident #88 had a blister on his/her leg. The Nurse assessed the area and indicated it was located on the Resident's right lower inner leg and was an intact fluid filled blister that measured 1 inch in diameter. Nursing Progress Note indicated a protective dressing was applied to the area. On 11/4/24 at 2:13 P.M., the surveyor observed Resident #88 was awake, dressed, and lying in a low positioned bed. The surveyor observed the Resident was wearing regular socks on his/her feet which were resting on the mattress. During an interview on 11/4/24 at 2:31 P.M., CNA #8 said she was very familiar with Resident #88. CNA #8 said the Resident currently had a blister on his/her inner leg, was not sure how the blister appeared and that it was raised and fluid filled. CNA #8 said she notified the Nurse about the Resident's blister and was not aware of any treatments/interventions that were currently in place. On 11/4/24 at 3:00 P.M., the surveyor, CNA #8 and Nurse #1 observed the Resident's right lower leg. Resident #88 was observed lying in bed and was awake. Nurse #1 put on gloves, instructed Resident #88 that she was going to observe his/her right leg and proceeded to lift the Resident's right pant leg and exposed a raised fluid filled blister located on his/her inner right calf approximately the size of quarter. The surveyor did not observe any redness around the fluid filled blister. During an interview at the time, Nurse #1 said the Resident's blister was previously identified by another Nurse and that she was just made aware of it today. Nurse #1 said she notified Unit Manger (UM) #1, an incident report was being completed and that the Physician and Resident's Representative were going to be notified. Nurse #1 said there were currently no treatment orders for the blister. During an interview on 11/4/24 at 3:07 P.M., UM #1 said she was completing an incident report about the Resident's blister today because she was just notified of the area. UM #1 said when a skin area was identified, the Nurse would complete an incident report, update the wound provider, and the Physician and the Resident Representative would also be notified. UM #1 said when staff notified her about the Resident's blister today, she assessed the area. UM #1 said it was a fluid filled blister about the size of a quarter which she thought could be from friction. UM #1 said the Physician was going to be notified and treatment orders for the area requested. Review of the Resident's clinical record indicated no documented evidence that the Physician and Resident Representative were notified prior to 11/4/24 about the blister on the Resident's leg. Further review of the clinical record indicated there were no treatment orders for the area until 11/4/24 (4 days after the 10/31/24 notification) when the Physician was notified, and a treatment order was obtained. Review of the November 2024 Physician's orders included the following that was initiated on 11/4/24: -Skin Prep twice daily, apply skin prep to the Resident's blister on right lower inner calf twice daily. -Do not apply if the blister opens. Change order. During an interview on 11/6/24 at 3:30 P.M., UM #2, who was also the facility Wound Nurse, said she evaluated Resident #88's blister on 11/5/24. UM #2 said the blister was located on the Resident's right calf, was quarter size and was in an odd location for a blister because the Resident had no edema (swelling). UM #2 said an order was obtained from the Physician to apply Skin Prep. UM #2 said she was not notified of the Resident's blister until 11/5/24, which was unfortunate because had she been notified, she would have assessed the area and implemented interventions.

Based on observation, interview and record review, the facility failed to provide assistance with personal hygiene for two Residents (#88 and #43) out of a total sample of 25 residents. Specifically, the facility failed to ensure Resident #88 and #43 were offered and/or provided with grooming assistance when both Residents required the assistance of staff for grooming activities. Findings include: 1. Resident #88 was admitted to the facility in August 2022, with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Parkinson's Disease (a progressive degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination) with Dyskinesia (uncontrolled, involuntary movements of the face, arms or legs). Review of the Activities of Daily Living (ADL: basic skills needed in daily life and include eating, bathing, toileting and grooming/personal hygiene) Care Plan, initiated 8/25/22, indicated Resident #88 had decreased ability to perform ADLs due to decreased cognition and mobility. The ADL care plan included the following intervention: -Assist to dependent of one staff for grooming (includes brushing teeth, shaving, hair and nail care), initiated 1/1/23 Review of the Minimum Data Set (MDS) Assessment, dated 8/1/24, indicated Resident #88: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 4 out of 15 -was dependent on staff for personal hygiene, including grooming tasks Review of the October 2024 and November 2024 Medication Administration Records (MARs) indicated the following Resident Behavior Monitoring which was documented every shift (7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M.) -No behaviors were documented from 10/1/24 through 10/31/24 -No behaviors were documented from 11/1/24 through 11/4/24 On 11/3/24 at 9:29 A.M., the surveyor observed Resident #88 dressed with shoes on and seated in a specialized wheelchair. The surveyor observed that the Resident had facial hair on his/her cheeks, chin and upper lip. During an interview with Resident #88's Representative, who was present at the time, he/she said Resident #88 was dependent on the staff for care including grooming needs and preferred to have the hair removed from his/her face. The Resident Representative said the Resident was very particular about how he/she looked prior to admission and would always have neat matching clothes and remove facial hair daily. On 11/4/24 at 8:49 A.M., the surveyor observed the Resident was seated in a specialized wheelchair in the unit dining room during breakfast. The surveyor observed Resident #88 was dressed, but facial hair remained on his/her cheeks, upper lip and chin. On 11/4/24 at 2:13 P.M., the surveyor observed that Resident #88 was awake, dressed and lying slightly upright in bed. The surveyor observed that hair remained on the Resident's cheeks, upper lip and chin. During an interview on 11/4/24 at 2:31 P.M., Certified Nurses Aide (CNA) #8 said she took care of Resident #88 today and was very familiar with his/her care. CNA #8 said the Resident was dependent on staff for ADL care. On 11/5/24 at 9:01 A.M., the surveyor observed the Resident dressed and seated in a specialized wheelchair during breakfast. The surveyor observed that the Resident remained with facial hair on his/her cheeks, upper lip and chin. During an interview on 11/5/24 at 9:17 A.M., Resident #88's Representative approached the surveyor and said the facility staff on the day shift (7:00 A.M. to 3:00 P.M.) are really good but there were not enough of them to care for the Residents on the unit. The Resident Representative further said there did not seem to be enough time for the staff to provide the care that the Residents needed. During an interview on 11/5/24 at 9:58 A.M. and 10:15 A.M., CNA #8 said she had worked with Resident #88 since 11/4/24. CNA #8 said facial hair removal should be offered daily and that Resident #88 preferred to have no facial hair. CNA #8 said said the Resident required total assistance from staff with all personal care including grooming/personal hygiene needs and does not refuse care. CNA #8 said she was able to partially remove the Resident's hair from under his/her chin but was unable to finish because the breakfast meal arrived and then she had other Residents to take care of so she did not have time to finish assisting Resident #88. During an interview on 11/5/24 at 10:15 A.M., Unit Manager (UM) #1 said Resident #88 should be provided facial hair removal daily as per his/her preference. UM #1 said she was aware that the Resident's family requested to have facial hair removed daily and and that this would be completed today. 2. Resident #43 was admitted to the facility in September 2020 with diagnoses including Dementia. Review of the ADL Care Plan, initiated 10/23/20, indicated Resident #43 had decreased ability to perform ADLs due to cognitive deficits, decreased activity tolerance and decreased mobility. The plan of care included the following intervention: -assistance to dependent of one staff for grooming, initiated 11/4/24 Review of the MDS Assessment, dated 9/12/24, indicated Resident #43 had: -severe cognitive impairment as evidenced by Brief Interview of Mental Status (BIMS) score of 3 out of 15 -was dependent on staff for personal hygiene Review of the October 2024 and November 2024 MARs indicated the following Resident Behavior Monitoring which was documented every shift: -No refusals of care behaviors were documented from 10/1/24 through 10/31/24 -No refusals of care behaviors were documented from 11/1/24 through 11/4/24 On 11/3/24 at 1:47 P.M., the surveyor observed Resident #43 dressed and seated in a specialized wheelchair. The surveyor observed the Resident had long facial hair on his/her chin and cheeks. On 11/4/24 at 8:04 A.M., the surveyor observed the Resident was dressed and seated in a specialized wheelchair. The surveyor observed that long facial hair remained on the Resident's chin and cheeks. During an interview on 11/4/24 at 1:11 P.M., CNA #10 said Resident #43 was able to do some of his/her facial hair removal with an electric razor, and then staff assist him/her to finish. CNA #10 said the Resident was receptive to staff assisting him/her with facial hair removal. CNA #10 said he tried to remove the Resident's facial hair everyday or every other day. During an interview on 11/4/24 at 1:19 P.M., CNA #8 said she regularly assisted with Resident #43's care. CNA #8 said the staff set the Resident up with the electric razor and he/she was able to use it to remove some of his/her facial hair but the staff had to assist with finishing. CNA #8 said Resident #43 was receptive to staff assistance with care and did have days when he/she required more assistance from staff with the task. On 11/5/24 at 7:34 A.M., the surveyor observed Resident #43 dressed and seated in a wheelchair in the dining room. The surveyor observed that long facial hair remained on the Resident's chin and cheeks. During an interview on 11/5/24 at 11:30 A.M., the Resident's Representative said Resident #43 preferred to have no facial hair and used to remove his/her facial hair daily prior to admission to the facility. During an interview on 11/5/24 at 10:10 A.M., UM #1 said Residents should have their facial hair removed daily or at least every other day. UM #1 said Resident #43 was receptive to care and liked to have his/her facial hair removed. UM #1 said it appeared that Resident#43 had not had his/her facial hair removed for a few days.

Based on record review and interview, the facility failed to develop a baseline care plan for one Resident (#73) out of a sample of three closed resident records reviewed. Specifically, the facility failed to develop a baseline care plan for Resident #73 within 48 hours of admission to the facility, when a comprehensive care plan was not developed in place of a baseline care plan, to provide effective and person-centered care of the Resident. Findings include: Resident #73 was admitted to the facility in May 2024, with diagnoses including Unspecified Fall and Displaced (out of alignment or in several pieces) Intertrochanteric (top of the thigh bone, where the hip and thigh meet) Fracture (cracking or breaking) of Right Femur (thigh bone). Review of Resident #73's Baseline Admission Care Plan, dated 5/26/24, indicated the following: -The Resident's date of birth. -The Resident's date of admission to the facility. -The Resident's medical history. -The Resident's Physician's name and contact information. Further review of the Baseline Care Plan indicated that no other sections of the Baseline Care Plan had been completed and included no initial goals for the Resident. Review of Resident #73's clinical record did not include any evidence that a Comprehensive Care Plan had been developed in place of a Baseline Care Plan. Further review of Resident #73's clinical record included a Nursing Progress Note that indicated the Resident was transferred to the hospital on 5/29/24 (more than 48 hours following the Resident's admission to the facility). During an interview on 11/6/24 at 8:02 A.M., the Social Worker (SW) said that nursing staff were responsible to complete Baseline Care Plans when Residents were admitted to the facility, and the SW was responsible to set up a Baseline Care Plan meeting for the Resident within 72 hours of admission. The SW said that she would review Resident #73's record, and that the Baseline Care Plan probably did not get completed because the Resident was at the facility for a short time. During a follow-up interview on 11/6/24 at 8:16 A.M., the SW said that the required Baseline Care Plan was not completed for Resident #73 following the Resident's admission to the facility.

Based on record review and interview, the facility failed to provide required documentation to the receiving hospital for one Resident (#73) of one applicable closed record, out of a sample of three closed records, when Resident #73's medical needs could not be met at the facility, and he/she required transfer to the hospital. Specifically, the facility failed to provide evidence that the required transfer documentation to ensure a safe and effective transition of care was provided to the receiving hospital when Resident #73 was transferred to the hospital from the facility. Findings include: Resident #73 was admitted to the facility in May 2024. Review of Resident #73's Nursing Progress Note, dated 5/29/24, indicated the following: -The Resident complained of discomfort and multiple episodes of non-productive coughing. -A new order for Mucinex was obtained and scheduled Acetaminophen had been administered as ordered. -The Resident's temperature was 103.1 degrees axillary (under the arm). -The on-call Physician was notified and gave an order to transfer the Resident to the hospital. Review of Resident #73's clinical record did not include any evidence that the following information was provided to the receiving hospital when the Resident was transferred on 5/29/24: -Contact information of the Practitioner (Physician) responsible for the care of the Resident. -Resident Representative information including contact information. -Advanced Directive information. -All special instructions or precautions for ongoing care, as appropriate. -Comprehensive care plan goals. -All other necessary information, . as applicable, to ensure a safe and effective transition of care. During an interview on 11/6/24 at 8:16 A.M., the Social Worker (SW) said that when a Resident was transferred to the hospital, facility staff were required to complete a SBAR (situation, background, assessment, recommendation) assessment which included all of the information required to be provided to the receiving hospital. The SW said that she reviewed Resident #73's clinical record and that facility staff did not complete an SBAR for Resident #73 when he/she was transferred to the hospital on 5/29/24. The SW further said there was no evidence the facility provided the required information to the receiving hospital when Resident #73 was transferred from the facility on 5/29/24. Please refer to F655.

Based on observation, interview, record and policy review, the facility failed to ensure that two Residents (#99 and #43) out of a total sample of 25 residents, were free of physical restraints, putting the Residents at potential risk of accidental falls and injury. Specifically, the facility failed to: 1. For Resident #99, assess for the use of bilateral half middle (placement in the middle of the bed) side rails (side rails: adjustable position, rigid bars that attach to the sides of a bed, ranging in sizes from full to one-half, one-quarter, or one-eighth lengths) while in bed which prevented the Resident from exiting the bed, and were not the quarter side rails as ordered by the Physician. 2. For Resident #43, assess the use of wedge cushions (a triangular shaped cushion used to aid in positioning for health issues or comfort) placement on the bed and one side of the Resident's bed positioned against the wall being used as potential restraints. Findings include: Review of the facility policy titled Restraint Management, revised 12/16/16, indicated the interdisciplinary team will determine the necessity to use a physical restraint on a resident as part of a person-centered approach to treat a medical symptom and at the same time promote a safe environment for the resident and the highest practicable level of physical functioning and psychosocial well-being. The policy also included the following: -when a resident's condition necessitates consideration for a restraint, alternative interventions must be attempted and fully documented in the Nursing Notes and in the Care Plan -when the appropriate alternatives outlined in the Care Plan are unsuccessful, the Restraint Assessment will be completed by the Licensed Nurse, prior to initiating the use of a restraint -The resident or resident representative will be included in the decision process. They will be fully informed of: >how the use of the restraint will treat the resident's medical symptoms and assist in attaining the highest practicable level of physical and psychological well-being >potential negative outcomes of restraint usage >alternatives to restraint use -if the resident or resident representative agrees to the use of the restraints, written authorization of Physical Restraint Consent is placed in the clinical record . -all restraints will have a specific Physician's order to include: >type of device >medical diagnosis/symptom (physical or physiological need) >how often the device is to be used >frequency of checking and removing (minimum of every 2 hours) -no restraint will be applied . unless there is a Physician's order -medical symptoms that would warrant the use of restraints are reflected in comprehensive assessment and care planning Review of the facility policy titled Side Rails, revised 10/17/17, indicated the facility provided an optimum safe sleeping environment for the resident while taking into individual residents' needs for side rails. The policy also included the following: -side rails may be an enabler, a restraint, or both, and require an assessment of the resident's mobility and cognitive functioning to determine the category of use and determine need. -side rails, even quarter rails, can be considered a restraint if side rails are raised and their use meets the criteria for the restraint as outlined in the practice guidelines. 1. Resident #99 was admitted to the facility in May 2024, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), muscle weakness and abnormal gait and mobility. Review of the Minimum Data Set (MDS) Assessment, dated 8/8/24, indicated Resident #99: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 6 out of 15. -had no range of motion deficits and did not utilize physical restraints. Review of the Side Rail Informed Consent form, dated and signed by the Resident's Representative on 5/14/24, indicated consent was given for the use of bilateral (both left and right) upper (placement at the top of the bed) quarter side rails. Review of the Nursing Quarterly Assessment, dated 8/8/24, indicated Resident #99: -was able to use to side rail to position when in bed and for balance stability when getting in/out of bed or coming to a seated position -had slightly limited mobility -was chair bound -had a low bed in place -requested or required side rails -had severe cognitive impairment -was able to request staff assistance and utilize the call bell -is assisted by staff in/out of bed (did not indicate he/she was dependent) -the side rails did not prevent ingress (entering)/egress (exiting) out of bed and were not considered a restraint -the assessment indicated the use of quarter upper right and left side rails. Review of the Falls Care Plan, initiated 5/16/24, indicated the following interventions: -educate resident/family on fall prevention strategies, initiated 5/16/24 -gait belt for all transfers, initiated 5/16/24 -keep call bell within reach, initiated 5/16/24 -mat at bedside, initiated 9/21/24 Review of the Activities of Daily Living (ADL) Care Plan, initiated 5/16/24, indicated the following intervention: -assist of one staff with transfers, initiated 11/13/24 (provided to the surveyor after survey exit) Review of the November 2024 Physician's orders included the following: -quarter side rails on both sides of the bed, initiated 5/14/24 -HCP invoked on 10/15/24 On 11/4/24 at 10:32 A.M., the surveyor observed Resident #99 lying in bed on his/her left side facing the door to enter the room. The surveyor observed that middle half side rails were in place on both sides of the Resident's bed and a mat was observed on the floor on the right side of the bed. On 11/4/24 at 11:23 A.M., the surveyor heard Resident #99 yelling for help from his/her room. The surveyor knocked and entered the room and observed the Resident was lying on his/her side in bed facing the doorway, the bilateral half middle side rails were up and a mat was on the right side of the bed on the floor. The Resident said he/she wanted to get out of bed but could not because of these things indicating the middle side rail positioned in front of his/her body. The surveyor initiated the call bell and Nurse #2 entered the room shortly after. Resident #99 repeated with Nurse #2 present, that he/she wanted to get out of bed and was unable to do so due to the middle side rail. During an interview at the time, Nurse #2 said the Unit Manager (UM) assesses Residents for the use of side rails, that the side rails would be assessed routinely and care planned. Nurse #2 further said that if Resident #99 was in bed, unless the side rails were assessed and ordered to be up, they should be in the down position. On 11/4/24 at 2:09 P.M., the surveyor observed the Resident lying upright in bed with eyes closed, and with bilateral half middle side rails in the up position. The surveyor observed a floor mat on the right side of the Resident's bed. On 11/4/24 at 2:42 P.M., the Resident was observed seated at the edge of the bed with a visitor. The surveyor observed that the side rail on the right side was in the down position at the time. On 11/5/24 at 5:48 A.M., the surveyor observed Resident #99 lying in bed his/her eyes closed, and the bed in a low position. The surveyor observed that the head of the bed was slightly elevated, the bilateral half middle side rails were in the up position and a floor mat was on the right side of the bed. On 11/5/24 at 5:49 A.M., the surveyor and Certified Nurses Aide (CNA) #13 observed Resident #99 in bed in his/her room. During an interview at the time, CNA #13 said Resident #99 required assistance of one staff with transfers on most occasions. CNA #13 said the Resident used the side rails to assist him/her with repositioning in bed and when transferring out of bed. CNA #13 said the half middle side rails and the floor mat were in place to keep the Resident safe and that the half middle side rails were up to keep him/her in bed. CNA #13 said the Resident would not be able to get out of bed with the half middle side rails in place. On 11/5/24 at 7:44 A.M., the surveyor and UM #1 observed Resident #99 in bed in his/her room. Resident #99 remained lying in a low positioned bed with his/her eyes closed with a floor mat on the right side of the bed and bilateral half middle side rails in the up position. During an interview at the time, UM #1 said Resident #99 currently had half middle side rails in place on both sides and should have quarter side rails up which would be positioned at the top of the bed as ordered by the Physician. UM #1 said she was not sure why the side rails are positioned in the middle part of the bed, that she was not familiar with these types of side rails and that the ones she was familiar with were positioned up near the head of the bed. UM #1 said the Resident had a fall out of bed a few months ago, that if side rails were to be used, the use would be routinely assessed, a consent would be obtained, a Physicians' order in place for their use and the side rail use would be care planned. The surveyor relayed the previous observation from 11/4/24 when Resident #99 was yelling out for help to get out of bed and he/she had the bilateral half middle side rails in place. UM #1 said the side rails should not be used to keep the Resident in bed, that he/she should not have had the half middle side rails in place, and that this could be considered a restraint. 2. Resident #43 was admitted to the facility in September 2020, with diagnoses including Dementia and falls history. Review of the MDS Assessment, dated 9/12/24, indicated Resident #43: -had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15. -had no range of motion deficits. -did not utilize restraints during the assessment reference period. Review of the Falls Care Plan, initiated 9/21/20, indicated the Resident was at risk for falls related to change in mobility, unsafe behaviors, cognition and tendency to crawl out of lower bed and onto the floor mattress. The Care Plan included the following interventions: -call bell within reach, initiated 9/21/20 -frequently used items within reach to prevent bending or reaching, initiated 3/22/22 -concave mattress (scoop mattress) on bed for spatial boundaries, initiated 11/3/22 -left side of bed against the wall with the floor mat to the right side of the bed, initiated 11/3/23 -encourage Resident to remain in common area when not in bed, initiated 11/28/23 -Resident to be out of bed before 8:00 A.M., initiated 3/6/24 -11:00 P.M. to 7:00 A.M. shift to get the Resident up in the morning, initiated 3/21/24 Review of the Resident's clinical record indicated that he/she experienced falls out of bed or wheelchair in his/her room on: -2/24/24 -2/29/24 -3/21/24 -6/8/24 Review of the Activities of Daily Living (ADL: basic skills needed in regular daily life including ambulating, dressing, bathing, eating) Care Plan, initiated 10/23/20, indicated the Resident required assistance of one staff with bed mobility, transfers and positioning. On 11/3/24 at 1:44 P.M., the surveyor observed that the Resident's bed was positioned with the left side against the wall. The surveyor observed two triangular wedges on top of the Resident's bureau and that the Resident was not in the room at the time. During an interview on 11/4/24 at 1:11 P.M., CNA #10 said Resident #43 required assistance of one staff with transfers and has his/her left side of the bed positioned against the wall because the Resident was at risk for falls. During an interview on 11/4/24 at 1:19 P.M., CNA #8 said that the Resident required assistance of one staff with transfers and toileting. CNA #8 further said that the Resident's left side of the bed was positioned against the wall and a mattress was placed on the floor on the right side of the bed because he/she was a fall risk. CNA #8 said the Resident also had wedge cushions that were placed underneath the fitted sheet on the right side of the bed (the side not positioned against the wall) so that he/she stayed in bed. On 11/5/24 at 5:50 A.M., the surveyor and CNA #13 observed Resident #43 in bed in his/her room. Resident #43 was lying in a low positioned bed with eyes closed. The surveyor observed that the left side of the bed was against the wall and there was a mat on the floor on the right side of the bed. The surveyor observed two triangular shaped wedge cushions were under the fitted sheet of the bed on the right side of the bed (opposite the bedroom wall). During an interview at the time, CNA #13 said Resident #43 has had some falls out of bed and the wedge cushions were in place to keep him/her in bed. CNA #13 further said the Resident was unable to get out of the bed with the wedge cushions in place. During an interview on 11/5/24 at 11:30 A.M., Resident #43's Representative said the Resident has had some falls and he/she knew there was an intervention added for his/her bed to be against the wall so that he/she can only get out of bed on the open side. During an inteview on 11/5/24 at 2:18 P.M., UM #1 said that Resident #43 has had previous falls and has his/her bed against the wall and a mat on the floor. UM #1 said the bed against the wall could be viewed as a potential restraint and that it had not been assessed as a potential restraint because the Resident could exit the bed from the right side (the side not against the wall). UM #1 further said the bed should be in the low position and a mat should be placed on the floor on the right side of the bed while the Resident was in the bed. UM #1 said the Resident was assisted out of bed early in the morning. The surveyor and UM #1 assessed Resident #43's room at this time, and observed the left side of the Resident's bed positioned against the wall and two wedge cushions located on the bureau. The surveyor relayed observations from 5:50 A.M. that morning, and UM #1 said the two wedge cushions should not be placed under the fitted sheet on the right side of the Resident's bed because it would impede the Resident's movement out of bed. UM #1 further said she did not know who put the wedge cushions in place or how long they have been used. UM #1 said that they would be considered a restraint, that a restraint assessment would need to be completed and consent obtained for the use of the devices. UM #1 further said she was not aware that staff were utilizing the wedge cushions and that no Residents on the unit should be using restraints as it could lead to harm if used without proper assessment.

Based on interview, and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC: notice issued to a resident who is receiving benefits under Medicare Part A when all covered services end) and/or Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for one Resident (#107), out of three residents reviewed. Specifically, the facility failed to issue: A. The NOMNC to Resident #107's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) when the Resident was determined to lack the capacity to make medical decisions. B. The SNF ABN notice to Resident #107's HCP so the HCP could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) website for SNF ABN last modified 9/10/24, <https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-snf-abn> indicated: -Skilled Nursing Facilities (SNFs) must issue a notice to Original Medicare (fee for service - FFS) beneficiaries in order to transfer potential financial liability before the SNF provides: >an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or >custodial care (non-medical assistance with daily tasks and basic living needs for those who are not sick or disabled). Resident #107 was admitted to the facility May 2024, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the Physician Determination Concerning Massachusetts Health Care Proxy, dated 6/11/24, indicated: -Resident #107 lacked the capacity to make and/or communicate health care decisions. -The cause and nature of the incapacity was due to Dementia. -Duration of the incapacity was expected to be permanent. Review of the medical record indicated that Resident #107 came off (Medicare benefits ended) his/her Medicare benefit on 6/27/24. Review of the NOMNC, dated 6/25/24, indicated Resident #107 had signed the document. The facility was unable to provide any SNF ABN notice corresponding with the Resident ending his/her Medicare benefit on 6/27/24, for review. During an interview on 11/4/24 at 11:41 A.M., the surveyor and MDS Nurse #1 reviewed Resident #107's record. MDS Nurse #1 said that the NOMNC on 6/25/24 was signed by the Resident but should have been issued to the HCP based on the documentation of resident incapacity and had not been issued to the HCP. MDS Nurse #1 said that a SNF ABN had not been issued to the Resident or his/her HCP and should have been issued.

Based on observation, interview, and record review, the facility failed to notify the Physician and/or responsible party of a change in condition for three Residents (#2, #88, and #43) out of a total sample of 25 residents. Specifically, the facility failed to: 1. Notify Resident #2's Physician, in a timely manner, of a change in the Resident's condition when the Resident experienced complications with his/her indwelling (inside one's body) urinary catheter (tube used to drain urine from the bladder into a bag outside of one's body), resulting in a delay in treatment. 2. Notify the Physician and the Resident's Representative timely about a blister that was identified on Resident #88's inner leg. 3. Notify Resident #43''s Resident Representative of multiple dental infections which required medical intervention of several courses of treatment with antibiotics. Findings include: Review of the facility's policy titled Physician Notification, dated 11/11/09 and revised September 2011, indicated the following: -Upon identification of a resident who has clinical changes, change in condition, ., a Licensed Nurse will perform appropriate clinical observations and data collection and report to the Physician as indicated. -The purpose was to communicate a change in resident's condition to the Physician and initiate intervention as needed/ordered. - If clinical findings indicate urgent notification: >notify the Physician >report all pertinent data >obtain and implement specific orders for intervention >notify supervisor/charge nurse >notify family of change in condition and ordered interventions -if clinical findings indicate routine notification, notify the physician as soon as possible during normal business hours -document: >findings related to change of condition on SBAR (Situation, Background, Assessment and Recommendation- structured communication framework that shares information about a patient's condition) >Physician notification and response >on 24-Hour Change of Status Report >family notification >interventions >resident's deposition 1. Resident #2 was admitted to the facility in September 2024, with diagnoses including Urinary Retention (condition where the bladder does not empty all the way, or at all), Obstructive Uropathy (blockage in the urinary system) and chronic Foley (type of indwelling urinary catheter) Catheter. Review of Resident #2's clinical record indicated the following active Physician orders: -Provide Foley catheter care, dated 9/1/24. -Foley privacy bag in place for bedside Foley drainage, dated 9/1/24. -Foley catheter output every shift, dated 9/1/24. -May change Foley catheter PRN (as needed) for occlusion or leakage. Change urinary catheter and drainage bag as a complete system. -Foley catheter continuous/site care/privacy bag. Site care QS (every shift). Privacy bag in place for bedside Foley drainage, dated 9/1/24. Further review of the active Physician's order indicated a blank space to enter the Foley catheter size and retention bulb (also known as retention balloon- a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body) size, but both the Foley catheter size and retention bulb size were left bank. Review of Resident #2's Urinary Catheter Care Plan, initiated 9/2/24, indicated: -Change catheter if closed system is interrupted and as needed to maintain patency (degree of openness to allow flow of urine). -Notify MD (Medical Doctor/Physician) of suspected catheter complications, as needed. Review of Resident #2's Minimum Data Set (MDS) Assessment, dated 9/4/24, indicated the following: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident had an indwelling urinary catheter. Review of Resident #2's Nursing Progress Note, dated 10/20/24 at 2:20 P.M. and completed by Nurse #5, indicated the following: -The Resident was observed to have urine in his/her incontinence brief after lunch. -Urine in the incontinence brief was abnormal since the Resident had a Foley catheter. -There were no Physician orders for what type of Foley catheter the Resident had or needed if the catheter needed to be replaced. Review of Resident #2's Nursing Progress Note, dated 10/20/24 at 2:45 P.M., indicated the following: -The Weekend Supervisor observed Resident #2's Foley catheter. -The Weekend Supervisor said the Foley catheter looked fine and to enter a note into the Physician Communication Book about the Resident's catheter leaking for the Physician to review the next day. -There were 200 milliliters (mL) of urine in the Foley catheter drainage bag as well as whatever was in the incontinence brief. Review of Resident #2's Nursing Progress Note, dated 10/21/24 at 6:17 A.M., indicated the following: -Certified Nurses Aide (CNA) alerted Nurse to lack of urine in the Resident's Foley bag. -The Resident's Foley catheter was still leaking. -The Resident's incontinence brief was full of urine. -A note was left in the Physician Communication Book. -The Resident appeared to have some discomfort in his/her genital area. Review of Resident #2's Nursing Progress Note, dated 10/21/24 at 8:47 A.M. and written by Nurse #2, indicated the Resident's Foley catheter was not draining. Further review of the Nursing Progress Note indicated Nurse #2 contacted the Physician and completed the following relative to the Physician's instructions: -Nurse #2 deflated the catheter balloon, advanced the catheter, then reinflated the balloon. -Nurse #2 flushed the catheter with 60 mL (milliliters) of normal saline (NS: sterile fluid solution). -An order was obtained to change the catheter with a size 16 French (Fr: unit corresponding to the outer circumference of a catheter) and 30 mL balloon if the catheter continued with no flow after flushing. Review of Resident #2's Nursing Progress Note, dated 10/21/24 at 12:04 P.M. and written by Nurse #2, indicated the following: -The Resident had roughly 200 mL of tea colored urine in his/her Foley catheter bag prior to Nurse #2 deflating the balloon and flushing the Foley catheter. -The Resident had urine in his/her incontinence brief. -Nurse #2 changed the Resident's Foley catheter to a 16 Fr/30 mL balloon urinary catheter. -When the new Foley catheter was advanced, some urine leakage was observed. -Nurse #2 advanced the Foley catheter further, got yellow urine return through the catheter with some sediment (particles in urine, visible to the naked eye, that can be a sign of various medical conditions including infection, kidney problems, and dehydration) and minor clotting (blood). -The Resident now had a new Foley catheter. On 11/6/24 at 8:12 A.M., the surveyor observed Resident #2 in his/her room lying in bed. The surveyor observed clear urinary catheter tubing, extending out from under the Resident's bed covers, that connected to a covered drainage bag. The surveyor observed that the tubing was draining clear light yellow urine. During an interview on 11/6/24 at 11:15 A.M., Nurse #5 said she worked at the facility and provided care to Resident #2 on 10/20/24. Nurse #5 said that Resident #2 experienced urinary leakage outside of his/her catheter on 10/20/24 and when she reviewed the Resident's Physician orders, there were no orders to flush the catheter and there were no orders with what size catheter to replace the Resident's catheter with if the catheter leaked. Nurse #5 said that at that time, she entered a note into the Physician Communication Book relative to the Resident's catheter leaking. Nurse #5 said that she entered a note into the Physician Communication Book because 10/20/24 was a weekend day and there were no Physicians in the facility on the weekends. Nurse #5 said that she could not do anything about the Resident's urinary catheter leaking because there were no orders in place. Nurse #5 said she did not call the Physician. During an interview on 11/6/24 at 11:20 A.M., Nurse #2 said that she worked at the facility and provided care to Resident #2 on 10/21/24. Nurse #2 said she observed the Resident with urine leakage from his/her Foley catheter. Nurse #2 said she reviewed the Resident's Physician orders and there were no orders to flush the catheter and no ordered size for replacing the urinary catheter. Nurse #2 said she then contacted the Physician regarding Resident #2's catheter leaking and obtained orders to flush the catheter and to replace the catheter with a size 16 Fr with a 30 mL balloon if flushing the catheter did not correct the problem of urine leakage. Nurse #2 said that she flushed Resident #2's Foley catheter and it continued to leak, so she replaced the catheter, per the order she obtained from the Physician on 10/21/24. During an interview on 11/6/24 at 12:51 P.M., the Director of Nursing (DON) said that the facility has Physician coverage 24-hours daily, seven days per week, and that a Physician can always be contacted by phone. The DON said Nurse #5 should have contacted the Physician on 10/20/24 when she observed that Resident #2's Foley catheter was leaking and found that Resident #2's Physician orders did not include the required information for what to do when Resident #2's Foley catheter leaked. The DON said that the Resident should not have had to wait until the following day for orders to be obtained from the Physician so that his/her Foley catheter could be changed. The DON further said that the delay in notifying Resident #2's Physician of the leaking Foley catheter resulted in a delay in care. Please refer to F690, F726 and F880. 37400 2. Resident #88 was admitted to the facility in August 2022, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), and abnormal posture. Review of the Minimum Data Set (MDS) Assessment, dated 8/1/24, indicated Resident #88: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 4 out of 15. -was dependent on staff for activities of daily living (ADLs: basic skills needed in regular daily life including ambulating, dressing, bathing, eating), positioning and transfers. -was at risk for pressure ulcers. -did not have pressure ulcers during the assessment period. Review of a Nursing Progress Note, dated 10/31/24 (Thursday) at approximately 9:00 P.M., indicated the Certified Nurses Aide (CNA) notified the Nurse about a blister on Resident #88's leg. The Nurse indicated that the area was assessed to be a fluid filled intact blister about inch in diameter, on the Resident's right, lower inner leg. Review of the Resident's clinical record on 11/4/24 indicated no documented evidence that the Physician and/or Resident Representative were notified of the blister identified on the Resident's lower leg on 10/31/24. During an interview on 11/4/24 at 3:00 P.M., Nurse #1 said she was not aware of the blister on Resident #88's right lower leg until today. Nurse #1 said she was not sure if the Physician and Resident's Representative were notified of the area. During an interview on 11/4/24 at 3:07 P.M., Unit Manager (UM) #1 said she was just notified of the blister on Resident #88's lower leg. UM #1 said when the Nurse was initially notified of the Resident's blister (on 10/31/24), an incident report should have been completed and the Physician, the Resident's Representative and the Wound Nurse should have been notified. UM #1 said she was unable to find evidence that this notification occurred, and would be notifying all parties today and obtaining orders for treatment. Please Refer to F684 3. Resident #43 was admitted to the facility in September 2020, with diagnoses including Dementia. Review of Resident #43's Nursing Progress Notes indicated the following: -6/12/24: complained of mouth and tooth pain, Nurse Practitioner (NP) evaluated the Resident and gave a new order to start Amoxicillin (antibiotic) 500 milligrams (mg), three times daily for 5 days. -6/19/24: recently completed antibiotics, complained of mouth, throat still hurting. The Resident's right sided gland was noted to be swollen. The NP was updated and a new order was given for Amoxicillin 500 mg three times daily for 10 days. Review of the MDS Assessment, dated 6/20/24, indicated Resident #43: -had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15. -had received an antibiotic during the assessment period. Review of the June 2024 Medication Administration Record (MAR) indicated Resident #43 was administered the following: -Amoxicillin: 500 milligrams (mg) three times daily for five days for an infected tooth, initiated 6/12/24 through 6/17/24 -Amoxicillin: 500 mg three times daily for 10 days for infection, initiated 6/19/24 through 6/29/24 -Kelfex (antibiotic): 500 mg twice daily for prophylaxis . initiated 6/21/24 through 6/30/24 Review of clinical record indicated no documented evidence that the Resident Representative was notified about the multiple courses of antibiotics administered to the Resident for suspected mouth/throat/tooth infection. During an interview on 11/5/24 at 11:30 A.M., Resident #43's Representative said he/she was not made aware of any dental problems, pain or infections that had occurred with Resident #43 over the last year. During an interview on 11/5/24 at 2:16 P.M., UM #1 said she reviewed Resident #43's clinical record and was unable to find documented evidence that the Resident's Representative was notified of his/her mouth pain and multiple treatments with antibiotics. UM #1 said when the Resident had a change in condition, his/her Representative should have been notified.

Based on observation, interview, and record review, the facility failed to ensure that dignity and privacy was maintained for one Resident (#26), out of a total sample of 25 residents and on one unit (Unit 2) out of three units observed. Specifically, the facility failed to: 1) ensure staff provided privacy for Resident #26 while assessing and providing care to the Resident's buttocks. 2) ensure staff were seated while assisting residents during meals in the Unit 2 dining room. Findings include: Review of the facility policy titled Residents' Rights Policy, revised October 2023, indicated the following: -A resident has the right to a dignified existence -The resident has a right to be treated with respect and dignity -The resident has a right to personal privacy 1) Resident #26 was admitted to the facility in April 2013, with diagnoses including Multiple Sclerosis (MS: a chronic autoimmune disorder of the central nervous system marked by numbness, weakness, loss of muscle coordination, and problems with vision, speech, and bladder control) and Cerebral Palsy (a group of neurological disorders that affect the ability to move, balance and maintain posture caused by brain damage to the developing brain before birth). Review of Resident #26's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible score of 15. -the Resident was dependent of staff for personal hygiene and for rolling (repositioning) left and right in bed. On 11/6/24 at 2:40 P.M., the surveyor and Nurse #5 observed Resident #26's bilateral buttocks during an assessment procedure. Nurse #5 entered the Resident's room and pulled the privacy curtain closed between Resident #26's bed and his/her roommate's bed but did not pull the privacy curtain closed between Resident #26's bed and the bedroom window that faced a public walkway. Nurse #5 then rolled the Resident in bed with him/her facing towards his/her roommate's bed, and leaving the Resident's exposed buttocks facing the window where a walkway and another resident seated in a wheelchair were visible to the surveyor from the Resident's bedside. During an interview on 11/6/24 at 2:50 P.M., Nurse #5 said that there was concern for Resident #26's privacy as the window was not covered during the assessment and care of the Resident's buttocks. 2) On 11/3/24 at 8:45 A.M., in the Unit 2 dining room, the surveyor observed Certified Nurses Aide (CNA) #3 and CNA #4 assisting residents with their breakfast meals while standing over the residents. On 11/5/24 at 8:42 A.M., the surveyor observed CNA #1 in the Unit 2 dining room assisting a resident with their breakfast meal while standing over the resident. The surveyor observed the Director of Nursing (DON) telling CNA #1 to sit but CNA #1 remained standing while assisting the resident. During an interview on 11/5/24 at 8:44 A.M., CNA #1 said she should have been sitting while assisting the resident during their breakfast but she did not. CNA #1 further said sitting while assisting the resident was important so she would be at the resident's level and not make the resident feel uncomfortable. During an interview on 11/5/24 at 9:59 A.M., the DON said that standing over a resident while assisting them with a meal is a concern for dignity and Resident Rights.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1, who was dependent on staff to assist him/her with activities of daily living, was free from physical abuse by a staff member. On 11/24/21, two staff members witnessed Certified Nurse Aide (CNA) #1 slap Resident #1 in the face and/or neck area, and then CNA #1 said words to the effect of, Oh my god, I'm so sorry, it was my first reaction. Findings include: The Facility's Policy titled, Resident Abuse Prevention, Investigating and Reporting Policy, revised February 2017, indicated that: - the Facility was responsible to ensure residents had an environment free from abuse, - defined abuse as a willful action by an individual who committed the act deliberately whether or not the individual intended to inflict injury or harm, and - Physical abuse included hitting and slapping, and non-accidental use of physical force that results in bodily injury, pain, or impairment. The Facility's Internal Investigation, dated 11/24/21, indicated that around 8:30 P.M. or 9:00 P.M., Certified Nurse Aide (CNA) #2 and CNA #3 witnessed Resident #1 become combative towards staff during care and he/she bit CNA #1, who reflexively slapped Resident #1 somewhere around neck and/or chin area. The Investigation indicated CNA #1 immediately said words to the effect of, oh my god, I am so sorry. The Investigation indicated that CNA #1's behaviors were reflexive to being bit by Resident #1 and because CNA #1 didn't intend to hurt Resident #1, the Facility did not find the incident was physical abuse of Resident #1. Although the Facility's Investigation's Investigation did not substantiate the incident as abuse of Resident #1 by CNA #1, the Federal Requirements require that staff must be in control of their own behaviors in a resident care setting and cannot excuse staff behaviors as a response or reaction to a resident behavior. Resident #1 was admitted to the Facility in October 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 10/11/21, indicated he/she had severe cognitive impairment. Review of Resident #1's Health Care Proxy Activation Form, dated 10/11/21, indicated his/her Health Care Proxy (HCP) was activated due to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's POC related to activities of daily living (ADL), effective 10/06/21, indicated Resident #1 would participate in ADLs as tolerated and he/she exhibited behaviors yelling and crying due to confusion. Review of Resident #1's Nurse Progress Note, dated 11/09/21 as a late entry for 11/08/21, indicated Resident #1 had increased anxiety and agitation when staff tried to assist him/her. Review of Resident #1's Nurse Progress Note, dated 11/10/21, indicated he/she had increased agitation toward staff. The Note indicated Resident #1 hit and kicked the CNA. The Note indicated Resident #1 verbalized he/she did not need help with getting up. Review of the Nurse Progress Note, dated 11/20/21, indicated that on 11/18/21, a nurse reported Resident #1 was combative (bit and scratched) with the CNAs while providing him/her with toileting assistance. Review of Resident #1's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility's Incident/Accident Report, dated 11/24/21, indicated that around 8:30 P.M. or 9:00 P.M., two staff members witnessed a staff member (later identified as CNA #1) hit Resident #1 on the neck and/or face area. During an interview on 01/04/22 at 12:15 P.M., Certified Nurse Aide (CNA) #3 said that on 11/24/21, she walked into Resident #1's bedroom because she heard him/her yelling. CNA #3 said she asked CNA #1 and CNA #2 if they needed help because Resident #1 sometimes became combative (kicking, punching) while staff assisted him/her with activities of daily living care. CNA #3 said she saw Resident #1, who was lying in bed, bite CNA #1's forearm. CNA #3 said CNA #1 said ow and immediately pulled her hand back about six inches and said she saw CNA #1 slap Resident #1 on the face and/or neck area. CNA #3 said Resident #1 said Ow after he/she was slapped by CNA #1. CNA #3 said the slap to Resident #1 was hard and loud. CNA #3 said CNA #1 said words to the effect of, oh my god, I'm sorry, that was my first reaction. During an interview on 01/06/22 at 2:06 P.M., Certified Nurse Aide (CNA) #2 said that on 11/24/21, around 9:00 P.M., she worked with CNA #1 to assist Resident #1 with evening care because he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #2 said as they transferred Resident #1 into bed, he/she began resisting care, kicking and biting. CNA #2 said Resident #1 usually calms down once they get him/her in bed, but that night he/she did not calm down. CNA #2 said she was standing on one side of Resident #1's bed and CNA #1 was on the other side with Resident #1 in bed. CNA #2 said that as she was dressing Resident #1, she saw CNA #1, who was facing Resident #1, quickly pull her hand back about 4 inches and she said she heard a slap. CNA #2 said CNA #1 said words to the effect of, Oh my god, that was just my reaction, I didn't mean it. CNA #2 said that after witnessing the incident, she was in shock and looked at CNA #3 who was also in the room. During an interview on 01/04/22 at 12:40 P.M., the Nurse Manager said that on 11/24/21, at the end of the shift, around 11:00 P.M., CNA #2 and CNA #3 reported witnessing an incident of abuse of Resident #1 by CNA #1. During an interview on 01/04/22 at 2:00 P.M., the Administrator said their Investigation determined that CNA #1's intent was not to harm Resident #1 during the incident but that CNA #1's response was due to Resident #1 biting her. During an interview on 01/04/22 at 1:39 P.M., the Director of Nursing said CNA #1 did not respond correctly to Resident #1 at the time of the incident on 11/24/21.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose admission physicians orders included [MEDICATION(S)] extended release (opioid medication for moderate to severe pain) to manage his/her acute pain related to newly diagnosed right tibia and fibula (two bones in the lower leg) fractures and [MEDICATION(S)] (nerve pain medication) for his/her chronic severe pain due to peripheral [CONDITION(S)], the Facility failed to; - ensure that nursing notified the physician that the medications were not available in the Facility, and that prescriptions needed to be sent to the pharmacy in order for the medications to be dispensed and delivered to the Facility. - ensure that nursing notified the physician when the medications were not delivered from the pharmacy, to obtained orders for an alternative pain medication, that was available the Facility's Pyxis (automated medication dispensing system), - ensure that nursing notified the physician when Resident #1 missed two doses of the [MEDICATION(S)] and [MEDICATION(S)], and as a result Resident #1 was sent back to the hospital due to uncontrolled severe pain. Findings include: Review of the Facility's Policy, titled Physician Notification, dated 9/2011, indicated that the physician will be notified if clinical findings indicate urgent notification, report all pertinent data and obtain and implement specific orders for interventions. Resident #1's admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 15 milligrams (mg) extended release by mouth at bedtime for pain (electronically written at 7:28 P.M.) - [MEDICATION(S)] 150 mg by mouth twice a day (electronically written at 7:30 P.M.) Review of Resident #1's Hospital Discharge Medication List, dated 7/12/21, indicated his/her next pain medication dose was due to be administered: - [MEDICATION(S)] extended release 15 mg by mouth at bedtime, the next dose was due on 7/12/21 at 9:00 P.M. - [MEDICATION(S)] 150 mg by mouth twice a day (every 12 hours), the next dose was due on 7/12/21 at 9:00 P.M. Review of the Nurse Progress Note, dated 7/12/21 at 8:40 P.M., written by Nursing Supervisor #1, indicated Resident #1 was admitted from the Hospital, had a cast with a wrap and an immobilizer on his/her right lower extremity, with extensive bruising to the lower extremity, pain noted with contact (touch) and that the resident reports no pain at rest. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 11:00 P.M. shift, Resident #1's pain intensity level was rated as a 5 (pain rating scale, range 0 for no pain to 10 for severe pain) moderate pain. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M.: - [MEDICATION(S)] extended release 15 mg by mouth at bedtime - [MEDICATION(S)] 150 mg by mouth twice a day (every 12 hours), at 9:00 P.M. During an interview on 7/30/21 at 3:05 P.M., Nursing Supervisor #1 said Resident #1 had acute leg pain due to the bone fractures in his/her right leg and chronic pain due to his/her history of peripheral [CONDITION(S)]. Nursing Supervisor #1 said she did not notify the Physician that Resident #1's two scheduled pain medications were not available in the Facility. During an interview on 7/30/21 at 11:05 A.M., Nursing Supervisor #2 said on 7/13/21 during the 11:00 P.M. to 7:00 A.M. shift, when she performed Resident #1's pain assessment, Resident #1 said that he/she was uncomfortable and was having difficulty sleeping. Nursing Supervisor #2 said Resident #1's scheduled pain medications ([MEDICATION(S)] and [MEDICATION(S)]) that were due to be administered at bedtime on 7/12/21 (scheduled for 9:00 P.M.) were not administered as ordered, because they were not available in the Facility. Review of the MAR, dated 07/2021, indicated Resident #1 was administered Tylenol 650 mg (analgesic, a medication for mild pain) on 7/13/21 at 2:58 A.M., by Nursing Supervisor #2 for complaints of right lower extremity pain, however there was no documentation related to the effect of the Tylenol. Nursing Supervisor #2 said she did not notify the Physician that Resident #1's scheduled [MEDICATION(S)] and [MEDICATION(S)] were not delivered from Pharmacy, or to request an alternative pain medication, for Resident #1, that was readily available in the Pyxis. During an interview on 7/30/21 at 2:00 P.M., Family Member #2 said on 7/13/21 at 8:00 A.M., Resident #1 called her and said he/she had not been given his/her pain medication at bedtime the night before (7/12/21), said that Resident #1 was upset and complained of excruciating pain in his/her right leg. Family Member #2 said that Resident #1 told her, he/she had called the Nurse on the unit and told her about his/her excruciating pain, but had not received any pain medication. Family Member #2 said immediately after speaking with Resident #1 on the phone, she called the Facility, spoke with Nurse #3 and informed him of Resident #1's severe pain. Family Member #2 said she went to the Facility to see Resident #1 on 7/13/21 in the morning, because of his/her complaints of excruciating pain. Family Member #2 said she spoke with Nurse #3, and asked him about Resident #1's pain medications, and that Nurse #3 said they did not have his/her pain medication and were waiting for Pharmacy to deliver them. Family Member #2 said Nurse #3 told her it would take approximately 45 minutes for the pain medications to be delivered. Family Member #2 said she went and waited with Resident #1 (approximately 50 minutes), and during that time he/she was in excruciating pain saying he/she just wanted to die. Family Member #2 said she spoke to Nurse #3 again as Resident #1 had not received the [MEDICATION(S)] after 45 minutes. Family Member #2 said Resident #1 kept yelling out help, help, that he/she was in such excruciating pain, Family Member #2 said she told the nursing staff that they had called an ambulance to take him/her to the Hospital Emergency Department for pain management. During an interview at 2:35 P.M., on 7/30/21, Nurse #3 said that Resident #1 had not received his/her scheduled pain medications on 7/12/21 during the 3:00 P.M. to 11:00 P.M. shift, had not received them during the 11:00 P.M. to 7:00 A.M. shift., and had not received them them prior to leaving the facility via ambulance on 7/13/21 at 9:22 A.M. The Hospital Emergency Note, dated 7/13/21 at 10:57 A.M., indicated Resident #1 did not receive his/her scheduled pain medications last night (7/12/21) and still did not receive his/her pain medications this morning (7/13/21). The Note indicated that Family insisted he/she be transferred to the Hospital for pain control, and at the Hospital, he/she was treated with [MEDICATION(S)] (opioid) extended release once stat (immediately) on 7/13/21 at 11:00 A.M., with good effect. During an interview on 7/30/21 at 9:00 A.M., the Director of Nurses (DON) said that Resident #1 was taking extended release [MEDICATION(S)] for acute pain and that Resident #1 should have received his/her extended release [MEDICATION(S)] or an alternative narcotic at bedtime on 7/12/21. The DON said no alternative medication was administered to Resident #1 to prevent or treat his/her severe pain. The DON said the Physician was not notified by nursing that Resident #1's pain medications were unavailable, and said there were alternative pain medications available in the Facility's Pyxis, that could have been ordered for Resident #1, had the physician been notified.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was newly admitted and required management of acute severe pain due to recent right tibia and fibula (bones of lower extremity) fractures, as well as management of his/her chronic pain due a history of severe peripheral [CONDITION(S)], the Facility failed to ensure that his/her pain was adequately treated and effectively managed. - Upon admission to the Facility, two of Resident #1's pain medications from his/her hospital discharge medication list, [MEDICATION(S)] extended release (opioid medication used to treat moderate to severe pain) and [MEDICATION(S)] (nerve pain medication) were not available in the Facility for his/her scheduled 9:00 P.M. doses, and he/she was not provided with an adequate alternative pain medication that could effectively treat his/her acute and chronic pain. - Resident #1 experienced excruciating and unmanageable leg pain, and told family members the pain was so severe he/she wanted to die. The [MEDICATION(S)] his/her admission, Family Members were told by nursing that Resident #1's pain medications should be delivered to the Facility around 9:00 A.M., when they did not arrive, Resident #1 was transferred to the Hospital Emergency Department, at the insistence of family, and was administered [MEDICATION(S)] (opioid) extended release for his/her pain and was admitted . Findings include: Review of the Facility's Policy titled Pain Management, dated 12/22/16, indicated the following: -The Facility ensures that pain management is provided to residents who require such services consistent with the comprehensive care plan and the resident's goals and preferences. -The Facility will maintain the highest level of comfort for all residents providing a system to identify, assess, treat and evaluate pain. Review of the Facility's Pharmacy's Policy, titled, Controlled Substances Prescriptions, dated 2/2015, indicated the following: - Controlled substances are administered for a legitimate medical purpose. - The Prescriber is contacted for direction when delivery of a medication will be delayed or the medication is not available or will not be available. Review of Resident #1's medical record, indicated that he/she was transferred from the Hospital and admitted to the facility on [DATE] at 6:30 P.M., but was discharged from the Facility and sent back to the Hospital the following morning on 7/13/21 at 9:22 A.M. (14 hour length of stay at the Facility), and was readmitted . Resident #1's admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Hospital Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] extended release 15 milligrams (mg), administered on 7/11/21 at 9:42 P.M. - [MEDICATION(S)] 150 mg by mouth twice a day (every 12 hours) administered on 7/12/21 at 8:35 A.M. Review of Resident #1's Hospital Discharge Medication List, dated 7/12/21, indicated his/her next pain medication doses were due to be administered: - [MEDICATION(S)] extended release 15 mg by mouth at bedtime, the next dose was due on 7/12/21 at 9:00 P.M. - [MEDICATION(S)] 150 mg by mouth twice a day (every 12 hours), the next dose was due on 7/12/21 at 9:00 P.M. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 15 milligrams (mg) extended by mouth at bedtime for pain, (electronically written at 7:28 P.M.) - [MEDICATION(S)] 150 mg by mouth twice a day, (electronically written at 7:30 P.M.) Review of Resident #1's Admission Nursing Assessment, dated 7/12/21 at 8:09 P.M., indicated Resident #1 was moderately cognitively impaired (a BIMS score of 12), and during the pain review, he/she was noted to have severe pain frequently over the past five days, which made it difficult for him/her to sleep. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 11:00 P.M. shift, Resident #1's pain intensity level was rated as a 5 (moderate pain). Review of the Medication Ordering Process (undated) indicated that if there is an urgent need for a new order or for an admission order, then the staff, must call and fax, this new medication order to the pharmacy. The Medication Ordering Process indicated new order cut off time is 7:00 P.M. on Monday through Friday, and 3:00 P.M. on Saturdays and Sundays. During an interview on 7/30/21 at 3:05 P.M., Nursing Supervisor #1 said Resident #1 had acute leg pain due to the bone fractures in his/her right leg and chronic pain due to his/her history of peripheral [CONDITION(S)]. Nursing Supervisor #1 said that Resident #1 was admitted on a weekday, his/her admission medication orders were entered into the computer after 7:00 P.M., but were not called into the Pharmacy even though they were put in after the cut off time (to ensure that Resident #1's medications were delivered and administered). Nursing Supervisor #1 said she did not notify the Physician that Resident #1's two scheduled pain medications were not available in the Facility. Review of Resident #1's Plan of Care related to Pain Management, dated 7/12/21 at 8:28 P.M., written by Nursing Supervisor #1, indicated that Resident #1 had pain, and interventions included to use a numerical pain tool for rating his/her pain and that his/her tolerable pain level was a score of 3 (pain rating scale, 0 for no pain and 10 for severe pain) and to administer the pain medications as ordered. Review of the Nurse Progress Note, dated 7/12/21 at 8:40 P.M., written by Nursing Supervisor #1, indicated Resident #1 was admitted from the Hospital, had a cast with a wrap and an immobilizer on his/her right lower extremity, with extensive bruising to the lower extremity, pain noted with contact (touch) and that the resident reports no pain at rest. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 11:00 P.M. shift performed by Nurse #3, assigned to the care of Resident #1, indicated his/her pain intensity was rated as a 5 (moderate pain). Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M.; - [MEDICATION(S)] extended release 15 mg by mouth at bedtime - [MEDICATION(S)] 150 mg by mouth twice a day (every 12 hours), at 9:00 P.M. Review of the MAR, indicated Resident #1 was administered Tylenol 650 mg (analgesic, medication for mild pain) on 7/13/21 at 2:58 A.M., by Nursing Supervisor #2 for complaints of right lower extremity pain. There was no documentation to indicate the effect of the pain medication or of Resident #1 was re-assessed by nursing. During an interview on 7/30/21 at 11:05 A.M., Nursing Supervisor #2 said on 7/13/21 during the 11:00 P.M. to 7:00 A.M. shift, when she performed Resident #1's pain assessment, Resident #1 said that he/she was uncomfortable and was having difficulty sleeping. Nursing Supervisor #2 said Resident #1's scheduled pain medications ([MEDICATION(S)] and [MEDICATION(S)]) that were due to be administered at bedtime on 7/12/21 (scheduled for 9:00 P.M.) were not, because they were not available in the Facility, but said the Facility should have received them first thing the following morning. Nursing Supervisor #2 said she did not order Resident #1's pain medications urgently from the Pharmacy, said that she did not know if Resident #1's pain management medications had been ordered urgently or routine, and said she did not know how to order the medications urgently or stat. Nursing Supervisor #2 said that there were alternative narcotic pain medications available (immediate release [MEDICATION(S)] and Percocet) in the automated medication machine (Pyxis). Nursing Supervisor #2 said she did not notify the physician that Resident #1's scheduled [MEDICATION(S)] extended release and [MEDICATION(S)] were not delivered from Pharmacy, nor that there were alternative pain medications readily available in the Pyxis. During an interview on 7/30/21 at 2:00 P.M., Family Member #2 said on 7/13/21 at 8:00 A.M., Resident #1 called her and said he/she had not been given his/her pain medication at bedtime the night before (7/12/21), said that Resident #1 was upset and complained of excruciating pain in his/her right leg. Family Member #2 said that Resident #1 told her, he/she had called the Nurse on the unit and told her about his/her excruciating pain, but had not received any pain medication. Family Member #2 said immediately after speaking with Resident #1 on the phone, she called the Facility, spoke with Nurse #3 and informed him of Resident #1's severe pain. Family Member #2 said she went to the facility to see Resident #1 on 7/13/21 in the morning, because of his/her complaints of excruciating pain. Family Member #2 said she spoke with Nurse #3, and asked him about Resident #1's pain medications, that Nurse #3 said they did not have his/her pain medication and were waiting for Pharmacy to deliver them. Family Member #2 said Nurse #3 told her it would take approximately 45 minutes for the pain medications to to be delivered. Family Member #2 said she went and waited with Resident #1 (approximately 50 minutes), and during that time he/she was in excruciating pain saying he/she just wanted to die. Family Member #2 said she spoke to Nurse #3 again as Resident #1 had not received the [MEDICATION(S)] after 45 minutes. Family Member #2 said Resident #1 kept yelling out help, help, that he/she was in such excruciating pain, Family Member #2 said she told the staff that they had called an ambulance to take him/her to the Hospital Emergency Department for pain management. Review of Resident #1's Pain Assessment, dated 7/13/21, completed during the 7:00 A.M. to 3:00 P.M. shift, there was no documentation to support his/her pain was assessed by nursing from 7:00 A.M. to 9:22 A.M., prior to the Family Members reporting to nursing that Resident #1 was complaining of excruciating pain. During an interview at 2:35 P.M., Nurse #3 said that Resident #1 had not received his/her scheduled pain medications on 7/12/21 during the 3:00 P.M. to 11:00 P.M. shift, had not received them during the 11:00 P.M. to 7:00 A.M. shift., nor prior to leaving the Facility via an ambulance on 7/13/21 at 9:22 A.M. Nurse #3 said that he did not document Resident #1's pain intensity score on 7/13/21, prior to being sent to the Hospital. The Hospital Emergency Department (ED) Note, dated 7/12/21 at 10:57 A.M., indicated Resident #1 was evaluated in the ED today, was released from the Hospital last night, 7/12/21 after being treated with pain medications for lower extremity tibia and fibula fractures. The ED Note indicated Resident #1 did not receive his/her scheduled pain medications last night at the facility and still did not receive his/her pain medications this morning 7/13/21. The ED note indicated family members insisted he/she be transferred to the Hospital for pain control, and at the Hospital, Resident #1 was treated with [MEDICATION(S)] (Opioid) extended release once stat (immediately) at 11:00 A.M., with good effect. During an interview at 9:00 A.M. on 7/30/21, the Director of Nurses (DON) said that Resident #1 was taking extended release [MEDICATION(S)] for chronic pain and that Resident #1 should have received his/her extended release [MEDICATION(S)] or an alternative narcotic at bedtime. The DON said there were no additional physicians orders in Resident #1's record to indicated that nursing administered an alternative medication to manage his/her pain or to prevent worsening his/her pain.

Based on record review, observation and staff interviews, the facility failed to follow the resident's plan of care relative to fall interventions and padded siderails, which resulted in a fractures shoulder, a laceration and multiple falls, for 3 sampled residents (#5, #10 and #16), in a total sample of 24 residents. Findings include: 1. For Resident #5, the facility failed to follow the resident's falls plan of care relative to the following: chair pad alarm did not activate and the resident was not in a supervised area, as planned. Resident #5 was admitted to the facility in 7/2014. Review of the falls care plan of 7/17/14 indicated the following interventions: well lit and uncluttered environment, items within reach, gait belt for all transfers, and bed and chair pad alarms. Review of the 8/12/14 Nurse's Progress Note indicated the resident experienced a fall, sustaining bruising on the hand. During an interview with Unit Manager (UM) #1 on 12/31/14 at 1:30 P.M., she said the progress note was in reference to the resident having an unwitnessed fall on 8/11/14. Review of the falls investigation indicated that the cause of the fall was that the resident was left in an unsupervised area. The falls care plan was updated to include: resident must be in a supervised setting when out of bed. Staff education was provided regarding this intervention and staff were also educated that the Nurse's area and unit common area must always have supervision. The falls care plan was updated on 9/2/14 to include: ambulate and transfer with 1 assist and gait belt. The falls care plan was updated on 11/11/14 to include: transfer with 2 assist. Review of the 11/19/14 Nurse's Progress Note indicated the resident experienced an unwitnessed fall (found inside doorway of an empty resident's room), sustaining a fractured shoulder and a bump/bruise over the eyebrow. During interview and review of the falls investigation with UM #1(on 12/31/14 at 1:30 P.M.), she said the resident's chair pad alarm did not activate, as planned, when the resident attempted to self transfer, out of the wheelchair, at the time of the fall. Further review of the falls investigation packet with UM #1, indicated a falls care plan (reviewed by the staff on 11/11/14) which continued to note the falls intervention that the resident must be in a supervised setting when out of bed. At the time of the fall, the resident was not in a supervised area, as planned. On 12/31/14 at 7:30 A.M., the surveyor observed the resident in the unit day room, sitting in a wheelchair, being fed by a CNA (certified nursing assistant). During an interview with CNA #3 on 12/31/14 at 1:15 P.M., she said "... we try to keep (Resident #5) in a supervised area but sometimes (she/he) wanders off...." During an interview with UM #1 on 12/31/14 at 1:30 P.M., it was discussed that the facility failed to follow the resident's plan of care relative to falls interventions. Please refer to F323 (Example #1) and F514 (Example #1). 2. For Resident #10, the facility failed to ensure the resident's left full siderail was padded the entire length, as care planned. The resident sustained [REDACTED]. Resident #10, was admitted to the facility in 4/2014, with [DIAGNOSES REDACTED]. Review of the care plan in place 4/21/14, indicated the resident required two staff for positioning and for transfers out of bed. The resident was care planned for a full left siderail to prevent the resident's left foot/heel boot (described as heavy) from sliding off the bed. The full left siderail was care planned to be padded for comfort and positioning. Review of the physician's orders [REDACTED]. Review of the nurse's note of 5/1/14 at 3:20 A.M., indicated that the resident was found with his/her left leg caught in the siderail. The resident sustained [REDACTED]. Review of the facility investigation of this skin tear of 5/1/14, indicated that although a blue triangle wedge/pad was placed against the left full siderail, the wedge/pad did not cover the length of the siderail, which allowed the resident's leg to get caught in the siderail. The new intervention, put in place on 5/1/14, to prevent further injuries, included: -Ensure light blue padding is at the top of the left siderail and the dark blue wedge/pad is attached to the lower half of the left siderail. Review of the nurse's note of 5/8/14 at 9:00 P.M., indicated staff responded to the resident's call for help. The resident was found with the left lower leg caught in the siderail. The resident's left lower leg was bleeding. The resident was transferred to the hospital for treatment to the lower left leg laceration. Review of the hospital emergency room note of 5/8/14 indicated the resident sustained [REDACTED]. Review of the nurse's note of 5/9/14 at 8:00 A.M., indicated that the hospital notified the facility that the laceration to the left leg was sutured with 30 sutures and 7 internal sutures. Review of the facility investigation into this injury indicated the root cause of the injury was that the padding was not on the bottom half of the siderail, as care planned, when the resident sustained [REDACTED]. Review of Certified Nursing Assistant (CNA) #1 and CNA #2's statements of what occurred during this event, indicated the lower half of the full left siderail was not padded when the resident caught his/her leg in the siderail. During interview on 1/5/15 at 12:30 P.M., Unit Manager (UM) #3 said that the resident had experienced a skin tear on 5/1/14 and 5/8/14 when the resident's leg was caught in the left full siderail. UM#3 said the resident was transferred to the hospital on [DATE] for evaluation and treatment of [REDACTED]. During interview on 1/5/15 at 1:30 P.M., it was discussed with UM #3 and the Director of Nurses (DON) that the resident did not have the lower pad on the full siderail, as care planned, when the resident's leg was caught in the full siderail on 5/8/14. The DON said that she would look into the matter and provide any additional information concerning these findings. During interview on 1/6/15 at 10:35 A.M., the DON said that there was no further documentation/information to dispute the findings that the full siderail was not fully padded, as care planned, on 5/8/14 when the resident's leg became caught in the siderail. The DON said the resident sustained [REDACTED]. Please refer to F323, Example #2 3. For Resident #16, the facility failed to follow the care plan to prevent 4 falls out of 6 falls, that occurred in a 4 month period. Resident #16, was admitted to the facility in 8/2014, with [DIAGNOSES REDACTED]. Review of the care plan to prevent falls due to unstable balance, confusion, forgetfulness, and mental status changes in place 8/22/14, included the following interventions: -Provide a well lit, uncluttered environment. -Place personal items within reach. -Individualize care plan to meet residents needs. Review of the staff training, provided by the Physical Therapist 9/19/14 to the nursing staff, indicated the resident was to be a 1 person assist with a rolling walker for ambulation and transfers. A bed and chair alarm were to be utilized. This training was signed by nursing staff including the charge nurse on 9/19/14 and was placed in the resident's clinical record . Review of the nurse's note of 9/21/14 indicated the resident was found on the floor at 7:10 A.M. Review of the facility fall investigation of 9/21/14 indicated the resident fell out of bed, while reaching for his/her grooming products, in the night stand. The investigation indicated that personal items were not within reach of the resident, as care planned, which contributed to the fall. The investigation indicated that the bed alarm was not attached, as planned. Review of the PT Treatment Encounter Note of 10/9/14 indicated PT notified nursing staff that the resident required assistance with all mobility utilizing a rolling walker, as the resident demonstrated impulsive and unsafe behaviors during independent ambulation. Review of the Staff Education Documentation sheet of 10/9/14 completed by the PT and signed by nursing staff including the charge nurse, indicated the resident was to be a 1 person assist with all transfers and ambulation. Review of the Physical Therapy notes of 10/9/14, which was located in the clinical record, indicated staff had agreed that the resident was a 1 assist during mobility with a rolling walker. Review of the nurse's note of 11/8/14 at 5:25 P.M., indicated the resident was found on the floor in the resident's room. Review of the investigation indicated the resident fell , when the resident attempted to ambulate alone, to the bathroom, and not with staff, as care planned. Review of the Rehabilitation Referral of 11/10/14 (submitted by Nursing staff to Rehabilitation Therapy Department) indicated that the resident had been self transferring for about a week or more before he/she fell (on 11/8/14). However, there was no indication, in the record as to why the resident had been allowed to ambulate independently for a "about a week" prior to falling 11/8/14, as the resident's status was transfer with one person assist for all ambulation since 10/9/14. The PT note of 11/11/14 indicated the resident was recently discontinued from therapy (10/9/14) and at that time, the recommendation was for the resident to be assisted with all ambulation. The care plan was updated on 11/11/14 to include: -Discontinue the bed alarm. -Replace with a motion sensor, -Keep wheelchair locked and at the bedside. -Keep walker next to the bed. Review of the nurse's note of 12/29/14 indicated the resident was found on the floor. Review of the investigation indicated Fritos crumbs were on the floor, causing the resident to fall. The resident was also found with both legs in one pant leg as the resident dressed his/herself. The floor was described as greasy and slippery. The resident sustained [REDACTED]. Review of the nurse's notes of 1/4/15 indicated the resident was found on the floor at 4:25 P.M. Review of the facility investigation of this fall indicated the motion sensor was on, but turned toward the window and did not sound, as care planned. The recommendation to prevent further falls, was to move the motion sensor from the bed and place it on a pole near the dresser. Surveyor observation on 1/7/15 at 11:00 A.M., was of the resident in bed. The motion sensor was still attached to the pole on the bed, and not on the pole near the dresser, as per the care plan. During interview on 1/7/15 at 11:30 A.M., it was discussed with the DON that the resident experienced 4 falls (from 9/21/14 to 1/4/15) when the care plan was not followed. Please refer to F323, Example #3.

Based on record review, observation, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 3 of 11 applicable residents (#5, #10 and #16), out of a total sample of 24 residents, which resulted in a laceration, a fractured shoulder, and multiple falls. Findings include: 1. For Resident #5, the facility failed to provide effective interventions and adequate supervision to prevent falls in order to provide an effective falls intervention program for the resident. Resident #5, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment of 7/10/14 identified the resident as exhibiting short and long term memory deficits, severely impaired decision making ability; requiring assistance during transfers and ambulation and being unsteady when moving from a seated to standing position, when walking/turning around and during surface to surface transfers (between bed and chair or wheelchair). Review of the falls care plan of 7/17/14, which identified the resident as being at risk for falls, due to unstable balance and exhibiting unsafe behaviors, indicated the following interventions: well lit and uncluttered environment, items within reach, gait belt for all transfers, and bed and chair pad alarms. Review of the 8/12/14 Nurse's Progress Note indicated the resident experienced a fall, sustaining bruising on the hand. During an interview with Unit Manager (UM) #1 on 12/31/14 at 1:30 P.M., she said the progress note was in reference to the resident having an unwitnessed fall on 8/11/14 when the resident attempted to stand up out of her/his wheelchair. Review of the falls investigation indicated that the resident was confused and disoriented and that the cause of the fall was that the resident was left in an unsupervised area. The falls care plan was updated on 8/11/14 to include: resident must be in a supervised setting when out of bed. Staff education was provided on 8/11/14 regarding this intervention and staff were also educated that the Nurse's area and unit common area must always have supervision. The falls care plan was reviewed by staff on 9/2/14 to include: ambulate and transfer with 1 person assist and gait belt. Review of the quarterly MDS assessment of 10/2/14 remained essentially unchanged from the previous assessment except to indicate that the resident experienced a fall. The falls care plan was reviewed by staff on 10/15/14 and remained unchanged. The falls care plan was updated on 11/11/14 to include: transfer with 2 assist. Review of the 11/19/14 Nurse's Progress Note indicated the resident experienced an unwitnessed fall at 1:30 P.M. (found inside doorway of an empty resident's room), sustaining a fractured shoulder and a bump/bruise over the eyebrow. During interview and review of the falls investigation with UM #1 on 12/31/14 at 1:30 P.M., she said the resident's chair pad alarm did not activate when the resident attempted to self transfer, out of the wheelchair, at the time of the fall, as planned. Further review of the falls investigation packet with UM #1, indicated a falls care plan (reviewed by the staff on 11/11/14) which continued to note the falls intervention that the resident must be in a supervised setting when out of bed. At the time of the fall, the resident was not in a supervised area, as planned. The falls care plan was updated to include: return resident to bed right after meals for rest. The falls care plan was updated on 11/22/14 to include: two assist with gait belt and handheld assist with all transfers and ambulation. On 12/31/14 at 7:30 A.M., the surveyor observed the resident in the unit day room, sitting in a wheelchair, being fed by a CNA (certified nursing assistant). During an interview with CNA #3 on 12/31/14 at 1:15 P.M., she said the resident "... needs 2 assist with transfers...is confused, (Resident #5's) safety awareness is not good...we try to keep (Resident #5) in a supervised area but sometimes (Resident #5) wanders off...." During an interview with UM #1 on 12/31/14 at 1:30 P.M., she said the resident has no safety awareness and can be impulsive and restless. It was further discussed that the facility failed to provide effective interventions and adequate supervision to prevent falls for this resident. 2. For Resident #10, the facility failed to ensure the resident's siderail was padded and contained no rough areas. The resident sustained [REDACTED]. Resident #10, was admitted to the facility in 4/2014, with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment of 4/11/14 indicated the resident was admitted from an acute care hospital where the resident was treated for [REDACTED]. The resident was coded as cognitively intact with a score of 14/15 on the Brief Interview of Mental Status (BIMS) exam. The resident was coded as: experiencing symptoms of delirium requiring extensive assistance of two staff for bed mobility and transfers not being steady without staff assistance for balance during transitions and walking having limited mobility of one lower extremity having a fall in the past 2-6 months prior to admission that resulted in a fracture having an unstageable pressure ulcer containing eschar and having a urinary tract infection and received antibiotics. Review of the care plan of 4/18/14, indicated the resident required two staff for positioning and for transfers out of bed. The resident wore a green heel/ boot to off load the resident's left heel. Review of the nurse's note of 4/21/14 indicated that a full left siderail was placed on the bed to prevent the resident's left foot/heel boot (described as heavy) from sliding off the bed. The note indicates the siderail was padded for comfort and positioning. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the nurse's note of 5/1/14 at 3:20 A.M., indicated that the resident was found with his/her left leg caught in the siderail. The resident sustained [REDACTED]. The skin tear measured 5 centimeters (cm) by 8 cm. Review of the facility investigation of this skin tear of 5/1/14, indicated that although a blue triangle wedge/pad was placed against the left full siderail, the wedge/pad did not cover the length of the siderail, which allowed the resident's leg to get caught in the siderail. The new intervention put in place on 5/1/14 to ensure the whole siderail was padded to prevent further injuries from the siderail included: -Ensure light blue padding is at the top of the left siderail and the dark blue wedge/pad is attached to the lower half of the left siderail. Review of the nurse's note of 5/8/14 at 9:00 P.M., indicated staff responded to the resident's call for help. The resident was found with the left lower leg caught in the left full siderail. The resident's left lower leg was bleeding. A pressure dressing was applied and 911 emergency services were called. The resident was transferred to the hospital. Review of the hospital emergency room note of 5/8/14, indicated the resident sustained [REDACTED]. Review of the nurse's note of 5/9/14 at 8:00 A.M., indicated that the hospital notified the facility that the laceration to the left leg had required 30 sutures and 7 internal sutures, to close the wound. Review of the facility investigation of 5/9/14 into this injury indicated the root cause of the injury was that the padding was not on the bottom half of the siderail, as care planned. The resident had removed his/her foot/heel boot and the resident's leg became stuck in the siderail. This investigation also indicated that a bolt on the inner left siderail was rough. Review of Certified Nursing Assistant (CNA) #1 and CNA #2's statements of what occurred during this event indicated the lower half of the full left siderail was not padded when the resident caught his/her leg in the siderail. The interventions implemented to prevent further injuries to the resident included: -Upon return from hospital, evaluate the continued use of a full siderail. -Maintenance to tape bolt area on rail that is rough in case pad dislocates Review of the physician's orders [REDACTED]. The resident's left lower leg was to be washed with a wound cleanser, patted dry and a Telfa island dressing was to be applied. The sutures were to be removed in 10 days. The Surveyor observed on 1/5/15 at 1:00 P.M., Resident #10 sitting in a wheelchair, in the day room, on the unit. The resident did not have any visible wounds to the lower left leg. The Surveyor observed on 1/5/15 at 1:00 P.M., that the resident's bed now had half rails on the left and right side. During interview on 1/5/15, at 12:30 P.M. Unit Manager (UM) #3 said that the resident had experienced a skin tear, when his/her leg was caught between the bed and the siderail on 5/1/14. UM#3 said the resident experienced another skin tear on 5/8/14, when his or her leg was caught in the siderail and was transferred to the hospital where the resident received multiple sutures. During interview on 1/5/14 at 1:30 P.M., it was discussed with UM#3 and the Director of Nurses (DON) that the resident had experienced a skin tear when the resident's leg was caught between the bed and the siderail on 5/1/14 and at that time, the intervention to prevent further injury was to pad the entire length of the left siderail. It was also discussed that the resident's left leg was caught in the siderail, again on 5/8/14, and that the full siderail was not padded on the lower half of the siderail, as care planned. The DON said that she would look into the matter and provide any additional information concerning these findings. During interview on 1/6/15 at 10:35 A.M., the DON said that there was no further documentation/information to dispute the findings that the left siderail was not fully padded (on 5/8/14), when the resident's leg was caught in the siderail, and the resident sustained [REDACTED]. 3. For Resident #16, the facility failed to provide adequate supervision and effective devices to prevent 6 falls, in a 4 month period. Resident #16, was admitted to the facility on ,[DATE], with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment of 8/20/14 indicated the resident was coded a 12/15 (moderately impaired memory) on the Brief Interview of Mental Status (BIMS) exam. The resident was coded as requiring extensive assistance of one staff for transfers, walking, dressing, hygiene, and bathing. The resident was coded as not being steady,without staff assistance during transitions and walking. The resident was coded as having limited mobility of one lower extremity. The resident was coded as requiring a walker. The resident was coded as having no falls. Review of the care plan of 8/22/14, to prevent falls, due to change in mobility, unstable balance, confusion, forgetfulness, and mental status changes included the following interventions: -Fall assessments to be done with MDS assessments and after a fall. -Include resident/family in the assessment process. -Educate resident/family on fall prevention strategies. -Provide a well lit, uncluttered environment. -Place personal items within reach. -Gait belt for all transfers. -Encourage participation in Diversional activities. -Individualize care plan to meet residents needs. Review of the nurse's note of 9/7/14 indicated the resident fell . Review of the 9/7/14 facility investigation of the fall indicated the resident fell at 8:15 P.M., while transferring from bed to a standing position. This investigation indicated the resident was sitting on the bed, lost his/her balance and slid to the floor. Staff were present. This investigation indicated the resident's bed was not locked when the transfer occurred. Further review of this investigation did not indicate any further action was taken regarding the resident's bed not being locked during the transfer. During interview on 1/7/15 at 9:45 A.M., the Director of Nurses (DON) said that the bed should have been locked. Review of the nurse's note of 9/19/14 at 4:20 P.M., indicated the resident experienced a fall on the "overnight shift". This note indicated the fall was not witnessed. The note indicated neuro checks were started after the fall. The facility could not locate an investigation or incident report of this fall. During interview (on 1/7/15 at 10:45 A.M.), the Director of Nurses (DON) said that no additional information could be located regarding the fall on 9/19/14, including an incident report. Review of the staff training provided by the Physical Therapist (PT) 9/19/14 to the nursing staff, indicated the resident was to be a 1 person assist with a rolling walker for ambulation and transfers. A bed and chair alarm were to be utilized. This training was signed by the nursing staff including the charge nurse on 9/19/14, Review of the nurse's note of 9/21/14 indicated the resident was found on the floor at 7:10 A.M. Review of the facility fall investigation indicated the resident fell out of bed, while reaching for his/her grooming products, in the night stand. The investigation indicated the resident was self grooming. The investigation indicated that personal items were not within reach of the resident, as planned, and contributed to the fall. The investigation described the resident as confused, attempting to groom self. The investigation indicated that the bed alarm was not attached. The new interventions to prevent further falls included: -Utilize a bed and chair alarm. -One assist for transfers and ambulation. Use a rolling walker. However, review of the staff training provided by the PT (9/19/14) indicated a bed alarm and chair alarm should have been in place, at the time of the fall and that the resident was a one assist for transfers and ambulation. This training had been signed by nursing staff and the charge. The falls investigation indicated that to prevent further falls, the resident's personal items would be kept within reach of the resident. However, review of the falls care plan, indicated this intervention should have been in place at the time of the fall. Review of the PT Treatment Encounter Note of 10/9/14 indicated PT again notified nursing staff that the resident required assistance with all mobility with a rolling walker, as the resident demonstrated impulsive and unsafe behaviors during independent ambulation. This note indicated nursing staff agreed to the above. Review of the Staff Training Documentation sheet of 10/9/14 completed by the PT indicated the resident was to be a 1 assist with all transfers and ambulation. Review of the quarterly MDS assessment of 11/7/14 indicated the resident was coded a 12/15 on the BIMS exam (moderately cognitively impaired). The resident was coded as requiring extensive assistance of one staff for transfers, walking, dressing, hygiene, and bathing. The resident was coded as not being steady without staff assistance. The resident was coded as having limited mobility on one lower extremity. The resident was coded for using a walker. The resident was coded as having no falls. Review of the nurse's note of 11/8/14 at 5:25 P.M., indicated the resident was found on the floor in the resident's room. Review of the investigation indicated the resident fell , when the resident attempted to ambulate alone, to the bathroom. Review of the Rehabilitation Referral of 11/10/14 (submitted by Nursing staff to Rehabilitation Therapy Department following the 11/8/14 fall indicated that the resident had been self transferring for about a week or more before he/she fell on [DATE]. However, there was no indication in the record, as to why the resident had been allowed to self transfer independently for "about a week" prior to falling 11/8/14, as the resident's status was transfer with one assistance for all ambulation since 10/9/14. The PT note of 11/11/14, indicated the resident was recently discontinued from (PT) (10/9/14) and at that time, the recommendation was for the resident to be assisted with all ambulation. The care plan was updated 11/11/14 to include: -Discontinue the bed alarm. -Replace with a motion sensor, -Keep wheelchair locked and at the bedside. -Keep walker next to the bed. Review of the nurse's note of 12/29/14 indicated the resident was found on the floor. Review of the investigation indicated the resident was found on the floor in his/her room. This investigation indicated Fritos crumbs were on the floor, causing the resident to fall. The resident was also found with both legs in one pant leg. The floor was cluttered with food particles and was described as greasy and slippery. The resident sustained [REDACTED]. The laceration was cleansed with normal saline and Tegaderm dressing was applied. The new interventions to prevent further falls included: -Use of a scoop mattress. -Motion sensor mounted to the bed on a pole. -Out of bed for all meals. -Assist resident with clothing management. Review of the nurse's notes of 1/4/15 indicated the resident was found on the floor at 4:25 P.M. The note indicated the resident sustained [REDACTED]. measuring 9 centimeters (cm) by 2.5 cm. Review of the 1/4/15 facility investigation of this fall, indicated the motion sensor was on, but turned toward the window and did not sound. The recommendation to prevent further falls, was to move the motion sensor from the bed and place it on a pole near the dresser. The Surveyor observed on 1/7/15 at 11:00 A.M., the resident in bed. The resident was observed to have a bruise on the back approximately 9 cm by 2 cm (not an abrasion as described in the incident of 1/4/15). The motion sensor was still attached to the pole on the bed, and not on the pole near the dresser, as planned. During interview on 1/7/15 at 11:30 A.M., it was discussed with the DON that the resident experienced 6 falls (from 9/7/14 to 1/4/15) when the supervision was not adequate and devices to prevent falls were ineffective.

Based on observation, record review, and staff interview, the Facility failed to provide adequate supervision and effective interventions to prevent accidents from occurring for 3 (#1, #15 and #21) of 13 applicable residents in a total sample of 23. Findings include: 1. For Resident #1 the Facility failed to provide adequate supervision to prevent falls. Resident #1 sustained 6 falls, 1 fall resulted in a fracture, 5 falls were unwitnessed, 5 falls occurred during the evening shift, and 2 of the falls occurred in other residents' rooms. Resident #1 was admitted to the Facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the falls care plan of [DATE] identified the following risk factors: - fell in the last year - Unstable balance - Incontinent & mobile - Confused/forgetful - Mental status varies - Exhibits unsafe behavior - Wanders on unit - Requires medications that affect balance/gait - Hearing problems - Mobility fluctuates during the course of the day The care plan also included the following interventions: - Educate the resident and family on fall prevention strategies. - Discourage sitting on the edge of seat. Use chair with armrests. - Never leave unattended in the bathroom. - Gait belt for all transfers. - Bed pad alarm. - Resident may ambulate/wander on unit independently after care is completed and steady on feet. Review of the admission Minimum Data Set (MDS) assessment of [DATE] indicated that Resident #1 had short and long term memory impaired with moderately impaired decision making ability; required extensive assist for transfers, supervision for ambulation, utilized a walker; and had no falls since admission. Review of the nurse's note and the Facility's internal investigation of [DATE] indicated that at 6:10 P.M. Resident #1 was returning from the small dining room, lifted his/her walker and fell to the floor. Resident #1 did not sustain an injury and the fall was witnessed. Review of the falls care plan indicated that on [DATE] the care plan was updated to include the following intervention: - Resident to be hand held (direct contact) when ambulating to the dining room. Review of the nurse's note and the Facility's internal investigation of [DATE] indicated that at 4:30 P.M. the resident was found on the floor in the small dining room with a rolling stool behind him/her and the walker to the side. Resident #1 did not sustain an injury. The fall was unwitnessed. Review of the Resident Fall Risk Assessment of [DATE] indicated the Facility identified the above risk factors along with the following additional risk factors factors for the resident:: - Needs assist with bed mobility, transfers, ambulation, or uses an assistive device. - Not steady, but able to stabilize without human assistance. - History of sleep disturbance - Contributing diagnosis Review of the quarterly MDS assessment of [DATE] indicated that Resident #1's short and long term memory was impaired with severely impaired decision making ability: required extensive assist for transfers, limited assistance for ambulation, utilized a walker, and had no falls since the last assessment. Review of the nurse's note and the Facility's investigation of [DATE] indicated that at 4:30 P.M. Resident #1 was found in another resident's room, lying on the floor, on the left side, complaining of pain in the left hip. Resident #1 was transported to the Hospital for an evaluation, which was negative for a fracture. The fall was unwitnessed. Review of the Resident Fall Risk Assessment of [DATE] indicated the risk factors remained unchanged. Review of the falls care plan indicated that on [DATE], the care plan was updated to include the following interventions: - Redirect resident when noted wandering and offer an activity. Review of the nurse's note and the facility's investigation of [DATE] indicated that at 4:00 P.M. Resident #1 was found on the floor in another resident's room, disrobed from the waist down, sitting between the two bed and feces was smeared on the floor. The fall was again, unwitnessed and occurred in another resident's room. Review of the Resident Fall Risk Assessment of [DATE] indicated the Facility identified the same risk factors with the following changes: - Not steady, only able to stabilize with human assistance. Review of the falls care plan indicated that on [DATE], the care plan was updated to include the following interventions:- Chair pad alarm when out of bed. - Transfer status: 1 assist with gait belt and walker. Review of the Resident Fall Risk Assessment of [DATE] indicated the Facility identified the same risk factors: Review of the annual MDS assessment of [DATE] indicated that Resident #1's short and long term memory was impaired, severely impaired decision making; extensive assist for transfers and ambulation, utilized a walker; and had no falls since the last assessment. Review of the nurse's note and the Facility's internal investigation of [DATE] indicated that at 7:50 P.M. Resident #1's alarm sounded and Resident #1 was found on the floor, lying on the left side, near the closet. Resident #1 was admitted to the hospital with [REDACTED]. The fall was unwitnessed. Review of the falls care plan indicated that on [DATE] the care plan was updated to include the following interventions: - Trial motion sensor in bed. - Bed in low position. Review of the nurse's note of [DATE] indicated that Resident #1 returned from the hospital. Review of the falls care plan indicated that on [DATE] the care plan was updated to include the following intervention: - 15 minute checks while in bed at night. Review of the significant change MDS assessment of [DATE] indicated that Resident #1's short and long term memory was impaired with severely impaired decision making ability"; required extensive assist for transfers and did not ambulate. Review of the nurse's note and the Facility's investigation of [DATE] indicated that at 5:20 A.M. Resident #1 was found on the floor. Resident #1 was incontinent of stool and the alarm did not sound. Resident #1 did not sustain an injury and the fall was unwitnessed. The Surveyor observed Resident #1 on [DATE] at 1:05 P.M. Resident #1 was sitting in a chair across from the nurse's station. Resident #1 wore sneakers, glasses and the chair pad alarm was underneath him/her. During a discussion and review of the falls with Unit Manager #2 on [DATE] at 10:19 A.M. Unit Manager #2 said the majority of Resident #1's falls occurred on the second shift, were unwitnessed and Resident #1, who was at risk for falls, was not adequately supervised to prevent the falls from occurring. 2. For Resident #21, the facility failed to provide adequate supervision to prevent falls. The resident fell and sustained a right orbital fracture, right maxillary sinus fracture and a subarachnoid hemorrhage. Resident #21 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the admission record indicated that the resident was admitted from another facility. The resident was transferred to the facility due to a need for a locked unit related to unsafe behaviors. Review of the admission records from the previous facility indicated the resident had a recent history of multiple falls at home, combative behavior, unsafe wandering behavior, and pain. During telephone interview ([DATE] at 12:00 P.M.) the Administrator of the previous facility indicated the resident had frequently been placed on 1:1 supervision due to unsafe behavior and unsteady gait. The Administrator said that the resident always required at least supervision with ambulation. Further review of the admission records sent to the facility, with the resident from the previous facility, indicated that the resident was unsafe ambulating alone. When the resident attempted independent ambulation, staff assisted the resident. The admission record indicated the resident frequently required 1:1 supervision. Review of the Admission Assessment of [DATE] indicated the resident was weak, had an unsteady gait but was independent with ambulation. This assessment indicated the resident had deficits in safety awareness due to cognitive decline, history of falls, difficulty with balance and was taking medication that would require increased safety precautions. Review of the Resident Fall Risk Assessment of [DATE] identified the resident as having the following risk factors for falls: -Resident had a known history of falls. -Resident was incontinent. -The resident's balance was not steady but able to stabilize without human assistance. -The resident was confused. -The resident experienced a change in mental status and exhibited unsafe behaviors. -The resident displayed wandering behaviors, nighttime wakefulness and sleep disturbances. -The resident was on medications that could affect gait and steadiness and the doses of the medications had been adjusted in the last 7 days. -The resident was at risk for falls due to osteoporosis, pain, and the fact that the resident was in a new environment. Review of the Interdisciplinary Therapy Screen of [DATE] indicated the resident was too agitated for the therapist to complete an evaluation. The therapist "recommend supervision with all mobility at this time for safety". Review of the admission care plans to prevent falls indicated the resident's ambulation status was contradictory. The Interim Care Plan of [DATE] to prevent falls indicated the resident was independent with transfers and ambulation. However, review of the Certified Nursing Assistant (CNA) care card identified by the Director of Nurses ([DATE] at 3:10 P.M.) as being the initial care plan that was utilized by CNAs, indicated that the resident was to be continually supervised by staff with ambulation. Review of the Self Care Deficit care plan of [DATE] indicated the resident was supervised with ambulation due to wandering. This care plan indicated the resident had a steady gait (inconsistent with the Nursing Assessment completed the same day that indicated the resident had an unsteady gait). Review of the nurse's note of [DATE] indicated the resident was admitted to the facility at 5:15 P.M. The resident's gait was described as steady, but fast. This note indicated the resident attempted to elope from the unit and was combative with staff. Review of the nurse's note of [DATE] indicated the resident displayed wandering behavior and rejected care. The note indicated the resident had a problem with balance and was wandering into other residents' rooms. The resident was aggressive with personal care attempts. This note indicated the resident was unsteady on his/her feet, ran down the hall and lightly bumped into the wall. This note indicated the resident "could have fallen without the assistance of staff." Further review of the record indicated that despite the unsteady gait, bumping into a wall and near fall described in the nurse's note of [DATE], no new interventions or increased supervision was documented to insure the resident's safety. Review of the nurse's note of [DATE] indicated the resident fell at 9:45 P.M. The note indicated the resident was ambulating independently in the hallway, fell hitting his/her head. The resident sustained [REDACTED]. The resident was transported to the local emergency room for evaluation and treatment. Review of the hospital emergency room report of [DATE] indicated the resident sustained [REDACTED]. Review of the falls investigation of [DATE] indicated the resident's fall was witnessed by two staff. The fall occurred in the hallway. The resident was walking independently in the hallway (exiting the dining room after breakfast) tripped and fell . This report indicated the resident had an unsteady gait or balance deficit and tripped over his/her own feet. The falls investigation indicated the resident was independent with walking. Review of Witness #1's written statement indicated the resident tripped over his/her own feet, falling forward. This statement indicated the resident said he/she was tired before the fall. Review of Witness #2's written statement indicated the resident was observed falling by a maintenance staff person as he turned his head in response to Witness #1 calling out as the resident fell . During interview on [DATE] at 3:45 P.M., Witness #2 stated that he saw the resident fall as he was entering the maintenance room on the unit. Witness #2 stated that he was not supervising the resident but just happened to be within 5 feet of the resident. During interview ([DATE] at 7:30 A.M.), Witness #1 said that she saw the resident fall in the unit hallway. Witness #1 said the resident had come out of the small dining room at the end of the hallway and was ambulating alone. The resident tripped on his/her feet and fell . Witness #1 stated she was not assigned to supervise the resident at the time and just happen to be in the hallway at the time the resident fall. Witness #1 said the resident was ambulating independently when the fall occurred. During interview ([DATE] at 12:30 P.M.), the Director of Nurses (DON) said that the facility was aware that the resident had experienced falls prior to the admission to the facility. The DON said that the record indicated that the Physical Therapist was unable to determine the ambulation status of the resident ([DATE] and [DATE]) due to agitation. The DON said that the care plan indicated the resident was both independent with ambulation and continually supervised when ambulating. During discussion it was also discussed with the DON that the facility failed to provide adequate supervision to prevent falls for this resident. Review of the nurse's note of [DATE] indicated the resident was readmitted to the facility from the hospital. Review of the nurse's note of [DATE] indicated the resident was confused with gait and balance being very unsteady. The resident required 1 to 1 supervision for safety. Review of the initial Minimum Data Assessment (MDS) of [DATE] indicated the resident had short and long term memory problems with severely impaired decision making ability. The resident was coded as requiring extensive assistance of two staff for transfers and ambulation. Review of the care plan in place [DATE] indicated the resident now used a scoot chair with a soft waist restraint, and a chair alarm. The resident's care plan indicated the resident was an assist with ambulation. Further review of the resident indicated the resident remained in the facility (on hospice) and expired on [DATE]. 3. For Resident #15, the facility failed to provide effective interventions and adequate supervision to prevent 3 falls. Resident #15, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment of [DATE] identified the resident as utilizing eyeglasses; exhibiting short and long-term memory deficits, moderately impaired decision making ability, inattention and disorganized thinking; requiring assistance during transfers and ambulation and exhibiting unsteady balance during transitions and ambulation. The falls care plan of [DATE] included the following interventions: provide well lit, uncluttered environment, never leave unattended in bathroom, bed pad alarm, wheelchair alarming seat belt, low bed and floor mats next to the bed. Review of the Fall Risk Assessment of [DATE] indicated that the resident exhibits unsafe behaviors and wanders. Review of the [DATE] Nurse's Note indicated the resident experienced an unwitnessed fall (3:00 P.M.), with no injuries. Further review indicated the resident was found on the floor, in another resident's shower room, after having removed (her/his) seatbelt. The falls care plan was updated to include: bladder pattern to determine scheduled toileting plan. Review of the [DATE] Nurse's Note indicated the resident experienced an unwitnessed fall (3:05 P.M.), sustaining an abrasion on the back area. Further review indicated the resident was found on the floor, in another resident's room, after having removed (her/his) seatbelt. The falls care plan was updated to include: offer and escort resident to scheduled activity or provide resident with diversional activity in the common area. During an interview with Unit Manager (UM) #2 on ([DATE] at 10:00 A.M.), she said the resident's care plan was updated regarding activity involvement so that the resident would receive staff supervision. Review of the quarterly MDS assessment of [DATE] remained essentially unchanged from the previous assessment except to note that the resident had experienced falls since the prior assessment. Review of the [DATE] Nurse's Note indicated the resident experienced an unwitnessed fall (6:45 P.M.), with no injuries. Further review indicated the resident was found on the floor, in another resident's room, after having removed (her/his) seatbelt. The falls care plan was updated to include: encourage bedtime between 6:00 P.M. and 6:30 P.M. and rehabilitation screen. On [DATE] at 3:55 P.M., the surveyor observed the resident in the Unit small day/activity room, sitting in a wheelchair, with other residents, at an activity and no staff members were present. At 3:57 P.M., Activity Assistant #1 entered the room and informed the surveyor that she had stepped out of the day/activity room to get some juice for the residents thus leaving the resident's alone. The resident's care plan had been updated (on [DATE]) regarding activity involvement so that the resident would receive staff supervision according to UM #2 (during interview on [DATE] at 10:00 A.M.). During an interview with CNA (Certified Nursing Assistant) #4 on [DATE] at 4:45 P.M., she said the resident routinely unfastens the wheelchair seat belt, will try to stand up from the wheelchair, will wander in and out of other resident's rooms, can be intrusive to others and becomes agitated on the 3:00 P.M. to 11:00 P.M. shift. During an interview with UM #2 on [DATE] at 10:00 A.M., she said Resident #15 does require more supervision especially due to her/his history of wandering in and out of other resident's rooms. It was also discussed with UM #2 that the facility failed to provide effective interventions and adequate supervision to prevent falls for this resident.