Every finding on record at Chicopee Rehabilitation and Nursing

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was cognitively intact, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 06/22/26, Ombudsman #2 witnessed the Administrator interact with Resident #1 in a demeaning and condescending manner.Findings include:Review of the Facility Resident Rights Policy, dated 2026, indicated the Facility will ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Further review of the Policy indicated that all owners, directors, officers, clinical staff, employees, independent contractors, consultants and others working for the Facility must treat each resident with respect and dignity and care regardless of diagnosis, severity of condition, or payment source. Resident #1 was admitted to the Facility in December 2022, diagnoses included acute kidney failure and diabetes mellitus. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/04/26, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 was wheelchair-bound and dependent on staff for transfers and toileting. During an interview on 08/04/26 at 9:15 A.M., Resident #1 said that during a meeting to discuss Resident Council events in May 2026 (exact date unknown), held in the presence of Ombudsman #2, the Administrator told him/her that he/she was ruminating (endlessly replaying negative thoughts) on the same issues, and said to him/her you should just move to another facility. Resident #1 further said that when he/she voiced his/her concerns, the Administrator responded by telling him/her, staff don't really like you, all the departments complain about you, everyone is tired of your complaining, and you should move on. During a telephone interview on 07/30/26 at 11:21 A.M., Ombudsman #2 said that on 05/22/26, when she accompanied Resident #1, at his/her request, to discuss Resident Council events with the Administrator, she heard the Administrator speak to Resident #1 in a condescending and demeaning manner. Ombudsman #2 said the Administrator told Resident #1 that he/she did not belong at the Facility, that staff did not like him/her (Resident #1), and that staff had complained about him/her. Ombudsman #2 said the Administrator did not treat Resident #1 with respect during that interaction. During an interview on 08/04/26 at 1:53 P.M., the Administrator said that Resident #1 had voiced numerous complaints and did not appear to be happy living at the Facility. The Administrator said that although Resident #1 qualified for long-term care, he believed that Resident #1 would be happier in a group home or an assisted living facility. The Administrator further said that on a few occasions, including the meeting on 05/22/26, he had told Resident #1 that he/she might be happier living elsewhere. The Administrator said that when making those statements, his intent was not to suggest that Resident #1 would be forced to leave the Facility, but rather to express his belief that another living arrangement might better suit his/her needs. The Administrator denied telling Resident #1 that staff did not like him/her.

Based on records reviewed and interviews, the facility failed to ensure newly hired employees' records contained evidence of the 2025-2026 COVID-19 vaccination for four employees (Certified Nursing Assistant [CNA] #5, Dietary Staff #1, Housekeeping Staff #1, Nurse #5), placing staff and residents at an increased risk of becoming infected with Coronavirus disease (COVID-19: an infection caused by the SARS-CoV-2 virus), out of a total of five newly hired employees records reviewed.Specifically, the facility failed to:Ensure the employees' records contained evidence of the 2025-2026 COVID-19 vaccination, or that the newly hired employees were offered the most up-to-date (2025-2026) COVID-19 vaccine or were provided information on obtaining the COVID-19 vaccine, when she/he was eligible.Ensure the employees' records contained evidence that education was provided regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine.Provide evidence that the COVID-19 vaccine status of staff was monitored (i.e., immunized or not). Findings include: Review of the US Center for Disease Control and Prevention (CDC) Overview of COVID-19 Vaccines and Vaccination guidance for health care providers, dated November 4, 2025, indicated but was not limited to the following:-The 2025-2026 COVID-19 vaccination is recommended for people ages six months and older.-.some people may be at increased risk for SARS-CoV-2 infection including healthcare workers and residents and employees in long-term care facilities . Review of the facility policy titled COVID-19 Infection Control, Education, and Vaccination Policy and Procedure, undated, included but was not limited to:COVID-19 Immunization and Vaccination:-When the COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine, unless the immunization is medically contraindicated, or the resident or staff member has already been immunized;-Before offering COVID-19 vaccine, all staff members are provided education regarding the benefits and risks and potential side effects associated with the vaccine;Documentation of Staff COVID-19 Vaccination:The facility shall maintain documentation related to staff COVID-19 vaccination that includes at a minimum, the following:-That staff were provided education, in a manner that they can understand, regarding the benefits and potential risks associated with COVID-19 vaccine;-Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and-The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).-The Facility shall maintain a roster of staff that received education (e.g., a sign in sheet), the date of the education, and sample of the educational materials that were used to educate staff.-The Facility shall document the vaccination status of each staff member (i.e., immunized or not). 1.CNA #5 was hired by the facility on 4/16/26. Review of the immunization record for CNA #5 indicated the most recent COVID-19 vaccination was received on 9/24/24. Review of CNA #5's employee file failed to indicate that the facility offered CNA #5 the 2025-2026 COVID-19 vaccine or information on obtaining the COVID-19 vaccine when he/she was eligible. The facility failed to provide evidence that CNA #5 received education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. 2. Dietary Staff #1 was hired by the facility on 3/31/26. Review of the immunization record for Dietary Staff #1 indicated the most recent COVID-19 vaccination was received on 1/4/22. Review of Dietary Staff #1's employee file failed to indicate that the facility had offered Dietary Staff #1 the 2025-2026 COVID-19 vaccine or information on obtaining the COVID-19 vaccine when he/she was eligible. The facility also failed to provide evidence that Dietary Staff #1 received education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. During an interview on 4/28/26 at 4:36 P.M., Dietary Staff #1 said the Food Service Director (FSD) had asked about their COVID-19 vaccine status during the initial interview. Dietary Staff #1 said that they had already received the initial vaccine and one more vaccine after that and that they could provide evidence of those vaccines. Dietary Staff #1 said that he/she had not been offered the most recent 2025-2026 COVID-19 vaccine. Dietary Staff #1 also said that no other staff members had asked about his/her COVID-19 vaccine status upon hire. 3.Housekeeping Staff #1 was hired by the facility on 3/13/26. Review of the immunization record for Housekeeping Staff #1 indicated he/she has not received the COVID-19 vaccination. Review of Housekeeping Staff #1's employee file failed to indicate that the facility had offered Housekeeping Staff #1 the 2025-2026 COVID-19 vaccine or information on obtaining the COVID-19 vaccine when he/she was eligible. The facility failed to provide evidence that Housekeeping Staff #1 received education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. 4.Nurse #5 was hired by the facility on 2/25/26. Review of Nurse #5's immunization record indicated the most recent COVID-19 vaccination was received on 9/21/21. Review of the employee file failed to indicate that the facility had offered Nurse #5 the 2025-2026 COVID-19 vaccine or information on obtaining the COVID-19 vaccine when he/she was eligible. The facility failed to provide evidence that Nurse #5 received education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. During an interview on 4/28/26 at 5:01 P.M., the Infection Preventionist (IP) said staff are provided education regarding the COVID-19 vaccination during new hire orientation and annually during the influenza season, but she is unable to provide evidence of education (i.e., sign in sheet, the date of education and sample of education provided). The IP said the facility does not offer the COVID-19 vaccine for staff because it is not mandated, and people do not want to receive the vaccine anymore. The IP said she does not require staff to sign a consent or declination for the COVID-19 vaccine because it is not mandated. The IP said she could look up the vaccine status of staff using the Massachusetts Immunization Information System (MIIS) if needed but did not have evidence of documentation of employee vaccine status (i.e., immunized or not).

Based on observations, interviews, and records reviewed, the facility failed to provide care and services that met professional standards of practice relative to the administration and storage of medications for two Residents (#44 and #34), out of a total sample of 16 residents. Specifically, For Resident #44, the facility failed to maintain professional standards of practice during the administration of medications, when medications were left unattended by the Nurse on 4/26/26 and 4/28/26 for the Resident to administer independently when the Resident had a preference and consented to have the Nurse administer medications on 3/19/26 and was not assessed by the facility staff for the ability to safely self-administer medications.For Resident #34, the facility failed to identify, assess, and obtain treatment orders for right lower thumb and right forearm linear scratches and reddened areas observed during survey, when a Certified Nurse Aide (CNA) was applying a non-prescribed topical medication (Hydrocortisone 1% cream- a mild corticosteroid) to the Resident's right lower thumb and right forearm linear scratches and reddened areas, and the medication was stored in an unlocked bedside table. Findings include:Review of the facility policy titled Administering Medications, revised April 2019, indicated:-Medications are administered in a safe and timely manner, and as prescribed.-Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. -Medications are administered in accordance with prescriber orders, including any required time frame.-Medications are administered within one (1) hour of their prescribed time .-The individual administering the medication initials the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones. -As required or indicated for the medication, the individual administering the medication records in the resident's medical record:>the date and time the medication was administered;>the dosage;>the route of administration;>any complaints or symptoms for which the drug was administered;>any results achieved and when those results were observed; and>the signature and titled of the person administering the drug.-Topical medications used in treatments are recorded in the resident's treatment administration record (TAR).-Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the American Medical Compliance article (https://americanmedicalcompliance.com/), titled Legal Responsibilities of Nurses in Medication Administration, dated March 24, 2025, indicated the following:-The Five Rights of Medication Administration state that Nurses must ensure:>Right patient (resident): confirm identity.>Right medication: check that the drug matches the physician's order.>Right dose: confirm that the dose is appropriate and correctly calculated>Right route: ensure the drug was given the correct was>Right time: administer the drug at the correct time-In addition, Nurses must:>administer medications as prescribed, monitor for side effects, document properly.>incomplete or false documentation can lead to legal action or loss of licensure 1. Resident #44 was admitted to the facility in March 2026 with diagnoses including Dementia with mild behavioral disturbance, Adult Failure to Thrive, and Mild Neurocognitive disorder, resided on the [NAME] Unit, and shared a room with three other residents. Review of the Minimum Data Set (MDS) Assessment, dated 3/26/26, indicated Resident #44 had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 points. Review of the Self-Administration of Medications form, signed by Resident #44 on 3/19/26, indicated:-The Resident will be advised of their right to administer their own medications and will be cautioned on the risks of doing so.-The Resident will also be made aware that when nursing staff issues medications, the Resident is relieved of their responsibility in their issue.-Resident #44 indicated on the form by written notation that he/she chose to have medications administered by the nursing staff. Review of Resident #44's April 2026 Physician's orders indicated the following:-Amlodipine Besylate (blood pressure medication), 5 milligrams (mg), 1 tablet, once daily, initiated 3/19/26-C-1000 (Ascorbic Acid- Vitamin C: vitamin supplement), 1000 mg, once daily, initiated 3/19/26-Eye Vitamins (Multivitamin with Minerals), 1 capsule daily, initiated 3/19/26-MSM 1000 mg (Methylsulfonymethane - supplement), 1 tablet daily, initiated 3/19/26-Multivitamin-Minerals, 1 tablet daily, initiated 3/19/26-Thiamine HCL 100 mg, 2 tablets daily, initiated 3/19/26-Vitamin D3, 1000 units daily, initiated 3/19/26 Further review of the April 2026 Physician's orders indicated:-The Resident's Health Care Proxy (HCP: representative designated to make health care decisions if the person was no longer able) was invoked, dated 3/31/26.-There were no medications prescribed that indicated Resident #44 was able to self-administer. On 4/26/26 at 10:20 A.M., the surveyor observed Resident #44 dressed and seated on the bed in his/her room. A medication cup with multiple pills was observed on the over the bed table positioned next to the Resident. The surveyor did not observe a Nurse present in the room or outside of the Resident's room. During an interview at the time, Resident #44 said the medication cup containing the pills were his/her morning medications that were provided to him/her by the Nurse. On 4/28/26 at 8:47 A.M., the surveyor observed Resident #44 dressed and seated on the bed in his/her room eating breakfast. A medication cup containing multiple pills was observed on the over the bed table positioned next to the Resident and there was no Nurse present in or outside of the Resident's room. During an interview at the time, Resident #44 said the medication cup containing pills were his/her medication from the facility that he/she takes after breakfast. During an interview on 4/28/26 at 8:58 A.M., Nurse #2 said she was Resident #44's Nurse. Nurse #2 said Resident #44 was alert and oriented and took his/her medications whole. The surveyor and Nurse #2 walked from the North Unit to the [NAME] Unit (where Resident #44 resided) to the Resident's room, and the Resident was not observed in the room at this time, and the medication cup with eight pills remained on the Resident's over the bed table. Nurse #2 said the medication cup on Resident #44's over the bed table was the Resident's vitamins and included Vitamin C, Vitamin D, Vitamin B and MSM that were provided from the facility. Nurse #2 said she should have stayed with Resident #44 until the medications were administered. Nurse #2 said Resident #44 had not been assessed and did not have Physician's orders to self-administer medications. Nurse #2 said she had already signed off on Resident #44's MAR that these medications were administered and should not have. Nurse #2 said that leaving Resident #44's medications unattended was a concern because another resident could have consumed them or Resident #44 may not take them. During an interview on 4/28/26 at 10:14 A.M., the Director of Nursing (DON) said Resident #44 could not self-administer his/her medications and the Nurse should not have left them medication cup containing pills for the Resident to consume without the Nurse present. The DON said there was no assessment completed or Physician's orders for Resident #44 to administer his/her medications. The DON said Nurse #2 should not have signed off on the MAR that Resident #44's medication had been administered when they had not been, and that by leaving the Resident's medications unattended, another resident could have consumed them, or Resident #44 may not have taken them. 2. Resident #34 was admitted to the facility in August 2021 with diagnoses including spastic hemiplegia (paralysis) affecting the left nondominant side, Cerebrovascular disease, Todd's paralysis, and subdural hemorrhage with loss of consciousness. Review of the facility policy titled Charting and Documentation, revised July 2017, indicated the following:-all services provided to the resident, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. -the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. -documentation of procedures and treatments will include care-specific details, including:>the date and time the procedure/treatment was provided;>the name and title of the individual(s) who provided the care;>the assessment data and/or any unusual findings obtained during the procedure/treatment;>how the resident tolerated the procedure/treatment;>whether the resident refused the procedure/treatment;>notification of family, physician or other staff, if indicated; and>the signature and title of the individual documenting. Review of the Agency for HealthCare Research and Quality article titled Toolkit for Improving Skin Care and MDRO (Multidrug Resistant Organism) Prevention in Long-Term Care (http;//www.ahrq.gov), dated September 2025, indicated the following under Conducting a Comprehensive Skin Assessment:-Attributes of a comprehensive skin assessment:>process for examining entire skin for abnormalities>requires looking at and touching skin from head to toe-Goals include to identify other important skin conditions and identify care planning needs.-Five Parameters of Comprehensive Skin Assessment:>temperature>turgor (firmness)>color>moisture level>skin integrity (skin intact, open areas, rashes)-Skin warmth or coolness can indicate skin damage including inflammation of the skin-Compare adjacent areas of skin for color.-Redness can indicate many skin problems (rash, infection)-For skin redness: make sure to get the etiology (cause) right so that the treatment is appropriate.-Comprehensive skin assessments must be standardized and ongoing-Document and report results-If there are problems, report results to the care team members and to the provider. Review of the MDS Assessment, dated 2/5/26, indicated Resident #34:-has intact cognition as evidenced by a BIMS score of 14 out of a possible 15 points. -has range of motion impairments on both upper and lower extremities on one side.-utilized a wheelchair.-was dependent on staff for bathing, dressing and personal hygiene needs. On 4/26/26 at 8:54 A.M., the surveyor observed Resident #34 seated in a specialized wheelchair in his/her room watching television. The surveyor observed the Resident's left arm was bent at the elbow and closed in a fist at his/her chest and the Resident's right hand was observed holding the remote control for the television. The surveyor further observed the Resident's right lower thumb, wrist and forearm areas were observed to have linear marks and the surrounding skin had irregularly shaped reddened areas. During an interview at the time, Resident #34 said the linear marks were scratches and that his/her skin was itchy. Resident #34 said a cream was applied to the area a few times daily which helps with the itch. Resident #34 said he/she was unable to open his/her left hand. On 4/26/26 at 3:14 P.M., the surveyor observed Resident #34 lying in bed with his/her eyes closed. The Resident's left hand was closed in a fist on his/her chest, and his/her right hand was closed over the left fist and the linear marks remained on the Resident's right lower thumb, wrist and forearm with the surrounding areas of red/pink skin. On 4/27/26 at 8:30 A.M., the surveyor observed Resident #34 dressed and seated in a specialized wheelchair during breakfast in the dining room. The Resident was using his/her right hand to feed him/herself, and numerous linear marks were observed on the Resident's right lower thumb, right wrist and forearm. The skin surrounding the linear marks was patchy pink/red and the Resident's forearm was observed to have an irregularly shaped reddened area approximately six inches in length. On 4/27/26 at 11:29 A.M., the surveyor observed Resident #34 dressed and seated in a wheelchair in his/her room watching television. The Resident's right hand remained with multiple linear scratches on the lower outer thumb, wrist and the irregularly shaped area on the Resident's right forearm was observed to be very bright red in color and several serous looking drops of fluid were observed on the skin. During an interview at the time, when the surveyor asked, the Resident did not say that the areas on his/her right hand, wrist and arm were itchy and when further asked if the Nurse was aware of the areas on his/her right hand and arm, the Resident said yes, then no. Review of Resident #34's clinical record indicated the following:-April 2026 Physician's orders that included:>weekly skin checks with showers, initiated 2/1/24>no treatment orders for the Resident's right thumb, wrist or forearm. -Weekly Skin Assessment, completed 4/16/26 that indicated the Resident's skin was intact and had no rashes. -Physician Progress Note, dated 4/9/26, that indicated the Resident's skin was warm and dry with no areas of breakdown. The note further indicated the Resident had generally limited movement except for his/her upper right extremity with contractures of left upper extremity, hips and knees.-Potential for Skin Impairment Care Plan, initiated 6/18/19 that indicated increased risk due to immobility and included the following interventions:>keep skin clean and dry. Use lotion on dry skin. Do not apply to open areas, initiated 6/18/19>Monitor for side effects of antibiotics and over-the-counter pain medications .rash or allergic reactions which could exacerbate skin injury, initiated 6/18/19-Skin Integrity Impairment Care Plan, initiated 11/24/25 that indicated the Resident had self-inflicted scratches to his/her left arm, thighs and included the following interventions also initiated on 11/24/25:>ensure fingernails are trimmed and filed.>skin checks each shift, notify nurse of changes. Further review of Resident #34's clinical record failed to indicate the Resident's areas on his/her right lower thumb, wrist and forearm had been identified and assessed by the licensed nursing staff. During an interview on 4/27/26 at 12:01 P.M., CNA #1 said that she was familiar with Resident #34 and had been working with him/her since the beginning of April. CNA #1 said the Resident required total assistance from staff with bathing, dressing, grooming, toileting, and mobility needs. CNA #1 said Resident #34 had no behaviors, was receptive to care, and had paralysis on his/her left side. CNA #1 said the Resident had a rash on his/her right hand and right arm from scratching and has had this rash since she started working with him/her. CNA #1 said the Resident's rash had not gotten worse since she started working with him/her, and that she applies a cream to the Resident's rashy areas in the morning and in the afternoon when the Resident goes back to bed which helps. The surveyor and CNA #1 went to Resident #34's room to observe the cream that she applied and the surveyor observed a pink basin in the Resident's bedside cabinet that contained bathroom toiletries and a box of Hydrocortisone Cream 1%. The tube of Hydrocortisone Cream 1% was opened. The surveyor observed that the box the tube of cream was in did not specify a resident name or ordering Physician. CNA #1 said the open Hydrocortisone Cream 1% was what she applies to Resident #34's skin in the morning and in the afternoon, and said the Nurses provided her with the Hydrocortisone Cream 1% to apply to the Resident. During an interview on 4/27/26 at 12:21 P.M., Nurse #1 said she was familiar and works with Resident #34 regularly. Nurse #1 said Resident #34 has red areas on his/her arms that come and go, that the Resident has a Reacher in his/her room and uses the Reacher to scratch his/her arms. Nurse #1 said the Resident has moisturizing lotion that can be applied to the skin. Nurse #1 said if a rash is observed, the Provider would be notified, and a treatment would be ordered. Nurse #1 reviewed Resident #34's Physician's orders and said the Resident did not have current treatment orders for his/her right hand, wrist or arm. Nurse #1 said she was not aware of Resident #34 having any skin areas on his/her right hand, wrist and forearm until today. Nurse #1 said she asked the Resident about the red areas and the Resident told her that he/she was itchy and scratched it. Nurse #1 said the last completed skin check on 4/16/26 indicated the Resident did not have any areas of concern. The surveyor and Nurse #1 went to Resident #34's room and observed the pink basin containing toiletries and the opened box/tube of Hydrocortisone Cream 1% in the Resident's bedside cabinet. Nurse #1 said the tube of Hydrocortisone Cream 1% was almost empty, and the surveyor observed her remove the cream from Resident #34's room. Nurse #1 said there was no resident name on the box of Hydrocortisone Cream 1% and that this was a treatment that required a Physician's order and the CNAs should not be applying it because it was a treatment to be administered by licensed nursing staff. During an interview on 4/27/26 at 1:47 P.M., the DON said a resident's skin is assessed on admission, and then weekly and with any changes. The DON said if staff noticed a change in the resident's skin, a skin assessment should be completed by the Nurse, the Physician should be notified and a treatment obtained for the area(s). The DON said the resident's skin area(s) would be monitored under the Treatment Administration Record (TAR). The DON said she evaluated Resident #34 skin this afternoon. The DON said the Resident would not be able to use the Reacher in his/her room to scratch his/her right hand/arm because the Resident was unable to use his/her left hand/arm. The DON also said the CNAs should not have been applying the Hydrocortisone Cream 1% to the Resident's red areas on the right hand, wrist and arm, that the Hydrocortisone Cream 1% would require a Physician's order, and the licensed nurses would need to apply it.

Based on observations, interviews and record review, the facility failed to ensure devices used to treat a decrease in range of motion (ROM) due to contractures and prevent further reduction or worsening of contractures were implemented as ordered by the Physician, for one Resident (#34), out of a total sample of 16 residents. Specifically, the facility failed to ensure the following devices were implemented as recommended by the Occupational Therapist (OT) and as ordered by the Physician increasing the potential for decreased range of motion, worsening contractures, pain, and impaired skin integrity:-A soft sling to be utilized during the day shift (7:00 A.M. to 3:00 P.M.) was applied to Resident #34's left arm to prevent worsening spasticity (tightening) of the elbow/arm.-A carrot (a soft carrot shaped device) was applied to the Resident #34's left hand at all times except when performing hygiene and checking skin integrity to prevent worsening of his/her left-hand contracture.In addition, the facility failed to ensure the Rehabilitation Department was notified to re-evaluate the use and appropriateness of the devices when the Resident had episodes of refusing the devices application. Findings include: Review of the facility policy titled Resident Mobility and Range of Motion, revised July 2017, indicated the following:-Residents will not experience an avoidable reduction in range of motion (ROM).-Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM.-Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. -The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed.-The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. -Interventions may include therapies, the provision of necessary equipment, and will be based on professional standards of practice-The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. -Documentation of the resident's progress towards the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. Resident #34 was admitted to the facility in August 2021 with diagnoses including Cerebrovascular disease, muscle weakness, Todd's paralysis, traumatic subdural hemorrhage with loss of consciousness and hemiplegia (paralysis) affecting the left nondominant side. Review of the OT Discharge summary, dated [DATE], indicated the following:-staff reeducated and trained on use of orthotic wear orders/schedule for the Resident's left UE (upper extremity).-devices included left hand carrot and left soft elbow splint Review of the Minimum Data Set (MDS) Assessment, dated 2/5/26, indicated Resident #34:-was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 points-had upper and lower ROM impairments on one side-was dependent on staff for bathing, dressing and personal hygiene needs-exhibited no behaviors or rejections of care during the reference period. Review of Resident #34's comprehensive care plans included the following:-Potential for Skin Impairment, initiated 6/18/19, with the following interventions:>left hand carrot orthotic to hand on at all times and remove every shift for skin inspection and hygiene, initiated 12/9/20>educate resident, family, caregivers of causative factors and measures to prevent skin injury, initiated 6/18/19-Activities of Daily Living deficit related to stroke with left hemiplegia, initiated 6/18/19 and included the following interventions:>Resident to have left hand carrot orthotic to hand at all times with removal every shift for hygiene and skin inspection, initiated 3/10/20>requires total assistance of staff with personal hygiene and dressing, initiated 6/18/19-Physical Mobility related to neurological deficits, initiated 6/21/19, and included the following intervention:>provide gentle range of motion as tolerated with daily care to left upper extremity. [NAME] soft elbow splint at AM and remove at lunch (3 hours), initiated 12/4/23 Review of the Interdisciplinary Care Plan Meeting, dated 2/18/26, indicated the Director of Rehabilitation was present at the meeting. Further review of the care plan meeting notes did not indicate concerns relative to the ordered orthotic devices (carrot, sling) or Resident refusals for the use of the devices. Review of the April 2026 Physician's orders indicated:-Resident to have left hand carrot orthotic to hand at all times with removal every shift for hygiene and skin inspection, initiated 12/9/20-Adaptive Positioning: left elbow splint on after AM care/dressing and remove before lunch, initiated 3/13/25 Review of the Certified Nurse Aide (CNA) Care Card, dated 4/27/26, indicated Resident #34:-was dependent on staff with dressing and personal hygiene-required left hand carrot orthotic to hand at all times with removal every shift for hygiene and skin inspection On 4/26/26 at 8:54 A.M., the surveyor observed Resident #34 dressed and seated in his/her room watching television and the Resident's left arm was bent at the elbow with his/her hand closed and positioned against their chest. The surveyor did not observe any devices in the Resident's left hand or on the left arm. During an interview at the time, Resident #34 said he/she could not open his/her left hand and that there were no devices used for his/her left hand. On 4/26/26 at 3:14 P.M., the surveyor observed Resident #34 lying in bed with his/her eyes closed. The Resident's left arm was observed bent at the elbow, and the left hand was closed in a fist and resting on the Resident's chest. The surveyor did not observe any orthotic devices in place on the Resident's left hand and arm. On 4/27/26 at 8:30 A.M., the surveyor observed Resident #34 dressed and seated in the dining room eating breakfast. The Resident's left hand was unable to be observed (it was under a towel). There was no soft splint observed on the Resident's left arm. On 4/27/26 at 11:29 A.M., the surveyor observed Resident #34 dressed and seated in a wheelchair in his/her room watching television. The Resident's left arm was bent at the elbow with his/her left hand closed in a fist and against the chest. The surveyor observed a loosely rolled washcloth in the Resident's left hand and white powder was observed in the crease of the Resident's left elbow. During an interview on 4/27/26 at 12:01 P.M., CNA #1 said Resident #34 required total assistance from staff with bathing, dressing care needs and had left sided paralysis. CNA #1 said Resident #34 was receptive to care and had no behaviors. CNA #1 said the Resident has a carrot that is put in his/her left hand for 30 minutes daily. CNA #1 said they will offer to put the carrot in the Resident's left hand in the morning and sometimes he/she refuses, so they re-approach him/her after lunch. The surveyor and CNA #1 went to the Resident's room where CNA #1 showed the surveyor the location of the carrot device. CNA #1 said the Resident also has a blue sling that the staff apply at night for the Resident's left arm. CNA #1 further said she works full time and typically Resident #34 will wear the carrot for about 30 minutes every other day. CNA #1 said if the Resident refuses to wear the carrot, she will notify the next shift CNA who will offer to apply it. The surveyor and CNA #1 observed Resident #34 who was seated in a wheelchair the dining room prior to lunch and observed the Resident's left arm was bent at the elbow, and his/her hand was closed in a fist and against his/her chest with a loosely rolled wash cloth in the Resident's left hand. CNA #1 said the Resident's left hand is contracted and can only open his/her hand a little bit. CNA #1 said they try their best to clean the left hand, but it is difficult. During an interview on 4/27/26 at 12:21 P.M., Nurse #1, who works full time, said Resident #34 has a carrot for his/her left hand but the Resident refuses to wear it and has the right to refuse to wear it. Nurse #1 said if the Resident refuses to wear the carrot, they will offer it again after lunch. Nurse #1 said if the Resident continues to refuse the carrot, they will document in the medical record. Nurse #1 said she was not sure of the purpose of the adaptive devices for the Resident. During a follow-up interview on 4/27/26 at 2:16 P.M., Nurse #1 said the Resident has adaptive devices for his/her contractures. Nurse #1 said the Resident has a carrot for the left hand and a sling to the left arm that should be applied during the day. Nurse #1 said when the Resident refuses to wear the recommended devices, the Nurses are made aware, they provide education and then they would document that the Resident refused. During an interview on 4/27/26 at 3:16 P.M., the OT said she has worked with Resident #34 on several occasions for contracture management. The OT said Resident #34 had a left arm contracture, had high spasticity and increased tone to the left arm. The OT said because of his/her contractures, the Resident had an increased risk of skin issues. The OT said the soft elbow sling should be applied in the morning and removed around lunchtime for approximately three (3) hours and that education was provided relative to this in March 2025 when the Resident was discharged from therapy. The OT said the purpose of the soft elbow sling was to allow a light stretch so that the Residents' left arm was not against the chest and to provide extension of the elbow. The OT said the Resident also has a carrot that was to put in his/her left hand due to left hand contracture to assist with keeping the hand open. The OT said the carrot device is able to be slid into the Resident's closed hand and pulled through the other side and that the Resident has been able to do assist the staff with applying this. The OT said she had completed a quarterly screen in August 2025 and had no new recommendations for Resident #34 and that the interventions remained appropriate. The OT said she was not aware that Resident #34 had been refusing to wear the orthotic devices (left arm sling and carrot), and she would expect the facility staff to notify her so that she can complete a rehabilitation screen and follow up. The OT said when therapy discharged the Resident from skilled services, Physician's orders were initiated for the adaptive devices and included a schedule for wearing. During an interview on 4/27/26 at 3:35 P.M., the Director of Rehabilitation (DOR) said she attended Resident #34's care plan meeting on 2/18/26, and there was no mention of the Resident refusing the recommended orthotic devices. The DOR said a rehabilitation screen should be completed anytime there was a concern and there was no screen submitted for Resident #34. During a follow-up interview on 4/28/26 at 9:26 A.M., the OT said she evaluated Resident #34 this morning. The OT said the Resident stated he/she had no concerns with wearing the recommended devices (carrot, sling). The OT said the Resident's current range of motion of the left arm/hand were about the same, that by not wearing the ordered orthotic devices (carrot, sling), the Resident could have a decrease in his/her range of motion and an increased risk of skin impairment.

Based on observations, interviews, and record review, the facility failed to provide reasonable accommodation pertaining to a bed for one Resident (#70) out of a total sample size of 16 residents. Specifically, for Resident #70, the facility failed to provide the option of a bed extender to prevent his/her lower extremities from hitting the wooden footboard, when the Resident was admitted with lower extremity cellulitis, an ankle sprain and a right heel deep tissue injury (DTI), placing him/her at risk for further lower extremity injury.Findings include: Review of the facility policy titled Resident Rights Policy and Procedure, dated 2019, indicated Residents have the right: -To a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. -This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Resident #70 was admitted to the facility in April 2026 with diagnoses including cellulitis of the right lower limb, sprain of calcaneofibular ligament of the right ankle and DTI (deep tissue injury) of right heel. Review of Resident #70's Height Record dated 4/24/26, indicated that he/she was 71 inches (5'11') in height. On 4/26/26 at 9:03 A.M., Resident #70 was observed lying in bed with the head of the bed slightly elevated. Resident #70's knees were bent and he/she was unable to straighten the legs without his/her feet without coming into contact with the wooden footboard. On 4/27/26 at 7:39 A.M., Resident #70 was observed lying in the bed with his/her legs extended over the wooden footboard with both posterior ankles' areas resting on the top of the footboard. CNA #2 was observed assisting Resident #70 with his/her socks. During an interview at the time, CNA #2 said she was aware the bed was too short for Resident #70 and had been like this since admission. CNA #2 said that the staff try to place a pillow between Resident #70's feet and the wooden footboard to prevent injury to the feet. During an interview on 4/27/26 at 12:36 P.M., Resident #70 said that the wooden footboard had been causing him/her some discomfort, and he/she indicated that the back of the legs and right ankle were bothered by the footboard. During an interview on 4/27/26 at 12:37 P.M., CNA #2 said that staff had been trying to prevent Resident #70's feet from coming into contact with the wooden footboard and had been placing a pillow in between the Resident's feet and the footboard but said the pillow did not work well. CNA #2 said that Resident #70 had been struggling with his/her feet coming into contact with the footboard since admission and would benefit from a longer bed. During an interview on 4/27/26 at 2:41 P.M., Nurse #3 said that Resident #70 had a bed extension added today and said that Resident #70 now appeared comfortable. Nurse #3 said that any Resident who requires a bed extension should be assessed as soon as possible. Nurse #3 said the purpose of the longer bed was to avoid discomfort and prevent development of pressure ulcers from the footboard and that the Resident appeared more comfortable with the bed extender. At the time of the interview, Resident #70 was observed lying in the bed with his/her legs fully extended and said that the new bed was much more comfortable. During an interview on 4/27/26 at 3:11 P.M., the Maintenance Director said that he provided Resident #70 a new bed with an extender today because staff said Resident #70's feet were touching the footboard, and it was bothering him/her. The Maintenance Director said that the building had plenty of beds available and that he had not been previously notified of Resident #70's request for a longer bed. During an interview on 4/27/26 at 4:02 P.M., the Director of Nursing (DON) said when CNA #2 had identified an issue with Resident #70's feet contacting with the footboard, he/she should have previously told someone, but did not. The DON said that the facility would have provided Resident #70 with a longer bed if it had been brought to their attention.

Based on observation, and interview, the facility failed to ensure that patient care equipment was maintained in a safe operating condition for one Resident (#3) out of a total sample of 17 residents. Specifically, for Resident #3, the facility failed to ensure that his/her wheelchair was maintained in safe condition when the left cushioned armrest of the Resident's wheelchair was missing leaving a metal bar and exposed screw and placing the Resident at risk of injury. Findings include: Resident #3 was admitted to the facility in May 2024 with diagnoses including Cerebral Infarct (Stroke) and Rheumatoid Arthritis. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 9 out of a total possible score of 15 -the Resident was dependent for transfers to and from the chair During an observation on 2/12/25 at 2:00 P.M., the surveyor observed Resident #3 sitting up in his/her wheelchair in the facility dining room. The surveyor observed that the left armrest of the wheelchair was missing and the head of a screw where the armrest would be attached was sticking up from the metal bar. During an observation and interview on 2/13/25 at 11:51 A.M., the surveyor and Nurse #5 observed Resident #3's wheelchair to be missing the left armrest with an exposed screw head sticking up from the metal bar where the armrest would be attached. Nurse #5 said the armrest should not be like that. Nurse #5 said that something like this should have been reported to maintenance immediately through the facility online work order system. Nurse #5 further said she would notify maintenance and the therapy department immediately. During an interview on 2/13/25 at 12:49 P.M., the Maintenance Director said that the employee handbook indicated that all staff are responsible to report any broken equipment immediately to maintenance or their supervisor. The Maintenance Director further said that the facility used an electronic system to send work orders directly to his phone and/or computer. The Maintenance Director said he had not received any work order before today (2/13/25) that Resident #3's wheelchair required repair. The surveyor and the Maintenance Director reviewed a photograph taken of Resident #3's wheelchair's missing armrest. The Maintenance Director said the missing armrest was a concern due to the potential for the Resident to be injured.

Based on observation, interview, and record review, the facility failed to ensure that infection control practices were implemented to prevent the spread of infection on two Units (North Unit and [NAME] Unit) of two units observed. Specifically, the facility failed to: 1. For Resident #164 who resided on the North Unit, ensure that staff utilized proper Enhanced Barrier Precautions (EBP - set of infection control practices that uses Personal Protective Equipment (PPE) such as gowns and gloves to reduce the spread of multidrug resistant organism to residents who are at risk due to having a wound or indwelling medical device). 2. For Resident #35 who resided on the North Unit, ensure that staff utilized proper Contact Precautions (set of infection control practices that are used when a resident is diagnosed with a condition that can spread from person to person by touch or by direct contact with contaminated objects and surfaces) when entering the Resident's room. 3. For Resident #54 who resided on the [NAME] Unit, ensure that staff use proper infection control practices to clean and disinfect scissors used to remove a soiled dressing before reusing the scissors to cut clean dressing materials. 4. For Resident #60 who resided on the North Unit: 1) initiate Transmission Based Precautions (TBP- measures implemented for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) when the Resident was symptomatic of infection and was awaiting laboratory results for a potential transmissible infection, and 2) adhere to Isolation/Droplet Precautions (used for diseases spread in tiny droplets caused by coughing and sneezing) increasing the risk for the potential spread of infection. Findings include: 1. Review of the facility policy titled Enhanced Barrier Precautions, revised March 2024, indicated: -Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention . -EBPs are indicated .for residents with wounds and/or indwelling medical devices . Resident #164 was admitted to the facility in February 2025 following surgery to place a Jejunostomy (J) Tube (tube surgically placed directly into the small intestine for the delivery of nutrition) and right sided Jackson Pratt (JP) drain (an indwelling medical device that is inserted through the skin into the body cavity allowing excess fluid to drain through a tube to a collection bag outside the body). Review of the Nursing Progress Notes dated 2/9/25, 2/10/25, and 2/11/25, indicated Resident #164's JP drain was leaking from the tube incision site. On 2/12/25 at 7:57 A.M., the surveyor observed signs posted outside Resident #164's door indicating Enhanced Barrier Precautions (EBP): Use gloves and gown for high contact care including dressing. The surveyor observed Resident #164 was sleeping in bed, and his/her shirt was saturated with fluid on the right side of his/her body. On 2/12/25 at 9:10 A.M., the surveyor observed Rehabilitation Staff Member #1 in Resident #164's room assisting the Resident with direct care. The surveyor observed Rehabilitation Staff Member #1 was only wearing gloves and no other PPE. During an interview at the time, Rehabilitation Staff Member #1 said she was unaware that Resident #164 was on EBP and thought Resident #164's roommate was on EBP. When the surveyor asked why a resident would be on EBP, Rehabilitation Staff Member #1 said any resident who has a catheter, drain, or wound would be on EBP. Rehabilitation Staff Member #1 further said Resident #164 had a JP drain and she was assisting him/her with changing his/her shirt as the JP drain had leaked. Rehabilitation Staff Member #1 said she had only been wearing gloves and should have also been wearing a gown. 42690 2. Resident #35 was admitted to the facility in July 2024 with diagnoses including Diabetes, small cell lung carcinoma (lung cancer) receiving chemotherapy, Chronic Obstructive Pulmonary Disease (COPD), and C-Diff (Clostridium difficile, a spore forming toxin that can develop in the intestines after antibiotic use and causes watery diarrhea. C-Diff can be spread from person to person by touch or by direct contact with contaminated objects and surfaces). On 2/13/25 at 10:54 A.M. the surveyor observed the following: -A Contact Precaution sign posted outside the Resident's door indicating: >everyone must clean their hands before entering and when exiting the room >provider and staff must also put on gloves before room entry >provider and staff must put on gown before room entry -PPE located outside of the Resident's door -Resident #35's call bell to be on -CNA #4 knock on the Resident's door and enter the room -CNA#4 did not perform hand hygiene or don (put on) the required PPE as indicated on the signage located outside of the Resident's door. During an interview at the time, CNA #4 said that the signage indicated to use hand sanitizer before and after entering the Resident's room and to don a gown and gloves when entering the Resident's room. CNA #4 said that she did not follow the requirements as listed on the Contract Precautions sign. 50563 3. Resident #54 was admitted to the facility in November 2024 with diagnoses including Dementia and an intertrochanteric fracture of the right femur. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of a possible score of 15. On 2/14/25 at 11:10 A.M., the surveyor observed the following during wound care provided to Resident #54 by Nurse #2: -Nurse #2 gathered needed supplies, performed hand hygiene, donned gloves, and entered Resident #54's room -Nurse #2 disinfected the overbed table -Nurse #2 doffed (removed) gloves, performed hand hygiene, draped the overbed table with a barrier and set up supplies -Nurse #2 performed hand hygiene, donned a gown and gloves -Nurse #2 cut off the soiled bandage with scissors and placed the scissors on the overbed table to the side of the barrier -Nurse #2 used wound cleanser to loosen and remove dressing from the wound bed -Nurse #2 doffed gloves, performed hand hygiene and donned new gloves -Nurse #2 cleansed the wound with wound cleanser and gauze -Nurse #2 doffed gloves, performed hand hygiene and donned new gloves -Nurse #2 applied skin prep to the peri-wound, Santyl to the wound bed followed by Dakins 1/4 strength soaked gauze -Nurse #2 doffed gloves, performed hand hygiene and donned new gloves -Nurse #2 covered the area with an abdominal pad and wrapped it with rolled gauze -Nurse #2 used the scissors that were used to cut off the soiled dressing to cut the rolled gauze to size without cleaning and disinfecting the soiled scissors -Nurse #2 taped the dressing to secure it During an interview on 2/14/25 at 11:30 A.M., Nurse #2 said that she should have cleaned and disinfected the scissors before using them to cut the new dressing material because the scissors were considered dirty after use on the soiled dressing, but she had not cleaned and disinfected the scissors. During an interview on 2/18/25 at 7:59 A.M., the Infection Control Preventionist (ICP) said that after scissors are used to cut off a dressing they should be cleaned and disinfected before being used to cut new dressing materials. The ICP further said that the old dressing is considered contaminated and using scissors that cut off an old dressing without cleaning and disinfecting them to cut new dressing materials could contaminate the new dressing. 37400 4. Resident #60 was admitted to the facility in January 2025 with diagnoses including Acute Respiratory Failure with hypoxia (low levels of oxygen in the blood) and Respiratory Syncytial Virus (RSV - contagious virus that affects the respiratory system and has cold-like symptoms such as a runny nose and cough). Review of the Minimum Data Set (MDS) Assessment, dated 1/31/25, indicated Resident #60: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -had no behaviors -required substantial/maximum assistance from staff with bathing, dressing and toileting needs -was not on Isolation or Quarantine for active infectious disease Review of the facility Matrix provided by the facility on 2/12/25 did not indicate Resident #60 was on TBP. Review of the Resident #60's clinical record indicated the following: -Nursing Note dated 2/10/25, Resident requesting cough medication, the Provider was made aware and new orders were obtained. -Skilled Nurse Note dated 2/10/25, Resident continued to have non-productive cough. -Nursing Note dated 2/11/25, Resident received chest X-ray today and results were normal. Nasal swab for Covid/Flu and RSV completed and will be picked up on 2/12/25. Review of the February 2025 Physician's orders included the following: -Flu/Covid-19/RSV viral swab - discontinue when specimen obtained, initiated 2/11/25 and discontinued 2/13/25 -chest X-ray for cough - discontinue when test completed, initiated 2/11/25 and discontinued 2/13/25 -Isolation Precautions, initiated 2/14/25 On 2/13/25 at 2:00 P.M., the surveyor observed Resident #60 dressed and seated in a wheelchair in his/her room. The surveyor did not observe TBP signage posted outside of the Resident's room. On 2/14/25 from 8:05 A.M. through 8:14 A.M., the surveyor observed the following: -8:05 A.M., Isolation Droplet/Contact Precaution signage posted outside of Resident #60's room which included the following instructions: *Stop. In addition to Standard Precautions, Staff and Providers must: >clean hands when entering and exiting >put on a gown and change (the gown) between each resident >put on an N95 respirator or facemask if N95 respirator is not available >put on eye protection (goggles or face shield) >put on gloves and change (the gloves) between each resident -a bin containing Personal Protective Equipment (PPE) which contained N95 masks, gowns and gloves. No eye protection was observed in the PPE bin. -8:06 A.M., Certified Nurses Aide (CNA) #2 opened the door to the room (from inside of the room) and was observed to be wearing an N95 mask and a gown while holding a bag with soiled items with her gloved hands. CNA #2 did not have eye protection on. CNA #2 doffed her gown, put it in a bag, and exited the room to discard the soiled items. CNA #2 did not discard her gloves or N95 mask after exiting the room. The door of the Resident's room was left open, and the surveyor observed Resident #60 dressed and seated in a wheelchair. -8:09 A.M., Resident #60 was observed to self-propel to the middle of the room, and position the wheelchair next to his/her roommate while having a conversation. Neither Resident had face masks on, and both Residents were observed to have intermittent coughing. -8:14 A.M., the surveyor observed Resident #60 seated in a wheelchair in the doorway to his/her room. During an interview at the time, Resident #60 said he/she had a cough. During an interview on 2/14/25 at 8:17 A.M., Nurse #2 said Resident #60 was placed on Isolation Precautions today because he/she had a laboratory test which was pending results. During an interview on 2/14/25 at 8:27 A.M., CNA #2 said the Isolation/Droplet Precaution signage posted outside of Resident #60's room was added today, and it was because the Resident had an RSV infection. CNA #2 said prior to entering Resident #60's room, she had put on an N95 mask, a gown and gloves. The surveyor and CNA #2 reviewed the Isolation/Droplet Precaution signage posted. CNA #2 said the Isolation/Droplet Precaution signage indicated she was supposed to put on eye protection prior to entering the Resident's room. CNA #2 said she didn't put eye protection on, and she knew she should have. CNA #2 looked in the PPE bin located outside of Resident #60's room and said there was no eye protection available in the PPE bin. CNA #2 further said there should be extra PPE supplies at the nurses station. The surveyor and CNA #2 walked to the nurses station, and were able to locate gowns, gloves and face masks, but were unable to find eye protection. On 2/14/25 from 8:35 A.M. through 8:44 A.M. the surveyor observed the following during the breakfast meal pass: -8:35 A.M., CNA #3 donned a gown, gloves and N95 mask prior to entering Resident #60's room to deliver the breakfast trays to his/her roommate. Resident #60 was observed dressed and seated in a wheelchair near the entrance of the room. After delivering the breakfast tray, CNA #3 stood at the entrance to Resident #60's room and requested Resident #60's breakfast meal while in close proximity to the Resident. -8:42 A.M., the Infection Preventionist (IP) was observed to restock the PPE bin outside of Resident #60's room with eye protection and then assisted CNA #3 with donning eye protection. -8:44 A.M., CNA #3 was observed to deliver and set up Resident #60's breakfast meal and Resident #60 was observed to say if you are dressed like that- I must have Covid .I ' m not stupid .I want information. During an interview on 2/14/25 at 8:45 A.M., CNA #3 said she did not don eye protection prior to entering Resident #60's room because there was no eye protection in the PPE bin. CNA #3 said she should have contacted the Director of Nursing (DON) or the IP to request more eye protection prior to entering the Resident's room but she did not. During an interview on 2/14/25 at 8:55 A.M., the IP said that she was not made aware until late on 2/13/25 about the RSV/Covid/Flu test that was pending for Resident #60. The IP said the testing was ordered by the Physician on 2/11/25, and at that time, Isolation/Droplet precautions should have been implemented, but it was missed. The IP said the facility had plenty of PPE available, that extra PPE supplies were located off the unit, and if the staff needed more, they knew to ask, and it would be restocked.

Based on record review, and interview, the facility failed to provide continuity of care related to Hospice Services for one Resident (#42) out of a total sample of 17 residents. Specifically, for Resident #42, the facility failed to: -designate a member of the interdisciplinary team (IDT) responsible for working with Hospice Representatives to coordinate care provided by the facility staff and Hospice staff. -obtain the most recent Hospice Plan of Care and ensure that it was readily available. Findings include: Review of the Hospice Nursing Facility Services Agreement dated May 31, 2023, indicated: -Nursing facility and Hospice shall develop procedures regarding communications and the documentation of such communications to ensure that the needs of the patient are addressed and met 24 hours a day. -Hospice will supply the facility a copy of the patient's plan of care which will specify the inpatient services to be provided. -The facility will have patient care policies consistent with those of hospice and agrees to abide by the palliative care protocols and plan of care established by the Hospice. -The facility shall identify an individual who is responsible for implementation of the agreement. Review of the facility policy titled Palliative/End of Life Care - Clinical Protocol, revised March 2018, indicated the following: -If Hospice becomes involved, both the attending physician and staff will retain an active role in the resident/patient's care and will not simply defer everything to the Hospice staff and practitioner. Resident #42 was admitted to the facility in January 2025 with diagnoses including cerebral infarction (stroke). Review of the Hospice Long Term Care Status Form dated 2/7/25, indicated Resident #42 signed onto Hospice Services on 2/7/25. Review of Resident #42's Hospice binder (binder used to store all Hospice documentation), indicated that no Hospice Plan of Care was on file in the facility. During an interview on 2/18/25 at 8:45 A.M., the Social Worker (SW) said each resident in the facility who was on Hospice Services had a Hospice binder that contained all the pertinent Hospice documentation for that resident. The SW further said she was unaware of who from the IDT at the facility was responsible to make sure Hospice documentation was maintained in the binder. During an interview on 2/18/25 at 9:02 A.M., with the Administrator and the Director of Nursing (DON), the DON said she was unsure if the facility had a designated staff member who ensured that all Hospice documentation was in each resident's hospice binder. The DON said she thought Hospice Staff needed to ensure that all Hospice documentation was in each resident's Hospice binder. The DON further said she was unsure if Resident #42's Hospice Plan of Care was readily available in his/her Hospice binder. During an interview on 2/18/25 at 9:08 A.M., Nurse #2 said she thought Hospice Staff maintained the Hospice binder for each resident. Nurse #2 said she was unsure if there was a staff member at the facility who ensured all Hospice documentation was readily available and could be reviewed whenever it was needed. The surveyor and Nurse #2 observed Resident #42's Hospice binder and Nurse #2 said she would expect there to be more documentation in the Resident's binder including nursing notes and Home Health Aides (HHA) notes as she knew both these Hospice disciplines had been in to see Resident #42 since he/she signed onto Hospice a few weeks ago. Nurse #2 further said she was unsure about the specifics of the Hospice Plan of Care outside of knowing a Nurse and HHA came into the facility to see the Resident regularly during the week. During a follow-up interview on 2/18/25 at 9:08 A.M., the DON said the facility had not designated a specific member from the facility's IDT to be the facility representative to communicate with Hospice and ensure Hospice documentation including the Hospice Plan of Care was readily available. The DON said she expected Hospice staff to maintain all this information. The DON further said she had called Hospice to get Resident #42's Hospice documentation because it was not available in the Resident's Hospice binder.

Based on interview, and record review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required for one Resident (#214), of five applicable residents reviewed for unnecessary medications, out of a total sample of 17 residents. Findings include: Resident #214 was admitted to the facility in December 2023 with diagnoses including Vascular Dementia. Review of Resident #214's Pharmacist Progress Notes indicated the following: -10/4/24: the Pharmacist indicated recommendations made, see Clinical Pharmacy Report -11/5/24: the Pharmacist indicated recommendations made, see Clinical Pharmacy Report Review of Resident #214's medical record did not provide evidence of the Pharmacy Recommendations and Clinical Pharmacy Reports indicated in the Pharmacist Progress Notes on 10/4/24 and 11/5/24. Further review of the medical record failed to indicate that the Physician had reviewed the 10/4/24 and 11/5/24 Pharmacy Recommendations. During an interview on 2/14/25 at 10:05 A.M., the surveyor requested evidence of the 10/4/24 and 11/5/24 Clinical Pharmacy Reports and Physician review of the Reports from the Director of Nursing (DON). The facility was unable to provide any additional information pertaining to the Clinical Pharmacy Reports and Physician Review of the Pharmacy Recommendations to the survey team at the time of survey exit.

Based on interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#35) out of a total sample of 17 residents. Specifically, for Resident #35, the facility failed to address significant weight loss and implement nutritional interventions when the Resident was identified to have greater than 10 percent (%) weight loss. Findings include: Resident #35 was admitted to the facility in July 2024 with diagnoses including Diabetes, small cell lung carcinoma (lung cancer) receiving chemotherapy, Chronic Obstructive Pulmonary Disease (COPD), C-Diff (Clostridium Difficile,) Chronic Kidney Disease, anxiety and depression. Review of the facility policy titled Weighing and Measuring the Resident, revised March 2011 indicated the following: a. one month 5% weight loss is significant; greater than 5% is severe. b. three months 7.5% weight loss is significant; greater than 7.5 is severe c. six months 10% weight loss is significant; greater than 10% is severe. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. -required set up or clean up assistance with eating. Review of Resident #35's Weight Summary from 7/24/24 through 2/1/25 indicated the following in part: -7/24/24: 163 pounds (lbs.) -8/3/24: 155 lbs. -1/3/25: 143 lbs. -1/21/25: 134 lbs. (significant weight loss of 17.79 % from 7/24/24 and greater than 10% in 6 months. Significant weight loss of 6.29 % from 1/3/25 and greater than 5% in 1 month). -2/1/25: 129.4 lbs. (significant weight loss of 16.52% and greater than 10% in 6 months. Significant weight loss of 9.51% from 1/3/25 and greater than 5% in 1 month). Review of the January 2025 Medication Administration Record (MAR) indicated: -ProHeal Liquid Protein, two times a day 30 ml (milliliters) in juice. Start date 10/28/24, Discontinue date 1/28/25 -Resident #35 refused (coded 15 [Resident refused] per the MAR legend code and initialed by the Nurse) the ProHeal Liquid Protein 31 times out of 55 opportunities. Review of the Nutritional Risk Evaluation completed on 1/27/25 for the assessment period from 1/16/25 to 1/22/25 indicated the following: -Weight Loss 5% or more in last month or loss of 10% or more in the last 6 months - YES. Not on a prescribed (weight) loss regimen. -Goal weight - stable, prevent loss -Regular house diet -Supplements - ProHeal increased to 60 ml BID (two times a day) (400 cals) -Weight status - acute condition resulting in temporary change - loss of 10 pounds, status post fluid gain -Continue diet -Recommendation - Increased ProHeal 60 ml in juice BID -Nutritional Plan - increased diet needs due to decline in appetite with C-Diff infection, and progressive weight loss noted. Increase juice with protein as (Resident) prefers no milky supplement. Review of Resident #35's Care Plan [sic] indicated the following: -The Resident is malnourished, evidenced by poor appetite regarding fear of swallowing, chewing difficulty regarding new lung cancer, shortness of breath and fluid weight gain - initiated on 7/24/24 and revised on 1/22/25. -ProHeal 60 ml in juice BID - initiated on 1/22/25 Further Review of the Care Plan indicated no update to reflect the discontinuation on 1/28/25 of the ProHeal Liquid Protein per the Physician orders on the January 2025 MAR. During an interview on 2/12/25 at 3:16 P.M., Resident #35 said that he/she did not really like the food at the facility, so he/she ate a lot of soup. Resident #35 said that his/her family would bring in chips and snacks. Resident #35 said that he/she used to get the liquid protein however does not get it anymore and does not know why. Resident #35 could not say whether he/she had been offered other food or dietary supplements. During an interview on 2/12/25 at 3:18 P.M., Nurse #1 said that Resident #35 was previously prescribed ProHeal Liquid Protein but often refused it, so the facility staff discontinued it on 1/28/25. Nurse #1 said Resident #35 had cancer, C-diff, and often refused the ProHeal Liquid Protein, and that the Resident would have weight loss because of these concerns. Nurse #1 further said that Resident #35 did not have any other nutritional supplements ordered at this time. During a follow-up interview on 2/12/25 at 4:15 P.M., Resident #35 said that the facility offered Hospice Services however, he/she declined because he/she wanted to continue chemotherapy treatment. During an interview on 2/12/25 at 4:48 P.M., Dietary Staff #1 said that the facility had protein shakes they could offer the Residents but could not recall if the facility had other types of supplemental or fortified foods (foods with nutrients added to help boost nutritional value). Dietary Staff #1 said when ordering food items, the staff had to go through a new process that included a predetermined list from the company with acceptable food/dietary items that are available for the staff to choose from. Dietary Staff #1 said that the additional items the staff want to order must be approved by a corporate person. Dietary Staff #1 said that they had limited control over what could be ordered. During an interview on 2/13/25 at 8:51 A.M., the Dietician said that Resident #35 was malnourished upon admission and had nausea. The Dietician said the Resident had a concerning weight loss but it was a part of the Resident's process. The Dietician said that while it was a significant weight loss it was not unexpected. The Dietician further said when a Resident had a significant weight loss the Provider should be made aware, but she did not usually document when the Provider was notified. The Dietician said for Resident #35 she just talked to the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). The Dietician said that these conversations are not usually documented. The Dietician was unable to provide any additional information that any conversations had occurred relative to Resident #35's recent weight loss. The Dietician said it had already been acknowledged that the Resident had previous weight loss and was going to continue to have weight loss because of his/her diagnoses. The surveyor requested evidence that the Provider had documented the Resident's previous or current weight loss and that it was to be expected. The facility did not provide any documentation of Resident #35's previous or current weight loss and that weight loss was to be expected by the end of the survey. The surveyor and the Dietician reviewed the Nutritional assessment dated [DATE] and the Dietician said Resident #35 had lost 10 pounds because of fluid gain while at the hospital, poor appetite, and that the Resident was not meeting the goals that had been set. The Dietician said because of her assessment of the Resident and noted weight loss, she increased the ProHeal Liquid Protein and directed it to be put into juice because the Resident could not have dairy. The Dietician said when she visited with Resident #35 last week, the Resident said he/she felt like he/she had been eating well and did not want to change anything. When the surveyor asked how the Dietician determined what the appropriate nutrition recommendations would be for a Resident, the Dietician said that she met with the Resident, reviewed the MAR and progress notes and will then determine the next course of action/recommendation. The Dietician reviewed the February 2025 MAR and said that the ProHeal Liquid Protein was not on the MAR, which indicated that it was no longer prescribed for the Resident. The Dietician said that she was unaware that the ProHeal Liquid Protein had been discontinued. The Dietitian reviewed the January 2025 MAR and said that the ProHeal Liquid Protein had been discontinued 1/28/25. The Dietician said that sometimes Resident #35 only took half of the prescribed 30 ml ProHeal Liquid Protein, and that's why a 15 was noted on the MAR. The surveyor and the Dietician further reviewed the MAR and observed an x to be in the ml (how much the Resident consumed) box, with a 15 followed by the Nurses' initials. The Dietician reviewed the legend located at the end of the MAR and said that a 15 indicated the Resident refused the ProHeal Liquid Protein. The Dietician said that it looked like the Resident refused the ProHeal Liquid Protein a lot. When the surveyor asked if increasing the ProHeal Liquid Protein as a new intervention for the most recent assessment (completed on 1/27/24), was an appropriate or effective intervention, based on the amount of refusals for the month of January, the Dietician said there are other interventions/options that could be trialed. The Dietician said that she did not know the Resident had refused the ProHeal Liquid Protein so often. During an interview on 2/13/25 at 9:46 A.M., the Physician Assistant (PA) said that he would have expected to be notified of Resident #35's significant weight loss. The PA said that he had been in the facility since the Resident experienced the most recent weight loss noted on 1/21/25 and 2/1/25 and did not recall being notified of the weight loss during those times in the facility. The PA said that he did not recall being made aware that the Resident had refused the nutritional supplement so often, however since it had been discontinued, it was possible he was made aware but could not recall. The PA said that he does not document every conversation or review every resident's weight, he expects the staff to communicate these areas of concerns with him. The PA further said that he could not recall if he had been asked to review Resident#35 for other/new interventions relative to the significant weight loss. The PA said that because this Resident is currently going through chemotherapy and C-Diff treatment it is tough to know if anything would help the Resident stabilize or gain weight. The PA further said that other options could have been offered, either other food or medication interventions to try and help the situation.

Based on interview, and record review, the facility failed to follow professional standards of practice relative to administering medication for one Resident (#42) out of a total sample of 17 residents. Specifically, for Resident #42, the facility failed to ensure that prescribed Insulin (medication used to treat diabetes) was administered within one hour before or one hour after the ordered time. Findings include: Review of the facility policy titled Administering Medications, revised April 2019, indicated the following: -Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Resident #42 was admitted to the facility in January 2025 with diagnoses including Type 2 Diabetes. Review of the Physician's Order Recap Report, from 1/14/25 through 2/28/25, indicated: -Lantus SoloStar Subcutaneous Solution 100 unit/milliliter (ml) (Insulin Glargine), Inject 18 units subcutaneously at bedtime (8:30 PM) with a start date of 1/23/25 and end date of 2/6/25. -Lantus SoloStar Subcutaneous Solution 100 unit/milliliter (ml) (Insulin Glargine), Inject 8 units subcutaneously at bedtime with a start date of 2/6/25. -HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro), Inject as per sliding scale .before meals (7:30 AM, 11:30 AM, 4:30 PM) with a start date of 1/16/25. Review of the Location of Administration Report from 1/1/25 through 1/31/25 indicated the following: -1 out of 9 administrations of Lantus Solo Star Solution 100 unit/ml (Insulin Glargine) Inject 18 units subcutaneously at bedtime was administered outside of one hour before and one hour after the ordered time frame. -15 out of 37 administrations of Humalog KwikPen Subcutaneous Solution Pen - injector 100 unit/ml (Insulin Lispro) Inject as per sliding scale .before meals was administered outside of one hour before and one hour after the ordered time frame. Review of the Location of Administration Report dated 2/1/25 through 2/28/25, indicated the following through 2/18/25: -6 of 12 administrations of Lantus SoloStar Subcutaneous Solution 100 unit/milliliter (ml) (Insulin Glargine) Inject 8 units subcutaneously at bedtime was administered outside of one hour before and one hour after the ordered time frame. -13 out of 38 administrations of Humalog KwikPen Subcutaneous Solution Pen - injector 100 unit/ml (Insulin Lispro) Inject as per sliding scale .before meals was administered outside of one hour before and one hour after the ordered time frame. During an interview on 2/18/25 at 8:37 A.M., Nurse #2 said Resident #42 was diabetic and had scheduled and sliding scale Insulin medication administered to him/her. Nurse #2 said the Resident had his/her blood sugars checked at 7:30 A.M., 11:30 A.M., and 4:30 P.M., prior to meals and sliding scale Insulin was administered at those times as ordered and a specific dose of Insulin was administered at bedtime. Nurse #2 said she worked during the day shift so she administered Resident #42's sliding scale Insulin when she was working. Nurse #2 said when she checks Resident #42's blood sugar, she would then draw up the amount of Insulin per his/her sliding scale, administer the Insulin, and then documented in the Resident's electronic medical record that the Insulin was given immediately after administering the medication. Nurse #2 said Resident #42's Insulin should be given around the time ordered by the Physician but can be administered in the hour before the ordered time or within an hour after the ordered time. Nurse #2 said if she had to administer any residents' Insulin outside of the one hour before or one hour after the ordered time frame, she would update the Physician and document why the Insulin was not administered within the correct time frame. During an interview on 2/18/25 at 9:19 A.M., the Director of Nursing (DON) said Resident #42's Insulin should be administered within an hour before or an hour after the ordered time. The DON further said medication given outside that time frame should have documentation such as a nursing note as to why it was not administered within the correct time frame. During an interview on 2/18/25 at 10:55 A.M., the Assistant Director of Nursing (ADON) said medication should be administered within the one hour before or one hour after the ordered time. The ADON further said she could not be sure if Resident #42's medication had been administered outside the accepted time frame on the days in question or if nursing staff did not document properly when the medication was given. The ADON said education would need to be provided to the nursing staff about proper medication administration and documentation of when medications were administered.

Based on interview, and record review, the facility failed to ensure that Significant Change in Status Minimum Data Set [MDS] Assessments (SCSA) was completed for one Resident (#54) out of a total sample of 17 residents. Specifically, for Resident #54, the facility failed to ensure that a SCSA was completed when the Resident had a decline in activities of daily living (ADLs) and developed a new pressure ulcer. Findings include: Review of the facility policy titled Comprehensive Assessment, revised March 2022, indicated the following: -the SCSA is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. Resident #54 was admitted to the facility in November 2024 with diagnoses including Dementia and an intertrochanteric fracture of the right femur. Review of Resident #54's MDS assessment dated [DATE], indicated: -the Resident required supervision for oral hygiene -the Resident required partial assistance for upper body dressing -the Resident required substantial assistance for lower body dressing -the Resident had no pressure ulcers Review of Resident #54's MDS assessment dated [DATE], indicated the following: -the Resident required substantial assistance for oral hygiene -the Resident was dependent for upper and lower body dressing -the Resident had an unstageable pressure ulcer Review of Resident #54's medical record indicated that no SCSA was completed between the November 2024 and February 2025 MDS assessments. During an interview on 2/13/25 at 3:47 P.M., the MDS Nurse said that the January 2025 documentation reflected that Resident #54 had had a decline in ADLs and developed an unstageable pressure ulcer. The MDS Nurse further said that a SCSA should have been completed but was not.

Based on observation, interview, and record review, the facility failed to notify the Physician/Physician Assistant (PA) of changes in condition for two Residents (#35 and #58) out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #35, notify the Physician/ PA timely of significant weight loss experienced by the Resident. 2. For Resident #58, ensure the Physician/PA was notified when the Resident had a significant weight change and continued significant weight decline. Findings include: Review of the facility policy titled Change In a Resident's Condition or Status, revised February 2011, indicated the following: -The nurse will notify the resident's attending physician or physician on call when there has been a (an): ---Significant change in the resident's physical/emotional/mental condition, ---Refusal of treatment or medications two (2) or more consecutive times. Review of the facility policy titled Weighing and Measuring the Resident, revised March 2011, indicated the following: a. one month 5% weight loss is significant; greater than 5% is severe. b. three months 7.5% weight loss is significant; greater than 7.5 is severe c. six months 10% weight loss is significant; greater than 10% is severe. 1. Resident #35 was admitted to the facility in July 2024 with diagnoses including Diabetes, small cell lung carcinoma (lung cancer) receiving chemotherapy, Chronic Obstructive Pulmonary Disease (COPD), C-Diff (Clostridium difficile), Chronic Kidney Disease (CKD), anxiety and depression. Review of Resident #35's Weight Summary Report from 7/24/24 through 2/1/25 indicated the following: >7/24/24 -163 lbs. (pounds) >8/3/24 -155 lbs. >1/3/25 -143 lbs. >1/21/25 -134 lbs. (17.79 % weight loss from 7/24/24 = severe weight loss of greater than 10% in 6 months.13.5% weight loss from 8/3/24 = severe weight loss of greater than 10% in 6 months. 6.29 % weight loss from 1/3/25 = severe weight loss of greater than 5% in 1 month). >2/1/25 -129.4 lbs. (16.52 weight loss from 8/3/24 = severe weight loss of greater than 10% in 6 months. 9.51% weight loss from 1/3/25 = severe weight loss of greater than 5% in 1 month). During an interview on 2/12/25 at 3:53 P.M., Nurse #1 said that after the Certified Nurses Aides (CNAs) obtain a residents' weight, they give it to the Nurses who then document the weight into PCC (Point Click Care, the electronic medical record used by the facility). Nurse #1 said that for a 3 lb weight fluctuation the staff will obtain a re-weight. Nurse #1 said if the reweight is still a loss, the staff will notify the Provider. Nurse #1 said all communication with the Providers are either completed by phone or documented in the communication binder located at the nurses station. The surveyor and Nurse #1 reviewed the communication binder and found no documented evidence that the Provider had been notified of Resident #35's weight loss, when significant weight loss occurred on 1/21/25 and 2/1/25. Nurse #1 said that for a significant weight loss she would typically call the Provider. Nurse #1 reviewed the nursing notes in PCC and found no documented evidence that the Provider had been made aware of Resident #35's significant weight loss. Nurse #1 further said that the Resident had cancer, C-diff, and refused the supplemental drinks, and that she would expect him/her to have weight loss. During an interview on 2/12/25 at 4:03 P.M., the Director of Nursing (DON) said she would have expected the Physician or PA to have been notified of Resident #35's weight loss on both 1/21/25 and 2/1/25. During an interview on 2/13/25 at 9:46 A.M., the PA said that he would have expected to be notified of Resident #35's significant weight loss. The PA said that he had been in the facility since the Resident experienced the most recent weight loss noted on 1/21/25 and 2/1/25 and did not recall being notified of the weight loss during those times he was in the facility. The PA said that he did not recall being made aware that the Resident had been refusing the nutritional supplements however since the supplements had been discontinued, it is possible he was made aware but could not recall. 42741 2. Resident #58 was admitted to the facility in December 2024 with diagnoses including malnutrition, muscle weakness, Stage 4 pressure wounds to bilateral buttocks, and cirrhosis of the liver. Review of Resident #58's Weight Summary Report from 12/18/24 through 2/12/25 indicated: >12/18/24: 144 lbs. >12/20/24: 143.8 lbs. >12/25/24: 142.2 lbs. >12/27/24: 108.0 lbs. (significant weight loss of 25% in less than one month since 12/18/24) >12/30/24: 104.4 lbs. >1/3/25: 101.4 lbs. (continued weight loss of 6% in less than one month since 12/27/24) >1/8/25: 101 lbs. >1/13/25: 99.2 lbs. >1/15/25: 99.6 lbs. >1/17/25: 101 lbs. >1/20/25: 102 lbs. >1/22/25: 102.2 lbs. >1/24/25: 102.5 lbs. >1/29/25: 96.2 lbs. >1/31/25: 96 lbs. (weight loss of 10.93% in one month since 12/27/24) >2/3/25: 95.9 lbs. >2/5/25: 95.4 lbs. >2/7/25: 96.2 lbs. >2/10/25: 96 lbs. >2/12/25: 97.3 lbs. (weight loss of 9.91% in one month and a half since 12/27/24) Review of the Nutrition Risk Evaluation, dated 12/13/24, indicated Resident #58's: -current weight was 144 lbs. -his/her historical weight within the last month was 156 lbs. -goal was for the Resident to remain at a stable weight and not gain. Review of the Dietician Note dated 1/8/25, indicated: -weight 101.4 lbs with progressive loss - .wound healing is stalled -increase 2.0 (nutrition supplement) to 120 milliliter (ml.) three times a day (TID) to stabilize weight and improve healing. Further review of the Dietician's Note did not indicate: >why Resident #58 had a significant weight loss of 25% from 12/18/24 to 12/27/24 >whether or not the initial weight taken was accurate or if the new weight of 101.4 lbs was a more accurate weight for the Resident >whether the Dietician had notified the Physician or PA of the significant weight loss or the Resident's continued weight loss Review of the most recent Dietician Note, dated 1/27/25 indicated: -weight holding and wound improving . -see Care Plan for new recommendations. Review of Resident #58's Malnutrition Care Plan, initiated 12/16/24, indicated the following recommendations corresponding with a start date of 1/27/25: --Resident #58 will safely consume 75% some meals to maintain weight within seven pounds or less than 155 pounds while healing wounds through next review date. {sic} -Increase 2.0 med pass (nutrition supplement) 180 ml., TID -ProHeal (protein supplement) 60 ml, twice daily (BID) -Vitamin D3, Multivitamin with minerals as ordered, Vitamin C, Zinc for 30 days Review of the January 2025 and February 2025 Physician's orders and Medication Administration Records (MARs)indicated all recommendations from the Dietician made on 1/27/25 were implemented and administered as ordered. No additional Nutrition Documentation was available after 1/27/25 to address the ongoing gradual weight loss Resident #58 started to have after the new recommendations by the Dietician were made on 1/27/25. Review of the PA Progress Note for the visit following the initial significant weight loss dated 12/31/24, indicated no documentation that the PA had been made aware of Resident #58's 25% significant weight loss. Review of the PA Progress Note dated 2/4/25, indicated no documentation that the PA had been made aware of the Resident's ongoing weight loss including the greater than 10% weight loss in the last month. Review of the PA Progress Note dated 2/6/25, indicated no documentation that the PA had been made aware of Resident #58's ongoing gradual weight loss. During an interview on 2/12/25 at 4:20 P.M., the surveyor and Nurse #4 reviewed Resident #58's weights since admission. Nurse #4 said when the Resident had the significant change in weight from 12/18/24 to 12/27/24, a reweigh should have been requested. Nurse #4 said a reweigh should be completed the same day or the following day from the possibly incorrect weight and this had not been done. Nurse #4 said if the Resident's weight continued to remain significantly lower, then the Dietician and the Physician should have been updated and a nursing note should have been written to indicate they had been updated. Nurse #4 said she was unable to find documentation that the Dietician or Physician had been updated. During an interview on 2/12/25 at 5:00 P.M., the Director of Nursing (DON) said if nursing staff noted a weight loss or gain of three or more pounds from a previous weight, then a reweigh should be done either the same day or the next day. The DON said Resident #58 was not reweighed until 12/30/24, after the initial significant weight loss was noted on 12/27/24. During an interview on 2/13/25 at 10:48 A.M., Resident #58's Resident Representative (RR) #1 said he/she thought Resident #58 weighed about 120-130 lbs. when the Resident lived in the community. During an interview on 2/13/25 at 1:21 P.M., the Dietician said if a Resident has a larger than 5% weight loss or greater, the facility should contact her so she can re-evaluate the Resident. The Dietician said she could not recall if the facility staff had contacted her when the initial significant weight loss was noted on 12/27/24. The Dietician further said she would expect the Resident to lose weight, as Resident #58 was being treated with diuretics but she was unsure of what Resident #58's baseline weight should be. The Dietician said she noted that the initial goal in the Malnutrition Care Plan was 155 lbs or less but she could not comment on what the expected weight range for Resident #58 should be. The Dietician said she had not been in communication with the Physician or PA regarding Resident #58's initial significant weight loss or continued gradual weight loss and she would expect nursing to update the Physician or PA regarding the weight loss as she provided nursing with weekly notes during the facility's Risk meetings. The surveyor requested Risk Meeting notes from the Dietician for Resident #58 but no Risk Meeting notes were provided to the survey team by the end of the survey. During an interview on 2/13/25 at 9:36 A.M., the PA said he would expect Resident #58 to have some weight loss as he/she was on diuretics but he was unaware that the Resident had a significant weight loss since being admitted to the facility. The PA said no staff at the facility had provided him with specific weight loss percentages for the Resident. The PA further said that he did not have a specific set of parameters he used for when nursing staff should notify him of changes in a Resident's weight. During an interview on 2/13/25 at 12:14 P.M., the DON said she was unable to find any documentation that staff had updated the Physician or PA regarding Resident #58's weight loss. The DON said she would have expected nursing staff to let the Physician or PA know if the Resident had a significant unexpected weight loss. The DON said the Dietician should be updating the Physician or PA if the Resident continued to have an ongoing gradual weight loss. Please Refer to F641 and F692

Based on interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for one Resident (#35) out of a total sample of 17 residents. Specifically, the facility failed to ensure that the most recent MDS Assessment was coded accurately relative to weight loss for Resident #35. Findings include: Resident #35 was admitted to the facility in July 2024 with diagnoses including Diabetes, small cell lung carcinoma (lung cancer) receiving chemotherapy, Chronic Obstructive Pulmonary Disease (COPD), C-Diff (Clostridium Difficile), Chronic Kidney Disease (CKD), anxiety and depression. Review of the facility policy titled Weighing and Measuring the Resident, revised March 2011, indicated the following: a. one month 5% weight loss is significant; greater than 5% is severe. b. three months 7.5% weight loss is significant; greater than 7.5 is severe c. six months 10% weight loss is significant; greater than 10% is severe. Review of Resident #35's Weight Summary from 7/24/24 through 12/1/24 indicated: -7/24/24: 163 lbs. (pounds) -11/4/24: 144.4 lbs. -12/1/24: 136.6 lbs. (5.4% weight loss in 1 month and a 16.20% weight loss in 6 months) Review of the MDS assessment dated [DATE] indicated the facility responded No or unknown to if the Resident experienced a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. During an interview on 2/13/25 at 11:07 A.M., the MDS Nurse said that sometimes staff will complete the required sections but not fully sign off on them, so she will go in and complete them. The MDS Nurse said that the Dietician is responsible for completing section K (where the weight information is assessed and documented). The surveyor and the MDS Nurse reviewed the weights documented from 7/25/24 through 12/1/24, and the 12/16/24 MDS Assessments. The MDS Nurse said that judging by the decrease in weight from 7/25/24 through 12/1/24, the Resident experienced a significant weight loss of over 10% in 6 months. During a follow-up interview on 2/13/25 at 2:20 P.M., the MDS Nurse said to calculate the weight loss, the staff should have used the most recent weight obtained in the last 30 days, closest to the MDS Assessment date of 12/16/24. The MDS Nurse said that the MDS assessment dated [DATE] should have been coded as a weight loss of greater than 5% or 10% but was not.

Based on observation, interview and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility staff failed to: 1a. Ensure kitchen cleanliness and store and prepare food in the main kitchen area in a manner that would prevent contamination and food-borne illnesses. 1b. Ensure food was stored in a manner to prevent food-borne illnesses in two out of two unit-based kitchen areas. 2. Ensure that a process was in place to safely reheat food and beverages for the residents. Findings include: Review of the facility policy titled; Cleaning Schedule from the Dietary Services Manual dated [DATE] indicated the following: -It is the responsibility of the Dietary Department to maintain all areas of the facility's kitchen and related areas in a clean and sanitary manner. -The Food Service Director (FSD) is responsible to identify, assign, monitor and manage the cleanliness of their department. -Cleaning schedules should be unique to each Dietary Department based on specific, unique areas and equipment. The ,d+[DATE] Schedule (referring to a systemic cleaning schedule) provided with this policy offers a template for FSDs to start with and edit to their specific departments. -Areas to be cleaned will be identified by the frequency the cleaning is needed, such as after each use, daily, weekly, and monthly. -Employees will be directed to initial each cleaning task to indicate the task was completed and staff unable to complete their task(s) must notify the FSD or the cook on duty to reassign the task(s) -FSD will monitor cleaning schedules by reviewing the cleaning schedules for initials and then review the work completed. Review of the Dietary Cleaning Schedule provided to the surveyor by the Administrator indicated that storage shelves should be wiped clean daily, sink and drain should be cleaned three times per day, utility carts should be cleaned after each use and floors should be swept and mopped every day. There was no schedule listed for oven cleaning. Review of a report from the facility's contracted pest control company dated [DATE], indicated: -There is a buildup of organic matter around the seals of the food disposal unit underneath the dishwashing sink that is a current fruit fly breeding site. Please clean the exterior of plumbing and repair any worn seals to prevent future build up. -Debris collecting in interior of juice gun. Please remove and clean juice gun to prevent unsanitary conditions and attraction by pests. **removed previous recommendation due to it not being addressed. 1a. During an initial kitchen observation on [DATE] at 7:16 A.M., the surveyor observed the following: -No hairnets stored outside of the kitchen area entryway. > Main Kitchen Area: -The kitchen contained boxes and items stored on top of other items, and crumbs on the floor. -Cleaning supplies stored on a shelf, the cleaning supply closet was propped open with a mop bucket that contained black particles inside. -Drain catch connected to a metal table next to the dishwasher with a caked-on brown substance. -Both ovens and stoves with caked-on grease. -Visible crumbs on top of the dishwasher. -One staff member next to food being served without a hair restraint. -Bearded staff member serving food without a beard restraint. >Reach-in Refrigerator: -Two bags of grated cheese, open and undated. -Three packages of sliced American cheese, open and undated. -Container of pickles, uncovered and undated. >Dry Storage Area: -40-pound box of sweet potatoes stored on the floor. -Open bag of egg noodles, undated. -Wooden doors to the dry storage cabinets smeared with a black/brown substance where staff placed their hands to open and close the doors. -Shelves in the dry storage cabinets were stained, sticky to touch with crumb observed. During an interview on [DATE] at 7:36 A.M., Cook #1 said Cook #3 cleaned the stoves every week. Cook #1 said the stoves did not appear to have been cleaned. During a follow-up kitchen observation on [DATE] from 11:00 A.M.-12:52 P.M., the surveyor observed the following: >Main Kitchen Area: -Cook #1 preparing and serving lunch without a beard restraint. -Interior microwave door and inside the microwave laden with splattered, dried on food. -Metal table behind the microwave with dried liquid stains and crumbs, food serving trays on top of the table, the side of the metal table had dried on splatters and crumbs. -Can opener bolted to the metal table had a black, caked-on, sticky substance on both the can opener base and the blade. -Area next to the dishwasher had a grey rubber gasket and white metal gutter laden with tan, brown, black, and rust colored sludge, the gasket contained wet food pieces. -Floor under the dishwasher was covered with dirt, dust, crumbs, grime, and a potato was seen against the wall. -Fruit flies flying around the garbage disposal. -Left oven interior door contained a large amount of reddish orange colored dried on splatters and dried black substance inside the oven. -Right oven with dried black substance inside the oven. -Both stovetops: front edges with dried on crumbs and adherent burnt-on sticky substance. -Exterior right-hand side wall of freezer next to the stoves was covered with adherent food particles. >Dry Storage Area: -Fruit flies congregated around the sheet pans and boxes of packaged sweeteners. -Utensil drawers with crumbs. -Cardboard box of Raisin Bran cereal stored on the floor with a wastepaper basket on top of the box. -Cardboard boxes of potatoes and bananas stored on top of the ice machine. > Reach-in Refrigerator: -Package of American cheese, open and undated. -White lunch meat, open and undated. -Sliced ham, open and undated. -Plastic container of pickles with no lid, open and undated. -Container of sour cream with an expiration date of [DATE]. -Jar of mayonnaise, open and undated. -Unsealed box of bacon, open and undated. -Plastic packages of mozzarella and cheddar cheese, open and undated. During an interview on [DATE] at 1:52 P.M., the Administrator said the Food Service Director (FSD) has been gone for three weeks and they only have Dietitian coverage six hours per week, with no dietary oversight from corporate. The Administrator said there was a cleaning schedule, but after reviewing various sanitation concerns with the surveyor, the Administrator said he did not think the Dietary staff were adhering to the cleaning schedule. The Administrator said he was aware of the fruit fly problem, and that the pest control company was at the facility one month prior. The Administrator said a previous Maintenance Director cut the metal counter next to the dishwasher to install a new dishwasher which resulted in a gap where food and liquid would spill on the floor, so the gasket and a gutter were installed to catch the food drippings. The Administrator further said that all opened containers of food should be labeled and dated. During an interview on [DATE] at 2:15 P.M., Cook #1 said the food and sludge build up accumulated on the gasket and gutter next to the dishwasher should be cleaned regularly and did not appear as though it had been. Cook #1 further said that he should have worn a beard restraint while preparing and serving food. Cook #1 said there was a kitchen cleaning schedule, and Cook #3 oversaw the main kitchen area which included areas with the stoves, refrigerators, dishwasher, counters, microwave, and floors. Cook #1 further said Cook #2 oversaw cleaning the back of the kitchen which included the dry storage area, ice machine and juice machine. Cook #1 said he did not know of any formal cleaning schedule or cleaning checklist. During an interview on [DATE] at 2:20 P.M., Cook #2 said all the opened food in the refrigerator should have been labeled, dated, and covered, the expired sour cream should have been discarded and none of this was done, as required. During an interview on [DATE] at 2:35 P.M., the Maintenance Director said he was aware of the fruit fly infestation in the kitchen and per the pest control company, the breeding area was under and around the dishwasher and garbage disposal. The Maintenance Director said he pest control company recommended keeping these areas clean and free from food debris. In addition, the Maintenance Director said the pest control company discovered debris accumulating in the interior of the juice guns located in the dry storage area and recommended removing and cleaning the juice guns to prevent unsanitary conditions and to prevent fruit fly infestation. The Maintenance Director said there had been a cleaning schedule in place and the fruit fly problem abated, however since the FSD position was vacant, he did not think anybody in the kitchen had taken ownership of the cleaning schedule because it did not appear to have been cleaned thoroughly or regularly. During another follow-up visit to the kitchen on [DATE] at 7:45 A.M., the surveyor observed: > Main Kitchen Area: -The area under the garbage disposal and dishwasher remained soiled with dirt and black debris with the potato still on the floor against the wall. -Fruit flies were still visible surrounding the garbage disposal, -Built-up food and sludge alongside the dishwasher, inside the gasket and gutter. -Stainless table on which the microwave was sitting remained laden with crumbs, debris, and liquid stains. > Dry Storage Area: -Large paper bag of flour that was opened, not in a sealed container. -Plastic container of flour, undated During an interview on [DATE] at 7:50 A.M., Cook #3 said that all opened food should be dated, and the flour should be stored in a sealed container. The surveyor observed that the undated items in the refrigerator that were observed on [DATE] and [DATE] were now labeled with the date of [DATE]. Cook #3 said that Cook #2 labeled the food items [DATE] instead of discarding them because they were likely opened on [DATE]. The surveyor explained that the items were found opened on [DATE] and Cook #3 said he could not speak to why Cook #2 labeled the items with a [DATE] open date. 1b. During an observation of the [NAME] Unit refrigerator on [DATE] at 9:10 A.M., the surveyor observed the following undated and/or unlabeled items: >Refrigerator: -container of cottage cheese, expiration date [DATE]. -open bottles of soda and apple cider vinegar. -a squeeze container of sour cream. -a container of peanut butter on top of the refrigerator >Freezer: -large bag of frozen meatballs During an observation of the North Unit kitchen on [DATE] at 9:53 A.M., the surveyor observed the following undated and/or unlabeled items: >Freezer: -multiple frozen pocket sandwiches. -four containers of frozen dessert. -an ice cream sandwich. -a pint of ice cream. -a frozen turkey dinner. -a bag of vegetarian chicken nuggets. During a follow-up observation of the [NAME] Unit refrigerator on [DATE] at 8:13 A.M., the surveyor observed the following undated and/or unlabeled items: >Refrigerator: -container of expired (expiration date [DATE]) cottage cheese. -a plastic container with pasta salad in a plastic bag. -container of peanut butter remained on top of the refrigerator. During a follow-up observation of the North Unit refrigerator on [DATE] at 8:35 A.M., the surveyor observed the following undated and/or unlabeled items: >Freezer: -multiple frozen pocket sandwiches. -four containers of frozen dessert. -ice cream sandwich. -pint of ice cream. -frozen turkey dinner. -bag of vegetarian chicken nuggets. On [DATE] at 10:38 A.M., the surveyor and Unit Manager (UM) #1 observed the [NAME] Unit refrigerator. UM #1 said that all resident food brought in, and all open containers of food should be labeled with a resident name and discarded after 72 hours. UM #1 said that the cottage cheese was not labeled, was expired and should have been removed from the refrigerator, and the peanut butter should have been labeled with the resident's name. UM #1 further said the Dietary Department was responsible for stocking and cleaning out the Unit refrigerators daily. On [DATE] at 11:08 A.M., the surveyor and Certified Nurses Aide (CNA) #2 observed the North Unit refrigerator. CNA #2 said that all resident food in the refrigerator and freezer should be labeled with the residents' name and the date the food was brought in. The surveyor and CNA #2 observed that several new take-out containers were placed in the refrigerator since the previous observation on [DATE] at 8:35 A.M. The new take-out containers were not labeled or dated. The food in the freezer all remained unlabeled. CNA #2 said that all the non-labeled food should have been labeled and if it was not labeled no one would know which resident the food belonged to or how long it was in the refrigerator. On [DATE] at 4:45 P.M., the surveyor requested the ,d+[DATE] Cleaning schedule referenced in the Dietary Services Manual from the Administrator. The Administrator was unable to provide the surveyor any evidence of the ,d+[DATE] cleaning schedule. 42741 2. Review of the facility policy titled Foods Brought by Family/Visitors, revised [DATE], indicated the following: -Food reheated by the facility staff utilizing the microwave. -Residents will be informed the temperature may be hot and to advise if temperatures are too cold. On [DATE] at 8:40 A.M., the surveyor observed CNA #3 reheating a drink in the North Unit microwave. CNA #3 said there was no way for her to measure the temperature of the drink to make sure it was not too hot or too cold. CNA #3 further said she was unaware of any instructions on reheating drinks or food to ensure they were reheated to the proper and safe temperature. On [DATE] at 11:59 A.M., the surveyor observed CNA #1 reheating a resident's left over food in the North Unit microwave. CNA #1 said there was no way for her to measure the temperature of the food to make sure that it was not too hot or too cold. CNA #1 further said she was unaware of any instructions on reheating drinks or food to ensure they were reheated to the proper and safe temperature. On [DATE] at 11:25 A.M., the Administrator said the facility had no process in place to ensure the safe reheating of food or drinks on the units. The Administrator said there were no thermometers on the units for the staff to check to make sure reheated drinks or food were heated to the proper temperature.

Based on observations and interviews, the facility failed to provide a resident environment that was free from potential hazards on one Unit (North Unit) out of two Units observed. Specifically, the facility staff failed to ensure that smoking materials were stored in a secured location, that was out of sight and not accessible to the residents. Findings include: On 2/27/24 between 8:00 A.M. and 9:13 A.M., the surveyor observed a box containing smoking materials (several packages of cigarettes and two lighters) sitting on top of a medication storage cart that was located next to the nursing station. The surveyor also observed that the smoking materials on the medication storage cart were visible and accessible to four residents who were congregated in the immediate area near the medication storage cart. During an interview on 2/27/24 at 8:45 A.M., Certified Nurses Aide (CNA) #1 said the resident smoking materials were stored in a box and kept on top of the medication storage cart near the nursing station. CNA #1 further said staff used to keep the smoking materials in the locked medication room, but the only person with a key to that room was the Nurse. CNA #1 said when it was time to smoke, the residents are anxious to get outside, that it was time consuming to have the Nurse come and unlock the medication room, especially if the Nurse(s) were busy, so now the smoking materials were kept on top of the medication storage cart next to the nursing station. During an interview on 2/27/24 at 9:34 A.M., the Nursing Supervisor said smoking materials should be stored in the locked medication room and should not be left on top of the medication storage cart within view of residents as this could pose a safety risk.

Based on observations, interviews, and policy review, the facility failed to ensure medications and medical supplies were stored in a secure manner on two Units (North Unit and [NAME] Unit) out of two units observed and the main hallway of the facility. Specifically, the facility staff failed to ensure that: 1. Two treatment carts and one medication/medical supply storage cart were locked and not accessible to residents, non-authorized staff and visitors. 2. A medication storage closet located on the main hallway of the facility was locked. Findings include: Review of the facility policy titled, Storage of Medications, undated, included but was not limited to the following: -Drugs and biologicals used in the facility are stored in locked compartments .only persons authorized to prepare and administer medications have access to locked medications. -Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 1a. On 2/27/24 at 7:58 A.M., the surveyor observed two unlocked carts on the North Unit next to the nursing station, which were both visible and accessible to residents seated nearby, non-nursing staff members, and visitors. The surveyor observed that the cart on the right of the nursing station included the following: -Box with smoking materials (cigarettes and lighters) placed on top of the cart. -The top drawer of the cart included various over-the-counter medications including vitamins, minerals, sleep aids, bowel medication and medications used to treat acid reflux (backward flow of stomach acid into the tube that connects your throat to your stomach). -The second drawer of the cart included several injection syringes and syringe needles. -The third drawer of the cart included various medical supplies and a bag of intravenous (IV) normal saline (a fluid intended to be administered through the veins, often used to treat dehydration). -The bottom drawer of the cart included oxygen tubing, wound treatment supplies, and a bottle of H-Chlor12 0.125 % [percent] (Sodium Hypochlorite-a bleach solution used as a disinfecting agent for wounds). The surveyor also observed that the second cart on the left of the nursing station included the following: -The top drawer of the cart included various tubes and bottles used to treat fungal infections of the skin, hemorrhoid ointment, box of hydrocortisone (used to treat skin irritation) ointment packets, box of bacitracin (antibiotic used to treat skin infections) ointment packets and a box of lubricating jelly ointment packets. -The second drawer of the cart included a tube of Santyl ointment (an ointment that removes dead tissue from a wound), a tube of Diclofenac Sodium (cream used to treat pain, swelling and inflammation), two bottles of Ammonium Lactate lotion (a medicated cream used to treat various skin conditions). -The third drawer of the cart included various tubes of wound treatment creams and a bottle of powder intended to treat fungal skin infections. -The bottom drawer of the cart included a bottle of Hibiclens (an antiseptic skin cleanser), a bottle of 0.25% Acetic Acid (a vinegar solution) and various other wound care supplies. During an observation and interview on 2/27/24 at 9:13 A.M., with Unit Manager (UM) #1, the surveyor observed that the two carts remained unlocked with multiple residents seated in the general vicinity of the unlocked carts. UM #1 said the cart on the left side of the nursing station was a treatment cart the other cart on the right side of the nursing station was a medication/medical supply storage cart, and both carts should remain locked when not in use because there were items in both carts that could pose a safety risk to the residents. 1b. On 2/27/24 5:20 P.M., the surveyor observed an unlocked treatment cart on the [NAME] Unit that was located in the hallway near an entrance door, next to the dining room and across the hall from two resident rooms. The surveyor also observed that there were residents in the dining room next to where the treatment cart was located, and no staff members in view of the treatment cart, as the staff were assisting in passing out dinner trays to the residents on the far end of the hallway. The surveyor observed the treatment cart in the [NAME] Unit hallway included the following: -The top drawer of the cart included two tubes of muscle and joint pain-relieving cream, multiple bottles and tubes of antifungal powders and creams, a disposable razor and various other wound care supplies. -The second drawer of the cart included a tube of muscle and joint pain-relieving cream, two bottles of Ammonium Lactate lotion, a tube of Lidocaine pain and itch relief cream, a large bottle of antifungal treatment and various other wound care supplies. -The third drawer of the cart included two tubes of muscle and joint pain-relieving cream, three bottles of antifungal creams and powders and various other wound care supplies. -The fourth drawer of the cart included a box containing a lice treatment kit, a bottle of Povidone Iodine (a solution used to decrease skin infection), a bottle of Acetic Acid and various other wound treatment supplies. On 2/27/24 at 5:24 P.M., the surveyor walked down the hall to locate a staff member. During an interview at the time, Nurse #4 said she had not used the treatment cart during her shift (she started work at 3:00 P.M.) and did not know the cart was unlocked. Nurse #4 said the cart should be always locked when not in use. The surveyor observed Nurse #4 returning to the meal cart located down the hallway without locking and securing the treatment cart. 44337 2. On 2/26/24 at 4:09 P.M., the surveyor observed that a closet, located in the main hallway of the facility was unlocked. The surveyor further observed that the closet contained multiple bottles of various medications, including but not limited to fever reducing medication, vitamins, stool softener and antacid medications. The closet door was observed to include a posted signage that stated Keep Door Locked at All Times - Licensed Staff Only. During an interview and observation on 2/26/24 at 4:13 P.M., of the closet in the main hallway of the facility with the Director of Nurses (DON), the DON said the Nurses have keys to the main hallway closet and can enter the closet to get over the counter medications (medications that are non-prescription). The surveyor observed that the DON opened the closet door by turning the doorknob without the use of a key. The DON said the closet was not locked, but should have been locked as required.

Based on observation, interview and record review, the facility failed to develop a care plan for one Resident (#28) and implement the plan of care for two Residents (#41 and #57) out of a total sample of 15 residents. Specifically, the facility staff failed to: 1. Develop a care plan relative to monitoring the side effects of an anticoagulant medication (medication used to thin the blood) for Resident #28. 2. Obtain laboratory testing relative to anticonvulsant medication (medication used to control seizure activity) monitoring as ordered for Resident #41. 3. Perform fingerstick blood sugar (FSBS) monitoring (used to measure the amount of glucose in the blood) as ordered for Resident #57. Findings include: 1. Resident #28 was admitted to the facility in March 2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- chronic lung disease that causes obstructed airflow making it hard to breathe) and Atrial Fibrillation (A-Fib-an irregular, often rapid heart rate that causes poor blood flow). Review of the Resident's February 2024 Order Summary Report indicated the Resident was prescribed Eliquis (an anticoagulant medication) 5 milligrams (mg), take one tablet by mouth twice a day. Review of the February 2024 Medication Administration Record (MAR) indicated that the Resident was administered the Eliquis medication as prescribed twice daily from 2/6/24 through 2/27/24. Review of the Resident's care plan indicated no care planning for the use and monitoring of side effects of the anticoagulant medication. During an interview on 2/27/24 at 12:44 P.M., the Director of Nurses (DON) said that any resident who is prescribed an anticoagulant medication needs to have a care plan developed to monitor for excessive bruising and bleeding. 2. Resident #41 was admitted to the facility in November 2022 with diagnoses of Major Depressive Disorder, Adjustment Disorder with Disturbance of Conduct, Mood Disorder, and Insomnia. Review of the facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, revised November 2018, indicated the following: -The Physician will identify, and order diagnostic and lab [laboratory] testing based on the resident's diagnostic and monitoring needs. -The staff will process test requisitions and arrange for tests. Review of Resident #41's February 2024 Order Summary Report indicated the Resident was prescribed Depakote(an anticonvulsant medication that can be used to help treat anxiety and contains Valproic Acid) 250 milligrams (mg) twice daily with a start date of 2/9/24. Review of the February 2024 MAR indicated the Resident was administered the Depakote medication as prescribed twice daily from 2/9/24 through 2/27/24. Review of the Physician's orders dated 2/15/24, indicated that the Resident was ordered to have a Valproic Acid level (a type of anticonvulsant medication monitored by examining the amount of medication in the blood) drawn on 2/20/24. Review of the February 2024 MAR indicated no documentation that the Valproic Acid level lab had been drawn as ordered. During an interview on 2/27/24 at 3:19 P.M., the surveyor and Nurse #2 reviewed Resident #41's medical record and Nurse #2 said she was unable to find any documentation that the Valproic Acid level lab was drawn as ordered. During a follow-up interview on 2/27/24 at 3: 26 P.M., Nurse #2 said she followed-up with the lab company and the Valproic Acid level lab was never drawn as ordered. During an interview on 2/27/24 at 3:40 P.M., Unit Manager (UM) #1 said the Valproic Acid level lab should have been drawn as ordered on 2/20/24, and it was not. UM #1 said that she was unsure why the lab was not drawn. 44337 3. Resident #57 was admitted to the facility in December 2020, with diagnoses including Diabetes Mellitus (DM -a group of diseases that result in too much sugar [glucose] in the blood), and traumatic amputation (the loss of a body part that occurs as a result of an accident or injury) of right lower extremity. Review of the Minimum Data Set assessment, dated 1/30/24, indicated Resident #57 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15. Review of the Physician's orders dated 2/27/24, indicated the following: -FSBS Three Times Daily Before Meals related to Type 2 Diabetes Mellitus .Initiated 11/28/23. -Humalog (fast-acting type of Insulin: medication injection used to control the amount of sugar in the blood) KwikPen Subcutaneous Solution Preparation Pen Injector 100 units per milliliter. Inject five (5) units subcutaneously (the layer of fatty tissue just beneath the skin) one time a day for DM, initiated 11/28/23 - Insulin Glargine (long-acting type of Insulin) Solution Pen-Injector 100 units per milliliter. Inject 22 units subcutaneously one time a day for DM, initiated 6/15/23. Review of the November 2023, December 2023, January 2024 and February 2024 MAR's indicated blank spaces corresponding to the Physician's order for FSBS monitoring three times daily before meals. Further review of the November 2023, December 2023, January 2024 and February 2024 MAR's provided no documented evidence that indicated FSBS's had been performed for Resident #57 as ordered. Review of the care plan, revised 2/20/24, indicated that Resident #57 was at risk for hypo/hyperglycemia (low/ high blood sugar levels), with an intervention of accuchecks (another term used for fingerstick blood sugar monitoring [FSBS]), as ordered, and to call the Physician for a blood sugar level of less than 70 [mg/dL] (milligrams per deciliter) or greater than 400 [mg/dL]. During an interview on 2/27/24 at 10:58 A.M., Nurse #3 said that the Resident had FSBS monitoring performed three days a week, two times a day, on Monday, Wednesday, and Friday according to a Physician's order initiated 4/26/23. Nurse #3 also said the Resident had FSBS monitoring daily because he/she was administered a scheduled dose of short-acting insulin daily at 11:30 A.M. Nurse #3 said that FSBS monitoring was documented on the MAR in the designated spaces next to the Physician order. The surveyor and Nurse #3 reviewed the Resident's current Physician orders and she said that there were two orders for monitoring the Resident's FSBS. Nurse #3 said one order was initiated 4/26/23, and another order was initiated 11/28/23 for FSBS three times daily before meals. Nurse #3 said that the most recent Physician's order initiated 11/28/23, should have been implemented but the order was never implemented because it had been entered into the computer incorrectly. Nurse #3 said the Resident's FSBS should have been monitored three times a day before each meal as ordered, but the FSBS had not been monitored as ordered.

Based on observation, record review, policy and interview, the facility failed to provide care and services for an indwelling urinary/Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine outside the body) for one Resident (#53) out of a total sample of 15 residents. Specifically, the facility staff failed to verify the correct size indwelling urinary catheter as ordered by the Physician and ensure the verified size catheter was in place for Resident #53, to prevent catheter related complications. Findings include: Review of the facility policy for Indwelling (Foley Catheter, Urinary Catheter) Catheter Insertion, last revised August 2022, indicated to verify that there is a Physician's order for this procedure. Resident #53 was admitted to the facility in June 2022 with diagnoses including urinary tract infection (UTI: bacterial infection of the urinary tract), disorder of the kidney and ureter (tubes made of smooth muscle that propel urine from the kidneys to the urinary bladder), and urinary retention (failure to eliminate) of urine. A review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #53 was unable to be interviewed as he/she was rarely or never understood. Further review of the MDS assessment indicated that the Resident had an indwelling urinary catheter. Review of Resident #53's Physician's orders for February 2024, indicated orders for two different sized catheters: -Change Foley catheter every 3 months and as needed 16 Fr (French scale or system used to size catheters), 30 cc (cubic centimeter) balloon (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) with a start date of 11/16/23. -Foley catheter 18 Fr, 30 cc (balloon) with a start date of 9/30/22. Review of Resident #53's Treatment Administration Record (TAR) for February 2024 indicated that the Foley catheter had been changed on 2/4/24 to a 16 Fr Foley catheter. Further review of the medical record indicated that the Foley catheter was last changed on 2/4/24. During an observation and interview on 2/27/24 at 2:11 P.M. with Unit Manager (UM) #1, UM #1 reviewed the Physician's orders and said that Resident #53 should have a size 16 Fr Foley catheter in place based on the most recent start date of 11/16/23. During an observation of the Foley catheter, UM #1 verified that the current Foley catheter size in place for Resident #53 was a size 18 Fr/30cc catheter. UM #1 said the Resident should have had the size 16 Fr [30 cc] Foley catheter in place and not the size 18 Fr/30cc size Foley catheter.

Based on observation, interview, policy and record review, the facility failed to provide appropriate care, services, and monitoring of a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication, also referred to as a feeding tube) for one Resident (#26) out of a total sample of 15 residents. Specifically, the facility staff failed to verify proper placement of a G-tube every shift as ordered by the Physician to prevent complications of enteral (passing through the gastrointestinal [GI] tract) feeding. Findings include: Review of the facility policy titled Administering Medication through an Enteral Tube, last revised November 2018, indicated to verify the placement of the feeding tube prior to administering medications or feeding. Resident #26 was admitted to the facility in November 2021 with a diagnosis of gastrostomy tube. Review of Resident #26's Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15, and had a feeding tube. Review of Resident 26's Physician's orders indicated to check the G-tube placement every shift, start date 3/8/22. Further review of the Physician's orders indicated that the resident received medications, feeding and supplements during each shift. Review of Resident #26's care plan for tube feeding indicated that the Resident required tube feedings in addition to meals for nutrition and hydration due to dysphagia, related to a cerebrovascular accident (CVA- stroke) with variable appetite, complicated by aphasia, cerebral palsy . Review of Resident #26's Medication Administration Record (MAR) for December 2023 indicated that the G-tube had not been checked for placement on: Day Shift- 12/3/23,12/21/23-12/22/23, 12/24/23, Evening Shift- 12/3/23, 12/21/23-12/22/23, 12/30/23 Night Shift- 12/3/23, 12/17/23, 12/22/23, 12/26/23, 12/30/23 Review of Resident #26's MAR for January 2024 indicated that the G-tube had not been checked for placement on: Day Shift- 1/3/24 -1/6/24, 1/17/24, 1/26/24 Evening Shift- 1/3/24 -1/5/24, 1/16/24, Night Shift- 1/2/24 -1/5/24, 1/16/24, 1/31/24 Review of Resident #26's Medication Administration Record (MAR) for February 2024 indicated that the G-tube had not been checked for placement on: Day Shift- 2/13/24, 2/18/24, Evening Shift- 2/5/24, 2/13/24, Night Shift- 2/7/24, 2/9/24, 2/13/24, 2/19/24, 2/24/24, 2/26/24 During an interview on 2/27/24 at 8:07 A.M., the surveyor and Unit Manager (UM) #1 reviewed Resident #26's MAR. UM #1 said that the G-tube placement should have been checked every shift and this had not been done as ordered. During an interview on 2/27/24 at 8:30 A.M., the Director of Nurses (DON) reviewed Resident #26's MAR. The DON said that the G-tube placement should have been checked every shift and it had not been done as ordered. The DON also said that if the Resident refused the tube feedings there would have been corresponding progress notes documenting the refusals to the referenced dates where the G-tube placement was not checked. The DON said there had been no refusals of the tube feedings. The surveyor requested the facility policy on care and services of the G-tube (G-tube placement process) from the DON. The facility staff did not provide the G-tube placement policy as requested through the time of the survey exit.

Based on observation, records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at an increased risk for falls and who required assistance of two staff members with the use of a mechanical lift for safe transfers, the Facility failed to ensure staff consistently implemented and followed interventions from his/her plan of care related to his/her individual care needs related to transfers. On 09/04/23 during the day shift, a Certified Nurse Aide transferred Resident #1 out of bed, alone, and without a mechanical lift, resulting in him/her being lowered to the floor. Resident #1 complained of right hip pain a few hours after the incident, an order for an x-ray was obtained, Resident #1 was diagnosed with a right proximal tibia and fibula (lower leg bones) fractures and was transferred to the Hospital Emergency Department (ED) for evaluation and further treatment. Findings include: Review of the Facility's Policy, titled Falls and Fall Risk-Managing, dated as revised March 2018, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling. The Policy also indicated the staff, with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/08/23, indicated that Resident #1 required total care with all Activities of Daily Living (ADLs), and required a mechanical lift with assistance from two staff members when transferring, because he/she was unable to bear weight. The Report indicated that on 09/04/23 at 12:30 P.M., CNA #1 attempted to stand-pivot transfer Resident #1 out of his/her bed, she was unable to support his/her weight and lowered him/her to the floor. Further review of the report indicated that CNA #1 had not asked co-workers about Resident #1's transfer status and had not reviewed his/her CNA Care Card. The Report indicated CNA #1 said she was informed by Resident #1 that he/she could stand, and pivot and she accepted his/her word for it. Resident #1 was admitted to the facility in January 2022, diagnoses included low back pain, spinal stenosis (an abnormal narrowing of the spinal canal that results in pressure on the spinal cord or nerve roots) and metabolic encephalopathy (a disease that affects brain structure or function and causes altered mental state and confusion). Review of Resident #1's Medical Record indicated his/her Health Care Proxy (HCP) was activated on 01/17/23. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/19/23, indicated that his/her cognitive status was severely impaired, with a score of 5 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 Resident #1 was dependent on two staff members for transfers in and out of bed, and sit to stand transfers was coded as not applicable. Review of Resident #1's Fall Risk Care Plan, reviewed and renewed with the Quarterly MDS completed 07/19/23, indicated he/she was at an increased risk for falls. The Care Plan included a goal for Resident #1 was to be free of injury from falls through the next review. Review of Resident #1's ADL Care Plan, dated as reviewed on 08/21/23, indicated he/she required a mechanical lift for transfers with assistance from two staff members. Review of Resident #1's Fall Risk Assessment, dated 08/22/23, indicated he/she was at an increased risk for falls. During an interview on 09/28/23 at 11:00 A.M., Resident #1 said he/she had a broken leg from a fall that happened a few weeks ago but he/she could not recall the date. Resident #1 said that a CNA (later identified as CNA #1) wanted to transfer him/her alone, and that he/she told the CNA, You need to go and get the mechanical lift, I don't get up too well and I am over 200 pounds. Resident #1 said CNA #1 stood him/her up, alone, without the lift and his/her knees buckled. Resident #1 said she sort of fell on me, hitting my knee. Review of Resident #1's X-ray Report, dated 09/05/23, indicated he/she was diagnosed with an acute appearing proximal (just below the knee) right tibia and fibula fractures. During an interview on 9/28/23 at 1:55 P.M., Nurse #1 said she was passing medications, on 09/04/23, when CNA #1 alerted her that Resident #1 was on the floor in his/her room. Nurse #1 said that when she entered Resident #1's room, she observed that he/she was on the floor, between the nightstand and his/her bed. Nurse #1 said CNA #1, told her she stood Resident #1 up from the bed and his/her knees buckled, so she lowered him/her to the floor. Nurse #1 said she notified Resident #1's Physician about his/her fall and complaint of right hip discomfort. Nurse #1 said that CNA #1 told her that she had not looked at Resident #1's CNA Care Card and was not aware that he/she required a mechanical lift and assistance from two staff members for transfers. Nurse #1 said that CNA #1 should have checked Resident #1's CNA Care Card to determine his/her transfer level for safety. During an interview on 09/28/23 at 3:27 P.M., Certified Nurse Aide (CNA) #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 09/04/23, and Resident #1 was on her assignment. CNA #1 said it was the first time she was assigned to Resident #1 and she was unfamiliar with his/her transfer status. CNA #1 said it was a busy morning and that she had not checked Resident #1's CNA Care Card for his/her transfer status nor had she asked any co-workers. CNA #1 said that when she asked Resident #1 how he/she transferred, he/she told her that he/she could stand and pivot. CNA #1 said sometime around 12:30 P.M. or 12:45 P.M. (unable to recall exact time) she attempted to stand-pivot Resident #1 to transfer him/her from the bed to a chair, alone and without a mechanical lift. CNA #1 said she positioned herself by cradling Resident #1's knees, between her own knees, and when he/she was unable to bear weight and stand she lowered him/her to the floor. During an interview on 09/28/23 at 12:45 P.M., Certified Nurse Aide #3 said that if she is unfamiliar with a resident's care needs or transfer status, the expectation is to reference the CNA Care Card in the electronic medical record via the tablet that is provided to the CNAs for documentation. During an interview on 09/28/23 at 1:31 P.M., the Assistant Director of Nurses (ADON) said she was unable to provide a paper copy of Resident #1's CNA Care Card, that was effective on 9/04/23 when the incident occurred, because it was maintained electronically. The ADON further said that resident CNA Care Cards were linked to the residents' care plans, therefore the transfer status that was active on Resident #1's Care Plan as of 09/04/23 would have been reflected on the CNA Care Card as well. The ADON further said that staff were expected to check the Care Plan or CNA Care Card to determine a Resident's transfer status when they were unfamiliar with a resident or there many have been a change in status. The ADON said CNA #1 was not familiar with Resident #1 and had not referenced Resident #1's CNA Care Card prior to initiating the transfer on 09/04/23, but should have.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at an increased risk for falls, and who required extensive assistance from two staff members with the use of a mechanical lift during transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and assistive device during a transfer to maintain his/her safety in an effort to prevent an incident and/or accident resulting in an injury. On 09/04/23, during the day shift, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without a mechanical lift and without a second staff member present to assist her, Resident #1's knees buckled, and she lowered him/her to the floor. Resident #1 complained of right hip pain a few hours after the incident, an order for an x-ray was obtained, Resident #1 was diagnosed with a right proximal tibia and fibula (lower leg bones) fractures and was transferred to the Hospital Emergency Department (ED) for evaluation and further treatment. Findings include: Review of the Facility's Policy, titled Falls and Fall Risk-Managing, dated as revised March 2018, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling. The Policy also indicated the staff, with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/08/23, indicated that Resident #1 required total care with all Activities of Daily Living (ADLs), and required a mechanical lift with assistance from two staff members when transferring, because he/she was unable to bear weight. The Report indicated that on 09/04/23 at 12:30 P.M., CNA #1 attempted to stand-pivot transfer Resident #1 out of his/her bed, she was unable to support his/her weight and lowered him/her to the floor. Further review of the report indicated that CNA #1 had not asked co-workers about Resident #1's transfer status and had not reviewed his/her CNA Care Card. The Report indicated CNA #1 said she was informed by Resident #1 that he/she could stand, and pivot and she accepted his/her word for it. Resident #1 was admitted to the facility in January 2022, diagnoses included low back pain, spinal stenosis (an abnormal narrowing of the spinal canal that results in pressure on the spinal cord or nerve roots) and metabolic encephalopathy (a disease that affects brain structure or function and causes altered mental state and confusion.). Review of Resident #1's Medical Record indicated his/her Health Care Proxy (HCP) was activated on 01/17/23. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/19/23, indicated that his/her cognitive status was severely impaired, with a score of 5 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 Resident #1 was dependent on two staff members for transfers in and out of bed, and sit to stand transfers was coded as not applicable. Review of Resident #1's Fall Risk Care Plan, reviewed and renewed with the Quarterly MDS completed 07/19/23, indicated he/she was at an increased risk for falls. The Care Plan included a goal for Resident #1 to be free of injury from falls through the next review. Review of Resident #1's ADL Care Plan, dated as reviewed on 08/21/23, indicated he/she required a mechanical lift for transfers with assistance from two staff members. Review of Resident #1's Fall Risk Assessment, dated 08/22/23, indicated he/she was at an increased risk for falls. During an interview on 09/28/23 at 11:00 A.M., Resident #1 said he/she had a broken leg from a fall that happened a few weeks ago but he/she could not recall the date. Resident #1 said that a CNA (later identified as CNA #1) wanted to transfer him/her alone, and that he/she told the CNA, You need to go and get the mechanical lift, I don't get up too well and I am over 200 pounds. Resident #1 said CNA #1 stood him/her alone, without the lift and his/her knees buckled. Resident #1 said she sort of fell on me, hitting my knee. During an interview on 9/28/23 at 1:55 P.M., Nurse #1 said she was passing medications, on 09/04/23, when CNA #1 alerted her that Resident #1 was on the floor in his/her room. Nurse #1 said that when she entered Resident #1's room, she observed that he/she was on the floor, between the nightstand and his/her bed. Nurse #1 said CNA #1 told her she stood Resident #1 from the bed and his/her knees buckled, so she lowered him/her to the floor. Nurse #1 said that CNA #1 told her that she had not looked at Resident #1's CNA Care Card and was not aware that he/she required a mechanical lift and assistance from two staff members for transfers. Nurse #1 said that CNA #1 should have checked Resident #1's CNA Care Card to determine his/her transfer level for safety. Nurse #1 further said that after the fall, Resident #1 had to be manually lifted from the floor to a chair before he/she could be mechanically lifted back to bed, because the mechanical lift could not reach his/her location on the floor. Nurse #1 said she notified Resident #1's Physician about his/her fall and complaint of right hip discomfort. Review of Resident #1's X-ray Report, dated 09/05/23, indicated a diagnosis of acute appearing proximal (just below the knee) right tibia and fibula fractures. Review of Resident #1's Nurse Progress Note, dated 09/05/23, indicated the Nurse Practitioner reviewed Resident #1's x-ray results and wrote an order to transfer him/her to the Hospital ED. Review of Resident #1's Hospital ED Discharge Summary, dated 09/05/23, indicated Resident #1 was diagnosed with right tibia and fibula fractures. The Summary indicated Resident #1 was discharged back to the Facility with instructions to remain non-weight bearing and to wear a knee immobilizer (a splint that prevents the knee from bending) on the right leg. During an interview on 09/28/23 at 3:27 P.M., Certified Nurse Aide (CNA) #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 09/04/23, and Resident #1 was on her assignment. CNA #1 said it was the first time she was assigned to Resident #1, and she was unfamiliar with his/her transfer status. CNA #1 said it was a busy morning and that she had not checked Resident #1's CNA Care Card for his/her transfer status nor had she asked any co-workers. CNA #1 said that when she asked Resident #1 how he/she transferred, he/she told her that he/she could stand and pivot. CNA #1 said that sometime around 12:30 P.M. or 12:45 P.M. (unable to recall exact time) she attempted to stand-pivot Resident #1 to transfer him/her from the bed to a chair, alone and without a mechanical lift. CNA #1 said she positioned herself by cradling Resident #1's knees, between her own knees, and when he/she was unable to bear weight and stand she lowered him/her to the floor. During an interview on 09/28/23 at 1:31 P.M., the Assistant Director of Nurses (ADON) said that Resident #1 rarely got out of bed and was not capable of a stand-pivot transfer. The ADON said that at the time of the fall, Resident #1 required a mechanical lift and assistance from two staff members for all transfers. The ADON said CNA #1 was not familiar with Resident #1 and had not referenced Resident #1's CNA Care Card prior to initiating the transfer on 09/04/23. The ADON said she was unable to provide a paper copy of Resident #1's CNA Care Card, that was effective on 9/04/23, because it was maintained electronically. The ADON further said that resident CNA Care Cards were linked to the care plans, therefore the transfer status that was active on Resident #1's Care Plan as of 09/04/23 would have been reflected on the CNA Care Card as well. The ADON said the Facility's investigation concluded that CNA #1 had not provided adequate staff assistance and had not utilized a mechanical lift, as required, when she transferred Resident #1 out of bed on 09/04/23, resulting in a fall and subsequent injury. The ADON said that CNA #1 should have used a mechanical lift, along with getting assistance from another staff member, when she transferred Resident #1 out of bed.

Based on records reviewed and interviews for 1 of 3 Residents (Resident #2), the Facility failed to ensure that acceptable parameters of nutritional status were maintained, to provide adequate interventions and evaluation of their effectiveness to prevent further significant weight loss. The Facility failed to: - Follow the physician's orders [REDACTED]. - Ensure current weights were documented in a consistent format for comparison to identify significant weight loss; - Document percent meal intake for comparison of decline or improvement to provide appropriate interventions; - Verify the accuracy of weights by reweighing Resident #2 when he/she had a significant weight loss of greater than 10% in a 2 month period. Findings include: The Facility's policy for Weight Assessment and Interventions, dated 9/2008 indicated the multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. - Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. - Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified nursing will immediately notify the Dietician in writing. - The Dietician will review the unit Weight Record by the 15th of the month to follow individual with trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 month - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 month - 10% weight loss is significant; greater than 10% is severe. The Nursing Admission Form dated 9/23/16, indicated Resident #2's admission weight was 107 lbs. The Dietician's Initial Evaluation record, dated 9/23/16, indicated Resident #1's ideal body weight was 96 lbs to 126 lbs. The evaluation record indicated Resident #2 needed supervision and cueing with eating, his/her intake for meals was 50%to 75% with a serum [MEDICATION NAME] of 3.4 grams/deciliter (normal 3.4 to 5.4 grams/deciliter - a measurement of protein in the blood to assess protein needs and evidence of malnutrition). The Nutrition and Dehydration Care Plan, dated 9/29/16, indicated Resident #2 was at risk for decline in nutrition related to dementia, confusion, and recent weight loss. The care plan indicated the goal was to maintain Resident #2's weight from 99 lbs. to 107 lbs and interventions included; - Give 4 ounces of a supplement before meals and Promod (a protein supplement) twice a day; - Offer alternative and or meal replacement for intake less than 50% for breakfast, lunch and supper; - Document weights weekly, and monitor and evaluate significant changes. A laboratory blood result report work, dated 9/27/16, indicated Resident #2's [MEDICATION NAME] (a measurement of protein in the blood to assess protein needs and evidence of malnutrition). was low, 2.9 grams per deciliter (Gm/dl), normal is 3.2 to 5.0 Gm/dl, this can be an indicator of malnutrition. The admission Minimum Data Set Assessment, dated 9/30/16, indicated Resident #2 had a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment, and required extensive assist of one with eating. The MDS indicated Resident #2 weighed 107 lbs. The physician's orders [REDACTED].#2 weekly. The Dietician's progress note, dated 10/6/16 indicated, Resident #2's appetite was poor, with intake 0 to 25 % and he/she was fully dependent on staff for feeding. The Certified Nursing Assistant Flow Sheet, dated October 2016, indicated Resident #2's percentage of meal intake had been left blank on 30 meals (out of 96, or 31%), as follows; Breakfast and lunch, 10/1/16, 10/2/16, 10/4/16, 10/6/16, 10/8/16, 10/10/16, 10/12/16, 10/15/16, 10/16/16, 10/20/16, 10/21/16, 10/24/16, 10/26/16, 10/29/16, and 10/30/16. The Certified Nursing Assistant Flow Sheet, dated November 2016, indicated that Resident #2's percentage of meal intake had been left blank for 27 meals (out of 90, or 30%), as follows; Breakfast and lunch on; 11/9/16, 11/12/16, 11/13/16, 11/17/16, 11/18/16, 11/22/16, 11/23/16, 11/24/16, 11/26/16, 11/27/16, 11/28/16, 11/29/16 and 11/30/16 breakfast, lunch and supper were left blank. Resident #2's vital signs and weight record, dated 2016, did not have any documented weights from October 1, 2016 through October 31, 2016. The first recorded weight was documented on 11/1/16 as - 101 lbs (a 6 lb weight loss from admission), no reweigh was performed. Further weights recorded indicated that on 11/5/16 Resident #2 weighed - 101.2 lbs. On he/she weighed 11/08/16 - 99 lbs. On 11/12/16 - it was blank indicating- no weight was taken. On 11/15/16 he/she weighed - 91 lbs (an 8 lbs weight loss from 7 days ago) - no reweigh was performed. On 11/22/16 he/she weighed - 97.2 lbs (a 6.2 lbs weight gain from 7 days ago) - no reweigh was performed. On 11/29/16 he/she weighed - it was blank indicating - no weight was taken. On 12/1/16 he/she weighed - 88.8 lbs (an 8.4 lbs weight loss from 9 days ago) - This weight was performed when the Surveyor asked the Associate Director of Nursing for a current weight for Resident #2. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 11:25 A.M. on 12/1/16. The ADON said that many of the resident's weights had not been transcribed to the appropriate vital sign and weight sheet for comparisons. The ADON said it was the Facility's practice that staff would reweigh a resident when there was a 3 lbs weight difference from the previous weight. The ADON said Resident #2 was not reweighed on 11/15/16 nor on 11/22/16 when there had been a greater than 3 lb weight loss or gain. The Dietician's note, dated 11/10/16, indicated Resident #2 had a 7.9% weight loss over 6 weeks and more supplements were added. The Surveyor interviewed Dietician #1 at 8:10 A.M. and 11:10 A.M. on 12/1/16. Dietician #1 said that Resident #2 had significant weight loss with an 18.2 lbs weight loss over approximately 2.5 months; this was a 17 % weight loss. (Greater than 7.5 % weight loss over 3 months is severe weight loss). Dietician #1 said that having weekly weights performed and documented in a consistent area has been an on going problem. Dietician #1 said that Resident #2's reweighs were not performed for major discrepancies between the previous weights and his/her meal percentage intake sheets were not accurately completed which caused a delay early detection of Resident #2's severe and unplanned weight loss.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #2), the facility failed to thoroughly assess Resident #2 after a witnessed fall. Although Resident #2 was screaming in pain, Nurse #2, with the assistance of the CNA's, transferred Resident #2 to the shower chair. Resident #2 was transferred to the hospital for evaluation and was diagnosed with [REDACTED]. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. A Facility Education Record titled Essential Care and Responsibilities after a Resident Fall, dated 6/29/2015 and 7/13/2015 and documented as signed by Nurse #2, indicated following a fall, staff were to assess the resident for signs of serious injury such as pain before attempting to move the resident, not to move the resident, and to call for an ambulance if severe injury is apparent or to transfer resident by a mechanical lift to their bed for further assessment. Resident #2's [DIAGNOSES REDACTED]. The Admission Nursing Evaluation, dated 7/15/16, indicated Resident #2 ambulated with a cane and/or walker with limited assist. The Fall Risk Care Plan, dated 7/15/16, indicated Resident #2 ambulated with a cane with supervision. A Therapy Progress Note, dated 7/16/16, indicated Resident #2 is able to ambulate with a cane with supervision and is appropriate for ambulation with a cane and staff assistance. The Physical Therapy Evaluation, dated 7/21/16, indicated Resident #2 requires supervision with weight bearing activity. A Nurse Progress Note, dated 7/22/2016, indicated Resident #2 was seen by Nurse #2 tripping over the wheelchair scale and falling to the floor landing on his/her left side. The physician was notified and ordered Resident #2 to be sent to the emergency room for evaluation. There was no documentation to indicate staff performed a clinical assessment on Resident #2 following his/her fall. The surveyor interviewed Nurse #2 at 2:30 P.M. on 10/5/16. Nurse #2 said that she saw Resident #2 enter the shower room and trip over the wheelchair scale and fall on his/her left hip. Nurse #2 said Resident #2 was screaming in pain and suspected Resident #2 had a [MEDICAL CONDITION] or words to that effect. Nurse #2 said she instructed CNA #1 and CNA #2 to transfer Resident #2 to a shower chair. This was not consistent with the Facility Education Record titled Essential Care and Responsibilities after a Resident Fall. The surveyor interviewed CNA #1 at 11:32 A.M. on 10/11/16. CNA #1 said Resident #2 was screaming and seemed to be in pain or words to that effect. CNA #1 said he assisted to transfer Resident #2 to a shower chair by lifting Resident #2 under his/her arms. The surveyor interviewed CNA #2 at 3:13 P.M. on 10/11/16. CNA #2 said she assisted to transfer Resident #2 to the shower chair by lifting Resident #2 under the arms as another CNA guided Resident #2's affected leg. CNA #2 said Resident #2 was yelling during the transfer and grimacing in pain or words to that effect. The surveyor interviewed the Director of Nurses at 1:19 P.M. on 10/7/16. The Director of Nurses said Nurse #2 should not have moved Resident #2 if a fracture was suspected. An Incident/Accident Report, dated 7/22/2016, indicated Resident #2 screamed in pain when anyone lifted his/her leg. Resident #2 was transferred and admitted to the hospital where he/she was diagnosed with [REDACTED].

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #2), the facility failed to administer pain medication to Resident #2 after a witnessed fall, who was screaming in pain. Resident #2 was transferred to the hospital for evaluation and diagnosed with [REDACTED]. Findings include: The Facility Policy titled Pain - Clinical Protocol, revised date June 2013, indicated the nursing staff will assess each individual for pain whenever there is a significant change in condition and when there is onset of new pain. A Facility Education Record titled Essential Care and Responsibilities after a Resident Fall, dated 6/29/2015 and 7/13/2015 and documented as signed by Nurse #2, indicated following a fall staff were to assess the resident for signs of serious injury such as pain. Resident #2's [DIAGNOSES REDACTED]. A Nurse Progress Note, dated 7/22/2016, indicated Resident #2 was seen by Nurse #2 tripping over the wheelchair scale and falling to the floor landing on his/her left side. The Physician was notified and an order was obtained to transfer Resident #2 to the Hospital emergency room for evaluation. The surveyor interviewed Nurse #2 at 2:30 P.M. on 10/5/16. Nurse #2 said that she saw Resident #2 enter the shower room and trip over the wheelchair scale and fall on his/her left hip. Nurse #2 said Resident #2 was screaming in pain and suspected Resident #2 had a [MEDICAL CONDITION] or words to that effect. However, Nurse #2 instructed CNA #1 and CNA #2 to assist her to transfer Resident #2 to a shower chair. This was not consistent with the Facility Education Record titled Essential Care and Responsibilities after a Resident Fall. The surveyor interviewed CNA #1 at 11:32 A.M. on 10/11/16 and at 8:37 A.M. on 10/12/16. CNA #1 said Resident #2 was screaming and seemed to be in pain or words to that effect. CNA #1 said he did not see Nurse #2 give medication to Resident #2 after the fall. The surveyor interviewed CNA #2 at 3:13 P.M. on 10/11/16 and at 10:52 A.M. on 10/12/16. CNA #2 said Resident #2 was yelling during the transfer and grimacing in pain or words to that effect. CNA #2 said she did not see Nurse #2 give medication to Resident #2 after the fall. There was no documentation to indicate staff performed a clinical assessment on Resident #2 following his/her fall or that he/she was medicated for pain. This was not consistent with the Facility's Policy titled Pain-Clinical Protocol. An Incident/Accident Report, dated 7/22/2016, indicated Resident #2 screamed in pain when anyone lifted his/her leg. Resident #2 fell at 8:15 P.M. and left the facility by ambulance to the hospital at 8:45 P.M. Resident #2 was admitted to the hospital with [REDACTED]. There is no documentation to indicate Resident #2 was medicated for pain. The Medication Administration Record, [REDACTED]. The Ambulance Patient Care Report, dated 7/22/16, indicated that on a scale of 0 to 10, Resident #2 complained of pain as a scale of 9. The Hospital Emergency Medicine Notes, dated 7/22/16, indicated Resident #2 received [MEDICATION NAME] (a medication to treat moderate to severe pain) intravenously (administered through a vein) in the emergency room . A Facsimile, at 11:02 A.M. on 10/12/16, received from the Director of Nurses, indicated there was no documentation in the Nurse's Notes or in the MAR indicated [REDACTED]. The Surveyor interviewed the Director of Nurses at 11:30 A.M. on 10/12/16. The Director of Nurses confirmed that she wrote the facsimile dated 10/12/16 and said she did not find any documentation that Resident #2 was medicated for pain after the fall.

Based on observation, record review and staff interviews, the facility failed to notify the Physician of 2 sampled residents (#9 and #11) in a total sample of 15, regarding a new burn (#11), and a new onset of shoulder pain (#9). Findings include: 1. For Resident #11, the facility failed to notify the Physician and family that the resident sustained [REDACTED]. Resident #11, admitted to the facility in 8/2009, had [DIAGNOSES REDACTED]. A nurse's note of 5/2/11 indicated that in the morning, the resident spilled hot coffee on both inner thighs. The 5/2011 treatment record documentation indicated the resident's inner thighs (that had been healing from hot [MEDICAL CONDITION] 4/18/11) now showed a marked decline including the development of necrotic tissue and drainage from 5/2/11 - 5/9/11. A Doctor's Progress Note dated 5/10/11 indicated the Physician became aware on this date that the resident's burn areas had deteriorated. The Physician did not document that she had any awareness the resident had been burned again on 5/2/11. During interview on 11/14/11 at 2:30 P.M., Nurse #4 said that after the resident sustained [REDACTED]. She also said that she could not remember contacting the Physician or family. Please refer to F279, F309, and F323, Example #1a. 2. For Resident #9 the facility failed to notify the Physician when the resident experienced a new onset of shoulder pain. Resident #9 was admitted to the facility in 3/2011. The [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident usually understands and is usually able to make self understood. In addition, the MDS indicated the resident was not experiencing any pain. Review of the 9/2011 Physician order's indicated the resident had an order to receive Tylenol 650 milligrams (mg.) every four hours if needed for pain. Review of the 9/2011 and 10/2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the 11/2011 MAR indicated [REDACTED] - 11/6/11 at 8:45 P.M., - 11/7/11 at 8:45 A.M. and at 6:00 P.M., - 11/8/11 at 3:00 A.M., 9:00 A.M. and 2:00 P.M. and - 11/9/11 at 12:00 A.M. and 8:15 A.M.. Each time the Tylenol was administered, the pain level was reassessed by the nurse, the assessment indicated the resident continued to experience some pain. On 11/9/11 during the initial tour on the unit, at 8:30 A.M., with Nurse #1, Resident #9 was observed by the surveyor lying in bed, dressed, with the head of the bed elevated to a seated position. The resident was rubbing his/her right shoulder with his/her left hand, moaning and verbally complaining of right shoulder pain. The surveyor asked Nurse #1 what was wrong with the resident's shoulder. Nurse #1 said the resident had been complaining of shoulder pain for a couple of days and the facility was going to talk to the doctor and maybe get an x-ray. On 11/9/11 at 10:45 A.M. during interview, Nurse #1 said Resident #9 was complaining of shortness of breath and was sweating. Nurse #1 spoke to the Physician and the decision was made to send the resident to the hospital. During a telephone interview with the Physician on 11/10/11 at 11:05 A.M., the Physician said that she was not aware the resident had been complaining of shoulder pain for 4 days. She further explained that she was in the facility on 11/7/11 and should have been notified. During a telephone interview with Nurse #2 on 11/10/11 at 3:05 P.M., ( Nurse #2 worked 11/6 - 11/9/11), she said that she had not notified the Physician of the shoulder pain because the Tylenol seemed to help, and she was still assessing the pain.

Based on observation, record review and staff interview, the facility failed to follow the written plan of care for falls and accidents for 2 of 7 applicable sampled residents (#3 and #11) in a total sample of 15 residents. Findings include: 1. For Resident #3, the facility failed to follow the care plan as follows: - Ensure the resident's alarm was on and functioning per care plan, and - To provide assistance for toileting. Resident #3, admitted to the facility in 4/2010, had [DIAGNOSES REDACTED]. The Fall Risk Care Plan updated (1/17/11) included: - Provide rolling walker and staff assistance for ambulation and toileting per resident schedule. - non-skid slipper socks on when in bed - tab alarm on in chair and bed The Fall Risk Care Plan (updated 7/19/11) included: - Bed and Chair alarms. A Nurse's Note of 9/16/11 indicated the resident was in the dining room at 9:15 A.M., stood up from the chair, ambulated unassisted, and fell to the floor. There were no apparent injuries. The resident had no alarms on per care plan. Review of the 10/2011 alarm check sheet indicated the resident had a sensor alarm on in the bed and chair, however, on 10/16/11 for the 3:00-11:00 P.M. shift, there was no documentation that the resident's alarm had been checked per facility policy. Review of the clinical record indicated that on 10/16/11 the resident was found on the bedroom floor at 9:10 P.M., sustaining a right wrist fracture. Review of the facility's investigation from 10/17-10/20/11 (staff interviews), indicated the numerous staff members said the resident's alarm did not sound due to not working properly. On 11/9/11 at 8:20 A.M., the resident was observed by the surveyor sitting in a wheelchair in the unit dining/activity room. The resident was trying to eat breakfast with the left hand, due to the cast on the right arm. Staff provided assistance as needed. Please refer to F323, Example #1. 2. For Resident #11, the facility failed to use a bed alarm per care plan. Resident #11, admitted to the facility in 8/2009, had [DIAGNOSES REDACTED]. The plan of care addressing falls, updated on 10/3/11, included the following approaches: - Provide resident with safety device/appliance: walker; wanderguard; bed and chair sensor pads, and bathroom alarms; floor mat alarm. Review of a nurse's note and post fall investigation of 10/10/11, indicated the resident fell on the floor in the bedroom at 10:15 P.M. The investigation indicated that staff responded to a Tabs Alarm, and found the resident kneeling beside the bed. The investigation also indicated the resident was supposed to have a Sensor Pad Alarm (bed alarm) per care plan, and not a Tabs Alarm due to the resident previously removing the Tabs Alarm. Review of a nurse's note and post fall investigation of 10/15/11 indicated the resident fell on the floor at 4:45 P.M. after removing the Tabs Alarm. The report indicated the fall was caused by the resident removing the Tabs Alarm, and that a new Sensor Pad Alarm was needed. The facility failed to provide the resident with a bed sensor alarm per care plan. On 11/14/11 at approximately 2:00 P.M., the surveyor observed the resident sitting in a recliner chair in the bedroom. The surveyor observed an alarmed floor mat on the floor approximately 3 - 4 feet in front of the resident, so if the resident stood up, the alarm would not sound until he/she had been ambulating unassisted. During interview with the Director of Nurses at 2:20 P.M. on 11/14/11, the surveyor shared the observations of the floor alarm being too far from the resident to be effective. The Director of Nurses said the mat should be directly in front of the resident to be effective. Please refer to F323, Example #2b.

Based on record review and staff interviews, the facility failed to ensure that 1 resident (#11) in a total sample of 15, received the necessary care and services to attain the highest level of functioning and well-being possible. Findings include: For Resident #11, the facility failed to obtain a treatment order in a timely manner for a burn after the resident spilled hot coffee onto healing blisters caused by the resident spilling hot liquids onto the thighs 2 weeks earlier. Resident #11, admitted to the facility in 8/2009, had [DIAGNOSES REDACTED]. Review of a nurse's note dated 4/18/11 indicated the resident sustained [REDACTED]. A physician's orders [REDACTED]. Review of the 4/2011 Treatment Records (from 4/26-4/30/11), indicated the resident'[MEDICAL CONDITION] healing (red perimeter with white centers and no drainage). A nurse's note dated 5/2/11 indicated that in the morning, the resident spilled hot coffee on both inner thighs (over the healing blisters). Review of the clinical record had no evidence of Physician notification to obtain new treatment orders. Staff continued with the physician's orders [REDACTED]. Review of the 5/2011 Treatment Record documentation indicated the resident's inner thigh burn areas had deteriorated beginning on 5/2/11 (after the second burn). Although nursing staff were applying the [MEDICATION NAME] two times a day, a new treatment order was not obtained for these deteriorated areas. A Doctor's Progress Note dated 5/10/11 indicated the Physician became aware on this date the resident's burn areas had deteriorated. The Physician indicated the resident's bilateral thigh blisters "are ulcerated" with "[MEDICATION NAME] exudate." Physician documentation showed no indication the Physician was aware the resident had been burned again on 5/2/11. A new order was to cleanse the areas with Normal Saline, and apply Solosite gel (wound [MEDICATION NAME] agent) covered with a translucent dressing twice daily. Interview on 11/14/11 at 1:30 P.M., Unit Manager (UM) #1 said that she could not recall being notified by Nurse #4 about the 5/2/11 burn incident. UM #1 told the surveyor that Nurse #4 should have done an incident report and called the Physician for new treatment orders. During interview on 11/14/11 at 2:30 P.M., Nurse #4, said she could not remember contacting the Physician or family regarding the incident on 5/2/11. Please refer to F323, Example #2a.

Based on observation, record review, and staff interview, the facility failed to provide adequate supervision and effective interventions to prevent accidents from occurring for 2 (#3 and #11) of 7 applicable residents with accidents in a total sample of 15. Findings include: 1. For Resident #3, the facility failed to provide supervision and assistance, and to check the functioning of the bed alarm per policy prior to going off shift. The resident got up unassisted (no alarm sounded to alert staff), fell in the bedroom, and sustained a fractured wrist. Resident #3, admitted to the facility in 4/2010, had [DIAGNOSES REDACTED]. Review of the Self Care Deficit Care Plan (updated 1/17/11 and 4/11/11) indicated the resident required assistance for transfers and ambulation due to low endurance and weakness. The Fall Risk Assessments dated 1/7/11 and 4/11/11 revealed the resident scored a total of 20. High risk is a total score of 10 or above. Review of the Fall Risk Care Plan updated (1/17/11 and 4/11/11) included: - Provide rolling walker and staff assistance for ambulation and toileting per resident schedule. - non-skid slipper socks on when in bed The 4/11/11 Quarterly MDS (Minimum Data Set) Assessment indicated the resident: had memory deficits; required limited assistance from staff for bed mobility, transfers, ambulation, dressing, and personal hygiene; required extensive assistance from staff for toilet use (including clothing adjustment); was occasionally incontinent of bladder; required staff assistance for balance, had no falls, and received antianxiety as well as antidepressant medications. A fall investigation of 4/12/11 indicated the resident was taken to the bathroom by a CNA (Certified Nursing Assistant), and while the resident was standing in front of the toilet with the walker, attempted (unassisted) to pull down the pants, and fell to the floor. There were no apparent injuries. The new intervention, which was added to the care plan, was to make sure the resident holds onto the walker, and the CNA will lower the resident's pants, as the resident tends to lose balance. The Annual MDS assessment dated [DATE] indicated no changes except that the resident had a fall with no injury. Review of the Fall Risk Care Plan (7/19/11) included: - Verbal reminders not to ambulate or transfer without assistance (despite cognitive deficits) - Provide resident with safety device/appliance: rolling walker and staff assistance for ambulation; Sensor Pad alarm in bed and chair; Ensure resident uses walker - Teach resident safety measures (despite having memory deficits) - Observe frequently and place in supervised area when out of bed - Non-skid slipper socks in bed A Nurse's Note of 9/16/11 indicated the resident was in the dining room at 9:15 A.M., stood up from the chair, ambulated unassisted, and fell to the floor. There were no apparent injuries. The intervention was to have the alarms on at all times. According to the above care plan, the resident should have had an alarm when sitting the chair. Review of the 10/2011 alarm check sheet indicated the resident had a sensor alarm in the bed and chair, however, on 10/16/11 on the 3:00-11:00 P.M. shift, there was no documentation that the resident's alarm had been checked to ensure proper functioning prior to the resident's CNA (Certified Nursing Assistant) leaving for the evening at 9:00 P.M. Review of the staffing sheet for 10/16/11 on the 3:00-11:00 P.M. shift, indicated that one CNA was a "no call no show" for the shift, which left the unit with three CNAs and two nurses on duty for 34 residents until 9:00 P.M., then only one CNA and one nurse from 9:00-11:00 P.M. Review of the clinical record revealed the resident was found on the bedroom floor on 10/16/11 at approximately 9:10 P.M. (approximately 45-60 minutes after a family member left the facility), and sustained a right wrist fracture. The resident was sent to the emergency room for treatment, and admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE] with a cast on the right arm. The fall investigation dated(10/17-10/20/11) indicated that at the time of the fall, the resident had: increased confusion; one side rail up; call bell within reach; bare feet, and the bed alarm was attached, however, did not sound. During the investigation, interview (conducted by the facility) with Nurse #6 on 10/17/11 indicated the alarm did not sound. During the investigation, interview (conducted by the facility) with a Hospice CNA (10/17/11) on the unit at the time of fall, the CNA wrote that she checked the alarm after the fall, and it (the alarm) was on, but not working due to the clip insert being broken. This CNA reported this to Nurse #6. During the investigation, interview (conducted by the facility) with the resident's 3:00-9:00 P.M. CNA (#2) on 10/20/11, indicated the CNA turned on the alarm when the resident returned from the hospital, however, the interview did not mention the alarm had been checked for proper functioning per policy. During interview (conducted by the facility) with the other 3:00-9:00 P.M. CNA (#1), on 10/20/11, indicated the CNA observed the resident in bed before 9:00 P.M., "but did not see or check the bed alarm!" CNA #1 also wrote, "...we were short staffed...." On 11/9/11 at 8:20 A.M., the resident was observed by the surveyor sitting in a wheelchair in the unit dining/activity room. The resident was trying to eat breakfast with the left hand, due to the cast on the right arm. Staff provided assistance as needed. During interview on 11/9/11 at 2:40 P.M., the resident's family member (that had been the visiting on 10/16/11), told the surveyor that he/she sees the resident almost daily, and that on the evening of 10/16/11, the resident was in a weakened state and more confused than usual. The family member said that he/she told Nurse #6 and CNA #1 to please keep a close eye on the resident, because he/she was leaving. The family member also told the surveyor that when the resident fell on [DATE], the resident was supposed to have had an alarm on the chair in the dining room. During interview on 11/14/11 at 11:00 A.M., the Director of Nurses said that she did not know that two CNAs left the unit at 9:00 P.M. on the evening of 10/16/11. She told the surveyor there should have been two CNAs on the unit from 9:00-11:00 P.M., and not just one. 2a. For Resident #11, the facility failed to put effective interventions in place after the resident burned him/herself while eating hot soup. The resident spilled hot coffee on the healing blisters 2 weeks later, causing further injury. Resident #11, admitted to the facility in 8/2009, had [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] indicated the resident: could not always understand directions, and could not always make self understood; had memory deficits, delusions and impaired vision (macular degeneration); was independent for bed mobility; required limited assistance from staff for transfers, ambulation (room and hallway), dressing, toilet use, and personal hygiene; required supervision from staff for eating; received antipsychotic and antidepressant medications; and had no falls. The Care Plan addressing Impaired Mobility (updated 2/2011 and 4/2011) had a goal that the resident "will comply with measures to promote safety and be free from injuries daily x (for) 90 days. The Approach Plan indicated that staff would "provide appropriate level of assistance to promote safety of resident." The Quarterly MDS assessment dated [DATE] indicated the following changes from the previous MDS Assessment: cognitively declined, required limited assistance from staff for bed mobility; required extensive assistance from staff for transfers, dressing, and toilet use, two falls with no injury. Review of a nurse's note dated 4/18/11 indicated the resident sustained [REDACTED]. Review of the clinical record and care plan revealed there were no interventions put into place after the burn of 4/18/11 to prevent the resident from sustaining further burns. Review of the 4/2011 Treatment Records (from 4/26-4/30/11), indicated the resident's burns were healing (red perimeter with white centers and no drainage). A Doctor's Progress Note dated 4/29/11 indicated the resident's inner thigh blisters were "resolving per staff." A nurse's note of 5/2/11 indicated that in the morning, the resident spilled hot coffee on both inner thighs (over the healing blisters). The note indicated there was no redness noted, and that from now on, the resident would have covers on the cups (not added to care plan), and be encouraged to eat in the dining room. Review of the clinical record had no evidence that the Physician and family were notified of the new burn area. Staff continued with the physician's orders [REDACTED]. Review of the 5/2011 Treatment Record documentation indicated the following: -5/1/11, the inner thighs areas red perimeter, whitish center and no drainage. - 5/2, (after spilling hot coffee on the previous burn sites), red perimeter with darkened center - 5/3, yellow center with dark gray areas on both thighs - 5/4, 5/5, 5/6, no documentation - 5/7, Blackened eschar surrounded by white tissue, perimeter remains red - 5/8, increased drainage, blackened areas surrounded by white tissue on both groin areas - 5/9, dark eschar in center with yellow eschar surrounding. Yellow drainage both thighs - 5/10, no documentation Review of the Care Plan addressing Skin Breakdown indicated the blistered areas were care planned (undated), and that the areas would heal by 7/2011. There were no interventions to prevent the resident from future burns. Review of the Nutritional Care Plan updated 5/9/11 indicated the resident would use a sippy cup (covered cup) for fluids. A Doctor's Progress Note dated 5/10/11 indicated the Physician became aware that the resident's burn areas had deteriorated on this date. The Physician indicated that the resident's bilateral thigh blisters "are ulcerated" with "fibrinous exudate." The Physician did not document any awareness that the resident had been burned again on 5/2/11. A new order was to cleanse the areas with Normal Saline and apply SoloSite gel (wound debriding agent) covered with a translucent dressing twice daily. A Doctor's Progress Note dated 6/13/11 indicated the Physician examined the resident's thigh wounds. The note indicated that both inner thighs had healed areas and a question of keloid formation (type of scar which can grow beyond the boundaries of the wound and may be accompanied by severe itchiness, pain, and changes in skin texture.) The new current care plans (rewritten on 7/7/11) included no carry over of interventions for the Risk of Burns or prevention of burns from the old care plans. During interview on 11/14/11 at approximately 11:15 A.M., the Director of Nurses said that she had no knowledge that the resident had gotten burned a second time, and that it did not get reported to her, otherwise she would have initiated an incident report and an investigation. Interview on 11/14/11 at 1:30 P.M., Unit Manager (UM) #1 said that she could not recall being notified by Nurse #4 after the incident. UM #1 told the surveyor that Nurse #4 should have done an incident report and passed it on to her (UM). The UM #1 said (after review of the care plan with the surveyor) there were no interventions written into the care plan to ensure the resident would not get burned again. During interview with the resident on 11/14/11 at approximately 2:00 P.M., told the surveyor that he/she did not want anyone looking at the wounds. The resident denied pain. During interview on 11/14/11 at 2:30 P.M., Nurse #4, said that after the resident got burned again on 5/2/11, she "thought" that she had told the Unit Manager, however, she said that she failed to initiate an incident report. She also said that she could not remember contacting the Physician or family regarding the incident. 2b. For Resident #11, the facility failed to use the correct alarms, and to put effective interventions in place after the resident continuously removed the alarms. Resident #11, admitted to the facility in 8/2009, had [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] indicated the resident: could not always understand directions, and could not always make self understood; had memory deficits, delusions and impaired vision (macular degeneration); required limited assistance from staff for transfers, ambulation (room and hallway); received antipsychotic and antidepressant medications; and had no falls. The plan of care addressing falls updated on 1/24/11, included the following approaches: - Ensure ambulation with walker and assist - Proper footwear - Clutter free environment - Remind resident to use call bell for assistance (despite short and long memory impairments per care plan) - Floor mat alarm, bed and chair alarms Review of a nurse's note and post fall investigation of 2/27/11 indicated the resident was found on the floor at 6:45 P.M. in the bedroom. There were no apparent injuries. The investigation indicated the resident got up from the chair, ambulated unassisted, and fell . The alarm was functioning at the time. The intervention was to encourage the resident to call before getting up (despite cognitive deficits), and continue the use of the alarm. Review of a nurse's note and post fall investigation of 4/3/11 indicated the resident fell on the floor at 10:15 A.M. in the bedroom when left alone (asleep in a chair) by an activity staff member. Staff heard the alarm sound and responded. There were no apparent injuries. The investigation indicated that staff would bring the resident to activities and to the dining room for meals. Naps would be in bed when tired. The Falls Care Plan updated 7/7/11 indicated the resident had cognitive deficits, poor safety awareness, an unsteady gait, requires assistance with a walker, and a history of falls. Interventions include: - Safety devices (walker; bed, chair, bathroom alarms; sensor pads; floor mat alarm; low bed). - Teach resident safety measures (ineffective intervention due to the resident's cognitive deficits). - Give resident verbal reminders not to ambulate or transfer without assistance (ineffective intervention due to the resident's cognitive deficits). Review of a nurse's note and post fall investigation of 8/11/11 indicated the resident fell on the floor at 4:40 A.M. in the bedroom. The investigation indicated that while the resident was sitting on the edge of the bed, the bed slid, causing the resident to fall on the floor. There were no apparent injuries. The intervention included having the bed replaced, and to check the brakes and wheels. The plan of care addressing falls updated on 10/3/11 included the following approaches: - Provide resident with safety device/appliance: walker; wanderguard; bed and chair sensor alarms; bathroom alarms, and floor mat alarm. Review of a nurse's note and post fall investigation of 10/10/11 indicated the resident fell on the floor in the bedroom at 10:15 P.M. The investigation indicated that staff responded to the Tabs Alarm and found the resident kneeling beside the bed. The investigation also indicated the resident was supposed to have a Sensor Pad Alarm, and not a Tabs Alarm because the resident kept removing the Tabs alarm. CNAs were inserviced in regards to the use of appropriate alarms. Review of a nurse's note and post fall investigation of 10/15/11 indicated the resident fell on the floor at 4:45 P.M. after removing the Tabs Alarm, and ambulating unassisted in the bedroom. There were no apparent injuries. The report indicated the fall was caused by the resident removing the Tabs Alarm, and that a new Sensor Pad Alarm was needed. Staff was again instructed on the proper alarms for this resident. Review of a nurse's note and post fall investigation of 11/5/11 indicated the resident fell on the floor at 6:30 A.M. The alarm did not sound. The resident complained of severe right knee and hip pain. X-rays were negative for fractures, but showed osteoarthritis. The resident's pain continued to escalate, although no injuries. The Physician ordered the narcotic pain medication Oxycodone scheduled and as needed for pain. The investigation indicated the resident turned off the alarm and stood unassisted, and that the alarmed floor mat had been properly placed on the opposite side of the bed as planned. Intervention planned: Velcro alarm box to back of headboard out of reach of the resident. On 11/14/11 at approximately 2:00 P.M., the surveyor observed the resident sitting in a recliner chair in the bedroom. The surveyor observed an alarmed floor mat on the floor approximately 3-4 feet in front of the resident. The surveyor observed that if the resident had gotten up, the alarm would not sound until he/she had been ambulating unassisted. During interview with the Director of Nurses on 11/14/11 at 2:20 P.M., the surveyor shared the observations and concerns of the floor pad alarm being too far from the resident to be effective. The Director of Nurses said the mat should be directly in front of the resident to be effective.