Every finding on record at Christopher House of Worcester

Based on observations, interviews, and record reviews, the facility failed to maintain a clean and homelike environment for one Resident (#123), out of a total sample size of 28 residents. Specifically, for Resident #123, the facility staff failed to maintain the Resident's wheelchair in a clean and sanitary manner when the Resident was dependent on the wheelchair use for mobility and the wheelchair was visibly soiled. Findings include: Review of the facility policy titled Wheelchair Cleaning Policy, last reviewed 9/25/24, included but was not limited to:-to ensure the safety, hygiene, and functionality of all wheelchairs in use by maintaining a consistent cleaning schedule and accurate tracking system. -wheelchairs will be cleaned once per week at a minimum until all wheelchairs are completed.-additional cleanings may be performed as needed due to visible soiling, spills, or infection control requirements. -the Housekeeping/Maintenance Department is responsible for ensuring all wheelchairs are cleaned weekly.-the Supervisor or Designated Staff Member will perform weekly audits of the cleaning log for compliance. -areas to be cleaned include: armrests, seat and back cushions, footrests, wheels and brakes, handles and frame. Resident #123 was admitted to the facility in September 2023 with diagnoses including spinal stenosis and cerebral infarction due to embolism of left middle artery. Review of the Resident's Minimum Data Set (MDS) Assessment, dated 6/8/25, indicated Resident #123: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) a score of 12 out 15 points. -required supervision to walk 10 feet due to medical condition or safety concern.-used a manual wheelchair. Review of the facility weekly Wheelchair Cleaning Schedules dated:-7/8/25, 7/17/25, 7/24/25, 7/31/25, 8/7/25, 8/18/25 and 8/25/25 failed to indicate that Resident #123's wheelchair had been cleaned weekly or was cleaned since June 2025. During an interview on 8/26/25 at 9:36 A.M., Resident #123 said the staff have not cleaned his/her wheelchair. The surveyor observed the Resident was seated in his/her wheelchair in the [NAME] dining area. The surveyor further observed the wheelchair frame had dried dark browns spots on the frame, the spokes and wheels were covered in flaky white debris, and the armrests were stained with a dark brown/black substance. On 8/27/25 at 9:46 A.M., the surveyor observed Resident #123 sitting in his/her wheelchair in the [NAME] Dining area. The Resident's wheelchair was observed with dried brown/black spots on the frame, the spokes of the wheels remained covered in flaky white debris and the armrests were stained with a dark brown/black substance. During an interview at the time, Resident #123 said that staff has not cleaned his/her wheelchair in a long time, and he/she hoped they did not expect him/her to clean it him/herself. On 8/27/25 at 1:30 P.M., the surveyor and Nurse #1 observed Resident #123's wheelchair. During an interview at the time, Nurse #1 said that Resident #123's wheelchair was dirty, covered in food debris, should have been cleaned and was not cleaned. During an interview on 8/27/25 at 1:57 P.M., Housekeeping Staff #1 said that Resident #123's wheelchair needs to be cleaned and that he would clean the wheelchair. Housekeeping Staff #1 said that the Housekeeping Department will have a better system in place so that wheelchairs will not be missed for future cleanings.

Based on record reviews, and interviews, the facility failed to complete Minimum Data Set (MDS) Assessments that accurately reflected the status of two Residents (#15 and #142) out of a total sample of 28 Residents.Specifically, for Resident #15, and Resident #142, the facility failed to ensure that the Brief Interview for Mental Status (BIMS) and Patient Health Questionnaire-9 (PHQ-9: questionnaire used to assess for Depression) were completed, placing the Resident's at risk for care that is not Resident driven and unidentified Depression. Findings include:1) Resident #15 was admitted to the facility in July 2025 with diagnoses including BiPolar Disorder and Mood Disorder. Review of the MDS assessment dated [DATE] indicated Resident #15: -was usually understood -usually understood others -BIMS assessment was not attempted -PHQ-9 assessment was not attempted During an interview on 8/26/25 at 9:04 A.M., Resident #15 appropriately understood and answered the surveyor's questions about his/her stay in the facility. Review of Resident #15's medical record failed to indicate that a BIMS assessment or PHQ-9 assessment had been conducted or attempted during the assessment period for the 7/15/25 MDS Assessment. During an interview on 8/28/25 at 12:27 P/M., the MDS Nurse said that Resident #15 should have participated in the assessments because he/she was able to be interviewed, he/she was not assessed, and should have been. The MDS Nurse also said that it is important to capture the Resident's response because the MDS assessment is Resident driven, and if you do not interview the Resident, it does not accurately reflect the Resident. 2) Resident #142 was admitted to the facility in March 2024 with diagnoses including Dementia and Delusional Disorder. Review of the MDS assessment dated [DATE] indicated Resident #142:-was usually understood-usually understood others-BIMS assessment was not attempted-PHQ-9 assessment was not attempted Review of Resident #142's Nursing Progress Notes indicated the following:-a Nursing Progress Note dated 5/12/25 at 1:17 P.M., indicated the Resident was alert and responsive and denied pain or discomfort.-a Nursing Progress Note dated 5/27/25 at 11:28 P.M., indicated the Resident is alert and able to make needs known. Further review of Resident #142's medical record failed to indicate that a BIMS assessment or PHQ-9 assessment had been conducted or attempted during the assessment period for the 5/27/25 MDS assessment. During an interview on 8/28/25 at 2:15 P.M., the MDS Nurse said there was no evidence that Resident #142 had a BIMS assessment or PHQ-9 assessment attempted in the medical record, but the assessments should have been attempted. During an interview on 8/28/25 at 2:34 P.M., the MDS Nurse said that the MDS was meant to be Resident driven and if the Resident was not involved in the assessment that the MDS would not accurately reflect the Resident. The MDS Nurse further said the PHQ-9 assessment was important to be attempted as it assessed the Resident for Depression.

Based on observation, interview, and record review, the facility failed to provide care and services as required for an indwelling urinary/Foley catheter for one Resident (#3) out of a total sample of 28 residents. Specifically, for Resident #3, the facility failed to ensure that a blocked indwelling urinary catheter was replaced with the correct sized catheter balloon as ordered by the Physician. Findings include: Review of the facility policy for Urinary Catheters, last revised 11/1/23, indicated: -to ensure appropriate use of indwelling or intermittent urinary catheters once necessity has been determined .-Catheter Removal: >the Licensed Nurse checks Physician's order for.catheter>documents findings as indicated Resident #3 was admitted to the facility in June 2025 with diagnoses including neurogenic bladder and obstructive uropathy. Review of Resident #3 August 2025 Physician's orders indicated: -Foley catheter care every shift, start date 6/30/25-Foley catheter change as needed for leakage, blockage or wear. Size 16 French (Fr: French scale system used to size catheters) with 30 cc (cc: cubic centimeter = ml balloon), start date 6/30/25 Review of Resident #3's July 2025 Treatment Administration Record (TAR) indicated:-Foley catheter size 16 Fr with a 30 cc (cubic centimeters) balloon.-the Foley catheter had been changed to a size 16 Fr with a 30 cc balloon as needed for a blockage or leakage on 7/31/25. Review of Resident #3's August 2025 TAR failed to indicate that the urinary catheter had been changed. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #3:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15. -was dependent for toileting -had an indwelling urinary catheter. Review of Resident #3's Care Plan for indwelling catheter, last revised 8/27/25, indicated:-change catheter per MD (Medical Doctor) order.-provide catheter care every shift. Review of Resident #3's clinical record indicated:-Nursing Progress Note dated 7/31/25 that documented the Resident's Foley catheter had been changed to a 16 Fr with 30 cc balloon due to a leakage. -Nursing Progress note dated 8/9/25 that documented the Resident's Foley catheter had been changed due to blockage. On 8/27/2025 at 10:08 A.M., the surveyor and Nurse #2 observed that Resident #3 had a 16 Fr catheter in place with a 10 cc balloon. During an interview at the time, Nurse #2 said that she had checked the Resident's Physician's orders earlier this morning and the Resident should have a 30 cc balloon in place but did not, and Nurse #2 notified her Unit Manager (UM). During an interview on 8/27/25 at 10:15 A.M., UM #1 said that Resident #3 should have a 30 cc balloon inserted, but he/she did not and must have had the urinary catheter incorrectly changed. UM #1 also said that she had just changed the Resident's Physician's order to a 10 cc balloon after the surveyor had requested to observe the current urinary catheter with Nurse #2 and found a size 10 cc balloon was in place.

Based on observations, interviews, and record reviews the facility failed to provide trauma-informed care according to professional standards of practice and accounting for the Resident's experiences for one Resident (#6) out of a total sample of 28 residents. Specifically, for Resident #6, the facility failed to:-assess the Resident for a history of trauma when the Resident was newly admitted to the facility.-recognize the Resident's experiences of traumatization when, during the Resident's stay at the facility, contracted Psychological Services identified that the Resident had a history of trauma, putting the Resident at risk for re-traumatization. Findings include: Review of the facility's policy titled Trauma Informed Care, last reviewed 9/6/22, indicated the following:-It is the policy of the facility to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice.-Care will be provided while considering the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. -Trauma-informed care is a holistic, person-centered approach to treatment that understands and incorporates the biological, psychological, neurological, and social impact of trauma on an individual.-Without screening, trauma histories and related symptoms often go undetected, and we may provide services for symptoms and disorders that may only partially explain the individuals' distress.-Universal screening for trauma history and trauma-related symptoms can identify individuals at risk for developing more pervasive and severe symptoms of traumatic stress.-All new admissions will be assessed for a history of traumatic events through interviews with the resident/resident representative, review of medical records, and observations .-Any resident with a history of a traumatic event . will have a person-centered comprehensive care plan developed with interventions implemented from a collaborative interdisciplinary team approach.-The goal is to decrease the risk of inadvertent re-traumatization of individuals who have experienced trauma .-On an ongoing basis, residents will be observed for changes in condition and/or behavior that may be indicative of trauma . such as: -Fearfulness. -Isolation. -Difficulty sleeping or nightmares. -Lack of interest. -Negative thoughts about themselves. -Feeling detached from family/friends. -Feelings of hopelessness. Resident #6 was admitted to the facility in August 2024 with diagnoses including Complete Paraplegia, Major Depressive Disorder, Anxiety Disorder, family history of other psychoactive substance abuse and dependence, Insomnia, and history of bilateral below the knee amputations (BKA). Review of Resident #6's clinical record indicated:-The Resident's 48-Hour Baseline Care Plan's section relative to trauma screening was not completed.-No evidence a trauma assessment had been completed by the facility staff for the Resident when the Resident was newly admitted to the facility. Review of the Minimum Data Set (MDS) Assessment, dated 1/29/25, indicated Resident #6:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points.-exhibited no behavioral symptoms during the observation period for the Assessment.-required substantial/maximal assistance to dependence on staff for bathing, dressing, toilet hygiene, and bed mobility. Review of the Psychological Services Evaluation, dated 3/4/25, indicated Resident #6:-was being evaluated for a medication review at the request of the facility due to concerns of increased depression, medical decision-making capacity.-Physician reported the Resident had been making questionable choices related to his/her care.-was alert and oriented.-stated that he/she felt traumatized every time he/she goes to the hospital.-stated every time he/she went in [to the hospital] something always went wrong, or [they] find something else wrong with him/her. -stated that he/she knew the risk of refusing treatment was death.-said that he/she did not want to die but did not feel the trauma, psychological effects of being in the hospital were worth it. Review of Resident #6's Care Plan dated 8/1/24 through 8/28/25, failed to indicate any evidence a person-centered care plan had been developed relative to the Resident's reported traumatic experiences relative to hospitalizations. On 8/26/25 at 1:32 P.M., the surveyor observed Resident #6 in his/her room, sitting up approximately 60 degrees in bed. The surveyor observed that the Resident was awake, and there was no natural light or lights on in the room.At this time, Resident #6 declined to speak with the surveyor. During an interview on 8/28/25 at 5:00 P.M., Social Worker (SW) #1 said Resident #6 was newly admitted to the facility in August 2024. SW #1 said she reviewed the Resident's record and there was no evidence a trauma assessment had been completed for the Resident when he/she was admitted to the facility. SW #1 said all new admissions were required to be assessed for a history of trauma and that a trauma assessment should have been completed for Resident #6 when he/she was admitted to the facility. The surveyor and SW #1 reviewed Resident #6's 3/4/25 Psychological Services Evaluation and SW #1 said the facility should have developed a care plan for the Resident, for trauma and triggers for trauma related to hospitalizations.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and secured in accordance with State and Federal requirements on one unit (Brookside unit) medication carts, out of total of four units and that medications were stored in a safe and secure manner for one Resident (#3) out of a total sample of 28 residents.Specifically, the facility failed to:1. ensure that one medication cart on the Brookside Unit was locked while the Nurse walked away from the medication cart multiple times and the unlocked medication cart was out of her sight, providing ready access of medications in the medication cart to unauthorized personnel and residents.2.For Resident #3, ensure that a prescribed inhaler was secured and not left on the Resident's nightstand table that was readily accessible to other residents and/or unauthorized individuals. Findings include: Review of the facility policy titled Storage of Medications, revised 2024, included but was not limited to:-Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.-Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.Review of the facility policy titled Medication Administration, revised 3/3/20, included but was not limited to:-Medications are administered by Licensed Nursing Staff only.-Medication carts are supplied on each unit in the facility for the storing and passing of medications.-During a medication pass, the cart is visible at all times. If more than 5 feet away, the medication cart is locked with the wheels locked also. 1. On 8/27/25 at 8:11 A.M. to 8:21 A.M., the surveyor observed the following during a medication pass administration with Nurse #2 on the Brookside Unit (Dementia Unit):-Nurse #2 said that she was in the process of assessing a resident's blood glucose finger stick.-Nurse #2 was observed to remove a plastic container from the medication cart and said that she needed to get more supplies from the supply room.-Nurse #2 left the plastic container with glucometer, lancets, and alcohol wipes on top of the medication cart and stepped away from her medication cart to walk into a supply room and close the door.-The surveyor observed that the Medication cart was unlocked, that residents were sitting in wheelchairs in close proximity of the medication cart, and other residents and staff members were walking by the medication cart.-Nurse #2 returned to the medication cart, placed supplies from the supply room on top of the medication, walked away from the medication cart a second time without securing the medication cart and entered the dining room, and had her back to the medication cart. -The surveyor observed a resident walking by the medication cart at the time and staff members in the area where the medication cart was positioned attempted to redirect the resident back to the dining room. -Nurse #2 returned to the medication cart with a resident, picked up the plastic container from the top of the medication cart with the glucose supplies and propelled the resident sitting in his/her wheelchair down the hall to the resident's room located at the end of the hall. The surveyor observed that the medication cart remained unlocked.-The surveyor and Nurse #2 entered the resident room located at the end of the hallway where Nurse #2 assessed the resident's blood glucose finger stick and was out of sight of the unlocked medication cart. -Nurse #2 returned to the medication cart after completing the finger stick, cleaned the glucometer and placed it inside the medication cart, and walked away from the medication cart to return the resident back to the dining room without securing the medication cart. -At 8:23 A.M., Nurse #2 was observed to return to the medication cart and locked the medication cart. During an interview on 8/27/25 at 8:54 A.M., Nurse #2 said she should lock the medication cart each time she walks away from the medication cart for safety. Nurse #2 said by not locking the medication cart, residents and other staff members walking by the medication cart can have access or remove medications from the medication cart. During an interview on 8/27/25 at 1:00 P.M., the Director of Nursing (DON) said that it was standard practice for nursing staff to ensure that medication carts are locked each time the Nurse stepped away from his/her medication cart. 2.Resident #3 was admitted to the facility in June 2025 with diagnoses including Dementia, Major Depressive Disorder and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of possible score of 15. On 8/27/25 at 8:25 A.M., the surveyor observed the following during a blood glucose assessment on Resident #3 completed by Nurse #2:-Spiriva Handihaler (tiotropium bromide) capsule and inhalation device labeled with the Resident's name, in a clear plastic zip lock bag on the Resident's nightstand table.-Nurse #2 performed the blood glucose finger stick assessment on Resident #3, walked to the bathroom, removed her gloves and washed her hands. The surveyor observed the Spiriva Handihaler remained on the Resident's nightstand table in the zip lock bag. During an interview on 8/27/25 at 8:56 A.M., Nurse #2 said the Spiriva inhaler should not be left on Resident #3's nightstand without the Nurse present. Nurse #2 said she brought the Spiriva inhaler into Resident #3's room when she was administering Resident #3's Albuterol inhaler and left the Spiriva inhaler in the room. Nurse #2 said she did not remove the Spiriva medication when she exited the room and should have removed the Spiriva medication at the time she exited the room to prevent other residents access to the medication. Nurse #2 said that Resident #3 was unable to self-administer his/her Spiriva inhaler and Licensed Staff administers the Resident's medication. During an interview on 8/27/25 at 1:00 P.M., the Director of Nursing (DON) said that it was standard practice for nursing staff to ensure that there was no medication left unattended on a resident nightstand table for other residents' safety.

Based on observation, interviews, and record reviews, the facility failed to maintain complete and accurately documented medical records relative to fluid intake and urinary output for one Resident (#5) out of a total sample of 28 residents.Specifically, the facility failed to maintain complete and accurate documentation of:1. Resident #5's fluid intake when the Resident was identified to have Congestive Heart Failure (CHF), required the use of diuretic medication, and was placed on fluid restriction.2.Resident #5's urine output when the Resident was identified to have CHF, was placed on fluid restriction, and the Resident had an indwelling urinary catheter, putting the Resident at risk for inadequate monitoring of his/her medical condition and fluid-related complications. Findings include:Review of the facility's policy titled Intake and Output Assessment/Documentation, last revised 12/1/24, indicated the following:-The objective was to maintain adequate fluid balance.-The nursing staff will document intake and output in the EHR (electronic health record). Resident #5 was admitted to the facility in May 2024 with diagnoses including CHF, Stage Four Chronic Kidney Disease, and Neuromuscular Dysfunction of Bladder. Review of the Minimum Data Set (MDS) Assessment, dated 8/13/25, indicated Resident #5:-was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15 total possible points.-had an indwelling urinary catheter.-was dependent upon facility staff for toilet hygiene. 1. Review of Resident #5's Dehydration Risk Care Plan, initiated 6/6/24 and last edited 8/12/25, indicated:-The Resident was at risk for dehydration.-Monitor fluid intake with meals. Review of Resident #5's Nurse Practitioner (NP) Progress Note, dated 8/15/25, indicated:-The Resident had altered mental status.-The Resident had retention of urine.-The Resident's chest x-ray results revealed pulmonary vascular congestion (condition where there is an excessive accumulation of fluid in the blood vessels of the lungs that can be caused by heart failure).-The Resident had acute on chronic systolic (congestive) heart failure.-Give extra dose of Bumex (diuretic medication) today.-Continue Bumex 5 milligrams (mg) q (every) day.-Add fluid restriction. Review of Resident #5's Physician orders, dated 8/15/25, indicated:-1.5 L (liter) fluid restriction.-Every shift: (days) 7:00 A.M. - 3:00 P.M., (evenings) 3:00 P.M. - 11:00 P.M., (nights) 11:00 P.M. - 7:00 A.M. Review of Resident #5's clinical record indicated the following documented fluid intake between 8/15/25 and 8/26/25:>8/15/25: -Medication Administration Record (MAR) indicated 420 mL (milliliters) total fluid intake over all three shifts. -Fluid intake recorded in the Vitals section of the electronic health record (EHR) indicated 600 mLs. -Paper Meal Intake Record indicated 240 mL of fluid intake for the supper meal. Breakfast and lunch columns indicated R (refused).>8/18/25: -MAR indicated 660 mL total fluid intake over all three shifts. -Fluid intake recorded in the Vitals section of the EHR indicated 720 mLs. -Paper Meal Intake Record indicated 480 mL fluid intake at breakfast and 480 mL fluid intake at supper (total = 960 mL). The lunch meal fluid intake was blank.>8/21/25: -MAR indicated 280 mL total fluid intake over all three shifts. -Fluid intake recorded in the Vitals section of the EHR indicated 220 mLs. -Paper Meal Intake Record indicated 480 mL fluid intake for breakfast. The lunch and supper meal fluid intakes were blank.>8/22/25: -MAR indicated 300 mL fluid intake over all three shifts. -Fluid intake recorded in the Vitals section of the EHR indicated 360 mLs. -Paper Meal Intake Record indicated 360 mL fluid intake at breakfast, 240 mL fluid intake at lunch, and 360 mL fluid intake at supper (Total = 960 mL).>8/26/25: -MAR indicated 440 mL total fluid intake over all three shifts. -Fluid intake recorded in the Vitals section of the EHR indicated 620 mLs. -Paper Meal Intake Record indicated 220 mL fluid intake at supper. The breakfast and lunch meal fluid intakes were blank. On 8/26/25 at 10:58 A.M., the surveyor observed Resident #5 lying in bed with the bed covers over the Resident's lower body. The surveyor observed a section of clear catheter tubing exiting from under the Resident's bed covers, leading to a urinary catheter collection privacy bag. The surveyor did not observe any urine in the catheter tubing and the contents of the urinary catheter collection bag were not visible. During an interview at the time, Resident #5 said he/she used to have a urinary catheter and that he/she no longer had a urinary catheter in place. 2. Review of Resident #5's Indwelling Urinary Catheter Care Plan, initiated 8/28/24 and last edited 8/12/25, indicated:>Resident had an indwelling urinary catheter related to urinary retention and neurogenic bladder.>Document urinary output every shift. >Record: -amount. -type. -color. -odor. Review of Resident #5's Nurse Practitioner (NP) Progress Note, dated 8/15/25, indicated:-Continue Foley catheter.-The Resident had acute on chronic systolic (congestive) heart failure. Review of Resident #5's clinical record failed to indicate any evidence that the Resident's urine output, including amount, type, color, and odor was documented every shift from 8/15/25 through 8/26/25. On 8/27/25 at 10:40 A.M., the surveyor observed Resident #5 sitting up in a wheelchair in his/her room and drinking a cup of coffee. During an interview at the time, Resident #5 said he/she had just returned from an appointment and that while he/she was out, his/her Resident Representative bought him/her a cup of coffee. Resident #5 said he/she loved coffee and that he/she was not aware of any restriction on the amounts of fluids he/she could drink. During an interview on 8/27/25 at 2:40 P.M., Certified Nurse Aide (CNA) #2 said she was responsible to provide care for Resident #5 on 8/27/25. CNA #2 said that she was not aware of Resident #5 requiring a fluid restriction. CNA #2 said that Resident #5 did not usually ask for drinks in addition to the fluids provided throughout the day and that the Resident usually drank all of the fluids that were provided to him/her. CNA #2 also said that Resident #5 had an indwelling urinary catheter and that staff were required to document the amount of urine output the Resident had every shift into the EHR. During an interview on 8/27/25 at 4:56 P.M., Nurse #4 said Resident #5 was on a fluid restriction and that the Resident had an indwelling urinary catheter. Nurse #4 said that she was responsible to document the total amount of fluid the Resident consumed during her shift, and that the total amount consumed would include all fluids the Resident was provided by all staff members. Nurse #4 also said that the CNAs were responsible to empty Resident #5's indwelling urinary catheter collection bag and report the total urine output to the Nurse responsible for the Resident's care. Nurse #4 said that the CNAs would empty Resident #5's urinary catheter collection bag on the current shift and would be required to tell Nurse #4 how much urine output the Resident had on the shift. Nurse #4 said the CNAs were responsible to document the exact amount of urine output for Resident #5 in the Resident's EHR. Nurse #4 said she was responsible to ensure the CNAs documented the urinary output in the EHR, and it was important to accurately record Resident #5's fluid intake and urine output as recording these measurements were ways to help monitor the Resident's fluid balance maintenance and urinary catheter function. During an interview on 8/28/25 at 2:33 P.M., Nurse #5 said that she was helping to cover the role of Staff Development Coordinator (SDC). Nurse #5 said that anytime a Resident was placed on fluid restriction and/or had an indwelling urinary catheter, fluid intake and urine output monitoring would be implemented. Nurse #5 said that nursing staff were responsible to document total fluid intake and urine output for a Resident on a fluid restriction. Nurse #5 said nursing staff were required to document exact measurements, in milliliters, of urine output for a Resident with an indwelling urinary catheter. Nurse #5 said that Nurses and CNAs responsible to care for Resident #5 were required to accurately record the Resident's fluid intake and urine output as the Resident had been placed on fluid restriction and had an indwelling urinary catheter. Nurse #5 said accurately recording the amount of fluid intake and urine output for Resident #5 was required as this was one way the facility staff would monitor the Resident's fluid balance.

Based on observation, interviews, and record reviews, the facility failed to maintain an effective infection control and prevention program to stop the spread of organisms and infections for one Resident (#52) out of a total sample of 28 residents. Specifically, for Resident #52, the facility failed to ensure that staff performed appropriate hand hygiene during glove changes while providing wound care for Resident #52 who was on Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's - bacteria that are resistant to three or more types of antimicrobial drugs]) during high contact resident care), placing the Resident at risk for contracting healthcare-associated infections. Findings include: Review of the facility's policy titled, Wound Care, last revised 2/9/24, included but was not limited to: -to protect our residents, our staff follow evidenced-based infection prevention practices to minimize pathogen transmission during wound care.-The following practices should be incorporated into all wound care procedures: 1. perform hand hygiene before and after wound care, even if gloves are worn.2. after removal of PPE (Personal Protective Equipment), including of gloves are changed during the procedure. -prevent contamination of wound care supplies.-place supplies on a clean surface in the resident room or treatment area.-maintain separation between clean and dirty supplies. Review of the facility policy for Enhanced Barrier Precautions (EBP), last revised 4/8/24, indicated: -EBP is used in conjunction with standard precautions and expands the use of PPE to don gowns and gloves during high contact resident care activities that provide opportunities for transferring MDRO's to staff hands and clothing.-EBP is indicated for wounds and indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Resident #52 was admitted to the facility in March 2025 with diagnoses including Vascular Dementia, Pressure Ulcer of Unspecified Part of the Back - Stage II, and Unspecified Severe Protein Calorie Malnutrition. Review of Resident #52's August 2025 Physician's orders indicated: -measure wound to mid back every Monday, start date 8/22/25.-maintain enhanced barrier precautions every shift, start date 8/26/25.-stage II wound to spine: wash wound with soap and water, pat dry, then apply Calcium Alginate, superabsorbent pad. Please include wound measurements when ordering for accurate dosing, once an evening, start date 8/27/25. On 8/27/25 at 3:48 P.M., the surveyor observed the following as Nurse #3 performed wound care, while CNA #1 assisted with positioning Resident #52, who was lying in bed:-3:51 P.M., Nurse #3 and CNA #1 doffed (removed) gloves and donned (put on) new gloves without performing hand hygiene between the glove change and continued caring for the Resident. -4:02 P.M., Nurse #3 doffed her gloves and donned new gloves without performing hand hygiene and continued providing wound treatment.-4:07 P.M., Nurse #3 doffed her gloves and donned new gloves without performing hand hygiene and continued with providing wound treatment.-4:11 P.M., Nurse #3 doffed her gloves and donned new gloves without performing hand hygiene and continued with providing wound treatment.-4:12 P.M., Nurse #3 doffed her gloves and donned new gloves without performing hand hygiene and continued with providing wound treatment.-4:22 P.M., Nurse #3 doffed her gloves and donned new gloves without performing hand hygiene and continued with providing wound treatment.-4:24 P.M., Nurse #3 doffed removed her gloves and donned new gloves without performing hand hygiene and continued with providing wound treatment. Nurse #3 removed a pen from her pant pocket below her gown with soiled gloves and wrote the date of the dressing on tape. -4:27 P.M., Nurse #3 doffed her gloves and donned new gloves without performing hand hygiene and continued to the conclusion of providing wound treatment to the Resident. During an interview on 8/27/25 at 4:36 P.M., Nurse #3 said that she should have performed handwashing after she removed her gloves and she did not. Nurse #3 also said that she should have used a clean pen to date the wound dressing, rather than use the pen that had been inside of her pant pocket. During an interview of 8/27/24 at 4:47 P.M., the Director of Nursing (DON) said that Nurse #3 should have sanitized her hands after removing her gloves and putting on new gloves. The DON also said Nurse #3 should have used a sanitary writing implement to date the wound dressing.

Based on interview, record and policy review, the facility failed to ensure that the Pneumococcal (bacterial infection caused by streptococcus pneumoniae/ pneumococci, that can range from ear and sinus infections to Pneumonia and blood stream infections) Vaccination was administered to two Residents (#35, and #81) for five applicable residents, out of a total sample of 29 residents. Specifically, the facility staff failed to: 1. identify whether Resident #35 was up to date with Pneumococcal Vaccinations, administer the Pneumococcal Vaccine when the Resident was not up to date, and determine whether he/she was eligible to receive the Pneumococcal Vaccine when the Resident/Representative consented to receive the vaccination. 2. identify whether Resident #81 was up to date with Pneumococcal Vaccinations, administer the Pneumococcal Vaccine when the Resident was not up to date, and determine whether he/she was eligible to receive the Pneumococcal Vaccine when the Resident/Representative consented to receive the vaccination thereby increasing the risk for facility acquired Pneumococcal infections. Findings include: Review of the facility's policy, titled Vaccines for Residents, dated November 2023, indicated nursing will: -Assess the immunization status of the resident. -Obtain a consent for vaccines. If the resident has been previously immunized, the information is documented. -Provide education materials to the resident/representative. Review of CDC guidelines titled Pneumococcal Vaccination Timeline for Adults, dated 3/15/23, indicated the following for adults aged [AGE] years and older: -Make sure your patients are up to date with Pneumococcal Vaccination. -If no Pneumococcal doses have been received, administer either one dose of PCV20 (Pneumococcal Conjugate Vaccine/ Prevnar 20: vaccine used to protect against 20 types of pneumococcal bacteria that commonly cause serious infections) or one dose of PCV15 (Pneumococcal Conjugate Vaccine 15-valent: vaccine used to protect against 15 types of pneumococcal bacteria that commonly cause serious infections in adults) followed by one dose of PPSV23 (Pneumovax 23: vaccine used to help protect against serious infections caused by 23 types of pneumococcal bacteria) no earlier than one year following the administration of the prior PCV15 dose. -If one dose only of PCV13 (Prevnar 13: vaccine used to protect against 13 types of pneumococcal bacteria that commonly cause serious infections) has been received at any age, one dose of PCV20 or PPSV23 should be administered no earlier than one year following the administration of the prior PCV13 dose. 1. Resident #35 was admitted to the facility in March 2023 with diagnoses including: Chronic Obstructive Pulmonary Disease (COPD- a chronic inflammatory lung disease that causes restricted airflow from the lungs and difficulty breathing) and Hypertensive Heart and Chronic Kidney Disease (CKD) without Heart Failure, Stage 3a (a group of medical problems that results when there is unmanaged high blood pressure for a prolonged time, with Stage 3a [CKD - mild to moderate loss of kidney function]). Review of Resident #35's medical record indicated the Resident was over [AGE] years of age. Review of Resident #35's Immunization Consent Form, dated and signed by the Resident on 3/2/23, indicated that Resident #35 consented to the administration of the Pneumococcal Vaccine. Review of Resident #35's Vaccination Administration Record, printed and provided by the facility on 6/14/24, indicated that the Resident received one dose of PCV13 on 7/1/2015. Further review of Resident #35's Immunization Report indicated no evidence the Resident had ever received any other dose of Pneumococcal Vaccination. 2. Resident #81 was admitted to the facility in October 2021 with diagnoses including: Diabetes Mellitus (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated blood glucose [sugar] levels in the blood). Review of Resident #81's medical record indicated the Resident was over [AGE] years of age. Review of Resident #81's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 99 indicating the Resident interview not successful. Review of Resident #81's Immunization Consent Form, dated and signed by the Resident Representative (RR) on 10/13/21, indicated the Resident/RR wished to have Resident #81 receive the Pneumococcal Vaccine if it was indicated. Review of Resident #81's Vaccine Administration Report, printed and provided by the facility on 6/14/24, indicated that the Resident received one dose of PCV13 on 7/31/2019. During an interview on 6/14/24 11:30 A.M., the Infection Preventionist (IP) said she began working as the IP in June 2024 and the facility follows CDC requirements for immunizations. The IP further said she has not audited residents for the need for Pneumococcal Vaccines since starting in her position. During a follow-up interview on 6/14/24 12:30 P.M., the IP said she located additional vaccination information in the Massachusetts Immunization Information System (MIIS) for Residents #35 and #81. The surveyor and the IP reviewed the facility's Pneumococcal Vaccine Policy and Immunization Records for Residents #35 and #81. The IP said she had not had the opportunity to assess each Residents' Pneumococcal Vaccination status. The IP further said Resident's #35 and #81 were eligible to receive another dose of Pneumococcal Vaccination per CDC guidelines and this should have been offered based on the Resident and/or Representative consenting to receive the vaccination.

Based on interview, record and policy review, the facility failed to ensure that one Resident (#130) of four applicable residents reviewed, out of a total sample of 29 residents, received care and services for his/her pressure ulcer (a wound, usually over a bony prominence, that is caused by unrelieved pressure to the area) in accordance with professional standards. Specifically, the facility failed to ensure a wound care recommendation from the hospital, that was approved by the facility Nurse Practitioner (NP) was implemented placing the Resident at risk for worsening of his/her pressure ulcer. Findings include: Resident #130 was admitted to the facility in April 2024 with diagnoses of Stage 4 Pressure Ulcer (a wound, usually over a bony prominence, that is caused by unrelieved pressure to the area and extends to muscle, tendon and or bone tissue), and Quadriplegia (paralysis, or inability to move below the neck including the arms and legs). Review of the Hospital After Visit Summary dated 5/29/24, for re-admission to the facility included a wound care recommendation to: -wash Resident #130's wound thoroughly with warm soap and water -pat dry -apply Santyl (an ointment used to help remove dead tissue from a wound) to the wound base -followed by saline moistened kerlix (type of bandage wrap) -and cover wound with square Mepilex (type of self-adhering foam dressing). Review of the Nurse's Progress Note (late entry) dated 5/29/24 at 10:14 A.M., indicated until a repeat debridement (procedure where dead tissue is removed from a wound either by surgical means or chemical means) was completed, the Resident should undergo twice a day Santyl wet-to-dry dressings (a dressing where bandage is moistened and then applied to wound and allowed to dry, causing dead tissue to adhere to the bandage and then be removed from the wound bed). Further Review of the Nurse's Progress Note dated 5/29/24 at 10:27 P.M., indicated that all of the hospital orders were reviewed with NP #1 and no new orders were obtained. Review of the Physician's orders dated 5/29/24 and discontinued 6/13/24, included: -an order for a treatment to the Resident's right ischium (an area over the back of the right hip) open area: >wash with soap and water then pat dry >apply Santyl to the wound bed >apply Triad (a zinc-based cream that provides a moisture barrier) to peri-wound (skin/area surrounding the wound) >followed by biatain (a type of self-adhering foam dressing) twice a day Review of the Wound Observation Records for the right ischium indicated deterioration of the wound as evidenced by the following: >5/29/24 at 11:01 A.M.- the wound healing status was documented as stable with light exudate (drainage from wound) that had no odor. Stage of the wound (how significant or bad the wound is with 1 being the least significant, 4 being the most significant and unstageable being unable to see the base of the wound) documented as Stage 2 >6/3/24 at 4:09 P.M.- the wound healing status was documented as stable with heavy exudate that had no odor. Stage of the wound documented as unstageable. >6/10/24 at 10:02 A.M.- the wound healing status was documented as declining with heavy exudate and odor documented as foul. Stage of the wound documented as unstageable. Review of the clinical record for Resident #130 indicated no evidence that the hospital discharge recommendation for wound care on 5/29/24 at 10:14 A.M., which included twice daily Santyl wet-to-dry dressing was implemented upon the Resident's re-admission to the facility. During an observation of the wound on 6/12/24 at 12:05 P.M. with UM #1, the wound was noted with a strong odor. The surveyor observed that the wound bed (the bottom of the wound) had a significant area (approximately 75% of the wound) with yellowish brown colored necrotic (dead) tissue. The surveyor observed that the remainder of the wound had healthy appearing red tissue and undermining (the tissue under the edge of the wound becomes eroded causing an open pocket underneath the skin extending out from the wound). The surveyor further observed UM #1 providing dressing care that included the following: -UM #1 cleansed the wound with soap and water -patted the wound dry -applied Santyl to the wound bed -applied Triad cream to the periwound -then covered the entire area with a biatain dressing The surveyor did not observe UM #1 applying the Santyl wet-to-dry dressings during the dressing care provided at the time of the observation. During an interview on 6/13/24 at 12:06 P.M., NP #1 said he would have given the order to implement whatever the hospital recommended for wound care on admission as he would not have seen the wound on the day of admission. During an interview on 6/13/24 at 4:34 P.M., the surveyor and the Admission Nurse reviewed the hospital recommendations and current Physician order for wound care. The Admission Nurse said that the hospital recommendations included using saline soaked kerlix as part of the dressing, but that this was not part of the Resident's current wound care orders. The surveyor and the Admission Nurse reviewed her personal notes that were written the day of the Resident's re-admission. The Admission Nurses's personal notes included the hospital recommendation for wound care and the use of saline soaked kerlix and indicated that the Admission Nurse reviewed the hospital recommendations for wound care with NP #1 when she wrote the admission Nursing Progress Note. The Admission Nurse further said she took the orders for Resident #130's wound care on admission from NP #1, but that the Nursing Supervisor helped her that evening and put in the orders for her. The Admission Nurse said that as the Nurse who took the orders it was her responsibility to ensure the orders were implemented correctly. The Admission Nurse said that the facility uses 24-hour chart checks, and the night shift Nurse will check the orders for each resident on their unit for the previous day after midnight to ensure they were entered correctly. The Admission Nurse said that the Nursing Supervisor and Unit Manager also review new admissions as well, to ensure orders are entered correctly. During an interview on 6/13/24 at 5:01 P.M., the surveyor and the Nursing Supervisor reviewed the hospital recommendations and current Physician's order for wound care for Resident #130. The Nursing Supervisor said she failed to enter the wet-to-dry portion of the Santyl dressing order upon the Resident's re-admission to the facility, and that this could have impacted the healing of the wound. During an interview on 6/14/23 at 1:38 P.M., the Director of Nursing (DON) said if a Nurse took an order to follow the hospital recommendation it was that Nurse's responsibility to ensure the order was entered correctly into the Resident's clinical record. The DON further said that if an order was obtained not to follow the hospital recommendation, it should have been documented in a progress note in the Resident's clinical record. The DON said that the night Nurse and Unit Manager (UM) would review orders for admissions and if there was a variance identified during the review, the person completing the review should have contacted the Provider (Physician, NP or Physician's Assistant) to verify which order should have been implemented and document the outcome of the conversation with the Provider in the Resident's clinical record as well as update the order if indicated.

Based on observation, interview, record and policy review, the facility failed to adhere to infection control standards in order to prevent the potential transmission of communicable diseases and infections within the facility for two Residents (#130 and #241), out of a total sample of 29 residents. Specially, the facility failed to: 1) For Resident #130, ensure that staff performed hand hygiene after the removal of gloves during a dressing change procedure placing the Resident at risk for infection in his/her wound. 2) For Resident #241, ensure that staff: a) wore the required Personal Protective Equipment (PPE-items used to prevent the spread of infection such as gowns, gloves, face masks) and/or wore the required PPE correctly while caring for the Resident, placing others at risk for exposure to a communicable disease (a disease or infection that is easily spread from one individual to another). b) changed a urinary catheter drainage bag (a bag used to collect urine) after it had been disconnected from the Foley Catheter (a thin, flexible tube placed through the urethra [the small tube that carries urine from the bladder to outside the body] and into the bladder) after the Resident was found self-ambulating, and positioned his/her urinary catheter drainage bag off the floor, to prevent the risk of infection. Findings include: Review of the facility policy titled Hand Hygiene dated 1/28/19, indicated but was not limited to the following: -Handwashing (cleaning the hands with soap and water) is required in the case of a resident with Clostridium Difficile (C-diff: an infection of the bowels that is considered a communicable disease and causes diarrhea) -Decontaminate hands if moving from a contaminated body site to a clean body site. Review of the facility policy titled Contact Precautions dated 1/28/19, indicated but was not limited to the following: -Contact Precautions, in addition to standard precautions are set in place for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident's environment. -Hand hygiene should be completed prior to donning (putting on) gloves -Gloves should be worn when entering the room and while providing care for a resident -A gown should be worn when entering the room if it is anticipated that clothing will have substantial contact with the resident, environmental surfaces Review of the facility policy titled Wound Care dated 2/9/24 indicated but was not limited to the following: -Perform hand hygiene, before and after wound care, even if gloves are worn, after removal of PPE including if gloves are changed during the procedure. -Gloves should be changed, and hand hygiene performed when moving from dirty to clean tasks. 1) Resident #130 was admitted to the facility in April 2024 with diagnoses of Stage 4 Pressure Ulcer (a wound, usually over a bony prominence, that is caused by unrelieved pressure to the are and extends to muscle, tendon and or bone tissue), and Quadriplegia (paralysis, or inability to move, below the neck including arms and legs). On 6/12/24 at 12:05 P.M., the surveyor observed the following during a wound care procedure for Resident #130: -Unit Manager (UM) #1 cleansed the wound with soap and water, removed her gloves and applied a new pair of gloves without performing hand hygiene, then proceeded to rinse the wound with water. -During the same wound care observation, UM #1 began to apply the dressing covering the wound, removed her gloves and put on a new pair of gloves without performing hand hygiene, and then returned and finished securing the dressing. During an interview on 6/14/24 at 11:45 A.M., the facility Staff Development Coordinator (SDC) said when gloves are changed, hand hygiene should be performed to prevent contamination of the gloves and potential spread of infection. 2a) Resident #241 was admitted to the facility in June 2024, with diagnoses including urinary tract infection (UTI: bacterial infection of the urinary tract), Enterocolitis (inflammation in both intestines at once, often caused by severe infections) due to Clostridium Difficile (C-Diff: a bacterium that causes an infection of the colon [the longest part of the large intestine]. Symptoms can range from diarrhea to life-threatening damage to the colon). Review of Resident #241's medical record indicated a Physician's order to maintain Contact Precautions for C-diff with a start date of 6/7/24. On 6/14/23 at 8:35 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 in Resident #241's room. CNA #1 was observed not wearing a gown or gloves and was assisting the Resident to organize his/her bedside table. The surveyor observed CNA #1 pick up the Resident's breakfast tray, exit the room, place the tray on the tray caddy and then proceed to the nurses station where she began to work without washing her hands. During an interview following the observation, the surveyor and CNA #1 reviewed the Contact Precautions sign that was hanging outside Resident #241's doorway. CNA #1 said the sign indicated she should have worn a gown and gloves to go into the Resident's room and provide care of any kind. CNA #1 also said she should have washed her hands when she left the room before having contact with the nurses' station. On 6/14/24 at 9:21 A.M., Rehabilitation Services Staff (Rehab Staff) #1 was observed in Resident #241's room completing rehabilitation exercises with the Resident. Rehab Staff #1 had on gloves and a gown however the gown ties at the waist were observed to be untied, with the gown falling away from Rehab Staff #1's clothing and person while she was assisting the Resident with his/her exercises. The surveyor and the facility Staff Development Coordinator (SDC) observed Rehab Staff #1 while still working with the Resident in his/her room. The SDC said Rehab Staff #1's gown should have been tied at the waist. The SDC further said there was a concern with the untied gown that Rehab #1 could become contaminated while caring for Resident #241 and the infection could spread to others. 45429 2b) Review of the Centers for Disease Control and Prevention (CDC) Guideline for Prevention of CAUTI (catheter associated urinary tract infection), dated 2009, section III, titled Proper Techniques for Urinary Catheter Maintenance indicated the following: -If breaks in aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Review of the Lippincott Nursing Procedure - 9th Edition (2023) Indwelling Catheter Care indicated the following: -Inspect the urinary catheter system for disconnections and leakage, because a sterile, continuously closed system is required to reduce the risk of catheter associated urinary tract infection. -Replace the catheter and drainage system using sterile no-touch technique (the practice of avoiding contamination by not touching key elements of the system) when a break in sterile technique, disconnection, or leakage occurs. Review of the facility policy for Urinary Catheters, last revised 11/1/23, indicated that nursing will insert and remove catheters using aseptic techniques and sterile equipment. Review of Resident #241's Physician's orders for June 2024 indicated the following: -Urinary bedside drainage bag and leg bag: change with each use, discard used bag and re-connect catheter using a new bag per protocol, initiated 6/7/24. -Urinary bedside drainage bag to be changed to a leg bag during the day as Resident allows, to use a new bag with each bag change with each use, discard used bag and re-connect catheter using new bag per protocol, initiated 6/7/24. Review of Resident #241's Nursing Progress Notes indicated that on 6/10/24 at 6:41 A.M., the Resident was found by Nurse #2 and had walked away from the catheter drainage bag causing it to disconnect. Further review of the Nursing Progress Notes indicated that Nurse #2 had reconnected the bag but the notes did not indicate that a new catheter bag had been placed. The surveyor observed Resident #241 lying in bed with the catheter drainage bag on the floor during the following dates and times: -6/11/24 at 9:17 A.M. -6/12/24 at 8:06 A.M. During an interview on 6/12/23 at 1:58 P.M., Nurse #3 said that a new drainage bag should have been placed after the drainage bag became disconnected from the urinary catheter. Nurse #3 also said that the catheter drainage bags should have been hanging from the Resident's bed frame and off the floor for infection control purposes. During an interview on 6/13/24 at 8:14 A.M., Nurse #2 said when the Resident's urinary catheter tubing disconnected on 6/10/24, she had used an alcohol wipe to sterilize the tube prior to re-connecting it to the drainage bag. Nurse #2 said that she should have changed the urinary drainage bag after it had become dislodged but did not do so as required.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose comprehensive plan of care indicated he/she required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, the Facility failed to ensure staff implemented and followed interventions in his/her care plan, when on 03/12/24, Certified Nurse Aide (CNA) #1 transferred Resident #1 from his/her wheelchair into bed with a Hoyer lift, without another staff member present to assist him. Resident #1 fell to the floor onto his/her knees then fell forward landing on his/her face. Resident #1 was transferred to the Hospital Emergency Department (ED) and diagnosed with a laceration, head injuries and fractures. Findings include: Review of the Facility's Policy, Care Planning and Assessment of Resident, with a reviewed date of 11/14/19, indicated the purpose of the assessment is to identify the resident's current health status, needs, and to develop an individualized interdisciplinary plan of care to address those needs and facilitate continuity of care. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) dated 03/19/24, indicated that on 03/12/24 at approximately 9:00 P.M., Resident #1 was observed lying in bed with a bloody nose and a large purple hematoma on his/her forehead with a 0.5 centimeter (cm) laceration. The Report indicated that during a transfer from Resident #1's wheelchair to the bed, the mechanical sling came loose, and Resident #1 fell on his/her knees, falling face forward (on the floor). The Report indicated that he/she was transferred to the Hospital Emergency Department (ED) and was found to have a small acute subdural hematoma (a pool of blood between the brain and the skull), small acute subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), and bilateral [NAME] II fractures (a pyramid shaped fracture along the nasal bridge which causes separation of the midface from the skull base). Review of Resident #1's Hospital ED Report, dated 03/12/24, indicated Resident #1 sustained the following injuries from a fall at the Facility: -small subdural hematoma -small subarachnoid hemorrhage -bilateral [NAME] II fracture with fracture line passing through the frontal nasal sutures (cranial suture between the frontal and nasal bones), bilateral nasal bones, lateral walls of maxillary sinus (part of nasal cavity), and inferior orbital rim (bone behind the lower eye lid) -extensive scalp edema in the frontal region (forehead), frontal scalp hematoma at the midline with overlying laceration Resident #1 was admitted to the Facility in December 2018, diagnoses included Alzheimer's Disease and unspecified (location of) osteoarthritis. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/06/24, indicated he/she had long and short-term memory impairments, significant impairment for decision making ability, was dependent for chair/bed-to-chair transfers with the assistance of two or more staff members, and had sustained no falls in the previous quarter. Review of Resident #1's Falls Care Plan, with an edited date of 03/04/24, indicated he/she required a Hoyer lift with the assistance of two staff members for all transfers. Review of Resident #1's care Kardex (used by the CNAs to determine individual care needs) indicated he/she required a Hoyer lift with the assistance of two staff members for all transfers and was non-ambulatory. Review of the Facility Investigation, which included written statements provided by staff, indicated that at approximately 9:00 P.M. on 03/12/24, CNA #1 reported to Nurse #1 that Resident #1 was in bed with a bloody nose. The Investigation indicated Nurse #1 observed Resident #1 lying in bed with a bloody nose and a large purple hematoma on his/her forehead with a 0.5 cm laceration. The Investigation indicated that Nurse #1 applied a cold pack to Resident #1's forehead and pressure to stop the bleeding (nose) and notified the Nursing Supervisor who called 911 to transfer Resident #1 to the Hospital ED. The Investigation also indicated that on 03/12/24 at approximately 9:30 P.M., the Director of Nurses (DON) conducted a telephone interview with CNA #1 who said that during Resident #1's transfer (from the wheelchair to the bed), the mechanical lift pad became loose and Resident #1 fell on his/her knees, face forward. Furthermore, the Investigation indicated that CNA #1 said he had not known that Resident #1 was injured before he transferred him/her off the floor and put him/her in bed. Review of a Nurse Progress Note, dated 03/12/24 at 10:39 P.M., (written by Nurse #1), indicated that he was called to Resident #1's room (by CNA #1) at approximately 9:10 P.M. The Note indicated he observed him/her with a bloody nose and a forehead hematoma with a laceration. The Note indicated Nurse #1 called for a supervisor immediately, 911 was called and Resident #1 was transferred to the Hospital ED. During an interview on 03/27/24 at 3:13 P.M., (which included review of his written statement), Nurse #1 said that on 03/12/24 at approximately 9:00 P.M., CNA #1 told him that Resident #1 had a bloody nose. Nurse #1 said that he went to Resident #1's room and observed him/her lying in bed with blood coming out of both nostrils. Nurse #1 said he also observed a small cut on Resident #1's forehead along with a purple bruise that went over his/her eyes, down the front of his/her nose, and under his/her eyes. Nurse #1 said he applied pressure to Resident #1's nose but could not get the bleeding to stop. Nurse #1 said he also applied an ice pack to his/her forehead. Nurse #1 said that he noticed blood on the floor in Resident #1's room. Review of a Nurse Progress Note dated 03/12/24 at 10:29 P.M., (written by the Nursing Supervisor), indicated that once Resident #1 left the Facility, the Nursing Supervisor interviewed CNA #1. The Note indicated that CNA #1 told the Nursing Supervisor that when he transferred Resident #1 from the wheelchair to the bed, he/she fell forward onto the floor face down. During an interview on 03/27/24 at 3:32 P.M., the Nursing Supervisor (which included review of her written statement), said she interviewed CNA #1 and he told her that he used the Hoyer lift by himself, to transfer Resident #1 from the wheelchair to bed, and that while he was lifting him/her, Resident #1 fell to the floor face first. The Nursing Supervisor said that CNA #1 told her that he then put Resident #1's bed in the lowest position and moved him/her (did not specify how) from the floor back into the bed without any assistance and without getting a nurse to assess Resident #1 immediately following the fall. The Nursing Supervisor said that she observed smeared dried blood on Resident #1's floor, between the wall and his/her bed. Review of the CNA #1 written Witness Statement, dated 03/12/24, indicated that on 03/12/24 at 8:30 P.M., he transferred Resident #1 from the wheelchair to the bed using the Hoyer lift. The Statement indicated as he (CNA #1) lifted Resident #1, the Hoyer pad became loose and Resident #1 fell on to his/her knees and hit his/her head. The Statement indicated that CNA #1 did not think Resident #1 appeared injured and he transferred him/her into bed (from the floor). During telephone interviews on 03/28/24 at 8:29 A.M. and 3:49 P.M., CNA #1 said that Resident #1 was on his assignment for the 3:00 P.M. to 11:00 P.M. shift on 03/12/24. CNA #1 said he was familiar with Resident #1, had often taken care of him/her and knew he/she required the use of a Hoyer lift for all transfers. CNA #1 said that he usually gets another staff member to assist him with Resident #1 during transfers, but had not that night. CNA #1 said he transferred Resident #1 by himself that night, both before and after the fall. CNA #1 said he knew he was supposed to have another staff member with him for assistance with mechanical lift transfers, but said he had not done so. CNA #1 said he was putting Resident #1 to bed and as he transferred him/her from the wheelchair with the Hoyer lift, the straps to the Hoyer pad became loose and Resident #1 fell forward knees first, then hit his/her head. CNA #1 said he had only lifted Resident #1 a few inches off the wheelchair before he/she fell to the floor. CNA #1 said after the fall, he then used the Hoyer lift to transfer Resident #1 off the floor and put him/her back into bed. During an interview on 03/28/24 at 10:55 A.M., the Director of Nurses (DON) said that her investigation indicated that CNA #1 had not gotten assistance from another staff member to help transfer Resident #1 from the wheelchair to the bed and then from the floor to the bed (after the fall). The DON said that CNA #1 should have followed Resident #1's care plan and should have requested and obtained assistance from another staff member to transfer Resident #1. The DON said that all mechanical lift transfers required two person assists.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in an injury, when on 03/12/24, while Certified Nurse Aide (CNA) #1 transferred Resident #1 from his/her wheelchair into bed without another staff member present to assist him. Resident #1 fell to the floor onto his/her knees then fell forward landing on his/her face. Resident #1 was transferred to the Hospital Emergency Department (ED) and diagnosed with a head laceration, head injuries and multiple facial fractures. Findings include: Review of the Facility's Policy, titled Mechanical Lifts, with a revision date of 1/25/22, indicated the following: -To provide safe transfers for residents. -With two assists, inspect and obtain appropriate sling (pad) for the type of mechanical lift. -Place a sling under the resident in bed and attach all four sling points. -Slowly raise resident off the bed, position over the seating device and slowly lower the resident to the seating device for proper positioning. -Follow the same procedure to return the resident to bed. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/19/24, indicated that on 03/12/24 at approximately 9:00 P.M., Resident #1 was observed lying in bed with a bloody nose and a large purple hematoma on his/her forehead with a 0.5 centimeter (cm) laceration. The Report indicated that during a transfer from Resident #1's wheelchair to the bed, the mechanical sling came loose, and Resident #1 fell on his/her knees, falling face forward (to the floor). The Report indicated that he/she was transferred to the Hospital Emergency Department (ED) and was found to have a small acute subdural hematoma (a pool of blood between the brain and the skull), small acute subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), and bilateral [NAME] II fractures (a pyramid shaped fracture along the nasal bridge which causes separation of the midface from the skull base). Review of the Facility Investigation, which included written statements provided by staff, indicated that at approximately 9:00 P.M. on 03/12/24, CNA #1 reported to Nurse #1 that Resident #1 was in bed with a bloody nose. The Investigation indicated Nurse #1 observed Resident #1 lying in bed with a bloody nose and a large purple hematoma on his/her forehead with a 0.5 cm laceration. The Investigation indicated that Nurse #1 applied a cold pack to Resident #1's forehead and pressure to stop the bleeding (from his/her nose) and notified the Nursing Supervisor, who called 911, to transfer Resident #1 to the Hospital ED. Review of Resident #1's Hospital ED Report, dated 03/12/24, indicated Resident #1 sustained the following injuries from a fall at the Facility: -small subdural hematoma -small subarachnoid hemorrhage -bilateral [NAME] II fracture with fracture line passing through the frontal nasal sutures (cranial suture between the frontal and nasal bones), bilateral nasal bones, lateral walls of maxillary sinus (part of nasal cavity), and inferior orbital rim (bone behind the lower eye lid) -extensive scalp edema in the frontal region (forehead), frontal scalp hematoma at the midline with overlying laceration Resident #1 was admitted to the Facility in December 2018, diagnoses included Alzheimer's Disease and unspecified (location of) osteoarthritis. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/06/24, indicated he/she had long and short-term memory impairments, significant impairment for decision making ability, was dependent for chair/bed-to-chair transfers with the assistance of two or more staff members, and had sustained no falls in the previous quarter. Review of Resident #1's Falls Care Plan, with an edited date of 03/04/24, indicated he/she required a Hoyer lift with the assistance of two staff members for all transfers. Review of Resident #1's care Kardex (used by the CNAs to determine individual care needs) indicated he/she required a Hoyer lift with the assistance of two staff members for all transfers and he/she was non-ambulatory. Review of a Nurse Progress Note, dated 03/12/24 at 10:39 P.M., (written by Nurse #1), indicated that he was called to Resident #1's room (by CNA #1) at approximately 9:10 P.M. The Note indicated he observed Resident #1 with a bloody nose and a forehead hematoma with a laceration. The Note indicated Nurse #1 called for a supervisor immediately, 911 was called and Resident #1 was transferred to the Hospital ED. During an interview on 03/27/24 at 3:13 P.M., (which included review of his written statement), Nurse #1 said that on 03/12/24 at approximately 9:00 P.M., CNA #1 told him that Resident #1 had a bloody nose. Nurse #1 said that he went to Resident #1's room and observed him/her lying in bed with blood coming out of both nostrils. Nurse #1 said he also observed a small cut on Resident #1's forehead along with a purple bruise that went over his/her eyes, down the front of his/her nose, and under his/her eyes. Nurse #1 said he applied pressure to Resident #1's nose but could not get the bleeding to stop. Nurse #1 said he also applied an ice pack to his/her forehead. Nurse #1 said that he noticed blood on the floor in Resident #1's room. Review of a Nurse Progress Note dated 03/12/24 at 10:29 P.M., (written by the Nursing Supervisor), indicated that she was called to Resident #1's room at approximately 9:10 P.M. and she observed him/her lying in bed on his/her back with an active bloody nose and a moderate amount of fresh blood. The Note indicated that she also observed him/her to have a large purple hematoma to the center of his/her forehead and slight bruising around both of his/her eyes and that his/her nose appeared swollen and tender to touch. The Note indicated that Nurse #1 provided first aid and she (the Nursing Supervisor) called 911. Further review of the Note indicated that once Resident #1 left the Facility, the Nursing Supervisor interviewed CNA #1. During an interview on 03/27/24 at 3:32 P.M., the Nursing Supervisor (which included review of her written statement), said on the evening of 03/12/24 she received a call from Nurse #1 that there was an emergency on his unit. The Nursing Supervisor said she immediately went to Nurse #1's unit and then to Resident #1's room where she observed Resident #1 lying in bed with a bloody nose and a hematoma that covered most of his/her forehead with a small laceration in the center of the hematoma. The Nursing Supervisor said she also observed bruising under both Resident #1's eyes and swelling in the nasal area. The Nursing Supervisor said that once Resident #1 was transferred to the Hospital ED, she started her investigation. The Nursing Supervisor said she interviewed CNA #1 and he told her that he used the Hoyer lift by himself, to transfer Resident #1 from the wheelchair to bed, and that while he was lifting him/her, he/she fell to the floor face first. The Nursing Supervisor said that CNA #1 told her that he then put Resident #1's bed in the lowest position and moved him/her (did not specify how) from the floor into the bed without any assistance and without getting a nurse to assess Resident #1 immediately following the fall. The Nursing Supervisor said that she observed smeared dried blood on Resident #1's floor, between the wall and his/her bed. Review of the CNA #1 written Witness Statement, dated 03/12/24, indicated that on 03/12/24 at 8:30 P.M., he transferred Resident #1 from the wheelchair to the bed using the Hoyer lift. The Statement indicated as he (CNA #1) lifted Resident #1, the Hoyer pad became loose and Resident #1 fell on to his/her knees and hit his/her head. The Statement indicated that CNA #1 did not think Resident #1 appeared injured and he transferred him/her back into bed (from the floor). During telephone interviews on 03/28/24 at 8:29 A.M. and 3:49 P.M., CNA #1 said that Resident #1 was on his assignment for the 3:00 P.M. to 11:00 P.M. shift on 03/12/24. CNA #1 said he was familiar with Resident #1 and had often taken care of him/her. CNA #1 said he knew he was supposed to have someone else with him while doing the mechanical lift transfer, and said he usually got another staff member to assist when transferring Resident #1, but said he had not that night. CNA #1 said as he transferred Resident #1 from the wheelchair with the Hoyer lift, the straps to the Hoyer pad became loose and Resident #1 fell forward knees first, then hit his/her head. CNA #1 said he had only lifted Resident #1 a few inches off the wheelchair before he/she fell to the floor. CNA #1 said that he forgot to add to his written statement, which he provided to the Facility, that after the fall he used the Hoyer lift (by himself) to transfer Resident #1 up off the floor and put him/her into the bed. CNA #1 said that he noticed Resident #1 was bleeding when he/she was on the floor and said he transferred Resident #1 off of the floor by himself because no other staff members were around. CNA #1 said that he cleaned the blood off Resident #1's floor before he notified Nurse #1 that Resident #1 had fallen and had a bloody nose. During an interview on 03/28/24 at 10:55 A.M., the Director of Nurses (DON) said that she was notified on 03/12/24 by the Nursing Supervisor that Resident #1 sustained injuries which included a bloody nose and bruise to the forehead and around his/her eyes. The DON said that she conducted a telephone interview with CNA #1 on 03/12/24 following the incident and that CNA #1 was tight lipped and said that the Hoyer pad came loose and that was how Resident #1 fell to the floor. The DON said that her investigation indicated that CNA #1 had not gotten assistance from another staff member to help transfer Resident #1 from the wheelchair to the bed and then from the floor to the bed (after the fall). The DON said that CNA #1 should have requested assistance from another staff member to transfer Resident #1. The DON said that all mechanical lift transfers required two person assists.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who on 03/12/24, experienced a fall to the floor during a transfer with the Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another), the Facility failed to ensure he/she was provided with quality of care that met acceptable standards of practice, when after the fall despite noting that while Resident #1 was on the floor he/she was bleeding from his/her nose, Certified Nurse Aide (CNA) #1 transferred Resident #1 off the floor and put him/her in bed, before notifying nursing so Resident #1 could be assessed for injuries. Resident #1 was transferred that evening to the Hospital Emergency Department (ED) for an evaluation and was diagnosed with a laceration, head injuries and fractures. Findings include: Review of the Facility's policy, Fall Procedure, with a revision date of 09/08/21, indicated the objective was to provide appropriate intervention, evaluation, documentation, and care plan adjustment and in the event of a fall the Licensed Nurse will conduct a physical assessment of the resident. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) dated 03/19/24, indicated that on 03/12/24 at approximately 9:00 P.M., Resident #1 was found with a bloody nose and a large purple hematoma on his/her forehead with a 0.5 centimeter (cm) laceration. The Report indicated that during a transfer from his/her wheelchair to the bed, the mechanical lift sling came loose, and Resident #1 fell on his/her knees, falling face forward (to the floor). The Report indicated that he/she was transferred to the Hospital Emergency Department (ED) and was found to have a small acute subdural hematoma (a pool of blood between the brain and the skull), small acute subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and bilateral [NAME] II fractures (a pyramid shaped fracture along the nasal bridge which causes separation of the midface from the skull base). Resident #1 was admitted to the Facility in December 2018, diagnoses included Alzheimer's Disease and unspecified (location of) osteoarthritis. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/06/24, indicated he/she had long and short-term memory impairments, significant impairment for decision making ability, was dependent for chair/bed-to-chair transfers with the assistance of two or more staff members, and had sustained no falls in the previous quarter. Review of Resident #1's Hospital ED Report, dated 03/12/24, indicated Resident #1 sustained the following injuries from a fall at the Facility: -small subdural hematoma -small subarachnoid hemorrhage -bilateral [NAME] II fracture with fracture line passing through the frontal nasal sutures, bilateral nasal bones, lateral walls of maxillary sinus, and inferior orbital rim. -extensive scalp edema in the frontal region, frontal scalp hematoma at the midline with overlying laceration Review of a Nurse Progress Note, dated 03/12/24 at 10:39 P.M., (written by Nurse #1), indicated that he was called to Resident #1's room (by CNA #1) at approximately 9:10 P.M. because Resident #1 had a bloody nose. The Note indicated he (Nurse #1) observed Resident #1 with a bloody nose and a forehead hematoma with a laceration. The Note indicated Nurse #1 called for a supervisor immediately, 911 was called and Resident #1 was transferred to the Hospital ED. During an interview on 03/27/24 at 3:13 P.M., (which included review of his written statement), Nurse #1 said that on 03/12/24 at approximately 9:00 P.M., CNA #1 told him that Resident #1 had a bloody nose. Nurse #1 said that he went to Resident #1's room and observed him/her lying in bed with blood coming out of both nostrils. Nurse #1 said he also observed a small cut on Resident #1's forehead along with a purple bruise that went over his/her eyes, down the front of his/her nose, and under his/her eyes. Nurse #1 said that he also noticed blood on the floor in Resident #1's room. Nurse #1 said he asked CNA #1 what happened, but that CNA #1 did not respond. Review of a Nurse Progress Note dated 03/12/24 at 10:29 P.M., (written by the Nursing Supervisor), indicated that she was called to Resident #1's room at approximately 9:10 P.M. and she observed him/her lying in bed on his/her back with an active bloody nose and a moderate amount of fresh blood. The Note indicated that she also observed him/her to have a large purple hematoma to the center of his/her forehead and slight bruising around both of his/her eyes and that his/her nose appeared swollen and tender to touch. Further review of the Note indicated that once Resident #1 left the Facility, the Nursing Supervisor interviewed CNA #1. The Note indicated that CNA #1 told her that when he transferred Resident #1 from the wheelchair to the bed, he/she fell forward onto the floor face down. During an interview on 03/27/24 at 3:32 P.M., the Nursing Supervisor (which included review of her written statement), said on the evening of 03/12/24, that once Resident #1 was transferred to the Hospital ED, she started her investigation. The Nursing Supervisor said she interviewed CNA #1, and he told her that he used the Hoyer lift by himself, to transfer Resident #1 from the wheelchair to bed, and that while he was lifting him/her, he/she fell to the floor face first. The Nursing Supervisor said that CNA #1 told her that he then put Resident #1 back into bed without getting a nurse to assess Resident #1 immediately following the fall. The Nursing Supervisor said that she had observed smeared dried blood on Resident #1's floor, between the wall and his/her bed. Review of CNA #1 written Witness Statement, dated 03/12/24, indicated that at 8:30 P.M., he (CNA #1) transferred Resident #1 from the wheelchair to the bed using the Hoyer lift. The Statement indicated as he (CNA #1) lifted Resident #1, the Hoyer pad became loose and he/she fell on to his/her knees and hit his/her head. The Statement indicated that CNA #1 did not think Resident #1 appeared injured and he transferred (did not specify how) him/her into bed (from the floor). During telephone interviews on 03/28/24 at 8:29 A.M. and 3:49 P.M., CNA #1 said that Resident #1 was on his assignment for the 3:00 P.M. to 11:00 P.M. shift on 03/12/24. CNA #1 said he was familiar with Resident #1 and often took care of him/her. CNA #1 said he was putting Resident #1 to bed and as he transferred him/her from the wheelchair with the Hoyer lift, the straps to the Hoyer pad became loose and Resident #1 fell forward, knees first, then hit his/her head. CNA #1 said he had lifted Resident #1 a few inches off the wheelchair before he/she fell to the floor. CNA #1 said that he noticed Resident #1 was bleeding when he/she was on the floor, and said he transferred Resident #1 off the floor by himself and put him/her in bed because no other staff members were around. CNA #1 said he knew he was supposed to call the nurse immediately after a resident fell , and that he knew a resident should not be moved until the nurse assesses them. CNA #1 said he used the the Hoyer lift to transfer Resident #1 off the floor and put him/her into bed. CNA #1 said that he then cleaned the blood off Resident #1's floor before he went and notified Nurse #1 that Resident #1 had a bloody nose and had fallen. Review of the Facility Investigation, including written statements by staff, indicated that at approximately 9:00 P.M. on 03/12/24, CNA #1 reported to Nurse #1 that Resident #1 was in bed with a bloody nose. Nurse #1 observed Resident #1 lying in bed with a bloody nose and a large purple hematoma on his/her forehead with a 0.5 cm laceration. The Investigation indicated that Nurse #1 applied a cold pack to Resident #1's forehead and pressure to stop the bleeding (from his/her nose) and notified the Nursing Supervisor who called 911 to transfer Resident #1 to the Hospital ED. The Investigation also indicated that on 03/12/24 at approximately 9:30 P.M., the Director of Nurses (DON) conducted a telephone interview with CNA #1, who said that during Resident #1's transfer (from the wheelchair to the bed), the mechanical lift sling (pad) became loose, and Resident #1 fell on his/her knees, face forward. Furthermore, the investigation indicated CNA #1 said he did not know that Resident #1 was injured before he transferred him/her from the floor to the bed and when asked why he transferred Resident #1 off the floor before notifying a nurse, CNA #1 did not respond. However, the statement made by CNA #1 to the DON during the facility's investigation, that he did not know Resident #1 was injured before transferring him/her off the floor after the fall and putting him/her in bed, conflicted with what CNA #1 said during an interview with the surveyor, in which CNA #1 said he noticed Resident #1 was bleeding when he/she was on the floor and he cleaned the blood off Resident #1's floor before he went to notify the nurse. During an interview on 03/28/24 at 10:55 A.M., the Director of Nurses (DON) said that she was notified on 03/12/24 by the Nursing Supervisor that Resident #1 sustained injuries which included a bloody nose and bruise to the forehead and around his/her eyes. The DON said that she conducted a telephone interview with CNA #1 on 03/12/24 following the incident and said CNA #1 was tight lipped and told her that the Hoyer pad came loose and that was how Resident #1 fell to the floor. The DON said that her investigation indicated that CNA #1 did not get assistance from another staff member to transfer Resident #1 from the wheelchair to the bed and then from the floor to the bed. The DON said that CNA #1 should have requested assistance of another staff member to transfer Resident #1 and that staff were not supposed to transfer a resident off the floor who had fallen, until a nurse assessed him/her for injury.

Based on observations, interviews, record and policy reviews, the facility failed to ensure that its staff implemented an infection prevention and control program in order to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to ensure its staff: 1) implemented a surveillance plan to identify the potential presence of Legionella (a bacteria that can grow and multiply in moist areas of a building water system and cause lung infections) within the facility, 2) implemented contact precautions for one Resident (#3), with a diagnosis of Extended Spectrum Beta-Lactamase (ESBL- enzyme found in bacteria that cause infections that are resistant to many types of antibiotics), 3) adhered to the Centers of Disease Control & Prevention (CDC) and Massachusetts Department of Public Health (MA DPH) guidance relative to work exclusion after one Employee (#1) tested positive for COVID -19 infection, and 4) minimized the risk of transmission of infections by implementing the required Personal Protective Equipment (PPE) for one Resident (#183) who tested positive for COVID-19 infection and was on Isolation Precautions. Findings include: 1. Review of the facility policy, Legionella Water Management Plan, indicated the following: -Flush all showers monthly. This will be documented. -Flush hot water storage tanks yearly. This will be documented. During an interview on 2/17/23 at 2:18 P.M., the Administrator reviewed the water management book with the surveyor and said that flushing the hot water tanks yearly to identify the presence of Legionella had not been conducted, as per the facility policy and Legionella Water Management Plan. She further said that it was determined by an outside contractor that this should not be done due to potential safety concerns. The Administrator said that the current Legionella Water Management Plan was not accurate, needed to be reviewed and revised and had not been done for over a year and a half. When the surveyor asked how often the interdisciplinary team should meet and review the Legionella Water Management Plan, the Administrator said at a minimum, it should be reviewed annually. 44222 2. For Resident #112 the facility staff failed to implement ESBL precautions as ordered by the Physician. Review of the facility policy titled Contact Precautions revised 1/28/2019, indicated: -contact precautions, in addition to standard precautions are set in place for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident's environment. -Hand Hygiene should be completed prior to donning (putting on) gloves, and after removal of gloves. -Gloves should be worn when entering the room and while providing care for a resident. -Gowns should be worn when entering the room if it is anticipated that clothing will have substantial contact with the resident. Review of facility policy titled Discontinuing Isolation Precautions for MDRO (Multi-drug resistant organisms - bacteria that have become resistant to certain antibiotics) revised 8/17/2021 indicated: - isolation precautions may be discontinued after treatment - obtain MD (medical doctor) order to discontinue precautions Review of the Contact Precaution Signage undated, indicated that staff must perform hand hygiene and put on a gown and gloves before entering a resident room. Resident #112 was admitted to the facility in January 2023 with a diagnosis of ESBL in the urine. Review of the Resident's Physician's orders for February 2023 included: -Xifaxan (a broad spectrum antibiotic) 550 milligrams by mouth twice a day to treat bacterial infection Ecoli, start date 1/19/23 open ended -ESBL in urine, maintain precautions at all times, start date 1/19/23 open ended Review of the Resident's Medication Administration Record (MAR) indicated that the Xifaxan was administered as ordered 1/19/23 through 2/14/23. Review of the Resident's Treatment Administration Record (TAR) indicated that the ESBL precautions were in place from 1/19/23 through 2/14/23 every shift as ordered. Review of the Resident's Care Plan created 1/25/23 indicated that the Resident had ESBL in the urine, to administer current treatment and ESBL precautions as ordered. During observations on 2/14/23 at 11:23 A.M., and 2/15/23 at 11:24 A.M., the surveyor observed the Resident lying in bed. There were no precaution signs posted, nor PPE supplies or waste receptacles available at the Resident's doorway. During an interview on 2/15/23 at 11:25 A.M., Rehabilitation Services Staff #1 said that she had been working with the Resident regularly for transfers and toileting and there have never been any special precautions in place that she was aware of, and currently the therapy staff were just using standard precautions for the Resident which included mask and gloves. During an interview on 2/15/23 at 2:00 P.M., Certified Nursing Assistant (CNA) #1 said that the Resident was not on any special precautions because he/she was not sick. The CNA further said that she had provided care for the Resident today including bathing, dressing, and incontinent care tasks. CNA #1 said that she did not wear a gown but only used a face mask and gloves when caring for the Resident. During an interview on 2/15/23 at 2:10 P.M., Nurse #1 said that the Resident was not on any special precautions. Nurse #1 and the surveyor reviewed the Physician's orders which indicated that the Resident had a current order for ESBL precautions. Further review of the TAR indicated that the nurses initialed that ESBL precautions were in place every shift. Nurse #1 said that she did initial that ESBL precautions were in place on the 14th and 15th of February for the 7:00 A.M. to 3:00 P.M. shift each day but the ESBL precautions were not in place. When asked what precautions should be in place for an order that said ESBL precautions, Nurse #1 said that it would be contact precautions. Nurse #1 said that contact precautions meant that the staff should wear a gown and gloves when giving direct care such as transfers, bathing and dressing care to the Resident. During an interview on 2/16/23 at 2:07 P.M., the Director of Nursing (DON) said that ESBL precautions and contact precautions meant the same thing. She further said that she was not aware that the Resident was currently being treated for an infection and that there was an active order for ESBL precautions. She said that the precautions should have been in place if there was an order and the Resident was currently being treated. 42761 3. The facility failed to ensure its staff adhered to infection surveillance requirements for one Employee (#1) during a facility outbreak of COVID-19. Specifically, the facility failed to ensure its staff adhered to return to work guidelines when Employee #1 tested positive for COVID-19 and was allowed to return to work earlier than the required timeframe for exclusion from work. Review of the CDC guidelines, titled Ending Isolation and Precautions for People with COVID-19: Interim Guidance, dated 8/31/22, indicated: Day zero is the date one's symptoms appear or when a specimen resulting in a positive test is collected. Review of The Commonwealth of Massachusetts (MA) Executive Office of Health and Human Services DPH Guidance for Health Care Personnel (HCP) with SARS-CoV2 Infection or Exposure, dated 10/13/22, included the following: - An isolating HCP who had COVID-19 symptoms may return to work: - After five days have passed since the first positive test was taken; AND - symptoms have substantially improved, including being fever-free, for 24 hours; AND - the HCP received a negative test on Day five or later. Review of the undated COVID-19 Return to Work Guidelines for HCP Policy provided by the facility included that the facility's protocols were dependent upon current DPH guidelines. Review of the facility's Long Term Care Respiratory Surveillance Line List indicated Employee #1 was symptomatic, with cough and myalgia (body ache), and tested positive for COVID-19 on 1/6/23. Review of Employee #1's January 2023 timecard indicated the following: - Employee #1 worked at the facility on 1/6/23 (Day zero). - Employee #1 returned to work at the facility on 1/10/23 (Day four since being symptomatic and testing positive for COVID-19). During an interview on 2/16/23 at 8:39 A.M., the DON said if an employee required exclusion from work due to testing positive for COVID-19, the employee would be excluded from work until five days passed since either testing positive or being symptomatic for COVID-19. The DON said the employee would be able to test again after five days passed and, if a negative test was obtained, the employee could return to work on Day six. The DON further said Employee #1 did not meet the requirements for return to work as the Employee was allowed to return to work on Day four following a positive test for COVID-19. The DON also said Employee #1 should have been restricted from work until Day 6 (1/12/23) as long as a negative test had been obtained on Day five. Please refer to F886 37400 4. For Resident #183, the facility failed to ensure its staff adhered to Isolation Precautions by wearing the required PPE in order to reduce and/or minimize the spread of COVID-19 infection. Review of the clinical record indicated Resident #183 tested positive for COVID-19 infection on 2/14/23. During an observation on 2/15/23 at 9:29 A.M., the surveyor observed Resident #183 was transferred to another room, and that Isolation Precautions signage was placed on the closed door to the room which indicated the following: -Stop, Isolation Droplet/Contact Precautions -In addition to Standard Precautions, staff and providers MUST: -clean hands when entering & exiting -gown (change between each resident) -N95 respirator -eye protection (goggles or face shield) -gloves (change between each resident) -keep door closed (unless safety concern or not on a physically separate unit) PPE was observed on an over-the-door rack with compartments which was hung on the outside of Resident #183's room and contained N95 masks, gowns, multiple sizes of gloves and face shields. During an observation on 2/16/23 at 9:31 A.M., the surveyor observed Nurse #2 enter Resident #183's room with a gown, gloves and N95 mask in place. Nurse #2 was not wearing eye protection. At 9:36 A.M., Nurse #2 was observed to open the door to the room to converse with the Respiratory Therapist. At this time, the surveyor asked Nurse #2 what PPE was required upon entering the Resident's room. Nurse #2 said that she needed to wear a gown, gloves and an N95 mask prior to entering the room. When the surveyor asked about eye protection, Nurse #2 said that she was caring for Resident #183's roommate (who was recovered) therefore she did not have to put on eye protection. She further said that when she provided care to Resident #183 (who was positive for COVID-19 and resided in the same room) she would have to put on eye protection. The surveyor and Nurse #2 reviewed the Isolation Precaution signage outside of Resident #183's room, and Nurse #2 was encouraged to speak with the Unit Manager (UM). During an interview on 2/16/23 at 9:56 A.M., Unit Manager (UM) #2 said that the staff are expected to put on a gown, gloves, an N95 mask and eye protection prior to entering an Isolation Precaution room. She further said even if there was a COVID positive and recently recovered and/or negative resident in the same room, staff were required to wear all the required PPE prior to entering the room because there was a COVID positive resident.

Based on interviews and documentation review, the facility failed to ensure its staff completed annual inspections of all bed frames, mattresses and bed rails as part of the regular maintenance program to identify areas of possible entrapment on four of four units. Findings include: During an interview and review of the annual bed inspections forms for all units on 2/17/23 at 8:00 A.M., the Director of Maintenance said that bed assessments and entrapment evaluations are conducted annually for all resident beds as part of the preventative maintenance program. The Director of Maintenance was able to provide the bed assessments from 2019 through 2021 but was unable to provide documented evidence that the annual inspections of the resident beds were completed in 2022. The Director of Maintenance said he did not recall if the bed assessments were completed in 2022, and that the facility did not have policy related to this process, but verbalized to the surveyor that inspection of resident beds including assessing for entrapment was to be conducted annually and when a mattress was changed/replaced. During an interview on 2/17/23 at 12:37 P.M., the Administrator said that there was no documented evidence that the annual bed inspections and assessments were completed in 2022, as required.

Based on observations, interviews, and record reviews, the facility failed to ensure its staff maintained a complete and/or accurate medical record for four Residents (#60, #85, #95 and #112), out of a total sample of 26 residents. Findings include: 1. For Resident #60, the facility failed to ensure its staff maintained an accurate medical record relative to the documentation of application and/or the administration of a) heel lift boots and b) contact precautions for Extended Spectrum Beta-Lactamase (ESBL- enzyme found in bacteria that cause infections that are resistant to many types of antibiotics). Resident #60 was admitted to the facility in January 2023, with diagnoses including Right Hip Fracture, falls and Urinary Tract Infections (UTI). Review of the February 2023 Physician's Orders included the following: -heel lift boots- at all times, may remove periodically for skin observations and hygiene every shift, initiated 1/14/23 -contact precautions for ESBL in the urine every shift, initiated 1/16/23 During observations on 2/15/23 at 9:05 A.M., and 2/16/23 at 9:26 A.M., the surveyor observed Resident #60 lying in bed with non-skid socks in place. There was no precautions signage outside of the Resident's room indicating he/she was on contact precautions and required personal protective equipment (PPE) with care. Review of the February 2023 Medication and Treatment Administration Records indicated the heel lift boots and contact precautions for ESBL were signed off by the nurses as administered from 2/14/23 through 2/15/23. During interview on 2/16/23 at 4:21 P.M., the Assistant Director of Nurses (ADON) said that Resident #60 had a diagnosis of ESBL in his/her urine prior to admission to the facility. She said that a urine culture was obtained on 1/18/23, was negative for ESBL and that the contact precautions should have been discontinued at that time. She further said that there should not be an order for heel lift boots to be on at all times, and that this order was probably obtained when the Resident transferred to the facility. The ADON said that the nursing staff should not have signed off that these orders were administered when they were not, and that the orders for the ESBL and heel lift boots needed to be discontinued/adjusted. 2. For Resident #85, the facility failed to ensure the Physician's Orders were accurate relative to his/her code status. Resident #85 was admitted to the facility in January 2023, with diagnoses of Hypertension (HTN) and malnutrition. Review of the February Physician's Orders included the following orders initiated on 1/26/23: -Full Code Status (administer life sustaining treatment/care if the heart was to stop, including cardiopulmonary resuscitation) -Do Not Intubate/Do Not Resuscitate (DNR/DNI-do not provide life sustaining treatment including chest compressions or intubation) Review of the clinical record indicated a Massachusetts Orders for Life-Sustaining Treatment (MOLST) form was completed on 10/14/22 which indicated Resident #85 was DNR/DNI. During an interview and review of the Resident's clinical record on 2/15/23 at 8:47 A.M., Nurse #3 said that there were conflicting orders relative to the Resident's code status in the Physician's Orders. During a follow-up interview on 2/15/23 at 10:42 A.M., Nurse #3 said that Resident #85 was DNR/DNI, and that the Physician's Orders were not accurate and needed to be modified. 44222 3. For Resident #95 the facility staff inaccurately documented the application of TED stockings (compression stockings used to gently squeeze the lower extremities to improve blood flow in the veins of the legs). Resident #95 was admitted to the facility in January 2021, with diagnoses of Hypertension (HTN) and Chronic Kidney Disease (CKD), Stage III. Review of the Minimum Data Set (MDS) Assessment, dated 11/16/2022, indicated Resident #95 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15. Review of the Resident's clinical record progress notes indicated on 2/6/23 that the Resident was seen by the N.P. (Nurse Practitioner) this morning, new order for TED stockings to (be) applied in the A.M. (morning) and removed in the evening. Review of the Resident's Physician's Orders for February 2023 included .TED stockings, special instructions: apply to bilateral lower extremities in the morning and remove in the evening .start date 2/6/2023. Review of the Resident's care plan, edited 2/6/23, indicated that the Resident should have TED stockings. Review of the Resident's Treatment Administration Record (TAR) for February 2023, indicated that TED Stockings were applied every morning from 2/6/23 through 2/15/23. During observations on 2/14/23 at 8:59 A.M., and at 3:00 P.M., the surveyor observed that the Resident was not wearing any TED stockings. During an observation on 2/15/23 at 9:53 A.M., the surveyor observed that the Resident was not wearing any TED stockings. The Resident told the surveyor that he/she never wears the TED stockings. During an interview and observation on 2/15/23 at 1:50 P.M., Nurse #1 said that the Resident had an order for TED stockings, and she had signed for the stockings today. Nurse #1 said that she believed that the Resident was wearing the stockings. During an observation with Nurse #1 and the surveyor, it was identified that the Resident was not wearing TED stockings. The Resident told Nurse #1 and the surveyor that he/she had not worn TED stockings in a very long time. Nurse #1 said that the TEDS stockings were documented as applied but the stockings had not been applied. 4. For Resident #112 the facility staff inaccurately documented the use of ESBL precautions. Resident #112 was admitted to the facility in January 2023 with a diagnosis of ESBL in the urine. Review of the Resident's Physician's Orders for February 2023 included: ESBL in urine, maintain precautions at all times, every shift, start date 1/19/23. Review of the Resident's Treatment Administration Record (TAR) indicated that the ESBL precautions were in place from 1/19/23 through 2/14/23 every shift as ordered. Review of the Resident's Care Plan created 1/25/23 indicated that the Resident had ESBL in the urine, to administer current treatment and ESBL precautions as ordered. During observations on 2/14/23 at 11:23 A.M., and 2/15/23 at 11:24 A.M., the surveyor observed the Resident lying in bed. There were no precaution signs posted, nor PPE supplies and waste receptacles available at the Resident's doorway. During an interview on 2/15/23 at 11:25 A.M., Rehabilitation Services Staff #1 said that she had been working with the Resident regularly for transfers and toileting and there have never been any special precautions in place that she was aware of, and currently the therapy staff were just using standard precautions for the Resident which included a mask and gloves. During an interview on 2/15/23 at 2:00 P.M., Certified Nursing Assistant (CNA) #1 said that the Resident was not on any special precautions because she was not sick. The CNA further said that she had provided care for the Resident today including bathing, dressing, and incontinent care tasks. CNA #1 said that she did not wear a gown but only used a face mask and gloves when caring for the Resident. During an interview on 2/15/23 at 2:10 P.M., Nurse #1 said that the Resident was not on any special precautions. Nurse #1 and the surveyor reviewed the Physician's Orders which indicated that the Resident had a current order for ESBL precautions. Further review of the TAR indicated that the nurses initialed that ESBL precautions were in place every shift. Nurse #1 said that she did initial that the ESBL precautions were in place on the 14th and 15th of February for the 7:00 A.M. to 3:00 P.M. shift, but the ESBL precautions were not in place. When asked what precautions should be in place for an order that said ESBL precautions, Nurse #1 said that it would be contact precautions which meant that the staff should wear a gown and gloves when giving direct care such as transfers, bathing and dressing care to the Resident. Nurse #1 then hung a contact precaution sign at the Resident's doorway and began to set up PPE supplies.

Based on interview and record review, the facility failed to ensure its staff conducted the required COVID-19 outbreak testing for residents on one out of four units, when the facility was experiencing an outbreak of COVID-19. Specifically, the facility failed to ensure its staff tested all residents on the Brookside Unit for 1) initial requisite outbreak testing when all residents with potential exposure could not be determined, and 2) every 48 hours following initial requisite outbreak testing until the Unit went seven days with no new positive cases after one Employee (#1) had worked on the Unit, became symptomatic, and tested positive, for COVID-19. Findings include: Review of The Commonwealth of Massachusetts (MA) Executive Office of Health and Human Services (EOHHS) Department of Public Health (DPH) memorandum, titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 10/13/22, included the following relative to outbreak testing: - Once a new case is identified, the facility should initiate outbreak testing. - Testing exposed .residents on the affected unit(s) must take place as soon as possible . - Once the facility has completed the requisite initial outbreak testing ., the facility should test staff and residents every 48 hours on the affected unit(s) until the facility goes seven days without a new case or a DPH epidemiologist directs otherwise. Review of The Commonwealth of MA EOHHS DPH memorandum, titled Updates to Long-Term Care Surveillance and Outbreak Testing, dated 12/1/22, included: If staff testing results indicate a positive COVID-19 staff member who worked while potentially infectious, then the provider must conduct outbreak testing of all potentially exposed residents .to ensure there are no additional cases . Review of the undated Surveillance Testing Program Policy provided by the facility included the following: If staff testing results indicate a positive COVID-19 staff member who worked while potentially infectious, then the facility must conduct outbreak testing of all potentially exposed residents .to ensure there are no additional cases . Review of Employee #1's January 2023 timecard indicated Employee #1 worked at the facility on 1/6/23. Review of the facility's Long Term Care Respiratory Surveillance Line List indicated Employee #1 worked on the Brookside Unit, was symptomatic with cough and myalgia (body ache), and tested positive for COVID-19 on 1/6/23. Review of the Nurse Shift to Shift Report Log, dated 1/6/23, included that 14 Residents (#1, #2, #3, #28, #30, #54, #58, #75, #84, #88, #89, #114, #115, and #120) on the Brookside Unit were tested for COVID-19 on 1/6/23. Further review of the Log did not indicate any other residents on the Brookside Unit were tested at that time for COVID-19. Review of the above mentioned Residents' clinical records included no evidence that any of these Residents were tested for COVID-19 every 48 hours, following the initial outbreak testing, to ensure no additional cases of COVID-19 occurred over the seven day period following Employee #1's positive test on 1/6/23. During an interview on 2/15/23 at 10:28 A.M., the Assistant Director of Nursing (ADON) identified herself as one of the designated Infection Preventionists at the facility. The ADON said that the facility had been experiencing an outbreak of COVID-19 and that there were positive COVID-19 resident cases on the Brookside Unit. During a follow-up interview on 2/15/23 at 2:24 P.M., the ADON said a COVID-19 outbreak would be identified if a resident tested positive, but if an employee tested positive, this would not necessarily be considered an outbreak of COVID-19. The ADON said the facility used a contact tracing method for testing when an employee tested positive for COVID-19, so if the positive employee provided direct care, his/her resident assignment would be tested , but no other residents on the unit would need to be tested . The ADON said she considered Employee #1 testing positive on 1/6/23 to be an isolated case, not an outbreak of COVID-19, even though the Employee worked as a Certified Nurse Aide on the Brookside Unit, and provided direct resident care that same day. During an interview on 2/16/23 at 8:29 A.M., the Director of Nursing (DON) said the facility used a contact tracing method for COVID-19 testing when an employee tested positive for COVID-19, so if an employee tested positive, their resident assignment would also be tested , but other residents on the unit would not be tested . The DON said only Residents on Employee #1's assignment on 1/6/23 were tested for COVID-19 after the Employee tested positive. The DON said those Residents should have been provided with follow-up COVID-19 testing every 48 hours until the Unit went seven days without another positive case, but this was not done, as required. The DON also said transmission of COVID-19 could not be prevented on the Brookside Unit once it was identified because most residents on the Unit could not be isolated or adhere to infection control practices. The DON said that in looking back at the COVID-19 outbreak on the Brookside Unit, given that most residents could not be isolated or adhere to infection control practices, all residents should have been included in the initial outbreak testing that occurred on 1/6/23 as there was potential that other residents on the Unit had been exposed. She also said all residents on the Unit should have been tested every 48 hours after 1/6/23, until no new cases were identified for seven days, but this was not done.

Based on record review and interview, the facility failed to ensure its staff developed a baseline care plan within 48 hours of admission to the facility for one Resident (#1), out of 26 total sampled residents. Specifically, the facility failed to ensure its staff developed a baseline care plan, or completed a comprehensive care plan in its place for Resident #1, within 48 hours of the Resident's admission to the facility to include the following: the Resident's a) risk for falls when the Resident had a history of repeated falls and sustained a fracture of the seventh thoracic (upper and middle part of the back) vertebra and b) provide communication for Resident's needs when a language barrier was present. Findings include: Review of the facility's policy, titled 48 Hour Baseline Care Plan, dated 8/2/18, included the following: - The objective was to promote continuity of care and communication among staff and residents/families. - A baseline care plan would be developed for each resident within 48 hours of admission. - The baseline care plan would address the most important problems or high-risk conditions .and be utilized as a guide for care until the comprehensive interdisciplinary care plan was developed. Resident #1 was admitted to the facility in December 2022 with diagnoses including Alzheimer's Disease and repeated falls. Review of the Nurse Practitioner Visit Note, dated 12/15/22, included the following: - Resident #1 was Spanish speaking. - The Resident had a history of repeated falls and fell prior to admission where the Resident experienced an acute fracture of the thoracic spine. Review of the Baseline Care Plan, initiated 12/19/22, included no information relative to the Resident's risk for falls or interventions that were required for the Resident's immediate healthcare needs related to falls. Further Review of the Baseline Care Plan included the Resident was of Spanish culture, but no information was included relative to the Resident's needs for communication. Review of the Resident's active Comprehensive Care Plan indicated the Fall Care Plan and Communication Care Plan were not developed until 12/21/22 (more than 48 hours after the Resident's admission to the facility). During an interview on 2/17/23 at 8:22 A.M., Unit Manager (UM) #3 said baseline care plans did not need to be completed for residents who were admitted for long term care. UM #3 said no baseline care plan had been completed for Resident #1 because he/she had been admitted for long term care. She also said Resident #1 could follow some English instructions but that he/she was primarily Spanish speaking. During an interview on 2/17/23 at 2:00 P.M., the Director of Nursing (DON) said staff were required to develop baseline care plans for all residents within 48 hours of being admitted to the facility. The DON said Resident #1 should have had a baseline care plan developed within 48 hours of his/her admission to the facility and that it should have included the Resident's risk for falls and communication needs, but this had not been completed, as required.

Based on observations, record reviews, and interviews, the facility failed to ensure that its staff implemented the plan of care for two Residents (#95 and #60), out of a total of 26 sampled residents. Specifically, the facility staff failed to follow the plan of care for: 1) the application of TED Stockings (compression stockings used to gently squeeze the lower extremities to improve blood flow in the veins of the legs) for Resident #95, and 2) implementation of a perimeter mattress for Resident #60. Findings include: 1) For Resident #95 the facility failed to follow the plan of care for the application of TED stockings. Resident #95 was admitted to the facility in January 2021 with diagnoses including Hypertension (high blood pressure) and Atrial Fibrillation (abnormal heart rhythm). Review of the Minimum Data Set (MDS) Assessment, dated 11/16/2022, indicated Resident #95 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15. Review of the Resident's clinical record progress notes indicated on 2/6/23 that the Resident was seen by the N.P. (Nurse Practitioner) this morning, new order for TED stockings to (be) applied in the A.M.(morning) and removed in the evening. Review of the Resident's Physician's Orders for February 2023 included: TED stockings, special instructions: apply to bilateral lower extremities in the morning and remove in the evening .start date 2/6/2023. Review of the Resident's care plan, edited 2/6/23, indicated that the Resident should have TED stockings. Review of the Resident's Treatment Administration Record (TAR) for February 2023, indicated that TED stockings were applied every morning from 2/6/23 through 2/15/23. During observations on 2/14/23 at 8:59 A.M., and at 3:00 P.M., the surveyor observed that the Resident was not wearing any TED stockings as ordered and care planned. During an observation and interview on 2/15/23 at 9:53 A.M., the surveyor observed that the Resident was not wearing any TED stockings. The Resident told the surveyor that he/she never wears TED stockings. During an interview and observation on 2/15/23 at 1:50 P.M., Nurse #1 said that the Resident had an order for TED stockings, and Nurse #1 had signed for the stockings today. Nurse #1 said that she believed that the Resident was wearing the stockings. During an observation with Nurse #1 and the surveyor, it was determined that the Resident was not wearing TED stockings. The Resident told Nurse #1 and the surveyor that he/she had not worn TED stockings in a very long time. Nurse #1 said that the TED stockings should have been applied but they were not. 37400 2. For Resident #60, the facility failed to ensure the staff implemented a fall intervention as care planned and as ordered by the Physician. Resident #60 was admitted to the facility in January 2023 with diagnoses including repeated falls and hip fracture. Review of the MDS Assessment, dated 1/20/23, indicated: -Resident #60 was cognitively intact as evidenced by a BIMS score of 13 out of 15 -required extensive assistance of two staff with bed mobility, transfers and toileting -had a history of falls with fracture prior to admission. Review of the Nurse's Progress Note, dated 2/3/23, indicated moaning was heard from the Resident's room at 3:30 A.M. The facility staff went to check on the Resident and found him/her sitting on the floor holding on to the bed rail while leaning against the bed. The Nurse indicated that the Resident's care plan was updated to add a perimeter mattress. Review of the Falls Care Plan, revised on 2/3/23, indicated Resident #60 was at an increased risk of falls and included the following intervention: Perimeter mattress to the Resident's bed. Review of the February 2023 Physician's Orders indicated an order initiated 2/3/23 for a perimeter mattress (wedge shaped foam form a sensory reminder at mattress edges). During an observation on 2/15/23 at 9:05 A.M., the surveyor observed Resident #60 lying in bed eating breakfast. The Resident was lying on a regular mattress and was not on a perimeter mattress, as care planned and as ordered by the Physician. During an observation on 2/16/23 at 9:26 A.M., the surveyor observed Resident #60 lying in bed on a regular mattress. The mattress was not a perimeter mattress, as care planned and as ordered by the Physician. During an observation on 2/16/23 at 12:45 P.M., the surveyor observed two men applying a perimeter mattress to Resident #60's bed. During an interview on 2/16/23 at 4:09 P.M., the Assistant Director of Nurses (ADON) said the perimeter mattress was placed on the Resident's bed today. She further said that she was not sure why it was not put on the Resident's bed prior to this day, but that it was an intervention that was should have been added on 2/3/23 after the Resident had fallen. During an interview on 2/17/23 at 8:00 A.M., the Director of Maintenance said that he was unaware of a request to change Resident #60's mattress until yesterday, and that if he was notified previously to change the mattress, it may have been missed. He further that the facility had plenty of perimeter mattresses available since 2/3/23.

Based on observation, interviews, and record review, the facility failed to ensure its staff provided care consistent with professional standards of practice to prevent pressure ulcers (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) from developing and promote healing of a pressure ulcer that had developed for one Resident (#20), out of three applicable residents who had pressure ulcers, out of a total sample of 26 residents. Specifically, the facility staff failed to: 1) perform weekly skin assessments when the Resident was identified as being at risk for developing pressure ulcers, and 2) provide treatment to a pressure ulcer that included adequate infection control practices. Findings include: 1) The facility failed to ensure its staff performed weekly skin assessments when the Resident was identified as being at risk for developing pressure ulcers. Resident #20 was admitted to the facility in September 2022 with a diagnosis of a wedge compression fracture (an injury to the spine in which the vertebrae (spine bones) are broken by either a crushing or wedging injury). Review of the Minimum Data Set (MDS) Assessment, dated 1/11/2023, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. Further review of the MDS Assessment indicated the Resident was at risk for the development of pressure ulcers and required limited assistance of two persons for bed mobility. Review of the facility policy titled Skin Assessment and Care, last revised 8/26/2022, indicated the following: -All patients/residents are assessed for risk of developing skin breakdown or pressure ulcers on admission and weekly thereafter. Review of the January 2023 Physician Orders indicated an order initiated on 11/21/2022 for the following: -Weekly skin checks. -Document on the observation form of weekly skin assessments. -Go to Resident tab and look for observation, then add observation and fill out weekly on Mondays (11:15 P.M. - 7:15 A.M.) Review of the February 2023 Physician Orders indicated an order initiated on 2/14/2023 for the following: -Weekly skin checks. -Document on the observation form of weekly skin assessments. -Go to Resident tab and look for observation, then add observation and fill out weekly on Tuesdays (7:15 A.M. - 3:15 P.M.) Review of the clinical record for Resident #20 indicated: -documented weekly skin assessments for the weeks of: 11/21/22, 12/5/22 and 1/2/23. -no evidence of any documentation that weekly skin observation were completed for the weeks of: 11/28/22, 12/12/22, 12/19/22, 12/26/22, 1/9/23, 1/16/23, 1/23/23, 1/30/23 and 2/6/23. During an interview on 2/16/23 at 10:00 A.M., Unit Manager #1 (UM#1) said that weekly skin assessments were done on the Resident's bath days. She said that Resident #20 came to the [NAME] unit from another unit on 1/10/23 and that his/her bath day was now on Tuesdays. During a review of the clinical record with the surveyor, UM#1 said that the only weekly skin observations in the record were dated 11/22/22, 12/6/22 and 1/3/23, and there was no further documentation evidence that any other weekly skin observations forms were completed as ordered. During an interview on 2/16/23 at 12:15 P.M., the Director of Nurses (DON) said that weekly skin observation forms were not completed as ordered for Resident #20, but they should have been completed. 2) The facility failed to ensure its staff performed pressure ulcer care that included adequate infection control practices. Review of a Progress Note, dated 2/13/23 at 1:59 P.M., indicated Resident #20 had the presence of a 10 centimeter (cm) by (x) 9 cm dark purple, dark red, non-blanchable (term indicating decreased blood flow) area near the left and right buttock and coccyx (tail bone). Review of the Resident's Physician's Orders indicated an order initiated 2/13/23 for the following: Right gluteal fold (upper portion of the thigh and lower portion of the buttock) and coccyx area: -cleanse with warm soapy water, pat dry. -use hydrophilic wound dressing (a wound dressing that comes in a cream form). -cover with Biotin dressing every three days or as needed if soiled. During an observation on 2/16/23 at 9:15 A.M., the surveyor observed Nurse #1 perform wound care for Resident #20 with the following process: -Nurse #1 performed hand hygiene (HH) and put on non-sterile gloves and removed the old dressing from the Resident's coccyx area. -She then removed dirty gloves, performed HH, and donned (put on) clean non-sterile gloves. -Nurse #1 then took the cap off the wound cleanser bottle and placed clean gauze over the mouth of the bottle. She then tipped the bottle upside down to moisten the gauze. -Nurse #1 cleaned the wound, which now appeared to have two open areas, with the moistened gauze. She measured the open areas of the wound at that time. -She then squeezed a large amount of the hydrophilic wound dressing cream to her gloved hand and then applied the hydrophilic wound dressing cream to the entire wound surface with her gloved hand. -Nurse #1 took off the dirty gloves, performed HH, donned clean non-sterile gloves and secured the Biotin dressing over the hydrophilic wound dressing cream. During an interview on 2/16/23 at 10:10 A.M., Nurse #1 said that she usually applies the hydrophilic wound dressing cream to wounds with her gloved hand. She said she uses an applicator when she applies different wound treatments, but does not use an applicator to apply the hydrophilic wound dressing cream. During an interview on 2/16/23 at 10:29 A.M., the DON said Nurse #1 should not have used her gloved hand to apply the hydrophilic wound dressing cream to the Resident's wound and that Nurse #1 should have used an applicator to apply the hydrophilic wound dressing cream.

Based on record review and interviews the facility staff failed to implement effective interventions to prevent 1 resident (#138), out of a total sample of 27 residents, from falling and sustaining a fracture. Findings include: Resident #138 was admitted to the facility in 7/2015 with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 8/9/18 and updated on 10/28/18, included the following interventions: - Bed in the lowest position. - Bed alarm at all times. - Limited to extensive assistance with transfers and ambulation. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/31/18, indicated that the resident was severely cognitively impaired, as evidenced by a score of 0 out of a possible 15 on the Brief Interview for Mental Status (BIMS), required extensive assistance with transfers and ambulation and had 1 fall with no injury since the last MDS Assessment. Review of the nurse's note, dated 1/5/19, indicated that the resident sustained [REDACTED].M., the resident was found on the floor on his/her buttocks and there was no apparent injury. The resident's bed alarm did not sound. The bed alarm was checked and the plug was loose from the cord to the alarm box. The resident's bed alarm was plugged back into the alarm box. Bed alarm checks every 15 minutes were initiated. Review of the facility's internal investigation, for the fall of 1/5/19 at 4:00 P.M., indicated the following interventions were immediately initiated: - 15 minute checks for safety for 48 hours. - Encourage the resident to use the call bell. - Check the bed alarm twice each shift to ensure the batteries are working and the alarm is plugged into the alarm box. Further review of the nurse's note, dated 1/5/19, indicated that the resident sustained [REDACTED].M. The resident was found on the floor, in the bathroom, on his/her right side. The resident's bed alarm did not sound. The resident complained of extreme pain to the right leg and hip. The resident was transferred into the bed utilizing a mechanical lift. The resident was assessed by a physician and an x-ray was ordered. Review of the facility's internal investigation for the fall of 1/5/19 at 8:00 P.M. indicated that the resident's bed alarm was loose and was not functioning. Review of the x-ray report, dated 1/5/19, indicated that the resident sustained [REDACTED]. The surveyor interviewed the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Nurse #1 on 4/10/19 at 2:01 P.M. Nurse #1 said that right after the fall at 4:00 P.M. the alarm was plugged in and functioning. The alarm was not an effective intervention to prevent the falls which occurred on 1/5/19, as the alarm did not function. The ADON said that the alarm should have sounded. The ADON further should have said that the call light was not activated at the time of the second fall and the resident was not cognitively able to activated the call light. The interventions were ineffective in preventing falls with injury.

Based on record review and staff interview, the Facility failed to recognize the signs and symptoms of an infected pressure sore acquired at the Facility and notify the physician for 1 resident (#16), in a total sample of 24 residents. Findings include: Resident #16 was admitted in 7/04. This Resident had the following pertinent Diagnoses: [REDACTED]. Review of the Nurse's Note of 4/24/12 on the 7:00 A.M. to 3:00 P.M. shift indicated that the right heel had drainage on the old dressing, the heel had new granulation skin surrounding dried "blood" scab, no drainage was noted, and there were no signs or symptoms of infection. Review of the Weekly Ulcer Summary Sheets of 5/4/12 indicated the right heel measured 6 centimeter (cm) in length by 6 centimeter in width, with no depth recorded, and the wound was not staged. Observation of the right heel dressing change on 5/10/12 at 7:20 A.M. with Nurse #1, when this Resident's right foot was lifted up for better visualization of the pressure sore, this Resident said, "Ow" (tenderness can be an indication of inflammation or infection). Nurse #1 opened a new bottle of normal saline, put the normal saline on a gauze pad, and then cleansed the wound bed. When Nurse #1 was measuring the wound bed, this Resident moved in bed when his/her foot was touched. The Surveyor stated, "(His/Her) foot is very tender to touch." Nurse #1 did not verbally respond. The wound was a large unstageable pressure sore. It had an eschar which measured at the shortest area 6.8 cm in length by 6 cm in width, and the longest area measured 7 cm in length by 6 cm in width, with no depth. The peri-wound area was bright red and measured 1 cm at 12 o'clock, 1 cm at 3 o'clock, 0.2 cm at 6 o'clock, and 0.8 cm at 9 o'clock. Additionally, at 8 o'clock, there was a 1 cm white area under the skin by the edge of the eschar. The tenderness, peri-wound redness and white area - possible purulence, could indicate inflammation or infection. When Nurse #1 was asked how does this wound look to you, she responded that, "This wound looks much better." During an interview with the Medical Director on 5/10/12 at 3:00 P.M., the Surveyor discussed the deterioration of the pressure ulcer: peri-wound redness, foot tenderness. The Medical Director agreed to examine the wound (the Resident was not the Medical Director's patient). During an interview on 5/10/12 at 3:35 P.M., the Medical Director said that the pressure sore was infected and there was pus underneath the eschar. Review of the physician's orders [REDACTED].M. indicated that the following orders were written: [MEDICATION NAME] (an antibiotic) 300 milligrams by mouth twice a day for 10 days, to discontinue baby (oil) to the right heel, and to cover/wrap the right heel eschar area with a dry sterile dressing daily and as needed, until the heel is assessed by the Primary Care Physician. Interview with Nurse #1 on 5/11/12 at 8:40 A.M., the Surveyor asked if she had recognized the tenderness and redness and area of white tissue (pus underneath) as an infected pressure sore. Nurse #1 stated, "No." Nurse #1 was then asked if she reported any changes in the wound bed yesterday (5/10/12) to the Physician after the dressing change, and she responded, "No, but the Medical Director saw her yesterday." The Surveyor informed Nurse #1 that the Surveyor asked the Medical Director to examine the wound, secondary to the foot tenderness and significant wound redness. The Medical Director stated that the pressure sore was infected, this Resident needed to be on a systemic antibiotic, and she would have the unit call the Resident's Physician. Please refer to F 314, Example #2.

Based on record review, observation and interviews, the Facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection for 2 of 5 applicable residents (#2 and #16) from a total sample of 24. Findings include: 1. For Resident #2, the Facility failed to prevent the development of an avoidable heel pressure sore (an unstageable pressure sore, which is a full thickness tissue loss covered with dead tissue on the left heel) by failing to provide pressure relieving interventions to the right heel on readmission following a [MEDICAL CONDITION]. The facility failed to: apply foam blocks and relieve pressure from the right heel. Resident #2 was admitted [DATE] and readmitted on [DATE]. This Resident had the following Diagnoses: [REDACTED]. The Admission Nursing Assessment of 12/22/11 at 5:30 P.M. indicated that this Resident was readmitted to the Facility status [REDACTED]. Under Skin Integrity, Findings, it stated that: 1. This Resident had a right hip incision of approximately 20 centimeters (cm) with 31 sutures (the right hip area was circled on the diagram of a person)... 2. Slightly reddened, blanchable and on a sheep skin pad (both heels were circled on the diagram). The Norton Plus Score was 6. This Resident was at high risk for pressure sores. Review of the physician's orders [REDACTED]. Review of the care plan of (11/14/11) for the potential for skin impairment indicated this Resident had impaired mobility due to advanced age, status [REDACTED]. There were no updated interventions to the skin care plan until 12/30/11. New interventions included: bed mobility with assistance of 1 to 2 persons and a cushion in the wheelchair. There were no pressure relieving measures to off load the heels, added to the care plan. This Resident was at increased risk for pressure sores secondary to an abductor pillow and blanchable heel redness and decreased mobility (redness over a bony prominence such as the heels can be a warning of a pressure sore) on the Admission Nursing Assessment of 12/22/11. Review of a significant change Minimum Data Set (MDS) assessment, dated 12/29/11, indicated for the Brief Interview for Mental Status this Resident had a score of 1, was severely cognitively impaired, an extensive assist of two persons for bed mobility, transfers, and was non-ambulatory. Under Section M 0150, the Resident was at risk for pressure sores. Under M 210, the Resident does not have any unhealed pressure ulcer(s). Review of the Nurse's Note of 1/24/12 at 2:00 P.M., indicated that this Resident had a fluid filled blister of the right heel with margins that were ecchymotic, it was a deep tissue injury. A treatment was initiated with baby oil and a dry sterile dressing. A heel float boot was applied to the right heel. Review of the Weekly Ulcer Summary Sheets of 1/24/12 indicated the right heel measured 5 centimeters (cm) in length by 5 cm in width. The depth and stage of the wound was left blank. Review of the Weekly Ulcer Summary Sheets of 2/21/12 indicated the right heel measured 6.5 cm in length by 5.2 cm in width. The stage of the pressure sore and the depth was left blank. Review of the Nurse's Note of 2/21/12 (no documented time) indicated there was sero-sanguinous drainage and an eschar on the Achilles tendon is soft with leakage from the surrounding blister area. Heel float boot and leg rests were causing continued pressure to affected areas. Review of the physician's orders [REDACTED]. Review of the Weekly Ulcer Summary Sheets of 3/14/12 indicated the right heel measured 6 cm in length by 4.5 cm in width. The stage of the wound and the depth were left blank. Review of the physician's orders [REDACTED]. Review of the Weekly Ulcer Summary Sheets of 4/12/13 (inaccurately documented the date as 2013 instead of 2012) indicated the right heel was unstageable, and measured 5 cm in length by 3 cm in width. Surveyor observed Resident #2 on 5/9/12 at 7:15 A.M. Resident #2 was in his/her Room with the door open, sitting at the side of the bed wearing sleepwear, with the right foot wrapped in Kling, and with the blue foam boot was not on the right foot. Certified Nursing Assistant (CNA) #1 and CNA #2 and Nurse #1 walked by this Resident's room while his/her door was open, and none of the staff members entered the room to apply the foam boot. Surveyor observed Resident #2 on 5/9/12 at 7:27 A.M. Resident #2 was in his/her Room lying in bed on his/her side with the right heel pressed into the mattress with the right foot wrapped in Kling, with the foam boot not on the right foot. CNA #1 and CNA #2 walked by this Resident's Room, and again did not apply the foam boot. During an interview with the Director of Nursing (DON) on 5/9/12 at 8:35 A.M., she stated that the heel float boot made the right heel worse. During an interview with the DON on 5/9/12 at 10:00 A.M., the Surveyor asked the DON who had written the Nurse's Note of 2/21/12, which stated that the heel float boot and the leg rests were causing continued pressure to the affected area. The DON said, "I wrote that Nurse's Note, and I should have written 'appeared to'." When the Surveyor asked, "Who issued this Resident the heel float boot?" the DON said, "I did." During the observation of the dressing change on 5/9/12 at 10:20 A.M., Nurse #1 washed hands and then removed the heel lift device and the Kling dressing with scissors. Nurse #1 then removed the Kling wrap, gauze pads and [MEDICATION NAME] (a Calcium Alginate) from the pressure sore. Nurse #1 washed her hands, and then measured the wound as 4.3 cm in length by 2.5 cm in width and 0.2 cm in depth. The wound base had pink granulation tissue with some slough, and Nurse #1 said that it was a stage 3 pressure sore. When the Surveyor asked Nurse #1 about the condition of the wound, she stated, "It is improving." Nurse #1 then washed the wound with a spray bottle of a sterile normal saline wound wash. Nurse #1 took the cap off of a bottle of normal saline spray, then held the nozzle of the spray 1.5 inches from the wound base, and pressed the nozzle down expelling a steady fast stream of normal saline, directly onto the wound bed. When the wound bed was sprayed, blood dribbled out of the sprayed area. Nurse #1 then applied pressure with a 3 by 3 gauze pad to the bleeding wound bed for approximately 8 seconds and the bleeding was stopped. Review of the instructions on the spray bottle of normal saline indicated, "Before using, expel a short stream of wound wash saline to clean nozzle." This had not been done. Observation on 5/9/12 at 1:40 P.M., found Resident #2 sitting up in a wheelchair across from the Nurse's Station. This Resident had a blue foam boot on the right foot, the right foot was on the top edge of the foot rest, not on the flat surface of the foot rest. The heel opening of the boot did not suspend the right heel, to off load pressure. The heel and Achilles area were pressed through this opening and up against the outer edge of the top edge of the right foot rest. Multiple staff members were walking by this Resident in the hall, and they did not change the position of the Resident's foot to off load the pressure of the Resident's right heel and Achilles on the edge of the foot rest. During an interview with Resource Nurse #1 on 5/9/12 at 1:50 P.M., the Surveyor asked Resource Nurse #1, "What does the lambs wool do?" Resource Nurse #1 stated, "I think it's more for comfort, I'm not sure if it is pressure relieving." The Surveyor asked, "Did they add the sheep skin pad to the care plan for an intervention on the skin care plan?" Resource Nurse #1 replied, "No." When Resource Nurse #1 was asked, "Do you think the Resident is at risk for a pressure sore with reddened blanchable heels?" Resource Nurse #1 stated, "Absolutely." The Surveyor asked, "Even though this Resident had a sign of pressure on his/her heels, blanchable redness, and was immobilized with the wedge cushion, were the heels off loaded for pressure?" Resource Nurse #1 replied, "No." During the interview and review of the care plan for skin impairment with Resource Nurse #1 on 5/9/12 at 2:00 P.M., the Surveyor asked if this Resident was on a pressure relieving mattress prior to the development of the pressure sore. Resource Nurse #1 said, "No, this Resident was on a pressure reducing mattress, prior to the pressure sore, and is still on a pressure reducing mattress." The Surveyor asked this Nurse to show her this Resident's abductor pillow (this is the device to immobilize the hips in abduction post [MEDICAL CONDITION]) and review how it is used. She said, "The abductor pillow wedge went between this Resident's legs when lying and sitting. It is a pink hard foam, triangle shape and the smaller end (would be placed) toward the groin, and the larger end progressively goes out, and there were 4 Velcro straps to hold the abductor pillow in place." The Surveyor asked, "Did this abductor wedge immobilize this Resident?" Resource Nurse #1 said, "Yes", The Surveyor then said, "But the Resident's heels were not off loaded?" Resource Nurse #1 said, "No." . Observation on 5/9/12 at 2:15 P.M., indicated Resident #2 sitting up in a wheelchair across from the Nurse's Station. This Resident's foam boot was on the right foot and the right foot was still resting on the top edge of the foot rest. During an interview with the Assistant Director of Nursing (ADON) on 5/10/12 at 10:37 A.M. and review of the medical record, the Surveyor asked the ADON to show the Surveyor documentation regarding skin checks that were being made when the heel float was first applied to be sure that the new boot was not causing pressure. The ADON indicated that the staff does document every shift on the treatment administration records that the boot is on, but there were no skin checks done when this new boot was applied. During an interview with the DON on 5/11/12 at 10:30 A.M., the Surveyor asked the DON how far from the wound bed should the spray nozzle of normal saline be held to clean a wound. The DON stated that the nozzle should be held at about 6 inches from the wound. The Surveyor asked if injury to the wound bed could be caused by holding the nozzle 1.5 inches from the wound bed. The DON answered that it should have been held at 6 inches. 2. For Resident #16, the Facility failed to identify that the Facility acquired right heel pressure sore had deteriorated and showed signs and symptoms of infection requiring new treatment orders. Resident #16 was admitted in 7/04. This Resident had the following pertinent Diagnoses: [REDACTED]. Review of a quarterly MDS assessment, dated 10/12/11, indicated short and long term memory impairment and moderate impairment for decision making, and was totally dependent, an assist of two for bed mobility and transfers, was non-ambulatory. Under Section M 0150, the Resident was at risk for pressure sores. Under M 210, the Resident does not have one or more unhealed pressure ulcer(s). Review of the Norton Plus Pressure Ulcer Scale of 10/14/11 indicated this Resident had a score 6, which is at high risk for a pressure ulcer. Review of the nurse's note of 12/27/11 on the 7:00 A.M. to 3:00 P.M. shift, indicated that a small reddened area was noted on the right inner heel, the Resident wore slipper socks with an elastic edge, and [MEDICATION NAME] spray (a capillary stimulate used to prevent and treat pressure sores) was ordered. Review of the physician's orders [REDACTED].M. to 3:00 P.M. shift was entered as the time of the order) included: apply [MEDICATION NAME] spray daily to the heels bilaterally at bedtime. Review of the Weekly Ulcer Summary Sheets of 1/29/12 indicated the right heel was staged as a deep tissue injury, which measured 0.8 centimeters (cm) in length by 0.6 cm in width and no depth was documented. Review of the Nurse's Note of 1/29/12 on the 7:00 A.M. to 3:00 P.M. shift, indicated that this Resident had a purplish discolored localized area and measured 0.8 cm by 0.6 cm with no depth, the skin was intact on the right heel, and the surrounding skin was red and blanchable. [MEDICATION NAME] was in use, and bilateral heel float boots were used while in bed, and just the right heel float boot was on at all times except off for hygiene. Review of the Weekly Ulcer Summary Sheets of 1/29/12 for the right heel pressure ulcer was staged as deep tissue injury, and measured 0.8 cm in length by 0.6 cm in width, and the depth of the wound was left blank. Review of the Weekly Ulcer Summary Sheets of 2/13/12 for the right heel pressure ulcer measured 3 cm in length by 2 cm in width. The stage and the depth of the wound was left blank. Review of the physician's orders [REDACTED]. Review of the Weekly Ulcer Summary Sheets of 3/23/12 indicated the right heel pressure ulcer measured 1.5 cm in length by 2 cm in width, DTI (deep tissue injury) was documented instead of the wound depth and the stage of the wound was left blank. Review of a quarterly MDS assessment, dated 3/28/12, indicated under Section M 210, the Resident has one or more unhealed pressure ulcer(s) at Stage 1 or higher, under M 700 the most severe tissue type for any pressure ulcer was a 4, necrotic tissue (Eschar) - black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than the surrounding tissue. Review of the Interim physician's orders [REDACTED].M. indicated to discontinue the Hydrogel to the right heel. A new order was obtained to wash the right heel pressure ulcer with a normal saline wash, followed by baby oil and a dressing change daily until healed; discontinue heel float boots; and apply eggcrate boots to both feet at all times. Review of the Weekly Ulcer Summary Sheets of 4/20/12 indicated the right heel pressure ulcer had increased in size and now measured 4 cm in length by 6 cm in width, and redness measuring 6 cm in length by 7 cm width. The depth of the wound left blank and the wound was not staged. Review of the Nurse's Note of 4/24/12 on the 7:00 A.M. to 3:00 P.M. shift indicated that the right heel had drainage on the old dressing, the heel had new granulation skin surrounding dried "blood" scab, and there were no signs or symptoms of infection. Review of the Weekly Ulcer Summary Sheets of 5/4/12 indicated the right heel ulcer had increased in size and now measured 6 cm in length by 6 cm in width. The depth was left blank and the wound was not staged. Observation of the right heel dressing change on 5/10/12 at 7:20 A.M. indicated that Nurse #1 washed hands and removed the egg crate boots on both feet. When this Resident's right foot was lifted up for better visualization of the pressure sore, this Resident said, "Ow" (tenderness can indicate inflammation or infection). Nurse #1 opened a new bottle of normal saline and put the normal saline on a gauze pad, and then cleaned the wound bed. When Nurse #1 was measuring the wound bed, this Resident moved in bed when his/her foot was touched. The Surveyor stated, "(His/Her) foot is very tender to touch." Nurse #1 did not verbally respond. The wound was a large unstageable pressure sore. It had an eschar which measured at the shortest area 6.8 cm in length by 6 cm in width, and the longest area measured 7 cm in length by 6 cm in width, with no depth. The peri-wound area was bright red and measured 1 cm at 12 o'clock, 1 cm at 3 o'clock, 0.2 cm at 6 o'clock, and 0.8 cm at 9 o'clock. Additionally, at 8 o'clock, there was a 1 cm white area under the skin by the edge of the eschar. The tenderness, peri-wound redness and white area (possible purulence) could indicate inflammation or infection. Nurse #1 cleansed the pressure sore with normal saline. Nurse #1 then took a 3 by 3 gauze pad and applied baby oil from a 16 ounce (oz) bottle. The Surveyor was unable to determine when the bottle of baby oil was opened, because it was undated. There was approximately 2 oz of fluid remaining in the bottle. The bottle of baby oil indicated it was for external use only and helps to relieve diaper rash and dryness, (there was no information indicating that it could be applied to an unstageable pressure sore with bright red edges). The following was listed under ingredients: mineral oil, fragrance and [MEDICATION NAME]. When Nurse #1 pressed the gauze pad soaked with baby oil against the eschar, the patient had facial grimacing (which could be an indication of tenderness). When Nurse #1 was asked how does this wound look to you, she responded that, "This wound looks much better." Nurse #1 then applied an abdominal dressing, Kling, secured the dressing with tape, and then applied the egg crate boots. Nurse #1 then put the dressing supplies (including the normal saline that had been used and was not dated when opened) back in a basin on the top of this Resident's wardrobe closet and shut the closet door. During an interview with the Medical Director on 5/10/12 at 3:00 P.M., the Surveyor discussed the use of baby oil for the dressing change. The Surveyor explained to the Medical Director that this Resident had peri-wound redness, and the foot was tender to touch. The Medical Director agreed to examine the wound (the Resident was not the Medical Director's patient). During an interview on 5/10/12 at 3:35 P.M., the Medical Director said that the pressure sore was infected, there was pus underneath the eschar, and he/she did not think the baby oil made it worse During an interview on 5/10/12 at 3:55 P.M., the Director of Nurses (DON) said that the Wound Protocol Book did not contain any evidence based practice literature regarding the use of over the counter baby oil, for the treatment of [REDACTED]. Review of the physician's orders [REDACTED].M. indicated that the following orders were written: [MEDICATION NAME] (an antibiotic) 300 milligrams by mouth twice a day for 10 days, to discontinue baby (oil) to the right heel, and to cover/wrap the right heel eschar area with a dry sterile dressing daily and as needed, until the heel is assessed by the Physician. Interview with Nurse #1 on 5/11/12 at 8:40 A.M., the Surveyor asked if she had recognized the tenderness and redness and area of white tissue (pus underneath) as an infected pressure sore. Nurse #1 stated, "No." Nurse #1 was then asked if she reported any changes in the wound bed yesterday (5/10/12) to the Physician after the dressing change, and she responded, "No, but the Medical Director saw her yesterday." The Surveyor informed Nurse #1 that the Surveyor asked the Medical Director to examine the wound, secondary to the foot tenderness and significant wound redness. The Medical Director stated that the pressure sore was infected, this Resident needed to be on a systemic antibiotic, and she would have the unit call the Resident's Physician.

5. For Resident # 19, the Facility failed to provide adequate supervision and assistance devices to prevent 7 falls. Resident #19 was admitted to the facility in 11/08 with [DIAGNOSES REDACTED]. Review of the care plan addressing the prevention of falls, from 3/11 to 1/12, included the following interventions: -Non-skid footwear when out of bed, -Ambulate with one assist with rolling walker, -call light in reach, -Hand bell when in recliner, -Pressure alarm recliner/ bed/wheelchair, -and black mat beside bed and closet. The Fall Risk Assessments (of 3/10/11, 6/6/11, 8/26/11, 10/20/11, 1/12/12, and 4/14/12) indicated the resident was at "high risk" for Falls with scores of 19, 19, 19, 16, 18, and 16 respectively. Review of Nursing Notes and the Incident/Accident Report of 3/2/11 (time unknown during the daytime shift) indicated that the bed alarm was sounding, and staff found the Resident on the floor at the bedroom entrance. The Resident had walked with the walker, barefoot (without non-skid footwear) and without staff assistance, as required by the care plan. The Resident was reminded to call for assistance, as staff found the Resident "non-compliant with alarms." No injury was noted. The quarterly MDS review of 3/17/11 indicated the resident had hearing devices, was severely impaired cognitively (BIMS score of 4/15), was depressed, required limited assist for transfers, and ambulation in the corridor, was independent for ambulation in the room, required extensive assist for dressing, toilet use, and bathing, was frequently incontinent of bladder, fell on ce with no injury prior to the last assessment, and was on antidepressant medication. Review of Nursing Notes and the Incident/Accident Report of 3/22/11 at 12:30 P.M. indicated the Resident self-transferred from the bedroom recliner, and fell . The Resident was found by staff leaning against the chair. Staff "heard the alarm when (staff)found the Resident on the floor." Neither a hand bell or call bell was noted to be in reach, as it was noted to be "N/A (Not Available) per the Investigation. The Resident was again encouraged to use the call light for assistance. A one week trial with the recliner's being "unplugged" was attempted, without success. No injury was noted. The Care Plan was updated 6/7/11 to encourage the Resident to stay out at the nursing desk. Review of Nursing Notes and Incident/Accident Report of 5/16/11 at 1:30 P.M. indicated the resident slide out of the recliner onto the mat. The Resident was encouraged to ask for assistance. No injury was noted. The quarterly MDS review of 6/9/11 indicated the resident had moderate difficulty hearing, required extensive assist for transfers and ambulation, had occasional bowel incontinence, had fallen since the last assessment without injury. Review of Nursing Notes and the Incident/Accident Report of 7/18/11 at 4:10 P.M. indicated the Resident was found by staff lying on the left side at the bedroom door. There was no evidence that the alarm was sounding at the time of the Resident's self transfer from a recliner, and no evidence the Resident was encouraged to be placed at the nursing desk. Review of Nursing Notes and the Incident/Accident Report of 8/5/11 at 6:00 P.M. indicated the Resident's chair alarm sounded and staff found the Resident sitting on the floor in another resident's room near a window. The Resident had fallen from a wheelchair, and staff had not monitored the Resident's wandering by placing the Resident near the Nursing desk for supervision. A significant change assessment of 9/1/11 for decline in Activities of Daily Living and new behaviors, indicated the resident had disorganized thinking, exhibited verbal and physical behaviors towards others, other behavioral symptoms, such as wandering, required extensive assist for all ADLs, had fallen since the last assessment and sustained a skin tear (when lowered to the floor by staff when ambulated to the bathroom on 8/4/11 at 2:45 P.M.) The care plan was updated to provide "2 assist for toilet transfers/care on 11/6/11. The quarterly MDS review of 10/27/11 indicated the resident now had altered level of consciousness, exhibited verbal behavior towards others only, was dependent for transfers, no longer ambulated in room or corridor, was frequently incontinent of bowel, fell since the last assessment, and was on antipsychotic medication daily. Review of Nursing Notes and the Incident/Accident Report of 11/24/11 at 4:30 P.M. revealed staff observed the Resident sliding down the recliner to the floor. Staff noted that the chair alarm did not ring. Additionally, the recliner pad that was placed under the Resident by staff, was on the wrong or "smooth side." Dycem was added to the recliner chair as a care plan intervention on 11/25/11, as well as to offer the resident a reclined geri-chair after meals. Review of Nursing Notes and the Incident/Accident Report of 1/21/12 at 9:00 P.M. revealed staff found the Resident sitting on a mat next to the Resident's bed. The bed alarm did not sound when the Resident attempted a self-transfer, as it was "not plugged in," per the fall investigation. Observation of the resident on 5/9/12 at 4:26 P.M. and 5/10/12, from 7:00 A.M. to 10:00 A.M. revealed the resident seated in a reclined geri chair with pressure alarm attached and Dycem under the resident's cushion pillow. During interview on 5/14/12 at 8:35 A.M., the Director of Nurses acknowledged that the resident sustained [REDACTED]. 6. Resident Hazards: Environmental tours of the Facility on 5/8/12, from 8:30 A.M. to 9:00 A.M., and on 5/9/12, from 7:00 A.M. to 8:00 A.M., with the Night Nursing Shift Supervisor revealed chemical hazards in the Belmont Unit Shower Suite. The Belmont Unit's Shower Suite was observed to be the only unit out of four units where the door was not secured by means of an electronic lock. On 5/8/12 at 8:58 A.M., the shower room to the right inside the doorway revealed a shelf with the following items on it: three (3) 7.5 fluid ounces (oz,) of Derma Daily, two (2) 7.5 oz. containers of Shampoo/Skin Cleanser, a (1) 7.5 oz. container of Body Oil, two (2) 8.0 fluid oz. container of Body Lotion, two (2) 4 oz. containers of Misty Sprays, and a wash basin containing 2 plastic razors. All the plastic containers stated "for External Use Only," and all items were within reach of unsuspecting residents. On 5/9/12 at 7:20 A.M., and at 8:00 A.M., with the Night Nursing Supervisor, the Belmont Shower Suite was again inspected and found to have the same unsecured number of items (10 containers) on the shelf and in the wash basin, within easy access to resident reach. Another 7.5 fluid oz. container of Shampoo/Skin Cleanser was also located on the left shower stall railing. Interview with the Night Nursing Supervisor on 5/9/12 at 8:00 A.M. acknowledged that these chemical hazards were supposed to be located in another location, inaccessible to residents. 4. For Resident #23, the Facility failed to provide adequate supervision and assistance devices to prevent 25 falls/accidents (20 of the falls/accidents were unwitnessed) in 13 months. Resident #23 was admitted to the Facility in 2/09 and discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of Nurses' Progress Notes and Investigation of 4/13/11 at 1:00 P.M. indicated that the wheelchair alarm was ringing. The Resident was found kneeling at the sink in Resident's bathroom. The Resident had refused care three times before the fall. No injuries were noted. Review of Nurses' Progress Notes and Investigation of 4/18/11 at 4:00 P.M. indicated that the alarm was ringing. The Resident was found sitting in front of the shower in the Resident's bathroom. No injuries were noted. One to one redirection was provided for Resident to ask for help if need to go to bathroom - noncompliant. Chair Pro Sensor alarm pad (cushion) applied to wheelchair. The Fall Risk Assessment score of 5/26/11 was 19 indicating a high risk to fall. The Interdisciplinary Progress Notes of 5/26/11 indicated that the Resident required assist with bathing, grooming, dressing, ambulation, locomotion, toilet use, transfers and positioning. Review of Nurses' Progress Notes and Investigation of 6/8/11 at 12:00 P.M. indicated that the wheelchair alarm was ringing. The Resident was found standing in Resident's bathroom washing undergarments in the shower. The Resident lost balance and began to fall. The CNA (Certified Nursing Assistant), responding to the alarm, assisted the Resident to the floor. Continues to be non-compliant with safety alarm. Redirected to not stand by self. Review of Nurses' Progress Notes and Investigation of 7/30/11 at 3:45 P.M. indicated that the alarm sounded. The Resident was found sitting on the floor on buttocks between the bed and wheelchair. The Resident stated, "I was trying to get into my wheelchair, and I fell ." There were no injuries. The Resident was encouraged to use the call bell. Review of Nurses' Progress Notes and Investigation of 8/5/11 at 6:00 P.M. indicated that the the alarm was sounding. The Resident was found sitting on the bathroom floor between toilet and unlocked wheelchair. There were no injuries. The Resident was provided 1 to 1 supervision at the nurses' desk due to increased behaviors. Review of Nurses' Progress Notes and Investigation of 8/7/11 at 9:45 A.M. indicated that the alarm was sounding. The Resident was found sitting on the bathroom floor. There were no injuries noted. Review of Nurses' Progress Notes and Investigation of 8/9/11 at 10:30 A.M. indicated that the alarm sounded, and the Resident was found attempting self transfer from wheelchair to toilet. The Resident was lowered to the floor by the CNA responding to the alarm. There were no injuries noted. At 11:20 A.M., the alarm sounded. The Resident was found kneeling on the floor of another resident's room. There were no injuries noted. Review of Nurses' Progress Notes and Investigation of 8/17/11 at 7:45 A.M. indicated that the alarm sounded. The Resident was found lying on the floor on left side. Resident stated, "I fell out of bed." There were no injuries noted. The air mattress was noted to be not level and replaced with a regular mattress. Review of Nurses' Progress Notes and Investigation of 8/20/11 at 8:00 A.M. indicated that the Resident was found sitting on the floor with back against bed. The alarm was sounding. There were no injuries noted. The Resident said, "I have to go to the bathroom." Toileting plan implemented. The MDS assessment of 8/24/11 for significant change in status indicated that the Resident's BIMS (Brief Interview for Mental Status) score was 4 indicating severely impaired cognitive status. The Resident had delusions, physical behavior symptoms directed towards others, wanders, required extensive assist of 2 with transfers and toilet use, was non-ambulatory, was dependent with bathing dressing and hygiene, was frequently incontinent of urine, was continent of bowel, and had 2 falls with no injury. Review of Nurses' Progress Notes and Investigation of 9/27/11 at 3:00 P.M. indicated that the bed alarm was sounding, and the Resident was found sitting on floor in bathroom near the toilet. The Resident attempted self transfer from bed to wheelchair to toilet. There were no injuries noted. Review of Nurses' Progress Notes and Investigation of 10/26/11 at 9:00 A.M. indicated that the alarm sounded. The Resident was found on floor in front of the toilet. There were no injuries noted. New intervention: Toilet immediately after meals. Review of Nurses' Progress Notes and Investigation of 10/30/11 at 8:45 P.M. indicated that the Resident was found sitting on right side in front of recliner chair in hallway. No alarms were in use at the time. There were no injuries noted. Review of Nurses' Progress Notes and Investigation of 11/20/11 at 7:30 A.M. indicated that the alarm sounded. The Nurse found the Resident trying to get out of bed, and the Nurse lowered the Resident to the floor. There were no injuries noted. The Resident stated, "I wanted to use the bathroom." The Fall Risk Care Plan of 11/21/11 included: *Low bed. *Toilet per schedule. *Reposition every 2 hours with assist. *Functional Maintenance Program for ambulation. *Ambulate as indicated. *No leg rests, anti-tippers on wheelchair, anti roll-back. *Hip savers. *Call bell/hand bell in reach. *Discourage and redirect when asking to go back to bed. *Offer recliner by nurses' station when tired or asking to go to bed. Review of Nurses' Progress Notes and Investigation of 11/23/11 at 7:30 A.M. indicated that the alarm sounded. The roommate came calling for help, and the Nurse found the Resident lying on right side. The Resident's legs were under the wheelchair. The Resident said that he/she put self on floor, but the resident sustained [REDACTED]. Review of Nurses' Progress Notes and Investigation of 12/22/11 at 9:45 P.M. indicated that the bed alarm sounded. The Resident was found sitting on the floor at foot of bed with head on wheelchair. The Resident stated that he/she slid out of bed. There were no injuries noted. The Fall Risk Care Plan was updated on 12/23/12 to include: pressure reducing perimeter mattress The quarterly MDS assessment of 2/8/12 for significant change in status indicated that the Resident's BIMS (Brief Interview for Mental Status) score was 8 indicating moderately impaired cognitive status. The Resident had delusions, verbal behavior symptoms directed towards others, other behavioral symptoms not directed at others, wanders, required extensive assist of 1 with transfers, ambulation and toilet use, required extensive assist with bathing dressing and hygiene, was frequently incontinent of urine and bowel, and had 2 falls with no injury. The Fall Risk Care Plan was updated on 2/10/12 to include: monitor for signs and symptoms of agitation and offer as needed (prn) medication, before escalation of behavior. The Fall Risk Care Plan was updated on 2/14/12 to include: *Chair Pro sensor pad alarm cushion in wheelchair (discontinued 2/21/12). *Bed pressure alarm Review of Nurses' Progress Notes and Investigation of 2/16/12 at 2:30 P.M. indicated that the bed alarm sounded. The Resident was found lying on the floor on back near toilet and against wall. The Roommate's family member was assisting the Resident with toilet use. The Resident slipped and was lowered to the floor by family member. There were no injuries noted. Review of Nurses' Progress Notes and Investigation of 2/18/12 at 3:30 P.M. indicated that the Resident was found sitting on floor in bedroom in front of the wheelchair. The resident indicated that he/she was attempting to get water from the bathroom sink to water a plant. When the Resident attempted to sit down, the Resident missed the seat and slid to the floor. "The Resident said, "I took the bell off the chair because it makes noise when I get up." Review of Nurses' Progress Notes and Investigation of 2/19/12 at 3:00 A.M. indicated that the alarm was sounding, and the Resident was found sitting on floor next to bed. There were no injuries noted. The Resident said, "I had to pee." Review of Nurses' Progress Notes and Investigation of 2/20/12 at 8:30 A.M. indicated that the Resident was found sitting on floor in front of toilet. The Resident had transferred self from bed into wheelchair. The bed alarm wire was torn apart and not attached. New intervention: apply ghost alarm to bed and chair. The Falls Care Plan was updated on 2/21/12 included: *Ghost alarm to wheelchair and bed. *Chair Pro Sensor pad alarm cushion in wheelchair (2/22/12). Review of Nurses' Progress Notes and Investigation of 2/23/12 at 8:40 A.M. indicated that the alarm sounded. The Resident was found sitting on floor beside bed. The Resident stated,"I had to pee and fell ." No injuries were noted. The Fall Risk Care Plan was updated to include: fall mat to floor on closet side of bed. Review of Nurses' Progress Notes and Investigation of 2/28/12 at 4:30 P.M. indicated the Resident was heard yelling for help. The Resident was found kneeling with upper body in bed. The chair alarm had malfunctioned. The Resident stated, "I almost made it to bed; I did not fall." Review of Nurses' Progress Notes and Investigation of 2/29/12 at 4:30 P.M. indicated the alarm sounded, and the Resident was found lying on the bathroom floor. There were no injuries. The Fall Risk Care Plan was updated to include: ghost alarm in bed, chair pressure alarm in all seating and bed pressure alarm. Review of Nurses' Progress Notes and Investigation of 3/2/12 at 2:30 P.M. indicated that the alarm was not installed and did not sound. The Resident was found sitting on the floor mat next to bed. The Resident stated, "I was trying to draw the curtains, lost balance and fell on floor mat." The Fall Risk Care Plan was updated on 3/2/12 to include: *1 to 1 if unable to redirect. *When available offer volunteer visits 1 to 1 with Resident in Resident's room for socialization. *Alarmed floor mat to window side of bed. Review of Nurses' Progress Notes and Investigation of 3/14/12 at 2:50 P.M. indicated that the alarm sounded, and the Resident was found lying on the dining room floor. The Resident was under the bedside table, and the wheelchair was over him/her. The resident sustained [REDACTED]. New interventions included: not to leave unit for hairdresser, therapy etcetera as increases agitation. Anti-tippers (front and back) added to wheelchair. Anti-tippers should have already been on the wheelchair per plan of care. On (5/15/12) at 8:48 A.M. during telephone interview with the Director of Nurses, the Surveyor discussed the concern for Resident #23 who sustained 25 falls/accidents. Based on observation, record review, and staff interview, the Facility failed to provide adequate supervision and effective interventions to prevent accidents from occurring for 5 (#9, #12, #18, 19 and #23) of 14 applicable residents with accidents in a total sample of 24. The Facility also failed to store chemicals in a secure setting on 1 of 4 residents' units. Findings include: 1. For Resident #9 the Facility failed to provide adequate supervision to prevent Resident #9 from falling and sustaining a laceration to the head which required 3 staples to close. Resident #9 was admitted to the Facility in 11/07 with [DIAGNOSES REDACTED]. Review of the falls care plan of 4/27/11 included the following interventions: - Non skid comfortable foot wear when out of bed. - Assist with transfers. - 2 bed pressure alarms - Perimeter mattress. The quarterly Minimum Data Set (MDS) assessment of 4/20/11 indicated that Resident #9 was cognitively impaired as evidenced by a score of 2 out of possible 15 on the Brief Interview for Mental Status (BIMS); extensive assistance with transfers, limited assistance with ambulation; and had 1 fall with injury (except major) since the last MDS assessment. Review of the Fall Risk Assessment of 4/27/11 indicated that the Resident was at high risk for falls. Review of the Nurse's Note and the Facility's investigation of 5/13/11 indicated that at 9:45 P.M. Resident #9 sustained a witnessed fall outside of the nurse's station. Resident #9 was walking behind a wheelchair and tripped on the wheelchair's back wheel. The Facility's investigation further indicated that the Certified Nurse Aide (CNA) was reeducated for not assisting Resident #9 with ambulation. The annual MDS assessment of 7/13/11 indicated that Resident #9 was cognitively impaired as evidenced by a score of 5 out of possible 15 on the BIMS; extensive assistance with transfers and ambulation; and had 1 fall with no injury since the last MDS assessment. Review of the Fall Risk Assessment of 7/18/11 indicated that Resident #9 was at high risk for falls. Review of the Nurse's Note and the Facility's investigation of 7/22/11 indicated that at 12:05 A.M. Resident #9 was sitting by the nurse's station and kept getting up and sitting down, lost his/her balance and fell to the floor. Resident #9 sustained a raised area to the left side of the head. On 7/22/11 the falls care plan was updated to include the following intervention: - 11:00 P.M. to 7:00 A.M. supervision due to safety. The quarterly MDS assessment of 10/5/11 indicated that Resident #9 was cognitively impaired as evidenced by a score of 4 out of possible 15 on the BIMS; extensive assistance with transfers and ambulation; and had 1 fall with injury (except major) since the last MDS assessment. Review of the Fall Risk Assessment of 10/6/11 indicated that Resident #9 was at high risk for falls. The quarterly MDS assessment of 12/28/11 indicated that Resident #9 was cognitively impaired as evidenced by a score of 5 out of possible 15 on the BIMS; extensive assistance with transfers and ambulation; and had no falls since the last MDS assessment. Review of the Fall Risk Assessment of 1/2/12 indicated that Resident #9 was at high risk for falls. Review of the Nurse's Note and the Facility's internal investigation of 1/8/12 indicated that at 10:20 A.M. a Laundry Staff Member observed Resident #9 on the floor in the small dining room. Resident #9 was left sitting in the dining room at the table after the breakfast meal, where no staff were present in the room. Resident #9's chair alarm did not sound and he/she sustained a laceration to the head requiring 3 staples. Review of the falls care plan indicated that on 1/9/12 the care plan was updated to include the following interventions: - Keep resident within staff eyesight while awake. - Encourage to keep in common area before and after meals. The quarterly MDS assessment of 3/21/12 indicated that Resident #9 was cognitively impaired as evidenced by a score of 4 out of possible 15 on the BIMS; extensive assistance with transfers and ambulation; and had 1 fall with injury (except major) since the last MDS assessment. Review of the Fall Risk Assessment of 3/28/12 indicated that Resident #9 was at high risk for falls. Review of the Nurse's Note and Facility's investigation of 4/1/12 indicated that at 2:20 P.M. Resident #9's bed alarm sounded. The nurse observed Resident #9 coming out of his/her room, turn to look at an agitated resident walking by the bedroom, lose balance and fall to the floor. Resident #9 sustained a right hip fracture. Review of the falls care plan indicated that on 4/6/12 the care plan was updated to include the following intervention: - Assist of 1 with rolling walker for transfers and ambulation. The significant change MDS assessment of 4/12/12 indicated that Resident #9 was cognitively impaired as evidenced by a score of 3 out of possible 15 on the BIMS; extensive assistance with transfers, did not ambulate in the room, limited assistance with ambulation in the corridor; and had 1 fall with major injury. major) since the last MDS assessment. On 4/13/12 the falls care plan was updated to include the following intervention: - Fall mats to both sides of bed. Review of the Nurse's Note and the Facility's investigation of 4/14/12 indicated that at 12:30 P.M. Resident #9 was sitting in a chair by the nurse's station, and the chair tipped over with Resident #9 still in the chair. The chair was noted to have a loose arm that came out and may have contributed to the fall. On 5/9/12 at 10:20 A.M. the Surveyor observed Resident #9 lying in bed on his/her left side, sleeping. The floor mats were on both sides of the bed. On 5/10/12 at 10 :45 A.M. the Surveyor observed the Resident in his/her room sitting on the edge of the recliner. A visitor, a nurse and a CNA were also present in the room. During a discussion with the Assistant Director of Nursing (ADON) on 5/10/12 at 10:50 A.M., the ADON said Resident #9 should have been supervised more closely and staff should have been monitoring the small dining room on 1/8/12 when Resident #9 fell and sustained the laceration. Resident #9's alarm did not sound. 2. For Resident #12 the Facility failed to provide a cognitively impaired resident with adequate supervision to prevent multiple falls. Five of the falls occurred in other residents' rooms. Resident #12 was admitted to the Facility in 1/10 with [DIAGNOSES REDACTED]. The annual MDS assessment of 3/2/11 indicated that Resident #12's short and long term memory was impaired and his/her cognitive skills for decision making were severely impaired; independent with transfers, independent with ambulation in room, supervision for ambulation in the corridor; and had no falls since the last MDS assessment. The Fall Risk Assessment of 3/3/11 indicated that Resident #12 was at high risk for falls. Review of the falls care plan of 4/23/11 included the following interventions: - Non-skid comfortable foot wear when out of bed. - Clutter free environment. - Gait belt for transfer/ambulation. Review of the Nurse's Note and the Facility's investigation of 5/2/11 indicated that at 1:30 P.M. the Nurse responded to a bed alarm and found Resident #12 on the floor in another resident's room, propelling himself/herself on the buttocks. Resident #12 did not sustain an injury. Review of the Nurse's Note and the Facility's investigation of 5/5/11 indicated that at 10:35 A.M. Resident #12 was found lying on a mat, beside the bed in another resident's room. Resident #12 did not sustain any injuries. Review of the falls care plan indicated that on 5/6/11 the care plan was updated to include the following intervention: - 1-2 assist for mobility as needed for balance. - Redirect as needed during wandering. The quarterly MDS assessment of 5/25/11 indicated that Resident #12's short and long term memory was impaired and his/her cognitive skills for decision making were severely impaired; limited assistance with transfers, independent with ambulation; and had 2 or more falls with no injury since the last MDS assessment. The Fall Risk Assessment of 5/31/11 indicated that Resident #12 was at high risk for falls. Review of the Nurse's Note and the Facility's investigation of 6/27/11 indicated that at 5:00 P.M. Resident #12 was found on the floor in another resident's room. Resident #12 did not sustain any injury. Review of the Nurse's Note and the Facility's investigation of 8/3/11 indicated that at 7:55 P.M. a resident alerted staff that Resident #12 fell next to the nurse's station. Resident #12 did not sustain an injury. The quarterly MDS assessment of 8/17/11 indicated that Resident #12's short and long term memory was impaired and his/her cognitive skills for decision making were severely impaired; limited assistance with transfers, limited assistance with ambulation in room, supervision for ambulation in the corridor; and had 2 or more falls with no injury since the last MDS assessment. Review of the Nurse's Note and the Facility's investigation of 8/17/11 indicated that at 5:00 A.M., Resident #12 was found sleeping on the floor beside the bed in another resident's room. Resident #12 did not sustain an injury. The Fall Risk Assessment of 8/19/11 indicated that Resident #12 was at high risk for falls. Review of the Nurse's Note and the Facility's investigation of 8/24/11 indicated that at 3:05 P.M., the nurse heard a noise in the hall and observed Resident #12 on the floor with a tray table beside him/her. The top of the table was not attached. Resident #12 did not sustain an injury. Review of the falls care plan indicated that on 8/26/11 the care plan was updated to include the following intervention: - Offer mid afternoon rest period with snack and beverage. Review of the Nurse's Note and the Facility's investigation of 9/23/11 indicated that at 2:45 P.M., Resident #12 was entering another resident's room and the other resident pushed Resident #12, out of the way, causing Resident #12 to fall. Resident #12 did not sustain an injury. The quarterly MDS assessment of 11/9/11 indicated that the Resident's short and long term memory was impaired and his/her cognitive skills for decision making were severely impaired; extensive assistance with transfers and ambulation; and had 2 or more falls with no injury since the last MDS assessment. The Fall Risk Assessment of 11/14/11 indicated that Resident #12 was at high risk for falls. Review of the falls care plan indicated that on 1/27/12 the care plan was updated to include the following intervention: - Merry Walker use with increased agitation and restlessness. The significant change MDS assessment of 2/1/12 indicated that the Resident #12's was short and long term memory was impaired and his/her cognitive skills for decision making were severely impaired; limited assistance with transfers and ambulation; and had no falls since the last MDS assessment The Fall Risk Assessment of 2/7/12 indicated that Resident #12 was at high risk for falls. The quarterly MDS assessment of 4/25/12 indicated that the Resident's was short and long term memory was impaired and his/her cognitive skills for decision making were severely impaired; extensive assistance with transfers and ambulation; and had 1 fall with no injury since the last MDS assessment The Fall Risk Assessment of 5/2/12 indicated that Resident #12 was at high risk for falls. Review of the Nurse's Note and the Facility investigation of 5/7/12 indicated that Resident #12 had a "near fall" and was found sitting on the strap of the Merry Walker. On 5/8/12 at 2:00 P.M. the Surveyor observed 2 staff members assisting Resident #12 into the Merry Walker (a device to assist with ambulation). On 5/9/12 at 9:00 A.M. the Surveyor observed Resident #12 seated at a table in the dining room with 6 other residents. A CNA was feeding Resident #12 the breakfast meal. On 5/10/12 at 10:30 A.M. the Surveyor observed Resident #12 in the hallway utilizing the Merry Walker. Resident #12 opened the soiled linen bins and pulled the soiled disposable undergarment bin with him/her as he/she walked. During a discussion with the ADON on 5/10/12 at 10:50 A.M., the Surveyor discussed the lack of supervision for Resident #12 who sustained multiple falls and several of the falls occurred in other resident's rooms. 3. For Resident #18. the Facility failed to provide adequate supervision to prevent multiple falls. Although the alarm sounded for 4 of the falls, it was not an adequate intervention to prevent the falls. Resident #18 was admitted to the Facility in 10/10 with [DIAGNOSES REDACTED]. The quarterly MDS assessment of 4/20/11 indicated that Resident #18 was cognitively impaired as evidenced by a score of 3 out of possible 15 on the BIMS; extensive assistance with transfers and ambulation; and had 2 or more falls with no injury since the last MDS assessment. Review of the falls care plan of 4/27/11 included the following interventions: - Bed pressure alarm. - Ambulate with 1 assist, hand held. Review of the Nurse's Note and the Facility Internal investigation of 5/15/11 indicated that at 7:00 A.M. Resident #18's bed alarm sounded, and Resident #18 was found on the floor at the foot of the bed. Resident #18 did not sustain an injury. Review of the Nurse's Note and the Facility investigation of 5/24/11 indicated that at 7:10 A.M. Resident #18's alarm sounded, and the Certified Nurse Aide (CNA) observed Resident #18 kneeling beside the bed. Resident #18 did not sustain an injury. Review of the falls care plan indicated that on 5/24/11, the care plan was updated to include the following intervention: - Staff to encourage resident to sit at nurse's station after getting dressed in the morning. Review of the Nurse's Note and the Facility investigation of 6/5/11 indicated that at 10:45 A.M., Resident #18 was sleeping in a recliner, woke up, attempted to stand and fell to the floor. Resident #18 did not sustain an injury. Review of the Nurse's Note and the Facility's investigation of 6/18/11 indicated that at 12:00 P.M

Based on record review and interview, the facility failed to ensure that 1 resident (#12) was free of any significant medication errors, in a total sample of 24. Findings include: For Resident #12, the facility failed to ensure Resident #12 received the correct medications ordered by the Physician. Resident #12 was admitted to the facility in 11/10 with [DIAGNOSES REDACTED]. Resident #12 did not have a [DIAGNOSES REDACTED]. Review of the Nurse's Note of 2/16/12 and the Facility's investigation indicated that at 7:30 A.M., the day shift nurse asked the night shift nurse the name of Resident #12 and the night shift nurse mistakenly told the day shift nurse the name of a different resident. Resident #12 received the following medications belonging to another resident, not ordered by the Physician: 70/30 [MEDICATION NAME], 12 Units; [MEDICATION NAME], 200 milligrams (mg); [MEDICATION NAME], 25 mg; [MEDICATION NAME],10 mg; [MEDICATION NAME], 5 mg; [MEDICATION NAME] 150 mg; and [MEDICATION NAME] 40 mg. This was immediately recognized. The Nurse's Note further indicated that the Nurse Practitioner was notified that Resident #12 received 7 medications including insulin, not ordered for this Resident, and ordered the following, which were administered at 8:00 A.M. to counteract the effects of the insulin: "[MEDICATION NAME] (emergency medication for hypoglycemic reaction) 1 mg, injection with 2 packets of sugar" and Resident #12 received Intravenous (IV) [MEDICATION NAME] 5% at 75 cubic centimeters (cc) per hour, 1 liter. At 9:20 A.M., Resident #12's Finger Stick Blood Sugar (FSBS) level was 77 milligrams per deciliter (mg/dl). [MEDICATION NAME] 1 mg, injection was given again. At 9:50 A.M. Resident #12 ate approximately 5 bites of toast with jelly and drank 4 ounces (oz) of juice. At 10:00 A.M. Resident #12's FSBS was 114 mg/dl. At 2:00 P.M. Resident #12's FSBS was 89 mg/dl. At 3:00 P.M., Resident #12's FSBS was 63 mg/dl. The Nurse Practitioner was updated and ordered [MEDICATION NAME] 1 mg, injection, which was administered and a second dose of IV [MEDICATION NAME] 5% at 75 cc per hour, 1 liter. Resident #12 was not responsive to verbal or tactile stimuli and "slept" in the recliner. At 4:00 P.M., Resident #12's FSBS was 152 mg/dl, at 5 P.M. 157 mg/dl, at 6:00 P.M. 121 mg/dl, and at 7:00 P.M. 137 mg/dl. At 7:30 P.M. Resident #12 was responsive to verbal stimuli, drank fluids which were well tolerated, ate some pudding and was becoming more alert. During interview with the Assistant Director of Nursing (ADON) on 5/10/12 at 10:50 A.M., the ADON said the following medications were given in error and were not ordered by the Physician for Resident #12: 70/30 [MEDICATION NAME], 12 Units; [MEDICATION NAME], 200 milligrams (mg); [MEDICATION NAME], 25 mg; [MEDICATION NAME],10 mg; [MEDICATION NAME], 5 mg; [MEDICATION NAME] 150 mg; and [MEDICATION NAME] 40 mg. The ADON further said that the day shift nurse asked the night shift nurse the name of Resident #12 and the night shift nurse mistakenly told the day shift nurse the name of a different resident.