Every finding on record at Day Brook Village Senior Living

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an invoked Health Care Proxy (HCP), and whose Health Care Agent (HCA) had submitted a written request for copies of his/her medical record, the facility failed to ensure the records were provided timely as required, when the HCA waited three weeks to get the requested copies.Findings include:Review of the Facility Policy titled Residents' Rights, dated as revised on 10/4/23, indicated:-The resident has the right to access personal and medical records pertaining to him or herself.-The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable.Resident #1 was admitted to the Facility in January 2023, diagnoses included Diabetes and Chronic Kidney Disease.Review of Resident #1's Medical Record included a Health Care Proxy (HCP), dated 01/09/23, which listed his/her son as his/her Health Care Agent (HCA).Review of Resident #1's current Physician's Orders indicated his/her HCP had been activated on 12/30/24 and his/her HCA (Family Member #1) was invoked.During a telephone interview on 09/23/25 at 11:30 A.M., Family Member #1 said he requested copies of Resident #1's medical records in writing via email to the Facility late in the day on 09/04/24 and still (as of 09/23/25) had not received them despite multiple emails and telephone calls to the Facility.Review of email correspondence between Family Member #1 and the Executive Director, provided by the Executive Director on 09/24/25, indicated the following:-09/04/25 at 1:29 P.M. - The Executive Director indicated to Family Member #1 that he was in receipt of Family Member #1's email requesting copies of Resident #1's medical records (originally sent to the Business Office Manager), indicated the team will work with the Medical Records Coordinator to complete his request, and indicated to expect the Medical Records Coordinator to follow up with him to complete the required Medical Record Request Form.-09/08/25 at 3:34 PM. - Family Member #1 replied to the Executive Director indicating that, as Resident #1's Legal Representative, he was entitled to access his/her medical records within 24 hours of his written request excluding weekends and holidays, and this right was not contingent on the completion of an internal facility form. Family Member #1 indicated he submitted his written request on 09/04/25 and indicated as of the date of this email (09/08/25), he had not received the records, nor had the Business Office Manager contacted him as he was told in a previous email. Family Member #1 indicated he was requesting all wound care records, physician/nursing notes, treatment documentation, wound care team assessments, photographs, staging reports, progress notes, any incident reports or internal communications related to Resident #1's pressure ulcer.-09/10/25 at 3:18 P.M. - Family Member #1 indicated he was deeply disappointed with how his recent request for Resident #1's medical records and care information had been managed.-09/10/25 at 5:16 P.M. - The Executive Director indicated he was unexpectedly out of work, asked Family Member #1 if he had the opportunity to complete the facility's Medical Record Request Form indicating it only takes a few minutes and indicated the form was an important piece of documentation.Review of Resident #1's Electronic Medical Record indicated it included a scanned copy of a Massachusetts Medical Records Release Form, signed and dated by Family Member #1 on 09/12/25.During a telephone interview on 09/23/25 at 1:05 P.M., the Long-Term Care Ombudsman said Family Member #1 called her upset about Resident #1's care and told her that he requested copies of his/her medical records repeatedly from the Facility without results.The Long-Term Care Ombudsman said she left messages with the Facility to have somebody contact her about the lack of response to Family Member #1, and she was finally able to reach the Social Worker on 09/23/25.The Long-Term Care Ombudsman said the Social Worker told her that the Facility had 30 days to provide Resident #1's medical records to Family Member #1. The Long-Term Care Ombudsman said she informed the Social Worker that the records should have been provided to Family Member #1 within 24-48 hours, as written in the regulations. During an interview on 09/24/25 at 2:00 P.M., the Administrative Assistant said Resident #1's medical records were mailed to Family Member #1 on 09/23/25 and provided a copy of the postal receipt to the surveyor that indicated an expected delivery date of 09/29/25. During an interview on 09/24/25 at 2:00 P.M., the Medical Records Coordinator said she was aware of Family Member #1's request for copies of Resident #1's medical records, and that she was notified by email by the Executive Director.The Medical Records Coordinator said she emailed a Medical Record Request Form to Family Member #1, which was completed by him and emailed back to the facility.After reviewing the completed Medical Records Request form with the surveyor, the Medical Records Coordinator said the Form was signed by Family Member #1 on 09/12/25, and scanned into Resident #1's Electronic Medical Record on 09/16/25 at 9:26 A.M.The Medical Records Coordinator said she believed the facility's policy was to release medical records within 30 days of receipt of the request, and that she was unaware of any regulation that stated otherwise.During an interview on 09/24/25 at 2:50 P.M., the Executive Director said that Family Member #1 emailed the Business Office Manager on 09/03/25 at 8:50 P.M. requesting Resident #1's medical records. The Executive Director said the Business Office Manager subsequently forwarded the email to both him and the Social Worker on 09/04/25 at 7:52 A.M., and at that time, he notified the Medical Records Coordinator to begin to print/copy Resident #1's medical records.The Executive Director said they require a Medical Record Release Form to be completed by whoever is requesting the medical records prior to releasing them, but the process can still begin prior to receiving the signed release form.The Executive Director said he offered to have Family Member #1 or his designee view Resident #1's medical records on or around 09/10/25, but Family Member #1 declined, and that the medical records were mailed to Family Member #1 on 09/23/25.During an interview on 09/25/25 at 3:15 P.M., the Quality Improvement Manager (QIM) said the Facility did not release Resident #1's medical records to Family Member #1 in a timely manner.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) and had developed a pressure injury that was new, the Facility failed to ensure nursing notified his/her Health Care Agent (HCA) when he/she was first assessed to have an alteration in his/her skin integrity, and when the pressure injury deteriorated.Findings include:Review of the Facility Policy titled Health and Medical Condition, Informing Residents of, dated as revised 01/05/17 indicated:-Each resident or resident representative admitted to our facility will be informed of his/her total health status and medical condition on an ongoing basis in a language that he/she can understand.-The resident will be advised of any significant change in his/her medical condition, medication, or treatment orders.-The resident's family/resident representative and the physician will be notified when there is a medical change in the resident's condition.Resident #1 was admitted to the Facility in January 2023, diagnoses included Diabetes and Chronic Kidney Disease.During a telephone interview on 09/23/25 at 11:30 A.M., Family Member #1 said Resident #1 was admitted to the Facility in 2023 without any pre-existing skin issues and to his knowledge he/she did not have any skin breakdown prior to April 2025, when Resident #1 was admitted to the Hospital for stomach issues.Family Member #1 said Hospital Nursing Staff alerted him that they completed an admission skin assessment on Resident #1 and found him/her to have a pressure injury on his/her lower back. Family Member #1 said when he brought this up to the Facility staff (exact person unknown), they told him that Resident #1 did not have this wound when he/she went to the hospital and that he/she returned from the hospital with the pressure injury. Family Member #1 said he brought his concern to the Executive Director who told him that the pressure injury did not start at the Facility, and that Resident #1 likely developed it while at the Hospital.Family Member #1 said Resident #1's wound worsened over time after returning to the Facility, and while he had regular contact with the Nursing staff via telephone, nobody informed him of the marked deterioration of Resident #1's wound until late August 2025 when he received a call from the Facility's Wound Nurse requesting his consent to debride (removal of damaged tissue using sharp instruments) his/her wound to facilitate healing.Review of Resident #1's New Onset Skin Assessment, dated 03/26/25, indicated Nursing staff assessed him/her to have an open area, defined as Moisture Associated Skin Damage (MASD).Review of Resident #1's Interdisciplinary Progress Notes included a Nursing Note, dated 03/26/25, that indicated that he/she was assessed to have an area of MASD, and that nursing staff notified his/her Provider and obtained treatment orders. Review of Resident #1's Medical Record indicated there was no documentation to support the nurse notified Family Member #1 (HCA) of this new wound. Review of Resident #1's Ongoing Skin Condition Assessment Records indicated:07/14/25 - wound progress was noted to be deteriorated - date family notified: HCP (health care proxy) aware, treatment changed.07/29/25 - wound progress was noted to be deteriorated - date family notified: AWARE, seen by Wound Nurse Practitioner, treatment changed.08/05/25 - wound progress was noted to be deteriorated (now with undermining, not present on 07/29/25) - date family notified: NA. Treatment changed today, see new orders.08/11/25 - wound progress noted to be deteriorated, with a treatment change and wound culture sent to the lab to rule out infection, antibiotics were ordered - date family notified: to update today.During a telephone interview on 10/01/25 at 2:46 P.M., the Wound Nurse said when a Resident develops a wound or skin alteration, it is the responsibility of the nurse that discovers the wound to complete an incident report, contact the Provider, and contact the resident's representative, and she said all of that information should be documented in a Nursing Progress Note and on the Incident Report.The Wound Nurse said if a wound deteriorates and/or if treatments change significantly, the resident's representative should be notified.The Wound Nurse said that Family Member #1 should have been notified on 03/26/25 when Resident #1 first developed MASD and should have been notified when the wound was assessed to have deteriorated on 07/14/25, 07/29/25, and 08/05/25.The Wound Nurse said when she calls residents' family members or representatives, she usually documents the phone call in a Progress Note (Skin-Wound Note). The Wound Nurse she said she did not recall if she called Family Member #1 when she assessed there to be a deterioration in his/her wound on 07/14/25 and 07/29/25, when she documented HCP Aware and that she needed to work on improving her documentation.The Wound Nurse said when Resident #1's wound deteriorated further on 08/05/25, if there wasn't a Skin-Wound Note in the Interdisciplinary Progress Notes and N/A documented on the Ongoing Skin Condition Assessment Record, that Family Member #1 was not notified, but that he should have been.During an interview on 09/25/25 at 12:52 P.M., Unit Manager #1 said Staff Nurses are responsible to complete weekly skin assessments on every resident, and if there is a new skin issue, they are responsible for notifying the resident's representative. During a telephone interview on 09/26/25 at 4:06 P.M., Unit Manager #2 said the resident's primary nurse is responsible for completing weekly skin assessments and if there is a new area of concern, or worsening of a wound, nurses are required to notify the resident's representative.During an interview on 09/25/25 at 3:15 P.M., with the Director of Nurses (DON) and the Corporate Quality Improvement Manager (QIM), the DON, QIM and the surveyor reviewed Resident #1's Interdisciplinary Progress Notes and Ongoing Skin Condition Assessment Records.The DON said she did not see any Nursing Progress Notes that indicated Nursing notified Family Member #1 after discovering he/she developed a wound on 03/26/25, or after the wound was assessed to have deteriorated on 07/14/25, 07/29/25, and 08/05/25. Both the DON and QIM said there was no evidence on the Ongoing Skin Condition Assessment that the Wound Nurse notified Family Member #1 of Resident #1's worsening wound on 08/05/25. On 09/24/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 09/17/25, which addressed the area of concern as evidenced by:A) On 08/26/25, an Interdisciplinary Progress note included a Skin/Wound Note, dated 08/26/26 that indicated Resident #1's Representative was contacted regarding his/her worsening wound.B) On 09/12/25, the Director of Nursing completed a Facility-wide audit to determine the notification process was followed for all Residents in the Facility that had developed wounds and/or had significant changes to wounds (including treatment changes). C) On 09/19/25, 09/26/25, the Unit Managers conducted Facility-wide audits to ensure that Resident Representatives have been notified for any Resident that have had any changes related to wound status or treatment of wounds. D) From 09/12/25 through 09/24/25, the Director of Nursing completed Nursing education, titled Notification Protocol for Residents with Change in Wound Status or Treatment, including review the Facility policies titled, Informing Residents of Health and Medical Condition, and Physician Notification.E) The Facility's Unit Managers will continue to perform weekly audits to ensure Physicians and Resident Representatives are notified of changes with wound status, as appropriate, and after 100% compliance has been attained weekly, random audits will continue until deemed otherwise.F) The deficient practice and audit results will be presented at the Monthly Quality Assurance Performance Improvement (QAPI) meeting on 10/08/25.G) The Director of Nursing and/or their Designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled Residents (Resident #1), the facility failed to ensure they maintained a complete and accurate medical record when Nursing documentation related to wound treatments and Certified Nurse Aide (CNA) documentation related to skin integrity and bathing were incomplete.Findings include:Review of the Facility's Policy titled, Clinical Documentation, dated as last revised 10/31/23, indicated:-Medication and Treatment: The licensed nurse notes the time and date of all medications and treatments administered on the Medication Administration Record (MAR) and or Treatment Administration Record (TAR). The nurse who administers the medication and/or treatment must document it on the resident's record. -Nursing Assistant Documentation: Completed at Point of Care using the Electronic Health Record (EHR). Resident #1 was admitted to the Facility in January 2023, diagnoses included Diabetes and Chronic Kidney Disease.Review of Resident #1's July 2025 TAR indicated he/she had new orders for treatments as follows: -Sacrum Wound: Apply collagen powder particles to wound bed and cover with calcium alginate/silver (a type of absorbent dressing) and foam dressing. Change daily. Initiated 07/01/25, stop date 07/14/25.Further review of the TAR indicated a code of M documented under this treatment on 07/11/25 and 07/12/25.-Sacrum Wound: Apply Santyl (an ointment that helps remove dead tissue from wounds), dime sized amount to wound base and cover with Aquacel (a type of absorbent dressing), initiated 07/14/25. Further review of the TAR indicated a code of M documented under this treatment on 07/16/25 and 07/18/25.Review of the code legend on the last page of the TAR did not include a code of M as a choice for nursing to enter or why the code would be used.During a telephone interview on 10/07/25 at 3:20 P.M., the Director of Nursing (DON) said she reviewed Resident #1's July TAR and she said she was not sure what the M on the TAR represented because there was no M listed as a choice on the code legend. The DON said she interviewed the nursing staff who were responsible to perform Resident #1's treatments on the days where M was documented and she said she determined that the nursing staff did not document they completed Resident #1's ordered treatments on 07/11/25, 07/12/25, 07/16/25, and 07/18/25, as required. Review of Resident #1's Skin Care by Day Reports (CNA Documentation that indicated whether CNAs were applying protective skin lotions/creams) indicated for the following shifts were left blank:June 2025Night Shift (11:00 P.M. - 7:00 A.M.) 3 out of 30 opportunities left blankDay Shift (7:00 A.M. - 3:00 P.M.) 7 out of 30 opportunities left blankEvening Shift (3:00 P.M. - 11:00 P.M.) 1 out of 30 opportunities left blankJuly 2025Night Shift: 5 out of 31 opportunities left blankDay Shift: 7 out of 31 opportunities left blankEvening Shift: 2 out of 31 opportunities left blankAugust 2025Night Shift: 3 out of 31 opportunities left blankDay Shift: 1 out of 31 opportunities left blankEvening Shift: 1 out of 31 opportunities left blankSeptember 2025Night Shift: 3 out of 26 opportunities left blankDay Shift: 11 out of 26 opportunities left blankEvening Shift: 7 out of 25 opportunities left blankReview of Resident #1's Bathing and Hygiene by Day Report (CNA Documentation that indicated whether the CNA's assisted Resident #1 with bathing and shampooing) indicated that following shifts and tasks were left blank:June 2025:Bathing and ShampooingNight Shift: 3 out of 30 opportunities left blankDay Shift: 7 out of 30 opportunities left blankEvening Shift: 1 out of 30 opportunities left blankJuly 2025:Bathing and ShampooingNight Shift: 5 out of 31 opportunities left blankDay Shift: 6 out of 31 opportunities left blankEvening Shift: 2 out of 31 opportunities left blankAugust 2025:Bathing and ShampooingNight Shift: 3 out of 31 opportunities left blankDay Shift: 1 out of 31 opportunities left blankEvening Shift: 2 out of 31 opportunities left blankSeptember 2025:Bathing and ShampooingNight Shift: 3 out of 25 opportunities left blankDay Shift: 11 out of 25 opportunities left blankEvening Shift: 7 out of 25 opportunities left blankDuring an interview on 09/24/25 at 1:05 P.M., Nurse #1 said Nursing and CNAs must document all their treatments and tasks in the computer and the documentation must be done by the end of their shift.During an interview on 09/24/25 at 10:30 A.M., CNA #1 said CNAs are required to document all the care they provide to the residents in the computer, and all the documentation needs to be entered by the end of their shift. CNA #1 said there are codes we can enter if a resident refuses or if they are out of the building, so there should be no blank spaces on our reports, and if there are, that means the CNA did not enter their documentation.During an interview on 09/24/25 at 4:45 P.M., CNA #2 said all CNA document the care they provide to the residents in the computer, and this documentation must be done by the end of the shift.During a telephone interview on 09/26/25 at 2:50 P.M., CNA #3 said CNAs document all care they provide to the residents in the computer, and the charting must be completed before they leave for the day.During a telephone interview on 10/01/25 at 1:20 P.M., CNA #4 said all CNA documentation is located in the computer and should be completed by the end of the shift. CNA #4 said if there are any blank spaces on the CNA reports, that meant that CNA documentation was not done. During a telephone interview on 10/07/25 at 9:30 A.M., the Director of Nursing (DON) reviewed the CNA Documentation she faxed to the surveyor and she said anywhere there are blank spaces, the CNA should have entered the appropriate code for the task. The DON said if there are any blank spaces, that meant the CNA did not complete their documentation, as required.

Based on observation, record review, and interview, the facility failed to establish a system of records of receipt and disposition of controlled medications consistent with applicable state and federal requirements for two out of four medication carts on one unit (Unit One) out of two units observed to prevent loss, diversion and/or accidental exposure. Specifically, the facility failed to: -destroy controlled substance medications (including opioids, narcotics, and sedatives) that were removed from two locked medication carts on unit one and were being stored in the Administrator's office for a documented duration of greater than one year. -ensure the transfer of controlled substance medications from one page of the facility-controlled substance medication log book to another page of the log book was reconciled by the appropriate and required licensed nursing staff. Findings include: Review of the facility policy titled, Management of Controlled Substance in Skilled Nursing Facilities, revised 9/29/22, indicated: -Purpose: a) To minimize the opportunity for abuse or diversion of controlled substances. b) To promote occupational and patient safety. -To initiate a transfer page, complete transfer information at the bottom of inventory page. -Two licensed nursing staff signatures - the recording nurse and the witnessing nurse are required. -Destruction will occur when medications are discontinued, or at a minimum twice monthly. On 4/1/25 at 10:30 A.M., during a medication administration observation on unit one, the surveyor and Nurse #6 reviewed the controlled substance medication documentation labeled Book 108. The surveyor observed that narcotic medications had been removed from the controlled substance medication book and had been signed by two staff members as removed from count since 1/15/24. The surveyor observed that one Nurse had transferred pages of controlled substance medications without a second Nurse verification of transfer to other pages. The surveyor further observed that the controlled substance documentation in Book 108 failed to indicate that the controlled substance medications had been destroyed. On 4/1/25 at 10:51 A.M., the surveyor and Nurse #6 reviewed the controlled substance medication documentation book labeled Book 109. Nurse #6 said the controlled substance medications had been discontinued and released to the Director of Nursing (DON) for destruction since 5/15/24. The surveyor observed that the controlled substance medications in Book 109 indicated one Nurse had transferred pages of controlled substance medications from one page to another page without a second Nurse verification. Nurse #6 said two Nurses should have verified and documented the transfer of the controlled substance medications from one page to another, but they had not. On 4/1/25 at 10:51 A.M., the surveyor and the Director of Nursing (DON) reviewed the controlled substance medication books. The DON said two Nurses were expected to verify and document the transfer of the controlled substance medication from one page to another page, but they did not. The DON further said that controlled substance medications that had been removed from the nursing medication cart on unit one was under double lock and key in the Administrator's office. During an interview on 4/1/25 at 11:07 A.M., the Administrator said controlled substance medications were expected to be destroyed monthly. During an interview at the time, the DON said the controlled substance medications had been removed from the two medication carts on unit one to be destroyed and were documented on a controlled substance disposal record but had not yet been destroyed since 1/15/24. During an observation on 4/1/25 at 11:10 A.M., the surveyor observed two cabinets in the Administrator's office, containing multiple different controlled substances medications. Review of the controlled substance medication log documented and under lock and key in the Administrator's office, indicated that the controlled substances were removed from unit one on the following dates: -1/25/24 -5/15/24 -7/15/24 -8/15/24 -10/23/24 -10/28/24 -11/16/24 -12/23/24 -1/8/25 -1/29/25 Review of the controlled substance medications located in the Administrator's office included: -multiple cards of Tramadol (opioid pain medication) for multiple residents -multiple vials of Lorazepam (antianxiety medication) for multiple residents -multiple cards of Oxycodone (opioid pain medication) for multiple residents -multiple vials of Morphine Sulfate liquid (opiate narcotic pain medication) for multiple residents -multiple cards of Lorazepam tablets for multiple residents -multiple tablets of Hydromorphone (opioid pain medication) for multiple residents -multiple doses of Lyrica (used to treat nerve pain) for multiple residents -multiple doses of Clonazepam (antianxiety) for multiple residents -multiple doses of Ambien medication (sedative medication) for multiple residents -multiple doses of Dilaudid medications (opioid medication) for multiple residents -doses of Vimpat medication (antiseizure) for multiple residents -doses of Nayzilam medication (antiseizures) for multiple residents During a follow-up interview on 4/1/25 at 3:45 P.M., the DON said the controlled substance medications should have been destroyed but the controlled substance medications were not destroyed. The DON further said two Nurses should have documented the transfer of the controlled substance medications from one page of the controlled substance book to another page, but did not.

Based on observation, and interview, the facility failed to provide resident choices for beverage and meal preferences, on one unit (Unit Two) out of two units observed. Specifically, the facility failed to ensure that fluids and meal preferences were honored when the meals tickets identified residents' choices of fluids and meals. Findings include: Review of the facility policy titled Nutrition Management, revised 9/30/24, indicated: -Residents will receive care and services to ensure acceptable parameters of nutritional status are maintained to the extent possible as indicated by the resident's clinical condition. -Purpose is to provide nutritional care and services to each resident, consistent with the resident's comprehensive assessment. -To recognize, evaluate, and address the nutritional needs of every resident, including, but not limited to, the resident at risk or currently experiencing impaired nutrition. -To provide a therapeutic diet that considers the resident's clinical condition and preferences, when there is a nutritional indication. -Sufficient fluid intake is offered to maintain proper hydration and health. -Is offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet. On 4/1/25 at 8:16 A.M., the surveyor observed the following during the breakfast meal activity on the Unit Two dining area: -Dietary Aide #1 serving meals in styrofoam plates accompanied by plastic eating utensils. -All the meals that were to be served were placed in a large cart. -Three Certified Nurses Aides (CNA's) brought the large cart out of the dining room and walked from resident room to resident room and distributed the meals to the residents in the rooms and in the hallways. -One staff member was observed with a cart that contained pitchers of orange juice and cranberry juice. -The staff members walked from resident room to resident room and served the Residents with either orange juice or cranberry juice. On 4/1/25 at 8:48 A.M., the surveyor reviewed the meal tickets for the residents on Unit Two. The surveyor observed that the residents' meals tickets included oatmeal, whole milk, hot beverage of choice, Lactaid milk, and/or fortified cream of wheat. The surveyor observed that none of the item choices listed on the meal tickets were offered to the unit residents. The surveyor also observed that one resident received orange juice with his/her meal, and his/her meal ticket indicated no orange juice, only Lactaid milk. During an interview on 4/1/25 at 9:10 A.M., the Food Service Director (FSD) said the meal tickets were based on resident needs and preferences and were evaluated by the Registered Dietitian (RD). During an interview on 4/1/25 at 9:24 A.M., with the Unit Two staff, CNA #2 said all the CNAs knew the residents likes and dislikes and the CNAs did not follow the information on the meal tickets. During an interview on 4/1/25 at 9:26 A.M., CNA #3 said the facility staff knew the residents' likes and dislikes and only offered beverages that the residents would like. During an interview on 4/1/25 at 9:31 A.M., CNA #4 said the facility staff had been working in the facility for a long period of time and knew what the residents' preferences were. CNA #4 said the staff did not follow what the meal tickets indicated. During an interview on 4/1/25 at 9:33 A.M., Nurse # 3 said the CNAs were very familiar with the residents' likes and dislikes and would only provide what the CNAs think the residents would prefer. During an interview on 4/1/25 at 9:40 A.M., Nurse #2 said he was an Agency Nurse and that the CNAs knew the residents and were aware of the residents' preferences. Nurse #2 said he depended on the CNAs to provide what the residents needed related to food and fluid preferences. On 4/1/25 at 12:15 P.M., the surveyor observed one staff member going from resident room to resident room and serving the residents with either orange juice or cranberry juice. During an interview on 4/1/25 at 1:23 P.M., the RD said the menu and the meal tickets had been new six months ago. The RD said the CNAs were very familiar with the residents on Unit Two. The RD said that she was not aware the residents' meal tickets for preferences were not being followed but would review and get back to the surveyor. During an interview on 4/1/25 at 3:53 P.M., the Director of Nursing Services (DNS) said she would expect the CNAs to follow the meal tickets based on the residents dietary and fluid preferences. During a follow-up interview on 4/1/25 at 4:37 P.M., the RD said the CNAs needed to follow the meal tickets for residents' diet, choices, and fluid needs. The RD further said the resident given orange juice should not have been given orange juice when the meal ticket said no orange juice. On 4/2/25 at 8:38 A.M., the surveyor and the RD reviewed the meal ticket for a resident that had been served his/her breakfast meal. The RD said the resident should have received fortified cream of wheat as indicated on the meal ticket, but he/she did not receive the fortified cream of wheat. The RD said the fortified cream of wheat had been ordered for the resident due to weight loss and the resident should have received the fortified cream of wheat as ordered. On 4/3/25 at 8:02 A.M., the surveyor observed the breakfast meal being set up in the Unit Two dining room. The surveyor observed the FSD read the meal tickets, and the Dietary Aide would serve the meals on the styrofoam plates. The surveyor observed other staff members were receiving the plated resident meals and setting up the meals to be distributed to the residents who were in their rooms or seated in the hallways. On 4/3/25 at 9:02 A.M., the surveyor and the FSD reviewed the meal tickets. The meal tickets indicated fruited yogurt, corned beef hash, and fresh melon fruit cup. During an interview at the time, the FSD said the fruited yogurt, the corned beef hash and the fresh melon fruit cup were not provided to the residents as indicated on the residents meal tickets. The FSD said that they should have reviewed the meal tickets and honored the preferences on the tickets, but they did not. The surveyor and the FSD reviewed one resident's meal ticket which indicated pancake with syrup and saw that the resident received dried toasted bread. The FSD was observed asking the Dietary Aide why the resident received dried toast and the Dietary Aide said she gave the resident dried toast because she knew what the resident liked. On 4/3/25 at 9:07 A.M., when the surveyor asked to interview the Dietary Aide, the Dietary Aide said she would not respond to the surveyor. The Dietary Aide would not provide her name when the surveyor requested. During an interview on 4/3/25 at 12:18 P.M., the RD said the facility had fresh melon fruit in stock and that the staff should have provided the fresh melon fruit to the residents as indicated on the residents meal tickets. The RD said the fruited yogurt was available as indicated on the residents dietary slips. The RD further said the corned beef hash was put on the meal tickets by the dietary staff in error as they did not have corned beef hash on the menu.

Based on observation, and interview, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in the facility's main kitchen. Specifically, the facility failed to implement safe food practices in the main kitchen relative to labeling, dating and storage guidelines. Findings include: Review of the facility policy titled Dietary: Sanitary Conditions, last revised 9/21/22, indicated: -store, prepare, distribute and serve food under sanitary conditions. -follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the presentation of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes. -when food is purchased by the nursing home, inspection for safe transport and quality upon receipt and proper storage helps ensure its safety. Keeping track of when to discard perishable foods and covering, labeling and dating all foods stored in the refrigerator or freezer is indicated. -Dry food storage - desirable practices include managing the receipt of dry food, removing foods not safe for consumption, keeping dry foods in closed containers and rotating supplies. During an initial walk-through of the facility's main kitchen on 3/31/25 at 7:13 A.M., the surveyor observed the following: >the walk-in Refrigerator: -3 unlabeled and undated large pitchers of juice >the walk-in Freezer: -one unlabeled and undated box of 40 powdered donuts -one opened, resealed, unlabeled and undated clear bag of waffles -one opened, resealed, unlabeled and undated clear bag of onion rings -one opened, resealed, unlabeled and undated clear bag of French fries -two opened, resealed, unlabeled and undated clear bags of cookie dough -one opened resealed, unlabeled and undated clear bag of bag of spring rolls -one open to air, unlabeled and undated, box of lemon bars >dry storage area: -one opened, resealed, undated bag of spaghetti -one opened, resealed, undated bag of pudding mix -one opened, resealed, undated bag of muffin mix -one opened, resealed, undated box of lasagna -one open to air, undated box of lasagna -one opened, resealed, undated bag of oatmeal During an interview on 3/31/25 at 7:24 A.M., Dietary Staff #4 said that the food items in the walk-in refrigerator and walk-in freezer should have been labeled and dated, and they were not. Dietary Staff #4 also said that many of the staff in the main kitchen were new. During an interview on 3/31/25 at 7:27 A.M., Dietary Staff #3 said that the items opened in the dry storage area probably should have been labeled and dated. During an interview on 3/31/25 at 11:40 A.M., the Food Service Director (FSD) said that all unlabeled and undated items should have been labeled and dated after the items were opened. The FSD also said that the items should have indicated when they should be thrown away by the dietary staff.

Based on observations, interviews, and records reviewed, the facility failed to maintain an effective pest control program to ensure that the facility was free of pests on one Resident Unit (Unit Two) of two Resident Units. Specifically, the facility staff failed to implement measures to eradicate and contain fruit flies located in the Unit Two Pantry, Unit Two hallways, and two Resident's rooms (#35 and #24), increasing the risk for rapid multiplicity of fruit flies and contamination. Findings include: Review of the facility's policy titled Pest Control, dated 2001 and updated 7/9/24, indicated the following: -The facility shall maintain an effective pest control program. -The facility maintain an on-going pest control program to ensure that the building is kept free of insects and rodents. -Maintenance services assist, when appropriate and necessary, in providing pest control services. Review of the Cleveland Clinic's guidance titled How To Get Rid of Fruit Flies for Good at https://health.clevelandclinic.org/how-to-get-rid-of-fruit-flies, dated 10/30/24, indicated the following: -Fruit flies are a nuisance. -Clean up any food spills and crumbs quickly. -Fruit flies have fondness for moist foods and humid climates. Review of the facility's Pest Control Service Inspection Report from the facility's contracted pest control company, dated 1/3/25, indicated the following: -Roach/Rodent/Fruit Fly service was provided. -An open condition for a large hole in the wall around the pipes in the cabinet under the Second Floor Pantry sink. -The hole in the wall could allow insects/rodents to enter. -The facility was responsible to fix the hole in the wall. -Action required for fixing the hole in the wall was first reported to the facility on [DATE]. Further review of the facility's Pest Control Service Inspection Reports indicated the following: -Pest control inspection services were provided at the facility on: 1/7/25, 1/17/25, 2/7/25, 2/21/25, 3/7/25, 3/20/25, and 4/1/25. -The Pest control company's recommendation for the facility to fix the hole in the wall around the pipes in the cabinet under the Second Floor Pantry sink continued to display on all of stated pest control visits. During an interview on 3/31/25 at 9:25 A.M., Resident #35's visitor said that he/she observed fruit flies in Resident #35's room when he/she visited the Resident at meal times. On 3/31/25 at 3:21 P.M., the surveyor observed two fruit flies flying outside of Resident #24's room and landed on the surveyor's computer. On 4/2/25 at 7:57 A.M., the surveyor observed a fruit fly flying in the hallway, outside of the Pantry and near the surveyor's head, on Unit Two. During an interview on 4/2/25 at 8:00 A.M., Certified Nurses Aide (CNA) #3 said she has been seeing a few fruit flies throughout the Sunrise hallway on Unit Two. CNA #3 said she could not say whether fruit flies were present on the Memory Lane hallway of Unit Two because she did not work on that hallway of the Unit. During an interview on 4/2/25 at 8:09 A.M., CNA #6 said she had been seeing fruit flies a lot in the Memory Lane hallway on Unit Two. CNA #6 said she had not communicated her observations of the fruit flies to the facility because there were only a few flies. CNA #6 said she would let her Nurse know if she saw more fruit flies than usual and if she saw fruit flies in the residents rooms. On 4/2/25 at 9:07 A.M., the surveyor observed a fruit fly on the wall behind Resident #35's head while the Resident was eating in his/her room. During an interview at the time, Resident #35's visitor, who was also in the room, said he/she visited the Resident daily during breakfast and that he/she often saw a couple of fruit flies in the room when the Resident was eating. Resident #35's visitor said he/she often had to swat the fruit flies away from the Resident when the Resident was eating breakfast. Resident #35's visitor said he/she was not sure if the facility administration was aware of the fruit flies in the Resident's room. The surveyor observed the fruit fly on the wall behind Resident #35's head fly off of the wall and into the air. During an interview on 4/2/25 at 9:12 A.M., Nurse #1 said she noticed more fruit flies in the hallways on Unit Two. Nurse #1 said she assumed maintenance knew and was working on a solution. On 4/2/25 at 10:03 A.M., the surveyor observed two fruit flies in Resident #24's room, on the Resident's overbed table. During an interview on 4/2/25 at 10:05 A.M., the Maintenance Director said fruit flies had been an on-going issue in the facility. The Maintenance Director said nursing staff reported increased fruit fly activity on Unit Two a few weeks prior and that pest control services had been in to inspect the facility. On 4/2/25 at 11:09 A.M., the surveyor observed the following in the Unit Two Pantry: -The top of the sink was sealed off with plastic wrap and blue tape. -A large hole in the wall around the pipes in the Unit Two Pantry cabinet under the sink. -Brown-colored water stains on the floor of the cabinet. -Evidence of rodent droppings on the floor of the cabinet. -One fruit fly in the cabinet which flew out of the cabinet after the surveyor opened the cabinet door. -One plate containing partially wet yellow egg yolk and a covered cereal bowl was on the counter near the sink. -The cover on the cereal bowl indicated: 4/2, 0700. -Dried yellow substance on the counter next to the plate. -Two fruit flies were flying around in the food service area of the Pantry. During an interview at the time, Dietary Aide (DA) #2 said the sink was not in use and the Pantry needed to be cleaned. During an interview on 4/2/25 at 1:12 P.M., the Maintenance Director said there was no hole in the cabinet under the sink in the Unit Two Pantry. The surveyor and the Maintenance Director observed the inside of the cabinet under the sink in the Unit Two Pantry where there was a large hole around the pipes. The Maintenance Director said that he did not see why this would be a problem since the hole in the wall never came up as an issue with the pest control company. The Maintenance Director said he has been the Maintenance Director at the facility for about two and a half years. The Maintenance Director said he was responsible to retrieve the pest control reports from an online portal and that pest control recommendations would be completed. The surveyor and the Maintenance Director reviewed the pest control company reports which indicated the need for the facility to fix the hole in the cabinet around the pipes under the Unit Two Pantry sink. The surveyor and the Maintenance Director further reviewed that this recommendation was first made on 7/5/19 and on all pest control reports reviewed by the surveyor from 1/3/25 through 4/1/25. During an interview on 4/2/25 at 2:10 P.M., the Administrator said fruit flies had been a problem for the facility in the past and that he thought the presence of fruit flies on Unit Two had just occurred, over the last couple of days. The Administrator said the facility had enhanced its pest control services with the pest control company and that the Maintenance Director was responsible to implement the recommendations made by the pest control company. On 4/2/25 at 2:22 P.M., the surveyor placed a call to the facility's contracted pest control company and left a message with reception. A representative from the pest control company did not return the surveyor's call by the end of the survey period on 4/3/25.

Based on record review, observations, and interviews, the facility failed to provide appropriate access to the call light for one Resident (#24) out of a total sample size of 18 residents. Specifically for Resident #24, the facility staff failed to place the Residents' call light within his/her reach placing Resident #24 at risk for unmet needs. Findings include: Review of the facility policy titled Resident's Rights Policy, revised 10/4/23, included but was not limited to: -Residents have rights and protections under Federal Law .are rendered without reprisals. < Residents have the right to reside and receive services in the facility with reasonable accommodation of needs and preferences except when to do so would endanger the health and safety of other residents. Review of the facility policy titled Call light answering, dated 5/2/05, included but was not limited to: < Prior to leaving the resident ask if there is anything else you can do for them. < Place the call light within reach of the resident. Review of the facility policy titled Initiating and Ending Clinical Nursing Procedures, dated 5/2/05, included but was not limited to: -It is the policy of this facility to follow all regulations and standards of care related to resident rights and provision of quality of care. To that end, all employees performing procedures in resident care settings will observe general practices relating to resident .dignity . and resident safety. <After performing the procedure, place call light within easy reach of the resident. Resident #24 was admitted to the facility in November 2024 with diagnoses including Parkinson's Disease and Hemiplegia/Hemiparesis following cerebral infarction affecting the left side. Review of the recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #24: -has adequate hearing, clear speech, was able to be understood by others and has the ability to understand others. -has functional limitation in range of motion (ROM) to one side of the upper and lower extremity. -was receiving Hospice end of life services. Review of Resident #24's Social Service Progress Note dated 2/7/25, included but was not limited to: -Resident #24 would not answer questions for the Brief Interview for Mental Status (BIMS) assessment, but the BIMS had been attempted. Review of Resident #24's Comprehensive Person-Centered Care Plan indicated: -Problem: Resident has Hemiplegia of left side. -Interventions included: Place call light within the Residents' reach of the unaffected side and answer [call light] promptly. During an interview on 4/1/25 at 9:22 A.M., Resident #24 said that he/she wanted to tell the Nurse that it was time for his/her medication. Resident #24 said that he/she had a button to push but could not find the button. The surveyor observed that the Residents' call light [button] was located on top of the nightstand, on the left side of the Residents' bed and out of the Residents' reach. During an interview on 4/1/25 at 9:35 A.M., Certified Nurses Aide (CNA) #1 said when Resident #24 needed a drink or something else that the Resident would use the call light to call for the staff. The surveyor and CNA #1 observed Resident #24 lying in bed and the call light was located on top of the nightstand on the left side of the Residents' bed and out of reach for the Resident. CNA #1 said that she had moved the call light to the nightstand when she repositioned the Resident about an hour earlier and forgot to put the call light back within the Residents' reach but should have put the call light back. CNA #1 said that placing call lights within reach was important to Residents so that Residents can use the call light to call for staff when something is wrong or if they needed something. During an interview on 4/2/25 at 9:31 A.M., Nurse #1 said that Resident #24 had the ability to use the call light to call for staff assistance when needed. The surveyor and Nurse #1 observed that Residents #24's call light was secured/clipped to the left side of the bed below the lowest bar of the siderail and out of the Residents' reach. Nurse #1 said that the call light was not within the Residents' reach and should be within reach so that the Resident could call for assistance when needed. Nurse #1 said that the call light should have been clipped to the Residents' shirt and within reach. During an interview on 4/3/25 at 7:45 A.M., the Director Of Nursing (DON) said that call lights should be within a residents' reach at all times so that residents could alert the staff for anything needed.

Based on record review, and interview, the facility failed to provide adequate nutritional care and services for two Residents (#54 and #35) out of a total sample of 18 residents, identified as being at risk for nutritional decline. Specifically: 1. For Resident #54, the facility failed to address significant weight loss and implement effective nutritional interventions when the Resident was identified as having greater than a 5 percent (%) weight loss in one month. 2. For Resident #35, the facility failed to provide the Resident with a diagnosis of Diabetes Mellitus (DM) the ordered glucose control nutritional supplement, when the nursing staff provided original nutritional supplements during meal times that were not ordered and MAR documentation indicated the Resident was receiving the glucose control supplement increasing the Resident's risk for inaccurate nutritional assessment and inappropriate management of blood sugar levels. Findings include: Review of the facility policy for Nutrition Management last revised 9/30/24, indicated: -Residents will receive care and services to ensure acceptable parameters of nutritional status are maintained to the extent possible as indicated by the resident's clinical condition. -Residents will receive a therapeutic diet when indicated. -Staff will consistently observe and monitor residents for changes and implement revisions to the care plan as needed. -provide a therapeutic diet that takes into account the resident's clinical condition and preferences when there is a nutritional indication. Resident #54 was admitted to the facility in May 2021 with diagnoses including Marfan Syndrome (rare genetic disorder of the connective tissue), hemiplegia and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 00 out of 15. -was dependent on staff assistance with eating. Review of Resident #54's 2025 Weights indicated: -1/23/25: 175 pounds (lbs.) -2/17/25: 169.6 lbs. -3/13/25: 156.9 lbs. (significant weight loss of 6.96% from 2/17/25 and greater than 5% in 1 month) Review of Resident #54's Progress Notes indicated: -Dietician Note dated 3/13/25, documenting question weight loss, follow with re-weigh. -Dietician Note dated 3/27/25, documenting re-weight obtained with a 12-pound weight loss in the past month. No snacks. No episodes of upset stomach or vomiting noted. (Dietician) Follow with nursing for nutritional interventions. Review of Resident #54's Nutrition Care Plan, last revised 3/27/25, indicated: -at nutritional risk due to dysphagia with history of cerebrovascular accident, right sided weakness, legally blind with resulting decreased ability to eat on own despite adaptive equipment, expressive aphasia and erosive esophagitis with occasional emesis. -notify Dietician if persistent weight loss. During an interview on 4/1/25 at 1:09 P.M., the Dietician said that she had not implemented interventions for Resident #54 after identifying his/her weight loss. The Dietician also said that she should have added a supplement, but wanted to speak with the Unit Manager (UM) first and did not have the time to do so. Review of Resident #54's clinical record failed to indicate that any intervention had been made following the Resident's weight loss until the surveyor discussion with the Dietician. 42761 2. Review of Nestle's At-a-Glance Nutritional Chart, dated 2019, indicated the following: -Boost Original is a moderate calorie, moderate protein nutritional supplement used to help fill nutritional gaps. -Boost Glucose Control was nutrition for people with Diabetes. -helps meet the unique nutritional needs of people with Diabetes as part of a comprehensive Diabetes management plan. Resident #35 was admitted from the hospital to the facility in January 2025 with diagnoses including Diabetes Mellitus. Review of Resident #35's Weights Summary indicated the following: -1/8/25: 178.3 pounds (lbs.) -2/5/25: 170.8 lbs. -3/27/25: 138.4 lbs. Review of Resident #35's Diabetes Care Plan, dated 1/6/25, indicated the following: -Diet as ordered by MD (Medical Doctor). -Provide diabetic appropriate snacks. Review of the Minimum Data Set (MDS) Assessment, dated 1/9/25, indicated Resident #35: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of 15 total possible points. -required substantial assistance for eating. -had experienced weight gain, not prescribed by the Physician. Review of Resident #35's Nutrition Care Plan, most recently revised 1/9/25, indicated: -Monitor intake at all meals. -Offer alternate choices as needed. -Document intake regarding % (percent) of solids and fluids consumed. -Weight every month on facility scale. -Provide diet as ordered. -Provide supplement as ordered by MD. Review of the Nutrition Consult, dated 1/6/25, indicated Resident #35: -was not receiving nutritional supplements. -had received intravenous fluids while in the hospital. -current weight was 178.3 lbs. -usual body weight (UBW) was 164.5 lbs. -was alert, confused, and forgetful. -usual intake was 0-100%, with an average of 40%. -The Dietician recommended: - follow meal intake and assess for additional nutrition interventions. Review of Resident #35's Physician order, dated 1/20/25, indicated: -controlled carbohydrates diet (restricts the intake of carbohydrates, and can be used to manage blood sugar levels). Review of Resident #35's Laboratory Blood Draw Report, dated 1/22/25, indicated the Resident's A1C (blood test used to measure the average amount of sugar in one's blood over the past three months) was 4.8 (less than 5.7 is considered in range). Review of Resident #35's clinical record indicated: -An order, dated 3/26/25, for Dietitian Consult. -Dietician Progress Note, dated 3/26/25, indicating a request for eight ounces (oz) of Boost Glucose Control drink supplement for the Resident, to be served with lunch for 21 days. -Physician order, dated 3/26/25, for one eight oz can/box Boost Glucose Control supplement drink with lunch for 21 days. Review of Resident #35's March 2025 Medication Administration Record (MAR) indicated: -The Resident received one eight oz can/box of Boost Glucose Control supplement drink with his/her lunch meal daily as ordered, on 3/27/25 through 3/31/25. -The Resident consumed 100% of the Boost Glucose Control supplement drink on 3/27/25, 3/28/25, 3/30/25, and 3/31/25. -The Resident consumed 20% of the Boost Glucose Control supplement drink on 3/29/25. Review of Resident #35's Physician Assistant (PA) Progress Note, dated 3/27/25, indicated: -Nursing reports decreased appetite. -Reported weight loss of 30 lbs. -The Resident had Hypokalemia, likely due to poor intake. -Resident does not appear to have lost that significant amount of weight on exam. -Repeat weight. -Encourage PO (by mouth) intake. -Dietician recommendations appreciated. -Dietician to follow. Review of Resident #35's Dietician Progress Note, dated 3/27/25, indicated the Resident had been re-weighed and experienced apparent approximate 30 lb weight loss in the past month. Review of Resident #35's April 2025 Medication Administration Record (MAR) indicated: -The Resident received one eight oz can/box of Boost Glucose Control supplement drink with his/her lunch meal daily, as ordered, on 4/1/25 through 4/3/25. -The Resident consumed 100% of the Boost Glucose Control supplement drink on 4/1/25 and 4/3/25. -The Resident consumed 50% of the Boost Glucose Control supplement drink on 4/2/25. On 4/2/25 at 9:07 A.M., the surveyor observed the following: -Resident #35 was sitting in a wheelchair, next to his/her bed, eating breakfast. -Resident #35 had a visitor who sat on the edge of the bed, next to the Resident. -There was an empty eight oz bottle of Boost Original nutritional supplement drink on the Resident's table and the supplement drink was in a plastic cup with ice and a straw. -The nutritional supplement drink bottle did not indicate glucose control, and indicated the drink contained 37 grams (g) of total carbohydrate. -The Resident repeatedly picked up the plastic cup containing supplement drink and drank from the straw. During an interview at the time, Resident #35's visitor said he/she came to the facility to visit with Resident #35 every day at breakfast time to encourage the Resident to eat. Resident #35's visitor said that staff at the facility were very helpful and always made sure the Resident had a Boost nutritional supplement drink with breakfast because the Resident did not always eat well. On 4/3/25 at 9:10 A.M., the surveyor observed the following: -Resident #35 was sitting upright in bed, eating breakfast. -The Resident had the same visitor as the previous day, who was sitting in a chair next to the Resident's bed. -There was an empty eight oz. bottle of Boost Original nutritional supplement drink on the Resident's table and the supplement drink was in a plastic cup with ice and a straw. -The nutritional supplement drink bottle did not indicate glucose control, and indicated the drink contained 37 grams (g) of total carbohydrate and 15 g of sugar. -The Resident alternated eating the breakfast meal and drinking the supplement drink. During an interview at this time, Resident #35's visitor said Certified Nurses Aide (CNA) #5 provided Resident #35 with the Boost Original supplement drink that morning at breakfast. Resident #35's visitor said the Resident liked the supplement drinks and that one was provided to the Resident every day with breakfast. Resident #35's visitor then said the Resident ended up drinking two of the supplement drinks the previous day (4/2/25) with breakfast. At this time, Nurse #7 entered the Resident's room holding a box of drink supplement and said she had a supplement drink for the Resident. Nurse #7 looked at the Resident's table and said, Oh, you already have one . then left the room with the additional box of drink supplement. Review of Resident #35's Meal Intake Record indicated the Resident consumed 100% of his/her breakfast meal on 4/2/25 and 4/3/25. Review of the Resident's clinical record failed to indicate any information relative to the nutritional drink supplements consumed by the Resident on 4/2/25 and 4/3/25. During an interview on 4/3/25 at 9:52 A.M., the Dietician said Resident #35 appeared to have had an approximate 30 lb weight loss over the previous month and that there may have been a problem with the accuracy of the scale. The Dietician said Resident #35 was supposed to receive one eight-ounce box of Boost Glucose Control drink supplement with lunch daily for 21 days and that staff were to monitor and record the amounts of meals and supplement drinks the Resident consumed. The Dietician said the Boost Glucose Control drink supplement was newly ordered due to the Resident's weight loss and diabetic condition. The Dietician said that Resident #35 had DM and that the Resident had always been concerned with his/her diabetic condition. The Dietician said she recommended the glucose control drink supplement for lunch time meals because lunch was when the Resident's intake appeared to be the lowest. The Dietician said for Residents with DM, it was important to consider the total carbohydrates in food and drinks when considering dietary needs. The Dietician then said the total carbohydrates in the Boost Original supplement drink that had been provided to resident #35 on 4/2/25 and 4/3/25 with breakfast contained 37 g of total carbohydrates. The Dietician said if the Resident was eating his/her meals and consuming regular drink supplements, this could impact the Resident's blood sugar and A1C levels. The Dietician also said nutritional supplements being provided to residents without an order and without her knowledge could impact her ability to accurately assess the residents' nutritional status and recommendations for nutritional interventions. The Dietician then said that she would review the Boost Glucose Control supplement drink contents for total carbohydrates and whether the Resident had any routine blood sugar monitoring in place and get back to the surveyor. During a follow-up interview on 4/3/25 at 10:08 A.M., the Dietician said the glucose control drink supplement contained 16 g of total carbohydrates compared to the Boost Original drink supplement that contained 37 g of total carbohydrates. During an interview on 4/3/25 at 10:55 A.M., CNA #5 said she gave Resident #35 a nutritional drink supplement every morning because she knew the Resident liked the drinks. CNA #5 said she would typically check with the Nurse before giving a resident a nutritional supplement drink and that she had not checked with the Nurse to see if giving the nutritional drink supplement to Resident #35 was okay. CNA #5 said she gave the Resident the nutritional drink supplement every day at breakfast because the Resident's visitor requested this and knew what the Resident liked. At this time, CNA #5 showed the surveyor the supply closet where the nutritional drink supplements were stored on the Unit. CNA #5 unlocked the supply closet door and the surveyor observed four different types of Boost nutritional drink supplements, including Boost Original and Boost Glucose Control. When the surveyor asked CNA #5 how she knew which supplement was to be provided for the residents, CNA #5 said she just always provided the Boost Original nutritional drink supplements. CNA #5 said she never provided Boost Glucose Control nutritional drink supplements to any resident. During an interview on 4/3/25 at 11:05 A.M., Nurse #7 said she overheard the surveyor speaking with Resident #35 about the nutritional supplement that morning at breakfast and she thought the Resident was supposed to receive one and did not get it. Nurse #5 said that was why she entered the room with a nutritional drink supplement for the Resident and that she assumed since the surveyor was speaking with the Resident about the supplement that the Resident was supposed to have one. During an interview on 4/3/25 at 11:40 A.M., Unit Manager (UM) #1 said she was not aware staff on the Unit had been providing nutritional supplement drinks to Resident #35 that were not ordered by the Physician. UM #1 said nutritional supplement drinks were to be provided to residents by a Nurse, according to the Physician's order. During an interview on 4/3/25 at 12:04 P.M., the Regional Nurse said that she realizes staff care and want to help the residents and that they may not realize providing additional nutrition supplements that are not ordered could impact a resident's medical care. The Regional Nurse said education needed to be provided to staff about the risk involved when nutritional inventions were not followed as ordered by the Physician.

Based on interview, and record review, the facility failed to conduct an admission assessment and document participation in the assessment to determine the necessary care and services required for one Resident (#88) out of three closed records reviewed. Specifically, for Resident #88, the facility failed to conduct direct observation and communication and complete an accurate Resident assessment upon admission, resulting in the Resident eloping from the facility. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, indicated the following relative to Cognition and Mood: -An interview is considered missed when the resident should have been interviewed, but the interview was not completed in the look back period of the assessment. -Regardless of the reason the interview was not completed -When a resident interview is missed: >C0100, is coded 1: Yes, the interview should be completed, and >The resident interview and staff assessment responses must be dashed if the interview was not completed. Resident #88 was admitted to the facility in January 2025 with diagnoses including alcohol use withdrawal, Wernicke Encephalopathy, Anxiety and Depression. Review of Resident #88's medical record indicated: -nursing admission assessment was not completed at the time of admission. -no nursing admission note with the date and time of the Resident's arrival to the facility, cognitive patterns, mood and behavior patterns, psychological well-being, and discharge planning was completed as required at the time of admission. Review of Resident #88's January 2025 medical record progress notes indicated: -1/24/25 at 12:00 P.M.: Social Services was informed that the Resident left AMA. Protective Services Referral was initiated. -1/24/25 at 15:59 (3:59 P.M.): Nursing Progress Note - Nursing called the Resident's cell phone and the Resident informed nursing that he/she was home safe. The Resident was not aware that he/she needed to sign a release form. The Resident stated he/she thought he/she could just leave when he/she wanted. -1/24/25 at 9:00 P.M.: NP [Nurse Practitioner]/PA [Physician Assistant] Progress Note - Resident seen, anxious and thinking of going home, discussed importance of staying and completing rehab, risk of going AMA, declined many questions, discussed with Social Service. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #88: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15 total possible points. During an interview on 4/3/25 at 12:31 P.M., Social Worker (SW) #1 said she did not see the Resident or assess the Resident upon admission. SW #1 said she was informed by the nursing staff that Resident #88 had left the facility. During an interview on 4/3/25 at 1:38 P.M., the MDS Nurse said SW #1 was the staff member who completed the MDS Section C (Cognition) and Section D (Mood) assessments for Resident #88. During an interview on 4/3/25 at 1:41 P.M., SW #1 said she should not have documented a BIMS of 0 on Resident #88 since she never saw the Resident. SW #1 said the MDS assessment for Resident #88 was documented inaccurately. During an interview on 4/3/25 at 12:43 P.M., Nurse #8 said she saw Resident #88 between the hours of 7:00 A.M. to 9:00 A.M. on 1/24/25, and the Resident informed her that he/she wanted to leave the facility. Nurse #8 said she told the Resident to wait until he/she was seen by the Physician. Nurse #8 further said she went to the Resident's room and found the Resident's room empty at 11:30 A.M. and alerted the DON. Please Refer to F689

Based on observation, interview, and record review, the facility failed to provide grooming assistance for one Resident (#55), out of a total sample of 18 residents. Specifically, the facility failed to ensure that Resident #55 was assisted with facial hair removal when he/she required assistance from staff with personal hygiene. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), effective 11/14/16, indicated: -each resident will receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological wellbeing, consistent with the resident's comprehensive plan of care. The ADL policy also included the following: >The facility will provide care and services for hygiene-bathing, dressing and grooming. >The care and services for ADLs will be based on the resident's ability as identified in MDS assessment, Rehab evaluation, nursing assessment and person-centered care plan. >Resident's abilities, personal choices and self-image are accounted for during ADLs. >ADLs are documented in the clinical record by staff member supporting ADLs. Resident #55 was admitted to the facility in January 2023 with diagnoses including Depression and Hyperparathyroidism. Review of a Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #55: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of eight out of a total possible score of 15. -required assistance with personal hygiene. Review of the Comprehensive Care Plan, last revised 3/20/25, indicated Resident #55: -had decreased ability to provide self-care. -decreased ability to perform ADLs. -required assistance with grooming. On 3/31/25 at 10:55 A.M., the surveyor observed Resident #55's chin to have long, thick facial hair. During an interview at the time, Resident #55 said he/she does not like to have any facial hair and that staff will help remove the facial hair when he/she remembers to ask for assistance. On 4/1/25 at 10:55 A.M., the surveyor observed that Resident #55 remained with long, thick facial hair on his/her chin. During an interview at the time, Resident #55 said he/she forgot to ask staff to remove the facial hair. During an interview on 4/1/25 at 10:51 A.M., Certified Nurses Aide (CNA) #8 said she is familiar with Resident #55 and has provided care for the Resident many times. CNA #8 said that Resident #55 needs needs assistance with all ADLs and the CNA is aware that Resident #55 prefers not to have facial hair because he/she has requested in the past that the facial hair be removed. CNA #8 said if Resident #55 did not ask to have his/her facial hair removed then CNA #8 would offer to remove the Resident's facial hair. CNA #8 said that she is not required to document removal of facial hair for Resident #55 in the clinical record. During an interview on 4/01/25 at 2:17 P.M., the Director of Nursing (DON) said that CNAs are expected to ask all residents with facial hair if they would like to have facial hair removed and the CNAs should have removed Resident #55's facial hair. The DON said that removal of facial hair should have been addressed with Resident #55's daily ADL care but that it was not addressed.

Based on record review, observations, and interviews, the facility failed to provide treatment and services adhering to professional standards of practice related to Hospice services for one Resident (#62) out of a total sample of 18 residents. Specifically, for Resident #62, the facility failed to ensure that Hospice recommendations for comfort medication orders were implemented in a timely manner leading to a delay in medication administration for the Resident. Findings Include: Review of the facility policy titled Hospice Program, last revised 3/28/22, indicated: -when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other comfort measures. -a member of the interdisciplinary clinical team from each facility and the hospice organization will be designated to ensure the coordination of care delivery. Resident #62 was admitted to the facility in January 2022 with diagnoses including Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 00 out of 15. -was receiving Hospice services. -was having physical/verbal/other behaviors directed and not directed towards others. -was rejecting care. -was wandering during the seven day look back period. Review of Resident #62's clinical record indicated: -the Resident started receiving Hospice services on 1/17/25 -a Hospice Recommendation to Physicians Form dated 1/17/25 that was signed by the Resident's Physician to please add the following comfort medication orders: >Morphine Sulfate (opiate analgesic medication) 20 milligrams (mg)/milliliters (ml): give 0.25 ml (5 mg) by mouth sublingually [under the tongue] every 2 hours as needed (PRN) for pain or shortness of breath (SOB). Call if using more than 3 doses in 24 hours >Lorazepam (antianxiety medication) 0.5 mg tablets: give 1 tablet by mouth every 6 hours as needed (PRN) for anxiety and restlessness >Acetaminophen (pain/fever reliever medication) 650 mg suppository: insert 1 suppository (650 mg) rectally every 6 hours as needed (PRN) for mild pain or fever >Hyoscyamine (anticholinergic/ antispasmodic) 0.125 mg sublingual tablet: place 1 tablet (0.125 mg) under the tongue every 4 hours as needed for terminal secretions >Bisacodyl (laxative) 10 mg suppository: insert 1 suppository (10 mg) rectally as needed for constipation >Sennas (stimulant laxative) 8.6-50 mg: give 1 to 2 tablets by mouth 2 times daily as needed for constipation. -a Hospice Recommendation to Physician Form dated 2/27/25, signed by the Resident's Physician for the same comfort medication orders listed on 1/17/25, which further documented: *current issue: *patient on Hospice services since January 2025. *Comfort medications not yet added to the medication profile. -a Hospice Nursing Progress Note dated 3/7/25, that indicated a plan for the night Nurse to follow up that all standard Hospice comfort medications get on the patient's (medication) orders. -a Hospice Recommendation to Physician Form dated 3/13/25, that documented: *current issue: *ACTION NEEDED. *Patient admitted to Hospice services on 1/17/25, in need of comfort medication orders. This is the third recommendation submitted. -a Hospice Nursing Progress Note dated 3/13/25, that indicated recommendations left WITH URGENCY to ensure comfort medications orders are in place at extended care facility. Review of the April 2025 Physician's orders for Resident #62 indicated that the comfort medications were ordered on 3/13/25 (55 days after the initial recommendation by Hospice). During an interview on 4/3/25 at 9:01 A.M., the Director of Nursing (DON) said that Hospice recommendations should be followed up by the facility within 24 hours of the recommendation. During an interview on 4/3/25 at 11:01 A.M., the DON said that the Hospice recommendations should have been implemented when they were initially recommended, and Hospice recommendations had not been implemented.

Based on record review, and interview, the facility failed to ensure the safety of one Resident (88) out of a total sample of 18 residents, who was at risk for elopement. Specifically, for Resident #88, the facility failed to assess on admission the Resident with a history of substance use disorder (SUD) for risk of elopement and initiate the elopement response when the Resident left the facility without staff being aware. Findings include: Review of the facility policy titled Elopement Prevention and Response, revised 2/24/25, indicated: -It is the policy of the facility to identify residents at risk for elopement through the completion of the Wandering/Elopement risk assessment and to provide a secure environment through the implementation of individualized care interventions. -It is the policy of the facility to ensure that residents who are at risk of elopement are escorted to and supervised during activities off unit such as rehab and outdoor activities. -Upon admission nursing will complete a wandering/elopement risk assessment. -If residents are determined to be at risk for elopement, a care plan goal and individualized approaches to ensure safety will be implemented in interdisciplinary team. -Care plan interventions will be based on assessment of risk factors for elopement including medical conditions, diagnoses including SUD (substance use disorder) history and risk for relapse and psychosocial triggers (new environment, change of routine, family dynamics). -At first notice that the resident does not seem to be in their usual/immediate living space, the resident is to be considered missing and supervisor (or highest-ranking on-site staff member) is notified. -If facility search is unsuccessful, the individual in charge will carry out the following: 1) Notify the Administrator and Director of Nursing (DON) 2) Notify the Police Department . Review of the facility policy titled Discharge Against Medical Advice (AMA), revised 2/20/19, indicated: -Ensure resident can make medical decisions. -Encourage the resident/legal representative to consult the attending physician before leaving the facility regarding his/her choice to leave the facility. -Place the documentation of staff/resident/legal representative interactions in the clinical record. Resident #88 was admitted to the facility in January 2025 with diagnoses of alcohol use withdrawal, Wernicke Encephalopathy, Anxiety and Depression. Review of Resident #88's medical record failed to indicate: -nursing admission assessment related to wandering or elopement risk. -nursing admission note to include the date and time of the Resident's arrival to the facility, assessment of mental status upon admission, and ambulation status. Review of Resident #88's January 2025 medical record progress notes indicated: -1/24/25 at 12:00 P.M.: Social Services was informed that Resident left AMA. Protective Services Referral was initiated. -1/24/25 at 15:59 (3:59 P.M.) Nursing Progress Note - Nursing called the Resident's cell phone and the Resident informed nursing that he/she was home safe. The Resident was not aware that he/she needed to sign a release form. The Resident stated he/she thought he/she could just leave when he/she wanted. -1/24/25 at 9:00 P.M.: NP [Nurse Practitioner]/PA[Physician Assistant] Progress Note - Resident seen, anxious and thinking of going home, discussed importance of staying and completing rehab, risk of going AMA, declined many questions, discussed with Social Service. During an interview on 4/3/25 at 12:29 P.M., the Director of Nursing (DON) said Resident #88 was admitted to the facility in January 2025. The DON said there was no nursing assessment completed for the Resident by nursing upon admission to the facility. The DON said that there was no nursing assessment of the Resident's cognitive status or whether the Resident was at risk for wandering/elopement. The DON further said there was no nursing admission note that could identify the time the Resident was admitted to the facility and if there were any obvious concerns the nursing staff could have identified and documented. During an interview on 4/3/25 at 12:22 P.M., the Registered Dietician (RD) said she had seen Resident #88 when he/she arrived at facility and had sent a diet slip to the kitchen so the Resident could receive his/her evening meal. During an interview on 4/3/25 at 12:31 P.M., Social Worker (SW) #1 said she did not see the Resident or assess the Resident upon admission. SW #1 said she was informed by the nursing staff that Resident #88 had left the facility. During an interview on 4/3/25 at 12:43 P.M., Nurse #8 said she saw Resident #88 between the hours of 7:00 A.M. to 9:00 A.M. on 1/24/25, and the Resident informed her that he/she wanted to leave the facility. Nurse #8 said she told the Resident to wait until he/she was seen by the Physician. Nurse #8 further said she went to the Resident's room and found the Resident's room empty at 11:30 A.M. and alerted the DON. During an interview on 4/3/25 at 1:19 P.M., the DON said she did not consider that Resident #88 had eloped as the facility called the Resident's home and the Resident said he/she was home safe. The DON said the Resident informed the facility staff that he/she had left the facility with an Uber driver. The DON said she sent paperwork and medications to the Resident's home and the Resident signed the AMA form. The DON said she should have initiated the facility's elopement policy, but she did not.

Based on record reviews, and interviews, the facility failed to accurately monitor the fluid intake for one Resident (#36) out of a total sample of 18 residents. Specifically, for Resident #36, the facility staff failed to accurately allot the daily fluid intake as ordered by the Physician and monitor the total daily fluid intake for the Resident dependent on renal dialysis, placing him/her at risk for complications related to fluid overload. Findings include: Review of the facility policy titled Dialysis Residents-Coordination of Care, revised 11/19/18, included: -The nursing facility is responsible for the overall quality of care and services the resident receives and provides the services, consistent with professional standards of practices, to residents receiving dialysis as outlined by their comprehensive person-centered plan of care. >A comprehensive person-centered plan of care . will include: -monitoring of .fluid needs and restrictions. >The facility remains responsible for the overall quality of care the resident receives including the customary standards of care provided by the facility and including the following: -monitoring fluid balance through recording and assessment of intake and output as indicated. Review of the facility policy titled Intake and Output-Monitoring of, revised 10/30/18 indicated: -Intake and output measurement is instituted based on .physician order. >Intake and output will be monitored for the following residents: -Residents receiving dialysis. >Record intake amounts in cc's (cubic centimeters) including: -PO (per os), amounts taken by mouth. >Total shift and daily intake .records. >Document: -Intake .in resident's medical record. Review of the facility policy titled Fluid Restriction, revised January 2009, included: -When a physician orders a fluid restriction due to specific clinical condition, close monitoring will be provided to maintain adequate hydration. >Verify physician order. Order must include volume or range of fluid permitted during a 24-hour period. >Notify dietary department. a. Dietary to calculate amount of fluids to be provided on meal trays. >Calculated remaining amount of fluids to be provided by nursing. a. Calculate amount allotted for each shift. >Document: a. Intake in medical record. Resident #36 was admitted to the facility in May 2023 with diagnoses including End Stage Renal Disease (ESRD) and dependence on renal dialysis. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #36: -was receiving dialysis. -was receiving a therapeutic diet. Review Resident #36's Comprehensive Person-Centered Care Plan, revised 2/2/24, included: -Problem: End Stage Renal Disease with need for Hemodialysis (HD). <Interventions included: Fluid restriction as ordered with intake monitoring (see nutritional care plan). -Problem: Nutrition/ ESRD with Hemodialysis. <Interventions included: Provide diet as ordered: 1200 ml (milliliters or cc's) Fluid Restriction. <Document intake regarding percentage of .fluids consumed. Review of Resident #36's March 2025 Physician orders included: >Hemodialysis every Tuesday, Thursday and Saturday. >Fluid Restriction 1200 ml: -Day Shift (7:00 A.M. - 3:00 P.M.) Fluid Restriction 1200 ml: Breakfast = 240 ml, Lunch = 240 ml, Nursing day = 600 ml. Add meal intake to total shift intake. -Evening Shift (3:00 P.M.-11:00 P.M.) Fluid restriction 1200 ml: Dinner =120 ml, Nursing eve (evening) = 480 ml. Add meal intake to total shift intake. -Night Shift (11:00 P.M.- 7:00 A.M.) Fluid restriction 1200 ml: Nursing night = 120 ml. During an interview on 4/1/25 at 11:38 A.M., Nurse #10 said that she was the Nurse assigned to Resident #36. Nurse #10 said that Resident #36 was prescribed a 1200 ml fluid restriction daily. Nurse #10 said that the Registered Dietitian (RD) and the Unit Manager (UM) determined how much fluid is allotted for nursing and the dietary department for a 24-hour period. Nurse #10 said that the completion and totaling of the 24-hour fluid intake for Resident #36 should be done by the 11:00 P.M.-7:00 A.M. (night shift) Nurse and was important because HD residents could have cardio-pulmonary distress if too much fluid was taken in during a 24-hour period. The surveyor and Nurse #10 reviewed Resident #36's Medication Administration Records (MARs) which indicated: -January 2025 MAR: total allotted daily intake was 1800 ml (not 1200 ml as ordered by the Physician) for 31 out of 31 days, and the total daily intake was not totaled for 12 out of 31 days. -February 2025 MAR: total allotted daily intake was 1800 ml (greater than the 1200 ml ordered by the Physician) for 28 out of 28 days, and the total daily intake was not totaled for 20 out of 28 days. -March 2025 MAR: total allotted daily intake was 1800 ml for 31 out of 31 days, and the total daily intake was not totaled for 20 out of 31 days. During an interview on 4/1/25 at 12:12 P.M., the Director of Nursing (DON) said the RD determined the fluids allotted by shift/per day for dining services and nursing. The DON said that once the RD determines the total fluid allotment, the order should be entered into the resident's electronic medical record (EMR) by the RD or unit Nurses. The DON said that accuracy of monitoring and recording of fluid restrictions was important so that residents are provided with what is ordered by the Physician. The DON said that the unit Nurses were responsible for documenting and totaling fluid intake records. During an interview on 4/1/25 at 12:55 P.M., the RD said that fluid restrictions are determined by the ordering Physician. The RD said that Nurses enter the orders for fluid restriction into the EMR as ordered by the Physician. The RD said that the 1200 ml fluid restriction allotment was a pre-set, pre-established template within the facilities computer system and therefore not determined by the RD. The RD said that she did not follow the daily fluid intakes once the order has been entered into the residents EMR. The surveyor and the RD reviewed Resident #36's MARs for January 2025, February 2025, and March 2025. The RD said that the allotted fluids template on the MARs had totaled 1800 ml and not the 1200 ml as ordered by the Physician. The RD said that the 1200 ml fluid restriction allotment in the facilities computer system was wrong and needed to be corrected. The RD said that Nurses should be totaling the daily 24-hour intake consistently but that was not done.

Based on interview, and records reviewed, the facility failed to ensure all required members of the QAPI Committee participated in quarterly QAPI meetings. Specifically, the facility failed to ensure the Infection Preventionist (IP) attended and participated in one of four consecutive quarterly QAPI meetings reviewed. Findings include: Review of the facility's four most recent quarterly QAPI meeting attendance sheets provided by the facility indicated the following: -All required members were present for the meeting held on 1/28/25. -All required members were present for the meeting held on 10/17/24. -All required members were present for the meeting held on 7/17/24. -The Administrator, Director of Nursing (DON), and Medical Director were present for the meeting held on 2/8/24. -The IP was not present for the meeting held on 2/8/24. During an interview on 4/3/25 at 1:45 P.M., the Administrator said that the facility did not have an IP when the quarterly QAPI meeting was held on 2/8/24.

Based on record review, observation, and interview the facility failed to adhere to infection control standards of practice for one Resident (#44) out of a total sample of 18 residents, and maintain sanitary medication storage for a medication administration cart on one unit (Unit Two) out of two units. Specifically, 1. For Resident #44, the facility staff failed to follow Physician orders for Enhanced Barrier Precautions (EBP's-the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing high contact wound care for the Resident. 2. the facility failed to maintain a clean medication administration cart during a medication administration observation on Unit Two putting the unit residents at risk for medication contamination. Findings include: 1. Review of the facility policy titled Enhanced Barrier Precautions, dated 1/10/23 included but was not limited to: -EBP's will be used in these conditions . <All residents on the unit with any wounds. -EBP's require gowns and gloves for all high contact care including . <Wound care, any skin opening requiring a dressing. Resident #44 was admitted to the facility in November 2024 with diagnoses including Pressure Ulcer (localized damage to the skin and/or underlying tissue that occurs as a result of long-term pressure) of the right heel area. Review of Resident #44's Comprehensive Person-Centered Care Plan indicated: -Problem: Pressure ulcer to right heel, effective 2/11/25. <Interventions: Treatment to area per Physician order. -Problem: EBP, last revised 2/25/25. <Interventions: EBP signage to residents' room and to utilize Personal Protective Equipment (PPE- special protective barriers like gloves, gowns, masks and/or goggles worn to create a barrier between a person and germs) per policy for high contact. Review of Resident #44's March 2025 Physician's orders indicated: -Right heel, day shift (7:00 A.M.-3:00 P.M.) apply collagen Puracol [brand] sheet, covered by foam and change daily. -Enhanced Barrier Precautions every shift. EBP signs posted on the resident's door with proper PPE. On 4/2/25 at 9:04 A.M., the surveyor observed Resident #44 seated in a wheelchair in his/her bedroom. The surveyor observed signage on the Resident's doorway which included: -ENHANCED BARRIER PRECAUTIONS. EVERYONE MUST: <Clean their hands, including before entering and when leaving the room. -PROVIDERS AND STAFF MUST ALSO: <Wear gloves and gowns for the following High-Contact Resident Care Activities: >Wound care: any skin opening requiring a dressing. On 4/2/25 at 11:02 A.M., the surveyor observed the following wound care provided to Resident #44: -Nurse #8 and Unit Manager (UM) #2 cleansed their hands with hand sanitizer, donned (put on) clean gloves and entered the Resident's room. -Nurse #8 and UM #2 were not observed to don gowns prior to entering the Resident's room. -Nurse #8 cleaned the work surface with a disinfectant wipe, allowed it to dry and then placed a clean towel on top of the disinfected work surface. -Nurse #8 discarded her gloves into a clear plastic trash bag being held by UM #2. Nurse #8 cleansed her hands with hand sanitizer and donned clean gloves. -Nurse #8 was then observed to set up dressing supplies on the clean work surface. -Nurse #8 doffed (removed) her gloves, discarded them into a clear trash bag being held by UM #2. Nurse #8 then cleansed her hands with hand sanitizer and donned clean gloves. -Nurse #8 removed the Resident's sock and shoe from the right foot followed by the old dressing that was in place on the Resident's right heel. -The old dressing was observed to contain a small amount of ensanguines (bloody) drainage and Nurse #8 discarded the old dressing into the clear plastic trash bag held by UM #2. -Nurse #8 then placed a clean dry towel under the Resident's right heel. -Nurse #8 doffed her gloves, discharged her gloves into the clear plastic trash bag being held by UM #2. Nurse #8 then cleansed her hands with hand sanitizer and donned clean gloves. -Nurse #8 cleansed the Resident's right heel wound with 4-inch x 4-inch gauze and normal saline solution. -Nurse #8 doffed her gloves and discarded them into the clear plastic trash bag held by UM #2, cleansed her hands with hand sanitizer and don new gloves. -Nurse #8 applied a 2-inch x 2-inch square of collagen Puracol dressing to the wound bed followed by a foam dressing. -Nurse #8 re-applied the Resident's sock and shoe. -UM #2 removed the residual dressing supplies from work surface and discarded them into the clear plastic trash bag. -UM #2 and Nurse #8 were observed to doff their gloves, discard the gloves into the clear plastic trash bag and cleanse their hands with hand sanitizer before exiting the Resident's room. The surveyor, Nurse #8, and UM #2, observed the EBP signage hanging on Resident #44's doorway. Nurse #8 said that the signage was for Resident #44 because the Resident required EBP. UM #2 said that the EBP signage was posted for Resident #44 because of the need for wound care. UM #2 said that all residents with wounds require EBP. Nurse #8 said that EBP prevents the residents from getting an infection from the staff. UM #2 said that she and Nurse #8 should have had gowns on when providing Resident #44's wound care but did not have gowns on. During an interview on 4/3/25 at 11:04 A.M., the Infection Preventionist (IP) said that all residents with wounds should be placed on EBP and that the nursing staff had been educated on the importance of EBP about a month ago. The IP said that EBP was needed to prevent residents from being exposed to germs by facility staff and that staff should be wearing gowns when providing wound care. 47901 2. Review of the facility policy titled General Cleaning and Maintenance of Equipment, revised 6/28/16, indicated: -Resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse. -Equipment and supplies will be cleaned and decontaminated as soon as practical after use. On 4/2/25 at 9:34 A.M., the surveyor observed Nurse #5 during the medication administration pass on Unit Two. The surveyor and Nurse #5 observed the medication administration cart to have a dried spilled liquid in the drawers and particles of medication pills left in the medication cart drawers, along with an old rusted scissors in a drawer. The surveyor further observed that the medication cart also contained stained dried dark particles in the corners of the drawers. During an interview at the time, Nurse #5 said she was an Agency Nurse and that this was her first time being on the medication cart. Nurse #5 said the medication cart could harbor bacteria which could lead to the spread of infections. On 4/2/25 at 9:37 A.M., the surveyor, Nurse #5, and Director of Nursing (DON) observed the same medication cart on Unit Two. The DON said the medication cart was dirty and needed to be cleaned. The DON said there was a cleaning schedule but was unsure when the medication cart was last cleaned and/or disinfected.

Based on interviews, and records reviewed, the facility failed to administer Pneumococcal Vaccinations for two Residents (#36 and #81) of five applicable residents, out of a total sample of 18 residents, increasing the Residents' risk for acquiring Pneumococcal illnesses. Specifically, the facility failed to administer Pneumococcal Vaccines for Residents #36 and #81, when the Residents were eligible to receive, and consented to, the Pneumococcal immunization. Findings include: Review of the facility's policy titled Resident Pneumococcal Immunization, dated September 2011 and revised 9/1/23, indicated the following: -Residents will be offered immunizations to protect them against Pneumococcal disease unless the vaccine is medically contraindicated, or the resident has already been immunized. -Pneumococcal immunizations will be provided as recommended by the CDC (Centers for Disease Control and Prevention) Advisory Committee for Immunization Practices (APIC) recommendations. -Standing orders signed by the Medical Director for Pneumococcal immunization will be utilized. -Individual orders from each attending physician are not required. -It is best to use the PneumoRecs VaxAdvisor app or website. -The PneumoRecs VaxAdvisor app helps vaccination providers quickly and easily determine which Pneumococcal Vaccines a patient needs and when. Review of the CDC guidance titled Pneumococcal Vaccine Recommendations, dated 10/26/24, indicated the following for individuals [AGE] years of age and older: -Administer PCV (Pneumococcal Conjugate Vaccine) 15 (Pneumococcal immunization that protects against 15 types of Pneumococcal disease), PCV20 (Pneumococcal immunization that protects against 20 types of Pneumococcal disease), or PCV21 (Pneumococcal immunization that protects against 21 types of Pneumococcal disease), for all adults [AGE] years or older: -Who have never received any Pneumococcal Conjugate Vaccine. -Whose previous vaccination history is unknown. -If PCV15 is used, administer a dose of PPSV23 at least one year later. -The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition. -If PCV20 or PCV21 is used, a dose of PPSV23 is not indicated. 1. Resident #36 was admitted to the facility in May 2023 with diagnoses including Diabetes Mellitus (DM) and End Stage Renal Disease (ESRD). Review of Resident #36's Immunization Record indicated the Resident received a dose of PPSV23 Vaccine on 1/17/19. Review of Resident #36's clinical record indicated the following: -The Resident was greater than [AGE] years of age. -No evidence the Resident had received any Pneumococcal immunizations since the dose of PPSV23 on 1/17/19. -Consent for administration of Pneumococcal immunization, dated 4/12/24. Review of the CDC PneumoRecs VaxAdvisor online calculator indicated the following recommendation for Resident #36: -Give one dose of PCV15, PCV20, or PCV21 at least 1 year after the last dose of PPSV23. 2. Resident #81 was admitted to the facility in June 2024 with diagnoses including Hypertension, DM, and Chronic Kidney Disease (CKD). Review of Resident #81's clinical record indicated the following: -The Resident was greater than [AGE] years of age. -The Resident consented to receive the Pneumococcal immunization on 10/21/24. -No evidence the Resident had ever received a Pneumococcal Vaccine. Review of the CDC PneumoRecs VaxAdvisor online calculator indicated the following recommendation for Resident #81: -Give one dose of PCV15, PCV20, or PCV21. -If PCV20 or PCV21 is used, their Pneumococcal vaccinations are complete. -If PCV15 is used, follow with one dose of PPSV23 to complete their Pneumococcal vaccinations. During an interview on 4/1/25 4:30 P.M., the Regional Infection Preventionist (IP) said that Resident's #36 and #81 were not up-to-date with their Pneumococcal immunizations and that providing the Pneumococcal immunizations to both Residents had been missed by the facility. The Regional IP said that neither Resident #36 nor Resident #81 had any medical contraindications for the Pneumococcal immunizations being administered.

Based on interview, and record review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) for one Resident (#389) out of a total sample of 18 residents. Specifically, for Resident #389, the facility failed to issue a SNF ABN to the Resident and/ or Resident Representative when effective date of coverage for skilled services ended. Findings include: Review of the Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: ,d+[DATE], indicated the following: -The ABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. -The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Employees or subcontractors of the notifier may deliver the ABN. ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain a copy of the ABN delivered to the beneficiary on file. -The beneficiary (or representative) must sign the notice to indicate that he or she has received the notice and understands its contents. If a representative signs on behalf of a beneficiary, he or she should write out representative in parentheses after his or her signature. The representative's name should be clearly legible or noted in print. -The beneficiary (or representative) must write the date he or she signed the ABN. If the beneficiary has physical difficulty with writing and requests assistance in completing this, the date may be inserted by the notifier. Resident #389 was admitted to the facility in [DATE]. Review of Resident #389's clinical record indicated: -the Resident was not his/her own responsible party. -the Resident's effective date of coverage for their skilled services ended on [DATE]. -the Resident remained in the facility and did not discharge. -no evidence that the SNF ABN had been issued to the Resident's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself). During an interview on [DATE] at 10:12 A.M, the Clinical Reimbursement Coordinator said that she should have issued the SNF ABN form to the Resident's Responsible party (HCP) after he/she had come off (expired) their skilled benefit but she did not issue the SNF ABN form.

Based on record review, and interview, the facility failed to accurately code a Minimum Data Set (MDS) Assessment for one Resident (#36) out of a total sample size of 18 residents. Specifically, for Resident #36, the facility staff failed to code the MDS accurately relative to antiplatelet (medication which prevents blood platelets from clumping together to form a clot) medication use. Findings include: Resident #36 was admitted to the facility in May 2023 with diagnoses including Aortic Valve Stenosis, Myocardial Infarction, and Hypertension. Review of Resident #36's March 2025 Physician orders included: -Enteric Coated Aspirin (antiplatelet medication) 81 mg (milligram), one tablet oral at noon for prevention of cardiac complications, effective 10/14/23. Review of the MDS assessment dated [DATE], indicated Resident #36: -was taking antianxiety, antidepressant, hypoglycemic and anticonvulsant medications. -was not coded for antiplatelet medication administration. During an interview on 4/1/25 at 10:27 A.M., MDS Nurse #1 said that the facility staff followed the Resident Assessment Instrument (RAI) Manual for guidance when completing a MDS assessment. MDS Nurse #1 said that Resident #36 was receiving an antiplatelet medication. MDS Nurse #1 said that Resident 36's MDS assessment dated [DATE], did not have an antiplatelet medication coded but should have. MDS Nurse #1 said that accurate MDS coding was important for person-centered care planning to ensure proper care and services were in place for Resident #36.

Based on record review and interviews, for one of three sampled residents (Resident #1) who was exhibiting signs and symptoms of Influenza, the facility failed to ensure he/she was provided with quality care and services that meet professional standards of practice, when after an Influenza test had been conducted on 03/06/25, with positive test results on 03/07/25, the test results were not obtained by nursing until 03/12/25, six days after the test was obtained, as a result Resident #1 was unable to receive antiviral medication used to treat Influenza putting him/her at risk for complications from influenza. Findings include: Review of the Facility's policy titled Laboratory and Radiology Services, dated as revised 11/17/16, indicated laboratory and testing will be performed as per medical provider orders and be communicated to the provider and recorded in the patient record in a timely and effective manner. The facility will promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of practitioner or per the ordering physician's order. Review of the Facility's policy titled, Influenza Outbreak Management, dated at revised 01/4/23, indicated residents of long-term care facilities can experience severe and fatal illness during influenza outbreaks. Preventing transmission of Influenza viruses and other infectious agents requires a multi-faceted approach that includes the following .Antiviral Treatment as recommended. Resident #1 was admitted to the facility in July 2020, diagnoses included unspecified dementia and major depressive disorder. Review of the Nurses' Progress Note, dated 03/6/25 indicated the Nurse Practitioner (NP) had been notified by a facility nurse that Resident #1 had a fever, cough and cold symptoms. The Nurses' Progress Note indicated that new Physician's orders for Resident #1 were obtained including a respiratory panel (a group of laboratory tests for the viruses that cause Influenza, COVID, and RSV). Review of Resident #1's Physician's Order, dated 03/06/25, indicated he/she had order for a respiratory panel laboratory test to include Influenza, COVID and RSV. Review of Resident #1's Laboratory Report, dated as specimen collected on 03/06/25, and resulted on 03/7/25, indicated Resident #1 was positive for Influenza. Review of the Nurse Practitioner's (NP) Progress Note, dated 03/12/25, indicated that no viral panel results for Resident #1 had been found at the facility and that the NP had obtained Resident #1's viral panel results from the offsite laboratory. The NP Progress Note indicated that staff appeared unaware of Resident #1's positive Influenza status, as he/she was not on precautions and there was no note indicating a provider was notified. The NP Progress Note also indicated that it was too late to start Tamiflu. During an interview on 03/27/25 at 7:45 A.M., the Nurse Practitioner (NP) said that the facility had not informed her or any other Provider of Resident #1's positive test result from 03/07/25, for Influenza. The NP said that if she had been made aware that Resident #1 had Influenza on 03/07/25, she would have offered him/her Tamiflu because Resident #1 was symptomatic and was at high risk for complications from influenza. The NP said that Tamiflu is not likely to work if it is started more than a day or two after the start of Influenza symptoms. The NP said that missed lab results have happened at the facility before. During an interview on 03/27/25 at 11:26 A.M., Nurse #1 said she had taken care of Resident #1 on 03/06/25 and that he/she had a fever and cough. Nurse #1 said that she obtained orders from the Nurse Practitioner for lab work, including a respiratory panel, and a chest x-ray. Nurse #1 said that she had taken care of Resident #1 again on 03/07/25 and that the Influenza test results had not been reported during her shift. Nurse #1 said she was not concerned that the respiratory panel results had not been reported because sometimes the respiratory panel takes two days. Nurse #1 said that she could have called the lab for the results. During an interview on 03/26/25 at 2:00 P.M., the Unit Manager said that the facility laboratory results are sent over to the facility and received from the laboratory printer on the nursing unit. The Unit Manager said there might have been a period-of-time when the lab printer was not working, but that the Nurse could have called the lab for the results. The Unit Manager said she was not aware that Resident #1 had Influenza until the NP told her on 03/12/25. The Unit Manager said that each Nurse was responsible for checking the lab printer for results for their assigned residents and following up with the Provider. During an interview on 03/26/25 at 3:30 P.M., the Infection Preventionist (IP) said that her process for monitoring infections in the Facility included listening to clinical reports, reviewing Nurse progress notes, and reviewing laboratory test results. The IP said that she had not been made aware that Resident #1 was positive for Influenza on 03/07/25. The IP said that his/her Nurse was responsible for checking Resident #1's lab results and notifying her of the results. During an interview on 03/26/25 at 4:15 P.M., the Director of Nurses (DON) said that the Nurse that swabbed Resident #1 on 03/06/25 should have looked for the Influenza test result the following day, and if the results were not available, she should have passed the information on in report for the next shift nurse to look for the results. The DON said if the Influenza test results had not been reported to the facility within a reasonable period of time the Nurse should have called the laboratory for the results. The DON said the facility did not obtain or act upon Resident #1's positive influenza test results timely.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, resided on a secured unit, had history of unwitnessed falls, and was assessed by nursing as being at high risk for falls, the Facility failed to ensure they provided an environment that was free of hazards and failed to provide adequate supervision to Resident #1 in an effort to maintain his/her safety and prevent incidents/accidents resulting in injury. - On 2/24/22 at 7:00 P.M., Resident #1 experienced an unwitnessed fall in the unit hallway that resulted in a laceration to his/her right eyebrow which required suture repair, with periorbital (around the eye) ecchymosis (black and blue discoloration from blood in the facial tissues) with a facial hematoma (collection of blood under the tissue). - On 3/13/22, the Nursing Progress Note, indicated that at approximately 9:00 P.M., Resident #1 entered the stairwell on the secured unit, he/she was agitated stating he/she was going home, and required redirection. - On 4/09/22 at 6:45 P.M., Resident #1 experienced a second unwitnessed fall, again in the unit hallway, which was noted by the facility to have been cluttered with devices and residents. Resident #1's injuries included a fractured mandible (lower jawbone), lacerations to his/her chin and right corner of his/her mouth, both of which required sutures to repair. Findings include: Review of the Facility's Policy titled Falls Risk Reduction, dated 11/28/18, indicated that all residents will be assessed for fall risk factors that include: - The resident's environment will remain free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. Review of Resident #1's Medical Record indicated his/her diagnoses included dementia and an anxiety disorder. Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated he/she was severely cognitively impaired, was a one-person physical assist for bed mobility, required supervision with transfers and ambulation, was totally dependent and required a two person assist with bed mobility and transfers. Resident #1's Behaviors Care Plan, dated as reviewed and current (per MDS 12/01/21), indicated his/her behaviors included wandering and agitation, interventions included to provide safety to him/her while enabling free movement around the Unit, and use of wanderguard bracelet. Resident #1's Falls Care Plan, dated 1/10/22, indicated he/she was at risk for falls due to confusion and forgetfulness. Resident #1's Activities of Daily Living (ADL) Care Plan, dated 1/30/22, indicated to provide supervision with ambulation. Review of Resident #1's Nursing Progress Note, dated 2/24/22, indicated he/she was found on the floor by a Certified Nurse Aide (CNA). The Note indicated Resident #1 was bleeding from his/her forehead, a compression dressing was applied (a method to stop the bleeding) and 911 was activated to transfer him/her to the Hospital. The Hospital Emergency Department Physician's Progress Note, dated 2/24/22, indicated Resident #1 presented after a fall from the standing position. The Note indicated Resident #1 was walking in the hallway, fell , and was found to have a laceration over his/her right eyebrow with associated periorbital ecchymosis (bruising), a facial hematoma (collection of blood outside of a blood vessel), and he/she required sutures to repair the laceration. Review of the Facility Investigation, dated 2/24/22 at 7:00 P.M., indicated that Resident #1 was found on the floor in the hallway, he/she had an unwitnessed fall which resulted in a right eye laceration. The Investigation indicated precipitating factor was his/her unsteady gait and weak lower extremity. The Investigated indicated new intervention for his/her safety was to provide adequate rest periods. During an interview on 5/10/22 at 5:20 P.M., Nurse #3 ( who was assigned to care for Resident #1 on 2/24/22), said Resident #1 was pleasantly confused at baseline, had a history of multiple falls and said she believed Resident #1 was independent with ambulation and did not require supervision. Nurse #1 said Resident #1 was unable to describe what happened when he/she fell on [DATE], but said Resident #1 had an unsteady gait. However, Resident #1's Plan of Care and MDS both indicated he/she required supervision with ambulation. Resident #1's Physician's Note, dated 3/10/22, indicated he/she was evaluated due to sustaining several falls recently at the Facility, an MRI (3/10/22) indicated he/she had a knee fracture (treated with a knee immobilizer). The Note indicated Resident #1 has poor insight, was not oriented to person, place or time, and that his/her recent and remote memory were abnormal. The Nursing Progress Note, dated 3/13/22 at 10:21 P.M., indicated that at approximately 9:00 P.M., Resident #1 entered the stairwell on the secured unit, he/she was agitated stating he/she was going home, and was redirected by a Certified Nursing Aide. Resident #1's Physician's Note, dated 3/16/22, indicated he/she was sitting in his/her wheelchair with a leg immobilizer on his/her left leg, the Physician reminded resident not to walk on this extremity. The Note indicated that nursing staff reported they found Resident #1 (who resides on the secured unit) in the stairwell. Review of Resident #1's Care Plan related to his/her wandering behaviors, (after he/she managed to successfully exit the unit) indicated staff to ensure his/her wanderguard bracelet was in place. Review of Resident #1's Nursing Progress Note, dated 4/09/22, indicated Resident #1 was alert but confused, and had been sitting in the hallway talking to another resident. The Note indicated that at 6:45 P.M., Nurse #2 was notified that Resident #1 was on the floor outside of Room 215, there was a large amount of blood coming from his/her mouth, with a laceration on the corner of Resident #1's mouth, and his/her right cheek was red and swollen. The Note indicated Resident #1 was unable to describe what happened, 911 was activated, and he/she was transferred him/her to the Hospital. The Hospital Emergency Department Physician's Progress Note, dated 4/09/22, indicated Resident #1 presented with a complaint of a laceration to the right corner of his/her mouth and chin, and he/she required sutures to the face and lip. Resident #1 was also found to have an acute lower jawbone fracture. Review of the Facility Investigation, dated 4/09/22, indicated that Resident #1 had an unwitnessed fall, was found lying on the floor in the hallway outside of room 215, he/she had a laceration to his/her mouth with a copious amount of bleeding and was holding his/her broken dentures. The Investigation indicated he medical conditions contributing to Resident #1's fall were dementia, and a previous left knee fracture. The Investigation also indicated the facility identified that the environmental trigger for the fall was clutter in the hallway outside of room 215, that there were too many residents and devices in the unit hallway. The Investigation indicated interventions included to keep the hallway clear of clutter and redirect residents out of the hallway. During an interview on 5/10/22 at 2:50 P.M., Nurse #2 said she was the Nurse assigned to care for Resident #1 on 4/09/22 when he/she fell . Nurse #2 said that there was clutter in the hallway and Resident #1 was not being supervised by staff at the time of the fall. During an interview on 5/10/22 at 2:30 P.M., and review of Nurse #1's written Witness Statement dated 4/09/22, indicated Nurse #1 was administering medications, she heard the residents (on Resident #1's Unit) yelling for help in the hallway, she responded and observed Resident #1 on the floor. Nurse #1 said prior to Resident #1's fall that day, he/she was in a wheelchair with a knee brace on (to stabilize a knee fracture), and he/she was visiting with another resident in the hallway outside of room 215. Nurse #1 said after he/she fell , Resident #1 was found on the floor leaning on his/her left arm holding his/her dentures, which were broken, there was blood coming from his/her mouth and he/she was complaining of mouth pain. Nurse #1 said Resident #1 was not being supervised at the time of the fall. Nurse #1 said the facility's Fall investigation indicated that a trigger for the fall was a safety hazard, due to clutter in the hall outside of room 215. Nurse #1 said the clutter consisted of chairs, tray tables and many residents in the hallway, and said the corrective action was to keep the hallway free from clutter to prevent another fall. During an observation on 5/10/22 at 3:10 P.M., of the hallway on Resident #1's unit where he/she had fallen, the Surveyor, accompanied by Nurse #1, noted there were two tray tables, a mechanical lift, a clean and dirty linen cart, a medication cart, and three residents in the hallway. Nurse #1 said that the hallway was cluttered. During an interview on 5/10/22 at 11:05 P.M., Unit Manager #1 said when Resident #1 fell on [DATE] and 4/09/22, both falls were unwitnessed and occurred in the hallway, and said her expectation was that Resident #1 should have a less cluttered environment and be provided with adequate supervision by staff.

Based on interviews and records reviewed, for one of the three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was free from physical abuse when, on 6/24/21 around 3:00 P.M., Certified Nurse Aide (CNA) #1 pushed Resident #1's head backward and poked Resident #1 in the ribs, and the incident was witnessed by several staff members. Resident #1 became upset and cried during the incident, and asked CNA #1 to stop and leave him/her alone. Findings include: Review of the Facility Resident Abuse Prevention, Investigation and Reporting Policy, revised as 2/17/17, indicated abuse was defined as willful infliction of injury, unreasonable confinement, intimidation of punishment which caused physical harm, pain or mental anguish. The Policy indicated that an act was considered willful if the individual committing the act did so deliberately, whether or not the individual intended to inflict injury or harm Review of Resident #1's clinical record indicted that his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Minimum Data Set assessment, dated 5/06/21, indicated that his/her cognitive patterns were severely impaired. Review of the Facility Internal Investigation, dated 6/24/21, indicated that on 6/24/21 around 7:30 P.M., staff reported an incident in which CNA #1 shoved (pushed) Resident #1 and poked Resident #1's side. Review of the Facility Internal Investigation Summary, undated, indicated that Resident #1 was interviewed about the alleged incident by the Social Worker and the Director of Nurses and stated that he/she did not recall an incident with CNA #1 on 6/24/21. However, during an interview on 7/07/21 at 12:00 P.M., with the Surveyor, Resident #1 said CNA #1 pushed or punched him/her on the head. During an interview on 7/07/21 at 11:00 A.M., CNA #2 said that on 6/24/21 around 3:00 P.M., she witnessed CNA #1 push Resident #1 by placing her (CNA #1) hand on the top of Resident #1's head and forehead and then she (CNA #1) pushed Resident #1's head back twice. CNA #2 said Resident #1 stated words to the effect of, stop, and, leave me alone, and said CNA #1 responded by tickling Resident #1's ribs. CNA #2 said that Resident #1 stated words to the effect of, leave me the [OBSCENITY] alone, with tears in his/her eyes. During an interview on 7/07/21 at 12:20 P.M., CNA #3 said while standing at the nursing station around 3:00 P.M. on 6/24/21, she heard Resident #1 become agitated , and heard Resident #1 say words to the effect of, stop. CNA #3 said that CNA #1 responded to Resident #1 with words to the effect of, I'm just playing with you. During an interview on 7/15/21 at 11:45 A.M., CNA #4 said that on 6/24/21 around 3:00 P.M. while at the nursing station, she heard Resident #1 complain that CNA #1 was hitting him/her and saw that he/she was crying. CNA #4 said she heard CNA #1 say to Resident #1, words to the effect of, I was just playing with you. CNA #4 said that she told CNA #1 that she had made Resident #1 cry and that Nurse #1 then told CNA #1 to leave Resident #1 alone. During an interview on 7/16/21 at 2:12 P.M. Nurse #1 said that on 6/24/21 around 3:00 P.M., he heard Resident #1's voice escalating and, when he turned to look toward the nursing station, Nurse #1 saw CNA #1 holding the handles of Resident #1's wheelchair to stop Resident #1 from propelling forward. Nurse #1 said Resident #1 was crying and agitated. Nurse #1 said that he told CNA #1 to leave Resident #1 alone. During an interview on 7/12 /21 at 3:14 P.M., CNA #1 said that while standing at the nursing station around 3:00 P.M. on 6/24/21, she brushed Resident #1's hair out of Resident #1's face and tickled his/her belly. CNA #1 said that Resident #1 started to cry and said she apologized and stopped. CNA #1 said that she intended the contact with Resident #1 as teasing. However, CNA #1's statement saying she apologized to Resident #1 seems suspect, as none of the other staff members who witnessed the incident and were interviewed, indicated CNA #1 apologized at any time Resident #1. The Facility Internal Investigation contained an email from the Director of Nursing, dated 6/25/21, which contained text messages (undated) sent by CNA #1 to the Director of Nursing. The text messages from CNA #1 indicated she (CNA #1) was playing around with Resident #1 by playfully tapping his/her head and tickling him/her. CNA #1's text message indicated that Resident #1 yelled at CNA #1 to stop and became upset.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted post-surgical repair of a right [CONDITION(S)], was being treated with a knee immobilizer to stabilize his/her right leg, was to be non-weight-bearing for six weeks, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility failed to ensure the skin under Resident #1's knee immobilizer was assessed by nursing for potential skin breakdown and to prevent the development of a pressure injury. For eight days, Resident #1's knee immobilizer remained in place on his/her right leg, without being removed by nursing to assess for skin breakdown. On 3/16/21, at Resident #1's post surgical follow-Orthopedic appointment, when his/her knee immobilizer was removed, the Orthopedic Provider noted a right lower calf skin pressure injury and documented the cause as being from the immobilizer. Findings include: The Facility Policy titled, Skin Integrity Management, dated 11/21/16, indicated that a comprehensive assessment will be completed on every resident and the resident receives care, to prevent pressure ulcers and not develop pressure ulcers, unless the resident's condition demonstrates that they were unavoidable. The Facility Policy titled, Pressure Ulcer Prevention Protocol, dated December 2015, indicated to inspect the skin daily during care, especially checking pressure points. Use pressure redistribution surfaces for bed and chairs, and pad skin subjected to device related pressure and inspect regularly. The Physician's Hospital Discharge Summary, dated 3/03/21, indicated Resident #1 was admitted to the Hospital for a right [CONDITION(S)] which was corrected surgically with good response. The Summary indicated the plan was to discharge him/her to a Nursing Home for short term rehabilitation. The Summary indicated Activity Restrictions and Instructions included, non-weight bearing for six weeks, and a knee immobilizer intact, at all times. Resident #1 was admitted to the Facility in September 2020, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Nursing Assessment, dated 3/09/21, indicated the following: -Skin assessment included sutures from the surgical repair of the hip; - stage one pressure injury (intact skin with non-blanchable redness), measuring 0.1 centimeters (cm) in length, 0.5 cm in width, on his/her buttocks. - The Norton Risk Factor Tool, indicated he/she was not at high risk for the development of a pressure injury, and that his/her activity level indicated he/she ambulated. (However this conflicted with the Hospital Discharge Summary that indicated Resident #1 was non-weight bearing for six weeks, due to surgical repair of his/her right [CONDITION(S)].) -Admission Baseline Care Plan indicated Resident #1 did not have an actual wound or skin problem and that he/she was not at risk for skin breakdown. (However this conflicted with the Admission Nursing Assessment that indicate Resident #1 had a stage one area on his/her buttocks.) Review of the Nursing Progress Note, dated 3/09/21, indicated Resident #1 had open areas on his/her buttocks, and were classified as a stage one pressure injury (intact skin with non-blanchable redness) . Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Order indicated knee immobilizer was to be on the right leg at all times. Review of the Admission Minimum Data Set, dated dated [DATE], indicated Resident #1 was severely cognitively impaired, was at risk for pressure injuries, and had an unhealed stage one pressure injury. The Care Area Assessment Summary, dated 3/22/21, indicated that based on Resident #1's skin assessment he/she triggered for a pressure injury care plan. Review of the Weekly Skin Checks Sheets, indicated there was no documenation to support weekly skin assessment were completed by nursing on 3/16/21 and 3/22/21, further reviewed indicated there were no nursing progress notes to support his/her skin was assessed for approximately 14 days. Resident #1's skin check was performed on 3/23/21, by the Wound Nurse to evaluate the pressure injury on the right lower calf. During an interview on 6/16/21 at 11:12 A.M., the DON said that the Norton Tool for assessing Resident #1's risk for pressure injury was not evaluated correctly, when it assessed him/her as not being at high risk, because his/her activity level was not documented correctly. The DON said that the Facility Policy for weekly skin checks was not followed. The Occupational Therapy Note, dated 3/12/21, indicated that the Occupational Therapist had educated the Nursing staff on right lower extremity skin checks for Resident #1 related to him/her having a knee immobilizer. During an interview on 6/16/21 at 11:00 A.M., the Occupational Therapist said since Resident #1 was at risk for a pressure injury developing under the immobilizer, the skin under the immobilizer needed to be assessed every shift. The Occupational Therapist said the rationale for these skin assessments is because if something is going to happen with skin breakdown, the area most at risk for Resident #1, would be the skin under his/her immobilizer. Review of Resident #1's medical record indicated there was no documentation to support that the skin checks under the immobilizer were performed by nursing after the Occupational Therapist in-service training. Review of the Orthopedic Follow Up Note, dated 3/16/21, indicated that Resident #1 had the staples over the surgical hip site removed and for daily dressing changes to be completed for the skin tears (later identified as an actual pressure injury) to his/her right calf. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physical Therapist's Note. dated 3/17/21, indicated that nursing staff approached the Physical Therapist and reported a wound on the right lower extremity (calf) from the knee immobilizer. The Note indicated lambs wool was provided and positioned between the right extremity and the knee immobilizer to reduce pressure and allow for the wound resolution. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse's Notes, dated 3/18/21 through 3/22/21, indicated there was no documentation to support nursing assessed Resident #1's right calf pressure injury under the knee immobilizer. Review of Resident #1's Pressure Ulcer Weekly Skin Log, indicated there was no documentation or assessment of the right calf pressure injury under the knee immobilizer until 3/23/21. During an interview on 6/16/21 at 3:15 P.M., Nurse #1 said that she observed Resident #1's right calf pressure injury over the weekend of 3/20/21, and said it was pretty advanced, and that it would take a lot for it to get to that extent. Nurse #1 said the nurses did not refer Resident #1 and the calf pressure injury found on 3/16/21, to the Wound Nurse and said that resulted in a delay of having his/her pressure injury evaluated by the Wound Nurse for six days. The Wound Nurses Note, dated 3/23/21, indicated that she was asked to evaluate Resident #1 for a leg wound on the right lower calf, which appeared as though this wound was caused from pressure from the immobilizer. The Note indicated the metal portion of the knee immobilizer was removed by the Therapy Department and lambs wool was placed in between the wound and the leg immobilizer. The Note indicated Resident #1's right calf wound had eschar (dead tissue) with scant drainage and fluctuant (a boggy feeling, usually pus which has accumulated beneath the skin) to the perimeter. The Note indicated Resident #1's right calf wound had peri-wound redness and warmth indicating acute [CONDITION(S)]. The Note indicated recommend treatment with [MEDICATION(S)] (an antibiotic medication) and to apply debridement agent (to get rid of dead tissue) the eschar, and obtain an air mattress (a pressure redistribution mattress). The Pressure Ulcer Weekly Skin Log, dated 3/23/21, indicated that Resident #1 had a pressure injury on the right lower calf which measured 11.5 centimeters (cm) by 4.5 cm with no depth. During an interview on 6/16/21 at 3:15 P.M., Nurse #1 said an air mattress had been recommended by the Wound Nurse on 3/23/21, to assist with offloading pressure on the right lower calf wound to assist with healing. Nurse #1 said the process for ordering the air mattress was to call the physician, obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record indicated there was no documentation to support an air mattress was ordered by the physician or delivered to the Facility for him/her. Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Right lower calf wound apply medi-honey (a wound treatment to debride dead tissue) every day, then cover with an abdominal dressing and rolled gauze. Review of Resident #1's bilaterally duplex lower extremity arterial evaluation, dated 3/24/21, indicated there was no evidence of a hemodynamically (the flow of blood in the legs) significant stenosis or occlusion. During an interview on 6/16/21 at 2:20 P.M., the DON said she called the Medical Company that delivers air mattresses and a staff member at the Medical Company said they were never called regarding an air mattress for Resident #1. The Wound Nurses Note, dated 3/30/21, indicated Resident #1's right lower calf wound still had peri wound redness, now had unstable eschar and slough (dead tissue). The Wound Nurses Note, dated 4/6/21, indicated that Resident #1 had pain in the right lower calf wound. Review of the Orthopedic Follow Up Consultation Note, dated 4/08/21, indicated Resident #1 had a full thickness (classified as a stage 4, which is a severe pressure injury, tissue loss with exposed bone, tendon or muscle) on the right calf and the resident was transferred to the Hospital Emergency Department for wound management. The Physician's History and Physical Note, dated 4/08/21, indicated four weeks after Resident #1 had right [CONDITION(S)] surgery, while at the Nursing Home, he/she developed a large right lower extremity wound which was a full thickness wound with a necrotic center, an X-ray showed [CONDITION(S)] and tissue infection, and he/she was admitted for further evaluation and treatment. The Physician's Discharge Summary, dated 4/14/21, indicated Resident #1 was admitted due to a right lower extremity wound and superficial femoral artery occlusion, an angiogram was performed but they were unable to [MEDICATION(S)] the lesion, he/she was treated with [MEDICATION(S)] and the right leg wound was debrided. Resident #1 was discharged to home with hospice due to his/her poor prognosis.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) the Facility failed to ensure his/her physician was notified when he/she experienced a significant decline in overall health status. Resident #1 exhibited signs and symptoms of a change in mental status, his/her oxygen desaturation levels dropped to 87% (normal oxygen saturation is greater than 90% - the amount of oxygen in the blood), his/her breathing was labored (abnormal breathing characterized by an increased effort to breath), he/she had decreased food and fluid intake over the course of two full shifts (approximately 16 hours) and nursing staff failed to notify his/her physician. - Resident #1 required emergent transfer to the Hospital Emergency Department for evaluation and was admitted to the Intensive Care Unit for treatment related to dehydration (significant loss of body fluid that impairs normal body functions), [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] (elevated sodium level) [MEDICAL CONDITION] (potentially life threatening condition caused by the body's response to an infection). Findings include: The Facility Policy titled, Physician Notification, dated 11/11/2009, indicated that a resident who has clinical changes or a change in condition, a Nurse will perform appropriate clinical observations and data collection and report to the physician as indicated. The Policy indicated clinician judgment and resident baseline should always be the primary determination of the timing of physician notification. Review of Resident #1's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated 1/22/19, and signed by the Health Care Proxy Agent, indicated to use artificial hydration (intravenous fluids) and to transfer to the Hospital if needed. An Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had a [DIAGNOSES REDACTED]. Review of the Care Plan for [MEDICAL CONDITION] medications, dated 1/22/19, indicated Resident #1 required [MEDICAL CONDITION] medication due to dementia with behavioral services, interventions included to monitor hydration and appetite, and to notify the physician of concerns. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Medication Administration Record, [REDACTED]. Review of Resident #1's Laboratory Work, indicated that Resident #1's baseline laboratory work was; - On 2/18/19, Resident #1's Blood Urea Nitrogen (BUN) was 23 milligrams per deciliter(mg/dl)(normal 5 to 25 mg/dl) with a creatinine was 0.88 mg/dl (normal 0.5 to 1.1 mg/dl), BUN and creatinine are indicators of dehydration and kidney function) and the sodium level (a indicator of fluid and electrolyte balance) was 140 milliequivalents per liter (meq/L)(normal 133 to 145 meq/L). - On 3/18/19, Resident #1's BUN was 45 mg/dl, creatinine was 1.20 mg/dl and the sodium level was 140 milliequivalents per liter (meq/L) and 143 meq/L. Lexicomp, Wolters Kluwer Clinical Drug Reference, dated 2019, indicated [MEDICATION NAME] is contraindicated (should not be administered) to residents who are dehydrated (a harmful reduction in the amount of water in the body). [MEDICATION NAME] can lead to profound diuresis (increased production of urine), resulting in fluid and electrolyte depletion. Close medical supervision and dose evaluation with dose adjustment (including discontinuation) are required to avoid dehydration. The Dental Consultation, dated 3/29/19, indicated Resident #1 had three tooth extractions done, with mild to severe mouth pain. The Nurse Progress Note, dated 4/1/19, indicated that Resident #1's was status [REDACTED]. The Nurse Progress Note, dated 4/2/19, indicated that Resident #1's appetite was poor this shift. The Nurse Progress Note, dated 4/3/19, indicated that Resident #1 refused supper but took the milkshake (240 milliliters). The Nutrition Note, dated 4/4/19, indicated that Resident #1 required a liquid consistency downgrade to nectar thick (consistency of honey) due to his/her swallowing difficulty, coughing with liquids. The Nurse Progress Note, dated 4/7/19, written by Nurse #2, indicated that Resident #1 was lethargic and required significant prompting when attempts were made to hydrate and/or feed. The Note indicated medications were not administered on the 3:00 P.M. to 11:00 P.M. shift, secondary to Resident#1's high risk of aspiration. The Note indicated Resident #1's breathing pattern was increased and slightly labored in comparison to his/her baseline. The Surveyor interviewed Nurse #2 at 12:29 P.M. on 5/17/19. Nurse #2 said he did not notify the Physician of Resident #1's change in mental status change, of his/her increased lethargy, inability to hydrate, feed or administer medications to Resident #1, of his/her increased and labored breathing. Review of Resident #1's medical record indcated there was no documentation in Nurse #2's progress note, or anywhere else in the record to support that the Physician was notified of his/her change in condition. The Nurse Progress Note, dated 4/8/19, written by Nurse #3, for the 11:00 P.M. to 7:00 A.M. shift, indicated that an as needed [MEDICATION NAME] (narcotic, treats moderate to severe pain) was administered at 12:15 A.M. for pain/facial grimacing with positive effect. The Note indicated Resident #1's oxygen saturation level was 87% on room air (normal is greater than 90%), oxygen at 2 liters was administered via nasal cannula, and Resident #1's oxygen saturation increased to 90%. The Surveyor interviewed Nurse #3 at 3:34 A.M. on 5/18/19. Nurse #3 said that although she knew that an oxygen saturation level of 87% was abnormal (normal is greater than 90), she could not remember if she took Resident #1's vital signs. Nurse #3 said she did not document Resident #1's temperature, pulse or blood pressure in the medical record. Nurse #3 said she did not assess Resident #1 for the potential for infection or dehydration, Nurse #3 said she must have listened to Resident #1's lung sounds but could not remember what his/her lung sounds findings were, and said she did not document the lung sounds in the medical record. Review of Resident #1's medical record indcated there was no documentation in Nurse #3's progress note, or anywhere else in the record to support that the Physician was notified of his/her change in condition. Review of Resident #1's clinical record indicated there was no documentation to support, including in Nurse #3's progress note, that the physician was notified of the need to administer oxygen. The Nurse Progress Note, dated 4/8/19, written by Nurse #4, indicted that at 8:15 A.M. Resident #1 was extremely lethargic. Vital signs indicated: an elevated tympanic temperature (a temperature obtained by placing an electronic probe in the ear canal) 101.2, usually indicative of fever (normal tympanic temperature is 99 F), Heart rate 99 beats per minute (bpm) (normal range 60 to 100 bpm), respiratory rate 20 breaths per minute (normal rate for an adult at rest 12 to 20) and blood pressure, hypotensive 86/44 (normal 120/80) on oxygen at 2 liters via nasal cannula with an oxygen saturation of 90% (low). The Note indicated the Physician was notified regarding Resident #1's (abnormal) vital signs and ordered that Resident #1 be transferred to the Hospital Emergency Department for evaluation. The Surveyor interviewed Nurse #4 at 12:07 P.M. on 5/20/19. and at 4:05 P.M. on 5/22/19. Nurse #4 said she assessed Resident #1 right away after she received report from Nurse #3 that Resident #1 received oxygen on the previous shift. Nurse #4 said that Resident #1 did not have a physician's orders [REDACTED].#4 said that Nurse #3 had not notified the physician of Resident #1's change in condition. Nurse #4 said that there was clearly a change in Resident #1's condition. Nurse #4 said she applied oxygen on the 7:00 A.M. to 3:00 P.M. shift on 4/8/19, because it was an emergency. Nurse #4 said she then immediately assessed Resident #1 after morning report, monitored his/her vital signs and notified Physician #1 regarding Resident #1's change in his/her condition. Nurse #4 said Physician #1 ordered that Resident #1 to be transferred emergently to the Hospital. Nurse #4 said Resident #1 was so lethargic he/she was not responding to her verbally, was hypotensive (low blood pressure) his/her pulse was 99 and that was elevated for Resident #1. Nurse #4 said Resident #1 looked really sick. The Physician's Hospital Emergency Department Note, dated 4/8/19, indicated last night (on 4/7/19), Resident #1 had worsening mental status and was not responsive. Upon arrival the Note indicated that Resident #1 had a fever of 101 degrees F, an elevated respiratory rate of 32 to 36 (normal respiratory rate (12 - 20), and was hypotensive with a blood pressure of 94/27. Resident #1 was severely dehydrated with a BUN of 107 mg/dl, a Creatinine of 2.4 mg/dl, white blood cells were 24,000 (normal 5,000 to 10,000) and critical laboratory values of both a Sodium level of 174 meq/L and a lactic acid level (elevated with severe infection or shock) of 2.7 millimoles per liter (mmol/L) (normal 0.5 to 2.0). The Note indicated Resident #1 was septic (a serious infection condition, which spreads to blood potentially leading to malfunctioning organs, shock and death) and a urinary tract infection. The Physician's Transfer Note to ICU, dated 4/8/19 indicated Resident #1 required correction of his/her significant [MEDICAL CONDITION] (an elevated Sodium level) and vaspressor (intravenous medication to increase the blood pressure) support to stabilize him/her, Resident #1 condition slowly improved, and he/she was transferred to a medical surgical unit. The Hospital Discharge Summary, dated 4/17/19, indicated Resident #1 had a urinary tract infection, [MEDICAL CONDITION], septic shock, acute [MEDICAL CONDITION] and acute [MEDICAL CONDITION] (brain disease or damage that presents with an altered mental state) The Surveyor interviewed Physician #1 at 4:16 P.M. on 5/22/19. Physician #1 said he evaluated Resident #1 right before the weekend of 4/7/19. Physician #1 said because Resident #1 was frail, at risk for dehydration, had a history of [REDACTED].#1 was at risk for dehydration. Physician #1 said he wanted to be notified if Resident #1's condition declined or if he/she was not taking meals. Physician #1 said Resident #1 could not afford to miss any meals because of his/her fragility. The Surveyor reviewed Resident #1's medical record with Physician #1. Physician #1 said that on 4/8/19 during the 11:00 P.M. to 7:00 A.M. shift Resident #1's oxygen saturation level of 87% was low and he would have remembered if he was notified and Physician #1 said he does not believe he was notified of that inadequate oxygen saturation level.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure nursing staff provide services that met professional standards of practice to adequately assess and monitor Resident #1's mental status, vital signs, (temperature, pulse, blood pressure), oxygen saturation (the amount of oxygen in the blood) and lung sounds, failed to recognize a significant change in health status for Resident #1 and failed to recognize the need for emergency care and transport to the Hospital, which resulted in the delay in emergency services and treatment. - Resident #1 required emergent transfer to the Hospital Emergency Department for evaluation and was admitted to the Intensive Care Unit for treatment related to dehydration (significant loss of body fluid that impairs normal body functions), [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] (elevated sodium level) [MEDICAL CONDITION] (potentially life threatening condition caused by the body's response to an infection). Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Facility policy, titled Oxygen Administration, dated 11/3/16, indicated that the oxygen therapy policy's purpose was to safely administer oxygen to maintain respiratory status. Oxygen is administered as ordered by the physician or as indicated by clinical or respiratory decision in a respiratory emergency. Oxygen is monitored by a licensed Nurse. Place the resident on oxygen at the ordered liter flow rate. Monitor oxygen saturation per the physician's orders [REDACTED]. Monitor response to oxygen therapy by evaluating the resident for respiratory rate, heart rate and the color of the resident. Document the date and time oxygen was started and the resident's response. The Lippincott Manual of Nursing Practice indicated septic shock occurs as the result of bacteria and/or their toxins circulating in the blood. The primary cause is the vasoactive mediators released by gram-negative bacteria affecting almost every physiologic system. Any septic focus has the potential to produce septic shock. - Rapid recognition and prompt interventions are essential to increase the chance of survival because a downward spiral of physiologic response will occur if shock is not treated. - Assess level of consciousness an important indicator of shock because it reflects cerebral perfusion. - Watch for increasing lethargy progression to obtundation (a mental status state similar to lethargy). -Monitor blood pressure, if the resident can compensate for shock, the blood pressure may initially rise. A significant decrease in blood pressure may not occur until late. - Assess pulse quality and rate change: The rate is usually increased. A weak thread pulse due to decreased cardiac output (amount of blood pumped by the heart) and increased peripheral vascular resistance ([MEDICATION NAME] of the blood vessels). -Assess the urinary output, a decrease in renal blood flow or pressure will result in decreased urinary output. Review of Resident #1's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated 1/22/19, and signed by the Health Care Proxy Agent, indicated to use artificial hydration (intravenous fluids) and to transfer to the Hospital if needed. An Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had a [DIAGNOSES REDACTED]. The Nurse Progress Note, dated 4/7/19, written by Nurse #2 indicated that Resident #1 was lethargic and required significant prompting when attempts were made to hydrate and/or feed. The Note indicated medications were not administered on the 3:00 P.M. to 11:00 P.M. shift, secondary to Resident#1's high risk of aspiration. The Note indicated Resident #1's breathing pattern was noted to be increased and slightly labored in comparison to his/her baseline. The Surveyor interviewed Nurse #2 at 12:29 P.M. on 5/17/19. Nurse #2 said he did not monitor Resident #1's vital signs or oxygen saturation to assess for infection, hydration and shock even though Resident #1 was lethargic, not taking fluids, food or medications and he/she had increased labored breathing. The Nurse Progress Note, dated 4/8/19, written by Nurse #3, for the 11:00 P.M. to 7:00 A.M. shift, indicated that an as needed [MEDICATION NAME] (narcotic, treats moderate to severe pain) was administered at 12:15 A.M. for pain/facial grimacing with positive effect. The Note indicated Resident #1's oxygen saturation level was 87% on room air (normal is greater than 90%), oxygen at 2 liters via nasal cannula was administered, and Resident #1's oxygen saturation increased to 90%. The Surveyor interviewed Nurse #3 at 3:34 A.M. on 5/18/19. Nurse #3 said that on 4/08/19 during her shift, Resident #1 had a low oxygen saturation level of 87% (oxygen saturation level less than 90%, indicates inadequate oxygen in the blood) on room air and said Resident #1 had not previously had inadequate oxygen levels. Nurse #3 said that although she knew that an oxygen saturation level of 87% was abnormal (normal is greater than 90), said she did not notify the physician of the need to administer oxygen to Resident #1. Nurse #3 said she must have listened to Resident #1's lung sounds but said she could not remember what Resident #1's lung sounds findings were. Nurse #3 said she could not remember if she took Resident #1's vital signs. Review of Resident #1's medical record, including nurse progress notes indicated, there was no documentation to support Nurse #3 obtained Resident #1's vital signs (temperature, pulse or blood pressure) or that she assessed Resident #1's lung sounds. The Nurse Progress Note, dated 4/8/19, written by Nurse #4, indicated that at 8:15 A.M. Resident #1 was extremely lethargic. Vital signs indicated: an elevated tympanic temperature (a temperature obtained by placing an electronic probe in the ear canal) was 101.2, usually indicative of fever (normal tympanic temperature is 99 F), Heart rate 99 (60 to 100), respiratory rate 20 (normal) and blood pressure, hypotensive 86/44 (normal 120/80) on oxygen via nasal cannula with an oxygen saturation of 90% (low). The note indicated the Physician was notified regarding Resident #1's (abnormal) vital signs and ordered that Resident #1 be transferred to the Hospital Emergency Department for evaluation. The Surveyor interviewed Nurse #4 at 12:07 P.M. on 5/20/19. and at 4:05 P.M. on 5/22/19. Nurse #4 said she assessed Resident #1 after she received report from Nurse #3 that Resident #1 received oxygen last night. Nurse #4 said that Resident #1 did not have an order for [REDACTED].>Nurse #4 said that there was clearly a change in Resident #1's medical condition. Nurse #4 said Resident #1 was so lethargic he/she was not responding to her verbally, which he/she had been able to do so at his/her baseline. Nurse #4 said she applied oxygen on the 7:00 A.M. to 3:00 P.M. shift on 4/8/19, because it was an emergency. Nurse #4 said she assessed Resident #1 and notified Physician #1 regarding Resident #1's change in condition. Nurse #4 said Physician #1 ordered that Resident #1 to be transferred emergently to the Hospital. An Emergency Department (ED) Physician's Note, dated 4/8/19, indicated last night (on 4/7/19), Resident #1 had worsening mental status and was non-responsive. The Note indicated upon arrival to the ED, Resident #1 had a fever of 101 degrees F, an elevated respiratory rate of 32 to 36 (normal respiratory rate is 12 - 20), and was hypotensive with a blood pressure of 94/27. The ED Physician's Note indicated Resident #1 was severely dehydrated with a Blood Urea Nitrogen (BUN) level of 107 milligrams per deciliter (mg/dl, normal range 5 to 25 mg/dl), and a Creatinine of level of 2.4 mg/dl (normal 0.5 to 1.1 mg/dl), (BUN and creatinine are indicators of dehydration and kidney function). The ED Physician's Note indicated Resident #1's white blood cell count was 24,000 (normal 5,000 to 10,000) and he/she had critical laboratory values for both Sodium level (an indicator of fluid and electrolyte balance) of 174 meq/L (normal 133 to 145 meq/L) and a lactic acid level 2.7 millimoles per liter (mmol/L) (normal range 0.5 to 2.0), which becomes elevated with severe infection or shock. The ED Physician's Note indicated Resident #1 was septic (a serious infection condition, which spreads to blood potentially leading to malfunctioning organs, shock and death) and a urinary tract infection. The ED Physician's Transfer Note to ICU, dated 4/8/19 indicated Resident required correction of his/her significant [MEDICAL CONDITION] (elevated sodium level) and treatment with a vaspressor (intravenous medication to increase the blood pressure) support to stabilize him/her. The Hospital Discharge Summary, dated 4/17/19, indicated Resident #1 had a urinary tract infection, [MEDICAL CONDITION], septic shock, acute [MEDICAL CONDITION] and acute [MEDICAL CONDITION] (brain disease or damage that presents with an altered mental state) The Surveyor interviewed Physician #1 at 4:16 P.M. on 5/22/19. Physician #1 said he evaluated Resident #1 just before the weekend of 4/7/19. Physician #1 said because Resident #1 was frail, had a history of [REDACTED].#1 was at risk for dehydration. Physician #1 said Resident #1 could not afford to miss any meals because of his/her fragility.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the facility failed to ensure that he/she was free from accidents and/or injuries, when he/she was given a meal with meat (whole pieces)that was not of an altered consistency (ground) per his/her physician's orders [REDACTED]. Findings included: Resident #1 was admitted to the Facility in (MONTH) 2019, [DIAGNOSES REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Resident #1's Plan of Care concern initiated 4/3/19, for the potential for alteration in gastrointestinal tract related to dysphagia and [MEDICAL CONDITION] stricture, indicated interventions included to provide food and fluids per physician's orders [REDACTED]. Review of the Facility's Investigation and per the report submitted via the Health Care Facility Reporting System (HCFRS) submitted on 4/12/19, On 4/05/19, Resident #1, who was on a ground consistency diet, was given a lunch meal that contained whole pieces of meat, and choked on a piece of the whole meat. The Investigation indicated Resident #1 had arrived late to the dining room, CNA #1 requested a meal for him/her, was given a meal that was not of an altered consistency (ground) and served it to Resident #1. The Investigation indicated Resident #1 started coughing, appeared to be choking, staff provide back blows, and Resident #1 coughed up and spit out a piece of meat. The Investigation indicated Resident #1 was assessed by the Nurse Practitioner, and transferred to the Hospital Emergency Department for evaluation. The Investigation indicated Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed CNA #1 at 12:50 P.M. on 4/29/19. CNA #1 said that on 4/5/19 Resident #1 arrived to the dining room for lunch at the end of the meal service and asked for the beef tenderloin. CNA #1 said she went to the kitchen and asked Cook #1 for Resident #1's plate of food. The Surveyor interviewed Cook #1 at 11:40 A.M. on 4/29/19. Cook #1 said that he/she prepared Resident #1's lunch plate on 4/5/19. Cook #1 said that CNA #1 asked for a regular plate which Cook #1 understood to mean the main meal and not the alternate. Cook #1 said that he did not ask CNA #1 who the plate was for and said he plated food without any of the food items being ground or mechanically altered. Cook #1 said that the main entrée for 4/5/19 included beef tenderloin. CNA #1 said that she served Resident #1 the plate Cook #1 provided. CNA #1 said that a few moments later another resident stated words to the effect of, Can you get (him/her) some water and CNA #1 saw that Resident #1 was coughing. CNA #1 said that she went to Resident #1 and asked if he/she was OK and he/she said yes and spat a large amount of phlegm from his/her mouth. CNA #1 said she hit Resident #1 about three times on the back and Resident #1 spat out a small piece of meat. CNA #1 said that after Resident #1 choked she noticed that Resident #1 had a piece of beef tenderloin which was not ground or mechanically altered. CNA #1 said that although she knew that Resident #1 generally ate ground or mechanically altered food, she did not check Resident #1's meal ticket and did not notice that the plate Cook #1 gave her contained unaltered (whole pieces) of beef tenderloin when she served Resident #1. The Surveyor interviewed the Nurse Practitioner at 10:00 A.M. 4/29/19. The Nurse Practitioner said that on 4/5/19 she responded to the dining room when staff members shouted that someone was choking. The Nurse Practitioner said that she saw that Resident #1 had been eating from a plate of unaltered food and she knew that his/her physician had ordered mechanically altered or ground food. The Nurse Practitioner said that Resident #1 had an [MEDICAL CONDITION] stricture diagnosed prior to admission to the Facility and had a history of [REDACTED].#1 in the dining room he/she had cleared the food from his/her throat, because Resident #1 was bringing up a large amount of secretions, she sent him/her to the hospital for an evaluation. On 4/29/19, the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A. Resident #1 was evaluated at the hospital on [DATE] and treated for [REDACTED]. B. Resident #1 was evaluated by Speech Therapy on 4/6/19 and the physician ordered continued treatment by the Speech Therapist. C. On 4/6/19, the Facility provided training to twenty nursing and kitchen staff members who regularly served meals to residents in the main dining room regarding the need to check each resident's meal ticket which reflected current physician orders [REDACTED]. D. On 4/6/19, the Director of Nurses and Food Service Manager audited the meal ticketing system to ensure meal tickets reflected current physician orders [REDACTED]. E. Beginning on 4/8/19 and continuing weekly, the Director of Nurses and two Nurse Managers conducted observations of meal service in the two Facility dining rooms. B. On 4/29/19, the Surveyor observed kitchen staff preparing plates for residents and nursing staff passing plates to residents after checking that the plated foods matched the meal tickets. F. The Director of Nurses said that she developed the plans to address the incident in which staff served Resident #1 a meal that did not comply with his/her diet in conjunction with the Administrator, the Food Service Manager, the Regional Director of Quality and the two Facility Nurse Managers. The Director of Nurses said that the implemented plan would be reviewed with all membership of the Quality Assurance Committee on 5/1/19.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that licensed nurses had the specific competencies and skill set necessary to safely care for Resident #1's nephrostomy tube (drainage tube placed into the kidney to drain urine directly from the kidney), as ordered by the Physician. Findings include: The Facility Policy Nephrostomy Tube Management, dated 01/14/14, indicated the following: -The care and maintenance of a nephrostomy tube will be provided by a licensed nurse per physician's orders [REDACTED]. -The purpose of irrigation is to keep the tube patent, not to lavage (washing out of a body cavity, with water or medicated solution) the renal pelvis. -Check the nephrostomy tube regularly for kinks and obstructions. Suspect obstruction when the amount of urine in the drainage bad is decreased or the amount of urine around the insertion site increases. - The collection bag should be emptied as frequently as necessary but at least every shift. - Maintain Intake and Output records for residents/patients with nephrostomy tubes. -Avoid clamping a nephrostomy tube as this may precipitate acute [MEDICAL CONDITION] (bacterial infection of the kidneys). A physician order [REDACTED]. -Notify the MD as soon as possible if patency cannot be restored by irrigation for further instructions/orders. The Clinical Innovation (ACI) Urology- Nursing Guidelines and Patient Information for nephrostomy care, dated (MONTH) 2012, indicated if total urine output form the nephrostomy is less than 30 milliliters (mls) per hour (that is less than 240 mls for an 8-hour shift), to notify the Physician and if no drainage occurs at all, to notify the Physician and refer Resident to Emergency Department. The Surveyor interviewed Nurse #1 at 1:45 P.M. on 04/16/19. Nurse #1 said she might have documented zero (0)millimeter (mls) in Resident #1's Medication and Treatment administration record for her shift on 12/04/18, and said that she had not received training or in-services by the facility on how to care for a nephrostomy. Nurse #1 said she could not recall what care or treatments she performed for Resident #1 during her shift. Review of Resident #1's clinical record indicated there was no documentation to support that Nurse #1 checked Resident #1's nephrsotomy tube for kinks or possible obstruction after she noted zero (0) mls of output on her shift. The Surveyor interviewed Nurse #2 at 8:00 A.M. on 04/22/19. Nurse #2 said he noted that Resident #1's nephrostomy tube bag was empty at the beginning of his shift and that he assumed it was already emptied. Nurse #2 said between 5:30 A.M. and 6:00 A.M. he noticed Resident #1's nephrostomy tube bag was still empty. Nurse # 2 said he was unsure of what to do and said he waited for the day shift nurse to come in at 7:00 A.M., to ask for directions. Review of Resident #1's clinical record indicated there was no documentation to support that Nurse #2 checked Resident #1's nephrsotomy tube for kinks or possible obstruction after he noted that the bag was still empty. The Surveyor interviewed Nurse # 3 at 1:50 P.M. on 04/16/19. Nurse #3 said she found Resident #1's nephrostomy tube clamped (shutoff position, meaning urine could not drain out). Nurse #3 said she flushed Resident #1's nephrostomy tube and said she noted a bright red, bloody return in the nephrostomy bag. Nurse #3 said she called the Specialist who advised that Resident #1 be transferred to the hospital. Nurse #3 said she even though she is comfortable caring for nephrostomy, she had not received in-service on caring for nephrostomy. The Surveyor interviewed the Interim Director of Nurses (DON) #1 at 3:50 P.M. on 04/16/19 and at 11:45A.M on 04/23/19. DON #1 said the Facility's Director of Nurses (DON #2) was responsible for providing education on nephrostomy care. DON #1 said DON #2 conducted education and competency training related to nephrostomy tubes and dressing change for nursing staff in (MONTH) (YEAR). DON #1 said she was unable to find the documentation related to the (MONTH) (YEAR) in-service. DON #1 said there were no other competencies for nursing related to Nephrostomy tube. DON #1 said the Facility had no documentation to support that Nurse #1, #2 and #3 were trained and competent to care for Resident #1's nephrostomy.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to follow Resident #1's plan of care to use a large size sling pad a mechanical lift transfer, when Certified Nurse Aide (CNA) #1 and CNA #2 transferred Resident #1 with a mechanical lift, used a small size sling pad, Resident #1 slipped off the sling pad during the transfer, on to the floor, and sustained a right ankle and right and left femur (thigh bone) fractures. Findings include: The Liko Viking M Mechanical Lift Instruction Guide, dateless, indicated to select the correct type, size, material, and design of sling pad and accessory to safely meet the patients needs. The Liko Fitting Advice Instruction Guide, dateless, indicated the sling pad size small is for patients that weigh between 44-66 pounds (lbs) and the large size sling pad is patients that weighed between 154-264 lbs. The Facility Policy, titled Mechanical Lifts, dated 12/28/16, indicated to use the mechanical lifts for transfer of residents who are non-weight bearing or have balance and mobility issues. The Policy also indicated to determine the sling pad size (check resident Care Guide). The Facility Policy, titled Use of Sling Pads for Hoyer Lifts, dated 8/3/2010, indicated to check the Care Guide for sling pad size. The Facility Policy titled Resident Care Guide, dated 12/1/14, indicated direct caregivers (CNA's) will read and follow each resident's Care Guide. The Policy also indicated to read the Care Guide for each resident daily before providing care to that resident. The Care Plan, dated as initiated 1/8/17, indicated Resident #1 was a mechanical lift with a two person assist and a large size sling pad. The Care Guide, dated 3/9/17, indicated Resident #1 was a mechanical lift for transfers with a two person assist and a large size sling pad. A Fall Risk Assessment, dated 9/2/17, indicated Resident #1 had a score of 21, score of 10 or higher indicates a high risk for falls. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had [DIAGNOSES REDACTED]. The MDS indicated Resident #1 was totally dependent with a two person assist with transfers. The Nutrition Assessment, dated 9/4/17, indicated the last known weight for Resident #1 was 153.6 lbs. in 7/2016. The Activities of Daily Living (ADL) Sheet, dated 9/1/17 through 9/30/17, indicated Resident #1 was totally dependent on staff with a 2 person assist for transfers. The Facility Investigation, dated 9/27/17, indicated Resident #1 had a small size sling pad on instead of the large size sling pad per his/her care plan, Resident #1 slid off the small size sling pad during the mechanical lift transfer and landed on the floor. The Investigation indicate Resident #1 complained of leg pain, his/her right ankle became swollen, turned purple/blue in color and the leg appeared shortened. The Investigation indicated Resident #1 was transferred to the hospital for further evaluation. The Hospital Discharge Summary, dated 10/3/17, indicated Resident #1 sustained a right femur (thigh bone) fracture, right ankle fracture that required surgical intervention and a left femur fracture that did not require surgical intervention. The Surveyor interviewed CNA #5 at 11:52 A.M. on 1/3/18. CNA #5 said that on 9/27/17, she placed a sling pad under Resident #1 during morning care in preparation to transfer his/her out of bed. CNA #5 said she was aware the Resident #1 was to use a large size sling pad, but said she did not check the sling pad size prior to placing under Resident #1. The Surveyor interviewed CNA #1 at 3:57 P.M. on 1/17/18. CNA #1 said she was aware that Resident #1 was to use a large size sling pad. CNA #1 said Resident #1 was already seated on the sling pad in his/her wheelchair and said she did not check the sling pad size prior to transferring Resident #1 with the mechanical lift. CNA #1 said she did not realize the sling pad was the size small pad until after Resident #1 had slipped out of the sling pad during the mechanical lift transfer and landed on the floor. The Surveyor interviewed CNA #2 at 12:33 P.M. on 1/5/18. CNA #2 said she was aware that Resident #1 was to use a large size sling pad . CNA #2 said Resident #1 was already seated on the sling pad in his/her wheelchair and that she did not check the sling pad size prior to transferring Resident #1 with the mechanical lift. CNA #2 said she did not realize the sling was the size small pad until after Resident #1 had slipped out of the sling during the mechanical lift transfer and landed on the floor. The Surveyor interviewed the Director of Nurses (DON) at 1:16 P.M. on 1/3/18. The DON said CNA #1 and CNA #2 did not utilize the correct size sling pad for Resident #1. The DON said CNA #1 and CNA #2 used a small size sling pad and should have used a large size sling pad. On 1/3/18, the Facility was found to be in past non-compliance. In response to the incident, the Facility took the following corrective action: A) A Facility wide audit was completed on 9/27/17 on all Residents who required a mechanical lift transfer to ensure the correct size sling pad was being used and the Care Guide was up to date with the correct sling pad size. B) The Facility Maintenance Director, on 9/28/17, inspected all the mechanical lifts to ensure they were in working order. C) The Facility Maintenance Director, on 10/2/17, inspected all beds of Residents who utilize a mechanical lift to ensure the lift was able to move easily under each bed. D) The Director of Nurses revised the Facility Policy titled Use of Sling Pads for Hoyer Lifts, on 9/27/17, to include: - Pull the sling pad leg supports under each thigh and bring up between the residents legs and criss-cross - The most common way of applying the sling pad is with the criss-crossed leg supports. An acceptable practice of applying the sling in a U shaped is no longer preferred, unless directed by therapy E) An in-service education on the updated Facility Policy titled Use of Sling Pads for Hoyer Lifts was completed on 9/27/17 with nursing staff by the Director of Nurses. F) The Maintenance Director or Designee will inspect the mechanical lifts and slings pads monthly. G) Random Monthly Audits will be conducted by the Director of Nurses or Designee to ensure the proper size sling pad according to the Residents plan of care is used during mechanical lift transfers. H) A Quarterly Assurance Performance Improvement (QAPI) meeting was held on 10/26/17 with the Medical Director present and the corrective action for the fall was reported to the Committee. I) A Monthly QAPI meeting was held on 12/1/17 and the results of the audits were reported to the Committee. J) The QAPI Committee will continue to review finding with additional measures to be implemented as needed. K) The Director of Nurses is responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to prevent Resident #1 from sustaining a right ankle and right and left femur (thigh bone) fracture when CNA #1 and CNA #2 transferred Resident #1 with a mechanical lift and used the wrong sized sling pad and Resident #1 slid off the sling pad during the mechanical lift transfer onto the floor. Findings include: The Liko Viking M Mechanical Lift Instruction Guide, dateless, indicated to select the correct type, size, material, and design of sling pad and accessory to safely meet the patients needs. The Liko Fitting Advice Instruction Guide, dateless, indicated the sling pad size small is for patients that weigh between 44-66 pounds (lbs) and the large size sling pad is patients that weighed between 154-264 lbs. The Facility Policy, titled Mechanical Lifts, dated 12/28/16, indicated to use the mechanical lifts for transfer of residents who are non-weight bearing or have balance and mobility issues. The Policy also indicated to determine the sling pad size (check resident Care Guide). The Facility Policy, titled Use of Sling Pads for Hoyer Lifts, dated 8/3/2010, indicated to check the Care Guide for sling pad size. The Facility Policy titled Resident Care Guide, dated 12/1/14, indicated direct caregivers (CNA's) will read and follow each resident's Care Guide. The Policy also indicated to read the Care Guide for each resident daily before providing care to that resident. The Care Plan, dated 1/8/17, indicated Resident #1 was a mechanical lift with a two person assist and a large size sling pad. The Care Guide, dated 3/9/17, indicated Resident #1 was a mechanical lift for transfers with a two person assist and a large size sling pad. A Fall Risk Assessment, dated 9/2/17, indicated Resident #1 had a score of 21, score of 10 or higher indicates a high risk for falls. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had [DIAGNOSES REDACTED]. The MDS indicated Resident #1 was totally dependent with a two person assist with transfers. The Nutrition Assessment, dated 9/4/17, indicated the last known weight for Resident #1 was 153.6 lbs. in 7/2016. The Activities of Daily Living (ADL) Sheet, dated 9/1/17 through 9/30/17, indicated Resident #1 was totally dependent on staff with a two person assist for transfers. The Facility Investigation, dated 9/27/17, indicated Resident #1 had a small size sling pad on instead of the large size sling pad per his/her care plan, and Resident #1 slid off the small size sling pad during the mechanical lift transfer and landed on the floor. The Investigation indicate Resident #1 complained of leg pain, his/her right ankle became swollen, turned purple/blue in color and the leg appeared shortened. The Investigation indicated Resident #1 was transferred to the hospital for further evaluation. The Hospital Discharge Summary, dated 10/3/17, indicated Resident #1 sustained a right femur (thigh bone) fracture, right ankle fracture that required surgical intervention and a left femur fracture that did not require surgical intervention. The Surveyor interviewed CNA #5 at 11:52 A.M. on 1/3/18. CNA #5 said she placed a sling pad under Resident #1 during morning care in preparation to be transferred out of bed. CNA #5 said she was aware the Resident #1 was to use a large size sling pad but said she did not check the sling pad size prior to placing under Resident #1. The Surveyor interviewed CNA #1 at 3:57 P.M. on 1/17/18. CNA #1 said she was aware that Resident #1 was to use a large size sling pad . CNA #1 said Resident #1 was already seated on the sling pad in his/her wheelchair and that she did not check the sling pad size prior to transferring Resident #1 with the mechanical lift. CNA #1 said she did not realize the sling pad was a size small until after Resident #1 had slipped out of the sling pad during the mechanical lift transfer and landed on the floor. The Surveyor interviewed CNA #2 at 12:33 P.M. on 1/5/18. CNA #2 said she was aware that Resident #1 was to use a large size sling pad . CNA #2 said Resident #1 was already seated on the sling pad in his/her wheelchair and that she did not check the sling pad size prior to transferring Resident #1 with the mechanical lift. CNA #2 said she did not realize the sling pad was size small until after Resident #1 had slipped out of the sling pad during the mechanical lift transfer. The Surveyor interviewed the Director of Nurses (DON) at 1:16 P.M. on 1/3/18. The DON said CNA #1 and CNA #2 did not utilize the correct size sling pad for Resident #1. The DON said CNA #1 and CNA #2 used a small size sling pad, but should have used a large size sling pad. On 1/3/18, the Facility was found to be in past non-compliance. In response to the incident, the Facility took the following corrective action: A) A Facility wide audit was completed on 9/27/17 on all Residents who required a mechanical lift transfer to ensure the correct size sling pad was being used and the Care Guide was up to date with the correct sling pad size. B) The Facility Maintenance Director, on 9/28/17, inspected all the mechanical lifts to ensure they were in working order. C) The Facility Maintenance Director, on 10/2/17, inspected all beds of Residents who utilize a mechanical lift to ensure the lift was able to move easily under each bed. D) The Director of Nurses revised the Facility Policy titled Use of Sling Pads for Hoyer Lifts, on 9/27/17, to include: - Pull the leg support straps under each thigh and bring up between the residents legs and criss-cross - The most common way of applying the sling is with the criss crossed leg supports. An acceptable practice of applying the sling pad in a U shaped is no longer preferred, unless directed by therapy E) An in-service education on the updated Facility Policy titled Use of Sling Pads for Hoyer Lifts was completed on 9/27/17 with nursing staff by the Director of Nurses. F) The Maintenance Director or Designee will inspect the mechanical lifts and sling pads monthly. G) Random Monthly Audits will be conducted by the Director of Nurses or Designee to ensure the proper sized sling pad according to the Residents plan of care, is used during mechanical lift transfers. H) A Quarterly Assurance Performance Improvement (QAPI) meeting was held on 10/26/17 with the Medical Director present and the corrective action for the fall was reported to the Committee. I) A Monthly QAPI meeting was held on 12/1/17 and the results of the audits were reported to the Committee. J) The QAPI Committee will continue to review finding with additional measures to be implemented as needed. K) The Director of Nurses is responsible for overall compliance.

Based on observations, interviews, record review, the facility staff failed to ensure an environment that was free of accidents/hazards relative to providing adequate supervision to prevent accidents, resulting in harm, for 1 sampled resident (#11), in a total of 17 sampled residents. Findings include: Resident #11 was admitted to the facility in 10/2013, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/12/16, indicated that Resident #11 exhibited a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (indicating severe cognitive impairment), required extensive assistance of 1 staff for eating, was at risk for developing pressure ulcers, and had Moisture Associated Skin Damage (MASD). Review of the Nutritional Status care plan, initiated 12/15/16, indicated that the resident had an increased risk of nutritional decline relative to a [DIAGNOSES REDACTED]. The interventions added to the care plan at this time included: Monitor meal and fluid intake, provide a covered glass and straws at meals, and make sure beverages are not too hot (let cool off or add ice cube). Review of the Cognitive Loss/Dementia care plan, initiated 12/21/16, indicated that the resident's memory loss puts him/her at risk for confusion, unmet needs, and a decreased sense of well being. Review of the Communication care plan, initiated 12/21/16, indicated that the resident was hard of hearing, had difficulty making him/herself understood, and had difficulty understanding others. Review of the Activity of Daily Living (ADL) care plan, initiated 12/21/16, indicated that Resident #11 required self care assistance related to poor activity tolerance, immobility and cognitive loss. The ADL care plan indicated that the resident required minimal to extensive assistance with eating depending on the day, assist of 1 staff (provide glass and straw at meals), and encourage resident to self feed as able. Review of the Interdisciplinary Notes, dated 2/24/17, indicated the resident was noted to have a red area on his/her left thigh, with 7 raised clear fluid filled blisters, measuring 13 centimeters (cm) x 6 cm. The Physician, Director of Nurses (DON) and Health Care Proxy (HCP) were notified, and orders were obtained. Review of the facility internal Incident/Accident Report, dated 2/24/17, indicated Resident #11 was noted to have a large reddened area on his/her left upper thigh, when the Certified Nursing Assistant (CNA) was providing care at 6:00 P.M. Further review of the investigation, indicated that the resident was in the Dining Room and said that his/her tea had spilled. The facility noted in the report that the resident had weakened strength in his/her hands, which may have contributed to the burn. Further review of the investigation, indicated the following interventions were added at the time of the incident: rehabilitation screen was submitted to review meal assistive devices, staff to pour hot beverage and let sit for a few minutes prior to giving it to the resident, and provide warm beverage- no hot beverages, in a cup with a lid and provide assistance, if needed. Review of the staff statement #1, dated 2/24/17, indicated that the staff member was in the process of serving drinks to other residents in the dining room, and that her back was turned away from Resident #11. The staff member stated that when she turned back around, she saw that Resident #11 had spilled his/her tea on the table. The staff member said that she cleaned up the table, and assisted Resident #11 with his/her meal. The statement also indicated that the staff member was not present to provide assistance and/or supervision to the resident, while the resident had his/her hot beverage, as care planned. Review of the staff statement #2, dated 2/24/17, indicated that the CNA was asked by the resident's daughter to get him/her into bed because the resident was observed to be wet. The CNA stated that the resident was transferred into bed, and a red area was noted on the resident's upper left leg, where his/her pants were observed to be wet. The CNA indicated that he/she reported the area to the nurse. Review of the Medication, Treatment and Task Administration Record report, dated 2/2017, indicated an order on 2/24/17 for Silvadene 1% cream, apply topically to affected area on left upper thigh twice daily and cover loosely with ABD pad (type of wound dressing for large wounds and/or wounds with heavy drainage). Review of the completed Rehabilitation Screen, dated 2/27/17, indicated that Resident #11 had a blister on his/her left thigh from spilled hot tea in the dining room at supper on 2/24/17. Further review of the screen, indicated that a Provale cup and a Spout sup cup were trialed, and refused by the family, due to the inability for the resident to utilize a straw to maintain independence. The screen further indicated that there was no therapy evaluation requested at that time. Review of the physician progress notes [REDACTED]. Further review of the note, indicated that the area affected required gentle debridement with normal saline and gentle gauze daily, and application of an anti-bacterial agent. The physician ordered Doxycycline (an antibiotic), 100 milligrams (mg), once daily for 5 days prophylactically, to treat concerning bacterial co-infection. Review of the Interdisciplinary Notes, dated 2/28/17, indicated that the blister to the resident's left thigh was open. The physician was in the facility, assessed the resident, the area was cleansed and a new treatment was ordered. Review of the the Medication, Treatment and Task Administration Record report, dated 4/2017, indicated that the wound continued to require a daily treatment and measured 8.5 cm x 3.75 cm, and had slough (yellow tissue) present. On 3/30/17 at 1:00 P.M., surveyor observed the Main Dining Room, where a resident and his/her visitor were seated at a table. The surveyor observed a coffee/hot water dispenser, located on a counter, within the main dining room, that was accessible to residents. The surveyor was able to dispense the coffee and hot water from the machine. The surveyor noted that no staff were present in the area at the this time. On 3/31/17 at 9:50 A.M., the surveyor observed the Main Dining Room was empty, although the doors to the area were open. The surveyor observed a coffee/hot water dispenser, located on a counter within the main dining room, that was accessible to residents. The surveyor was able to dispense hot water into a disposable paper cup from the stack of paper cups, located on the counter. The surveyor observed the outside of the paper cup to be very hot. On 4/4/17 at 2:50 P.M., the surveyor observed that the Main Dining Room was accessible/open. The surveyor observed that the coffee/hot water dispenser, located on the counter within the Main Dining Room, was accessible, and the surveyor was able to dispense hot water from the machine without assistance/supervision from staff. During an interview on 4/4/17 at 3:15 P.M., the Food Service Director (FSD) said that the coffee/hot water dispenser was for staff and family use, and was not for residents. The FSD said that families and/or staff can serve residents from this dispenser with supervision. The surveyor observed, during the time of the interview with the FSD, that there was no signage indicating that assistance is needed for residents to utilize the coffee/hot water dispenser. The FSD further said that she started taking temperatures of the coffee/hot water dispenser in the Main Dining Room, after a resident was burned. During an interview, on 4/4/17 at 3:45 P.M., CNA #7 said that she assists with serving residents beverages in the Main Dining Room. CNA #7 said that the staff utilize the refrigerator and the coffee/tea dispenser to serve the residents. During an interview, on 4/4/16 at 3:50 P.M., CNA #4 said that CNAs serve the beverages to residents who eat meals in the Main Dining Room. CNA #4 said that the kitchen staff stock the refrigerator with cold items, and stock cups/mugs on the counter and pull out drawers. She further said that CNAs use the coffee/hot water dispenser on the counter for coffee/hot water for residents. During an interview, on 4/4/17 at 4:20 P.M., the Assistant Director of Nurses (ADON) said that at the time of the incident, Resident #11 was able to hold a cup independently. She further said that after the incident occurred, staff were instructed to stay with the resident during the meal, as care planned.

Based on records reviewed and interviews for 1 of 3 Residents (Resident #2), who used continuous continuous oxygen, the Facility failed to: - Ensure Resident #2's oxygen plan of care was followed for 3 liters per minute of oxygen for approximately 2 months. The Surveyor observed that Resident #2 had a nasal cannula in his/her nostrils, but the portable oxygen tank was turned off while he/she propelled him/herself in a wheelchair down the hall. CNA #2 later turned Resident #1's oxygen to 2 liters per minute (the incorrect flow rate). Five Nurse's notes from 11/2016 through 12/2016 documented the incorrect flow rate, as 2 liters per minute, not 3 liters per minutes as ordered by the physician. Findings include: The Facility's Policy on Oxygen Therapy, dated 10/2016, stated that oxygen therapy will be administered according to the specific order of the physician. Obtain a physician's orders [REDACTED]. 2. Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set, dated dated [DATE], indicated Resident #2 had a Brief Interview for Mental Status score of 14, cognitively intact with no rejection of care that would be necessary to achieve the resident's health and well being. The physician's orders [REDACTED].#2 was to receive continuous oxygen via nasal cannula at 3 liters per minute to maintain an oxygen saturation greater than 89% (normal greater than 90%). The Nursing Assistant Care (CNA) Card, dated 8/2016, indicated the CNAs were to check Resident #2's portable oxygen every shift. On 12/16/16, at 8:20 A.M., the Surveyor observed Resident #2 propelling his/her wheelchair down the hall with a nasal cannula in his/her nostrils, and the dial on the portable oxygen tank was on 0, indicating the oxygen was off with no oxygen being supplied to Resident #2. The Surveyor interviewed CNA #2 at 8:21 A.M. (the CNA taking care of Resident #2 on 12/16/16 on the 6:00 A.M. 2:00 P.M. shift). CNA #2 said she transferred Resident #2 from bed to his/her wheelchair, but she did not check if Resident #2's portable oxygen was turned on. The Surveyor observed CNA #2 then turn Resident #2's oxygen to 2 liters per minute. At 8:22 A.M. on 12/16/16, CNA #3 came out of a Resident Room and said (in front of Resident #2) to the Surveyor that Resident #2 shuts off his/her own oxygen. The Surveyor interviewed Resident #2 at 8:23 A.M. on 12/16/16. Resident #2 said No, I don't touch the dial on my oxygen, only the Nursing staff does. At 8:40 A.M. the Surveyor observed Resident #2 in the Dining Room having breakfast, and his/her portable oxygen was set at 2 liters per minute. At 9:45 A.M. the Surveyor observed Resident #2 in his/her room, and his/her portable oxygen was set at 2 liters per minute. The Surveyor interviewed Nurse #3 at 9:55 A.M. on 12/16/16. Nurse #3 said Resident #2's oxygen was ordered at 3 liters per minute. Nurse #3 and the Surveyor observed together that Resident #2's the oxygen flow rate was at 2 liters per minute. Nurse #3 said that is the incorrect flow rate, and she changed the flow rate to 3 liter per minute. The Surveyor interviewed CNA #2 at 9:57 A.M. on 12/16/16. CNA #2 said that Resident #2's oxygen flow rate is 2 liters per minute. The Nurses' notes indicated Resident #2 oxygen was administered at 2 liters per minute on the following dates:. - on 11/16/16 at 12:51 P.M. - on 11/16/16 at 10:10 P.M. - on 12/06/16 at 11:26 A.M. - on 12/07/16 at 12:03 P.M. - on 12/14/16 at 1:08 P.M. The Surveyor interviewed the DON at 2:00 P.M. on 12/16/16. The DON said that the progress notes in Resident #2's record, indicated an incorrect oxygen flow rate of 2 liters per minute, and it should have been 3 liters per minute.

Based on record review and interview, the facility failed to follow the written plan of care to prevent falls with injury for 1 of 6 applicable sampled residents (# 10) in a total sample of 18. Findings included: For Resident # 10, the facility failed to follow the written care plan to provide timely toileting after meals, nap times, and proper bed height that resulted in injurious falls. Resident #10 was admitted to the facility in March of 2010 with a [DIAGNOSES REDACTED]. The falls prevention care plan of 9/13/10, due to concerns that the resident was forgetful, was legally blind, hard of hearing, and incontinent of urine, had the goal the resident was to be free of falls and related injury. Interventions included: -Keep height of bed at thigh high level, -One person assist for toileting; staff to stay with resident, and toilet during 1st rounds (11:00 P.M. to 7:00 A.M.), 4:30 A.M. and 6:30 A.M., -And toilet the resident after meals and put the resident down for a nap. Nursing Notes and Investigation, dated 11/26/10 at 2:00 P.M., indicated the resident got up from the dining room chair, and fell . The CNA (Certified Nursing Assistant) assigned to the dining room was assisting another resident and did not witness the fall. The resident had not been toileted after meal completion and placed for a nap by staff, as planned. The resident complained of left hip pain, was sent to the hospital and found to have incurred a left [MEDICAL CONDITION] with surgical intervention. Staff were inserviced on the care plan intervention for toileting and nap time after meals. Nursing Notes and Investigation, dated 12/07/10 at 7:30 A.M., indicated another resident alerted staff that Resident #10 had fallen. The resident was observed kneeling beside the bed. No injury was noted, however the bed was not at the proper height, per the care plan. Staff had not toileted the resident with identified urgency of urination, at 6:30 A.M., as planned. Nursing Notes and Investigation of 12/31/10 at 3:20 A.M. revealed staff found the resident sitting on the floor next to the bed. The resident needed to go to the bathroom, and staff had not toileted the resident at 1st rounds, per the care plan intervention. No injury was noted. Nursing Notes and Investigation of 1/28/11 at 1:45 P.M. indicated staff heard a noise and found the resident on the floor in the dining room, bleeding from a scalp laceration. The resident had not been toileted after the lunch meal and put to bed for a nap as care planned. The resident was sent to the local hospital and returned with 8 staples. Interview with Unit Manager #1 on 4/11/11 at 9:30 A.M. confirmed the resident did not use the "push" call bell to alert staff of independent transfers and ambulation, was very lethargic throughout the day and evening, and required effective supervision in the dining area and bedroom to prevent falls. Interview with the Director of Nursing on 4/11/11 at 11:30 A.M. acknowledged efforts were made to revise the Resident's fall risk care plan; yet also acknowledged that the interventions were not consistently effective or followed. Please refer to F 323, Example 1.

Based on record review, interview, and observations, the facility failed for 2 sampled residents (#10 and #15) of 6 residents with falls out of a total sample of 18 residents to provide effective interventions and adequate supervision to prevent injury. Findings included: 1. For Resident # 10, the facility failed to provide effective interventions and adequate supervision as well as following the care plan related to toileting the resident, scheduled nap times after meals, and providing proper bed height to prevent 8 falls (from 8/15/10 to 1/28/11), of which two falls resulted in a fractured hip and a laceration with 8 staples. Resident #10 was admitted to the facility in March of 2010 with a [DIAGNOSES REDACTED]. The admission care plan indicated the resident was at risk for falls due to a change in living environment, with a goal to remain free from falls and related injuries. Interventions included: -Upon arrival, orient and familiarize the resident to room and neighborhood, -Orient resident to call bell and make sure it is within resident's reach and resident is able to use it, -Monitor resident responses to medications and report promptly side effects, -Provide resident with increased supervision for first 72 hours of stay by means of Q (every) 15 minute checks, -PT (Physical Therapy)/OT (Occupational Therapy) screen as indicated, -Keep room and walkways clear of clutter, -Make sure resident wearing proper footwear, -Observe resident for fatigue and encourage resident to sit and rest or take a nap as needed, -Resident walks with one assist, -Resident transfers with one assist, -Resident uses a walker to walk, -Make sure bilateral hearing aides are in, -Make sure glasses are on, -And if on psychoactive medications, check resident's orthostatic blood pressures monthly, Nursing Notes revealed the resident had fallen from an unsecured shower chair, on 3/23/10, in the shower room. The resident did not have on shower shoes and the shower chair brakes were not engaged. A new care plan was written on 3/23/10, after the resident's first fall. The goal was that the resident would be safe from injury due to the resident not remembering what was safe and "not wanting to break anything." The approaches were: -Keep height of bed at upper resident thigh level, -Slipper socks when in bed, -Lock wheels of shower chair and use shower shoes, -Bilateral hearing aids, -And transfer independently. Fall Risk assessments of 3/23/10, 8/28/10, 11/10/10, 11/25/10, 12/7/10, 12/31/10, and 1/28/11 indicated increasing "high fall risk" scores of 14, 12, 17, 20, 22, 21, and 21 respectively. The resident's quarterly Minimum Data Set (MDS) review of 6/11/10 indicated the resident had short term memory issues, was moderately impaired cognitively, usually understood, had no mood or behavior issues, transferred, ambulated, and toileted self independently, was continent of bowel and bladder, inaccurately was coded as having no falls, and was administered antipsychotic medication daily. Nursing Notes of 6/17/10 at 1:59 P.M. indicated the resident wandered the unit halls requiring redirection many times, as well as getting out of bed at 10:30 P.M. when incontinent of urine. Nursing Notes of 6/24/10 at 2:07 P.M. indicated the resident was unable to remember things, and attempts to redirect had little effect. Nursing documentation of 8/2/10 at 1:29 P.M. indicated the resident ambulated with unsteady gait and was confused. Nursing Notes and Investigation, dated 8/15/10 at 12:05 P.M., indicated staff witnessed the resident stand up from the dining room chair and fall to buttocks (the second fall since admission). No injury was noted. The resident's answer was "setting the table." The care plan was updated to provide 1 person assist for ambulation. Nursing documentation of 8/16/10 at 6:02 A.M. and 8/17/10 at 9:13 P.M. indicated the resident attempted to stand and ambulate independently several times. Staff noted on 8/21/10 at 1:52 P.M. that the resident's pattern was to be up all night on the 11:00 P.M. to 7:00 A.M. shift (1st rounds), and "slept all day." Record documentation and investigation of 8/28/10 at 1:00 A.M. indicated staff heard the sound of a door close and found the resident sitting on the floor near the nightstand with basin out (the third fall since admission).The resident stated that "Peggy's in the closet." No injury was noted. Staff noted the resident's bed was in the lowest position not at the resident's thigh level, as specified in the care plan. The resident was evaluated by Rehabilitation to increase strength and balance, as well as re-assess the bed height. The care plan was updated 8/28/10 to include a "modified" call device. The resident's 9/13/10 significant change MDS assessment for decline in memory, ambulation, Activities of Daily Living (ADLs), and bladder continence indicated the resident now had long term memory loss, altered perception of surroundings, periods of lethargy, wore hearing aids, was highly impaired visually, required limited one person assist for transfers and ambulation, extensive assist for dressing, toilet use, hygiene, and bathing, was frequently incontinent of bladder, and had fallen in the last 30 and 31-180 days. The care plan was re-written 9/13/10, due to concerns that the resident was forgetful, was legally blind, hard of hearing, and incontinent of urine. The goal was to be free of falls and related injury, with the interventions of: -Keep height of bed at thigh high level, -Use 1/2 rails for bed mobility, -Apply hearing aids, -Wear slipper socks, -Ambulation with 1 person assist and gait belt, -Locked shower chair and shower shoes as indicated, -And one person assist for toileting; staff to stay with resident, and toilet during 1st rounds, 4:30 A.M. and 6:30 A.M. Nursing Notes of 10/18/10 at 9:40 P.M. noted the resident was put in a recliner due to lethargy and repeated unsafe rising. Nursing Notes and Investigation, dated 11/10/10 at 9:45 A.M., indicated a staff member, who was doing dishes in the dining room, saw the resident push a dining room chair back and tipped over with the chair onto the left side. (This was the fourth fall since admission.) No injury was noted, and the resident indicated the need to be toileted. Staff were instructed to toilet the resident after meals and put the resident down for a nap. Nursing Notes and Investigation, dated 11/25/10 at 1:00 A.M., indicated a Certified Nursing Aide (CNA) found the resident sitting on the floor near the bathroom door, with "P.J." and brief pulled half way down. The resident was going to the bathroom independently. No injury was noted. The resident was toileted and voided. (This was the fifth fall since admission.) Nursing Notes and Investigation, dated 11/26/10 at 2:00 P.M., indicated the resident got up independently from the dining room chair and fell . The CNA assigned to the dining room was assisting another resident and did not witness the fall. The resident had not been toileted after meal completion and placed for a nap, as planned. The resident complained of left hip pain, was sent to the hospital and found to have incurred a left hip fracture with surgical intervention. Staff were inserviced on the care plan interventions for toileting and nap time after meals. (This was the sixth fall.) Nursing Notes and Investigation, dated 12/07/10 at 7:30 A.M., indicated another resident alerted staff that Resident #10 had fallen (the seventh time). The resident was observed kneeling beside the bed. No injury was noted; however, the bed was not at the proper height per the care plan. Staff were reminded to toilet the resident at 6:30 A.M., per the care plan, due to the resident's urgency of urination. The care plan was updated to include non-skid strips next to the resident's bed, bringing the resident to the dining room for a snack, hipsters, the use of rolled blankets or pillows under a fitted sheet on both sides of the bed, and placing the bed against the wall. Nursing Notes of 12/8/10 at 6:17 A.M. noted occasional resident attempts to rise without assist; on 12/10/10 at 2:10 P.M. walking from the bathroom independently to the bed; on 12/12/10 at 9:15 P.M. attempting to get out of bed; and on 12/14/10 at 10:21 P.M., needing constant reminders not to get up alone in the Dining Room. The 12/13/10 significant change MDS for continued decline in resident cognition and ADLs indicated the resident was severely impaired cognitively, required 2 assists for transfers, toilet use, dressing, toileting, hygiene, bathing with one assist, extensive assist of 2 persons for ambulation, limited assist of one for eating, was not steady for balancing, and had a fall and fracture in the last 6 months. Nursing Notes and Investigation of 12/31/10 at 3:20 A.M. indicated that staff found the resident sitting on the floor next to the bed. The resident needed to go to the bathroom, and staff were instructed to toilet the resident at 1st rounds, per the care plan. No injury was noted. (This was the eighth fall since admission.) Nursing Notes on 1/14/11 at 3:15 P.M. indicated that the resident was ambulating independently in the room, and needed redirection numerous times. On 1/18/11 at 9:00 P.M., the resident was observed getting out of bed without using the call bell. Nursing Notes and Investigation of 1/28/11 at 1:45 P.M. indicated staff heard a noise and found the resident on the dining room floor, bleeding from a scalp laceration. The resident had not been toileted after the lunch meal or put to bed for a nap, as care planned. The resident was sent to the local hospital and returned with 8 staples to the scalp. The care plan was updated to place the resident in the small dining room for meals. (This was the 9th fall since admission and the 2nd one with serious injury.) Nursing Notes of 1/30/11 at 8:37 P.M. and 2/13/11 at 9:51 P.M. indicated instances of the resident transferring out of bed unassisted all night long. On 4/10/11 at 5:00 P.M. the resident was found standing up in the bathroom unassisted and requiring constant supervision. The quarterly MDS review of 3/16/11 indicated the resident had fallen, and sustained a laceration and fracture. Observation of the resident on 4/7/11 at 11:18 A.M. and at 12:00 P.M. revealed the resident asleep in a recliner in the unit dining room with glasses on. From 1:15 P.M. to 1:40 P.M., the resident was asleep in bed with 1/2 rails up and anti-skid strips next to bed which was against the wall. On 4/11/11 at 8:15 A.M. the resident was observed asleep in a recliner in the unit dining room. Interview on 4/11/11 at 8:50 A.M. with the resident's primary daytime CNA #1 confirmed the resident used to be independent in transfers and ambulation, but now required total care. The resident usually napped throughout the day either in the dining room recliner or bed. At times, the resident slept during meals. The resident was incontinent of bowel and bladder, tended to get up impulsively, and forgot to use the call bell. CNA #1 indicated the resident was at high risk for falls. Interview with Unit Manager #1 on 4/11/11 at 9:30 A.M. confirmed the resident did not use the "push" call bell to alert staff of independent transfers and ambulation, was very lethargic throughout the day and evening, and required supervision in the dining area and bedroom to prevent falls. Interview with the Director of Nursing on 4/11/11 at 11:30 A.M. acknowledged efforts were made to revise the Resident's fall risk care plan, but interventions were not consistently effective or followed. Please refer to F 282. 2. For Resident #15, the facility failed to provide effective interventions or supervision to alert staff of unsafe resident transfers, ambulation, and toileting, to prevent repeated unwitnessed falls with injury. Resident #15 was admitted to the facility in 4/07 with [DIAGNOSES REDACTED]. Record review and Assistant Director of Nursing interview (on 4/12/11 at 11:00 A.M.) revealed the resident had a history of [REDACTED]. The quarterly MDS review of 4/12/10 indicated the resident had short and long term memory issues, was moderately impaired cognitively, was easily distracted with periods of altered perception, usually understood, transferred, toileted, and ambulated with supervision (ambulated independently on the unit), required extensive assist for dressing, hygiene, and bathing, was continent of bowel and bladder, and had fallen in the last 30 and 31-180 days. The care plan, dated from 4/10 to 8/16/10, indicated the resident was at risk for falls due not "remembering what is safe, not wanting to break anything and the medicine the resident took." The care plan goal was to be safe from injury. Interventions included: -Notify resident where call bell is, -Keep bed locked in lowest position, -Don't leave bedside table in room, -One person assist on "11-7," -When going to bathroom, staff to stay with resident, -Slipper socks when in bed, -Bathroom to be clean and dry, -Redirect wandering residents away from resident, -One person assist for ambulation and supervised toileting. -and Assist with escort in and out of dining room and seating. Fall Risk assessments of 6/25/10, 8/5/10, 12/28/10, 1/7/11, and 1/27/11 indicated increasing "high fall risk" scores of 9, 10, 15, 15, and 19 respectively. Nursing Notes and Investigation of 7/25/10 at 7:20 P.M. indicated the resident had an unwitnessed fall in the dining room when attempting to rise. The resident tripped over another chair or another resident's walker that was positioned close by. Notes of 7/26/10 at 6:15 A.M. indicated the resident had a large bruise on the right elbow from the fall. The care plan was updated to have a clutter free dining area and for staff assist with escorting the resident in and out of dining room and with seating. Nursing Notes and Investigation of 8/5/10 at 7:45 A.M. indicated the resident was escorted out of the bathroom and seated in a bedroom chair. The resident was told to remain in the chair while the CNA made the roommate's bed. The resident stood up, lost balance and fell , landing against the wall and nightstand. Notes of 8/6/10 indicated the resident sustained [REDACTED]. The care plan was updated to assist the resident with transfers and ambulation. The care plan was re-written on 8/17/10 with the approaches of -Keep bed locked in lowest position, -Encourage resident to wear proper footwear, -Have glasses on daily, -Don't leave bedside table in room, -Slipper socks when in bed, -Bathroom to be clean, dry, and clutter free, -When going to bathroom, staff to stay with resident, -And one-two person(s) to walk with resident and assist in/out of bed and chairs. A significant change MDS of 8/19/10 for delirium, ADLs, and urinary continence, indicated the resident now had episodes of disorganized speech, restlessness, mental function variance, required limited assist for transfers and ambulation, extensive assist for toileting, was frequently incontinent of bladder, used of pads/briefs, had unsteady gait, had fallen in the last 30 and 31-180 days, and received antipsychotic medication daily. The 11/10/10 quarterly MDS review confirmed the resident's status on the 8/19/10 MDS for decline in ADLs and continence. Nursing Notes and Investigation of 12/28/10 indicated the resident was transferred to a recliner and given a prn (as needed) antipsychotic medication for agitation at 11:00 P.M. The resident was observed attempting to put legs over the recliner and sustained a skin tear on the left shin. At 2:30 A.M., the resident was asleep in the recliner that was located in the hallway. At 3:45 A.M., staff heard a cry from the resident, and found the resident on the floor (approximately 10 feet from the recliner) with a large laceration on the left side of the head, and bleeding profusely. The resident was sent to the local hospital, and returned with a large bruise around the left eye with a bandage covering sutures. The resident's care plan was updated 12/29/10 to have two assists for transfers and ambulation, and toilet the resident on the last rounds for the evening shift. Additionally, the resident was to wear hipsters at all times, use of rolled blankets or pillows under a fitted sheet on both sides of the bed, and encourage day-time naps in the recliner. Nursing Notes and Investigation of 1/7/11 at 1:00 A.M. indicated staff heard the resident crying, and found the resident lying on the bedroom floor, head resting on the floor, in front of the bed. A soiled brief and wet bathroom floor (of urine) was evident, as well as a skin tear to the left elbow. The resident had an unwitnessed and unassisted ambulation to the bathroom. The care plan was updated 1/7/11 to toilet the resident at 12:00 A.M. if awake, offer toileting at 5:00 A.M., place the bed against the wall with a scoop mattress, and provide a soft call bell near the resident, in bed. The care plan was re-written on 1/25/11 with the following interventions: -Keep bed locked in lowest position, -Don't leave bedside table in room, -Slipper socks when in bed, -Turn on lamp at night for more light, -Toilet last rounds of "3-11 p(m) shift (about 10:30 p), around 12 mn (midnight), and 5:30 a.m." -When going to bathroom, staff to stay with resident, -Have bed against wall, -And scoop mattress, anti-skid strips. Nursing Notes and Investigation of 1/27/11 at 3:10 P.M. indicated the resident had another unwitnessed fall. Staff heard a thump and found the resident on the floor, on back with feet facing the bed, and head towards bathroom door. The resident was noted to have a 1 centimeter lump on the occipital lobe with slight ecchymosis. The care plan was updated 1/28/11 to include the use of rolled blankets or pillows under a fitted sheet on both sides of the bed, and encourage day time naps in the recliner with the propping of the resident to one side of the recliner. A 2/3/11 significant change MDS assessment for communication, cognition, delirium, ADLs, and bowel continence, indicated the resident was now severely impaired cognitively, sometimes was able to understand and be understood, was inattentive, had disorganized thinking, and an altered level of thinking, required extensive assist of two for transfers, ambulation in the room, was dependent for ambulation on the unit, for toilet use, hygiene, dressing and bathing, had unsteady balance, required a wheelchair, was occasionally incontinent of bowel, had fallen since admission or prior assessment, and injury (laceration/skin tears.) Nursing Notes of 3/12/11 at 10:30 P.M. and 3/15/11 at 11:00 P.M. noted the resident climbing out of bed independently. Observation on 4/11/11 at 4:00 P.M. revealed the resident in a recliner in the dining room with glasses and geri-sleeves on. On 4/12/11, from 7:45 A.M. to 8:15 A.M., the resident was observed seated in a dining room chair at the table for breakfast, sleeping during the meal with cues by staff to eat. Interview with the resident's primary daytime CNA # 2 on 4/12/11 at 9:30 A.M. confirmed the resident had significantly declined over the last year, was now incontinent of bowel and bladder, required two person assist for ADLs and a wheelchair, slept during the daytime in a recliner in the dining room, and had to be supervised very closely due to unpredictable and numerous independent attempts to transfer out of chairs or bed. Interview with the Director of Nursing, Assistant Director of Nursing and Administrator on 4/12/11 at 11:00 A.M. acknowledged that efforts had been made to revise the Resident's fall risk care plan and maintain resident dignity; acknowledged that the interventions and supervision to prevent the number of unwitnessed events were not consistently effective to prevent falls with injury.