Every finding on record at Dwyer Home

Based on observations, interviews, policy review, and record review for one Resident (#239), of 12 sampled residents, the facility failed to ensure his/her comprehensive and individualized plan of care was implemented. Specifically, the facility failed to follow his/her care plan and maintain aspiration precautions as indicated. Findings include: Review of the facility's policy titled Aspiration Precautions, dated November 2013, included the following: -All residents will be assessed upon admission, annually and upon change of condition by the interdisciplinary team for swallowing difficulties. Residents found to be at risk with swallowing and have potential for choking will be placed on aspiration precautions. -Each resident who is placed on aspiration precautions will have interventions placed in their plan of care. Resident #239 was admitted to the facility in November 2023 with diagnoses that included aspiration pneumonia (respiratory infection caused by something other than air being inhaled into your lungs) and dysphagia (difficulty swallowing). Review of the most recent Minimum Data Set (MDS) assessment indicated Resident #239 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 13 out of 15. Review of the Hospital Discharge Summary, dated 11/27/23, indicated Resident #239 was at risk for aspiration and recurrent aspiration pneumonia. Resident #239 was treated with antibiotics. Review of the Physician's Orders included but was not limited to: -No added salt diet, pureed texture, and nectar thick liquids -Maintain aspiration precautions every shift for aspiration pneumonia and dysphagia. Review of the Physician's Progress Note, dated 11/28/23, indicated Resident #239 has history of aspiration. Review of the Speech Therapy evaluation and plan of treatment, dated 11/27/23, indicated Resident #239 was a high aspiration risk. Swallow strategies included but were not limited to: -Compensatory Strategies/Positions: Small bites/sips -Alternate solids/liquids -90-degree seating at all meals Review of the interdisciplinary care plan, date initiated 11/30/23, included but was not limited to the following interventions: -All staff to be informed of resident's special dietary and safety needs -Maintain aspiration precautions at all times -Resident to eat only with supervision -Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly -Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards -Alternate small bites and sips. Use a teaspoon for eating. Do not use straws. -Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris. Review of the Certified Nursing Assistant (CNA) Kardex (summary of resident's care and preferences) indicated but was not limited to: -Eating/Nutrition -Alternate small bites and sips. Use a teaspoon for eating. Do not use straws. -Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris. -Keep head of the bed elevated 45 degrees during meal and 30 minutes afterwards. -Resident to eat only with supervision On 12/6/23 at 12:55 P.M., the surveyor observed Certified Nursing Assistant (CNA) #1 seated in a chair, in the common area, while Resident #239 was consuming his/her lunch meal. Resident #239 was heard coughing during his/her meal. CNA #1 had no interaction with Resident #239 as he/she ate. On 12/7/23 at 8:12 A.M., the surveyor observed CNA #1 deliver a breakfast tray to Resident #239. CNA #1 set up the tray and left the room. Resident #239 had started to eat his/her breakfast independently and without supervision. Resident #239 was observed coughing while eating. Resident #239 had coughed up phlegm and spit it in his/her napkin. During an interview on 12/7/23 at 11:29 A.M., CNA #1 said she had served Resident #239's breakfast first. CNA #1 said Resident #239 was to be supervised when he/she eats. CNA #1 said she should have passed Resident #239's tray last. CNA #1 said she should have stayed with him/her. CNA #1 said she was to cue Resident #239 during his/her meal to take small bites and to slow down if he/she ate too fast. During an interview on 12/7/23 at 11:32 A.M., Charge Nurse #1 said Resident #239 was at risk for aspiration. Charge Nurse #1 said Resident #239 needed to always have staff with him/her while he/she was eating. During an interview on 12/7/23 at 11:42 A.M., Speech Therapist (SLP) #1 said Resident #239 was to be supervised at all times when eating. SLP #1 said Resident #239 was assessed as very high risk for aspiration. SLP #1 said staff had been educated on following the aspiration precautions for Resident #239. During an interview on 12/8/23 at 9:54 A.M., the Director of Nursing (DON) said the SLP would have met with staff and educated them on aspiration precautions for Resident #239. The DON said education was word of mouth and was reflected on the care plan. The DON said aspiration interventions for Resident #239 were carried over to the CNA Kardex, and the expectation was that the CNAs would follow the aspiration interventions on the CNA Kardex.

Based on observation, record review, and interview, the facility failed to ensure an extra dose of an antibiotic was not administered to one Resident (#16), out of a total sample of 12 residents. Specifically, the facility failed to monitor the date and the time the Resident should have received the last dose. Findings include: Resident #16 was admitted to the facility with diagnoses including urinary tract infection, hematemesis, pressure of right heel stage 2, and pressure of right heel stage 1. Review of Resident #16's medical record indicated a Physician's Order to administer Keflex (Antibiotic) Oral Capsule 500 MG by mouth four times a day for wound infection until 12/6/23. Review of the Medication Administration Record (MAR) dated December 2023, indicated the first dose of Keflex 500 MG Capsule was administered on 12/1/23 at 6:00 P.M. to Resident #16. Review of the MAR indicated Resident #16 received 21 doses of Keflex 500 MG, exceeding the total amount of 20 doses. Further review of the medical record failed to indicate a rationale for the excess dose of Keflex administered on 12/6/23 at 6:00 P.M. During an interview on 12/08/23 at 01:49 P.M., Nurse Manager #1 said the Resident received an extra dose of the Keflex 500 MG. During an interview on 12/08/23 at 01:52 P.M., the Director of Nurses (DON) reviewed the MAR with the Nurse Manager in the presence of the surveyor. After reviewing, the DON confirmed Resident #16 received an extra dose of the prescribed antibiotic.

Based on observation, interview, document review, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to ensure medications and vaccines were stored at proper temperatures to preserve their integrity in one of two medication refrigerators reviewed. Findings include: Review of the facility's policy titled Medication Storage, dated January 2023, indicated but was not limited to the following: -Medications requiring refrigeration or temperatures between 2 degrees ( ) Celsius (C) (36 Fahrenheit (F) and 8 C (46 F) are kept in a refrigerator with a thermostat to allow temperature monitoring. -A temperature log or tracking mechanism is maintained to verify that temperature has remained within acceptable limits. -The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. -Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check as problems are identified, and recommendations are made for corrective action to be taken. Review of Sanofi Manufacturer's Instructions for Use (IFU), revised September 2015, indicated but was not limited to the following: -Tubersol (Tuberculin Purified Protein derivative (Mantoux) is indicated to aid diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease). Storage and Stability: -Store at 2 to 8 C (35 to 46 F). Do not freeze. Discard product if exposed to freezing. Review of the Pfizer Manufacturer's IFU, revised June 2021, indicated but was not limited to the following: -Prevnar 20 is a vaccine indicated for active immunization for the prevention of pneumonia and invasive disease caused by Streptococcus pneumoniae serotypes in adults [AGE] years of age and older. How Supplied/Storage and Handling: -Upon receipt, store refrigerated at 2 to 8 C (36 to 46 degrees F). -Do not freeze. Discard if the vaccine has been frozen. On 12/7/23 at 10:28 A.M., the surveyor reviewed the medication storage room refrigerator with Charge Nurse #1. The surveyor observed eight boxes of Tubersol, four boxes of the Prevnar 20 vaccine, various insulin pens (preloaded with insulin to treat diabetes), and Performist inhalation solutions (helps to manage symptoms of chronic obstructive pulmonary disease) stored inside the medication refrigerator. Review of the December 2023 Refrigerator/Freezer Temperature Log indicated the following twice daily refrigerator temperatures: -Seven of seven 6:00 A.M. temperatures documented from December 1st through December 7th as 30 F, (all below the required range) -Six of six 6:00 P.M. temperatures documented from December 1st through December 6th as 30 F to 32 F, (all below the required range) -No documentation of problems identified, or recommendations made for corrective action to be taken During an interview on 12/7/23 at 10:28 A.M., Charge Nurse #1 said all the temperatures documented were 30 F to 32 F. She said the temperature log just indicated that the temperature should be below 41 F, but there was no low range listed. She said the temperatures shouldn't be too low because they could freeze medications stored inside. During an interview on 12/7/23 at 12:45 P.M., Charge Nurse #1 said the 11:00 P.M.-7:00 A.M. shift was responsible for checking temperatures and Charge Nurse #2 was responsible for overseeing the process, but she was out on leave. Nurse Manager #1 entered the nurses' station and said below range temperatures could affect the integrity of the medications/vaccines stored inside. Charge Nurse #1 said if temperatures are below range, then staff should notify maintenance but was not sure if that was done and said at least four separate staff members documented below range temperatures on the log, but only one signed it who was not available for interview. During an interview on 12/7/23 at 12:47 P.M., the Maintenance Director said staff will notify him verbally or send a work order if temperatures are out of range but said no staff had notified him. He said he was not aware of any of the out-of-range temperatures for the month of December. During an interview on 12/7/23 at 3:31 P.M., the Director of Nursing (DON) said normal medication refrigerator temperatures should be between 35 F and 46 F and said the 11:00 P.M.-7:00 A.M. shift was responsible for checking the temperatures twice a day to ensure they are within the normal range. The DON said she didn't know the process if temperatures were documented as out of range and would have to look but said she'd notify maintenance as it could be a thermometer issue. The DON said below range temperatures could affect the efficacy of the medications stored inside and all the nurses who documented on the temperature log were supposed to sign their name but did not.

Based on record review, document review, Nursing Facility Service Agreement, and interview, the facility failed to ensure Hospice provided information and documentation regarding care and services as required in the provider contract agreement, including a designated facility coordinator for one Resident (#18), out of a total sample of 12 residents. Specifically, the facility failed to ensure the hospice service provider completed hospice information in the Resident's record, which included initial certification, the most current Hospice Plan of Care, and the Physician Recertification of Terminal Illness in order to assure coordination and collaboration of care. Findings include: Review of the Hospice Care Facility Services Agreement, signed 8/10/2017, included but was not limited to: - The plan of care will reflect the participation of the Hospice, Facility and the Hospice Patient and family to the extent possible. - The plan of care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care. - The facility shall designate an individual within the facility who shall be responsible for the implementation of the provision of the agreement and ensure coordination of care between the Hospice and the facility. - Hospice shall provide the facility with sufficient information to ensure the provision of facility services under this agreement is in accordance with hospice patient's plan of care. -Such information shall include: (a) the most recent plan of care, medication information and physician orders. (b) the hospice election form and any advanced directives. (c) physician certification and recertification of terminal illness. (d) names and contact information for hospice personnel involved in providing hospice services. 1. Resident #18 was admitted to the facility in July 2021 with diagnoses which included chronic obstructive pulmonary disease, acute respiratory failure, hypoxia, panic disorder, anxiety, and dependence on supplemental Oxygen. Review of Resident #18's medical record indicated a Physician's Order, dated 5/3/23, for evaluation and admission to hospice care. Review of the Minimum Data Set (MDS) assessment, dated 11/02/23, indicated Resident #18 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status score of 8 out of 15. The MDS indicated the Resident received hospice services. Review of the Resident's Hospice binder included a Hospice checklist, blank Hospice forms, and one Hospice nursing assessment dated [DATE]. Further review failed to indicate the binder included the required Hospice Physician Certification of Terminal Illness and the Plan of Care. Further review of the binder failed to include any Hospice assessment before and after 10/12/23. On 12/7/23 at 3:51 P.M., the surveyor entered the Resident's room and observed a staff with a Hospice badge. During an interview on 12/7/23 at 3:52 P.M., Hospice Nurse #1 said she attended to the Resident once weekly. After the visit, the Hospice nurse left, did not update the nursing staff on the Resident, and did not document her visit in the office binder. During an interview on 12/8/23 at 11:54 A.M., Nurse Manager #1 said Resident #18 currently receives hospice services. Nurse Manager #1 said there was no schedule of services from hospice and was unaware when a service provider would be at the facility to provide care to Resident #18. The surveyor inquired with the Nurse Manager who the facility hospice coordinator was. Nurse Manager #1 said once the physician initiated an order for hospice services, the nurse on shift at the time called the referral into the hospice provider indicated by the physician and was unaware of any designated facility hospice coordinator. During an interview on 12/8/23 at 12:00 P.M., Certified Nurse Aide #1 (CNA) said Resident #18 currently received hospice services. During an interview on 12/12/23 at 3:10 P.M., Social Worker #2 said she was not the designated hospice coordinator. She said it is a collaboration between nursing and Hospice. During an interview on 12/12/23 at 3:34 P.M., Nurse Manager #1 said she was not the designated hospice coordinator. Nurse Manager #1said she would contact Hospice. Nurse Manager #1 reviewed the Hospice Binder and noticed no pertinent information from Hospice. Nurse Manager #1 said the hospice was responsible for organizing and updating the hospice binder with current paperwork. Nurse Manager #1 and the surveyor reviewed Resident #18's hospice binder. Nurse Manager #1 was unable to locate the most current Hospice Physician Certification of Terminal Illness and the Plan of Care. During an interview on 12/12/23 at 3:42 P.M., the Director of Nurses said she would be in touch with Hospice to ensure proper coordination of care.

Based on observation, policy review, and staff interview, the facility failed to ensure that infection control measures were consistently implemented to prevent the potential transmission of infectious diseases, including COVID-19, from resident to resident. Findings include: Review of the facility's Nursing Policy and Procedures for Mask and Face Covering Requirement, dated 11/8/2022, indicated the following: Persons over the age of 5 years old are required to wear a mask or face covering that always covers their mouth and nose when visiting the [NAME] Home. All long-term care facility personnel are required to wear a facemask while they are in the facility, consistent with the DPH Comprehensive PPE Guidance. The fit of the masks should be as follows: -Cover the nose and mouth. -Fit securely and comfortably against the side of the face. -Be secured with ties or ear loops. -Allow for breathing without restriction. Review of the Centers for Disease Control and Prevention (CDC) education tools used by the facility to teach all staff the requirement for safely removing PPE after caring for a resident on contact or droplet precautions. The CDC teaching tool indicated: USE SAFEWORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION. -Keep hands away from face -Limit surfaces touched -Change gloves when torn or heavily contaminated -Perform hand hygiene Remove all PPE before exiting the patient room except a respirator, if worn. On 1/31/23 from 10:40 A.M. to 11:15 A.M. and then at 1:00 P.M., the surveyor observed the following breaches in infection control: - On the Southwest Wing, Nurse #1 prepared to enter the room of a resident on Droplet/Contact precautions. Nurse #1's N-95 respirator mask was positioned below the nose and not providing adequate protection. - On the Northeast Unit, CNA #1 was in a resident's room identified as Droplet/Contact isolation. CNA #1 wore full Personal Protective Equipment (PPE) consisting of an N-95 respirator, eye protection, gown, and gloves, providing care to the resident. CNA #1 reached her body out of the room, with contaminated PPE still donned, to retrieve something from the precaution cart that was situated outside the door to the room. - At 11:05 A.M., Nurse #1 was at the medication (med) cart located near the central nurses' station preparing medication. Nurse #1 repeatedly pressed her hand against the mouth portion of the N-95 respirator while leaning over the med cart. Nurse #1 touched the narcotic register, and then opened the top drawer of the cart to begin preparing medications. Nurse #1 failed to sanitize her hands after repeatedly touching the N-95 respirator. - At 11:15 A.M., Nurse #2 carried a red, plastic, biohazard container containing multiple contaminated sharp instruments, such as needles and syringes, past the nurses' station just outside the soiled utility room. Nurse #2 placed the biohazard container on top of the med cart and secured the opening to the container. She then opened the door to the soiled utility room and left the biohazard container in the room. Nurse #2 did not sanitize the surface of the med cart after placing the biohazard container on top of the med cart. - At 1:00 P.M., the Medical Director was standing at the nurses' station with a surgical mask hanging from one ear. The elastic loop for the other ear was unsecured, the mask hung freely and with neither the nose nor mouth covered. During an interview on 1/31/23 at 10:55 A.M., CNA#1 said that she should not have come out of the precaution room without doffing (removing) her contaminated PPE and performing appropriate hand hygiene. During an interview on 1/31/23 at 11:15A.M., Nurse #2 said that she should not have placed the biohazard container on top of the med cart, and at a minimum, should have sanitized the surface of the med cart afterwards. During an interview on 1/31/23 at 11:25 A.M., the Infection Control Nurse (ICN) said that the infection control breaches observed by the surveyor regarding Nurse #1, Nurse #2, and CNA #1 were not acceptable, nor were they in accordance with the facility's infection control practices and the education provided to each staff member. During an interview on 1/31/23 at 11:25 A.M., the ICN said that all staff are required to follow the Mask and Face Covering policy and are required to wear a mask that covers their nose and mouth at all times while in the facility. The ICN also said that there are signs posted upon entering the facility (observed by the surveyor) that instruct all who enter that a mask must be worn at all times.

Based on observation, interviews, and policy review, the facility failed to have an effective policy which addressed the reheating of residents' food brought in from home in accordance with professional standards to ensure food safety. Specifically, the facility failed to provide thermometers and adequate instructions to reheat residents' food brought in from home to an internal temperature of 165 degrees Fahrenheit (F) to prevent potential foodborne illnesses. Findings include: Review of the Food and Drug Administration (FDA) Food Code (2017) indicated reheating foods in the microwave as follows: -Reheated cooked foods present a risk because they have passed through the danger zone multiple times during cooking, cooling, and reheating. The PHF/TCS (Potentially Hazardous Foods/Time and Temperature Control for Safety) food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees F for at least 15 seconds before service. Review of the facility's policy titled Outside Food and Food from Home Policy, dated March 2021, included but was not limited to the following: -It is the Dietary Department's Responsibility to prepare and deliver food safely to our residents, families, and staff. This policy ensures proper handling, serving, and storage of any food items brought into our community from outside sources. The Dietary Department's Director and staff will ensure proper safe handling practices are observed as demonstrated by the department's Food Safety competencies and education to prevent foodborne illness outbreaks. -In support of our community Residents, families, and visitors in understanding safe food handling practices, a copy of the food handling safety guidelines will be included/ reviewed with our admission paperwork and reviewed annually during Care Conferences. Review of the current facility admission package failed to include safe food handling practices instructions. On 03/17/22 at 10:55 A.M., the surveyor observed kitchenettes on the North, East, South, and West Units, and the kitchenette by the nurses' station. All five kitchenettes had a microwave; the facility's policy titled Outside Food and Food from Home, dated March 2021, was posted in each kitchenette. There were no reheating instructions included in the policy for Food Brought from Home and no thermometers were available to ensure the food was reheated to an internal temperature of 165 degrees F. During an interview on 03/17/22 at 01:09 P.M., Certified Nursing Assistant (CNA) #1 said the nursing staff is not allowed to heat up any food for the residents. She said, if you want food reheated for the residents, you have to bring the food to the kitchen, and the kitchen staff will reheat the food. During an interview on 03/17/22 at 01:35 P.M., Dietary Staff #1 said food brought from home for residents is never reheated in the kitchen. During an interview on 03/17/22 at 01:37 P.M., Dietary Staff #2 said they don't reheat resident food in the kitchen, they have microwaves on all the units. During an interview on 03/17/22 at 01:40 P.M., Cook #1 said food brought from home is never allowed in the main kitchen. During an interview on 03/17/22 at 01:45 P.M., the Director of Nurses (DON) said the staff is not allowed to reheat resident foods; they are instructed to bring the food to the main kitchen and they [kitchen staff] reheat the food. The surveyor informed the DON that the kitchen staff said they do not heat up food brought in from home for the residents. The DON was unsure how resident's food brought from home was reheated. During an interview on 03/17/22 at 1:50 P.M. the DON, Infection Control Nurse (IC Nurse) and the Food Service Manager, all agreed after viewing the policy for Outside Food and Food from Home, it did not provide instructions on reheating food, or the food should be reheated to an internal temperature of 165 F to prevent foodborne illnesses. The IC Nurse said food from home can't be brought into the kitchen to be reheated, it is the family's responsibility to reheat the food in the kitchenette microwaves. The surveyor asked how family members ensure they are heating the food to an internal temperature of 165 F. The IC Nurse said they do not supply thermometers because of potential infection control breaches in the cleaning process. The Food Service Manager said she does not have any disposable thermometers now, but could order some.

Based on staff interview and review of the facility assessment tool, the facility failed to ensure staff were provided annual competency training to ensure resident safety. Findings include: A review of the Facility Assessment tool, updated 5/25/21, documented staff training for employees is completed annually. The assessment tool indicated the following, but was not limited to: - fire safety - hand hygiene - Resident Rights - Abuse, Neglect, and Exploitation - Infection Control A review of three out of three employee records indicated that no annual competencies for resident safety were completed. During an interview on 3/17/22 at 1:24 P.M., the Staff Development Coordinator (SDC) said she has not completed any annual competencies or trainings in the past two years because she has just been focusing on COVID-19.

Based on observations and interviews, the facility failed to maintain three out of five resident kitchenette refrigerators in working order to maintain food temperatures of 41 degrees Fahrenheit (F) or below to prevent potential foodborne illnesses. Findings include: Review of the Food and Drug Administration (FDA) Food Code (2017), indicated the following: -Refrigeration - The facility's refrigerators and/or freezers must be in good working condition to keep foods at or below 41 degrees F and the freezer must keep frozen foods frozen solid. -Hazardous nature of the food. Although almost any food can be contaminated, certain foods are considered more hazardous than others and are called potentially hazardous foods (PHF) or Time/Temperature Controlled for Safety (TCS) food. Examples of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt, and cottage cheese; -Time and temperature control of the food. Time in conjunction with temperature controls is critical. The longer food remains in the danger zone, the greater the risks for growth of harmful pathogens. Bacteria multiply rapidly in a moist environment in the danger zone. -Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a foodborne illness outbreak if consumed. During an interview on 03/17/22 at 10:55 A.M., the Food Service Manager said the unit refrigerator temperatures are probably a little high because the dietary aide was just cleaning and restocking them. The Food Service Manager and the surveyor observed the five kitchenettes; the following internal thermometer readings and product temperatures were recorded as follows: West Unit: Thermometer 49.0 F, Glucerna drink 46.5 F, and individual container of applesauce 47.2 F (not within acceptable range) North Unit: Thermometer 52.0 F, Vanilla shake 49.2 F (not within acceptable range) East Unit: Thermometer 45.0 F, Milk 42.5 F (not within acceptable range) South Unit: Thermometer 54.0 F, Prune juice 45.0 F (not within acceptable range) Nursing station kitchenette: Thermometer 40.0 F On 03/17/22 at 05:00 P.M., the surveyor rechecked all five kitchenette refrigerators' internal temperatures and the temperature of the milk stored in the refrigerators. The findings showed three of the five refrigerators were not holding the milk temperatures in a safe acceptable range of 41.0 F or below as indicated by the following recorded temperatures: West Unit: Thermometer 45.0 F, Milk 48.7 F (not within acceptable range) North Unit: Thermometer 44.0 F, Milk 46.6. F (not within acceptable range) East Unit: Thermometer 45.0 F, Milk 41.0 F South Unit: Thermometer 49.0 F, Milk 48.1 F (not within acceptable range) Nursing station kitchenette: Thermometer 40.5 F, Milk 39.8 F During an interview on 03/17/22 at 05:10 P.M., the Administrator was informed that three out of five unit refrigerators were not holding an internal temperature of 41.0 F or below as required for food safety. The Administrator said he has maintenance coming and will take the refrigerators out of service until they maintain the correct temperatures.

Based on record review, observations, and staff interview, the facility failed to ensure that staff met professional standards of practice for two Residents (#33, #21), out of a total sample of 12 residents. Specifically, the facility failed 1.) For Resident #21, to accurately document neurological vital signs after the Resident fell , and failed to document in a nurse's progress note after two Resident falls; and 2.) For Resident #33, to accurately document neurological vital signs after the Resident fell . Findings include: Review of the facility's policy titled Neurological Assessment, revised 10/2010, indicated the following but was not limited to: -Neurological assessments are indicated: - following an unwitnessed fall - following a fall or other accident/ injury involving head trauma The following information should be recorded in the resident's medical record: - date and time the procedure was performed Review of the Neurological Observation Form indicated but was not limited to the following: - monitor every 15 minutes times four, every 30 minutes times two, every four hours times five, every shift times six, and subsequently as needed. - a general observation nursing note must be written at least every shift for at least 72 hours - all residents status post [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #21 was admitted to the facility in July 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 2/24/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the Resident was cognitively intact. Review of Resident #21's Fall Incident Reports indicated the Resident has had six falls since October 2021. Specifically, three of six falls were lacking nursing notes or neurological observations for the following reviewed falls: a. Witnessed fall 11/3/21 (No time reported), Resident lost his/her balance while transferring with certified nursing assistant (CNA) in the bathroom. Documented skin tear right finger. -Review of Nursing notes, dated 11/3/21, indicated there is no documentation Resident fell , no summary and no time of fall. No subsequent notes for the following 72 hours indicating Resident was monitored post fall or the skin tear was monitored. b. Unwitnessed fall 11/17/21(No time reported), Resident called out for help. Resident found sitting on the floor between wheelchair and bed. Resident reported reaching for something. resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . -There was no Neurological Observation form provided for review, unknown if Neurological observations were completed per policy. -No nursing note for 11/18/21 7:00 A.M. to 3:00 P.M. shift. c. Witnessed fall 1/13/22 at 7:00 P.M. (second fall on 1/13/22) Nurse walking by Resident's room witnessed Resident sliding out of locked wheelchair landing on his/her buttocks. Documented abrasion right shoulder blade. -No nursing note documenting Resident's second fall of the evening, summary of fall, or injuries sustained. 2.) Resident #33 was admitted to the facility in July 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 3/1/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating the Resident was moderately cognitively impaired. Review of the Fall Incident Reports indicated Resident #33 had falls on 1/19/22 (times two falls) and 3/3/22, and indicated the following: - On 1/19/22 at 1:15 P.M., the Resident was found on the floor on his/her left side. Review of the neurological vital signs form indicated the assessment was initiated at 1:15 P.M. after the fall per facility protocol. - On 1/19/22 (no exact time documented, but nurse's note was written at 10:55 P.M.), the Resident was found on the floor during the nurse medication pass. Review of the neurological vital signs form indicated the assessment was not restarted at the time of the second fall. - On 3/3/22 at 4:00 P.M., the Resident was found on the floor next to his/her bed. Review of the neurological vital signs indicated the assessment was initiated at 4:00 P.M. Further review of the assessment indicated no documented evidence that the neurological assessment was completed between 4:15 P.M. through 6:15 P.M. when the assessment should have been completed a total of seven times to ensure the Resident was in stable condition. During an interview on 3/17/22 at 11:37 A.M., the Director of Nurses said neurological vital signs are not always started if the resident is alert and oriented and can tell staff whether or not they have hit their head. She said that if neurological vital signs are indicated then they should be completed.

Based on record review and interview, the facility failed to revise the plan of care for one Resident (#33), out of a total sample of 12 residents. Specifically, the facility failed to revise the plan of care to ensure care approaches were individualized and appropriate for Resident #33 who was at risk for falls. Findings include: Resident #33 was admitted to the facility in July 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 3/1/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating the Resident is moderately cognitively impaired. The MDS also indicated the Resident has difficulty focusing attention, is easily distracted, and has difficulty keeping track of what is being said. Review of the medical record indicated the Resident had five falls between 12/31/21 and 3/14/22. Review of the Fall Incident Reports indicated three out of the five falls revolved around the Resident attempting to bring themselves to the bathroom. Review of the Fall Incident Report, dated 1/19/22, indicated Resident #33 sustained two falls as follows: - At 1:15 P.M., the Resident was found kneeling on both his/her knees on their left side. The Resident told staff he/she was trying to put on dry pants. - Review of the nurse's note, dated 1/19/22 at 10:55 P.M., indicated the Resident was found on the floor. The report indicated the Resident was trying to get to the bathroom. Review of the Fall Incident Report, dated 3/3/22 at 8:15 P.M., indicated Resident #33 was found on the floor. The report indicated the Resident was trying to get to the bathroom. Review of the Interdisciplinary Team (IDT) review forms, dated 1/20/22 and 3/2/22-3/4/22, for incident and accidents indicated the interventions for each of the falls was to toilet or offer incontinent care to the Resident. Review of the IDT Care Plan, initiated 9/24/19, indicated Resident #33's fall risk was related to unsteady gait and poor safety awareness secondary to ataxia (disorder that affects balance), brain cancer, history of frequent falls, and psychoactive medication use. The goal identified was that the Resident would be free from falls. Interventions to achieve goal included but were not limited to: - Be sure the Resident's call light is within reach and encourage the Resident to use it for assistance as needed. The Resident needs prompt response to all requests for assistance. (revised 5/27/21) -CNAs [certified nurse aide] are to notify nursing if clothing does not fit properly and not to dress Resident in clothing that does not fit properly (1/3/22) - Educate the Resident/family/caregivers about safety reminders and what to do if a fall occurs (revised 5/27/21) - Ensure Resident is wearing appropriate sneakers/non-skid socks when ambulating or mobilizing in wheelchair (revised 5/27/21) - Mesh banner with red stop sign draped across bathroom door to discourage Resident from attempting to self-toilet (2/26/20) - Offer toileting and incontinent care after lunch (1/20/22) - Offer toileting every two hours while awake (11/12/19) - CNA to transfer Resident back to wheelchair after finishing supper (3/15/22) - Staff to toilet Resident daily before breakfast (7/13/20) - Resident to be toileted prior to the 7:00 A.M.-3:00 P.M./ 3:00 P.M.-11:00 P.M. change of shift (3/3/22) Further review of the Fall Care Plan, revised 5/27/21, indicated toileting was used as an intervention four times after falls occurred. During an interview on 3/16/22 at 3:51 P.M., Resident #33 said he/she has fallen a few times but doesn't remember what he/she was doing when they fell . Resident #33 said he/she is not sure if staff come and assist him/her to the bathroom. During an interview on 3/17/22 at 8:30 A.M., Rehab Staff #1 said she does not participate in the IDT review and only knows about falls if a referral to therapy is made. During an interview on 3/17/22 at 11:37 A.M., the Unit Manager and the Director of Nurses said interventions for falls need to be stronger. Although the Plan of Care, revised 5/27/21, for the risk of falls included approaches to prevent falls, there was no documented evidence that the IDT reviewed the effectiveness of the interventions being put in place to prevent falls.

Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN/ CMS- ) was completed and signed to ensure the Resident/Resident Representative was fully informed of the services being discontinued and a determination was made to continue or discontinue services at a skilled level of care for two Residents (#6, #24), out of three sampled residents who received SNF ABN notices, as required by Centers for Medicare & Medicaid Services (CMS). Findings include: The SNF ABN (CMS- ) notice is administered to a Medicare recipient when the facility determines that the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all of the Medicare benefit days for that episode. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. 1. Resident #6 was admitted to the facility in January 2022, under a skilled level of care. A Notice of Medicare Non-Coverage was issued to Resident #6 indicating the last covered day of skilled Medicare Part A services was 2/16/22. Review of the medical record failed to indicate the SNF ABN (CMS- ) was completed and signed by Resident #6 and/or his/her resident representative. 2. Resident #24 was readmitted to the facility in January 2022, under a skilled level of care. A Notice of Medicare Non-Coverage was issued to Resident #24 indicating the last covered day of skilled Medicare Part A services was 1/26/22. Review of the medical record failed to indicated the SNF ABN (CMS- ) was completed and signed by Resident #24 and/or the resident representative. During an interview on 3/16/22 at 3:15 P.M., Social Worker #1 reviewed the ABN notices. She said the ABN notice should be filled out completely, signed, and dated by the resident or resident representative. She said looking at the forms for Resident #24 and Resident #6, they were not completed correctly and should have a signature.

Based on observation, and interview, the facility failed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to adhere to standard and droplet precautions while entering a quarantine room designated to a resident who was under investigation related to a recent admission from the hospital and to limit visitors to the facility to only those essential for the patient's physical or emotional well-being and care. Findings Include: In accordance with the Centers for Disease Control and Prevention, a bulletin titled Coronavirus Disease 2019 (COVID-19), Infection Control Guidance, dated May 18, 2020 indicates the following: Current data suggest person-to-person transmission most commonly happens during close exposure to a person infected with [MEDICAL CONDITION] that causes COVID-19, primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes. Droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs of those within close proximity. Transmission also might occur through contact with contaminated surfaces followed by self-delivery to the eyes, nose, or mouth. -HCP who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. -Limit visitors to the facility to only those essential for the patient's physical or emotional well-being and care (e.g., care partners). During the facility tour on 6/16/2020 the following observations were made: 1) At 1:27 P.M., the surveyor observed Human Resource (HR) Personal #1 touring a visitor through the facility and patient care areas. The HR #1 was interviewed at 1:30 P.M., with the Infection Control Nurse present. He said he was conducting an interview for an available position and was giving the potential new hire a tour of the facility. The Infection Control Nurse then said only essential staff members should be in the building to reduce the spread of infection and the facility should not be conducting tours of the units at this time. 2) At 1:36 P.M., the surveyor observed Certified Nursing Assistant #1 entering the room of a resident without the use of a gown, gloves or eye protection. The resident had been identified as a resident under quarantine due to a recent admission from the hospital. The room was marked with a sign indicating full personal protective equipment was required prior to entering. During an interview with CNA #1, she said she should have donned full personal protective equipment prior to entering the resident's room to provide care.

Based on Resident interview, group interview, and staff interview, facility staff failed to ensure that prompt efforts were made to resolve grievances voiced relative to accuracy of menus, and notification of changes in menus. Findings include: During the resident screening process on 7/15/19 and 7/16/19, five residents on the North wing complained that the kitchen runs out of food a lot, they frequently don't get want they order from the menu, and that they are told by staff that the kitchen had run out of the meal they selected, so another food item was served instead. The residents also said that they are not informed ahead of time that the meal they selected from the menu was not available, and a replacement meal would be served. One resident said that he/she was looking forward to eating chicken tenders on Sunday evening, but when the food tray arrived, there were no chicken tenders. He/she was given chicken salad with no bread, and was not informed of the change ahead of time in order to choose his/her alternate him/herself. A resident group meeting was held on 7/16/19 at 10:00 A.M. with nine residents in attendance. Eight of nine residents actively participated in the group discussion, and said that frequently, the food served at mealtimes was not accurate according to what they had selected from the weekly menu. They explained that once a week, facility staff assist them in choosing their meal selections from options on the weekly menu. They said that their meals of choice are either circled or highlighted with a marker, and this information is then brought to the kitchen. All eight residents said that frequently, when meals are delivered to them in either the dining room, or in their rooms, the meal they had chosen was not what they received. When they asked staff why they were not given the meal they selected, they were told that the kitchen had run out of it. They said that they were not aware that the meal they were expecting was not going to be available until they sat down at the table in the dining room, or it was delivered to them in their rooms. The residents said that a menu meeting is held the first Wednesday of every month to discuss the menus, food preferences, etc. They said that they have brought up the concern of not being served meals they selected. The residents said that no explanation has been provided, and the problem persists. Review of the menu meeting minutes indicated the following: -3/26/19- Smothered steak, Salisbury steak, kielbasa, and crusty rolls will no longer going to be served. If an entree needs to be changed from the weekly menu choice, the facility's supervisor staff need to notify so we can inform our Residents of the change. The posted menus should also indicate a change has been made to today's entree choice. -3/27/19- After investigating, all Resident meal tracker tickets have the wrong menu printed on it. This has been an ongoing issue with the Health Care Services meal tracker system. Our concern is how the wrong tickets get sent out from the kitchen. The dietary supervisor responded that nursing staff should remove the tickets from the trays prior to serving the Resident the tray. Residents complained that a croissant sandwich was hard, and cold. The facility dietician checked the tray of the Resident who returned the meal untouched, and noted that the croissant may have been partially frozen. The dietary supervisor's response to the Resident's complaint was that a cold sandwich results in a cold croissant. -5/1/19- A Resident stated that he/she does not receive the meal that he/she ordered. No response to the issue was noted. During interview with the food service manager on 07/17/19 at 10:28 A.M. and 2:00 P.M., feedback from individual Resident interviews, group interview, and menu meeting minutes were discussed. He said that once in a while he does not order enough food, and a change needs to be made to the menu. When that occurs, a sign is then posted in the facility to notify of the change, but Residents that remain in their room are not notified of the menu change. He said that every tray has a printed meal tracker ticket on it which included food preferences, diet, allergies [REDACTED]. He said that Residents are seeing the meal printed on the ticket, and think that is what they ordered. He said that the problem is with the meal tracker ticket software, and neither he nor his manager know how to fix the problem, and it persists. At approximately 2:30 P.M., the food service manager provided the survey team with a name and telephone number of an out of state, regional dietician who he said may know what is going on with the system and can provide answers. As of the time of exit, the facility had no plan in place to address the Residents' ongoing complaints of not receiving meals they selected from the printed menus with staff assistance, and no plan to address the problem with the meal tracker software. The facility failed to ensure that prompt efforts were made to respond and resolve grievances voiced by Residents related to accuracy of menus, and notification of changes in menus. The issue was identified in menu meeting minutes in 3/2019, and as of the time of exit on 7/17/19 at 3:00 P.M., the issue persists.

Based on document review and staff interview, the facility failed to ensure that a clinically qualified nutrition professional was designated to serve as the director of food and nutrition services. The food service director(FSD) was interviewed on 7/15/19 at 10:30 A.M. The surveyor asked the FSD what his credentials were to serve as the food service director. The FSD said he was hired on 3/6/18 and is serve safe certified and he has his allergen certification, but was not a certified dietary manager or a certified food service manager, as required. The FSD said the company he works for plans to send him for the appropriate certification. The facility administrator was interviewed on 7/17/19 at approximately 11:50 A.M. and said he was aware that the FSD did not meet the current requirements to serve as the director of food and nutrition services, but stated the food service company that employs the FSD had enrolled him in a Nutrition and Food Service Professional Training. The facility administrator provided the surveyor with a copy of an email from the food service company which stated the registration for the training for the FSD was submitted on 7/17/19 at 12:14 P.M. The facility's FSD does not meet the required qualifications for director of food and nutrition services.

Based on records reviewed, and interviews the Facility failed, for one of one sampled employees (Certified Nurse Aide #1), to ensure a Massachusetts Nurse Aide Registry background check was conducted after hire and prior to orientation in accordance with their Policy and Procedures. Findings include: The Facility's Abuse and Neglect Policy and Procedure, dated 06/06/18, indicated the following: all employees after hire, but prior to orientation are required to have their name submitted to the Nurse Aide Registry; and employees hired, as a Certified Nursing Assistant must be in good standing with the Nurse Aide Registry. Review of CNA #1's Personnel File indicated she was hired on 04/24/18. CNA #1's Pre-Employment Verification form indicated CNA #1 was in good standing on the Nurse Aide Registry as of 03/08/18. CNA's #1 Personnel File lacked documentation confirming a Nurse Aide Registry background check was conducted. The Surveyor interviewed the Administrator at 12:35 P.M. on 10/04/18. The Administrator said the Scheduling Coordinator conducted the Facility's Nurse Aide Registry background checks. The Administrator said it was unclear if all employees had Nurse Aide Registry background checks conducted through the Department of Public Health. The Surveyor interviewed the Scheduling Coordinator at 10:20 A.M. on 10/09/8. The Scheduling Coordinator said there was no record to indicate CNA #1 had a Nurse Registry background check conducted. The Scheduling Coordinator said for approximately four years, she conducted online license checks, however did not contact the Nurse Aide Registry through the Department of Public Health to conduct background checks for Certified Nurse Aides.

Based on observations and interviews the Facility staff failed to provide food that accommodated the preferences of 1 Residents (#40) in a total sample of 12 Residents. Findings include: Resident #40 was admitted to the Facility in 06/2018 with a [DIAGNOSES REDACTED]. Resident #40 was interviewed on 07/11/18 at 8:20 A.M. The Resident said that he/she would like to speak with the Registered Dietician at the Facility regarding food preferences, specifically how he/she likes to eat eggs. Review of the medical record for Resident #40 indicated that the Dietician completed a Medical Nutritional Therapy Assessment on 06/19/18. The diet/nutrition plan indicated that the Resident was on a cardiac diet, puree texture, nectar thick liquids and a 1500 milliliter fluid restriction. The form also indicated that the resident had no food allergies [REDACTED]. Review of the physicians orders for diet indicated that on 6/20/18 the diet for Resident #40 was upgraded to moist ground with nectar thick liquids. On 07/08/18 the diet was upgraded to ground consistency with nectar thick liquids. On 7/10/18 the diet was upgraded again to mechanical soft diet with thin liquids. Review of the progress notes from the electronic medical record did not include documentation that the Dietician had discussed food preferences with the Resident during the transition in food textures. The Dietician was interviewed on 07/12/18 at 2:40 P.M. The Dietician said that the process to obtain food preferences was for the Dietician or the Food Service Supervisor (FSS) to meet with a resident upon admission. The Dietician said that due to the amount of hours (12 per week) she was in the Facility, it was usually the FSS who met with the Residents to ensure food preferences were documented. The Surveyor asked the Dietician to meet with Resident #40 to discuss food preferences as the Resident requested. Resident #40 was observed to be in his/her room in bed on 07/13/18 at 8:30 A.M. The Resident said he/she had met with a woman the day before who he/she believed to be the Dietician. While speaking with the Resident, Certified Nurses Aid (CNA) #1 brought a breakfast tray in for Resident #40. Before the cover was taken off the plate the Resident said words to the effect of I bet the eggs are scrambled. The CNA removed the cover from the plate to reveal toast and scrambled eggs with ham and red peppers. The Resident's meal tray also included oatmeal and the Resident requested honey from the CNA stating that he/she had told staff previously that this was his/her preferred way to eat oatmeal. The FSS was interviewed on 07/13/18 at 10:30 A.M. The FSS was unsure at this time if the Dietician had relayed the food preferences of Resident #40 to the kitchen staff. The FSS said that the usual communication method was through a slip completed by nursing or through an email from the RD. The FSS returned a couple of minutes later with an email that was sent on 07/12/18 at 3:18 P.M. from the RD to the FSS stating that Resident #40 does not like scrambled eggs but gets them almost every day for breakfast. The email also stated that the Resident does like fruit and oatmeal. The email did not include any other preferences, including that the Resident prefers honey with his/her oatmeal. During further interview with the FSS on 7/13/18 at 2:00 P.M., he said that there was no formal guideline to obtain and document Resident food preferences. The FSS was not aware of who was to obtain the information other than the Dietitian. A binder provided by the FSS which included a Nutrition Baseline Care Plan Worksheet for the Residents of the Facility, was reviewed. The worksheet was two pages long and included information regarding likes, dislikes and diet level. Review of the binder indicated that there was not a worksheet completed for Resident #40. The Dietician was informed on 07/13/18 at 3:30 P.M. that Resident #40 had received scrambled eggs that morning. The Dietician said she would review the communication process with the kitchen.

Based on record review, interview and observation, the Facility failed to revise the plan of care for 1 Resident (#41), from a total sample of 12, to ensure the plan of care reflect current needs and approaches. Findings include: For Resident #41, the Facility staff failed to revise the plan of care to ensure care approaches were individualized and appropriate for a Resident at nutritional risk. Resident #41 was admitted to the Facility in 5/2018 with co-morbidities including a history of spinal surgery,[MEDICAL CONDITIONS] reflux disorder, [MEDICAL CONDITION] disease, pacemaker, cancer, [MEDICAL CONDITION] and depression. The nutritional assessment dated [DATE], indicated Resident #41 admitted to not eating well, refusal of nutritional supplements and included a diet order for 2 gram (Na) sodium puree foods. The nutrition plan dated 5/8/18 was to monitor and the was goal to maintain weight at 165 to 175 pounds with approaches to provide a diet of 2 gram Na (Sodium) puree foods, encourage intake and consider nutritional supplements. Review of the Minimum Data Set (MDS) completed 5/15/18, indicated Resident #41 was cognitively intact with a BIMS (brief interview of mental status) score of 15 of 15, who required assistance (one to two persons) for transfers, mobility, dressing, hygiene and bathing needs. Weight status was recorded at 170 pounds and this Resident received a therapeutic diet (diet order 5/4/18 read: No Added Salt, Puree texture, Regular Consistency 2 gram Sodium) with unknown weight loss. Weight records dated 5/23/18, documented the Resident's last weight at 169 pounds, with Resident refusals to be weighed to date(7/13/18). Record review of blood laboratory values dated 7/10/18 indicated the Resident had low total serum protein and [MEDICATION NAME] levels, continued poor intake and refusal to allow weight measurement or nutritional supplements. Review of the care plan dated 7/10/18 failed to include any nutrition interventions or reflect an accurate diet plan provided. On 7/11/18, a clinical progress note by the Dietitian reported Resident #41 ate in his/her room, had poor intake, was educated on eating protein rich foods and refused trial nutrition supplements. Although the plan of care dated 7/10/18, for the problem and risk of skin breakdown included an approach to encourage fluid and nutritional intake, there was no specific nutritional intervention other than a general mention to offer snacks, fluids and adequate nutrition. Observed on 7/13/18 during the breakfast service, Resident #41 had plate of bacon, cereal, coffee and juice. The tray card indicated Resident #41 was on a No Added Salt diet of regular foods consistency. Since the initial plan of care upon admission, there had been no interventions or revisions to reflect current nutritional approaches. Interview with the Unit Nurse on 7/13/18 at 1:30 P.M. was unable to explain why the current physician diet order for Resident #41's read 2 gram Na (sodium) puree and NAS regular. Later the Unit Nurse said it must have been entered incorrectly in the electronic record and not noticed or addressed by the Dietitian. Interview with the Director of Nurses' on 7/13/18 at this time said that currently dietary staff do not routinely attend care plan meetings. Interview with the Dietitian on 7/13/18 at 3:15 P.M., was uncertain for discrepancy of the Resident's diet order and said that she is unable to attend care plan meetings and thought a prior speech recommendation may have changed the diet texture to and from the puree diet .

Based on observation, record review and interviews, the facility failed to ensure a Resident safe environment with adequate supervision to avoid accidents for 3 Residents (#3,#4 & #16 ) from a total sample of 16 Residents. Findings include: 1. For Resident #4, the facility failed to provide adequate supervision to prevent an avoidable accident that resulted in a cervical neck fracture. After two recent falls attempting to self-transfer, Resident #4 had an unwitnessed fall out of a wheel chair that resulted in injury after staff left the Resident unattended to attend to another Resident's personal alarm. Resident #4 was admitted in 8/2015 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident usually understands parts of communication, has a BIMS (Brief Interview for Mental Status) score of 4/15, indicating severe cognitive impairment. For activities of daily living, the Resident requires extensive assistance for all care needs, except to eat, was continent of bowel with some bladder incontinence. The plan of care for fall risk dated 11/15/16, indicated Resident #4 ambulated short distances with two person assist, use of a low bed and safety alarm when in bed and a floor mat. Nursing summary documentation dated 12/16/16, indicated Resident #4 was totally dependent for dressing, grooming, bathing, wheelchair use, and transferred with assist due to weakness and unsteady gait. Record review indicated on 12/23/16 during the 11:00 P.M. to 7:00 A.M. shift, Resident #4 was found at 3:45 A.M. on the floor seated beside the bed holding onto the side rail with right arm. The Resident was asked where he/she was going and responded that he/she was looking for someone. Further review of the incident documentation indicated the Resident was last checked at 1:15 A.M., and had no explanation why he/she got up; at that time the Resident was incontinent of urine. The Resident had no complaints of pain or injury. Neuro checks and vital signs were done. The post fall review plan suggested to move the room closer to the nursing the station and 15 minute checks from 2:00 A.M. to 5:00 A.M. indefinitely. Review of the Fifteen Minute Check log documentation indicated the fifteen minute checks were done as follows: - On 12/24/16 the 15 minute checks were documented from 11:00 P.M. to 3:00 P.M. - For 12/25/16, the 15 minute checks were documented from 3:00 P.M. to 11:00 P.M., but not 2:00 A.M. to 5:00 A.M. as planned. - On 12/26/16, the fifteen minute check log did not begin at 2:00 A.M. as planned. The documentation started at 3:45 A.M., when the resident was found on the floor. A 12/26/16 nurse's note indicated Resident #4 was found at 3:45 A.M. sitting on the floor mat, holding onto the side rail, with alarm sounding. The Resident was assessed and had no complaints of pain or injury, neuro checks and vital signs completed. Further review indicated the Resident was found incontinent. The nurse's note indicated that a room change closer to the nurses station would be suggested due to recent falls and increased risk for injury. The Resident was moved on 12/27/16. Daily neuro checks and vitals were monitored. Post fall, the plan of care was updated to include use of personal alarms to bed and chair, floor mats and low bed, 15 minute checks (2:00 -5:00 A.M.). On 12/29/16, a 3:00-11:00 P.M. nurse's note indicated Resident #4 was found at 8:30 P.M. on the floor with a large hematoma on the left forehead, which was edematous with a small amount of bleeding. The note indicated the Resident was alert and stated that he/she fell out of the chair. The Resident had been transported to his/her room by the certified nurse aide (CNA) and told to stay put and that the CNA would be right back. The Resident complained his/her head hurt but able to move extremities, except not able to move left leg as well as the right leg. The note indicated a lift was used to transfer to bed. Hand grasps, PERL (brief neurological assessment of eyes, reaction to light) and vitals were assessed. The physician and family were notified. Although the nurse's note failed to indicate all the details of the fall, review of the incident investigation indicated Resident #4 was found in front of the wheelchair by the bathroom, lying on left side with a hematoma/abrasion to left forehead. As stated above, the nurse's note indicated a lift was used to transfer the Resident back to bed. Although the incident investigation indicated that the nurse caring for the Resident at the time of fall reported the Resident was log rolled toward the bed and lifted onto the bed. Emergency medical transport was called to transport Resident #4 for evaluation. Review of transport team report indicated that facility nursing staff had moved Resident #4 from the floor after the fall, back to bed. The physical examination report indicated the Resident was found conscious, pleasantly confused with a large hematoma on their left forehead with 8/10 pain with movement from both legs and minor pain. A C-collar was applied and transferred to stretcher and to hospital for further evaluation. The hospital examination [DIAGNOSES REDACTED]. Computed tomography (CT scan ) of head was negative, the Ct of the spine showed fractured cervical neck bone C-2, C-3. The treatment included application of a Miami J collar (neck immobilizer) to be worn continuously, to promote healing and medication for pain. Resident #4 was observed during the survey visit 3/7/17-3/9/17 wearing the neck collar at all times except to be assisted with meals until further follow-up spine consultation scheduled for 4/2017. 2. For Resident #3, the facility failed to provide adequate supervision and effective interventions to prevent avoidable falls for a Resident who had sustained 3 unwitnessed falls, one fall resulting in a fractured ankle. Resident #3 was admitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. Review of the nurses notes dated 1/6/16 indicated that the Resident had an unwitnessed fall at 10:45 P.M. The nurse documented that the Resident had increased agitation that day. The staff heard the alarm and entered the room to find the Resident sitting on the floor. It was also observed by the nurse that the Resident had knocked over the TV stand. The resident sustained [REDACTED]. The documented intervention was to toilet the Resident more frequently. Interview with SDC on 3/8/17 at 2:00 P.M. said that the nurse did not complete the incident and accident report and failed to obtain witness statements since the fall was unwitnessed. On 7/15/16 at 12:00 P.M. a second fall occurred in the Main dining room. Resident #3 was seated in a wheel chair with the Resident's family member was seated next to him/her at the time of the fall. The receptionist called the nursing unit at 12:15 P.M. to inform the nurse that the Resident had fallen in the main dining Room. The nurse went to the dining room and observed the Resident on the floor on their right side and the Resident was assessed by the nurse. The resident sustained [REDACTED]. Although the plan was to have PT/OT re-educate the family member on supervision and safety, there was no information regarding the level of supervision at the time of the accident/fall. On 10/14/16 at 1:00 A.M. the Resident had a third fall which resulted in a fractured ankle. Review of the incident report and nursing note dated 10/14/16 identified the Resident as confused and requiring physical assist of one with activities of daily living including transfer, ambulation and toileting. The incident report also identified the Resident required 1 assist with transfer and ambulates with gait belt and rolling walker with 1 assist. The narrative portion of the incident report indicated that at 1:00 A.M. the Resident requested to be toileted. The CNA (CNA #1) brought the Resident to the toilet and told the Resident to stay seated (on the toilet). The CNA left the bathroom and went into the Resident room, adjacent to the bathroom, to obtain clean clothing and change the Resident's wet bed. Review of the CNA's statement, the CNA heard a crack and ran back into the bathroom and observed the Resident sliding down along the wall to the right of the toilet. The CNA documented that she saw the Resident's foot twisted and the blood coming out and called the nurse for help. Review of the nurse's statement dated 10/14/16 indicated when she entered the Resident's bathroom she observed the Resident sitting on the bathroom floor and the Resident's right foot was completely turned outward and observed bleeding from the Resident's right ankle. The nurse immediately transferred the Resident to the hospital and was admitted with a right open malleolar fracture and underwent surgery. The nurse documented the cause of the incident was due to the Resident's noncompliance with sitting on the toilet. The care plan was revised to never leave the Resident alone in the toilet. CNA #1 was interviewed on 3/9/17 at 7:00 A.M. and said that she was the CNA who was caring for the Resident on the night of the fall (10/14/16). CNA #1 said that there are only two CNAs working at night and she placed the Resident on the toilet and told him/her to stay until she returned. The CNA said that she went to get a nightgown and heard a crack and returned to the bathroom and observed the Resident sliding down along the wall. The CNA immediately went for assistance. The Surveyor asked CNA #1 if the Resident required supervision and assistance with toileting and she said yes. The CNA said she left the Resident alone for a minute. Review of the CNA flow sheets for November indicated that the Resident required physical assist of 2 for ambulation, and physical assist of 1 with transfer and toileting. 3. For Resident #16, the facility failed to ensure that adequate staff supervision and gait belt assistance was used to prevent an avoidable fall in the bathroom. Resident #16 was admitted to the facility 5/2016 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment completed 2/21/17, indicated that the Resident was cognitively intact and required a 2 person assistance assist using a mechanical lift for toileting/ bathroom transfers. The Resident was high risk for falls. Resident #16 was interviewed on 3/22/17 at 3:00 P.M. and said that the CNA staff are constantly changing especially the agency staff on the 3-11 shift, which every Tom, Dick and Harry takes care of me. The Resident complained that the CNAs providing care don't know the care that he/she needs and said that he/she fell in the bathroom getting off the toilet because the CNA didn't know how to help. I tried to get up using the bars (grab bars in the bathroom) and she didn't help .I think she wasn't close enough to catch me. Review of the 3/17/17, 7-3 shift nurse's note indicated that at around 8:00 A.M. Resident #16 had a witnessed fall while being assisted by CNA #9 and was lowered to the floor when his/her legs got tired. Patient was assisted to sitting position gait belt was available and four people assisted to transfer from the floor to chair .no complaints of pain or discomfort noted. Review of the 3/17/17 incident report (completed by the agency nurse) indicated that the resident required 2 assist to transfer (no mention was made about the mechanical left), and was lowered to the floor by CNA #9. The nurse failed to include the Resident's explanation of the incident and indicated that a gait belt was in use at the time (not used.) Even though 3 additional staff members were called to assist the Resident to the chair, no statements were available for review. Review of an unsigned 3/17/17 supervisory review, later identified as the Staff Development Coordinator (SDC), indicated that the CNA #9 (identified as agency) did not use the gait belt and did not use the mechanical lift when transferring Resident #16. The SDC indicated that CNA #9 was educated on gait belts, finding out how a Resident is to be transferred safely (where to get reliable accurate info.) The SDC was interviewed on 3/22/17 at 3:00 P.M., and said that she could not explain why sections on the incident report were incomplete and contradictory and said no statements were available from the involved staff and the Resident. The SDC said that she was the first responder and saw the resident on the bathroom floor without the use of the gait belt and EZ lift (a late entry was added after surveyor inquiry). The SDC said that she competed the supervisory review and in addition to the CNA requiring education, the SDC said that the facility to ensure that the CNA was provided an accurate account of the care and information that the Resident required in order complete her assignment.

Based on observation, record review and interviews, the Facility failed to ensure care and services provided were done in a respectful manner that recognized the individual's needs in order to maintain dignity and enhance quality of life for 1 Resident (#8) from a total sample of 16 Residents. Findings include: For Resident #8, the facility failed to ensure agency staff were familiar with the Resident's care needs. During interview, the Resident said that the agency nurse aide staff were unfamiliar with my condition and did not feel they acted respectful. The Resident said that the nurse aide expected him/her to self transfer from the wheelchair to the toilet and was not aware that the Resident was paraplegic and could not ambulate. Record review indicated Resident #8 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the 12/12/16 Minimum Data Set assessment indicated Resident #8 was alert and oriented, with a BIMS (brief interview for mental status) score 15 of 15; and responsible for self, with no mood or behavior indicators. For activities of daily living this Resident required extensive assistance for transfers, dressing, toilet use and limited assistance for hygiene and bathing. Mechanical transfer and chair devices were used for mobility as the Resident was non ambulatory with lower extremity impairment due to paralysis. Review of the plan of care dated 12/19/16, indicated the Resident was able to provide self care to upper body and requires assist of 2 staff with EZ stand device for toilet transfers. The long term goal identified in Resident #8's plan of care, indicated that the facility would maintain optimal functioning status in a safe environment, to help make him/her feel secure, less anxious, providing necessary care with dignity and privacy and encourage self-esteem as a member of the facility community. Documentation on 2/20/17, in the day night report book indicated, Resident #8 had requested no agency nurse aides please. Record review and plan of care failed to mention any concerns. Additionally on 3/4/17, nursing documentation indicated Resident #8 was extremely angry with agency aide. Further interview with Resident #8 revealed staffing concerns at the facility, especially the 3:00 to 11:00 P.M. shift and that agency staff are not supervised or perform the job consistently. Resident #8 voiced concerns that several weeks ago an agency nurse aide brought me into the bathroom but was not aware of my condition and told me to move my legs. The Resident said the nurse aide did not know I use the lift, so I had to sit there and wait until the nurse aide could find help. The Resident said that this matter made him/her upset and concerned, especially for other residents that can not speak up. During another instance, the Resident said the agency nurse aide transferred me into bed and I thought I was going to roll right off the bed; the Resident said that the nurse aide was unfamiliar on how to handle my legs. During interview the Resident said that he/she has told the Administrator and Director of Nurses, but things do not change. Review of the nurse aide kardex Resident Care Guide provided for review indicated that Resident #8's care card was blank, and incomplete. During interview on 3/9/17 at 5:05 P.M., the SDC nurse said that some of the care cards have not been updated. During interview with the Administrator on 3/9/17 regarding facility grievances, a grievance log was provided which indicated that on 2/22/17 the Social Worker resolved a communication issue, by providing education and support to Resident #8 and education to staff. The social worker was unavailable for interview on 3/9/17. Further interview on 3/9/17, SDC said that she believes the Social Worker did speak to Resident #8 regarding concerns of [MEDICAL CONDITION] comments and provided a copy of an email correspondence from the SDC to the Social Worker. A hand written note signed by the Social Worker dated 2/22/17, indicated the she met with the Resident and apologized and provided Resident #8 and staff with Residents Rights information. Although the SDC said that it was a known preference that this Resident preferred not to be assigned to an agency nurse aide, there was no documentation in the nurse aide care kardex that identified what the Resident's care needs were as the Resident's Care Guide was blank. Therefore, there was no guide for nurse aides unfamiliar with this Resident to assure proper care could be consistently offered in a respectful manner that recognized the individual's needs, maintain dignity and to enhance his/her quality of life. refer to F353

Based on record review, staff interview and observation, the Facility failed to ensure for 1 (#6) of 16 sampled Residents, whose [DIAGNOSES REDACTED]. Findings include: Resident #6 was admitted to the Facility 2/2017 and his/her [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #6 had moderate cognitive impairment according to the BIMS (Brief Interview for Mental Status) with a score of 7, and he/she required assistance of the nursing staff for all of his/her activities of daily living, including transfers and ambulation. Review of the care plan dated 2/24/17, indicated that Resident #6 was at risk for skin breakdown due to poor nutritional status and hydration. Interventions included to float his/her heels because Resident #6 dug his/her heels into the bed. Review of the wound flow sheet dated 3/5/17, indicated that Resident #6 had a left heel pressure sore, stage 2 (presents as a partial thickness skin loss involving dermis or epidermis). The nurse documented that the wound presented as an abrasion, blister or crater that was described as a ruptured serum filled blister. The flow sheet indicated that the blister measured 3 centimeters (cm) by 4 cm. There was no documented evidence that the staff identified Resident #6's left heel as having a blister/pressure sore prior to 3/5/17. Review of the physician's orders [REDACTED]. The care plan was updated on 3/6/17, indicated that Resident #6 was to wear booties to both feet at all times. Review of the care plan review focus note, dated 3/6/17, indicated that Resident #6 had a stage 2 left heel pressure sore that measured 5 cm by 3 cm with a purple color noted, that was observed on 3/5/17 to be an intact blister, despite documentation that it was a ruptured blister on the wound flow sheet. Review of the care plan focus note indicated that Resident #6 was assessed as having a stage 2 pressure sore on 3/5/17. The physician's orders [REDACTED]. Surveyor #1 observed Nurse #1 on 3/7/17, while providing wound care to Resident #6's left heel pressure sore. Surveyor #1 observed that Resident #6's left heel had a large exposed area of red, raw looking skin, that covered approximately half of Resident #6's left heel (no measurements were taken at the time of the observation). Nurse #1 said that Resident #6's left heel had opened up when he/she slid out of the wheelchair on 3/5/17, and she was not sure if Resident #6 had a blister prior to 3/5/17. Nurse #1 said Resident #6 had a pressure relieving mattress. Surveyor #1 interviewed the Staff Development Coordinator (SDC) on 3/7/17 at 12:45 P.M. The SDC said that Resident #6 's left heel blister was found on 3/5/17 and he/she was non compliant with off loading his/her heels. The SDC said both of Resident #6's heels were red and boggy (soft and discolored). Surveyor #1 interviewed the Director of Nursing (DON) on 3/7/17 at 2:15 P.M. The DON said that because there was a question about the quality of the pressure relieving mattresses in the Facility, she had all Residents off load their heels to prevent pressure sores, but did not provide any time frame when this occurred. On 3/9/17, Surveyor #2 and the SDC observed Resident #6's left heel pressure sore during a dressing change. Surveyor #2 observed a moderate amount of yellow drainage stuck to the old dressing. Surveyor #2 observed a dime sized area of dark colored skin and skin fragments of the broken blister. Surveyor #2 observed that measurements obtained were 2.7 cm by 4.0 cm by 0.1 centimeter (depth). The DON was interviewed on 3/9/17 at 10:45 A.M. and said that the facility had a Physician Wound Consultant who visited on 3/6/17 but the facility did not refer Resident #6 to the Wound Physician because they did not feel the pressure sore was bad enough for the Resident to be seen. The Facility staff were unable to provide evidence that Resident #6 was provided services to prevent the development of the left heel pressure sore, including assessment of the pressure sore when it was a stage 1. The Facility staff did not provide evidence that alternative methods were attempted to offload Resident #6's left heel.