Every finding on record at Foremost at Sharon LLC

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who developed Moisture-Associated Skin Damage (MASD) to his/her coccyx, the Facility failed to ensure they notified his/her Physician of the Wound Nurse Practitioner's recommendations for wound care and as a result, the treatment recommendations were never implemented.Findings include:Review of the Facility's Policy titled, Change of Condition in a Resident Status, dated 03/2017, indicated the Facility would notify the resident's physician when there had been a need to alter the resident's medical treatment significantly. Review of the Facility Policy titled, Pressure Ulcer/Injury Risk Assessment, dated as revised 03/2022, indicated to document in medical record addressing MD notification if new skin alteration noted with change of plan of care. Resident #1 was admitted to the Facility in August 2025, diagnoses included unspecified dementia, seizures, syncope and collapse, hypertension muscle weakness and type 2 diabetes mellitus.Review of the Wound Nurse Practitioner's Initial Progress Note, dated 09/15/25, indicated that Resident #1 was seen for assessment and treatment recommendations for a MASD to his/her coccyx measuring 1.5 centimeters (cm) by 2 cm. The Note indicated to clean the coccyx wound with normal saline, pat dry, apply zinc (topical ointment used for wound healing) and collagen sprinkles (used for wound healing and stimulate new tissue growth) daily. Review of a Wound Nurse Practitioner's Progress Note, dated 09/22/25, indicated that Resident #1 was seen for assessment and treatment recommendations for a MASD to his/her coccyx. The Note indicated that MASD was improved and continue with the following treatment: clean the coccyx wound with normal saline, pat dry, apply zinc and collagen sprinkles daily. Review of Resident #1's Physician's Orders, for the month of September 2025, indicated there was no documentation to support that a Physician's order was obtained for the Wound Nurse Practitioner's recommendations for wound care.Review of Resident #1's Treatment Administration Record (TAR), dated 09/01/25 through 09/30/25, indicated there was no documentation to support that the Wound Nurse Practitioner's recommendations for treatment was implemented. Review of Resident #1's Nurse Progress Notes and Physician Progress Notes, dated 09/15/25 through 09/23/25, indicated there was no documentation to support that the physician was notified of the Wound Nurse Practitioner's recommendations for wound care for Resident #1's coccyx. During an in-person interview on 12/30/25 at 2:40 P.M. and a subsequent telephone interview on 01/12/26 at 9:41 A.M, Nurse #1 said that she was familiar with and was assigned to care for Resident #1 many times during his/her stay at the facility. Nurse #1 said that she was unaware that Resident #1 had been seen by the Wound Nurse Practitioner and that there were new recommendations for wound care to Resident #1's coccyx. Nurse #1 said that when a resident is seen by the Wound Nurse Practitioner and there are new treatment recommendations, the nurses notify the Physician of the recommendations made by the Wound Nurse Practitioner and the Physician gives an order for the new treatments. Nurse #1 said that nurses document in the nurse progress notes that the physician was notified and a physician's order is written by the nurse. Nurse #1 said she could not explain why the physician was not notified of the Wound Nurse Practitioners' recommendations. During a telephone interview on 01/05/26 at 12:32 P.M., Physician #1 said that Resident #1 had a wound to his/her coccyx and that the Facility has a Wound Nurse Practitioner who consults with the Facility and makes recommendations for wound care. Physician #1 said that she expects that the Facility notify her of the Wound Nurse Practitioners recommendations for wound care and said she could not recall if the Facility notified her of the recommendations for wound care for Resident #1's coccyx wound. Physician #1 said that she would have implemented the Wound Nurse Practitioner's recommendations for wound care for Resident #1's coccyx wound if she had been notified. During an interview on 12/30/25 at 3:30 P.M., the Director of Nurses (DON) said that Resident #1 was seen by the Wound Nurse Practitioner and new treatment recommendations were made for Resident #1's coccyx wound. The DON said that it is her expectation that nurses notify the physician of the Wound Nurse Practitioners recommendations and obtain an order from the physician to implement the wound treatment recommendations. The DON said she could not explain why the physician was not notified of the Wound Nurse Practitioners' recommendations and why the recommendations were not implemented.

Based on records reviewed and interviews for one of three sampled residents (Resident # 1), who developed a wound to his/her coccyx and required wound care, and required a sling to his/her left arm due to a fractured left clavicle, the Facility failed to ensure nursing developed and implemented a comprehensive person-centered care plan with interventions, treatment goals and outcomes that addressed, ) his/her wound care needs and 2) care and monitoring needs related to his/her fractured left clavicle. Findings include:Review of the Facility's Policy titled, Comprehensive Care Plans, dated as revised April 2022, indicated that: - a comprehensive, person-centered care plan that includes objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;- the care planning process will include an assessment of residents' strengths and needs, reflect treatment goals, timetables and objectives in measurable outcomes;- assessments of resident's are ongoing and care plans are revised as resident's conditions change;-care plans shall be reviewed and updated when there is a significant change in the resident's conditionReview of the Facility's Policy titled, Pressure Ulcer/Injury Risk Assessment, dated as revised March 2022 indicated that:-conduct a comprehensive skin assessment with every risk assessment;-once inspection of the skin is completed, document the findings on a facility-approved skin assessment tool;-develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin and the resident's overall clinical condition;-interventions must be based on current, recognized standards of care;-effects of the interventions must be evaluated;-the care plan must be modified as the resident's condition changes or if current interventions are deemed inadequate.Resident #1 was admitted to the Facility in August 2025, diagnoses included unspecified dementia, seizures, syncope and collapse, hypertension muscle weakness and type 2 diabetes mellitus.1) Review of Resident #1's Norton Plus Pressure Ulcer Scale Assessment, dated 08/14/25, indicated that Resident #1 was assessed by nursing as being at high risk for the development of pressure ulcers.Review of Resident #1's Skin Observation Tools, dated 08/22/25, 08/27/25, and 9/12/25, indicated that a small open area was identified on his/her coccyx.Review of Resident #1's Nurse Progress Note, dated 09/12/25, indicated that a small open area was noted on his/her buttocks.Review of a Wound Nurse Practitioner's Initial Progress Note, dated 09/15/25, indicated that Resident #1 was seen for assessment and treatment recommendations for Moisture-Associated Skin Damage (MASD) to his/her coccyx measuring 1.5 centimeters (cm) by 2 cm. The Note indicated to clean the coccyx wound with normal saline, pat dry, apply zinc (topical ointment used for wound healing) and collagen sprinkles (used for wound healing and stimulate new tissue growth) daily.Review of Resident #1's Care Plan related to Actual Alteration in Skin Integrity, dated as initiated on 08/08/25 and revised on 10/19/25, indicated there was no documentation to support that nursing documented the location of the actual wound when an open area was observed on his/her coccyx on 08/22/25.Review of Resident #1's Medical Record from 08/22/25 through 09/23/25, indicated there was no documentation to support a Care Plan related to his/her new open area and MASD to the coccyx with interventions, treatment, goals and outcomes, had been developed and implemented by nursing to meet his/her wound care needs by nursing.During an in-person interview on 12/30/25 at 2:40 P.M. and a subsequent telephone interview at 9:41 A.M., Nurse #1 said that she was familiar with and was assigned to care for Resident #1 many times during his/her stay at the facility. Nurse #1 said that Resident #1 had an open area on his/her coccyx. Nurse #1 said that it was not the staff nurses' responsibility to develop and/or update the resident care plan. Nurse #1 said that it was the responsibility of the Minimum Data Set (MDS) nurse and the Director of Nurses to develop a resident care plan and update the care plan as needed.During an interview on 12/30/25 at 3:30 P.M., the Director of Nurses (DON) said that Resident #1 had an open area to his/her coccyx. The DON said that both the staff nurses and the MDS Nurse were responsible for developing the initial care plans and that the MDS nurse updates the care plans with any new interventions. The DON said it was her expectation that all care plans are comprehensive and any actual wound care plan identifies the location of the wound and be updated with new interventions.2) Review of a Nurse Progress Note, dated 08/22/25, indicated that an x-ray of Resident #1's left shoulder was obtained, showed a left clavicle fracture and Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation.Review of a Hospital ED Discharge summary, dated [DATE], indicated that Resident #1 was seen in the ED for evaluation of left shoulder pain after a fall. The Summary indicated that an x-ray of the left shoulder showed a midshaft fracture of the left clavicle and to manage the fracture, wear a simple sling on the left arm. The Summary further indicated to check skin around the sling every day, loosen it if your fingers [NAME] or become numb, turn cold and blue and not to put weight on left arm until seen by an orthopedic doctor.Review of Resident #1's Medical Record from 08/23/25 through 09/03/25, indicated there was no documentation to support a Care Plan related to his/her left clavicle fracture, use of a sling to the left arm, non-weight bearing status to his/her left arm and monitoring the left arm for numbness, with interventions, treatment, goals and outcomes, had been developed and implemented by nursing to meet his/her needs.Review of a Nurse Progress Note, dated 09/03/25, indicated that Resident #1 returned from an orthopedic appointment and had new recommendations for weight bearing (to left arm) as tolerated with a walker.During an interview on 12/30/25 at 3:30 P.M., the DON said that Resident #1 fell and fractured his/her left clavicle and returned from the ED with a sling. The DON said that it was her expectation that a care plan for a fractured left clavicle, use of a sling, non-weight bearing status and monitoring of the left arm, was developed and implemented by nursing upon Resident #1's return from the ED.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who developed an open area to his/her coccyx and sustained a fracture to his/her left clavicle after a fall, the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice when 1) he/she was not seen by the facility's Wound Nurse Practitioner in a timely manner and 2) treatment orders from the Hospital Emergency Department (ED) related to the left clavicle fracture were not implemented.Findings include:Resident #1 was admitted to the Facility in August 2025, diagnoses included unspecified dementia, seizures, syncope and collapse, hypertension muscle weakness and type 2 diabetes mellitus.1) Review of Resident #1's Skin Observation Tools, dated 08/22/25, 08/27/25, and 9/12/25, indicated that a small open area was identified on his/her coccyx and would follow up with the Wound Nurse Practitioner.Review of Resident #1's Nurse Progress Note, dated 09/12/25, indicated that a small open area was noted on the buttocks.Further review of Resident #1's Medical Record indicated that although an open area on his/her coccyx was identified by nursing on 8/22/5, Resident #1 was not evaluated and assessed by the Wound Nurse Practitioner until 9/12/25, three weeks after nursing started documenting it on the Skin Observation Tool. Review of a Wound Nurse Practitioner's Initial Progress Note, dated 09/15/25, indicated that Resident #1 was seen for assessment and treatment recommendations for a MASD to his/her coccyx measuring 1.5 centimeters (cm) by 2 cm. The Note indicated to clean the coccyx wound with normal saline, pat dry, apply zinc (topical ointment used for wound healing) and collagen sprinkles (used for wound healing and stimulate new tissue growth) daily.During an in-person interview on 12/30/25 at 2:40 P.M. and a subsequent telephone interview on 01/12/26 at 9:41 A.M, Nurse #1 said that she was familiar with and was assigned to care for Resident #1 many times during his/her stay at the facility. Nurse #1 said that Resident #1 had an open area on his/her coccyx and he/she should have been seen and assessed by the Wound Nurse Practitioner in a timely manner. Nurse #1 said that the Wound Nurse Practitioner comes in weekly on Mondays and it should not have taken three weeks for Resident #1 to be seen and assessed by the Wound Nurse Practitioner. During an interview on 12/30/25 at 3:30 P.M., the Director of Nurses (DON) said that the Wound Nurse Practitioner comes in weekly on Monday's and nursing notifies the Wound Nurse Practitioner of any new residents with an open area. The DON said that it was her expectation that residents who have an open area be assessed by the Wound Nurse Practitioner the next time she was due at the facility. The DON said she was unaware that it took three weeks for the Wound Nurse Practitioner to assess Resident #1's wounds and said it should not have taken that long.2) Review of Resident #1's Fall Risk Assessment, dated 08/07/25, indicated that nursing assessed him/her at High Risk for Falls.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/20/25, indicated that at 10:00 A.M. Resident #1 was observed by staff lying on the floor across from the nurses' station. The Report indicated that an x-ray was ordered and revealed an acute moderately displaced fracture of the left clavicle and Resident #1 was transferred to the Hospital ED for evaluation and treatment.Review of a Nurse Progress Note, dated 08/22/25, indicated that an x-ray of Resident #1's left shoulder was obtained, showed a left clavicle fracture and Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation.Review of a Hospital ED Discharge summary, dated [DATE], indicated that Resident #1 was seen in the ED for evaluation of left shoulder pain after a fall. The Summary indicated that an x-ray of the left shoulder showed a midshaft fracture of the left clavicle and to manage the fracture, wear a simple sling on the left arm. The Summary further indicated to check skin around the sling every day, loosen it if your fingers [NAME] or become numb, turn cold and blue and not to put weight on left arm until seen by an orthopedic doctor.Review of Resident #1's Medical Record which included but was not limited to his/her Treatment Administration Record (TAR), Medication Administration Record (MAR) and Nursing Progress Notes from 08/23/25 through 09/03/25, indicated there was no documentation to support that nursing monitored Resident #1's left arm, that non-weightbearing status was maintained, and that a sling was provided to him/her and implemented.Review of a Nurse Progress Note, dated 09/03/25, indicated that Resident #1 returned from an orthopedic appointment and had new recommendations for weight bearing as tolerated with a walker.During an in-person interview on 12/30/25 at 2:40 P.M. and a subsequent telephone interview on 01/12/26 at 9:41 A.M, Nurse #1 said that she was familiar with and was assigned to care for Resident #1 many times during his/her stay at the facility. Nurse #1 said that she was unaware that Resident #1 sustained a fall at the facility and fractured his/her left clavicle. Nurse #1 said she was unaware that Resident #1 returned from the Hospital ED with orders for a sling, non-weight bearing of the left arm and to monitor his/her left arm and could not recall him/her wearing a sling. Nurse #1 said that when a resident has a fractured arm and is in a sling, nursing should monitor the arm for Circulation Sensation Motion (CSM) of the extremity and document it in the medical or treatment administration record.During an interview on 12/30/25 at 3:30 P.M., the DON said that Resident #1 fell and fractured his/her left clavicle and returned from the ED with a sling. The DON said that it was her expectation that staff implement the orders from the Hospital ED Discharge Summary and that nursing documents in the medical record the use of a sling and monitoring of the left arm following his/her fracture.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had developed an open area to his/her coccyx, and was non-weight bearing, required the use of a sling and monitoring by nursing due to a left clavicle fracture, the Facility failed to ensure they maintained a complete and accurate medical record, when 1) there was no nursing documentation related to his/her coccyx wounds characteristics and progress towards healing and 2) there was no nursing documentation on his/her Treatment Administration Record (TAR) or Nurse Progress Notes to support nursing monitored Resident #1's left arm per Hospital Discharge Summary recommendations. Findings Include:Review of the Facility's Policy tilted, Charting and Documentation, dated as revised April 2022, indicated the following:-services provided to the resident to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record;-objective observations, treatments or services performed, are documented in the resident medical record;-documentation of treatments will include care-specific details including: the date and time the treatment was provided, the assessment data and/or any unusual findings obtained during the treatment;Review of the Facility's Policy titled, Medical Record, dated as revised April 2022, indicated that the Medical Record reflects an interdisciplinary approach to assessment, Care Planning, care delivery and documentation should include the provision of and response to nursing care and treatment provided.Review of the Facility's Policy titled, Pressure Ulcer/Injury Risk Assessment, dated as revised March 2022, indicated the following:-conduct a comprehensive skin assessment with every risk assessment;-once inspection of the skin is completed, document the findings on a facility-approved skin assessment tool;-document in the resident's medical record, the condition of the resident's skin, the size and location of any red areas;-initiate a pressure or non-pressure form related to the type of alteration in skin if new skin alteration noted.Resident #1 was admitted to the Facility in August 2025, diagnoses included unspecified dementia, seizures, syncope and collapse, hypertension muscle weakness and type 2 diabetes mellitus.1) Review of Resident #1's Skin Observation Tools, dated 08/22/25, 08/27/25, and 9/12/25, indicated that a small open area was identified on his/her coccyx.Review of a Medication Administration Record (MAR), dated 08/22/25 through 09/23/25, indicated he/she had a physician's order to apply silver sulfadiazine cream 1% (topical antimicrobial medication used primarily for the prevention of wound sepsis) topically every shift to coccyx.Review of a Nurse Progress Note, dated 09/12/25, indicated that a small open area was noted on the buttocks.Review of Resident #1's Medical Record and MAR from 08/22/25 through 09/23/25, indicated there was no documentation to support that nursing assessed Resident #1's coccyx wound, that nursing documented the condition of the resident's skin, the size of the open area, the wounds characteristics and that a pressure form related to the type of alteration in skin was implemented.During an in-person interview on 12/30/25 at 2:40 P.M. and a subsequent telephone interview on 01/12/26 at 9:41 A.M, Nurse #1 said that Resident #1 had an open area on his/her coccyx and had a treatment for silver sulfadiazine cream. Nurse #1 said that whenever a treatment order is written for a wound, the nurses document the assessment and description of the wound on the Medication Administration Record or Treatment Administration Record when they complete the treatment of the wound. Nurse #1 could not explain why there was no documentation in Resident #1's medical record that described the characteristics of Resident #1's coccyx wound.During an interview on 12/30/25 at 3:30 P.M., the Director of Nurses (DON) said that Resident #1 had a small open area to his/her coccyx and had a treatment for the wound. The DON said that it is her expectation that the nurses assess the wound and document the description of the wound in the Medical Record after they perform the treatment to the wound.2) Review of a Nurse Progress Note, dated 08/22/25, indicated that an x-ray of Resident #1's left shoulder was obtained, showed a left clavicle fracture and Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation.Review of a Hospital ED Discharge summary, dated [DATE], indicated that Resident #1 was seen in the ED for evaluation of left shoulder pain after a fall. The Summary indicated that an x-ray of the left shoulder showed a midshaft fracture of the left clavicle and to manage the fracture, wear a simple sling on the left arm. The Summary further indicated to check skin around the sling every day, loosen it if your fingers [NAME] or become numb, turn cold and blue and not to put weight on left arm until seen by an orthopedic doctor.Review of Resident #1's Physician Orders, dated August 2025 and September 2025, indicated there was no documentation to support that a Physician's order related to the Hospital ED Discharge Summary orders for Resident #1's left arm to be in a sling, monitoring of his/her left arm and non-weight bearing status, ere obtained. Review of Resident #1's Treatment Administration Records, dated August 2025 and September 2025, indicated there was no documentation to support that his/her left arm was in a sling, monitored by nursing staff and non-weight bearing status was maintained.Review of Resident #1's Nurse Progress Notes, dated 08/23/25 through 09/02/25, indicated there was no documentation to support that his/her left arm was placed in a sling, monitored by nursing staff and non-weight bearing status was maintained.Review of an Orthopedic Consult, dated 09/03/25, indicated that Resident #1 could bear weight to his/her left arm as tolerated.During an in-person interview on 12/30/25 at 2:40 P.M. and a subsequent telephone interview on 01/12/26 at 9:41 A.M, Nurse #1 said that she was familiar with and was assigned to care for Resident #1 many times during his/her stay at the facility. Nurse #1 said she was unaware that Resident #1 returned from the Hospital ED with orders for a sling, non-weight bearing of the left arm and to monitor his/her left arm. Nurse #1 said she could not recall him/her wearing a sling. Nurse #1 said that when a resident has a fractured arm and is in a sling, nursing should monitor the arm for Circulation Sensation Motion (CSM) of the extremity and document it in the Medical Record.During an interview on 12/30/25 at 3:30 P.M., the DON said that Resident #1 fell and fractured his/her left clavicle and returned from the ED with a sling. The DON said that it was her expectation that staff implement the orders from the Hospital ED Discharge Summary and that nursing documents in the medical record the use of a sling and monitoring of the left arm.

Based on observation, record review, and interviews, the facility failed to provide residents with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed to develop effective interventions to prevent nine falls for one Resident (#26), out of a total sample of 15 residents. Findings include: Review of the facility's policy titled Falls and Fall Risk Managing, revised 3/2022, indicated, but was not limited to, the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on an assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of falling is identified as unavoidable. -The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help staff reconsider possible causes that may not have been previously identified. Review of the facility's policy titled Comprehensive Care Plans, revised 4/2022, indicated, but was not limited to, the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. -Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change. -The interdisciplinary team must review and update the care plan: *when there has been a significant change in the resident's condition; *when the desired outcome is not met; *when the resident has been readmitted to the facility from a hospital stay; *at least quarterly, in conjunction with the required quarterly MDS assessment. Resident #26 was admitted to the facility in October 2024 with diagnoses including dementia and atrial fibrillation on anticoagulation (blood-thinning medication). Review of the Minimum Data Set (MDS) assessment, dated 4/7/25, indicated that Resident #26 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Further review of Resident #26's MDS assessment indicated the Resident had two or more falls since admission or the prior assessment. Review of Resident #26's medical record indicated Resident #26 had nine falls from 11/4/24 to 6/1/25. Review of Resident #26's Morse Fall Scale Evaluations, completed on 10/1/24, 11/4/24, 1/1/25, 1/16/25, 2/4/25, 4/16/25, 5/4/25, and 6/2/25 indicated the Resident was at high risk for falls. Review of Resident #26's progress notes indicated, but was not limited to, the following: a. Nurses' notes -11/4/24 at 12:29 A.M.: Nurse notified by CNA (Certified Nursing Assistant) that Resident #26 was sitting on the floor holding the right side of his/her head. Upon examination, the Resident had a raised lump on the right side of his/her head and his/her right thumb appeared slightly swollen. The Nurse Practitioner (NP) was notified and ordered the Resident be transferred to the hospital for evaluation. -11/4/24 at 4:43 A.M.: The Resident returned from the hospital, all tests and x-rays were negative. Resident was seen by nurse leaning out of bed to pick his/her eyeglasses up off of the floor and the nurse explained to the Resident the importance of safety and using call bell. -11/18/24 at 8:13 P.M.: The Resident was observed sitting on the floor in the hallway. -1/14/25 at 2:07 P.M.: The Resident was transferred to hospital after he/she fell and hit his/her head and reported pain in his/her head, back, and side. The Resident was taking a blood thinning medication. -1/17/25 at 5:45 A.M.: The Resident was observed sitting on the floor by staff at 7:30 P.M. The Resident stated he/she was fixing his/her sandals. -1/17/25 at 6:22 A.M.: The Resident was readmitted to the facility on [DATE] at 6:00 P.M. after he/she was hospitalized after an unwitnessed fall. CT imaging (computed tomography, a medical imaging technique that combines a series of x-ray images and uses computer processing to create cross-sectional images of bones, blood vessels, and soft tissues inside the body) showed evidence of an acute L3 fracture (a broken third lower back bone). -2/4/25 at 5:19 P.M.: Around 12:40 P.M., the Resident was seen by staff scooting on his/her buttocks. The Resident reported to have fallen off his/her bed. The on-call NP was notified and close monitoring was recommended. -3/2/25 at 9:54 P.M.: The Resident had a witnessed fall without a head strike. -5/4/25 at 6:25 P.M.: At 4:30 P.M., the Resident came to the nursing station and reported to the nurse that he/she fell while fixing belongings in his/her closet. -6/1/25 at 3:21 P.M.: At about 10:00 A.M., the Resident's roommate notified the nurse the Resident fell in his/her room. The nurse found the Resident in the room on the floor. -6/1/25 at 10:12 P.M.: At 5:00 P.M., an Activities staff member reported to the nurse the Resident was sitting on the floor. The Resident stated he/she was looking for his/her shoes. Review of Resident #26's fall incident reports indicated, but was not limited to, the following: -11/4/24 at 12:54 A.M.: CNA alerted nurse that Resident was sitting on the floor. The Resident was noted to have a baseball sized lump on the right side of his/her head and his/her right thumb was bruised and slightly swollen with limited movement. The Resident stated he/she had to go to the bathroom and tripped. The Resident was transferred to the hospital for evaluation -11/18/24 at 7:00 P.M.: Resident was observed sitting on the floor on the hallway [sic]. Resident stated he/she forgot his/her walker. -1/14/25 at 2:12 P.M.: Resident was found by activities staff on the floor in emotional distress. Resident reported that he/she fell and was experiencing pain in his/her head, back, and hip and hit his/her head when he/she fell. The Resident was transferred to the hospital for evaluation. Imaging done at the hospital showed evidence of an acute L3 fracture. -1/16/25 at 11:22 P.M.: Resident was observed sitting on the floor. Resident stated he/she was fixing his/her sandals. [Note: the incident report is timed 11:22 P.M., but staff statements indicated the fall occurred at 7:30 P.M.] -2/4/25 at 12:40 P.M.: Resident was seen by staff sitting on the floor of his/her room scooting on his/her buttocks. Resident stated that he/she fell off the bed and that he/she was getting up in order to bring a stuffed animal to his/her roommate. -3/2/25 at 10:30 A.M.: Resident slipped out of his/her bed onto the floor while trying to dress self. Fall was witnessed by the nurse on duty and the Resident was assisted to sit on the side of the bed and assisted with dressing. -5/4/25 at 4:30 P.M.: Resident came to the nursing station and reported he/she fell while fixing belongings in his/her closet. -6/1/25 at 6:02 A.M.: Activities staff was hanging calendars on the Resident's unit and when she entered the Resident's room she saw the Resident on the floor sitting by his/her bed. The Resident said he/she was unable to get up [Note: the incident report is timed 6:02 A.M., but neurological assessment monitoring indicated the fall occurred at 10:00 A.M.] Of note, only one incident report was provided to the surveyor for 6/1/25; however, review of the Resident's medical record indicated Resident #26 had fallen twice on 6/1/25, once at approximately 10:00 A.M. and once at approximately 5:00 P.M. Review of Resident #26's Care Plans indicated, but was not limited to, the following: 1. Focus: FALL RISK: [Resident #26] is at risk for falls due to uses assistive device (walker) for walking, takes psychotropic drugs -Interventions: *02/4/2025 Resident is frequently monitored for safety and use of walker is encouraged at all times *02/6/2025 Resident is assisted with toileting. *1/16/2025 Be sure walker is placed at bedside as a reminder for resident to use when getting out of bed. *1/14/24 [sic] Medical work up - To follow up with Rehab *3/2/25 Staff to provide supervision and assistance with ADLs (activities of daily living) *5/6/25 PT eval *6/2/25 Resident will be assisted with changing clothing *Anticipate and meet the Resident's needs (initiated 2/4/25) *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 (initiated 2/4/25) *Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (initiated 10/1/24) *Follow facility fall protocol (initiated 10/1/24) 2. Focus: new compression fracture of the L2 (a broken second lower back bone) -Interventions: *Assist with ambulation as he/she allows as needed (initiated 1/21/25) *Refer to rehab as indicated for eval and treatment (initiated 1/21/25) *Requires assist of two bed mobility [sic] (initiated 1/21/25) Further review of Resident #26's Care Plans failed to indicate new fall prevention interventions were implemented after the Resident had falls on 11/4/24 and 11/18/24 and only one new intervention was implemented after the Resident's two falls on 6/1/25. During an interview on 6/5/25 at 12:33 P.M., Certified Nursing Assistant (CNA) #2 said if a resident has a fall, the staff who finds the resident stays with them and calls for help. After the nurse has assessed the resident, the nurse will tell/inform the CNAs on the unit the resident had a fall and let them know if there are any new interventions implemented. During an interview on 6/5/25 at 12:37 P.M., CNA #3 said when a resident has a fall, the nurse does a report in the electronic health record and the CNAs are able to see if the resident has fallen and specific fall interventions put in place. During an interview on 6/5/25 at 12:44 P.M., Nurse #1 said when a resident has a fall, the nurse assesses the resident and completes an incident report. Nurse #1 said the nurse does not update the resident's care plan at that time. Nurse #1 said the Director of Nursing (DON) will review the incident report to make sure it is complete and the circumstances of the fall are identified. Nurse #1 said the DON will review the fall with others on the management team and the team will implement a new intervention. During an interview on 6/5/25 at 2:03 P.M., the DON said when a resident falls, the nurse completing the incident report should implement a new fall prevention intervention and update the resident's care plan. The DON said every fall should have a new care plan intervention implemented afterward and the nurse should evaluate the circumstances of the fall and implement an intervention that relates to the cause of the fall. The DON said if the intervention implemented is not appropriate, the care plan can be revised later when the fall is reviewed with the management team. The DON said the CNAs can see fall prevention care plan interventions in the electronic medical record and the nurse should also verbally communicate new interventions to the CNAs. The DON said a new fall prevention care plan intervention should have been implemented every time Resident #26 had a fall.

Based on observation, record review, and interview, the facility failed to complete an inspection of the bed rails, to identify areas of possible entrapment for three Residents (#1, #19, and #24), out of a sample of 15 residents. Specifically, the facility failed to: 1. For Residents #1 and #19, complete a new assessment of the bed, side rails and mattresses in active use for potential entrapment when the bed mattress was changed from the previously assessed mattresses, placing the Residents who had limited mobility and utilized bilateral side rails, at risk for possible entrapment; and 2. For Resident #24, to ensure the mattress bolster/extender (an object used to fill gaps between the mattress and footboard of a bed) was in place to fill the gap between the mattress and the footboard with the metal bed frame exposed, leaving the Resident at risk for entrapment and/or injury. Findings include: Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/2006, indicated: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in death and serious injuries. There are 7 zones of bed entrapment: Zone 1 (within the rail), Zone 2 (under the rail), Zone 3 (between rail and mattress), Zone 4 (Under the rail, at the ends of the rail), Zone 5 (between split bed rails), Zone 6 (between the end of the rail and the side edge of the head or footboard) and Zone 7 (Between the head or footboard and the mattress end). Review of guidance from the FDA titled Recommendations for Health Care Providers about Bed Rails, dated 07/09/2018, included: - Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body. - Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards. Review of the facility's policy titled Proper Use of Side Rails, last revised 1/2025, indicated but was not limited to the following: -The purposes of this policy is to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. -When used for mobility or transfer, an assessment will include a review of the resident's risk of entrapment from the use of side rails. 1A. Resident #1 was admitted to the facility in January 2025 and had moisture associated skin damage. Review of the Minimum Data Set (MDS) assessment, dated 6/1/25, indicated Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15, had moisture associated skin damage and utilized a pressure reducing device in bed. On 6/3/25 at 8:20 A.M., the surveyor observed Resident #1 lying in bed awake, bilateral side rails up and in use, and an air mattress was in place. On 6/5/25 at 1:30 P.M., the surveyor observed Resident #1 sitting upright in bed awake, bilateral side rails up and in use, and an air mattress was in place. Review of comprehensive care plans indicated Resident #1 received an air mattress on 5/16/25 to relieve pressure. B. Resident #19 was admitted to the facility in February 2021 and had wounds to his/her right foot. Review of the MDS assessment, dated 5/15/25, indicated Resident #19 had severe cognitive impairment as evidenced by a BIMS score of 00 out of 15, had three venous/arterial ulcers and an infection in his/her foot and utilized a pressure reducing device in bed. On 6/3/25 at 8:16 A.M., the surveyor observed Resident #19 lying asleep in bed with bilateral side rails up and in use and an air mattress was in place. On 6/4/25 at 9:46 A.M., the surveyor observed Resident #19 sitting upright in bed with bilateral side rails up and in use and an air mattress was in place. Review of the medical record indicated the following Physician's Orders: -Side rails: 1/4 two up as an enabler/positioning (4/2/24) -Place perimeter mattress on bed (1/10/25) Review of comprehensive care plans indicated Resident #19 received an air mattress on 5/16/25 to relieve pressure, setting to resident comfort level. 2. Resident #24 was admitted to the facility in January 2024 and had diagnoses including chronic kidney disease. Review of the MDS assessment, dated 4/9/25, indicated Resident #24 had moderate cognitive impairment as evidenced by a BIMS score of 8 out of 15. On 6/3/25 at 8:00 A.M., the surveyor observed Resident #24 lying in bed asleep on a regular mattress. The metal bed frame was exposed at the foot of the bed with a gap approximately 6 from end of mattress to the footboard. No mattress bolster/extender was installed on the bed. On 6/4/25 at 10:50 A.M., the surveyor observed Resident #24 lying in bed awake on a regular mattress. The metal bed frame was exposed at the foot of the bed with a gap approximately 6 from end of mattress to the footboard. No mattress bolster/extender was installed on the bed. On 6/5/25 at 11:00 A.M., the surveyor observed Resident #24 lying in bed awake on a regular mattress. The metal bed frame was exposed at the foot of the bed with a gap approximately 6 from end of mattress to the footboard. No mattress bolster/extender was installed on the bed. On 6/5/25 at 2:00 P.M., the surveyor observed Resident #24 lying in bed awake on a regular mattress. The metal bed frame was exposed at the foot of the bed with a gap approximately six inches from end of mattress to the footboard. No mattress bolster/extender was installed on the bed. During an interview on 6/4/25 at 10:00 A.M., the Maintenance Director said he has only worked at the facility for a few weeks and was not aware that regular side rail safety assessments were required and that safety assessments needed to be conducted whenever a mattress is changed. During an interview on 6/4/25 at 11:40 A.M., the Regional Director of Operations provided the survey team with a three-ringed binder containing side rail safety assessments for 2024. He said he could not find any other side rail safety assessments and the documentation in the binder is all they have. Review of the Bed Entrapment Assessment documentation binder: -failed to indicate Resident #1's bed had ever been measured for risk of entrapment. -failed to indicate Resident #19's bed was measured for risk of entrapment when the Resident received a perimeter mattress on 1/10/25 and an air mattress on 5/16/25. -failed to indicate Resident #24's bed (with a regular mattress) was measured for risk of entrapment. The last assessment, dated 4/30/24, indicated Resident #24 had an air mattress. During an interview with the Maintenance Director and the Regional Maintenance Director on 6/5/25 at 2:10 P.M., the Regional Maintenance Director said bed rail safety inspections should have been conducted when Residents #1, #19 and #24 had a change in mattress. The Regional Maintenance Director said Resident #24's mattress is too small for the bed frame and the gap between the mattress and footboard should not be that big. He said there should be a filler piece in place to fill the gap. He said a filler piece was likely in place at some point and may have gotten removed when the bed was changed and not put back into place.

Based on observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for one Resident (#41), out of a total sample of 15 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the use of Buspirone (anti-anxiety), Trazodone (antidepressant also used to treat anxiety) and Sertraline (selective serotonin reuptake inhibitor used to treat anxiety) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment. Findings include: Review of the facility's policy titled Comprehensive Care Plans, revised April 2022, included but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive, person-centered care plan will include: -measurable objectives and timeframes; -describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -reflect treatment goals, timetables, and objectives in measurable outcomes; -identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. Resident #41 was admitted to the facility in April 2025 and has diagnoses including generalized anxiety disorder. Review of the Minimum Data Set assessment, dated 4/19/25, indicated Resident #41 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 8 out of 15, required partial to moderate assistance with activities of daily living and received antianxiety and antidepressant medication daily. Review of the medical record indicated Physician's Orders for: -Buspirone HCI 15 milligrams (mg), one tablet two times a day for anxiety (4/12/25, discontinued 5/20/25) -Buspirone HCI 15 mg, one tablet three times a day for anxiety (5/20/25) -Trazodone 50 mg, give 0.5 tablet one time a day for anxiety (4/12/25) -Sertraline 100 mg one time a day for anxiety (4/13/25) Review of April 2025 through June 2025 Medication Administration Records (MAR) indicated Buspirone, Trazodone, and Sertraline were administered as ordered by the physician. Review of comprehensive care plans included but was not limited to: -Focus: The resident uses psychotropic medications. Trazodone, Buspirone and Sertraline related to anxiety (initiated: 4/13/25). -Interventions: Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. Observe/document/report PRN (as needed) any adverse reactions. Observe/record occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. -Goal: The resident will remain free from psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The resident will reduce the use of psychotropic medication through the review date. Review of a Social Service Assessment, dated 4/12/25, indicated #41 was pleasant and social, attends group activities of his/her choosing, is alert and oriented to person and place, has short-term memory fluctuations. The assessment failed to indicate Resident #41 exhibited disrobing, inappropriate response to verbal communication, and violence/aggression towards staff or others. Review of a Nursing Evaluation, dated 4/12/25, indicated a section titled Neurological/Cognitive/ Facility Orientation/ Antipsychotics/Psychotropics. Under the care plan section of this field, a box was checked with pre-populated interventions: Observe/Record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. There was no section under the care planning section to type in resident-specific targeted behaviors. Further review of comprehensive care plans failed to indicate a care plan had been developed for the use of Buspirone, Trazodone and Sertraline that identified Resident specific targeted behaviors, Resident-specific interventions, including non-pharmacological approaches, and measurable goals of treatment to meet the Resident's needs. During an interview on 6/5/25 at 8:56 A.M., Nurse #1 and the surveyor reviewed Resident #41's comprehensive care plans. She said Resident #41 likes to walk around both on and off the unit, will occasionally refuse medications and can perseverate (repeated thoughts) on things such as wanting to use the telephone. She said she is not aware of any behaviors of disrobing, inappropriate response to verbal communication, violence or aggression toward staff and others and does not know why his/her symptoms of anxiety were not included in the Resident's care plan. During an interview on 6/5/25 at 11:45 A.M., the Director of Nursing (DON) and the surveyor reviewed Resident #41's comprehensive care plans for the use of psychotropic medications. She said the Resident does not have a history of disrobing, inappropriate response to verbal communication, violence/aggression toward staff and others and has not exhibited that since being admitted . She said the listing of behaviors may be part of a batch order in the electronic medical record and the care plan should only include signs, symptoms and behaviors specific to Resident #41. She said the care plan is supposed to also include non-pharmacological interventions and measurable goals of treatment and does not.

Based on interviews and record review, for one Resident (#26), of 15 sampled residents, the facility failed to provide timely dental services. Specifically, for Resident #26, the facility failed to initiate replacement of a broken/missing partial upper denture timely. Findings include: Review of the facility's policy titled Dental Services, revised 1/2025, indicated, but was not limited to, the following: -If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay. -All dental services provided are recorded in the resident's medical record. Resident #26 was admitted to the facility in October 2024 with diagnoses including dementia and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 4/7/25, indicated that Resident #26 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Further review of MDS Section L, Oral/Dental Status, failed to identify any concerns with Resident #26's dental condition. Review of a document in Resident #26's medical record titled Care Plan Meeting, dated 1/15/25, indicated the Resident's partial upper denture was broken and dental services were requested by the Resident/Resident Representative. Review of Resident #26's Comprehensive Nutritional Evaluations, dated 1/4/25 and 3/31/25, failed to indicate the Resident's partial upper denture had broken or was missing. Review of Resident #26's progress notes indicated, but was not limited to, the following: -On 10/22/24, a piece of the Resident's partial upper denture broke and the Resident requested to see the dentist. The note indicated the dentist would come on 11/19/24. -On 10/24/24, the Resident's family was contacted to obtain information on the Resident's dentist and the family would provide the appointment date. -On 10/25/24, the Resident's family informed the facility that they were not able to obtain information on the Resident's dentist. Nurse #1 indicated in the note that they were going to find a dentist in the area and she would contact the Resident's physician for a dental referral. -On 11/22/24, the Resident misplaced her partial dentures in the bathroom trash. -On 1/15/25, while the Resident was out of the facility at the hospital, the Resident's scheduled care plan review was done with the Resident's Representative, who requested a dental consult due to the Resident's complaint that his/her partial upper denture was broken. The note indicated the issue would be addressed when the Resident returned to the facility. -On 1/16/25, the Resident returned to the facility. -On 5/1/25, the Resident went to a dental appointment and returned with no new orders. Review of Resident #26's medical record indicated he/she signed a consent form for consultant dental services in the facility on 10/1/24. Review of a patient billing ledger from an outside dental provider indicated Resident #26 was seen for a comprehensive oral evaluation on 5/1/25. Review of Resident #26's initial exam report from the consultant dentist in the facility, dated 5/15/25, indicated the Resident's partial upper denture was lost. The dentist indicated an x-ray visit would be initiated to aid in the prior authorization for a new partial upper denture to be ordered. Review of Resident #26's medical record failed to include care plan information about the Resident's use of a partial upper denture or that the partial upper denture had been broken. Further review of the medical record failed to indicate that the Resident had been evaluated to ensure that he/she was able to eat and drink adequately while awaiting dental services. During an interview on 6/3/25 at 9:18 A.M., Resident #26 said he/she was missing a partial upper denture composed of five teeth. Resident #26 said he/she had recently seen a dentist but could not remember on what date. During an interview on 6/4/25 at 2:18 P.M., the Director of Nursing (DON) said Resident #26 was seen by a consulting dentist at the facility after he/she was seen by the outside dentist on 5/4/25. During an interview on 6/5/25 at 8:24 A.M., Nurse #2 said that when a Resident's dentures get broken, the facility's consultant dentist should be called and the dentures sent out to be repaired. During an interview on 6/5/25 at 11:23 A.M., Resident Representative #1 said Resident #26's issues with his/her partial upper denture began months ago and there was a delay in the facility addressing the issue. Resident Representative #1 said there was much phone and email correspondence with the facility over the course of months before the Resident was able to be seen by a dentist in May. Resident Representative #1 said she was not sure why it took so long for the Resident to be seen by a dentist. As of the survey exit on 6/5/25, Resident #26's record failed to indicate that a new partial upper denture had been ordered.

Based on observation, interviews, and record review, the facility failed to adhere to infection control standards of practice to prevent contamination and the potential spread of infections for one Resident (#41), out of a total sample of 15 residents. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's - bacteria that are resistant to three or more types of antimicrobial drugs]) when the Resident was identified as having wounds on his/her right foot. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, last revised 9/2022, indicated but was not limited to: -Enhanced barrier precautions are an infection prevention intervention designed to reduce the transmission of multidrug resistant organisms in the facility. The precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those with an increased risk of contracting an MDRO. -Use of enhanced barrier precautions includes but is not limited to residents with indwelling medical devices or wounds (regardless of MDRO colonization or infection status) in addition to those residents with confirmed colonization or infection with an MDRO. Resident #19 was admitted to the facility in February 2021 and had diagnoses including diabetes mellitus and atherosclerotic heart disease. Review of the Minimum Data Set assessment, dated 5/15/25, indicated Resident #19 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15 and had three venous/arterial ulcers and an infection in his/her foot. Review of a Nurse's Note, dated 5/3/25, indicated Resident #19 was noted with necrotic areas on the bottom of the second and third right foot. The Nurse Practitioner has an order to apply Betadine daily as well as Bacitracin ointment between right little toe for open area (sic). Review of a Physician's encounter note, dated 5/7/25, indicated the Resident had several wounds that were scabbed, a few necrotic areas on his/her right foot likely due to peripheral vascular disease. The note indicated the Resident had a superimposed infection and would start the Resident on antibiotic treatment. Review of Physician's orders indicated the Resident was prescribed the antibiotic Keflex three times a day from 5/7/25 to 5/14/25. Further review of the medical record failed to indicate EBP was put into place upon identification of the wounds and infection to Resident #19's right foot. On 6/3/25 at 8:16 A.M., the surveyor observed no EBP sign posted outside of Resident #19's room and no personal protective equipment (PPE: items such as gown and gloves worn by the staff member to decrease the chance of spread of infection) was readily available. On 6/3/25 at 8:18 A.M., the surveyor observed Certified Nursing Aide (CNA) #1 reposition Resident #19 while he/she was lying in bed. The CNA was not wearing a gown and/or gloves while providing high contact care. Review of the medical record indicated a Physician's order for EBP was initiated on 6/3/25, 31 days after the wounds were identified to Resident #19's right foot. During an interview on 6/4/25 at 9:41 A.M., Nurse #1 said the Resident was placed on EBP due to wounds on his/her foot. She could not explain why the EBP were not put into place when the wounds were first identified on 5/3/25. During an interview with the Infection Preventionist (IP) on 6/5/25 at 8:56 A.M., the surveyor shared the 6/3/25 observation of no EBP sign posted at Resident #19's door, no PPE readily accessible in the vicinity of the Resident's room, and CNA #1 repositioning Resident #19 in bed without wearing PPE. The IP said any resident with a wound is supposed to be on EBP and she could not explain why the Resident was not placed on EBP on 5/3/25 when the wounds were identified to his/her right foot. During an interview on 6/5/25 at 9:40 A.M., the surveyor shared the observation made on 6/3/25 at 8:18 A.M. of no EBP sign posted at Resident #19's door, no PPE readily accessible in the vicinity of the Resident's room, and CNA #1 providing high contact care to Resident #19 without wearing PPE. The DON said Resident #19 has a wound and should be on EBP. She could not explain why Resident #19 was not placed on EBP when the wounds were first identified on 5/3/25.

Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#23), out of a total sample of 18 residents, received care and treatment to prevent and to promote healing of a pressure injury consistent with professional standards of practice. Specifically, the facility failed to implement treatments as ordered and notify the physician of worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to a stage 2 pressure ulcer (PU- partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the Resident's left ischial tuberosity (bone in the lower part of the pelvis that absorbs weight when you sit). Findings include: Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, revised March 2022, indicated but was not limited to the following: -Risk factors that increase a resident's susceptibility to develop or to not heal PU/PIs include but are not limited to impaired/decreased mobility and decreased functional ability -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries -Conduct a comprehensive skin assessment with every risk assessment -The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate Documentation: -The type of assessment conducted -Any change in the resident's condition, if identified -The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified -Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted -Documentation in the medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated -Report other information in accordance with facility policy and professional standards of practice Resident #23 was admitted to the facility in July 2017 and had diagnoses including Alzheimer's disease and MASD on the left buttock. Review of the Minimum Data Set (MDS) assessment, dated 4/25/24, indicated Resident #23 had short and long-term memory problems, severely impaired cognitive skills for daily decision making, was dependent on staff for turning and repositioning and was non-ambulatory. The MDS also indicated that Resident #23 had MASD and utilized a pressure reducing device in bed. Review of a Norton Plus Pressure Ulcer Scale, dated 4/23/24, indicated Resident #23 had a score of 6.0 (score of less than 10 is very high risk) and was at very high risk for developing pressure ulcers. Review of the comprehensive care plans indicated but was not limited to the following: FOCUS: Resident has bowel/bladder incontinence related to dementia, impaired mobility (4/11/21). GOAL: Resident will remain free from skin breakdown due to incontinence. INTERVENTIONS: Clean peri-area with each incontinence episode. FOCUS: Resident has impaired functional mobility related to bilateral upper extremity contractures and one side lower extremity contracture, weakness (7/31/21) GOAL: Safety will be comfortable in environment and have no skin breakdown. INTERVENTIONS: Totally dependent for positioning in bed and chair. FOCUS: Skin: Actual alteration in skin integrity related to left buttock (4/1/24). GOAL: Resident will have signs of healing and/or resolution of non-pressure skin issue. INTERVENTIONS: Consult and treatment by Certified Wound Medical Doctor (MD) or Certified Wound Nurse as needed (prn); observe for signs/symptoms of infection and report to MD and obtain prescription (Rx); weekly documented skin check. Further review of comprehensive care plans failed to indicate a care plan for pressure ulcer risk had been developed. Review of the medical record indicated Resident #23 was seen weekly by the facility's Wound Care consultant. Review of the Wound Care Consultant's note, dated 4/2/24, indicated the MASD to the Resident's left buttock measured 2.5 centimeters (cm) in length x 0.5 cm in width x 0.1 cm depth, had scant serous exudate (clear or slightly yellow wound drainage) and was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) due to incontinence. The Wound Care consultant indicated the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the MASD indicated the following instructions: -Incontinence care. -Pat dry. -Apply collagen powder (supports new blood vessel formation, granulation tissue formation, the debridement of the wound and the ability of the wound to re-epithelize) with barrier cream twice a day (BID). Review of the Physician's Orders/treatment administration record (TAR) indicated the order was implemented on 4/2/24. Review of the medical record indicated the Wound Care Consultant saw Resident #23 on 4/9/24, 4/16/24 and 4/23/24 with no new treatment recommendations for the MASD. Review of the Wound Care Consultant's note, dated 4/30/24, indicated the MASD to the Resident's left buttock measured 5 cm in length x 3 cm in width x 0.2 cm depth, had moderate serous exudate and was macerated. The Wound Care consultant indicated the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the MASD indicated the following instructions: -Incontinence care. -Pat dry. -Skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to periwound (the area around the wound). -Apply collagen powder, calcium alginate with silver (used for moderate to heavily exuding, partial- to full-thickness wounds including pressure injuries) -Cover with border dressing daily and prn. Review of the Physician's Orders/treatment administration record (TAR) indicated the order was implemented on 5/2/24, two days after the recommendation was made. Review of the Wound Care Consultant's note, dated 5/7/24, indicated the MASD to the Resident's left buttock measured 3 cm in length x 3 cm in width and had no exudate and the tissue was 100% epithelial (thin layer of tissue that covers organs, glands, and other structures within the body). The Wound Care consultant indicated the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the MASD indicated the following instructions: -Incontinence care. -Apply barrier cream twice daily and prn Further review of the medical record failed to indicate Resident #23's attending physician/NP was notified of the Wound Care consultant's recommendation for a change in treatment. Review of the Physician's Orders/treatment administration record (TAR) indicated the previous order was not discontinued and continued to be administered until 5/30/24, 23 days after the Wound Care consultant recommended a new treatment. According to the National Institute of Health (2012), it is recommended that silver dressings should be used for 2 weeks initially and then the wound, the patient, and the management approach should be re-evaluated. Review of the complete medical record failed to indicate the Resident was seen by the Wound Care consultant on 5/14/24. Review of the Nurse Practitioner (NP)'s Progress note, dated 5/14/24, indicated Resident #23 had a wound to his/her left buttock due to moisture-associated dermatitis, the wound is epithelialized, and the Resident is followed by the wound specialist. The NP's assessment indicated Resident #23 was at high risk for further skin breakdown and moisture-associated dermatitis due to his/her immobility and incontinence and to continue barrier cream and prompt incontinence care. Review of the medical record indicated the Wound Care Consultant saw Resident #23 on 5/21/24 with no new treatment recommendations for the MASD. Review of the Wound Care Consultant's note, dated 5/28/24, indicated the MASD to the Resident's left buttock had increased in size and measured 7 cm in length x 4 cm in width x 0.2 cm in width, had scant serous exudate, and the tissue was 100% dermis (composed of connective tissue). The Wound Care Consultant's note indicated that the wound is expected to heal and the plan of care was discussed with staff. New treatment recommendations for the MASD indicated the following instructions: -Incontinence care -Apply skin prep to periwound -Apply wound gel and cover with sacral dressing daily and prn Further review of the medical record indicated the Wound Care Consultant's treatment recommendation was implemented on 5/31/24, three days after the Wound Care Consultant recommended a change in treatment. Review of the Wound Care consultant's note, dated 6/4/24 and signed at 4:08 P.M., indicated Resident #23's MASD to the left buttock deteriorated to a Stage 2 pressure ulcer on the left ischial tuberosity. The wound measured: 4 cm in length x 3 cm width x 0.2 cm depth, had moderate serous exudate and [NAME] (sic) discoloration with biofilm (forms when microorganisms adhere and proliferate on the surface of the skin). The Wound Care Consultant's note also indicated that the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the stage 2 PU indicated the following instructions: -Incontinence care -Apply skin prep to periwound. -Apply Collagen powder and calcium alginate with silver, and cover with sacral dressing daily and prn. Review of a Weekly Wound Rounds document, dated 6/5/24 and signed as complete by the Director of Nursing (DON), indicated Resident #23 had acquired a stage 2 pressure ulcer to the left ischium with moderate serous drainage and measured 4 cm in length x 3 cm in width x 0.2 cm in depth. The note indicated the physician was notified of the stage 2 PU on 6/5/24. The document indicated the current treatment plan was: -Incontinence care. -Apply skin prep to periwound. -Apply collagen powder and calcium alginate with silver and cover with sacral dressing daily and prn. Review of a 6/6/24 Late Entry Note, written by the DON at 7:11 A.M., indicated Resident #23 continues to have MAD (Moisture Associated Dermatitis) to the coccyx area. Dressing changed as ordered. The noted failed to indicate Resident #23 had a stage 2 PU to his/her left ischium tuberosity. During a treatment observation on 6/6/24 at 2:07 P.M., the surveyor observed Nurse #1 perform a dressing change to Resident #23's left ischium wound. The wound bed had a mostly beefy-red wound base with a small amount of tan slough (non-viable yellow, tan, gray, green or brown tissue) present. Nurse #1 checked the orders in the medical record and applied wound gel to the wound base and it was covered with a silicone super absorbent dressing. Review of a Nurse's Note, dated 6/6/24, indicated the dressing was changed to Resident #23's left buttock. The old dressing had scant sanguineous drainage and small slough (dead tissue, usually cream or yellow in color) was noted on the wound. During an interview on 6/7/24 at 11:38 A.M., the DON said the Wound Care Consultant comes into the facility every Tuesday and the Assistant Director of Nursing (ADON) usually rounds with them. He said if there were any changes with a wound and new treatment recommendations, the consultant would inform the ADON during the visit. He said they would wait for the Wound consultant to send their note, then contact the physician with treatment recommendations. The DON reviewed the Weekly Wound Round note, dated 6/5/24, that he completed. He said he spoke to the physician, and she approved the Wound Care Consultant's recommendations. He could not explain why the treatment orders were not entered into the electronic medical record until 6/7/24. He said he should have entered the orders when he received them from the Physician on 6/5/24. During an interview on 6/7/24 at 11:52 A.M., the ADON said on Tuesday, when the Wound Care consultant was in the facility, she was too busy to round with her and didn't see Resident #23's wound and was not told the Resident developed a stage 2 PU. She said she saw the Wound Care NP in the hallway and she told her she was going to recommend a change in treatment. The ADON said the Wound Care consultant's notes are sent to the DON who then puts it in the Resident's medical record. She said she didn't see the report until yesterday (6/6/24), and after she got home, she entered the order into Resident #23's medical record without first contacting the Physician and obtaining an order for the treatment. During a telephone interview on 6/7/24 at 12:17 P.M., Physician #1 said she usually reviews the Wound Care consultant reports but has not had a chance to review Resident #23's report yet. She said she had not spoken to the DON or anyone else to inform her that Resident #23 had developed a stage 2 PU and the Wound Care consultant had new treatment recommendations. Physician #1 said when she is not there, the NP is there and they may have notified her. She said if the NP was told about it, she would have written a note in daily rounding notes. The Physician said she was looking in Resident #23's medical record on her computer and said the NP had not written a note regarding Resident #23. She said she could only see the note from the Wound Care provider. She said her expectation is that facility staff would call either her or the NP with a change in condition and/or change in treatment either the day the recommendation is made, or no later than the following day. She said for a recommendation made on 6/4/24, it should not take until 6/7/24 to communicate the information and implement the new treatment. During a telephone interview on 6/7/24 at 12:50 P.M., the NP said she was in the facility on 6/4/24 and did not see the Wound Care consultant. She said she was in the facility yesterday (6/6/24) and was not notified that Resident #23 had developed a new stage 2 PU or was made aware of any treatment recommendations by the Wound Care consultant. The NP said she does not receive a copy of Wound Care consultant reports. She said she thinks they get emailed to the DON. On 6/7/24 at 12:38 P.M., a voice message was left for the Wound Care Consultant with no return call. Review of the medical record indicated a Nurse's Note, dated 6/7/24, indicated Corporate staff #1 contacted Physician #1 regarding the Wound Care consultant's treatment recommendation from the last visit on 6/4/24. The Physician agreed to the recommendation. Review of the medical record indicated the following Physician's order was entered into the electronic medical record on 6/7/24, three days after the recommendation was made: -Left buttock: skin prep, apply collagen powder and calcium alginate with silver, cover with sacral dressing daily/prn. Review of the June 2024 Treatment Administration Record (TAR) indicated this order was not initiated until 6/8/24, four days after the Wound Care consultant made the recommendation for a change in treatment for the newly acquired stage 2 PU.

Based on observations, interviews, and records reviewed, for one Resident (#36), of 18 sampled residents, the facility failed to provide Foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag to drain urine from the bladder) care and management consistent with professional standards of practice. Specifically, for Resident #36, the facility failed to: -Ensure his/her Foley catheter was properly positioned to ensure adequate drainage from the bladder, -Document care and maintenance of a Foley catheter, -Implement provider orders for Intake and Output (I&O) monitoring to ensure adequate output, and -Notify his/her provider of an abnormal radiology report resulting in Resident #36 being hospitalized for four days due to a malpositioned (wrong or faulty position) Foley catheter resulting in bilateral hydroureteronephrosis (swelling of both kidneys and ureters, a thin tube that drains urine from the kidney to the bladder, which occurs when urine can't drain and builds up in the kidneys and ureters), impaired kidney function, and a urinary tract infection. Findings include: Review of the facility's policy titled Intake Monitoring, dated as revised 4/2022, indicated but was not limited to: -the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period -at the end of your shift, total the amounts of all liquids the resident consumed in the clinical record Review of the facility's policy titled Output Monitoring, dated as revised 4/2022, indicated but was not limited to: -the purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period -pour or drain the urine from the bedpan, urinal, or catheter into the graduate (measuring container) -record the amount noted on the output side of the intake and output record -document in the clinical record amount of output Review of the facility's policy titled Catheter Care, dated as revised 4/2022, indicated but was not limited to: -perform twice daily with A.M. and P.M. care, and as needed after incontinence or bowel movements Review of the facility's policy titled Indwelling Catheter Care, dated as revised 4/2022, indicated but was not limited to: -catheter care will be performed at least daily and as needed (PRN) and in accordance with a physician's and/or nursing order. Review of Human Anatomy & Physiology, Ninth Edition, Urinary Bladder, indicated that a moderately full bladder holds approximately 500 milliliters of urine but can hold nearly double that if necessary. The maximum capacity of the bladder is [PHONE NUMBER] milliliters and when it is over distended it may burst. Review of Lippincott Manual of Nursing Practice, Eleventh Edition, Catheterization Procedure, indicated that a urinary catheter should be inserted 6 to 10 inches and advanced another 1 inch once urine flow is observed. Resident #36 was admitted to the facility in February 2024 with the following diagnoses: dementia and neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly in which the bladder may empty spontaneously or may not empty at all). Review of the Minimum Data Set (MDS) assessment, dated 3/22/24, indicated Resident #36 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15, and had an indwelling catheter. Review of Resident #36's care plans indicated but was not limited to: -Focus: Resident #36 has a urinary catheter related to obstructive uropathy (condition in which the flow of urine is blocked) and was at risk for developing complications, dated 3/30/24 and revised 6/11/24. -Goal: Resident will have no signs or symptoms of complications from the use of catheter through next review, dated 3/30/23 -Interventions: 1. Follow up with urology as indicated, dated 3/30/24 2. Monitor labs ordered and report results to physician, dated 3/30/24 3. Provide catheter care every shift, dated 3/30/24 Further review of Resident #36's March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate documented evidence that the facility provided Foley catheter care and maintenance of the Foley catheter. During an interview on 6/11/24 at 10:23 A.M., Nurse #4 said a resident with a Foley catheter should have orders for the care and maintenance of the Foley catheter. Nurse #4 said the electronic medical record should have documented evidence of the care and maintenance of the Foley catheter. Review of Resident #36's Encounter Note, written by Physician #1 and dated 3/11/24, indicated but was not limited to: -Urinary retention, suspect neurogenic bladder. The Foley catheter is draining well. He/she should follow-up with urology as an outpatient. Review of Resident #36's Skilled Nursing Note, dated 3/11/24, indicated but was not limited to: -His/her partner is currently with him/her. Intermittent screaming noted, redirected with no effect. Review of Resident #36's Encounter Note, written by Nurse Practitioner (NP) #1 and dated 3/12/24, indicated but was not limited to: -Foley catheter was changed last night due to concern that urine was not draining properly. -Nursing reports catheter has been putting out adequate amount of urine today. -Upon my exam he/she has approximately 400 milliliters (ml) clear yellow urine in drainage bag and does not have any palpable bladder distention or suprapubic tenderness. -He/she denies urinary or suprapubic discomfort. -Nursing reports he/she is moving his/her bowels. -Received a call this afternoon that his/her significant other was still concerned he/she was retaining urine but nursing reports he/she does not appear to have any bladder distention. -Unfortunately, the facility does not have a bladder scanner (a noninvasive tool used to measure urine volume in the bladder). -Asked nursing to place resident on Intake and Output (I&O) for 2 days so we can ensure he/she was drinking enough fluids and putting out enough urine. Review of Resident #36's Nursing/Health Status Note, dated 3/12/24, indicated but was not limited to: -Seen by NP new order for I&O to monitor fluids intake. Review of Resident #36's March 2024 MAR and TAR failed to indicate documented evidence that I&O monitoring occurred between 3/12/24 and 3/15/24. Review of Resident #36's orders failed to indicate evidence that I&O monitoring was ordered between 3/12/24 and 3/15/24. During an interview on 6/12/24 at 8:35 A.M., Nurse #4 said when a resident was on I&O monitoring there would be an order in the electronic medical record the nurses would record and monitor the total amount every shift. During an interview on 6/12/24 at 8:14 A.M., the Assistant Director of Nurses (ADON) said if an order is given for I&O monitoring, the order will be put into the electronic medical record. The nurse will calculate what the patient drinks and tally it daily. The Certified Nursing Assistants (CNA) document in the electronic record but the nurse is responsible for totaling and entering the total in the resident's record. During an interview on 6/11/24 at 11:05 A.M., NP #1 said she had been following Resident #36 for a concern with urinary retention and she believed nursing was monitoring I&O. NP #1 said she saw Resident #36 the day before his/her hospitalization and observed urine in the drainage bag. Review of Resident #36's Skilled Nursing Note, dated 3/12/24, indicated but was not limited to: -His/her partner is currently with him/her. Intermittent screaming noted, redirected with no effect. Review of Resident #36's Encounter Note, written by Physician #1 and dated 3/13/24, indicated but was not limited to: -Yesterday his/her family spoke to nursing about concern that his/her Foley was not putting out enough urine despite adequate fluid intake. -Nursing did change Foley catheter. Foley catheter was changed on 3/11 due to concern that urine was not draining properly. -Today nursing reports Foley does appear to be putting out an adequate amount of urine. -Patient is a limited historian but denies any suprapubic discomfort or feeling like he/she is retaining urine. Review of Resident #36's Skilled Nursing Note, dated 3/13/24, indicated but was not limited to: -His/her partner is currently with him/her. Intermittent screaming noted, redirected with no effect. Review of Resident #36's Encounter Note, written by NP #1 and dated 3/14/24, indicated but was not limited to: -Chief complaint/nature of presenting problem was abdominal distention. -His/her significant other was concerned last weekend that his/her Foley was not putting out enough urine despite adequate fluid intake. -Nursing changed the Foley catheter on 3/11. -Today nursing reports Foley is putting out an adequate amount of urine. Patient is a limited historian but denies any super pubic discomfort or feeling like he/she retaining urine. -Upon exam his/her abdomen is noted to be distended and firm. He/she does report mild abdominal pain. He/she cannot tell me when his/her last bowel movement was. -Foley draining clear yellow urine, no palpable bladder distention or suprapubic tenderness. -Plan: abdomen is firm and distended on exam today. He/she has a history of significant constipation and is on an aggressive bowel regimen. Ordered a fleet enema (liquid medication used to help someone have a bowel movement, a laxative) times one now and a stat X- ray of his/her abdomen including the kidneys, ureter and bladder (KUB) to assess for ileus (the inability of the intestine to contract normally leading to a build-up of food material)/obstruction. Review of Resident #36's Nurse's Note, dated 3/14/24, indicated but was not limited to: -One time enamel [SIC] given for constipation; he/she had a large bowel movement (BM). New order to obtain KUB, KUB done this afternoon, results pending. Review of Resident #36's KUB radiology report, dated 3/14/24, indicated but was not limited to: Findings: Air is scattered in the colon with minimal dilation of a few bowel loops. No significant small bowel areas seen. There is a soft tissue density arising out of the pelvis to the level of the fourth lumbar vertebra. No other masses or significant calcifications are seen. No fecal retention is seen. Conclusion: There is nonspecific bowel gas pattern. A minimal ileus of the colon may be present. There is a soft tissue density arising out of the pelvis which could be an abnormally distended urinary bladder or possibly a pelvic mass. Pelvic ultrasound is recommended for further evaluation. Further review of Resident #36's KUB radiology report, dated 3/14/24, indicated: -examination date: 3/14/24 at 16:09 -reported date: 3/14/24 at 16:26 During a telephonic interview on 6/13/24 at 11:19 A.M., the Laboratory/Radiology Services Consultant said the KUB results were faxed to the unit that Resident #36 was residing on on 6/13/24 at 16:29. Review of Resident #36's Encounter Note, written by Physician #1 and dated 3/15/24, indicated but was not limited to: -Upon exam his/her abdomen is noted to be distended and firm. -He/she does report mild abdominal pain. -I have personally reviewed all the available labs and tests. -KUB revealed a nonspecific bowel gas pattern. A minimal ileus of the colon may be present. There is a soft tissue density arising out of the pelvis which could be an abnormally distended urinary bladder or possibly a pelvic mass. Pelvis ultrasound is recommended for further evaluation. -Plan: Abdomen is nontender, but firm and distended on exam today. He/she is a poor historian but does report mild abdominal pain. Foley catheter is draining clear yellow urine. No signs of urinary obstruction. Nursing changed the Foley catheter on 3/11. A pelvic ultrasound cannot be obtained at our facility in the next 48 hours due to being a weekend, so I would advise hospital transfer. Review of Resident #36's medical record failed to indicate facility staff notified the provider of the KUB results prior to the physician visit on 3/15/24. During an interview on 6/11/24 at 1:01 P.M., Physician #1 said on 3/15/24 she reviewed Resident #36's KUB report and called the significant other due to concerning results. Physician #1 said the Resident needed to be sent to the hospital because an ultrasound needed to be obtained. Physician #1 said prior to the Resident's transfer urine was observed in the drainage bag. Physician #1 said it was possible for urine to continue to accumulate in the drainage bag even if the catheter was displaced. Physician #1 said the hospital staff replaced the Foley catheter which resolved the Resident's issues. Review of Resident #36's Interdisciplinary Team (IDT) Discharge & Recapitulation Summary, dated 3/15/24, indicated but was not limited to: -Resident was transferred to hospital related to a distended abdomen Review of Resident #36's Hospital paperwork, specifically the Patient Visit Information, dated 3/17/24, indicated but was not limited to: -He/she was admitted for malfunctioning urinary catheter. -His/her catheter was replaced and it is now functioning properly. -He/she was also noted to have been constipated but has been moving his/her bowels. -He/she was noted to have a urinary tract infection which was treated. Review of Resident #36's Hospital paperwork, specifically the Discharge Summary, dated 3/18/24, indicated but was not limited to: -Resident #36 was transferred to rehab 1.5 weeks prior and 3-4 days ago the healthcare proxy (HCP) noticed Resident #36 was having progressively worsening distention of his/her bladder which then progressed to having worsening oral intake and poor participation in physical therapy. HCP also noted diaphoresis (excessive or abnormal sweating for no apparent reason) and he/she was complaining of difficulty urinating. -In the Emergency Department, Resident #36 was mildly tachycardic (a heartrate greater than 100 beats per minute) to 106, and his/her labs showed a serum creatinine (a blood or urine test that indicates how well your kidneys are filtering waste from your blood) of 2.12 (the typical range for serum creatinine is: for adult men, 0.74 to 1.35 milligrams/deciliter and for adult women, 0.59 to 1.04 milligrams/deciliter) and a blood urea nitrogen (BUN, test reveals how well your kidneys are working) of 67 (a BUN of 6 to 24 milligrams/deciliter is considered normal), his/her urinalysis (a review of the urine) was grossly infected and his/her abdominopelvic computerized tomography scan (CT scan, a type of imaging that uses X-ray techniques to create detailed images of the body) indicated bilateral hydronephrosis and a distended urinary bladder with the Foley catheter positioned within the tip of the penile urethra. -Foley catheter was replaced and 2500 milliliters of urine was removed with improvement in his/her abdominal distention. He/she was administered antibiotics and admitted to the hospital for further management. -Creatinine was down to 0.63 after Foley catheter decompression. -Renal ultrasound was obtained on 3/17/24 to reassess hydronephrosis and indicated no evidence of hydronephrosis on the right (which had been on the CT scan) and bladder was decompressed. Review of Resident #36's CT Scan Report, dated 3/15/24 at 3:37 P.M., indicated but was not limited to: -There was bilateral hydroureteronephrosis which could have been related to the degree of the bladder distention -The ureters were dilated at the level of the ureterovesical junction (UVJ, where the ureter meets the bladder) bilaterally. -The urinary bladder was markedly distended. -The bladder measured over 19 centimeters in craniocaudal (a standard view taken from above) dimension. -There was a malpositioned Foley catheter that appeared to be within the penile urethra. Proximal to this there is a low-density which could be related to distention of the urethra versus the Foley catheter balloon. Review of Resident #36's Encounter Note, written by NP #1 and dated 3/19/24, indicated but was not limited to: -He/she was sent to the Hospital on 3/15/24. -He/she was found to have bilateral hydroureteronephrosis, distended urinary bladder, and fecal loading. -Foley catheter was changed and 2500 milliliters (mL) of urine was removed. -He/she returned to the facility on [DATE]. During an interview on 6/11/24 at 1:41 P.M., the Director of Nurses (DON), the Director of Clinical Services, and the surveyor reviewed Resident #36's medical record. The DON and Director of Clinical Services said they were unable to provide documented evidence of the care and maintenance of the Foley catheter prior to 3/15/24, there was no order or documented evidence of I&O monitoring prior to 3/15/24, and there was no documented evidence from the nurse that a provider was notified of the KUB report. The DON said Resident #36 was transferred to the hospital on 3/15/24 around 11:30 A.M. due to a distended abdomen and abnormal KUB results. Refer to F838

Based on document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Ensure a water management program was implemented to minimize the risk of Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic pathogens in building water systems by accurately measuring and documenting water temperatures; 2. For Resident #211, ensure staff wore personal protective equipment (PPE) and perform hand hygiene as required for Contact Precautions (infection control precautions used for patients who may be infected with certain infectious agents for which additional precautions are needed to prevent infection transmission); and 3. For Resident #35, properly store an oral syringe to minimize the risk of contamination. Findings include: 1. Review of the facility's policy titled Legionella, last revised April 2022, indicated but was not limited to the following: - Policy: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. - Guidelines: 1. As part of the infection prevention and control program, the facility has a water management program, which is over seen by the water management team. 3. The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by the facility is based on applicable federal and state regulations. 5. The water management program may include the following elements: e. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; i. A plan for when control limits are not met and/or control measures are not effective. Review of the facility's Legionella Preventive Procedures listed on the Legionella Identified Dead Ends Monthly checklist, undated, indicated but was not limited to: - Hot water tanks should be above 140 degrees Fahrenheit, and we must maintain circulatory hot water at 120 degrees Fahrenheit for the floors. - When Flushing Turn the Hot Water on and record temperature. Acceptable range is 77 degrees Fahrenheit and 113 degrees Fahrenheit. - After 5 minutes of flushing move to the next site Further review of the Legionella Identified Dead Ends Monthly Checklist indicated but was not limited to the following: - 12/07/23 The facility ran the water in the basement for five minutes but failed to document the temperature of the water. - 12/15/23 The facility ran the water in the basement for five minutes but failed to document the temperature of the water. - 12/20/23 The facility ran the water in the basement for five minutes but failed to document the temperature of the water. - 12/28/23 The facility ran the water in the basement for five minutes but failed to document the temperature of the water. - 3/7/24 The facility ran the water in both hot water tanks for five minutes but failed to document the temperature of the water. - 3/14/24 1. The facility ran the water in both hot water tanks for five minutes but failed to document the temperature for both hot water tanks. 2. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes. - 3/21/24 1. The facility ran the water in both hot water tanks for five minutes but failed to document the temperature for both hot water tanks. 2. The temperature of the water in the basement was 71 degrees Fahrenheit after running for five minutes. 3. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes. - 3/28/24 1. The facility ran the water in both hot water tanks for five minutes but failed to document the temperatures for both hot water tanks. 2. The temperature of the water in the basement was 71 degrees Fahrenheit after running for five minutes. 3. The temperature of the water on the Massapoag was 73 degrees Fahrenheit after running for five minutes. - 4/12/24 1. The temperature of the water in the basement was 68.3 degrees Fahrenheit after running the water for five minutes. 3. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running the water for five minutes. - 4/18/24 1. The facility ran the water in the basement for five minutes but failed to document the temperature of the water. 2. The temperature of the water on the Massapoag was 71 degrees Fahrenheit after running for five minutes. - 4/25/24 1. The facility ran the water in the basement for five minutes but failed to document the temperature of the water. 2. The temperature of the water on the Massapoag was 71 degrees Fahrenheit after running for five minutes. - 5/1/24 1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes. 2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes. - 5/10/24 1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes. 2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes. - 5/17/24 1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes. 2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes. - 5/24/24 1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes. 2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes. - 5/31/24 1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes. 2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes. During an interview on 6/11/24 at 4:21 P.M., the Maintenance Director said the process was to let the hot water run for five minutes then check the temperature and record the temperatures of the two water tanks, in the basement, and on the Massapoag unit. The Maintenance Director and surveyor reviewed the Legionella Identified Dead Ends Monthly Checklist for the above dates. The Maintenance Director said he should have recorded the temperatures after running the water for five minutes and that he would sometimes take the temperature of the water on the cold side. The Maintenance Director said he should have taken the temperature of the hot water instead of the cold water. During an interview on 6/11/24 at 4:21 P.M., the Regional Maintenance Director said he had been responsible for taking the temperature of water in the basement in December and he should have recorded the temperature of the two hot water tanks but did not. During an interview on 6/12/24 at 2:19 P.M., the Administrator said the expectation was for the water temperatures to be taken and recorded accurately and per policy. The Administrator said she was aware that the Maintenance Director would at time take the temperature of the cold water and she has not reviewed the temperature logs for the last few months and should have. 46562 2. Review of the facility's policy titled Infection Control, dated as revised 5/23, indicated but was not limited to the following: -When there is likely exposure to spores (reproductive cells that can develop into new organisms) (i.e., Clostridium difficile (C-diff, a spore forming toxin that can develop in the intestines after antibiotic use and causes watery diarrhea) Note: Alcohol-based hand rubs are ineffective against spores. For the effective mechanical removal of spores, wash hands for 30-60 seconds with soap and water or 2% Chlorhexidine Gluconate (a germicidal liquid). Review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions, dated as revised 4/22, indicated but was not limited to the following: -In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's room. -Examples of infections requiring Contact Precautions include, but are not limited to: diarrhea associated with Clostridium difficile. -In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, not sterile) when entering the room. -Remove gloves before leaving the room and perform hand hygiene. -Wear a disposable gown upon entering the Contact Precautions room or cubicle. -The facility will implement a system to alert staff to the type of precaution the resident requires. Review of the Centers for Disease Control and Prevention (CDC) Contact Precautions sign, undated, indicated but was not limited to: -Everyone must: clean their hands, including before entering and when leaving the room. -Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Resident #211 was admitted to the facility in June 2024 with diagnoses including enterocolitis due to C-diff and sepsis (an infection of the bloodstream). Review of the Physician's Orders for Resident #211 indicated but was not limited to the following: -Contact or droplet precautions for C-Diff. The resident remains in his/her room alone. All services are brought to the resident in room (e.g. rehabilitation, activities, dining, etc.) every shift for infection- C-diff, dated 6/7/24; -Contact Precautions, dated 6/6/24; -Maintain contact precautions for C-diff (staff to perform hand hygiene upon entering and exiting room and to don (put on) appropriate Personal Protective Equipment (PPE) gowns and gloves, don eye protection as indicated for risk of splashes and sprays of bodily fluid. Perform Hand Hygiene by washing hands with soap and water every shift for Precautions maintain PPE precaution [SIC], dated 6/6/24 Review of the Care Plan for Resident #211 indicated but was not limited to the following: -Focus: Resident has active infection and is being treated in attempt to prevent the spread. Is symptomatic and/or has a positive test indicating contagious stage (stool, C-diff). -Interventions: Transmission based precaution (contact) On the following dates of the survey, the surveyor observed: -6/6/24 at 10:20 A.M., Social Worker #1 standing in Resident #211's room talking to the Resident with no PPE donned. At 10:28 A.M., the Social Worker left the room and did not perform hand hygiene. A CDC Contact Precautions sign was observed on the doorframe and a PPE bin was located outside of the door. -6/10/24 at 8:19 A.M., Certified Nursing Assistant (CNA) #2 was observed in Resident #211's room changing the television channel with no PPE on. CNA #2 then exited the room with Resident #211's breakfast tray, holding it with both hands. CNA #2 then used one hand to open the tray cart and placed the breakfast tray on the cart. CNA #2 then performed hand hygiene with alcohol-based hand rub and proceeded down the hallway. A CDC Contact Precautions sign was observed on the doorframe and a PPE bin was located outside of the door. During an interview on 6/12/24 at 11:18 A.M., the Infection Preventionist said when a resident is suspected or confirmed to have C-diff, the staff must wear a gown and gloves and wash their hands with soap and water and utilize bleach wipes when cleaning equipment. The Infection Preventionist said a C-diff meal tray should not have been carried down the hallway. During an interview on 6/11/24 at 9:21 A.M., the Assistant Director of Nurses (ADON) said, that residents on contact precautions related to C-diff, staff should don gown and gloves when entering the resident's room and remove the PPE before exiting the room. The ADON said that staff should wash their hands with soap and water after removing their PPE to prevent the spread of C-diff. 3. On 6/11/24 at 7:23 A.M., on the [NAME] Unit Medication Cart, the surveyor observed: -One bottle of liquid Atovaquone (an antimicrobial medication) Oral Suspension belonging to Resident #35 with an oral syringe secured to the bottle by an elastic band. The syringe tip was uncapped and exposed. During an interview on 6/11/24 at 7:23 A.M., Nurse #4 said that the syringe tip should be covered and should not be exposed. During an interview on 6/11/24 at 10:39 A.M., the Director of Nurses (DON) said oral syringes should be covered or stored in a closed bag to prevent potential contamination. 50740

Based on document review and interview, the facility failed to ensure their arbitration agreement provides for the selection of a neutral venue that is convenient to both parties. Findings include: Review of a list of residents with signed Arbitration Agreements, provided by the facility on 6/6/24 and 6/13/24, indicated a total of 45 residents/representatives had signed the facility's binding Arbitration Agreement. Review of the Arbitration Agreement in use by the facility until 6/5/24, failed to indicate the residents or their representatives had the right to a neutral venue agreed upon by both parties. During an interview on 6/13/24 at 3:30 P.M., Corporate Staff #2 said that last week they updated the facility's Arbitration Agreement to provide for the selection of a neutral venue that is convenient to both parties. He said they have started the process of having residents/representatives that previously signed the Arbitration Agreements sign the updated version. Review of a list of residents provided by Corporate Staff #2 indicated that 11 of 45 residents had signed the updated Arbitration Agreement. During interviews on 6/13/24 at 4:00 P.M. and 4:15 P.M., the Director of Admissions (DOA) said the facility's Arbitration Agreement was updated last week to include the selection of a neutral venue that is agreed upon by both parties. The DOA said she drafted a letter identifying the changes made to the agreement and sent the letter and new agreement to residents/representatives who previously signed it.

Based on interview, policy review, and record review, the facility failed to notify the Resident's Physician/Physician extender about changes in condition, to re-evaluate the potential need to alter the treatment plan for one Resident (#23), from a total sample of 18 residents. Specifically, the facility failed to notify the physician/physician extender of the deterioration of moisture-associated skin damage (MASD-caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) on the Resident's left buttock to a stage 2 pressure ulcer (PU- partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) and the Wound Consultant's treatment recommendations, resulting in a delay of treatment. Findings include: Review of the facility's policy titled Change of Condition in a Resident Status, dated March 2017, indicated but was not limited to: -the Nurse will notify the resident's physician where there has been a significant change in the resident's physical, emotional and mental condition, a need to alter the resident's medical treatment significantly, or abnormal laboratory results - a significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions or requires interdisciplinary review and/or revision to the care plan -the Nurse will assess the resident's change of condition and document the findings in the medical record Review of the facility's policy titled Charting and Documentation, dated as revised April 2022, indicated but was not limited to: -any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the medical record and notification of the physician and family. 1. Resident #23 was admitted to the facility in July 2017 and had diagnoses including Alzheimer's disease and MASD on the left buttock. Review of the Minimum Data Set (MDS) assessment, dated 4/25/24, indicated Resident #23 was dependent on staff for turning and repositioning and was non-ambulatory. The MDS also indicated that Resident #23 had MASD and utilized a pressure-reducing device in bed. Review of the medical record indicated Resident #23 was seen weekly by the Wound Care consultant for management of ongoing MASD since April 2024. Review of the Wound Care Consultant's note, dated 6/4/24 and signed at 4:08 P.M., indicated Resident #23's MASD to the left buttock deteriorated to a Stage 2 pressure ulcer (partial thickness skin loss with exposed dermis) on the left ischial tuberosity (bone in the lower part of the pelvis that absorbs weight when you sit). The wound measured: 4 centimeters (cm) in length x 3 cm width x 0.2 cm depth, had moderate serous exudate (clear or slightly yellow wound drainage) and [NAME] (sic) discoloration with biofilm (forms when microorganisms adhere and proliferate on the surface of the skin). The Wound Care consultant note also indicated that the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the stage 2 pressure ulcer (PU) indicated the following instructions: -Incontinence care -Apply skin prep to periwound (area surrounding the wound) -Apply Collagen powder and calcium alginate with silver, and cover with sacral dressing daily and as needed (prn). Review of a Weekly Wound Rounds document, dated 6/5/24 and signed as complete by the Director of Nursing (DON), indicated Resident #23 had acquired a stage 2 PU to the left ischium with moderate serous drainage and measured 4 cm in length x 3 cm in width x 0.2 cm in depth. The note indicated the physician was notified of the stage 2 PU on 6/5/24. The document indicated the current treatment plan was: -Incontinence care. -Apply skin prep to periwound. -Apply collagen powder and calcium alginate with silver and cover with sacral dressing daily and prn. During an interview on 6/7/24 at 11:38 A.M., the DON reviewed the Weekly Wound Round note, dated 6/5/24, that he completed. He said he spoke to the physician, and she approved the Wound Care Consultant's recommendations. During an interview on 6/7/24 at 11:52 A.M., the ADON said she was too busy to round with the Wound Care consultant on 6/4/24, didn't see Resident #23's wound and was not told the Resident developed a stage 2 PU. The ADON said she saw the Wound Care Consultant in the hallway and she told her she was going to recommend a change in treatment. The ADON said she saw the Wound Care consultant's report on 6/6/24, and after she got home, she entered the order into Resident #23's medical record without first contacting the Physician to notify her of the recommendation and obtaining an order for the new treatment. During a telephone interview on 6/7/24 at 12:17 P.M., Physician #1 said she had not spoken to the DON or anyone else on 6/5/24 to inform her that Resident #23 had developed a stage 2 PU and the Wound Care consultant had new treatment recommendations. Physician #1 said when she is not there, the Nurse Practitioner (NP) is there and they may have notified her. She said if the NP was told about it, she would have written a note in daily rounding notes. The Physician said she was looking in Resident #23's medical record on her computer and said the NP had not written a note regarding Resident #23. She said her expectation is that facility staff would call either her or the Nurse Practitioner (NP) with a change in condition and/or change in treatment either the day the recommendation is made, or no later than the following day. During a telephone interview on 6/7/24 at 12:50 P.M., the NP said she was in the facility on 6/4/24 and did not see the Wound Care consultant. She said she was in the facility on 6/6/24 and was not notified by the DON or any other facility staff that Resident #23 had developed a new stage 2 PU or had any treatment recommendations by the Wound Care consultant. Review of a Nurse's Note, dated 6/7/24, indicated Corporate staff #1 contacted Physician #1 on 6/7/24 to notify her of the Wound Care consultant's treatment recommendation from the last visit on 6/4/24, three days after the Wound Care consultant identified the stage 2 PU to the Resident's left ischial tuberosity. Review of the medical record indicated the following Physician's order was entered into the electronic medical record on 6/7/24, three days after the recommendation was made: -Left buttock: skin prep, apply collagen powder and calcium alginate with silver, cover with sacral dressing daily/prn. Review of the June 2024 Treatment Administration Record (TAR) indicated this order was not initiated until 6/8/24, four days after the Wound Care consultant made the recommendation for a change in treatment for the newly acquired stage 2 PU. Refer to F686

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for one Resident (#23), in a total sample of 18 residents. Specifically, the facility failed to ensure the MDS accurately reflected the Resident's pressure ulcer risk. Findings include: Resident #23 was admitted to the facility in July 2017 and had diagnoses including chronic kidney disease and adult failure to thrive. Review of a Norton Plus Pressure Ulcer Scale, dated 4/23/24, indicated Resident #23 had a score of 6.0 (score of less than 10 is very high risk) and was at Very High Risk for developing pressure ulcers. Review of the most recent MDS assessment, dated 4/25/24, indicated Section M-Skin Conditions section M0150 (risk of pressure ulcers) question: Is this resident at risk for developing pressure ulcers? The answer was documented No. During an interview on 6/10/24 at 8:33 A.M., the MDS Coordinator reviewed section M of Resident #23's 4/25/24 MDS and the [NAME] Pressure Ulcer Risk assessment, dated 4/23/24. She said the Resident scored a 6.0 which indicated a high risk for developing pressure ulcers. She said she clicked No by mistake on the 4/25/24 MDS assessment for pressure ulcer risk and needed to do a modification to the MDS to accurately reflect the Resident's risk.

Based on record review, interviews, and policy review, the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#23), out of a total sample of 18 residents. Specifically, for Resident #23, the facility failed to ensure the comprehensive care plan was revised to reflect a newly developed Stage 2 pressure ulcer (PU- partial thickness skin loss with exposed dermis) and a change in treatment. Findings include: Review of the facility's policy titled Comprehensive Care Plans, revised April 2022, included but was not limited to: - The comprehensive, person-centered care plan is developed within seven days of the completion of the comprehensive assessment (MDS). -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. - The Interdisciplinary team must review and update the care plan: a. When there has been a significant change in the residents' condition. b. When the desired outcome is not met. c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment, that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Resident #23 was admitted to the facility in July 2017 and had diagnoses including Alzheimer's disease and Moisture Associated Skin Damage (MASD) on the left buttock. Review of the Minimum Data Set (MDS) assessment, dated 4/25/24, indicated Resident #23 was dependent on staff for turning and repositioning and was non-ambulatory. The MDS also indicated that Resident #23 had MASD and utilized a pressure-reducing device in bed. Review of the comprehensive care plans indicated but was not limited to the following: FOCUS: Resident has bowel/bladder incontinence related to dementia, impaired mobility (4/11/21). GOAL: Resident will remain free from skin breakdown due to incontinence. INTERVENTIONS: Clean peri-area with each incontinence episode. FOCUS: Resident has impaired functional mobility related to bilateral upper extremity contractures and one side lower extremity contracture, weakness (7/31/21). GOAL: Safety will be comfortable in environment and have no skin breakdown. INTERVENTIONS: Totally dependent for positioning in bed and chair. FOCUS: Skin: Actual alteration in skin integrity related to left buttock (4/1/24). GOAL: Resident will have signs of healing and/or resolution of non-pressure skin issue. INTERVENTIONS: Consult and treatment by Certified Wound Medical Doctor (MD) or Certified Wound Nurse as needed (prn); observe for signs/symptoms of infection and report to MD and obtain prescription (Rx); weekly documented skin check. Review of the medical record indicated Resident #23 was seen weekly by the facility's Wound Care consultant for evaluation of MASD. Review of Resident #23's medical record included a Skin Observation Tool, dated 5/29/24 and completed by Nurse #1, which indicated newly identified open areas on the Resident's coccyx. Review of the Wound Care consultant's note, dated 6/4/24, indicated Resident #23's MASD to the left buttock deteriorated to a Stage 2 pressure ulcer (partial thickness skin loss with exposed dermis) on the left ischial tuberosity (bone in the lower part of the pelvis that absorbs weight when you sit). The wound measured: 4 cm in length x 3cm width x 0.2 cm depth, had moderate serous exudate and [NAME] (sic) discoloration with biofilm (forms when microorganisms adhere and proliferate on the surface of the skin). The Wound Care consultant note also indicated that the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the stage 2 PU indicated the following instructions: -Incontinence care -Apply skin prep to periwound. -Apply Collagen powder and calcium alginate with silver, and cover with sacral dressing daily and as needed (prn). Further review of comprehensive care plans failed to indicate the comprehensive care plan was reviewed and revised when a Stage 2 PU was identified by the Wound Care consultant with a recommendation for a change in treatment. During an interview on 6/7/24 at 11:37 A.M., Nurse #1 said she did not update the comprehensive care plan to reflect the change in the Resident's skin.

Based on record review and interview, the facility failed to implement the Physician's order to monitor blood glucose levels three times per day before meals for one Resident (#34), out of a sample of 18 residents. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #34 was admitted to the facility in May 2024 with diagnoses which included type two diabetes mellitus without complications, cerebral infarction (stroke), pneumonia, and dysarthria/anarthria (the inability to produce clear, articulate speech). Review of the Minimum Data Set (MDS) assessment, dated 5/25/24, indicated Resident #34 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which is indicative of severe cognitive impairment. Further review of the MDS indicated Resident #34 received insulin as ordered by the physician. Review of Resident #34's current Physician's orders included: -Levemir FlexPen subcutaneous solution pen-injector, 100 units/milliliter (mL). Inject 6 units subcutaneously two times a day for control of high blood sugar; start date 5/22/24. -Metformin oral tablet 500 milligrams (mg). Give 1 tablet by mouth two times a day for blood sugar, please administer with meals; start date 5/22/24. -Fingersticks (a procedure for obtaining blood to measure a numeric blood glucose level) before meals for diabetes; start date 5/24/24. -Please check fasting sugars before meals for type two diabetes; start date 6/4/24. Further review of Resident #34's medical record indicated but was not limited to: -On 5/23/24, the Physician entered the order for fingersticks three times daily before meals into the Electronic Health Record (EHR). -On 5/27/24, Nurse #4 confirmed the Physician's order for fingersticks three times daily before meals. Review of Resident #34's May and June 2024 Medication Administration Record (MAR) indicated: -Resident #34 received Levemir and Metformin as ordered by the Physician. -No documentation of fingersticks having been performed from 5/24/24 through 6/3/24. -No documentation of blood glucose values between 5/24/24 through 6/3/24. Review of Physician's assessment notes on the following dates indicated but was not limited to the following: 5/22/24 - Clinical Assessment: High risk of diabetes complications. Plan: Diabetes- patient was resumed on Metformin and Lantus (the brand name for Levemir). Fingersticks should be monitored before meals. 5/24/24 - Clinical Assessment: High risk of diabetes complications. Plan: Fingersticks should be monitored before meals. I ordered fingersticks three times a day before meals. Review of Nurse Practitioner's assessment note, dated 6/4/24, indicated but was not limited to: Clinical Assessment - Type 2 diabetes mellitus with unspecified complications. He/she is on Levemir and Metformin. There is an order to check fingersticks before meals, but results not recorded in EHR. I have updated the order so results will be in EHR. Review of Resident #34's medical record indicated no documentation of fingersticks or blood glucose values from 5/24/24 until 6/4/24 at 7:44 P.M. at which time the first fingerstick was documented with a value of 201 mg/deciliter (dL). The total of missed fingerstick opportunities during this timeframe was 35. During an interview on 6/11/24 at 10:23 A.M., Nurse #4 said when a Physician enters a medication or treatment order into the EHR, nursing would see the order, in red print, and would confirm the order. Nurse #4 said for Resident #34, she confirmed the Physician's fingerstick order on 5/27/24. Nurse #4 said nursing documented fingersticks and blood glucose values in the EHR. Nurse #4 and the surveyor reviewed the Resident's EHR and Nurse #4 said she could not find documentation of fingersticks being performed or blood glucose values prior to 6/4/24. During a telephonic interview on 6/11/24 at 1:06 P.M., the Physician said she would expect staff to implement her recommendations to monitor Resident #34's blood sugars three times a day before meals beginning 5/24/24. During an interview on 6/11/24 at 4:15 P.M., the Director of Nursing (DON) said when a Physician enters an order into the EHR, nursing must confirm and implement the order. The DON said the Physician's order for fingersticks was confirmed by Nurse #4 on 5/27/24. The DON said he expected nursing to have confirmed and implemented this order within 24 hours after the Physician entered it. The DON said he could not find documentation of fingersticks being performed per Physician's order or blood glucose values from 5/24/24 through 6/3/24. The DON said he expected to at least see documentation for fingersticks and blood glucose values beginning on 5/27/24 since nursing confirmed the order on 5/27/24. During an interview on 6/12/24 at 11:01 A.M., the DON said he would expect nursing to be cognizant in this situation and realize Resident #34 was not receiving fingersticks or blood glucose monitoring per Physician's orders.

Based on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on one unit (Borderland) of three units in the facility. Specifically, the facility failed to ensure a storage closet and storage area in the shower room was securely locked and hazardous items were not easily accessible to wandering residents. Findings include: On 6/6/24 at 8:16 A.M., the surveyor observed three residents wandering the hallways of the Borderland Unit (secure Dementia Special Care Unit). On 6/6/24 at 8:30 A.M. on the Borderland Unit, the surveyor approached a closed door labeled shower room and entered. Inside the shower room was a storage room with a closed door. The door was unlocked. The surveyor observed the following items in the unlocked and unsecured storage room: -Two oxygen concentrators -2 filled portable oxygen tanks -Three-tiered cart with drawers that contained a bottle of shampoo & body wash and a bottle of Difeel Biotin Pro-Growth Shampoo. On 6/6/24 at 9:29 A.M., the surveyor approached a closed door near the unit bathroom. The door had a numerical combination lock on it, but the door was not pulled tight and secured and was easily pushed open. The surveyor observed the following items in the unlocked and unsecured storage closet: -An open box containing packages of disposable razors was on the shelf -Two bottles of moisturizing body lotion -Five packets of A & D ointment skin protectant -One bottle of mouthwash -One can of shaving cream At the conclusion of the observation, the surveyor pulled the door closed tightly and ensured the storage closet was secured. On 6/11/24 at 8:25 A.M., the surveyor approached a closed door near the unit bathroom. The door had a numerical combination lock on it, but the door was not pulled closed and secured and was easily pushed open. On 6/11/24 at 8:26 A.M., the surveyor and Activity Director observed the unlocked and unsecured storage closet. She said the door to the storage closet and storage room in the shower room should be closed so residents can't access items that may be hazardous.

Based on record review, policy review, and interview, the facility failed to monitor adverse consequences of an anticoagulation medication (used to prevent the blood from clotting, a blood thinner) prescribed for one Resident (#34), out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Anticoagulation Therapy, revised 4/2022, indicated but was not limited to: Monitoring and Follow-Up -the staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. -if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. Resident #34 was admitted to the facility in May 2024 with diagnoses which included cerebral infarction (stroke), hypertension (high blood pressure), and dysarthria/anarthria (the inability to produce clear, articulate speech). Review of the Minimum Data Set (MDS) assessment, dated 5/25/24, indicated Resident #34 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which is indicative of severe cognitive impairment. Further review of the MDS also indicated Resident #34 had received anticoagulant medication. Review of Resident #34's current Physician's Orders indicated but was not limited to: -Lovenox injection solution (an anticoagulant) prefilled syringe 40 milligrams (mg)/0.4 milliliters. Inject 1 vial subcutaneously one time a day for blood thinner; start date 5/22/24. -Clopidogrel (antiplatelet) 75 mg. Give 1 tablet by mouth one time a day for blood thinner; start date 5/22/24. -Aspirin 81 mg. Give 81 mg by mouth one time a day for prevention; start date 5/22/24. Review of Resident #34's May 2024 and June 2024 Medication Administration Record (MAR) indicated he/she was administered Lovenox, Clopidogrel, and Aspirin as ordered. Review of Resident #34's Physician's History and Physical Note, dated 5/22/24, indicated but was not limited to: -Plan: Deep Vein Thrombosis (DVT) prophylaxis - patient is on Lovenox per hospital records. He/she is at high risk of bleeding due to being on Aspirin, Plavix, and Lovenox. Review of Resident #34's Nurse Practitioner Follow-Up note, dated 5/23/24, indicated but was not limited to: -Clinical Risk Assessment: High risk of bleeding complications. -Assessment: Current use of anticoagulant therapy. Currently on Lovenox. Will need to monitor closely for signs of bleeding, especially since he/she is also on Aspirin and Plavix. Review of Resident #34's Physician Follow-Up note, dated 5/24/24, indicated but was not limited to: -Clinical Risk Assessment: High risk of bleeding complications. -Plan: Deep Vein Thrombosis (DVT) prophylaxis - patient is on Lovenox per hospital records. He/she is at high risk of bleeding due to being on Aspirin, Plavix, and Lovenox. Review of Resident #34's Nurse Practitioner Follow-Up note, dated 6/6/24, indicated but was not limited to: -Clinical Risk Assessment: High risk of bleeding complications. Further review of Resident #34's past and current Physician's orders, specifically during the time the Resident received anticoagulant medication, indicated there was no order for monitoring possible side effects or adverse complications related to the anticoagulant medication. During an interview on 6/12/24 at 10:20 A.M., the Physician said it was standard to monitor for bleeding and bruising when receiving anticoagulant medication and Resident #34 should have had an order to monitor for possible complications, such as bleeding and bruising, while he/she received anticoagulant medication. During an interview on 6/12/24 at 11:01 A.M., the Director of Nursing (DON) said Lovenox was an anticoagulant medication, and he expected residents receiving anticoagulant medication to be monitored for bleeding and bruising. The DON and the surveyor reviewed Resident #34's past and current Physician's orders. The DON said he was not able to find an order to monitor Resident #34 for adverse consequences of anticoagulation medications. The DON said Resident #34 should have had an order to monitor for adverse consequences of anticoagulation medications but did not.

Based on record review, policy review, and interview, the facility failed to ensure the drug regimen was free from unnecessary psychotropic medications for one Resident (#34), out of a total sample of 18 residents. Specifically, the facility failed to monitor Resident #34 for potential adverse consequences and behaviors when administering antidepressant medication. Findings include: Review of the facility's policy titled Psychotropic Medication, revised 4/2022, indicated but was not limited to: -To administer and monitor the effects of psychoactive medications when prescribed. -Monitoring for drug side effects leads to early identification and reporting in accordance with state/federal regulations. Resident #34 was admitted to the facility in May 2024 with diagnoses which included depression, anxiety disorder, cerebral infarction (stroke), and dysarthria/anarthria (the inability to produce clear, articulate speech). Review of the Minimum Data Set (MDS) assessment, dated 5/25/24, indicated Resident #34 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which is indicative of severe cognitive impairment. Further review of the MDS also indicated Resident #34 was taking an antidepressant with indication. Review of Resident #34's current Physician's Orders indicated, but were not limited to the following: -Mirtazapine (an antidepressant) tablet 15 milligrams (mg). Give 1 tablet by mouth at bedtime for antidepressant. Start date 6/5/24. -Trazodone (an antidepressant) tablet 50 mg. Give 0.5 tablet by mouth three times a day for antidepression. Start 5/22/24. -Antidepressant (potential side effects): stiff neck, tremors, confusion, tardive dyskinesia, dry mouth, blurred vision, constipation, urinary retention, hypotension, sedation/drowsiness, increased falls/dizziness, cardiac abnormalities, anxiety/agitation, appetite change/weight change, headache, insomnia, weakness, visual disturbances, sweating/rashes; chart number of side effects every shift. Order date: 6/6/24. Start date: 6/6/24. -Behavior monitoring - Antidepressant: 1. Target behavior [Specify: depressed, sad, crying, tearfulness, withdrawn, mood changes, no behavior] chart number of episodes every shift. Intervention: 1 Positive reinforcement, 2 Redirection, 3 one-to-one, 4 Music/Television, 5 Food/Fluid offered, 6 Medication offered, 7 Other. Outcome: I Improved, U Unchanged. Order date: 6/6/24. Start date: 6/6/24. Review of Resident #34's past Physician's Orders indicated but were not limited to the following: - Mirtazapine tablet 7.5 mg. Give 1 tablet by mouth at bedtime for antidepressant for 14 days. Start 5/21/24, End 6/4/24. Order completed. - Mirtazapine tablet 7.5 mg. Give 1 tablet by mouth in the morning for antidepressant for 14 days. Start 5/22/24, End 6/5/24. Order discontinued. Review of Resident #34's May and June 2024 Medication Administration Record (MAR) indicated he/she was administered Mirtazapine and Trazodone per Physician's orders. Further review of Resident #34's past and current Physician's Orders, specifically during the time the Resident was receiving antidepressant medication, indicated there was no Physician's order for monitoring potential side effects or behaviors related to antidepressant medication from 5/21/24 through 6/5/24, which equals 16 days with no orders or documentation of antidepressant medication side effects or behavior monitoring. During an interview on 6/11/24 at 10:42 A.M., Nurse #4 said nursing monitors side effects and behaviors of residents on antidepressant medication. During a telephonic interview on 6/11/24 at 1:06 P.M., the Physician said residents on antidepressants are usually monitored for drowsiness (a potential side effect of antidepressant medication) and she expected residents receiving antidepressant medication to be monitored for drowsiness. During an interview on 6/12/24 at 11:01 A.M., the Director of Nursing (DON) and the surveyor reviewed Resident #34 medical record. The DON said his expectation for any resident with a diagnosis of depression and receiving antidepressant medication is to be monitored for potential side effects and behaviors. The DON said Resident #34 should have been monitored for side effects and behaviors related to antidepressant medication during the entire course of his/her antidepressant medication treatment.

Based on interview, observation and record review, for 1 of 18 sampled Residents (Residents #1), the Facility failed to ensure residents were cared for in a manner that promotes enhancement quality of life and recognized individuality. audio/videotape footage provided to the Surveyors by the police captured Activities of Daily Living (ADL) care provided to Resident #1 from the end of February 2017 through 3/7/17 that indicated, but was not limited to, the following: : multiple staff members initiating care for Resident #1 without first explaining the care to be provided; staff entering Resident #1's room without knocking; staff leaving Resident #1's television on loud while Resident #1 slept; staff leaving Resident #1's radio tuned to a hip/hop station and playing loudly; staff left Resident #1 laying naked, uncovered and exposed in his/her for bed while staff stood by but staff were not actively providing any care to him/her, and staff spoke in front of Resident #1 in a language that was not in his/her preferred language of English. Findings include: 1. Surveyor #1 interviewed Resident #1's Health Care Agent at 4:20 P.M. on 3/13/17 and Family Member #1 at 4:35 P.M. on 3/13/17. The Health Care Agent said she asked and allowed Family Member #1 to install and operate an audio/video camera in Resident #1's room from the end of February 2017 through 3/7/17. Between 3/17/17 and 4/21/17, Surveyors reviewed approximately 47.5 hours of audio/videotape footage of Resident #1's room, provided by the police, that portrayed approximately 41 instances of concerns with Dignity and 125 concerns with Quality of Life/Resident Rights that included, but was not limited to, the following: * Multiple instances of CNA #1, CNA #2, and unidentified CNAs not explaining ADL care to Resident #1 prior to initiating care. * At least two instances in which CNA #1 and an unidentified CNA removed Resident #1's pants after Resident #1 stated words to the effect of, Don't pull on my pants! and removed Resident #1's incontinence brief without explaining the care to be provided to Resident #1 ahead of time. * At least one instance in which CNA #1 and an unidentified CNA did not explain care to Resident #1 and stood silently behind Resident #1 while undressing him/her. * At least one instance in which an unidentified CNA did not talk with Resident #1 during meal service. * At least three instances where CNA #1 grabbed and removed Resident #1's glasses off his/her face without explaining care ahead of time. * At least one instance where CNA #1 picked up Resident #1 in a bear hug and transferred him/her from the wheelchair to his/her bed. Resident #1 said words to the effect, Hey! Hey! Stop that! and CNA #2 came from behind Resident #1 and forcefully pulled down his/her pants. Staff did not speak with Resident #1 before initiating ADL care or during ADL care for him/her, and made no effort to console Resident #1 when he/she became agitated and when Resident #1 was observed to be visibly upset. 2. * Multiple instances in which multiple unidentified staff members entered Resident #1's room without first knocking on his/her door. 3. * Multiple instances in which multiple unidentified staff members exit Resident #1's room while leaving Resident #1's television volume playing loudly and while Resident #1 slept. 4. * Multiple instances in which multiple unidentified staff members provided care to Resident #1 with Resident #1's radio tuned to a hip/hop station and playing loudly. 5. * Multiple instances in which staff members left Resident #1 laying naked, uncovered and exposed in his/her for bed while staff stood by but staff were not actively providing any care to him/her. * An instance where Resident #1's breasts were exposed and the privacy curtain was not closed, and a third unidentified staff member came into Resident #1's bedroom and asked if the other 2 CNAs wanted to work a double (shift) that day. 6. * An instance where one unidentified CNA told another unidentified CNA words to the effect, She (Resident #1) was one fresh one! 7. * At least 15 instances in which unidentified CNAs spoke in front of Resident #1 in a language that was not in his/her preferred language of English. Although Resident #1 was unable to be interviewed by Surveyor #1 due to his/her cognitive deficits, the Reasonable Person Concept presumes that an unimpaired person would experience pain or mental anguish from these interactions with CNA #1 and CNA #2 and multiple staff members.

Based on records reviewed and interviews and for 1 of 18 sampled Residents (Resident #1), the Facility failed to develop a care plan to address Resident #1's resistance to care. Although audio/videotape footage captured in Resident #1's room from the end of February 2017 through 3/7/17 portrayed multiple instances of Resident #1's resistance to care, the behavioral symptoms had not been identified on his/her care plan and no additional care plan interventions were communicated. Findings include: The Documentation of Resident Incapacity Form dated 11/3/15, indicated that Resident #1's Physician activated Resident #1's Health Care Proxy indefinitely due to dementia, memory loss and disorientation. The Quarterly Minimum Data Set (MDS) Assessment, completed 1/25/17, indicated Resident #1 required extensive assistance with a two person physical assist with bed mobility and with transfers. The MDS Assessment indicated Resident #1 was sometimes understood and sometimes understood others, had moderately impaired decision-making and his/her behavioral symptoms were limited to wandering. The Altered Cognitive/Communication Care Plan, revised on 2/16/17, indicated Resident #1 required assistance with decision making secondary to memory loss, and missing part of messages related to the [DIAGNOSES REDACTED].#1 as needed, repeating and rephrasing to enhance comprehension, using simple yes/no answers for questions, anticipating resident's needs, paying attention to non-verbal cues and allowing the resident ample time to respond to questions. Surveyor #1 interviewed Resident #1's Health Care Agent at 4:20 P.M. on 3/13/17 and Family Member #1 at 4:35 P.M. on 3/13/17. The Health Care Agent said she asked and allowed Family Member #1 to install and operate an audio/video camera in Resident #1's room from the end of February 2017 through 3/7/17. Between 3/17/17 and 4/21/17, Surveyors reviewed the audio/videotape footage provided by the police. The captured audio/videotape footage portrayed multiple instances of Resident #1's resistance to care including: * Swatting at staff members, * Struggling to pull away from staff members providing care, and * Making angry and threatening statements during care including words to the effect, Wait and see what is up for you!, How dare you do this!, You ought to be ashamed of yourselves!, Get away from me!, Knock it off!, and Get the hell away from me! In spite of Resident #1's observed behavior and being visibly upset, staff did not attempt to reassure, reapproach, distract or console Resident #1. Instead, staff acted without regard for Resident #1's agitated behavior and continued with the task at hand, ignoring Resident #1's pleas. Prior to 3/13/17, Resident #1's Altered Cognitive/Communication Care Plan did not identify that Resident #1's behavioral symptoms included being resistance to care.

Based on record review and interview, the facility failed to ensure sufficient nursing staff to provide nursing and related services to provide supervision to prevent accidents for two Residents residing in two of three units , #12 who resided on the Massaboag Unit and #13 residing on the Borderland Unit in a building with only three nursing units in total. 1. For Resident #13, the facility failed to provide adequate staff to provide supervision to prevent a fall with serious injury. Record review on 5/15/14 indicated that Resident #13 had an unwitnessed fall in the dining room of the Borderland Unit (the locked Dementia Unit) on 5/7/14 at 7:35 A.M. that resulted in a head injury, a Subarachnoid Hematoma. The surveyor requested and received the facility staffing as worked for 5/7/14. According to the 7:00 A.M.-3:00 P.M. staffing schedule the Borderland Unit had one Licensed Practical Nurse (LPN#1) and 2 CNAs scheduled. Resident #13 was admitted ,[DATE]. [DIAGNOSES REDACTED]. Record review on 5/15/14 indicated that the Resident required assistance with all of the activities of daily living. The Resident was an assist with ambulation, and supervised for eating during meals. Included in the physician orders [REDACTED]. Review of the Minimum Data Set for 3/21/14 indicated that the Resident was able to participate in the Brief Interview for Mental Status (BIMS). The Resident's Cognitive Status was determined to be a "4" (severely impaired). Review of the Resident's care plan for "Dementia, Exhibiting Behaviors" indicated: "RT (resident) tries to stand frequently, unsafe to do so without assistance." Review of the Resident's care plan for Falls indicated: "I am at risk for falls secondary to decreased balance, decreased safety awareness and r/t (related to [DIAGNOSES REDACTED], CAD ([MEDICAL CONDITION] and AFIB ([MEDICAL CONDITION])." Approaches included on the "Falls care plan" dated 2/10/14: lift off alarm at all times; assist with ambulation/transfers PRN (as needed); do not leave resident alone in bathroom. Additional approaches included: on 3/27/14 "room move closer to nsg (nursing) station" , and installation of anti-tippers to the wheelchair on 4/5/14. Review of the Behavioral health E&M Review written by the mental health consultant nurse practitioner dated 4/17/14 indicated "Discussed with staff, chart reviewed. Last week several days of significant restlessness , anxiety, multiple attempts to stand, periods of agitation, crying ,... [MEDICATION NAME] increased." Review of the Incident/Accident Report dated 5/7/14 indicated that "Resident was found lying on her right side in the dining room with (his/her) wheelchair behind (him/her). (He/she) sustained a small laceration at the end of (his/her) right eyebrow and a hematoma to right temple. The Incident/Accident Report made no mention of any alarm sounding. Review of the statement written by the Acting DON indicated: "Resident A sustained a fall out of (his/her) wheelchair at 7:35 A.M. while in the dining room waiting for (his/her) breakfast. The Resident received care at 7:00 A.M. The CNAs were giving care to other residents when the fall occurred. The housekeeper was in the dining room when the Resident fell but did not witness the fall..."The investigation revealed that the Resident was transferred by 2 CNAs to the w/c. The alarm in (his/her) chair was properly functioning. The Resident was transferred to the dining room at 7:30 A.M. Fall occurred at 7:35 A.M. Review of the CNA statements dated 5/7/14 indicated that both CNA#1 and CNA#2 were attending another resident who needed assist of two at the time of the incident. Review of the statement taken from the housekeeper who was in the dining room cleaning dated 5/7/14 at 7:30 A.M. indicated " While I was cleaning in the Borderland dining room, CNA #1 brought (resident name) into the dining room. I turned my back to clean the sink and I heard something hit the floor. When I turned around, I saw (resident name) on the floor and I began yelling for help. CNA#2 came out of the first room and called for help." The statement of the housekeeper did not include any mention of an alarm sounding. Review of LPN#1 statement indicated that she was on another unit at the time of the incident and returned to her after hearing the "Daisy Alert" called and according to her statement "I saw (Resident name) lying on (his/her) right side on the floor with the wheelchair behind (him/her). The dycem (cloth used to prevent sliding out of the wheelchair) was on the seat of the wheelchair. She was noted to have a laceration below (his/her) right eyebrow and was bleeding along with a hematoma to right temple. Resident was unable to verbalize what happened or what (he/she) was trying to do. According to the Report, the Resident was sent to the emergency room for evaluation. Review of the emergency room discharge summary dated 5/7/14 indicated the results of the first CT Scan of the head to be "interhemispheric SAH (subarachnoid hematoma)." A second CT Scan taken 6 hours later indicated the bleeding had stopped. During interview with the Acting Director of Nursing (DON) on 5/15/14 at 11:00 A.M. the DON said that the nurse was supposed to supervise the dining room while the CNAs brought residents to the dining room. The nurse administering medications had been called away to another unit for a "Daisy Alert"and therefore was not available to supervise the dining room. In summary, LPN #1 was not on the unit and therefore unavailable to supervise the dining room because she had been called away to another unit for a event on another unit. Neither CNA #1 nor CNA #2 were available to supervise the dining room because they were occupied getting other residents ready to go to the dining room for breakfast. The housekeeper is not a part of the nursing staff and does not provide supervision for residents. 2. For Resident #12, the facility failed to provide adequate staff to provide supervision to prevent a fall with injury. Resident #12 was admitted ,[DATE]. [DIAGNOSES REDACTED]. Record review on 5/15/14 indicated that the Resident had a fall on 11/10/13 at 8:00 A.M. while unsupervised in the Massaboag Unit dining room. The fall resulted in the Resident sustaining a laceration of the left thigh that required transfer to the emergency room where the Resident received 7 sutures to the wound. The surveyor requested and received the facility staffing as worked for 11/10/13. According to the 7:00 A.M.-3:00 P.M. staffing schedule the Massaboag Unit had one Registered Nurse (RN#1) scheduled. One CNA (CNA#3) was scheduled from 6:00 A.M. to 2:00 P.M. and one CNA (CNA#4) was scheduled from 7:00 A.M. to 12:30 P.M. and a third CNA from 12:30-3:00 P.M. Record review on 5/15/14 indicated that the Resident was non ambulatory and required total assistance with all of the activities of daily living. Included in the physician orders [REDACTED]. Review of the Minimum Data Set for 3/21/14 indicated that the Resident was unable to participate in the Brief Interview for Mental Status (BIMS) so a staff assessment was conducted. The Resident's Cognitive Status was determined to be a "3" (severely impaired). According to the facility Fall Scene Investigation Report dated 11/10/13, under fall description details section #1 the time of the event was 8:05 A.M. In section #2 A diagram noted the placement of a "Bradeur Chair" (Broda Chair) alongside a table set for 4 residents. In section #6 the Resident was noted to be "waiting for breakfast in the dining room. Staff was gathering the residents for the meal." "Found on R (right) side." According to the Fall Scene Investigation Report dated 11/10/13, under the contributing factors section #8, the Resident was "confused with dementia-reported baseline". According to the Fall Scene Investigation Report dated 11/10/13, under section #13 "lift off alarm was not working/box replaced". According to the Incident/Accident Report dated 11/10/13 "unwitnessed fall from w/c (wheelchair) found on R side on floor with head toward windowed wall and feet toward exit." According to the Fall Scene Investigation Report dated 11/10/13, under the fall team meeting notes section "Resident in dining room unattended waiting for breakfast. Found on floor from w/c (wheelchair). Resident was not reclined in Broda Chair". The conclusion of the the Fall Scene Investigation Report dated 11/10/13 said "Poor trunk control r/t (related to) Parkinson Disease. Sitting upright in Broda Chair with Dining Room table in front of (him/her) waiting to be fed"when he/she fell out of the Broda chair". According to statements written by CNA #3 and CNA #4 who were working on the unit from 7:00 A.M.-3:00 P.M., CNA #3 was not aware of any falls, and CNA #4 stated that the Resident was in the dining room waiting for breakfast with other residents and that CNA #4 was busy taking care of another resident and did not witness the incident. According to the statement of RN #1, "I heard a resident yelling in the DR (dining room) when I was standing @ (at) the med (medication) cart in the hallway to DR. Upon entering the DR I noticed (name) lying on the floor next to his/her Broda chair." During interview with the Acting DON on 5/15/14 at 11:00 A.M. the DON said that the nurse was supposed to supervise the dining room while the CNAs brought residents to the dining room. The nurse administering medications had the medication (med) cart in the hallway to the dining room and thus could supervise the residents. During interview on 5/15/14 at 3:00 P.M. with RN#1 (the nurse passing medications on the day of the incident), the surveyor asked if the nurse was supposed to be supervising the dining room while the CNAs brought in other residents for breakfast. RN#1 said that the Resident had been placed out of direct line of sight to the right side of the dining room by the CNA. RN #1 told the surveyor that although the med cart was in the hallway to the dining room, it was not positioned to observe the dining room, it was positioned up against the wall to be out of the way. RN#1 said that she was not supervising the dining room. RN#1 said she was pouring medications for administration and administering them to residents. RN#1 said that the med cart was not and does not face the dining room, it is always up against the wall. RN#1 said that she was concentrating on pouring the medications and not looking into the dining room. In summary, RN#1 was involved in pouring medications for Residents prior to breakfast and was engaged in a task that demanded her full attention. Neither CNA #3 nor CNA #4 were able to supervise the residents in the dining room because they were occupied with getting other residents ready to be brought to the dining room for breakfast.

Based on record review, observations and staff interview, the facility failed to provide adequate supervision and effective interventions to prevent falls with injury for 2 Residents (#12 and #13) in a total sample of 15 sampled and 1 non sampled residents. Resident #12 and #13 reside on two different units in a facility with three nursing units. Findings include: 1. For Resident #13, the facility failed to provide adequate supervision to prevent an accident that resulted in a serious injury. Record review on 5/15/14 indicated that Resident #13 had an unwitnessed fall in the dining room of the Borderland Unit (the locked Dementia Unit) on 5/7/14 at 7:35 A.M. that resulted in a Subarachnoid Hematoma head injury. The surveyor requested and received the facility staffing as worked for 5/7/14. According to the 7:00 A.M.-3:00 P.M. staffing schedule the Borderland Unit had one Licensed Practical Nurse (LPN#1) and 2 Certified Nursing Assistants (CNAs) scheduled. Resident #13 was admitted ,[DATE]. [DIAGNOSES REDACTED]. Record review on 5/15/14 indicated that the Resident required assistance with all of the activities of daily living. The Resident was an assist of 2 people with transfer, and supervised for eating during meals. Included in the physician orders [REDACTED]. Review of the Minimum Data Set for 3/21/14 indicated that the Brief Interview for Mental Status (BIMS) determined the Resident's Cognitive Status was a "4" (severely impaired). Review of the Resident's care plan for "Dementia, Exhibiting Behaviors" indicated: "RT (resident) tries to stand frequently, unsafe to do so without assistance." "Restlessness". Review of the Resident's care plan for Falls indicated: "I am at risk for falls secondary to decreased balance, decreased safety awareness and r/t (related to [DIAGNOSES REDACTED], CAD (coronary artery disease and AFIB (atrial fibrillation)." Approaches included on the "Falls care plan" dated 2/10/14: lift off alarm at all times; assist with ambulation/transfers PRN (as needed); do not leave resident alone in bathroom. Review of the "Behavioral Health ...Review" written by the mental health consultant nurse practitioner dated 4/17/14, indicated "Discussed with staff, chart reviewed. Last week several days of significant restlessness , anxiety, multiple attempts to stand, periods of agitation, crying ,... Zoloft increased." Review of the Incident/Accident Report dated 5/7/14 indicated that "Resident was found lying on her right side in the dining room with (his/her) wheelchair behind (him/her). (He/she) sustained a small laceration at the end of (his/her) right eyebrow and a hematoma to right temple. Review of the statement written by the Acting DON indicated: "Resident A sustained a fall out of (his/her) wheelchair at 7:35 A.M. while in the dining room waiting for (his/her) breakfast. The Resident received care at 7:00 A.M. The CNAs were giving care to other residents when the fall occurred. The housekeeper was in the dining room when the Resident fell but did not witness the fall..."The investigation revealed that the Resident was transferred by 2 CNAs to the w/c. According to the investigation the alarm in (his/her) chair was properly functioning. The Resident was transferred to the dining room at 7:30 A.M. Fall occurred at 7:35 A.M. The Incident/Accident Report made no mention of any alarm sounding. Review of the CNA statements dated 5/7/14 indicated that both CNA#1 and CNA#2 were attending another resident who needed assist of two at the time of the incident. Review of the statement taken from the housekeeper who was in the dining room cleaning dated 5/7/14 at 7:30 A.M. indicated " While I was cleaning in the Borderland dining room, CNA #1 brought (resident name) into the dining room. I turned my back to clean the sink and I heard something hit the floor. When I turned around, I saw (resident name) on the floor and I began yelling for help. CNA#2 came out of the first room and called for help." The statement of the housekeeper did not include any mention of an alarm sounding. Review of LPN#1 statement indicated that she was on another unit at the time of the incident and returned to her after hearing the "Daisy Alert" called and according to her statement "I saw (Resident name) lying on (his/her) right side on the floor with the wheelchair behind (him/her). The dycem (cloth used to prevent sliding out of the wheelchair) was on the seat of the wheelchair. She was noted to have a laceration below (his/her) right eyebrow and was bleeding along with a hematoma to right temple. Resident was unable to verbalize what happened or what (he/she) was trying to do. The statement of LPN#1 did not include any mention of an alarm sounding. In written statements dated 5/7/14, both CNA #1 and CNA#2 were engaged in helping other residents at the time of the accident. In LPN#1's written statement dated 5/7/14 she was attending to a resident on another unit at the time of the accident. Review of the staffing list provided by the facility for 5/7/14 for the 7:00 A.M. shift indicated that LPN #1, CNA #1 and CNA #2 were the only staff scheduled to work on that unit. As both CNA #1 and CNA #2 were occupied with other residents and LPN #1 was assisting on another unit, there was no nursing staff available to supervise the Resident in the dining room at the time the Resident fell out of the wheelchair. According to the Report, the Resident was sent to the emergency room for evaluation. Review of the emergency room discharge summary dated 5/7/14 indicated the results of the first CT Scan of the head to be "interhemispheric SAH (subarachnoid hematoma)." A second CT Scan taken 6 hours later indicated the bleeding had stopped. During interview with the Acting Director of Nursing (DON) on 5/15/14 at 11:00 A.M. the DON said that LPN#1 was supposed to supervise the dining room while the CNAs brought residents to the dining room. LPN#1 had been called away to another unit for a "Daisy Alert"and therefore was not available to supervise the dining room and the CNAs were helping another resident. 2. For Resident #12, the facility failed to provide adequate supervision to prevent an accident resulting in an injury. Resident #12 was admitted ,[DATE]. [DIAGNOSES REDACTED]. The Resident resided on the Massaboag Unit. The surveyor requested and received the facility staffing as worked for 11/10/13. According to the 7:00 A.M.-3:00 P.M. staffing schedule the Massaboag Unit had one Registered Nurse (RN#1) scheduled. One CNA (CNA#3) was scheduled from 6:00 A.M. to 2:00 P.M. and one CNA (CNA#4) was scheduled from 7:00 A.M. to 12:30 P.M. and a third CNA from 12:30-3:00 P.M. Record review on 5/15/14 indicated that the Resident was non ambulatory and required total assistance with all of the activities of daily living. Included in the physician orders [REDACTED]. Review of the Minimum Data Set for 3/21/14 indicated that the Resident was unable to participate in the Brief Interview for Mental Status (BIMS) so a staff assessment was conducted. The Resident's Cognitive Status was determined to be a "3" (severely impaired). Record review indicated that on 11/10/13 at 8:00 A.M. the Resident had a fall while unsupervised in the Massaboag Unit dining room. The fall resulted in the Resident sustaining a laceration of the left thigh that required transfer to the emergency room where the Resident received 7 sutures to the wound. According to the facility Fall Scene Investigation Report dated 11/10/13, under fall description details section #1 the time of the event was 8:05 A.M. In section #2, a diagram noted the placement of a "Bradeur Chair" (Broda Chair) alongside a table set for 4 residents. In section #6, the Resident was noted to be "waiting for breakfast in the dining room. Staff was gathering the residents for the meal." "Found on R (right) side." According to the Fall Scene Investigation Report dated 11/10/13, under the contributing factors section #8, the Resident was "confused with dementia-reported baseline". According to the Fall Scene Investigation Report dated 11/10/13, under section #13, "lift off alarm was not working/box replaced". According to the Fall Scene Investigation Report dated 11/10/13, under the fall team meeting notes section, "Resident in dining room unattended waiting for breakfast. Found on floor from w/c (wheelchair). Resident was not reclined in Broda Chair". The conclusion of the the Fall Scene Investigation Report dated 11/10/13 said "Poor trunk control r/t (related to) Parkinson Disease. Sitting upright in Broda Chair with Dining Room table in front of (him/her) waiting to be fed" when he/she fell out of the Broda chair". According to statements written by CNA #3 and CNA #4 who were working on the unit from 7:00 A.M.-3:00 P.M., CNA #3 was not aware of any falls, and CNA #4 stated that the Resident was in the dining room waiting for breakfast with other residents and that CNA #4 was busy taking care of another resident and did not witness the incident. According to the statement of RN #1, "I heard a resident yelling in the DR (dining room) when I was standing @ (at) the med (medication) cart in the hallway to DR. Upon entering the DR I noticed (name) lying on the floor next to his/her Broda chair." During interview with the Acting DON on 5/15/14 at 11:00 A.M. the DON said that the nurse was supposed to supervise the dining room while the CNAs brought residents to the dining room. The nurse administering medications had the medication cart in the hallway to the dining room and thus could supervise the residents. During interview on 5/15/14 at 3:00 P.M. with RN#1 (the nurse passing medications on the day of the incident), the surveyor asked if the nurse was supposed to be supervising the dining room while the CNAs brought in other residents for breakfast. RN#1 said that the med cart was in the hallway to the dining room to be out of the way. RN#1 said that she was not supervising the dining room, she was pouring medications for administration and administering them to residents. RN#1 said that the med cart was not and does not face the dining room, it is always up against the wall. RN#1 said that she was concentrating on pouring the medications and not looking into the dining room. Please see F353