Every finding on record at Hampden Post Acute

Based on observations, interviews, and records reviewed, the facility failed to adhere to infection control standards of practice to prevent contamination and the potential spread of infections on two units (Unit B1 and Unit A2) out of three units and five Residents (#60, #121, #122, #15, and #5) out of a total sample of 24 residents. Specifically, the facility failed to ensure:On Unit B1, that facility staff adhered to the appropriate Personal Protective Equipment (PPE) protocols for removal of PPE for two Residents (#60 and #121) who were on Transmission-Based Precautions (TBP) for COVID/Influenza infections.On Unit A2, that facility staff:-adhered to the appropriate PPE protocols for three Residents (#122, #15, and #5) when posted signage indicated Droplet Precautions.-ensured the correct signage was posted for Resident #122 and Resident #5, who were also on Contact Precautions, in addition to Droplet Precautions.-performed hand hygiene as required, to prevent contamination and the potential spread of infection. Findings include:Review of the facility's policy titled Isolation - Categories of Transmission - Based Precautions [TBP], revised September 2022, indicated but was not limited to the following: Policy statement: Transmission-Based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk for transmitting the infection to other residents. Policy interpretation and implementation: >Transmission-Based Precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-Based Precautions are Contact, Droplet and Airborne. >When a resident is placed on Transmission-Based Precautions, appropriate notification is placed on the room entrance door.so that personnel and visitors are aware of the need for and the type of precaution.The signage informs the staff of the type of CDC precautions(s), instructions for use of PPE. -Contact Precautions: >Staff and visitors wear gloves when entering the room.Gloves are removed and hand hygiene performed before leaving the room. >Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room. -Droplet Precautions: >Masks are worn when entering the room, >Gloves, gown and goggles are worn if there is risk of spraying respiratory secretions. Review of the facility's policy titled Handwashing/Hand Hygiene, revised October 2023, indicated but was not limited to the following: -Policy statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. -Policy interpretations and implementation: >All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. -Indications for Hand Hygiene: >.Immediately before touching a resident, >.After touching a resident, > After touching the resident's environment, >.Immediately after glove removal. -Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. Review of the facility's policy titled Infection Prevention and Control Program, dated December 2023, indicated but was not limited to the following: -Policy statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitor, and other individuals providing services under a contractual arrangement. -Prevention of infection: Important facets of infection prevention include: > .instituting measures to avoid complications or dissemination, >educating staff and ensuring that they adhere to proper techniques and procedures.>implementing appropriate.Transmission-Based Precautions when necessary; and >following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). 1a. Resident #60 was admitted to the facility in September 2025. On 1/16/26 at 9:38 A.M., the surveyor observed that Resident #60's room on Unit B1 had a Droplet Precaution sign posted at the doorway. The surveyor observed Social Worker (SW) #1 remove her gloves, gown and face shield upon exiting Resident #60's room but did not remove her N95 mask. During an interview at the time, SW #1 said she did not remove her N95 mask but should have. SW #1 said the importance of removing all PPE when exiting a room requiring TBP's was to stop the spread of infection. 1b. Resident #121 was admitted to the facility in December 2025. Review of Resident #121's Order Summary Report with active orders as of 1/20/26, indicated: Droplet/Contact Precautions every shift for COVID/Flu, start date 1/13/26 On 1/20/26 at 9:01 A.M., the surveyor observed an Isolation Precaution sign posted at the doorway of Resident #121's room on Unit B1. The surveyor observed the Laboratory Technician remove her gloves, gown and face shield upon exiting Resident #121's room but did not remove her N95 mask. During an interview at the time, the Laboratory Technician said she usually leaves the N95 mask on after exiting residents' rooms who were on TBP. 2a. Resident #122 was admitted to the facility in February 2022. Review of the January 2026 Physician's Orders indicated: -Droplet/Contact Precautions related to Respiratory Syncytial Virus (RSV), every shift, start date 1/18/26 On 1/20/26 at 8:19 A.M., the surveyor observed the following relative to Resident #122's room on Unit A2: -Droplet Precaution signage posted which indicated: *everyone to cleanse hands including before entering and when leaving the room, *make sure eyes, nose and mouth are fully covered before room entry, *and remove face protection before room exit. -A PPE bin across from the Resident's room contained masks, eye protection and gloves. -CNA #3 entered Resident #122's room with a surgical mask in place and put on (donned) gloves. CNA #3 did not don eye protection or a gown. -Resident #122 was seated in a wheelchair inside of the room, was not wearing a mask, and was observed occasionally coughing. -CNA #3 assisted Resident #122 with getting dressed, and then removed and discarded her gloves and mask, removed the Resident's breakfast tray from the room and walked down the hallway. 2b. Resident #5 was admitted to the facility in April 2025, and Resident #15 was admitted to the facility in January 2024. Both Resident #5 and Resident #15 resided in the same room on Unit A2. Review of Resident #15's January 2026 Physician's Orders indicated: -Tamiflu 75 milligrams for prophylaxis for 10 days, initiated 1/18/26. Review of Resident #5's January 2026 Physician's Orders indicated: -Tamiflu 75 milligrams for prophylaxis for 10 days, initiated 1/18/26. -Respiratory Panel for cough and congestion, ordered 1/19/26. -Droplet/Contact Precautions for Upper Respiratory symptoms every shift, initiated 1/20/26. On 1/20/26 at 8:08 A.M., the surveyor observed the following Resident #15 and Resident #5's room: -Droplet Precaution signage posted outside of Resident #15 and Resident #5's room indicated for everyone to cleanse hands including before entering and when leaving the room, and to make sure eyes, nose and mouth are fully covered before room entry, and to remove face protection before room exit. -A PPE bin was observed near the Residents' room and contained masks, eye protection and gloves. -CNA #4 entered the room with only a surgical mask in place and exited the room a short time after. CNA #4 did not have gloves, eye protection or a gown and did not remove her mask and perform hand hygiene upon exiting the room. CNA #4 returned to the room with CNA #3 a few minutes later. Both CNA #3 and CNA #4 were observed entering the Resident's room with only surgical masks and gloves on and repositioned Resident #5 in his/her bed. CNA #4 was observed to remove her gloves, perform hand hygiene upon exiting the room but did not remove the surgical mask and was observed going to the Unit dining room. On 1/20/26 at 8:37 A.M., the surveyor observed CNA #3 entering Resident #5 and #15's room with a surgical mask and gloves on and did not don eye protection or a gown. CNA #3 sat in a chair at the bedside and assisted Resident #15 with his/her breakfast meal. Resident #5, who was also in the room and was in the adjacent bed was observed intermittently coughing. During an interview on 1/20/26 at 8:44 A.M., CNA #4 said Resident #5 was put on precautions the previous day (1/19/26) because the Resident became sick. CNA #4 said prior to entering Resident #5's room, staff should put on a mask, gloves and eye protection. CNA #4 said she did not put on eye protection when she entered Resident #5's room and should have. CNA #4 said she did not remove her surgical mask upon exiting the room and should have according to the posted signage outside of the Resident's room. During an interview on 1/20/26 at 8:49 A.M., CNA #3 said she should have put on eye protection when she entered Resident #5 and #15's room according to the signage posted outside of the room but she did not. On 1/20/26 at 8:53 A.M., the surveyor observed CNA #2 entering Resident #5 and #15's room with only a surgical mask in place. Resident #5 was observed coughing. CNA #2 assisted in raising the head of Resident #5's bed, conversed with him/her at bedside, collected the Resident's breakfast tray and exited the room without removing her surgical mask and performing hand hygiene. During an interview on 1/20/26 at 8:55 A.M., CNA #2 said the Droplet Precaution signage outside of the Resident #5 and #15's room was for Resident #15 because he/she was sick and was not aware of any concerns with Resident #5. Upon reviewing the Droplet Precautions signage with the surveyor, CNA #2 said she would need to put on a gown, gloves, and eye protection when working with Resident #15, but would not need to do that for Resident #5. During a follow-up interview on 1/20/26 at 9:00 A.M., CNA #2 said she spoke with the Assistant Director of Nurses (ADON) who said she should have put all of the PPE on according to the signage posted prior to entering the Resident # 5 and #15's room and should have removed all of the PPE, including the surgical mask, upon exiting the room and performed hand hygiene. On 1/20/26 at 9:56 A.M., Laundry Staff #1 was observed to enter Resident #5 and #15's room with a gown, gloves and surgical mask in place, she did not have on eye protection. Laundry Staff #1 walked past Resident #5, who was observed lying in bed, and put clean laundry in Resident #15's closet. Upon exiting the room, Laundry Staff #1 was observed to remove the gown, gloves and mask and put on a new surgical mask without performing hand hygiene. During an interview on 1/20/26 at 9:59 A.M., Laundry Staff #1 said she put on a gown, gloves and surgical mask to deliver laundry in Resident #15's room. Laundry Staff #1 said she did not put on eye protection prior to entering the Residents' room because she was only dropping off laundry and was not aware that she needed to. Laundry Staff #1 said she did not perform hand hygiene after removing the PPE and prior to putting on a new surgical mask. Laundry Staff #1 said it was important to follow the signage because of spreading infections. During a follow-up interview on 1/20/26 at 10:04 A.M., Laundry Staff #1 said she spoke with the Nurse who said she needed to also put on eye protection when entering a Droplet Precaution room and perform hand hygiene after removing/putting on PPE. During an interview on 1/20/26 at 4:05 P.M., Unit Manager (UM) #1 said several residents on the A2 Unit were being treated for Influenza A and RSV. UM #1 said Resident #122 was positive for RSV and Resident #5 had respiratory symptoms on 1/19/26 and was put on Droplet Precautions pending respiratory panel results. During an interview on 1/21/26 at 11:38 A.M., with the Infection Preventionist (IP) and the Regional Director of Clinical Services, the IP said the facility adheres to the CDC guidance on infections and PPE use. The IP said when a resident becomes symptomatic of an infection, the Nurses would assess the resident's symptoms, notify the provider and depending on the symptoms, initiate precautions pending any pending laboratory tests. The IP said Resident #122 was on Droplet/Contact precautions for RSV infection. The IP said Resident #5 was put on Droplet/Contact Precautions pending a respiratory panel and because he/she continued to have respiratory symptoms, so they remained in place. The IP said Resident #5 should be on Droplet and Contact Precautions and that all staff prior to entering the Resident's room should put on a mask, eye protection, gown and gloves. The IP said Contact Precaution signage should also have been posted outside of Resident #122 and Resident #5 and #15's room in addition to the Droplet Precautions signage but was not. The IP said upon exiting the room, all PPE should be discarded, including the surgical mask and hand hygiene preformed prior to donning another mask. The IP said it would be important for staff to don the appropriate PPE and doff PPE correctly and perform hand hygiene to prevent the spread of infectious diseases.

Based on record review, and interview, the facility failed to provide care and services that met professional standards of quality related to implementing Physician orders for medications and conducting assessments for one Resident's (#1) closed record out of three total closed resident records reviewed. Specifically, for Resident #1, the facility failed to ensure that:-Nurse #2 administered Physician ordered medications and completed vital signs and pain assessments as ordered when Nurse #2 held (not administered and not completed) Resident #1's medications and assessments on two shifts for two days with the Resident's consent not signed documented as the reason for holding care and services. -Nurse #2 reviewed and implemented Resident #1's admission agreement that included consent to admission and treatment, placing the Resident at risk for medical complications. Findings include:Review of the facility's Admissions Policy, dated 2001 and revised December 2006, indicated the following:-The primary purpose of the Policy was to establish uniform guidelines for personnel to follow in admitting residents to the facility.-Objectives of the Admissions Policy included: -To admit residents who can be adequately cared for by the facility. -To review with the resident, and/or his/her representative, the facility's policies and procedures relating to . resident care . Review of the facility's Medication Administration Policy, dated 2001 and revised April 2019, indicated the following:-Medications are administered in a safe and timely manner, as prescribed.-Medications are administered in accordance with prescriber orders, including a required time frame. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated the following:-The Resident had been admitted to the hospital with diagnoses of Pneumonia and Acute Hypoxic Respiratory Failure.-The Resident was being treated with an antibiotic medication, twice a day, for Pneumonia.-The Resident's last day of antibiotic treatment for Pneumonia was scheduled to be 9/21/25. -The Resident's discharge disposition was: Skilled Nursing Facility/Rehab. Resident #1 was admitted to the facility in September 2025 with diagnoses including Pneumonia, Acute Respiratory Failure with Hypoxia, Acute Pyelonephritis (infection of the kidney) Type 2 Diabetes Mellitus, and Glaucoma. Review of Resident #1's September 2025 signed admission Agreement indicated the following:-The admission Agreement was signed by the Resident and the facility's Admission's Director.-The admission Agreement was effective on the date the Resident was admitted to the facility.-The Resident designated an Attending Physician.-The Resident consented to admission and treatment.-Consent to admission and treatment included but was not limited to: -admission to the facility. -While in the facility to be under the care and treatment of an attending physician. - Consent to medically necessary routine nursing and other services . Review of Resident #1's Nursing Health Status Note, dated 9/21/25 and written by Nurse #2 at 11:17 A.M., indicated: Resident's consents are not signed .unable to give medications this A.M. until consent to treat is signed. Review of Resident #1's Nursing Health Status Note, dated 9/21/25 and written by Nurse #2 at 1:08 P.M., indicated: Resident's consents are not signed, unable to give medication. Review of Resident #1's Medication Administration Note, dated 9/23/25 and written by Nurse #2 at 2:19 P.M., indicated: Consents are not signed, this Nurse did not give medications this shift. Review of Resident #1's September 2025 Medication Administration Record (MAR) indicated ordered medications were held and assessments not completed for the Resident as follows:-Amlodipine Besylate five milligram (mg) Oral Tablet, ordered for Hypertension (high blood pressure), scheduled for 9:00 A.M.: held on 9/21/25 and 9/23/25.-Ferrous Sulfate 325 mg Tablet ordered for supplementation and scheduled for 8:00 A.M.: held on 9/21/25 and 9/23/25.-Docusate Sodium 100 mg Oral Tablet ordered for constipation and scheduled for 9:00 A.M.: held on 9/21/25.-Senna-S Oral Tablet 8.6-50 mg (Sennosides-Docusate Sodium) ordered for constipation and scheduled for 9:00 A.M.: held on 9/21/25 and 9/23/25.-Amoxicillin-Pot Clavulanate (antibiotic medication) Oral Tablet 875-125 mg ordered for Pneumonia and scheduled for 9:00 A.M.: held on 9/21/25.-Brimonidine Tartrate Ophthalmic Solution 0.2% ordered for Glaucoma and scheduled for 9:00 A.M.: held on 9/21/25 and 9/23/25.-Dorzolamide HCl Ophthalmic Solution 2% ordered for Glaucoma and scheduled for 9:00 A.M.: held on 9/21/25 and 9/23/25.-Timolol Maleate Ophthalmic Solution 0.5% ordered for Glaucoma and scheduled for 9:00 A.M.: held on 9/21/25 and 9/23/25.-Humalog Injection Solution (Insulin) 100 Unit/Milliliter (mL) per sliding scale subcutaneously before meals ordered for blood sugars scheduled for 11:30 A.M.: not completed on 9/21/25 and 9/23/25.-May wean off of O2 (oxygen) to RA (room air) as tolerated every shift related to Pneumonia scheduled for the day shift: not completed on 9/21/25 and 9/23/25.-Monitor Resident for pain every shift for pain management, scheduled for the day shift: not completed on 9/21/25 and 9/23/25.-Vital signs (blood pressure, temperature, pulse, respirations, O2 sats) every shift for seven days after admission, scheduled for the day shift: not completed on 9/21/25 and 9/23/25.-Tubersol Solution (used for Tuberculosis [TB] testing) 5 Unit/0.1 mL one time only between 6:00 A.M. on 9/21/25 through 6:00 A.M.: not completed on 9/23/25. During an interview on 1/23/26 at 12:56 P.M., the Admissions Director said she completed the admission Agreement with Resident #1 when the Resident was admitted to the facility which included a consent for treatment. During an interview on 1/23/26 at 1:33 P.M. Nurse #2 said that she was unable to remember anything about Resident #1. During an interview on 1/23/26 at 3:40 P.M., the Regional Director of Clinical Services said Resident #1 would not have been admitted to the facility without an agreement to be transferred to the facility from the hospital. The Regional Director of Clinical Services said that the Resident should have been provided with ordered interventions. During an interview on 1/23/26 at 3:40 P.M., the Physician said whether or not consent for treatment had been obtained by the facility when Resident #1 was admitted , the Resident and/or his/her Representative agreed for the Resident to be admitted to the facility following his/her hospitalization with a treatment plan in place. The Physician said the facility should have provided all ordered interventions while the Resident was in the facility and not held any ordered interventions.

Based on observations, interviews, and records reviewed, the facility failed to maintain a medication administration error rate of less than five percent (%) when three medication errors were made out a total of 41 opportunities, resulting in a medication error rate of 7.32%. Specifically, for Resident #121, Nurse #4 failed to:1. ensure the correct medication dose was administered to the Resident, when Calcium 600 mg/ Vitamin D 200 units was ordered by the Physician and Calcium 600 milligrams (mg)/ Vitamin D [10 micrograms (mcg) = 400 units] was administered.2. ensure that the correct medication dose was administered when Vitamin B12 100 mcg was ordered by the Physician and Vitamin B12 500 mcg was administered.3. ensure that the correct medication solution was administered when Cefazolin 2 gm in Sodium Chloride 0.9 gm per 100 milliliters (ml) intravenous (IV) solution was ordered by the Physician and Cefazolin (antibiotic) 2 grams (gm) in Dextrose 100 ml IV solution was administered. Findings include:Review of the facility policy titled Administering Medications, revised April 2019, indicated but was not limited to:-Policy statement: Medications are administered in a safe and timely manner, and as prescribed.-Policy interpretation and implementation:>Medications are administered in accordance with prescriber orders.>The individual administering medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #121 was admitted to the facility in December 2025 with diagnoses including infection of left hip prosthesis. Review of Resident #121's Order Summary Report with active orders 1/21/26, indicated but was not limited to the following:-Calcium -Vitamin D tablet 600 - 200 mg - units. Give one tablet by mouth one time a day for supplementation. Start date 12/17/25-Vitamin B12 oral tablet 100 mcg. Give one tablet by mouth one time a day for supplement. Start date 12/17/25-Cefazolin in Sodium Chloride Intravenous Solution 2 - 0.9 gm/100 ml - %. Use two grams intravenously every eight hours for IV antibiotic until 1/24/26. Start date 1/11/26 On 1/21/26 at 8:57 A.M., during a medication administration pass, the surveyor observed Nurse #4 administer the following medications to Resident #121:-One tablet of Calcium 600 mg plus Vitamin D 10 mcg (400 units) orally.-One tablet of Vitamin B12 500 mcg orally.-Cefazolin 2 gm in Dextrose 100 ml intravenously. Review of Resident #121's January 2026 Medication Administration Record (MAR), indicated Nurse #4 electronically signed off that she had administered the following:-Calcium-Vitamin D 600-200 mg-units, one tablet by mouth at 8:00 A.M. on 1/21/26.-Vitamin B12 100 mcg, one tablet by mouth at 8:00 A.M. on 1/21/26.-Cefazolin in Sodium Chloride 2-0.9 gm/100 ml-% 2 gm intravenously at 8:00 A.M. on 1/21/26. During an interview on 1/21/26 at 12:38 P.M., Nurse #4 said Resident #121 was ordered to receive Calcium 600 mg plus Vitamin D 200 units. Nurse #4 said she had administered the wrong dose (400 units) of Vitamin D. Nurse #4 said that Resident #121 was ordered to receive Vitamin B12 100 mcg (not the 500 mcg administered). Nurse #4 said that Resident #121 was ordered to receive Cefazolin in Sodium Chloride solution, but Cefazolin in Dextrose solution was administered. Nurse #4 said there was a concern when medications were not administered per the Physician's orders. Nurse #4 said there could be interactions with other medications when medications were not administered as ordered by the Physician. During an interview on 1/21/26 at 1:58 P.M., Resident #121's Physician said the expectation was that medications were administered as ordered by the Physician. During an interview on 1/21/26 at 2:10 P.M., the Director of Nursing (DON) said the expectation was that Nurses performed the six [sic] rights of medication administration prior to administering a medication. The DON said that there was a concern when medications were not administered as ordered by the Physician.

Based on observations, interviews, and records reviewed, the facility failed to ensure that one Resident (#69) of one applicable resident reviewed for dental services, out of a total sample of 24 residents, received routine dental services. Specifically for Resident #69, the facility failed to ensure that routine dental services were provided when dental consent for treatment was obtained and requested by the Resident and Resident Representative (RR) in June 2023, resulting in the Resident experiencing dental pain and discomfort. Findings include: Review of the facility policy titled Dental Service, dated December 2016, indicated routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessments and plan of care. The policy also included the following: -routine and 24-hour emergency dental services are provided to our residents through: >a contract agreement with a licensed dentist that comes to the facility monthly >a referral to the resident's personal dentist >referral to community dentists>referral to other health care organizations that provide dental services -Medicare and Medicaid residents will be billed for routine and emergency dental services -all dental services provided are recorded in the resident's medical record Resident #69 was admitted to the facility in June 2023 with diagnoses including dementia and anxiety. Review of the Minimum Data Set (MDS) Assessment, dated 11/6/25 indicated Resident #69: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points -sometimes understands and sometimes understood -was dependent on staff with oral hygiene -had no dental issues -was not on a modified consistency diet. During an interview on 1/16/26 at 10:10 A.M., Resident #69 said his/her teeth hurt. The surveyor was unable to visualize the Resident's teeth during the interview. When the surveyor asked how long his/her teeth has been hurting, the Resident was unable to provide a timeline. Review of the Resident's clinical record included the following: -Physician Orders that indicated the Resident's Health Care Proxy (HCP: an elected representative designated to make health care decisions when a person was no longer able to do so) was invoked on 6/13/23. -A Dental Consent Form, signed by Resident #69's HCP on 6/30/23, which indicated he/she would like to have the facility's dental office provide dental care for the Resident. -January 2026 Physician's Orders which included dental consults ., initiated 3/3/25. Further review of the Resident #69's clinical record failed to indicate evidence of routine dental care being provided since the consent for dental services had been signed on 6/30/23. During an interview on 1/20/26 at 3:59 P.M., Unit Manager (UM) #1 said she reviewed Resident #69's clinical record and was unable to find evidence that the Resident had been evaluated by the Dentist in the last six months. UM #1 said she contacted the facility's Dental Provider to request any information on whether the Resident had been seen. On 1/21/26 at 2:53 P.M., the surveyor observed Resident #69 dressed and seated in a wheelchair in his/her room. During an interview at the time, the surveyor asked the Resident how he/she was doing today and the Resident said his/her teeth hurt, he/she would like to see the Dentist but hasn't been seen. The Resident pointed to teeth on the upper right side of his/her mouth and said he/she told a facility staff a few weeks ago about his/her request to see the Dentist. Resident #69 also said he/she was having difficulty swallowing sometimes. The surveyor notified the Assistant Director of Nurses (ADON) and the floor Nurse of the Resident's complaints of dental pain. Review of the Health Status Note, dated 1/21/26, written by the Assistant Director of Nurses (ADON) indicated the following: -Resident #69 reported tooth pain of seven out of ten to his/her upper right side of jaw [sic]. -Assessment revealed two broken teeth, no redness or swelling noted. -Resident was afebrile (without elevated temperature). -Tylenol (pain reliever) was administered with good effect and improvement in pain. -Diet was downgraded to mechanical soft and Speech Language Pathologist (SLP) evaluation requested . During an interview on 1/21/26 at 3:14 P.M., with the ADON, who was covering the unit for UM #1, said she spoke with Resident #69 who complained of right upper/back dental pain. The ADON said pain medication was administered, and a request was put in for the Dentist to see Resident #69. The ADON said she was unable to find evidence that Resident #69 had received dental care, but the facility had reached out to request additional information from the Dentist. During an interview on 1/21/26 at 4:44 P.M., Resident #69's HCP said he/she had signed paperwork consenting to dental services previously and to his/her knowledge Resident #69 had never been evaluated by the Dentist. The Resident's HCP said the Resident had requested dental services numerous times due to dental discomfort and difficulty with chewing, and that facility staff had been notified of this request, but the HCP could not recall when this occurred. The Resident's HCP said the facility contacted him/her today and informed him/her that the Resident would be evaluated by the Dentist this week. Review of the Health Status Note dated 1/22/26 included the following: -Resident #69 was seen today for complaints of tooth pain and was evaluated by the Dental Provider. -Resident is scheduled to have teeth #7/ #10/ #11 extracted on 1/29/26 . During an interview on 1/23/26 at 1:17 P.M., the Regional Director of Clinical Services said there was no indication Resident #69 was seen by the Dental Provider since consent was signed in June 2023. During an interview on 1/23/26 at 1:56 P.M., the Director of Nursing (DON) said the facility's current Dental Provider had not changed when dental consent was obtained for Resident #69 in June 2023. The DON said had the facility been aware of the Resident's dental discomfort, they would have referred him/her to the Dentist. The DON said there was no record that routine dental care had been provided to Resident #69 after dental consent had been obtained in 2023.

Based on observations, and interviews, the facility failed to post nursing staff data daily, at the beginning of each shift, relative to licensed and unlicensed nursing staff directly responsible for resident care per shift as required. Specifically, the facility failed to post nursing staff data that included the actual hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse's Aides (CNAs). Findings include:Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, revised August 2022 indicated the following in part:-The facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. -Daily, the number of licensed nurses (Registered Nurses, Licensed Practical Nurses and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (Certified Nurses' Aides and Nurses' Aides) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. On 1/20/26 the surveyor failed to observe that the nursing staff data was available for review in a prominent location in the facility. On 1/21/26 at 9:57 A.M., the surveyor failed to observe the nursing staff data posted and available for review in a prominent location in the facility. During an interview at the time, the facility Receptionist said the information was not kept in the lobby area, however, a full schedule of the nursing staff was kept by the employee time clock, that was not in a public area. During an interview on 1/21/26 at 10:00 A.M., the Scheduler said she was not sure who was responsible for posting the nursing staff data. The Scheduler said she believed the posting was in the front lobby but was not sure. During an interview on 1/21/26 at 10:01 A.M. the Director of Nursing (DON) said she believed the nursing staff data was in the lobby in the enclosed bulletin board. The surveyor and the DON observed the enclosed bulletin board located in the lobby and did not find the nursing staff data posted. The DON said there should be something posted that included the number of hours for nursing staff in the building for that day, but that information was not posted as required.

Based on observation, record and policy review, and interview, the facility failed to ensure an environment that was free from accidental hazards for one Resident (#16), out of a total sample of 20 residents. Specifically, the facility failed to provide a smoking apron for use during smoking activities for Resident #16 when the safety intervention was indicated in the Resident's comprehensive smoking assessment and care plans to ensure the Resident's safety related to smoking. Findings include: Review of the facility's policy titled Smoking Policy and Procedure - Smoking Facility, undated, indicated but was not limited to the following: -Licensed staff will conduct a smoking assessment upon admission prior to being allowed to participate in smoking times or with an observed change in the ability of the resident to smoke safely. -the use of appropriate safety precautions such as smoking aprons, fire retardant blankets, etc., will be determined based on this assessment. -these assessments are typically conducted on admission/readmission and at least quarterly thereafter. Resident #16 was admitted to the facility in April 2024, with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease that causes obstructed airflow from the lungs and difficulty breathing). Review of Resident #16's most recent Minimum Data Set assessment (MDS), dated [DATE], indicated that the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15. Review of Resident #16's care plan for smoking dated 4/25/24, indicated: -supervise with smoking -to wear smoking apron as indicated Review of Resident #16's Smoking Evaluation dated 5/8/24, indicated the following recommendations: -supervision while smoking -smoking apron During an observation on 9/9/24 at 10:41 A.M., the surveyor observed Resident #16 sitting outside smoking a cigarette on the patio with supervision. The surveyor observed that the Resident was not wearing a smoking apron. During an interview of 9/9/24 at 10:41 A.M., Additional Staff #1 (smoking supervisor) said that there were no residents smoking outside at this time who required any specialized equipment while smoking. During an interview on 9/10/24 at 8:38 A.M., Unit Manager (UM) #1 said that the nursing staff completed the smoking evaluations. UM #1 also said that the recommendations documented on the smoking evaluations should be implemented while the Resident is outside smoking. During an observation on 9/10/24 at 10:04 A.M., the surveyor observed Resident #16 sitting outside smoking a cigarette on the patio with supervision. The Resident was not observed to be wearing a smoking apron. During an interview on 9/10/24 at 10:31 A.M., Resident #16 said that he/she used to wear a smoking apron and has not used one when smoking in three to four weeks. During an interview on 9/10/24 at 10:35 A.M., Additional Staff #1 said that he had been a smoking monitor in the facility for a while. Additional Staff #1 also said that he had never seen Resident #16 use a smoking apron nor had he ever put a smoking apron on Resident #16. During an interview on 9/10/24 at 1:12 P.M., UM #1 said Resident #16 should have been using a smoking apron while smoking cigarettes outside and he had not been.

Based on interview, record and policy review, the facility failed to accurately execute Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) for one Resident (#73) out of a total sample of 20 residents. Specifically, for Resident #73, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #73's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself). Findings include: Resident #73 was admitted to the facility in May 2021, with diagnoses including Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) and Hemiplegia (paralysis of one side of the body). Review of the facility policy for Advance Directives, last revised May 2022, indicated: -prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative about the existence of any written advanced directives. -if the resident or resident representative refuses treatment, the facility and care providers will determine the decision-making capacity of the resident and invoke the decisions of the legal representative if appropriate to the situation. Review of Resident #73's clinical record revealed: -a MOLST form signed on 12/23/21 by Resident #73's HCP -a HCP activation form dated 3/3/22, after the MOLST form had been signed by the HCP Review of Resident #73's care plans last revised 5/20/24, indicated: -invoked HCP, date 3/22/22 -honor my MOLST form -ensure there is Physician's order in my medical record to verify and honor my health care proxy's wishes Review of Resident #73's September 2024 Physician's orders indicated an order to invoke the HCP on 3/3/22. During an interview on 9/11/24 at 1:53 P.M., Social Worker (SW) #1 said that the MOLST form was not valid as it had been signed by the HCP before the Resident had been deemed incapacitated by his/her Physician.

Based on observation, interview, record and policy review, the facility failed to implement a resident-centered, meaningful, and engaging activity program for one Resident (#72) out of a total sample of 20 residents. Specifically, the facility failed to ensure that staff offered and encouraged engagement in activities identified as being preferences for Resident #72. Findings include: Review of the facility policy titled Activities and Social Services, dated 2001 revised 2024, indicated that: -the facility will provide, based on the comprehensive assessment and care plan and the preferences of each resident, -an ongoing program to support residents in their choice of activities, -both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Resident #72 was admitted to the facility in May 2022, with diagnoses including Dementia (a general decline in cognitive abilities that affects a person's ability to perform everyday activities), Mood Disturbance (a disconnect between actual life circumstances and the person's state of mind), and Behavioral Disturbance (when a person behaves in a manner that may put themselves or others at risk). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident: -was severely cognitively impaired -experienced no hallucinations or delusions during the observation period -had physical and verbal behaviors noted 1-3 days of the observation period with no impact noted on the Resident or others -had an overall improved behavioral status -family felt it was very important to participate in religious services -family felt it was somewhat important to go outside, do things with groups of people, keep up with the news, be around pets, listen to music, and to do favorite activities Review of the Resident's Activity Evaluation dated 6/4/24 indicated that the Resident: -enjoyed watching Television (TV) and listening to music -was interested in playing Dominoes, sports, and fishing -enjoyed visiting with his family -required assistance getting to the activities Review of Resident #72's Activity Care Plan revised 6/4/24, indicated interventions of: -assist to and from activities of interest -involve in activities that are not dependent on spoken communication .Rosary, Catholic service -offer to take (the Resident) outside for fresh air since this is of interest. Review of the Resident's Behavioral Logs for July 2024, August 2024, and through September 8th, 2024 indicated that the Resident had one day of verbally aggressive behavior on 8/7/24 that improved with staff intervention. There was no other verbal or physical behaviors recorded by staff during that period. Review of the Resident's Activity Attendance Log indicated the following: -July 2024: indicated on 7/1/24 and 7/2/24 an activity calendar was provided to the Resident. -August 2024: the Resident attended Balloon exercising on 8/7/24. -September 2024: the Resident had a 1:1 visit from staff in their room on 9/2/24, and was escorted to the Hallway on 9/4/24. No other activities were recorded for the Resident in the monthly logs. On 9/9/24 at 8:53 A.M., the surveyor observed the Resident lying in bed with his/her eyes open looking up at the ceiling. The surveyor observed an activities calendar on the wall on the other side of the room from the Resident. The surveyor observed that the television was off, and there were no pictures, no music player, no signs of any activities in the Resident's room. On 9/9/24 at 4:20 P.M., the Resident was seen sitting in a chair in his/her room. The surveyor observed that the TV was not on and the Resident was alone in their room. The surveyor did not observe the Resident participating in any activities throughout the day. On 9/10/24 at 11:30 A.M., the surveyor observed the Resident sitting in a wheelchair in their room, and there was no music, no TV, and no activity material within reach. During an interview on 9/10/24 at 3:47 P.M., the Activity Director (AD) said that she was not aware that the Resident's TV was not working. The AD said that she looked into it and the TV remote had gone missing, so the TV could not be turned on. The AD said that she did not know how long it had been since the TV remote went missing. The AD said that she thought there was a radio or some music in the Resident's room, and was not aware that there wasn't. The surveyor and the AD reviewed the Resident's Activity Participation Log and the AD said that there was no activity recorded for the Resident in the month of July 2024, one activity of Balloon exercise on 8/7/24, and 2 activities in September 2024; an individual visit on 9/2/24, and in hallway on 9/4/24. The AD said that in hallway meant that the Resident was brought in their wheelchair out to the hallway so they could see what was going on. The surveyor and the AD reviewed the Resident's Activity Care Plan and the AD was unable to say why the Resident did not attend musical events, religious services, or outside time as recommended in the care plan. Review of the activity calendars for July 2024, August 2024, and September 2024, indicated numerous religious and musical programs. The AD said that the Resident should have participated but she could not provide any evidence that he/she had participated or been offered activities. The AD said that there were numerous religious and musical events each month and she was not aware that the Resident was not attending, or any reason why he/she would not attend. The AD was unable to provide any evidence that the Resident had declined or was unable to participate in the activities of interest. During an interview on 9/10/24 at 3:40 P.M., Activity Aide #1 said the way activity participation was recorded was that an activity calendar was printed out for each resident. The residents' names were put on the calendar, and then the activity staff highlight in yellow any activity that each resident participated in over the course of the month. Activity Aide #1 reviewed the Resident's activity participation logs for July 2024 through September 2024 and said that it looked accurate. Activity Aide #1 said she could not remember any time when the Resident attended any religious services, musical events, or had been taken outside for fresh air. Activity Aide #1 said that maybe sometimes the Resident had behaviors and could not participate.

Based on record and policy review, and interview, the facility failed to ensure that a gastrostomy tube (g-tube, a feeding tube that is placed directly into the stomach through an abdominal wall incision for the enteral [passing through the gastrointestinal tract] administration of food, fluids, and medication) care and management was provided in accordance with professional standards of practice for one Resident (#19) out of a total sample of 20 residents. Specifically, for Resident #19, the facility failed to: 1) obtain a Physician's order or care plan for g-tube replacement should it become dislodged. 2) replace the Resident's g-tube with a new g-tube after it was dislodged during a shower, to decrease the risk of contamination and infection to the Resident. Findings include: Resident #19 was admitted to the facility in October 2015, with diagnoses including Gastrostomy (surgical procedure to insert a g-tube) and Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area). Review of the facility policy titled Changing a Feeding Tube, last revised 2024, indicated the following: -verify there is a physician's order for this procedure. -replace the feeding tube as ordered or as directed in the plan of care, or if the feeding tube becomes worn, clogged or is removed unexpectedly. -discard old gastrostomy tube in designated container. Review of Resident #19's most recent Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #19: -was unable to complete the Brief Interview for Mental Status exam because they are rarely or never understood -was dependent for Activities of Daily Living (ADL-daily self-care activities) Review of Resident #19's clinical record did not indicate any instructions, Physician's orders or care plan interventions on how facility staff should respond in the event the Resident's g-tube become dislodged. Further review of Resident 19's clinical record revealed a Nursing Progress Note dated 7/27/24 that indicated: -Resident #19's g-tube became dislodged while the Resident was taking a shower. -the Nurse cleaned, sanitized, and re-inserted the g-tube. -the Nurse was notified by the Unit Manager (UM) that the Resident should have been sent out to the hospital. During an interview on 9/11/24 at 9:26 A.M., Nurse #2 said that Resident #19's g-tube was only to be changed at the hospital should it become dislodged, and it was not to be changed in the facility. During an interview on 9/11/24 at 3:43 P.M., the Director of Nursing (DON) said that she had not been made aware of Resident #19's g-tube dislodgment. The DON also said that the facility staff should have sent Resident #19 out to the hospital to have a new g-tube replaced and that was not done. During an interview on 9/12/24 at 12:32 P.M., with Nurse #1 (the Nurse working on 7/27/24), Nurse #1 said when Resident #19's g-tube became dislodged on 7/27/24, she had cleaned the g-tube with alcohol and hot water after the g-tube had fallen on the bathroom floor. Nurse #1 said that the facility had no g-tube supplies and there were no Physician's orders on what to do if the g-tube became dislodged. Nurse #1 said that she should have spoken to the Physician before she re-inserted Resident #19's g-tube, however she had notified the Physician afterward. Please Refer to F726

Based on observation, interview, facility assessment, record and policy review, the facility failed to ensure that the licensed nurses working in the facility had the specific competencies (measurable patterns of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) required to provide the care needed by the resident population for five Nurses (#1, #3, #4, #5 and #6) out of five applicable Nurses. Specifically, the facility failed to: 1. ensure that Nurse #1 had completed a competency for care and management of a gastrostomy tube (g-tube: a tube that is placed directly into the stomach through an abdominal wall incision for the enteral [passing through the gastrointestinal tract] administration of food, fluids, and medication) prior to providing care for Resident #19 who had a g-tube in place, which was dislodged during shower care, fell on the floor, and Nurse #1 re-inserted the same g-tube that was dislodged and contaminated from contact with the floor. 2. ensure that Nurse #3, Nurse #4, Nurse #5 and Nurse #6 had completed basic nursing competencies by the staffing agency prior to working in the facility. Findings include: Review of the Facility assessment dated [DATE] indicated the following: -Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population . >Orientation Clinical Competencies: person centered care, ADLs [activities of daily living: things such as dressing, bathing, etc.], disaster drills, infection control, medication administration, measurements(e.g. [blood pressure, weight] etc.), resident assessments, specialized services (e.g. colostomy care (a surgical opening of the bowel through the abdomen to allow feces to pass), etc.). 1. Review of the facility policy titled Changing a Feeding Tube (another name for a g-tube and similar devices) last revised 2024, included: -verify that there is a Physician's order for this procedure. -feeding tube replacement must be performed by a Licensed Nurse who has received training and demonstrated competency in this procedure. -discard old gastrostomy tube in designated container. Resident #19 was admitted to the facility in October 2015, with diagnoses including Dysphagia (difficulty swallowing foods or liquids), Protein-Calorie Malnutrition (state of inadequate intake of food including protein, calories and other essential nutrients), and Gastrostomy (surgical procedure to insert a g-tube). Review of the Resident's clinical record indicated no Physician's orders for the change and/or replacement of a g-tube. Review of Nurse #1 Nursing Progress Note dated 7/27/24 at 5:28 P.M., indicated the following for Resident #19: -g-tube became dislodged during a shower being provided by a CNA -g-tube was cleaned, sanitized and re-inserted -Unit Manager (UM) informed Nurse #1 that the Resident should have been sent out to the hospital During an interview on 9/11/24 at 3:43 P.M., the Director of Nursing (DON) said that staff should have sent the Resident out to have the g-tube replaced. During a follow-up interview on 9/12/24 at 10:43 A.M., the DON said she had spoken to her contact at the staffing agency used by the facility and the staffing agency did not complete competencies with the Nurses they provided to work at the facility. The DON further said that she had assumed that staff from the staffing agency had competencies completed by the agency but that the facility did not confirm this before Nurses worked in the facility. The DON said that the facility should have ensured Nurses from the staffing agency had received basic nursing competencies prior to them working in the facility. During an interview on 9/12/24 at 12:32 P.M., Nurse #1 said she had not received any education or competency for skills including care for a g-tube, before or during the time she worked at the facility. 2. During an interview on 9/12/24 at 10:43 A.M., the surveyor and the DON reviewed sampled Nurses (#3, #4, #5 and #6) and the DON confirmed they were staffing agency Nurses. The DON was unable to provide evidence that Nurse #3, Nurse #4, Nurse #5 and Nurse #6 had completed competencies before working in the facility. During an interview on 9/13/24 at 11:40 P.M., the DON said the expectation was the facility would confirm that all agency Nurses have competencies completed before working in the facility. The surveyor and the DON reviewed the following Nurses in the sample (Nurse #1, #3, #4, #5, and #6) and the DON said none of the agency Nurses had competencies confirmed with the staffing agency before they started working at the facility.

Based on interview, record and policy review, the facility failed to offer the Influenza Vaccination as recommended for one Resident (#15) out of five applicable Residents, in a total sample of 20 Residents, putting the Resident at risk for developing infections. Specifically, the facility failed to ensure that Resident #15 was offered, received or declined the seasonal Influenza Vaccine during the 2023 through 2024 flu season. Findings include: Review of the facility policy titled Influenza Vaccine, dated October 2022, indicated the following: -Between October 1st and March 31st each year, the Influenza Vaccine shall be offered to residents and employees. -A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record. Resident #15 was admitted to the facility in October 2018, with diagnoses including Chronic Obstructive Pulmonary Disease (lung disease that causes obstructed air flow and breathing problems) and Tracheostomy Status (a medical procedure that involves creating an opening in the neck in order to place a tube into a person's trachea, or windpipe to assist with breathing). Review of Resident #15's medical record indicated a legal Guardianship (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) was implemented on 10/3/22. Further review of Resident #15's Immunization Record indicated the following: -No indication that administration of the 2023 through 2024 Influenza Vaccine was offered, received or declined. During an interview on 9/12/24 at 9:24 A.M., the Infection Preventionist (IP) said she had sent the consent form for the 2023 through 2024 Influenza Vaccine to Resident #15's Guardian but the Guardian did not return or respond to the consent form. During a follow-up interview on 9/13/24 at 10:23 A.M., the IP said she was unable to find any documentation in Resident #15's medical record that indicated the 2023 through 2024 Influenza Vaccine had been offered to the Resident. During an interview on 9/13/24 at 11:42 A.M., the Director of Nursing (DON) said that all residents should be offered the Influenza vaccinations as not having the vaccination could have an impact on the Resident's health. During a follow-up interview on 9/13/24 at 2:30 P.M., the DON said that when the consent forms were not received back from Resident #15's Guardian, the facility staff should have followed up with the Guardian.

Based on observations, interviews, and record review, the facility failed to provide care consistent with professional standards of practice to prevent a facility-acquired pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence which will often present as an open ulcer because of intense and/or prolonged pressure. Soft tissue damage related to pressure may also be affected by skin temperature and moisture) for one Resident (#65) out five applicable residents, in a total sample of 22 residents. Specifically, the facility staff failed to assess the Resident's skin based on facility policy and professional standards, resulting in the development of a Stage 3 pressure injury (Full-thickness skin and tissue loss in which subcutaneous (beneath the skin) fat may be visible in the ulcer and granulation tissue (new connective tissue) and epibole (rolled edges) are often present), and subsequent wound infections, requiring multiple hospitalization s and surgical interventions. Findings include: Review of the facility policy titled, Skin Check, undated, indicated the following: - It is the policy of the facility to perform skin checks on all residents who reside at the facility. Skin checks are to be performed by a Licensed Nurse on admission and weekly thereafter. Skin checks may also be performed as needed, such as per Physician's order, upon resident/family request, or any other circumstances that require a skin check. The plan of care begins at admission. - In response to the completed skin check, the facility shall activate skin interventions promptly . Skin checks may be scheduled on the resident's preferred day schedule or per Physician's order. Resident #65 was admitted to the facility in February 2023 with diagnoses including Cervical Disc Disorder with radiculopathy (compressed nerve in the neck resulting in pain, muscle weakness and numbness), urinary tract infection, low back pain, other specified Spondylopathies (inflammation in the spine) and a Neurogenic Bladder (lack of bladder control due to a brain, spinal cord or nerve problem), requiring use of a suprapubic catheter (a hollow flexible tube inserted into the bladder through the abdomen, used to drain urine). Review of the Clinical Admission assessment dated [DATE], indicated the Resident did not have any skin issues. Review of the Admission [NAME] Scale (an assessment tool widely used to assess the risk for pressure ulcer in adult patients. The five subscale scores of the [NAME] Scale are added together for a total score that ranges from 5-20) dated 2/21/23 indicated a score of 14 (A lower [NAME] score indicates higher levels of risk for pressure ulcer development. Generally, a score of 14 or less indicates at-risk status). Review of Resident #65's Physician's orders indicated the following: - Weekly skin check - complete weekly skin check documentation on weekly skin assessment UDA in the evaluation section of Point-Click-Care (the facility's electronic health record system), initiated 2/21/23. - Hydrocortisone External Cream 2.5% (Hydrocortisone Topical, a steroid cream used to reduce swelling, itching and redness), apply to rectal area topically three times a day, 14 days on (use) and 7 days off (do not use) for hemorrhoids, initiated 2/21/23. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident was at risk of developing pressure injuries, -did not currently have any pressure injuries -and interventions included a pressure reducing device for the Resident's bed and application of ointments/medications other than to his/her feet. Further review of the MDS assessment indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Resident's Skin Care Plan dated 3/5/23 indicated the following: - The Resident was at risk for skin breakdown due to pain, impaired mobility, and suprapubic catheter use (a tube inserted through the abdomen into the bladder to drain urine). - A Licensed Nurse should check my skin weekly. - I need a pressure relief mattress on my bed. - I need to be reminded to turn and position myself. - I need the help of staff to turn/reposition me every two hours to prevent me from getting skin breakdown as needed. - Please apply house barrier cream to my bony prominences each shift. - Please perform a [NAME] Plus assessment quarterly. Review of the Weekly Skin Check Assessments indicated the following: - 3/14/23 - Skin clean and intact - 3/21/23 - Skin clean and intact - 3/28/23 - Skin clean and intact - 4/4/23 - Skin clean and intact - completed by Unit Manager (UM) #4 - 4/11/23 - Skin clean and intact - completed by UM #4 - 4/18/23 - Skin clean and intact - completed by UM #4 Review of the Weekly Pressure Injury Evaluations, dated 4/20/23, indicated the following: -Stage 3 pressure injury to the sacrum (area below the lumbar spine and above the tailbone) measuring 11 centimeters (cm) long by (x) 3.5 cm wide x 1.5 cm deep. -The wound bed contained yellow slough, firm wound edges, moderate amount of serous (clear fluid) drainage. -The peri-wound (area surrounding wound) had hardened skin and was painful. During an interview on 6/23/23 at 2:25 P.M., UM #4 said on 4/20/23, Resident #65 told her that his/her hemorrhoids have been bothering him/her and asked the UM to assess the area. UM #4 said she observed the area and discovered Resident #65 had a very large wound to his/her sacral area (area below the lumbar spine and above the tailbone). UM #4 said she had been completing the weekly skin checks prior to 4/20/23, but she never assessed the Resident's sacral area during that time. During an interview on 6/27/23 at 9:44 A.M., CNA (Certified Nurses Aide) #1 said the Resident usually did all his/her own personal care, including showering without the assistance of the CNAs, therefore they were not aware of the Resident's wound prior to it being discovered on 4/20/23. During an interview on 6/27/23 at 10:33 A.M., Nurse #7 said it is the responsibility of the nursing staff to complete weekly skin checks on all residents. She further said this is often done on shower days and that the CNAs were also good about letting Nurses know when there was a concern with a resident's skin. Nurse #7 said it is the responsibility of the Nurses to ask all residents, including those who are independent with care to assess their skin, and if the resident should refuse assessment, it should be documented in the medical record. Nurse #7 further said that skin checks should include the entire body, head to toe, front and back. Review of the Initial Progress Note, dated 4/20/23 by the facility's Wound Care Physician indicated the following: -Patient seen today for a Stage 3 coccyx (small triangular bone at the base of the spine) pressure injury measuring 11 cm x 3.5 cm x 1.5 cm. -Noted to have moderate serosanguineous drainage (drainage consisting of blood and clear fluid). -Tissue containing 80% slough and 20% epithelial tissue (a type of body tissue that forms covering on all internal and external surfaces of the body). Review of Resident 65's medical record indicated the Resident was transferred to the hospital on 4/24/23. Review of the Emergency Medicine Note, dated 4/24/23 indicated the following: -Resident said he/she was sent to the hospital for further evaluation as to why he/she had been feeling so unwell for the past few months, feeling generally weak, with decreased appetite. Notes a sacral wound which has been treated at the facility but stated over the past week the wound started to become very foul-smelling and during this time he/she experienced worsening nausea, increasing fatigue and feeling more unwell. -Examination: large foul-smelling and necrotic (dead tissue) appearing sacral wound tracking into intergluteal cleft (groove between buttocks below the sacrum to the perineum (area between the anus and vulva or scrotum). - Laboratory work showing leukocytosis (high WBCs-white blood cell count), computerized tomography (CT) scan concerning for possible cellulitis (skin infection)/soft tissue infection/abscess (pocket of pus) formation. -Surgery contacted for possible debridement (the removal of dead, damaged, or infected tissue to improve the healing potential of remaining healthy tissue). Review of the Hospital Operative Note, dated 4/25/23 indicated the following: - Resident brought to operating room, intubated (breathing tube placed into the trachea/windpipe) and sedated by Anesthesia. -Using a surgical blade, the eschar (dead, devitalized tissue) overlying the wound were sharply incised (cut) down to the subcutaneous tissue down to the muscle layer. -Using a combination of electrocautery (instrument that is electrically heated) and sharp dissection we debrided to the best of our ability. -At the superior (top) pole of the wound, there was a pocket of purulent (pus) fluid noted. -Over 20 square cm of tissue was removed, and we deemed the sacral decubitus ulcer (pressure injury) to be a Stage 4, down to the muscle layer overlying the sacrum. Review of the Hospital Discharge Summary, dated 4/29/23 indicated the following: - Resident admitted for treatment of necrotic sacral wound infection with left gluteal crease abscess and surrounding soft tissue infection. Review of the facility's Physician Assistant (PA) post-hospitalization progress note dated 5/2/23 indicated the following: -Resident was admitted to the hospital with necrotic sacral wound infection with left gluteal crease abscess and was treated with intravenous (medicines/fluids given through a tube or needle inserted into a person ' s veins) antibiotics and seen by surgery for debridement. -He/she was discharged from the hospital and was to continue with a ten day course of Augmentin (an oral antibiotic) to end on 5/9/23 and has been referred to the wound clinic. -Plan to continue with daily wound care, turn and reposition every two hours and as needed, off-load (reduce pressure/weight on a body part) bony prominences, monitor for incontinence (lack of control of bowel and/or bladder) and moisture control and optimize nutrition. Review of the facility's Physician Assistant (PA) progress note dated 5/17/23 indicated the following: - Wound with strong odor and serosanguineous drainage, peri-wound with erythema (redness). Needs debridement therefore will send to the emergency department. Review of a Nursing progress note dated 5/17/23 indicated the following: - PA in to visit Resident and notified this author the Resident would need to be sent to the emergency department for debridement of wound as well as concern over the odor from the wound. Review of the Hospital Discharge Summary dated 5/22/23 indicated the following: - Large decubitus ulcer (bedsore) evaluated by the medicine team, plastic surgery team and general surgery team. -He/she went to the operating room and had a debridement. -We have been using a wound-vac (a type of therapy that utilizes negative pressure using a suction pump, tubing, and a wound covering/dressing to remove excess wound drainage and to promote healing in chronic wounds) since the surgery. -We discussed the potential for a diverting colostomy (a surgical procedure that [NAME] the colon and diverts the upper part to an artificial opening within the abdomen) and possible reconstruction with plastic surgery. -The wound cultures grew Enterococcus (a type of bacteria) and Methicillin-Resistant Staphylococcus Aureus (MRSA, a bacteria resistant to certain antibiotics) and he/she is being discharged on antibiotics. Review of a Wound Clinic progress note dated 6/8/23 indicated the following: - Pre-procedure diagnosis of Wound #1 is a pressure injury. There was an excisional skin/subcutaneous/muscle debridement with a total area of 75 square centimeters. -Post-debridement measurements: 12.5 cm length x 6 cm width x 4 cm depth. During an observation and interview on 6/21/23 at 11:37 A.M., the surveyor observed Resident #65 to be seated in a wheelchair with a wound-vac being used to treat the pressure injury. The Resident said he/she did not have a wound when he/she entered the facility. During an interview on 6/23/23 at 8:40 A.M., Resident #65 said prior to the wound, he/she slept in a recliner chair with no pressure relief. The Resident said he/she began having pain in his/her backside, and thought it was hemorrhoids. Resident #65 said the Nurses provided medication for hemorrhoids for him/her to self-administer without checking the area that was causing pain. Resident #65 said when the pain did not improve after using the hemorrhoid cream, he/she asked the Nurse to look at the area and the wound was identified. The Resident reiterated that staff did not look at his/her skin routinely until he/she asked. They never asked to check my skin and I would have never refused. Review of Resident 65's care plan failed to indicate a care plan for the self-administration of Hydrocortisone cream and failed to indicate the Resident, who was at risk for skin breakdown did not sleep on a pressure relieving mattress, but instead slept in his/her recliner chair full-time. Review of the Nursing 2022 Drug Handbook, 42nd Edition by Wolters Kluwer, copyright 2022, pg. 729 indicated the following: - Hydrocortisone (topical), adverse reactions: skin - impaired wound healing, fragile skin, petechiae (small red or purple spots that can appear on the skin), erythema (redness), sweating. During an observation and interview on 6/27/23 at 10:55 A.M., the surveyor observed Nurse #3 perform wound care for the Resident. The surveyor observed the Resident lying in his/her bed on an air mattress. The surveyor also observed a fitted sheet, a folded sheet and a soaker pad underneath the Resident, who was also wearing an incontinence brief. After observing Nurse #3 remove the wound-vac and the associated dressings from the wound, the surveyor observed a wound measuring approximately 11 cm long x 7 cm wide with the wound bed containing approximately 75% tan slough with scattered dark brown areas and 25% granulation tissue. The wound was surrounded by blanchable erythema (reddened skin that turns white when pressed). Nurse #3 stated that when a Nurse performs a skin check, it is head to toe as well as front and back. Nurse #3 further said that the Resident should not be laying on multiple layers of linens as the increased heat and moisture caused by the layers are not good for wound healing.

Based on observation and interview, the facility failed to maintain the storage of medications and biologicals according to professional standards in two of three medication storage rooms, and three of six medication carts. Findings include: Review of the facility policy titled, Storage of Medications, revised [DATE] included, but not limited to: - The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. - Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. -Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Review of the facility policy titled, Emergency Medication Policy, revised [DATE], included, but not limited to: - The facility has emergency medications on each unit so that residents' medical needs are being met timely. -Whenever a medication is used the resident's name, quantity of medication, and date must be documented on the enclosed sheet in the kit next to an item used. -The sheet must be faxed to the pharmacy promptly upon opening the kit, and the pharmacy should be called to verify receipt of the information faxed. A copy of the faxed confirmation and documentation of verbal communication to the pharmacy must be kept in the pharmacy book. -This process must be completed within 24 hours. If a new kit is not received within 24 to 48 hours, the unit manager/responsible nurse must reach out to the pharmacy for the kit to be replaced stat (as soon as possible). Review of the Federal Drug Administration web page titled, Insulin Storage and Effectiveness, dated [DATE] at https://www.fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency, indicated the following: - It is recommended that Insulin be stored in a refrigerator at approximately 36 to 46 degrees Fahrenheit. Unopened and stored in this manner, these products maintain their potency until the expiration date on the package. 1a. During an observation on [DATE] at 8:15 A.M., of the Unit B1 Medication Storage Room with Nurse #5, the following expired or unlabeled items were found: - One box containing three opened vials of Moderna Covid (an infectious respiratory illness) Vaccines with a sticker on the box indicating: Do Not Use beyond [DATE]. - One box containing two opened vials of Moderna Covid Vaccines with no expiration date found. - One opened vial of Moderna Covid Vaccine with a sticker indicating to Do Not Use beyond [DATE]. - Two Glargine (long-acting) Insulin pens with no specific resident name listed. - One unopened Lantus (long-acting) Insulin vial with a missing resident sticker. - One opened Emergency Insulin Kit with a Glargine Insulin vial and Humulin N (intermediate-acting) Insulin vial missing. During an interview on [DATE] at 8:30 A.M., Nurse #5 said the two boxes containing the Moderna Covid Vaccines and the vial of the Moderna Covid Vaccine were expired and should have been removed. She said the two Glargine Insulin pens and the Lantus vial were not resident-specific and should have been removed. Nurse #5 further said she could not find the form that should have been faxed to the pharmacy when the Insulin Kit was opened and the Glargine and Humulin N Insulin vials were removed, as required. 1b. During an observation on [DATE] at 8:40 A.M., of the Unit A2 Medication Storage Room with Unit Manager (UM) #2, the following expired or undated items were found: - The medication refrigerator contained a bottle of Omeprazole Powder Suspension for a specific resident with a sticker indicating to Do Not Use after [DATE]. - There were several resident specific Insulin vials stored in the medication refrigerator and the temperature reading was observed to be 34 degrees Fahrenheit. During an interview on [DATE] at 8:45 A.M., UM #2 said the Omeprazole Powder Suspension was no longer an active order and the medication should have been removed from the refrigerator. She further said the refrigerator temperature was too low, as it should be at least 36 degrees. During a recheck of the Unit A2 Medication refrigerator temperature on [DATE] at 10:20 A.M., the surveyor along with Nurse #6 observed the temperature reading was 30 degrees. Nurse #6 said the temperature was too low and not within the required ranges. 2a. During an observation on [DATE] at 8:15 A.M., of the Unit B1 back hall Medication Cart with Nurse #5, the surveyor observed one packaged bandage roll, one Xeroform Petroleum Dressing (used to cover and protect low to non-draining wounds) package and one Wound Cleanser Spray. Nurse #5 said all the items found should not have been stored in the medication cart and instead they should have been stored in the Treatment Cart. 2b. During an observation on [DATE] at 8:50 A.M., of the Unit A2 front hall Medication Cart with Nurse #1, the surveyor observed numerous nasal cannulas (a device used to deliver supplemental Oxygen) in a drawer. Nurse #1 said the nasal cannulas should not have been stored in the medication cart. 45435 2c. On [DATE] at 8:37 A.M., the surveyor observed the Unit B2 front hall Medication Cart to include the following: -Haldol (an antipsychotic medication) liquid, bottle open and not dated. -(3) Fluticasone (a medication used to treat allergies) nasal spray bottles prescribed for the same Resident, filled on [DATE], [DATE] and [DATE], all opened and not dated. -Vashe wound solution (a cleansing solution used for wound care) open, not dated. -Printer ink cartridge During an interview on [DATE] at 6:45 A.M., Nurse #7 said the Haldol liquid and Fluticasone nasal sprays should have been dated when they were opened and that they were not, as required. She further said one of the Fluticasone bottles looked disgusting. Nurse #7 then said that Vashe wound cleanser and the printer ink cartridge should not have been stored in the medication cart.

Based on record review and interviews, the facility failed to maintain complete and accurate medical records related to Physician's orders for three Residents (#23, #14, and #83) out of a total sample of 22 residents, and for three Residents (#89, #86, and #104) out of a sample of five residents for immunization review. Specifically, the facility failed to: 1. Ensure Physician's orders reflected the Residents' wishes related to Advanced Directives for three Residents (#23, #14, and #83). 2. Ensure a medication listed in the electronic medical record (EMR) accurately reflected the medication being administered to one Resident (#83). 3. Ensure the accuracy and completeness of immunization consents for three Residents (#89, #86, and #104). Findings include: 1a. Resident #23 was admitted to the facility in [DATE], and readmitted in [DATE]. Review of the EMR indicated the following Physician's orders initiated [DATE]: -Do Not Resuscitate (DNR - not to do cardiopulmonary resuscitation (CPR) in an emergency). -Do Not Intubate (DNI - do not insert a breathing tube into the trachea, via the nose or the mouth, to restore normal breathing). Review of the Resident's chart included a Massachusetts Order for Life Sustaining Treatment form (MOLST - a standardized medical order form that relays a person's wishes to accept or refuse medical treatment, including life extending treatments), signed by the Resident's Representative on [DATE] and the Physician on [DATE] that indicated: Attempt Resuscitation and to Intubate and Ventilate. During an interview on [DATE] at 11:47 A.M., the surveyor and Nurse #4 reviewed the Resident's EMR and MOLST form together. Nurse #4 said she must have entered the Physician's order incorrectly and the order should have matched the MOLST which indicated to attempt resuscitation and to intubate and ventilate. 1b. Resident #14 was admitted to the facility in [DATE]. Review of the EMR indicated a Physician's order dated [DATE] that the Resident was a Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of the Resident's chart included a MOLST form signed by the Resident on [DATE] and the Physician on [DATE] that indicated DNR and DNI. During an interview on [DATE] at 1:50 P.M, Nurse #7 said the Physician's order and the MOLST form provided conflicting information and they should have matched. She further said if the Resident's heart were to stop, the first place she would have looked to verify the Resident's wishes for life sustaining treatment would have been the EMR and this did not accurately reflect the Resident's wishes. During an interview on [DATE] at 2:05 P.M., Unit Manager #4 said the Medical Records department audited all the Resident's charts and missed the discrepancy. She further said the Physician's order should match the MOLST and did not as required. 37700 1c. Resident #83 was admitted to the facility in [DATE] with a diagnosis of Malignant Neoplasm (Cancer) of the Prostate. Review of the EMR indicated the following Physician's orders: - Full Code, initiated [DATE]. - DNR/DNI, initiated [DATE]. Review of the MOLST form, signed on [DATE], indicated DNR/DNI. During an interview on [DATE] at 12:00 P.M., after reviewing the MOLST form and Physician orders, Unit Manager (UM) #2 said the MOLST form was completed on [DATE] and indicated for the Resident to be DNR/DNI, and the order for the Full Code was not discontinued, as required. 2. On [DATE] at 8:05 A.M., during an observation of a medication administration for Resident #83, Nurse #3 administered Artificial Tears, one drop into the Resident's right eye. Review of the Physician's order, dated [DATE], indicated to administer Artificial Tears 1%, (Carboxymethylcellulose Sodium-generic name), instill one drop into the left eye two times a day. Review of the Artificial Tears packaging indicated the solution contained Glycerin 0.2%, Hypromellose 0.2% and Polyethylene Glycol 400 1%. During a telephone interview on [DATE] at 10:43 A.M., Pharmacist #2 said the ingredients listed on the Artificial Tears packaging have the same effect as the generic name listed on the MAR (Medication Administration Record). During an interview on [DATE] at 11:00 A.M., UM #2 said when the Artificial Tears order is put into the EMR, the Carboxymethylcellulose Sodium is automatically put into the system as the generic name of the Artificial Tears. She said the generic name does not match the ingredients listed on the Artificial Tears packaging, as required. 42741 3a. For Resident #89 the facility failed to utilize the correct Resident Immunization Consent or Declination Form for the Resident and/or Resident's Representative to consent to the 20-Valent Pneumococcal Conjugate Vaccine (PCV20 - a type of Pneumococcal Vaccination). Resident #89 was admitted to the facility in [DATE]. Review of the Resident Immunization Consent or Declination Form dated [DATE] indicated the Resident and/or Resident's Representative consented to receive the Pneumococcal Polysaccharide Vaccine 23 (PPSV23-a type of Pneumococcal Vaccination). Review of the Resident's Immunization Section in the EMR indicated Resident #89 received the PCV20 on [DATE]. During an interview on [DATE] at 3:23 P.M., Unit Manager (UM) #2 said the Resident had received the PCV20 on [DATE]. She reviewed the consent form with the surveyor and said the consent form should have indicated the Resident had consented to receiving the PCV20 not the PPSV23. 3b. Resident #86 was admitted to the facility in [DATE]. Review of the Resident Immunization Consent or Declination Form dated [DATE] indicated the Resident and/or Resident's Representative signed the consent form but there was no indication on the form what specific immunizations the Resident and/or Resident's Representative were consenting to have administered. During an interview on [DATE] at 2:34 P.M., UM #1 said the consent form was not completed fully. She further said the form should indicate which immunizations the Resident and/or Resident's Representative was consenting to, and nothing had been completed on the form to indicate which immunizations were consented to have administered. 3c. Resident #104 was admitted to the facility in [DATE]. Review of the Resident Immunization Consent or Declination Form dated [DATE] indicated the Resident and/or Resident's Representative signed the consent form on [DATE] but there was no indication on the form what immunizations the Resident and/or Resident's Representative was consenting to have administered. During an interview on [DATE] at 3:23 P.M., UM #2 said the consent form was not completed fully. She further said the form should indicate which immunizations the Resident and/or Resident's Representative was consenting to have administered. During an interview on [DATE] at 10:25 A.M., the Director of Nursing (DON) said the facility had a new Resident Immunization Consent or Declination Form that included the PCV20. She said staff should not be utilizing the old form when obtaining consent for the PCV20 and this should have been done for Resident #89. She further said the Resident Immunization Consent or Declination Form should be filled out in its entirety, so when someone reads the form, they would know which immunizations the Resident and/or Resident's Representative had consented to or declined.

Based on observation, record review and interview, the facility failed to follow professional standards relative to checking the placement of a gastrostomy tube (GTube/GT - a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) for one Resident (#86), out of two applicable residents, in a total sample of 22 residents. Specifically, the facility staff did not check the GT for placement as required, prior to administering Resident #86's medications. Findings include: Review of the Enteral Feedings-Safety Precaution Policy, revised May 2022, included, but not limited to: -Check enteral tube placement prior to each feeding and administration of medication. Review of the [NAME] Nursing Procedures-9th Edition for Enteral (passing through the intestine) Gastrostomy and Jejunostomy (an opening into the small intestine) Tube Feeding and Care, included, but not limited to: -Verify tube placement by using at least two of the following methods: *Observe for a change in the external length or incremental marking on the tube at the exit site to determine whether the tube has migrated (moved). *Observe for a change in volume of aspirate from the feeding tube. *Review routine chest and abdominal X-ray reports. *Aspirate tube contents and inspect the visual characteristics of the tube aspirate. Resident #86 was admitted to the facility in May 2021 with a diagnosis of a Cerebral Infarction (Stroke). Review of the Minimum Data Set (MDS) Assessment, dated 5/22/23, indicated in Section K that the Resident had a feeding tube that was utilized for nutrition, and he/she was receiving 51% or more for total caloric intake. During a medication administration observation on 6/22/23 at 9:15 A.M., the surveyor observed Nurse #4 access the GT and administered each ordered medication. The surveyor did not observe Nurse #4 check the GT for proper placement prior to administering the medications. During an interview on 6/22/23 at 9:35 A.M., Nurse #4 said she did not check the GT for placement prior to the administration of medications as required.

Based on record review and interview, the facility failed to provide monitoring for adverse side effects of psychotropic medication (medication which affects mood and behavior) use and behaviors for two Residents (#22 and #90), out of a total sample of 22 residents. Findings include: Review of the facility policy titled Psychoactive Medication Use, revised December 2022, indicated the following: -Residents receiving psychotropic medications are monitored for adverse consequences. Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, revised March 2022, indicated the following: -If the resident is being treated for altered behavior or mood, the interdisciplinary team (IDT) will seek and document any improvements or worsening in the individual's behavior, mood, and function. -The IDT will monitor for side effects and complications related to psychoactive medications . 1. Resident #22 was admitted to the facility in July 2021 with diagnoses including Schizoaffective Disorder and Major Depressive Disorder. Review of the June 2023 Physician's orders indicated the Resident was receiving Trazodone (an antidepressant medication) 25 milligrams (mg) by mouth at bedtime with a start date of 6/14/23. Further review of the June 2023 Physician's orders indicated no order to monitor for adverse side of effects of antidepressant use or to monitor for behaviors. Review of the Resident's Mood Care Plan, initiated 4/23/23 indicated the following interventions: -Monitor/record/report to Medical Doctor (MD) as needed (PRN): >acute episode feelings or sadness [sic] >loss of pleasure and interest in activities >feelings of worthlessness or guilt >change in appetite/eating habits >change in sleep patterns >diminished ability to concentrate >change in psychomotor skills -Monitor/record/report to MD PRN mood patterns for signs and symptoms (s/sx) of depression, anxiety, sad mood as per facility behavior monitoring protocols. Review of the Behavioral Health Group Physician Assistant (PA) Note, dated 6/9/23, indicated the following: -Monitor for changes in mood/affect. During an interview on 6/26/23 at 1:33 P.M., Nurse #1 said nursing monitored for adverse side effects of psychotropic medications and for signs and symptoms of changes in mood. She said this information should have been documented every shift in the Medication Administration Record (MAR). Nurse #1 reviewed the Resident's medical record and said she was unable to find a Physician's order for monitoring the side effects of antidepressant use or to monitor mood and there should have been an order in place. 2. Resident #90 was admitted to the facility in July 2021 with diagnoses including Bipolar Disorder and Major Depressive Disorder. Review of the June 2023 Physician's orders indicated the Resident was receiving Zyprexa (an antipsychotic medication) 10 mg one time daily with a start date of 4/17/23 and Remeron (an antidepressant medication) 45 mg at bedtime with a start date of 10/05/22. Further review of the June 2023 Physician's orders indicated no orders to monitor for adverse side effects of antidepressant use or antipsychotic use or to monitor for behaviors. Review of the Resident's Psychotropic Medication due to Bipolar Disorder and Depression Care Plan, initiated 8/25/22, indicated the following interventions: -Monitor for side effects and effectiveness Q-shift (every shift). -Monitor/record occurrences of target behavior symptoms and document per facility protocol. Review of the Resident's Antidepressant Medications due to Depression, Weight Loss, and Bipolar Disorder Care Plan, initiated 8/25/2022, indicated the following interventions: -Monitor/document side effects and effectiveness Q-shift. Review of the MD progress note dated 6/16/23, indicated to continue to monitor mood and affect. During an interview on 6/26/23 at 1:54 P.M., with Unit Manager (UM) #2 and Nurse #1, UM #2 said when a resident is on psychotropic medications, the resident should be monitored for adverse side effects of those medications and for behaviors every shift and documentation should have been completed on the Treatment Administration Record (TAR). Nurse #2 said she reviewed Resident #90's chart and was unable to find an order to monitor for adverse side effects of psychotropic medication use or to monitor for behaviors as required.

Based on observation, interview and record review, the facility failed to provide an as needed (PRN), pain medication upon request resulting in increased pain and discomfort for one Resident (#312), out of a total sample of 22 residents. Findings include: Review of the Unavailable Medications Policy, revised April 2022, included, but not limited to: -When a medication is ordered for a resident, the facility must ensure that the medication is always available for the resident . -If medication is not available for a resident, the Licensed Nurse must update the Physician and the pharmacy promptly. -The medication must be ordered STAT (immediately) and sent by the pharmacy or per Physician's orders. Resident #312 was admitted to the facility in June 2023 with a diagnosis of Intraspinal Abscess (an infection that forms in the space between the skull bones and brain lining) and Granuloma (a tiny cluster of white blood cells and other tissue that can be found in the body). Review of the Minimum Data Set (MDS) Assessment, dated 6/22/23, indicated the Resident had occasional pain and the worst pain was at a 9, on a scale of 1 to 10. Further Review of the MDS Assessment indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 14 out of 15. Review of the Physician's orders indicated an order for Percocet 5-325 (a narcotic consisting of Oxycodone 5 milligrams (mg) and Acetaminophen 325 mg) one tablet every 4 hours PRN for pain related to Dorsalgia (back pain). On 6/22/23 at 7:45 A.M., the surveyor observed a fingerstick blood sugar check being performed by Nurse #4. Resident #312 complained to Nurse #4 of pain intensity at 5 on a scale of 1 to 10, and requested a Percocet tablet. Nurse #4 reviewed the Medication Administration Record (MAR) and went into the narcotic drawer to obtain an ordered Percocet but the medication was not available for the Resident. Nurse #4 informed the surveyor the facility Emergency Kit (E-Kit) did not contain Percocet and she needed to call the Physician Assistant (PA) for a prescription renewal. During an interview on 6/22/23 at 9:52 A.M., Resident #312 said he/she had not received a Percocet yet and the pain had increased to an intensity level of 9. During an interview on 6/22/23 at 9:55 A.M., Nurse #4 said she would be calling the PA and the pharmacy to check when the Percocet was going to be delivered to the facility. During an interview on 6/22/23 at 10:15 A.M., the Director of Nurses (DON) said the Physician should have been notified when staff realized the Percocet was not available, in order to obtain a different pain medication order until the Percocet was delivered, and the Physician was not notified as required.

Based on observation, interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Findings include: Review of the facility's weekly nursing schedule, dated 6/21/23 through 6/27/23 indicated an RN was not scheduled to work for eight consecutive hours on Saturday, 6/24/23. During an interview on 6/27/23 at 11:01 A.M., the Staffing Coordinator said that she struggles with getting an RN on the schedule every day. During an interview on 6/27/23 at 1:59 P.M., the Staffing Coordinator said there was not an RN scheduled to work in the building on 6/24/23. During an interview on 6/27/23 at 2:07 P.M. the Director of Nurses (DON) said the facility did not have an RN scheduled to work every other Saturday and that there was not an RN scheduled to work in the facility on 6/24/23 as required.

Based on observation, interview, and record review, the facility failed to follow professional standards of care regarding respiratory equipment for two Residents (#55 and #362), out of a total sample of 22 Residents. Specifically, the facility staff failed to store respiratory equipment per policy to prevent contamination and infection. Findings include: Review of the facility policy titled, Respiratory-Prevention of Infection, dated 11/2022, indicated the following: Infection Control Considerations Related to Medication Nebulizer/Continuous Aerosol: -store the circuit (a device used to change liquid medication into a fine mist to be breathed directly into the lungs) in a plastic bag, mark with date and Resident's name, between uses. -discard the administration set-up every seven days. 1. Resident #55 was admitted to the facility in January 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Review of the Physician's orders dated 6/22/2023 indicated the Resident had an order for Budesonide inhalation suspension (a medication used to treat Asthma and COPD) 0.5 milligrams (mg) in 2 milliliters (mls), inhale orally one time a day. Review of the June 2023 Medication Administration Record (MAR) indicated the Resident was administered Budesonide inhalation 0.5 mg in 2 ml daily. On 6/21/23 at 10:16 A.M., and 6/22/23 at 8:26 A.M., the surveyor observed a nebulizer circuit setup attached to a nebulizer machine on Resident #55's bedside table. The nebulizer circuit setup was not stored in a plastic bag and was not dated. During an interview and observation on 6/22/23 at 8:58 A.M., Unit Manager (UM) #2 said the nebulizer circuit setup should have been dated, and bagged after use and was not as required. 2. Resident #362 was admitted to the facility in October 2022 with diagnoses including Chronic Respiratory Failure (CRF-condition when the lungs cannot get enough oxygen in the blood or eliminate enough carbon dioxide from the body) and COPD. Review of the Physician's orders dated 6/22/2023 indicated the Resident had an order for the following: -Budesonide suspension 0.5 mg in 2 mls, inhale orally via nebulizer two times a day. -Ipratropium-Albuterol solution (a medication used to relax and open the airways to facilitate breathing) 0.5-2.5 mg in 3 ml, 1 vial inhale orally every six hours. Review of the June 2023 MAR indicated the Resident was administered Budesonide suspension and Ipratropium-Albuterol by inhalation via nebulizer daily. On 6/21/23 at 8:41 A.M., the surveyor observed a nebulizer circuit setup attached to a nebulizer machine on Resident #362's bedside table. The nebulizer circuit setup was not stored in a plastic bag and was not dated. During an interview and observation on 6/22/23 at 9:54 A.M., UM #2 said the nebulizer circuit setup should be dated, and bagged after use and was not as required.

Based on observation, interview, and record review the facility failed to secure unattended medications on one out of three units. Specifically, unattended medications were left on the windowsill in a resident's room, to be accidentally ingested by another resident(s). Finding include: Review of the facility policy titled, Storage of Medications, dated 5/2022, indicated the following: -Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 6/22/23 at 7:15 A.M., the surveyor observed on the windowsill in room [ROOM NUMBER], a medication cup containing 7 tablets and another medication cup containing 10 milliliters (mls) of red liquid that was left unattended. During an interview and observation on 6/22/23 at 7:21 A.M., Nurse #2 said the medication should not be left on the windowsill. He said that he did not put the medication on the windowsill and was not sure how long it had been there. Nurse #2 said that the medications were not from this morning. Nurse #2 further stated that he had worked the prior evening and the resident's family was standing by the window and he would not have been able to see if the medications had been there at that time. During an interview on 6/22/23 at 8:54 A.M., Unit Manager (UM) #2 said medications should never be left at the bedside and should be administered or removed from the resident's room by the Nurse as required.

Based on records reviewed and interviews for one of four sampled residents (Resident #1), who was assessed by nursing to be at increased risk for falls, with three unwitnessed falls in his/her room after all of which he/she was found on the floor by staff, the facility failed to ensure adequate safety measures were put in place in an effort to maintain his/her safety in an effort to prevent incidents/accidents resulting in injury. 07/18/22, Resident #1 sustained a fourth unwitnessed fall and was again, found by staff on the floor beside his/her bed. Resident #1 was transferred to the Hospital Emergency Department where he/she was admitted to the Hospital for surgical repair of a right femoral (thigh bone) fracture. Findings Include: Review of the Facility Policy titled Assessing Falls and Their Causes, dated as revised 2010, indicated that an incident report for resident falls was to be completed no later than twenty-four hours after a fall occurs. The Policy indicated post fall documentation should include appropriate interventions taken to prevent future falls. Review of the Facility Policy titled Falls and Falls Risk Managing, dated as revised 2017, indicated that based on previous evaluations and current data, to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falls and to try to minimize complications from falling. The Policy indicated that staff, with the input of the attending Physician will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The Policy indicated if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remained relevant. The Policy indicated if the resident continued to fall, staff will re-evaluate the situations and whether it was appropriate to continue or change current interventions. Resident #1 was admitted to the facility in October 2018, diagnoses included cerebral infarction (stroke), [CONDITION(S)] (comprehension and communication disorder), dementia, [CONDITION(S)] (paralysis on one side), and [CONDITION(S)] (weakness) following cerebral infarction affecting the right, dominant side. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she had short-term and long-term memory impairment and his/her ability to make decisions regarding tasks of daily living were severely impaired. The MDS indicated Resident #1 was non-ambulatory and required extensive assistance from two staff members for bed mobility and transfers. Review of Resident #1's At Risk for Falls Care Plan, dated as initiated 01/10/20 (and included no further updates), indicated he/she was at risk for falls due to right sided [CONDITION(S)] and a history of falls. The Care Plan included a goal to keep Resident #1 safe from falls and fall related injuries. Interventions identified for Resident #1 included the following: -Check for pain and medicate as ordered. -Cue as needed to enhance safe functional activities. -Cue verbally and visually to enhance the level of safety with transfers and ambulation. -Do fall assessment on admission, quarterly and with a fall. Review of the Facility Incident Report, dated 01/07/22, indicated that staff found Resident #1 on the floor next to his/her bed. The Report indicated Resident #1 was in his/her bed prior to the fall. Review of the Facility Incident Report, dated 02/26/22, indicated that a staff member found Resident #1 on the floor next to his/her bed. The Report indicated that the portions of the investigation that assessed predisposing environmental, situational and physioiolgical factors, were left blank. Review of Resident #1's Quarterly Nursing Evaluation, dated 05/09/22, indicated that he/she was assessed by nursing as being at an increased risk for falls. Review of Resident #1's Nurse Progress Note, dated 05/14/22, indicated he/she was found on the floor beside his/her bed. Review of Resident #1's Medical Record indicated there was no documentation to support that any new interventions had been established or attempted, in effort to prevent similar falls, after he/she was found on the floor beside his/her bed on 01/07/22, 02/26/22, and 05/14/22. Review of a Facility Incident Report, dated 07/18/22 at 5:13 A.M., indicated a CNA found Resident #1 on the floor next to his/her bed. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 07/18/22, indicated that while staff were performing rounds on 07/18/22 at approximately 5:13 A.M., Resident #1 was found on the floor next to his/her bed. The Report indicated an x-ray was obtained which revealed Resident #1 sustained a right femoral shaft fracture and he/she was admitted to the Hospital for treatment. Review of the Hospital Discharge Note, dated 07/25/22, indicated Resident #1 was admitted to the Hospital with a right femoral fracture for which he/she underwent surgical repair. During an interview on 10/27/22 at 3:15 P.M., the Unit Manager said she worked the 11:00 P.M. to 7:00 A.M. shift on 07/18/22 and said that during the shift, a CNA notified her that Resident #1 was on the floor beside his/her bed. The Unit Manager said that when she assessed Resident #1, he/she was grimacing and was unable to tell her what happened. The Unit Manager said she notified the Nurse Practitioner about the fall and obtained an order to transfer Resident #1 to the Hospital Emergency Department for further evaluation. The Unit Manager said although she was not sure of the procedure, follow-ups to fall incidents were done by the Assistant Director of Nursing (ADON) and said that the ADON determined if there were to be new interventions after a fall. During an interview on 10/27/22 P.M. at 9:50 A.M. and 4:47 P.M., the Assistant Director of Nursing (ADON) said that an Incident Report and Post Fall Investigation was not completed after Resident #1 was found on the floor beside his/her bed on 05/14/22 and said they should have been done. The ADON said Resident #1's fall interventions were not re-evaluated, modified, and no new interventions were established after any of his/her falls on 01/27/22, 02/26/22, and 05/14/22. The ADON said Resident #1 fall interventions should have been re-evaluated for effectiveness after each of his/her falls, in an effort to maintain his/her safety.

Based on records reviewed and interviews for two of four sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that 1) for Resident #1, who had been found on the floor in his/her room by staff after experiencing three unwitnessed falls, that his/her plan of care was updated and that interventions were re-evaluated for effectiveness, and who then experienced a fourth unwitnessed fall resulting in a fracture, and 2) for Resident #2, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Facility's Policy, titled Falls and Falls Risk, Managing, dated as revised in 2017, indicated 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, based on previous evaluations and current data. The Policy indicated staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. Further review of the Policy indicated if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. The Policy indicated when monitoring subsequent falls and fall risk, if the resident continues to fall, staff will re-evaluate the situation whether it is appropriate to continue or change current interventions. Review of the Facility's Policy, titled Care Plans - Comprehensive, dated as revised in 2018, indicated an individualized comprehensive Care Plan that includes measurable objectives and timetables to meet residents' medical, nursing, mental and psychological needs is developed for each resident. The Policy indicated the assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes. 1. Resident #1 was admitted to the facility in October 2018, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she had short-term and long-term memory impairment and his/her ability to make decisions regarding tasks of daily living were severely impaired. The MDS indicated Resident #1 was non-ambulatory and required extensive assistance from two staff members for bed mobility and transfers. Review of Resident #1's At Risk for Falls Care Plan, dated as initiated 01/10/20, indicated he/she was at risk for falls due to right sided [CONDITION(S)] and a history of falls. The Care Plan included a goal to keep Resident #1 safe from falls and fall related injuries. Interventions identified for Resident #1 included the following: -Check for pain and medicate as ordered. -Cue as needed to enhance safe functional activities. -Cue verbally and visually to enhance the level of safety with transfers and ambulation. -Do fall assessment on admission, quarterly and with a fall. Review of the Facility Incident Report, dated 01/07/22, indicated that staff found Resident #1 on the floor next to his/her bed. Review of the Facility Incident Report, dated 02/26/22, indicated that a staff member found Resident #1 on the floor next to his/her bed. Review of Resident #1's Quarterly Nursing Evaluation, dated 05/09/22, indicated that he/she was assessed by nursing as being at an increased risk for falls. Review of Resident #1's Nurse Progress Note, dated 05/14/22, indicated he/she was found on the floor beside his/her bed. Review of Resident #1's Medical Record indicated there was no documentation to support that any new interventions had been established or that care plan interventions were re-evaluated for effectiveness in effort to prevent similar falls, after he/she was found on the floor beside his/her bed on 01/07/22, 02/26/22, and 05/14/22. There was no documentation to support how the facility planned to further address Resident #1's safety concerns or how to potentially prevent him/her from sustaining an injury from unwitnessed falls. During an interview on 10/27/22 at 4:47 P.M., the Assistant Director of Nurses (ADON) said Resident #1's At Risk for Falls Care Plan had not been updated after his/her falls on 01/27/22, 02/26/22 and 05/14/22. The ADON said that after a fall occurs, it was the Unit Manager's responsibility to update the Care Plan with any new or revised interventions and said his/her Care Plan should have been updated after each of the falls. Review of the Facility Incident Report, dated 07/18/22 at 5:13 A.M., indicated a CNA found Resident #1 on the floor next to his/her bed. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 07/18/22, indicated that while staff were performing rounds on 07/18/22 at approximately 5:13 A.M., Resident #1 was found on the floor next to his/her bed. The Report indicated an x-ray was obtained which revealed Resident #1 sustained a right femoral shaft fracture and was admitted to the Hospital for treatment. Review of the Hospital Discharge Note, dated 07/25/22, indicated Resident #1 was admitted to the Hospital with a right femoral fracture for which he/she underwent surgical repair. 2) Resident #2 was admitted to the Facility in September 2021, medical history included dementia. Review of Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 10 (scores of 8-12 indicates moderately impaired cognition). During an interview on 10/26/22 at 1:25 P.M., CNA #1 said Resident #2 was typically on her assignment when she worked the 7:00 A.M.-3:00 P.M. shifts. CNA #1 said that since Resident #2 was admitted to the Facility, he/she was able to leave the unit to walk around the Facility or go outside to the front of the Facility by himself/herself. During an interview on 10/26/22 at 2:40 P.M., CNA #2 said she typically worked on the 7:00 A.M. to 3:00 P.M. shift. CNA #2 said Resident #2 could go outside any time he/she wanted and said although he/she would typically go outside in the front of the Facility, she had once seen him/her sitting in a chair in the back of the Facility. During an interview on 10/26/22 at 3:05 P.M., CNA #3 said she typically worked on the 7:00 A.M. to 3:00 P.M. shift and said Resident #2 would leave the unit to walk around the Facility or to go outside in front of the Facility. During an interview on 10/26/22 at 3:22 P.M., CNA #4 said he worked both the 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. shifts. CNA #4 said on 10/19/22 he saw Resident #2 downstairs in the first floor lobby at 12:15 A.M. and said it was not unusual for him/her to go down to the lobby during the night. During an interview on 10/26/22 at 3:46 P.M., CNA #5 said that at 10:30 P.M. when she arrived for her 11:00 P.M. to 7:00 A.M. shift on 10/19/22, as she was speaking to a co-worker in the first floor lobby, she observed Resident #2 prop the front door (main lobby) of the Facility open, go outside for a few seconds, and come back inside the Facility. CNA #5 said Resident #2 went in and out a few times and said she told Resident #2 to go back to his/her unit. CNA #5 said it was not uncommon for Resident #2 to come and go off his/her unit during the evening shift. During an interview on 10/27/22 at 10:00 A.M., Resident #2's Physician said he/she had mild to moderate cognitive impairment at most and said he/she would go outside but could not leave Facility property without a responsible party with him/her. During an interview on 10/27/22 at 10:18 A.M., Resident #2's Nurse Practitioner said he/she would walk around the Facility and would go outside to smoke and converse with people. During an interview on 10/31/22 at 9:44 A.M., Nurse #3 said he worked on the 11:00 P.M. to 7:00 P.M. shift and had been assigned to Resident #2 many times. Nurse #3 said Resident #2 would leave the unit and would go downstairs or outside during the night. During an interview on 10/27/22 at 2:37 P.M., the Unit Manager said it was alright for Resident #2 to leave the unit anytime he/she wanted to. The Unit Manager said Resident #2 had been leaving the unit and going outside since she started working at the Facility seven to eight months prior. Review of Resident #2's Medical Record indicated there was no documentation to support that the Facility had established an individualized Care Plan with measurable goals and interventions that addressed and outlined Resident #2's ability to leave the unit, what hours were appropriate to leave the unit, what locations were appropriate for him/her to go when he/she left the unit, safety concerns regarding him/her propping the main door lobby open after hours, or how staff would be made aware when he/she left the unit. During an interview on 10/27/22 at 3:56 P.M., the Assistant Director of Nursing (ADON) said Resident #2 enjoyed going outside to sit in the sun or sitting in the first floor lobby. The ADON said not all residents were able to go outside by themselves like Resident #2 did. The ADON said she was not aware that Resident #2 had still been going outside and said she was not aware that he/she had been leaving the unit and going outside at all different hours. The ADON said there should have been a Care Plan established that addressed Resident #2 being able to leave the unit and go outside by himself/herself.

Based on observations, record reviews, and interviews, the facility failed to ensure that its staff provided adequate supervision, and reduce the risk of accidents/ hazards for three Residents (#178, # 175 and #104) out of a total sample of 30 residents. Specifically the facility failed to provide supervision for: 1) Resident #178 who eloped from the facility, was found off the facility premises in an altered medical status and was transported to the hospital for evaluation, and 2) Resident #175 and #104, during smoking and access to smoking materials. 3) Reduce the risk of accidents/hazards relative to ensuring laundry dryer lint filters were properly cleaned as required, hazardous smoking materials were stored properly on one Unit (B1), and medications and treatments were stored properly on one Unit (A2). Findings include: 1. For Resident #178 the facility failed to provide adequate supervision to prevent elopement which resulted in a hospitalization . Review of the facility policy titled Discharging a Resident without a Physician's Approval, dated October 2012, indicated, but is not limited to the following: - Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident's attending Physician will be promptly notified. - If the resident or representative (sponsor) insists upon being discharged without the approval of the attending Physician, the Resident and/or Representative (sponsor) must sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the Resident's medical record and witnessed by two staff members. Review of the facility policy titled Wandering and Elopements, dated March 2019, indicated the following: -If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the Resident's legal Representative, the attending Physician, law enforcement official, and (as necessary) volunteer agencies (i.e., emergency management rescue squads, etc.). Resident #178 was admitted to the facility in May 2022 with the following diagnoses: muscle weakness and abnormalities of gait and mobility. Review of the Minimum Data Set (MDS) Assessment, dated 6/6/22, indicated Resident #178 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15 indicating moderate cognitive impairment. Review of the progress notes indicated Resident #178 was on a MLOA (medical leave of absence) on 6/25/22, 6/26/22, and 6/27/22. The progress notes did not indicate the date, time or reason Resident #178 was on the MLOA. Review of the clinical record did not indicate Physician Orders for Resident #178 to be transferred or discharged from the facility. Review of the clinical record did not indicate any documented evidence that Resident #178 had signed a Release from Responsibility for Discharge (Against Medical Advice or AMA) form. Review of the hospital Emergency Medicine Note, dated 6/24/22 at 7:16 P.M., indicated the following: -Resident #178 currently resided at a skilled nursing/rehab facility, a bystander called 911, after finding Resident #178 lying on the ground. The Resident was found to be hypotensive (low blood pressure), mildly [CONDITION(S)] (rapid heart rate) which improved with one liter of Intravenous (IV) fluids, hypomagnesemic (low magnesium in the blood) and to have Pneumonia on x-ray. Resident #178 reported to hospital staff that he/she felt lightheaded and dizzy and was unsure if he/she had passed out or not. Review of the hospital History and Physical Note, dated 6/24/22 at 10:57 P.M., indicated the following: -Resident #178 was found lying on the side of the road, a bystander called 911, and Resident #178 complained of lower back pain and was Spanish speaking only. Staff at the nursing home facility reported that Resident #178 had eloped. Resident #178 indicated in the hospital note that he/she had walked for about one and a half hours in the heat until he/she could not walk anymore and collapsed by the roadside. hospitalization of Resident #178 was requested for continued care. Review of the hospital Social Service Form, dated 6/27/22 at 12:39 A.M., indicated Resident #178 eloped from the nursing home facility and was brought to Emergency Department via ambulance after he/she was found lying on the side of the road. When asked why the resident left the nursing home facility, he/she reported that he/she just wanted to go home. During an interview, on 6/28/22 at 11:42 A.M., the Director of Nursing (DON) said Resident #178 went home and that the facility did not complete an investigation of the incident. She further said there should have been documentation in the chart as to how Resident #178 was discharged from the facility but there was not. During an interview on 6/28/22, at 12:32 P.M., the DON said she had been notified the evening of 6/24/22, by Nurse #15, that Resident #178 had left the facility against medical advice (AMA). The DON said that she had called Nurse #15 today for more details, but he had not responded. She said that she had called Unit Manager (UM) #1 today, 6/28/22, and was waiting for her to update the progress notes for Resident #178. Review of the Nurses Progress Note, dated 6/28/22, at 12:54 P.M., indicated UM #1 spoke to Nurse #15 on 6/24/22, at 10:07 P.M. who informed her that he had received a call from the hospital reporting that Resident #178 had been transported to the hospital by ambulance. The note indicated Nurse #15 told UM #1 that the Resident had packed his/her belongings and had signed out at some point during the 3:00 P.M. to 11:00 P.M. shift. The note indicated Nurse #15 told UM #1, that Resident #178 had left the facility and walked off the premises, must have passed out, and that someone called 911 to help him/her. During an interview on 6/28/22 at 2:29 P.M., UM #1 said that she received a telephone call from Nurse #15 on 6/24/22 at approximately 6:50 P.M. She said Nurse #15 informed her that he had received a call from the hospital reporting that Resident #178 had been taken there and he/she had signed out of the building at the front desk. UM #1 said that she informed the DON via text message. In addition, UM#1 said that the following morning (on 6/25/22), she received a call from the day shift (7:00 A.M. to 3:00 P.M.) Nurse reporting Resident #178 missing. She further said that Resident #178 received a Notice of Medicare Non-Coverage (NOMNC-a form which must be delivered at least two days before covered services end) on 6/24/22. During an interview on 6/28/22 at 3:51 P.M., Certified Nurse Aide (CNA) #9 said she saw Resident #178 standing in the doorway of his/her room with a bag in his/her hand on 6/24/22 at 3:00 P.M. She said she asked the day shift Nurse if the Resident was going home and was told that he/she was not scheduled to be discharged . CNA #9 said sometime after 4 :00 P.M., she asked Nurse#15 if he had seen Resident #178 and Nurse #15 said that he had not seen him/her. CNA #9 said she then went outside and saw Resident #178 standing outside in the front of the facility where other Residents were sitting. She said she did not notice any belonging with him/her. She said when she returned to the nursing unit, she informed Nurse #15 that the Resident was outside. CNA #9 said that this was the only time she checked for the Resident outside and that when she delivered Resident #178's dinner tray to his/her room between 5:30-6:00 P.M., the Resident was not there. CNA #9 said at approximately 6:30-7:00 P.M., she was at the desk, and Nurse #15 received a telephone call from the hospital. CNA #9 said that Nurse #15 left the unit, went to the reception desk, and returned and told her that he had looked at the Leave of Absence sign-out sheet and Resident #178 had signed out of the facility. Review of the facility Release of Responsibility or Leave of Absence form, located at the reception desk, indicated Resident #178 did not sign out of the facility. During an interview on 6/29/22 at 9:41 A.M., Receptionist #2 said she was at the reception area on 6/24/22 from 4:15 P.M. to 6:30 P.M. and did not see Resident #178 outside of the building. She further said she did not see anyone in the driveway or walking on the road. Receptionist #2 said that there was a group of regulars that go outside, and that they were the only residents that she saw leave the building. Receptionist #2 said if a resident she does not know approaches the front doors, she will ask them to wait while she calls the Nurse and asks the Nurse if they can go outside. She said that she was not aware of a system to identify which residents can go outside unsupervised. During an interview on 6/29/22 at 10:25 A.M., Medical Records Staff said that she was at the reception area on 6/24/22 at 4:00 P.M., and gave report to Receptionist #2 when she came in. Medical Records Staff said that she did not see any Residents other than the regulars leave the building. She said that there was an Elopement book at the reception desk that identifies Residents that are at risk for elopement. She said that the doors are always locked from the outside, but people can leave at any time unless they are wearing an alarm at which point a staff member would need to enter a code. Review of Resident #178 Baseline Care Plan, dated 5/31/22, indicated no documented evidence that the Resident was assessed for elopement risk. During an interview on 6/28/22, at 3:00 P.M., Social Worker (SW) #1 said that she had learned today, about ten minutes previously, that Resident #178 had left the building on 6/24/22 and was admitted to the hospital. She said the Resident had been given a NOMNC on 6/24/22, that he/she wanted to go home on 6/24/22 after receiving the NOMNC letter, but she informed the Resident that he/she would need to stay at the facility until the next week when services could be arranged. SW #1 said that the Resident had agreed to stay at the facility. During an interview on 6/29/22 at 10:40 A.M., Nurse Practitioner (NP) #1 said she worked in the facility on 6/25/22 and was informed on that morning that Resident #178 had eloped the evening before and was brought to the hospital. During an interview on 6/29/22 at 12:16 P.M., the Administrator said the incident involving Resident #178 was reported to him as a discharge AMA, and that the Resident had a right to leave the facility. The Administrator said Resident #178 did not sign an AMA Release of Responsibility for Discharge form nor did Resident #178 sign a Release of Responsibility Leave of Absence form indicating he/she was leaving the facility. During an interview on 6/29/22 at 12:16 P.M., the DON said that she received a text message from Nurse #15 on 6/24/22 after 10:00 P.M. indicating that Resident #178 had signed out AMA. The DON said that she could not investigate the incident without a statement from Nurse #15 and that he had not returned her calls. On 6/28/22 at 2:25 P.M.,. the surveyor called and text messaged Nurse #15. Nurse #15 called back on 7/8/22 at 9:23 A.M. During an interview on 7/8/22, at 9:23 A.M., Nurse #15 said he reported to work on 6/24/22 at 3:00 P.M. and did not see Resident #178 in his/her room or on the unit. He further said that the Resident could have been gone before he reported to work. He said that he was very busy and there was only one CNA working on the unit at 3:00 P.M. He said that he had not been notified that the Resident was outside. Nurse #15 said at approximately 6:30 P.M., he received a call from the hospital telling him that Resident #178 was in the emergency room . 2. For Resident #175, the facility staff failed to implement their Smoking Policy/Procedure relative to supervision provided and location of smoking materials. Review of the facility Smoking Policy and Procedure, undated, indicated the purpose of the policy was to protect residents' rights while ensuring the highest level of safety for both residents and staff from the serious consequences that may result from fire and and/or smoking activities. The policy also indicated: -for safety reasons, residents may not possess smoking paraphernalia including but not limited to tobacco products, lighters, matches or other smoking materials. These items must be turned over to facility staff so they may store them. -during designated smoking times, these items will be provided to residents to use in the designated smoking area under supervision -facility staff are responsible for igniting/lighting all resident smoking materials -designated smoking times are 10:30 A.M., 1:30 P.M., 4:00 P.M. and 8:30 P.M. -the facility reserves the right to conduct random, routine and for suspicion room searches for smoking materials not surrendered by the resident/resident agent. The facility will endeavor to conduct searches within the presence of the resident/agent and always maintain resident dignity. If the resident/agent is not present, two senior facility staff members must conduct the search, with the consent of the Administrator. All smoking contraband will be removed and properly stored. Resident #175 was admitted to the facility in June 2022. Review of the Resident Smoking List, provided to the survey team upon entrance, indicated Resident #175 was listed as an active smoker. Review of the Smoking Evaluation, dated 6/16/22, indicated Resident #175 was a smoker and required constant supervision when smoking. Review of Resident #175's Comprehensive Plan of Care did not indicate he/she smoked. During an observation and interview on 6/28/22 at 8:26 A.M., Resident #175 who was dressed and seated at the edge of the bed in his/her room, said that he/she was an independent smoker and was able to go outside to smoke whenever he/she wanted. Resident # 175 said that smoking materials including his/her cigarettes and lighter were kept in his/her unlocked bedside drawer and that he/she was able to keep them because he/she was an independent smoker. During an interview on 6/29/22 at 9:14 A.M., Nurse #13 said that residents who smoke were supposed to be supervised by facility staff and adhere to a smoking schedule. She further said that smoking materials should be locked up by the facility staff and a process should be in place for distributing smoking materials during the resident smoking breaks, but there was not one in place. Nurse #13 said that she has worked at the facility for over a year, had attempted to talk to facility administration about these safety concerns and nothing has been done. On 6/29/22 at 5:45 P.M., the surveyor observed Resident #175 seated outside in a stationary chair smoking a cigarette. There was no staff present with Resident #175 during the observation. During an interview on 6/29/22 at 12:09 P.M., the Administrator said that the facility had independent and supervised smokers. He said that residents who smoke have been assessed by facility staff and if they are determined to require supervision then a facility staff member had to be outside with them during the scheduled smoking times. The Administrator said that smoking materials must be kept at the Nurses medication cart for all residents who smoke and are returned to the Nurse after the smoking break concluded. The Administrator was informed by the surveyor during the interview regarding the concerns about unsecured smoking materials in Resident #175's room and the determination per the smoking assessment that Resident #175 was to be supervised. 3. The facility failed to ensure smoking materials were stored securely when not being used on the B1 Unit. During an interview on 6/23/22 at 1:12 P.M., Resident #104 said he/she kept his/her cigarettes and lighter in his/her room. During an observation on 6/27/22 at 10:12 A.M., the surveyor observed a lighter in the open in Resident #104's room, on the bedside table, while the Resident was not in his/her room. During an interview on 6/27/22 at 10:14 A.M., the surveyor and Nurse #5 observed the lighter in Resident #104's room. At the time of observation Nurse #5 said the lighter should not be in the Resident's room, as it is a hazard, and it should be locked up in the Nurse's cart. She proceeded to remove the lighter and notified the Resident that it was being put in the Nurse's cart. 4. The facility failed to ensure staff cleaned the lint filter for one of three dryers in the laundry room. On 6/21/22 at 2:58 P.M., while touring the laundry room with the Housekeeping Director, the surveyor observed that one of three dryers had a thick coating of lint in the filter. Review of the Dryer Lint Trap Log for June 2022 indicated the dryer had not been cleaned since 10:00 A.M Further review of the sheet indicated no documentation that the lint filters had been cleaned from 1:00 P.M. on 6/14/22 till 1:00 P.M. on 6/15/22. During an interview following the observation the House Keeping Director said the lint filter should be cleaned every hour and the lint build up that was observed in the dryer was more than an hours' worth of lint. He further said he was unable to tell if the lint filters have been cleaned during the times in question on 6/14/22 and 6/15/22, and the hours that were not signed off on, for 6/21/22. He said that the lint filter cleaning log should be signed off on directly after the lint filters are cleaned and this had not been done on the days in question as required. 5. The facility staff failed to ensure one medication cart out of three units and one treatment cart (a cart containing various medical supplies and topical ointments and liquids) out of three units were secured as required. Review of the facility policy titled, Storage of Medications, dated 2017, included the following: - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On the Unit B1 on 6/24/22 at 8:07 A.M., the surveyor observed an unlocked, unattended medication cart next to the Nurse's station. There was no facility staff observed anywhere in the immediate vicinity, and residents and a visitor were in the immediate area of the medication cart. At 8:10 A.M., a facility staff member came out of a Resident's room to tend to an employee of a transportation company who had arrived to transport a Resident to an appointment. The entire duration of the employee's interaction was with the transportation employee, her back was turned away from the unlocked medication cart. At 8:12 A.M., Nurse #16, who was behind closed doors in Room 111, located behind the Nurse's station, opened the door to the room, poked her head out, went back in and closed the door. At 8:14 A.M., Nurse #16 then exited Room 111 to look for assistance with the Resident in Room 111, observed the surveyor at the Nurse's station and observed the medication cart was not locked and subsequently secured the cart. She said the cart should have been locked and it was not as required. On Unit A2 on 6/30/22 at 10:50 A.M., the surveyor observed an unlocked, unattended treatment cart in a hallway around the corner from the Nurse's station. There were Residents in the immediate area. At this time, Nurse #4 and Nurse #9 were seated at the Nurse's station around the corner conversing. The surveyor alerted both Nurses of the unsecured treatment cart around the corner. They nodded acknowledgment and went back to their conversation. On 6/30/22 at 11:20 A.M., the surveyor observed the treatment cart remained unlocked, still with Residents in the immediate vicinity and Nurse #4 and Nurse #9 at the Nurse's station around the corner. The surveyor again brought their attention to the unlocked treatment cart. Nurse #4 apologized and said she thought the surveyor secured it for them when it was mentioned at 10:50 A.M., got up from the Nurse's station, went around the corner and locked the cart. 6. The facility failed to ensure that a medication cart was locked when unattended on the A2 Unit. On 6/27/22 at 4:56 P.M., the surveyor observed one of the medication carts on the A2 Unit unattended and unlocked. There were Residents and staff in the hallway by the cart. During an interview on 6/27/22 at 4:59 P.M., Nurse #6 said the medication cart should be locked and she said she did not do that as required. During an interview on 6/27/22 at 5:01 P.M., Unit Manager (UM) #2 said the medication cart should be locked when unattended and this was not done as required.

Based on observations, interviews and record reviews the facility failed to ensure staff provided care in accordance with professional standards of practice for five Residents (#28, #70, #43, #95 and #117), out of the 30 residents sampled specifically when they 1) Failed to properly store medications, 2) Allowed unlicensed staff to apply prescription medications, 3) Failed to obtain specialty consults as ordered by the physician, 4) Failed to administer medication in a timely manner, 5) Failed to follow medication and treatment orders prescribed by the physician and 6) Failed to collaborate with hospice for the Patient's plan of care. Findings include: 1. For Resident #28, the facility failed to provide care consistent with professional standards for a skin condition by: A) improperly storing prescription creams, B) application of prescription treatments by unlicensed personnel, C) failing to obtain a psychiatric consult, and D) administering medications beyond the two-hour medication administration window which resulted in increased physical and emotional discomfort for the Resident. Resident #28 was admitted to the facility in September 2021 with Psoriasis (a long-[MEDICATION(S)] skin disease characterized by raised, red, dry and itchy patches) and anxiety disorder. Review of the Minimum Data Set (MDS) Assessment, dated 3/23/22, indicated the Resident scored 15 out of 15 on the Brief Interview of Mental Status (BIMS) and was cognitively intact. On 6/21/22 at 11:46 A.M., the surveyor observed a large container of prescription cream in Resident #28's room. The Resident stated he/she has had Psoriasis for a long time, but this was the worst the Psoriasis had been. Resident #28 also said that a Dermatologist had seen and ordered medications for the rash. On 6/22/22 at 11:55 A.M., the surveyor observed Resident #28 lying in bed and observed a reddened rash on his/her bilateral lower arms, face and lower legs. There was a large container of prescription cream on the top of the dresser and the pharmacy label indicated it was to be applied twice daily. Resident #28 said the rash was all over his/her body, he/she had always had it, and the Dermatologist thought the rash had worsened due to stress and ordered a Psychiatric consult. On 6/23/22 at 10:24 A.M., the surveyor observed Resident #28 in his/her room. There were patches of redness and scabbed areas over his/her back, abdomen, groin, arms, and legs with several small superficial open areas. Resident #28 said the rash was a little less itchy, but he/she had scratched it a lot. The Certified Nurse's Aide (CNA) #6 arrived to provide care and showed the surveyor the prescription cream that was in the top drawer of the dresser. During an interview at the time of the observation, CNA #6 said that the CNAs put the cream on when Resident #28 asked for it and said that the Nurses also applied the cream. He said when he was in the room providing care, he had applied the cream himself, rather than get the Nurse who is all the way up the hallway. During an interview on 6/28/22 at 9:23 A.M., Resident #28 said he/she was concerned about the staffing on weekends and nights, and that medications were not given on time; one day morning medications were not given until 2:30 P.M. Resident #28 said that he/she knows which medicines he/she gets and when he/she was supposed to get them, it was upsetting to get the medications so late and when he/she gets upset the rash and itch worsens. Review of Resident's record indicated Resident #28 declined to self-administer medications and preferred the Nurse to administer medications. Review of the June 2022 Physician's Orders indicated the following active orders: -[MEDICATION(S)] (a medication used to treat itching) tablets give 10 milligrams (mg: measurement denoting strength) by mouth three times a day -[MEDICATION(S)] Cream 0.05% (a topical skin treatment to decrease inflammation and irritation) apply to generalized skin rash every day and evening shift, and as needed for psoriasis (6/9/22). -Triamcinolone [MEDICATION(S)] Cream 0.1% (a treatment applied directly to the skin to reduce redness, swelling and itching) apply to skin rash/[CONDITION(S)] topically two times a day for psoriasis 5/18/22. -[MEDICATION(S)] (a medication used to treat anxiety disorder) tablet 20 mg by mouth once a day (9/16/21) Review of the Medication Administration Audit Report for June 2022 indicated the following: -[MEDICATION(S)] was documented as given outside the two-hour medication window five times out of 28 opportunities during the month of June. -[MEDICATION(S)] was documented as given outside the two-hour medication window on the day shift four times out of 56 opportunities during the month with medication given at 2:24 P.M. on 6/10/22 and 1:33 P.M. on 6/25/22. On the evening shift, [MEDICATION(S)] was documented as administered beyond the two-hour window nine times out of 28 opportunities during the month of June. -Triamcinolone was documented as administered outside the two-hour medication window eight times on the day shift and eight times on the evening shift during the month of June. -[MEDICATION(S)] was documented as administered outside the two-hour administration window five times on the day shift and four times on the evening shift in the month of June. Review of the Resident's record indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] There was no evidence in the record that the Psychiatric consult had been completed. Review of the Nursing Care Plan indicated a Skin Rash Care Plan was initiated 6/24/22, during the survey. During an interview on 6/28/22 at 12:41 P.M., Unit Manager (UM) #2 said she was not aware of late administration of medications. She said there were times when the Nurses were not available to administer resident medications at 7:00 A.M., but should definitely be on the medication cart by 8:00 A.M. to dispense Resident medications. She said there was supposed to be a medication error report completed if medications are given outside the administration time (one hour before/after the scheduled administration time). During an observation on 6/23/22 at 11:32 A.M., UM #2 accompanied the surveyor to Resident #28's room and together observed the Triamcinolone cream and [MEDICATION(S)] cream, both with pharmacy labels, which were in the Resident's top dresser drawer. The [MEDICATION(S)] cream was uncapped. There was also a tube of hydrocortisone cream, unlabeled, in the Resident's dresser drawer. During an interview at the time of observation, UM #2 said that prescription creams were to be locked up in the treatment cart at all times, and prescription treatments should only be applied by Licensed Nurses as ordered, after an assessment of the rash. She said the prescription creams were improperly stored and not locked up as required and were being applied by unlicensed personnel which was against the facility policy. During an interview on 6/30/22 at 2:08 P.M., the Regional Nurse Assistant confirmed that there was an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. For Resident #70, the facility failed to provide diabetic care in accordance with professional standards of practice by failing to: A) routinely administer insulin on a timely basis, B) implement an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Nursing Care of the Older Adult with Diabetes Mellitus, revised November 2020 indicated the purpose of the policy was to provide an overview of diabetes in the older adult including symptoms, complications, and the principles of glucose monitoring and refers the reader to Standards of Medical Care in Diabetes by the American Diabetes Association for further education and guidelines. In addition, the policy included the following: -complications from diabetes can be contributed to uncontrolled [CONDITION(S)] and subsequent damage to the vasculature and overtreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -glycemic targets (goals for blood sugars) are 90-130 milligrams per deciliter (mg/dl) for a fingerstick blood sugar done prior to meals for a healthy older adult and can be less stringent for adults with chronic illnesses. Resident #70 was admitted to the facility in February 2022 with Diabetes Mellitus (a chronic condition that affects the body's ability to process glucose: blood sugar). Review of the Physician's Orders for June 2022 included the following: -If blood sugar is greater than 400 mg/dl, recheck and notify Physician. Once the patient is treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . -[MEDICATION(S)] solution (a medication used to increase insulin secretion and delay emptying of the stomach in an effort to lower blood sugar elevations after meals) pen injector 0.75 mg/0.5 milliliter (ml): one application subcutaneously (SC: under the skin) one time every Monday for diabetes, initiated 6/20/22. -[MEDICATION(S)] (Insulin [MEDICATION(S)]: a type of short acting insulin administered around mealtime used to control blood sugar) solution 100 unit/ml inject subcutaneously as per sliding scale (dosage of medication based on the blood sugar at the time of administration), initiated 4/2/22 -Insulin [MEDICATION(S)] solution 100 units/milliliter inject 3 units SQ before meals for diabetes management (initiated 6/23/22) -Insulin [MEDICATION(S)] ([MEDICATION(S)]: a long acting insulin used in the management of diabetes to reduce blood sugar) solution 20 units SQ for glycemic control at bedtime ordered 6/16/22 and discontinued on 6/22/22. A new order for [MEDICATION(S)] 5 units daily was ordered on 6/22/22 and a new order for insulin [MEDICATION(S)] 18 units SQ daily written at 10:45 A.M. on 6/23/22 and discontinued on the same day, and Insulin [MEDICATION(S)] 5 units SC daily at 1:30 P.M. initiated on 6/23/22 -Insulin [MEDICATION(S)] solution, inject 5 international units SQ at bedtime for glycemic control (initiated 6/23/22) -Decrease [MEDICATION(S)] to 5 units daily, check FBS at 4:00 A.M. and 6:00 A.M. daily (initiated 6/22/22) -Insulin [MEDICATION(S)] solution 100 units/ml, inject 3 units SQ before meals for diabetes (initiated 6/23/22) A) Review of the Medication Administration Audit Report for June 2022 indicated: -the [MEDICATION(S)] Insulin ordered to be administered prior to the breakfast meal was administered late three times out of 12 opportunities -the [MEDICATION(S)] Insulin ordered to be administered prior to the lunch meal was administered late twice out of 16 opportunities -the [MEDICATION(S)] insulin ordered to be administered prior to lunch was administered late twice out of five opportunities -the [MEDICATION(S)] insulin ordered to be administered prior to breakfast was administered late once out of five opportunities -the [MEDICATION(S)] Insulin administration ordered to be administered prior to supper meal was documented as given late one time on the 3:00 P.M. to 11:00 P.M. shift out of five opportunities -the bedtime dose of [MEDICATION(S)] insulin was documented as administered late on six out of 20 opportunities -the [MEDICATION(S)] Insulin ordered to be administered prior to the supper meal was documented as administered late twice out of five opportunities During an interview and review of the 6/2022 Medication Administration Audit Reports on 6/30/22 at 9:46 A.M. with the surveyor, UM #2 said the medication pass process was pouring the medications for the resident, administering the medications to the resident, and then returning to the medication cart to document that the medications were administered. If the medication administration was not charted at the time of administration, she said that was a medication error and an error report needed to be completed. She said further that the late administration had to be reported to the on-call physician or practitioner because other medications may have to be adjusted as a result. UM #2 said she was not able to provide the medication error reports to the surveyor as none were completed for this Resident. B) Review of the 6/2022 Physician's Orders indicated Endocrinology consults ordered on 4/4/22 and 6/2/22. Review of the Resident's clinical record indicated no documented evidence that outpatient endocrinology consults were scheduled and/or completed for Resident #70, as ordered by the Physician. C) The facility failed to ensure staff obtained and documented results of fingerstick blood sugars as ordered. Review of the June 2022 Physician's Orders indicated an order to add an additional fingerstick blood sugar daily at 4:00 A.M. (initiated on 6/20/22). Further review of the Physician's Orders indicated an additional order, initiated 6/22/22, to check the Resident's fingerstick blood sugar daily at 4:00 A.M. and 6:00 A.M. Review of the June 2022 Medication Administration Record (MAR) indicated the 4:00 A.M. fingerstick blood sugar was documented as completed on 6/21/22, 6/22/22 and 6/23/22, but there was no documented evidence of the results in the Resident's clinical record. Further review June 2022 MAR indicated no documented evidence that the order to check the Resident's blood sugar at 6:00 A.M. was transcribed into the MAR and was completed as ordered. During an interview on 6/23/22 at 12:32 P.M., Nurse Practitioner (NP) #1 said she had ordered additional blood sugar testing during the night because the Resident's blood sugar was very labile (likely to change), had bottomed out at night resulting in Resident #70 being transferred to the hospital. NP #1 reviewed the June 2022 MAR with the surveyor, and said the 4:00 A.M. blood sugars had been charted as done but the results were not evident within the clinical record. She further said she was very frustrated because orders for Resident #70 were not implemented. D. and E.) The facility failed to ensure staff provided the necessary monitoring and treatment to prevent and treat an episode of [CONDITION(S)] which resulted in the Resident being sent to the emergency room . Review of the facility policy titled Management of [CONDITION(S)] (a low blood sugar, as defined by the American Diabetes Association as less than 70 milligrams per deciliter: blood concentration), revised 11/2020, indicated the following: -signs and symptoms of [CONDITION(S)] have a sudden onset and may include weakness, moist skin, excessive perspiration, stupor, and unconsciousness -[CONDITION(S)] may be classified as: Level 1: blood glucose less than 70 mg/dl but greater than 54 mg/dl, Level 2: Blood glucose less than 54 mg/dl, Level 3: altered mental and or physical status requiring assistance for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -if a Resident has Level 3 [CONDITION(S)] and is unresponsive: call 911, administer [MEDICATION(S)], notify the provider, remain with the resident, place the resident in a safe place and monitor the resident's vital signs. Review of the clinical record indicated Resident #70 was sent to the hospital on seven occasions since his/her admission. Review of Hospital Progress Notes, dated 3/31/22, indicated that Resident #70 was a brittle diabetic, had been discharged from the hospital for [CONDITION(S)] earlier that day, and was re-presenting to the hospital via emergency medical services with a concern for [CONDITION(S)]. The note further indicated that the [CONDITION(S)] was suspected to be medication induced as the dosage of insulin [MEDICATION(S)] was capped (not to be administered more then) 4 units by the endocrine team (composed of specialists in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record indicated that Resident #70 was transferred to the emergency roiagnom on [DATE] for [CONDITION(S)] and unresponsiveness. Review of the June 2022 Physician's Orders indicated the following: -Glucerna (a dietary supplement drink for diabetics) ordered 4/28/22 -Carbohydrate Controlled diet, regular texture, thin liquids consistency ordered 2/14/22. -[MEDICATION(S)] ([MEDICATION(S)]: a rapid acting injectable form of glucose used to reverse low blood sugars in an unresponsive resident): inject 1 milligram subcutaneously every four hours as needed for hypoglycemic protocol. Special instructions: if fingerstick blood sugar is below 60 mg/dl and unable to swallow, recheck fingerstick in 10 minutes and update provider (initiated 2/8/22) -Glucose 45 Gel 40% (a rapid acting form of sugar given orally) give one dose by mouth every 4 hours as needed for hypoglycemic protocol (initiated 2/8/22) -Monitor for signs and symptoms of hypo/[CONDITION(S)] every shift (initiated 2/8/22) Review of a Nurse's Progress Note, dated 6/19/22 at 9:24 P.M., indicated the Resident was found unresponsive and diaphoretic (sweating) with a fingerstick blood sugar of 60 mg/dl. Emergency Medical Services (EMS) was called and when they arrived, they rechecked the Resident's blood sugar and it was 36 mg/dl. Review of the June 2022 MAR indicated no documented evidence that Resident #70 had received [MEDICATION(S)], as ordered by the Physician. Review of hospital records Emergency Medicine Note, dated 6/19/22 at 8:24 P.M., indicated Resident #70 presented with [CONDITION(S)], the symptoms had resolved, and that EMS had administered [MEDICATION(S)] along with an intravenous infusion of dextrose (sugar) and water. The note indicated the Resident was responsive and felt well at the time of the hospital admission, was diagnosed was [CONDITION(S)] and acute insulin reaction, and discharged back to the facility on the same day at 9:35 P.M. During an interview on 6/29/22 at 5:10 P.M., Nurse #6 said she administered Resident #70's insulin via sliding scale per his/her Fingerstick Blood Sugar reading and when she went to administer the evening medications she noted that the Resident was drowsy, diaphoretic, and awake but not responding. Nurse #6 said a Fingerstick Blood Sugar was checked and it was 60 mg/dl. She said she called the EMS, who arrived shortly after as she passed by them when going downstairs to print up transfer forms. Nurse #6 said she left Resident #70 with a Certified Nurses Aide during this time. Nurse #6 further said there was no [MEDICATION(S)] available in the building, so she was not able to administer the dosage of [MEDICATION(S)] as ordered and that she was unsure what the Resident's meal consumption was at supper that night. Nurse #6 said that Residents with diabetes usually get a snack at bedtime, and that the Certified Nurses Aides give them whatever was available. Review of the Meal Percentage Intake Sheets, dated 6/19/22, indicated Resident #70 was documented as consuming 76-100% of his/her supper meal at 4:05 P.M. Review of the Evening Snack documentation for 6/19/22, indicated Resident #70 consumed 100% of an evening snack at 3:50 P.M. During an interview on 6/29/22 at 9:03 A.M., the Corporate Food Service Director (FSD) said that Resident #70 was diabetic and was on a Carbohydrate Controlled Diet. He said the evening tray line starts around 4:30 P.M., and that Resident #70's tray was on the last cart delivered in the building. The Corporate FSD said the kitchen staff deliver a tray of snacks to the units twice daily at 7:00 A.M. and 7: 00 P.M. and that it was the responsibility of the Nursing staff to provide the diabetic residents with a snacks from the snack trays provided. During an interview on 6/29/22 at 3:27 P.M., CNA #5 said she didn't think Resident #70 ate dinner the night of 6/19/22. She said there was supposed to be five CNAs on the unit, but on that day there were only two CNAs on that evening because it was Father's Day weekend. She said resident charting was difficult when the unit was short staffed. CNA #5 said that supper trays arrive to the unit between 4:30 P.M. and 5:30 P.M., and that she usually documented Resident intake of meals at the end of the shift. During a review of the CNA documentation for 6/19/22, CNA #5 said the documentation indicated Resident #70 consumed the supper meal prior to when it would have been delivered. She further said that the documentation indicated Resident #70 consumed his/her evening snack prior to when it would have been delivered at 7:00 P.M., and that she was unsure if the documentation was accurate. She further said she should have documented the amount consumed by Resident #70 after the meal/evening snack was provided and not prior to ensure the documentation was correct. During an interview on 6/30/22 at 9:46 A.M., UM #2 said the CNAs were responsible for documenting the percentage of a meal or snack taken by Residents, and that the documentation should be completed after the meal or snack was consumed. UM #2 said Resident #70's documented intake prior to the meal/evening snack served on 6/19/22 was inaccurate and made it impossible to know how much he/she actually consumed, if any, on the evening shift (3:00 P.M. to 11:00 P.M.). She further said Residents with diabetes should receive an evening snack, and that Resident #70 currently did not have a Physician's Order to provide one. UM #2 further said that the Nurse should be monitoring and documenting intake every shift for diabetic resident and if a nurse administered insulin prior to a meal, and then the meal was not consumed by the Resident, that this could result in a low blood sugar level. UM #2 said the facility staff cannot safely provide care for 48-53 residents with only two Nurses and two CNAs. During an interview on 6/30/22 at 12:52 P.M., the Regional Nurse Assistant said that there were only two CNAs on the A2 Unit on the evening of 6/19/22. She said that there was [MEDICATION(S)] in the building and the [CONDITION(S)] protocol should have been followed and was not for Resident #70. 3. For Resident #43, the facility failed to ensure the air mattress was set at the appropriate setting. The resident has a history of skin impairment requiring preventative measures to maintain skin integrity. Resident #43 was admitted to the facility in August 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2022 Physician's Orders, initiated on 3/30/22, indicated for an air mattress to be applied to the Resident #43's bed which was to be set to weight/comfort, set the air mattress at 180 (pounds/lbs) and to monitor the setting/function every shift. Further review of the June 2022 Physician's Orders indicated additional orders to float the Resident's heels and numerous treatments to be administered to his/her right foot and toes. In addition, there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #43's clinical record indicated the following weights: -161.2 (6/14/22) -160.9 (5/9/22) -167.7 (4/4/22) -167.7 (3/31/22) On 6/21/22 at 1:24 P.M., the surveyor observed Resident #43 lying in bed with the air mattress set to 200 lbs. On 6/24/22 at 8:20 A.M., the surveyor observed Resident #43 lying in bed with the air mattress set to 200 lbs. There was a sticker on the air mattress box which indicated to set the air mattress to 200 lbs. On 6/29/22 at 1:51 P.M., the surveyor observed Resident #43 lying in bed with the air mattress set to 200 lbs. Review of the 6/2022 Treatment Administration Record (TAR) indicated the Resident's air mattress was monitored on most shifts (some missing documentation was noted), and indicated that the air mattress setting was at 180 lbs on the dates observed by the surveyor (6/21/22, 6/24/22 and 6/29/22). During an observation and interview on 6/30/22 at 1:15 P.M., the surveyor who was accompanied by the Regional Nurse Assistant, observed Resident #43's air mattress which was set between 180 and 200 lbs. The sticker on the air mattress box indicated for it to be set at 200 lbs. When the surveyor asked what the air mattress should be set at, Regional Nurse Assistant said that it should be set to the Resident's weight. She further said that resident weights are obtained monthly and that the air mattress settings should be updated based on the newly obtained weight. The Regional Nurse Assistant said that Resident #43's air mattress was not set appropriately, was not based on his/her most recent weights, and the Physician's Order needed be updated. 4. For Resident #95, the facility failed to provide evidence of ongoing collaboration with Hospice services relative to the development, implementation and revision of the coordinated plan of care. Review of the facility policy entitled Hospice Program, updated 2017, indicated when a resident participated in a hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. Resident #95 was admitted to the facility in December 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the June 2022 Physician's Orders indicated an order, dated 4/29/22, for a Hospice referral and for admission Hospice services if indicated. Review of the Change of Status Minimum Data Set (MDS) Assessment, dated 5/11/22, indicated Resident #95 was receiving Hospice services while in the facility. On 6/21/22 at 11:35 A.M., the surveyor observed the door to Resident #95's room was closed. During an interview at this time, Nurse #8 said that Resident #95 was on Hospice services and was receiving care from facility staff at that time. On 6/24/22 at 8:10 A.M., the surveyor observed Resident #95 lying in bed with his/her eyes open, dressed in a hospital gown. Review of the Resident #95's Comprehensive Plan of Care did not indicate a Hospice Plan nor any indication of services and frequency of services provided by the Hospice entity. During a review of the clinical record with Nurse #8, Nurse #2 and the Regional Nurse Assistant on 6/30/22 at 3:00 P.M. indicated weekly progress notes from the Hospice Nurses regarding medication recommendations only. There was no documented evidence of Hospice services provided to Resident #95 nor a Hospice plan of care. Nurse #2 and Nurse #8 said that an older lady visited Resident #95 and checked in with facility staff once in a while and would ask if they want the Resident's vital signs (blood pressure, respiratory rate, temperature, pulse), but they were unclear if she was a Nurse or another discipline. Both Nurse #2 and Nurse #8 said that they were not aware of how frequently the Hospice Nurses or other Hospice interdisciplinary staff members including Social Work or Chaplin visit Resident #95, and that the facility and Hospice should be collaborating regarding the Resident's plan of care. 5. For Resident #117, the facility failed to ensure that the air mattress used to prevent skin conditions was set appropriately. Resident #117 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MDS Assessment, dated 5/26/22, indicate that Resident #117 was at risk for developing pressure ulcers and used a pressure reducing device for the bed. Review of Resident #117's Skin Care Plan, revised 3/28/22, included an intervention for the air mattress to be set at 4 BARS (setting on the mattress which indicated firmness/softness)/comfort, and to check the setting/function every shift. Review of Resident #117's June 2022 Physicians Orders, revised 3/28/22, indicated the air mattress was to be set at 4 BARS/comfort, and to check the setting/function every shift to promote positive skin integrity. On 6/21/22 at 9:46 A.M., Resident #117 was observed lying on his/her air mattress set at 5 BARS. The setting box to the air mattress had a label that indicated for the mattress to be set at 4 BARS. On 6/22/22 at 11:40 A.M., Resident #117 was observed lying on his/her air mattress set at 5 BARS. On 6/23/22 at 8:11 A.M., Resident #117 was observed lying on his/her air mattress set to 5 BARS. On 6/23/22 at 8:33 A.M., Nurse #1 said that she looked at the TAR or the Physician's Orders for instructions on the Resident's air mattress and said that it was not set appropriately.

Based on observation, interview and record review, the facility failed to ensure that it's staff managed pain, consistent with professional standards, during a dressing change for one sampled Resident (#70) out of a total sample of 30 residents. Findings include: Review of the facility policy titled: Administering Pain Medications, revised March 2020, indicated the following: -The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals and includes assessing the potential for pain. Resident #70 was admitted to the facility in February 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Physician's Orders for June 2022 included the following orders: -Acetaminophen (Tylenol: a mild pain reliever) 325 milligrams (mg) tablets: give two tablets every 4 hours as needed for pain (2/8/22) -[MEDICATION(S)] Sodium Gel 1% (a topical pain reliever): Apply to legs topically every eight hours as needed for leg pain (2/10/22) -[MEDICATION(S)] (a pain medication used to treat neuropathic pain: pain caused by nerve damage or dysfunction) 400 mg by mouth three times a day for pain (2/16/22) -[MEDICATION(S)] (a synthetic drug used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Clinical Admission Evaluation, dated 2/8/22, indicated that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/27/22 at 11:06 A.M., the surveyor observed Nurse #9 in Resident #70's room as she prepared to provide wound care. The surveyor observed the left heel dressing was peeling off around the periphery (edges) of the dressing and had old blood-tinged drainage on it and the center of the dressing was adhered to the wound. The old dressing on the right heel was removed easily but the left heel dressing was stuck to the Resident's foot. Nurse #9 repeatedly sprayed wound cleanser to the old dressing on the left heel, to moisten the dressing and help remove it from the wound bed. Resident #70 was observed with facial grimacing and tensing the left leg, and drawing the left foot away from Nurse#9 as she attempted to peel the old dressing off the wound on the left foot. At 11:13 A.M., during the procedure, Unit Manager (UM) #2 came into the room and stood at the Resident's side. The Resident reached out and grabbed UM #2's hand and told her that he/she was in pain. UM #2 provided reassurance to the Resident and instructed Nurse #9 to medicate the Resident with pain medication, as the old dressing was being removed. The old left heel dressing was noted to be saturated with serosanguinous (a mixture of old blood and body fluid) and purulent (pus containing) drainage. Wound care was provided as ordered and the remainder of the procedure was uneventful. At 11:24 A.M., the surveyor observed Nurse #9 as she assessed the Residents pain by asking the Resident to rate the pain on a scale of 1-10, and Resident indicated it was number 6 on the 1-10 scale and was medicated at this time. During an interview at the time of the observation, Nurse #9 said that the dressing was stuck to the Resident's wound and she should have medicated the Resident prior to the dressing change. During an interview on 6/27/22 at 11:47 A.M., U.M. #2 said the Resident should have been assessed for pain prior to the dressing change and pre-medicated. She said it had been several days since the dressing was last changed and was stuck to the wound which increased the Resident's pain during the procedure.

Based on observations, interviews and record reviews, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence and occurs as a result of intense and/or prolonged pressure or pressure in combination with shear: force pushing down such as between patient and bed) through use of A.) an air mattress and special booties to relieve pressure and shear, and B.) provide the necessary treatment and services to promote healing and prevent infection of the wounds when they developed such as providing daily dressing changes, and responding to presence of infection for one sampled Resident (#70), out of a total sample of 30 residents. Findings include: Resident #70 was admitted to the facility in February 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/21/22 at 9:56 A.M., the surveyor observed Resident #70 lying in a regular bed with dressings present on his/her bilateral heels which were not dated/timed or initialed. During an interview, Resident #70 said the wounds were painful. The surveyor observed dressing supplies on the windowsill and bedside table in the room. There was no evidence that the resident was on a specialty mattress. On 6/22/22 at 12:32 P.M., the surveyor observed Resident #70 seated in a wheelchair at the bedside, fully dressed and eating lunch. He/she was wearing non-skid socks with sandals and did not have booties on. On 6/27/22 at 10:13 A.M., the surveyor observed the Resident #70 lying in bed and he/she moved his/her feet out from under the covers. The Surveyor observed the Resident's feet were dry, the toenails were very long, and extended over the end of his/her toes and were discolored and thick. There was a gauze dressing on the right foot, and a border dressing on the left heel, both which were peeling off the feet around the edges. The dressing on the right foot was dated 6/24/22. The dating of the left foot dressing was not visible in the Residents position. The bottom sheet on the bed had dried brown stains on lower portion of sheet by the Resident's feet. The left heel dressing was noted to be stained with old serosanguinous (a mixture of blood and serum: thin watery body fluid) drainage. On 6/28/22 at 11:08 A.M., the surveyor observed Resident #70 seated in a wheelchair at the bedside wearing non-skid slipper socks. There were no protective booties on his/her feet. On 6/29/22 at 11:18 A.M., the surveyor observed Resident #70 lying in bed on a regular mattress and had on slipper socks. His/her right heel was elevated on a pillow. The Surveyor observed protective booties were lying on the floor next to the side of the Resident's bed. On 6/30/22 at 9:01 A.M., the Surveyor observed Resident #70 lying in bed, head elevated, eating breakfast. The outlines of the resident's feet were visible under sheet and the Surveyor noted there were no protective booties on. Review of the Minimum Data Set (MDS) Assessment, dated 2/14/22, indicated Resident #70 was at risk for pressure ulcer development and had no pressure areas on admission. Review of a Progress Note, dated 2/22/22, indicated the Resident had large blisters on bilateral heels and an open area on upper coccyx. Review of a Progress Note, dated 2/26/22, indicated the Resident had a necrotic (dead skin/tissue) left heel wound. Review of the MDS Assessment, dated 2/28/22, indicated: there were pressure ulcers present: two stage 2 pressure ulcers and one unstageable pressure ulcer. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Air mattress to bed, set to weight/resident comfort; monitor setting and function every shift (3/25/22) -Heel protectors for a Deep Tissue Injury (DTI) Left heel (2/10/22) -Order Z boots (a type of padded protective booties to relieve pressure) to keep patient's heels elevated every shift (4/28/22) -sacral area: inspect skin daily, apply foam dressing to area every day (4/2/22) -Weekly skin check (2/8/22) -Wound documentation Left heel every day (2/28/22) -Wound documentation Right heel every day (3/10/22) -Wound documentation sacrum every day (5/19/22) -Cleanse bilateral heels with Normal Saline, pat dry, apply [MEDICATION(S)] (a product used to prevent infection and promote the healing of pressure wounds) pad to wound bed, skin prep to wound edge, apply ABD and kerlix every day for wound care (6/27/22) Review of the June 2022 Treatment Administration Record (TAR) indicated: -all wound assessments and treatments were signed off as being completed, with the exception of when the Resident was in the hospital -[MEDICATION(S)] Resistant Enterococci (VRE: bacteria, normally present in the intestines that are resistant to [MEDICATION(S)], a powerful antibiotic) precautions were documented as being maintained every shift -Air mattress was signed off as being checked every shift Review of the June 2022 Medication Administration Record (MAR) indicated: -Z boots to keep heels elevated were signed off on all shifts as done with the exception of when the resident was hospitalized . During an interview on 6/23/22 at 12:37 P.M., Nurse Practitioner #1 said the Resident developed wounds while at the facility, and subsequently developed an infection and was put on [MEDICATION(S)]. During an interview on 6/27/22 at 10:20 A.M., Nurse #9 said the dressings are the ones she put on Friday 6/24/22. She said the wound care is supposed to be done daily and had not been completed as ordered. During an interview on 6/27/22 at 10:52 A.M., Certified Nurse's Aide (CNA) #5 said if a resident wears protective boots, the nurses usually tell the aides. She was not aware that boots were ordered for Resident #70. She further said the Resident had a regular mattress. During an interview on 6/27/22 at 11:05 A.M., Nurse #9 said Resident #70 had an air mattress but did not have it anymore. On 6/27/22 at 11:24 A.M., the surveyor observed Nurse #9 looking for protective booties and found them in the closet. Nurse #9 said that nursing had to sign them off as being applied so the nurses should apply them, not the CNAs. On 6/27/22 at 11:38 A.M., the surveyor reviewed the June 2022 MAR and TAR with Unit Manager (UM) #2 who said that that the VRE precautions were being signed off as being done and they are no longer in effect. She also said the air mattress was being signed off on the TAR and there was no air mattress in use for this Resident. During an interview on 6/28/22 at 12:33 P.M., UM #2 said Resident #70 had a regular mattress on his/her bed and was not on an air mattress. She said the Resident was at risk for skin breakdown, had pressure wounds, and there was a doctor's order for an air mattress and the order was not followed as required.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure care and treatments provided were completed in accordance with professional standards of practice. 1) Resident #2, had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] resulting in a very itchy, uncomfortable rash to develop all over his/her body. 2) Resident #1, who was assessed as being at increased risk for skin breakdown, developed Moisture Associated Skin Damage (MASD, inflammation or skin erosion caused by prolonged exposure to moisture such as urine or stool) and fungal involvement of his/her skin, however skin treatments were not completed per facility protocol, to help prevent inflammation and skin breakdown. Finding include: 1) Review of the Facility's Policy titled Medication and Treatment Orders, dated 2017, indicated that orders for medications and treatments will be consistent with principles of safe and effective practice. Medications shall be administered only upon a written order and by licensed authorized persons. Resident #2's most recent Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact, required an extensive assist of one staff member for bed mobility, was totally dependent for transfers with a two person assist and was non-ambulatory, and he/she had [CONDITION(S)] (paralysis of all four limbs). Resident #2's Treatment Administration Record (TAR), dated January 2022, indicated nursing to apply triple antibiotic to to a dry crusted area (a scab) on left lower extremity daily. Review of Resident #2's Nursing Progress Note, dated 1/28/22, indicated Resident #2 complained of itching all over his/her body, [MEDICATION(S)] (a medication for itching) was administered. Review of Resident #2's Physician's Progress Note, dated 1/28/22, indicated Resident #2 reported that a CNA applied a tube of triple antibiotic ointment over his/her arms and legs, he/she developed a significant rash where the ointment was applied. The plan was to treat him/her with [MEDICATION(S)] for itching as needed. During an interview on 2/15/22 at 2:00 P.M., Nurse #1 said that CNA #1 applied a tube of triple antibiotic ointment to Resident #2's area of skin with psoriasis (a chronic skin condition) and applied it all over his/her body, causing him/her to have new raised red [CONDITION(S)] on his/her abdomen, chest, legs and both arms. Nurse #1 said where the triple antibiotic ointment was applied, the skin glistened, and said she washed the ointment off Resident #2's skin. During an interview on 2/15/22 at 2:30 P.M., Nurse Practitioner #1 said the triple antibiotic ointment for Resident #2, was ordered to be applied to a dry crusted area (a scab) on his/her left lower extremity and was to be administered by the Nurses, not by a CNA, and said the ointment was not meant to be applied all over his/her entire body. 2) Review of the Facility's Skin Protocol titled Routine Skin Interventions, dated 2018, indicated that routine skin interventions are performed for the prevention or therapeutic measures intended to minimize a resident's risk for skin breakdown. During an interview on 2/14/22 at 1:00 P.M., Resident #1 said he/she did not receive the topical ointment to protect and treat his/her skin for days, causing his/her skin to be red and itchy. Resident #1 said during the 11:00 P.M. to 7:00 A.M. shift, when he/she was incontinent of urine, the nursing staff frequently would not change him/her on that shift. Resident #1 said he/she would sometimes go for eight hours without having his/her soiled brief changed, even after he/she had requested it to be changed. Resident #1 said there are times he/she gets upset because he/she needed to be changed more frequently than once per shift due to his/her rash with his/her incontinence. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact, was totally dependent for care, required a two person assist with bed mobility and transfers, was non-ambulatory, was incontinent of bowel and bladder, had no skin breakdown issues, and that he/she did not reject or refuse care. Review of Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On physical examination he/she had contact [CONDITION(S)] on his/her back and behind his/her right thigh, nursing to treat him/her with hydrocortisone cream twice a day and [MEDICATION(S)] cream (for fungal skin infections). Review of Resident #1's Bladder and Bowel Incontinence Care Plan, dated 7/12/21, indicated that he/she would remain free of skin breakdown due to incontinence and brief usage, interventions included to check every shift for incontinence, wash, rinse and dry perineum, change after incontinence episodes and apply house barrier cream (a topical treatment to provide a barrier between the skin and irritants such as urine and feces) after incontinence care. Review of Resident #1's Skin Care Plan, dated 7/12/21, indicated that he/she was at risk for skin breakdown due to deconditioning, weakness and incontinence, interventions included to apply barrier cream to his/her boney prominence's every shift, and to turn and reposition every two hours. Review of Resident #1's Physician Wound Sheets, dated 7/20/21 and 8/17/21, indicated Resident #1 had red [CONDITION(S)] with erosion, crust and scales on the sacrum (flat triangular shaped one between the hips) and coccyx (tailbone area, below the sacrum), perineum (area between anus and genitals) and right lateral thigh, caused by Moisture Associated Skin Damage (MASD, is inflammation or skin erosion caused by prolonged exposure to moisture such as urine or stool) and fungal involvement treat with [MEDICATION(S)] and Triamcinolone (topical anti-fungal agents) and offloading per Facility policy. Review of Resident #1's Physician Orders, dated 9/03/21, indicated to apply a thin layer of triad cream (a treatment used to adhere to the skin which covers a wound and protects the wound area from incontinence) to the open areas on the right posterior thigh every day and evening. Review of Resident #1's Physician Wound Sheet, dated 9/07/21, indicated that Resident #1's skin [CONDITION(S)] were improving on the sacrum, coccyx, perineum, and right lateral thigh, caused by MASD and fungal involvement, continue offloading with turning and positioning. However, review of Resident #1's Physician Wound Sheets, dated 9/14/21, indicated that Resident #1's skin [CONDITION(S)] on the sacrum, coccyx, perineum, and right lateral thigh, with erosions, crusts and scales, were not improving. Review of Resident #1's Physician Orders, dated 9/15/21, indicated to apply [MEDICATION(S)] 0.1% to the sacrum, coccyx perineum and right posterior thigh areas twice a day for MASD. Resident #1's Treatment Administration Record (TAR), dated September 2021, indicated to apply [MEDICATION(S)] 0.1% to the sacrum, coccyx perineum and right posterior thigh areas twice a day. Further review of Resident #1's TAR indicated that on 9/16/21, for the day shift and evening shift, nursing did not initial the treatment boxes, they were left blank, indicating the treatment was not done. Resident #1's TAR also indicated to apply triad cream to the open area, on 9/16/21 in the morning and the evening, nursing did not initial the treatment boxes, they were left for both shifts, indicating the treatment was not done. Review of the Resident #1's Physician Wound Sheet, dated 9/21/21, indicated that Resident #1 continued with skin [CONDITION(S)] on the sacrum, coccyx, perineum and right lateral thigh, and Resident #1's skin condition was not improving, Resident #1 must be turned every two hours, change briefs during turning if wet, clean would with normal saline, dry the wound and apply [MEDICATION(S)] and Triamcinolone twice a day. Review of the Certified Nurse Aide (CNA) Flow Sheets, dated September 2021, indicated interventions to prevent skin breakdown included to apply house barrier cream to the coccyx, heels, buttocks, and hips every shift. However, further review of the CNA flow sheets indicated there was insufficient documentation to support that CNAs' consistently applied the barrier cream, as the following dates and times were left blank: During the 7:00 A.M. to 3:00 P.M. shift: - for 11 days, from 9/02/21 thru 9/12/21, - for 5 days, from 9/14/21 thru 9/18/21, - for 1 day, on 9/21/21, and - for 4 days, from 9/23/21 thru 9/26/21 - (for a total of 21 of 25 days documentation was left blank) During the 3:00 P.M. to 11:00 P.M. shift: - for 10 days, from 9/03/21 thru 9/12/21, - for 13 days, from 9/14/21 thru 9/26/21 - (for a total of 23 of 25 days, documentation was left blank). During the 11:00 P.M. to 7:00 A.M. shift: - for 3 days, from 9/02/21 thru 9/04/21, - for 1 day, on 9/08/21, and - for 2 days, from 9/12/21 thru 9/13/21, - for 4 days, from 9/15/21 thru 9/18/21, - for 2 days, from 9/21/21 thru 9/22/21, - for 1 day, on 9/26/21 - (for a total of 13 of 25 days, documentation was left blank). Further Review of the CNA Flow Sheets, dated September 2021, indicated interventions for bladder incontinence, with the frequency of Resident #1 changes were to be performed every shift. However, review of the CNA flow sheets indicated there was insufficient documentation to support that CNAs' consistently provided incontinence care, as the following dates and times were left blank: During the 7:00 A.M. to 3:00 P.M. shift: - for 11 days, from 9/02/21 thru 9/12/21, - for 5 days, from 9/14/21 thru 9/18/21, - for 1 day, on 9/21/21, and - for 4 days, from 9/23/21 thru 9/26/21 - (for a total of 21 of 25 days, documentation was left blank). During the 3:00 P.M. to 11:00 P.M. shift: - for 10 days, from 9/03/21 thru 9/12/21, - for 13 days, from 9/14/21 thru 9/26/21 - (for a total of 23 of 25 days, documentation was left blank). During the 11:00 P.M. to 7:00 A.M. shift: - for 3 days, from 9/02/21 thru 9/04/21, - for 1 day, on 9/08/21, and - for 2 days, from 9/12/21 thru 9/13/21, - for 4 days, from 9/15/21 thru 9/18/21, - for 2 days, from 9/21/21 thru 9/22/21, - for 1 day, on 9/26/21 - (for a total of 13 of 25 days, documentation was left blank). Review of the CNA Flow Sheet, dated September 2021, indicated interventions to reposition every 2 hours on each shift (or twelve repositions per day) to prevent skin breakdown. However, further review of the CNA flow sheets indicated there was insufficient documentation to support that CNAs' consistently provided him/her with repositioning, as the following dates and times were left blank: During the 7:00 A.M. to 3:00 P.M. shift: - for 11 days, from 9/02/21 thru 9/12/21, - for 5 days, from 9/14/21 thru 9/18/21, - for 1 day, on 9/21/21, and - for 1 day, on 9/26/21 - (for a total of 21 of 25 days, documentation was left blank). During the 3:00 P.M. to 11:00 P.M. shift: - for 10 days, from 9/03/21 thru 9/12/21, and - for 13 days, from 9/14/21 thru 9/26/21 - (for a total of 23 of 25 days, documentation was left blank). During the 11:00 P.M. to 7:00 A.M. shift: - for 2 days, from 9/02/21 thru 9/03/21, - for 1 day, on 9/08/21, - for 2 days, from 9/12/21 thru 9/13/21, - for 4 days, from 9/15/21 thru 9/18/21, - for 2 days, from 9/21/21 thru 9/22/21, and - for 1 day, on 9/26/21 - (for a total of 12 of 25 days, documentation was left blank). During an interview on 2/18/22 at 2:14 P.M., the Director of Nurses said the CNA Flow Sheets for incontinence indicate when Resident #1's incontinent briefs or pads were changed. During an interview on 2/16/22 at 1:00 P.M., Nurse #4 said that for preventing Resident #1's skin breakdown, she expected that the staff would apply barrier cream every shift and that treatments would be applied as ordered. Nurse #4 said these interventions were not consistently being done as required. Review of Resident #1's Nursing Progress Note, dated 9/27/21, indicated Resident #1 was visited by Family Members and they had concerns that Resident #1 may have [CONDITION(S)]. The Note indicated Family Members requested that he/she be sent out to the Hospital, that the Ambulance Service was called and were on their way to transport him/her to the Hospital. Resident #1's Physician Emergency Department Note, dated 9/28/21, indicated Resident #1 was bed bound and evaluated for a rash because the Facility was not treating the rash, an antibiotic was administered for a possible [CONDITION(S)] and [MEDICATION(S)] for a possible allergic component. Resident #1's Physician's Admission Note, dated 9/28/21, indicated that Resident #1's Family was visiting at the Facility and felt he/she was not being appropriately cared for. On physical examination Resident #1's hands and nails were dirty, his/her back was diffusely erythematous (reddened), warm, pruritic (itchy), he/she may have skin irritation from being bed bound on his/her back most of the day. diagnosed with irritant [CONDITION(S)] with fungal involvement.

Based on observations, record reviews and interviews, the facility staff failed to notify the Physician/Nurse Practitioner of changes in the resident's skin condition that resulted in a formation of a wound for one sampled Resident (# and an 56) and an increase in a skin rash for one sampled Resident ( #99), out of a total of 28 sampled residents. Findings include: Review of the facility Physician Notification Policy, dated 2017, included that physician notification is classified as follows: Report immediately, Report Non-Immediately and Routine. -Report Immediately - is defined As Soon As Possible (ASAP), promptly upon determination that the clinical presentation warrants immediate physician/practitioner notification. -Report Non-Immediately - is defined as notification of the physician preferably the same day but no later than 24 hours after the clinical outcome is assessed and determined non-immediate and/or non-urgent diagnostic results are received. -Routine - is defined as notification of the physician upon the next occurring phone call or scheduled visit. 1). Resident #56 was admitted to the facility in October of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) Assessment, dated 4/13/21, indicated the resident had severe cognitive impairment for daily decision making skills. Review of the progress note, dated 5/3/21, indicated that the resident was complaining of pain in the right foot. A small reddened area was noted on the lateral side of the right foot along with swelling. [MEDICATION(S)] (an antibacterial) ointment and a foam dressing were applied to the area. There was no documentation found to indicate the physician had been notified and had ordered a treatment. Review of the Physician Communication book did not indicate any notification to the physician of the reddened area. Review of the Wound Physician Communication book did not list Resident #95 to be assessed by the wound physician for any skin issues. There was no documentation found to indicate the physician had been notified of the change in the skin integrity of the right foot until 5/20/21 (17 days after the initial observation of the area) when the area worsened and an X-ray and treatment orders were obtained. During an interview, on 5/20/21 at 12:55 P.M., Nurse #2 said there was no documentation found in the medical record to indicate the physician had been notified on 5/3/21 of the reddened area on the right foot. She said the Physician Communication and Wound Physician books did not indicate the resident's right foot needed to be addressed or assessed. She said the area on Resident #56's right foot was round in shape with slough (shedding dead skin) and purulent (pus) drainage noted. She further said an X-ray, an antibiotic and wound treatment orders were obtained on 5/20/21. 2. Review of the facility policy titled, Skin Checks - Bath Sheet Process, dated 2018, indicated the following: - The purpose of skin checks was to identify, record, and report resident skin alterations, ensuring prompt assessment and treatment. - Should skin alteration that is new or has worsened be identified, the assigned nurse shall be called so that a prompt assessment can be performed. - The nurse shall alert the physician to new findings. Resident #99 was admitted to the facility in March of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #99's most recent Minimum Data Set Assessment, dated 4/23/21, indicated a Brief Interview of Mental Status score of 15, indicating that the resident was cognitively intact. During an observation and interview, on 5/18/21 at 9:25 A.M., the surveyor observed Resident #99 seated on his/her bed, scratching at both forearms that had multiple breaks in the skin and were bleeding. Resident #99 said that his/her Hospice worker had provided a cream for dry skin approximately a week and a half prior, and within a couple of days of using the cream, his/her skin became very itchy, and he/she could not stop scratching it which caused it to bleed. Resident #99 said that the Hospice worker instructed him/her to stop using the cream, but that he/she still scratched at both forearms because they were still itchy. Resident #99 further said that a family member brought him/her a box of Band Aids which helped with the bleeding, but that no one at the facility had assessed his/her forearm skin condition, he/she had not been seen by a doctor for this condition, and that no treatment was being provided for the breaks in his/her skin. Review of Resident #99's May 2021 Treatment Administration Record indicated the following: - A physician order, dated 4/12/21 with no stop date, for weekly skin audits on shower days, every day shift every Wednesday. - Weekly skin audits on shower days were signed off as completed on 5/5/21, 5/12/21, and 5/19/21. Review of Resident #99's care plan indicated the following: - Resident #99 will have intact skin. - Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #99's clinical record indicated no documented evidence that the changes in his/her forearms' skin condition was reported to the physician. During an observation and interview on 5/20/21 at 2:56 P.M., Unit Manager #1 (UM #1) observed Resident #99 with the surveyor and said that the Resident had breaks in his/her skin on both forearms. UM #1 said that the facility protocol required staff to notify the physician of any changes in a resident's skin condition and that Resident #99's change in forearm skin condition should have been reported to the physician. During the interview, UM #1 reviewed Resident #99's record and said that there was no documented evidence that staff notified the physician of changes in Resident #99's skin condition, but they should have, as required. Prior to survey exit, facility staff provided the following information: - [NAME] Weekly Skin Check assessment completed on 5/22/21. - A physician skilled wound care note, dated 5/24/21, that indicated Resident #99 had multiple maculopapular [CONDITION(S)] (flat and raised abnormal changes in the skin) on both forearms. Aggressive, weekly follow-up care was recommended.

Based on interviews and records reviewed, for two of three sampled Residents (Resident #1 and Resident #3), the Facility failed to ensure residents were free from abuse, when on 9/23/20, Certified Nurse Aide (CNA) #1 slapped Resident #1 on the buttocks and then slapped Resident #3 on the buttocks and shoulders. Resident #1 said being slapped on the buttocks stung and Resident #3 said that CNA #1's slap on his/her shoulders was forceful and said when CNA #1 slapped him/her on the buttocks hurt and was humiliating. Findings include: The Facility's Policy titled Abuse Prevention Program, undated, indicated that Facility residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. 1. Review of Resident #1's most recent Minimum Data Set (MDS) Assessment, dated as completed 8/30/20, indicated that his/her cognitive patterns were intact. The Surveyor interviewed Resident #1 at 10:40 A.M. on 10/8/20. Resident #1 said that during the night shift that started on 9/22/20 and ended on 9/23/20, CNA #1 assisted him/her in the bathroom. Resident #1 said that when he/she told CNA #1 that he/she could pull down his/her own pants, CNA #1 ignored him/her and continued trying to pull down Resident #1's pants. Resident #1 said that when he/she repeated that he/she could pull down his/her own pants, CNA #1 slapped Resident #1 on the buttocks three times. Resident #1 said that the slaps stung. The Facility Internal Investigation contained statements by Nurse #2 and the Social Worker dated 9/23/20 which document their interviews with Resident #1. The statements indicated that Resident #1 told Nurse #2 and the Social Worker that CNA #1 slapped him/her three times on the buttocks. The Social Workers statement indicated that Resident #1 said the slaps were hard enough to sting Review of the Police Report, dated 10/11/20, indicated that on 9/29/20 Resident #1 told the Police Officer that CNA #1 struck him/her three times on the buttocks and the strikes really stung. 2. Review of Resident #3's most recent Minimum Data Set (MDS) Assessment, dated as completed 9/10/20, indicated that his/her cognitive patterns were intact. The Surveyor interviewed Resident #3 at 10:55 A.M. on 10/8/20. Resident #3 said that during the night shift that started on 9/22/20 and ended on 9/23/20, CNA #1 assisted him/her in the bathroom. Resident #3 said that when he/she pulled down his/her pants, CNA #1 repeatedly whacked his/her buttocks. Resident #3 said he/she told CNA #1 not to hit his/her buttocks and CNA #1 asked Resident #3 why. Resident #3 said he/she told CNA #1 that he/she did not like it when CNA #1 hit his/her buttocks. Resident #3 said that when he/she walked back to his/her bed, CNA #1 hit the backs of both of his/her shoulders with her (CNA #1's) two hands. Resident #3 said that she told CNA #1 not to do that again and stated that he/she did not like that and would not tell CNA #1 to stop again. Resident #3 said that CNA #1 asked Resident #3 why not and left Resident #3's room. Resident #3 said that although the strike by CNA #1 on his/her shoulders was more forceful and hurt more than being struck by CNA #1 on the buttocks, said being struck on the buttocks was also humiliating. The Facility's Internal Investigation contained statements by the Unit Manager and the Social Worker dated 9/23/20 which documented their interviews with Resident #3. The statements indicated that Resident #3 told the Unit Manager and the Social Worker that CNA #1 slapped him/her three times on the buttocks and once on the back. Review of the Police Report, dated 10/11/20, indicated that on 9/29/20 Resident #3 told the Police Officer that CNA #1 struck him/her twice on the buttocks and once forcefully on the upper back. Review of the Facility Staffing Schedule indicated CNA #1 worked for an Agency and was assigned to the Unit where Resident #1 and Resident #3 resided from 12:00 A.M. to 6:00 A.M. on 9/23/20. The Surveyor interviewed CNA #1 at 1:50 P.M. on 10/16/20. CNA #1 said that she did not hit Resident #1 or Resident #3 and she thought she was accused because she worked for an Agency. CNA #1 was unable to explain the consistent statements of Resident #1 and Resident #3 and their similar characterization of her slapping their buttocks. On 10/8/20, the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) Resident #1 and Resident #3 were offered a supportive visit by the Facility Social Worker 9/23/20 and remain on-going. B) The Unit Manager conducted skin checks and interviews with all Unit B2 Residents on 9/23/20 without finding additional potential victims. C) On 9/23/20, the Facility instructed the Agency to remove CNA #1 from all future shifts at the Facility and notified the Police of the allegation. D) On 10/7/20, the Facility Initiated Mandatory Training for all staff on Respect in the workplace, Culture of Safety and Resident Abuse. E) On 10/7/20, the Facility implemented a Safety Audit tool to be performed by the Social Worker or Unit Manager to audit the experiences of three to five Residents weekly. F) The Administrator and Director of Nurses said that the Facility informed all QA members of the alleged incident and the Plan of Correction and the status of the corrective actions and audits would be reviewed at the next scheduled monthly QAPI meeting. G) The Administrator, Director of Nurses and/or their designees are responsible for overall compliance.

Based on interview and record review the facility staff failed to ensure that pain management was provided for one Resident (#81) out of a total sample of 25 residents. Findings include: Resident #81 was admitted to the facility in 1/2014. Review of the facility's policy for Pain Management, with revision date of 7/2015, indicated the following: Policy: Resident's pain will be addressed and managed . Guidelines: -Pain will be reassessed .when new pain occurs. -Pain management interventions will be documented in the Medication Administration Record [REDACTED]. -The effectiveness of pain management strategies will be evaluated at the time that the strategy takes effect on the MAR indicated [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/19/18, indicated the resident had impaired short and long term memory deficits, severely impaired decision making ability, had no observed signs or symptoms of pain, and had not used any as needed (PRN) pain medications. Review of the 1/2019 Medication Administration Record [REDACTED].M. on 1/14/19, and did not indicate why the medication was administered or if it was or was not effective. Review of the clinical record indicated no nurse's note was written on 1/14/19. Further review of the 1/2019 MAR indicated [REDACTED]. 0.25 ml was administered on 1/15/19 at 2:44 A.M. for right arm pain with relief. There were no other administrations of pain medications on 1/15/19. Review of a nurse's note, dated 1/15/19 at 1:00 P.M., indicated the resident was whimpering and guarding his/her right arm. Upon evaluation, there was pronounced swelling to the medial aspect of the right elbow as well as significant bruising. The resident was screaming in pain when the right arm was abducted (pulled away) from the body. Resident became combative stating, I don't want that! Leave me alone! Review of a nurse's note, dated 1/15/19 at 6:00 P.M., indicated the resident returned from the emergency room . Review of the hospital discharge summary, dated 1/15/19, indicated the resident was diagnosed with [REDACTED]. Review of the Investigation Statement for Event form, dated 1/15/19 and signed by Nurse #4, indicated that Nurse #4 took care of the resident on 1/14/19 from 3:00 P.M.- 9:00 P.M. The resident's daughter approached Nurse #4 at or around 4:30 P.M. and requested pain medication be administered to resident #4 for complaints of right shoulder pain and having trouble lifting the right arm. Nurse #4 examined the resident and did not see bruising or swelling but did observe the resident to have discomfort when the right arm was lifted. Nurse #4 administered Tylenol 650 milligrams with good improvement and wrote that no injury was seen or suspected. Review of a Witness Statement for (Resident #81) signed by CNA #1, indicated that CNA #1 gave care to resident #81 on 1/14/19 (3:00 P.M.-11:00 P.M. shift). CNA #1 said she observed the resident's daughter touch the resident and the resident cried out in pain when his/her right arm was touched. CNA #1 had not noticed the resident to have pain in the right arm prior to then. CNA #1 went to Nurse #4 but Nurse #4 was on break, so she went back to the resident's daughter to tell her that, and the resident's daughter was crying and said Nurse #4 had told her that pain medication had already been given. Review of an emailed statement for (Resident #81) signed by CNA #2 on 1/15/19 at 11:55 A.M., indicated CNA #2 went into this resident's room on 1/15/19 at 1:30 A.M. to do personal care with Nurse #5 and the resident was holding his/her right arm and screaming in pain. CNA #2 asked Nurse #5 if the resident had fallen because he/she was not acting like their usual self and Nurse #5 said she had no report of the resident falling. Review of a statement (for Resident #81) signed by Nurse #5 on 1/15/19 indicated that when she went in to check on the resident (on the 11:00 A.M. -7:00 A.M. shift) the resident was holding his/her right arm and complaining of pain. When Nurse #5 brought in the pain medication (at 2:44 A.M.) CNA #2 was giving care to the resident and the resident continued to complain of right arm pain. Nurse #5 double checked the report to be sure the resident hadn't fallen. Nurse #5 thought maybe the resident was laying on his/her right arm the wrong way. Review of the Investigation Statement for Event, dated 1/15/19 and signed by CNA #3, indicated she had taken care of Resident #81 that morning. She and another CNA had transferred the resident and CNA #3 indicated the resident was clearly uncomfortable during the transfer. When she and the other CNA undressed the resident to get him/her ready for the shower, CNA #3 noticed a bruise to the right arm, the elbow was swollen and purple. CNA #3 notified the nurse on duty. During an interview on 3/14/19 at 1:20 P.M., with the Director of Nurses (DON) and Unit Manager #1, the DON said that the nurse on the 3:00 P.M.-11:00 P.M. should have written a nurse's note if he had assessed the right arm for injury and should have written why the resident was administered Tylenol and what kind of effect it had. The only documentation that an assessment was performed was provided in the witness statements. The resident was not administered any pain medications between 1/14/19 at 3:30 P.M- 1/15/19 at 2:44 A.M., and from 1/15/19 at 2:44 A.M.- 1/15/19 at 11:00 A.M. (when the resident was transferred to the hospital for an evaluation).

Based on records reviewed and interviews for one of three sampled residents (Resident #2), the Facility failed to ensure he/she was free from an incident of misappropriation and financial exploitation, when Certified Nurse Aide (CNA) #1 took a personal bank check from Resident #2's checkbook which was in a locked drawer, without his/her knowledge or consent. CNA #1 wrote the check out to herself in the amount of $350.25, forged Resident #2's signature on the check and then cashed it. Findings include: The Policy titled, Resident Abuse, dated 4/2017, indicated that: - The resident has the right to be free from abuse, neglect, mistreatment of [REDACTED]. - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. -Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Misappropriation of Resident Property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Resident #2's medical record Face Sheet indicated he/she was admitted to the Facility in (MONTH) (YEAR) and [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #2 was cognitively intact and was able to make his/her own decisions. The Facility's Investigation, dated 1/16/19, indicated that on 1/15/19 at approximately 5:00 P.M., Family Member #1 called the Facility to report that Resident #2 had two personal checks (#200 and #201) missing from his/her checkbook. The Investigation indicated that check #201, was written out to CNA #1, (a full-time employee at the Facility) for the amount of $350.25, that the check was dated 1/8/19, was cashed on 1/9/19, and the check memo section indicated the check was for a Christmas Gift. The Investigation indicated that the signature line had Resident #2's name written in, but that Family Member #1 said the handwriting on check #201 was not in Resident #2's handwriting. The Investigated contained a copy of check #201. The Surveyor interviewed the Director of Nursing (DON) at 9:00 A.M. on 1/30/19. The DON said that when interviewed, Resident #2 said he/she never gave CNA #1 permission to take a personal check of his/hers and had not given CNA #1 a check as a Christmas gift. The DON said that the Facility's Investigation findings were that CNA #1 had misappropriated Resident #2's check (#201) and wrote it out for the amount of $350.25, to herself. The Police Report, dated 1/15/19, indicated that Police Officer #1 responded to the Facility for a report of a fraud case. The Report indicated that Resident #2 told Police Officer #1 that he/she had two missing personal checks (#200 and #201) from his/her checkbook, that he/she kept the checkbook locked in a nightstand with the keys on his/her person on a wrist band at all times, except when he/she showers. The Report indicated that Resident #2 said if someone wanted to take the wrist band with the key from him/her when he/she slept, that he/she was a very sound sleeper and may not feel somebody attempt to remove the wrist band. The Report indicated Resident #2 said he/she does not hand the key to anyone else. Resident #2 said he/she never willing gave any member of the nursing staff one of his/her personal checks. On 1/18/19 Police Officer #1 went to the Credit Union where Resident #2's check had been cashed and obtained photos of the check being cashed and had a facial profile of the female cashing the check, who was confirmed to be CNA #1. The Surveyor interviewed Family Member #1 at 12:27 P.M. on 1/30/19. Family Member #1 said Resident #2 keeps his/her check book locked in a drawer. Family Member #1 said that check #200 and #201 were missing and that check #201 was made out to a person, in the amount of $350.25. Family Member #1 said she knew check #201 was not written nor signed by Resident #2, because the handwriting was very different form Resident #1's handwriting. The Surveyor interviewed Resident #2 at 2:10 P.M. on 1/30/19. Resident #2 said he/she was upset about the stolen check(s) because he/she absolutely never wrote a check to any CNA as a Christmas gift and that check #201 had been forged. The Surveyor interviewed CNA #1 at 12:00 P.M. on 2/1/19. CNA #1 said she worked on the 11:00 P.M. to 7:00 A.M. shift for approximately the past 1.5 years at the Facility and had been assigned to care for Resident #2, in 1/2019. CNA #1 said that she did take one check from Resident #2, and that she made the check out to herself for $350.25. CNA #1 said Resident #2's check was not a gift and said she did steal the money.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 11 applicable residents (#3), in a total sample of 24 residents. Findings include: For Resident #3, the facility failed to provide adequate supervision and effective interventions to prevent falls. The resident had 12 falls between 10/30/16 and 4/28/17, 8 of the falls out of the bed, without a mat on the floor. The fall of 4/28/17 out of the bed to the floor, resulted in a Left Hip Fracture. The Resident had 4 additional falls following the fracture, for a total of 16 falls between 10/30/16 and 8/22/17. Resident #3 was admitted to the facility in 10/2016 with a history of falls, and [DIAGNOSES REDACTED]. Review of a Fall Risk Assessment completed on the day of admission to the facility indicated that the Resident scored 16 which indicated the Resident was a High Risk for falls. (Total Score above 10 represents HIGH RISK). The assessment indicated the resident had 3 or more falls in the past 3 months. Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had adequate vision with glasses; severely impaired cognition; was feeling down and depressed, tired and little energy; did not ambulate, required extensive assistance of one for transfers, and toilet use; utilized a wheelchair with assistance on the unit; was frequently incontinent of bowel and bladder; had a fall in the last month prior to admission; had a fall in the last 2-6 months prior to admission; and received antidepressant medication for 6 days, out of the last 7 days. Review of the plan of Care for Falls dated 10/26/16 indicated that the Resident was at risk for falls due to impaired balance, weakness, poor safety awareness, incontinence, and the use of antidepressant medication. Interventions included: - Fall Assessment Quarterly and per facility protocol. - Keep frequently used items within easy reach. - Keep walkways free of clutter. - (Resident) uses medication which could cause dizziness. Monitor closely and report issues to nurse/MD (Medical Doctor). Review of a nursing note dated 10/30/16 indicated the Resident had an unwitnessed fall and was found on the floor in the bathroom at 4:30 P.M Review of the investigation indicated the Resident toileted him/herself and fell when getting back into the wheelchair. The resident had no injuries. The plan of care was updated to include bed and chair alarms at all times. Review of the nursing note of 11/13/16 indicated the resident fell out of the bed onto the floor with no injury at 7:30 A.M Review of the investigation indicated the Resident stated the Resident was trying to get up to go to the bathroom. The care plan was updated to provide the Resident with education regarding falls and call light use, despite the resident having severely impaired cognition. The Nursing note of 12/18/16 indicated the Resident fell out of the bed onto the floor at 5:00 A.M The investigation indicated the resident sustained [REDACTED]. The plan of care was updated to include staff education. The surveyor asked what the staff was educated on, and the DON indicated that she would get back to the Surveyor, as the care plan just indicated, Staff Education. On 12/26/16, the Falls Care Plan was updated to include to offer back to bed to the Resident at 8:00 P.M. Review of a Quarterly MDS assessment dated [DATE] indicated the Resident was occasionally incontinent of bowel and bladder; had 2 or more falls with no injury; and 1 fall with injury (except major); and received antidepressant medication for 7 days, out of the last 7 days. The resident had 4 more unwitnessed falls, out of the bed, onto the floor, according to the nursing notes, on 2/2/17, 2/3/17, 3/11/17, and 3/13/17. Review of investigations indicated: 2/2/17 - 4:30 A.M. - No injury - Alarm did not sound, found unplugged - Resident found kneeling on floor next to the bed. The care plan was updated to include call light demonstration, and education to call for help, despite the Resident's severely impaired cognition. 2/3/17 - 9:10 P.M. - No injury - Resident found on floor between beds in the room. Resident stated he/she wanted to go to the bathroom and forgot he/she had to wait. Care plan not updated. 3/11/17 - 10:40 P.M. - No injury - Alarm sounded, Resident found on the floor - Tried to get out of bed to go to the bathroom. Care Plan updated for Medical work-up. 3/13/17 - 10:55 P.M. - No injury - Resident found lying on floor on left side. The Care Plan was updated to start a 3 day Voiding Pattern. No pattern. The resident was toileted upon arising, before and after meals, before bed, and three times during the night during rounds. Review of a Nursing note of 3/16/17 indicated that the resident fell at 3:10 P.M. and was found on the floor in front of the toilet in his/her bathroom. The resident sustained [REDACTED]. Review of a Nursing note of 3/19/17 indicated at 12:15 A.M. the alarm sounded, and the Resident was found sitting on the floor in front of the roommate's bed. Review of the investigation indicated the resident had no injury. The care plan was updated to move the resident closer to the nurses station. Review of a Nursing note of 3/31/17 indicated the Resident had an unwitnessed fall at 3:40 P.M. Review of the Investigation indicated that the Resident was on the floor in his/her room near the bathroom with the wheelchair across the room. The wheelchair alarm did not sound as planned (malfunctioned). The resident complained of left hip pain which subsided, and the resident sustained [REDACTED]. Left hip x-rays were obtained. Results no definite acute fracture. The Resident was moved to a room closer to the nursing station and an alarm was attached to the bathroom door. A Fall Risk Assessment Completed on 4/7/17 indicated that the Resident scored 19, indicating a High Risk for falls. The Resident scored 3 points higher than on the date of admission to the facility, when the resident scored 16. (Total Score above 10 represents HIGH RISK). Review of a Quarterly MDS assessment dated [DATE] indicated the Resident had trouble sleeping; displayed wandering behaviors 4 to 6 days; was occasionally incontinent of bowel and frequently incontinent of bladder; had 2 or more falls with no injury; and 1 fall with injury (except major); and received antidepressant medication for 7 days, out of the last 7 days. Review of a Nursing note of 4/11/17 at 7:25 P.M. indicated that the Resident was wandering in and out of other Resident's rooms in the wheelchair. A Certified Nursing Assistant (CNA) witnessed the Resident stand from the wheelchair, lean forward, and fall to the floor. Review of the investigation indicated the resident sustained [REDACTED]. Review of an Situation Background Assessment Recommendation (SBAR) Communication Form dated 4/28/17 indicated the Resident's alarm sounded at 11:00 P.M., and the resident was found sitting on the floor next to his/her roommates bed. The Resident's left leg was twisted to the side. The Resident was sent to the emergency room for evaluation. Review of the Incident Report form dated 5/2/17 indicated that the Resident rolled out of bed, and was admitted to the hospital with [REDACTED]. This was the Resident's 8th fall out of the bed onto the floor with no mat for protection. A Quarterly MDS Assessment completed on 10/26/17 indicated the Resident Scored 11/15 on the BIMS indicating moderately impaired cognition; had verbal behavioral symptoms directed towards others 1 to 3 days; was extensive assist of two for transfer; was frequently incontinent of bowel and bladder; had 2 falls with no injury; and received antidepressant and antipsychotic medication for 7 days, out of the last 7 days. The Surveyor observed the Resident on 11/6/17 at 1:15 P.M. sitting in a wheelchair by the Nursing station with the alarm on as planned. The Surveyor observed the Resident on 11/6/17 at 3:30 P.M. sitting in the Unit hallway in the wheelchair with the alarm on as planned. On 11/7/17 at 9:15 A.M., the Surveyor observed the Resident lying in the bed, with the bed in the low position, approximately 14 inches from the bed to the mat, with the alarm on as planned. During interview with Nurse #1 on 11/7/17 at 9:25 A.M. she said that the Resident used to fall frequently, but has settled down and is not such a high fall risk any more. During an interview with CNA #1 on 11/9/17 at 5:05 P.M., he said that the Resident is at risk for falling, and has to be supervised. The Resident has a bed and chair alarm and a mat next to the bed. He/she has to be watched carefully. During an interview with CNA #2 on 11/9/17 at 5:10 P.M., she said that the Resident has had a lot of falls and remembers bruises on the Resident's forehead. The CNA said that she never leaves the Resident alone, and helps him/her to do everything. During interview with the DON and UM #2 on 11/8/17 at 11:30 A.M., the DON said that not all of the interventions for falls were effective. She said the interventions after the falls of 11/13/16 and 2/2/17 were ineffective, because the Resident had a BIMS score of 4/15, and it was not reasonable to educate the Resident regarding falls, and the use of the call light. The surveyor asked the DON about the alarms which did not sound during the falls of 2/2/17 and 3/31/17, and she made no comment. On 11/9/17 at 4:00 P.M. the DON approached the surveyor and said that she could not find any information regarding what the staff was educated on after the Resident fell on [DATE].

Based on records reviewed and interviews for 1 of 3 Residents (Resident #2), the Facility failed to ensure that the use of assistive device, a personal alarm was turned on, resulting in the alarm failing to sound to alert staff prior to Resident #2 attempting to transfer without assistance and falling. Resident #2 fell and sustained a fractured sacrum and extension into the sacroiliac joint as a result of the. The personal alarm was in place and did not sound and the Director of Nurses (DON) said it was determined the Resident's chair alarm was not sounding, because it was not turned on. Findings include: Resident #2 was admitted in 10/2014. Resident #2's [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment, dated 12/23/15 indicated Resident #2 was at high risk for falls. Review of Resident #2's Falls Care Plan, dated 10/7/15, indicated he/she required a chair alarm while in the wheelchair. Review of the Fall investigation and Nurse's Note, dated 2/12/16 indicated Resident #2 fell in the Day Room at 7:00 P.M. and sustained a fractured sacrum with extension into the sacroiliac joint. This fall investigation of 2/12/16, stated There was no alarm going off when resident fell out of the wheelchair. The Certified Nursing Assistant (CNA) statements indicated 3 of 4 CNAs did not hear an alarm sound. CNA #1 (the CNA assigned to Resident #2) statement indicated that she arrived on the Unit after Nurse #3 was already with Resident #2. CNA #1 claimed that Resident #2's alarm was sounding. The Surveyor interviewed Nurse #3 at 2:45 P.M. on 3/17/16. Nurse #3 said that at 7:00 P.M. on 2/1/16, she was notified by a Family Member that Resident #2 had fallen in the Day Room. Nurse #3 said that she ran to the Day Room and was the 1st staff member to arrive in the Day Room. Nurse #3 found Resident #2 on the floor lying on his/her side. Nurse #3 said that the alarm was attached to the wheelchair and it was not sounding. The Surveyor interviewed NS #4 at 3:05 P.M. on 3/18/16. NS #4 said that he/she was at the entrance of the Day Room at approximately 7:00 P.M. on 2/12/16, when he/she witnessed Resident #2 just as Resident #2 landed on the floor. NS #4 said there were no staff members in the Day Room and there was no alarm sounding when Resident #2 fell . NS #4 said that the first staff member to arrive was the Unit Nurse (Nurse #3) who stayed with Resident #2. The Surveyor interviewed the Director of Nurses (DON) and the Assistant Director of Nursing (ADON) at 9:30 A.M. on 3/17/16. The DON and ADON both said that CNA #1's account of the incident was false, that Resident #2's chair alarm was not sounding.

Based on records reviewed and interviews for 1 of 3 Residents (Resident #2), the facility failed to ensure that nursing staff followed Resident #2's fall prevention plan. Resident #2 whose plan of care included use of personal alarm, fell and sustained a fractured sacrum with extension into the sacroiliac joint. The personal alarm did not sound to alert the staff that Resident #2 was attempting to get up unassisted. Findings include: Resident #2 was admitted in 10/2014. Resident #2's [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment, dated 12/23/15 indicated Resident #2 was at high risk for falls. Review of Resident #2's Falls Care Plan, dated 10/7/15, indicated he/she required a personal alarm while in the wheelchair. Review of the Fall investigation and Nurse's Note both, dated 2/12/16 indicated Resident #2 fell in the Day Room at 7:00 P.M. and sustained a fractured sacrum with extension into the sacroiliac joint. This fall investigation of 2/12/16, stated, There was no alarm going off when resident fell out of the wheelchair. The Certified Nursing Assistant (CNA) statements indicated that 3 of 4 CNAs did not hear an alarm sound. CNA #1's (the CNA assigned to Resident #2) statement indicated that she arrived on the Unit after Nurse #3 was already with Resident #2. The Surveyor interviewed Nurse #3 at 2:45 P.M. and Non-Sampled Resident #4 at 3:05 P.M. on 3/17/16 both stated that the chair alarm was not sounding. The Surveyor interviewed the Director of Nurses (DON) at 9:30 A.M. on 3/17/16. The DON said that the falls care plan was not followed for having the personal alarm in the on position for Resident #2. The DON said CNA #1's claims related to the use of alarm were determined to not be accurate and corrective action was taken in response.

Based on record review and staff interviews, for three of four sampled residents (Resident #1, Resident #3 and Resident #4), the Facility failed to ensure: 1) that the certified nurse aides followed the plan of care regarding transfer of Resident #1 when on 10/20/13, Certified Nurse Aide (CNA) #1 and CNA #2 transferred Resident #1 to the Broda chair not in accordance with the plan of care. Resident #1 slid out of the Broda chair and sustained a fractured left leg; 2) that a chair alarm was used when Resident #3 was out of bed per plan of care, and 3) that a wanderguard was used on Resident #4's wheelchair at all times per plan of care. Findings include: 1) CNA #1 and CNA #2 said they did not review the CNA Care Card prior to the transferring of Resident #1 to the broda chair. Resident #1's care card, updated 7/10/13, indicated that Resident #1 used a sit-to-stand lift with 2 assist to the wheelchair. The Surveyor interviewed CNA #1 on 11/5/13 at 12:00 P.M. CNA #1 said she did not check Resident #1's Care Card prior to transferring Resident #1 to the Broda chair because the care cards were not updated. CNA #1 said she and CNA #2 transferred Resident #1 using the Hoyer lift (a mechanical lift that transfers the resident in a seated position). CNA #1 said the Broda chair was in the upright position and the footrest was disengaged (folded upright, engaged is in the down position). CNA #1 said after Resident #1 was seated in the Broda chair, CNA #2 removed the Hoyer lift and left the room. The Surveyor interviewed CNA #2 on 11/5/13 at 10:10 A.M. CNA #2 said she assisted CNA #1 with Resident #1's transfer on 10/20/13. CNA #2 said she did not check Resident #1's Care Card prior to the transfer. CNA #2 said she and CNA #1 transferred Resident #1 with a 2-person stand and pivot assist and did not use any equipment during the transfer. CNA #2 said they transferred Resident #1 into the Broda chair which was locked. CNA #2 said the footrests were folded up. CNA #2 said she left the room after Resident #1 was seated in the Broda chair. CNA #2 said Resident #1 was seated in the Broda chair which was in the upright position with the footrest folded up. Please refer to F 323. 2) The Resident Admission Record indicated that the Facility admitted Resident #3 in August 2013. The Physician order [REDACTED]. The CNA Care Care, updated October 2013, indicated that Resident #3 used a chair alarm when out of bed. The Surveyor toured the Long Term Care Unit on 11/5/13 at 12:20 P.M. The Surveyor observed Resident #3 seated at a table in the dayroom in a wheelchair recliner eating his/her lunch. The Surveyor observed the wheelchair was without a chair alarm. The Surveyor interviewed Unit Manager #1 during the tour. Unit Manager #1 said Resident #3 should have a chair alarm. Unit Manager #1 asked staff for the location of Resident #3's chair alarm. 3) The Resident Admission Record indicated that the Facility admitted Resident #4 in March 2011 and [DIAGNOSES REDACTED]. The Physician order [REDACTED]. Unit Manager #1 said the Wanderguard was placed on Resident #4's wheelchair otherwise he/she removed it. The Surveyor toured the Long Term Care Unit on 11/5/13 at 12:20 P.M. The Surveyor observed Resident #4's wheelchair and noted the Wanderguard was attached to Resident #4's left ankle.

Based on record review and staff interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure that the certified nurse aides followed the plan of care regarding transfer of Resident #1. On 10/20/13, Certified Nurse Aide (CNA) #1 and CNA #2 transferred Resident #1 to the Broda chair. CNA #1 and CNA #2 said they did not review the CNA Care Card prior to the transfer. CNA #1 and CNA #2 transferred Resident #1 to the Broda chair not in accordance with the plan of care. Resident #1 slid out of the Broda chair and sustained a fractured left leg. Findings include: Resident #1's care card, updated 7/10/13, indicated that Resident #1 used a sit-to-stand lift with 2 assist to the wheelchair. The annual Minimum Data Set (MDS) assessment, dated 9/18/13, indicated that Resident #1 had cognitive loss, required extensive assist of 2 persons for transfers, and used a wheelchair for mobility. The Surveyor interviewed CNA #3 on 11/5/13 at 8:45 A.M. CNA #3, Resident #1's primary CNA, said nursing staff transferred Resident #1 via sit-to-stand transfer lift (a device that assisted Resident #1 to a standing position and transferred Resident #1 to the Broda chair) with 2 assists since January 2013. CNA #3 said Resident #1 had been using the Broda chair for seating since July 2013. CNA #3 said the information about the transfer/seating devices was documented on the CNA Care Card. CNA #3 said Resident #1's Care Card was up to date regarding transfer and seating information. The Broda Chair Operating Manual, section 2.5, indicated that the manufacturer recommended that the staff tilt the resident back immediately after being seated in the chair to prevent sliding from or falling forward out of the chair. The Surveyor interviewed CNA #1 on 11/5/13 at 12:00 P.M. CNA #1 said she did not check Resident #1's Care Card prior to transferring Resident #1 to the Broda chair because the care cards were not updated. CNA #1 said she and CNA #2 transferred Resident #1 using the Hoyer lift (a mechanical lift that transfers the resident in a seated position). CNA #1 said the Broda chair was in the upright position and the footrest was disengaged (folded upright, engaged is in the down position). CNA #1 said the Broda chair was covered with a blanket and an incontinence pad was placed on the seat of the Broda chair. CNA #1 said Resident #2 wore a brief with pants over the brief. CNA #1 said after Resident #1 was seated in the Broda chair, CNA #2 removed the Hoyer lift and left the room. The Surveyor interviewed CNA #2 on 11/5/13 at 10:10 A.M. CNA #2 said she assisted CNA #1 with Resident #1's transfer on 10/20/13. CNA #2 said she did not check Resident #1's Care Card prior to the transfer. CNA #2 said she and CNA #1 transferred Resident #1 with a 2-person stand and pivot assist and did not use any equipment during the transfer. CNA #2 said they transferred Resident #1 into the Broda chair which was locked. CNA #2 said the footrests were folded up. CNA #2 said an incontinence pad was placed on the seat of the Broda chair. CNA #2 said Resident #1 had on a brief and pants over the brief. CNA #2 said there was no nonskid surface on or under the incontinence pad. CNA #2 said she left the room after Resident #1 was seated in the Broda chair. CNA #2 said Resident #1 was seated in the Broda chair which was in the upright position with the footrest folded up. CNA #2 said she assumed that Resident #1's buttocks would have been further back in the Broda chair if he/she had been transferred with a sit-to-stand lift. CNA #1 said after CNA #2 left the room, she began to recline Resident #1 and Resident #1 started to slip out of the Broda chair. CNA #1 said she attempted to stop Resident #1 from sliding and could not so she lowered Resident #1 to the floor. CNA #1 said she looked down and Resident #1's left leg was at an awkward angle. CNA #1 said she called for the nurse. The Surveyor interviewed Nurse #1 on 11/5/13 at 10:45 A.M. Nurse #1 said she responded to CNA #1's call for nurse assist. Nurse #1 said she did not recall seeing a Hoyer lift in the vicinity of Resident #1's room. Nurse #1 said Resident #1 did not have a Hoyer lift pad on the Broda chair or under him/her on the floor. Nurse #1 said the Broda chair was in the upright position and the foot rest was folded upright. Nurse #1 said Resident #1 was seated on the floor and his/her left leg was bent under the right leg. Nurse #1 said she asked CNA #1 what she was doing prior to Resident #1's fall. Nurse #1 said CNA #1 said she had turned from Resident #1 to straighten out his/her bed, Resident #1 yelled out, and CNA #1 turned and saw Resident #1 sliding. Nurse #1 said CNA #1 said she lowered Resident #1 to the floor. The Surveyor interviewed the Director of Nurses (DON) on 11/5/13 at 9:30 A.M. The DON said she attributed the fall to operator error because CNA #1 did not immediately recline Resident #1 after he/she transferred Resident #1 to the Broda chair.