Every finding on record at Haverhill Rehabilitation and Healthcare Center

Based on record review and interview, the facility failed to maintain an effective way to track and measure performance of the Quality Assurance and Performance Improvement (QAPI) program. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI), dated 3/1/25, indicated the following: - It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. - The QAPI plan shall address the following elements: * Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: * Tracking and measuring performance. * Establishing goals and thresholds for performance improvements. * Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. - The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: - Data collection and analysis at regular intervals. Review of the QAPI minutes for March 2025 indicated the following: - Topic : Antipsychotic Use Report - Discussion: 22 Residents utilizing antipsychotic medications - Recommendations/ Actions: The next meeting for psych rounds will be scheduled 4/29/25 at 2 P.M. Review of the QAPI minutes for April 2025 indicated the following: - Topic: Pharmacy - Discussion: Triggering High - Recommendations/Actions: Putting a plan in place with Medical Director PRN antipsychotics. - Topic: Maintenance Repairs - Discussion: Discussing a timeframe - Recommendations/Actions: Outside vendors, help from other facilities, ongoing rounds/repairs - Topic: Falls - Discussion: 15 falls in March 2025. 6 on [NAME] (1:45 pm-4:45 pm), 5 on Pentucket (7:10 am, 7p3-10pm [sic]), and 4 on [NAME] (8:30 am, 2 pm, dinnertime. - Recommendations/Actions: Utilizing day rooms more, what is working?, what is not? Review of the minutes and QAPI plan failed to indicate any measures of tracking QAPI performance and/or outcomes of QAPI performance. During an interview on 4/24/25 at 1:35 P.M., the Administrator said that he follows performance through morning meetings and the Director of Nursing keeps track of falls. The Administrator said he keeps identified issues on the QAPI plan until compliance is achieved or the target goal. The Administrator could not say what the compliance or target goal was for the issues identified on the QAPI plan.

Based on record review and interview the facility failed to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. Findings include: Review of the facility policy titled Infection Prevention and Control Program, dated revised 2/1/24, indicated that the facility maintains an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Further review indicated a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents . Review of the facility's infection control line listing dated January 2025 indicated that the name of the resident, the suspected infection, the signs and symptoms a resident is exhibiting, the dates of treatment, the antibiotic prescribed and the name of the organism is documented. Further review indicated that for 10 out of 23 listed infections the signs and symptoms column was blank. Review of the facility's infection control line listing dated February 2025 indicated that 13 out of 23 listed infections the signs and symptoms column was blank. Further review indicated that for 4 out of 8 urinary tract infections the organism column was blank. Review of the facility's infection control line listing dated March 2025 indicated that 9 out of 20 suspected infections the signs and symptoms column is blank. Further review indicated that 3 out 6 suspected urinary tract infections had no listed organism. During an interview on 4/24/25, at 1:49 P.M., the Infection Preventionist (IP) said that the documents she handed the surveyor were the past three months of infection surveillance line listing the facility completed. The IP said that the facility uses the Mcgeers criteria for determining if the suspected infection qualifies for treatment. She then said that the Mcgeers criteria requires a specific number of signs and symptoms for each type of suspected infection to qualify as a treatable infection. The IP then said that the facility does not document the outcomes of treatment to see if the treatment was effective. The IP said that she does not look for trending to determine if there is a particular group of rooms or staff member that would be responsible for the spread of infections. The IP said that all of the columns in the monthly line listings should be complete in order to accurately track the infections in the building. The IP said that the line listings should include outcome and trends should be identified and acted upon.

Based on record review, policy review and interview the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics. Findings include: Review of the facility policy titled Antibiotic Stewardship -Review and Surveillance of Antibiotic Use and Outcomes dated revised December 2016 indicated that antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Further review indicated that the IP (infection Preventionist) will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Further review indicated that the outcome of the use of the antibiotic will be reviewed and documented, but failed to indicate when that review will take place. Review of the current January, February and March 2025 line listings with the Infection Preventionist (IP), indicated that 32 antibiotics were prescribed and started in January, 20 in February and 25 in March. The line listings failed to failed to indicate any follow up or review with the physician or nurse practitioner following the initiation of the antibiotic for 77 out of the 77 antibiotics prescribed. During an interview on 4/24/25 at 1:49 P.M. the IP said that when an antibiotic is prescribed there is no review for the appropriateness or the efficacy of the antibiotic until she has time to review the infection control line listings that are completed each month. The IP then said that antibiotics should be reviewed within 48-72 hours of initiation of the antibiotic.

Based on record review and interviews, the facility failed to develop and/or implement care plans for two Residents (#68 and #67) out of a sample of 29 Residents. Specifically, 1. For Resident #68, the facility failed to develop a substance use disorder care plan. 2. For Resident #67, the facility failed to implement geri sleeves (skin protectors) to bilateral arms and legs. Findings include: A review of the facility policy titled 'Safety for Residents with Substance Use Disorder' implemented on 3/1/25 indicated the following: -It is the policy of this facility to create an environment that is free of accident hazards as possible, for residents with a history of substance use disorder. -Care planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety. 1. Resident #68 was admitted to the facility in December 2023 with diagnoses including major depressive disorder, opioid abuse, PTSD (post-traumatic stress disorder) and alcoholic cirrhosis of liver without ascites. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating moderate cognitive impairment. A review of Resident #68's social service history and evaluation dated 1/5/24 indicated the following: -Psycho-social assessment, ETOH (Alcohol), Yes-Alcoholic Cirrhosis, Opioid Abuse. A review of Resident #68's care plan failed to indicate care plans for a history of alcohol abuse and opioid abuse that identified interventions, triggers and a plan for support for the Resident. During an interview and medical record review on 4/24/25 at 9:09 A.M., the Social Worker said the Resident should have care plans developed for a history of alcohol abuse and opioid abuse. 45343 2. Resident #67 was admitted to the facility in January 2025 with diagnoses that included Type 2 Diabetes Mellitus, myexedema coma (thyroid hormone regulation disruption), bipolar, and depression. Review of Resident #67's most recent Minimum Data Set (MDS) dated [DATE], revealed that he/she had a Brief interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating moderate cognitive impairments. Further review of the MDS indicated Resident #67 required total dependence with personal hygiene and is at risk for pressure ulcers. On 4/22/25 at 8:12 A.M. and 10:30 A.M., on 4/23/25 at 7:00 A.M., 8:12 A.M., and 12:30 P.M., and on 4/24/25 at 7:54 A.M. and 8:40 A.M., Resident #67 was observed lying in his/her bed. Resident #67 was not wearing his/her bilateral upper and lower extremity geri-sleeves. Review of Resident #67's physician order, dated 3/1/25, indicated the following: Geri-sleeves to lower arms and legs at all times. Remove for care. Review of Resident #67's nursing progress notes for the past 30 days failed to indicate the Resident refused bilateral upper and lower extremity geri-sleeves. During an interview on 4/24/25 at 8:11 A.M., Resident #67 said he/she used to wear sleeves on his/her arms and legs but has not worn them in about a month. During an interview on 4/24/25 at 8:24 A.M., Nurse #3 said she was not aware if Resident #67 should be wearing geri-sleeves and has not seen them in his/her room. Nurse #3 said the geri-sleeves should be worn as ordered by the physician. During an interview on 4/24/25 at 8:38 A.M., Nurse #2 said she thought Resident #67 came in with orders for booties but unsure if there were orders for geri-sleeves. Nurse #2 said the physician's order should be followed and any refusals should be documented in the medical record. During an interview on 4/24/25 at 9:01 A.M., the Administrator said he expects the geri-sleeves to be worn as ordered and documented in the nurse's note if the resident refuses.

Based on record review and interviews, the facility failed to respond to concerns voiced by residents in the monthly resident council meetings. Specifically, the facility failed to act promptly upon the grievances of the issues identified during the monthly resident council meetings. Findings include: A review of the facility policy titled 'Resident Council' with a revision date of February 2021 indicated the following: -The facility supports residents' rights to organize and participate in the resident council. -The purpose of the resident council is to provide a forum for discussion of concerns and suggestions for improvement. -Council meetings are scheduled monthly or more frequently if requested by residents. The date, time and location of the meetings are noted in the activities calendar. -A Resident council response form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item (s) of concern. A review of the Resident council minutes for the months of February, March and April 2025 indicated the following: -2/3/25-Nursing: Aides and nurses are still on their cell phones, especially service people, but also ours. The call lights are taking too long to be answered on all floors, all shifts. [sic] -3/6/25-Nursing: Nurses continue using their cell phones and ear buds on their med carts. Aides on Pentucket and [NAME] on 7-3 and 3-11 are speaking Spanish in the resident rooms and in the halls. Aides are on their phones in resident bathrooms. [sic] -4/7/25-Nursing: Residents in room [ROOM NUMBER] said they have to wait for long periods of time for call lights to be answered. During a Resident council meeting held on 4/23/25 at 11:08 A.M., 16 out of 16 residents in attendance said Aides and Nurses are still using their cell phones and using ear buds while working on the units. They said call lights are taking more than an hour to be answered, and staff are speaking Spanish in front of them. The residents said they have brought up these concerns in resident council meetings, but they are not being addressed. A review of the Resident Council Record failed to indicate supporting documentation for resolutions for the above resident concerns from the monthly resident council meetings from February-April 2025. During an interview on 4/23/25 at 3:08 P.M., the Activities Director said she runs resident council meetings every month and writes the Resident council minutes. The Activities Director said any concerns brought up by the residents in the resident council meetings should be reported to the Administrator so he can get the concerns addressed timely and get resolutions. The Activities Director said the concerns should be reported to the Administrator after each Resident council meeting every month. The Activities Director said after the resolutions are obtained, the supporting documentation should be filed in the Resident council binder. The Activities Director said she did report these concerns to the previous facility Administrator. During an interview on 4/23/25 at 2:06 P.M., the Administrator said all Resident Council concerns should be reported to him monthly so he can have the concerns/grievances addressed in a timely manner. The Administrator said he could not locate any resolutions about the concerns from the Resident Council meetings from February-April 2025 from the previous facility Administrator. The Administrator said the Resident Council concerns should be addressed with a resolution obtained each time they are brought up by the residents in the meeting. The Administrator said if the residents bring up concerns monthly, they should be addressed monthly. The Administrator said the supportive documentation of the resolutions obtained after the concerns have been addressed should be filed with the Resident Council minutes.

Based on interview and record review, the facility failed to provide a prompt resolution or follow up on a grievance for one Resident (#41) out of a total sample of 29 residents. Specifically, the facility failed to follow up on a grievance regarding a lost hearing aid. Findings Include: Review of the facility policy titled Resident and Family Grievances, dated 3/1/25, indicated the following: -It is the policy of this facility to support each resident's and family member rights to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. -Prompt efforts to resolve include the facility acknowledgement of complaint/grievance and actively working toward resolution of that complain/grievance. -A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) facility stay. -The grievance official, or designee, will keep the resident appropriately apprised of progress towards the resolution of the grievances. -For investigations regarding allegations of neglect, abuse, injuries of unknown source, and/or misappropriation of resident property, a report of the investigative results will be submitted to the State Survey Agency, and or other officials in accordance with State law, within five working days of the incident. Review of the grievance book indicated a grievance dated 4/23/25, which indicated the following grievance from Resident #41: - Patient stated he/she is missing right hearing aid, dated 2/15/25. - Social worker interview Resident #41 who said he/she is missing her left hearing aid. At the time the social worker spoke to him/her at approximately 10:30 A.M., he/she had old left side hearing aid in, Resident #41 said he/she has a right hearing aid, but it whistles, note dated 2/17/25. - Confirmed on 2/20/25 with Resident and family missing left hearing aid. Wants to see audiologist here and get replacement, note dated 2/20/25. - Update: Referred to Health Drive, awaiting signed consent, note undated. On 4/23/25 at approximately 11:00 A.M., during Resident Council Meeting, Resident #41 expressed to a surveyor that he/she was missing their hearing aid. The surveyor observed Resident #41 wearing a left hearing aid only and positioned herself on his/her left side for the duration of the meeting. During an interview on 4/23/25 at 1:40 P.M., Resident #41's daughter confirmed Resident was missing his/her left hearing aid, not her right, and it went missing shortly after the Resident was admitted to the facility in February. Resident #41's daughter said the Resident is currently wearing his/her old left hearing aid but it does not work very well. Resident #41's daughter said she filed a grievance report at the time the left hearing aid went missing but never heard anything after that about getting a replacement. Resident #41's daughter said she was just asked to fill out another consent form and dropped it off at the desk. Review of Resident #41's physician's orders indicated the following: CONSULT: Dentist, Podiatrist, Optometrist, Audiology Consult as needed, dated 2/12/25. Review of Resident #41's medical record failed to indicate the lost left hearing aid, or the Resident was seen by the audiologist. During an interview on 4/24/25 at 8:58 A.M., the Administrator said he was not aware of Resident #41's missing hearing aid. The Administrator said he would expect when a grievance is filed regarding a lost hearing aid, there would be an investigation, and the facility would work with the Resident and family to get the Resident a replacement hearing aid.

Based on observation, record review and interview, the facility failed to ensure one Resident (#154) received care in accordance with professional standards of practice, out of a total sample of 29 residents. Specifically, for Resident #154 the facility failed to obtain physician's orders for the placement and care of a Midline (an intravenous (IV) line inserted into the upper arm to deliver medications and fluids over a longer period of time than a standard IV). Findings include: Review of the facility policy titled Midline/Extended Dwell Catheter, dated January 2022 indicated a prescriber's order is required for a vascular access device. Resident #154 was admitted to the facility in April 2025 with diagnoses including urinary tract infection, recent fall and high blood pressure. Review of the document titled Infusion Support Systems and dated 4/16/25, indicated that a Midline was placed in Resident #154's basilic vein of the right upper arm at 11:50 A.M. Review of the physician's orders dated April 2025 failed to indicate a physician's order for the placement of a Midline. Further review failed to indicate an order for the care of the Midline. Review of the treatment administration record dated April 2025 failed to indicate the use of a Midline or for the care of a Midline. Review of the care plan failed to indicate the use of a Midline. During an interview on 4/23/25 at 12:23 P.M. Unit Manager #1 said she could not find a physician's order for the Midline or for the care of the Midline. During an interview on 4/23/25 at 12:29 P.M. the Director of Nursing said that there should be a doctor's order for the placement of a Mid Line and how to care for the Midline.

Based on record review and interview, the facility failed to obtain rehab services to maintain one Resident's (#88) activities of daily living (ADL) out of a total sample of 29 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated March 2018 indicated the following: - Residents will be provided with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. - A resident's ability to perform ADL's will be measured using clinical tools, including the MDS (minimum data set) Review of the facility policy titled Patient Care Management- Evaluation and Treatment, dated 9/8/21, indicated the following: - All patients identified as needing an assessment of functional status and potential to benefit from rehabilitation services, are to be evaluated to determine the appropriate plan of care. - Evaluations are initiated within 24 hours, or per facility policy, of receipt of physician's order or authorization. - Therapy intervention is based on the initial evaluation, with changes to the treatment plan based on an ongoing assessment of the patient requiring physician orders. Resident #88 was admitted in August 2024 with diagnoses including anxiety, dementia, and unsteadiness on feet. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #88 scored a 10 out of a possible 15 on the Brief Interview for Mental Status exam, indicating moderate cognitive impairment. Review of the MDS indicated Resident #88 requires substantial/maximal assistance to dependence with activities of daily living. Review of the physical therapy discharge summary for Resident #88, dated 9/6/24, indicated Resident #88 was discharged with the following: - Roll left and right- Setup or clean-up assistance - Sit to Stand- Supervision or touching assistance - Chair/bed to chair transfer- Supervision or touching assistance - Toilet transfer- Partial/moderate assistance - Tub/shower transfer- Partial/moderate assistance Review of the nursing progress note, dated 11/20/24, indicated the following: Discussed residents care needs with interdisciplinary team. Decline in ADL's noted since last MDS completion, decided will change to a significant change MDS. Resident #88 is awake/alert today, oriented to self. Sometimes understands, staff dependent for care needs, oversight and coaxing at meal time. Pleasantly confused as is baseline. Review of the care task sheet for November 2024 indicated Resident #88 required the following: - Toileting- Substantial/maximal assistance to dependence - Shower/bathing- Substantial/ maximal assistance to dependence - Roll left and right- Substantial/maximal assistance to dependence - Sit to Stand- Substantial/maximal assistance to dependence - Toilet Transfer- Varies from supervision to dependence Review of the medical record and therapy notes failed to indicate that Resident #88 was evaluated by therapy after a decline in activities of daily living. During an interview on 4/23/25 at 9:01 A.M., the Director of Rehab said he was not here at the time of Resident #88's decline, but if there is a decline in a Resident's ability, then the rehab department should be notified so a screen and evaluation can be done to determine if a Resident is appropriate for rehab services. The Director of Rehab said he could not find a screen or evaluation for Resident #88 after his/her decline in ADL's in November 2024.

Based on record review and interview, the facility failed to provide services to maintain adequate hearing for one Resident (#41) out of a total sample of 29 residents. Specifically, the facility failed to assist the Resident with replacing his/her lost hearing aid. Findings include: Resident #41 was admitted to the facility in February 2025 with diagnoses including left femur fracture, anemia, and anxiety. Review of Resident #41's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) Exam score of 13 out of 15 which indicates he/she is cognitively intact. The MDS also indicates Resident #41 requires substantial/maximal assistance from staff for functional daily tasks. On 4/23/25 at approximately 11:00 A.M., during Resident Council Meeting, Resident #41 expressed to a surveyor that he/she was missing their hearing aid. The surveyor observed Resident #41 wearing a left hearing aid only and positioned herself on his/her left side for the duration of the meeting. During an interview on 4/23/25 at 1:40 P.M., Resident #41's daughter confirmed the Resident was missing his/her left hearing aid, that it went missing shortly after the Resident was admitted to the facility in February, and Resident #41 is currently wearing an old left hearing aid that doesn't work very well. Resident #41's daughter said she filed a grievance report at the time but never heard anything after that about getting a replacement. Resident #41's daughter said she was just asked to fill out another consent form and dropped it off at the desk. Review of Resident #41's physician's orders indicated the following: CONSULT: Dentist, Podiatrist, Optometrist, Audiology Consult as needed, dated 2/12/25. Review of Resident #41's medical record failed to indicate the Resident was seen by the audiologist. During an interview on 4/24/25 at 8:48 A.M., Nurse #2 said the social worker, the director of nursing and the unit manager would work together to setup audiology services and to facilitate getting the Resident a replacement hearing aid. During an interview on 4/24/25 at 8:58 A.M., the Administrator said he would expect Resident #41 to be seen by an audiologist and be provided with a replacement hearing aid.

Based on observation, record review and staff interviews, the facility failed to ensure that one Resident (#67) out of a total sample of 29 residents, received proper foot care (Podiatry services). Findings include: Resident #67 was admitted to the facility in January 2025 with diagnoses that included Type 2 Diabetes Mellitus, myexedema coma (thyroid hormone regulation disruption), bipolar, and depression. Review of Resident #67's most recent Minimum Data Set (MDS) dated [DATE], revealed that he/she had a Brief interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating moderate cognitive impairments. Further review of the MDS indicated Resident #67 required total dependence with personal hygiene. Review of the facility policy titled Activities of Daily Living (ADL's), dated 3/1/25, indicated the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming, and oral care. -The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on comprehensive assessment. Review of the facility policy titled Nail Care, dated 3/1/25, indicated the following: -The purpose of this procedure is to provide guidelines for the provision of care to resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: -Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke. -If a resident has a toe infection, diabetes mellitus, neurological disorder, renal failure, or PVD (peripheral vascular disease), toenail trimming should be performed by a physician or practitioner. During an observation and interview on 4/23/25 at 8:10 A.M., Resident #67's toenails were observed as being long, jagged and yellow. The Resident said he/she has not had their toenails cut and has not been seen by a podiatrist. Review of Resident #67's medical record failed to indicate the Resident had ever been seen by podiatry. Further review of the medical record indicated Resident #67 signed a consent form for podiatry services on 1/23/25. During an interview on 4/24/25 at 8:26 A.M., Nurse #3 said when the nurse or Certified Nursing Assistant (CNA) observe long toenails, they will notify the unit secretary, and the resident will be added to the next scheduled podiatry visit. Nurse #3 said she was not aware Resident #67 needed his/her toenail cut. During an interview on 4/24/25 at 9:01 A.M., the Administrator said he would expect residents who need their toenails cut to be seen by the podiatrist as needed.

Based on record review and interview, the facility failed to follow up on significant weight changes for one Resident (#94) out of a total of 29 residents. Findings include: Resident #94 was admitted in February 2025 with diagnoses including dysphagia (difficulty chewing/swallowing) Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #94 could not participate in the Brief Interview for Mental Status exam due to severe cognitive impairment. Review of the care plan for Resident #94 indicated Resident #94 is at altered nutrition and hydration status due to cerebral infarct and cognitive deficits. The care plan did not indicate any interventions related to nutrition. Review of the care plan indicated Resident #94 requires a tube feeding related to dysphagia. Review of the weight record for Resident #94 indicated the following weights: * 02/24/25 - 172 pounds * 03/06/25 - 151.1 pounds (12% significant loss from previous weight) * 03/10/25 - 172.1 pounds (12% significant gain from previous weight) * 03/13/25 - 149 pounds (13% loss from previous weight) * 03/18/25 - 160.5 pounds (7% gain from previous weight) * 03/19/25 - 159.3 pounds * 04/09/25 - 159.3 pounds Review of the weights indicated Resident #94's weights fluctuated significantly from 3/6/25 to 3/18/25. Review of the initial nutrition assessment, dated 3/3/25, indicated Resident #94's weight was 172 pounds with recommendations to monitor intake, weight, labs, and skin integrity. During an interview on 4/24/25 at 8:17 A.M., the Dietitian said that she is usually notified in morning meeting of significant weight changes. The Dietitian said she would expect to be notified of any change of 5 pounds or more so she could evaluate the Resident. The Dietitian said that the weights entered into the electronic medical record should be accurate and that the nurses should re-weigh a resident if there is a large fluctuation in weight. The Dietitian said that she would typically write a note for any resident she saw for a significant weight change, but was not notified of the weight changes. Review of the medical record failed to indicate that the dietitian, physician, or nursing staff followed up on the significant weight changes.

Based on observations, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#97) out of sample of 29 residents. Specifically, 1. For Resident # 27, the facility failed to include a physician's order for the use of oxygen in the medical record and have oxygen set at a specified flow rate. Findings include: Review of the facility policy titled Oxygen Administration dated revised October 2010, indicated to verify there is a physician's order for the administration of oxygen before applying. Further review indicated to review the resident's care plan to assess for any special needs of the resident. 1. Resident #97 was admitted to the facility in April 2025 with diagnoses including asthma, anxiety and malnutrition. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #97's cognition is moderately impaired as evidenced by a scored 10 out of 15 on the Brief Interview for Mental Status assessment. Further review indicated that Resident #97 requires partial to maximal assistance with activities of daily living. On 4/22/25 at 8:10 A.M. the surveyor observed Resident #97 sitting on the edge of the bed receiving oxygen (O2) via nasal cannula at 1 L/min (liters per minute). On 4/23/25 at 7:35 A.M. the surveyor observed Resident #97 sitting on the edge of the bed receiving O2 via nasal cannula at 1 L/min (liters per minute). Review of the physician's orders dated April 2025 failed to indicate an order for the administration of oxygen. Review of the care plan failed to indicate a care plan was developed for the use of oxygen. During an interview on 4/23/25 at 9:47 A.M. Nurse #1 said Resident #97 should have had a physician's order and a care plan developed for the use of oxygen. During an interview on 4/23/25 at 12:29 P.M. the Director of Nursing said that there should be a physician's order and a care plan developed for the use of oxygen.

Based on record review and interviews, the facility failed to develop a personalized Post Traumatic Stress Disorder (PTSD) care plan for one Resident #68 out of a sample of 29 Residents. Specifically, the facility failed to develop a care plan for the Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident. Findings include: A review of the facility policy titled 'Trauma Informed Care implemented on 3/1/25 indicated the following: -It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing and/or re-traumatization. -The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), Admission Assessment, the history and physical, the social history/assessment, and others. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which retraumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. Resident #68 was admitted to the facility in December 2023 with diagnoses including major depressive disorder, opioid abuse, PTSD and alcoholic cirrhosis of liver without ascites. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating moderate cognitive impairment. A review of a brief trauma questionnaire dated 1/5/24 indicated the following: -Serious accident at work, home or during recreational activities-it happened to the Resident personally. -Exposure to toxic substance (for example, dangerous chemicals, radiation)-it happened to the Resident personally. -Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)-it happened to the Resident personally. -Any other very stressful event or experience- it happened to the Resident personally. A review of the care plans initiated 3/26/24, 6/5/24 and 4/14/25 respectively indicated the following: -Potential for alteration in mood related: Resident has a diagnosis of Anxiety disorder, PTSD. [sic] -Resident receives antipsychotic medication related: Resident has a diagnosis of Anxiety Disorder, PTSD. [sic] -Resident is at risk of skin breakdown related to decreased mobility and lack of motivation at times, PTSD. [sic] Further review of the care plans above failed to indicate that the Resident's traumatic experiences had been documented with interventions to mitigate triggers. During an interview and medical record review on 4/24/25 at 9:09 A.M., the Social Worker said the Resident's PTSD care plan was not personalized. She said the Resident's PTSD care plan should include all the traumatic events identified in the brief trauma questionnaire, identify triggers which may re-traumatize the Resident and identify ways to reduce the exposure to the triggers.

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biological's in accordance with State and Federal requirements. Specifically; the facility failed to ensure medications were not left at the bedside for one Resident (#97) out of a total of 29 sampled residents. Findings include: Review of the facility policy titled Medication Labeling and Storage dated 2001, indicated that the nurse is responsible for maintaining medication storage . in a clean, safe and sanitary manner. Further review indicated that medications stored at bedside are to be kept locked in a secure container. Resident #97 was admitted to the facility in April 2025 with diagnoses including asthma, anxiety and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #97's cognition is moderately impaired as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status exam, indicating moderate cognitive impairment. Further review indicated that Resident #97 requires partial to maximal assistance with activities of daily living. On 4/22/25 at 7:50 A.M., the surveyor observed an albuterol inhaler (used to treat asthma) on Resident #97's over the bed table. Resident #97 was in his/her room and said that he/she uses it sometimes. On 4/22/25 at 1:34 P.M., the surveyor observed an albuterol inhaler on Resident #97's over the bed table. Resident #97 was not in the room and the room door was open. On 4/23/25 at 7:35 A.M., the surveyor observed an albuterol inhaler on Resident #97's over the bed table. Review of the physician's orders dated April 2025 failed to indicate an order for self administration of medications. Review of the care plan failed to indicate a plan of care was develope for the self administration of medications. Review of the facility document titled Atlas- NSG: Admission/Readmission Evaluation - V 7 - - V 2, dated 4/5/25 indicated that Resident #97 did not want to self administer medications. Review of the medical record failed to indicate Resident #97 was assessed for the ability to self administer medications. On 4/23/25 at 9:47 A.M., the surveyor and Nurse #1 observed an Albuterol inhaler on Resident #97's over the bed table. During an interview on 4/23/25 9:47 A.M. Nurse #1 said Resident #97 should not have an inhaler at bedside. During an interview on 4/23/25 9:47 A.M. Resident #97 said one of the staff left it for him/her.

Based on record review and interview, the facility failed to follow a physician's order for a fluid restriction for one Resident (#46) out of a total sample of 29 residents. Findings include: Review of the facility policy titled Fluid Restriction, dated 3/1/25, indicated the following: - It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders. - The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes. - Water will not be provided at bedside unless calculated into the daily total fluid restriction. - The resident has the right to refuse the fluid restriction, and if refused, documentation should support the reason for the refusal, the education of the risks and benefits, and any supporting documentation of the resident's continued refusal, assessment for any changes in condition related to the refusal, and the notification of the physician about the resident's refusal. Resident #46 was admitted in May 2024 with diagnoses including heart failure, end stage renal disease, and dependence on renal dialysis. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #46 scored a 13 out of a possible 15 on the Brief Interview for Mental Status, indicating intact cognition. Review of the MDS indicated Resident #46 requires dialysis. During an observation and an interview on 4/24/25 at 7:32 A.M., Resident #46 was lying in bed and had a styrofoam cup next to him/her with liquid inside, as well as one 16 oz and two 8 oz bottles of water at his/her bedside. Resident #46 said he/she is aware of his/her fluid restriction and tries to follow it as best as he/she can. Review of the physician's orders indicated Resident #46 required a 1,200 milliliter (ml) fluid restriction per every 24 hours. The breakdown of the fluid restriction for nursing is indicated as follows: - 250 ml on day shift - 200 ml on evening shift - 150 ml on night shift Review of the medical record indicated that the remaining 600 ml are provided by dietary. Review of Resident #46's tray tickets indicated he/she receives 600 ml total for the day from the dietary department. Review of the Medication Administration Record (MAR) for April 2025 indicated Resident #46 was receiving 237 ml of a nutritional supplement daily from 4/1/25 to 4/17/25 from nursing. Review of the Medication Administration Record (MAR) for April 2025 indicated Resident #46 received the following amount of fluid for the day between nursing and dietary: - 1,487 ml on 4/2/25 - 1,357 ml on 4/5/25 - 2,217 ml on 4/6/25 - 2,537 ml on 4/13/25 - 1,537 ml on 4/18/25 During an interview on 4/24/25 at 8:21 A.M., the Dietitian said that she would expect nursing to monitor if the Resident was consuming fluids out of the fluid restriction range and would at least expect to have a conversation with the Resident and his/her dialysis center if the fluid restriction could not be met. The Dietitian was unaware that Resident #46 was receiving fluids outside of his/her fluid restriction. During an interview on 4/24/25 at 9:29 A.M., the Director of Nursing said that she would expect the fluid restriction to be followed as ordered for Resident #46.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 11/28/24 was readmitted to the Facility during the day shift and per nursing required assistance of two staff members for bed mobility and during the provision of care because he/she had not been re-evaluated by rehab. The Facility failed to ensure he/she was provided the necessary level of staff assistance during care, when the Certified Nurse Aide (CNA) assigned to meet his/her care needs for the evening shift was not given report by nursing regarding his/her change in care status, the CNA provided care alone, Resident #1 rolled out of bed to the floor, and sustained a head laceration that required two staples to close. Findings include: The Facility's Policy, titled Falls Management Program, dated 01/2018, indicated it is the policy of the Facility to ensure that the resident environment remains as free from hazards as is possible and to provide adequate supervision and assistance devices to reduce the risk of accidents. The Policy indicated supervision refers to an intervention and means of mitigating the risk of an accident and an obligation to provide adequate supervision to prevent accidents. The Policy indicated adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. Resident #1 was admitted to the Facility in August 2024, diagnoses included Cerebral Vascular Accident (stroke) with right hemiparesis (muscle weakness or partial paralysis on one side of the body), speech and language deficits, Pneumonia (an infection that inflames air sacs in one or both lungs which may fill with fluid), Chronic Respiratory Failure (lungs are unable to supply enough oxygen to the lungs), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and make it difficult to breathe), Type II Diabetes (a long-term condition which the body has trouble controlling blood sugar and using it for energy), Hypertension (high blood pressure), Anxiety, Depression, muscle weakness and difficulty with walking. Review of Resident #1's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy (HCP) Act, dated 08/30/24, indicated Resident #1's Physician determined Resident #1 lacked the capacity to make or communicate health care decisions, because of his/her stroke with expressive language disorder, his/her HCP was activated. Resident #1 was readmitted to the Facility during the day shift on 11/28/24 after the need for a five day Hospital Admission for Pneumonia. The Discharge Summary indicated Resident #1 presented to the Hospital on 11/24/24 to due respiratory symptoms and Resident #1's diagnoses included acute on Chronic Hypoxic (absence of oxygen) Respiratory Failure (Chronic Obstructive Pulmonary disease exacerbation) in the setting of Pneumonia. Review of Resident #1's Nursing Re-admission Note, dated 11/28/24, written by Nurse #1 at 2:00 P.M., indicated Resident #1 returned to the Facility around 11:30 A.M., and he/she required the assistance of two staff to complete care, needed to transfer with Hoyer lift and wheelchair [for mobility]. The Note indicated Resident #1 was bed bound upon re-admission and had no movement to his/her right upper extremity. During a telephone interview on 02/11/25 at 2:20 P.M., Nurse #1 said that on the morning of 11/28/24 Resident #1 was readmitted to the Facility after being treated for Pneumonia at the Hospital. Nurse #1 said upon return to the Facility Resident #1 required two staff member assistance with bed mobility, and with care, since he/she had not been re-evaluated by Physical Therapy. Nurse #1 said during the change of shift report at 3:00 P.M., she reported to the oncoming evening shift nurse that Resident #1 had returned from the Hospital at around 11:30 A.M., and that he/she required the assistance of two staff to complete care, that he/she required a Hoyer lift for transfers and he/she needed to be monitored for safety. Review of the Report submitted by the Facility via the Health Care Facilities Reporting System (HCFRS), dated 12/05/24, indicated that on 11/28/24, at approximately 7:00 P.M., Certified Nurse Aide (CNA) #1 was providing care to Resident #1 (dependent on staff for ADL's and transfers), assisted Resident #1 to roll onto his/her right side, placed his/her left hand to grab onto the side-rail and while CNA #1 was providing care to him/her, Resident #1 let go of the side-rail and rolled out of bed, hitting his/her head on the nightstand before hitting the ground. The Report indicated Resident #1 sustained a head laceration from the fall, was bleeding from the right side of his/her head, was sent to the Hospital Emergency Department (ED) and required two staples to close the wound. Review of Resident #1's Hospital Emergency Department Note, dated 11/28/24, indicated he/she was diagnosed with a laceration to the back of his/her head after a mechanical fall, rolled out of his/her bed and required surgical repair of two staples to the scalp. The Note indicated Resident #1 was non-ambulatory at his/her baseline, and reported right hip pain since his/her fall. During a telephone interview on 02/11/25 at 3:50 P.M., Nurse #2 said she was the nurse assigned to care for Resident #1 during the 3:00 P.M., to 11:00 P.M., shift on 11/28/24. Nurse #2 said she was aware Resident #1 had been in the Hospital for treatment of Pneumonia and had been readmitted to the Facility earlier in the day. Nurse #2 said she was also made aware during the change of shift report (at 3:00 P.M.) by the day shift nurse that Resident #1 required the assistance of two staff members to complete care and for bed mobility. Nurse #2 said on 11/28/24, at the start of her shift, that she was not aware which CNA was assigned to provide care to Resident #1, and said at the start of the shift report was not given immediately to the CNA's since it is a busy time. Nurse #2 said report is usually given once the unit settles down. Nurse #2 said at times she would speak to a CNA sooner to give report if the resident was sick or if they needed attention. Nurse #2 said she had never worked with CNA #1 before 11/28/24, and was not sure if CNA #1 had worked with Resident #1. Nurse #2 said on 11/28/24, she did not have time to give report to CNA #1 that Resident #1 had just come back from the Hospital and required an assist of two with care and bed mobility, prior him/her falling that night. During a telephone interview on 02/12/25 at 6:10 P.M., CNA #1 said on 11/28/24 during the 3:00 P.M., to 11:00 P.M. shift, she was assigned to care for Resident #1. CNA #1 said she was not familiar with Resident #1 and had not provided care for him/her in the past. CNA #1 said she was given an assignment sheet that indicated the residents whom she was assigned to care for that shift, but that there were no other details were listed on the assignment sheet. CNA #1 said she knew how/where to access and review the CNA's resident care Kardex's, but said the information on them is not always descriptive. CNA #1 said on 11/28/24 she did not have a chance to speak to Resident #1's nurse prior to providing care to Resident #1. CNA #1 also said she could not recall if she had spoken to any of the other CNAs on the unit that night regarding Resident #1's bed mobility and care status. CNA #1 said she was unaware Resident #1 required the assistance of two staff to complete his/her ADL care, including bed mobility, and said she provided personal hygiene care and bed mobility to Resident #1, without any help from another staff member. CNA #1 said Resident #1 was unable to roll onto his/her side independently, CNA #1 said she repositioned Resident #1 using both of her hands she rolled him/her onto his/her right side, provided hand over hand assistance for Resident #1's left hand so he/she could grab onto and hold the half side-rail and then positioned Resident #1's left leg crossed over on top of his/her right leg. CNA #1 said she supported Resident 1's back and hip with one hand while providing care to him/her with her other hand. CNA #1 said before she could reposition Resident #1 onto his/her back, Resident #1 let go of the side-rail, and rolled off the right side of the bed next to his/her nightstand. CNA #1 said she heard a boom and Resident #1 was on the floor. Nurse #2 said she was in the hallway approximately 7:00 P.M. and had been informed by CNA #1, that Resident #1 fell and was on the floor. Nurse #2 said upon entering Resident #1's room, Resident #1 was on the floor in a twisted position, against his/her nightstand, laying on his/her right side and was mumbling (his/her baseline). Nurse #2 said she lifted Resident #1's head a little to place a pillow behind his/her head and observed a pool of blood on the floor, that she did not move Resident #1 any more and called 911. Nurse #2 said Resident #1 was moving his/her left hand and was indicating he/she wanted to get off the floor. Nurse #2 said when the Emergency Medical Technicians (EMT's) arrived and moved Resident #1, that was when she observed Resident #1 had a laceration on the back of his/her head. During a telephone interview on 02/12/25 at 8:29 A.M., Nurse Supervisor #1 said that on 11/28/24 she was called to Resident #1's room and had been notified Resident #1 fell out of bed and was on the floor. Nursing Supervisor #1 said upon entering Resident #1's room, Nurse #1 and a CNA, who she did not know (later identified as CNA #1), were with Resident #1. Nursing Supervisor #1 said Resident #1 was on his/her side, near his/her bed, alert and on the floor. Nurse Supervisor #1 said she interviewed CNA #1, who had provided care for Resident #1 on 11/28/24, and said CNA #1 told her she had been providing care to Resident #1, that Resident #1 was on his/her side and he/she fell out of bed onto the floor. During a telephone interview on 02/12/25 at 11:39 A.M., the Director of Nurses (DON) said her expectations were at the change of shift the previous shift Supervisor/Licensed Nurse would report to the oncoming Licensed Nurse details regarding a resident who had returned from the Hospital to the Facility during their shift, including the resident's medical status and changes in level of care and/or staff assistance. The DON said her expectation was also for the Licensed Nurse to report the same information to the residents' CNA, to ensure the necessary level of staff assistance is provided. The DON said the CNA's are also responsible for obtaining information prior to providing care to the resident.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2) who had an invoked Health Care Proxy (HCP), the Facility failed to ensure they obtained written Informed Consents for his/her psychotropic medications from his/her HCP, prior to administering the medications. Findings include: The Facility's Policy titled, Psychotropic Medication Management and Informed Consent, dated 01/2022, indicated it is Policy of this Facility that psychotropic medications or medications identified with psychoactive properties shall not be administered to a resident without Informed Written Consent. The Policy indicated in addition, these drugs are not given (schedule or PRN (as needed)) unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. The Policy indicated documentation of Informed Consent is required for any medication that is used in the treatment of a psychiatric diagnosis or symptom, which includes drugs to treat depression, anxiety disorders, attention deficit/hyperactivity disorders or other psychiatric indications. The Policy indicated prior to initiating the first dose of a psychotropic medication, an Informed Consent will be signed by the competent resident, invoked Health Care Proxy, as appropriate. The prescriber will discuss with the resident or the resident's legal representative the purpose of the medication as well as the risks and benefits. This discussion may take place by phone. The Policy indicated a Facility representative must then document this discussion by completing the form, including all necessary signatures within a reasonably proximate time period, so as not to negate Informed Consent. The Policy indicated a new Informed Consent document is required for each psychoactive medication being prescribed and a new Informed Consent is required each time a new or renewed prescription falls outside the dosage range to which the resident or resident's representative previously consented, or once a year, whichever is shorter. The Policy indicated the Informed Written Consent shall be kept in the resident's medical record and verbal consent by telephone, even if witnessed by a second staff member of the facility does not constitute written consent. Resident #2 was admitted to the Facility in November 2024, diagnoses included fracture of his/her lower end of the left humerus (break of the long bone in the upper arm from the shoulder to elbow) and the ulnar (the long bone in the forearm that runs parallel to the radius) collateral ligament sprain (located on the inner side) of left elbow, Osteoporosis with a pathological fracture (weaken bones without causing symptoms that are noticed or felt), Lewy Body Dementia (a progressive brain disease that causes problems with thinking, movement, mood and behavior), Hypertension (high blood pressure), Seizure disorder (condition that involves having seizures, are abnormal electrical surges in the brain), Atrial Fibrillation (irregular heart beat), and Cerebrovascular Accident (stroke). Review of Resident #2's Hospital Discharge Summary, dated 11/25/24, indicated Resident #2 Health Care Proxy(HCP) said Resident #2 had a poor reaction to Seroquel (quetiapine, psychotropic and antipsychotic drug to treat schizophrenia, bipolar disease or depression), in the past, worsened agitation occurred, and antipsychotic's were not appropriate at the time given Resident #2's diagnosis of Lewy Body Dementia. The Summary indicated Resident #2's HCP was amenable to trial Depakote (divalproex, psychotropic drug to treat seizures/mood stabilizer), sprinkles 125 milligram (mg) twice a day to help with agitation and it was started in the hospital for a mood stabilization. The Summary indicated at bedtime Resident #2 received Trazodone (psychotropic drug to aid with sleep), 25 milligram (mg) and Melatonin (aid with sleep) 3 milligram (mg) to aid with his/her sleep at night. Review of Resident #2's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy (HCP) Act, dated 11/29/24, indicated Resident #2's Physician determined Resident #1 lacked the capacity to make or communicate health care decisions, because of his/her progressive Lewy Body Dementia, his/her HCP was activated. Review of Resident #2's Minimum Data Set (MDS) Admission Assessment (a comprehensive assessment of each resident's functional capabilities), dated 12/01/24, indicated he/she was severely cognitively impaired. The MDS indicated Resident #2 displayed behavioral symptoms of delusions displayed verbal and physical behaviors towards others and other behaviors direct to self. Review of Resident #2's Medication Administration Record (MAR) for the month November 2024 and December 2024, indicated Resident #2's Physician Medication Orders for psychotropic medication were as follows: A. Depakote Sprinkles, delayed release (releases the active ingredient later than immediately after administration) sprinkle, Administer 125 milligram (mg) tablet by mouth twice a day (8:00 A.M. and 8:00 P.M.) (Start Date: 11/26/24 - End Date: 11/27/24) - Depakote Sprinkles, delayed release sprinkle, Administer 125 milligram (mg) capsule by mouth once a day (11:00 A.M.) (Administer with Lunch) (Start Date: 11/27/24 - End Date: 12/03/24) - Depakote Sprinkles, delayed release sprinkle, Administer 125 milligram (mg) capsule by mouth twice a day (8:00 A.M. and 8:00 P.M.) (Administer with Breakfast and Bedtime Snack) (Start Date: 12/03/24 - End Date: 12/07/24) B. Lacosamide (vimpat, anti-epileptic and psychotropic drug to treat seizures), 150 milligram (mg) tablet, Administer 1.5 tablets by mouth twice a day (9:00 A.M. and 9:00 P.M.) (Start Date: 11/26/24 - End Date: 11/30/24) - Lacosamide 150 milligram (mg) tablet, Administer 225 milligram (mg) tablets by mouth twice a day (9:00 A.M. and 9:00 P.M.) (Start Date: 11/27/24 - End Date: 12/07/24) C. Seroquel 25 milligram (mg) tablet, Administer 12.5 milligram (mg) by mouth three times a day PRN (as needed) (Start Date: 12/02/24 - End Date: 12/03/24) D. Trazodone 50 milligram (mg) tablet, Administer 12.5 milligram (mg) tablet by mouth daily (9:00 P.M.) (Start Date:11/25/24 - End Date: 11/27/24) - Trazodone 50 milligram (mg) tablet, Administer 25 milligram (mg) tablet by mouth at bedtime (9:00 P.M.) (Start Date:11/27/24 - End Date: 12/07/24) During a telephone interview on 02/12/25 at 11:25 A.M., Nurse #5 said on 11/27/24, she called the Physician to clarify Resident #2's medication orders including his/her Depakote frequency and dosage of Trazodone, because Resident #2's family member was concerned Resident #2 was not prescribed the correct medications. Nurse #5 said new orders were obtained to decrease the Depakote frequency and increase the dose of Trazodone. Nurse #5 said Resident #2 had already been receiving Depakote and Trazodone, and that Informed Consent should have been completed. Nurse #5 said she did not review Resident #2's written and signed Informed Consents relating to his/her medications prior to administration and said she was not familiar with the Facility's Policy and Procedures related to psychotropic Informed Consents. During a telephone interview on 02/13/25 at 11:14 A.M., Nurse #4 said on 12/02/24, Resident #2 had increased confusion and agitation. Nurse #4 said she called the Nurse Practitioner and obtained a new order of Seroquel 12.5 milligrams (mg) three times a day PRN (as needed). Nurse #4 said she called the Nurses Practitioner since Resident #2 had been combative and she was unable to redirect him/her. Nurse #4 said she was unaware that an Informed Consent was needed to be completed prior to Resident #2 receiving psychotropic medications. Nurse #4 said on 12/02/24, she had administered a dose of Seroquel with good effect. Nurse #4 said she does recall the Seroquel being discontinued, since Resident #2's HCP did not want Resident #2 to receive Seroquel, but does not recall the details. During a telephone interview on 02/12/25 at 1:16 P.M., Nurse Practitioner #2 said on 12/03/24 she had assessed Resident #2 and spoke to his/her HCP who knew Resident #2's medication history. Nurse Practitioner #2 said the HCP had concerns regarding Resident #2's medication orders and said he/she was not taking the same medications compared to the Hospital. Nurse Practitioner #2 said the HCP shared with her that Seroquel has not worked in the past and did not want Resident #2 to receive the medication. Nurse Practitioner #2 said the Seroquel was discontinued. During an interview on 02/06/24 at 11:08 A.M., the Director of Nurses (DON) said Resident #2 did not have any written and signed Informed Consents in his/her Medical Record. The DON said she spoke with Unit Manager #2 regarding Resident #2's medication Informed Consents. The DON said Unit Manager #2 informed her that there had been an Informed Consent completed for Resident #2's Depakote. However the Facility was unable to locate Resident #2's Informed Consent in his/her medical chart, on the unit or stored in the Facility Medical Records Department. The DON said she was unable to locate and provide any documentation to support that for Resident #2, they had obtained written and signed Informed Consents for his/her Lacosamide, Seroquel, or Trazodone. The DON said it is her expectation that a Nurse obtains written and signed Informed Consent for residents regarding his/her psychotropic medications and the medication was discussed with the resident and or the resident's legal representative prior to medication administration. The DON said it her expectation that the a Nurse is aware of the Informed Consent Policy.

Based on observation, record review and interview, the facility failed to identify and address a new onset of limited range of motion for one Resident (#18) out of a total of 23 sampled residents. Findings include: On 5/30/24 the Administrator informed the the surveyor that the facility does not have a policy regarding limited range of motion or contracture management. Review of the National Library of Medicine articles titled Range of Motion and Limited Range of Motion 9/20/22, indicated: Range of motion (ROM) means the extent or limit to which a part of the body can be moved around a joint or a fixed point; the totality of movement a joint is capable of doing. Range of motion of a joint is gauged during Passive ROM (assisted) PROM or Active ROM (independent) AROM. ROM is usually assessed during a physical therapy assessment or treatment. Normal values depend on the body part, and individual variations. The purpose of ROM exercises are prevention of the development of adaptive muscle shortening, contractures, and shortening of the capsule, ligaments, and tendons. When a joint does not move, fully and easily in its normal manner, it is considered to have a limited range of motion. Resident #18 was admitted to the facility in October 2018 with diagnoses including dementia and arthritis. A diagnosis of dysphagia was added to his/her clinical record in January 2024. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #18 scored two out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS indicated Resident #18 is dependent on staff for eating, transfers and dressing. Additional review of Resident #18's MDS' dated 10/10/23, 1/9/24, and 4/9/24, indicated he/she had no upper extremity (shoulder, elbow, wrist, hand) impairments. On 5/28/24 at 8:04 A.M., the surveyor observed Resident #18 seated in his/her wheelchair in the Pentucket dining room. Resident #18's hands were closed into fists. When asked if he/she could open his/her hands, Resident #18 opened his/her right hand but not his/her left hand. Resident #18 was only able to move his/her fingers slightly on his/her left hand. Resident #18 then attempted to use his/her right hand to pull back his/her fingers on the left hand but was unsuccessful. Review of Resident #18's clinical record indicated that Resident #18 had not been screened, (to determine if he/she could benefit from therapy services) or received services with either Physical Therapy (PT) or Occupational Therapy (OT) since 2018. The PT and OT discharge summaries from 2018 did not indicate that Resident #18 had any limited range of motion in his/her hands. Review of Resident #18's clinical progress notes, diagnoses and care plans did not indicate Resident #18 had limited range of motion in his/her hands, nor did the record indicate that staff were performing range of motion exercises with Resident #18 to prevent contractures or decreased range of motion. Review of Resident #18's most recent Nurse Practitioner and Physician notes did not indicate Resident #18 had a limited range of motion in his/her hands. Review of the Activities note dated 5/28/24 indicated: Resident #18 has a tough time feeding himself/herself or picking things up by hand without assistance as his/her hands don't work like they did. During an interview on 5/28/24 at 2:28 P.M., Certified Nursing Assistant (CNA) #1 said that Resident #18 had been closing his/her hands in a fisted position for a while. CNA #1 said that Resident #18 cannot open his/her hands completely and the CNA's do not place a hand towel in his/her palms and Resident #18 does not utilize hand splints. During an interview on 5/29/24 at 10:56 A.M., CNA #2 and CNA #3 said that Resident #18 cannot open one of his/her hands completely. CNA #3 said that he/she had been unable to open his/her hand for a few weeks. During interviews on 5/29/24 at 10:59 A.M., and 5/30/24 at 9:50 A.M., Unit Manager (UM) #1 said that Resident #18 has arthritis in his/her hands and he/she had been holding his/her hands in fists since she became the Unit Manager in the fall of 2023. UM #1 said that the expectation would be for CNAs to alert nursing staff regarding any changes in range of motion and a referral to would be placed to rehab (rehabilitation) services. UM#1 said she would alert the rehab department to screen Resident #18's range of motion. When asked if Resident #18 had a stroke or any other neurological issue which could be related to his/her limited range of motion, UM #1 said no. On 5/29/24 at 11:08 A.M., the surveyor entered the [NAME] unit and observed UM #1 speaking with the Rehab Director. UM #1 introduced the surveyor to the Rehab Director and then told the Rehab Director that Resident #18 needed to be screened by rehab because CNAs had reported his/her hand was contracted. During an interview on 5/29/24 at 11:22 A.M., Family Member #1 said that Resident #18 had been holding his/her hands in a closed fist position for approximately six to eight months. During an interview on 5/30/24 at 9:37 A.M., the Rehab Director said that the rehab department does not do routine screens of residents and that referrals and screens are based on nursing requests. On 5/30/24 at 10:02 A.M., the surveyor observed Occupational Therapist (OT) #1 assess Resident #18's hand for limited range of motion. OT #1 was able to provide passive range of motion (PROM) but could not fully open Resident #18's hand. While moving Resident #18's fingers into an open position, OT #1 said, that's a little tight, I can feel it. There was a buildup of an unknown substance on Resident #18's left palm and OT#1 offered to use a face cloth for hygiene. OT #1 said that she could not say if Resident #18 had developed a new contracture. OT #1 said that Resident #18's fingers remained in a fixed, flexed position and could not be fully ranged on his/her left hand. Review of OT #1's evaluation note dated 5/30/24 indicated: Reason for referral: Referral to OT to assess LUE (left upper extremity)/hand ROM d/t concern for [question] contracture/decreased ROM. Pain Assessment: c/o (complaints of) increased pain with attempts to perform PROM to 3rd/4th/5th digits past approx [sic] 90 degrees flexion and when performing hand hygiene to L (left) hand. UE (upper extremity) ROM: LUE = impaired. Clinical Impressions: Pt (patient) was agreeable in hand hygiene and trialing face cloth for gentle stretching to L hand digits to maintain skin integrity and prevent further contracture. Max A (maximum assistance) hand hygiene to L hand with use of warm cloth and soap. C/O occas [sic] pain with hand hygiene, subsiding with rest. [Question] if pt would benefit from possible splint d/t (due to) arthritic pain vs. positioning strategies to L hand in order to increase ROM vs prevent further decrease of ROM, maintain skin integrity, improve pt comfort and decrease risk for/prevent further contracture. During a follow up interview on 5/30/24 at 1:25 P.M., the Rehab Director said that Resident #18's limited ROM in his/her left hand was not a contracture and could be related to tone (the muscles becoming resistant to passive stretching.) The Rehab Director said that Resident #18's hands had been like that for a while. The Rehab Director was not aware that there was no information in the clinical record to indicate the onset of Resident #18's limited range of motion, and staff statements to the surveyor ranged between months and weeks since Resident #18 could fully open his/her hand. During an interview on 5/30/24 at 11:35 A.M., the Director of Nursing (DON) and Staff Development Coordinator (SDC) said that when residents demonstrate limited range of motion, it is expected for staff to involve the rehab department, alert the physician and the health care proxy (HCP). During an interview on 5/30/24 at 12:50 P.M., Nurse Practitioner (NP) #1 said that staff are expected to notify her or the physician for any onset of limited range of motion or contracture. NP #1 said that she had seen Resident #18 a couple weeks ago and spoke with his/her HCP. NP #1 said that she did not recall being told about any changes in Resident #18's range of motion. When asked if residents with arthritis could develop contractures or limited range of motion, NP #1 said that anyone who is not moving their bodies regularly could develop contractures or limited range of motion.

Based on observation, record review and interview the facility failed to ensure for one Resident (#162) out of two applicable residents out of a total sample 23 residents that professional standards of care were developed and implemented for the care of a hemodialysis access site. Specifically, the care and treatment of an internal jugular (IJ) catheter, (a type of central venous catheter that is inserted in the internal jugular vein for hemodialysis). Findings include: Resident #162 was admitted to the facility in May 2024 with diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, end stage renal disease, and dependence on renal dialysis. (Hemodialysis is a treatment for advanced kidney failure that filters wastes, salts and fluid from your blood). Review of the Minimum Data Set assessment dated [DATE] indicated Resident #162 had intact cognition with a score of 13 out of 15 on the Brief Interview for Mental Status exam, required partial to moderate assistance with most activities of daily living and is on dialysis. During an interview and observation on 5/28/24 at 8:39 A.M., Resident #162 was sitting on the side of his/her bed. Resident #162 said he/she goes out three times a week for dialysis. Resident #162 pulled at his/her clothing, revealing a catheter on his/her right chest, the end of the catheter was wrapped in gauze. Resident #162 said the staff at the dialysis center take care of the catheter and dressing. Review of Resident #162's acute care hospital discharge summary dated as created 5/21/24, indicated a past medical history of ESRD (end stage renal disease) on HD (hemodialysis) via right chest dialysis cath (catheter) MWF (Monday, Wednesday, Friday). Further, under imaging findings: lines/tubes: Tunneled right IJ (internal jugular) dialysis catheter present, tip in the right atrium. Further review of Resident #162's medical record indicated the following: -A nursing observation document dated 5/21/24, skin comments: right chest port-a-cath. -A care plan dated 5/23/24, hemodialysis related to renal failure. Goal: Maintain vascular access. Interventions dated 5/23/24 included: Assess and document vital signs, including blood pressure in the arm where the access site is not located, avoid constrictive clothing, jewelry or excessive pressure on affected extremity, avoid vital signs and blood draws in access extremity (specify site) left blank, maintain integrity of dressing if present monitor for any reports of pain, numbness, tingling in extremity with access site, monitor for extremity swelling distal to the access site, monitor patency of shunt by palpating for thrill and bruit, shunt fistula location: right chest. Review of the interventions on the hemodialysis care plan indicated interventions regarding an extremity fistula (a shunt placed in an arm for dialysis access) and failed to be specific and individualized for Resident #162's IJ catheter for hemodialysis access. Review of Progress notes for Resident #162 entered by nursing indicated the following: -5/21/24 Res has a right sided port-a-cath. Review of nursing progress notes dated 5/21/24 at 2:32 P.M., 5/22/24 at 11:30 A.M., 5/22/24 at 4:43 P.M., 5/28/24 at 11:55 P.M., failed to address the presence of the right IJ catheter, or a plan of care for the care, and monitoring of the IJ catheter. Review of the current physician's orders history failed to indicate an order or medical plan of care for the IJ catheter located on Resident #162's right chest. On 5/29/24 at 8:44 A.M., Resident #162 was observed with a right chest catheter with the end wrapped in gauze and gauze at the insertion site. During an interview on 5/29/24 at 3:17 P.M., Nurse #3 said she was the nurse who admitted Resident #162 and did the assessments and paperwork with the Resident. Nurse #3 said another nurse reviewed and obtained the orders. Nurse #3 said vital signs are done before and after Resident #162's dialysis days, they update the communication book that the Resident brings to dialysis. Nurse #3 said the Resident has a right port-a-cath and there are supposed to be orders for monitoring of the catheter. Nurse #3 reviewed the orders and said that there was no order for the monitoring of the right port-a-cath. During an interview on 5/29/24 3:25 P.M., Charge Nurse #1 said Resident #162 should have physician's orders for the monitoring of the chest catheter. During an interview on 5/29/24 at 4:44 P.M., Nurse #2 said Resident #162 was back from dialysis. Nurse #2 said she checks in with the Resident upon return and checks his/her vital signs. Nurse #2 said she would check the catheter for patency, bruit and thrill, (patency assessed by feeling the 'thrill' or vibration of blood through the access or using a stethoscope to listen to the 'bruit' or 'whoosh' of blood through the access). The presence of an external catheter on Resident #162's right chest is not an arterial/venous graft site and therefore cannot be checked for bruit and thrill. During an interview on 5/30/24 at .7:43 A.M., Unit Manager #3 said the IJ dialysis catheter should be monitored for bleeding, drainage and that the dressing is intact and should have physician orders. Unit Manager #3 said this is the first dialysis patient she has seen since starting at the facility a few months ago. Unit Manager #3 said no recent education was provided for residents requiring dialysis or residents requiring IJ catheters. During an interview on 5/30/24 at 11:19 A.M. the Director of Nursing said referrals to the facility are reviewed before accepting a resident, to ensure the facility can provide for their care. The DON said she is cautious about IJ catheters, and the plan of care should have physician's orders to monitor the catheter access site. See F726

Based on observation, record review and interview the facility failed to ensure licensed nursing staff possessed the appropriate competency and skills to care for one Resident (#162) out of two applicable residents, requiring dialysis, out of a total sample of 23 residents, and 2. the facility failed to ensure nursing staff had been provided with education or demonstrated necessary competencies to care for residents in the facility with specialized needs, inclusive of dialysis care and treatment. Findings include: Review of the Facility assessment dated [DATE] indicated that for specialized services, on average, the facility has an average of three residents receiving IV medications, two residents receiving dialysis, and 38 residents receiving injections. The Facility Assessment also indicated: Staff training/education and competencies: Staff that are hired all go through facility orientation. On day two, new employees receive 8 hours of dementia training inclusive of abuse, neglect, non-pharmacological interventions then four hours of partially interactive training annually thereafter. Length of orientation is based on experience; new grads receive additional training on the units. We have preceptors and senior aides to guide new staff as well as charge nurses on the units. All new hires are signed off on an orientation check list before working independently on the unit. If an issue is identified and additional education is needed, that will be provided to the individual as well as to others in the department. The Facility Assessment did not indicate methods or means for ongoing competency evaluation or training for licensed nurses related to specialized treatments. 1. Resident #162 was admitted to the facility in May 2024 with diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, end stage renal disease, and dependence on renal dialysis. (Hemodialysis is a treatment for advanced kidney failure that filters wastes, salts and fluid from your blood). Review of the Minimum Data Set assessment dated [DATE] indicated Resident #162 had intact cognition with a score of 13 out of 15 on the Brief Interview for Mental Status exam, required partial to moderate assistance with most activities of daily living and is on dialysis. During an interview and observation on 5/28/24 at 8:39 A.M., Resident #162 was sitting on the side of his/her bed. Resident #162 said he/she goes out three times a week for dialysis. Resident #162 pulled at his/her clothing, revealing a catheter on his/her right chest, the end of the catheter was wrapped in gauze. Resident #162 said the staff at the dialysis center take care of the catheter and dressing and the facility staff do not provide any care to the catheter. Review of Resident #162's acute care hospital discharge summary dated as created 5/21/24, indicated a past medical history of ESRD (end stage renal disease) on HD (hemodialysis) via right chest dialysis cath MWF (Monday, Wednesday, Friday). Further, under imaging findings: lines/tubes: Tunneled right IJ (internal jugular) dialysis catheter present, tip in the right atrium. (An IJ dialysis catheter is a type of central venous catheter that is inserted in the internal jugular vein for hemodialysis). Further review of Resident #162's medical record indicated the following: -A nursing observation document dated 5/21/24, skin comments: right chest port-a-cath. -A care plan dated 5/23/24, hemodialysis related to renal failure. Goal Maintain vascular access. Interventions dated 5/23/24 included: Assess and document vital signs, including blood pressure in the arm where the access site is not located, avoid constrictive clothing, jewelry or excessive pressure on affected extremity, avoid vital signs and blood draws in access extremity (specify site) left blank, maintain integrity of dressing if present monitor for any reports of pain, numbness, tingling in extremity with access site, monitor for extremity swelling distal to the access site, monitor patency of shunt by palpating for thrill and bruit, shunt fistula location: right chest. Review of the interventions on the hemodialysis care plan indicated interventions regarding an extremity fistula (a shunt placed in an arm for dialysis access) which is not what Resident #162 has for dialysis access and failed to be specific and individualized for Resident #162's IJ catheter for hemodialysis access. Review of the current physician's orders history failed to indicate an order or medical plan of care for the IJ catheter located on Resident #162's right chest. On 5/29/24 at 8:44 A.M., Resident #162 was observed with a right chest catheter with the end wrapped in gauze and gauze at the insertion site. During an interview on 5/29/24 at 4:44 P.M., Nurse #2 said Resident #162 was back from dialysis. Nurse #2 said she checks in with the Resident upon return and checks his/her vital signs. Nurse #2 said she would check the catheter for patency, bruit and thrill, (patency is assessed by feeling the 'thrill' or vibration of blood through the access or using a stethoscope to listen to the 'bruit' or 'whoosh' of blood through the access). The presence of an external catheter on Resident #162's right chest is not an arterial/venous graft site and therefore cannot be checked for bruit and thrill. During an interview on 5/29/24 3:25 P.M., Charge Nurse #1 said Resident #162 should have physician's orders for the monitoring of the chest catheter. Charge Nurse #1 said she was not aware what an IJ catheter would require for emergency preparedness and that they have not had many residents on the unit who require dialysis or have an IJ catheter. During an interview on 5/30/24 at 7:43 A.M., Unit Manager (UM) #3 said the IJ dialysis catheter should be monitored for bleeding, drainage and that the dressing is intact and should have physician orders. UM #3 said this is the first dialysis patient she has seen since starting at the facility a few months ago. UM #3 said no recent education was provided for residents requiring dialysis or residents requiring IJ catheters. During an interview on 5/30/24 at 11:19 A.M. the Director of Nursing said referrals to the facility are reviewed before accepting a resident, to ensure the facility can provide for their care. The DON said she is cautious about IJ catheters. 36876 2. Review of employee records indicated that three of four licensed nursing staff had no evidence that nursing competencies had been evaluated upon hire or annually. During an interview on 5/30/24 at 10:32 A.M., the Staff Development Coordinator (SDC) said that the expectation is upon hire, nursing staff have their competencies evaluated. The SDC had only been working in the facility for a few months and was unable to locate evidence that three of the four selected nursing staff reviewed had nursing competencies evaluated. The SDC agreed that one of the four who had received competency training and evaluation, was not inclusive of dialysis training.

Based on observation, record review and interview, the facility failed to provide appropriate treatment and interventions to prevent the worsening of a pressure injury and traumatic wound for 1 Resident (#63) out of a total of 21 sampled Residents. Findings include: Resident #63 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #63's most recent Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired and requires assistance with bathing and dressing. The MDS also indicated he/she had one sided lower extremity impairment. On 3/11/22 at 12:00 P.M., the surveyor observed Resident #63 resting in bed wearing a multi podus boot (a protective orthosis that corrects foot misalignments and minimizes the chance of skin breakdown.) Resident #63 was unable to participate in the interview process due to his/her cognition. Review of the Wound Physician's note dated 1/5/22 indicated: General Notes; Wound of the base of the right 1st toe appears necrotic (dead tissue). *Wound #1: Right malleolus (ankle) is a chronic unstageable pressure injury. Subsequent wound measurement are .5 CM X 1 CM with no measurable depth. Wound bed is 100% slough (necrotic tissue in the process of separating from viable portions of the body). *Wound #2: Right medial metatarsal (big toe): 1.2 CM X 1.9 CM X .1 CM *Recommendations: Maintain right foot in rigid frame multi podus boot. Deploy kickstand laterally to prevent external rotation. Change out to LARGE size this week. Review of Resident #63's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Three times a day, initiated 1/26/22; 21 days after it was first recommended by the Wound Physician. During an interview with Unit Manager #2 on 3/11/22 12:26 P.M. she said that Resident #63 sustained the toe injury due to wearing a multi podus boot that was too small for him/her. Unit Manager #2 was unable to find documentation to indicate if the wound was the result of wearing the boot over time, or if it was the result of a one time injury. Unit Manager #2 said that after Resident #63's toe was injured, the wound physician requested a larger multi podus boot and it took a while to get one. Review of Resident #63's clinical record indicated he/she had been seen by the Wound Physician on 1/5/22 and then not again until 1/26/22. Resident #63 was hospitalized from 1/14/22 through 1/19/22. Review of the Wound Physician's notes indicated: 1/26/22: *Wound #1: Right lateral malleolus: 1.1 CM X 1 CM with no measurable depth. *Wound #2: Right medial metatarsal: 2 CM X 2.4 CM X .1 CM. *Recommendations: Maintain right foot in rigid frame multi podus boot. Deploy kickstand laterally to prevent external rotation. Change out to LARGE size this week. 2/2/22: *Wound #1: Right lateral malleolus: 1.1 CM X 1 CM with no measurable depth. *Wound #2: Right medial metatarsal: 2 CM X 2.4 CM X .1 CM. Wound bed: 100% epitheliazation (new skin) *Recommendations: Maintain right foot in rigid frame multi podus boot. Deploy kickstand laterally to prevent external rotation. Change out to LARGE size this week. 2/9/22: *Facility has still been unable to obtain multi podus boot. *Wound #1: Right lateral malleolus: 1.5. CM X 1.6 CM X .1 CM. Wound bed: 100% epitheliazation *Wound #2: Right medial metatarsal: 2 CM X 2 CM with no measurable depth. Wound bed has 100% eschar (dead skin) Procedures: Debridment (a surgical procedure to remove the dead skin from the wound) of Wound #2. (Indicating a worsening of the toe wound from the previous visit on 2/2/22.) *Recommendations: Maintain right foot in rigid frame multi podus boot. Deploy kickstand laterally to prevent external rotation. Change out to LARGE size this week. No other recommendations regarding treatments or interventions were made. 2/16/22: *Facility has still been unable to obtain multi podus boot. *Wound #1: Right lateral malleolus: 1.6 CM X 1 CM X .1 CM. Wound Bed: 20% epitheliazation and 80% slough. (indicating a worsening of the wound from the previous visit on 2/9/22). *Wound #2: Right medial metatarsal: 2 CM X 2 CM. Wound bed: 60% eschar, 40% slough. *Recommendations: Maintain right foot in rigid frame multi podus boot. Deploy kickstand laterally to prevent external rotation. Change out to LARGE size this week. No other recommendations regarding treatments or interventions were made. 2/23/22: *Facility has still been unable to obtain multi podus boot. Wound of the lateral malleolus has evidence of soft tissue infection today with localized redness, swelling and warmth. The wound is exuding a large amount of serosanguinous fluid (an indication of bacteria). *Wound #1: Right lateral malleolus: 2 CM X 3 CM X .1 CM. There is a heavy amount of sero-sanguineous drainage noted. Wound bed has 100% slough. The wound is deteriorating. *Wound #2: Right medial metatarsal: 2 CM X 2 CM. Wound bed: 100% eschar. Procedures: Debriedment of Wound #1. *Recommendations: Maintain right foot in rigid frame multi podus boot. Deploy kickstand laterally to prevent external rotation. Change out to LARGE size this week. 3/2/22: *Facility has still been unable to obtain size large multi podus boot. Staff informs provider today that hospice will not cover the boot, however, therapy should be able to obtain. Wound of lateral malleolus appeared infected at previous encounter. Small amount of purulent drainage expressed from wound. Tissue culture grew [CONDITION(S)] and beta [CONDITION(S)] strep which was resistant to [MEDICATION(S)]. Wound #1: Right lateral malleolus: 2 CM X 3 CM X .1 CM. Light amount of purulent drainage noted. Wound bed has 80% eschar and 20% slough. Wound #2: Right medial metatarsal: 2 CM X 2 CM. Wound bed: 100% eschar. *Recommendations: Maintain right foot in rigid frame large multi podus boot. Deploy kickstand laterally to prevent external rotation. During an interview with Unit Manager #1 on 3/11/22 at 11:31 A.M., she said that Resident #63 was transferred to the unit after he/she was hospitalized in January, 2022. Unit Manager #1 said that she was not made aware that Resident #1 was in need of a multi podus boot until around the time he/she went on hospice services. (Resident #64 was admitted to hospice on 2/9/22.) Unit Manager #1 said that Resident #63 received his/her large sized multi podus boot a couple weeks ago and did not wear any other kind of boot until then. During an interview with the Director of Rehab on 3/11/22 at 12:35 P.M., he said that he could not recall when he was first asked about obtaining a boot for Resident #63. He said that there had been issues obtaining a boot because Resident #63 was admitted to hospice at some point in February 2022 and there was confusion regarding who would pay for it. The Director of Rehab said that Resident #62's boot was given to him/her last week: approximately 8 weeks after first recommended by the Wound Physician. During an interview with the Wound Physician on 3/11/22 at 2:28 P.M., he said that the major concern regarding Resident #63's wound healing was positioning. The Wound Physician said that the multi podus boot with kick stand would assist Resident #63 best as his/her stroke and subsequent right sided [CONDITION(S)] impacted how he/she positions his/her foot. The Wound Physician said that the facility had been taking a long time to get the multi podus boot and he was not aware that Resident #63 had received it last week.

Based on interview, record review and policy review the facility failed to ensure significant weight changes were addressed and interventions implemented timely to prevent further significant weight loss/gain for 2 Residents (#12 and #15) out of a total sample of 21 residents. Findings include: Review of facility policy titled 'Weighing & Measuring' revised 10/2019 indicated the following: *Policy- Residents are weighed and measured per the following protocol to provide a baseline and an on-going record of the resident's body weight: -To determine and monitor nutritional status and medical condition. *Procedure: - Notify the licensed nurse if weight is 3 or more pounds different (gain or loss) from prior weight (excluding residents on a weight reduction diet). -Re-weigh the resident within 24 hours to verify the accuracy of the weight. -Changes of 5% in 30 days, 7.5% in 90 days or 10% in 180 days must be evaluated for significant change in resident status. -Notify the dietitian and attending physician of significant unplanned weight loss. 1) For Resident #12, the facility failed to identify and address a significant weight loss. Resident #12 was admitted to the facility in May 2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS) The MDS further indicated no behaviors or rejection of care and that the Resident requires assistance with care activities. On 3/09/22 at 9:25 A.M., Resident #12 was observed in bed with a breakfast tray in front of him/her. The breakfast tray had large amounts of food remaining and the Resident appeared thin and frail. The Resident was also observed to be edentulous (had no teeth). Review of Resident #12's medical record indicated the following: -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -A Dietitian quarterly review dated 12/14/21 which indicated the Resident was on a house ground diet with house shake three times per day with meals. Intake continues to fluctuate from 26-75%. Needs to be cued and eat out side of room. Weight is 94.2 slow return of weight seen. Review of Resident #12's recorded weights indicated: -11/09/2021: 96.1 pounds (lbs.) -2/13/2022: 88.8 lbs. which is a 7.60 % loss from November's weight. A reweigh was done which indicated a weight of 87.2 lbs. -3/10/22: 88.8 lbs. Further review of Resident #12's medical record failed to indicate the dietitian was notified of the significant weight loss and failed to indicate any new interventions to address the significant weight loss had been implemented. During an interview on 3/11/22 at 2:01 P.M., Nurse #6 said that if a resident's weight varies significantly from week to week , the dietitian and physician should be notified. Nurse #6 said a progress note should be written for any significant weight change that the provider was notified about the loss. During an interview on 3/14/22 at 9:20 A.M., the Dietitian said she has been at the facility for about two months. She said that there are weekly weight meetings with nursing staff. The Dietitian said she is unfamiliar with Resident #12, but that she thinks the Resident does not have a great appetite. The Dietitian said that she was not notified of the Resident's significant weight loss and should have been. The Dietitian said that there had been previous interventions put in place such as a house shake for the Resident prior to the significant weight loss but said if the interventions weren't working and the Resident continued to lose weight, the weight loss should have been addressed and new interventions added. 2) For Resident #15, the facility failed to identify and address a weight gain. Resident #15 was admitted in August 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 13 out of 18 on the Brief Interview for Mental Status Exam (BIMS). Further review of Resident #18's MDS indicated the Resident requires assistance with care activities and requires [CONDITION(S)] (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). During an interview on 3/11/22 at 1:58 P.M., the Resident said he/she is weighed at the facility weekly. Resident #18 said that he/she thinks he/she has had a weight gain recently. Review of Resident #15's medical record indicated the following: -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #15's weights indicated the following: -1/17/22: 168.7 lbs -1/31/22: 178.8 lbs (an increase of 10.1 lbs from the previous weight) -2/7/22: 178 lbs -2/13/22: 175.2 lbs -2/14/22: 177 lbs -2/21/22: 176.3 lbs -2/28/22: 175.3 lbs -3/7/22: 183.8 lbs (an increase of 8.5 lbs from the previous weight) Further review of Resident #15's medical record failed to indicate the dietitian was notified of the Resident's weight changes and failed to indicate any interventions to address the weight gain. During an interview on 3/11/22 at 2:01 P.M., Nurse #6 said that if a resident's weight varies significantly from week to week , the dietitian and physician should be notified. Nurse #6 said a progress note should be written for any significant weight change that the provider was notified about. During an interview on 3/11/22 at 2:11 P.M., the Dietitian said she was unfamiliar with Resident #15 but said she thinks the Resident may have had a weight gain. The Dietitian said she would expect to be notified for a weight gain or loss of more than 3 lbs in a resident receiving [CONDITION(S)] and on a fluid restriction to see if any interventions should be added.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to provide supervision necessary to prevent a fall with injury when Resident #1's pressure sensitive bed alarm did not sound to alert staff when Resident #1, who was cognitively impaired, required assistance and was identified as high fall risk, got out of bed unassisted, fell in his/her room, and as a result, sustained a fractured left wrist. Findings include: The Facility Policy titled Falls Management Program, dated 1/2018, indicated staff would monitor the effectiveness of the interventions and modify the plan of care. The Facility's Greenleaf Unit Rounds Sheet, dated 5/1/18, indicated staff checked that all resident bed and chair alarms were in place and functioning during rounds at the 3:00 P.M. change of shift. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 4/10/18, indicated Resident #1 required extensive assistance of two staff members for transfers and ambulation. The Care Plan, dated 4/16/18, indicated Resident #1 was assessed as at risk for falls, and interventions included a bed and chair alarm (a pressure sensitive pad that sounds to alert staff when a resident is transferring themselves). The Nurse's Note, dated 5/1/18, indicated Resident #1 was found in his/her room in a seated position with his/her back up against the bathroom door after an unwitnessed fall. The Note indicated Resident #1's bed alarm had not sounded. The Note indicated Resident #1 was complaining of left arm and wrist pain, and indicated Resident #1 was transferred to the Hospital. The emergency room Report, dated 5/1/18, indicated Resident #1 had a fractured left wrist as a result of an unwitnessed fall at the Facility. The Surveyor interviewed Certified Nurse Aide(CNA) #2 at 1:29 P.M. on 8/10/18. CNA #2 said that on 5/1/18, just before dinner time, Resident #1 was discovered sitting on the floor with his/her back up against the bathroom door in his/her room by his/her roommate, who alerted staff. CNA #2 said Resident #1's bed alarm was in place but not functioning at the time of the fall. CNA #2 said it was common that resident alarms would not work. The Surveyor interviewed CNA #3 at 9:40 A.M. on 8/14/18. CNA #3 said at the change of every shift, CNAs from the offgoing and oncoming shifts were to do rounds, which included checking for placement of personal alarms. CNA #3 said the protocol was for staff to look to see that the alarms were in place, but staff did not check that the alarms were functioning. This was not consistent with the Facility's Greenleaf Unit Rounds Sheet. The Surveyor interviewed Nurse Supervisor #1 at 10:54 A.M. on 8/14/18. Nurse Supervisor #1 said the CNAs were to round at the change of each shift, and were to check for the placement of alarms, however they did not always check that the alarms were functioning. This was not consistent with the Facility's Greenleaf Unit Rounds Sheet. The Surveyor interviewed the Head of Central Supply at 2:55 P.M. on 8/10/18 and at 3:42 P.M. on 8/14/18. The Head on Central Supply said the Facility did not have user manuals for either of the two types of pressure sensitive bed/chair alarms in use at the Facility. The Head of Central Supply said the Facility did not make routine inspections of the bed and chair alarms, as it was up to the CNAs to check alarms for functioning at each shift change, and The Head of Central Supply said she would repair or send the alarms out for repair as needed. The Surveyor interviewed the Director of Nurses (DON) at 1:55 P.M. on 8/10/18. The DON said CNAs were to complete rounds at every shift change and CNAs were to check every resident bed/chair alarm for placement and functioning at every shift change. The DON said staff were to use the button on the Residents' bed/chair alarm box, which would cause the alarm to beep once to check for functioning. The DON said the Facility did not make routine inspections of the bed/chair alarms, as it was up to the CNAs to check alarms for functioning at each shift change. The DON said the Facility did not have a written policy for resident's personal bed/chair alarms.

Based on interviews and records reviewed, the Facility failed to prevent a significant medication error for 1 out of 3 sampled residents (Resident #2), when Resident #2 was administered Resident #3's [MEDICATION NAME] (an opioid pain medication). Resident #2 became unresponsive and was transferred to the emergency room where he/she was administered [MEDICATION NAME] for the reversal of opioid overdose. Findings include: The Facility policy titled Medication Administration, dated March 2009, indicated the nurse would identify the resident before medications were administered. Methods of identification of residents included checking the resident's identification wrist band, an identification photo attached to the medical record, calling the resident by name, and, if necessary, verifying resident identification with other Facility personnel. Resident #2 was admitted to the facility on [DATE], and his/her [DIAGNOSES REDACTED]. physician's orders [REDACTED].#2 was not prescribed [MEDICATION NAME]. An Admission Minimum Data Set (MDS) assessment, dated 12/23/16, indicated Resident #2 was severely cognitively impaired. Resident #2 was not able to be interviewed due to severe cognitive decline. Resident #3 was admitted to the facility on [DATE], and his/her [DIAGNOSES REDACTED]. A Quarterly MDS assessment, dated 12/7/16, indicated Resident #3 was cognitively intact. physician's orders [REDACTED].#3 was prescribed [MEDICATION NAME] 40 milligrams(mg) twice daily for pain. Resident #2 and Resident #3 have the same first name, and reside on the same unit in the same hallway of the Facility. A Nurse Progress Note, dated 1/6/17, timed 1:20 A.M. indicated Resident #2 was transferred to the emergency room after he/she was found unresponsive, making grunting noises, and with a low oxygen level during rounds. A Medication Occurrence Fact Sheet, dated 1/6/17 indicated Resident #2 was administered [MEDICATION NAME] 40mg in error, some time on 1/5/17. An emergency room Summary, dated 1/6/17, indicated Resident #2 was admitted through the emergency room , was unresponsive with snoring respirations and pinpoint pupils, and required [MEDICATION NAME] (a medication used to reverse the effects of opioid medications) after having been administered opiate medications which were not prescribed to Resident #2. A Hospital Urine Toxicology Screen, dated 1/6/17, indicated Resident #2 tested positive for [MEDICATION NAME] (the short acting version of [MEDICATION NAME]), which was not prescribed for Resident #2. Nurse #1 was interviewed at 1:18 P.M. on 3/16/17 and again at 8:43 A.M. on 3/17/17. Nurse #1 said she did not recall administering Resident #2 any medication not prescribed to him/her, any distractions during the medication administration, and said she identified Resident #2 before administering medications. The Director of Nurses was interviewed at 9:38 A.M. on 3/16/17 and throughout the survey. The Director of Nurses said she interviewed Nurse #1 several times during her investigation of the medication error, and Nurse #1 denied making a medication error. The Director of Nurses said Resident #2's positive urine toxicology report from the Hospital, indicated Resident #2 did receive [MEDICATION NAME]. Resident #2 was transferred to the Hospital where [MEDICATION NAME] was administered to reverse the opiod effects of [MEDICATION NAME].

Based on record review and staff interview, the facility failed to provide adequate supervision to prevent a fall with injury on 6/28/16, for Resident #3 out of a total sample of 23 residents. Findings include: Resident #30 was admitted to the facility in 6/2016, with [DIAGNOSES REDACTED]. Review of the resident's clinical record on 8/15/16, indicated an initial Minimum Data Set (MDS) was completed on 6/9/16, which indicated the resident was totally dependent with transfers, ambulation, required extensive assistance with toilet use and was totally incontinent of bladder and bowel. The resident's care plan dated 6/2/16, for alteration in activities of daily living indicated the resident required a maximum assist of one for toileting. A nursing note dated 6/28/16, indicated the resident was alert and orientated times three, had an unsteady gait and utilized a walker with one assist. According to the Certified Nursing Assistants daily flow sheets for 6/2016, prior to the fall on 6/28/16, the resident required extensive assist of one with toilet use. Review of the incident report dated 6/28/16, indicated the resident was taken to the bathroom by a Certified Nursing Assistant (CNA), requested privacy while in the bathroom, sat on the toilet, and was given the call bell light string to call for assistance. The CNA left the resident's room to obtain linen from the cart in the hallway. Another nurse on the floor heard the resident call for help and found the resident on the bathroom floor. According to the incident report, the resident had a chair and bed alarm because the resident was a high risk for falls. The resident complained of left hip pain and an x-ray was ordered by the physician. The x-ray indicated the resident had sustained a left hip fracture and the resident was transported to the hospital for surgical repair of the hip. The incident report indicated that the CNA received a written verbal warning, should have remained with the resident and not have left the resident's room. According to the incident report and the Resident Safety Inservice dated 6/29/16, residents who are alarmed or coded as supervised should never be left alone in bathrooms. The Resident Safety Inservice indicated that staff must be within reach of the residents even if the residents request privacy. Staff must remain right outside of the bathroom door with the door open so the residents are within sight. Review of the plan of correction after this incident included inservices for all licensed nursing staff and CNAs on resident safety, was added to the general orientation of new staff, and all staff who cared for residents with alarms/or coded as supervised would never be left alone in the bathrooms. The facility conducted fall reviews weekly and continues to meet weekly.

Based on observation, record review and staff interview, the facility failed to provide the necessary care and services in order to control the dental pain of 1 Resident (#11) and maintain a fluid restriction for 1 Resident (#5) who required [MEDICAL TREATMENT] secondary to [MEDICAL CONDITION] in a sample of 22 residents. Findings include: 1. For Resident #11, the facility failed to provide the dental care necessary to control pain from a tooth which required extraction. Resident #11 was admitted to the facility in 1/1998, with [DIAGNOSES REDACTED]. Review of the annual minimum data set ((MDS) dated [DATE], indicated that the resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating a moderately impaired cognitive status. The resident had occasional pain at level 7 out of a possible score of 1 to 10, with 10 being the greatest amount of pain. The quarterly MDS dated [DATE], indicated that the resident had a BIMS score of 8, indicating a moderately impaired cognitive status. The resident had no dental problems and no pain. Review of the facility pain policy was dated 3/31/14, indicated that "a pain assessment form will be completed annually and with a significant change in condition relative to the resident's pain management status." Despite the fact that the facility evaluated and treated the resident for his/her back pain, the facility failed to evaluate the resident for his/her mouth pain. On 2/26/14, the physician's progress note indicated "A problem is tooth aching at lower - gums that (Resident #11) thinks should come out. Five teeth at lower gum, one tooth upper. On 2/27/14, the physician wrote an order which read as follows: "Please look into dental care for extraction of lower teeth (5 total). The tooth further to the right is causing pain." On 4/26/14, the physician wrote "(Resident #11's) main problem are (1) teeth and (2) scaly itchy skin... Outside of pain from teeth, no other pain... left lower teeth anterior and posterior need extraction - presently arrangements trying to be made. Review of nurses notes from 9/20/13 to 5/20/14, indicated that the only nursing documentation about teeth extractions and dental pain was on 2/26/14, when the physician had visited the resident. The 2/26/14 nursing note was the last and only nursing documentation regarding the resident's mouth pain in over three months. During interview on 6/3/14 at 11:50 A.M., the resident said that he/she had mouth pain and although people said that they were working on providing dental care, they had not been successful and the pain continued. The resident also said that he/she was currently having pain and asked this surveyor to tell the nurses. This surveyor then told Medication Nurse #3 about the pain and she said that she was unaware as no one had told her. Medication Nurse #3 also said that although the resident receives pain medication for his/her back pain and a swish and swallow medication before every meal which contains the pain medication [MEDICATION NAME], she did not assess or ask the resident if he/she had mouth pain. Nurses progress notes were copied on 6/3/14 at 2:35 P.M. The last nurses note was dated 5/20/14. However, on 6/4/14, a review of the notes indicated that the nurses had documented and backdated a nursing note for 6/2/14 at 10:00 A.M. and 6/3/14 at 2:30 P.M. (This documentation was after the day and time when the nurses notes were previously copied on 6/3/14.) The nurses notes dated 6/2/14 and 6/3/14, stated the following "Call placed to facility dentist today they saw (him/her) in March made recommendations to have teeth extracted." During interview on 6/3/14 at 11:50 A.M., Charge Nurse #3 said that they were aware that the resident needed dental work done. She also said that they had been unsuccessful in obtaining an appointment, since the resident needed to go by stretcher and a former dental group that he/she had used could not take him/her. On 6/5/14, the resident was seen by the dentist and had one tooth extracted. Please refer to F411. 2. For Resident #5 the facility failed to ensure that this resident, who undergoes [MEDICAL TREATMENT] treatments, followed a fluid restriction as required to treat [MEDICAL CONDITION]. Resident #5 was admitted to the facility in 12/2013, with [DIAGNOSES REDACTED]. Review of the care plan dated 2/9/14, for therapeutic diets due to end stage [MEDICAL CONDITION] indicated that the resident was to follow a 1200 cc fluid restriction Review of the June, 2014, physician's orders [REDACTED]. Observation on 6/3/14, revealed that at lunch the resident had a large (looking as if it contained about 20 ounces (oz) - equaling 591 cc) glass of water on his/her over bed table. The resident also had a bowl of soup and a 4 ounce glass of cranberry juice on his/her tray. At breakfast on 6/4/14, the resident had another large glass of water, a cup of coffee (approximately 240 cc), 4 oz glass of apple juice (120 cc) and 4 oz glass of milk (120 cc). During interview on 6/4/14 at 1:30 P.M., Charge Nurse #3 said that there were no specific I&O (intake and output) sheets to record fluid intake. Charge Nurse #3 did say that the I&O's were recorded on the medication administration record (MAR). Upon review of the MARs for June, 2014, and May, April and March, 2014, no I&O information was available and no other information was available in the medical record to indicate that the 1200 cc fluid restriction was followed. During interview on 6/4/14 at 1:30 P.M., the nurse functioning as the Nursing Supervisor said that there was no documentation that the fluid restriction was followed and there was no way of knowing if the fluid restriction was followed. During interview on 6/4/14 at 1:30 P.M., Charge Nurse #3 said that she would have to speak with the facility Dietitian to determine how much fluid the resident was to receive from dietary and nursing. Additionally, they would have to speak to the resident to decide what he/she really wanted for fluids since soup was really important to him/her.

Based on record review, observation and staff interview, the facility failed to ensure that 1 sampled Resident (#11) from a sample of 22 residents received routine and emergent dental care/services so that the resident received the necessary treatment to relieve pain from a tooth that required extraction. Findings include: Resident #11 was admitted to the facility in 1/1998, with [DIAGNOSES REDACTED]. Review of the annual minimum data set ((MDS) dated [DATE], indicated that the resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating a moderately impaired cognitive status. The resident had occasional pain at level 7 out of a possible score of 1 to 10, with 10 being the greatest amount of pain. The quarterly MDS dated [DATE], indicated that the resident had a BIMS score of eight, indicating a moderately impaired cognitive status. The resident had no dental problems and no pain. On 2/26/14, the physician's progress note indicated "A problem is tooth aching at lower - gums that (Resident #11) thinks should come out. Five teeth at lower gum, one tooth upper. On 2/27/14, the physician wrote an order which read as follows: "Please look into dental care for extraction of lower teeth (5 total). The tooth further to the right is causing pain." On 4/26/14, the physician wrote "(Resident #11's) main problem are (1) teeth and (2) scaly itchy skin... Outside of pain from teeth, no other pain... left lower teeth anterior and posterior need extraction - presently arrangements trying to be made. Review of nurses notes from 9/20/13 to 5/20/14, indicated that the only nursing documentation about teeth extractions and dental pain was on 2/26/14, when the physician had visited the resident. Although, the physician had documented that the resident had pain and concerns about his/her dental pain, nursing failed to address the issues. During interview on 6/3/14 at 11:50 A.M., the resident said that he/she had mouth pain and although people said that they were working on providing dental care, they had not been successful and the pain continued. Nurses progress notes were copied on 6/3/14 at 2:35 P.M. The last nurses note was dated 5/20/14. However, on 6/4/14, a review of the notes indicated that the nurses had backdated and documented a nursing note for 6/2/14 at 10:00 A.M. and 6/3/14 at 2:30 P.M. (This documentation was after the day and time when the nurses notes were previously copied on 6/3/14.) The nurses note dated 6/3/14, says the following "Call placed to facility dentist today they saw (him/her) in March made recommendations to have teeth extracted." During interview on 6/3/14 at 11:50 A.M., Charge Nurse #3 said that they were aware that the resident needed dental work done. She also said that they had been unsuccessful in obtaining an appointment, since the resident needed to go by stretcher and a former dental group that he/she had used could not take him/her. On 6/5/14, the resident was seen by the dentist and had one tooth extracted.

Based on record review and interview for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that: * Resident #1's chair alarm was in place and functioning, per the plan of care, when on 8/13/13, Resident #1 fell out of the wheelchair and fractured his/her left 5th metacarpal; * Resident #2 was supervised in the bathroom, per the plan of care, when on 12/31/13, Resident #2 fell while attempting to self transfer off the toilet, fracturing the right hip. Findings include: The Record of Admission indicated Resident #1 was admitted to the Facility in May, 2011 with [DIAGNOSES REDACTED]. The Physician Order, dated 4/24/13, indicated Resident #1 used a bed and chair alarm at all times. The Morse Fall scale, dated 6/4/13, indicated Resident #1 was at a high risk for falls. The quarterly Minimum Data Set (MDS) assessment, dated 6/10/13, indicated Resident #1 was severely cognitively impaired. The Nursing Summary, dated 8/13, indicated Resident #1 required assistance to ambulate due to an unsteady gait and poor safety awareness. The summary indicated he/she required the assistance of one person for transfers and toileting. The Incident Report, dated 8/13/13, indicated Resident #1 was toileted by Certified Nurse Aide (CNA) #1 at 12:30 P.M., CNA #1 saw that there was no alarm box attached to Resident #1's chair alarm pad which was in the chair and no alarm sounded when she stood Resident #1 from the chair. The report indicated that CNA #1 did not replace the alarm box and at 2:00 P.M., Resident #1 was found sitting on the floor in his/her room. The results of the left hand X-ray, dated 8/14/13, indicated Resident #1 had a non displaced fracture of the left 5th metacarpal. The Surveyor interviewed CNA #1 on 1/24/14 at 4:15 P.M. CNA #1 said when she took Resident #1 to the bathroom at approximately 12:30 P.M. on 8/13/13, she saw the alarm pad in the wheelchair and saw that there was no alarm box attached to it. She said she was aware that Resident #1 used a chair alarm, but did not think about it at the time. She said that after she toileted Resident #1, she put him/her back in the wheelchair with a table in front of him/her, and left the room. She said she did not attach an alarm box to the chair pad in Resident #1's chair. The Record of Admission indicated Resident #2 was admitted to the Facility in September, 2011 with [DIAGNOSES REDACTED]. The Fall Risk Care Plan, dated 10/2/13, indicated Resident #2 was not to be left alone in the bathroom. The Morse Fall Scale, dated 10/8/13, indicated Resident #2 was at a high risk for falls. The Nursing Summary, dated 11/13, indicated Resident #2 required the assistance of one person for ambulation and transfers. The Certified Nurse Aide (CNA) Flow Sheet, dated 12/13, indicated Resident #2 required extensive assistance for transfers. The Incident Report, dated 12/31/13, at 8:20 P.M., indicated Resident #2 fell after he/she was left alone in the bathroom, by CNA #7, and tried to get off the toilet alone. The Incident Report indicated Resident #2 sustained a fractured right hip. The Surveyor interviewed CNA #7 on 1/28/14 at 2:40 P.M. CNA #7 said that on 12/31/13, she put Resident #2 in the bathroom and when she heard another resident alarm sound she went to answer the alarm. She said by the time she returned Resident #2 fell . She said she is per diem and doesn't have time to read the care cards or care plans. She said she should not have left Resident #2 alone in the bathroom. The Surveyor interviewed Nurse #6 on 1/24/14 at 3:00 P.M. Nurse #6 said she was at the nurses' station, right across from Resident #2's room and did not hear any other alarms sounding. She said that any resident using an alarm needs to be in eyesight of staff when using the bathroom. The Surveyor interviewed the Director of Nurses (DON) on 1/28/14 at 12:00 P.M. The DON said that the Facility policy indicated that a resident using any type of safety alarm was not to be left alone in the bathroom and any resident requiring assistance with ambulation or transfer required the use of a gait belt.