Every finding on record at Hellenic Nursing & Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure nursing staff provided assistance with Activities of Daily Living (ADLs) for one Resident (#89), out of a total sample of 26 residents. Specifically, for Resident #89 the facility failed to provide assistance with the removal of facial hair. Findings include:Review of the facility's policy titled Activities of Daily Living (ADL) Supporting, dated 3/18, indicated the following: Policy-Residents will be provided with care, treatment and services as 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. Policy Interpretation and Implementation:-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). Resident #89 was admitted to the facility in March 2022, with diagnoses including chronic kidney disease Stage 4, atrial fibrillation, Type 2 Diabetes Mellitus, and dementia. Review of Resident #89's most recent Minimum Data Set (MDS) assessment, dated 7/23/25, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating he/she had intact cognition. Further review of the MDS indicated Resident #89 required supervision or touching assistance to partial or moderate assistance for self-care activities. During an interview on 8/26/25 at 8:02 A.M., Resident #89 said he/she normally does not have facial hair and would like it removed but needs a razor and assistance. On 8/26/25 at 8:02 A.M., and 12:14 P.M., 8/27/25 at 8:14 A.M., 9:59 A.M., 12:50 P.M., and 3:03 P.M., and 8/28/25 at 8:13 A.M., the surveyor observed Resident #89 with long chin hair, approximately an inch long. Review of Resident #89's ADL care plan last revised, 8/26/25, indicated the following:Grooming: Continue supervision to assist of 1. Review of Resident #89's personal hygiene care card (documentation indicating level of care provided for combing hair, shaving, applying make-up, and washing/drying face and hands), indicated Resident #89 requires continued supervision to assist of 1 to complete personal hygiene. During an interview on 8/28/25 at 8:28 A.M., Unit Manager #1 said the Certified Nursing Assistants (CNAs) normally shave residents during morning care with their permission. Unit Manager #1 said Resident #89 is mostly independent, requires supervision and is not known to refuse care. Any refusals should be documented in the medical record. During an interview on 8/28/25 at 9:02 A.M., the Director of Nursing said he would expect facial hair to be removed with the resident's permission during routine care, and any refusals should be documented in the medical record. During an interview on 8/28/25 at 9:51 A.M., CNA #2 said we remove facial hair with the resident's permission during morning care. CNA #2 said Resident #89 does not normally refuse care, but he/she likes to do it themselves. CNA #2 said if a resident refuses care she will let the nurse know. CNA #2 said she will ask Resident #89 now if he/she would like their facial hair removed. Review of Resident #89's nursing progress notes failed to indicate he/she refused ADL care.

Based on record review and interview, the facility failed to follow up on a significant weight change in a timely manner and failed to implement a nutrition intervention as recommended by the Registered Dietitian (RD) for one Resident (#11), out of a total of 26 residents. Specifically, the facility failed to assess a significant weight loss for over 11 weeks and implement interventions for a nutrition supplement as recommended by the RD for Resident #11.Findings include:Review of the facility's policy titled 'Weight Assessment and Interventions', dated March 2022, indicated but was not limited to:-Resident weights are monitored for undesirable or unintended weight loss or gain.-Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing.Resident #11 was admitted to the facility in July 2019 with diagnoses including dysphagia, oropharyngeal phase (difficulty swallowing), adult failure to thrive, and dementia.Review of Resident #11's Minimum Data Set (MDS) assessment, dated 6/26/25, indicated Resident #11 could not participate in the Brief Interview for Mental Status (BIMS) due to impaired cognition. The MDS further indicated Resident #11 was setup assistance for meals, had triggered for a non-prescribed weight loss and was on a mechanically altered diet.Review of the weight report for Resident #11 indicated the following weights:12/1/24- 129.0 pounds (lbs.)1/3/25- 106.0 lbs.Review of the weights indicated Resident #11 lost 23 lbs. in one month, which is a significant weight loss of 21.7%.Review of Resident #11's nutrition care plan indicated the following:Focus: Resident is at potential nutritional risk due to inadequate by mouth intakes, need for altered diet, diagnosis of dementia, dysphagia, hypertension, hyperlipidemia, failure to thrive.Review of Resident #11's Physician's Order, dated 6/26/24, indicated the following:-Glucerna (an oral nutrition supplement) two times a day Glucerna 240 milliliters (mls) by mouth, document percentage in the medication administration record (MAR).Review of the nutritional assessment completed by the RD, dated 3/25/25, indicated Resident #11 would maintain stable weight within +/- five pounds of 128 lbs. The RD did not assess Resident #11's significant weight loss until over 11 weeks after the significant weight loss was documented.Further review of the nutritional assessment indicated the following plan/recommendation from the RD:-Recommend increasing Glucerna from twice a day to three times a day.Review of the medical record failed to indicate the Glucerna was increased to three times a day.During an interview on 8/28/25 at 8:41 A.M., Unit Manager #2 said the Resident is on Glucerna twice a day. She said if a resident is weighed and there is a significant weight loss the dietitian will be notified. She further said she was not sure if the dietitian was aware of Resident #11's weight change between December and January. Unit Manager #2 said the dietitian can write orders in the medical record, but the nurses have to approve it after speaking with the physician. She said she was not aware Resident #11's Glucerna had been recommended to be increased to three times a day.During an interview on 8/28/25 at 8:44 A.M., Nurse #1 said Resident #11 accepts Glucerna and he/she receives it twice a day.During an interview on 8/28/25 at 8:54 A.M., the RD said she keeps track of Resident's weights using the electronic medical record and if a resident has a significant weight change the system will alert her. The RD said if a Resident flags for a significant weight change, she will request the resident to be reweighed to confirm it and once confirmed she will assess the resident as soon as possible. The RD and the surveyor reviewed Resident #11's weight history and the RD assessment from 3/25/25. The RD said Resident #11 should have been assessed much sooner and she was not sure why the recommendation for Glucerna three times daily was never implemented. The RD then said Resident #11 is at risk of losing more weight without the recommended interventions being implemented.During an interview on 8/28/25 at 9:44 A.M., Certified Nursing Assistant (CNA) #2 said Resident #11 likes to eat breakfast but not the other offered meals. She said that the Resident will at times refuse to get weighed but once reapproached he/she will allow to be weighed.

Based on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#10), out of 27 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Review of the Long Term Care Facility Outpatient Dialysis Services Agreement, dated 6/15/07, indicated but was not limited to the following: 3. Resident Information. The Facility shall ensure that all appropriate medical and administrative information accompany all residents at the time of transfer or referral to the Center. This information, shall include, but is not limited to, where appropriate, the following: a. Resident's name, address, date of birth, and Social Security Number; b. Name, address and telephone number of the resident's next of kin; c. Resident's third party payor data; d. Appropriate medical records, including history of the resident's illness, including laboratory and x-ray findings; e. Treatment presently being provided to the resident, including medications; f. Name, address and telephone number of the nephrologist with admitting privileges at the Center referring the resident to the Center; and g. Any advance directive executed by the resident. Resident #10 was admitted to the facility in October 2021 with diagnoses including end stage renal disease and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 6/25/24, indicated Resident #10 was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. Further review of the MDS indicated the Resident received dialysis treatments. Review of the Physician's Orders indicated Resident #10 had dialysis three times weekly. Review of the Dialysis Communication Book indicated that no dialysis communication forms were completed by the facility from 10/28/23 through 8/27/24. Further review of the dialysis communication book indicated that communication forms were completed by the dialysis center for communication to the facility 10/28/23 through 8/27/24. Review of Resident #10's Progress Notes failed to indicate the facility called the dialysis center and provided verbal communication from 10/28/23 through 8/27/24. During an interview on 8/27/24 at 12:40 P.M., Unit Manager (UM) #2 said that the nurse should complete the facility's Dialysis Communication Form in the Resident's dialysis communication book before the Resident leaves for dialysis. UM #2 reviewed the dialysis communication book with the surveyor and said that she did not see any completed Dialysis Communication Forms in the book. During an interview on 8/27/24 at 12:45 P.M., Nurse #2 said that the nurse on duty when the Resident leaves for dialysis is responsible for completing the Dialysis Communication Form and that she reviews the Resident's dialysis book when he/she returns from dialysis. During a telephonic interview on 8/27/24 at 3:49 P.M., the Dialysis Nurse said that the facility does not usually complete a communication form to share information with the dialysis center on a regular basis but will report if something out of the ordinary occurs with the Resident. During an interview on 8/29/24 at 10:25 A.M., Nurse #2 said that the facility utilizes the paper communication forms in the Resident's dialysis communication book to communicate with the dialysis center.

Based on observation and interview, the facility failed to store, prepare and serve food in accordance with professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was properly labeled in two out of two refrigerators in the kitchen; and 2. Properly label, date, and store food products in two of two nourishment kitchenettes. Findings include: Review of the facility's policy titled Food Storage: Cold Foods, revised ,d+[DATE], indicated but was not limited to: - All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. - All refrigerated, ready-to-eat Time/Temperature Control Safety (TCS) prepared foods that are to be held for more than 24 hours at a temperature of 41 degrees Fahrenheit or less, will be labeled and dated with a prepared date (Day 1) and use by date (Day 7). Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3- 501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in ,d+[DATE].17(A). 1. On [DATE] at 7:35 A.M., the surveyor along with the Food Service Manager (FSM) observed the following in Refrigerator #1 and #2 in the main kitchen: - Refrigerator #1: one large, opened package of American cheese opened [DATE] no use by date, one large bowl of egg salad dated [DATE] no use by date. - Refrigerator #2: one container of feta cheese dated [DATE] no use by date. One bag of parmesan cheese delivered [DATE] opened and undated. During an interview on [DATE] at 9:10 A.M., the FSM said the kitchen staff should have labeled the refrigerated food items with an opened and a use by date. She said the items in use stored in the main kitchen refrigerators were not properly labeled. 2. Review of the facility's policy titled Food Brought by Family/Visitors, reviewed [DATE], indicated but was not limited to: - The nursing staff is responsible for discarding perishable foods on or before the use by date. - The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). On [DATE] at 9:50 A.M., the surveyor along with the FSM observed the following in the second-floor nourishment kitchenette: - One bottle of apple juice dated [DATE] and no use by date. - One small container of applesauce dated [DATE] and no use by date. - One bottle of peach flavored iced tea with no resident name or date. - One take-out food container dated [DATE]-[DATE] with no resident name. - One plastic shopping bag that contained meat, cucumbers, and a bowl of stew with no resident name or date. - One dish containing stuffing, green beans and turkey meat dated [DATE], indicated room [ROOM NUMBER] without a name. - One 16-ounce cup containing watermelon, honeydew, and pineapple that appeared to be deteriorating. - Garlic parmesan refrigerated dinner, which appeared partially eaten, with no resident name or date. - One small jar of tartar sauce, which the FSD said is not supplied by the facility, with no resident name or date. - Three packages of frozen dinners in the refrigerator with no resident name or date. - One container of prepared food consisting of baked chicken with no resident name or date. - One carton box of shrimp scampi, a la vodka with Italian sausage. - One box of meatloaf with mashed potatoes not labeled. - One box of macaroni and cheese dinner not labeled. - One lunch box on the counter. During an interview on [DATE] at 9:51 A.M., the FSM said foods brought from home are to be verified by nurses and to be labeled and stored in the refrigerator. She also said beverages and dairy products must have an opening and discard date. On [DATE] at 9:55 A.M., the surveyor along with the FSM, observed the following in the third-floor nourishment kitchenette: - One bottle of hot sauce, the FSM said was not supplied by the facility, with no resident name or date. - One can of chicken noodle soup with no resident name. - One box of spaghetti, stored in the cabinet next to the refrigerator with no resident name or date. - One brown bag of fast-food containing chicken nuggets, one cheeseburger, one fish sandwich, two containers of French fries, dated [DATE] with no resident name indicated. - Six slices of oatmeal bread, which the FSM said was not supplied by the facility, with no resident name or date. - Three zipper bags containing soup in the refrigerator with no resident name or date. - Two blueberry muffins with no resident name or date. - One snack pack of garlic hummus and chips with no resident name or date. - One can of coconut water, unopened, with no resident name or date. On [DATE] at 9:55 A.M., the surveyor observed in the third-floor nourishment kitchenette refrigerator splashes and spills of liquid substances on refrigerator shelves and the sides of the interior. The surveyor observed containers of food set on top of the spilled substances. During an interview on [DATE] at 10:10 A.M., the FSM said the items observed in the refrigerator should be labeled with the resident's name and a use by date. The FSM said any items in kitchenettes that have no resident name or date should be thrown away. The FSM said the kitchenette refrigerator was dirty and should have been clean by the dietary aides who were supposed to clean the kitchenette and the refrigerator prior to restocking snacks and beverages. Review of the Dietary Morning Checklist - Kitchenettes undated indicated: Check the refrigerator temperature, and freezer; check and discard expired items, Check labels and dates - if no label and date for Resident Food notify Nurse or Certified Nursing Assistant; Check Inventory - milk, juice, supplement shake, bread, snack and condiments, post menu of the day. During an interview on [DATE] at 7:40 A.M., the Administrator said dietary is responsible to clean the refrigerator in the kitchenettes.

Based on record review and interview, the facility failed to ensure that residents and/or their representatives were fully informed in advance and given information necessary to make health care decisions including the dose and benefits of psychotropic medications prior to their use for one Resident (#32), from a total sample of 27 residents. Findings include: Review of the facility's policy titled Policy and Procedure for Informed Consent for Psychotropic Medications, dated 3/17/16, indicated but was not limited to: -It is the policy of the facility that informed consent for the administration of psychotropic medications will be obtained prior to the administration of any psychotropic medication, including antipsychotic medications and medications used out of class for alternate clinical purpose. -Documentation will include: -Dose range for the medication -Purpose of the medication -Risks of use of the medication; if on antipsychotics, the black box warning is reviewed for use of antipsychotics in dementia related psychosis -Benefits of use of the medication Resident #23 was admitted to the facility in June 2020 with diagnoses including dementia with behavioral disturbance and bipolar disorder. The Resident's Health Care Proxy was activated on 10/28/20. Review of the Minimum Data Set (MDS) assessment, with a reference date of 6/18/24, indicated that Resident #23 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and was administered psychotropic medication daily. Review of the medical record indicated Physician's Orders including but not limited to: -Bupropion (antidepressant) HCI 75 milligrams (mg), give one tablet one time a day and -Bupropion HCI 75 mg, give two tablets one time a day for a total daily dose of 225 mg for bipolar disorder (1/13/24) Review of April 2024 through August 2024 Medication Administration Records (MAR) indicated Bupropion was administered as ordered by the physician. Review of psychotropic consent forms indicated a consent form for Bupropion was renewed (annually) and signed by the Health Care Proxy 4/9/24. The consent form failed to identify the dose administered, failed to indicate the benefits of the medication and indicated a dose range of 0-200 mg and not up to 225 mg that the Resident is administered daily. During an interview on 8/28/24 at 11:35 A.M., Unit Manager #2 and Nurse #2 reviewed Resident #23's medical record and said the psychotropic consent for Bupropion should indicate the dose administered, benefits of the medication, and a dose range that includes the total amount of medication administered daily.

Based on record review and interview, the facility failed to ensure the Physician/Practitioner was notified of a change in treatment for one Resident (#17), out of a total sample of 27 residents. Specifically, the facility failed to ensure the Physician/Practitioner was notified when the Wound Consultant recommended the initiation of an antibiotic. Findings include: Resident #17 was admitted to the facility in July 2024 with the following diagnoses: Stage 4 pressure ulcer on his/her right calf (a wound with full thickness tissue loss with exposed bone, tendon, or muscle). Review of the Minimum Data Set (MDS) assessment, dated 7/30/24, indicated Resident #17 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and had one Stage 4 pressure ulcer that was present on admission. Review of the Wound Consultant's Wound Evaluation and Management Summary, dated 8/2/24, indicated but was not limited to: -Stage 4 pressure wound of the right, upper calf, full thickness: Additional Wound Detail: Augmentin (antibiotic) 875 milligrams (mg) twice daily for seven days Review of Resident #17's August Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate he/she had received Augmentin as recommended by the wound consultant. Review of Resident #17's Order Recap Report from 8/1/24 through 8/29/24 failed to indicate Augmentin 875 mg twice daily for seven days had been initiated. Review of Resident #17's progress notes from 8/1/24 through 8/29/24 failed to indicate the Physician/Practitioner was made aware of the Wound Consultant's recommendation to start Augmentin. During an interview on 8/28/24 at 3:07 P.M., Unit Manager #1 reviewed Resident #17's medical record and said there was no indication that an antibiotic had been ordered. During an interview on 8/28/24 at 3:51 P.M., the Infection Control Nurse said there was no record that Resident #17 received Augmentin during the month of August. During a telephonic interview on 8/28/24 at 1:34 P.M., the Wound Consultant said when he had a recommendation, he verbalized it to the nursing staff and included it on his Wound Evaluation and Management Summary report. The Wound Consultant said he had intended for Resident #17 to start Augmentin. During an interview on 8/29/24 at 10:13 A.M., Physician #1 said the Wound Consultant's recommendation to initiate Augmentin was not brought to his attention. Physician #1 said he spoke with his Practitioner and his Practitioner had not been made aware of the Wound Consultant's recommendation either. During an interview on 8/29/24 at 10:55 A.M., Nurse #7 said she completes wound rounds with the Wound Consultant. Nurse #7 said she did not recall the recommendation to initiate Augmentin for Resident #17. Nurse #7 said she should have seen the recommendation to start an antibiotic on the Wound Evaluation and Management Summary report and should have called the Physician/Practitioner. During an interview on 8/29/24 at 10:19 A.M., the Infection Control Nurse said Physician/Practitioners should be made aware of all recommendations.

Based on observations and interviews, the facility failed to maintain a clean, safe, comfortable, and homelike environment for the residents at the facility, for 1 of 3 nursing units. Findings include: Review of the facility's policy titled Homelike Environment, dated as revised February 2021, indicated but was not limited to: -Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible -The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment. On the following days of survey, the Surveyor observed the following in the C Unit Lounge: On 8/26/24 at: -9:27 A.M., eight resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs (a wheelchair that provides comfort, support, and mobility), a mattress, a rolling walker, and a set of leg rests. -11:02 A.M., six resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. -3:40 P.M., eight resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. On 8/27/24 at: -8:26 A.M., nine resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. -10:08 A.M., seven resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. An activity was on-going at this time. -12:00 P.M., six resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. On 8/28/24 at: -8:02 A.M., nine resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. -9:45 A.M., eight resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. -12:07 P.M., seven resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. -4:48 P.M., nine resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. On 8/29/24 at: -7:54 A.M., seven resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. -10:17 A.M., eight resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. An activity was on-going at this time. -12:33 P.M., seven resident wheeled positioning devices which included standard wheelchairs, high back wheelchairs and Broda chairs, a mattress, a rolling walker, and a set of leg rests. During an interview on 8/29/24 at 9:42 A.M., Resident #71 said the Unit Lounge had been used as a storage room and with all the equipment in the room it was not welcoming or inviting. Resident #71 said the room was meant for the residents to use and not for storing the equipment. During an interview on 8/26/24 at 10:15 A.M., Resident Representative #1 said the Unit C Lounge looked more like a storage closet than an activity room/resident space. Resident Representative #1 said she has seen that the room has been heavily occupied by equipment that included wheelchairs, a mattress, a window screen and rolling walkers. During an interview on 8/29/24 at 9:38 A.M., Activities Assistant #1 said the Unit C Lounge was the room the facility used for most activities. Activities Assistant #1 said the room was also used to store equipment that is not in use. During an interview on 8/29/24 at 8:01 A.M., Certified Nursing Assistant (CNA) #4 said the C Unit Lounge is used for activities and occasionally as an additional dining room. CNA #4 said the equipment in the room was there because it was not currently in use and kept the residents' rooms less cluttered. During an interview on 8/29/24 at 10:17 A.M., Nurse #1 said when resident equipment was not in use it was stored in the Lounge to keep the resident rooms from being cluttered. During an interview on 8/29/24 at 12:50 P.M., the Maintenance Director said the facility goal was to keep resident areas clear of equipment and at one point the C Unit Lounge had been cleared of equipment. During an interview on 8/29/24 at 1:01 P.M., the Administrator said the C Unit Lounge was used to store wheelchairs when a resident was not using it, instead of in their rooms. The Administrator said unassigned equipment and mattresses should not be stored in the Unit Lounge.

Based on record review and interview, the facility failed to ensure staff developed a baseline or comprehensive care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care for two Residents (#96 and #251), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #96, to develop and implement a baseline care plan related to falls; and 2. For Resident #251, to ensure staff provided the resident and/or their representative with a summary of the baseline care plan within 48 hours of his/her admission. Findings include: Review of the facility's policy titled Care Plans - Baseline, last revised March 2022, indicated but was not limited to: - Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable. - The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. - The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. - Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. Resident #96 was admitted to the facility in June 2024 with diagnoses of legally blind and epilepsy (seizure disorder). Review of Resident #96's Minimum Data Set (MDS) assessment, dated 6/24/24, indicated he/she had a severe cognitive deficit as evidenced by staff assessment for mental status. Review of Resident #96's Fall Risk Evaluation, dated 6/18/24, indicated that he/she had a high fall risk as evidenced by a fall score of 19. Review of the medical record indicated Resident #96 sustained a fall on 7/8/24. Further review of the medical record indicated a care plan for Falls had been established on 7/8/24, 20 days (480 hours) after Resident #96's admission. During an interview with a record review on 8/28/24 at 2:32 P.M., Unit Manager (UM) #1 reviewed Resident #96's admission fall assessment and care plans. UM #1 said Resident #96 had a fall score of 19 which indicated he/she was a high fall risk and should have had a baseline care plan for falls but did not. During an interview on 8/28/24 at 2:56 P.M., the Staff Development Coordinator (SDC) said baseline care plans were put in on admission as comprehensive care plans. The SDC said a fall care plan should have been initiated within 48 hours of admission. 46562 2. Resident #251 was admitted to the facility in August 2024 with the following diagnoses: dementia and behavioral disorders. Review of the medical record indicated Resident #251 was alert and confused at baseline. Review of the Brief Interview or Mental Status (BIMS) Evaluation, dated 8/18/24, indicated he/she was severely cognitively impaired as evidenced by a BIMS score of 0 out of 15. During an interview on 8/26/24 at 10:15 A.M., Resident Representative #1 said she had not discussed Resident #251's goals or plan of care with the facility since he/she was admitted . Resident Representative #1 said a family member had been present daily since his/her admission, but the facility had not initiated a meeting to establish their goals and/or to find out Resident #251's baseline. Resident Representative #1 said Resident #251 had been at the facility for over a week without a meeting to establish his/her treatment plan. Review of Resident #251's Interdisciplinary Baseline Care Plan Attendance documentation failed to indicate his/her representative had been present. During an interview on 8/28/24 at 2:32 P.M., Unit Manager #1 said a baseline care plan meeting should be held within 48 hours of admission to establish a resident's goals and update his/her plan of care. Unit Manager #1 said a copy of this information should be provided to the resident and/or their representative. During an interview on 8/28/24 at 2:39 P.M., Social Worker #1 said baseline care plan meetings should be conducted within 48 hours of admission. The surveyor and Social Worker #1 reviewed the Interdisciplinary Baseline Care Plan Attendance documentation and Social Worker #1 said the meeting had been conducted telephonically in which they discussed Resident #251's history and his/her baseline. During a follow-up telephonic interview on 8/29/24 at 12:14 P.M., Resident Representative #1 said the day after Resident #251 was admitted she met with the facility to sign admission paperwork and on that day, she asked to speak with the social worker or nursing manager but that did not occur. Resident Representative #1 said the social worker had called her on the evening of 8/26/24 but had not contacted her prior to that. Resident Representative #1 said I do not know how they were able to create goals or establish care without talking to the family because her loved one could not speak for themselves. During a follow up interview on 8/29/24 at 10:43 A.M., Social Worker #1 said she wanted to clarify that Resident #251's baseline care plan had not occurred as previously reported due to an urgent issue arising at the facility. Social Worker #1 said she has since reached out to the Resident Representative and a meeting was set for 8/30/24.

Based on observations, interviews, and records reviewed for two Residents (#35 and #52), out of 27 sampled residents, the facility failed to develop and/or implement comprehensive care plans to reflect the individual needs of the resident. Specifically, the facility failed: 1. For Resident #35, to develop and implement a comprehensive person-centered care plan to address the Resident's diagnoses of dementia with behavioral disturbance and psychotic disorder with delusions; and 2. For Resident #52, to develop and implement a comprehensive person-centered care plan to address trauma informed care related to post-traumatic stress disorder (PTSD) diagnosis. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, indicated but was not limited to the following: -Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his/her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR (Pre-Admission Screening and Resident Review) recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; e. reflects currently recognized standards of practice for problem areas and conditions. 1. Resident #35 was admitted to the facility in June 2024 with diagnoses including dementia with behavioral disturbance and psychotic disorder with delusions. Review of the Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #35 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 4 out of 15. Further review of the MDS indicated that the Resident exhibited verbal behaviors, wandering, and other behaviors (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) and that the cognitive loss/dementia and behavioral symptoms care areas were triggered for the Resident and addressed in the Resident's Care Plan. Review of Resident #35's Physician's Orders included but was not limited to the following: - HCP (Health Care Proxy) ACTIVATED 6/27/24 (6/27/24) -ANTIPSYCHOTIC MEDICATION: Monitor for dry mouth, constipation, blurred vision, disorientation/confusion difficulty urinating, hypotention [sic], dark urine, yellow skin, N/V, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) (6/27/24) Review of Resident #35's Kardex failed to indicate target behaviors that the Resident should be monitored for related to his/her diagnoses of dementia with behavioral disturbance and psychotic disorder with delusions. Review of Resident #35's Care Plan included but was not limited to the following: -Focus: [Resident #35] uses psychotropic medications (specify medications) [sic] r/t Behavior management -Goal: The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date -Interventions: a. Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift (every shift). b. AIMS (Abnormal Involuntary Movement Scale) assessment every 6 months and PRN (as needed). c. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Further review of the Resident's Care Plan failed to indicate that a care plan was developed related to the Resident's impaired cognition related to his/her dementia diagnosis. Additionally, Resident #35's Care Plans failed to indicate that a care plan was developed related to the Resident's behavioral disturbance related to his/her diagnoses of dementia and psychotic disorder with delusions. Review of Resident #35's Progress Notes included but was not limited to the following: -7/23/24 at 10:29 P.M.: Resident noted to be agitated in the evening, yelling and shouting. -7/20/24 at 2:15 P.M.: Resident stated no its not after being told these are your medications and no I told you no after trying to administer medications again. Resident Refused after medication education stating, I don't care, I said no. -7/8/24 at 6:53 A.M.: Resident alert and responsive, confusion, awake most of night. Resident very disturbing behaviors to other resident shouting able to be redirected. Kept looking to go home and for his/her truck. -7/7/24 at 10:54 P.M.: Resident noted to be alert but confused, yelling out and disturbing other residents. Also resisting care, wanting to leave. During an interview on 8/29/24 at 12:19 P.M., the MDS Nurse said that she would expect that care areas triggered on the MDS would be addressed in the Resident's care plan. 49428 2. Review of the facility's policy titled Trauma Informed Care Policy, undated, indicated but was not limited to the following: -if a resident has a history of trauma that is documented or if they have triggered from the assessment, the Social Worker (SW) and interdisciplinary team (IDT) need to immediately formulate a plan of care to assist the resident in coping within the facility with whatever issue has been identified. -the plan of care needs to be specific and include anything that has been shared that can trigger a memory of the incident. Resident #52 was admitted to the facility in July 2023 with diagnoses including unspecified dementia with agitation, anxiety disorder, major depressive disorder (MDD), and chronic PTSD (mental health condition that is triggered by a terrifying event, either by experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event). Review of Resident #52's MDS assessment, dated 5/16/24, indicated Resident #52 had a BIMS score of 0 out of 15, which is indicative of severe cognitive impairment. Further review of the MDS indicated Resident #52 had active diagnoses that included dementia, anxiety, depression, and PTSD; and the Resident displayed physical, verbal, and other behavioral symptoms directed toward others. Review of Resident #52's Physician's Orders indicated but was not limited to the following: -Seroquel, 25 milligrams (mg) by mouth one time a day related to chronic PTSD, MDD, severe with psychotic symptoms, start 3/6/24; -Seroquel, 50 mg by mouth one time a day related to chronic PTSD, MDD, severe with psychotic symptoms, start 3/6/24. During an interview on 8/28/24 at 2:56 P.M., Social Worker (SW) #1 reviewed Resident #52's care plan. SW #1 said a trauma informed care care plan, which would include documentation of PTSD triggers, was not completed for the Resident. SW #1 said she could not find documentation of specific trauma or triggers related to the Resident's PTSD in the Resident's medical record. During an interview on 8/29/24 at 9:53 A.M., Unit Manager (UM) #1 said any resident with a diagnosis of PTSD must have a trauma informed care care plan that would include information such as PTSD triggers. UM #1 said Resident #52 should have a trauma informed care plan but did not.

Based on observation, interviews, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#35 and #63), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #35, a. to ensure that the Resident's fingerstick blood sugar was obtained per physician's order, b. to ensure that a physician's order was in place for the care and maintenance of the Resident's catheter drainage bag, and c. to ensure that a voiding trial (a procedure in which the ability of the bladder to empty after removal of a urinary catheter is measured) on 8/23/24 was implemented per physician's order; and 2. For Resident #63, to ensure physician's orders were complete for the management of a continuous glucose monitoring sensor and included orders to remove and change the device every 14 days. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Review of the facility's policy titled Diabetes - Clinical Protocol, revised November 2020, indicated but was not limited to the following: -As indicated, the Physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters such as glycosuria, weight gain or loss, hypoglycemic episodes, etc. Review of the facility's policy titled Insulin Administration, revised September 2014, indicated but was not limited to the following: -Characteristics and Types of Insulin Type: Long-acting Onset: 1-2 hours Peak: up to 8 hours Duration: up to 24 hours Review of the facility's policy titled Catheter Care, Urinary, revised August 2022, indicated but was not limited to the following: -Changing Catheters 1. Do not change indwelling catheters or drainage bags at routine, fixed intervals. 2. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Resident #35 was admitted to the facility in June 2024 with diagnoses including infection and inflammatory reaction due to indwelling urethral catheter, diabetes mellitus, urinary tract infection, obstructive and reflex uropathy, and benign prostatic hyperplasia. Review of the Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #35 was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 4 out of 15. Further review of the MDS indicated the Resident had an indwelling urinary catheter and diagnosis of diabetes. a. Review of Resident #35's Physician's Orders included but was not limited to the following: - Fingerstick; contact MD below 70 above 350 one time a day (scheduled at 7:00 A.M.) (7/10/24) - Lantus (long-acting insulin) 100 units/milliliter; Inject 10 units subcutaneously one time a day (scheduled at 8:00 P.M.) (6/27/24) Review of Resident #35's Medication Administration Records (MAR) for July 2024 and August 2024 indicated that the fingersticks were obtained daily as ordered at 7:00 A.M. 7/10/24 through 8/28/24, but no values for the fingersticks obtained were documented on the MAR. Review of Resident #35's Weights and Vitals Summary showed that the Resident's blood sugar was documented as 160 milligrams (mg)/deciliter (dL) on 8/15/24 at 5:44 A.M. and 130 mg/dL on 8/11/24 at 7:06 A.M. From 7/10/24 through 8/26/24, 41 blood sugar values were entered in the Resident's record between 7:04 P.M. and 12:57 A.M., outside of the scheduled 7:00 A.M. time per the physician's order for fingersticks. b. Review of Resident #35's Physician's Orders included, but was not limited to, the following: - Foley Catheter Care every shift (7/30/24) - Foley catheter size 16 Fr (French) (7/30/24) - Irrigate Foley with 60 ml NS as needed (8/18/24) No physician's order for replacement/changing of the Resident's catheter drainage bag was identified. Review of Resident #35's August 2024 MAR indicated that the Resident completed a course of Linezolid (an antibiotic) for treatment of a Vancomycin-resistant Enterococci (a bacteria resistant to Vancomycin, an antibiotic commonly used to treat enterococci infections) urinary tract infection on 8/8/24. Review of Resident #35's Treatment Administration Records (TAR) failed to indicate that his/her catheter drainage bag had been changed. c. Review of Resident #35's Physician's Orders included, but was not limited to, the following: - Foley Catheter Care every shift (7/30/24) - Foley catheter size 16 Fr (French) (7/30/24) - Void trial-reinsert foley if unable to void 8hrs, abdominal pain or distention one time only for retention for 1 Day (8/6/24) - Void trial-reinsert >400cc, abdominal distention, inability to void >8 hours (8/23/24) Review of Resident #35's TAR for July 2024 and August 2024 indicated that a voiding trial was completed 8/23/24; however, the TAR indicated that Foley catheter care was completed every shift on 8/23/24. Review of Resident #35's Progress Notes indicated, but was not limited to, the following: -On 8/20/24, Nurse #2 indicated that the Physician Assistant (PA) ordered a voiding trial for Friday (8/23/24) at 6:30 A.M. -On 8/21/24, Nurse #2 indicated that a voiding trial was scheduled for Friday (8/23/24) at 6:30 A.M. -On 8/26/24, Nurse #2 indicated that the Resident's catheter was removed at 7:00 A.M. for an attempted voiding trial but was reinserted as the Resident had not voided at 3:00 P.M. -On 8/27/24, Physician Assistant #1 indicated that the Resident had failed the voiding trial and that his/her blood sugar monitoring was without indications of hypoglycemia. No physician's order for a voiding trial on 8/26/24 was identified in the Resident's record. No progress note was entered on 8/23/24 indicating a voiding trial was attempted on that date or that communication with the physician had occurred to obtain an order to change the date of the voiding trial. No progress note was entered on 8/23/24 that indicated a voiding trial was attempted on that date. No progress note was entered that indicated communication with the physician had occurred to inform him/her that the voiding trial was not completed on 8/23/24 and/or to obtain an order to change the date of the voiding trial. During an interview on 8/28/24 at 2:59 P.M., Nurse #2 said that the Resident had undergone catheter removal for a voiding trial in the morning on 8/26/24, but was unable to void and the catheter was reinserted that afternoon. 34145 2. Review of the facility's policy titled Blood Glucose Monitoring-Continuous Policy, dated January 2023, indicated but was not limited to: -Staff should change out the site monitor/transmitter per manufacturer recommendations. Review of [NAME] Freestyle Libre Continuous Glucose Monitoring (CGM- https://www.freestyle.[NAME]/us-en/home.html) guidelines, included but was not limited to: -the Libre CGM is a small sensor-based system that provides real-time glucose readings day and night, without fingersticks; -The sensor is applied to the back of the upper arm with a simple, disposable device called an applicator. When the sensor is applied, a small (5 millimeter) filament (needle) is inserted just under the skin and held in place with a small adhesive pad; -There is a needle (sharp) in the applicator to insert the filament in the back of your upper arm so the sensor can monitor your glucose; -The sensor lasts up to 14 days and it is recommended to rotate application site of the sensor between arms. Review of Quick Start Guide for FreeStyle Libre 2 Reader (cgmmonitors.com/how-to-apply-freestyle-libre-sensor/) indicated, but was not limited to: -Select site on the back of upper arm. Do not use other sites as these may result in inaccurate glucose readings. -Wash site using a plain soap, dry, and then clean with alcohol wipe. Allow site to air dry before proceeding. -Place Sensor Applicator over site and push down firmly to apply Sensor. CAUTION: Do not push down on Sensor Applicator until placed over prepared site to prevent unintended results or injury. -Rotate application sites: To avoid skin irritation or tissue buildup, it's essential to rotate the sensor's application site regularly. Do not apply the sensor to the same spot consecutively. This helps maintain accurate readings and reduces the risk of skin-related issues. Resident #63 was admitted to the facility in February 2024 and had diagnoses including diabetes mellitus, type 1. Review of the MDS assessment, dated 5/27/24, indicated Resident #63 had moderate cognitive impairment as evidenced by a BIMS score of 8 out of 15 and received insulin injections daily. Review of August 2024 Physician's Orders indicated, but was not limited to: -FreeStyle Libre 2 Reader Device (Continuous Glucose System Receiver), 1 unit three times a day for diabetes mellitus (DM) monitoring using sliding scale as ordered (5/23/24) The physician's orders failed to include an order to change the device every 14 days. Review of August 2024 MAR/TAR and the entire medical record failed to indicate staff changed the sensor every 14 days as recommended by the manufacturer. During an interview on 8/30/24 at 8:38 A.M., Unit Manager #2 reviewed Resident #63's medical record. She said Resident #63 did not have a physician's order to change the device every 14 days but there should be. Telephone calls with voice messages left for Physican #2 on 8/30/24 and 9/13/24 were not returned.

Based on observation, record review, and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#57), out of a total sample of 27 residents. Specifically, the facility failed to fully develop and implement interdisciplinary care plans related to his/her dominant language of Albanian and failed to ensure staff provided person-centered care and services to determine and support the Resident's communication needs. Findings include: Resident #57 was admitted to the facility in May 2019 and had diagnoses including Alzheimer's disease, major depressive disorder, and adjustment disorder. Review of the Minimum Data Set assessment, dated 7/9/24, indicated Resident #57's preferred language was Greek and requires an interpreter to communicate with his/her physician and health care staff. Review of the care plan for communication problems, initiated 5/12/19, indicated Resident #57 has a language barrier and prefers to speak in Albanian, but can understand some Greek and English words. The care plan indicated a language translator will be used for communication. Review of the care plan for Resident #57's dependence on staff for meeting emotional, intellectual, physical, and social needs, initiated 6/10/19, indicated all staff to converse with the Resident while providing care: I speak Albanian and Greek with limited English. On 8/26/24 at 9:25 A.M., the surveyor observed Resident #57 ambulating independently in his/her room. The surveyor greeted the Resident with good morning. The Resident's roommate told the surveyor that Resident #57 does not understand or speak English. During an interview on 8/26/24 at 9:26 A.M., Resident #57's Health Care Proxy (HCP) said Resident #57 speaks Albanian and Greek only and there is only one staff person that speaks Greek, but he/she hasn't seen her in a long time. The HCP said staff call him a lot to translate and he doesn't mind, but it would be very helpful if they had some basic words and pictures posted on the bulletin board in the Resident's room for staff to use so they could communicate with him/her. The HCP said there is not a communication book or translation service available for staff to use to communicate with Resident #57. The surveyor and HCP looked around the Resident's room and were unable to find a communication book or information about the availability of a language translation service. As the surveyor was leaving Resident #57's room on 8/26/24 at 9:32 A.M., Nurse #1 greeted Resident #57 in Spanish, [NAME] estas?. Resident #57 did not respond. On 8/26/24 at 9:30 A.M., the surveyor inspected the nursing station and vicinity, including all shelving and accessible storage areas and found no language communication book or information about the availability of a language translation service. On 8/27/24 at 2:00 P.M., the surveyor observed Resident #57 standing in his/her doorway. The surveyor greeted the Resident with good morning. The Resident began to speak in his/her language. At this time, Certified Nursing Assistants (CNA) #1 and #5 were standing outside of the Resident's room. During an interview, the CNAs said they have Resident #57 on their assignment regularly and neither of them speak Albanian or Greek and cannot communicate with the Resident or understand what he/she is trying to say. CNA #1 said she asks the family to translate when they are in to visit, but they don't come in every day. The CNAs said there was no communication book with pictures or simple phrases available to assist in communicating with Resident #57 and they were not aware of the availability of a language translation service. During an interview on 8/27/24 at 2:10 P.M., Nurse #1 said she cannot speak Albanian or Greek and uses hand gestures to try and communicate with Resident #57. She said one of the physicians that comes to the facility can speak Greek and one staff person from consultant service provider that occasionally comes to the facility also speaks Greek. On 8/27/24 at 2:15 P.M., the surveyor again inspected the nursing station and vicinity, including all shelving and accessible storage areas and found no language communication book or information about the availability of a language translation service. During an interview on 8/27/24 at 2:35 P.M., Volunteer #1 said he/she usually comes to the facility on ce a week. He/she said the staff can't speak Greek and it is sad that they can't communicate and engage the residents for which English is not their primary language. The Volunteer said there used to be someone here that could speak Greek, but he/she hasn't seen her in a while. The Volunteer said he/she is not aware of a language translation service available to residents, staff and volunteers. During an interview on 8/28/24 at 11:35 A.M., the surveyor asked Unit Manager #2 and Nurse #2 what resources are available for staff to communicate with non-English speaking residents. They said they try to interpret Resident #57's gestures to figure out what he/she needs, but don't know of any resources when they are not in the building. Nurse #2 said she is not aware of the availability of a language translation line. Unit Manager #2 said the social worker had just brought up a telephone number for a translation line and put it somewhere at the nursing station. Nurse #2 searched the nursing station and vicinity and moved a large computer monitor away from the wall to access a piece of paper tacked to a cork board with the words Translator Services and a telephone number printed on it. Unit Manager #2 and Nurse #2 said they didn't know the telephone number was there, did not know the translation service was available, and had never called the number. Unit Manager #2 removed a red binder, labeled Unit B Greek Translation, from a shelving unit holding medical records. The surveyor shared observations on 8/26/24 and 8/27/24 of no communication book at the nursing station and vicinity including all shelving and accessible storage areas. Unit Manager #2 could not explain why no staff, Health Care Proxys or volunteers interviewed were aware of the existence of a Greek language communication book and language translation service. Unit Manager #2, Nurse #2 and the surveyor reviewed the communication binder. A page in the binder listed four names of Greek translators available. Nurse #2 said she didn't know how old the book was, because three out of the four names listed no longer worked at the facility. She said the fourth name was a contracted consultant service provider and is not available to interpret unless she is in the building seeing her patients. Unit Manager #2 said Resident #57's physician speaks Greek and is always available to translate for staff. During an interview on 8/29/24 at 8:58 A.M., Physician #1 said he is Resident #57's attending physician and he speaks Greek with both residents and their families. He said if there is a medical problem, staff call him. He gave an example that if the Resident isn't feeling well, they call him to translate to find out what is going on. He said he only performs translation for medical issues and does not translate for anything non-medical.

Based on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental and psychosocial well-being for one Resident (#251), out of 27 sampled residents. Specifically, for Resident #251, the facility failed to consistently provide activities based on the comprehensive assessment and care plan. Findings include: Resident #251 was admitted to the facility in August 2024 with the following diagnoses: dementia and behavioral disorders. Review of the medical record indicated Resident #251 was alert and confused at baseline. Review of the Brief Interview for Mental Status (BIMS) Evaluation, dated 8/18/24, indicated the Resident scored 0 out of 15 indicating he/she was severely cognitively impaired. Review of Resident #251's care plans included but were not limited to: -Focus: Resident admitted for long term care. Resident in need of 24 hour care and supervision, dated 8/16/24. Interventions: Encourage/involve in daily activities, dated 8/16/24 -Focus: Resident #251 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits due to dementia, depression, anxiety, anemia, physical limitations due to gait and balance problems, dated 8/22/24. Interventions: I need 1:1 bedside/in-room visits and activities if unable to attend out of room events, dated 8/22/24. Invite Resident #251 to scheduled activities. I enjoy Musical Events, dated 8/22/24 Review of Resident #251's August 2024 Activity Participation Record indicated but was not limited to: -8/16/24: TV/Radio, 1:1 visit, Family Visit -8/17/24: TV/Radio -8/18/24: TV/Radio, Outside Family Visit -8/19/24: TV/Radio, Family Visit, Entertainment -8/20/24: TV/Radio, Family Visit -8/21/24: TV/Radio -8/22/24: TV/Radio -8/23/24: TV/Radio -8/24/24: TV/Radio, Family Visit, Holy Communion, 1:1 Visit -8/25/24: TV/Radio, Family Visit -8/26/24: TV/Radio, Family Visit -8/27/24: TV/Radio, 1:1 visit -8/28/24: TV/Radio, 1:1 visit -8/29/24: TV/Radio, 1:1 visit On the following dates and times of survey, the surveyor observed Resident #251: On 8/27/24: -8:27 A.M., lying in bed, no TV/music, with no staff engagement -10:08 A.M., sitting in his/her chair, door to room partially closed, no TV/music, with no staff engagement. Multiple residents observed in the C Unit Lounge participating in an exercise group -10:29 A.M., sitting in his/her chair, door to room partially closed, no TV/music, with no staff engagement. Multiple residents observed in the C Unit Lounge participating in an exercise group -12:12 P.M., sitting in his/her chair, door to room partially closed, no TV/music, with no staff engagement On 8/28/24: -7:58 A.M., lying in bed, no TV/music, with no staff engagement -9:44 A.M., sitting in his/her chair, no TV/music, with no staff engagement -11:52 A.M., lying in bed, no TV/music, with no staff engagement -2:46 P.M., sitting in his/her chair looking at a paper on his/her overbed table, no TV/music, with no staff engagement. Multiple residents observed in the C Unit Lounge participating in a music activity. -4:48 P.M., sitting in his/her chair, no TV/music, with no staff engagement On 8/29/24: -7:55 A.M., lying in bed, no TV/music, with no staff engagement -9:47 A.M., sitting in his/her chair with a baby doll in hands, no TV/music, with no staff engagement -10:11 A.M., sitting in his/her chair, no TV/music, with no staff engagement. Multiple residents observed in the C Unit Lounge participating in an exercise group -12:33 P.M., sitting in his/her chair, no TV/music, with no staff engagement During an interview on 8/26/24 at 10:15 A.M., Resident Representative #1 said Resident #251 was used to being involved in structured activity. Resident Representative #1 said Resident #251 was not being engaged by the staff and had not been to any activities. During an interview on 8/28/24 at 2:17 P.M., Certified Nursing Assistants (CNA) #2 and #3 said Resident #251 stayed in his/her room most of the time with his/her baby doll and family photos. CNA #2 said his/her family visited often and that Resident #251 had gone to one or two group activities. During an interview on 8/28/24 at 12:02 P.M., Nurse #4 said Resident #251 was new to her, but from what she has seen, Resident #251 sits in his/her room with the baby doll and seemed content with that. Nurse #4 said she was not aware if Resident #251 had attended activities. During an interview on 8/29/24 at 10:53 A.M., Social Worker #2 said she was reviewing Resident #251's medical record and that goal of care was to get him/her involved in a routine and activities. During an interview on 8/29/24 at 1:48 P.M., the Activities Director said she would go in and provide 1:1 visits with Resident #251. The Activities Director said Resident #251's family visited often and he/she spent time with them outside. The Activities Director provided the surveyor with a copy of Resident #251's August 2024 Activity Participation Record and said any activities he/she had participated in would be recorded. The Activities Director said the (Activity Participation Record) sheets were updated daily and were accurate at this time.

Based on observation, record review, and interview, the facility failed to ensure residents were free from accident hazards for two Residents (#32 and #62), out of a total sample of 27 residents. Specifically, the facility failed to complete his/her quarterly smoking evaluations. Findings include: Review of the facility's policy titled Smoking Policy and Procedure, dated as revised 11/1/2018, indicated but was not limited to: -All residents expressing the desire to smoke tobacco products or use E-cigarettes will be assessed upon admission to the center, when there is a change in status and quarterly. On 8/26/24 at 1:30 P.M. and 8/29/24 at 9:07 A.M., the surveyor observed Residents #32 and #62 smoking in the facility's designated smoking area with staff supervision. a. Resident #32 was admitted to the facility in June 2020 and had diagnoses including bipolar disorder and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 3/19/24, indicated Resident #32 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15 and utilized tobacco products. Review of the medical record indicated the last smoking and safety assessment was conducted on 12/18/23. Further review of the entire medical record failed to indicate any smoking and safety assessments were conducted after 12/18/23. b. Resident #62 was admitted to the facility in March 2021 and had diagnoses including bipolar disorder and anxiety. Review of the MDS assessment, dated 1/2/24, indicated Resident #32 had moderate cognitive impairment as evidenced by a BIMS score of 8 out of 15 and utilized tobacco products. Review of the medical record indicated the smoking and safety assessment were conducted on: -1/20/23 -6/16/23 -4/1/24 -7/1/24 Further review of the medical record indicated no quarterly smoking and safety assessments were conducted in 4/2023, 9/2023, 12/2023 and 3/2024. During an interview on 8/27/24 at 1:49 P.M., Unit Manager #2 said smoking and safety assessments are to be completed quarterly. She said some assessments were missed and not done quarterly for Residents #32 and #62.

Based on record review, policy review, and interview, the facility failed to monitor adverse consequences (side effects) of anticoagulant medications (used to prevent the blood from clotting; a blood thinner) for one Resident (#41), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Anticoagulation-Clinical Protocol, last revised November 2018, indicated but was not limited to: - Monitor and Follow-Up 5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. Resident #41 was admitted to the facility in January 2024 with diagnoses of atrial fibrillation and hypertension. Review of Resident #41's Minimum Data Set (MDS) assessment, dated 7/25/24, indicated Resident #41 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS indicated that Resident #41 received anticoagulant medication. Review of Resident #41's current Physician's Orders indicated but was not limited to: - Rivaroxaban (Xarelto, anticoagulant medication) 20 milligrams (mg), give 1 tablet by mouth one time a day for AFIB (atrial fibrillation), dated 3/7/24 Review of Resident #41's August 2024 Medication Administration Record (MAR) indicated he/she received Rivaroxaban as ordered. Further review of Resident #41's medical record failed to indicate Resident #41 was monitored for adverse consequences of anticoagulant medication. During an interview on 8/29/24 at 9:04 A.M., Nurse #8 said residents who received anticoagulant medications should be monitored for adverse consequences. Nurse #8 reviewed Resident #41's physician's orders and said the Resident had an order for anticoagulant medication and had received it as ordered. Nurse #8 said Resident #41 should have had an order to monitor for adverse consequences of anticoagulant medication but did not. During an interview on 8/29/24 at 9:10 A.M., Nurse #5 said any resident who takes an anticoagulant medication should have an order to monitor for adverse consequences. During an interview on 8/29/24 at 12:09 P.M., the Staff Development Coordinator (SDC) said residents who take anticoagulant medications should be monitored for adverse consequences every shift. During an interview on 8/29/24 at 1:33 P.M., Unit Manager (UM) #1 said all residents who receive an anticoagulant medication should have an order to monitor for adverse consequences.

Based on record review and interview, the facility failed to ensure one Resident's (#56) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 27 residents. Specifically, the facility failed to ensure an as needed antipsychotic medication was limited to 14 days, or extended beyond 14 days with a documented clinical rationale and duration. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, last revised July 2022, indicated but was not limited to: - Policy Statement: - Residents will not receive medications that are not clinically indicated to treat a specific condition. - Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. - Policy Interpretation and Implementation: 1. Resident will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 16. PRN (as needed) orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rationale for continued use. The duration of the PRN order will be indicated in the order. Resident #56 was admitted to the facility in July 2024 with a diagnosis of Alzheimer's disease. Review of Resident #56's August 2024 Physician's Orders indicated but were not limited to: - Quetiapine (antipsychotic medication) 25 milligrams (mg), Give 1 tablet by mouth every six hours as needed for Breakthrough Aggression and Agitation with an end date listed as indefinite. (dated 8/9/24) - Quetiapine 25 mg, give half a tab (12.5 mg) two times daily for Breakthrough Aggression and Agitation related to Alzheimer's disease (dated 8/9/24) Review of Resident #56's medical record failed to indicate that Quetiapine 25 mg as needed was re-evaluated after 14 days. During an interview on 8/28/24 at 3:21 P.M., Unit Manager (UM) #1 said any resident who had an order for an as needed anti-psychotic medication should have the order for no longer than 14 days. UM #1 reviewed Resident #56's medical record and said the Resident had an order for an as needed anti-psychotic medication, Quetiapine, that did not have a stop date and was put into the physician's orders as indefinitely. UM #1 said the order for Quetiapine should have been 14 days, and then the physician should have re-evaluated the medication. During an interview on 8/29/24 at 10:15 A.M., the Staff Development Coordinator said as needed anti-psychotic medications should be prescribed for no longer than 14 days.

Based on record review, policy review, and interview, the facility failed to ensure that concerns addressed by the Resident Council Group have sufficient follow-up to address and prevent recurrence. Findings include: Review of the facility's policy titled Complaint/Grievance Policy and Procedure, undated, indicated the following: *Voiced grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. During the Resident Group interview on 6/28/23 at 11:08 A.M., nine residents were in attendance, and 8 of 9 residents reported: * Despite repeatedly voicing concerns, month after month, the staff speak Creole on the units, it continues. * Snacks are not passed at nighttime and if they ask the staff for a snack the staff say that they are too busy. The Resident Group suggested the surveyor look back at past year's monthly resident council minutes and said that these concerns are documented. Review of the past year's Resident Council Meeting minutes indicated: * May 2023: residents stated that (Certified Nursing Assistants) CNAs are speaking in their native language AND snacks are not given out to the resident. * April 2023: Residents state that CNAs spend too much time on their phones in patient rooms. They are speaking in their native language in patient rooms. AND Resident stated that the snacks are not given out at 2pm and 8pm. this only occurred once. * March 2023: Resident requested a snack wagon for evening distribution * November 2022: All residents present at the meeting stated that on 9-11p.m shift, staff speak in their own language and staff speaking their native language where residents can hear and residents are upset because they don't understand the conversation. * October 2022: All residents present at the meeting stated that on all shifts staff speak in their own language. * September 2022: All residents present at the meeting stated that on all shifts staff speak in their own language. * July 2022: staff continue to speak in their own language at times. During an interview on 6/29/23 at 8:06 A.M., the Activities Director said that she coordinates the monthly Resident Council meetings and takes the minutes. After each meeting she said she meets with the Nursing Home Administrator (NHA) to review the concerns. The Activities Director said, They keep complaining about the languages even though we try to address that through staff development, and that the snacks are not available in the evening. She thinks that the kitchen may not be sending up enough snacks but is not sure. During an interview with the NHA and Director of Nurses (DON) on 6/29/23 at 8:24 A.M., they said that they are aware that languages and snacks are ongoing issues and that they are at the point they might start writing people up because they have heard this ad nauseam. The NHA said it is her expectation that grievances be resolved within 48 to 72 hours.

Based on observation, record review, policy review, and interview, the facility failed to ensure four Residents (#75, #46, #31, and #21) were free from restraints, out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #75, to assess the use of a rolled-up Hoyer pad and pillows under the fitted sheet on both sides of the Resident as a potential restraint; 2. For Resident #46, to assess the use of multiple blankets under the sheets on both sides of the bed as a potential restraint; 3. For Resident #31, to assess the use of blankets under the fitted sheet on one side of the Resident as a potential restraint; and 4. For Resident #21, to assess the Resident's bed up against the wall as a potential restraint. Findings include: Review of the facility's policy titled Use of Restraints, dated 11/2020, included the following: - Restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. - Restraints should only be used to treat the resident's medical symptoms and never for discipline, staff convenience or for the prevention of falls. - If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition and this restricts his/her typical ability to change position or place that device is considered a restraint. - There shall be a restraint assessment and review to determine the need. 1. Resident #75 was admitted to the facility in November 2020 with diagnoses including Alzheimer's disease, seizures, and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/6/23, indicated Resident #75 was rarely or never understood and cognitive skills for daily decision making were severely impaired. Further review of the MDS indicated Resident #75 required extensive assistance with bed mobility. On 6/28/23 at 12:26 P.M., the surveyor observed Resident #75 lying in bed with a Hoyer pad (a sling used to lift a resident from one surface to another) rolled underneath a fitted sheet along the right side of the Resident and a pillow secured underneath the fitted sheet alongside of the left side of the Resident. On 6/28/23 at 3:20 P.M., the surveyor observed Resident #75 with a Hoyer pad rolled underneath a fitted sheet along the right side of the Resident and a pillow secured underneath the fitted sheet alongside the left of the Resident. On 6/29/23 at 6:47 A.M., the surveyor observed Resident #75 with a Hoyer pad underneath the right side of the fitted sheet beginning at the Resident's head down to the Resident's abdomen and a pillow secured underneath the fitted sheet along the left side of the Resident's body. During an interview on 6/29/23 at 7:14 A.M., Nurse #11 said she believes the items were secured underneath the fitted sheet to prevent Resident #75 from falling out of bed. Nurse #11 was unable to say if it was typical to use a Hoyer pad underneath the Resident's sheets. During an interview on 6/29/23 at 10:13 A.M., the Director of Nursing (DON) was unsure why there would be blankets/pillows or other items underneath the fitted sheet but said she had seen it in the past for positioning. The DON said the pillows/blankets were possibly placed under the fitted sheet, so they didn't slide out of place. The DON said she had never seen a Hoyer pad used for positioning. The DON was unsure if the items would be considered a restraint if the Resident was unable to move the items. The DON said the expectation would be not to limit the movement of a resident and an assessment to be completed. The DON was unable to tell the surveyor if there was an assessment that the facility used. Review of the medical record failed to indicate that Resident #75 was assessed for the use of blankets/pillows or other items placed bilaterally alongside the Resident as a restraint. 2. Resident #46 was admitted to the facility in July 2020 with diagnoses including dementia and hypertension. Review of the most recent MDS assessment, dated 3/30/23, indicated Resident #46 was unable to complete the Brief Interview for Mental Status (BIMS) exam and was assessed by staff to have severe cognitive impairment. On 6/27/23 at 8:12 A.M., the surveyor observed Resident #46 lying in bed with a pillow under the fitted sheet on the left side of his/her body and blankets stuffed under the fitted sheet on the right side of his/her body. On 6/28/23 at 3:46 P.M., the surveyor observed Resident #46 lying in bed with blankets rolled up underneath the fitted sheet on the right side of his/her body and a large bath blanket rolled under the left side of his/her body. On 6/29/23 at 6:40 A.M., the surveyor observed Resident #46 lying in bed with blankets rolled up underneath the fitted sheet on the right side of his/her body and a large blanket rolled up under the left side of his/her body. During an interview on 6/29/23 at 7:11 A.M., Nurse #11 accompanied the surveyor to Resident #46's room. Nurse #11 said she was the nurse on the night shift and did not know why Resident #46 had the blankets underneath the fitted sheet but that was a way the staff used to prevent falls. Nurse #11 was unsure of the expectation when it comes to placing items underneath the fitted sheet, and said she thinks it was to prevent falls. During an interview on 6/29/23 at 7:52 A.M., Certified Nursing Assistant (CNA) #10 said she had Resident #46 on the assignment that day and that Resident #46 does try to get out of bed in the morning. Review of the medical record failed to indicate that Resident #46 was assessed for the use of blankets and/or pillows under the fitted sheet on both sides of the bed as a potential restraint. 3. Resident #31 was admitted to the facility in September 2015 with diagnoses including type 2 diabetes mellitus, hypertension, and dementia with behavioral disturbance. Review of the MDS assessment, dated 3/23/23, indicated a BIMS score of 1 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated Resident #31 required extensive assistance with bed mobility. On 6/27/23 at 8:28 A.M., the surveyor observed Resident #31 sitting up in bed with blankets rolled up under the right side of the fitted sheet and a pillow along the left side underneath the fitted sheet. Review of Resident #31's care plans revised, failed to indicate a restraint care plan. Review of Resident #31's Physician's Orders, dated June 2023, failed to indicate the use of a restraint. Review of the medical record failed to indicate that Resident #31 was assessed for the use of blankets or pillows placed bilaterally alongside the Resident as a potential restraint. On 6/28/23 at 8:13 A.M. and 12:34 P.M., the surveyor observed Resident #31 lying in bed with a blanket along the right side of the Resident secured under the fitted sheet. On 6/29/23 at 6:43 A.M., the surveyor observed Resident #31 lying in bed with a blanket secured underneath the fitted sheet along the right side of the Resident, and a pillow secured under the fitted sheet alongside the Resident on the left. During an interview on 6/29/23 at 6:54 A.M., CNA #7 accompanied the surveyor to Resident #31's room. CNA #7 said she did not have Resident #31 on the assignment but said she believes the pillows and blankets were placed so that the Resident does not get up. During an interview on 6/29/23 at 7:11 A.M., Nurse #11 observed Resident #31 with the surveyor. Nurse #11 said she does not know why the blankets and pillows were placed in Resident #31's bed but said she noticed it over the night shift. Nurse #11 said she thinks the placement of the blanket and pillows is to prevent falls. During an interview on 6/29/23 at 10:13 A.M., the DON was unsure why there would be blankets or pillows underneath the fitted sheet but said she had seen it in the past for positioning. The DON said the pillows/blankets were possibly placed under the fitted sheet, so they didn't slide out of place. The DON was unsure if the items would be considered a restraint if the Resident was unable to move the items. The DON said the expectation would be not to limit the movement of a resident and an assessment to be completed. The DON was unable to tell the surveyor if there was an assessment that the facility used. 4. Resident #21 was admitted to the facility in November 2021 with diagnoses including Alzheimer's disease, muscle weakness, and unsteadiness on feet. Review of the most recent MDS assessment, dated 4/26/23, indicated Resident #21 was rarely or never understood and cognitive skills for daily decision making were severely impaired. On 6/28/23 at 8:10 A.M. and 8:52 A.M., the surveyor observed Resident #21 lying in a bed that was pushed up against the wall, with upper side rails in place, full length bolsters, as well as a pillow secured underneath the left side of the fitted sheet. Review of Resident #21's Physician's Orders, dated June 2023, failed to indicate the use of a bed up against the wall or full-length bolsters. Review of the medical record failed to indicate that Resident #21 was assessed for the use of a bed up against the wall as a restraint. On 6/28/23 at 3:50 P.M., the surveyor observed Resident #21 in bed, with full length bolsters, and the bed up against the wall. On 6/29/23 at 6:46 A.M., the surveyor observed Resident #21 lying in their bed that was up against the wall, with both upper side rails raised and full-length bolsters. During an interview on 6/29/23 at 7:59 A.M., CNA #9 said she was unsure why Resident #21's bed was up against the wall, but it was always like that. CNA #9 said Resident #21 tries to get out of bed sometimes. During an interview on 6/29/23 at 10:13 A.M., the DON was unaware that Resident #21's bed was up against the wall. The DON was unsure if the bed against the wall was considered a restraint or restricting Resident #21's movement. The DON said the expectation would be to complete an assessment to evaluate if the devices are restricting the resident's movement. The DON was unable to tell the surveyor if there was an assessment that the facility used to assess. During an interview on 6/29/23 at 12:03 P.M., Unit Manager #2 said she was unsure why Resident #21's bed was against the wall but said it should not be. When Unit Manager #2 was asked if there was a Restraint Assessment available for review on the floor, Unit Manager #2 said there were no residents with restraints on the floor.

Based on observation, record review, and interview, the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to four dependent Residents (#87, #40, #54, and #12), out of a total sample of 26 residents. Specifically, 1. Resident #87's facial hair was not removed timely; and 2. Residents #40, #54, and #12 were not supervised with eating. Findings include: 1. Resident #87 was admitted to the facility in December 2021 and had diagnoses that included dementia, anxiety disorder, and need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/6/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #87 scored a 9 out of 15, indicating moderate cognitive impairment. The MDS further indicated Resident #87 required 1 person physical assistance with personal hygiene. During an observation and interview on 6/27/23 at 8:02 A.M., the surveyor observed Resident #87. He/she had long [NAME] hair. Resident #87 said he/she would like it removed but the girls never do (it). During a record review on 6/27/23 at 11:04 A.M., the following was indicated: * The current Activity of Daily Living (ADL) care plan indicated grooming physical assist of 1. * The current Kardex (resident specific care instructions) indicated Resident #87 requires 1 person physical assistance with personal hygiene. * The record, including daily Certified Nursing Assistant (CNA) documentation for the month of June, failed to indicate Resident #87 refused to have [NAME] hair removed. On 6/28/23 at 8:13 A.M., the surveyor observed Resident #87 dressed and walking back to his/her room. Resident #87 had long [NAME] hair covering his/her [NAME]. During an interview on 6/28/23 at 8:20 A.M., Resident #87 said that the girls had still not shaved his/her [NAME] hair and that he/she wanted it removed. On 6/29/23 at 7:22 A.M., the surveyor observed the Resident sleeping in bed and had [NAME] hair covering his/her [NAME]. During an observation and interview on 6/29/23 at 9:33 A.M., the surveyor observed Resident #87 dressed for the day; the [NAME] hair was in place, and Resident #87 said no one offered to remove the [NAME] hair. Resident #87 said he/she could not recall if he/she had asked to have it removed. During an interview with Resident #87's Certified Nursing Assistant (CNA) #1 on 6/29/23 at 10:11 A.M., CNA #1 said Resident #87 needed assistance with his/her personal hygiene, including staff to remove his/her facial hair. CNA #1 said Resident #87 occasionally refused a shower but did not refuse other care. On 6/29/23 at 10:22 A.M., the surveyor observed the CNA approach Resident #87 to offer grooming care and he/she agreed. Resident #87 told CNA #1 that he/she had been picking at the [NAME] hair and doesn't want it. During an observation and interview on 6/29/23 at 12:20 P.M., the surveyor observed Resident #87 smiling brightly. Resident #87 said CNA #1 had showered and shaved him/her and that he/she now feels like a million bucks. During an interview on 6/29/23 at 12:23 P.M., Nurse Unit Manager #3 said if a resident refuses care the CNAs should tell the nurse who would reapproach the resident. Nurse Unit Manager #3 said that if after that they couldn't get the care done the nurse would document it. 43807 2a. Resident #40 was admitted to the facility in June 2022 with diagnoses including dysphagia (difficulty chewing and swallowing). Review of the most recent MDS assessment, completed in 6/9/23, indicated a BIMS of 4 out of 15 indicating severe cognitive impairment. During an observation and interview on 6/27/23 at 8:27 A.M., the surveyor observed the Resident propped up in bed eating breakfast on his/her own. The Resident asked the surveyor to help butter his/her biscuit. The Resident said no one helps him/her at meal times. Review of the Activities of Daily Living Care Plan (ADL), initiated 6/5/23, indicated the following: *Eating-continual supervision to assist Review of the Kardex Care Plan, initiated 6/29/23, indicated the following: *Eating-continual supervision to assist On 6/28/23 at 8:12 A.M., the surveyor observed Resident #40 in his/her room, propped up in bed eating breakfast on his/her own without supervision. On 6/28/23 at 12:15 P.M., the surveyor observed Resident #40 in his/her room, propped up in bed eating lunch on his/her own without supervision. During an interview on 6/28/23 at 12:18 P.M., CNA #6 said Resident #40 is independent with all his/her meals, so she drops off his/her tray and leaves the room. CNA #6 said if the Resident was continual supervision with assistance, she would have to stay in the room during the whole meal to cue him/her. During an interview on 6/28/23 at 12:21 P.M., Nurse #10 said Resident #40 is continual supervision with assistance at all meals, the CNAs should sit with the Resident and cue him/her during all meals. During an interview on 6/29/23 at 8:16 A.M., the Director of Nurses (DON) said that continual supervision with assistance means that Resident #40 should be supervised at all meals. 45343 2b. Resident #54 was admitted to the facility in March 2020 with diagnoses including dysphagia, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and cognitive communication deficits. Review of Resident #54's most recent MDS assessment, dated 5/25/23, indicated Resident #54 has a BIMS exam score of 6 out of 15, indicating severe cognitive impairment. The MDS further indicated Resident #54 requires extensive assistance of 1 person for eating. On 6/28/23 at 8:39 A.M., 6/29/23 at 8:41 A.M., and 6/29/23 at 8:53 A.M., the surveyor observed Resident #54 sitting up in bed eating breakfast. There was no staff present to supervise or assist Resident #54. During a record review on 6/29/23 at 6:39 A.M., the following was indicated: * Resident #54's care plan, dated as last revised on 5/18/23, indicated the following: Eating: Eats under continual supervision. * Resident #54's Kardex indicated Eating: Extensive assistance, one-person physical assist. During an interview on 6/29/23 at 7:47 A.M., Resident #54 said he/she never receives any assistance or supervision during his/her meals. During an interview on 6/29/23 at 8:16 A.M., the DON and the Administrator said the expectation for continual supervision with assist for meals is the staff would be in the room with the resident during meals and will provide cueing and/or assistance. During an interview on 6/29/23 at 8:58 A.M., Nurse #3 said Resident #54 can eat on his/her own after his/her meal tray is set up. 43882 2c. Resident #12 was admitted to the facility in August 2019 with diagnoses including dysphagia and dementia. Review of Resident #12's most recent MDS assessment, dated 5/18/23, indicated a BIMS score of 5 out of 15, indicating severe cognitive impairment. The MDS further indicated Resident #12 requires supervision/cueing while eating. On 6/27/23 at 7:55 A.M., the surveyor observed Resident #12 standing in a dining room alone feeding him/herself breakfast. On 6/28/23 at 8:55 A.M. and 9:02 A.M., the surveyor observed Resident #12 in a dining room alone eating breakfast unsupervised. Review of Resident #12's medical record indicated the following: * Care Plan, with a revision date of 6/24/22, indicated Resident #12 had a self-care performance deficit and required continue [sic] supervision to assist of 1 with eating. * Care Plan, with an initiation date of 11/22/22, indicated Resident #12 has a history of unplanned weight loss and to provide maximum assistance with eating at meals and snacks. During an interview on 6/29/23 at 7:48 A.M., CNA #7 said Resident #12 did not require supervision while eating. During an interview on 6/29/23 at 11:53 A.M., Nurse Unit Manager #2 said staff tries to keep Resident #12 within eye shot while eating. Nurse Unit Manager #2 said if the care plan says Resident #12 requires continuous supervision while eating then staff should be providing continuous supervision.

Based on observations, policy review, and interviews, the facility failed to store food in sanitary conditions, specifically, label and date leftover food items and dispose of food items after their use by date. Findings include: Review of the facility's policy titled 'Food Handling' indicated the following: *Foods that are prepared and not placed into service are considered unused portions. *Unused portions that have been properly handled, refrigerated, covered, labeled, and dated with use by dates or frozen and reheated and served according to the HACCP Food Flow Charts can be served by the use by date. *Foods that are marked with the manufacturer's use by date that are properly stored can be used until that date as long as the product has not been combined with any other food or prepared in any including portioning. Once a product has been prepared or portioned, a new use by date is established. Follow the use by dating guidelines (Appendix) to establish a new date. On 6/27/2023 at 7:19 A.M., the surveyor observed the following undated food items in the kitchen's refrigerator: *Leftover nectar milk *Leftover dessert *Leftover salad (brown in color) *Leftover macaroni salad On 6/27/2023 at 7:19 A.M., the surveyor observed the following labeled food items in the kitchen's refrigerator: *Leftover Tuna sandwiches labeled 3/26/23 During an interview on 6/27/23 at 7:39 A.M., Diet Aide #1 said all leftover food items should be dated and thrown out after three days. During an interview on 6/28/23 at 12:10 P.M., the Food Service Director said all leftover food items should be labeled and dated and disposed of within three days.

Based on observation and interview, the facility failed to provide a dignified existence for one Resident (#16), out of a total sample of 26 residents. Findings include: Resident #16 was admitted to the facility in May 2023 and had diagnoses that included Alzheimer's disease and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/24/23, indicated that on the Brief Interview for Mental Status exam Resident #16 scored a 6 out of 15, indicating severe cognitive impairment. The MDS further indicated Resident #16 requires one person physical assistance with Activities of Daily Living (ADLs). During an interview on 6/27/23 at 7:50 A.M., Resident #16 said that he/she had been wearing the same underwear for four days and that his/her butt is itchy and sticky. Resident #16 said he/she had complained to all the Certified Nursing Assistants (CNAs) each day for four days and that the CNAS have told Resident #16 that he/she has no underwear with his/her name on them. On 6/27/23 at 7:56 A.M., the surveyor overheard Resident #16 tell a CNA that he/she had been wearing the same underwear for four days and that his/her butt is itchy and sticky. The CNA responded, but you do not have anymore (underwear). The CNA then offered to shower Resident #16 and he/she agreed. During an interview on 6/27/23 at 8:16 A.M., Resident #16 told the surveyor the CNA put him/her in a diaper after the shower. During a record review the following was indicated: * Resident #16's Kardex (resident specific care instructions) indicated Resident #16 required extensive one person physical assistance with personal hygiene and dressing. * The Certified Nursing Assistant Behavior Monitoring and Interventions documentation for the month of June failed to indicate Resident #16 had any behaviors. During an interview with Resident #16's CNA (#1) on 6/29/23 at 10:16 A.M., CNA #1 said that Resident #16 had been complaining since last week that he/she had no underwear but they looked and couldn't find them, so we are putting a diaper on him/her, but he/she doesn't like it. CNA #1 said that Resident #16 was continent and should wear underwear. During an interview on 6/30/23 at 7:38 A.M., Social Worker #1 said that she was not aware that Resident #16 was missing underwear and that if she had been she would have provided Resident #16 with underwear, adding so that he/she would not have to wear a diaper. During an interview on 6/30/23 at 8:18 A.M., the Nursing Home Administrator (NHA) said that Resident #16 should not have to wear a diaper as the resolution to missing underwear; that's a dignity issue. The NHA said that if she or the social worker had been made aware that Resident #16 did not have underwear, the first day it was identified, the facility would have ensured Resident #16 was provided with underwear to wear, not a diaper.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who during December 2022 was noted to have increased pain during rehabilitation therapy session which continued to worsen over several days, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice, when despite Rehabilitation Staff reporting to nursing multiple days in a row that Resident #1 was exhibiting and complaining of pain, including screaming and yelling out in pain during some of his/her therapy sessions, Resident #1 was not assessed by nursing related to his/her new onset of acute pain. On 12/27/22, an x-ray of Resident #1's left femur (bone of upper leg) was obtained revealing he/she had a displaced subcapital femoral neck fracture (fracture line extends through the junction of the head and the neck of the bone) and he/she required hospitalization for surgical intervention to repair the fracture. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of Facility Policy titled, Pain Assessment and Management, undated, indicated that the pain program is based on a facility-wide commitment to resident comfort. The Policy also indicated the following; -Conduct a comprehensive pain assessment upon admission to the facility; -Upon quarterly review; -When there is a significant change in condition; -When there is onset of new pain or worsening of existing pain; and -Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. Resident #1 was admitted to the Facility in January 2022, diagnoses included dementia, diabetes mellitus, adult failure to thrive, osteoarthritis of knees, and legal blindness. Review of Resident #1's Health Care Incapacitation Form, dated 2/02/22, indicated his/her Health Care Proxy (HCP) had been activated, and his/her Health Care Agent (HCA) was making his/her health care decisions. Review of Resident #1's Facility Incident Report, dated 12/09/22, indicated he/she was being moved forward in his/her wheelchair by another resident (later identified as a guest of a resident), when Resident #1 placed his/her feet on the ground and tipped forward (falling out of the wheelchair) onto the floor on his/her left side. The Report indicated Resident #1 did not complain of pain at the time of the incident. Review of Resident #1's Nurse Progress Note, dated 12/11/22, indicated he/she complained of pain in both legs, the Nurse Practitioner (NP) was made aware and a physicians order was obtained to complete x-rays of both knees and both hips. Review of Resident #1's x-ray results dated 12/11/22, indicated both knees showed osteoarthritis with no fracture and the bilateral hip x-ray showed mild degenerative changes, no fracture, and to consider cross-sectional imaging to better evaluate. Review of Resident #1's Physical and Occupational Therapy Progress Notes, dated 12/16/22 through 12/22/22 indicated the following; -12/16/22, while working with occupational therapy Resident #1 complained of left hip/knee pain during treatment, nursing notified (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M. ); -12/19/22, while working with occupational therapy Resident #1 complained of left lower extremity pain, nursing made aware (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.); -12/20/22, while working with occupational therapy Resident #1 complained of pain above the left knee, nursing aware (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.) ; -12/21/22, while working with physical therapy Resident #1 complained of left thigh pain throughout standing trials this session, communicated with nursing (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.); and -12/22/22, while working with occupational therapy Resident #1 complained of above the knee pain, he/she was screaming and yelling when putting weight on left lower extremity, nursing made aware (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M. and 3:00 P.M. 11:00 P.M.). Review of Resident #1's Physical Therapy (PT) Discharge Summary Report, dated 12/24/22, indicated PT was discontinued (last treatment date 12/22/22) secondary to his/her inability to participate related to complaints of left leg pain. Review of Resident #1's Occupational Therapy (OT) Discharge Summary Report, dated 12/26/22, indicated OT was discontinued (last treatment date 12/22/22) secondary to Resident exhibiting a change in medical status. Review of Resident #1's Medical Record, indicated there was no documentation to support that nursing staff performed the following; -Assessed Resident #1 at any time with each notification of complaints and evident signs of new and acute pain as reported by therapy staff; -Notified his/her physician of new and acute pain; -Followed up with the physician regarding the recommendation on the 12/11/22 x-ray report to consider cross sectional imaging to better evaluate; or -Administered pain medication per physicians orders for his/her complaints of pain. During an interview on 4/12/23 at 1:16 P.M., Nurse #1 said that the rehabilitation department staff had reported Resident #1's pain to her but said Resident #1 could be behavioral and complained at times. Nurse #1 said she does not remember what days or at what times therapy reported Resident #1's complaints of pain to her, but said she was not aware that Resident #1 was screaming and yelling in pain while working with therapy. Review of Resident #1's Medication Administration Record (MAR), dated December 2022, indicated there was no documentation to support nursing staff monitored his/her pain each shift. Nurse #1 said upon admission a standing order is added to each resident's Medication Administration Record (MAR) that they should be assessed by nursing every shift for signs and symptoms of pain and the results need to be documented on the MAR by nursing staff. Nurse #1 said Resident #1 did not have an order entry on his/her MAR to monitor pain every shift, but he/she should have. During an interview on 4/12/23 at 1:54 P.M., the Director of Nurses (DON) said she did realize that Resident #1's MAR did not include an order to monitor his/her signs and symptoms of pain every shift, or a place on the MAR for nursing to document their findings. The DON also said that some of Resident #1's scheduled weekly pain assessments had not being completed. The DON said it was the Facility's expectation that nursing staff monitor each resident every shift for signs and symptoms of pain, (chronic, new, and acute), medicate each resident as order by their physician for pain, and notifying the physician with any new findings. Review of Resident #1's Nursing Progress Note dated 12/27/22, indicated he/she was confused, combative, and resistive to care, nursing staff informed his/her Physician of the change in his/her pain and a physician's order was obtained to repeat the x-ray of Resident #1's left leg (16 days after the original x-ray was performed). Resident #1 was found to have a fracture of his/her left leg, and he/she was transported and admitted to the Hospital, as he/she required surgical intervention to repair the fracture.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who on 12/09/22 had experienced a fall from his/her wheelchair, the Facility failed to ensure that after Rehabilitation Staff reported to nursing about a week after his/her fall, for multiple days in a row that Resident #1 complained of pain during his/her rehabilitation therapy sessions, that he/she had screamed and yelled out in pain during therapy, that nursing adequately assessed and managed his/her pain. On 12/27/22, an x-ray of Resident #1's left femur (bone of upper leg) was obtained revealing he/she had a displaced subcapital femoral neck fracture (fracture line extends through the junction of the head and the neck of the bone) and he/she required hospitalization for surgical intervention to repair the fracture. Findings include: Review of the Facility Policy, titled Pain Assessment and Management, undated, indicated that the pain program is based on a facility-wide commitment to resident comfort. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his/her clinical condition and treatment goals. The Policy further indicated the following; -Perform a new pain assessment when there is an onset of new pain or worsening of existing pain; -Assess the resident's pain at least each shift for acute pain or significant changes in levels of chronic pain; -Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain; -Verbal expressions such as groaning, crying, screaming; -Behaviors such as resisting care, irritability, depression, decreased participation in usual activities; -Limitations in his/her level of activity due to presence of pain; -Insomnia; -Ask the resident if he/she is experiencing pain; and -Review the Medication Administration Record (MAR) to determine how often the resident requests and receives pain management and to what extent the administered medications relieve the resident's pain. Resident #1 was admitted to the Facility in January 2022, diagnoses included dementia, diabetes mellitus, adult failure to thrive, osteoarthritis of knees, and legal blindness. Review of Resident #1's Health Care Incapacitation Form, dated 2/02/22, indicated his/her Health Care Proxy (HCP) had been activated, and his/her Health Care Agent (HCA) was making his/her health care decisions. Review of Resident #1's Facility Incident Report, dated 12/09/22, indicated he/she was being moved forward in his/her wheelchair by another resident (later identified as a guest of a resident), when Resident #1 placed his/her feet on the ground and tipped forward (falling out of the wheelchair) onto the floor on his/her left side. The Report indicated Resident #1 did not complain of pain at the time of the incident. Review of Resident #1's Nurse Progress Note, dated 12/11/22, indicated he/she complained of pain in both legs, the Nurse Practitioner (NP) was made aware and a physicians order was obtained to complete x-rays of both knees and both hips. Review of Resident #1's Medication Administration Record (MAR), dated 12/11/22, indicated at 4:20 P.M., he/she was administered Tylenol 325 milligram (mg) two tablets (for a total of 650 mg) for complaints of pain in both legs. Review of Resident #1's Physicians Orders, dated 12/11/22, indicated he/he was to have an x-ray of both of his/her hips and both knees. Review of Resident #1's x-ray results dated 12/11/22, indicated both knees showed osteoarthritis with no fractures and the bilateral hip x-ray showed mild degenerative changes, no fracture, and consider cross-sectional imaging to better evaluate. Review of Resident #1's Care Plan related to pain, indicated he/she was at risk for pain secondary to physical disabilities and diabetic neuropathy. The Care Plan goals indicated that Resident #1 would be free from pain through the next review date and approaches for Resident #1 included the following; -Anticipate the Resident's need for pain relief and respond immediately to any complaints of pain; -Monitor, record, and report to nurse any signs and symptoms of non-verbal pain; changes in breathing, vocalizations such as moaning, grunting, and yelling out; behaviors such as restless, aggressive, and irritable; -Monitor, record, and report to nurse resident complaints of pain or request for pain medication; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from the residents past experience; and -Complete a pain assessment quarterly and as needed. Review of Resident #1's Medication Administration Record (MAR), for December 2022, indicated he/she had an active physicians order for Tylenol Tablet 325 milligrams (mg), give two tablets by mouth every four hours as needed for pain. Review of Resident #1's Physical and Occupational Therapy Progress Notes, dated 12/16/22 through 12/22/22 indicated the following; -12/16/22, while working with occupational therapy Resident #1 complained of left hip/knee pain during treatment, nursing notified (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M.); -12/19/22, while working with occupational therapy Resident #1 complained of left lower extremity pain, nursing made aware (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M. and 3:00 A.M. to 11:00 P.M.); -12/20/22, while working with occupational therapy Resident #1 complained of pain above his/her left knee, nursing aware (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.) ; -12/21/22, while working with physical therapy Resident #1 complained of left thigh pain throughout standing trials this session, communicated with nursing (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.); and -12/22/22, while working with occupational therapy Resident #1 complained of above the knee pain, he/she was screaming/yelling when putting weight on left lower extremity, nursing made aware (reported to Nurse #1 who worked 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.). Review of Resident #1's Medical Record, indicated there was no documentation to support that nursing staff performed the following according to the Facility Policy to address or help alleviate Resident #1; -Assessed Resident #1 at any time with each notification of complaints and evident signs of new and acute pain reported by therapy staff; -Notified his/her physician of new and acute pain; -Followed up with the physician regarding the x-ray recommendation to consider cross sectional imaging to better evaluate; -Performed a Pain Assessment quarterly and with each change in pain symptoms (per medical record his/her last Pain Assessment was completed on 4/28/22) -Administered pain medication per his/her physicians orders, related to complaints of pain Review of Resident #1's MAR, dated for the month of December, 2022, indicated that on 12/18/22, Resident #1 received his/her only dose of Tylenol despite the reports of continued and worsening pain reported to nursing staff from the rehabilitation staff on multiple occasions from 12/16/22 through 12/22/22. Further review of the MAR indicated there was no documentation to support Resident #1 was assessed every shift for pain by nursing staff. During an interview on 4/12/23 at 1:16 P.M., Nurse #1 said that the rehabilitation department staff had reported Resident #1's complaints of pain to her, but she does not recall when. Nurse #1 said Resident #1 could be behavioral and complained at times. Nurse #1 said she was not aware that he/she was screaming/yelling out in pain with therapy. During an interview on 4/12/123 at 1:07 P.M., the Unit Manager said she was not aware that Resident #1 was complaining of pain and said she would have called the Physician services to notify them about the change in his/her pain symptoms. Review of Resident #1's Nursing Progress Note dated 12/27/22, indicated he/she was confused, combative, and resistive to care, nursing staff informed his/her Physician of the change in his/her pain and a physician's order was obtained to repeat the x-ray of Resident #1's left leg (16 days after the original x-ray was performed). Resident #1 was found to have a fracture of his/her left leg, he/she transported and admitted to the Hospital, as he/she required surgical intervention to repair the fracture. During an interview on 4/12/23 at 1:54 P.M., the Director of Nurses (DON) said she did not realize that Resident #1 had been complaining or exhibiting signs and symptoms of pain with therapy. The DON said it was the Facility's expectation that nursing staff assess each resident every shift for signs and symptoms of pain, inform the Physician of any changes in pain, and administer medication as ordered to maintain comfort.

Based on observations, interview, record review, and policy review, the facility failed to recognize, re-evaluate and ensure treatment was provided to manage signs and symptoms of pain for one Resident (#66), out of a total sample of 21 residents. This failure resulted in a delay in addressing pain in a resident with advanced dementia, who is unable to make his/her needs known. Findings include: Review of the facility's policy, Pain Management (undated), indicated, but is not limited to: -It is the policy of the facility to recognize and treat pain promptly in order to maintain the comfort level of our residents -Pain assessments will be done on admission and re-admission, quarterly, and upon any new onset or change in current pain level Standards: -Recognize and treat pain promptly -Promise residents adequate and prompt analgesic care Clinical Approaches: -Assess pain systematically -Deliver interventions in a timely, logical, and systematic fashion Assessment: -Pain is assessed by location, intensity, quality, duration, and frequency -Factors that should be considered when assessing: depression, cognitive status -Behavioral cues that can be indicative of pain: Grunting, increased activity, groaning, rocking, twitching, crying, calling out -Objective Reports of pain: non-verbal/cognitively impaired residents require the use of objective data. Use of facial expression and a scale to indicate the intensity. Documentation: -Pain Assessment sheets -Pain Flow Sheets with Wong-Baker scale for documentation of pain and to monitor for effectiveness and response of pain treatment -Nursing progress notes to be written with each new sudden onset of pain describing location, quality, duration, interventions, and outcomes Resident #66 was admitted to the facility with diagnoses including dementia and arthritis. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #66 had severely impaired cognitive skills for daily decision making, exhibited no behaviors, required extensive assistance/dependence on staff for activities of daily living, was on a pain management program, and received hospice services. The Resident was unable to participate in a pain assessment interview, and the staff assessment for pain indicated that Resident #66 did not exhibit any non-verbal indicators of pain, or possible pain in the review period. Review of April 2021 physician's orders indicated Resident #66's pain medication regimen as follows: -Tramadol 25 milligrams (mg) three times daily for pain (initiated 2/15/21) -Tylenol 325 mg, give two tablets every six hours as needed for mild pain (initiated 1/27/21) Review of the medical record indicated an interdisciplinary care plan for pain, initiated 9/24/20, that includes, but is not limited to: Focus: Resident has potential for pain related to arthritis Goal: Resident will be pain free through next review date Interventions: -Administer pain medication as ordered -Anticipate resident's need for pain relief and respond immediately -Monitor/record/report to nurse any sign/symptom of non-verbal pain: vocalizations (grunting, moans, yelling out), restless, squirmy, constant motion, crying -pain assessment quarterly and as needed On 4/27/21 at 1:45 P.M., the surveyor observed Resident #66 in his/her room seated in a Broda chair (positioning chair). The Resident was moaning, crying, restless, and was repeatedly lifting his/her legs and arms up and down. Review of the Medication Administration Record (MAR) and nursing progress notes indicated that Resident #66 had been administered Tylenol 650 mg at 12:47 P.M. At 2:04 P.M., the effectiveness of the pain medication was documented: Unknown. On 4/28/21 at 12:30 P.M., the surveyor observed Resident #66 in his/her room seated in a Broda chair (positioning chair). The Resident was positioned diagonally in the chair, with his/her head leaning on the upper left portion of the chair, and his/her right foot dangling off the right side of the foot support. The Resident was crying, moaning, restless, and was reaching for his/her groin area. The Resident appeared to be writhing in the chair and attempting to reposition him/herself. On 4/28/21 at 12:45 P.M., the surveyor observed Unit Manager #1 standing next to Resident #66 holding his/her hand as he/she sat in the Broda chair. The Resident was crying, writhing in the chair, and reaching for his/her groin area. The Resident appeared to be continuously attempting to reposition him/herself. The surveyor asked the Unit Manager if she felt that the movements the Resident was doing indicated that the Resident was in pain. The Unit Manager said, No, and that Resident #66 cries frequently because he/she misses his/her dead spouse. The Unit Manager said that she knows the Greek word for pain, and when she asks the Resident, he/she always says no. During an interview on 4/28/21 at 2:00 P.M., Unit Manager #1 said that following the surveyor's inquiry about the Resident's behavior, she contacted the Hospice Nurse. The Hospice Nurse recommended an increase in the Resident's Tramadol from 25 mg three times a day to 50 mg three times day, and said she would assess the Resident's chair for increased comfort at her next visit. The Unit Manager said that she contacted the Nurse Practitioner (NP), who approved the recommendation to double the dose in pain medication. Review of the medical record failed to indicate that the Unit Manager, Hospice nurse, or NP conducted an assessment to determine the cause of the Resident's pain, or conducted a physical assessment of the Resident's body. Review of the comprehensive care plans identified that the Resident would cry, but failed to indicate that the Resident had behaviors of writhing, wriggling, or lifting his/her legs up and down. Further review of the medical record failed to indicate that Resident #66 exhibited behaviors of writhing, wriggling, or lifting his/her legs up and down. Following the increase in pain medication, the surveyor made the following observations: On 4/29/21 at 8:24 A.M., Resident #66 was lying in bed sleeping. The Resident appeared comfortable, and was not crying, writhing, or wriggling in bed. On 5/4/21 at 11:37 A.M., Resident #66 was seated in a reclined position in his/her Broda chair. The Resident was awake and appeared comfortable, and was not crying, writhing, or trying to reposition him/herself in the chair. On 5/5/21 at 12:35 P.M., 12:52 P.M., and 1:26 P.M., Resident #66 was lying in bed awake. The Resident appeared comfortable, and was not crying, writhing, or wriggling in bed.

Based on record review and interview, the facility failed to 1. Identify and address a significant weight loss for 1 Resident (#6) and 2. Implement interventions to prevent a significant weight loss for 1 Resident (#56) out of total of 26 sampled residents. Findings include: Review of the facility policy titled Weighing and Measuring the Resident dated 2001 and revised in (MONTH) 2011 indicated the following: -Report significant weight loss/weight gain to the nurse supervisor. -The threshold for significant and unplanned and undesired weight loss/gain will be based on the following criteria: -1 month-5% weight loss is significant, greater than 5% is severe -3 months-7.5% weight loss is significant, greater than 75% is severe -6 months-10% weight loss is significant, greater than 10% is severe Review of the facility policy titled Weight Assessment and Intervention undated indicated the following: -Resident weights are an important indicator of nutritional and overall health status. All residents will be weighed on admission and at least weekly unless otherwise ordered by the physician. -Any weight change of greater than 3 pounds between consecutive weekly weights and 5 pounds between consecutive monthly weights necessitates a re-weight within 24 hours, with the licensed staff present to verify information. -If a weight loss meets the definition of significant, the physician and health care proxy (as appropriate) will be notified. -Interventions for undesirable weight loss should focus first on food (extra food, snacks, calorie-dense food, etc.). Liquid nutritional supplements may be considered if resident caloric intake remains inadequate to stabilize or increase weight. Interdisciplinary team members should consider possible interventions relevant to their discipline. The physician may order tests, appetite stimulants, or medications as appropriate. 1. For Resident #6, the facility failed to identify and address a significant weight loss. Resident #6 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of Resident #6's annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #6 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderate cognitive impairment. During an interview with Resident #6 on 10/9/19 at 11:18 [NAME]M., he/she said he/she had lost almost 10 pounds (lbs) since last month, and he/she does not like the food at times, but should be eating more. Review of Resident #6's medical record indicated he/she had a height of 61 inches. On 10/9/19 at 12:40 P.M., the surveyor reviewed Resident #6's Weight Summary in his/her medical record. The Weight Summary indicated the following: -7/1/19: 88.0 lbs. -8/1/19: 88.0 lbs. -9/1/19: 90.1 lbs. -10/1/19: 81.8 lbs. The resident sustained [REDACTED]. Further, based on Resident #6's height and weight on 10/1/19, his/her Body Mass Index (BMI) was 15.5, indicating the resident was underweight. Further review of Resident #6's Weight Summary failed to indicate a re-weight was obtained within 24 hours per facility policy. Review of Resident #6's physician's orders indicated the following: -An order dated 2/6/19 for regular diet with ground texture, thin liquids, and fortified foods. -An order dated 2/6/19 for house supplements twice daily at lunch and dinner. -An order dated 2/6/19 for liquid protein 30 ml by mouth daily. Review of Resident #6's Quarterly Nutritional assessment dated [DATE] indicated the following: -Significant weight loss: Requested reweigh - 8 pounds weight loss this month. -Usual percentage of meal intake/meal patterns: 50-75% of meals -Comments/Recommendations: Weight recorded indicative of significant weight loss - requested re-weigh. -Supplements in place to promote intake, D/C liquid protein - skin intact resident often refuses, Registered Dietician to follow. Review of Resident #6's nursing progress notes for 10/2019 failed to identify Resident #6's significant weight loss or if a re-weigh was obtained after 10/1/19. The progress notes also failed to indicate if Resident #6's physician was informed of the weight loss. Review of Resident #6's physician's progress notes failed to indicate that the MD was aware of Resident #6's weight loss. Review of Resident #6's care plans indicated that Resident #6 had a nutritional problem due to below Ideal Body Weight (IBW) and need for mechanical soft diet. During an interview with Unit Manager #4 on 10/10/19 at 10:52 [NAME]M., she said the residents' weights on the unit are obtained by the Certified Nursing Assistants (CNA) and recorded on a weight sheet and then she transcribes the weights into the electronic health record. Review of the CNA weight sheet failed to indicate a re-weigh to verify the weight change on 10/1/19 was obtained per policy. During an interview with Unit Manager #4 on 10/10/19 at 10:55 [NAME]M., she said she was not aware that Resident #6 had a weight loss, despite entering the weight in the electronic medical record. She said the Dietician will tell her if a re-weigh is needed or a weight loss has occurred. She said she was unaware of the Dietician's recommendations from 10/7/19 to re-weigh Resident #6 or to discontinue the liquid protein. She said significant weight losses should be reported to the physician. She said a re-weigh should have been obtained to verify if the resident sustained [REDACTED]. During an interview with Unit Manager #4 on 10/10/19 at 11:55 [NAME]M., she said the staff obtained a re-weigh for Resident #6 today. She said that Resident #6's current weight was 83 pounds, indicating a 7.1 pound (7.8%) significant weight loss from 9/1/19. During an interview with the Dietitian on 10/11/19 at 12:43 P.M., she said the re-weigh for Resident #6 should have been obtained within 24 hours of the weight obtained on 10/1/19. She said she wrote a recommendation to obtain a re-weigh in her assessment of Resident #6 on 10/7/19 so she could better assess the resident's nutritional status, and nursing should have seen the recommendation in the electronic health record. She also said the physician should have been notified when the weight loss was discovered. During an interview with Unit Manager #4 on 10/11/19 at 1:24 P.M., she said she did not notify the Dietician or physician after verifying Resident #6 sustained a weight loss with the re-weigh performed on 10/10/19. 2. For Resident #56, the facility failed to implement interventions in response to an identified severe weight loss. Resident #56 was admitted to the facility in 8/2019 with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set Assessment ((MDS) dated [DATE] indicated that Resident #56 was unable to complete the Brief Interview for Mental Status Assessment and had moderate cognitive impairment. The MDS also indicated that Resident #56 required assistance with bed mobility, ambulation and bathing, and was independent with eating. Review of Resident #56's Weight Loss Care Plan, initiated 8/21/19, indicated the following: Goal: Resident #56 will continue to consume at least 50% of meals and snacks through review date. Interventions: -Encourage fluid intake with meals and in between meals. 8/21/19 -Meal setup and monitor tolerance of diet. 8/21/19 -Obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as indicated. 8/21/19 -Obtain weekly weights x 4 weeks and monthly if stable. Add to weekly weight report 9/3. 8/21/19, revised 9/3/19 -Offer diabetic snack at bedtime. 8/21/19 -Provide and serve HCC diet as ordered. 8/21/19 -Dietitian to evaluate and make diet changes and recommendations PRN (as needed). 8/21/19 -Recommend Glucerna 120ml x2 daily, fortified foods. 9/3/19, revised 9/25/19 Review of Resident #56's weights indicated the following: 8/19/19 135 lbs. (pounds) 8/20/19 133.4 lbs. 8/26/19 134 lbs. 8/27/19 133.6 lbs. 8/28/19 133.2 lbs. 9/2/19 126 lbs. (a severe weight loss of 6.7% of his/her total body weight in less than 30 days) Review of the Dietitian's note dated 9/3/19 indicated that Resident #56 had been hospitalized (8/21/19-8/25/19 due to a gastro-intestinal bleed) and that Resident #56's intake was poor. The Dietitian recommended the use of Glucerna (a supplement) 120 ml twice a day. Review of Resident #56's Medication Administration Record [REDACTED]. Review of the clinical record indicated that Resident #56 was hosptalized on [DATE], (two days after starting the Glucerna) and returned to the facility on [DATE]. Upon his/her return to the facility, Resident #56 did not have an order to continue his/her supplements. Additional Review of Resident #56's weights indicated the following: 9/18/19: 124 lbs. 9/19/19: 123.8 lbs. 9/20/19: 123 lbs. 9/25/19: 122.6 lbs. (a severe weight loss of 9.91% of his/her body weight since 8/19/19) Review of the Dietitian progress notes indicated the following: 9/18/19: Resident #56 was discussed during weekly risk meeting. Resident #56 returned from the hospital last night, awaiting admission weight. Will continue with weekly weights for unplanned weight loss prior to discharge. Supplements in place. (Per the MAR, Resident #56 was not receiving any supplements upon his/her return to the facility on [DATE].) 9/25/19: Resident #56 was discussed during weekly risk meeting. His/her weight was 123 lbs. Intakes fair to poor. Recommend starting Glucerna 120 ml 3 times a day, fortified food 3 times a day. RD to follow. Review of Resident #56's physician's orders indicated an order dated 9/30/19 for Glucerna, 2 times a day. The order was written 5 days after the Dietitian's recommendation for the use of Glucerna for 3 times a day on 9/25/19. On 10/11/19 at 8:00 [NAME]M., the surveyor observed Resident #56 eating breakfast in his/her room. He/she appeared thin and frail. Review of Resident #56's meal slip did not indicate that he/she receives fortified foods with his/her meals. During an interview with the Food Service Director (FSD) on 10/11/19 at 8:31 [NAME]M., he reviewed Resident #56's meal slip and confirmed that Resident #56 does not receive fortified food with meals. The FSD said that when a resident's diet changes, the dietary department receives a notification slip from the nursing department. The FSD said he did not receive any slips indicating that Resident #56 was to have fortified foods with meals. Review of the diet book failed to indicate that a diet change slip was completed and sent to the dietary department. Additional review of Resident #56's weights indicated the following: 10/2/19: 119 lbs. 10/5/19: 113 lbs. (a significant weight loss of 8.9% of his/her body weight since his/her return from the hospital without the supplements and additional Dietitian's recommendations) Review of the clinical record failed to indicate that the Dietitian was alerted to Resident #56's continued weight loss or if additional interventions were put in place to address the weight loss. During an interview with CNA #2 on 10/11/19 at 9:18 [NAME]M., she said that Resident #56 had had poor intake since his/her admission to the facility. CNA #2 said that Resident #56's weights varied and the scale used to weigh Resident #56 has been consistent. During an interview with the physician on 10/11/19 at 9:25 [NAME]M., he said that he was aware of Resident #56's weight loss. He said that when a resident loses weight, he is notified by the nursing staff of recommendations made by the Dietitian and will then write orders based on those recommendations. During an interview with the Assistant Director of Nursing (ADON) on 10/11/19 at 9:28 [NAME]M., she said that she was the covering unit manager on Resident #56's unit. She said that Resident #56's initial orders for Glucerna dropped off when Resident #56 was in the hospital and it was not reinstated upon his/her return to the facility. The ADON could not say why the Dietitian's recommendations for Resident #56 to receive fortified food with meals and Glucerna 3 times a day were not implemented. During an interview with the Dietitian on 10/11/19 at 12:33 P.M., she said that when she makes recommendations to address a resident's weight loss, the nursing department then relays those recommendations to the physician or the dietary department. She said that she was not aware that Resident #56 was not receiving fortified meals or supplements as recommended.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility refused to readmit Resident #1 on 11/24/18 following an evaluation at the hospital and on 11/27/18 the Facility issued a Notice of its intention to discharge Resident #1 to the Hospital with less than thirty days' notice. The Hospital boarded Resident #1 in the emergency department for 5 days until the Facility rescinded its Discharge Notice and allowed Resident #1 to return. Findings included: The Transfer and Discharge Notice Policy indicated that the Facility shall provide a resident with thirty days written notice of an impending transfer or discharge except in limited circumstance. Resident #1 was admitted to the Facility eleven months before the Survey following a [MEDICAL CONDITION] (TBI). Resident #1's most-recent Minimum Data Set (MDS) Assessment Form completed 8/28/18 indicated that Resident #1's cognitive patterns were moderately impaired. Resident #1's care plan concern initiated during (MONTH) (YEAR) indicated Resident #1 had the potential for verbal and physical aggression and poor impulse control and interventions included leaving Resident #1 alone when he/she was angry because he/she preferred to be left alone. Resident #1 was hospitalized at the time of the Survey. The Progress Note, dated at 8:15 P.M. on 11/24/18, indicated that Resident #1 threw a ceramic plate on the floor and lunged at, punched, and grabbed the neck of Nurse #1. The Surveyor called Nurse #1 on 11/30/18, 12/12/18 and 12/19/18. Although Nurse #1 left a voicemail for the Surveyor on 12/13/18, the Surveyor could not reach Nurse #1 for an interview. Nurse #1's written statement dated 8:15 P.M. on 11/24/18 indicated that at 6:15 P.M., Resident #1 approached her gesturing aggressively with his/her dinner plate and threw his/her plate to the floor. Nurse #1's written statement indicated Resident #1 lunged at her and punched the right side of her jaw, grabbed her by the neck and punched her repeatedly in the back of the head. Nurse #1's written statement indicated that the Volunteer and Nurse #2 pulled Resident #1 off her and the police and emergency medical services transported Resident #1 to the hospital. The Surveyor interviewed the Volunteer at 12:00 P.M. on 11/29/18. The Surveyor interviewed Nurse #2 at 1:30 P.M. on 12/1/18. The Volunteer and Nurse #2 said Resident #1 punched Nurse #1 and they pulled Resident #1 away from her. The Surveyor interviewed the Nurse Supervisor at 11:15 A.M. on 11/29/18. The Nurse Supervisor said that she spoke to Nurse Practitioner #1 on 11/24/18 and received an order to transfer Resident #1 to the hospital for an evaluation. The Expedited Notice of Transfer of Discharge indicated that on 11/24/18 the Facility transferred Resident #1 to the hospital. The Notice did not indicate a reason for the transfer. The Bed Hold Policy and Notice indicated that Resident #1's bed at the Facility would be held for Resident #1 until 12/14/18. The Nurse Supervisor said that the hospital staff called the Facility on 11/24/18 and 11/25/18 and stated that Resident #1 was ready to return to the Facility. The Nurse Supervisor said that she discussed Resident #1's return to the Facility by telephone with the Director of Nurses and told the hospital staff that she and the Director of Nurses did not feel safe having Resident #1 return to the Facility over the weekend. The Surveyor interviewed the Director of Behavioral Admissions at the Hospital at 12:30 P.M. on 11/30/18. The Director of Behavioral Admissions said that the hospital psychiatrically evaluated Resident #1 in the emergency department on 11/24/18, 11/25/18 and 11/26/18. The Director of Behavioral Admissions said that the three psychiatric evaluation determined that Resident #1 did not require hospitalization and hospital staff contacted the Facility about Resident #1's return. The Director of Admissions said that initially the Facility staff told hospital staff they did not feel comfortable with Resident #1 returning to the Facility over the weekend. The Director of Behavioral Admissions said that she contacted Facility administration after the third psychiatric evaluation on 11/26/18 and told the Director of Nurses and Administrator that Resident #1 did not require hospitalization and was ready to return to his/her bed at the Facility. The Director of Behavioral Admissions said that the Director of Nurses and Administrator told her that they would not accept Resident #1 back to the Facility and on 11/27/18 the Facility faxed a Discharge Notice to the Hospital. The Director of Behavioral Admissions said Resident #1 had no changes to his/her plan of care while in the emergency department and had been cooperative and without behavioral symptoms. The Expedited Notice of Transfer or discharge date d 11/27/18 indicated that the Facility notified Resident #1 and Family Member #1 of the Facility's intention to discharge Resident #1 to the Hospital effective 11/25/18 because Resident #1 endangered the health and safety of individuals in the Facility. The Surveyor interviewed Nurse Practitioner #1 at 1:00 P.M. on 12/12/18. Nurse Practitioner #1 said that she gave the order to transfer Resident #1 to the hospital for evaluation on 11/24/18. Nurse Practitioner #1 said the Facility staff did not discuss with her their intention to discharge Resident #1 to the hospital. The Surveyor interviewed Physician #1 at 12:30 P.M. on 12/11/18. Physician #1 said that he heard that Resident #1 was evaluated at the hospital and the Facility did not want to allow Resident #1 to return to the Facility. Physician #1 said that he was not contacted by the Administrator or the Director of Nurses about documenting the specific needs Resident #1 had which the Facility could not meet, the Facility's efforts to meet those needs and the specific services the hospital provided to meet the needs of Resident #1 which could not be met at the Facility The Surveyor interviewed the Director of Nurses and the Administrator at 9:00 A.M. on 11/29/18. The Director of Nurses said that the Nurse Supervisor told her that Resident #1 was evaluated at the Hospital following the incident in which Resident #1 assaulted Nurse #1 on 11/24/18 and the hospital called on 11/24/18 and 11/25/18 and asked to send Resident #1 back to the Facility. The Director of Nurses said that she told the Nurse Supervisor that Resident #1 could not come back into the Facility because the Facility was going to look into issuing Resident #1 a Notice of Discharge on 11/26/18. The Administrator said that the Notice of Discharge was issued to Resident #1 on 11/27/18 with a discharge date of [DATE]. The Administrator and Director of Nurses said that they spoke with Hospital staff on 11/26/18, 11/27/18 and 11/28/18 and told Hospital staff that the Facility would not accept Resident #1 back. The Hospital Director of Behavioral Admissions said that after receiving the Notice of the Facility's intention to discharge Resident #1 to the hospital she and Hospital leadership staff had multiple phone calls with Facility leadership. The Director of Behavioral Admissions said that on 11/28/18, the Facility Administrator told her that the Facility would accept Resident #1's return on 11/29/18. The Director of Behavioral Admissions said that although the Facility ultimately accepted Resident #1 back, Resident #1 was forced to board unnecessarily in the hospital emergency department for 5 days when the Facility refused to respect his/her right to return to the Facility following his/her evaluation at the Hospital.

Based on interviews and records reviewed, for one of three sampled Residents (Resident #1), the Facility failed to ensure that Nurse #1 provided care in accordance with Resident #1's care plan. At 6:15 P.M. on 11/24/18, Nurse #1 moved toward Resident #1 after he/she became angry and agitated and Resident #1 punched Nurse #1 repeatedly and scratched her neck. Following the incident, the Facility transferred Resident #1 to the hospital emergency department and refused to allow him/her to return to the Facility for 5 days. Findings include: Resident #1 was admitted to the Facility eleven months before the Survey following a [MEDICAL CONDITION] (TBI). Resident #1's most-recent Minimum Data Set (MDS) Assessment Form completed 8/28/18 indicated that Resident #1's cognitive patterns were moderately impaired. The MDS indicated Resident #1 did not exhibit behavioral symptoms. Resident #1's care plan concern initiated during (MONTH) (YEAR) indicated that his/her cognitive function and thought processes were impaired and interventions included providing Resident #1 with necessary cues and stopping and returning when agitated. Resident #1's care plan concern most recently revised during (MONTH) (YEAR) indicated that Resident #1 exhibited episodes of verbal outburst and interventions included encouragement, support and maintaining safety and re-approaching when difficult to redirect. Resident #1's care plan concern initiated during (MONTH) (YEAR) indicated Resident #1 had the potential for verbal and physical aggression and poor impulse control and interventions included leaving Resident #1 alone when he/she was angry because he/she preferred to be left alone. Resident #1 was hospitalized at the time of the Survey. The Progress Note dated at 8:15 P.M. on 11/24/18 indicated that Resident #1 threw a ceramic plate to the floor, lunged at, punched and grabbed Nurse #1. The Surveyor called Nurse #1 on 11/30/18, 12/12/18 and 12/19/18. Although Nurse #1 left a voicemail for Resident #1 on 12/13/18, the Surveyor could not reach Nurse #1 for an interview. Nurse #1's written statement dated at 8:15 P.M. on 11/24/18 indicated that at 6:15 P.M. Resident #1 approached her, gestured aggressively with his/her dinner plate and shattered his/her plate on the floor. Nurse #1's written statement indicated Resident #1 lunged at her and punched the right side of her jaw, grabbed her by the neck and punched her repeatedly in the back of the head. Nurse #1's written statement indicated that the Volunteer and Nurse #2 pulled Resident #1 off her and the police and emergency medical services were called to the Facility and transported Resident #1 to the hospital. The Surveyor interviewed Nurse #2 at 1:30 P.M. on 12/11/8. Nurse #2 said that she saw Resident #1 approach Nurse #1 with his/her dinner tray. Nurse #2 said Resident #1 told Nurse #1 that his/her dinner was cold and asked Nurse #1 to get him/her another tray. Nurse #2 said Nurse #1 told Resident #1 that she would not get him/her another tray and she would heat his/her plate in the microwave. Nurse #2 said Resident #1 told Nurse #1 that he/she did not want his/her meal heated and he/she wanted a new tray from the kitchen. Nurse #2 said the volume of Resident #1's voice increased and Nurse #1 responded to Resident #1's louder voice by screaming words to the effect of Hey in a loud voice. Nurse #2 said Resident #1 slammed his/her plate on the floor shattering it and Nurse #2 told him/her that he/she could not do that. Nurse #2 said Resident #1 told her that he/she wanted a new tray and Nurse #1 said that she was not going to call the kitchen. Nurse #2 said Resident #1 told Nurse #1 again that he/she wanted a new tray and he/she did not want his/her plate heated in the microwave. Nurse #2 said that Resident #1 moved toward Nurse #1 and waved his/her hands and his/her walker and loudly screamed words to the effect of why don't you want to help me and I need your help. Nurse #2 said that Nurse #1 walked toward Resident #1 and told him/her that he/she needed to go to his/her room. Nurse #2 said that Resident #1 grabbed Nurse #1's shirt and Nurse #1 turned her back toward Resident #1. Nurse #2 said that Resident #1 punched Nurse #1's back several times and Nurse #2 called for help. Nurse #2 said she and the Volunteer pulled Resident #1 away from Nurse #1 and Resident #1 easily accepted her verbal redirected to go to his/her room. Nurse #2 said that she told Resident #1 he/she could not act that way because other residents were nearby and Resident #1 told her that he/she would never hurt a resident but Nurse #1 was rude. The Surveyor asked Nurse #2 why she did not intervene in the situation between Resident #1 and Nurse #1. Nurse #2 said that although she did not want to second guess Nurse #1's actions in the situation, Nurse #2 said she moved away from Resident #1 because he/she was so upset and she would not have put herself in a position to be close enough to an upset resident for the resident to grab or punch. Nurse #2 said that she thought Nurse #1 was familiar with Resident #1's care plan. Nurse #2 said that following an incident in which Resident #1 threw a chart earlier in the shift, Nurse #1 told Nurse #2 about Resident #1's bad temper including an incident two months earlier in which Resident #1 flipped a medication cart. Despite being aware of Resident #1's history and care plan, Nurse #1 moved toward and argued with Resident #1 when he/she was agitated instead of leaving Resident #1 alone in respect of his/her preference to be left alone when upset and without providing encouragement and support while maintaining safety.

Based on interviews and records reviewed, for one of three sampled residents (Residents #1), the Facility failed to ensure a referral to a communcity group home program was made for ten weeks following Resident #1's discharge planning meeting on 9 /21/18 . Findings included: Resident #1's record indicated that he/she was admitted to the Facility eleven months before the Survey following a [MEDICAL CONDITION] (TBI). Resident #1's most-recent Minimum Data Set (MDS) Assessment Form completed 8/28/18 indicated that Resident #1's cognitive patterns were moderately impaired. Resident #1 care plan concern initiated during (MONTH) (YEAR) indicated that his/her placement at the Facility was short term and interventions included ascertaining barriers to community discharge. Resident #1's Progress Note dated 9/21/18 indicated a discharge planning meeting was held with Family Member #1. The Progress Note indicated that since Resident #1's admission, Family Member #1 expressed a preference for Resident #1 to remain at the Facility however Resident #1 consistently and routinely stated that he/she wanted to discharge from the Facility. The Progress Note indicated that although Family Member #1 initially resisted discharge planning, during the meeting on 9/21/18 she agreed to allow Resident #1 to be evaluated by a community group home program which specialized in the care of patients with TBIs. The Progress Note indicated that a referral was made to the Program Coordinator for the TBI Program on 9/21/18. The Surveyor interviewed Social Worker #1 at 10:30 A.M. on 11/29/18. Social Worker #1 said she left two voicemail messages for the Program Coordinator since 9/21/18 and had not heard back. The Surveyor asked Social Worker #1 whether she had done anything else in relation to Resident #1's discharge planning since the meeting with Family Member #1 on 9/21/18, ten weeks prior to the Survey and she said that she had not. The Surveyor interviewed the Program Coordinator at 12:30 P.M. on 11/29/18. The Program Coordinator said that Resident #1 had not been referred to the TBI Program. The Program Coordinator said she initiated a screening of Resident #1's discharge potential during the summer months of (YEAR) because the Medicaid office notified her that he/she triggered for discharge potential on the MDS assessment. The Program Coordinator said she met with Resident #1 and realized that because he/she had a guardian, discharge arrangements would need to be made with the involvement of his/her guardian. The Program Coordinator said she told Social Worker #1 and Social Worker #2 that she was available to work with Resident #1 and Family Member #1 if Family Member #1 was interested in discharge planning. The Program Coordinator said she visited the Facility monthly and visited that Facility the week prior to Survey. The Program Coordinator said that no one informed her during her visits or by telephone that Family Member #1 wanted to pursue Resident #1's referral to the TBI Program. The Surveyor interviewed Family Member #1 at 4:00 P.M. on 12/11/8. Family Member #1 said that she spoke to the Program Coordinator about the TBI Program for the first time on 12/11/18 two and one half months since the Facility discharge planning meeting on 9/21/18 when the plan for the referral was put in place. The Surveyor interviewed the Administrator at 11:00 A.M. on 11/30/18. The Administrator said that he thought Social Worker #1 referred Resident #1 to the TBI program after the 9/21/18 meeting and Resident #1 was waiting for the evaluation to be completed and a bed in the TBI group home program to become available. The Administrator said he was not aware that the Program Coordinator had not received Resident #1's referral. The Progress Note dated at 8:15 P.M. on 11/24/18 and Nurse #1's written statement dated at 8:15 P.M. on 11/24/18 indicated that at 6:15 P.M. Resident #1 threw a ceramic plate to the floor, lunged at a nurse, punched the nurse in the jaw and repeatedly in the back of the head and grabbed the nurse's neck. Nurse #1's written statement indicated that the Volunteer and Nurse #2 pulled Resident #1 off her and the police and emergency medical services were called the Facility to transport Resident #1 to the hospital. The Surveyor interviewed Physician #1 at 12:30 P.M. on 12/11/18. Physician #1 said the Facility was not an appropriate placement for Resident #1. Physician #1 said Resident #1 should probably go home and Family Member #1, who was his/her guardian, did not want Resident #1 to go home. Physician #1 said he heard the Facility attempted to arrange Resident #1 discharge to a group home in the community. Physician #1 said he could see Resident #1 becoming frustrated about the placement.

Based on observation, record review, and staff interview, the facility failed to ensure that residents who entered the facility without pressure sores did not develop pressure sores for 3 (#7, #8, and #16) of 5 residents reviewed for pressure sores, and for 1 (#15) of 5 residents with pressure sores. the Facility failed to provide prompt and appropriate nutritional interventions for a resident with a hospital acquired pressure sore, from a sample of 24 Residents. Findings include: 1. Resident #8 was originally admitted in 10/2011 with [DIAGNOSES REDACTED]. The resident was sent out to the hospital in 10/2015 treated for [REDACTED]. The most recent MDS (Minimum Data Sheet), signed as being completed 10/7/15, indicated that the resident had clear speech, could understand/could be understood, and had a BIMS (Brief Interview for Mental Status) score of 12/15. The MDS indicated that the resident was totally dependent for activities of daily living to include bed mobility and transfers. The MDS did not code the Resident for having any pressure sores. The Resident's record was reviewed on 12/9/15. The Facility Readmission Nursing Assessment, signed as being completed on 10/15/15 at 5:30 P.M., indicated that upon return from the hospital on [DATE], the Resident did not have a pressure sore. Review of the nurse's notes on 12/9/15, indicated no documentation from 10/15/15 of the Resident having a pressure sore. On 10/30/15 at 11:00 A.M. a nurse documented the presence of a Stage II pressure sore that was found during AM care, on the Resident's right lateral heel, which measured 5 cm long by 3 cm wide by 0.2 cm deep. The nurse's note indicated that the pressure ulcer had a moderate amount of bloody drainage with the periwound (skin surrounding the pressure sore) described as pink and blanchable. Additionally, the nurse described some of the pressure sore wound bed remained intact with dark blood noted under the surface. The physician was made aware and ordered topical treatment to the wound consisting of normal saline wash followed by Allevyn gentle border, change every three days and PRN (as needed) until resolved. According to the Facility Skin Assessment Policy, any change in the skin assessment will be communicated to the Interdisciplinary Team for further review of care. Review of the Resident's Care Plan on 12/9/15, indicated that at the time the Resident developed the right heel pressure sore, a low-air loss mattress was being utilized for pressure off-loading. In spite of the low-air loss mattress, the Resident developed the right lateral heel pressure sore on 10/30/15. Further review of the care plan indicated no additional off-loading devices for the resident's heel, from the time the pressure sore was first observed on 10/30/15, until 11/10/15 when an off-load cushion, a dry clean dressing to the right heel, daily and PRN, and weekly wound rounds were added to the Resident's plan of care. The care plan failed to identify how the resident's right heel wound, noted to be unstageable on 11/6/15, would be off-loaded and remain free of pressure while the resident was seated upright in the wheelchair. The Resident was observed daily throughout the survey, including on 12/9/15 at 12:35 P.M., when the Resident was observed sitting upright in a high-back wheelchair in the hallway on Unit C. The resident's feet, that were covered by white socks, were observed resting directly on a blue foam cushion that was placed directly on the metal wheelchair footrest. Both of the Resident's feet were observed to be pressing on the blue foam cushion which was observed to be bottomed out and providing ineffective pressure off-loading. The Resident's right heel pressure sore was observed on 12/9/15 at 12:25 P.M. with Nurse # 1 present. A large, half-dollar size area of thick, black, adherent necrotic tissue was observed on the Resident's right lateral heel. A small area of the pressure sore was open at the lower portion draining a small amount of serosanguinous drainage. Nurse #1 confirmed the treatment of [REDACTED]. Interview with Nurse #1 on 12/9/15 at 12:35 P.M., said pressure off-loading was not effective with the Resident's feet resting on the blue, foam cushion, that was bottomed out and resting directly on the metal footrest. Nurse #1 said he would contact the Physical Therapist to evaluate the Resident for a device that would provide more effective pressure relief, to enhance healing of the right heel pressure sore, while the resident was sitting in the wheelchair. The Facility Wound Nurse was interviewed on 12/9/15 at 1:40 P.M. regarding her role in evaluating, assessing, and treating the Resident's facility acquired right heel pressure sore. The Wound Nurse said that she was not aware that the Resident had a pressure sore. She said, I only assess the wound if I am told about it. She also said, no one told me that he/she had a wound. The Wound Nurse said that she would investigate the breakdown in communication and why she was not made aware of the Resident's right heel pressure sore. UM #1 said to the Surveyor on 12/9/15 at 1:40 P.M. that the physical therapist had evaluated the Resident for more effective off-loading of the right heel. She said that the physical therapist would provide an open heel type of boot that would relieve pressure on the heel and pressure sore. Additionally, UM #1 said that the physical therapist was going to lower the footrest of the wheelchair to provide additional pressure relief. Upon further interview of the Wound Nurse on 12/10/15 at 10:00 A.M. who discussed her actions upon learning from the Surveyor about the Resident's wound on 12/9/15, said that the RD (Registered Dietician) had not recommended any nutritional interventions in order to enhance healing of the resident's right heel pressure sore until 12/9/15. The Wound Nurse said that the RD thought the Resident's wound was just a small area of eschar. The RD was interviewed on 12/10/15 at 11:42 AM, nearly a month and a half following the Resident's development of a facility acquired, unstageable, right heel pressure sore, measuring 5 cm x 2 cm with thick, black, necrotic tissue. The RD informed the surveyor that she was not aware of how significant the pressure sore was. The RD said she would recommend to the physician that the Resident's tubefeeding formula be doubled, due to the Resident's poor oral intake and his/her increased nutritional requirements for wound healing. During interview with UM #2 on 12/15/15 at 10:00 AM, said that the facility's Wound Care Protocol requires the Unit Managers to discuss any wounds during clinical rounds in the morning. According to UM #2, the Resident's right heel wound was reported as a scab. The DON (Director of Nursing) and Administrator were interviewed over concerns regarding Resident #8's development of a now, Unstageable, 5 cm x 2 cm pressure ulcer, with black adherent necrosis in such a rapid fashion, and the failure by the facility to provide the necessary care, treatment, and assessment to prevent further pressure to the right heel wound and interventions to enhance wound healing. Both, said that the Facility had failed to implement their policy for the care and treatment of [REDACTED]. They also said, that communication was ineffective between the various members of the interdisciplinary team, to include CNAs, licensed nurses, the Wound Nurse, the Registered Dietitian, and the Rehabilitation Department, in regards to treatment of [REDACTED]. Both, the DON and the Administrator informed the Surveyor that the Facility had developed, and was in the process of implementing a plan to address concerns regarding the Facility's ineffective skin prevention, pressure ulcer assessment, treatment, and evaluation program. 2. Resident #16 was admitted in 6/2014 with [DIAGNOSES REDACTED]. According to the most recent MDS, signed as being completed 12/1/15, the resident was assessed to have clear speech, was usually understood, could understand, and had a BIMS score of 12/15. The MDS indicated that the Resident was totally dependent for bed mobility, transfers, and was incontinent of bowel and bladder. The assessment indicated the presence of one unhealed pressure sore. The Norton Plus Pressure Ulcer Scale assessment dated [DATE], indicated a score of 9, which indicated the Resident was at High Risk (10 or less). Record review on 12/11/15, indicated that at the start of the survey on 12/8/15, the resident did not have any pressure sores documented. On 12/9/15, as the result of the Facility completing a full assessment of the condition of all residents' skin, prompted by concerns raised by the Surveyor, the Resident was found to have a new, facility acquired, Stage II pressure sore on the left buttock that measured 3.0 cm long x 0.1 cm wide, by 0.1 cm deep. The wound was described on the Weekly Wound Assessment Form as being pink, moist, and superficial. The periwound was noted to be pink and intact. The wound was being treated with a product called Dermavase. The Weekly Wound Assessment Form indicated that the Resident's low air loss mattress was replaced on 12/10/15. Record review indicated in a nurse's note dated 12/10/15, that a superficial area was noted to the left buttock that had reopened. The nurse's note also indicated that the wound team was notified, the wound was measured, a new treatment was to be started, the Resident will continue to be turned side to side every two hours, and a low air loss mattress was to be delivered. UM #1 was interviewed on 12/11/15 at 2:55 PM regarding Resident #16's development of a new Stage II pressure sore to the left buttock. UM #1 said that during a skin assessment, that was performed on all of the residents on Unit C, the Resident was found to have a new Stage II, left buttock pressure sore that measured 3 cm long x 0.1 cm wide x 0.1 cm deep. UM #1 said that there had been no reports by the CNAs, prior to 12/9/15, of the resident having a pressure sore on the left buttock. UM #1 also said that the Resident's low air loss mattress was not functioning properly and was underinflated. She did not know how long the low air loss mattress had been malfunctioning for, but indicated that a replacement mattress had been ordered. The Resident's wound was observed with UM #1 on 12/15/15 at 9:10 AM. The area was noted to be a horizontal, linear slit on the left buttock, approximately 1 inch by approximately 1/8 inch, red in color with no drainage. The periwound was pink and abraded. As a result of the pressure sore developing on the left buttock, the physician was notified and ordered a Foley catheter be inserted into the bladder with continuous drainage, increase liquid protein to twice daily, and zinc sulfate 220 mg daily. On 12/10/15 at 9:25 AM, the Resident was observed lying on his/her back in bed at an approximate 45 degree angle (causing increased risk of shearing). The Resident was awake and alert, and observed receiving his/her medications from the medication nurse. On 12/11/15 at 12:00 P.M., the Resident was observed sitting in bed at an approximate 60 degree angle with the feet appearing to be elevated (causing an increased risk of shearing) with a sheet covering them. The Resident was awake and alert and complained that he/she had to wait too long for staff to bring her a diet soda. On 12/11/15 at 3:25 PM, the Resident was observed lying on his/her back with his/her eyes closed and the head of the bed at an approximate 15 to 20 degree angle. On 12/15/15 at 9:00 AM, the resident was observed lying flat in bed with his/her eyes closed and the head of the bed at an approximate 20-30 degree angle. During interview with UM #1 on 12/15/15, regarding the Resident's positioning and the facility acquired left buttock pressure sore, said the Resident is totally dependent for positioning and needs to be positioned off of the left buttock in order for the pressure sore to heal. 3. Resident #7 was admitted in 11/2014 with [DIAGNOSES REDACTED]. According to the most recent MDS (Minimum Data Set), signed as being completed 12/1/15, the resident had clear speech, was understood and could understand, and had a BIMS score of 11/15. The MDS indicated that the Resident was dependent for bed mobility, transfers, and ADLs. The MDS also indicated that the resident was incontinent of bowel and bladder and did not have a pressure sore. Record review on 12/10/15, indicated that on 11/30/15, the Weekly Wound Assessment Form indicated that the Resident had been observed with a Stage II pressure sore on the coccyx that measured 1.2 cm long x 1.0 cm wide. the wound bed and periwound were both described as red. The initial treatment was listed on the form to be NSW (normal saline wash) followed by Duoderm, change every Monday, Wednesday, and Friday. Further record review on 12/10/15, indicated a delay in both nursing providing additional pressure relief to the Resident's bed, and a delay in the RD (Registered Dietician) providing consultation in regards to this Resident's added nutritional needs, in order to enhance healing of the coccyx pressure sore. During interview with the RD on 12/10/15 at 12:40 PM, she said that she had only learned about the Resident's pressure sore on Tuesday 12/8/15, although the Resident's coccyx pressure sore was first observed and documented on the Weekly Wound Assessment Form on 11/30/15. The RD said her recommendations made on 12/8/15 for liquid protein, Vitamin C, and Zinc were started on 12/9/15. The Resident was observed on 12/8/15 at 12:25 PM, lying in bed feeding himself/herself dinner. The Resident was sitting up in bed at approximately a 60 degree angle. The Resident appeared to have slid down and was slouching in the bed. The Resident was observed on 12/10/15 at 2:00 P.M. The Resident was lying on his/her back at a 45 degree angle (increasing the risk of shearing) with the Resident observed to have slid down in the bed. The mattress on the Resident's bed appeared to be a regular, foam type mattress with no added pressure relieving properties. Nurse #2 said, that in light of the Resident's coccyx pressure sore, the Resident would benefit from an air mattress due to her increased risk of developing additional pressure sores, his/her incontinence, and decreased nutritional intake. Nurse #2 confirmed that the Wound Nurse had not seen the Resident's pressure sore. UM #1 was interviewed on 12/10/15 at 2:15 PM, regarding any plan to provide the Resident with a pressure relieving mattress. UM #1 said, We don't usually get an air mattress unless they have 2 or more pressure sores. Interview with the Administrator on 12/11/15 at 3:45 PM, contradicted UM #1's assertion that the Facility would only obtain a pressure relieving mattress for a resident with two or more Stage II pressure sores. The Administrator said that he is willing to obtain a pressure relieving mattress for any resident who demonstrates the need. He also said that nursing just needs to let him know that a resident requires the pressure relieving mattress so he can order it. 4. Resident #15 was admitted in 11/2015, with [DIAGNOSES REDACTED]. According to the most recent MDS, signed as being completed 12/2/15, the resident had clear speech, could understand, and was sometimes understood. The Resident scored 00/15 on the BIMS (Brief Interview for Mental Status), showed inattention, disorganized thinking, and experienced feeling down. The MDS did not indicate that the Resident had a pressure sore. Record review on 12/15/15, indicated that on the date of admission to the facility in 11/2015, the Resident was assessed to have an unstageable pressure sore on the left heel that measured 6.0 cm long x 8.0 cm wide, described on the Weekly Wound Assessment Form as being covered with eschar. The perimeter of the wound was documented to be pink at the wound edges. The treatment of [REDACTED]. The Weekly Wound Assessment Form indicated that the Wound Committee was notified on 11/18/15. Record review on 12/15/15, indicated that, although the Wound Committee was notified of the Resident's Unstageable Pressure sore to the left heel, no recommendations were made by the RD to enhance wound healing. Review of the Resident's laboratory values for [MEDICATION NAME] and total protein revealed both were significantly low at: [MEDICATION NAME]-2.7 L (normal 3.2-5.2) and Total Protein-4.8 L (normal 6.4-8.3). Although, the RD noted the resident's increased protein needs on her initial assessment on 11/18/15, due to the presence of the left heel pressure ulcer, additional protein and nutritional interventions were not recommended by the RD until 12/9/15, when protein liquid 30 cc twice daily, Vitamin C 500 mg twice daily, and Zinc Sulfate 220 mg daily were recommended, and ordered by the physician on 12/9/15. During interview with the Administrator on 12/15/15, regarding delays in nutritional interventions being recommended for residents with pressure sores, along with prompt assessment, care, and treatment of [REDACTED]. The action plan to address the ineffective wound care program was developed as a result of shortcomings identified during the Facility's current annual survey, to include multiple facility-acquired pressure sores, ineffective assessment, care, prevention and treatment of [REDACTED].

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure assessment and identification of significant changes in condition. Resident #1 had a [DIAGNOSES REDACTED]. On 6/6/15, Resident #1 presented with new complaints of arm pain and was unable to lift his/her arms to feed his/herself, but no assessment was completed in response to the changes until 6/8/15 when Resident #1 was noted by staff to have arm swelling and bruises. It was determined the changes in Resident #1 were because he/she had impacted fractures of the long bones in both Resident #1's upper arms. The treating Emergency Department Physician and the Orthopedist Physician said Resident #1's injuries were new, excessive force was required to result in the type of injuries sustained by Resident #1; and Resident #1 did not cause these injuries himself/herself. Findings include: The Documentation of Resident Incapacity Form indicated that on 10/13/14, Physician #1 activated Resident #1's Health Care Proxy due to dementia. The Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #1 had no pain, Resident #1 had a [DIAGNOSES REDACTED].#1 was able to feed himself/herself with supervision and set-up; and had no impairment of upper extremities. The Nurses' notes, dated from 5/30/15 to 6/5/15, indicated Resident #1 was diagnosed with [REDACTED]. There was no documentation to indicate that during this period of acute illness, Resident #1 complained of arm pain, experienced changes in range of motion or ability to move his/her arms, or was noted to have a change in ability to feed his/herself. The Surveyor interviewed Resident #1's Health Care Agent at 11:15 A.M. on 7/7/15. The Health Care Agent said Resident #1 was in bed at approximately 2:00 P.M. on 6/6/15, and did not feel like getting out of bed, which was unusual behavior for Resident #1. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 4:20 P.M. on 7/8/15. CNA #1 said that, during the 7:00 A.M. to 3:00 P.M. shift on 6/6/15, Resident #1 had a hard time standing; needed to be fed breakfast and dinner and because this represented a change in Resident #1, CNA # 1 reported what she observed to Nurse #1. The Nurse's Note, dated 6/6/15, during the 7:00 A.M. to 7:00 P.M. shift, indicated Resident #1 looked pale, his/her appetite was poor, and he/she had complaints of right arm pain. The Nurse's Note and physician's orders [REDACTED].#1 was notified of these changes in Resident #1's condition and ordered for staff to obtain laboratory blood tests on 6/7/15. The nurse's note did not include any documentation to indicate that the nursing staff performed an assessment of Resident #1's right arm to determine whether Resident #1 had any additional changes in condition. The Surveyor interviewed Nurse #1 at 3:15 P.M. on 7/8/15. Nurse #1 said that after morning care on 6/6/15, Resident #1 complained of right arm pain and later told Nurse #1 he/she had pain in his/her left arm. Nurse #1 said Resident #1 refused to feed himself/herself and therefore had to be fed. These changes represented a change in condition from Resident #1's prior level of functioning. The Nurse's Note, dated 6/7/15, during the 7:00 A.M. to 7:00 P.M. shift, indicated Resident #1 refused to feed himself/herself, and new doctor's orders were obtained for a Culture and Sensitivity (C&S) on urinalysis. The Surveyor interviewed Certified Nurse Aide (CNA) #2 at 4:50 P.M. on 7/8/15. CNA #2 said that, during the 7:00 A.M. to 3:00 P.M. shift on 6/7/15, Resident #1 told her, words to the effect, My arms are sore. CNA #2 said Resident #1 was unable to lift his/her arms, and as a result, she had to feed Resident #1 his/her lunch, and she reported this information to the Nurse #1. Nurse #1 said that on 6/6/15 and 6/7/15, staff did not report that Resident #1 had bruising or swelling of his/her arms. Nurse #1 said when she gave Resident #1 his/her medications in the morning on 6/7/15 Resident #1's hand was shaking. Although Nurse #1 said no staff member reported observing bruising or swelling, there was no indication Nurse #1 performed an assessment of Resident #1's arms in response to his/her shaking, inability to lift the arms, and complaints of pain. Nurse #1 said because Resident #1 looked pale and the Health Care Agent questioned if Resident #1's right arm pain could be due to a cardiac issue. Nurse #1 said she called Physician #1 and obtained an order for [REDACTED].#1 said she thought Resident #1 was dehydrated and therefore told Nurse Manager #1 she thought this was why Resident #1 didn't feed himself/herself. Nurse #1 said she and Nurse Manager #1 did a skin check on Resident #1 and no bruises or swelling were noted on Resident #1's arms. This is not consistent with the documentation contained within the nurses' notes for 6/6/15 and 6/7/15 and was not consistent with the account of Unit Manager #1, who said a skin assessment was performed after the bruising was noted on 6/8/15. The Surveyor interviewed Nurse Manager #1 at 11:20 A.M. on 7/9/15. Nurse Manager #1 said, during the 7:00 A.M. to 3:00 P.M. shift on 6/6/15, Resident #1 was confused, pale, and not his/her usual self and the physician was informed. Nurse Manager #1 said no one reported to her that Resident #1 had any bruises, complaints of arm pain, or that Resident #1 was no longer able to feed himself/herself on 6/6/15 or 6/7/15. The Surveyor interviewed Certified Nurse Aide (CNA) #3 at 12:40 P.M. on 7/8/15. CNA #3 said during breakfast on 6/8/15, Resident #1 was not eating and was having trouble feeding himself/herself, so CNA #3 assisted Resident #1 with eating. CNA #3 said while trying to change Resident #1 out of his/her pajama top, Resident #1 could not lift up his/her arms and made a face, like a grimace. CNA #3 said she observed bruises on both sides of Resident #1 arms, from the elbow to the shoulder and all around his/her arms, and immediately reported what she observed to Charge Nurse #1. The Nurse's Note, dated 6/8/15, during the 7:00 A.M. to 7:00 P.M. shift, indicated Resident #1's upper arms had bruised areas, with swelling surrounding the elbows and up to the shoulder, and he/she was stiff and sore to range of motion. The Nurse's Note indicated Resident #1 was given [MEDICATION NAME] (Tylenol), 650 milligrams for complaints of joint pain, with good effect. The Surveyor interviewed Charge Nurse #1 at 5:50 P.M. on 7/15/15. Charge Nurse #1 and Unit Manager #1 said at approximately 10:00 A.M. on 6/8/15, Resident #1 was observed to have upper arm bruises to both arms. Charge Nurse #1 said that looked like they could have been caused by a blood pressure cuff. Charge Nurse #1 said Physician #1 ordered Resident #1 to be sent to the emergency department for an evaluation. Health Care Agent #1 said after Resident #1 was noted to have bruises (6/8/15), Nurse #1 told him the bruises on Resident #1's upper arms could have been caused by a blood pressure cuff. The Health Care Agent said that on 6/8/15, Resident #1's bruises looked like four fingerprint indentations on both his/her arms. The Surveyor interviewed Physician #1 (Resident #1's Primary Care Physician) at 12:55 P.M. on 7/8/15. Physician #1 said, at approximately 9:30 A.M. on 6/8/15, he assessed Resident #1's bruises on his/her upper arms and noted his/her shoulders were rigid. Physician #1 said Resident #1's shoulders were rigid before, and he/she had frozen shoulder before this incident. Physician #1 said he thought the fractures were old and not caused by trauma but because he/she had frozen shoulders and lifted himself/herself up, using the arms rests of the wheelchair. Physician #1 said that on 6/8/15, he ordered Resident #1 be sent to the hospital for an evaluation. The Hospital's Emergency Department Report, dictated by the Emergency Department Physician (Physician #2) on 6/8/15, indicated Resident #1 had bilateral upper extremity bruising, and that Physician #2 said the bruising was not (caused) from a blood pressure cuff. The Surveyor interviewed Physician #2 at 4:35 P.M. on 7/22/15. Physician #2 said, at approximately 3:00 P.M. on 6/8/15, he evaluated Resident #1 and he/she had bruises on both upper arms that were, words to the effect of, suspicious. Physician #2 said the marks looked similar to finger marks, and were not consistent with bruises caused by a blood pressure cuff, as Charge Nurse #1 told the Health Care Agent. The Radiology Report, obtained at 9:12 P.M. on 6/8/15, indicated Resident #1's bones appeared diffusely demineralized and he/she had bilateral (both sides) impacted humeral neck fractures that showed no callus. The Hospital's Consultation Report, dated 6/9/15, indicated Resident #1 was evaluated by an Orthopedist (Physician #3) on this date, and he/she had acute fractures of both humeral heads (long bones in the upper arm) and Resident #1 had no significant function in either upper extremity. The Hospital Consultation Report indicated Resident #1 had complaints of shoulder pain, Resident #1 could not move either arm, and the Health Care Agent reported that the Facility staff gave no explanation as to what could have caused these injuries. Physician #2 said that on 6/9/15, he viewed Resident #1's x-rays, and the bruises and said the bilateral fractured humeral heads were consistent with new injuries that could have been caused by a fall. Physician #2 said that excessive force had to have been applied to both of Resident #1's upper arms to cause the new injuries (fractures, swelling, and bruising). The Surveyor interviewed Physician #3 (the Orthopedist) at 1:25 P.M. on 7/10/15. Physician #3 said he observed Resident #1's injuries, at approximately 6:45 P.M. on 6/9/15, and he believed something, words to the effect of, significant and egregious(conspicuously bad) happened to cause Resident #1's injuries. Physician #3 said that Resident #1's bones had no callus and callus was a late sign (of healing) that you would not expect to see until approximately four to six weeks after a new injury. Physician #2 and Physician #3 said Resident #1 could not have caused these injuries to himself/herself. Physician #2 and Physician #3 said had Resident #1 fallen, Resident #1 would have needed help to get up off the floor if he/she had sustained these injuries as a result of a fall. Physician #2 and Physician #3 said Resident #1 was unable to provide any information as to what may have caused his/her bruises and injuries due to his/her cognitive deficits.

Based on record review and interviews, the Facility failed to ensure that 1 of 3 sampled residents (Resident #1) received appropriate care with transfers as indicated in his/her written plan of care (two-person assist with gait belt), when on 11/28/13 at 9:50 P.M. Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 into bed with no gait belt or second caregiver and Resident #1 fell and fractured his/her right hip. Findings include: Resident #1's physician orders [REDACTED]. Resident #1's up-to-date activities of daily living (ADL) plan of care on the day of the incident (11/28/13) included instruction for caregivers to use a gait belt and assistance of two caregivers to transfer (move between surfaces/positions) Resident #1. The Surveyor interviewed CNA #2 in the afternoon of 12/23/13. CNA #2 said she worked the shift in question on the same side of the unit with CNA #1. CNA #2 said that just before 10:00 P.M., Resident #1 was still up, seated in his/her wheelchair and CNA #2 briefly spoke to him/her. CNA #2 said that a short time later she observed CNA #1 wheel Resident #1 past CNA #2 toward his/her room, presumably to put him/her to bed. CNA #2 said that a few moments later CNA #1 ran out of Resident #1's room and past CNA #2 en route to the nurses' station. CNA #2 said CNA #1 said, "(Resident #1) is on the floor!" The Surveyor interviewed CNA #1 at 2:07 P.M. on 1/9/14. CNA #1 said that she, alone, brought Resident #1 to his/her room to go to bed at about 10:00 P.M. on 11/28/13. CNA #1 said that, as always, Resident#1 refused any hands on assistance from CNA #1 (including no gait belt), but allowed her to position his/her wheelchair beside his/her bed so that his/her strong left side was closest to the raised bed side rail. CNA #1 said Resident #1, as usual, grasped the side rail and pulled himself to a standing position. CNA #1 said that instead of turning him/herself and sitting on the bed, Resident #1's right leg buckled and he/she fell to the floor. CNA #1 said she then ran to get Nurse #1. The Surveyor reviewed CNA #1's written statement about the incident and the documented interviews that took place between CNA #1 and the DON/Unit Manager on the day of the incident and the day after the incident. All of these documented statements/interviews corroborated CNA #1's statements to the Surveyor. CNA #1 said that all of the CNAs that worked with Resident #1 had transferred Resident #1 in the manner she described above or in a similar fashion, but always contrary to the written care plan/plan of care (assist of two with gait belt). CNA #1 said that, over the years, she and other CNAs had repeatedly notified their nurses of Resident #1's insistence on accomplishing his/her transfers as he/she saw fit (i.e. no method that matched the Facility's written care plan for him/her). CNA #1 said she was aware that Resident #1's care card (derived from his/her care plan) indicated that Resident #1 was an assist of two with a gait belt for transfers. CNA #1 said that she and the other CNAs had been following Resident #1's instructions relative to his/her transfers and that this practice was generally known by nurses and some rehabilitation staff. The Surveyor interviewed Nurse #1 at noon on 12/23/13. Nurse #1 said when she arrived in Resident #1's room immediately after the incident, he/she was laying on the floor and was the only person in the room. Nurse #1 said this caused Nurse #1 to suspect that CNA #1 had attempted to transfer Resident #1 alone (contrary to the care plan). Nurse #1 said she also observed that Resident #1 had no gait belt on. Nurse #1 said she asked CNA #1 about how she transferred Resident #1, but received unsatisfactory/vague responses from her. CNA #2 said that just prior to the incident, she did not offer, and CNA #1 did not ask for, assistance with Resident #1's wheelchair to bed transfer, even though CNA #2 knew CNA #1 was about to transfer Resident #1 without assistance from a second person. CNA #2 said Resident #1 routinely refused to allow him/herself to be transferred by two caregivers. CNA #2 said she had never reported this situation to her nurses (s). The Surveyor interviewed CNA #3 at 1:55 P.M. on the day of survey. CNA #3 said he/she often assisted Resident #1 during the 7:00 A.M. to 3:00 P.M. shifts. CNA #3 said that Resident #1 regularly insisted that only one CNA assist him/her to get out of bed. CNA #3 described Resident #1's explicit preferred manner of transferring out of the bed (which was similar to CNA #1's description above). CNA #3 said he/she followed Resident #1's instructions regarding this assistance because Resident #1 would become very upset/angry if a different procedure was attempted. CNA #3 said that he/she could sometimes even have a second caregiver in Resident #1's room during the transfer, but Resident #1 would not allow the second caregiver to touch him/her. CNA #3 said Resident #1 particularly did not want/would not tolerate anyone touching his/her impaired (right) side. CNA #3 said he/she believed CNA #4 and Nurse #3 knew that Resident #1 disallowed two hands-on caregivers for transfers and that CNAs, therefore, often/always transferred him/her with only one caregiver and a gait belt. The Surveyor interviewed CNA #4 at 2:05 P.M. on the day of survey. CNA #4 said that he/she always had a second person with him/her when providing Resident #1's transfers, which required assistance from two-caregivers. CNA #4 described that he/she would apply the gait belt to Resident #1 (which Resident #1 disliked) then stand and transfer Resident #1 from bed to wheelchair. CNA #4 said that the second CNA would not provide any hands-on assistance to Resident #1 during the transfer, but was present as a (contact guard) in case Resident #1 (suddenly) needed additional hands-on support. The Surveyor asked CNA #4 how he/she and a second CNA transferred a resident who required a two-person assist when the resident did not reject the assistance. CNA #4 stated that she and the other CNA approached the resident to be transferred, notified the resident of their intent to transfer the resident and applied the gait belt around the resident's waist. CNA #4 stated that both CNAs then supported the resident by holding the gait belt and placing their hands on the resident's arms as support and safely accomplished the transfer. CNA #4 acknowledged to the Surveyor that the transfer method described immediately above differed from the transfer method routinely practiced on Resident #1. The Surveyor interviewed Nurse #3 at 2:17 P.M. and Nurse #4 at 4:42 P.M. on 12/31/13. Nurse #3 and Nurse #4 said they were unaware that CNAs ever or routinely transferred Resident #1 in a manner contrary to his/her care plan. Nurse #3 said he knew the CNAs who cared for Resident #1 were fully-aware of his/her care needs. Nurse #3 and Nurse #4 said they always reminded the CNAs they worked with to call for help with Resident #1's care if no second CNA was immediately available. Nurse #4 said he usually had a consistent male CNA on-duty to care for Resident #1. Nurse #4 said it was not unusual for him to assist this CNA with Resident #1's transfers.