Every finding on record at Holy Trinity Eastern Orthodox N & R Center

Based on observations, and interviews, the facility failed to provide adequate assistance for Activities of Daily Living (ADLs) for one Resident (#37) out of a total sample of 19 residents. Specifically, for Resident #37, the facility failed to ensure that fingernail care was provided when the Resident was dependent on staff for ADL care. Findings include: Review of the facility policy titled Fingernail Care-Personal Care Needs, updated 9/1/23, indicated: -The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. -Routine cleaning and inspection of nails will be provided on an ongoing basis. -Principles of nail care: >Nails should be kept smooth to avoid skin injury. >Only licensed nurses shall trim or file fingernails of residents with diabetes. Resident #37 was admitted to the facility in March 2024 with diagnoses including Cerebral Infarction, Hemiplegia affecting the right dominant side, and Type 2 Diabetes Mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #37: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15. -was usually able to understand others and to make him/herself understood. -had no incidents of behaviors or refusals of care. -was dependent on staff for personal hygiene and grooming. Review of the ADL Care plan, initiated 3/26/24, indicated Resident #37: -had an ADL self-care performance deficit. -was dependent on staff for personal hygiene. Review of the Resident #37's Comprehensive Care Plan, initiated 11/14/25, failed to indicate any evidence of behaviors or refusals of care. On 12/30/25 at 11:59 A.M., the surveyor observed that Resident #37 was seated in a wheelchair and wearing a brace on his/her right hand. The surveyor further observed the fingernails on the Resident's right hand were long, untrimmed, and the index fingernail was curling towards the skin. During an interview at the time, Resident #37 said he/she did not remember when the fingernails were last trimmed but he/she does not like them long. During an interview on 12/30/25 at 2:02 P.M., CNA #1 said she had completed all ADL care for Resident #37 and had not noticed at the time that the fingernails on the right hand needed nail care. The surveyor and CNA #1 observed Resident #37's nails and CNA #1 said the fingernails were too long, sharp, and needed to be cut. CNA #1 said CNAs are responsible for providing nail care but was unsure when Resident #37 last had nail care completed on the right hand. CNA #1 said she had not offered Resident #37 nail care and he/she had not refused nail care. On 12/30/25 at 2:04 P.M., the surveyor and Nurse #1 observed Resident #37's fingernails. During an interview at the time, Nurse #1 said the Resident's right hand fingernails were overdue to be cut, were too long, and jagged. Nurse #1 said that CNA #1 should have noticed the Resident's right hand fingernails were too long when she applied the hand brace during ADL care. Nurse #1 said that she had not been told Resident #37 had long nails or that he/she had refused any care. During an interview on 12/30/25 at 2:12 P.M., the surveyor and the Unit Manager (UM) #1 observed Resident #37's right hand fingernails and UM #1 said the fingernails were too long and should have been cut prior to today. UM #1 said she did not receive any report about the Resident refusing fingernail care. On 12/30/25 at 2:13 P.M., the surveyor observed Nurse #1 ask Resident #37 if she could trim his/her fingernails and the Resident was in agreement. Nurse #1 proceeded to gather supplies and trimmed Resident #37's fingernails. During an interview on 12/30/25 at 3:24 P.M., the Director of Nursing (DON) said that CNAs are responsible for providing nail care and if they have difficulty, then should ask a Nurse for help. The DON said she was made aware that Resident #37's right hand fingernails were too long and needed to be cut. The DON said that nails should be monitored for the need of nail care and should be cut monthly.

Based on observation, interview, and record review, the facility failed to develop a care plan for the use of a positioning aid for one Resident (#6) out of a total sample of 18 residents. Specifically, for Resident #6, the facility failed to ensure a care plan was developed for the use of bilateral (both sides) wedge cushions (a triangular shaped cushion used to aid in positioning for health issues or comfort) while the Resident was in bed. Findings include: Review of the facility policy titled Body Positioning, released 1/17/17, indicated the following: -Positioning techniques should be used with residents with stroke and other neurological impairments for the following reasons: >Orthopedic enhancement of postural alignment >Increase stability -Documentation >In the care plan, document positioning needs and interventions and approaches to meet resident's needs. Resident #6 was admitted to the facility in March 2020, with diagnoses including a history of Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) with spastic hemiplegia [paralysis of one side of the body] affecting the right side (a possible side effect from a stroke that causes muscles to be in a constant state of contraction). Review of the most recent Minimum Date Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 7/31/24, indicated Resident #6: -was dependent for bed mobility, -never spoke, -was rarely and/or never understood, -and rarely and/or never able to understand. During an observation on 9/18/24 at 9:54 A.M., the surveyor observed Resident #6 lying in bed and he/she had large wedge cushions bilaterally placed on either side of his/her upper body. During an observation on 9/19/24 at 8:53 A.M., the surveyor observed Resident #6 to be lying in bed. The surveyor further observed that large wedge cushions were bilaterally placed on either side of his/her upper body. Review of Resident #6's September 2024 Physician's orders did not indicate any order in place for the use of the bilateral wedge cushions. Review of Resident #6's Care Plan did not indicate that a care plan had been developed for the use of the bilateral wedge cushions while Resident #6 was in bed. Further review of the Resident's medical record indicated no additional documentation on when the bilateral wedge cushions were recommended for use for the Resident or who recommended that the Resident needed the bilateral wedge cushions. During an interview on 9/19/24 at 9:06 A.M., Nurse #1 said there should be a care plan developed when a Resident utilized wedge cushions in bed, so staff knew to place them on either side of the Resident when he/she was in bed. During an interview on 9/19/24 at 9:27 A.M., Certified Nurses Aide (CNA) #1 said Resident #6 utilized the bilateral wedge cushions when he/she was in bed because he/she had a stroke and needed the wedge cushions for positioning. During an interview on 9/19/24 at 9:43 A.M., Unit Manager (UM) #1 said Resident #6 used the bilateral wedge cushions when he/she was in bed. UM #1 said the use of wedge cushions while in bed to help with positioning had been recommended by the Therapy Department and there should have been a care plan in place for the use of the wedge cushions. UM #1 further said a care plan for the use of wedge cushions for Resident #6 had not been developed. During an interview on 9/19/24 at 11:12 A.M., the Director of Rehabilitation (DOR) was unable to find any documentation that Resident #6 had been evaluated by the Therapy Department for the use of bilateral wedge cushions while in bed. The DOR said when a Resident needed a positioning aid the Therapy Department would evaluate the use of a positioning aid, document in therapy notes that the positioning aid was needed and why, acquire a Physician's Order for the use of the positioning aid, update or create a Care Plan for the positioning aid, and provide education to staff, and this was not done for Resident #6. The DOR further said she could find no documentation on when the bilateral wedge cushions were recommended or who recommended the bilateral wedge cushions for Resident #6's use while he/she was in bed.

Based on record and policy review, and interview, the facility failed to ensure that a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASRR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for one Resident (#73) out of a total sample of 18 residents. Specifically, for Resident #73, the facility staff failed to request a Level II PASRR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care. Findings Include: Resident #73 was admitted to the facility in August 2023, with diagnoses including Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations) and Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #73's Level I PASRR screen from a previous nursing facility admitted d 4/7/22, indicated that he/she had a history of a mood disorder, severe anxiety, and did not meet criteria for SMI, therefore a Level II PASRR evaluation was not needed. Review of the facility policy for Pre-Admission Screening and for Mental Disorder (MD) and/or Intellectual Disability (ID) Patients, last reviewed 2/16/24, indicated the following: -Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if .there is a significant change in status that results in new evidence of possible mental disorder, intellectual disability or a related condition. -Social Services will be responsible for coordinating updates as needed per state requirements. -Social Services will be responsible for notifying the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a patient who has a MD or ID for patient review. Review of the Behavioral Health Note dated 10/5/23, indicated the Resident was experiencing increased behaviors (yelling), delusions (false beliefs) and hallucinations (false perceptions of objects or events involving the senses: sight, sound, smell, touch and taste). Further review of the Behavioral Health Note indicated that Resident #73 had been given an increase in the antipsychotic (drugs used to treat psychosis- a collection of symptoms that affect your ability to tell what is real and what is not) medication Zyprexa for management of these symptoms. Review of Resident #73's Social Services Progress Notes indicated that the Resident had experienced repeated episodes of calling out and yelling behaviors during the following dates: -10/6/23 - 10/8/23 -10/15/23 -11/2/23 -11/9/23 -11/12/23 -11/14/23 -11/16/23 -11/26/23 -11/27/23 Review of Resident #73's medical record indicated that the Resident had been diagnosed with Visual Hallucinations on 10/26/23 and Delusional Disorder on 10/30/23. Further review of the Resident's medical record failed to indicate that the Level I PASRR was updated and re-submitted for an additional Resident Review (a review that assesses the need for a more in-depth assessment: Level II evaluation) when new mental health diagnoses were identified on 10/26/23 and 10/30/23. Review of Resident #73's Psychosocial/Behavior care plan, last revised 8/29/24 indicated: -The Resident has a history of audio and visual hallucinations that can be very upsetting to him/her. -The Resident has a disruptive behavior of constant/repetitive calling out for others. -The Resident can become weepy at times. During an interview on 9/23/24 at 9:35 A.M., Social Worker (SW) #1 said that she was responsible for reviewing the PASRR evaluations. SW #1 also said that she had not been aware until May 2024 that the facility was required to re-submit a Level I when a Resident had a change in condition such as a new mental health diagnosis. SW #1 further said that Resident #73's Level I PASRR had not been re-submitted to the Department of Mental Health PASRR office but that it should have been.

Based on observations, policy reviews and interviews, the facility failed to ensure its staff adhered to Infection Control policies/practices by encouraging social distancing and mask wearing for residents who were negative for COVID-19 infection and who were in close contact with symptomatic COVID-19 positive Residents (#18 and #23). The facility also failed to ensure appropriate donning (putting on) and doffing (removing), use of personal protective equipment (PPE), conduct testing by staff in a manner to minimize the spread of COVID-19 infection during an active outbreak on two of three units observed. Findings include: Review of the facility policy titled Protective Attire Technique, revised 2022, indicated that employees wear appropriate protective attire when providing care to residents in isolation. The policy also included the following: -Order of protective attire application and removal: Application: 1. gown 2. mask/eyewear/face shield 3. gloves Removal: 1. gloves 2. gown 3. mask/eyewear/face shield Review of the facility policy titled Corona Virus (COVID-19) Transmission Precautions, revised 4/2023, indicated in order to prevent transmission of COVID-19 to others . a plan will be implemented to ensure minimal risk of exposure and further positive cases. -Masks will be worn as indicated by facility protocol or guidance at the time of entry if indicated as determined by COVID-19 cases in the facility. -Eye protection is worn as indicated by facility protocol and or guidance at the time of entry if indicated as determined by COVID-19 cases in the facility. The policy also included the following: -COVID-19 is primarily transmitted from person to person via respiratory droplets, produced when an infected person coughs or sneezes. The virus spreads between people who are in close contact with one another, i.e. within 6 feet of each other for more then 15 minutes. It is possible that a person with COVID-19 can transmit this through surfaces or objects, by touching these objects and then touching their own mouth, nose or possibly their eyes, and could potentially transmit the virus. Review of the Massachusetts Department of Public Health (MA DPH) Memorandum titled Comprehensive PPE Guidance, dated 5/5/23, included the following PPE requirements for staff when caring for patients with suspected or confirmed COVID-19: -DPH recommends that a fit-tested N95 filtering face-piece respirator or alternative and eye protection be used when caring for patients with suspected or confirmed COVID-19. If there is any contact with potentially infectious material, an isolation gown and gloves should also be used. -Respirators: Proper use of respiratory protection by health care personnel (HCP) requires a comprehensive program (including medical clearance, training, and fit testing) that complies with the Occupational Safety and Health Administration (OSHA) ' s Respiratory Protection Standard. -N95 respirators should always be discarded after doffing, such as when leaving a patient room . -Eye Protection: Disposable eye protection should be discarded when it is removed for any reason; it should not be reused. Reusable eye protection should be cleaned and disinfected when visibly soiled and after removal/doffing. -Isolation Gowns: Gowns should be disposed of or laundered after each patient encounter -Gloves: Gloves should be worn when there is any contact with potentially infectious material. HCP should perform hand hygiene prior to donning and after doffing gloves. Upon entrance to the facility on [DATE], the survey team was informed by the receptionist that there was a COVID-19 outbreak on the Courtyard Unit and N95 masks were to be worn at all times while on the Unit. During the initial pool process on the Courtyard Unit, on 6/6/23 at approximately 8:40 A.M., Nurse #4, who worked on Courtyard Unit, informed the surveyor that N95 masks and eye protection (face shield or goggles) were to be worn while on the Courtyard Unit. 1. Resident #18 was admitted to the facility in November 2021. Review of the Minimum Data Set (MDS) Assessment, dated 2/27/23, indicated Resident #18 was severely cognitively intact as evidenced by a Brief Interview of Mental Status Score of 3 out of 15. Review of the clinical record indicated Resident #18 tested positive for COVID-19 infection on 6/4/23 and was placed on Isolation Precautions. On 6/6/23 at 10:29 A.M., the surveyor observed Isolation signage outside of the Resident's room. The Resident was observed inside of the room, was not wearing a mask and was actively coughing. On 6/6/23 at 11:20 A.M. through 11:48 A.M., the surveyor observed Resident #18 self-propelling in a wheelchair through the common areas of the Courtyard Unit and into the common area where other residents were seated. Resident # 18 refused to wear a face mask despite attempts from staff to apply, and refused to leave the common area where an activity was occurring and other residents were positioned. The surveyor observed seven residents seated in the common area with the Activities Aide. Some residents did not have face masks in place and some had face masks that was not worn appropriately (did not cover the mouth and/or nose). The Activities Aide, was wearing an N95 mask, and did not have protective eyewear in place. The surveyor observed Resident #18 approach the Activities Aide and several other residents during the observation and attempted to converse with the other residents who did not have face masks on or face masks that covered their mouth/nose. During the observation, the surveyor did not observe facility staff assist the other residents with distancing away from Resident #18, attempt to engage Resident #18 in any individual activity, or assist with appropriate mask wearing of the residents who were in the common area near Resident #18. During an interview on 6/6/23 at 11:48 A.M., Certified Nurse Aide (CNA) #8 said Resident #18 refuses to wear a face mask and refuses to stay in his/her room. When asked by the surveyor how the facility staff are keeping the other residents on the Unit safe from COVID-19 exposure, CNA #8 said that they encourage and assist residents with wearing face masks. When the surveyor asked about the residents in the common area with Resident #18 who were not wearing a face mask or wearing the face masks appropriately, CNA #8 said that she would assist the residents with appropriate mask wearing. On 6/6/23 at 3:56 P.M. through 4:00 P.M., the surveyor observed Resident #18 in the common area with four residents watching a television program. Resident #18 did not have face mask in place and the four residents seated near him/her had surgical masks that were not worn appropriately (not covering the mouth and/or nose). Resident #18 was actively coughing and within close proximity of the four other residents. A CNA was observed monitoring the activity and did not provide education to Resident #18 to cover his/her nose/mouth when coughing, did not offer him/her a face mask or attempt to reposition other residents away from him/her, or assist the other residents with appropriate face mask wearing. 2. Resident #23 was admitted to the facility in July 2018. Review of the clinical record indicated the Resident tested positive for COVID-19 infection on 5/31/23 and was placed on Isolation precautions. On 6/6/23 at 9:37 A.M., the surveyor observed Isolation signage and a PPE bin outside of Resident #23's room. CNA #9 entered the room wearing an N95 mask, eye protection, gown and gloves in place. CNA #9 assisted setting up the Resident's breakfast tray and assisted with making his/her bed. Shortly after, the surveyor observed CNA #9 remove her gown and gloves and exit the room. The surveyor did not observe CNA conduct hand hygiene upon exiting the room, nor did CNA #9 remove her N95 mask or discard or disinfect her eye protection. During an interview immediately following the observation, CNA #9 said that Resident #23 was on Isolation precautions because he/she was positive for COVID-19 infection. She said that prior to entering the room, staff were to wear an N95 mask, gown, gloves and eye protection. She further said when exiting the room, staff were to remove their gown and gloves but did not need to remove their N95 mask or eye protection. 3. On 6/6/23 at 8:33 A.M., the surveyor observed breakfast service on the Courtyard Unit where numerous residents were seated. The Dietary Aide, who was serving the breakfast meal, had a surgical face mask in place and did not have an N95 mask and eye protection on. The surveyor observed CNA #4, who was serving breakfast meals to the residents, wear only an N95 mask and did not have eye protection in place. On 6/6/23 at 4:20 P.M., the surveyor observed a Dietary Aide in the common area near the Unit refrigerator. He had a surgical mask on, not an N95 mask, and did not have eye protection on. Resident #18, who was COVID-19 positive, was in the common area near the Unit refrigerator. 4. On 6/6/23 from 1:14 P.M. through 1:45 P.M., the surveyor observed Housekeeping Staff #1 enter resident rooms who were identified as COVID-19 positive. The residents' rooms were observed to have Isolation Precaution signage posted outside of the room indicating that staff had to complete the following: - conduct hand hygiene prior to entering and upon exiting room - don a N95 mask, eye protection, gown and gloves prior to entering the room The surveyor observed Housekeeping Staff #1 donn an N95 mask, gown, gloves and eye protection in place prior to entering the first COVID-19 positive room and exit shortly after, without doffing the N95 mask and eye protection. The surveyor observed Housekeeping Staff #1 continue to enter the remaining COVID-19 positive rooms and prior to exiting, was observed to remove only her gown and gloves, and did not remove her N95 mask nor remove or disinfect her eye protection. After exiting the last room, the surveyor observed Housekeeping Staff #1 doff her gown and gloves, conduct hand hygiene and walk down the hallway where other residents/staff were located with her cart. During an interview on 6/6/23 at 1:50 P.M., Housekeeping Staff #1 said that she cleans the rooms of residents who are on Isolation Precautions at the end of her shift. She said that she does not change her N95 mask nor clean/disinfect her eye protection after exiting these rooms, but will change her N95 mask and discard her eye protection at the end of her shift after these rooms are completed. On 6/6/23 at 4:32 P.M., the surveyor relayed the observations from the Courtyard Unit with the Director of Nurses (DON), the Infection Preventionist (IP) and the [NAME] President (VP) of Clinical Operations. The VP of Clinical Operations said the COVID-19 outbreak started on 5/30/23 and outbreak testing identified additional staff and residents who were positive. She said when caring for a resident who was on Isolation Precautions, an N95 mask, eye protection, gown and gloves are to be worn. She said when exiting the Isolation room, all PPE was to be disposed of, hand hygiene conducted and a new N95 mask and eye protection donned. The VP of Clinical Operations said there was no shortage of PPE, but if facility staff are using reusable eye protection, like goggles, they were to disinfect them immediately upon exiting the Isolation room. She further said that communication was sent to facility staff on the PPE expectations on the Unit, and that all department managers like Maintenance, Rehabilitation, Dietary and Activities were also notified of what the PPE expectations were on the Unit due to the COVID-19 outbreak. The VP of Clinical Operations said that when staff were on the Courtyard Unit and not caring for the residents who are on Isolation precautions, they were to wear N95 mask and eye protection and were to encourage all residents to wear face masks and encourage social distancing (remaining six feet apart). 5. On 6/7/23 at 3:22 P.M., the surveyor observed multiple Nurses and CNAs enter the Courtyard Unit for the 3:00 P.M. to 11:00 P.M. shift and congregate near the nurse's station. The Nurses and the CNAs were observed to conduct COVID-19 testing via rapid testing method at the nurse's station where other staff and residents were observed. The surveyor observed the staff being tested lower their N95 masks to obtain a nasal swab sample, insert the sample into the test kit and reposition their masks over their noses. The test kits with pending COVID-19 tests were observed to be placed on the desk of the nursing station while the staff waited for results. An unmasked resident was observed self-propelling around and behind the nurse's station during this observation. On 6/8/23 at 12:46 P.M., the surveyor reviewed the facility education and outbreak plan with the VP of Clinical Operations, the IP, the DON, and the Administrator. The VP of Clinical Operations said after the outbreak occurred, facility staff were educated on 5/31/23 on Isolation precautions, appropriate donning and doffing, outbreak testing schedule, importance handwashing and encouraging residents on the Courtyard Unit to remain six feet apart and wear surgical masks, and for staff to wear N95 masks while on the Unit. Review of the education provided indicated the Courtyard Unit also received education by Unit Manager (UM) #2 on what to do when a resident who was on Isolation precautions refused to remain in their rooms and included keeping other residents at least six feet apart, encouraging all residents to wear face masks, engaging the resident on isolation in an activity that they could do on their own, and clean/disinfect the area after they leave. The VP of Clinical Operations said that on 6/4/23, the staff identified that Resident #18, who was symptomatic, did not comply with the Isolation precautions, and at that time, the Courtyard Unit instituted N95 masks and protective eyewear for all staff, which included Rehabilitation, Dietary, Activities and Maintenance staff, when on the unit. She further said that the facility staff were educated on the process for conducting rapid testing for COVID-19 and that when facility staff were conducting the test, they should be in an office space away from other staff/residents. She further said that the COVID-19 testing should not be conducted on the Unit at the Nurse's station. 37086 6. On 6/6/23 the surveyor observed CNA #1, on the Hillside Unit, with no face mask on (required, as the facility was in an active COVID-19 outbreak) from 4:20 P.M. through 5:00 P.M. The surveyor observed CNA #1 interacting with several residents during this time. During an interview on 6/6/23 at 5:04 P.M., CNA #1 said she would like to be able to wear a mask but she could not because she had a hard time breathing and the masks made her tired.

Based on observations and interview, the facility failed to ensure provided meals were palatable and of appropriate temperatures on two (Village Unit and Courtyard Unit), out of the two units observed. Findings include: During the initial pool process on 6/6/23 the survey team identified the following meal concerns: -Cold food -Bland food -Overcooked food 1. On 6/7/23 at 11:53 A.M., the surveyor observed the steam table arrive on Village Unit for lunch service. On 6/7/23 at 12:01 P.M., the surveyor observed the start of lunch trays being served to the residents in the Village dining room. On 6/7/23 at 12:32 P.M., the final meal had been delivered and the surveyor obtained the following temperatures and palatability with Activities Assistant #1: -pureed mac and cheese: 99 degrees Fahrenheit (F) tasted lukewarm, not hot, bland, with a runny consistency -pureed mixed vegetables:100 degrees (F), tasted lukewarm, not hot, bland, with a runny consistency -pureed stuffed peppers: 100 degrees (F), tasted lukewarm, not hot, with a runny consistency -regular consistency mixed vegetables: 98 degrees (F), tasted lukewarm and bland 2. On 6/7/23 at 11:59 A.M., the surveyor observed the steam table arrive on Courtyard Unit for lunch service. On 6/7/23 at 12:04 P.M., the surveyor observed the start of lunch trays being served to the residents in the Courtyard Dining Room. On 6/7/23 at 12:44 P.M., a test tray was conducted and the following temperatures obtained with Dietary Aide #2: -regular texture stuffed pepper: 121 degrees F, tasted lukewarm -ground mixed vegetables: 120 degrees F, tasted lukewarm -puree carrots: 115 degrees F, tasted cold -pureed mac and cheese: 100 degrees F, tasted lukewarm and had a runny consistency -strawberry mousse: 50 degrees F, tasted greasy, oily, and strong artificial strawberry flavor During an interview on 6/7/23 at 1:00 P.M., Dietary Staff #2 said that there were times that the resident meal trays were sitting on the service counter waiting to be distributed by staff. Dietary Aide #2 further said the plates were not warmed and the covers for the plate allowed for venting which did not help with keeping the food warm. On 6/8/23 at 11:57 A.M., the surveyor reviewed the dining observations from lunch on 6/7/23 from the Village and Courtyard Units, and the obtained temperatures during the test trays with the Food Service Director (FSD). The FSD said that the temperatures of the food were usually taken prior to leaving the kitchen when the food was put into the steamtable. She further said the ideal temperatures for the hot items would be around 145 degrees F. The FSD said that hot food temperatures of 98 to 120's were not acceptable and that those temperatures were concerning. She further said that the pureed food consistency should hold its shape, like uncooked muffin mix, and should not be runny/liquidy and spreading across the plate when served.

Based on observations, interviews, and record reviews, the facility failed to implement the plan of care for four Residents (#4, #10, #18 and #75), out of a total sample of 19 residents. Specifically the facility failed to: 1) For Resident #4, implement the plan of care relative to Activities of Daily Living (ADLs) and swallowing. 2) For Resident's #10 and #18, ensure the Physician's Orders relative to medication parameters were implemented. 3) For Resident #75, ensure the plan of care relative to fall prevention was implemented. Findings include: 1. For Resident #4 the facility failed to ensure the plan of care and/or Physician's Orders were implemented relative the level of supervision and adaptive equipment as recommended by the Speech Language Pathologist (SLP- clinician who assess, prevent, diagnose and treat swallowing disorders) to reduce the risk of aspiration (inhalation of food/fluid/substances into the airway and lungs). Resident #4 was admitted to the facility in April 2017 with diagnoses including Dysphagia (difficulty swallowing), Peripheral Vascular Disease (PVD- circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and muscle weakness. Review of a Minimum Data Set (MDS) Assessment, dated 4/17/23, indicated Resident #4 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15, and required supervision when eating. Review of the SLP Discharge Summary, dated 3/1/23, indicated the following: -education was provided to Resident and staff on levels of swallowing difficulty, diet level, safe swallow strategies, -supervision during meals to increase carryover of safe swallow strategies, and -upgrade to thin liquids with the use of the Provale cup (limited flow cup for the delivery of thin liquids) and ensuring that all beverages are provided with the Provale cup . Review of the ADL Care Plan, revised 5/5/23, indicated Resident #4 required assist with ADLs and included the following interventions: -continual supervision during eating, one staff to eight resident (1:8 group) -cue Resident on proper eating techniques -Resident utilizes Provale cup Review of the June 2023 Physician's Orders included the following: -Use Provale cup with thin liquids On 6/6/23 at 9:00 A.M., the surveyor observed Resident #4 seated in a wheelchair in his/her room eating breakfast which was on an overbed table positioned in front of him/her. No staff were present in the room. During a brief interview, Resident #4 was observed to cough and bring up chewed breakfast food. The surveyor asked if he/she was okay, and the Resident responded yes, but I need a bucket. The surveyor relayed the Resident's request to Certified Nurse Aide (CNA) #3, who provided assistance. During an interview with CNA #3, the surveyor relayed the previous observations and CNA #3 said the Resident was okay to eat by him/herself and was cleared by the SLP to do so. On 6/6/23 at 10:52 A.M., the surveyor observed the Resident seated in a wheelchair in his/her room with an overbed table placed in front of him/her. A bin was observed on the overbed table positioned in front of the Resident and contained some chewed up food mixed with fluids. On 6/7/23 at 9:28 A.M., the surveyor observed the Resident seated in a wheelchair in his/her room with an overbed table positioned in front of him/her, finishing a bowl of hot cereal. The Resident asked the surveyor for more hot cereal and the surveyor exited the room and went to the unit dining area where breakfast was being served. CNA #5 was observed to get a bowl of hot cereal and accompanied the surveyor to Resident #4's room. She was observed to provide the Resident with the bowl of hot cereal, instruct him/her to eat slowly and then leave the room while the Resident was eating. On 6/7/23 at 12:32 P.M., the surveyor observed the Resident seated in a wheelchair in his/her room eating lunch. There was no staff in the room providing supervision during the meal, as care planned. The Resident had a regular hot beverage cup (not a Provale cup) containing coffee, and was observed to drink from it during the observation. During an interview on 6/8/23 at 8:55 A.M., the SLP said that she had worked with Resident #4 for swallowing. She said he/she was impulsive and needed to be cued by staff to slow down while eating. She further said that supervision should be provided during the meal and that all liquids should be provided in the Provale cup to prevent risk of aspiration. The SLP said the facility had numerous Provale cups, that there are usually some available on the unit, but if there were not, the unit staff could contact the Dietary Department to request more. During an interview on 6/8/23 at 9:29 A.M., Unit Manager (UM) #2 said Resident #4 typically eats in the unit dining room and that supervision should be provided by staff while he/she was eating. She further said that Resident #4 had an increased risk of aspiration and if not eating in the dining room, staff would have to supervise him/her while eating in his/her room. UM #2 said all of the Resident's liquids should be provided in the Provale cup, as care planned, that the Resident had not been refusing the specialized cup, and that if there were none available on the unit, staff could call the Dietary Department to get more. During a follow-up interview on 6/8/23 at 10:41 A.M., the SLP said she re-evaluated Resident #4 and that he/she was back to old habits of shoveling food and not taking time to chew/swallow his/her food. The SLP said once the Resident was given verbal cues, he/she did not have any issues and that facility staff needed to provide supervision and cues to slow him/her down while eating. 2. For Resident's #10 and #18, the facility staff failed to ensure the Physician's Orders were implemented on when to hold a blood pressure medication for administration relative to specific parameters. a) Resident #10 was admitted to the facility in December 2021 with diagnoses including Cerebral Infarction (Stroke) and Hypertension (HTN - high blood pressure). Review of the Physician's Orders, dated April 2023 through June 2023 included the following: -Metoprolol Tartrate (medication to treat high blood pressure) 25 milligrams (mg), give two tablets twice daily for Hypertension. -Hold if Systolic (phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) Blood Pressure (BP) is less then 100 or heart rate (HR) is less then 60. -Lisinopril (medication to treat high blood pressure) 20 mg, give one tablet in the evening for Hypertension. -Hold for Systolic BP less then 100 or HR less then 60. Review of the April 2023 MAR indicated the following: -on 4/7/23 Metoprolol which was scheduled at 6:00 A.M. was documented as administered when the Resident's Systolic BP was 95 (parameter indicated to hold was if less than 100) Review of the May 2023 MAR indicated the following: -on 5/31/23 Metoprolol scheduled at 5:00 P.M. was documented as administered when the Resident's Systolic BP was 92. Review of the June 2023 MAR indicated the following: - on 6/2/23 Metoprolol and Lisinopril scheduled at 5:00 P.M. and 6:00 P.M., respectively, was documented as administered when the Resident's Systolic BP was 90. On 6/8/23 at 9:59 A.M., UM #2 reviewed the Resident's clinical record with the surveyor. UM #2 said that the Resident's blood pressure medication Metoprolol was administered and should have been held on 4/7/23, 5/31/23 and 6/2/23. She further said that Lisinopril was administered and should also have been held on 6/2/23. b) Resident #18 was admitted the the facility in April 2022 with diagnoses including Hypertension and Chronic Kidney Disease. Review of the Physician's Orders from April 2023 through June 2023 included the following: -Metoprolol 25 mg, give 0.5 tablet twice daily for Hypertension. -Hold if Systolic BP is less then or equal to 100, hold if Diastolic (phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood) BP is less then or equal to 60 and hold if HR is less then or equal to 60. Review of the April 2023 MAR indicated the following dates and times when Metoprolol was administered: -4/2/23 at 9:00 P.M., the Resident's HR was 60, -4/3/23 at 9:00 A.M., the Resident's HR was 60, -4/11/23 at 9:00 A.M., the Resident's Diastolic BP was 60 -4/12/23 at 9:00 A.M., the Resident's Diastolic BP was 55 -4/22/23 at 9:00 A.M., the Resident's Diastolic BP was 60 -4/23/23 at 9:00 P.M., the Resident's Diastolic BP was 55 -4/27/23 at 9:00 P.M., the Resident's Diastolic BP was 58 Review of the May 2023 MAR indicated the following dates and times Metoprolol was administered: -5/11/23 at 9:00 A.M., the Resident's Systolic BP was 92 -5/17/23 at 9:00 A.M., the Resident's Diastolic BP was 55 -5/4/23 at 9:00 P.M., the Resident's Systolic BP was 93 -5/7/23 at 9:00 P.M., the Resident's Diastolic BP was 58 -5/10/23 at 9:00 P.M., the Resident's Diastolic BP was 57 -5/11/23 at 9:00 P.M., the Resident's Diastolic BP was 51 -5/16/23 at 9:00 P.M., the Resident's Diastolic BP was 53 -5/17/23 at 9:00 A.M., the Resident's Diastolic BP was 55 -5/18/23 at 9:00 P.M., the Resident's Diastolic BP was 59 -5/20/23 at 9:00 P.M., the Resident's Diastolic BP was 58 Review of the June 2023 MAR indicated the following dates and times Metoprolol was administered: -6/2/23 at 9:00 A.M., the Resident's Systolic BP was 98 and his/her Diastolic BP was 55 -6/4/23 at 9:00 A.M., the Resident's Systolic BP was 98 and his/her Diastolic BP was 59 -6/6/23 at 9:00 A.M., the Resident's Diastolic BP was 60 On 6/8/23 at 10:07 A.M., UM #2 reviewed the Resident's MARs for April 2023 through June 2023 with the surveyor. She said the Metoprolol was administered on the reviewed dates/times and should have been held according to the parameters within the Physician's orders. She further said if the Resident had a low blood pressure or heart rate and the medication was administered, the blood pressure and/or heart rate could drop even lower which could be concerning. 37086 3. For Resident #75 the facility failed to ensure that foot rests on the wheelchair were used during transport only. Resident #75 was admitted to the facility in September 2022 with a diagnosis including Alzheimer's Disease. Review of an incident report dated 6/2/23, indicated the Resident sustained an unwitnessed fall in his/her room. The Resident was found on the floor with his/her right leg caught up in the leg rests. Further review indicated, under the section for supervisor evaluation and follow-up- the Resident had a fall related to the foot rests on the wheelchair. The Resident was attempting to get up and tripped on the foot rest. Plan was to use the foot rests when transporting the Resident in the wheelchair. Review of the Resident's care plan for falls, with goal date of 6/20/23, indicated the following intervention: -No foot rests on the wheelchair unless transporting the Resident. On 6/6/23 at 3:42 P.M., the surveyor observed the Resident in his/her room, seated in a wheelchair with bilateral foot rests. On 6/7/23 at 9:05 A.M., the surveyor observed the Resident in the dining room, seated in a wheelchair with bilateral foot rests. On 6/7/23 at 2:42 P.M., the surveyor observed the Resident in the dining room, seated in a wheelchair with bilateral foot rests. During an interview on 6/7/23 at 3:43 P.M., Unit Manager (UM) #1 said the Resident was supposed to have wheelchair foot rests on only during transport. UM #1 looked at Resident #75, who was still in the dining room, seated in a wheelchair with bilateral foot rests. UM #1 said Resident #75 should not have the foot rests on and that she did not know the Resident had them on the last two days.

Based on observations, interviews and record review, the facility failed to maintain complete and accurate medical records for one Resident (#10), out of a total sample of 19 Residents. Specifically, the facility staff failed to ensure: a) Residuals (amount of liquid drained from the stomach following administration of enteral feeding [a form of nutrition that is delivered into the digestive system as a liquid via a feeding tube]) were documented in the clinical record. b) The order to obtain residuals was discontinued when the Resident transitioned to taking all meals by mouth. Findings include: Resident #10 was admitted to the facility in December 2021 with diagnoses including Cerebral Infarction (stroke), Dysphagia and Gastrostomy (G-tube: a feeding tube surgically inserted through the abdomen and into the stomach to deliver liquid food/fluids/medications). Review of the MDS Assessment, dated 2/6/23, indicated Resident #10 was severely cognitively impaired as obtained from staff interview, was dependent on staff with eating, and had a feeding tube which provided greater then 51% caloric needs and greater then 501 cubic centimeters (cc's) of fluids daily. Review of the Physician's Orders, dated January 2023 through June 2023, included the following: -check G-tube residual volumes, hold for residual of 30 cc's or greater for one hour. If the residual remains greater then 30 ccs, call the Provider for further directions (initiated 8/19/22). Further review of the Physician's Orders indicated G-tube feedings were discontinued on 4/13/23 and the Resident was on a modified consistency diet, all meals with the assistance from staff. Review of the Resident's Medication Administration Record (MAR) and Treatment Administration Records (TAR) from January 2023 through June 2023 indicated no documented evidence that residuals were obtained. On 6/7/23 at 8:42 A.M., the surveyor observed CNA #7 assisting Resident #10 with the breakfast meal. During an interview at that time, CNA #7 said the Resident was doing well with eating by mouth and was currently off the G-tube feedings. On 6/7/23 at 12:22 P.M., the surveyor observed Nurse #2 assisting Resident #10 with the lunch meal. Nurse #2 said Resident #10 was doing well with eating by mouth. When the surveyor inquired about the residual checks for Resident #10, Nurse #2 said that he was still checking them. On 6/7/23 at 3:08 P.M., Nurse #2 reviewed Resident #10's clinical record with the surveyor. He said that he checked G-tube residuals whenever he was administering medications or fluids to the Resident. When asked, Nurse #2 said that he was not sure if there were parameters when checking the Resident's G-tube residuals but upon reviewing the Physician's order said there were parameters indicated. Nurse #2 further said that there was no place to document the amount obtained when checking the Resident's residuals because the order was entered incorrectly so there was no designation on where this information should be documented (MAR or TAR). He further said that he checks the residuals but does not document the amounts obtained. On 6/8/23 at 9:49 A.M., UM #2 reviewed the clinical record with the surveyor. UM #2 said she spoke with the Provider who discontinued the residual checks because Resident #10 was no longer receiving feedings through the G-tube. She further said that when the Resident was receiving G-tube feedings, the residuals should have been checked and the amount obtained documented within the MAR or TAR. UM #2 said that the order was entered incorrectly so the amounts obtained from the residual checks were not documented and should have been.

Based on observations, interviews and record review, the facility staff failed to ensure access to a call light (a device used to alert staff of a request/need) for one Resident (#4), out of a total sample of 19 residents. Specifically, Resident #4's call light was not accessible during meals when he/she was eating in his/her room without staff presence/supervision. Findings include: Resident #4 was admitted to the facility in April 2017 with diagnoses of Acute Respiratory Failure with Hypercapnia (where the lungs are unable to adequately oxygenate the blood and eliminate carbon dioxide, resulting in abnormally elevated carbon dioxide levels) and Dysphagia (difficulty with swallowing). Review of the Minimum Data Set (MDS) Assessment, dated 4/17/23, indicated Resident #4 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Review of the Activities of Daily Living (ADL) Care plan, revised 5/5/23, included the following intervention: -call light to be within reach On 6/6/23 at 9:00 A.M., the surveyor observed Resident #4 seated in a wheelchair in his/her room eating breakfast. The call light was observed clipped to its cord against the wall behind the Resident and was not accessible. During an interview, the Resident was observed to cough and bring up chewed breakfast food. The surveyor asked Resident #4 if he/she was okay, the Resident responded yes, but I need a bucket. The surveyor alerted Certified Nurse Aide (CNA) #3 who was down the hallway outside of the Resident's room, who said he would assist. On 6/6/23 at 10:52 A.M., the surveyor observed Resident #4 seated in his/her room in the same position as earlier observed. An emesis bucket was observed on the Resident's overbed table. The call light remained clipped to its cord against the wall and was not accessible. On 6/7/23 at 8:27 A.M., the surveyor observed the Resident seated in his/her room in a wheelchair. The call light was not accessible and was located behind the bedside table which was located behind the Resident. Another call light was observed between the side rail and the mattress of the bed and was not visible nor accessible to the Resident. During the observation, the Resident asked the surveyor for something to drink. The surveyor relayed the request to Unit Manager (UM) #2 who assisted the Resident. On 6/7/23 at 9:28 A.M., the surveyor observed Resident #4 seated in a wheelchair in his/her room with a breakfast plate on an overbed table in front of him/her. The Resident requested more hot cereal from the surveyor who relayed the request to CNA #5 who was in the unit dining room area. CNA #5 obtained the hot cereal and accompanied the surveyor to Resident #4's room. During an interview, CNA #5 said Resident #4 required assistance with care/transfers and was able to alert staff to his/her needs by utilizing the call light. The surveyor asked CNA #5 if the Resident's call light was accessible to him/her. CNA #5 was observed to look around, pull the cords from the wall where the call lights were attached, pull the call light out from behind the bedside table which was behind the Resident, and place the call light on the Resident's lap. CNA #5 said that it was not accessible and should have been since he/she used it frequently to request assistance. During an interview on 6/8/23 at 9:29 A.M., UM #2 said Resident #4 had swallowing difficulty and was at risk for aspiration (when food/fluid/other material enter a person's airway and into the lungs). She further said the Resident should have his/her call bell accessible at all times to alert staff of needs/requests.

Based on record review and interview, the facility failed to report out of range laboratory values to the Physician for Resident (#75), and to obtain Physician ordered laboratory services for one Resident (#4), out of a total sample of 19 residents. Specifically 1. For Resident #75, the facility failed to ensure its staff reported an out of range Valproic Acid level of 40 micrograms per milliliter (ug/ml), [normal range is ,d+[DATE] ug/ml], and 2. For Resident #4 the facility failed to provide Physician ordered laboratory services for liver function tests (LFTs- a test to help diagnose and monitor liver disease or damage) and Hemoglobin A1c (a test that measures the average blood sugar levels over the past three months) tests. Findings include: 1. Resident #75 was admitted to the facility in [DATE] with diagnoses including Alzheimer's Disease, Major Depressive Disorder and anxiety disorder. Review of the Valproic Acid (level of Valproic acid in the blood when taking Depakote- a medication used as a mood stabilizer; a low level indicates the medication is ineffective and a high level indicates toxicity) laboratory test, dated [DATE], indicated a result of 30 ug/ml (out of reference range). Review of a Physician's order, dated [DATE], indicated to increase the Depakote to 500 milligrams (mg) twice a day for seven days and check the Valproic Acid level on [DATE]. Review of the Valproic Acid laboratory test, dated [DATE], indicated a result of 42 ug/ml (out of reference range). Review of the clinical record indicated no evidence that the Physician was notified of the laboratory result on [DATE]. Review of the Physician's orders indicated no new order for Depakote was obtained on [DATE]. Review of the [DATE] Medication Administration Record (MAR) indicated the Resident was administered Depakote 500 mg by mouth twice a day from [DATE] through [DATE]. During an interview on [DATE] at 4:20 P.M., Unit Manager (UM) #1 reviewed the clinical record with the surveyor and said the Physician should have been notified of the laboratory result on [DATE] and a new order for Depakote should have been obtained since the original order was only good for seven days (expired on [DATE]). 37400 2. For Resident #4, the facility failed to ensure its staff obtained laboratory services as ordered by the Physician. Resident #4 was admitted to the facility in [DATE] with diagnoses including Type II Diabetes (DM II) and Fatty Liver. Review of the [DATE] Physician's Orders indicated the following: -obtain Liver Function Tests (LFTs) every six months (every April and October) -obtain HgbA1c (blood test to assess average blood sugar levels over the past three months) every three months (every January, April, July, October) Review of the Resident's clinical record indicated the the Resident's HgbA1c was last obtained in [DATE]. There was no further documented evidence that the HgbA1c level was drawn after that date (scheduled in January and [DATE]). Further review of the clinical record indicated there was no documented evidence that LFT's were obtained as ordered by the Physician. On [DATE] at 9:29 A.M., the surveyor reviewed Resident #4's clinical record with Unit Manager (UM) #2. UM #2 said that the ordered lab work for obtaining the HgbA1c was last completed in [DATE] and should have been obtained in January and [DATE] but was missed. She further said the LFTS were last completed in [DATE] and should have been completed in [DATE] and [DATE]. UM #2 said when there was a Physician's Order for scheduled lab work, the process included submitting these orders to the laboratory for scheduled lab work to be completed as ordered and this did not appear to have been done.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive physical assistance of two staff members with bed mobility and toilet use, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety to prevent incidents and/or accidents resulting in an injury. On 12/05/22, Certified Nurse Aide (CNA) #1 who was assigned to care for Resident #1, provided incontinence care and repositioned him/her in bed without another staff member present to provide assistance, when CNA #1 rolled Resident #1 onto his/her side, Resident #1 rolled out of bed and landed face down on the floor. Resident #1 was bleeding from his/her head and face and was transferred to the Hospital Emergency Department for evaluation. Upon return, Resident #1 was monitored and treated for pain management. Findings include: Review of the Facility's Policy, titled Fall Prevention, dated as 7/20/2020, indicated that to maintain and promote each residents' independence and level of function while minimizing the risk for fall-associated injury and that a fall risk will be documented on the facility Fall Risk Assessment tool. The Policy indicated that preventative care planning for the resident at risk for falls should involve all relevant disciplines and all team members be aware of the risks and benefits of interventions and will be entered into the resident care plan. Review of the Report submitted by the Facility via the Health Care Reporting System (HCFRS), dated 12/09/22, indicated that on 12/05/22 at approximately 2:15 P.M., Resident #1 had a fall from his/her bed while being positioned during incontinence care. The Report indicated Resident #1 remained in the prone position on the floor until EMS (Emergency Medical Services) arrived and he/she was transferred to the Hospital Emergency Department for evaluation. The Report indicated that Resident #1 returned to the Facility with an abrasion to the inner side of his/her nose, ecchymosis (bruising) and swelling to his/her right eye. The Report indicated that Resident #1 was placed on a pain regimen that included, scheduled Tylenol every six hours for seven days. Resident #1 was admitted to the Facility in November 2017, diagnoses included cerebral infarction (stroke), dysphagia (difficulty swallowing), epilepsy, polyosteoarthritis (damage to joint cartilage, resulting in joint pain and swelling), and gastro-esophageal reflux disease. Review of Resident#1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/24/22, indicated that Resident #1 required extensive physical assistance of two staff members for bed mobility and toilet use which included incontinence care. Review of Resident #1's Fall Risk Assessment, dated 10/21/22, indicated that he/she was assessed by nursing as being at increased risk for falls. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, (confirmed with the Director of Nurses as the plan of care that was in effect at the time of the fall) indicated that his/her level of staff assistance varied from an extensive assistance of two staff members to being totally dependent on two staff members for bed mobility/positioning, and he/she was totally dependent and required two staff members for toilet use (which included incontinence care). Review of Resident #1's CNA Care Kardex, (per the Director of Nurses as the Resident Kardex that was in effect at the time of the fall), indicated that he/she required physical assistance of two staff members to being totally dependent of two staff members for bed mobility/positioning and was totally dependent on two staff members for toilet use (which included incontinence care). Review of a Nurse Progress Note, dated 12/05/22, indicated that Resident #1 had a witnessed fall out bed and that he/she was found on the floor in the prone position with moderate bleeding, that Nursing was called immediately, the Physician Assistant (PA) responded, and assessed Resident #1. The Note indicated that orders were received to send Resident #1 out via 911, EMT's (Emergency Medical Technician) arrived and noted that Resident #1 had an open area on the bridge of his/her nose and right side of his/her forehead. The Note indicated that Resident #1 was transferred to the Hospital Emergency Department for evaluation. During an interview on 01/04/23 at 10:22 A.M., Nurse #1 said that on 12/05/22, CNA #1 called her into Resident #1's room and said that she found Resident #1 lying face down on the floor with blood around his/her head and face, and that he/she was moaning in discomfort while she was assessing him/her. Nurse #1 said that she told Nurse #2 to call a Facility medical emergency and 911 and said that the Physician Assistant responded to the Facility medical emergency call, assessed Resident #1, and ordered he/she be sent to the Emergency Department for evaluation. Nurse #1 said that CNA #1 told her that while she was providing care to Resident #1, he/she rolled off the bed onto the floor. Nurse #1 said that Resident #1 required the assistance of two staff members with bed mobility, positioning, and incontinence care. Nurse #1 said she was not aware that CNA #1 had provided care to Resident #1 by herself. Review of CNA #1's Written Witness Statement, dated 12/05/22, indicated that while she was providing incontinence care to Resident #1, he/she slipped out of his/her bed. During an interview on 01/04/23 at 11:17 A.M., CNA #1 said that on 12/05/22, she was assigned to and provided incontinence care to Resident #1 while he/she was in bed, which included needing to reposition him/her. CNA #1 said she turned and repositioned Resident #1 in bed alone, without another staff member to help her. CNA #1 said that while providing incontinence care to Resident #1, she rolled him/her onto his/her side and tucked the soiled (dirty) linen under his/her body. CNA #1 said that she then rolled him/her over onto his/her other side and when she pulled the soiled linen out from under his/her body, he/she rolled off the bed, and fell to the floor. CNA #1 said she was not aware that Resident #1 required two staff members to assist with bed mobility and incontinence care. CNA #1 said that she knew how to access the CNA Care Kardex (indicates each individual resident's ADL care needs and level of staff assistance required) in the computer, but said she did not access or review Resident #1's CNA Care Kardex prior to providing care to him/her. Review of a Hospital Emergency Department Report, dated 12/06/22, indicated that Resident #1 was seen in the Emergency Department after a fall out of bed and that his/her face and forehead had struck the ground. The Report indicated that Resident #1 sustained a contusion to his/her right frontal scalp and an epistaxis (nosebleed). Review of Resident #1's Nurse Progress Notes dated 12/06/22 through 12/31/22 indicated the following: 11:00 P.M.-7:00 A.M. shifts: -that Resident #1 returned from the emergency room , and he/she had a large ecchymotic (bruise) area to OD (right eye), two scabs to bridge of nose and a crescent shaped laceration to his/her forehead above slightly to the right of his/her eye, blood was cleansed from his/her face and hair, and large amount of dried crusted blood inside his/her nose. Resident #1 was placed on neuro checks (evaluate for changes in clinical status or neurological function) because he/she hit his/her head. -S/P (status post) fall, Resident #1 has large purple ecchymosis surrounding OD and now OS (left eye) has reddish purple ecchymosis and scabs to nose intact, laceration to forehead approximated (close together), and abrasions to abdomen and chest remain unchanged. -bruising to face is fading yellowish purple. -ecchymosis to face is fading and is now yellow green color. -S/P fall with ecchymotic area to face is fading. -S/P fall with ecchymosis to face which is now fading. -S/P fall with ecchymosis to his/her face and forehead greenish yellow in most spots and resolving. -ecchymosis is resolving and is greenish yellow in most spots. -ecchymotic areas resolving and is greenish yellow in most spots. -S/P fall with ecchymotic areas resolving and at this point areas are light yellow in most spots. 7:00 A.M.-3:00 P.M. shifts: -bruise underneath left eye and laceration on left thigh -bruising to face/scabs. Pain with repositioning notified PA and new order for scheduled Tylenol every six hours times one week. -bruises remain on his/her face. -bruising to eyes fading yellowish purple. -bruises to right eye healing with yellowish color noted and forehead and bridge of nose discolored fading. -forehead and bridge of nose scabbed and improving, and under eyes pale yellow green coloring fading. -discoloration to right eye fading. 3:00 P.M.-11:00 P.M. shifts: -bruises to face/scrapes noted and swelling to septum (between the nostrils). -purple bruises and dry scabs on face intact. -bruising to face/scabs remain. -right thigh superficial abrasion intact, S/P fall, fading bruises on face. -discoloration to right eye fading its color to yellow and light purple color and bruising to eyes and nasal areas remain. -forehead, under eyes and nasal areas bruises resolving slowly. -facial swelling and bruising decreased, bruising yellowing under eyes, and forehead and bridge of nose scabbed, and purple yellowish bruising on face area. -bruising to face is fading yellowy green color. During an interview on 01/03/23 at 2:49 P.M., the Director of Nurses (DON) said that CNA #1 was providing incontinence care to Resident #1 by herself, and when she rolled him/her over he/she slipped out of bed onto the floor. The DON said that Resident #1's plan of care indicated that he/she required physical assistance of two staff members for bed mobility, positioning and incontinence care, and said that Resident #1 was not provided the appropriate level of staff assistance, per his/her plan of care in order to maintain his/her safety.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive physical assistance of two staff members with bed mobility and toilet use, the Facility failed to ensure that staff implemented and followed interventions identified in his/her plan of care related to the need for two staff members to assist during care. On 12/05/22, Certified Nurse Aide (CNA) #1, who was assigned to care for Resident #1, provided incontinence care and repositioned him/her in bed without another staff member present to provide assistance, and when she repositioned Resident #1 onto his/her side, he/she rolled out of bed and landed face down on the floor. Resident #1 was bleeding from his/her head and face and was transferred to the Hospital Emergency Department for evaluation. Findings include: Review of the Facility's Policy, titled Resident Assessment Individualized Plan of Care, dated as 8/01/2018, indicated that an individualized plan of care will be established and monitoring the effectiveness of the plan and provision of care, treatment, and services on an ongoing basis. The Policy indicated that care plans will include each resident's physical, functional, and psychosocial status; and needs appropriate to the resident circumstance and goals to attain and maintain each resident's highest possible level of functioning. Resident #1 was admitted to the Facility in November 2017, diagnoses included cerebral infarction (stroke), dysphagia (difficulty swallowing), epilepsy, polyosteoarthritis (damage to joint cartilage, resulting in joint pain and swelling), and gastro-esophageal reflux disease. Review of Resident#1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/24/22, indicated he/she required extensive assistance of two staff members for bed mobility, positioning, and toilet use, which included incontinence care. Review of Resident #1's Fall Risk Assessment, dated 10/21/22, indicated that he/she was assessed by nursing as being at increased risk for falls. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, (confirmed with the Director of Nurses as the plan of care that was in effect at the time of the fall) indicated that his/her level of staff assistance varied from an extensive physical assistance of two staff members to being totally dependent on two staff members for bed mobility/positioning, and he/she was totally dependent and required two staff members for toilet use (which included incontinence care). Review of Resident #1's CNA Care Kardex, (per the Director of Nurses as the Resident Kardex that was in effect at the time of the fall), indicated that he/she required physical assistance of two staff members to being totally dependent of two staff members for bed mobility/positioning and was totally dependent on two staff members for toilet use (which included incontinence care). Review of the Report submitted by the Facility via the Health Care Reporting System (HCFRS), dated 12/09/22, indicated that on 12/05/22 at approximately 2:15 P.M., Resident #1 had a fall from his/her bed while being positioned during incontinence care. The Report indicated Resident #1 remained in the prone position on the floor until EMS (Emergency Medical Services) arrived and he/she was transferred to the Hospital Emergency Department for evaluation. The Report indicated that Resident #1 returned to the Facility with an abrasion to the inner side of his/her nose, ecchymosis (bruising) and swelling to his/her right eye. The Report indicated that Resident #1 was placed on a pain regimen that included, scheduled Tylenol every six hours for seven days. Review of a Nurse Progress Note, dated 12/05/22, indicated that Resident #1 had a witnessed fall out bed and that he/she was found on the floor in the prone position with moderate bleeding, that Nursing was called immediately, the Physician Assistant (PA) responded, and assessed Resident #1. The Note indicated that orders were received to send Resident #1 out via 911, EMT's (Emergency Medical Technician) arrived and noted that Resident #1 had an open area on the bridge of his/her nose and right side of his/her forehead. The Note indicated that Resident #1 was transferred to the Hospital Emergency Department for evaluation. During an interview on 01/04/23 at 10:22 A.M., Nurse #1 said that on 12/05/22, CNA #1 called her into Resident #1's room and said she found Resident #1 lying face down on the floor with blood around his/her head and face, and that he/she was moaning in discomfort while she was assessing him/her. Nurse #1 said that CNA #1 told her that while she was providing care to Resident #1, he/she rolled off the bed and fell on to the floor. Nurse #1 said that Resident #1 required the assistance of two staff members with bed mobility, positioning, and incontinence care, and said she was not aware that CNA #1 had provided care to Resident #1 by herself. Review of CNA #1's Written Witness Statement, dated 12/05/22, indicated that while she was providing incontinence care to Resident #1, he/she slipped out of his/her bed. During an interview on 01/04/23 at 11:17 A.M., CNA #1 said that on 12/05/22, she was assigned to and provided incontinence care to Resident #1 while he/she was in bed, which included needing to reposition him/her. CNA #1 said she turned and repositioned Resident #1 in bed alone, without another staff member there to help her. CNA #1 said that while providing incontinence care to Resident #1, she rolled him/her onto his/her side and tucked the soiled (dirty) linen under his/her body. CNA #1 said that she then rolled him/her over onto his/her other side and when she pulled the soiled linen out from under his/her body, he/she rolled off the bed, and fell to the floor. CNA #1 said she was not aware that Resident #1 required two staff members to assist with bed mobility and incontinence care. CNA #1 said that she knew how to access the CNA Care Kardex (indicates each individual resident's ADL care needs and level of staff assistance required) in the computer, but said she did not access or review Resident #1's CNA Care Kardex prior to providing care to him/her. Review of Resident #1's ADL Documentation Report dated December 2022 (known as Certified Nurse Aide documentation flow sheet), indicated that on 12/05/22, Certified Nurse Aide #1 documented that Resident #1 was total dependent with bed mobility and toilet use on the day shift with physical assist of one person. During an interview on 01/03/23 at 2:49 P.M., the Director of Nurses (DON) said that Resident #1's plan of care indicated that he/she required assistance of two staff members for bed mobility, positioning and incontinence care, and said that Resident #1 was not provided the appropriate level of staff assistance, per his/her plan of care in order to maintain his/her safety. Review of a Hospital Emergency Department Report, dated 12/06/22, indicated that Resident #1 was seen in the Emergency Department after a fall out of bed and that his/her face and forehead had struck the ground. The Report indicated that Resident #1 sustained a contusion to his/her right frontal scalp and an epistaxis (nosebleed).

Based on policy review, document review, and interview, the facility failed to ensure its staff adhered to requirements for COVID-19 outbreak testing related to: 1) testing frequency and 2) documentation of test results for one staff member (CNA #1) out of three sampled staff members. Findings include: Review of the facility's policy titled Testing and Reporting, revised December of 2020, indicated: -Facility staff were required to adhere to CMS guidance related to COVID-19 testing Review of Centers for Medicare and Medicaid Services (CMS) document titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency Related to Long Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool, dated August 26, 2020 indicated the following: -The LTC facility must test all staff for COVID-19 -The LTC facility must conduct testing based on parameters set forth by the Secretary, including but not limited to testing frequency -For outbreak testing, all staff should be tested , and all staff that tested negative should be retested every 3-7 days until testing identifies no new cases of COVID-19 infection for a period of at least 14 days since the most recent positive result. -The LTC facility must document that testing was completed and the results of each staff test for each instance of testing During an interview on 2/23/21 at 8:20 A.M., the Infection Preventionist (IP) said that the facility had experienced an outbreak of COVID-19 and that the most recent positive test result was on 2/5/21. She further said that facility staff were required to be tested for COVID-19 every three days during outbreak testing. 1. Review of the facility's February 2021 COVID-19 testing log indicated no documented evidence that CNA #1 was tested for COVID-19 between 2/1/21 and 2/11/21. Review of CNA #1's timecard indicated that she worked at the facility on the following eight dates: 2/1/21, 2/2/21, 2/3/21, 2/4/21, 2/5/21, 2/8/21, 2/9/21, and 2/10/21. During an interview on 2/23/21 at 2:36 P.M., the IP said that CNA #1 worked full time at the facility and that she had never tested positive for COVID-19. The IP said that the facility required staff who were negative for COVID-19 to be tested every three days during outbreak testing. The IP further said that she could find no documented evidence that CNA #1 was tested for COVID-19 between 2/1/21 and 2/11/21, as required. 2. Review of the facility's February 2021 COVID-19 testing log indicated that CNA #1 was tested for COVID-19 using the Binax NOW COVID-19 test (rapid testing card used to detect COVID-19) on 2/12/21 and 2/18/21. Further review of the log indicated no documented evidence that CNA #1's COVID-19 test results were documented, as required. During an interview on 2/23/21 at 2:36 P.M., the IP reviewed the facility's February 2021 staff COVID-19 testing logs and said that CNA #1's results were not documented for tests conducted on 2/12/21 or 2/18/21 and that there was no other documentation that indicated the results of these tests, as required.

Based on document review, policy review, record review and interview, the facility failed to ensure all staff were screened for signs and symptoms of COVID-19 at the start of their shift as required. Findings include: Review of the Centers for Disease Control and Prevention (CDC), considered a national standard by the Centers for Medicare and Medicaid Services (CMS), indicated the following on their website: Preparing for COVID-19 in Nursing Homes, dated November 20, 2020, indicated to: -Screen all Health Care Personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. -Actively take their temperature and document absence of symptoms consistent with COVID-19. Review of the facility policy for COVID-19, dated 12/28/20, indicated the following: -Surveillance for COVID-19, implement daily active surveillance for respiratory illnesses-COVID-19 like symptoms among all residents and HCP . -Employees will complete medical questionnaire per CDC guidelines. -Employees will have their temperature taken at the facility prior to their shift. Review of the daytime schedule for the Dietary Department, dated 1/26/21, indicated one cook and two dietary aides. Review of the Employee COVID-19 Screening Log, dated 1/26/21, indicated the cook, and Dietary Aides #1 and #2 had not been screened for signs and symptoms (including absence of fever) of COVID-19 prior to their shift, as required. During an interview on 1/26/21 at 1:20 P.M., the Infection Preventionist said that all staff were screened via the front lobby area prior to their shift and all screening logs were kept there. During an interview on 1/26/21 at 2:25 P.M., the Administrator reviewed the Dietary Schedule and the Employee COVID-19 Screening Log with the surveyor and said the kitchen staff usually took their own temperatures because there was no one at the front desk when they reported to work in the morning. She said the staff didn't have access to the screening logs so they couldn't fill them out. The Administrator said they needed a better system for the employees who report to work during off hours.

Based on policy review, record review and interview, the facility failed to ensure staff administered the pneumococcal vaccine to one resident (#2), and offered the pneumococcal vaccine to one resident (#3), out of five sampled residents. Findings include: Review of the facility policy titled Pneumonia, dated 11/2/18, indicated: -Offer the pneumococcal vaccine to residents on admission. 1. For Resident #2 the facility failed to ensure staff administered the pneumococcal vaccine when the resident indicated he/she wished to receive it. Resident #2 was admitted to the facility in October of 2019. Review of the Vaccine Information Sheet/Consent for Administration, signed and dated by the resident and staff member on 11/8/19, indicated the resident wished to receive the pneumococcal vaccine. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/2/20, indicated the resident's pneumococcal vaccine was not up to date and had not been offered. Review of the clinical record did not indicate the pneumococcal vaccine had been administered. During an interview on 1/26/21 at 1:25 P.M., the Infection Preventionist (IP) said she couldn't find any indication that the pneumonia vaccine had been administered. 2. For Resident #3 the facility failed to ensure staff offered the pneumococcal vaccine as required. Resident #3 was admitted to the facility in August of 2020. Review of the Significant Change in Status MDS, dated [DATE], indicated the resident's pneumococcal vaccine was not up to date and had not been offered. Review of the clinical record did not indicate the resident had been offered the pneumococcal vaccine. During an interview on 1/26/21 at 1:25 P.M., the IP said she reviewed the resident's record and was unable to find any evidence that the resident was offered the pneumonia vaccine on admission.

Based on document review, policy review, interview and observation, the facility failed to ensure staff maintained an infection prevention and control program, relative to Personal Protective Equipment (PPE) and hand hygiene, to help prevent the development and transmission of communicable diseases, infections and/or the COVID-19 virus. Findings include: Review of the Centers for Disease Prevention and Control (CDC) website, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 11/4/20, indicated the following; -Implement universal use of PPE for HCP working in facilities located in areas with moderate to substantial community COVID-19 transmission. HCP should wear eye protection in addition to their facemask's to ensure the eyes, nose and mouth are all protected from exposure to respiratory secretions during patient care encounters. -PPE use when caring for a patient with suspected or confirmed severe acute respiratory syndrome coronavirus-2 ([DIAGNOSES REDACTED]-CoV-2): *HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. *Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. *Put on clean, non-sterile gloves upon entry in the patient room or care area. Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. Review of the CDC website, Preparing for COVID-19 in Nursing Homes, dated 11/20/20, indicated the following: -HCP should wear a facemask at all times while they are in the facility. -Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room. Review of the CDC website for Hand Hygiene in Healthcare Settings, undated, indicated the following: HCP should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -After touching a patient or the patient's immediate environment. -Immediately after glove removal. Review of the facility's [MEDICAL CONDITION] COVID-19 Transmission Precautions Policy, revised date 12/7/20, indicated the following: -To prevent transmission of COVID-19 to others, upon entering the building a screening process is completed. KN95 masks are worn and eye protection is worn in resident care areas. PPE is supplied by the facility. -General PPE used with COVID-19 cases in the last 14 days. Wash hands and gowns for direct care. Review of the facility's PPE Coach/Audit/Educational Tool, undated, indicated the following: -N95 masks are worn at all times, if your touch your mask, clean your hands. -Handwashing/Gloves; staff do not wear gloves in the hallway. -Staff will need a face shield or goggles in any patient care areas. -Donning PPE: wash or gel hands, put on gown, mask and eye protection and gloves. During an interview on 1/5/21 at 8:15 A.M., the Administrator, the Infection Control Nurse (ICN) and the Director of Nurses (DON) said the census was 79 and the bed capacity was 113. The DON said there were six COVID-19 positive residents and they were on the COVID-19 dedicated unit (Village Unit). The ICN said there were three COVID-19 positive staff, with the most recent diagnosed in the last few days. The ICN said COVID-19 negative staff and residents, as well as recovered staff and residents with exposure, or symptoms, were being tested every three to seven days. During a tour of the facility's three resident care areas on 1/5/20 between 9:00 A.M. and 10:30 A.M., the following concerns were observed on three of three units: Hillside Unit -The surveyor observed Certified Nursing Assistant (CNA) #1 in a resident room, feeding the resident. The surveyor observed CNA #1's facemask down around her neck and her goggles on the top of her head, in her hair. The surveyor observed the aide use her bare hand to touch the front of her mask and pull it up to her cover her mouth only. The CNA told the surveyor that she had been previously educated on proper PPE use and hand hygiene -The surveyor observed Nurse #1 in a resident's room, standing on the left side of the bed, touching and assisting the resident who was lying in the bed. The surveyor observed Nurse #1 wearing a facemask and her goggles were on top of her head in her hair. She did not have on gloves or an isolation gown. A sign outside of the room indicated the following PPE use for high contact care; facemask, eye protection, gloves and an isolation gown. Courtyard Unit -The surveyor observed Housekeeper #1 cleaning in a resident room. The surveyor observed Housekeeper #1 exit and re-enter the same room, three different times to get something from her cart. She did not doff (remove) her gloves before exiting the room and perform hand hygiene. Village Unit -The surveyor observed Nurse #2 walk in to the COVID-19 unit. The surveyor observed her enter a work area room and don (put on) a reusable isolation gown. Nurse #2 did not perform hand hygiene before donning the isolation gown. She was observed returning to her medication cart to work. During an interview on 1/5/21 at 3:00 P.M., the surveyor reviewed the infection control observational concerns with the DON, the ICN and the Administrator. The DON and ICN said CNA #1 should have had on her mask and goggles when feeding the resident, and Nurse #1 should have had on her goggles, as well as an isolation gown and gloves while physically touching a resident. The DON said Housekeeper #1 should not have been in the hallway with gloves on. The ICN said Nurse #2 should have performed hand hygiene before donning the isolation gown when she returned to the COVID-19 unit and CNA #1 should have performed hand hygiene after touching the outside of her facemask with her bare hand, as required.

Based on observation, interview, and record review the facility (A.) failed to ensure staff properly monitored three residents (#2, #3 and #5) out of three applicable sampled residents, for fever at least daily; (B.) failed to ensure staff properly used Personal Protective Equipment (PPE), (C.) failed to ensure staff provided masks and kept residents socially distanced, related to COVID-19. Findings include: A. Review of the Centers for Disease Control and Prevention (CDC) website, Preparing for COVID-19 in Nursing Homes, updated 11/20/20, indicated the following: -Actively monitor all residents upon admission and at least daily for fever (T=100.0 Fahrenheit (F)) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions . 1. Resident #2 was admitted to the facility in April of 2007. Review of the December of 2020 physician's orders indicated an order for [REDACTED]. Review of the December of 2020 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not indicate Resident #2's temperature was monitored daily as required. 2. Resident #3 was admitted to the facility in July of 2020. Review of the December of 2020 physician's orders did not indicate an order for [REDACTED]. Review of the December of 2020 MAR and TAR did not indicate Resident #3's temperature was monitored daily as required. 3. Resident #5 was admitted to the facility in February of 2017. Review of the December of 2020 physician's orders indicated an order for [REDACTED]. Review of the December of 2020 MAR and TAR did not indicate Resident #5's temperature was monitored daily as required. During an interview on 12/22/20 at 1:05 P.M., Nurse #2 said the orders to check vital signs, including temperatures, varied with each resident. She said if residents displayed symptoms of being sick, their temperatures were checked but it wasn't standard and was not usually done daily. During an interview on 12/22/20 at 4:00 P.M., the Director of Nurses (DON) said the staff was supposed to monitor and record resident temperatures at least daily. B. Review of the CDC website, Preparing for COVID-19 in Nursing Homes, dated 11/20/20 indicated the following: Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or Health Care Personnel is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The health department can assist with decisions about testing of asymptomatic residents. During an interview on 12/22/20 at 7:20 A.M., the DON said the facility was in an active outbreak of COVID-19. She said the residents who were COVID-19 recovered, had COVID-19 greater than six months ago. She said the staff were using full PPE (mask, eye protection, gown, gloves) for high contact care of COVID-19 recovered (because they were greater than six months recovered) and COVID-19 negative (never positive) residents. On 12/22/20 at 8:50 A.M., on the Courtyard Unit, the surveyor observed the podiatrist cutting a resident's toenails in his/her room. The podiatrist had a mask, eye protection, gown, and gloves on. She removed the gloves and performed hand hygiene before exiting the resident's room. She then proceeded to another resident's room wearing the same gown. Outside of the resident's room was a sign to see the nurse before entering and a PPE cart was outside of the room. The surveyor observed the podiatrist take a washable gown out of the PPE cart outside of the resident's room and donned it over the gown she was wearing. She went into the resident's room to provide foot care. She removed the washable gown prior to exiting the resident's room but continued to wear the original gown. The surveyor observed the podiatrist proceed to another resident's room to provide foot care, wearing the same base gown. She did not remove the gown after each resident encounter and before exiting the resident's room, as required. During an interview on 12/22/20 at 9:25 A.M., the podiatrist said that per her company's policy, she was to wear a gown at all times. She said for residents who were COVID-19 negative, she wore a gown over a gown. She said that it was her understanding she was following the facility protocol by wearing a gown at all times. Review of the CDC website, Use of PPE, dated 8/19/20 indicated the following: How to Take Off (Doff) PPE Gear: More than one doffing method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of doffing, -Remove gloves -Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. -Healthcare personnel may now exit patient room. C. Review of the CDC website, Preparing for COVID-19 in Nursing Homes, dated 11/20/20, indicated residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility .Implement aggressive social distancing measures (remaining at least 6 feet apart from others). On 12/22/20 at 9:45 A.M., on the Courtyard Unit, the surveyor observed three residents seated within reach of each other, adjacent to the Nurses' Station. Two of the three residents did not have a face mask on. At 10:05 A.M., the surveyor observed Activity Assistant (AA) #1 wheel a resident down the hallway and into the communal area on the unit. The resident did not have a face mask on. The AA left the resident in the common area and proceeded towards the residents seated adjacent to the Nurses' Station. During an interview on 12/22/20 at 10:06 A.M., AA #1 said that she brought the residents into the communal area first, and then would pass out masks to the residents who didn't have them. During an interview on 12/22/20 at 10:07 A.M., the Rehabilitation Director said the three residents seated adjacent to the Nurses' Station were less than six feet apart and that one of them wasn't usually compliant with his/her face mask.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure that staff reported an allegation of abuse within two hours as required by facility policy and Federal regulations. On the morning of 05/27/19, Resident #1 reported to Certified Nurse Aide (CNA) #2 that CNA #1 inappropriately touched his/her genitals. CNA #2 reported Resident #1's allegation to Nurse #1, who did not report the alleged incident until approximately seven hours later. Findings include: Review of the Facility's Abuse, Neglect and Exploitation: Investigation policy, revised 11/28/17, indicated that a staff member who received or witnesses an allegation of abuse, neglect, exploitation or mistreatment would immediately report the event to the nursing supervisor. Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of the Facility's Internal Investigation, dated 05/27/19, indicated that it included a written statement from CNA #2. CNA #2's written statement indicated that at approximately 7:30 A.M. on 05/27/19, Resident #1 said CNA #1 put his hand on his/her genitals on more than one occasion and that CNA #1's actions made him/her uncomfortable. CNA #2's written statement also indicated that she notified Nurse #1 of Resident #1's allegation. The Surveyor interviewed CNA #2 at 2:36 P.M. on 06/11/19. CNA #2 said that on the morning of 05/27/19 at approximately breakfast time, she and CNA #1 went to provide care to Resident #1. CNA #2 said Resident #1 became upset and said he/she did not want CNA #1 in his/her room, to get CNA #1 out of his/her room. CNA #2 said that after CNA #1 left the room, she asked Resident #1 why he/she was upset. CNA #2 said Resident #1 told that a couple of days prior, CNA #1 touched his/her genitals and made him/her uncomfortable. CNA #2 said she made sure Resident #1 was safe, and immediately reported Resident #1's allegation to Nurse #1. Review of the Facility's Internal Investigation, dated 05/27/19, indicated that it included a written statement from Nurse #1. Nurse #1's written statement indicated that an incident was reported to her by a CNA, and that the Director of Nursing Services (DNS) was notified. The Statement did not indicate what incident Nurse #1 was notified of, or when. Review of the Facility's Internal Investigation, dated 05/27/19, indicated that it included a written statement from the Nurse Supervisor. The Nurse Supervisor's written statement indicated that he was notified of Resident #1's allegation at approximately 3:00 P.M. during shift report. The Surveyor interviewed the Nurse Supervisor at 3:14 P.M. on 06/11/19. The Nurse Supervisor said that on 05/27/19 during shift report, Nurse #1 told him that Resident #1 alleged he/she was touched inappropriately. The Nurse Supervisor said he asked Nurse #1 if she notified anyone of Resident #1's allegation, and said Nurse #1 said she had not. The Nurse Supervisor said he immediately notified the DNS of Resident #1's allegation. The Surveyor interviewed the Director of Nursing Services (DNS) at 1:17 P.M. on 06/11/19. The DNS said she was notified by the Nurse Supervisor of Resident #1's allegation at approximately 3:15 P.M. on 05/27/19. The DNS said she thought that staff had just learned of Resident #1's allegation at that time, and had reported it to her immediately. The DNS said she was not aware that Resident #1's allegation was reported to Nurse #1 by CNA #2 at approximately breakfast time on the morning of 05/27/19. There was no documentation to support that Nurse #1 immediately notified the Administrator or their designee of Resident #1's allegation of being inappropriately touched by CNA #1.

Based on interview and record review, the facility staff failed to assure that services being provided met professional standards of quality for 2 residents (#19 and Non-Sampled #1) in a total sample of 22 residents . Findings include: 1. For Resident #19, the facility staff failed to obtain a dosage for [MEDICATION NAME] (pain reliever) that was being administered every morning. Review of the facility's Medication Orders Policy, undated, indicated the following; -Medication orders specify the strength of the medication where indicated and the dose. Resident #19 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Review of the resident's Hospital Discharge Medication List, dated 10/28/17, indicated the following; [MEDICATION NAME], 500 milligrams (mg) by mouth daily and 250 mg by mouth nightly. Review of the 10/2017 admission physician's orders [REDACTED]. Review of the 10/2017 and 11/2017 Medication Administration Records indicated 1 tablet of [MEDICATION NAME] was administered daily at 9:00 A.M. from 10/28/17 through 11/9/17. The dose was not documented. During an interview on 11/10/17 at 10:25 A.M. , Nurse #1 said she administers 325 milligrams (mg) of [MEDICATION NAME] to resident in the morning. During an interview on 11/10/17 at 10:30 A.M., Unit Manager (UM) #1 said the morning dose of [MEDICATION NAME] did not indicate a dosage but should have. He said the order would be clarified. 2. For Non-Sampled Resident #1 (NS #1), facility staff failed to utilize a needle sheath after withdrawing up insulin to administer to a resident. Review of the facility Subcutaneous Injection Medication Administration Policy, dated 9/1/04, indicated that after withdrawing the prescribed amount of medication into a syringe, the needle of the syringe needs to be covered with a needle sheath. NS #1 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of the 11/10/2017 Medication Review Report indicated an order for [REDACTED]. During an observation of the medication pass on 11/9/17 at 7:25 A.M., Nurse #2 withdrew 3 units of Humalog Insulin into a syringe at the medication cart. She did not cover the needle of the syringe with a needle sheath after drawing up the insulin. She then administered the insulin to NS #1 at the bedside. During an interview on 11/10/17 at 11:00 A.M., Nurse #2 said she said she could not fully recall but might not have activated the needle sheath after withdrawing the insulin.

Based on observation, interview and record review, the facility staff failed to ensure the necessary care and treatment, including medical and nursing care, for respiratory services was provided for 1 resident (#19) in a total sample of 22 residents. Findings include: For Resident #19, the facility staff failed to obtain a physician's orders [REDACTED]. Review of the facility's Oxygen Administration Policy, dated 1/17/17, indicated the following; -In the skilled nursing facility setting, oximetry monitoring and clinical examinations determine the adequacy of O2 therapy. -Monitor the resident's response to oxygen therapy using physical assessment and pulse oximetry. Resident #19 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Review of a Nurse's Note, dated 10/29/17 at 14:08 P.M., indicated the resident continued on O2 at 3 liters (L)/minute (m) and a note, dated 10/30/17 at 8:42 A.M., indicated the resident was compliant with the O2. Review of the 10/2017 physician's orders [REDACTED]. Review of Nurse's note, dated 11/1/17 at 16:49 P.M., indicated the resident was non-compliant to O2 and was redirected with effect, and a note, dated 11/6/17 at 15:42 P.M., indicated O2 was applied at 3 L/m via nasal cannula (n/c) Review of the 11/2017 physician's orders [REDACTED]. Review of the 10/2017 and 11/2017 Treatment Administration Record did not indicate daily monitoring of respiratory status and/or response to O2 therapy, and did not indicate the regular monitoring of the O2 equipment. Additionally, review of the Nurse's notes since admission did not indicate daily documentation of the resident's respiratory status and/or response to the administration of O2. During an observation on 11/10/17 at 9:00 A.M., the resident was seated in a wheel chair in the unit dining room. He/she was wearing O2 via N/C, and the portable O2 tank was set at 3 L. During an interview on 11/10/17, Unit Manager #1 said there was not a physician's orders [REDACTED]. He said there should have been orders for the O2 administration and nursing should have monitored the O2 equipment.

Based on observation, policy review and staff interview, the facility staff failed to ensure that medications and biologicals were of current date to provide reliability of strength and accuracy of dosage in 2 of 3 units. Findings include: Review of the undated Medication Storage Policy indicated that outdated, contaminated , or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedure for medication destruction, and reordered from the pharmacy, if current order exists. 1. During an inspection of the Courtyard East medication cart on [DATE] at 8:50 A.M., one bottle of Melatonin (medication used to help with sleep) was found with an illegible expiration date. During an interview on [DATE] at 8:55 A. M, Nurse #3 said the expiration date on the Melatonin bottle was illegible and removed the bottle from the medication cart. 2. During an inspection of the Hillside West medication cart on [DATE] at 10:00 A.M., one bottle of Fish Oil Gel Caps( vitamin supplement) was found with an expiration date of ,[DATE]. During an interview on [DATE] at 10:05 A.M., Nurse #4 said the Fish Oil Gel Caps were expired and removed the bottle from the medication cart.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of [REDACTED]. - On [DATE] at approximately 12 midnight staff found Resident #1 on the floor following an unwitnessed fall. Resident #1 was assisted back to bed, however, staff did not complete a thorough clinical evaluation or neurological assessment on Resident #1, which resulted in a delay of transfer to the Hospital for evaluation of possible injury. - On [DATE], the following morning, at approximately 11:00 A.M., Resident #1 presented with slurred speech and he/she complained of neck pain. Resident #1 was given Tylenol (an [MEDICATION NAME] medication) and when he/she continued to experience a decline in mental status, 50 minutes later, the physician was notified. - Did not immediately transfer Resident #1 to the Hospital after the physician ordered for Resident #1 to be evaluated. Resident #1 was transferred to the Hospital, at approximately 12:15 P.M. (approximately 1 hour and 15 minutes from the time a change in mental status was first noticed), where he/she was diagnosed with [REDACTED].#1 died the following day. Findings include: 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. The Facility's Policy, titled Fall Prevention Program, not dated, indicated in response to a fall: - staff are to notify the Charge Nurse immediately; - it is imperative that a resident is not moved from the floor until an assessment has ruled out a serious injury; - moving a Resident with serious injury may result in further injury; - a fall with suspected or possible serious injury (fracture, spine/neck or heady injury) call for emergency transfer; - Nurse will take vital signs which will include Neurological signs and document until transport arrives. Resident #1's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1 was alert and oriented, required physical assistance from 1 person with transfers and ambulation, and he/she had a history of [REDACTED]. The Fall Care Plan, dated as reviewed on [DATE], indicated staff were to keep Resident #1's call light within reach, provide visual reminders on the bathroom door to remind Resident #1 to call for help, and staff were to perform hourly rounds to ensure Resident #1's safety. Resident #1's medication orders, dated as reviewed on [DATE], indicated he/she was prescribed [MEDICATION NAME] (antiplatelet agent that keeps blood from clotting, with known side effect which includes increased risk of bleeding, which can be severe or life threatening). A Late Entry Nurse Progress Note, dated [DATE], indicated that after breakfast on [DATE] Resident #1 told staff that he/she had fallen out off bed around midnight and bumped his/her head on the night stand. The Note indicated that on assessment Resident #1 had no visual bruising or swelling on his/her head, neurological signs were within normal limits, his/her speech was clear and no facial drooping was noted (normal assessment findings). There was no documentation to indicate, and Nurse #2 said the Physician was not notified at this time that Resident #1 told staff he/she had fallen and hit his/her head. The Nurse Progress Note indicated at 11:00 A.M. Resident #1's Family Member reported Resident #1's speech was slurred (abnormal assessment findings, indicative of a possible medical emergency). The Note indicated that on assessment Resident #1 was able to move all extremities, his/her hand grasps were strong, and his/her eyes were reactive. The Note indicated that at 11:50 A.M. Resident #1 complained of neck pain, he/she was given Tylenol and staff members called the Physician who gave an order to transfer Resident #1 to the Hospital for evaluation. The Note indicated Resident #1 left the Facility at 12:15 P.M. (approximately 1 hour and 15 minutes from the time his/her Family Member reported to staff a change in his/her mental status). Resident #1's Medication Administration Record [REDACTED].M. he/she received prescribed [MEDICATION NAME] 75 mg. Although Resident #1 reported to staff on the 7:00 A.M. to 3:00 P.M. shift that he/she had fallen the night before and hit/his head, there was no documentation to support that staff on the 11:00 P.M. to 7:00 A.M. shift completed a neurological assessment on Resident #1. The Neurological Assessment Record, dated [DATE], indicated staff performed a neurological assessment on Resident #1 a total of only four times, between 10:15 A.M. and 11:15 A.M. The Facility's Internal Investigation Report, dated as completed on [DATE], indicated that on [DATE] Resident #1 fell during the night and was assisted off the floor by two staff members, one Nurse and one Certified Nurse Aide (CNA). The Report indicated Resident #1 ate breakfast and took prescribed A.M. medications, he/she started showing neurological changes including slurred speech around lunch time, the Physician was informed and Resident #1 was transferred to the emergency room for further evaluation at approximately 12:15 P.M. The Report indicated the Facility was notified by the Hospital on the following morning that Resident #1 died at 10:30 A.M. on [DATE]. The Surveyor interviewed Nurse #2 at 10:05 A.M. on [DATE]. Nurse #2 said she received the change of shift report from Nurse #1 at 7:00 A.M. on [DATE]. Nurse #2 said that Nurse #1 did not report any falls and/or unusual incidents. Nurse #2 said at approximately 10:00 A.M. she stopped by to speak with Resident #1, which was her usual routine, and asked him/her how he/she was feeling. Nurse #2 said that Resident #1 told her he/she had fallen and hit his/her head on the night stand during the night, but she did not inform the physician. Nurse #2 said Resident #1 told her two black men whom he/she did not recognize, picked him/her up off the floor and helped him/her back to bed. The Surveyor interviewed Nurse #1 at 2:09 P.M. on [DATE]. Nurse #1 said he was employed by a Staffing Agency and he worked the 11:00 P.M. to 7:00 A.M. shift at the Facility on [DATE]. Nurse #1 said he had no recollection of Resident #1 and had no recollection of anyone falling on his shift. The Surveyor interviewed Certified Nurse Aide (CNA #1) at 1:09 P.M. on [DATE]. CNA #1 said, and a signed statement documented by CNA #1 as part of the Facility's Internal Investigation indicated, that during the night of [DATE], time not noted, CNA #1 heard a loud sound and when he entered Resident #1's room, Resident #1 was lying on the floor. CNA #1 said Nurse #1 was also in the room and Nurse #1 told him that Resident #1 had fallen. CNA #1 said he and Nurse #1 helped Resident #1 up off the floor and walked Resident #1 to the bathroom. CNA #1 said Nurse #1 then left Resident #1's room while he remained with Resident #1 and assisted him/her back to bed after he/she had finished using the bathroom. CNA #1 said that sometime later, he was unsure of the exact time, Nurse #1 approached him and told him not to tell anyone about Resident #1's fall. CNA #1 said he did not report to the 7:00 A.M. to 3:00 P.M. CNA who relieved him the following morning that Resident #1 fell during the night, and it was not until a few days later when questioned during the Facility's Internal Investigation, that he came forward with this information. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 presented with progressive somnolence and worsening bleeding of acute traumatic sudural hemorrhage. The Summary indicated that given Resident #1's advanced age and progressive neurological decline, surgical intervention was deemed too risky. The Summary indicated that upon discussion with family members, all of Resident #1's medications were discontinued and he/she was place on care and comfort measures. The Discharge Summary indicated Resident #1's time of death was documented as 10:31 A.M. on [DATE].

Based on records reviewed and interviews for one of three sampled residents (Resident #1) the facility failed to ensure staff provide appropriate care in accordance with professional standards of practice and in accordance with Resident #1's choices related to care. On [DATE] at approximately 12 midnight, Resident #1, who had a history of [REDACTED]. Resident #1 was assisted back to bed, however, staff did not conduct a neurological assessment on Resident #1 for possible injury, or notify the physician. -The following morning Resident #1 reported to nursing staff on the day shift that he/she fell during the night, had hit his/her head, and staff failed to inform his/her physician of the fall at that time. Resident #1 experienced a decline in mental status, was transferred to the Hospital. where he/she was diagnosed with [REDACTED].#1 was deemed too risky for surgical intervention and he/she died the following day, on [DATE]. Findings include: The Facility's Policy, titled Fall Prevention Program, not dated, indicated in response to a fall: - staff are to notify the Charge Nurse immediately; - it is imperative that a resident is not moved from the floor until an assessment has ruled out a serious injury; - moving a Resident with serious injury may result in further injury; - a fall with suspected or possible serious injury (fracture, spine/neck or heady injury) call for emergency transfer; - Nurse will take vital signs which will include Neurological signs and document until transport arrives. Review of Resident #1's physician's orders [REDACTED]. Resident #1's medication orders, dated as reviewed on [DATE], indicated he/she was prescribed [MEDICATION NAME] (antiplatelet agent that keeps blood from clotting, with known side effect which includes increased risk of bleeding, which can be severe or life threatening). Resident #1's Medication Administration Record [REDACTED].M. he/she had received prescribed [MEDICATION NAME] 75 mg that day, as ordered. A Late Entry Nurse Progress Note, dated [DATE], indicated that after breakfast on [DATE] Resident #1 told staff that he/she had fallen out off bed around midnight and bumped his/her head on the night stand. The Note indicated that on assessment Resident #1 had no visual bruising or swelling on his/her head, neurological signs were within normal limits, his/her speech was clear and no facial drooping was noted (normal assessment findings). There was no documentation to indicate, that the Physician was not notified at this time that Resident #1 told staff he/she had fallen and hit his/her head. There was no documentation to support that staff on the 11:00 P.M. to 7:00 A.M. shift completed a neurological assessment on Resident #1 after the unwitnessed fall, or that staff checked on Resident #1 throughout the remained of the shift. The Nurse Progress Note indicated at 11:00 A.M. Resident #1's Family Member reported Resident #1's speech was slurred (abnormal assessment findings, indicative of a possible medical emergency). The Note indicated that on assessment Resident #1 was able to move all extremities, his/her hand grasps were strong, and his/her eyes were reactive. The Note indicated that approximately 50 minutes later, Resident #1 complained of neck pain, he/she was given Tylenol and staff members called the Physician who gave an order to transfer Resident #1 to the Hospital for evaluation. The Note indicated Resident #1 left the Facility at 12:15 P.M. (approximately 1 hour and 15 minutes from the time his/her Family Member reported to staff a change in his/her mental status). The Neurological Assessment Record, dated [DATE], indicated staff performed a neurological assessment on Resident #1 a total of only four times, between 10:15 A.M. and 11:15 A.M. This was not consistent with the Facility's Fall Prevention Program and Standards of Practice for Neurological Assessment following a fall. The Facility's Internal Investigation Report, dated as completed on [DATE], indicated that on [DATE] Resident #1 fell during the night and was assisted off the floor by two staff members, one Nurse and one Certified Nurse Aide (CNA). The Report indicated Resident #1 ate breakfast and took prescribed A.M. medications, he/she started showing neurological changes including slurred speech around lunch time, the Physician was informed and Resident #1 was transferred to the emergency room for further evaluation at approximately 12:15 P.M. The Report indicated the Facility was notified by the Hospital on the following morning that Resident #1 died at 10:30 A.M. on [DATE]. The Surveyor interviewed Nurse #2 at 10:05 A.M. on [DATE]. Nurse #2 said she received the change of shift report from Nurse #1 at 7:00 A.M. on [DATE]. Nurse #2 said that Nurse #1 did not report any falls and/or unusual incidents. Nurse #2 said at approximately 10:00 A.M. she stopped by to speak with Resident #1, which was her usual routine, and asked him/her how he/she was feeling. Nurse #2 said that Resident #1 told her he/she had fallen and hit his/her head on the night stand during the night, and said Resident #1 told her two black men whom he/she did not recognize, picked him/her up off the floor and helped him/her back to bed. Nurse #2 said she did not immediately notify the Physician when Resident #1 reported he/she had fallen and hit his/her during the night. Nurse #2 said she first notified the Physician at 11:50 A.M. after Resident #1 had a change in mental status and Resident #1 was transferred to the Hospital for further evaluation. The Surveyor interviewed Nurse #1 at 2:09 P.M. on [DATE]. Nurse #1 said he was employed by a Staffing Agency and he worked the 11:00 P.M. to 7:00 A.M. shift at the Facility on [DATE]. Nurse #1 said he had no recollection of Resident #1 and had no recollection of anyone falling on his shift. The Surveyor interviewed Certified Nurse Aide (CNA #1) at 1:09 P.M. on [DATE]. CNA #1 said, and a signed statement documented by CNA #1 as part of the Facility's Internal Investigation indicated, that during the night of [DATE], time not noted, CNA #1 heard a loud sound and when he entered Resident #1's room, Resident #1 was lying on the floor. CNA #1 said Nurse #1 was also in the room and Nurse #1 told him that Resident #1 had fallen. CNA #1 said he and Nurse #1 helped Resident #1 up off the floor and walked Resident #1 to the bathroom. CNA #1 said Nurse #1 then left Resident #1's room while he remained with Resident #1 and assisted him/her back to bed after he/she had finished using the bathroom. CNA #1 said that sometime later, he was unsure of the exact time, Nurse #1 approached him and told him not to tell anyone about Resident #1's fall. CNA #1 said he did not report to the 7:00 A.M. to 3:00 P.M. CNA who relieved him the following morning that Resident #1 fell during the night, and it was not until a few days later when questioned during the Facility's Internal Investigation, that he came forward with this information. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 presented with progressive somnolence and worsening bleeding of acute traumatic subdural hemorrhage. The Summary indicated that given Resident #1's advanced age and progressive neurological decline, surgical intervention was deemed too risky. The Summary indicated that upon discussion with family members, all of Resident #1's medications were discontinued and he/she was place on care and comfort measures. The Discharge Summary indicated Resident #1's time of death was documented as 10:31 A.M. on [DATE].

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a history of [REDACTED].#1 on the floor following an unwitnessed fall. - After the fall, Resident #1 was assisted back to bed, however, staff did not notify the Physician that Resident #1 had fallen, which resulted in a delay of transfer to the Hospital for evaluation of possible injury. The following morning, at approximately 10:00 A.M. Resident #1 reported to staff that he/she had fallen the night before and hit his/her head, however, staff did not immediately notify the Physician. At approximately 11:00 A.M., Resident #1 presented with slurred speech and he/she complained of neck pain. Resident #1 was given Tylenol (an [MEDICATION NAME] medication), but a physician was not called until approximately 50 minutes later, when Resident #1 continued to experience a decline in mental status. - After the order was obtained to transfer Resident #1 to the emergency department for evaluation, the staff failed to immediately have Resident #1 transferred. Resident #1 was transferred to the Hospital, at approximately 12:15 P.M. (approximately 1 hour and 15 minutes from the time a change in mental status was first noticed), where he/she was diagnosed with [REDACTED]. Resident #1 was deemed too risky for surgical intervention and he/she died the following day, on [DATE]. Findings include: Resident #1's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1 was alert and oriented, required physical assistance from 1 person with transfers and ambulation, and he/she had a history of [REDACTED]. The Fall Care Plan, dated as reviewed on [DATE], indicated staff were to keep Resident #1's call light within reach, provide visual reminders on the bathroom door to remind Resident #1 to call for help, and staff were to perform hourly rounds to ensure Resident #1's safety. Resident #1's medication orders, dated as reviewed on [DATE], indicated he/she was prescribed [MEDICATION NAME] (antiplatelet medication, keeps blood from clotting, side effect which includes increased risk of bleeding which can be severe or life-threatening) every day. The Facility's Internal Investigation Report, dated as completed on [DATE], indicated that on [DATE] Resident #1 fell during the night and was assisted off the floor by two staff members, one Nurse and one Certified Nurse Aide (CNA). The Report indicated Resident #1 ate breakfast and took prescribed A.M. medications, he/she started showing neurological changes including slurred speech, around lunch time, the Physician was informed, and Resident #1 was transferred to the emergency room for further evaluation at approximately 12:15 P.M. The Investigation Report indicated the Facility was notified by the Hospital the following morning that Resident #1 died at 10:30 A.M. on [DATE]. A Late Entry Nurse Progress Note, dated [DATE], indicated that after breakfast on [DATE], Resident #1 told staff that he/she had fallen out off bed around midnight and bumped his/her head on the night stand. The Late Entry Note indicated that on assessment Resident #1 had no visual bruising or swelling on his/her head, neurological signs were within normal limits, his/her speech was clear and no facial drooping was noted (normal assessment findings). The Nurse Progress Note, dated [DATE], indicated at 11:00 A.M. Resident #1's Family Member reported Resident #1's speech was slurred (abnormal assessment finding, indicative of a possible medical emergency). The Note indicated that on assessment Resident #1 was able to move all extremities, his/her hand grasps were strong, and his /her eyes were reactive. The note did not include information to indicate a physician was immediately informed of the changes in Resident #1's ability to speak following a fall in which the resident struck their head. The Note indicated that at 11:50 A.M., Resident #1 complained of neck pain, he/she was given Tylenol and staff members called the Physician who gave an order to transfer Resident #1 to the Hospital for evaluation. Although Resident #1 reported to staff on the 7:00 A.M. to 3:00 P.M. shift that he/she had fallen the night before and hit/his head, there was no documentation to support that staff on the 11:00 P.M. to 7:00 A.M. shift notified the Physician that Resident #1 had fallen. The Surveyor interviewed Nurse #2 at 10:05 A.M. on [DATE]. Nurse #2 said she received the change of shift report from Nurse #1 at 7:00 A.M. on [DATE]. Nurse #2 said that Nurse #1 did not report any falls and/or unusual incidents. Nurse #2 said at approximately 10:00 A.M. she stopped by to speak with Resident #1, which was her usual routine, and asked him/her how he/she was feeling. Nurse #2 said that Resident #1 told her he/she had fallen and hit his/her head on the night stand during the night. Nurse #2 said she did not immediately notify the Physician when Resident #1 reported he/she had fallen and hit his/her during the night. Nurse #2 said she first notified the Physician at 11:50 A.M. after Resident #1 had a change in mental status and Resident #1 was transferred to the Hospital for further evaluation. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 presented with progressive somnolence and worsening bleeding of acute traumatic subdural hemorrhage. The Summary indicated that given Resident #1's advanced age and progressive neurological decline, surgical intervention was deemed too risky, and Resident #1 died at 10:31 A.M. on [DATE].

Based on records reviewed and interviews for 1 of 4 sampled Residents (Resident #4), the facility failed to provide Resident #4 with a thoroughly pureed diet that resulted in Resident #4 to choke on a piece of un-pureed food. On 4/10/17 during the dinner time meal, Resident #4 choked on his/her food, required the Heimlich Maneuver (abdominal thrusts used to treat an upper airway obstruction to remove a foreign body) to be administered, nursing staff dislodged an un-pureed piece of pear from his/her mouth, Resident #4 developed pneumonia 4 days later and required antibiotic therapy to treat the pneumonia. Findings include: The Facility Policy, titled Diet Orders, dated 3/24/15, indicated a puree texture is all food is pureed and have a smooth texture with a consistency of whipped potatoes. The [DIAGNOSES REDACTED].#4's [DIAGNOSES REDACTED]. The My Personal Care Plan, dateless, indicated Resident #4's diet as puree consistency, aspiration precautions, supervision/cueing at meals. A Narrative Care Plan, dated 11/4/16, indicated Resident #4 needs to be fed part of meals due to decreased initiation. A Speech Therapy Discharge Summary, signed 12/13/16, indicated Resident #4 was recommended to have puree consistency diet. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #4 was on a mechanically altered diet, and required total dependence of 1 assist with meals. A Nutrition Progress Note, dated 1/27/17, indicated Resident #4 was on a puree diet, dependent for feeding, and had a choking episode that required the Heimlich maneuver on 11/23/16. The Certified Daily Flow Sheet, dated April 2017, indicated Resident #4 is totally dependent on staff for eating his/her dinner meal. The Physician Orders, dated April 2017, signed 4/7/17, indicated Resident #4's diet as puree and requires to be fed meals. A Nurse Practitioner Progress Note, dated 4/7/17, indicated Resident #4 has chronic oropharyngeal dysphagia due to progressive dementia, had a choking episode that required the Heimlich maneuver on 11/23/16, required assistance with meals, and a puree diet. An Incident Report, dated 4/10/17, indicated Resident #4 had a choking episode exhibited by difficulty breathing, inability to cough forcefully, lips turned blue in color, and was administered the Heimlich maneuver without success, and one piece of uncrushed pear was removed by a staff members finger. A Nurse Progress Note, dated 4/10/17, indicated Resident #4 was eating a pureed diet assisted by staff, began to exhibit difficulty breathing, inability to cough forcefully, and his/her lips turned blue. The Heimlich maneuver was performed without success, Resident #4's mouth was opened and a piece of uncrushed pear was scooped out of Resident #4's throat. A Nurse Progress Note, dated 4/14/17, 11-7 shift, indicated Resident #4 had a temperature of 99.9 degrees (average range is 98.6 degrees Fahrenheit) and was administered Tylenol (a medication used to reduce fever). A Physician's Interim Telephone Order, dated 4/13/17, indicated obtain a chest x-ray in the morning. A Nurse Progress Note, dated 4/14/17, 7:00 A.M. to 3:00 P.M. shift, indicated Resident #4 was noted to have some respiratory distress, crackles on lung auscultation (abnormal lung sounds), a chest x-ray was obtained and was positive (indicating a pneumonia), and was started on antibiotics. A Radiology Report, dated 4/14/17, indicated Resident #4 had a left base minimal infiltrate. The findings were worse than the chest x-ray taken on 4/10/17. A Nurse Practitioner Progress Note, dated 4/14/17, indicated Resident #4 had an acute aspiration pneumonia (a lung infection developed from inhaled food or liquid into the lungs), minimal left base infiltrate on chest x-ray, and was started on Flagyl and Vantin (antibiotics used to treat infections) for the aspiration pneumonia. A Physician's Interim Telephone Order, dated 4/14/17, indicated Resident #4 was ordered Flagyl 500 mg (milligrams) by mouth three times daily for 7 days and Vantin 200 mg by mouth every 12 hours for 7 days. The Surveyor interviewed Dietary Aide #2 at 10:33 A.M. on 4/27/17. Dietary Aide #2 said he pureed the pears for the evening meal on 4/10/17. Dietary Aide #2 said he checks for chunks in the puree by stirring the puree with a slotted spoon. The Surveyor interviewed Nurse #4 at 3:30 P.M. on 4/26/17. Nurse #4 said he was feeding Resident #4 his/her pureed pears when he/she began to cough. Nurse #4 said Resident #4's cough decreased in force, his/her eyes widened, and his/her lips turned blue, and then he/she stopped coughing. Nurse #4 said he administered the Heimlich maneuver several times without success. Nurse #4 said he opened Resident #4's mouth and scooped out a grape size piece of pear. Nurse #4 said Resident #4 began to breathe better. Nurse #4 said he checked Resident #4's bowl of pureed pears and the unit food serve station pureed pears and found more pieces of uncrushed pear in both. Nurse #4 said the pureed fruit was definitely pears. The Surveyor interviewed Nurse #5 at 3:57 P.M. on 4/26/17. Nurse #5 said she saw Resident #4 begin to cough, his/her lips turn blue, and assisted Nurse #4 while he administered the Heimlich maneuver. Nurse #5 said Nurse #4 scooped out a grape size piece of pear. Nurse #5 said she has seen chunks of fruit in the pureed fruits before, that this was not the first time, that she removes the chunks herself, but has not reported this to anyone. The Surveyor interviewed Nursing Supervisor #3 at 4:10 P.M. on 4/26/17. Nursing Supervisor #3 said after the incident on 4/10/17, she checked what was left of Resident #4's bowl of pureed pears and said it was difficult to see but did find a dime size chunk of pear. The Surveyor interviewed Certified Nurse Assistant (CNA) #9 at 4:41 P.M. on 4/26/17. CNA #9 said she has come across chunks of food in the pureed diets before, but has not reported this to anyone. The Surveyor interviewed the Dining Service Manager at 9:45 A.M. on 4/26/17. The Dining Service Manager said there is no written procedure to check the puree foods once the staff has pureed the food in the food processor. The Surveyor interviewed the Director of Nurses at 1:41 P.M. on 4/26/17. The Director of Nurses said they saved the container that the pureed pears were served from on 4/10/17. The Director of Nurses said it was definitely pears and there were chunks of pear in the pureed pears.

Based on records reviewed and interviews for 1 of 4 sampled Residents (Resident #4), the facility failed to provide Resident #4 with a thoroughly pureed diet, as ordered by the Physician and as Care Planned. On 4/10/17 during the dinner time meal while being fed by a staff, Resident #4 began choking on his/her food, required the [MEDICATION NAME] Maneuver (abdominal thrusts used to treat an upper airway obstruction to remove a foreign body) to be administered, and nursing staff dislodged an un-pureed the piece of pear from Resident #4's mouth. Findings include: The Facility Policy, titled Diet Orders, dated 3/24/15, indicated a puree texture is all food is pureed and have a smooth texture with a consistency of whipped potatoes. The Facility Policy, titled MDS 3.0 Resident Care Plan Policy and Procedures, dateless, indicated the care plan should be a working tool, resident specific, and all disciplines should be familiar with it and follow it. The [DIAGNOSES REDACTED].#4's [DIAGNOSES REDACTED]. The My Personal Care Plan, dateless, indicated Resident #4's diet as puree consistency, aspiration precautions, and supervision/cueing at meals. A Narrative Care Plan, dated 11/4/16, indicated Resident #4 needs to be fed part of meals due to decreased initiation. A Speech Therapy Discharge Summary, signed 12/13/16, indicated Resident #4 was recommended to have puree consistency diet. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #4 was on a mechanically altered diet, and required total dependence of 1 assist with meals. A Nutrition Progress Note, dated 1/27/17, indicated Resident #4 was on a puree diet, dependent for feeding, and had a choking episode that required the [MEDICATION NAME] maneuver on 11/23/16. The Certified Daily Flow Sheet, dated April 2017, indicated Resident #4 is totally dependent on staff for eating his/her dinner meal. The Physician Orders, dated April 2017, signed 4/7/17, indicated Resident #4's diet as puree and requires to be fed meals. A Nurse Practitioner Progress Note, dated 4/7/17, indicated Resident #4 has chronic oropharyngeal dysphagia due to progressive dementia, had a choking episode that required the [MEDICATION NAME] maneuver on 11/23/16, required assistance with meals, and a puree diet. An Incident Report, dated 4/10/17, indicated Resident #4 had a choking episode exhibited by difficulty breathing, inability to cough forcefully, lips turned blue in color, and was administered the [MEDICATION NAME] maneuver without success, and one piece of uncrushed pear was removed by a staff members finger. A Nurse Progress Note, dated 4/10/17, indicated Resident #4 was eating a pureed diet assisted by staff, began to exhibit difficulty breathing, inability to cough forcefully, and his/her lips turned blue. The [MEDICATION NAME] maneuver was performed without success, Resident #4's mouth was opened and a piece of uncrushed pear was scooped out of Resident #4's throat. The Surveyor interviewed Dietary Aide #2 at 10:33 A.M. on 4/27/17. Dietary Aide #2 said he pureed the pears for the evening meal on 4/10/17. Dietary Aide #2 said he checks for chunks in the puree by stirring the puree with a slotted spoon. The Surveyor interviewed Nurse #4 at 3:30 P.M. on 4/26/17. Nurse #4 said he was feeding Resident #4 his/her pureed pears when he/she began to cough. Nurse #4 said Resident #4's cough decreased in force, his/her eyes widened, and his/her lips turned blue, and then he/she stopped coughing. Nurse #4 said he administered the [MEDICATION NAME] maneuver several times without success. Nurse #4 said he opened Resident #4's mouth and scooped out a grape size piece of pear. Nurse #4 said Resident #4 began to breathe better. Nurse #4 said he checked Resident #4's bowl of pureed pears and the unit food serve station pureed pears and found more pieces of uncrushed pear in both. Nurse #4 said the pureed fruit was definitely pears. The Surveyor interviewed Nurse #5 at 3:57 P.M. on 4/26/17. Nurse #5 said she saw Resident #4 begin to cough, his/her lips turn blue, and assisted Nurse #4 while he administered the [MEDICATION NAME] maneuver. Nurse #5 said Nurse #4 scooped out a grape size piece of pear. Nurse #5 said she has seen chunks of fruit in the pureed fruits before, that this was not the first time, that she removes the chunks herself, but has not reported this to anyone. The Surveyor interviewed Nursing Supervisor #3 at 4:10 P.M. on 4/26/17. Nursing Supervisor #3 said after the incident on 4/10/17, she checked what was left of Resident #4's bowl of pureed pears and said it was difficult to see but did find a dime size chunk of pear. The Surveyor interviewed Certified Nurse Assistant (CNA) #9 at 4:41 P.M. on 4/26/17. CNA #9 said she has come across chunks of food in the pureed diets before, but has not reported this to anyone. The Surveyor interviewed the Dining Service Manager at 9:45 A.M. on 4/26/17. The Dining Service Manager said there is no written procedure to check the puree foods once the staff has pureed the food in the food processor. The Dining Service Manager said she is not aware of chunks of food remaining in the pureed foods prior to this incident. The Surveyor interviewed the Director of Nurses at 1:41 P.M. on 4/26/17. The Director of Nurses said they saved the container that the pureed pears were served from on 4/10/17. The Director of Nurses said it was definitely pears and there were chunks of pear in the pureed pears.

Based on observation, record review and interviews, facility staff failed to ensure that 2 of 2 applicable sampled residents (#4 and #12) out of a total sample of 21 residents, did not develop new pressure ulcers. Findings include: 1. For Resident #4, the facility staff failed to ensure the resident did not develop a new pressure ulcer to his/her right antecubital (the depression in front of the elbow) space. Resident #4 was originally admitted to the facility in 2/2014 and readmitted in 12/2015 with [DIAGNOSES REDACTED]. Review of the care plan, dated 5/26/16, indicated the resident was at risk for alteration in skin integrity based on Norton Plus score (an assessment done to determine risk of skin breakdown), due to impaired safety awareness, [MEDICAL CONDITION], and impulsivity. Interventions included weekly skin assessments to be done by a nurse. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident had short term memory impairment and had moderately impaired cognition. He/she required 2 person assistance for dressing, hygiene, bathing, positioning, and transfers. Review of the physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR), dated 8/1/16, indicated for staff to apply geri-sleeves to BUE at all times and remove for care. Nurses initialed this treatment as being done every shift from 8/1/16- 8/25/16. Review of the weekly skin assessments indicated a skin assessment was done by a nurse on 8/25/16, during the 7:00 A.M.-3:00 P.M. shift which indicated the right elbow area was dry/scabbed. Although there were weekly skin assessments documented, there was no evidence that the open pressure area in the Antecubital space was being monitored/treated until 8/25/16 when the record indicates there was an unstageable wound, as evidenced by the slough on the wound base. Review of the Nurse's Note, dated 8/25/16, during the 3:00-11:00 P.M. shift indicated that during the removal of the geri-sleeves by a Certified Nurses Aide (CNA), an open area to the right arm antecubital space was noted. The wound measured 0.2 inches x 1 inch x .25 inches; the perimeter was red and warm; the center was moist with yellow slough; there was an odor; and the area was painful to the resident. The Nurse Practitioner (NP) was updated and ordered to discontinue the geri sleeves, start a normal saline wash followed by Hydrogel (a product used to promote wound healing) and cover with a dry clean dressing twice daily. The NP also ordered [MEDICATION NAME] (anti-infective medication) 100 milligrams twice daily for 10 days. Review of the Wound Care Specialist's initial evaluation, dated 9/1/16, indicated the resident had a Stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) of the right anterior elbow of at least 7 days duration, measuring 0.8 centimeters (cm) x 3.5 cm x 0.3 cm. Tendon was visible within the wound. Review of the Wound Care Specialist evaluation, dated 10/13/16, indicated the Stage 4 pressure ulcer of the right anterior elbow measured 2.0 cm x 2.0 cm x 0.4 cm with undermining 0.4 cm at 12:00 o'clock, (refers to the anatomical position in relation to a clock). During an observation of the dressing change to the right antecubital space on 10/19/16 at 9:30 A.M. with Nurse #2, the old dressing was removed with moderate amount of sero-sanguinous drainage present at the right anterior elbow. The wound bed was pink and clean, surrounding skin was intact and fragile. During an interview on 10/19/16 at 10:00 A.M., CNA #3 said she had been the primary caregiver for this resident for a long time. She said the geri-sleeves were put on by the 11:00 P.M.-7:00 A.M. CNA and were kept on until the skin checks were done. She said the skin checks were done weekly. The record indicated that the geri sleeves were removed for care daily. During an interview on 10/21/16 at 3:00 P.M., the Director of Nurses (DON) said the nurse who did the weekly skin check on 8/25/16, during the 7:00 A.M.-3:00 P.M. shift, did an incomplete assessment which resulted in disciplinary action. She said the nurse later told the DON that the resident was resistive, and therefore she was only able to check the visible areas. The DON said there was no other documentation of skin integrity for the right arm except on weekly skin assessments. She said the facility did not have a policy related to the care and management of geri-sleeves. 2. For Resident #12, the facility staff failed to ensure the resident did not develop new pressure ulcers on the bilateral heels. Resident #12 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. Review of the Initial Nursing Assessment, dated 7/7/16, indicated the resident's bilateral heels were red. Review of the Norton Plus Pressure Ulcer Scale dated 7/14/16 and 7/21/16, indicated scores of 10. A score of 10 or less equals a high risk for skin breakdown. Review of the facility's policy Intensive Skin Care Program Positioning Program, with revision date of 12/1997, indicated the following: *Positioning procedure will be followed for all residents who are found to be at risk of pressure sores and in need of assistance with positioning, as noted in the care plan. *Positioning efforts and outcomes can be monitored easily through direct observation of residents and documentation on positioning sheets. Equipment includes egg crate (not a pressure relieving device), alternating air mattress or gel mattress. Review of the Admission MDS assessment, dated 7/14/16, indicated the resident had a score of 5 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment, was at risk for developing a pressure ulcer, had a pressure relieving device for bed/chair, and received application of ointments/medications other than to feet. Also, the resident required 2 assist for bed mobility and transfers, ambulated with assist of 1 and was dependent with locomotion on and off the unit. Review of the skin preventative measures care plan dated 7/18/16, indicated to do treatments as ordered to the (R) elbow and buttocks, weekly skin assessments and frequent turning and positioning. Review of the 7/2016, 8/2016 and 9/2016 TARs indicated Dermaseptine (skin protectant) was applied to buttocks every shift. There were no positioning device in place or preventative skin care to bilateral heels, despite the policy requiring equipment devices and positioning for reducing pressure. Review of the 7/2016, 8/2016 and 9/2016 CNA flow sheets indicated house protectant was applied to hips/coccyx every shift. There was no preventative skin care to bilateral heels. Review of Nurses Note dated 9/9/16, indicated the outer right heel had a purple intact area and the right heel had an unstageable 2.0 cm x 2.0 cm area with a scabbed center and no drainage. The left heel had an unstageable 2.0 cm x 2.0 cm area with a scabbed center, and no drainage. Review of the TAR, dated 9/9/16-9/21/16, indicated to do a normal saline wash (NSW), then apply skin prep, followed by a dry, clean dressing to bilateral heels daily. Review of the Wound Care Specialist's initial evaluation, dated 9/22/16, indicated the resident had Stage 4 pressure wounds to the left and right heel of at least 13 days duration, and they were both Stage 4 due to periosteum (thin membrane covering bone) being visible. Both wounds were debrided via surgical excision. Review of the TAR, dated 9/22/16, indicated to discontinue previous treatments to bilateral heels and begin NSW, pat dry and apply [MEDICATION NAME] 2% (antibacterial ointment) followed by a wound size piece of calcium alginate (absorbs drainage and maintains a moist wound environment) followed by foam dressing daily to bilateral heels. Further review of the 9/2016 TAR indicated that on 9/23/16, (14 days after the bilateral pressure ulcers were found), facility staff were to elevate the resident's heels on a cushion when in bed as tolerated every shift. Review of the 3 day Activity Log initiated to capture the lower extremity movements of the resident in and out of bed, dated 9/23/16-9/26/16, indicated the resident was observed rubbing his/her legs up and down when in bed only twice on 9/26/16, between 11:15 P.M. and 4:00 A.M. Further review of the 9/2016 TAR indicated that, on 9/27/16-18 days after the bilateral pressure ulcers were found- an air mattress to the bed was initiated. Review of the Wound Consult Progress Note, dated 9/29/16, indicated the Physician recorded the wounds to be pressure on 9/22/16 in error. He changed the etiology to shear due to the resident having been observed (per the 3 day Activity Log) repeatedly rubbing his/her heels twice in 3 days into the bed sheets. During an interview with the DON and Administrator on 10/25/16 at 9:15 A.M., the DON said she thought there had been preventative measures in place upon the resident's admission, such as skin prep to heels or a wedge/cushion to the bed. The DON said she didn't know why those measures hadn't been put into place.

Based on record review and interview for 1 of 3 sampled residents (Resident #1, the Facility failed to ensure Certified Nursing Assistant (CNA) #1 and CNA #2 performed a safe transfer for Resident #1. On 9/6/15, Resident #1 had a change in mental status; Resident #1 was too lethargic to be an active participant with the sit to stand mechanical lift but at 7:18 A.M., staff used the device to transfer Resident #1 from bed. Resident #1 experienced changes in condition and when hospitalized , was found to have rib fractures, vertebral fractures of the 6th, 7th, and 12th vertebra, and what was described as a large chest wall hematoma (a collection of blood), and hypotension (low blood pressure) from hemorrhagic shock due to bleeding into the chest cavity. In addition, the Facility failed to ensure CNA #1, who unsafely transferred Resident #1 and continued to use the equipment after 9/6/15, had the additional training for use of mechanical lifts as of the survey date (6.5 weeks after Resident #1 sustained injuries). Findings include: Resident #1 was admitted to the Facility in 11/2008, with [DIAGNOSES REDACTED]. The Department of Labor and Industries booklet, Frequently Asked Questions about Sit-to-Stand Patient/Resident Devices, undated indicated, Sit to Stand devices are used to transfer residents between two seated postures; was designed to support only the upper body of the resident and therefore requires the resident to be able to bear some weight. The booklet indicated that a Sit-to-Stand mechanical lift should only be used with residents who can bear some body weight; and, use of the lift requires that patient/resident to be able to sit up on the edge on the bed with or without assistance, and to be able to bend their hips, knees, and ankles. The manufacturer's guidelines for the sit-to-stand aide, dated 5/11/07, indicated that the device (lift) was intended for residents who were able to actively participate in the standing exercise. The guidelines indicated there were two different sling-bar alternatives to be used with the sit-to-stand vests and the resident's functional status determined the choice of sling-bar and vest to be used. Resident #1's vest/strap was placed by staff around the back and front of chest, and was secured with a plastic clip buckle on the front of Resident #1's chest during a transfer. The Facility's policy, for the sit to stand mechanical lift, Ready Stand, dated 2/1998, indicated this policy did not include guidance for staff regarding when the sit-to-stand lift should be used, or when it should not be used. The Facility's competency evaluation form and competency assessment form for the stand-to-aide did not incorporate guidance on when the sit-to-stand lift was used or when it should not be used, only how to use it. The significant change Minimum Data Set of 7/24/15 indicated Resident #1 had short and long term memory impairment, was moderately cognitively impaired, and required a two-person assist with transfers, and was non ambulatory. The Nurse's Note, dated 9/6/15 at 10:30 A.M., indicated Nurse #1 called the Physician to report Resident #1 was diaphoretic (sweaty), lethargic and unresponsive, required supplemental oxygen, and had an elevated blood glucose level. The note indicated there was a new physician's orders [REDACTED]. The Nurse's Note, dated 9/6/15 at 4:30 P.M., indicated that Resident #1 was unresponsive; had an elevated body temperature and blood glucose level, required supplemental oxygen. The note indicated the Nurse Practitioner was called and ordered that Resident #1 be transferred to the hospital for evaluation. The Hospital Emergency Department (ED) Report indicated Resident #1 was admitted at 4:41 P.M. on 9/6/15 and presented with altered mental status and increased lethargy. The Hospital's Chest CT (Computerized Tomography) scan of 9/8/15 indicated Resident #1 had a large hematoma (a collection of blood) in the left lower lateral chest wall measuring approximately 11 centimeters (cm) by 6.5 cm. The Hospital's Discharge Summary, dated 9/10/15, indicated Resident #1 was admitted to the Cardiac Care Unit on 9/6/15, after Resident #1's hemoglobin was found to be 4.2 gm/dl (critically low level, indicative of possible internal bleeding) and INR (laboratory blood test used to monitor the effectiveness of Coumadin) was elevated at 5.2 (normal 2.0 to 3.0). The Hospital record indicated that upon physical examination, on 9/6/15, Resident #1 was found to have significant bruises of the chest, which was thought to be caused by use of a lifting device in the setting of an INR of 5.2. The Hospital record indicated Resident #1 was hypovolemic (decreased circulating intravascular volume), anuric (urinary output of less than 50 cubic centimeters), had altered mental status changes, and had fractured ribs of his/her chest right and left and thoracic and vertebral fractures of the 6th, 7th, and 12th. After Resident #1 was emergently hospitalized , the Facility completed an investigation. The investigative report (undated) and Nurse's Note of 9/6/15, indicated that at approximately 7:18 A.M., Resident #1 was transferred from the bed to the wheelchair with the Sit-to-Stand lift and with a physical assistance from two CNAs and at the time of the transfer, was very weak. The report indicated Resident #1 continued to be sleepy through out the day on 9/6/15 and later that evening, Resident #1 had increased lethargy, became unresponsive, and was sent to the emergency room . The report indicated that Resident #1 did not sustain a fall, but did let go (did not maintain the hand grip needed for a safe transfer) of the sit-stand lift. Resident #1 was prescribed Coumadin and the INR was elevated at 5.2, and when evaluated at the hospital, Resident #1 had bruising across his/her chest and pubic area. The Director of Nurses (DON) note of 9/10/15 indicated the DON was called by a hospital Physician who stated that Resident #1 was admitted with hemorrhagic shock due to the transfer with the Sit-to Stand lift. The hospital Physician said that Resident #1 was admitted with bruising all around his/her chest area and had rib fractures. The Surveyor interviewed the Director of Nursing (DON) at 9:00 A.M. on 10/22/15. The DON said that Resident #1 was not feeling well prior to getting him/her up with this lift and CNA #1 and CNA #2 probably should not have gotten him/her up. Instead the CNAs should have asked a Nurse to assess Resident #1 prior to any transfer. The Surveyor interviewed Physician #1 at 11:00 A.M. on 10/22/15. Physician #1 said Resident that on 9/6/15, Resident #1 had a urinary tract infection with probable sepsis (the initial [DIAGNOSES REDACTED]. The Surveyor interviewed Nurse #1 at 11:50 A.M. on 10/22/15, Nurse #1 was assigned to Resident #1 on 9/6/15 during the 7:00 A.M. to 3:00 P.M. shift. Nurse #1 said that on 9/6/15 between 8:30 A.M. and 9:30 A.M., CNA #1 called her to Resident #1's room. CNA #1 said that Resident #1 did not look well. Resident #1 sitting in a wheelchair in his/her room, Resident #1's eyes were closed, his/her respiratory rate was 24 to 30 per minute, he/she was sweaty and unresponsive. Nurse #1 clarified and said that Resident #1 was responsive, but that she meant lethargic. Nurse #1 said that, during a transfer in the Sit-to-Stand lift, Resident #1 would have a big belt around his/her upper abdomen secured with a buckle in the front. The Surveyor interviewed CNA #1 at 12:20 P.M. on 10/22/15. CNA #1 said that during the 6:00 A.M. to 2:30 P.M. shift on 9/6/15, she was assigned to take care of Resident #1 and at approximately 6:40 A.M., CNA #1 said that she dressed Resident #1 in bed. CNA #1 said that Resident #1 appeared to her to be sleeping at the time of the transfer, but she did not think of getting a Nurse because she already started the lift, and decided to just put him/her in the wheelchair. CNA #1 said that she had to get Resident #1 up and sit him/her at the side of the bed, but Resident #1 was weak, but did not inform a nurse. CNA #1 said that as part of the transfer process, when using a sit-to-stand lift, she put the strap on around Resident #1's chest. CNA #1 said that as they lifted Resident #1 in the lift, Resident #1 did not hold on to the stand aide tightly (needed for a safe transfer), so CNA #2 supported Resident #1 by holding onto his/her pants from behind. CNA #1 and CNA #2 said they then put Resident #1 into the wheelchair and he/she was not opening his/her eyes. CNA #1 said she thought something was wrong with Resident #1 and informed Nurse #1. CNA #1 said that normally, Resident #1 actively participated with transfers using the lift, but on 9/6/15, was passive. CNA #1 said she did not think there was another way to transfer Resident #1 because the staff followed what was written on the care card. CNA #1 said that she did not believe Resident #1 was hanging from the lift during the transfer. The Surveyor interviewed Physical Therapist #1 at 3:30 P.M. on 10/22/15, Physical Therapist #1 explained what is required for a resident to safely use the sit-to-stand mechanical lift. The Physical Therapist at this Facility normally determined which type of lift each resident requires. Physical Therapist #1 said that a resident has to be able to participate with the transfer, be alert enough, have adequate sitting balance, be able to hold their upper body up, be able to bend their knees, and hold on to the lift with an adequate hand grip. Physical Therapist #1 said that if a Resident was not responding to you and their eyes were closed, then staff were not use the sit-to-stand mechanical lift. The DON said that she has changed practices after this incident on 9/6/15. The DON said that since Resident #1 was not feeling well prior to the transfer, the CNAs should have asked the Nurse to assess Resident #1. The DON said more inservice training with this lift was required. The DON said straps support the Resident but the Resident has to be able to bear weight when using the sit to stand mechanical lift. The DON said that Resident #1 was transferred to the hospital on [DATE] because of lethargy and he/she was not eating. One of the corrective actions included staff will be in-serviced on use of the sit-to-stand lift. However, the Facility failed to ensure CNA #1, who unsafely transferred Resident #1 had the additional training with mechanical lifts as of the survey date (6.5 weeks after Resident #1 sustained injuries). CNA #1 said that she was still using the sit to stand lift for transferring Residents.