Every finding on record at Julian J Levitt Family Nursing Home

Based on interviews, and record reviews, the facility failed to implement a system of surveillance for infection tracking, placing residents at risk for inadequate infection monitoring and spread of infections. Specifically, the facility failed to: -Maintain an up-to-date infection line listing for tracking incidents of infection in the facility when the facility's Infection Prevention and Control Plan indicated an up-to-date infection line listing would be maintained. -Include required information on the infection line listing for infection monitoring and tracking. Findings include: Review of the facility's policy titled Infection Control Guidelines for all Nursing Procedures, dated February 2014, indicated the following: -The purpose was to provide guidelines for general infection control while caring for residents. -The Infection Control Nurse, interchangeable referred to as Infection Preventionist (IP), and/or the Director of Nursing (DON) are responsible for the Infection Control Program in the facility. Review of the facility's Infection Prevention and Control Plan, undated, indicated: -The purpose was to establish a program to identify, treat and track infections . in an effort to prevent infectious disease processes for continuous quality improvement. -A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. -Its purpose is to identify infections and monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. -Surveillance is one of the most important elements of an infection control program. -Surveillance is defined as the collection, assembly and analysis of infections in the facility. -Surveillance provides knowledge of the specific and unique problems in each facility and is the foundation for the entire program. -Key components include: >To obtain optimum control of infections by identification of the numbers and characteristics of both community and facility acquired infections. >To identify and measure baseline information about the frequency and type of facility acquired infections. >To provide a basis for evaluating effects of infection control measures and policies. -The IP serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility. -To facilitate the collection of relevant resident infection data, a line listing form will be used to collect data by incidence as it is verified. -The line listing will include but is not limited to: >Resident identification >Room number >Date of admission >Date of onset of symptoms >Specific signs and symptoms >Site of infection >Organism(s) >Treatment -The update [sic] McGeer criteria or other nationally-recognized surveillance criteria will be used to define infections. -Periodic review of line listing by IP or other nursing staff will be done to look for evidence of clustering, cross contamination, trends or other patterns of deviation from standards. -At the end of each month, data will be review [sic] and analyzed and documented. During an interview on 5/1/25 at 3:53 P.M. the Infection Preventionist (IP) said she was new to the IP role and that the Staff Development Coordinator (SDC) and Director of Nursing (DON) were assisting her with infection prevention in the facility. The IP said the facility used McGeer criteria for infections and that she used a monthly line listing to track residents on antibiotic medication for infections. The IP also said she would use the information on the line listing to see if there were any trends for infections in the facility. The IP said she would complete the line listing at the end of each month for residents identified to have had infections requiring antibiotic treatment during the month. The IP provided the surveyor with a manilla folder labeled April. The surveyor observed that the folder included several completed McGeer infection criteria worksheets and failed to include any line listing. When the surveyor asked, the IP said the line listing had not yet been started for April 2025. During an interview on 5/6/25 at 9:55 A.M. with the IP and SDC, the IP said the antibiotic line listing for April 2025 had been completed. The IP and the SDC both said that the antibiotic line listing was the only infection tracker line listing used for the facility. The surveyor, the IP, and the SDC reviewed the completed April 2025 Line Listing for Antibiotic Use and observed as follows: -The columns on the Antibiotic Use line listing indicated: >Resident Name and Room Number (#). >Start Date. >Antibiotic. >Care Plan (Yes/No). >End Date. >Progress Documented. >Culture/Sensitivity. >Site. >Signature. -There were no columns to indicate: *date of admission *date of onset of symptoms *specific signs and symptoms, and organism(s) -The Line Listing for Antibiotic Use indicated 23 active resident infections treated with antibiotics during the month of April 2025. >Thirteen infections were listed as urinary infections. >Five infections were listed as viral infections. >Three infections were listed as skin/wound infections. >One infection was listed as sepsis. >No resident room numbers were recorded on the Line Listing. >The antibiotic column was not filled in for four residents. The IP and SDC both said the column titled Start Date referred to the antibiotic start date and that there were no columns on the line listing for symptom onset, and specific signs and symptoms of infection. When the surveyor asked how monitoring trends of infections in the facility was completed without completing the line listing until the end of the month, the SDC said, Right. During an interview on 5/6/25 at 2:00 P.M., the DON said the facility did have a line listing for tracking infections in addition to the Line Listing for Antibiotic Use. The DON said the Infection Tracker Line Listing was a shared document on the computer and that several staff could access the Tracker. At this time, the DON showed the facility's Infection Tracker Line Listing to the surveyor which included the following columns: -First Name. -Last Name. -Floor. -Long Term Care (LTC)/Short Term Rehab (STR). -Onset Date (or date of admission if admitted with). -Diagnosis. -Diagnostic Test. -Type of Infection. -Facility Acquired? -Catheter? (UTI Only). -Microorganisms. -MDRO (multi-drug resistant organism). -Precautions. -Met McGeers Criteria? -Infection Care Planned? -MD/NP Notified? -Responsible Party Notified? -Clinical Notes. -The Infection Tracker Line Listing failed to include resident room numbers, and specific signs and symptoms of infection. The DON said she would provide a copy of the facility's Infection Tracker Line Listing to the surveyor for residents with active infections during the month of April 2025. On 5/6/25 at 3:15 P.M., the facility provided the Infection Tracker Line Listing for residents with active infections during the month of April 2025 to the surveyor. The surveyor reviewed the facility's Infection Tracker Line Listing as follows: -Twelve residents were listed on the Infection Tracker Line Listing for a total of 12 infections (one resident was listed twice for a UTI with the same onset date). -Three of the 12 residents listed on the Infection Tracker Line Listing as having infections and being treated with an antibiotic medication were not indicated on the facility's Line Listing for Antibiotic Use. -Fourteen of the residents listed on the facility's Line Listing for Antibiotic Use as having infection and being treated with antibiotic medication were not indicated on the facility's Infection Tracker Line Listing. -Resident room numbers were not indicated on the facility's Infection Tracker Line Listing. -Specific signs and symptoms of infection were not listed on the facility's Infection Tracker Line Listing for any resident on the Line Listing. During a follow-up interview on 5/7/25 at 1:10 P.M., the DON said the facility's Infection Tracker Line Listing was to be used to track all infections in the facility. The DON said that the Unit Managers (UMs) at the facility had access to the Infection Tracker Line Listing and that the UMs were supposed to enter resident information into the Infection Tracker Line Listing upon the onset of infection symptoms. The DON said if a resident was not on the Infection Tracker Line List, it was because the UM did not enter the information. The DON said the Infection Tracker Line Listing did not contain information including resident room numbers and signs and symptoms of infection. The DON said including resident room numbers and infection signs and symptoms would be important because each unit at the facility had three wings, and it would be important to identify whether similar symptoms and infections were occurring on like-assignments and if clusters of infections were occurring. The DON said the Infection Tracker Line Listing would need to be updated to ensure accuracy, and that as the DON at the facility, she was responsible for the IPCP (Infection Prevention and Control Program).

Based on observation, interview, and record reviews, the facility failed to ensure personal care was provided with respect and dignity, in a manner to maintain and enhance quality of life for one Resident (#539) out of a total sample of 36 residents. Specifically, the facility failed to: -Ensure that Resident #539 was covered/clothed as requested by the Resident when during personal care, staff left the Resident exposed and uncovered in his/her bed, when the Resident required assistance from staff for personal care, resulting in the Resident feeling disrespected and dehumanized. -Ensure a timely response to Resident #539's undignified experience which increased the Resident's risk for further undignified experiences at the facility. Findings include: Resident #539 was admitted to the facility in April 2025 with diagnoses including Osteoarthritis of bilateral knees, muscle weakness, difficulty in walking, need for assistance with personal care, Osteoarthritis of the right shoulder, pain in right shoulder, and pain in right knee. Review of Resident #539's At Risk Care Plan initiated 4/16/25, indicated: -The Resident was at risk for falls, skin breakdown, Activities of Daily Living (ADL) functioning limitations and pain related to a diagnosis of [muscle] weakness. -Staff were to provide assistance with ADL completion. Review of the Physical Therapy (PT) Care Plan initiated 4/17/25, indicated Resident #539: -has generalized weakness. -required assistance with transfers. Review of the Occupational Therapy (OT) Care Plan initiated 4/17/25, indicated Resident #539: -required assistance with upper body and lower body dressing. Review of the Facility's Record of Resident Grievance for Resident #539, dated 4/17/25, indicated: -The Certified Nurses Aide (CNA #5) took the blankets down and took [pulled] the Resident's hospital gown up and left the room to get the supplies. -The Resident felt exposed and felt their dignity was violated. -The outcome, dated 4/18/25, included communication with family and Resident. -The resolution was that CNA #5 was not to enter Resident #539's room. -The Resident's daughter had called and left a message for Unit Manager (UM) # 1. UM #1 had left a return voicemail for the Resident's daughter. The Resident was updated that his/her daughter was called and stated [daughter aware with correction]. Further review of the Record of Resident Grievance Form indicated Resident #539 (who was his/her her own decision maker) did not sign the Grievance outcome. Review of the Minimum Data Set (MDS) Assessment, dated 4/22/25, indicated Resident #539: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. -was able to make him/herself understood and understood others. -demonstrated no behaviors. -required moderate assistance from staff to perform rolling from left to right. -required moderate assistance from staff for completion of toileting. -required moderate assistance from staff for dressing. Review of Resident #539's ADL Care Plan initiated on 4/29/25, indicated: -was unable to perform ADLs independently due to Osteoarthritis of the right knee and right shoulder. -required assistance from staff for bathing and dressing. -required assistance with mobility. During an interview on 4/30/25 at 2:32 P.M., Resident #539 said on 4/16/25, during the 11:00 P.M. to 7-00 A.M. (11-7) shift, a CNA was rude and disrespectful to him/her. Resident #539 said that he/she had used the bed pan, and urine had spilled onto the bed and hospital gown that he/she wore at that time. Resident #539 said the while CNA was assisting him/her to change the hospital gown and bedding, the CNA removed the Resident's hospital gown, and while the CNA was changing the bed linen, the CNA left the Resident naked and exposed. Resident #539 said that he/she told the CNA that he/she was cold and asked to be covered. Resident #539 said the CNA did not answer him/her, left him/her exposed, uncovered and cold, and pointed towards the wall (to indicate where Resident #539 needed to turn). Resident #539 said the CNA then left the room. Resident #539 said the CNA made him/her feel very nervous and vulnerable and the CNA was in charge of the situation. The Resident said the CNA was mean and disrespectful by not responding to him/her when he/she asked to be covered, and that being left naked and exposed was a very undignified experience. Resident #539 said that around 7:30 A.M. to 8:00 A.M., (on 4/17/25) he/she told Nurse #4 what had happened and gave Nurse #4 the details of the incident and explained how he/she felt mistreated. Resident #539 said that same day, mid-morning, he/she then told Rehabilitation (Rehab) Staff # 1 in detail about the previous night's events, and Rehab Staff #1 said he/she should not have been treated that way. Resident #539 said around 3:15 P.M. on 4/17/25, CNA #5 entered his/her bedroom to provide care, and he/she told the CNA that he/she had reported the incident from the previous night, did not want care provided from CNA #5 and the CNA exited the room. Resident #539 said later in the evening on 4/17/25 around 6:00 P.M., Unit Manager (UM) #1 came to see him/her, and he/she told UM #1 all the same details, and that he/she felt mistreated, disrespected, undignified, and dehumanized. Resident #539 said UM #1 told Resident #539 that she would talk with CNA # 5 about what happened. During an interview on 4/30/25 at 4:28 P.M., with the Director of Nursing (DON) and Administrator on 4/30/25 at 4:28 P.M., the DON said UM #1 notified her about Resident #539's complaint about CNA #5, and that it was a customer service complaint. The DON said UM #1 handled the Resident's complaint by conducting education with the staff and was not sure if a grievance form had been completed. The DON said she did not know why UM #1 did not speak with Resident #539 until 6:00 P.M on 4/17/25. The DON also said she was not sure why CNA #5 had gone back into Resident #539's room if CNA #5 had been educated by UM #1 to not provide care to Resident #539. During a follow-up interview on 5/2/25 at 9:05 A. M., Resident #539 said the following: -On 4/17/25 around 7:30 A.M., the Resident told Nurse #4 that the CNA on the 4/16/25 (11-7 P.M.) shift made the Resident feel disrespected and undignified, relative to leaving the Resident naked and exposed, and that the CNA was mean and unkind. -Nurse #4 appeared to the Resident to be exasperated that the event had occurred. -Mid-morning, on 4/17/25, Resident #539 told Rehab Staff #1 about the event that occurred on the 4/16/25 (11-7 P.M.) shift with the CNA. -SW #1 came to see the Resident on 4/17/25 between 3:00 P.M. and 3:30 PM at which time the Resident told SW #1 the details of the event that occurred with the CNA during the previous night's 11-7 (P.M.) shift. -The Resident said SW #1 listened to him/her and said, Oh, that's terrible. -Resident #539 said that UM #1 visited him/her around 6:30 P.M. on 4/17/25 and said to Resident #539 that she was going to speak with CNA# 5 about the incident. -Resident #539 said that at no point on 4/17/25 did any staff members he/she spoke with about the 4/16/25 event offer to file a formal complaint or grievance, and that he/she did not put anything in writing. -Resident #539 said no staff member came back to discuss the outcome of his/her reported incident with CNA #5 until 4/30/25, after he/she made the surveyor aware of the situation. -Resident #539 said he/she did not feel like things were handled appropriately and nothing ever came of reporting the event until [the surveyor] came into the facility. During an interview on 5/2/25 at 11:07 A.M., Rehabilitation Staff #1 said she did the Physical Therapy Evaluation for Resident #539 on 4/17/25. Rehab Staff #1 said she recalled the Resident being a little upset about something that happened during the (11-7 P.M.) shift with a staff member, but did not remember the details of what the Resident said. Rehab Staff #1 said she reported the Resident's complaint to UM #1 around 11:00 A.M. on 4/17/25. During an interview on 5/2/25 at 11:42 A.M., Nurse # 4 said that when he went to see Resident #539 on 4/17/25 in the morning, the Resident reported that he/she felt disrespected by a staff member on the prior (11-7 P.M.) shift. Nurse #4 said he could not recall the details of what the Resident had said, but that the Resident was angry about the incident, and that Nurse #4 told UM #1 and SW #1 right away because they were sitting in the office near the Resident's room. Nurse #4 said that anytime a facility receives a complaint from a Resident, the facility process was for a staff designee to complete an investigation right away, and that the incident should be reported to the DON and the Administrator immediately. During an interview on 5/2/25 at 12:33 P.M., UM #1 said that she and SW #1 were notified by Nurse #4 on 4/17/25 around 7: 30 A.M. that Resident #539 had a concern about staff on the (11-7 P.M.) shift. UM #1 said she was told by SW #1 that SW #1 would go see the Resident. UM #1 said she was unsure of when SW # 1 went to see Resident #539 about the complaint, but that around 3:00 P.M., SW #1 told her that the Resident had a concern involving an (11-7 P.M.) shift CNA and the that the CNA should be educated on customer service. UM #1 said that shortly after 3:00 P.M., CNA #5 had already gone back into Resident #539's room to take vital signs at the beginning of her shift and then CNA #5 came to speak with UM #1 because Resident #539 told CNA #5 that he/she had reported CNA #5 and did not want the CNA to provide care for him/her. UM #1 said she then educated CNA #5 about customer service, obtained a statement about the incident on 4/17/25 from the CNA, and instructed CNA #5 not to go into Resident #539's room. UM #1 said SW #1 completed a Grievance Form, and UM #1 completed education to CNA #5 as an outcome to the grievance. UM #1 said that she was under the impression SW #1 would have followed-up with the Resident right away after the incident had been reported to them at 7:30 A.M. and was not sure why SW #1 did not see the Resident until around 3:00 P.M. UM #1 said she did not speak with the Resident about the 4/16/25 incident until sometime between 5:00 P.M. and 6:00 P.M. on 4/17/25 (9.5 - 10.5 hours after the Resident's report to Nurse #4). UM #1 said the Resident told her that the CNA #5 was unfriendly, had a flat affect, and had left him/her naked and exposed which made him/her feel uncomfortable. UM #1 said Resident #539 was upset to have been left naked and when the Resident asked to be covered, the CNA did not cover him/her and gestured for him/her to roll over leaving him/her exposed. UM #1 said that if a Resident had a complaint or concern, a staff member should have interviewed the Resident as soon as possible and should have informed administration. UM #1 said she though the Resident's concern about CNA #5 was a customer service concern that could be corrected with staff education. During an interview on 5/2/25 at 1:22 P.M., SW #1 said on 4/17/25 between 7:30 A.M.- 8:30 A.M., Nurse #4 told her that Resident #539 that a complaint from the (11-7 P.M.) shift. SW #1 said she went into the Resident's room around 8:30 A.M. but the Resident was working with a therapy staff member at the time, so SW #1 told Resident #539 that she would come back. SW #1 said that her workday got very busy, and she forgot to return to see the Resident until around 3:00 P.M. SW #1 said Resident #539 told her about the incident with CNA #5 at that time. SW #1 said Resident #539 told her that CNA #5 did not introduce herself, did not talk to the Resident, and instead of asking the Resident to roll over in the bed, pointed with her finger. SW #1 said Resident #539 further said that CNA #5 removed the Resident's hospital gown, and the Resident told the CNA that he/she was cold, and asked to be covered up, but the CNA left the room for supplies without covering the Resident as requested. Resident #539 told SW #1 that she thought the situation was undignified. SW #1 said she then returned to the office and told UM #1 that CNA #5 needed to be educated for dignity related to leaving Resident #539 exposed and cold while providing care. SW #1 said the Resident was bothered and saddened by the event on 4/17/25, and that Resident #539 said he/she would never treat a patient the way CNA #5 treated him/her. SW #1 said at the time of her interview with Resident #539 on 4/17/25, CNA #5 had already gone into the Resident's room and the Resident had told the CNA to leave. SW #1 said she completed a Grievance Form on 4/17/25, gave it to UM #1 but it was left on the UM's desk and forgotten about until 4/30/25, when the surveyor inquired about the incident that occurred on 4/16/25. SW #1 said that she should have gone back right away to see Resident #539 in the morning of 4/17/25 but did not because she forgot and got busy. During an interview on 5/2/25 at 3:26 P.M., the Administrator said a thorough investigation should have been completed immediately after Resident #539 had voiced a complaint to Nurse #4 on 4/17/25 at 7:30 A.M. The Administrator said when the Resident was unavailable to speak with SW #1 in the morning on 4/17/25, SW #1 should have gone back as soon as possible to ask thorough questions about the incident details and to check on how the Resident was doing. The Administrator said she and the DON completed a follow-up investigation after the surveyor brought it to their attention on 4/30/25, and Resident #539 was very clear about feeling intimidated and vulnerable on 4/17/25. The Administrator also said since SW #1 did not go back to interview the Resident right away, there was a several hour delay in the initial investigation. The Administrator said completing a through investigation on 4/17/25 would have prevented CNA #5 from going into Resident #539's room on 4/17/25 in an attempt to provide care.

Based on record review, and interview, the facility failed to refer one Resident (#77) for a Preadmission Screening and Resident Review (PASRR- a federal and state-required process that is designed to, among other things, identify evidence of serious mental illness [SMI] and/or intellectual or developmental disabilities [ID/DD] in all individuals [regardless of source of payment] seeking admission to Medicaid-or Medicare-certified nursing facilities) Level II Evaluation (an evaluation conducted to determine if an individual with a newly evident or possible SMI, ID, or a related condition for Level II resident review upon a significant change in status assessment) out of a total sample of 36 residents. Specifically, for Resident #77, the facility failed to refer the Resident for a Level II PASRR Evaluation after receiving a new diagnosis of Psychosis. Findings include: Resident #77 was admitted to the facility in December 2017 with diagnoses including history of alcohol abuse and Depression. Review of the Diagnosis List indicated Resident #77 has the following current diagnoses in part: -Dementia-onset 2/22/24 -Anxiety-onset 2/22/24 -Psychosis-onset 9/26/24 -Delusional Disorder-onset 9/26/24 Review of the PASRR completed 11/12/17, failed to indicate that Resident #77 had a serious mental health disorder that would indicate a Level II Evaluation was required. Review of the H&P (History and Physical) completed on 11/26/17, indicated Resident #77 was diagnosed with alcohol abuse and Depression. Further review of the H&P failed to indicate documented evidence of diagnoses of Psychosis, Anxiety, and Delusional Disorder. Review of the Behavioral Health Note dated 3/29/23, indicated Resident #77 was diagnosed with Dementia, Psychosis, Depression, Anxiety, and Alcohol Abuse. Further review of Resident #77's medical record failed to indicate documented evidence that a PASRR Level II Evaluation was conducted after a newly evident or possible serious mental health disorder was identified on 3/29/23 or 9/26/24. During an interview on 5/7/25 at 12:19 P.M., Social Worker (SW) #2 said that she could not speak to the Behavioral Health Note dated 3/29/23, that indicated Resident #77's Psychosis diagnosis. SW #2 said that the Psychosis diagnosis, as far as she was aware, was added on 9/26/94, and when that new mental health diagnosis was identified, a request for a PASRR Level II Evaluation should have been made to the PASRR office but had not been made, as required.

Based on observations, record review, and interviews, the facility failed to ensure one Resident (#52) received treatment and care in accordance with professional standards of practice, out of total sample of 36 residents. Specifically, for Resident #52, the facility failed to follow-up with a recommendation made by the Ophthalmologist to increase the use of Refresh Optive Ophthalmic (a preservative-free eye drop designed to relieve dry eye symptoms) from two times per day to four times per day. Findings include: Resident #52 was admitted to the facility in September 2024 with diagnoses including Myasthenia Gravis and Dementia. Review of the Provider Encounter Progress Note, dated 1/9/25, indicated the following in part: -Patient had bilateral ectropion (condition in which your eyelid turns outward) with retracted lower lid history of recurrent conjunctivitis (eye infection) . Review of the Ophthalmologist Report of Consultation, dated 3/10/25, indicated the following: -Recommended to use Refresh Optive in both eyes four times a day -Consultant signature -Provider initials Review of Resident #52's active Physician orders as of 5/5/25, indicated the following order: -Refresh Optive Mega-3 Ophthalmic Solution 0.5-1-0.5 %. Instill one drop in both eyes two times a day for eye health, initiated 1/9/25. Review of the March 2025 through May 2025 Medication Administration Records (MARs) indicated: -Refresh Optive Mega-3 Ophthalmic Solution 0.5-1-0.5 % was administered as ordered, two times per day. -the administered frequency failed to reflect the Ophthalmologist's recommendation made on 3/10/25, for four times per day. On 4/30/25 at 3:41 P.M., the surveyor observed Resident #52 seated in his/her wheelchair in his/her room with Health Care Proxy (HCP)/family present. Resident #52 was observed to have red, watery bilateral lower lids, and a yellow crusty substance on the left upper lid. During an interview at the time, Resident #52's HCP said Resident #52 used eye drops and that his/her eyes usually looked that way. During an interview on 5/5/25 at 2:19 P.M., Unit Manager (UM) #2 said the two initials on the Ophthalmologist Consultant Report dated 3/10/25 belonged to the Ophthalmologist and the Provider at the facility. UM #2 said that this indicated that the Provider reviewed and agreed with the recommendations made by the Ophthalmologist. UM #2 said after the recommendations had been reviewed and accepted by the Provider, the Nurse should have changed the order to reflect the new recommendation to increase the Refresh Optive Mega-3 Ophthalmic Solution 0.5-1-0.5 % from two times a day to four times a day and that did not occur.

Based on observation, interview, and record reviews, the facility failed to provide treatment for hearing loss for one Resident (#121), out of a total sample of 36 residents. Specifically, the facility failed to ensure recommendations made from the Audiologist (professional that specializes in diagnosing, treating, and managing hearing loss and balance disorders) were implemented for Resident #121 in order to improve his/her hearing ability. Findings include: Resident #121 was admitted to the facility in October 2021 with diagnoses including need for assistance with personal care and hearing loss. Review of the Cognitive Impairment/Communication Care Plan initiated 5/10/22, indicated Resident #121: -had an alteration in communication due to difficulty hearing, and included the following interventions also initiated 5/10/22: >Audiology Consult as needed. >Use assistive hearing device as needed. >Utilize communication board/paper as needed. Review of the Request for Service Form, signed by Resident #121 on 5/15/23, indicated he/she consented to Audiology Services. Review of the Provider Note dated 1/15/25, indicated Resident #121: -was currently receiving Debrox (medication applied directly inside the ears to loosen and unclog built-up earwax) to his/her ears in anticipation of audiology visit this week . -was receiving communication via white board . Review of the January 2025 Medication Administration Record (MAR) indicated Debrox Otic Solution, 5 drops to both ears twice daily for five days for ear wax removal, initiated 1/10/25 through 1/16/25. Review of the Audiology Consult, dated 1/22/25 indicated Resident #121: -was seen due to increased complaints of newly decreased hearing -communication was via use of a white board -had visibly occluding (obstructed) cerumen (earwax) on the left ear -had some non-occluding cerumen on the right ear -had perforation of tympanic membrane (ruptured ear drum) present in the right ear -hearing aids were cleaned and checked for fit, Resident was pleased with sound quality of hearing aids -the left hearing aid may need manufacturer repair due to weak sound quality -was unable to complete pure tone testing and speech testing due to visibly occluded cerumen in both ears, the wax was too deep for removal .wax needs removal -Recommendation for Attending Medical Doctor (MD)/Nursing Staff: >wax needs removal in the left ear. >Medical Consult due to: wax removal needed-left ear. >Change (hearing aid) batteries weekly. >Clean hearing aids after use. >Daily use of hearing aids is recommended. >Please contact MD for wax removal orders. >Please open battery door when hearing aids were not in use. -Action to be taken by Audiologist: Re-evaluate Resident after wax removal Review of the Provider Note dated 2/10/25, indicated Resident #121 was very hard of hearing and communicated through a white board. Further review of the Provider Note failed to indicate the results or any mention of the Audiologist's Recommendations from 1/22/25. Review of the Minimum Data Set (MDS) Assessment, dated 2/15/25, indicated Resident #121: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -required substantial/maximum assistance with personal hygiene, dressing upper body -understands and was understood -had highly impaired hearing and utilized hearing aids Review of the Social Service assessment dated [DATE], indicated: -Resident was seen by Audiology with a report that his/her (ear) wax was impacted and to be taken out . Review of the Resident's clinical record failed to indicate documented evidence of the facility follow-up relative to the Audiologist's Recommendations from 1/22/25. On 4/30/25 at 11:00 A.M., the surveyor observed Resident #121 dressed in a hospital gown and lying in bed. When the surveyor attempted to conduct an interview, the Resident said he/she couldn't hear a thing and instructed the surveyor to utilize the white board located in the room. The Resident was also observed with no hearing aids in place during the observation. On 5/2/25 at 11:05 A.M., the surveyor observed the Resident lying in bed, dressed in a hospital gown and watching television with closed captions on and he/she was not wearing hearing aids. During an interview using the whiteboard for communication, the Resident said he/she could not recall having another audiology appointment after the one in January 2025, and could not recall any follow-up from the January 2025 appointment relative to his/her hearing. Resident #121 said he/she had wax in his/her inner ears and that the Audiologist cleaned his/her hearing aids. Resident #121 further said after the hearing aids were cleaned by the Audiologist, they worked better for about three days and then had wax built up on them again and were not helpful with his/her hearing. When the surveyor asked about his/her hearing aids, the Resident said he/she thought the hearing aids may be in a drawer in his/her room but was not sure where they were located. Resident #121 said he/she was not sure anything could be done to help with his/her hearing, but he/she would like to be able to hear better. On 5/7/25 at 9:56 A.M., the surveyor and Unit Manager (UM) #3 reviewed Resident #121's clinical record. During an interview at the time, UM #3 said Resident #121 utilized a white board to communicate because he/she was hard of hearing. UM #3 said she could not recall Resident #121 using hearing aids and would have to look into the Audiologist's Recommendations from January 2025. UM #3 also said she would look into the location of the Resident's hearing aids. During an interview on 5/7/25 at 11:25 A.M., Certified Nurses Aide (CNA) #1 said Resident #121 was very hard of hearing and that facility staff utilized a white board to communicate with him/her. CNA #1 said she was not aware that Resident #121 had hearing aids. During a follow-up interview on 5/7/25 at 10:20 A.M., UM #3 said she was able to locate the hearing aids in the Resident's room. UM #3 said she was unable to verify that the Audiologist's Recommendations from 1/22/25 were implemented and/or reviewed with the Provider for follow-up. UM #3 said when a Consultant evaluates a Resident, the report would be emailed to the facility, printed out and reviewed with the facility Provider. UM #3 said the Provider would initial the Consult Form to indicate it was reviewed and would implement new orders if indicated. UM #3 said the Audiology Consult dated 1/22/25 for Resident #121 was not initialed as reviewed by the Provider. UM #3 further said there was no indication that there was follow-up to the Audiologist's Recommendations, that she had reviewed the Resident's clinical record for orders for wax removal after the 1/22/25 and was unable to find that this was implemented.

Based on records review, and interviews, the facility failed to obtain laboratory services as ordered by the Physician for one Resident (#143) of five applicable residents, out of a total sample of 36 residents. Specifically, the facility failed to obtain laboratory services as ordered by the Physician, to check Resident #143's Keppra (Levetiracetam: medication used to manage seizures) level, placing the Resident at risk for inadequate medication monitoring and complications related to medication use. Findings include: Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol, undated, indicated the following: -The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. -The reason for getting a test often affects the urgency of acting upon the result. Resident #143 was admitted to the facility in May 2024 with diagnoses including Epilepsy. Review of Resident #143's Final Levetiracetam Level Result, drawn 2/27/25 with results obtained on 3/3/25, indicated the Resident's Levetiracetam level was 4.5 ug (microgram)/mL (milliliter), (reference range is 3.0 - 60.0 ug/mL). Review of Resident #143's Physician Assistant (PA) Progress Note, dated 5/2/25, indicated the following: -The Resident was noted with a decline in status and weight loss. -The Resident was a full code (use of all possible medical interventions to be used to sustain one's life) status. -The Resident had a seizure disorder and was maintained on Keppra. -No recent seizure activity. -Obtain Keppra level. Review of Resident #143's May 2025 Physician orders indicated: -Keppra oral tablet 500 milligrams (mg), give one tablet by mouth two times a day for seizure disorder, dated 8/30/24. -An order, dated 5/2/25, for . Keppra level on 5/5/25. Review of Resident #143's May 2025 Medication Administration Record (MAR) indicated: -Keppra was administered to the Resident as ordered by the Physician. -The box indicating Keppra level on 5/5/25 was blocked off with an x. Review of Resident #143's clinical record failed to include any evidence the Resident's Keppra level was drawn on 5/5/25. During an interview on 5/7/25 at 1:10 P.M. the Director of Nursing (DON) said Keppra level results usually took a couple of days to be communicated to the facility from the lab, so the results may not have been available yet. The DON said she would provide the laboratory requisition slip as evidence the Keppra level was drawn for Resident #143 on 5/5/25. During an interview on 5/7/25 at 3:30 P.M., Unit Manager (UM) #4 said a Keppra level was ordered to be drawn for Resident #143 on 5/5/25. UM #4 said the Keppra level was not drawn for the Resident because no laboratory requisition had been completed by the facility. During a follow-up interview on 5/7/25 at 3:53 P.M., the DON said potential risks for not obtaining lab services to draw Resident #143's Keppra level included an increased risk for seizure activity if the Keppra level was too low and increased risk of toxicity if the level was too high.

Based on interviews, and record reviews, the facility failed to maintain complete and accurate clinical records for three Residents (#155, #533, and #423) out of a total sample of 36 residents. Specifically, 1. For Resident #155, the facility failed to record the Resident's post void residual (PVR: amount of urine remaining in the bladder after one urinates) when PVRs were ordered to monitor the Resident's Kidney Disease, placing the Resident at risk for inadequate monitoring of his/her medical condition. 2.For Resident # 533, the facility failed to document the administration of a newly ordered dose of Lasix (diuretic medication that helps reduce fluid buildup in the body), when the Resident experienced symptoms of Congestive Heart Failure (CHF: type of heart failure that occurs when the heart cannot pump blood as well as it should), placing the Resident at risk for inadequate monitoring of his/her medical condition. 3. For Resident #423, the facility failed to document the administration of PRN (as needed) antipsychotic (medication used to treat psychosis, a mental health condition where individuals experience difficulties distinguishing between reality and what is not real) medication as required, placing the Resident at risk for inadequate monitoring of his/her medical condition. Findings include: 1. Resident #155 was admitted to the facility in September 2024 with diagnoses including Urinary Tract Infection (UTI), Acute Kidney Failure, and Dementia. Review of Resident #155's Physician Progress Note, dated 4/21/25, indicated: -The Resident had a positive urinalysis (UA: urine test often done to check for UTI and/or kidney disease). -The Resident had Acute Kidney Injury (AKI) and Acute Renal Failure. -The Resident had Chronic Kidney Disease. -Bladder scan (non-invasive ultrasound of the bladder used to determine how much urine remains in one's bladder after urination) for [urine] retention issues. Review of Resident #155's April 2025 Physician orders indicated the following: -An order, dated 4/21/25: -PVR every shift for kidney disease for three days. ->(greater than) 350 [milliliters], insert Foley catheter. Review of Resident #155's April Medication Administration Record (MAR) indicated: -PVRs were recorded on the night shift on 4/21/25, 4/22/25, and 4/23/25. -PVRs were recorded on the day shift on 4/22/25, 4/23/25, and 4/24/25. -PVR was recorded on the evening shift on 4/23/25. -No PVRs were recorded on the evening shifts on 4/22/25 and 4/24/25. Review of Resident #155's clinical record failed to include any evidence that the Resident's PVRs were recorded for the evening shifts on 4/22/25 and 4/24/25. During an interview on 5/7/25 at 11:15 A.M., Unit Manager (UM) #2 said Nurse #7 and Nurse #8 were responsible for Resident #155's care for the evening shifts on 4/22/25 and 4/24/25. During an interview on 5/7/25 at 2:01 P.M., Nurse #8 said she did not usually work on the hallway where Resident #155 resided. Nurse #8 said that she was not responsible to provide care for the Resident between 4/22/25 and 4/24/25, when PVRs were to be completed and recorded in the Resident's record. During an interview on 5/7/25 at 2:06 P.M., Nurse #7 said she was familiar with and had provided care for Resident #155. Nurse #7 said if the Resident had an order for PVRs every shift, then the PVRs would be completed. Nurse #7 said if she was the Nurse to have completed the Resident's PVR, she would have written the PVR amount on her resident report sheet and may not have entered the PVR amount in the Resident's record. During an interview on 5/7/25 at 1:10 P.M., the Director of Nursing (DON) said when PVRs were ordered to be completed for a Resident, the Nurses were responsible to record the PVR amounts in the Resident's record when the bladder scan for PVR was completed. The DON said Resident #155 had a UTI at the time the PVRs were ordered and that the Resident had kidney disease. The DON said recording the PVR amounts was an important piece for monitoring the Resident's condition, to ensure the Resident was urinating enough. The DON said the Resident's PVR amount should have been recorded in the Resident's clinical record for the evening shifts on 4/22/25 and 4/24/25. 3. Resident #423 was admitted to the facility in February 2025 with diagnoses including vascular Dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and anemia. Review of the Minimum Data Set (MDS) Assessment, dated 2/17/25, indicated Resident #423 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of seven out of a total of 15 possible points. Review of Resident #423's Hospital Discharge summary, dated [DATE], indicated the following order: -Seroquel 12.5 milligram (mg), by mouth two times a day as needed (PRN), for agitation. Review of Resident #423's Physician's orders for May 2025 indicated: -Seroquel Oral tablet, give 12.5 mg by mouth every 12 hours as needed for agitation related to vascular Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety for 14 days, started 5/2/25. On 5/6/25 at 10:02 A.M., the surveyor observed Resident #423's Seroquel medication card with Nurse #6 with the following findings: -the Seroquel medication card was received from the pharmacy on 5/3/25 -the Seroquel medication card had (14 full tabs) 28 half tabs. -four pills were missing on the medication card. During an interview at the time, Nurse #6 said she was not sure when the medications were administered to the Resident, because there was no record on the MAR and there was no Progress Note. Review of Resident #423's May 2025 Medication Administration Records (MAR) failed to indicate that the Resident was administered PRN Seroquel medication on any days in May 2025. During an interview on 5/7/25 at 10:57 A.M., Nurse #2 said she would occasionally pick up shifts on the unit where Resident #423 resided. Nurse #2 said the Resident had increased behaviors in the evenings. Nurse #2 said she would usually give Resident #423 his/her PRN Seroquel and would usually put the medication in ice cream before the Resident's behaviors got to the point where it would be difficult to manage. Nurse #2 said she would not always document the administration of the medication, but she should. During a follow-up interview on 5/7/25 at 1:28 P.M., the DON said the Nurses should have signed off the administration of the Seroquel medications when they were administered but they had not always done so. 2. Resident #533 was admitted to the facility in April 2025 with diagnoses including Acute on Chronic Heart Failure, Ischemic Cardiomyopathy, and Hypertension (HTN). Review of the Resident #533's Skilled Nursing Note dated 4/28/25, indicated the Resident had a weight gain of 4 lbs. (pounds) and the Provider ordered Lasix 20 mg (milligrams) to be given in the P.M. [sic] for 3 days. Review of the Resident #533's Medication Administration Record for April 2025 indicated the following: -Lasix 20 mg in P.M. [sic] for 3 days was ordered to start on 4/28/25. -Lasix 20 mg was administered on 4/29/25 as ordered. -Lasix 20 mg was administered on 4/30/25 as ordered. Review of Resident #533's clinical record failed to include any evidence that the Resident was administered Lasix 20 mg as ordered on 4/28/25. During an interview on 5/6/25 at 8:46 A.M., the surveyor and Nurse #5 reviewed the April 2025 MAR and Nurse #5 said that the order for Lasix 20 mg in the P.M. was not signed off as given on 4/28/25 but should have been signed off if it was given. Nurse #5 said the Resident would be at risk for worsening Congestive Heart Failure if the medication was not given as ordered.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another), the Facility failed to ensure his/her environment was as free of incidents/accidents as possible, when on 11/19/24, Certified Nurse Aide (CNA) #3 and CNA #4, who had set up and prepared him/her for transfer out of bed, did not properly set up (position of the legs/base) the Hoyer lift, as they transferred Resident #1 the lift started to tip over sideways, Resident #1 was lowered to the floor by staff during the incident, and the Hoyer lift completely tipped over landing on the floor next to the resident. Findings include: Review of the Battery Operated Patient Lift Owners manual (specific to the Hoyer lifts the Facility utilized), provided to the surveyor by the Facility, indicated the following instructions to transfer a person from bed: - Open the base (legs) and move the lift slowly towards the patient and position the spreader bar (the area where the Hoyer sling, that holds a patient, attaches to the lift), over the patient's chest. - Lower the cradle to a point where the sling's loops can reach the cradle's hooks and attach the sling to the cradle hooks. - Lift the patient above the bed by using the hand control. - Pull lift away from the bed and rotate the patient so they are facing the back of the lift. - Close the base (legs) and slowly move patient over the wheelchair (wheelchair wheels must be locked) or commode, opening the base for stability. - Then lower the patient onto the surface by pressing the down button. Review of the Facility's Competency titled, Skill Performance - Mechanical Lift indicated the following step: - Position lift over resident in bed (or in front of resident if in chair). Spread open and lock mechanical lift feet. - Guide lift away from starting point (bed or chair) - Position resident over bed or chair - First assist repositions themselves to support resident in sling, use sling loops to ensure correct potion as resident is lowered into chair (or bed). Review of the Facility Investigation, dated 11/19/24, which included written statements provided by staff, indicated that on 11/19/24 at 8:15 A.M., after Resident #1 received morning personal care, he/she was in the Hoyer lift, the lift tipped over and he/she was lowered to the ground. Resident #1 was admitted to the Facility in February 2024, diagnoses included Dementia and recent fall resulting in a Subdural Hematoma (pool of blood between the brain and it's outermost covering), Subgleal Hematoma (blood accumulation between the skull and scalp) and Subarachnoid Hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/12/24, indicated he/she had severe cognitive impairment and was dependent on staff for chair/bed-to-chair transfers. Review of Resident #1's ADL Care Plan, reviewed and renewed with his/her October 2024 MDS, indicated he/she was dependent on two staff members for transfers and utilized a Hoyer lift. Review of Resident #1's Care Kardex (used by the CNAs to determine individual care needs) indicated he/she required assistance of two staff members with a mechanical lift (Hoyer). Review of a Nursing Progress Note written by Nurse #1, dated 11/19/24 at 8:58 A.M., indicated Resident #1 was receiving care in the morning with two CNAs (CNA #3 and CNA #4) present while he/she was in the Hoyer lift. The lift tipped over and the Resident #1 was lowered to the ground by the CNAs, and no injuries were observed. During an interview on 01/08/25 at 2:21 P.M., Nurse #1 said on the morning of 11/19/24 at approximately 8:15 A.M., another staff nurse notified her that Resident #1 was on the floor. Nurse #1 said when she arrived to Resident 1's room, CNA #3, CNA #4, and his/her spouse were present, the wheelchair (which was empty) was facing her, the Hoyer lift was lying sideways on the floor, and Resident #1 was seated on the floor leaning against the wheelchair. Nurse #1 said she assessed Resident #1 by obtaining his/her vital signs and performed a physical and a neurological assessment. Nurse #1 said she determined Resident #1 had no injuries and was not exhibiting signs or symptoms of pain. Nurse #1 said CNA #3 and CNA #4 reported to her that Resident #1 had not hit his/her head, and he/she was safely transferred into his/her wheelchair. Nurse #1 said after the incident, the Executive Director, along with CNA #3 and CNA #4 attempted a re-enactment. Nurse #1 said based on that re-enactment it was determined that the CNAs had failed to widen the base legs of the Hoyer lift, and once the CNAs attempted to move Resident #1 into his/her wheelchair, the weight shift caused the Hoyer lift to tip, that the CNAs were unable to stabilize the Hoyer lift, so they had no choice but to lower Resident #1 to the floor for his/her safety. Nurse #1 said that when residents are being lifted and lowered while in the Hoyer lift, the legs (base) should be in an open position to provide balance and stability. During an interview on 01/09/25 at 9:45 A.M., which included review of her written Witness Statement, CNA #3 said that on 11/19/24 at approximately 8:15 A.M., she and CNA #4 utilized a Hoyer lift to attempt to transfer Resident #1 out of bed to his/her wheelchair. CNA #3 said that when they started to move Resident #1 into his/her wheelchair, she was behind him/her guiding his/her upper body and CNA #4 was next to him/her near his/her legs, the Hoyer tipped sideways toward CNA #4 and actually hit her (CNA #4) in the face. CNA #3 said she and CNA #4 grabbed a hold of the Hoyer sling Resident #1 was seated in, lowered him/her to the floor, and the Hoyer lift ended up sideways on the floor, as well. CNA #3 said that she and CNA #4 made a mistake by not opening the Hoyer legs. The surveyor asked CNA #3 if she knew she was supposed to widen the Hoyer lift legs, but that she did not realize that was supposed to be done. CNA #3 said she thought that the reason to open and close the legs at the base of the Hoyer was to fit the Hoyer lift around objects such as larger wheelchair wheels. During an interview on 01/09/25 at 10:15 A.M., which included review of her written Witness Statement, CNA #4 said that on 11/19/24 at approximately 8:15 A.M., she and CNA #3 were using a Hoyer lift to transfer Resident #1 from his/her bed to his/her wheelchair. CNA #4 said CNA #3 was behind Resident #1 and that she was near his/her leg and as they were moving him/her, the Hoyer began to tilt sideways and while tilting, it hit her face. CNA #4 said that she and CNA #3 decided it would be safer to lower Resident #1 to the floor, and when they lowered him/her down, the Hoyer lift fell down sideways. CNA #4 said that when she and CNA #3 transferred Resident #1, they did not have the legs (base) to the Hoyer lift in the open position, and was unaware that having the legs open while lifting and lowering a resident was required for balance and safety. During an interview on 01/08/25 at 3:10 P.M, Unit Manager #1 said she was told CNA #3 and CNA #4 lowered Resident #1 to the floor on 11/19/24 at 8:15 A.M. because the Hoyer lift tilted sideways due CNA #3 and CNA #4 failing to open the Hoyer lift legs (base) causing a weight shift resulting in the Hoyer lift to tip. During an interview on 01/09/25 at 9:50 A.M., the Occupational Therapist (OT) said in order to operate a Hoyer lift safely, the (base) legs must be in the open position prior to and while lifting a resident, and should be open when lowering a resident back down (to the destination surface), and that the widened base provides stability and balance to the Hoyer lift, preventing it from tipping over in the event of a weight shift. During an interview on 01/09/25 at 1:30 P.M., the Director of Rehabilitation said that she could not speak to the incident on 11/19/24 at 8:15 A.M., when Resident #1 was lowered to the floor by CNA #3 and CNA #4, as she was not involved in the related investigation. The Director of Rehabilitation with the surveyor, reviewed the Hoyer lift owner manual that indicated the base (the legs) should be open prior to lifting and prior to lowering a resident. The Director of Rehabilitation said reasoning behind having the base open was to provide a wider base of support for increased stability, and keeping the legs in the narrow position could render the Hoyer lift unstable and a weight shift could cause the Hoyer lift to tip. The Director of Rehabilitation further said that because of this, the Hoyer legs/base should be open when lifting and lowering a patient. During an interview on 01/09/25 at 2:35 P.M., the Director of Nursing (DON) said she was not working on 11/19/24 when Resident #1 was lowered to the floor by CNA #3 and CNA #4, but said however that the Executive Director and another staff member, along with CNA #3 and CNA #4 re-enacted the incident shortly after it occurred. The DON said that all clinical staff, which included certified nurse aides were provided education and competencies related to mechanical lift transfers upon hire and annually. During an interview on 01/09/25 at 3:15 P.M., the Executive Director (ED) said on 11/19/24, she received a call that Resident #1 had experienced an incident where he/she was lowered to the floor. The ED said that she, along with one of the nurse managers went up to the unit and had CNA #3 and CNA #4 re-enact what they did. The ED said the CNAs showed her how the wheelchair was positioned near the bed and how they transferred Resident #1 from the bed to the chair (by going over the wheelchair arm rest). The ED said she asked them if they were sure they had opened the legs, and said the CNAs told her they were sure they were open but said they were unsure at what point in the process the Hoyer base legs were open or closed. On 01/09/24, the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) On 11/19/24, Resident #1 was immediately assessed by nursing for injuries, none were noted and he/she did not voice any complaints of pain. B) On 11/19/24, and 11/21/24 the Director of Rehabilitation and the Staff Development Coordinator re-educated CNA #3 and CNA #4 regarding Hoyer lift usage which included a written competency and return demonstration. C) On 11/20/24, Resident #1 was re-assessed by Rehabilitation staff to determine if he/she required alternative seating. D) On 11/20/24, 11/21/24 and 11/22/24, the Staff Development Coordinator and the Director of Rehabilitation provided in-person education to all clinical staff titled, Full Body Mechanical Lift which included competencies with demonstration. E) On 11/19/24, the Staff Development Coordinator provided education to all clinical staff titled, Hoyer Transfer Protocol which indicated until further notice all Hoyer lift transfers required two CNAs and one Nurse be present to ensure the Hoyer lift base is opened for stability while lowering a resident into a wheelchair. The Education included a written page from the Hoyer lift owners manual that highlighted the following: - Pull lift away from the bed and rotate the patient so they are facing the back of the lift - Close the base and slowly move patient over the wheelchair, opening the base for stability. F) On 11/20/24 and ongoing, the Rehabilitation department is screening all residents in the Facility that require a total mechanical lift to ensure appropriate Hoyer sling size, appropriate seating and auditing/observing clinical staff during Hoyer transfers to ensure correctness and safety is maintained. G) On 11/20/24 and ongoing, the Rehabilitation department, Nurse Managers, and Staff Nurses are conducting random audits to ensure mechanical lift transfers are carried out appropriately and safely. H) On 11/20/24 an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held. The Facility leadership team developed a plan of correction related to the deficient practice. The Project Leader is the Executive Director, Key Area for Improvement - Hoyer Transfers. I) Effectiveness of this plan will be reviewed during Monthly QAPI meetings until further notice. J) Director of Nursing and Executive Director will be responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who's comprehensive care plan indicated he/she required assistance of two staff members for bed mobility, the Facility failed to ensure staff implemented and followed interventions in his/her care plan, when on 04/28/24 Certified Nurse Aide (CNA) #1 provided care to Resident #1, who was in bed, without another staff member present to assist her. CNA #1 rolled Resident #1 on his/her side, away from her, Resident #1 rolled off the bed, fell on to the floor, landing on his/her right side and immediately complained of pain. Resident #1 was transferred to the Hospital Emergency Department (ED) and diagnosed with acute non-displaced (stable) fractures of the right superior and inferior pubic rami (group of bones that make up the pelvis). Findings include: Review of the Facility's undated policy, titled Care Plans-Comprehensive, indicated residents will have a person-centered comprehensive care plan developed and implemented to meet preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/03/24, indicated that on 04/27/24 (per interview with the Director of Nurses the correct date of the incident was 04/28/24), Resident #1 slid out of bed during care. The Report indicated that he/she was transferred to the Hospital ED and was found to have pelvic fractures. Review of Resident #1's Hospital Discharge Summary, dated 04/28/24, indicated Resident #1 sustained acute non-displaced fractures of the right superior and inferior pubic rami, and the fractures did not require surgical intervention. Resident #1 was admitted to the Facility in May 2019, diagnoses included general Osteoarthritis and Rheumatoid Arthritis. Review of Resident #1's Fall Risk Assessment, dated 02/28/24, indicated he/she was at increased risk for falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/02/24, indicated he/she scored a 15 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS also indicated that he/she was totally dependent on staff for bathing, dressing, hygiene, transfers, incontinent care, and was non-ambulatory. During an interview on 05/21/23 at 8:18 A.M., Resident #1 said that about three weeks ago, he/she rolled out of bed onto the floor and broke his/her pelvis. Resident #1 said there were always supposed to be two staff members to provide his/her care but that day, there was only one CNA (identified as CNA #1), Resident #1 said CNA #1 washed him/her that morning and then rolled him/her onto his/her side. Resident #1 said that if they had used two CNAs like they were supposed to one of them would have been able to hold onto him/her so he/she would not have fallen out of bed. Review of Resident #1's Falls Care Plan, with a review date of 03/14/24, indicated he/she required assistance of two staff members for bed mobility and transfers. Review of Resident #1's Behavior Care Plan, with a review date of 03/14/24, indicated he/she required assistance of two staff members for care due to accusatory behaviors. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, with a review date of 03/14/24, indicated he/she utilized bilateral 1/4 side rails in bed and required two staff members for turning and repositioning. Review of Resident #1's Care Kardex card (used by the CNAs to determine individual care needs) indicated he/she required assistance of two staff members for bed mobility and had padded side rails. During an interview on 05/21/24 at 1:22 P.M., (which included review of her 4/28/24, Nurse Progress Note) Nurse #1 said that on 04/28/24 at approximately 11:00 A.M., CNA #1 called for help and said that Resident #1 fell . Nurse #1 said it shocked her that Resident #1 had fallen because he/she was non ambulatory and had no previous falls. Nurse #1 said that she noticed immediately that Resident #1's side rails were down and that she asked CNA #1 (in the presence of Resident #1) why the side rails were down. Nurse #1 said Resident #1 answered her and said that he/she told CNA #1 to put the side rail down. Nurse #1 said that Resident #1 had always required assistance of two staff members for positioning and provision of care, but said CNA #1 did not have another staff member assist her that day. During a telephone interview on 05/22/24 at 2:01 P.M., (which included review of her 4/28/24, Nurse Progress Note) the Nursing Supervisor said that on 04/28/24 at approximately 11:00 A.M., CNA #1 called for help and said that Resident #1 fell . The Nursing Supervisor said she entered Resident #1's room with Nurse #1, and said she observed that both side rails were down and the bed was in a high position. The Nursing Supervisor said that immediately following the incident, she spoke with CNA #1 and reviewed Resident #1's care plan with her, which indicated he/she required assistance of two staff members for bed mobility and that he/she was also required that bilateral side rails were in use. During a telephone interview on 05/21/24 at 2:11 P.M., (which included review of her 4/28/24, Written Witness Statement) CNA #1 said that Resident #1 was on her assignment for the 7:00 A.M. to 3:00 P.M. shift on 04/28/24. CNA #1 said she was familiar with Resident #1 and had taken care of him/her before. CNA #1 said she was in the middle of washing Resident #1 in bed and once she was ready to roll Resident #1 onto his/her side to wash his/her back, Resident #1 told her to put the side rail down. CNA #1 said she told Resident #1 she could remove the padding to make it easier for Resident #1 to hold onto the side rail but that Resident #1 insisted she (CNA #1) put the side rail down, so she did. CNA #1 said once she began to roll Resident #1 (away from her) onto his/her side, he/she rolled off the bed and she could not catch him/her. CNA #1 said the bed was in the high position at the time of the fall. CNA #1 said she knew that Resident #1 required assistance of two staff members for mechanical lift transfers but until this incident happened, said no one had told her that Resident #1 also required assistance of two staff members for mobility and positioning. CNA #1 said she did not know Resident #1 also required assistance of two staff members due to accusatory behaviors. CNA #1 said she had recently completed her orientation and that no one showed her where the CNA Care Kardex cards was located. However, review of CNA #1's Education Acknowledgement Form, dated and signed by CNA #1 on 03/19/24, indicated CNA #1 acknowledged she was educated on the resident Care Kardex Cards and Care Plans. The Form indicated CNAs and nurses are required to check and be knowledgeable of resident's plan of care by checking the Care Kardex Cards or Care Plans before providing care. Review of CNA #1's Employee Conference Record, dated 04/29/24 and signed by the Director of Nurses (DON) and CNA #1, indicated CNA #1 failed to follow the plan of care when she provided care to Resident #1 without another staff member's assistance which was reflected as a requirement on his/her care plan. The Record indicated Resident #1 slid from the bed and sustained a fracture. During an interview on 05/21/24 at 3:45 P.M., the Director of Nurses (DON) said that her investigation indicated that CNA #1 had not gotten assistance from another staff member to help with Resident #1's bed mobility during care. The DON said CNA #1 should have followed Resident #1's care plan, that CNA #1 should have requested and obtained assistance from another staff member to help care for Resident #1 in bed.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required assistance of two staff members for bed mobility, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and required assistive device (bilateral side rails) to maintain his/her safety and prevent an incident/accident resulting in an injury, when on 04/28/24 during the provision of care, Certified Nurse Aide (CNA) #1, who had not gotten another staff member to assist her, put the side rails down, rolled Resident #1 on to his/her side in bed, Resident #1 rolled off the bed onto the floor, landing on his/her right side and immediately complained of pain. Resident #1 was transferred to the Hospital Emergency Department (ED) and diagnosed with acute non-displaced (stable) fractures of the right superior and inferior pubic rami (group of bones that make up the pelvis). Findings include: Review of the Facility's undated policy for Activities of Daily Living (ADL), indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility provides assistance with activities of daily living as needed. The policy indicated ADL included (but was not limited to), positioning and transfers. The policy indicated ADL assistance will be provided according to the needs of the residents. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/03/24, indicated that on 04/27/24 (per interview with the Director of Nurses the correct date of the incident was 04/28/24), Resident #1 slid out of bed during care. The Report indicated that he/she was transferred to the Hospital ED and was found to have pelvic fractures. Review of Resident #1's Hospital Discharge Summary, dated 04/28/24, indicated Resident #1 sustained acute non-displaced fractures of the right superior and inferior pubic rami, the fractures did not require surgical intervention. Resident #1 was admitted to the Facility in May 2019, diagnoses included general Osteoarthritis and Rheumatoid Arthritis. Review of Resident #1's Fall Risk Assessment, dated 02/28/24, indicated he/she was at increased risk for falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/02/24, indicated he/she scored a 15 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS also indicated that he/she was totally dependent on staff for bathing, dressing, hygiene, transfers, incontinent care, and was non-ambulatory. During an interview on 05/21/23 at 8:18 A.M., Resident #1 said that about three weeks ago, he/she rolled out of bed onto the floor and broke his/her pelvis. Resident #1 said there was always supposed to be two staff members to provide his/her care but that day, there was only one CNA (identified as CNA#1). Resident #1 said that CNA #1 washed him/her that morning and then rolled him/her onto his/her side. Resident #1 said that his/her right leg slid over his/her left leg and he/she rolled off the bed onto the floor. Resident #1 said that if they had used two CNAs like they were supposed to one of them would have been able to hold onto him/her so he/she would not have fallen out of bed. Resident #1 said he/she has not been out of bed since the fall because he/she would not be comfortable in his/her wheelchair. Resident #1 said that he/she continues to have right sided pain. Review of Resident #1's Falls Care Plan, with a review date of 03/14/24, indicated he/she required assistance of two staff members for bed mobility and transfers. Review of Resident #1's Behavior Care Plan, with a review date of 03/14/24, indicated he/she required assistance of two staff members for care due to accusatory behaviors. Review of Resident #1's ADL Care Plan, with a review date of 03/14/24, indicated he/she utilized bilateral 1/4 side rails in bed and required two staff members for turning and repositioning. Review of Resident #1's Care Kardex Card (used by the CNAs to determine individual care needs) indicated he/she required assistance of two staff members for bed mobility and had padded side rails. During an interview on 05/21/24 at 1:22 P.M., (which included review of her 4/28/24, Nurse Progress Note) Nurse #1 said that on 04/28/24 at approximately 11:00 A.M., CNA #1 called for help and said that Resident #1 fell . Nurse #1 said that she went to Resident #1's room and observed him/her lying on the floor on his/her right side. Nurse #1 said Resident #1 was alert and complained of right sided pain but there was no visible injury. Nurse #1 said it shocked her that Resident #1 had fallen because he/she was non ambulatory and had no previous falls. Nurse #1 said that she noticed immediately that Resident #1's side rails were down and asked CNA #1 (in the presence of Resident #1) why the side rails were down. Nurse #1 said Resident #1 answered her and said that he/she told CNA #1 to put the side rail down. Nurse #1 said that Resident #1 had always required assistance of two staff members for positioning and when providing care, but that CNA #1 did not have another staff member assist her that day. Nurse #1 said Resident #1 has not been out of bed since his/her fall because Resident #1 does not feel like he/she could tolerate sitting in his/her wheelchair. During a telephone interview on 05/22/24 at 2:01 P.M., (which included review of her 4/28/24, Nurse Progress Note) the Nursing Supervisor said that on 04/28/24 at approximately 11:00 A.M., CNA #1 called for help and said that Resident #1 fell . The Nursing Supervisor said she entered Resident #1's room with Nurse #1 and Resident #1 was on the floor, lying on his/her right side, and said he/she had right sided pain. The Nursing Supervisor said Resident #1 was transferred to the Hospital ED. The Nursing Supervisor said she observed that both side rails were down and the bed was in a high position. The Nursing Supervisor said that immediately following the incident, she spoke with CNA #1 and reviewed Resident #1's care plan with her, which indicated he/she required assistance of two staff members for bed mobility and when providing care, as well as also requiring bilateral side rails in use. The Nursing Supervisor said Resident #1 now has more pain than he/she did prior to the fall on 04/28/24. During a telephone interview on 05/21/24 at 2:11 P.M., (which included review of her 4/28/24, Written Witness Statement) CNA #1 said that Resident #1 was on her assignment for the 7:00 A.M. to 3:00 P.M. shift on 04/28/24. CNA #1 said she was familiar with Resident #1 and had taken care of him/her before. CNA #1 said she was in the middle of washing Resident #1 in bed and once she was ready to roll Resident #1 onto his/her side to wash his/her back, Resident #1 told her to put the side rail down. CNA #1 said she told Resident #1 she could remove the padding on the side rail so Resident #1 could hold onto the rail but that Resident #1 insisted she (CNA #1) put the side rail down, so she did. CNA #1 said once she began to roll Resident #1, onto his/her side away from her, he/she rolled off the bed and she could not catch him/her. CNA #1 said she knew that Resident #1 required assistance of two staff members for mechanical lift transfers but until this incident happened, but no one told her that Resident #1 required assistance of two staff members for mobility and positioning. CNA #1 and she did not know Resident #1 required assistance of two staff members during care due to accusatory behavior. CNA #1 said she had recently completed her orientation and that no one showed her where the CNA Care Kardex was located. However, review of CNA #1's Education Acknowledgement Form, dated and signed on 03/19/24 by CNA #1, indicated CNA #1 acknowledged she was educated on the residents' Care Kardex Cards and Care Plans. The Form indicated CNAs and nurses are required to check and be knowledgeable of resident's plan of care by checking the (Kardex) Care Cards or Care Plans before providing care. Review of CNA #1's Employee Conference Record, dated 04/29/24 and signed by the Director of Nurses (DON) and CNA #1, indicated CNA #1 failed to follow the plan of care when she provided care to Resident #1 without another staff member's assistance which was reflected as a requirement on his/her care plan. The Record indicated Resident #1 slid from the bed and sustained a fracture. During an interview on 05/21/24 at 3:45 P.M., the Director of Nurses (DON) said that Resident #1 required assistance of two staff members for repositioning, bed mobility, and due to accusatory behaviors, as indicated on his/her resident Kardex Care Card. The DON said that on 04/28/24 at approximately 11:00 A.M., CNA #1 lowered Resident #1's side rail, rolled him/her onto his/she side [away from her] without the assistance of another staff member for assistance, Resident #1 rolled off the bed, onto the floor, and sustained pelvic fractures. The DON said she was unaware that Resident #1 had not been out of bed since the fall on 04/28/24. The DON said CNA #1 should have followed Resident #1's care plan and Kardex, that CNA #1 and should have requested and obtained assistance from another staff member to help provide care for Resident #1, who was in bed

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who were severely cognitively impaired, the Facility failed to ensure Resident #1 and Resident #2's right to personal privacy was respected, when on 03/14/24, Certified Nurse Aide (CNA) #1 used her personal cell phone to participate in a non-work related, live video call, while providing care to Resident #1 and Resident #2, without the consent of the residents or their representatives. Findings include: Review of the Facility's Residents Rights Policy, undated, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The Policy indicated that the Federal and State laws guarantee certain basic rights to all residents of the facility, these rights include the resident's right to privacy and confidentiality. The Policy indicated the Facility would make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Review of the Facility's Mobile Device Use Policy, undated, indicated: - The Facility recognizes that cellular phones and other wireless devices have become a general means of communication within our culture. This policy is to ensure there is no interference with job performance, HIPPA violations, and resident privacy with the use of cell phones. - Photo, video, or audio recording with a personal mobile device is strictly prohibited. - Mobile device usage for personal reasons is limited to before shift, after shift, and on breaks in nonresident care areas. Use of cell phones in resident care areas is strictly prohibited. Review of the Facility's Internal Investigation Report, undated, indicated on 03/14/24 a staff member reported that CNA #1 answered an incoming video call while providing care to Resident #1 and Resident #2. The Report indicated that CNA #1 did not end the call and continued with resident care. The Report indicated CNA #1 confirmed during an interview, that she answered the video call, placed the phone down (on speaker mode) and continued with the call during the provision of care to Residents #1 and Resident #2. A) Resident #1 was admitted to the Facility in February 2024, diagnoses included Parkinson's Disease and neurocognitive disorder with Lewy Bodies (progressive dementia that results from protein deposits in nerve cells of brain). Review of Resident #1's most recent Minimum Data Set (MDS) assessment, dated 02/14/24, indicated he/she had severely impaired cognitive skills for daily decision making, and that he/she was dependent on staff for activities of daily living (ADLs) and mobility. Review of Resident #1's Medical Record indicated his/her Health Care Proxy (HCP) was activated on 02/09/24. During a telephone interview on 04/10/24 at 11:18 A.M., Certified Nurse Aide (CNA) #2 (which also included a review of her written witness statement dated 03/14/23) said that while she was in the shower room on 03/14/24, she was assisting CNA #3 with getting Resident #1 to his/her chair after being weighed. CNA #2 said CNA #1 was called to the shower room to help. CNA #2 said that CNA #1 answered a video call on her personal cell phone and remained on the call in the shower room, while she assisted with care for both Resident #1 and Resident #2. CNA #2 said that when she and CNA #3 got Resident #1 into his/her recliner chair, he/she was agitated. CNA #2 said CNA #1 turned her phone to show Resident #1's face and said to the person on the phone, look at this [guy/girl], he/she needs to calm down. CNA #2 said she heard the person on the phone reply yeah, he/she does need to calm down! During a telephone interview on 04/10/24 at 11:31 A.M., Certified Nurse Aide (CNA) #3 (which also included a review of his written witness statement dated 03/14/23) said that he was not sure if CNA #1 was using her phone during care with Resident #1, because his full attention was on the resident. During a telephone interview on 04/17/24 at 08:02 A.M., Certified Nurse Aide (CNA) #1 (which also included a review of her written witness statement dated 03/14/23) said she was supervising residents in the dining room when at the end of the lunch meal she was asked to help the CNAs that were performing resident care in the shower room. CNA #1 said that after she entered the shower room, she received a video call on her personal phone from her family member. CNA #1 said she answered the video call while assisting with Resident #1, and said she turned the phone's camera toward his/her face and said to the person on the phone, look at him/her, he/she needs to calm down. B) Resident #2 was admitted to the Facility in September 2023, diagnoses included Alzheimer's Disease, anxiety disorder, and aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension). Review of Resident #2's most recent MDS assessment, dated 01/11/24, indicated he/she had severely impaired cognitive skills for daily decision making, and that he/she was dependent on staff for ADLs and mobility. Review of Resident #2's Medical Record indicated his/her HCP was activated on 09/21/23. CNA #2 said that after assisting Resident #1, she returned to the bathroom to assist Resident #2. CNA #2 said she asked CNA #1 for help transferring Resident #2 off of the toilet and back into his/her wheelchair. CNA #2 said that CNA #1 entered the bathroom, while the video call on her personal cell phone was still active, and she (CNA #1) turned the phone to video Resident #2 and said, look at him/her too. CNA #2 said that CNA #1 then propped the phone (which was on speaker mode) on the bathroom sink while the video call was still active. CNA #2 said that she could not be sure if the person on the phone could see Resident #2 during personal care, but said she recalled hearing a female voice on the phone say, you guys look like you could use some help. Review of the Director of Nurses (DON) Written Summary of her interview with CNA #1, dated 03/14/24, indicated CNA #1 told the DON that she angled the camera at Resident #2 and said look at him/her before placing her phone on the sink area which was on the other side of the bathroom. The Summary indicated CNA #1 admitted she propped her cell phone up so that she could continue her phone conversation, however CNA #1 was adamant that Resident #2's care and transfer were not in view of the phone's camera. CNA #1 told the Surveyor she went into the bathroom to assist CNA #2 with transferring Resident #2 from the toilet back into his/her wheelchair. CNA #1 denied showing Resident #2's face on the video call and denied saying look at him/her. CNA #1 said that although the video call was still active, she propped the phone on the sink, so the camera was pointed at her (CNA #1's) back, obstructing the view of Resident #2. CNA #1 said that while the view of Resident #2 during care was obstructed, the audio was not. When the Surveyor asked CNA #1 if she recalled the person on the phone saying, you guys look like you need some help she told the surveyor that the comment was made by the person on the phone while she was assisting with Resident #1, not Resident #2. CNA #1 said she did not obtain consent from Resident #1 and Resident #2, or the Resident's Representatives, prior to including their audio and/or video during her personal video call. Although CNA #1 told the surveyor that she did not turn the phone's camera toward Resident #2 and say, look at him/her (as CNA #2 indicated in her interview with the DON on 3/14/24 and to the Surveyor on 04/10/24), CNA #1's statement seems suspect given her admittance to doing so, during her interview with the DON on 03/14/24, immediately following the incident. During an interview on 04/10/24 at 1:40 P.M., the Director of Nurses (DON) said CNA #1 should not have used her personal cell phone device in a resident care area. The DON said that after she and the Administrator interviewed CNA #1, they sent her home pending the results of the investigation. The DON said the outcome of the Facility's internal investigation was that CNA #1 had violated the privacy of Residents #1 and #2, violated Facility policy and went against the standard of care provided at the Facility. On 04/10/24, The Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, The Plan of Correction is as follows: A. Facility Administration suspended Certified Nurse Aide (CNA) #1 on 03/14/24 during the investigation and terminated her on 03/15/24. B. On 03/14/24, Resident #1 and Resident #2 were assessed by nursing and had no ill effects from the incident. C. On 03/14/24, Resident #1 and Resident #2 were assessed by Social Services and found to be comfortable in their surroundings. Both Resident #1 and Resident #2 received additional support visits from Social Services on 03/15/24 and 03/16/24. D. On 03/14/24, since it was determined by the facility that all residents where potentially at risk to be effected by this issue, the Director of Nurses and Department Heads educated all staff regarding the Facility's Mobile Device Use Policy, Resident Rights and Customer Service. E. The area of concern will be reviewed at the April 2024 QAPI meeting on 04/22/24, and the committee will continue to review the issue monthly for a minimum of three months, to ensure substantial compliance. F. The Administrator and Director of Nursing are responsible for overall compliance.

Based on interview and record review the facility failed to ensure accurate medical records were maintained for five Residents (#21, #141, #78, and #262) out of a total sample of 35 residents. Specifically, the facility staff failed to: 1. For Resident #21, ensure Physician's orders accurately indicated the process for maintaining the Resident's enteral nutrition (a form of nutrition delivered into the digestive system as a liquid/ also referred to as tube feed) on dialysis (treatment used to treat end stage renal disease[ESRD]) days and the Resident's total amount of enteral nutrition formula consumed daily was documented each shift as ordered. 2. For Residents #141, #78, and #262, ensure the Residents Advanced Directives (wishes a person makes regarding end of life care) decisions made on their Massachusetts Medical Orders for Life Sustaining Treatment (MOLST- document that provides specific instruction on medical care one wishes to receive or not receive) was documented accurately throughout the medical record. Findings include: 1. For Resident #21 the facility failed to ensure accurate Physician orders were in place for the administration of enteral nutrition through a g-tube when the Resident left the facility for dialysis and returned to the facility after dialysis treatments. The facility staff also failed to ensure the amount of enteral nutrition that the Resident received was documented each shift as ordered by the Physician. Resident #21 was admitted to the facility in [DATE] with diagnoses including ESRD (End Stage Renal Disease - a condition where the kidneys have reached an advanced state of loss of function), dependent on dialysis, dysphagia (difficulty swallowing), and utilized a g-tube (gastronomy tube: tube inserted directly into the stomach to provide nutrition and water). During the initial screening process on [DATE] at 11:53 A.M., the surveyor observed Resident #21's room was empty and his/her enteral nutrition formula was hung at the bedside. The surveyor was told by facility staff that Resident #21 was currently off the unit at dialysis. On [DATE] at 1:42 P.M., the surveyor observed that Resident #21 was not in his/her room and the enteral nutrition formula was hung at bedside. When the surveyor inquired about the Resident, facility staff said he/she was currently off the unit at dialysis. Review of the February 2024 Physician's orders indicated the following: -Enteral Nutrition via Pump-Two Cal (a type of enteral nutrition formula) at 40 milliliters (ml) per hour for 17 hours via pump per g-tube. Start infusion at 6:00 A.M. and continue until 11:00 P.M., one time a day, and remove per schedule, start date of [DATE]. -Document total amount of formula provided each shift, start date of [DATE]. -Dialysis days: Monday, Wednesday, Friday .pick up 3:00 P.M., .start date of [DATE]. Further review of the Resident's Physician's orders indicated no order for stopping and/or holding his/her g-tube enteral nutrition while he/she was out at dialysis on Mondays, Wednesdays, and Fridays. Review of the February 2024 Medication Administration Record (MAR) indicated no documentation on the total amount of enteral nutrition formula provided on the following shifts: -[DATE] no documentation on 7:00 A.M. to 3:00 P.M. (Day shift), or 11:00 P.M. to 7:00 A.M. (Night shift). -[DATE] no documentation on Day shift -[DATE] no documentation on Night shift -[DATE] no documentation on Night shift During an interview [DATE] at 10:42 A.M., Nurse #6 said when the Resident goes to dialysis on Monday, Wednesday, and Friday, his/her tube feed is stopped when he/she leaves the facility and then the tube feed is resumed when he/she returns to the facility from dialysis. The surveyor and Nurse #6 reviewed the current Physician's orders and Nurse #6 said there is no indication in the orders that the tube feed should be stopped when the Resident goes to dialysis and resumed when he/she returns from dialysis. During an interview on [DATE] at 5:11 P.M., Nurse #10 said Resident #21 goes to dialysis on Monday, Wednesday, and Friday. Nurse #10 said the Resident's tube feed is stopped when he/she leaves the facility and when the Resident returns to the facility from dialysis he/she has the g-tube reconnected to continue his/her tube feeding. During an interview on [DATE] at 12:54 P.M., the Dietitian said the Resident's tube feed should be held while he/she was out at dialysis. The Dietitian further said an order should be in place with directions on holding the Resident's enteral nutrition when he/she leaves the facility for dialysis and restarting the enteral nutrition when he/she returned to the facility from dialysis. The Dietician said the Nurses should document how much formula the Resident received each shift. During an interview on [DATE] at 11:33 A.M., the Director of Nurses (DON) said on [DATE], [DATE], [DATE], and [DATE], there were omissions on the MAR for the amount of formula the Resident received on the shifts in question. The DON also said that she did not believe there was an order in place that addressed stopping and resuming the Resident's enteral nutrition on his/her dialysis days. 2a. For Resident #141 the facility failed to ensure the Physician's orders accurately indicated the Resident's wishes documented on his/her MOLST form. Resident #141 was admitted to the facility in [DATE] with diagnoses including Cardiomyopathy (chronic disease of the heart muscle which makes it difficult to deliver blood to the body and can lead to heart failure) and chronic kidney disease (CKD - when the kidneys are damaged and cannot filter blood the way that it should). Review of the Resident's MOLST form signed by Resident #141 and the Physician Assistant (PA), dated [DATE], indicated the Resident wished to be transferred to the hospital. Review of the February 2024 Physician's orders indicated an order for Do Not Transfer to Hospital, start date [DATE]. During an interview on [DATE] at 1:18 P.M., Nurse #4 said if she needed to check if Resident #141 wished to be transferred out to the hospital, she would review the Physician's orders. The surveyor and Nurse #4 reviewed the Physician's orders and Nurse #4 said the Physician's orders indicated the Resident did not wish to be transferred to the hospital. The surveyor and Nurse #4 then reviewed the Resident's MOLST and Nurse #4 said the MOLST indicated that the Resident wished to be transferred to the hospital. Nurse #4 further said the MOLST and the Physician's order did not match and that the Physician's orders were inaccurate and need to be corrected. During an interview on [DATE] at 1:50 P.M., Unit Manager (UM) #1 said any documentation in the medical record related to advanced directives should accurately reflect the Resident's wishes on the MOLST and for Resident #141 the Resident's Physician's orders did not accurately reflect the Resident's wishes documented on his/her MOLST form. 44129 2b. For Resident #78 the facility failed to ensure the Physician's orders and Care Plan accurately reflected the advanced directives documented on the Resident's MOLST. Resident #78 was admitted to the facility in [DATE] with diagnoses including: Parkinson's Disease (a chronic degenerative disorder of the central nervous system), Chronic Pulmonary Edema (a condition in which too much fluid accumulates in the lungs), and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the Resident's MOLST form signed and dated by the Physician on [DATE] indicated the following: -Attempt Resuscitation (perform cardiopulmonary resuscitation also known as CPR, in the event the heart stops beating) -Intubate and Ventilate (place a breathing tube down the throat to assist with breathing) -Transfer to Hospital -Use Dialysis short term only (a procedure to remove waste products and excess fluid from the blood) -Use Artificial Nutrition short term only (liquid food and fluids given by tube inserted into the stomach, also known as a feeding tube) -Use Artificial Hydration short term only (fluids directly administered into a vein) Review of the February 2024 Physician's orders indicated the following: -Do not resuscitate (DNR), initiated [DATE] -Do not intubate (DNI) and ventilate (DNV), initiated [DATE] -No dialysis, initiated [DATE] -No feeding tubes, initiated [DATE] Review of the Resident's Advanced Directives Care plan last revised [DATE] indicated: -DNR -DNI -No dialysis -No tube feed During an interview on [DATE] at 1:09 P.M., Nurse #1 said if the Resident's heart were to stop, the first place she would look to determine what the Resident's wishes are would be the MOLST form. The surveyor and Nurse #1 reviewed Resident #78's MOLST form (which indicated the Resident wished to be resuscitated) and Physician's orders (which indicated DNR, DNI, No dialysis and tube feed) and Nurse #1 said the MOLST and the Physician orders should match, and they did not. During an interview on [DATE] at 1:33 P.M., Nurse #2 said the first place she would look to determine a code status would be the computer if she were logged on and whatever (code status) was on the most recent MOLST form. Nurse #2 said the MOLST form should match the Physician's orders, but did not in this case for Resident #78, which could lead to confusion. During an interview on [DATE] at 1:40 P.M., Unit Manager (UM) #2 said if a resident were to code (stop breathing or heart stops beating), she would look for their code status wherever she could locate the information the quickest, the electronic health record (EHR) if she was signed into the computer, or the MOLST form in the paper chart if the EHR was unavailable to her. UM #3 further said the MOLST form dated [DATE], was the most recent one on file for Resident #78, and the Physician orders and Care Plan should reflect the most recent MOLST, but they did not and there was a discrepancy. 42690 2c. For Resident #262 the facility failed to ensure that accurate and consistent information relative to the Resident's Advanced Directives was included in the medical record. Resident #262 was admitted to the facility in February 2024 with diagnoses including Acute Respiratory Failure with hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide), malignant neoplasm of larynx (laryngeal cancer or throat cancer), tracheostomy status (a medical procedure that involves creating an opening in the neck in order to place a tube into a person's trachea, or windpipe), Congestive Heart Failure (CHF- a group of signs and symptoms, caused by an impairment of the heart's blood pumping function), malignant neoplasm of urethra (urethral cancer), Chronic Obstructive Pulmonary Disease (COPD-is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the MOLST form signed by Resident #262 on [DATE] and by the Physician Assistant (PA) on [DATE], indicated the following: -Do Not Resuscitate -Do Not Intubate or Ventilate -Transfer to the hospital Review of the Advanced Directives Care Plan initiated on [DATE] indicated the following: -Full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of the Minimum Data Set (MDS) Assessment, dated [DATE] indicated the following: -Resident scored a 12 out of 15 on the Brief Interview of Mental Status (BIMS) indicating moderate cognitive impairment. -Resident wishes to be Do Not Resuscitate and Do Not Intubate. Review of the Physician Assistant (PA) acute/follow-up progress note dated [DATE], and signed by the PA on [DATE], indicated in part, .Code Status .was discussed with patient in length, he/she wishes to remain a full code at this time. Review of the Social Service Assessment, dated [DATE] indicated the following: -Full Code Review of the February 2024 Physician orders indicated the following orders initiated on [DATE]: -DNR -DNI Review of the Nurse Practitioner (NP) encounter progress note dated [DATE] and signed by the NP on [DATE] indicated, in part, .Code Status .was discussed with patient in length he/she wishes to remain a full code at this time. During an interview on [DATE] at 2:16 P.M., Social Worker (SW) #3 said the MOLST form that was signed by the Resident on [DATE], and signed by the PA on [DATE], indicated the Resident wished to be DNR/DNI. SW #3 said the initial Advanced Directives Care Plan was developed on [DATE] and indicated the Resident wished to be a full code. SW #3 said the Social Service Assessment completed on [DATE] indicated the Resident wished to be a full code. SW #3 further said that she could not speak to the reason why the information did not match as required. During an interview on [DATE] at 3:30 P.M., Nurse #11 said that if a resident becomes unresponsive, she would stay with the resident while having someone retrieve the MOLST. The surveyor and Nurse #11 reviewed Resident #262's MOLST form that indicated DNR/DNI. Nurse #11 said that she would honor the Resident's MOLST and would not initiate resuscitation. During an interview on [DATE] at 4:28 P.M., the surveyor and the Director of Nurses (DON) reviewed the medical record notes relevant to Resident #262's advanced directives. The DON said that there was a discrepancy in the documentation and agreed that it was difficult to discern if in fact the Resident wished to be resuscitated in the event of a respiratory and/or cardiac arrest. The DON said that the Physician order dated [DATE] indicated the Resident wished to be a DNR/DNI. The DON further said that the encounter note dated [DATE] indicated the NP spoke with the Resident at length and that the Resident wish was to continue full code status. The DON said that she would continue to look for admission orders that addressed the Residents code status as there appeared to be no orders prior to [DATE]. The DON requested time to obtain the progress note written by the PA that she felt would corroborate the MOLST form that was signed by the Resident on [DATE] and later signed by the PA on [DATE]. On [DATE] at 9:05 A.M., the DON provided the surveyor a copy of the PA Progress Note. The progress note indicated the following: Code Status -This was discussed with patient in length, he/she wishes to remain full code at this time. The DON was unable to further comment on the multiple discrepancies throughout the medical record of the Resident's advanced directive wishes, or if the advanced directives had ever been fully discussed with the Resident after he/she signed the MOLST form upon admission to the facility.

Based on observation, interview, record and policy review, the facility failed to ensure that staff adhered to infection control standards for residents on Transmission-based Precautions on three Units (C1, C2, and A1) out of six units observed, to prevent contamination and mitigate the spread of infection. Specifically, the facility staff failed to ensure: 1. On the C1 and C2 Units, that the required personal protective equipement (PPE) was worn when caring for COVID-19 positive residents on Isolation Precautions. 2. On the A1 Unit, that the appropriate PPE was worn when providing services in a room identified for Droplet Precautions. Findings Include: Review of Facility Policy titled Personal Protective Equipment (PPE), undated, indicated the following: -Masks, Eye Protection, and Face Shields: Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and resident-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. -Residents on contact and/or isolation precaution will have precaution setup available to staff and family members including Personal Protective Equipment (PPE). Review of Facility Policy titled COVID-19 Infection Control Protocol, revised 11/6/23, indicated the following: -The facility will follow transmission-based protocol in use of PPE according to Department of Health guidelines: >N-95 (mask), gown, gloves, and eye protection will be utilized for confirmed positive cases. Review of the Isolation Precautions sign, updated 3/9/23 and utilized by the facility, indicated the following: Staff and Providers must: -Clean hands: when entering and exiting -Gown: change between each resident -N95 Respirator mask -Eye Protection (goggles or face shield) -Gloves: change between each resident -Keep door closed (unless safety concern or not on physically separate unit) -Use patient dedicated or disposable equipment. Clean and disinfect shared equipment. Review of the Droplet Precautions sign, undated, and utilized by the facility, indicated the following: Everyone must: -Clean their hands, including before entering and leaving the room -Make sure their eyes, nose, and mouth are fully covered before room entry -Utilize a Face Shield or Goggles with a mask -Remove face protection before room exit 1a. On 2/15/24 at 9:30 A.M., during an observation on the C1 Unit, the surveyor observed Nurse #7 preparing to enter room [ROOM NUMBER]. The surveyor observed signage outside the room indicating Isolation Precautions and staff requirements were to clean hands when entering and exiting the room, wear a gown, N95 respirator mask, eye protection of goggles or face shield, and gloves. Nurse #7 was observed performing hand hygiene, and donning (putting on) an N95 mask, gown, and gloves. The surveyor did not observe Nurse #7 donning eye protection (face sheild or goggles) prior to entering the isolation precautions room. During an interview on 2/15/24 at 9:33 A.M., the surveyor and Nurse #7 reviewed the precautions signage posted outside room [ROOM NUMBER] which indicated the use of PPE including eye protection of goggles or face shield. Nurse #7 said that she should have been wearing eye protection when in the room, and had not been wearing any eye protection as indicated on the Isolation Precautions sign. During an interview on 2/14/24 at 2:12 P.M., the Infection Control Preventionist (ICP) said the expectation for staff going into a room identified as Isolation Precautions would be to don PPE which includes a gown, gloves, eye protection, and N95 masks as indicated via signage outside of the resident's room. On 2/15/24 at 4:45 P.M., the surveyor observed Certified Nurses Aide (CNA) #8, who was wearing a blue surgical mask prepare to enter room [ROOM NUMBER] with Isolation Precautions signage on the door. The surveyor observed CNA #8 don a gown, gloves, and a face shield, but did not change the blue surgical mask already being worn to an N95 mask prior to entering the isolation room. During an interview on 2/15/24 at 4:58 P.M. with Unit Manager (UM) #4, the surveyor relayed what was observed prior to CNA #8 entering room [ROOM NUMBER]. The surveyor requested that UM #4 verify that the required PPE was being used by CNA #8. The surveyor observed UM #4 check the PPE storage bin located outside of room [ROOM NUMBER] and then proceeded to refill the N95 masks in the PPE storage bin. UM #4 then donned an N95 mask, gown, gloves, and eye protection and entered the room where CNA #8 was assisting the Resident. During a follow-up interview on 2/15/24 at 5:01 P.M., UM #4 said that she observed CNA #8 wearing a surgical mask in room [ROOM NUMBER] and provided the CNA with an N95 mask. UM #4 said that CNA #8 should have been wearing an N95 mask as indicated on the Isolation Precaution signage and she was not wearing one as required. 44129 1b. On 2/14/24 at 12:15 P.M., during an observation on C2 Unit, the surveyor observed CNA #9 enter a resident room with an Isolation Precaution sign hung outside the door. CNA #9 entered the resident room without first donning any eye protection. The surveyor observed that CNA #9 was not wearing any eye protection when exiting the Isolation Precaution room at 12:20 P.M. During an interview at the time, CNA #9 said the resident in the isolation room was positive for COVID-19, and that he should have donned eye protection prior to entering the isolation room. During an interview on 2/14/24 at 2:10 P.M., UM #2 said when staff entered a room where a resident was under isolation precautions for COVID-19, the staff must first don a gown, an N-95 mask, gloves and eye protection. UM #2 further said that CNA #9 should have worn eye protection when he entered the isolation room. 49422 2. On 2/15/24 at 1:30 P.M., during an observation on the A1 Unit, the surveyor observed Droplet Precautions signage posted outside of room [ROOM NUMBER]. The Droplet Precautions sign indicated that staff should perform hand hygiene, wear a mask, and eye protection such as goggles or a face shield. The surveyor observed Housekeeper #1 enter room [ROOM NUMBER] that was identified for droplet precautions. The surveyor further observed that Housekeeper #1 was wearing only a surgical mask and no other required PPE as listed on the droplet precautions sign. The surveyor observed that Housekeeper #1 did not change the surgical mask, or perform hand hygiene as indicated on the Droplet Precaution signage when exiting the precautions room. During an interview at the time, the surveyor reviewed the Droplet Precautions sign with Housekeeper #1. Housekeeper #1 said that she put on a gown (which was not required) and removed the gown in the resident's room. When the surveyor asked Housekeeper #1 if she wore eye protection while in the room, Housekeeper #1 shook her head and indicated that she did not wear eye protection. During an interview on 2/16/24 at 11:50 A.M., the ICP said that Housekeeper #1 should have worn eye protection when servicing a room with Droplet Precautions in place.

Based on observations, interviews, and record review, the facility failed to provide care and services to accommodate the needs of one Resident (#128) out of a total sample of 35 residents. Specifically, for Resident #128 who was ordered for 15-minute safety checks, the facility staff failed to respond to a call light in a timely manner to provide assistance with repositioning, personal care and meal assistance. Findings include: Resident #128 was admitted to the facility in January 2024 with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), Dysphagia (difficulty swallowing), Aphasia (inability to speak), fall with hip fracture, surgical wound infection with a wound vac (negative pressure wound therapy, a therapeutic technique using a suction pump, tubing, and a dressing to remove excess fluids and promote wound healing), and COVID-19. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of one out of a possible 15. Further review of the MDS Assessment indicated the Resident sustained a fall with a fracture prior to admission, and was dependent on staff for assistance with eating, toileting, hygiene, mobility, and transfers. Review of the February 2024 Physician's orders included: -Initiate 15-minute checks, start date 2/5/24 (assess the Resident for safety every 15 minutes). On 2/15/24 at 7:40 A.M., the surveyor heard two staff members discussing that Resident #128 was observed to be agitated that morning and had been pulling on his/her wound vac tubing. On 2/15/24 between 9:30 A.M. to 9:55 A.M., the surveyor observed that no staff members conducted a 15-minute check on the Resident. The surveyor entered the Resident's room at 9:55 A.M. and observed the Resident seated in a recliner chair next to his/her bed, and was slumped sideways. The Resident was observed to be wearing a top with no bottoms. The Resident was further observed sitting on an absorbent pad with his/her bottom exposed and his/her incontinent brief wrapped around his/her thighs. The surveyor observed a sheet crumpled on the floor in front of the Resident and an overbed table containing the Resident's untouched breakfast tray placed within arm's reach of the Resident. The Resident was observed alternatively reaching out to the table, grabbing at his/her incontinent briefs, crossing, and uncrossing his/her legs repeatedly, bending his/her knees, and attempting to pull up his/her legs towards his/her stomach. The surveyor observed the Resident grab a cup of orange juice from the breakfast tray and dropped the cup, spilling the contents on the floor. The surveyor was unable to locate any staff members after looking outside the door to obtain assistance. The Resident's call bell cord was observed tied to the bed rail on the opposite side of the bed. The surveyor pushed the call bell button and activated the call light for the Resident at 9:57 A.M. The surveyor also remained with the Resident to ensure his/her safety until assistance arrived. The surveyor continued to observe the Resident as he/she continued to move around in his/her recliner, alternatively grabbing at items within his/her reach and moving his/her legs and torso. The surveyor observed the Resident pick up his/her spoon, attempt to place the spoon into the food and bring the spoon back to his/her mouth. The surveyor observed the Resident lean forward at the waist, attempted to put his/her fingers into his/her food, and subsequently brought his/her hand to his/her mouth. -At 10:14 A.M., the surveyor observed the Resident lean forward to reach his/her breakfast tray on the overbed table, and slid the tray off the table and onto the floor, spilling the contents on the side of his/her recliner chair and the floor. -At 10:15 A.M., (18 minutes after the surveyor pushed the call bell button for assistance), Certified Nurses Aide (CNA) #3 arrived in the room to assist the Resident. During an interview on 2/15/24 at 10:45 A.M., CNA #3 said the Resident had been agitated, and usually sat outside of his/her room for supervision, however the Resident was now on Isolation Precautions because he/she was Covid positive and had to stay in his/her room with the door closed. When the surveyor asked CNA #3 how did staff ensure the Resident was safe behind his/her closed door, CNA #3 said the Resident was to be checked for safety every 15 minutes. When the surveyor reviewed with CNA #3 that more than 30 minutes had passed without the staff observating the Resident or conducting 15-minute checks, CNA #3 said staff should have been checking in on the Resident every 15 minutes. During an interview on 2/16/24 at 10:15 A.M., CNA #5 said call lights should be answered by any staff who notices the call light, including non-clinical staff members. CNA #5 further said 15 minutes was too long to wait for a call bell to be answered. During an interview on 2/16/24 at 10:18 A.M., CNA #3 said all staff were responsible for answering call lights. She said she was not aware of a facility policy that dictates how quickly a call light should be answered. During an interview on 2/16/24 at 10:25 A.M., Nurse #1 said that all staff were responsible for answering call lights and the call lights should be answered promptly. Nurse #1 further said residents should not wait longer than 10-15 minutes maximum. During an interview on 2/16/24 at 11:11 A.M., the Assistant Director of Nursing (ADON) said every single employee in the facility was responsible for answering the call lights. The ADON further said it was the expectation to check with the Resident, find out what the Resident needed and defer to the individual who would be responsible to take care of what the Resident needed. The ADON said if a Nurse was nearby, but in the middle of a medication pass when a call light was on, the expectation would be for that Nurse to seek out assistance from another staff member to check on the resident and that a resident should not wait more than five minutes to have their call light answered. Refer to F656

Based on observation, interview, policy and record review, the facility failed to ensure that baseline care plans were developed for two Residents (#261 and #262) out of total sample of 35 residents. Specifically, the facility failed to: 1. For Resident #261, develop a baseline care plan relative to communication within 48-hours for Resident #261 who was nonverbal. 2. For Resident #262, develop a baseline care plan that included Physician orders for care and services relative to Oxygen (O2) use and laryngectomy care within 48-hours of admission. Findings include: Review of the facility policy titled Care Plans - Preliminary, undated, indicated the following: -A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of an admission. -To assure that the resident's immediate care needs are met and maintained, a preliminary (interim) care plan will be developed within twenty-four (24) hours of the resident's admission. -The Interdisciplinary Team will review the Attending Physician order (e.g. dietary needs, medications, and routine treatments, etc.) and implement a nursing care plan to meet the resident's immediate care needs. -The preliminary (interim) care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. 1. Resident #261 was admitted to the facility in February 2024 with the following diagnoses: Aphasia (a comprehension and communication [reading, speaking, or writing] disorder resulting from damage or injury to the specific area in the brain), unspecified sequelae of cerebral infarction (stroke - affects your blood flow to the brain causing cell death). Review of a progress note dated 2/2/24, indicated the following: -Multiple CVA's (Cerebrovascular Accident - Stroke) -Severe aphasia present with spouse stating he/she is able to understand conversation Review of the medical record indicated no documented evidence that a baseline care plan had been developed relative to the Resident's communication deficits. During an interview on 2/15/24 at 10:57 A.M., Unit Manager (UM) #3 said that the facility did not have a form or assessment that they refer to as a baseline care plan, but they do complete nursing assessments upon admission as well as an admission care plan that reviews falls, skin and activities of daily living (ADL) function. The surveyor and UM #3 reviewed the assessments and care plans and UM #3 said that she did not see a baseline care plan relative to communication for Resident #261. During an interview on 2/20/24 at 11:16 A.M., Certified Nurses Aides (CNA) #6 and #7 said that they were not at work the day the Resident was admitted to the facility but met him/her very soon after admission. CNA #6 and #7 both said that it could be difficult to communicate with the Resident if his/her family was not there to help. CNA #7 said that occasionally the Resident will shake his/her head but really is not able to answer basic questions or make his/her basic needs known verbally. During an interview on 2/21/24 at 8:46 A.M., the surveyor and Social Worker (SW) #2 reviewed the 48-72 Hour Admission Care Conference form. SW #2 said the document indicated that Resident #261 did not have any functional limitations related to hearing, vision, cognitive, speech, falls or elopement. The surveyor asked if this was an accurate representation of the Residents' speech/communication ability and SW #2 said that it was not as he/she is unable to communicate. SW #2 said that the Resident does however communicate better with his/her family, just not with the facility staff. SW #2 further said that it did not appear that a baseline communication care plan had been developed for Resident #261 within the first 48 hours of his/her admission to the facility, but one should have been. 2. Resident #262 was admitted to the facility in February 2024 with the following diagnoses: Acute Respiratory Failure with hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide), malignant neoplasm of larynx (laryngeal cancer or throat cancer), laryngectomy status (a surgical removal of the larynx [voice box] that creates a surgical opening in the neck, called a stoma, for breathing), Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs), malignant neoplasm of urethra (urethral cancer), Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes obstructed airflow and breathing problems). Review of the facility policy titled oxygen Administration, undated, indicated the following: -Verify that there is a Physician's order for this procedure. -Review the Physician's orders and facility protocol for oxygen administration. -Review the resident's care plan to assess for any special needs of the resident. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated the following: -Resident #262 scored a 12 out of 15 on the Brief Interview of Mental Status (BIMS) assessment indicating moderate cognitive impairment. Review of the hospital discharge note, dated 2/6/24 indicated the following: -Liters per minute (LPM): 5 LPM -Mode of delivery (Oxygen): tracheostomy mask (trach mask - allows for the delivery of O2 and aerosol via a mask placed over a laryngectomy stoma) Review of the 48-72 Hour Admission Care Conference form indicated no documented evidence that Resident required the use of oxygen or that he/she required specialized services relative to the laryngectomy. Review of the February 2024 Physician orders indicated the following: -May administer Oxygen 3.5 Liters [sic] via trach mask at 28% continuous every shift, ordered on 2/14/24 -Change and date oxygen tubing weekly on 11-7 (P.M.) on Wednesday night, ordered on 2/12/24 -Cover laryngectomy stoma for showers, ordered on 2/12/24 -Monitor laryngectomy stoma for white voice prosthesis placement (a valve that allows speaking) every shift, ordered on 2/12/24 -Monitor stoma to neck for redness or drainage every shift, ordered on 2/12/24 Review of Laryngectomy Stoma Care Plan indicated that it was initiated on 2/13/24 (greater than 48 hours after the Resident's admission to the facility). During an observation and interview on 2/14/24 at 11:30 A.M., the surveyor observed that the Resident was receiving Oxygen at 2.5 LPM via a trach mask placed over his/her laryngectomy stoma. When the surveyor asked, the Resident said he/she was unsure of what liter flow the Oxygen was supposed to be set at. During an interview on 2/20/24 at 1:02 P.M., the surveyor and Unit Manager (UM) #3 reviewed the 48-72 Hour Admission Care Conference form. UM #3 said she did not see any indication why the Resident was receiving continuous Oxygen, and any documentation that the Resident had a laryngectomy. During a follow-up interview on 2/20/24 at 1:26 P.M., the surveyor and UM #3 reviewed the Resident's admission orders and care plans. UM #3 said that the Resident was on Oxygen when he/she was admitted to the facility and that an Oxygen order was not in place until 2/12/24 (greater than 48 hours after admission). UM #3 said that a baseline care plan had not been developed within 48 hours of admission.

Based on observations, interviews, and record review, the facility failed to ensure a plan of care was implemented for one Resident (#128) out of a total sample of 35 residents. Specifically, the facility staff failed to: 1. Conduct safety checks every 15 minutes, per Physician's order. 2. Assist the Resident with his/her breakfast meal per his/her plan of care. Findings include: Resident #128 was admitted to the facility in January 2024 with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), Dysphagia (difficulty swallowing), Aphasia (inability to speak), fall with hip fracture, surgical wound infection with a wound vac (negative pressure wound therapy, a therapeutic technique using a suction pump, tubing, and a dressing to remove excess fluids and promote wound healing), and COVID-19. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of one out of a possible 15. Review of the February 2024 Physician's orders indicated: -initiate every 15-minute check, initiated 2/5/24 (assess the Resident for safety every 15 minutes). 1. On 2/15/24 between 9:30 A.M. to 10:15 A.M., the surveyor observed that no staff members conducted a 15-minute check on Resident #128 as ordered. The surveyor observed the Resident seated in a recliner chair next to his/her bed in his/her room. The Resident was observed to not be fully dressed and was only wearing a top and no bottom garment. The surveyor observed that the Resident was slumped sideways in the recliner chair, seated on an absorbent pad with his/her bottom exposed and his/her incontinent briefs wrapped around his/her thighs. The surveyor further observed that a crumpled sheet was laying on the floor in front of the Resident. The Resident was observed alternatively reaching out to an overbed table placed within arm's reach of the Resident with a breakfast meal tray, grabbing at his/her incontinent briefs, crossing, and uncrossing his/her legs repeatedly, bending his/her knees, and attempting to pull up his/her legs towards his/her stomach. The surveyor observed the Resident grabbing items from the breakfast tray and spilling on the recliner chair and floor. The surveyor was unable to locate any staff members after looking outside the door to obtain assistance for the Resident. The surveyor pushed the button for the call bell which was tied to the bed rail on the opposite side of the bed from the Resident and activated the call light to summon assistance. The surveyor also remained with the Resident to ensure his/her safety until staff arrived. While the surveyor was waiting for staff to respond, the Resident was observed to continue squirming back and forth in the recliner chair, and was able to slide his/herself forward, which resulted in his/her bottom being on the edge of the chair seat, and at risk for sliding off the chair and onto the floor. During an interview on 2/15/24 at 10:45 A.M., CNA #3 said the Resident had been agitated, and usually sat outside of his/her room for supervision, however the Resident was currently on Isolation Precautions for COVID-19 and had to remain in his/her room with the door closed. When the surveyor asked CNA #3 how staff ensured that the Resident was safe behind his/her closed room door, CNA #3 said the Resident was to be checked for safety every 15 minutes. When the surveyor reviewed with CNA #3 that more than 30 minutes had passed without staff checking on the Resident, she said staff should have been checking in on the Resident every 15 minutes. 2. Review of the Resident's MDS assessment dated [DATE], indicated the Resident experienced coughing and/or choking during meals or when swallowing medications and required partial to moderate assistance with eating. Review of the Resident's Care Plan indicated the following: -Risk for Aspiration (when something such as food or liquid enters your airway or lungs by accident which may cause serious health problems such as pneumonia) due to dysphagia and esophageal dysmotility (a condition in which food and fluids do not easily pass through one's throat), initiated 1/17/24. Intervention: Supervise Resident for all meals. -Nutrition, initiated 1/19/24. Interventions: Assist Resident with feeding and monitor Resident during meals and report signs/symptoms of choking and/or swallowing difficulties. -Activities of Daily Living (ADLs: fundamental skills required to independently care for oneself, such as eating, bathing, and mobility), initiated 1/19/24. Intervention: Assist Resident during meals. Review of the Resident's most recent Care Card (a communication tool for clinical staff that provides a summary of a resident's care needs) indicated the Resident required assistance with eating. On 2/15/24 between 9:30 A.M. to 10:15 A.M., the surveyor observed the Resident grab a cup of orange juice from the breakfast tray and dropped the cup, spilling the contents on the floor. The Resident also grabbed a spoon from the breakfast tray, and attempted unsuccessfully to eat by placing the spoon into the food and bringing it to his/her mouth. The Resident then proceeded to lean forward at the waist and attempted to place his/her fingers into his/her food and brought his/her hand back to his/her mouth. The Resident was further observed to continue reaching forward towards his/her breakfast tray, ultimately pushing the breakfast tray sideways on the table with his/her fingertips and spilling contents from the tray to the floor. During an interview on 2/16/24 at 10:01 A.M. with CNA's #4 and #5, CNA #4 said the Resident required staff to assist him/her with all meals and the information pertaining to meal assistance was accessible to all CNAs on the Resident's Care Card. CNA #5 said the Resident required staff assistance for meals and should not have been left alone in his/her room with a meal tray because he/she was at risk for choking. During an interview on 2/20/24 at 12:42 P.M., the Speech Language Pathologist (SLP) said the Resident experienced significant esophageal dysmotility, was an impulsive eater and required staff assistance with all meals. The SLP further said that due to the Resident's condition, food tended to sit in his/her throat putting him/her at risk for aspiration pneumonia (pneumonia caused when food or liquid is accidentally inhaled into the airways and lungs). The SLP said the Resident required staff to be present to ensure the Resident did not shovel the food into his/her mouth as well as to assist the Resident by cueing him/her to sip fluids between bites of food to aid in the food moving down the Resident's esophagus (throat). During an interview on 2/21/24 at 8:00 A.M., Unit Manager (UM) #2 said the Resident required assistance with meals and should not have had his/her breakfast meal with him/her while alone in the room.

Based on interviews and record review the facility failed to ensure an audiology (hearing services) appointment was arranged for one Resident (#123) out of a total sample of 35 residents. Specifically, the facility staff failed to ensure that Resident #123, who had diagnosed hearing loss was provided with audiology services as required. Findings include: Review of the facility policy titled Services Provided by Other Providers, undated, indicated the following: -Resident will be screened for services needed that are provided by other providers including podiatry, eye and dental services, podiatry, psychiatric services, and others. This is part of their rights living in the facility. [sic] -Audiology consult and services will be provided either in-house or out of the facility. -Documentation of services provided will be documented. [sic] Resident #123 was admitted to the facility in October 2021 with a diagnosis of hearing loss. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating he/she was cognitively intact. During an interview on 2/15/24 at 9:25 A.M., the surveyor and the Resident had to communicate with the use of a white board, with the surveyor writing down the questions for the Resident to read as he/she was unable to hear the surveyor when they spoke to him/her. Resident #123 said he/she used to have hearing aids, but they did not work well so he/she did not have them at the facility. The Resident further said the last time he/she was seen by an Audiologist (health care professional who diagnose, manage, and treat hearing, balance, or ear problems) was about three years ago. He/she said he/she would love to be able to hear better and see if his/her hearing aids could be adjusted to help him/her hear. Review of the Social Services Progress Note dated 5/15/23, indicated the Resident had signed up for audiology services with the facility's contracted company. Further review of the Resident's medical record indicated no documentation that the Resident had been seen by audiology services. During an interview on 2/15/24 at 9:53 A.M., Nurse #6 said the Resident previously had hearing aids but no longer wore them. Nurse #6 said all audiology documentation should be in the Resident's medical record and she was unable to find any documentation that the Resident had seen an Audiologist while in the facility. During an interview on 2/15/24 at 12:39 P.M., Social Worker (SW) #1 said the Resident had completed the consent form for audiology services on 5/15/23 but she was unable to find any documentation that the Resident had been seen by audiology services since completing the consent form. SW #1 further said at the time of admission residents are offered audiology services, but she could not tell if Resident #123 had been offered services at the time of his/her admission. SW #1 said ancillary services such as audiology are not provided regularly to residents throughout the year unless staff notice changes in a resident, and there was no set process to assess annually if a resident were to need ancillary services such as audiology. During a follow-up interview on 2/15/24 at 2:41 P.M., SW #1 said the Audiologist had been at the facility in June 2023, August 2023, and October 2023, and she was unsure why Resident #123 had not been seen by the Audiologist.

Based on observation, policy review and interview, the facility failed to ensure that medications were appropriately secured on two Units (A1 and [NAME] 1) out of five units observed. Specifically, the facility staff failed to ensure that unattended medication storage carts were securely locked and not accessible to residents, staff and visitors. Findings include: Review of the facility policy titled Storage of Medication, undated, indicated: -The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Review of the facility policy titled Administering Medication, undated, indicated the following: - During the administration of medications, the medication cart will be kept closed and locked when out of sight of the medication Nurse. On 2/20/24 at 3:22 P.M., the surveyor observed that medication cart #2 on the A1 Unit was left unattended and unlocked. The unattended, unlocked medication cart was located between rooms [ROOM NUMBERS] with the cart drawers facing the hallway making the drawers accessible to be opened by anyone walking by the cart. The surveyor also observed that the resident assignment sheet was left on top of the medication cart and resident information was visible. The surveyor observed Nurse #8 entering room [ROOM NUMBER] while the surveyor was waiting for the Nurse to return to the unattended medication cart. The surveyor also observed one Certified Nurses Aide (CNA) who answered call lights in rooms [ROOM NUMBERS] and walked by the unlocked, unattended medication cart four times. During an interview when Nurse #8 returned to her medication cart, Nurse #8 said her medication cart was unlocked and the cart should not have been unlocked. Nurse #8 also said her resident assignment sheet should have been turned face down on the top of the medication cart. On 2/20/24 at 3:29 P.M., the surveyor observed that a medication cart on the [NAME] 1 Unit was left unattended, and unlocked. The unattended medication cart was located between rooms [ROOM NUMBERS]. The surveyor observed Nurse #9 exiting room [ROOM NUMBER], which was located two doors away from the unattended, unlocked medication cart. During an interview following the observation when Nurse #9 returned to her medication cart, Nurse #9 she said her medication cart should not have been left unlocked.

Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) Assessments were completed accurately for two Residents (#125 and #159) out of a total sample of 35 residents. Specifically, the facility staff failed to accurately reflect on the MDS Assessment: 1. For Resident #125, that the correct weight was entered on the Annual MDS. 2. For Resident #159, an accurate discharge status when completing an unplanned discharge MDS Assessment. Findings include: 1. Resident #125 was admitted to the facility in November 2022 with a diagnosis of Diabetes (chronic condition that affects the way the body processes blood sugar/glucose) and weight loss. Review of the Annual MDS assessment dated [DATE], Section K: Swallowing/Nutritional status documented the Resident's weight as 137 pounds. Further review of the resident's clinical record indicated a weight of 144 pounds documented on 10/23/23. During an interview on 2/20/24 at 3:05 P.M., the surveyor and the MDS Nurse reviewed Section K of the MDS assessment dated [DATE], where the weight was documented as 137 pounds. The surveyor and the MDS Nurse also reviewed the clinical record which showed 144 pounds for 10/23/23, and was within the seven day look back period for the 10/28/23 MDS assessment. The MDS Nurse said the 137 pounds listed on the MDS Assessment was coded incorrectly, and the appropriate weight was 144 pounds. 2. Resident #159 was admitted to the facility in January 2024 with a diagnosis of after care of injury of peroneal nerve (peroneal nerve branches from the sciatic nerve and provides sensations to the front and sides of the legs and top of the feet) at lower level of left leg. Review of the Unplanned Discharge MDS assessment dated [DATE], Section A: Identification Information indicated that Resident #159's Discharge Status was coded as Home/Community. Review of Resident #159's progress notes indicated that the resident was discharged to a hospital on 1/18/24. During an interview on 2/20/24 at 3:05 P.M., the surveyor and the MDS Nurse reviewed the 1/18/24 Discharge MDS Assessment for Section A2105 Discharge status which indicated a discharge status to Home/ Community. The MDS Nurse said that the Discharge status on the 1/18/24 MDS Assessment was coded incorrectly and should have indicated a discharge to the hospital.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), who was assessed to by nursing to be at an increased risk for falls and required extensive assistance from two staff members for safe transfers, the Facility failed to ensure they developed individualized plans of care that were consistent with his/her assessments, that care plan interventions were specific to his/her identified care needs related to level of staff assistance required during transfers to maintain his/her safety, and that interventions in place on his/her resident care card were consistently implemented by staff On 02/05/23, although Resident #2's Care Card (utilized by Certified Nurse Aides to determine level of assistance required by each resident) indicated he/she required assistance of two staff members for safe transfers, Certified Nurse Aide (CNA) #2 transferred Resident #2 without another staff member present to assist her, Resident #2 lost his/her balance, fell , and was later transferred to the Hospital Emergency Department where he/she was diagnosed with a right distal femur (thigh bone) fracture, was admitted , and required surgical intervention to repair the fracture. Findings include: Review of the Facility's Policy, titled Care Plans, undated, indicated Residents will have a person-centered comprehensive care plan developed and implemented to meet his/her other preferences and goals and to address the resident's medical, physical, mental, and psychosocial needs. Resident #2 was admitted to the facility in December 2021, medical diagnoses included dementia and anemia. Review of Resident #2's Fall Risk Assessment, dated 01/29/23, indicated he/she had a score of 13, which indicated he/she was at an increased risk for falls. Review of the Facility's Incident Report, dated 02/05/23, indicated that CNA #2 reported that while she was transferring Resident #2 with a walker at 11:50 A.M., his/her legs buckled, and he/she fell to his/her knees. Review of Resident #2's Hospital Discharge Summary, dated 02/11/23, indicated Resident #2 was admitted to the Hospital on 02/05/23 and was diagnosed with a right femur fracture, related to a mechanical fall at the facility, for which he/she underwent surgical repair. The Summary Indicated Resident #2's hospital stay was further complicated by post operative blood loss anemia. Review of CNA #2's Written Witness Statement, dated 02/05/23, indicated that when she (CNA #2) transferred Resident #2, with assist of one, he/she had difficulty standing up from the edge of his/her bed. The Statement indicated that once Resident #2 was standing, he/she then started to tip forward, she (CNA #2) tried to lower him/her to the floor, but it was too late, and he/she fell to the floor on his/her knees. Review of a Facility Employee Conference Record, dated 02/05/23, indicated CNA #2 told the Director of Nurses (DON) that she had transferred Resident #2 with one assist based on Resident #2's Care Card. The Conference report indicated that the DON reviewed Resident #2's Care Card and it indicated he/she required assistance from two staff members with transfers. Review of Resident #2's Care Card (Certified Nurse Aide, reference guide, identifies residents specific care needs, including number of staff required to provide assistance during tasks), undated, indicated he/she was dependent and required assistance of two staff members for transfers. During an interview on 02/23/23 at 1:36 P.M., Certified Nurse Aide #3 said that even prior to his/her fall on 02/05/23, Resident #2 required assistance from two staff members when transferring. CNA #3 said she references the resident Care Card to determine what level of assistance a resident requires to safely transfer them. During an interview on 02/23/23 at 1:15 P.M., Physical Therapist (PT) #1 said she evaluated Resident #2 on 01/30/23 after he/she returned from the hospital for a blood transfusion. PT #1 said that prior to the fall on 02/05/23, Resident #2 required minimal to moderate assistance from two staff members for safe transfers and said that had been his/her baseline. Review of Resident #2's Activity of Daily Living (ADL) Flowsheets dated January 2023, (as documented by the CNAs) indicated that he/she was dependent on two staff members for transfers on the day shift, but often required a mechanical lift for transfers in the evening. Review of Resident #2's ADL Flowsheets, dated February 2023, (as documented by the CNAs) indicated that prior to his/her fall on 2/05/23, he/she was dependent on two staff members for transfers on the day shift and consistently required a mechanical lift for transfers on the evening shift. Review of Resident #2's Occupational Therapy Evaluation, dated 01/30/23, indicated he/she had recently returned from the Hospital after a blood transfusion for anemia and required assistance of two staff members to transfer. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 12/31/22, indicated Resident #2 required extensive physical assistance from two staff members for transfers. Review of Resident #2's At Risk for Falls Care Plan, dated as reviewed 01/12/23, indicated he/she was at risk for falls due to decreased safety awareness, history of falls, unsteady gait and weakness related to anemia. A Care Plan goal indicated that Resident #2 would not have falls with injury through 02/27/23, and interventions included that staff were to assist with transfers and mobility. Further review of Resident #2's Falls Care Plan, indicated it did not identify or describe the level of assistance he/she required or the number of staff required to assist him/her with transfers and mobility, in order to maintain his/her safety. Review of Resident #2's Activities of Daily Living (ADL) Care Plan, dated as reviewed 01/12/23, indicated interventions included staff to assist with transfers. Further review of Resident #2's ADL Care Plan, indicated it did not identify or describe the level of assistance he/she required or the number of staff required to assist him/her with transfers and mobility, in order to maintain his/her safety. During an interview on 02/23/23 at 2:36 P.M., Nurse #2 said that while she was working the evening shift on 02/05/23, CNA #2 came to tell her that Resident #2 had fallen during a transfer and was on the floor. Nurse #2 said that CNA #2 told her that while she was transferring Resident #2 with assist of one, his/her knees buckled, and he/she fell to the floor. Nurse #2 said Resident #2 required two staff members for safe transfers and CNA #2 should not have transferred him/her alone. During an interview on 02/23/23 at 4:00 P.M., the Director of Nurses (DON) said Resident #2 required assistance of two staff members for safe transfers, as indicated on his/her Care Card. The DON said that on 02/05/23 at approximately 11:35 A.M., CNA #2 attempted to stand Resident #2 from the edge of the bed and had difficulty. The DON said that instead of getting a second staff member to assist with the transfer, CNA #2 transferred Resident #2 by herself, resulting a fall with an injury. The DON said Resident #2's Care Plans did not specify the level of assistance he/she required and that his/her Care Plans should have been updated by nursing

Based on records reviewed and interviews for one of three sampled residents (Resident #2), who was assessed by nursing as being at an increased risk for falls, and who required extensive assistance from two staff members during transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance during a transfer to maintain his/her safety in an effort to prevent an incident and/or accident resulting in an injury. On 02/05/23, during the day shift, Certified Nurse Aide (CNA) #2 transferred Resident #2 without a second staff member to assist her, Resident #2 lost his/her balance, fell , as was later transferred to the Hospital Emergency Department where he/she was diagnosed with a right distal femur (thigh bone) fracture, he/she was admitted and required surgical intervention to repair the fracture. Findings include: Resident #2 was admitted to the facility in December 2021, medical diagnoses included dementia and anemia. Review of Resident #2's Fall Risk Assessment, dated 01/29/23, indicated he/she had a score of 13, which indicated he/she was at an increased risk for falls. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 12/31/22, indicated that his/her cognitive patterns were moderately impaired, with a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated Resident #2 required extensive physical assistance from two staff members for toileting and transfers. Review of Resident #2's Care Card (Certified Nurse Aide, reference guide, identifies residents specific care needs, including number of staff required to provide assistance during tasks), undated, indicated he/she was dependent and required assistance of two staff members for transfers. Review of Resident #2's Occupational Therapy Evaluation, dated 01/30/23, indicated he/she had recently returned from the hospital after a transfusion for anemia and required assist of two staff members to transfer. Review of Resident #2's Activity of Daily Living (ADL) Flowsheets, dated January 2023, (as documented by the CNAs) indicated that he/she was dependent on two staff members for transfers on the day shift, often required a mechanical lift for transfers in the evening. Review of Resident #2's ADL Flowsheets, dated February 2023, (as documented by the CNAs) indicated that, even prior to his/her fall on 2/05/23, he/she was dependent on two staff members for transfers on the day shift and consistently required a mechanical lift for transfers on the evening shift. During an interview on 02/23/23 at 1:15 P.M., Physical Therapist (PT) #1 said she evaluated Resident #2 on 01/30/23 after he/she returned from the hospital where he/she was admitted for anemia and required a transfusion. PT #1 said that prior to the fall on 02/05/23, Resident #2 required assistance from two staff members for safe transfers and that had been his/her baseline. PT #1 further said that Resident #2's anemia made him/her weak and that nursing staff could downgrade a resident's transfer status to require a mechanical lift for safety reasons, at any time. During an interview on 02/23/23 at 3:12 P.M., Nurse #1 said that two CNAs attempted to stand-pivot transfer Resident #2 into bed, during the evening shift on 02/03/23, and he/she was too weak to transfer. Nurse #1 said the CNAs had to use a mechanical lift to safely get Resident #2 into bed, so she sent a screen request to the Rehabilitation Department. Review of Resident #2's Rehabilitation Screen, dated 02/03/23 indicated staff were finding it unsafe to transfer him/her into bed without a mechanical lift. The Screen also indicated Resident #2's legs were too weak to utilize a sit to stand lift. Review of the Facility's Incident Report, dated 02/05/23, indicated that CNA #2 reported that while she was transferring Resident #2 with a walker at 11:50 A.M., his/her legs buckled, and he/she fell to his/her knees. Review of Resident #2's Hospital Discharge Summary, dated 02/11/23, indicated Resident #2 was admitted to the Hospital on 02/05/23 and was diagnosed with a right femur fracture, related to a mechanical fall at the facility, for which he/she underwent surgical repair. The Summary Indicated Resident #2's hospital stay was further complicated by post operative blood loss anemia. Review of CNA #2's Written Witness Statement, dated 02/05/23, indicated that when she (CNA #2) transferred Resident #2, with assist of one, he/she had difficulty standing up from the edge of his/her bed. The Statement indicated that once Resident #2 was standing, he/she then started to tip forward, she (CNA #2) tried to lower him/her to the floor, but it was too late and he/she fell to the floor on his/her knees. Review of a Facility Employee Conference Record, dated 02/05/23, indicated CNA #2 told the Director of Nurses (DON) that she had transferred Resident #2 with one assist based on Resident #2's Care Card. The Conference report indicated the Director of Nurses (DON) reviewed Resident #2's Care Card and it indicated he/she required assistance from two staff members with transfers. During an interview on 02/23/23 at 2:36 P.M., Nurse #2 said that while she was working the evening shift on 02/05/23, CNA #2 came to tell her that Resident #2 had fallen during a transfer and was on the floor. Nurse #2 said she entered Resident #2's room and he/she was sitting on the floor with his/her back against the bed. Nurse #2 said that CNA #2 told her that while she was transferring Resident #2 with assist of one, his/her knees buckled, and he/she fell to the floor. Nurse #2 said Resident #2 required two staff members for safe transfers and CNA #2 should not have transferred him/her alone. During an interview on 02/23/23 at 4:00 P.M., the Director of Nurses (DON) said Resident #2 required assistance of two staff members for safe transfers, as indicated on his/her Care Card. The DON said that on 02/05/23 at approximately 11:35 A.M., CNA #2 attempted to stand Resident #2 up from the edge of the bed and had difficulty. The DON said that instead of getting a second staff member to assist, CNA #2 transferred Resident #2 by herself, resulting a fall. The DON said Resident #2 was sent to the emergency department and was diagnosed with a right femur fracture.

Based on observations, interviews and record reviews, the facility staff failed to ensure the plan of care was implemented for 4 sampled Residents ( #45, #92, #131,and #146), in a sample of 35 residents. Findings include: 1. For Resident #92, the facility staff failed to ensure a motion sensor alarm was on as care planned. Resident #92 was admitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 6/1/18, indicated Resident #92 had moderate cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 10 out of 15, and required extensive assistance of 1 person with bed mobility, transfers and ambulation within his/her room. Review of the Falls Care Plan, dated 6/12/18, indicated Resident #92 was at risk for falls and injuries related to impaired mobility, weakness and [MEDICAL CONDITION]. The following intervention was included in the plan of care: motion sensor alarm Review of a nurse's note, dated 6/21/18, indicated Resident #92 had a fall in his/her room at 6:30 P.M. Review of the facility investigation, dated 6/21/18, indicated Resident #92 was seen ambulating in his/her room, and fell to the floor, sustaining an abrasion to his/her left knee. The following intervention was indicated on the investigation to prevent reoccurrence: Educate staff of the importance of the alarm. Further review of the investigation indicated a staff in-service conducted on 6/21/18 on making sure the motion sensor was on while the resident was in his/her room. Review of a nurse's note, dated 7/8/18, indicated Resident #92 had a fall in his/her room at 8:30 A.M. The note indicated the resident was found by a Certified Nurse Aide (CNA) face down on the floor, and sustained an injury to his/her lip, complained of chest pain, and was sent to the emergency room for evaluation. Review of the facility investigation, dated 7/8/18, did not indicate the motion sensor was on as care planned prior to the fall. Further review of the investigation indicated a staff member statement that stated she did not see or hear anything and was near the nursing station (next to the resident's room), and was told by the resident's visitor that Resident #92 was on the floor. Review of a nurse's note, dated 7/8/18, indicated Resident #92 was readmitted to the facility for treatment of [REDACTED]. Review of the Falls Care Plan, dated 7/08/18 included the following intervention: staff education Review of a nurse's note, dated 8/13/18, indicated Resident #92 had a fall at 9:45 P.M. Review of the facility investigation, dated 8/13/18, indicated a CNA responded to the Resident's call bell and found him/her on the floor. The following intervention was indicated on the investigation to prevent reoccurrence: staff discipline. Further review of the investigation indicated a written conference, dated 8/21/18, indicating the resident's motion sensor was not on at the time of the (8/13/18) fall. During an interview on 10/5/18 at 10:35 A.M., Unit Manager (UM) #2 said Resident #92 was at risk for falls because of his/her is impulsive, has unsteady gait and [MEDICAL CONDITION]. She said the purpose of the motion sensor alarm was to alert the facility staff of the resident's movement so they could assist him/her and prevent falls. She said the motion sensor was not on as care planned in the 6/21/18 and 8/13/18. She further said there was no indication the motion sensor alarm was on, as care planned for the 7/8/18. 2. For Resident #146 the facility staff failed to ensure the Physician' order for a Gastrointestinal (GI) consult was completed, as ordered. Resident #146 was admitted to the facility 12/2017 with [DIAGNOSES REDACTED]. Review of the Physician's Progress Note, dated 5/10/18, indicated Resident #146 had been given food items from family that are not included on his/her prescribed diet. The note indicated there was a concern for choking, and the resident was on a pureed diet. The Physician indicated to continue the pureed diet until he/she was evaluated by GI. Review of the Physician's Telephone Orders, dated 5/10/18, indicated an order for [REDACTED].>Review of the Speech Therapy Evaluation, dated 6/7/18, indicated Resident #146 was referred for a bedside swallow evaluation due to difficulty swallowing. The evaluation indicated the therapist consulted with the resident's physician prior to the evaluation and it was determined the plan was for Resident #146 to have a GI consult for possible diet advancement. Review of the Dietitian Progress Note, dated 6/21/18, indicated Resident #146 was evaluated by Speech Therapy, and was to remain on the pureed diet until evaluated by GI. Review of the 10/2018 physician's orders [REDACTED]. Review of the clinical record did not indicate Resident #146 had a GI consult, as ordered by the Physician. During an interview on 5/10/18 at 11:53 A.M., Unit Manager (UM) #2 said the GI consult was not scheduled for Resident #146, and should have been. 3. For Resident #131, the facility staff failed to apply an [MEDICATION NAME] (moisturizing cream/lotion) to affected areas as ordered by the Physician. Resident #131 was admitted to the facility in 3/2018. Review of Quarterly Minimum Data Set (MDS) Assessment, dated 9/4/18, indicated the resident had moderately impaired cognition as evidenced by a score of 11 out of 15 on the Brief Interview of Mental Status (BIMS). Review of the nurse's noted, dated 9/7/18, indicated the resident had a new rash on his/her back. Review of the physician's orders [REDACTED]. Review of the Treatment Administration Records (TARs), dated 9/7/18 through 10/4/18 indicated the staff did not apply or offer to apply the cream 10 out of the 27 days. On 10/3/18 at 9:09 A.M. during an interview with Resident #131 he/she said, I break out in a rash on my back and the nurses are not doing anything about it. The resident then lifted his/her shirt and showed the surveyor his/her back. The surveyor observed what looked like dry, scaly patches of skin. On 10/4/18 at 1:35 P.M. during an interview with Unit Manager (UM) #5 she said that there was very little documentation to indicate that the resident was offered the cream for his/her back. UM #5 said that she was not sure if the cream had been applied. 4. For Resident #45, the facility staff failed to properly set an air mattress at 140 pounds (lbs.) according to the physician's orders [REDACTED].>Resident #45 was admitted to the facility in 5/2017. Review of the physician's orders [REDACTED]. On 10/3/18 at 11:03 A.M., the surveyor observed Resident #45 sleeping in his/her bed. The air mattress was set at 200 lbs. as indicated on the air mattress control panel. On 10/4/18 at 2:32 P.M., the surveyor observed Resident #45 sleeping in his/her bed. The air mattress was set at 240 lbs. On 10/4/18 at 2:59 P.M., the surveyor, accompanied by Nurse #3, entered the resident's room. Nurse #3 said the air mattress setting was set at 240 lbs. The nurse said it should be set at 140 lbs. Please refer to F842.

Based on records reviewed and interviews, for two of five residents (Resident #3 and Resident #5), the Facility failed to provide adequate assistance and supervision to prevent accidents with injury, when Resident #3, who required extensive assistance with meals, was left unsupervised with his/her meal tray, spilled hot tea onto him/herself and sustained a burn to his/her hip that required treatment and Resident #5, who required staff assistance with toileting, had an unwitnessed fall in the bathroom and sustained a ten centimeter laceration on his/her hand which required seven sutures to close. Findings include: 1. The Facility Policy titled, Incident Management, dated 2/2017, indicted all residents will be assessed to ensure appropriate interventions are in place and a score above 10 will be considered a high risk for falls. The Alteration in Bladder Elimination Care Plan, dated 10/11/17, indicated to encourage Resident #5 to use the call light or request assistance for toileting and provide privacy during elimination as able while maintaining safety. The Psychiatric Note, dated 3/12/18, indicated Resident #5, was admitted from the hospital after he/she sustained a [MEDICAL CONDITION] from a fall at home. He/she had an unwitnessed fall at the facility in 12/2017, in which she sustained a laceration to the head requiring sutures. The Note indicated Resident #5 had a history of [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #5 was diagnosed with [REDACTED]. The Activity of Daily Living Care Plan, dated 4/5/18, indicated interventions included Resident #5 was to have a one person assist with transfers and ambulation, with a wheeled walker or wheelchair. The Nurse Progress Note, dated 4/11/18, Resident #5 was observed on the bathroom floor at approximately 6:40 P.M. on 4/11/18, he/she sustained a ten cm right hand laceration which had a moderate amount of bleeding, a pressure dressing was applied, and he/she was transferred to the Hospital Emergency Department for treatment. The Facility's Internal Investigation, dated 4/12/18, indicated on 4/11/18 at approximately 6:40 P.M., Resident #5 had an unwitnessed fall in the bathroom. The Investigation indicated, he/she was found in the hallway bathroom floor (unit bathroom off the hallway). Resident #5's laceration was treated with seven sutures in the Emergency Department, to close the wound. The Witness Statement, dated 4/11/18, from Certified Nurse Aide (CNA) #2 indicated prior to Resident #5's fall in the bathroom, CNA #2 brought him/her to the hallway bathroom, but was also the assigned CNA to monitor the other residents in the Dining Room, located approximately 25 feet away from the bathroom. CNA #2 monitored both the other residents in the Dining Room and Resident #5 (who was in the bathroom) from the hallway. CNA #2's statement indicated she left the bathroom ajar door and stayed in the hallway while Resident #5 used the toilet but turned her head and Resident #5 ended up on the floor. The Witness Statement, dated 4/11/18, from Nurse #1 indicated she interviewed Resident #5 after the fall and Resident #5 said he/she was left alone in the bathroom when he/she fell and was getting up from the toilet and the floor was wet and he/she fell . The Surveyor interviewed Nurse #1 at 6:35 A.M. on 8/21/18. Nurse #1 said CNA #2 was outside the bathroom door, not in Resident #5's line of sight and CNA #2 did not make Resident #5 aware that CNA #2 was outside of the bathroom door. Nurse #1 said Resident #5 was an assist of one with transfers and ambulation and said you can't leave him/her alone in the bathroom because he/she is impulsive. Nurse #1 said CNA #2 was assigned to monitor the other Residents in the Dining Room and should not have tried to also toilet and monitor Resident #5 in the bathroom at the same time, because you need to keep your eyes on Resident #5 while she is on the toilet. 2. Resident #3's Quarterly Minimum Data Set (MDS) Assessment, completed 12/5/17, indicated that his/her cognitive patterns were moderately impaired and he/she required the extensive assistance of one staff member for meals. The Surveyor interviewed Resident #3 at 4:30 P.M. on 8/20/18. Resident #3 did not recall the incident in which he/she spilled coffee and sustained a burn. Review of the Facility's Internal Investigation, dated 12/14/17, indicated it contained a copy of Resident #3's Care Plan and CNA Care Card initiated (MONTH) (YEAR) which indicated that Resident #3 was to be assisted with all meals and would have a two-handled cup with no lid for liquids. The Surveyor interviewed Certified Nurse Aide (CNA) #3 at 10:30 A.M. on 8/22/18. CNA #3 said that she recalled the incident in which Resident #3 burned him/herself with hot tea. CNA #3 said she could not recall whether she was assigned to care for Resident #3, but she recalled that she served him/her the dinner tray in the dining room. CNA #3 said that she placed the meal tray with the hot cup of tea in front of Resident #3 and left Resident #3 alone with the tray while she served other residents. CNA #3 said that the hot cup of tea was in a regular mug and was not in a two-handled mug. CNA #3 said Resident #3 picked up the hot cup of tea and spilled it on him/herself. The Incident Report which documented Resident #3's burn, dated 12/14/17, indicated that Resident #3 had a small superficial pink open area three centimeters (cm) by two cm on his/her right hip. The Incident Report indicated that the physician was notified and ordered Resident #3's burn to be treated with [MEDICATION NAME]. CNA #3 said that although the Facility kept resident's care information on a CNA Care Card in a computerized tablet, said she could not recall checking the tablet for Resident #3's care needs for eating. CNA #3 said that the information in the tablet was not always up to date and said she relied on his/her co-workers to tell her about the resident's needs. The Surveyor interviewed Nurse #5 at 3:30 P.M. on 8/21/18. Nurse #5 said that CNA #3 told her that Resident #3 spilled hot tea on him/herself and she assessed the burn and notified the physician. Nurse #5 said that she investigated the incident and educated CNA #3. Nurse #5 said that because Resident #3's CNA Care Card indicated that he/she was to be assisted during meals, CNA #3 should not have left Resident #3 unsupervised with his/her tray.

Based on records review and interviews for one of six sampled residents (Resident #1), the Facility failed to prevent a significant medication error. Resident #1 was administered a sustained released patch, [MEDICATION NAME] (a cognitive enhancing medication that blocks a chemical released by nerve cells in the brain) without a Physician's order. Resident #1 had a decline in mental status, was nauseous, vomited, and was hypertensive (which can be a reaction to [MEDICATION NAME]). Resident #1 was transferred to the Emergency Department and admitted for observation. Findings included: The Policy titled, General Dose Preparation and Medication Administration, dated 1/1/13, indicated that prior to administration of medication, Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, and to the correct resident. During medication administration, identify the resident per Facility policy. The Policy titled, Resident Identification, dated 3/2013, indicated that two resident identifiers will be used prior to care, treatment, or services. The identifiers that may be used: the primary choice, a picture of Resident, and secondary choice, the identification by a Health Care Agent or family member, Resident stating his/her birth date or identification by an employee who knows the resident. Resident #1 was admitted to the Facility in 3/2017, [DIAGNOSES REDACTED]. The Physician's Note, dated 10/12/17 and timed at 12:59 P.M. indicated that at noon today the Physician was notified by nursing that the family had found an [MEDICATION NAME] on Resident #1's back, he/she was not prescribed an [MEDICATION NAME]. The Physician ordered to monitor Resident #1's vital signs every 30 minutes for 12 hours, and monitor for increased sedation for the next eight hours and encourage oral fluids. The Nurses Note, dated 10/13/17 and timed at 1:14 P.M., indicated Resident #1 was drowsy. The Nurses Note, dated 10/12/17 and timed at 6:14 P.M., indicated Resident #1 remained drowsy, nauseous and had an increased blood pressure. [MEDICATION NAME] 5 mg (one time ordered by the physician for the increased blood pressure) was administered at 3:15 P.M. Physician order obtained to send Resident #1 to the hospital if systolic blood pressure was greater than 190 or pulse was less than 50 beats per minute. The Nurses Note, dated 10/12/17 and timed at 7:33 P.M., indicated Resident #1 blood pressure at 6:10 P.M. was 207/62 (normal 120/80). The Transfer to Hospital Form, dated 10/12/17, indicated Resident #1 had an elevated blood pressure, and a wrongfully placed [MEDICATION NAME]. The Facility investigation, dated 10/12/17, indicated a medication error was made when Nurse #1 placed an [MEDICATION NAME] on Resident #1 when there was no physician's order. The investigation indicated that a patch was found on Resident #1 by a Family Member. The investigation indicated Resident #1 had not been properly identified by the Nurse during the medication pass and that there was also a concern that Resident #1 also received another resident's oral medications; [MEDICATION NAME] and [MEDICATION NAME]. Resident #1 experienced a change in status including increased lethargy and elevated blood pressure and he/she was sent to the Emergency Department. The Physician's Emergency Department report indicated Resident #1 was evaluated for altered mental status with elevated blood pressure, which stabilized. He/she was admitted for ongoing observation for a possible medication reaction. The Surveyor interviewed Family Member #1 at 9:15 A.M. on 12/8/17. Family Member #1 said that on 10/12/17 at 12:14 P.M., (Resident #1) complained of nausea and was so groggy she had to hold on to him/her when walking him/her to the bathroom, which was unusually. Family Member #1 said she found a patch on Resident #1 that indicated it was Rivastigmine (generic name for [MEDICATION NAME]) 9.5 mg/24 hours which was not one of Resident #1's medications and reported this immediately to the Nurse. The Surveyor interviewed Physician #1 at 2:30 P.M. on 12/5/17. Physician #1 said that Resident #1 was lethargic and had an elevated blood due to the [MEDICATION NAME] applied to him/her in error. On the day of the Survey 12/8/17, the Facility provided documentation to support concerns identified in this survey were addressed. In response to the incident the Facility took the following corrective action: The Nursing staff were educated from 10/13/17 through 10/19/17 on the medication pass protocol with emphasis on the 5 rights of medication pass and resident identification. The Nursing staff were educated from 11/15/17 through 11/22/17 on the National Patient Safety Goals for a least 2 methods to identify residents correctly and use of medications safely as part of their Quality Assurance Performance Improvement plans. The Unit Managers have monitored the Medication Pass process on their units with the medication administration observation audit check list on a weekly basis. The Surveyor reviewed the results of the completed audits. The results of the audits indicated that the Facility was monitoring medication administration on a weekly basis. The Director of Nurses is responsible for the implementation of the plan for complying with the two methods of Resident identification with medication pass and the safe use of medications. The Director of Nurses will bring the results of the Quality Improvement Committee and is responsible for overall compliance.

Based on records reviewed, observations. and interviews, the facility failed to ensure side rails were evaluated to ensure they were not an entrapment hazard for 173 of 176 residents at the facility who used side rails. On [DATE], an Incident Report indicated Resident #5 was found, by a Certified Nurse Aide (CNA) #4, entrapped between the bed and the side rail. Three staff members said they observed Resident #5's head was on the mattress, with the bottom bar of the side rail across the front of his/her neck, and his/her body and his/her legs off the bed. CNA #2 said Resident #5 was just hanging there, looked terrified, and he/she was holding onto the side rail with both hands as if holding on for dear life, or words to that effect. The facility took no corrective action to evaluate the side rails used, and 15 days later Resident #4, was observed by four staff members dead and entrapped in the rail, which was the same type of rail used by Resident #5. - The facility does not have records of any assessments, evaluation of risk versus benefits, and consents related to side rail use. Review of Resident #4 and Resident #5's records indicated no assessment for entrapment, risks or benefits of side rail use, or consents were noted. The Director of Nurses said that consents were not obtained and no assessments were performed. - The Facility was unable to provide any records related to ensuring that the mattresses, beds, and rails are being used per manufacture's recommendations. - The Facility had no preventative maintenance records to ensure that measurements were completed to ensure that the zones around the side rails did not exceed the recommendations of the FDA. Findings include: 1. Resident #5 was admitted to the Facility in February 2017 with [DIAGNOSES REDACTED]. A Resident ADL (Activity of Daily Living)/Daily Care List, dated [DATE], indicated that Resident #5 had a bed alarm in use, and required side rails with bolsters (a long narrow cushion used for support or as a barrier). A Significant Change Minimum Data Set (MDS), dated [DATE], indicated that Resident #5 required the extensive assistance of 2 or more persons for bed mobility and transfers (how a resident moves between surfaces, including to or from a bed), and Resident #5 had moderate cognitive impairment. The Incident Investigation Report, dated [DATE], indicated that Resident #5 was found by a CNA, entrapped between the bed and the side rail. The report indicated that bolsters were added to Resident #5's bed after the incident. A Nurse's Note, dated [DATE] at 3:52 P.M., indicated that at 2:30 P.M., Resident #5 was found stuck in-between his/her air mattress and the left side rail of his/her bed. The note indicated that staff was able to get Resident #5 unstuck safely, and maintenance was paged to set up bolsters and assess the side rails on his/her bed. Surveyor #1 and Surveyor #2 interviewed Certified Nurse Aide (CNA) #4 at 11:19 on [DATE]. CNA #4 said that on [DATE] at approximately 1:00 P.M., she assisted Resident #5 into bed. CNA #4 said that approximately 45 minutes later, she walked by Resident #5's room on her way to assist another resident and glanced into Resident #5's room. CNA #4 said she couldn't see Resident #5 in the bed, and so entered the room to check on him/her. CNA #4 said she observed Resident #5 with his/her head on the mattress, the bottom of the side rail across the front of his/her neck, and his/her legs off the bed. CNA #4 said Resident #5 appeared tense and nervous, but she and CNA #3 could not move Resident #5 without choking him/her, so CNA#2 assisted them to move Resident #5 from under the side rail and back into bed. CNA #4 said there were no bolsters on Resident #5's bed at the time of the incident, that they were not put in place until afterwards. Surveyor #1 and Surveyor #2 interviewed CNA #3 at 9:34 A.M. on [DATE]. CNA #3 said she heard CNA #4 call for help, and when she responded, she observed Resident #5 hanging from the side rail and holding on for dear life, or words to that effect. CNA #3 said she and CNA #4 called for more help because there was no way they could have moved Resident #5 by themselves. CNA #3 said she, CNA #2, and CNA #4 moved Resident #5 from under the side rail and back into bed. Surveyor #1 and Surveyor #2 interviewed CNA #2 at 9:00 A.M. on [DATE]. CNA #2 said he heard a CNA screaming for help and when he went into Resident #5's room, he observed Resident #5's head on his/her mattress with the bottom of the side rail across the front of his/her neck, and his/her body hanging off the bed on the opposite side of the rail. CNA #2 said Resident #5 was holding on to the side rail with both hands as if he/she was hanging on for dear life, or words to that effect. CNA #2 said Resident #5 was clearly in distress and appeared petrified. CNA #2 said CNA #3 and CNA #4 were in Resident #5's room trying to figure out how to get Resident #5's head out from between the mattress and the side rail without hurting him/her. CNA #2 said one CNA held the side rail to keep it still, another held Resident #5's head still, and he picked up Resident #5's body and tried to hold him/her as flat as possible so they could slide his/her head out and place him/her onto the bed. Surveyor #1 and Surveyor #2 interviewed Nurse #3 at 10:58 A.M. on [DATE]. Nurse #3 said that Resident #5 did not have bolsters on his/her bed at the time of the incident. This was not consistent with the Resident ADL (Activity of Daily Living)/Daily Care List. Although Resident #5 had Bolsters added to the bed, there was no indication that the beds of all Residents with side rails were evaluated to ensure that the distance between the mattress and side rail was not large enough to allow someone to become entrapped in the rail. Surveyor #1 and Surveyor #2 interviewed the Maintenance Supervisor at 11:53 A.M. on [DATE]. The Maintenance Supervisor said he had not been made aware that Resident #5 was entrapped between his/her mattress and side rail and did not know if all the side rails in the Facility were evaluated. Surveyor #2 interviewed Unit Manager #1 at 9:20 A.M. on [DATE]. Unit Manager #1 said bolsters were not implemented on Resident #5's bed until after he/she was caught under the side rail, as an intervention to prevent him/her from getting too close to the side rail because his/her bed was old, or words to that effect. Surveyor #1 and Surveyor #2 interviewed the Administrator at 2:30 P.M. on [DATE]. The Administrator said he reviewed and signed all incident reports personally, and incidents are discussed in Morning Meeting, however after reviewing his notes from Morning Meeting on [DATE], the day after Resident #5 was entrapped, he said he did not have anything in his notes to indicate that there was anything mentioned that concerned him. The Administrator said he did not pursue what entrapped meant, in reference to Resident #5's incident report from [DATE]. A Risk Management/Quality Assurance Confidential Report of Event form dated [DATE] indicated that Resident #5 had been found by a CNA entrapped between the bed and mattress. The Administrator's Signature section of the form was blank. The Interdisciplinary Note, dated [DATE], indicated that Resident #5 was found stuck between his/her air mattress and the left side rail, and that a voicemail was left for the Medical Director. Surveyor #1 and Surveyor #2 interviewed the Medical Director at 1:46 P.M. on [DATE] and at 11:11 A.M. on [DATE]. The Medical Director said she did not know of the incident with Resident #5 until it was briefly mentioned after Resident #4's death on [DATE]. The Medical Director said she was not given any information about Resident #5 being entrapped in the side rail and she was on a leave of absence and did not return until several days after it occurred. During the interview with the Surveyors, the Medical Director reviewed Resident #5's clinical record and observed a progress note, dated [DATE], which indicated that a voicemail was left for her regarding the incident. The Medical Director said she did not recall receiving any voicemail or other notification about the incident. The Medical Director said on [DATE] that she still was not aware of the specifics of the [DATE] incident involving Resident #5, including the position of Resident #5's body when he/she was found by staff. The Medical Director said Facility staff had not spoken with her about it, and she had not seen the related incident report. 2. Resident #4 was admitted to the Facility in in [DATE], and readmitted in [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated that Resident #4 required the extensive physical assistance for 2 or more persons with bed mobility, and the full staff performance of 2 or more persons for transfers; and that Resident #4 had severe cognitive impairment. CNA #2 said that on [DATE] between 7:00 A.M. and 7:30 A.M., he observed Resident #4 lying in bed on his/her left side, with his/her legs hanging off of the bed from approximately mid-thigh down. CNA #2 said Resident #4's head was twisted sideways and to the right, in-between the bottom of the side rail and the frame of the bed, and his/her right hand was holding onto the side rail. CNA #2 said he had to physically pull on the side rail in order for staff to pry, or words to that effect, Resident #4 out and reposition him/her on the bed because Resident #4's head was under the side rail and prevented them from being able to lower the side rail. CNA #2 said that when Resident #4 was repositioned in the bed, he observed an indentation down the right side of Resident #4's face from where the side rail bar had been. CNA #2 said he told the Director of Nurses (DON), on [DATE] or [DATE], how Resident #4 was when he found him/her on [DATE]. CNA #3 said that on [DATE], she responded to CNA #2's requests for help with Resident #4. CNA #3 said that when she entered Resident #4's room, she observed him/her lying in bed with his/her legs hanging off of the bed from approximately mid-thigh down and his/her feet touching the floor. CNA #3 said Resident #4's head was twisted to the right and appeared to be stuck between the mattress and the bottom of the side rail, with a golf ball sized pool of saliva on the floor under Resident #4's mouth. CNA #3 said that in order to reposition Resident #4 onto the bed, CNA #2 had to pull on the side rail so that staff could free Resident #4's head because his/her head prevented them from lowering the side rail. CNA #3 said Resident #4 was obviously deceased when she entered the room, that his/her legs were cold to the touch and were bluish in color. CNA #4 said that on [DATE], she entered Resident #4's room in response to CNA #2's requests for help. CNA #4 said Resident #4 appeared deceased , that he/she was a smoky gray and blue in color, or words to that effect, and had saliva running out of his/her mouth onto the floor. CNA #4 said Resident #4's head was twisted to the right side, with his/her face was between the bottom of the side rail and the mattress, and the lower part of his/her body was off of the bed. CNA #4 said the side rail had to be physically pulled on to move it away from Resident #4's face so that staff could reposition him/her onto the bed. CNA #4 said she observed a mark from the eye to the jawline, like an indentation, consistent with where the bottom of the side rail had been on his/her face. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 10:18 A.M. on [DATE]. Nurse #2 said that on [DATE], she observed Resident #4 in bed with his/her legs hanging off of the bed and his/her face stuck in the side rail. Nurse #2 said Resident #4's face from just behind the eyes forward was protruding beyond the side rail, with the bar from the side rail running along his/her face. Nurse #2 said Resident #4's face appeared swollen, his/her lips cyanotic, with saliva running out of his/her mouth, and his/her legs were blue in color and mottled (irregular patches of skin discoloration as a result of diminished circulation). Nurse #2 said Resident #4 did not have a pulse at that time. Nurse #2 said CNA #2 had to pull the side rail upwards and out away from the bed in order to be able to reposition Resident #4 onto the bed because the position of Resident #4's head prevented staff from being able to lower the side rail. Nurse #2 said it still took effort to free Resident #4's head from between the bed frame and bottom of the side rail. Nurse #2 said she called the Medical Director, and informed her that Resident #4 was found pulseless, with his/her face in the side rail. Nurse #2 said she informed the DON that staff found Resident #4 with his/her face under the side rail. The Medical Director said she was told that Resident #4 was found pulseless and had passed away but it wasn't until [DATE] or [DATE] that staff told her Resident #4's head had been trapped in the side rail and that staff was concerned that the use of side rails contributed to Resident #4's death. The Maintenance Request, dated [DATE], indicated that Resident #5's side rail was very loose and needed bolsters as soon as possible. 3. There was no documentation at the time of survey of assessments for the use of side rails for Resident #4 or Resident #5, or that Resident #5 was reassessed following an alleged incident of entrapment in the side rail on [DATE]. Surveyor #2 interviewed Unit Manager #1 at 9:20 A.M. on [DATE]. Unit Manager #1 said side rail assessments were completed at the time of a resident's admission to the Facility, and if the resident requested side rails. Surveyor #1 and Surveyor #2 interviewed the DON at 3:12 P.M. on [DATE]. The DON said that all resident related assessments were to be completed by licensed nurses according to the MDS schedule. The DON said the Facility used a Safety/Restraint Assessment, but that this assessment was not an assessment for the use of side rails. The DON said the Facility did not have an assessment for the use of side rails. The DON said, as of [DATE], Resident #5 still had side rails in use but they added bolsters to block the gap where Resident #5 got his/her neck caught. 4. Surveyor #1 and Surveyor #2 interviewed the Maintenance Supervisor at 11:53 A.M. on [DATE]. The Maintenance Supervisor said the Facility's resident beds were of varying brands and models, and side rails were attached at the request of nursing. The Maintenance Supervisor said he did not know if the side rails were recommended for use with the brands and models of beds used by the Facility, and was unable to find the manufacturer's specifications for the use of the side rails, or the type of bed used by Resident #4 and Resident #5. The Maintenance Supervisor said his department used a computer program to schedule checks of the side rails, but could not recall how often or when the last checks were completed. The Maintenance Supervisor was later able to provide documentation of the side rail checks for Resident #4's and Resident #5's unit, which was dated [DATE]. The MicroAir User Manual for the air mattress in use for Resident #4 included a warning that indicated; Patient entrapment with bed side rails may cause injury or death and the mattress must fit the bed frame and side rails snugly to prevent patient entrapment. Follow the manufacturer's instructions. Monitor patient frequently. Read and understand the Owner's/Operator's Manual prior to using this equipment. Proper patient assessment, monitoring, maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, mattress thickness, size or density could increase the risk of entrapment. The manual provided links to the Food and Drug Administration (FDA) website and another site published by the Hospital Bed Safety Workgroup. The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued by the FDA [DATE], recommended that the limit measured between the mattress support platform and the lowest portion of the side rail was 2 ,[DATE] inches and the gap that forms between the mattress compressed by the patient and the lowermost portion of the side rail, should be less than 2 ,[DATE] inches. Surveyor #1 and Surveyor #2 accompanied the Maintenance Supervisor to obtain measurements of the bed model that was in use for Resident #4 and Resident #5 at the time of the incidents. The measurement from the mattress support platform and the lowest portion of the side rail 7.0 inches. The measurement from the mattress to the bottom of the side rail was 2.5 inches with no compression of the mattress. Both measurements were in excess of the FDA measurement recommendations. Surveyor #2 interviewed the Customer Service Representative at 10:17 A.M. on [DATE]. The Customer Service Representative said that model of bed had not been manufactured since prior to 2009. The Customer Service Representative said the replacement parts for that model of bed were also no longer being manufactured or sold, and hadn't been for approximately the same length of time. The DON said she checked the Facility's paper and online policies, and the Facility did not have a policy and procedure in place on the use and implementation of resident side rails. Unit Manager #1 said the Facility's policy for side rail use was that if the side rails were needed for positioning or enabling movement, then they were utilized. The DON said staff did not obtain consent for the use of the side rails, and she did not know why. There was no documentation at the time of survey that Resident #4 and Resident #5 had consents in place, or a review of the risks and benefits, for the use of side rails.

Based on records reviewed and interviews, the facility failed to ensure the installation and maintenance of side rails was conducted in accordance with manufacturer's recommendations and specifications. The facility failed to conduct regular inspections of side rails in an attempt to identify areas of possible entrapment. The facility failed to ensure that side rails, mattresses, and bed frames were compatible. - On 08/22/17, the Facility provided documentation which indicated that 173 of 176 residents in the Facility had side rails on their beds. - On 07/31/17, an Incident Report indicated Resident #5 was found, by a Certified Nurse Aide (CNA) #4, entrapped between the bed and the side rail. CNA #2 said he observed Resident #5's body to be outside the bed with his/her head on the bed with the bottom of the side rail across his/her neck and Resident #5 was just hanging there, looked terrified, and he/she was holding onto the side rail with both hands as if holding on for dear life, or words to that effect. There was no documentation at the time of survey that Resident #5 was assessed for the use of side rails before installation, or after the incident. There was no documentation at the time of survey of any consent by Resident #5 or his/her representative for the use of side rails. There was no documentation at the time of the survey to indicate that the Facility determined that the side rails were compatable for use on the bed or that they were inspected to ensure they were a safe distance from the frame and mattress. - On 08/15/17, CNA #2 said he observed that Resident #4's head was twisted sideways and held firmly in place from just behind the eyes by the bed frame and bottom bar of the side rail. CAN #2 said that the side rail had to be physically manipulated up and away from Resident #4's head in order to reposition his/her body back onto the bed. Resident #4's face was observed to be swollen and his/her lips were cyanotic (a bluish discoloration of the skin due to low levels of oxygen in the blood), and an indentation from the bottom bar of the side rail was observed running partway down Resident #4's face. Resident #4 was determined to be deceased . There was no indication at the time of the survey that all residents' beds were evaluated to ensure that side rails did not pose a risk of entrapment. Findings include: Surveyor #1 and Surveyor #2 interviewed the Maintenance Supervisor at 11:53 A.M. on 8/22/17. The Maintenance Supervisor said the Facility's resident beds were of varying brands and models, and side rails were attached at the request of nursing. The Maintenance Supervisor said he did not know if the side rails were recommended for use with the brands and models of beds used by the Facility. The Maintenance Supervisor said he was unable to find the manufacturer's recommendations and specifications for use of the side rails, or the type of bed used by Resident #4 and Resident #5. The Maintenance Supervisor said his department used a computer program to schedule checks of the side rails, but could not recall how often the checks were completed, or when the last checks were completed. The Maintenance Supervisor was later able to provide documentation of the side rail checks for Resident #4's and Resident #5's unit, which was dated 05/26/17. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses (DON) at 3:12 P.M. on 8/22/17. The DON said she did not know how often the side rails were checked, as checks were done by maintenance. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 10:15 A.M. on 8/22/17. Nurse #2 said she did not know if there were scheduled maintenance checks for the side rails. The Maintenance Request, dated 07/31/17, indicated that Resident #5's side rail was very loose and needed bolsters as soon as possible. The MicroAir User Manual for the air mattress in use for Resident #4 included a warning that indicated; Patient entrapment with bed side rails may cause injury or death and the mattress must fit the bed frame and side rails snugly to prevent patient entrapment. Follow the manufacturer's instructions. Monitor patient frequently. Read and understand the Owner's/Operator's Manual prior to using this equipment. Proper patient assessment, monitoring, maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, mattress thickness, size or density could increase the risk of entrapment. The manual provided links to the Food and Drug Administration (FDA) website and another site published by the Hospital Bed Safety Workgroup. The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued by the FDA 3/10/06, recommended that the limit measured between the mattress support platform and the lowest portion of the side rail was 2 3/8 inches and the gap that forms between the mattress compressed by the patient and the lowermost portion of the side rail, should be less than 2 3/8 inches. Surveyor #1 and Surveyor #2 accompanied the Maintenance Supervisor to obtain measurements of the bed model that was in use for Resident #4 and Resident #5 at the time of the incidents. The measurement from the mattress support platform and the lowest portion of the side rail 7.0 inches. The measurement from the mattress to the bottom of the side rail was 2.5 inches with no compression of the mattress. Both measurements were in excess of the FDA measurement recommendations. Surveyor #2 interviewed the Customer Service Representative at 10:17 A.M. on 08/24/17. The Customer Service Representative said that model of bed had not been manufactured since prior to 2009. The Customer Service Representative said the replacement parts for the model of bed were also no longer being manufactured or sold, and hadn't been for approximately the same length of time.

Based on records reviewed and interviews, for 2 of 5 sampled residents (Resident #4 and Resident #5), the Facility failed to notify the attending Physician of the circumstances surrounding two incidents of side rail entrapment. - On [DATE], an Incident Report indicated Resident #5 was found, by a Certified Nurse Aide (CNA) #4, entrapped between the bed and the side rail. CNA #4 said she observed Resident #5's head was on the mattress, with the bottom bar of the side rail across the front of his/her neck, and his/her body and his/her legs off the bed. CNA #2 said he observed Resident #5's body to be outside the bed with his/her head on the bed with the bottom of the side rail across his/her neck and Resident #5 was just hanging there, looked terrified, and he/she was holding onto the side rail with both hands as if holding on for dear life, or words to that effect. - On [DATE], CNA #2 said he observed that Resident #4's head was twisted sideways and held firmly in place from just behind the eyes by the bed frame and bottom bar of the side rail. CNA #2 said that the side rail had to be physically manipulated up and away from Resident #4's head in order to reposition his/her body back onto the bed. Resident #4's face was observed to be swollen and his/her lips were cyanotic (a bluish discoloration of the skin due to low levels of oxygen in the blood), and an indentation from the bottom bar of the side rail was observed running partway down Resident #4's face. Resident #4 was determined to be deceased . Findings include: 1. Resident #5 was admitted to the Facility in February 2017 with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS), dated [DATE], indicated that Resident #5 required the extensive assistance of 2 or more persons for bed mobility and had moderate cognitive impairment. The Incident Investigation Report, dated [DATE], indicated that Resident #5 was found by a CNA, entrapped between the bed and the side rail. Surveyor #1 and Surveyor #2 interviewed Certified Nurse Aide (CNA) #4 at 11:19 A.M. on [DATE]. CNA #4 said that on [DATE] at approximately 1:00 P.M., she assisted Resident #5 into bed and approximately 45 minutes later, she walked by Resident #5's room glanced into Resident #5's room, but she could not see Resident #5's legs in the bed, and so entered the room to check on him/her. CNA #4 said she observed Resident #5 with his/her head on the mattress, the bottom of the side rail across the front of his/her neck, and his/her legs off the bed. CNA #4 said she and CNA #3 could not move Resident #5 without choking him/her. CNA #4 said CNA#2 assisted them to move Resident #5 from under the side rail and back into bed. CNA #4 said she informed the Unit Manager. Surveyor #1 and Surveyor #2 interviewed CNA #3 at 9:34 A.M. on [DATE]. CNA #3 said she heard CNA #4 call for help, and when she responded, she observed Resident #5 hanging from the side rail and holding on for dear life, or words to that effect. CNA #3 said she and CNA #4 called for more help because there was no way they could have moved Resident #5 by themselves. CNA #3 said she, CNA #2, and CNA #4 moved Resident #5 from under the side rail and back into bed. Surveyor #1 and Surveyor #2 interviewed CNA #2 at 9:00 A.M. on [DATE]. CNA #2 said he heard a CNA screaming for help and when he went into Resident #5's room, he observed Resident #5's head on his/her mattress with the bottom of the side rail across the front of his/her neck, and his/her body hanging off the bed on the opposite side of the rail. CNA #2 said Resident #5 was holding on to the side rail with both hands as if he/she was hanging on for dear life, or words to that effect. CNA #2 said Resident #5 was clearly in distress and appeared petrified. CNA #2 said CNA #3 and CNA #4 were in Resident #5's room trying to figure out how to get Resident #5's head out from between the mattress and the side rail without hurting him/her. CNA #2 said one CNA held the side rail to keep it still, another held Resident #5's head still, and he picked up Resident #5's body and tried to hold him/her as flat as possible so they could slide his/her head out and place him/her onto the bed. The Interdisciplinary Note, dated [DATE], indicated that Resident #5 was found stuck between his/her air mattress and the left side rail, and that a voicemail was left for the Medical Director. Surveyor #1 and Surveyor #2 interviewed the Medical Director at 1:46 P.M. on [DATE] and at 11:11 A.M. on [DATE]. The Medical Director said she did not know of the alleged incident with Resident #5 until it was briefly mentioned after Resident #4's death on [DATE]. The Medical Director said she was not given any information about Resident #5 being entrapped in the side rail and she was on a leave of absence and did not return until several days after it occurred. During the interview with the Surveyors, the Medical Director reviewed Resident #5's clinical record and observed a progress note, dated [DATE], which indicated that a voicemail was left for her regarding the alleged incident. The Medical Director said she did not recall receiving any voicemail or other notification about the alleged incident. The Medical Director said that as of [DATE], Facility staff had not spoken with her about the incident with Resident #5 and she had not seen the related Incident Report. 2. Resident #4 was admitted to the Facility in in [DATE], and readmitted in [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated that Resident #4 required the extensive physical assistance for 2 or more persons with bed mobility and had severe cognitive impairment. CNA #2 said that on [DATE] between 7:00 A.M. and 7:30 A.M., he entered Resident #4's room and observed Resident #4 lying in bed with his/her legs hanging off of the bed from approximately mid-thigh down. CNA #2 said Resident #4's head was twisted sideways and to the right, in-between the bottom of the side rail and the frame of the bed, and he/she appeared deceased based on the color and temperature of his/her skin. CNA #2 said he had to physically pull on the side rail in order for staff to pry, or words to that effect, Resident #4 out and reposition him/her on the bed. CNA #2 said that when Resident #4 was repositioned in the bed, a large amount of saliva poured out of his/her mouth, and he observed an indentation down the right side of Resident #4's face from where the side rail bar had been. CNA #3 said that on [DATE], she responded to CNA #2's requests for help with Resident #4. CNA #3 said that when she entered Resident #4's room, she observed him/her lying in bed with his/her legs hanging off of the bed from approximately mid-thigh down, with his/her feet touching the floor. CNA #3 said Resident #4's head appeared to be stuck between the mattress and the bottom of the side rail, and a golf ball sized pool of saliva was on the floor under Resident #4's mouth. CNA #3 said that in order to reposition Resident #4 onto the bed, CNA #2 had to pull on the side rail so that staff could free Resident #4's head. CNA #3 said Resident #4 was obviously deceased when she entered the room, that his/her legs were cold to the touch and were bluish in color. CNA #4 said that on [DATE], she entered Resident #4's room in response to CNA #2's requests for help. CNA #4 said Resident #4 appeared deceased , that he/she was a smoky grey and blue in color, or words to that effect, and had saliva running out of his mouth onto the floor. CNA #4 said Resident #4's head was twisted to the right side, and his/her face was between the bottom of the side rail and the mattress. CNA #4 said the side rail had to be physically pulled on to move it away from Resident #4's face so that staff could reposition him/her onto the bed. CNA #4 said she observed a mark from the eye to the jawline, like an indentation, consistent with where the bottom of the side rail had been on his/her face. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 10:15 A.M. on [DATE]. Nurse #2 said that when she responded to CNA #3's cries for help from Resident #4's room on [DATE], she observed Resident #4 in bed, with his/her legs hanging off of the bed and his/her face stuck in the side rail. Nurse #2 said Resident #4's face from just behind the eyes forward, was protruding beyond the side rail, with the bar from the side rail running along his/her face. Nurse #2 said Resident #4's face appeared swollen, his/her lips cyanotic, with saliva running out of his/her mouth, and his/her legs were blue in color and mottled. Nurse #2 said Resident #4 did not have a pulse at that time. Nurse #2 said CNA #2 had to pull the side rail upwards and out away from the bed in order to be able to reposition Resident #4 onto the bed, but that it still took effort to free Resident #4's head from between the bed frame and bottom of the side rail. Nurse #2 said she called the Medical Director, and informed her that Resident #4 was found pulseless, with his/her face in the side rail. The Medical Director said she was told that Resident #4 was found pulseless and had passed away but it wasn't until [DATE] or [DATE] that staff told her Resident #4's head had been trapped in the side rail and that staff was concerned that the use of side rails contributed to Resident #4's death.

Based on records reviewed and interviews, for one of six sampled residents (Resident #6), the facility failed to ensure transfer to the hospital in a timely manner after an acute change in condition following an unwitnessed fall, despite having a physician's orders [REDACTED]. The Facility failed to ensure that Nurse #4 conducted neurological assessments (assessments conducted to monitor for impairment of brain function) on Resident #6 after his/her unwitnessed fall in accordance with the facility's policy and professional standards of practice. The Facility failed to ensure that the physician was notified of the fall at the time of the incident, so that orders could be obtained for any necessary care and treatment for [REDACTED]. - On [DATE] at approximately 6:45 P.M., Resident #6 sustained an unwitnessed fall. At approximately 8:20 P.M., Resident #6 exhibited twitching of his/her left lower extremity and became unresponsive. An untimed physician's orders [REDACTED].M. on [DATE], indicated to transfer Resident #6 to the emergency room (ER) for further evaluation and treatment, but the ambulance was not requested until approximately 69 minutes later. Resident #6 was declared dead at the hospital at 12:33 A.M. on [DATE] from injuries that were documented as catastrophic and nonsurvivable. Findings include: Resident #6 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. endarterectomy (removal of part of the inner lining of an artery because of narrowing) with post-operative removal of a hematoma (a solid swelling of clotted blood within the tissues). The physician's orders [REDACTED].#6 was ordered medications including: [MEDICATION NAME] (a medication used to help prevent blood clots), Metropolol (to treat high blood pressure), and [MEDICATION NAME] (a blood thinning medication). There was no indication that the plan of care included documented advanced directives from Resident #6 and/or his/her legal representative that he/she did not want to be transferred to the hospital. 1. The Facility's internal investigation indicated that Resident #6 was observed on the floor of his/her room at approximately 6:45 P.M. on [DATE] by Certified Nurse Aide (CNA) #6 and CNA #7 after they responded to a loud noise from the room. The investigation indicated that Resident #6 was assessed by Nurse #4, and then assisted back to bed by Nurse #4, CNA #6 and CNA #7. The Interdisciplinary Note, dated at 11:53 P.M. on [DATE] and modified at 7:07 A.M. on [DATE] by Nurse #4, indicated that at approximately 7:05 P.M., she notified the attending physician (the Medical Director) and obtained a new medication order. The note did not indicate the reason Nurse #4 notified the Medical Director. There was no documentation at the time of survey to indicate what the original contents of Nurse #4's note were, as the note was edited more than 5 days after it was initiated. The Facility's internal investigation indicated that at approximately 8:20 P.M. on [DATE], CNA #6 reported Resident #6 was thrashing about; Nurse #4 reassessed Resident #6 and noted that he/she had a significant change in status. The Interdisciplinary Note, dated at 11:53 P.M. on [DATE] and modified at 7:07 A.M. on [DATE] by Nurse #4, indicated that at approximately 8:25 P.M., Nurse #4 obtained an order from the Medical Director to transfer Resident #6 to the ER for further evaluation and treatment. There was no documentation at the time of survey that Nurse #4 took action to immediately transfer Resident #6 to the ER. The Facility's internal investigation indicated that at approximately 9:30 P.M. on [DATE], Nurse #5 responded to Resident #6's unit after receiving a report of an unresponsive resident. The investigation indicated that Nurse #5 assessed Resident #6, and noted his/her pupils were sluggish (responding slowly to changes in light levels) and he/she was not responding to a sternal rub (a painful grinding motion on the person's breastbone designed to assess the person's level of consciousness). The investigation indicated that Nurse #4 called 911 at that time, approximately one hour after obtaining a physician's orders [REDACTED]. The Transfer/Discharge Form, dated [DATE], indicated that Nurse #4 administered all HS (hour of sleep) medications, including [MEDICATION NAME] (a sedative and antidepressant medication). The Medication Administration Record, [REDACTED].M., 9:00 P.M. or at the hour of sleep including [MEDICATION NAME]. The Prehospital Report from the ambulance company, dated [DATE], indicated that the request for an ambulance for an unresponsive resident was received at 9:34 P.M. from the Facility. The report indicated that Emergency Medical Services (EMS) assessed Resident #6 at approximately 9:43 P.M., and noted that Resident #6's pupils were equal, dilated (enlarged) and not reactive to light (which indicated an important change in his/her condition and could signal a life-threatening emergency and possible brain death), he/she withdrew only slightly to a strong sternal rub, and his/her GCS was 6 (Glascow Coma Scale; an assessment based on eye, verbal and motor criteria; a score of less than 8 indicates severe [MEDICAL CONDITION]). The Hospital Record indicated that at approximately 10:18 P.M., Resident #6 arrived at the Hospital ER with a GCS of 6. The record indicated that Resident #6 did not have any facial bruising, abrasions or wounds. The record indicated that computerized tomography scans (CT; a series of X-ray images taken from different angles to create cross-sectional images of the bones, blood vessels and soft tissues inside the body) of Resident #6's head and body were conducted. The record indicated that the head CT revealed a large left subdural hematoma (SDH; a pool of blood between the brain and its outermost covering), a possible minimal subarachnoid hemorrhage (SAH; bleeding within the area between the brain and the tissues that cover the brain), a minimally displaced fracture (a non-alignment of the broken pieces of bone) of the right nasal bone, a mildly comminuted fracture (a break or splinter of the bone into more than two fragments) of the anterior nasal spine of the maxilla (the area at the base of the nose), and non-displaced fractures of the 9th and 10th ribs on the right side of Resident #6's body. The Neurosurgery Consultation Note, dated [DATE], indicated that the results of the head CT were a nonsurvivable event, and that there was no intervention that could reverse the damage Resident #6 had suffered. The Discharge/Transfer Note from the Hospital, dated [DATE] at 12:40 A.M., indicated that Resident #6 was pronounced dead at 12:33 P.M. on [DATE]. Surveyor #1 interviewed the Director of Nurses (DON) at multiple times on [DATE]. The DON said she had been unable to interview Nurse #4 since [DATE] about discrepancies in her written statement and the timeline of events following Resident #6's fall because Nurse #4 had not responded to the Facility's attempts to reach her. There was no documentation at the time of survey regarding the reason for the delay of more than 60 minutes in transporting Resident #6 to the hospital after Nurse #4 received a physician's orders [REDACTED].#6 becoming unresponsive following an unwitnessed fall. 2. Pursuant to a publicized nursing article titled Neurological Checks for head injuries: LTC Clinical Pearls: Powered by HCPro's Long-Term Nursing Library, [DATE]th, 2013, indicated: - Assess the resident for changes in level of consciousness. - Assess the resident immediately after the fall, then frequently throughout the shift. Assessment should continue for a minimum of 72 hours. - Perform neurological assessment every 15 minutes for two hours; then every 30 minutes for two hours; then every 60 minutes for four hours; then every eight hours for 16 hours; and then every eight hours until at least 72 hours have elapsed and resident is stable - Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength. The Facility's Incident Management policy, dated ,[DATE], indicated that neurological signs must be initiated for all unwitnessed falls. The Facility's Neuro Checks policy, dated ,[DATE], indicated that: - Neurological checks would include: pupil reaction to light, including equality of pupil reaction and size; grips to assess equality of strength; movement of all extremities; and, the level of consciousness will be checked for any increased lethargy (sleepiness), restlessness, or confusion. - Neurological checks would be completed every 15 minutes for one hour; every half hour for two hours; and, every four hours for 24 hours. - Licensed staff would document neurological signs of the designated flow sheet, to be placed in the resident's chart upon completion. There was no documentation at the time of survey that the Facility's Neuro Checks policy followed accepted standards of practice regarding the frequency of neurological checks following a resident's fall. The Post Fall Neuro Signs Check Flow Sheet, with entries dated [DATE], indicated that Resident #6's pupil reaction was not documented by Nurse #4 for the checks completed between 8:15 P.M. and 9:45 P.M. The flow sheet also indicated that Nurse #4 was unable to obtain vital signs (temperature, pulse, respiratory rate and blood pressure) at 8:45 P.M., after Resident #6 was reportedly unresponsive. The DON said she attempted to speak with Nurse #4 about the missing documentation regarding Resident #6's pupil reactions. The DON said Nurse #4 grabbed the flow sheet from her, and wrote Perrla (pupils equal, round, react to light, accommodation (a reflex of the eyes when focusing on an object)) in the four missing areas. The DON said Nurse #4 left the Facility before the DON could ask her to initial the new documentation and mark them as late entries. There was no documentation at the time of survey that Resident #6's neurological assessments were thoroughly completed after 8:15 P.M. in accordance with Facility policy or professional standards of practice. 3. The DON said she spoke with the Medical Director in an attempt to reconcile the timeline of events following Resident #6's unwitnessed fall as provided to her by Nurse #4. The DON said the Medical Director checked her cellphone call log for [DATE], and reported that she had a missed call from the Facility at approximately 7:00 P.M., but had not spoken with anyone. The DON said the Medical Director said she had not spoken with anyone at the Facility about Resident #6's fall until after 8:00 P.M. on [DATE].

Based on records reviewed and interviews, for 3 of 6 sampled residents (Resident #4, Resident #5, and Resident #6), the facility failed to report incidents which seriously affected the health, safety, and well-being of the residents to the Department of Public Health (DPH) as required. - On [DATE], Certified Nurse Aide (CNA) #2, CNA #3, CNA #4 and Nurse #2 said they observed that Resident #4's head was twisted sideways and held firmly in place from just behind the eyes by the bed frame and bottom bar of the side rail. CNA #2, CNA #3, CNA #4 and Nurse #2 said that the side rail had to be physically manipulated up and away from Resident #4's head in order to reposition his/her body back onto the bed. Resident #4 was determined to be deceased . As of [DATE], the incident had not been reported to the DPH. - On [DATE] at approximately 6:45 P.M., Resident #6 sustained an unwitnessed fall, and became unresponsive approximately an hour and a half later. A physician's orders [REDACTED].#6 to the emergency room (ER) for further evaluation and treatment. The ambulance was not requested until 9:34 P.M., approximately 69 minutes after the physician's orders [REDACTED]. Resident #6 was declared dead at the Hospital at 12:33 A.M. on [DATE] from injuries that were documented as catastrophic and nonsurvivable. As of [DATE], the incident had not been reported to the DPH. - On [DATE], an Incident Report indicated Resident #5 was found by CNA #4, entrapped between the bed and the side rail. CNA #2, CNA #3 and CNA #4 said they observed Resident #5's head was on the mattress, with the bottom bar of the side rail across the front of his/her neck, and his/her body and legs off of the bed on the opposite side of the side rail from his/her head. As of [DATE], the incident had not been reported to the DPH. Findings include: The Facility's Incident Management policy, issued ,[DATE], did not include guidelines for reporting unexpected incidents to the DPH. 1. Resident #4 was admitted to the Facility in in [DATE], and readmitted in [DATE], with [DIAGNOSES REDACTED]. Surveyor #1 and Surveyor #2 interviewed CNA #2 at 9:00 A.M. on [DATE]. CNA #2 said that on [DATE] between 7:00 A.M. and 7:30 A.M., he observed Resident #4 lying in bed on his/her left side, with his/her legs hanging off of the bed from approximately mid-thigh down. CNA #2 said Resident #4's head was twisted sideways and to the right, in-between the bottom of the side rail and the frame of the bed, and his/her right hand was holding onto the side rail. CNA #2 said he had to physically pull on the side rail in order for staff to pry, or words to that effect, Resident #4 out and reposition him/her on the bed because Resident #4's head was under the side rail and prevented them from being able to lower the side rail. CNA #2 said that when Resident #4 was repositioned in the bed, he observed an indentation down the right side of Resident #4's face from where the side rail bar had been. CNA #2 said he told the Director of Nurses (DON) on either [DATE] or [DATE], how Resident #4 was when he found him/her on [DATE]. Surveyor #1 and Surveyor #2 interviewed CNA #3 at 9:34 A.M. on [DATE]. CNA #3 said that on [DATE], she observed Resident #4 lying in bed with his/her legs hanging off of the bed from approximately mid-thigh down and his/her feet touching the floor. CNA #3 said Resident #4's head was twisted to the right and appeared to be stuck between the mattress and the bottom of the side rail. CNA #3 said that in order to reposition Resident #4 onto the bed, CNA #2 had to pull on the side rail so that staff could free Resident #4's head because his/her head was under the side rail and prevented them from lowering the side rail. CNA #3 said she told the DON how she observed Resident #4. Surveyor #1 and Surveyor #2 interviewed CNA #4 at 11:19 on [DATE]. CNA #4 said that on [DATE], she observed Resident #4 lying in bed with the lower part of his/her body off of the bed. CNA #4 said Resident #4's head was twisted to the right side, with his/her face was between the bottom of the side rail and the mattress. CNA #4 said the side rail had to be physically pulled on to move it away from Resident #4's face so that staff could reposition him/her onto the bed. CNA #4 said she observed a mark from the eye to the jawline, like an indentation, consistent with where the bottom of the side rail had been on his/her face. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 10:18 A.M. on [DATE]. Nurse #2 said that on [DATE], she observed Resident #4 in bed with his/her legs hanging off of the bed and his/her face stuck in the side rail. Nurse #2 said Resident #4's face from just behind the eyes forward was protruding beyond the side rail, with the bar from the side rail running along his/her face. Nurse #2 said Resident #4's face appeared swollen, his/her lips cyanotic, with saliva running out of his/her mouth, and his/her legs were blue in color and mottled (irregular patches of skin discoloration as a result of diminished circulation). Nurse #2 said Resident #4 did not have a pulse at that time. Nurse #2 said CNA #2 had to pull the side rail upwards and out away from the bed in order to be able to reposition Resident #4 onto the bed because the position of Resident #4's head prevented staff from being able to lower the side rail. Nurse #2 said it still took effort to free Resident #4's head from between the bed frame and bottom of the side rail. Nurse #2 said she informed the DON that staff found Resident #4 with his/her face under the side rail. Surveyor #1 and Surveyor #2 interviewed the DON at 3:12 P.M. on [DATE]. The DON said she felt that Resident #4 had some sort of cardiac event, or words to that effect. However, the DON was not present at the time that Resident #4 was found, did not assist in removing Resident #4's head and body away from the side rail, and her comment was not consistent with the four staff members who actually found, witnessed, and assisted in moving Resident #4 from the side rail on [DATE]. Review of the DPH's Health Care Facility Reporting System (HCFRS; a web-based system used by healthcare providers to file reports with the DPH) on [DATE] indicated that the Facility had not reported the incident of Resident #4's entrapment in the side rail or his/her death, 23 days after the incident occurred. 2. Resident #6 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. endarterectomy (removal of part of the inner lining of an artery because of narrowing) with post-operative removal of a hematoma (a solid swelling of clotted blood within the tissues). The Facility's internal investigation indicated that Resident #6 was observed on the floor of his/her room at approximately 6:45 P.M. on [DATE] by Certified Nurse Aide (CNA) #6 and CNA #7 after they responded to a loud noise from the room. The investigation indicated that Resident #6 was assessed by Nurse #4, and then assisted back to bed by Nurse #4, CNA #6 and CNA #7. The investigation indicated that at approximately 8:20 P.M. on [DATE], Nurse #4 reassessed Resident #6 and noted that he/she had a significant change in status. The Interdisciplinary Note, dated at 11:53 P.M. on [DATE] and modified at 7:07 A.M. on [DATE] by Nurse #4, indicated that at approximately 8:25 P.M., Nurse #4 obtained an order from the Medical Director to transfer Resident #6 to the ER for further evaluation and treatment. The Prehospital Report, dated [DATE], indicated that the request for an ambulance was received at 9:34 P.M. from the Facility, approximately 69 minutes after Nurse #4 received the physician's orders [REDACTED].#6 to the Hospital. The Hospital Record, dated [DATE] and [DATE], indicated that Resident #6 underwent computerized tomography scans (CT; a series of X-ray images taken from different angles to create cross-sectional images of the bones, blood vessels and soft tissues inside the body). The record indicated that Resident #6's CT scans revealed a large left subdural hematoma (SDH; a pool of blood between the brain and its outermost covering), a possible minimal subarachnoid hemorrhage (SAH; bleeding within the area between the brain and the tissues that cover the brain), a minimally displaced fracture (a non-alignment of the broken pieces of bone) of the right nasal bone, a mildly comminuted fracture (a break or splinter of the bone into more than two fragments) of the anterior nasal spine of the maxilla (the area at the base of the nose), and non-displaced fractures of the 9th and 10th ribs on the right side. The Neurosurgery Consultation Note, dated [DATE], indicated that the results of the head CT were a nonsurvivable event, and that there was no intervention that could reverse the damage Resident #6 had suffered. The Discharge/Transfer Note Hospital HIM, dated [DATE] at 12:40 A.M., indicated that Resident #6 was pronounced dead at 12:33 P.M. on [DATE]. Surveyor #1 interviewed the Director of Nurses (DON) and Vice President of Quality at 8:17 A.M. on [DATE]. The DON said she was notified by the Hospital that Resident #6 had died , but as of the date of interview, had not reported the death to the DPH because her internal investigation was not complete. At 11:58 A.M. on [DATE], the DON said she would report Resident #6's death to the DPH via HCFRS. Review of the DPH's HCFRS on [DATE] indicated that the Facility had not reported the death of Resident #6 within 24 hours of admission to the Hospital from the Facility, 29 days after the incident occurred. 3. Resident #5 was admitted to the Facility in February 2017 with [DIAGNOSES REDACTED]. CNA #4 said that on [DATE] at approximately 1:45 P.M., she observed Resident #5 with his/her head on the mattress, the bottom of the side rail across the front of his/her neck, and his/her legs off of the bed. CNA #4 said Resident #5 appeared tense and nervous, but she and CNA #3 could not move Resident #5 without choking him/her, so CNA#2 assisted them to move Resident #5 from under the side rail and back into bed. CNA #3 said she heard CNA #4 call for help, and when she responded, she observed Resident #5 hanging from the side rail and holding on for dear life, or words to that effect. CNA #3 said she and CNA #4 called for more help because there was no way they could have moved Resident #5 by themselves. CNA #3 said she, CNA #2, and CNA #4 moved Resident #5 from under the side rail and back into bed. CNA #2 said he heard a CNA screaming for help and when he went into Resident #5's room, he observed Resident #5's head on his/her mattress with the bottom of the side rail across the front of his/her neck, and his/her body hanging off of the bed on the opposite side of the rail. CNA #2 said Resident #5 was holding on to the side rail with both hands as if he/she was hanging on for dear life, or words to that effect. CNA #2 said Resident #5 was clearly in distress and appeared petrified. CNA #2 said that in order to move Resident #5 without hurting him/her, one CNA held the side rail to keep it still, another held Resident #5's head still, and he picked up Resident #5's body and tried to hold him/her as flat as possible so they could slide his/her head out and place him/her onto the bed. The Interdisciplinary Note, dated [DATE] and written by Unit Manager #1, indicated that Resident #5 was found stuck between his/her air mattress and the left side rail. The Incident Investigation Report, dated [DATE], indicated that Resident #5 was found by a CNA, entrapped between the bed and the side rail. Surveyor #1 and Surveyor #2 interviewed the Administrator at 2:30 P.M. on [DATE]. The Administrator said he reviewed and signed all incident reports personally, and incidents are discussed in Morning Meeting. The Administrator then reviewed his notes from the Morning Meeting on [DATE], the day after Resident #5 was entrapped, and said he did not have anything in his notes to indicate that anything of concern was mentioned to him. The Administrator also said he did not pursue what entrapped meant, in reference to Resident #5's incident report from [DATE]. Review of the DPH's HCFRS on [DATE] indicated that the Facility had not reported the incident of Resident #5's entrapment in the side rail, 38 days after the incident occurred.

Based on records reviewed and interviews, for one of five sampled residents (Resident #4), the facility failed to accurately report, to the attending physician (the Medical Director) and Medical Examiner, the position and the condition of the body at the time of death. - The Facility failed to ensure that the Medical Director was provided with accurate information related to Resident #4 having to be pried from between his/her mattress and side rail. - The Facility failed to follow acceptable standards related to notification of the Medical Examiner and related to the Registered Nurse Pronouncement of Death. - On [DATE], Certified Nurse Aide (CNA) #2, CNA #3, CNA #4 and Nurse #2 said they observed Resident #4's head twisted sideways and held firmly in place from just behind the eyes by the bed frame and bottom bar of the side rail. CNA #2, CNA #3, CNA #4 and Nurse #2 said that the side rail had to be physically manipulated up and away from Resident #4's head in order to reposition his/her body back onto the bed. Findings include: Massachusetts General Law, Part One, Title V1, Chapter 38, Section 3, indicated that it shall be the duty of any person having knowledge of a death which occurs by accident or unintentional injury, regardless of time interval between the incident and death, and regardless of whether such injury appears to have been the immediate cause of death, or a contributory factor thereto, to immediately notify the office of the chief medical examiner, or the medical examiner designated to the location where the death has occurred, of the known facts concerning the time, place, manner, circumstances and cause of such death. 1. Resident #4 was admitted to the Facility in in [DATE], and readmitted in [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set, dated dated [DATE], indicated that Resident #4 required the extensive physical assistance of two or more persons with bed mobility (the ability to move from one bed position to another) and had severe cognitive impairment. The Incident Investigation Packet, dated [DATE], indicated that at approximately 3:15 P.M., Resident #4 fell forward out of his/her wheelchair onto the floor. The packet indicated that Resident #4 sustained and abrasion/contusion to the right forehead, and a skin tear to the webbing between the thumb and forefinger on his/her right hand. Surveyor #1 and Surveyor #2 interviewed CNA #2 at 9:00 A.M. on [DATE]. CNA #2 said that on [DATE] between 7:00 A.M. and 7:30 A.M., he observed Resident #4 lying in bed on his/her left side, with his/her legs hanging off of the bed from approximately mid-thigh down. CNA #2 said Resident #4's head was twisted sideways and to the right, in-between the bottom of the side rail and the frame of the bed, and his/her right hand was holding onto the side rail. CNA #2 said he had to physically pull on the side rail in order for staff to pry, or words to that effect, Resident #4 out and reposition him/her on the bed because Resident #4's head was under the side rail and prevented them from being able to lower the side rail. CNA #2 said that when Resident #4 was repositioned in the bed, he observed an indentation down the right side of Resident #4's face from where the side rail bar had been. CNA #2 said he told the Director of Nurses (DON) on [DATE] or [DATE], how Resident #4 was when he found him/her on [DATE]. Surveyor #1 and Surveyor #2 interviewed CNA #3 at 9:34 A.M. on [DATE]. CNA #3 said that on [DATE], she observed Resident #4 lying in bed with his/her legs hanging off of the bed from approximately mid-thigh down and his/her feet touching the floor. CNA #3 said Resident #4's head was twisted to the right and appeared to be stuck between the mattress and the bottom of the side rail. CNA #3 said that in order to reposition Resident #4 onto the bed, CNA #2 had to pull on the side rail so that staff could free Resident #4's head because his/her head was under the side rail and prevented them from lowering the side rail. CNA #3 said that when she told the DON how she observed Resident #4, the DON told her she didn't see what she saw, or words to that effect. CNA #3 said she told the DON that she was not going to say anything differently than what she had seen. Surveyor #1 and Surveyor #2 interviewed CNA #4 at 11:19 A.M. on [DATE]. CNA #4 said that on [DATE], she observed Resident #4 lying in bed with the lower part of his/her body off of the bed. CNA #4 said Resident #4's head was twisted to the right side, with his/her face was between the bottom of the side rail and the mattress. CNA #4 said the side rail had to be physically pulled on to move it away from Resident #4's face so that staff could reposition him/her onto the bed. CNA #4 said she observed a mark from the eye to the jawline, like an indentation, consistent with where the bottom of the side rail had been on his/her face. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 10:18 A.M. on [DATE]. Nurse #2 said that on [DATE], she observed Resident #4 in bed with his/her legs hanging off of the bed and his/her face stuck in the side rail. Nurse #2 said Resident #4's face from just behind the eyes forward was protruding beyond the side rail, with the bar from the side rail running along his/her face. Nurse #2 said Resident #4's face appeared swollen, his/her lips cyanotic, with saliva running out of his/her mouth, and his/her legs were blue in color and mottled (irregular patches of skin discoloration as a result of diminished circulation). Nurse #2 said Resident #4 did not have a pulse at that time. Nurse #2 said CNA #2 had to pull the side rail upwards and out away from the bed in order to be able to reposition Resident #4 onto the bed because the position of Resident #4's head prevented staff from being able to lower the side rail. Nurse #2 said it still took effort to free Resident #4's head from between the bed frame and bottom of the side rail. Nurse #2 said she called the Medical Director, and informed her that Resident #4 was found pulseless, with his/her face in the side rail. Nurse #2 said she informed the DON that staff found Resident #4 with his/her face under the side rail. The Commonwealth of Massachusetts Department of Public Health Registry of Vital Records and Statistics Pronouncement of Death, dated [DATE] and completed by the DON, indicated that Resident #4's time of death was 7:35 A.M., and the case was not referred to the Medical Examiner. Surveyor #1 and Surveyor #2 interviewed the Medical Director at 1:46 P.M. on [DATE] and at 11:11 A.M. on [DATE]. The Medical Director said that on [DATE], she was told that Resident #4 was found pulseless and had already passed away, and so gave an order for [REDACTED]. The Medical Director said that had she been aware of those concerns, especially given Resident #4's fall a few days prior, she would have told the Facility to refer the case to the medical examiner. Surveyor #1 and Surveyor #2 interviewed the DON at 3:12 P.M. on [DATE]. The DON said she felt that Resident #4 had some sort of cardiac event, or words to that effect. Although the DON said she felt that Resident #4's death was related to a cardiac event, or words to that effect, the DON was not present at the time that Resident #4 was found, did not assist in removing Resident #4's head and body away from the side rail, and her comment was not consistent with the four staff members who actually found, witnessed, and assisted in moving Resident #4 from the side rail on [DATE]. There was no documentation at the time of survey that the Medical Examiner was notified at the time of the Registered Nurse Pronouncement of Death that Resident #4 was found under the side rail on his/her bed and was deceased . 2. The Physician's Interim/Telephone Order for RN (Registered Nurse) pronouncement of Resident #4 indicated that the order was received at 7:35 A.M. on [DATE]. The Medical Director said that when she was contacted on [DATE] about Resident #4 being found pulseless, she was informed that the DON was in the room conducting the RN pronouncement. When asked if she had already given the order for the RN pronouncement at that time, the Medical Director said well, the DON was doing an assessment of Resident #4, or words to that effect.

Based on record review and staff interview, the facility staff failed to ensure that 1 Resident (#28) out of a total sample of 28 residents, was free from a significant medication error. Findings include: Resident #28 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of the 4/19/17 Hospital Discharge Summary and Discharge Medication Page, reviewed by Nurse #3 and verified by the Physician on 4/19/17, indicated that Resident #28 had the following sliding scale insulin [MEDICATION NAME]/Humalog orders: Insulin [MEDICATION NAME] units/ml (milliliter) subcutaneous injection, 3 times a day before meals: 200 - 249 4 Units 250 - 299 6 Units 300 - 349 8 Units 350 - 399 10 Units - Call if greater than 400. Nurse #3 then transcribed the orders on the physician's orders [REDACTED]. The Orders were transcribed by Nurse #3 as follows: [MEDICATION NAME] 100U/ml sliding scale coverage TID (three times daily) w(with)/meals. For FSBS (Finger Stick Blood Sugar) 200-249 give 4U Humalog (subcutaneously). For FSBS 250 - 299 give 6U Humalog For FSBS 300 - 349 give 8U Humalog For FSBS 350 - 399 give 10U Humalog For FSBS over 400 give 12U Humalog + notify MD. The handwritten U after the doses (6, 8, 10, and 12) on the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED].M. the resident's blood sugar was 343. Nurse #2 administered 80 units of [MEDICATION NAME]/Humalog Insulin instead of the ordered dose of 8 units by the Physician. At 11:30 A.M. the residents FSBS was 141, and at 1:30 P.M. the residents FSBS was down to 46. A family member was visiting the resident. The resident was given orange juice with 4 sugar packets and a packet of Insta-Glucose and the Physician was notified. An order was obtained to give 1 pack of glucose gel now for blood sugar of 46, and repeat if sugar is still below 60 within 15 minutes. Transfer patient to emergency room . Nurse #2 administered another packet of glucose gel and blood sugar was 54. Family member called 911, and the resident was transferred to the hospital. Upon arrival to the Emergency Department Resident #28's blood sugar was in the 90's (but he had received treatment by the paramedics with D50). Review of the Facility's Policy regarding, Do not use Abbreviations, dated 3/2004 indicated that U was an unapproved abbreviation, and to write out the word Units. On 6/20/17 at 3:15 P.M. the surveyor interviewed the Director of Nursing, the Vice President of Quality Improvement, and the Director of Staff Education and Infection Control. During the interview the Director of Nursing indicated that Nurse #2 had been questioned on 3 separate occasions as to the amount of insulin that had been administered on 4/22/17. Nurse #2 indicated she administered 8 Units when questioned by the Supervisor on 4/22/17, by the Director of Nursing on 4/25/17, and by the Director of Nursing and Director of Staff Education on 4/26/17. After leaving and going to her car on 4/26/17, Nurse #2 returned and approached the Vice President of Quality Improvement and the Director of Staff Education and indicated, I did it, I gave (the resident) 80 units. On 4/26/17, Nurse #2 resigned her position immediately. The Director of Nursing indicated to the Surveyor that the nurse would have been terminated on that same date. She was reported to the Licensing Board on 4/27/17. The Director of Nursing indicated to the Surveyor that she felt Nurse #3's actions using the wrong abbreviation U instead of writing out the word Units when transcribing the sliding scale insulin orders caused Nurse #2 to make the medication error. Nurse #2 read 8U (instead of 8 Units), which looked like 80 Units. Nurse #3 was terminated and reported to the Licensing Board.

Based on record review, observation and staff interview, the facility failed to ensure the plan of care had been followed for 6 sampled residents (#2, #6, #7, #9, #19, and #22), from a total of 30 sampled residents. Findings include: 1. For Resident #9, the facility failed to follow the plan of care relative to assistance with ambulation. Resident #9 was admitted to the facility in 7/2010 with a [DIAGNOSES REDACTED]. Review of the Routine Care Plan, dated 2/28/15, included the following interventions: - Assist of 1 with gait belt for transfers when in room. - Keep call light within reach; keep floors clean, dry and free of clutter; keep assistive devices within reach; keep personal articles used frequently within reach while in bed; ensure appropriate, clean eyewear; assess and provide adequate lighting; encourage wearing of non-skid shoes or slippers for all transfers/ambulation; - Encourage resident to ask for help to stand resident. - Resident to take rest periods when ambulating longer distances (going to lobby or auditorium). - Remind resident that walker needs to be kept in close proximity at all times. - Assist of 1 with Activities of Daily Living (ADL's), toileting and bed mobility. Supervision with transfers and ambulation. Recommendation from therapy to have chair placed in bathroom for grooming tasks resident declined - refuses. - Resident agrees to allow a Certified Nurse Aide (CNA) to stand right next to her in the bathroom for grooming ADL's with a gait belt on. - Resident in agreement to allow a CNA to supervise her with ambulation, no gait belt necessary per therapy. - Assist of 1 with all activities in room with a gait belt. Review of the nurse's note, dated 7/20/15 indicated that at 10:30 A.M. the resident was found on the floor lying on his/her right side in the bathroom. Further review of the nurse's note, indicated that the resident said that he/she was attempting to turn to exit the bathroom, lost his/her balance and fell . The resident did not sustain an injury. The fall was unwitnessed. Further investigation indicated that the skid strips in the resident's bathroom were loose. The resident was not assisted by staff in the bathroom, as care planned. Review of the Routine Care Plan indicated that on 7/20/15, the care plan was updated to include the following intervention: - Skid strips removed from the resident's bathroom. Review of the nurse's note, dated 10/6/15, indicated that at 11:45 A.M. the resident was walking in the hallway when the wheel of his/her walker caught on the wheel of another resident's wheelchair and Resident #9 sustained a fall. The resident was ambulating with the Social Worker at the time. Further investigation indicated that the resident sustained [REDACTED]. The resident was sent to the hospital and returned at 8:30 P.M. The resident sustained [REDACTED]. Review of the Routine Care Plan indicated that on 10/9/15, the care plan was updated to include the following interventions: - Resident assist of one with gait belt while ambulating. Review of the nurse's note, dated 1/27/16, indicated that the resident was ambulating with staff from the dining room table to the living room. The resident fell and sustained a fractured clavicle. Further investigation indicated that Resident #9 was walking with a CNA. Another resident called to the CNA, the CNA turned away from Resident #9, and Resident #9 continued to walk, unassisted. Resident #9 fell and sustained a fractured clavicle. The resident was not assisted with ambulation, as care planned. The surveyor observed Resident #9 on 4/14/16 9:25 A.M., Resident #9 was ambulating with a CNA with hand held assist, and a gait belt. The resident's glasses were on his/her face. The surveyor observed Resident #9 on 4/20/16 at 10:05 A.M., Resident #9 was sitting in the living room with a gait belt on. Resident #9 was sitting in a circle with a group of residents hitting and kicking a large balloon back and forth. During an interview with Unit Manager (UM) #1 on 4/20/16 at 2:45 P.M., she said that Resident #9 should have had staff ambulating with him/her, as per the care plan. Please refer to F323. 2. For Resident #19, the facility failed to follow the plan of care relative to the use of non skid footwear and a wheeled walker. Resident #19 was admitted to the facility in 9/2015, with a [DIAGNOSES REDACTED]. Review of the Routine Care Plan, dated 9/8/15, indicated the following interventions: - Well lit, clutter free environment. Review of the Routine Care Plan, indicated that on 9/12/15 the care plan was updated to include the following intervention: - Encourage use of wheeled walker when out of the room. Review of the Admission MDS (Minimum Data Set), dated 9/15/15, indicated a Brief Interview for Mental Status (BIMS) score of 8/15. A score of 8 indicates moderate cognitive impairment. The MDS also indicated that the resident required assist for transfers and ambulation. Review of the nurse's note, dated 9/20/15, indicated that at 6:30 P.M., the resident was found on the floor in his/her room. The resident said he/she was getting ready for bed, lost his/her balance, and fell . The resident did not sustain an injury. Further investigation indicated that the resident was not wearing shoes or socks and his/her slippers were nearby. The fall was unwitnessed. Review of the nurse's note, dated 12/10/15, indicated that at 9:30 A.M., the resident fell to the floor while in the shower room and hit his/her head near the occipital bone. Some soft tissue swelling appeared throughout the day. Further investigation indicated that the CNA was walking with the resident and stopped to get some gloves. The CNA heard a noise and the resident was on the floor. The fall was unwitnessed. Review of the Routine Care Plan, indicated that on 12/10/15 the care plan was updated to include the following intervention: - Use of wheeled walker to ambulate to and in the shower room. Review of the nurse's note, dated 12/19/15, indicated that at 12:50 P.M., the resident was found, lying on the floor on his/her left side, in his/her room. The resident's walker was behind the door, and was not used by the resident, as care planned. The resident did not sustain an injury. The resident's walker was not within reach. Further investigation indicated that the resident was found on the floor in his/her room. The fall was unwitnessed. Review of the nurse's note, dated 12/27/15, indicated that at 2:15 P.M. the resident was found on the floor in his/her room in a seated position at 2:15 P.M. The resident sustained [REDACTED]. Further investigation indicated that the door to the resident's room was closed, and the resident was wearing sandals. Review of the Routine Care Plan, indicated that on 12/30/15 the care plan was updated to include the following intervention: - Encourage resident to leave door to room open. Review of the nurse's note, dated 1/6/16, indicated that at 10:00 A.M., the resident was found on the floor. The resident stated he/she hit his/her head on the dresser. There was no apparent injury. Further investigation indicated that the resident was wearing sandals with a chunky heel. Review of the Routine Care Plan, indicated that on 1/7/16 the care plan was updated to include the following intervention: - Resident to have shoes that are flat, no chunky heels. Review of the Quarterly MDS (Minimum Data Set), dated 03/03/16, indicated a Brief Interview for Mental Status (BIMS) score of 6/15. A score of 6 indicates severe cognitive impairment. Review of the nurse's note, dated 3/5/16, indicated that at 6:40 P.M. the resident sustained [REDACTED]. There was no apparent injury. Further investigation indicated that the resident was wearing scuff-style slippers on his/her feet at the time of the fall. Review of the Routine Care Plan, indicated that on 3/5/16 the care plan was updated to include the following intervention: - Resident to wear secure, non-slip footwear at all times when out of bed. Review of the nurse's note, dated 3/15/16, indicated that at 9:25 A.M. the resident screamed, I fell . There was no apparent injury. Further investigation indicated that the resident was found on the floor and the wheeled walker was not in reach of the resident. Review of the nurse's note,dated 3/16/16, indicated that the resident sustained [REDACTED]. The resident did not sustain an injury. Review of the Routine Care Plan, indicated that on 3/21/16 the care plan was updated to include the following intervention: - Rearrange furniture for easier pathways for ambulating in room. Review of the nurse's note, dated 4/8/16, indicated that at 5:30 A.M., the CNA heard the resident yelling and found the resident on the floor in his/her bathroom. The resident did not sustain an injury. Further investigation indicated that the resident was found on the floor in the bathroom and had sandals with the chunky heel on his/her feet. The resident was not wearing non skid footwear, as care planned. There was no apparent injury. The fall was unwitnessed. Review of the Routine Care Plan, indicated that on 4/8/16 the care plan was updated to include the following intervention: - Reinforce and encourage resident to wear secure non slip footwear and to use walker when in his/her room. The surveyor observed Resident #19 on 4/20/16 at 10:45 A.M. in his/her room. The resident was sitting in a chair, with glasses on, a walker in front of him/her and had full shoes on his/her feet. During a discussion with UM #3 on 4/20/16 at 2:10 P.M., he said that the resident required the use of the walker and tended to look around while walking and lose his/her balance. During a discussion with UM #1 on 4/20/16 at 2:30 P.M., she said that Resident #19 sustained several falls that were unwitnessed UM #1. UM#1 also said that the resident's sandals had a chunky heel, not sercure non slip footwearas planned, and were not immediately removed from the resident's room, as planned. Please refer to F323. 3. For Resident #6, the facility failed to follow the resident's falls care plan relative to the following: wheelchair alarm was not utilized/did not activate, 15 minute checks were not consistently conducted, resident was not in supervised area when in her/his wheelchair, call bell was not within reach and the motion sensor alarm did not activate, as planned. Findings include: Resident #6 was admitted to the facility in 10/2015 with [DIAGNOSES REDACTED]. Review of the falls care plan of 10/19/15 indicated the following interventions: call bell within reach, assistance during transfers and bed and chair alarms. Review of the 10/28/15 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. During interview with Unit Manager (UM) #1 (on 4/13/16 at 11:00 A.M.), UM #1 said the chair alarm was not on/did not activate at the time of the fall, as planned. Review of the 11/14/15 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. Review of the Staff In Service Sheet of 11/14/15 indicated that the resident would be placed on 15 minute checks for a 48 hour period. During interview with UM #1 (on 4/13/16 at 11:00 A.M.), she said the facility had no evidence that the 15 minute checks were conducted on 11/14/15 between 9:00 P.M. and 12:00 A.M. and that the checks were not conducted on 11/15/16, as planned. Review of the 12/9/15 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. During interview with UM #1 (on 4/13/16 at 11:00 A.M.), she said the resident's wheelchair alarm did not sound, as planned. Review of the investigation indicated that the resident would be placed on close supervision/15 minute checks. Further investigation indicated that the 15 minute checks were not conducted between 9:00 A.M. and 10:30 A.M., as planned. The falls care plan was updated to include: wheelchair cushion provided. Review of the 1/27/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, sustaining bilateral knee abrasions and a hip contusion. The falls care plan was updated to include a motion sensor. Review of the 1/29/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. The falls care plan was updated to include: keep resident in supervised area when up in wheelchair. Review of the 4/6/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. During interview with UM #1 (on 4/13/16 at 11:00 A.M.), she said the resident was not in a supervised area when he/she was in her/his wheelchair, as planned. On 4/12/16 at 8:25 A.M., the surveyor and UM #1 observed the resident in bed and the call light was on the floor, not within the resident's reach, as planned. As the surveyor entered the room and passed by the motion sensor alarm, the alarm did not activate, as planned. On 4/12/16 at 3:50 P.M., the surveyor observed the resident, in her/his wheelchair, in the hallway, however, no staff were in the area to provide the resident with supervision, as planned. During interview with UM #1 (on 4/13/16 at 11:00 A.M.), it was discussed that the facility failed to follow the resident's falls care plan. On 4/14/16 between 3:25 P.M. and 3:40 P.M., the surveyor observed the resident, in her/his wheelchair, in the hallway, however, no staff were in the area to provide the resident with supervision, as planned. On 4/19/16 at 7:35 A.M., the surveyor observed the resident, in her/his wheelchair, in the hallway, however, no staff were in the area to provide the resident with supervision, as planned. Please refer to F 323. 4. For Resident #22, the facility failed to follow the resident's falls care plan relative to the following: motion alarm was not on, bed alarm did not activate, 15 minute checks were not completed, chair alarm was observed not on and the resident was observed not to be in a supervised area, as planned. Findings include: Resident #22 was admitted to the facility in 12/2015. Review of the falls care plan of 12/28/15 indicated the following interventions: call bell within reach, clutter free environment and bed in locked position. Review of the 12/30/15 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. The falls care plan was updated to include: bed alarm, motion sensor alarm in room and resident to be placed in a supervised area while awake. The falls care plan of 3/15/16 was updated to include a chair alarm. Review of the 3/26/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. During interview with UM #1 (on 4/20/16 at 8:35 A.M.), she said the resident's motion alarm was not on and the bed alarm wire was disconnected from the alarm box and did not activate, as planned. The falls care plan was updated to include 15 minute checks for 24 hours. During further interview with UM #1, she said the facility had no evidence that the 15 minute checks were completed after the fall, as planned. Review of the 3/27/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury During interview with UM #1(on 4/20/16 at 8:35 A.M.), she said that although the falls care plan was updated to include a motion sensor, the motion sensor had already been utilized and had been part of the resident's falls care plan, prior to this fall. On 4/19/16 at 1:25 P.M., the surveyor observed the resident, in the unit day room, sitting in a wheelchair and the chair alarm was not on, as planned. At 1:50 P.M., the surveyor observed the resident self propelling his/her wheelchair down the hall, no staff were in the area, therefore, the resident was not in a supervised area, as planned. During an interview with CNA (Certified Nursing Assistant) #2 on 4/19/16 at 4:00 P.M., she said .we need to constantly watch (him/her), (he/she) needs to be in a supervised area at all times On 4/20/16 at 7:55 A.M., the surveyor observed the resident, in her/his wheelchair, in the hallway, however, no staff were in the area to provide the resident with supervision, as planned. During interview with UM #1 (on 4/20/16 at 8:35 A.M.), it was discussed that the facility failed to follow the resident's falls care plan. Please refer to F 323. 5. For Resident #7, the facility failed to follow the resident's falls care plan relative to the following: motion sensor did not activate during surveyor observation and the resident's call bell was not within reach, as planned. The facility also failed to follow their gait belt policy (plan of care for residents), as planned. Findings include: Resident #7 was admitted to the facility in 9/2009 with [DIAGNOSES REDACTED]. Review of the falls care plan of 1/20/15 indicated the resident's call bell would be within reach. Review of the facility's current gait belt policy (plan of care) indicated that gait belts would be used primarily with residents who have deficits in balance/gait disturbances along with cognition deficits to facilitate safe transfers and ambulation. Review of the falls care plan of 4/14/15 remained essentially unchanged. Review of the falls care plan of 5/1/15 indicated a motion sensor alarm would be utilized while the resident was in bed. Review of the falls care plan of 7/7/15 remained essentially unchanged, the resident's call bell would be within reach. Review of the falls care plan of 9/23/15 indicated that the resident required assist with ambulation, with a gait belt. Review of the falls care plan of 12/29/15 remained essentially unchanged. Review of the 1/10/16 Interdisciplinary Note indicated the resident experienced a fall, with no injury. During interview with UM #1 (on 4/19/16 at 9:00 A.M.), UM #1 said that while the resident was standing with the CNA, the resident fell . She further said that the CNA was not utilizing a gait belt, as she should have been, at the time of the fall, as planned. Review of the falls care plan of 3/24/16 remained essentially unchanged. On 4/13/16 at 1:20 P.M., the surveyor observed the resident in bed and as the surveyor entered the room and passed by the motion sensor alarm, the alarm did not activate, as planned. On 4/14/16 at 3:50 P.M., the surveyor along with Nurse #1 observed the resident in bed and the call bell was on the floor and not within reach, as planned. On 4/19/16 at 7:25 A.M., the surveyor observed the resident's call bell hanging down from her/his bed and was not within reach, as planned. During interview with UM #1 (on 4/19/16 at 9:00 A.M.), it was discussed that the facility failed to follow the resident's falls care plan. 6. For Resident #2, the facility failed to follow the resident's plan of care for falls relative to the chair alarm, bed alarm, motion detector alarm, and keeping the call bell within the resident's reach. Resident #2 was admitted to the facility in 10/2014 with a personal history of falls with closed rib fractures. Other [DIAGNOSES REDACTED]. Review of the fall care plan dated 12/22/15 indicated the following: - Assist with transfers with 1 staff. - Wheelchair for mobility through facility. - Keep call light within reach. - Toileting needs and schedule every 2 - 3 hours and as needed/Uses toilet/bed pan and wears adult brief. - Motion sensor alarm in place to help ensure residents safety. - Observe for behaviors that place resident at risk for fall/injury. - Resident not to be left alone in bathroom. - Bed/Chair alarms. Review of a nursing note dated 1/4/16 indicated that the nurse found the resident on the floor in his/her room after hearing a loud noise at 7:45 P.M The resident stood from the wheelchair to shut the door in the room and fell . The chair alarm was not on the wheelchair, and the motion detector was not on as care planned. On 1/5/16 the motion sensor (detector) alarm was discontinued and an anti-rollback device was installed to the wheelchair. Review of a nursing note dated 2/27/16 indicated that at 7:30 P.M. the resident slid out of the bed and was found crawling out of his/her room by the nurse. The bed alarm was not on as care planned. A motion detector was added to the plan of care. Review of the nursing note of 3/5/16 indicated that the resident had 2 falls. The first fall occurred at 4:45 P.M. out of the resident's wheelchair, with no injury. The resident was put back to bed. The second fall occurred at 5:05 P.M. when the resident was found sitting on the right side of the bed. The bed and chair alarms were on as planned; however, the motion detector was not on which was put into place after the fall of 2/27/16. On 4/12/16 at 2:05 P.M., the surveyor observed Resident #2 in the bed in the room about to take a nap with his/her eyes closed. Nurse #2 had just left the room, and the resident's call bell was out of the resident's reach on the floor on the left side of the bed despite the care plan to keep the call bell within the resident's reach. The motion detector was also not on as care planned. At 3:05 P.M. the surveyor observed the call bell cord wrapped around the top left side rail of the bed. The motion detector was not on. During interview on 4/20/16 at 11:20 A.M., with CNA #4, she said that the resident was at risk for falls and had a bed, chair alarm and a motion detector alarm for safety. During interview on 4/20/16 at 11:30 A.M. with UM #1 she said that the plan of care was not followed regarding the chair alarm during the fall of 1/4/16, and also the bed alarm during the fall of 2/27/16. UM #1 also stated that the care plan was not always followed regarding the motion detector being on, and the resident's call bell being within reach. Please refer to F323

Based on observation, record review and interview, the Facility failed to ensure that 5 of 15 residents with falls (#2, #6 ,#9, #19 and #22). received adequate supervision and assistance devices, in a total sample of 30. Findings include: 1. For Resident #9, the facility failed ensure the resident received adequate supervision to prevent a fracture. Resident #9 was admitted to the facility in 7/2010 with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 5/29/15, indicated that the resident was cognitively intact, required extensive assistance with transfers and ambulation in room, supervision with ambulation in the corridor, and had no falls. Review of the Routine Care Plan, dated 2/28/15,with no updates until 3/6/15, included the following interventions: - Assist of 1 with gait belt for transfers when in room. Supervision with transfers at the nurse's station. Observe for and educated on proper technique and use of devices. - Bed alarm, Chair alarm (room only). - Keep call light within reach; keep floors clean, dry and free of clutter; keep assistive devices within reach; keep personal articles used frequently within reach while in bed; ensure appropriate, clean eyewear; assess and provide adequate lighting; encourage wearing of non-skid shoes or slippers for all transfers/ambulation; - Encourage resident to ask for help to stand resident. - Resident to take rest periods when ambulating longer distances (going to lobby or auditorium). - Remind resident that walker needs to be kept in close proximity at all times. - Assist of 1 with Activities of Daily Living (ADL's), toileting and bed mobility. Supervision with transfers and ambulation. Recommendation from therapy to have chair placed in bathroom for grooming tasks resident declined - refuses. - Resident agrees to allow a Certified Nurse Aide (CNA) to stand right next to her in the bathroom for grooming ADL's with a gait belt on. - Resident in agreement to allow a CNA to supervise her with ambulation, no gait belt necessary per therapy. - Assist of 1 with all activities in room with a gait belt. Review of the Routine Care Plan indicated that on 3/6/15, the care plan was updated to include the following intervention: - Supervision with ambulation in the hallway. Review of the nurse's note, dated 7/20/15 indicated that at 10:30 A.M. the resident was found on the floor lying on his/her right side in the bathroom. Further review of the nurse's note, indicated that the resident said that he/she was attempting to turn to exit the bathroom, lost his/her balance and fell . The resident did not sustain an injury. The fall was unwitnessed. Further investigation, indicated that the skid strips in the resident's bathroom were loose. The resident was not assisted by staff in the bathroom, as care planned. Review of the Routine Care Plan indicated that on 7/20/15, the care plan was updated to include the following intervention: - Skid strips removed from the resident's bathroom. Review of the Fall Risk Assessment, dated 8/9/15, indicated that the resident was not at high risk for falls. Review of the annual MDS Assessment, dated 8/19/15, indicated that the resident was moderately cognitively impaired, required extensive assistance with transfers and ambulation in room, supervision with ambulation in the corridor, and had 1 fall with injury (except major). Review of the nurse's note, dated 10/6/15, indicated that at 11:45 A.M. the resident was walking in the hallway when the wheel of his/her walker caught on the wheel of another resident's wheelchair. the resident was ambulating with the Social Worker at the time. Further investigation indicated that the resident sustained [REDACTED]. The resident returned at 8:30 P.M. The resident sustained [REDACTED]. Review of the Routine Care Plan indicated that on 10/7/15, the care plan was updated to include the following interventions: - Assist of 1 for transfers and ambulation with wheeled walker. Review of the Routine Care Plan indicated that on 10/9/15, the care plan was updated to include the following interventions: - Resident assist of one with gait belt while ambulating. Review of the quarterly MDS Assessment, dated 11/13/15 , indicated that the resident was cognitively intact, required extensive assistance with transfers and ambulation, and had 1 fall with major injury. Review of the nurse's note, dated 1/27/16, indicated that the resident was ambulating with staff from the dining room table to the living room. The resident fell and sustained a fractured clavicle. Further investigation indicated that Resident #9 was walking with a CNA, with a gait belt on. Another resident called to the CNA, the CNA turned away from Resident #9 and Resident #9 continued to walk, unassisted. Resident #9 fell and sustained a fractured clavicle. the resident was not assisted with ambulation as care planned. The Surveyor observed Resident #9 on 4/14/16 9:25 A.M. Resident #9 was ambulating with a CNA with hand held assist and a gait belt. The resident's glasses were on his/her face. The Surveyor observed Resident #9 on 4/20/16 at 10:05 A.M. Resident #9 was sitting in the living room with a gait belt on. Resident #9 was sitting in a circle with a group of residents hitting and kicking a large balloon back and forth. During an interview with Unit Manager (UM) #1 on 4/20/16 at 2:45 P.M., she said that the Resident #9 should have had staff ambulating with him/her. 2. For Resident #19, the facility failed to provide supervision to prevent falls and to follow the plan of care relative to the use of non-skid socks and a wheeled walker. The resident, who was cognitively impaired, kept the door to his/her room closed. The resident experienced 5 unwitnessed falls in his/her room and 2 unwitnessed falls in his/her bathroom. Resident #19, was admitted to the facility in 9/2015, with a [DIAGNOSES REDACTED]. Review of the Routine Care Plan, dated 9/12/15 indicated the following intervention: - Encourage use of wheeled walker when out of the room. Review of the admission MDS Assessment, dated 9/15/15 indicated that the resident was moderately cognitively impaired, required assist for transfers and ambulation and had no falls. Review of the nurse's note, dated 9/20/15, indicated that at 6:30 P.M., the resident was found on the floor in his/her room. The resident said he/she was getting ready for bed, lost his/her balance, and fell . The resident did not sustain an injury. Further investigation indicated that the resident was not wearing shoes or socks and his/her slippers were nearby. The fall was unwitnessed. Review of the quarterly MDS Assessment, dated 12/9/15, indicated that the resident was moderately cognitively impaired, required assist for ambulation and transfers and had 1 fall with no injury. Review of the nurse's note, dated 12/10/15, indicated that at 9:30 A.M.,. the resident fell to the floor while in the shower room and hit his/her head near the occipital bone. Some soft tissue swelling appeared throughout the day. Further investigation indicated that the CNA was walking with the resident and stopped to get some gloves. The CNA heard a noise and the resident was on the floor. The fall was unwitnessed. Review of the Routine Care Plan, indicated that on 12/10/15 the care plan was updated to include the following intervention: - Use of wheeled walker to ambulate to and in the shower room. Review of the nurse's note, dated 12/19/15, indicated that at 12:50 P.M., the resident was found, lying on the floor on his/her left side, in his/her room. The resident's walker was behind the door and was not used. The resident did not sustain an injury. The resident's walker was not within reach. Further investigation indicated that the resident was found on the floor in his/her room. The fall was unwitnessed. Review of the nurse's note, dated 12/27/15, indicated that at 2:15 P.M., the resident was found on the floor in his/her room in a seated position at 2:15 P.M. The resident sustained [REDACTED]. Further investigation indicated that the door to the resident's room was closed. Review of the Routine Care Plan, indicated that on 12/30/15 the care plan was updated to include the following intervention: - Encourage resident to leave door to room open. Review of the nurse's note, dated 1/6/16, indicated that at 10:00 A.M., the resident was found on the floor. The resident stated he/she hit his/her head on the dresser. There was no apparent injury. Further investigation indicated that the resident was wearing sandals with a chunky heel. Review of the Routine Care Plan, indicated that on 1/7/16 the care plan was updated to include the following intervention: - Resident to have shoes that are flat, no chunky heels. Review of the quarterly MDS Assessment, dated 3/3/16, indicated that the resident was severely cognitively impaired, required limited assistance with transfers and ambulation, had 2 or more falls with injury (except major) and 1 fall with no injury. Review of the nurse's note, dated 3/5/16, indicated that at 6:40 P.M., the resident sustained [REDACTED]. There was no apparent injury. Further investigation indicated that the resident was wearing scuff-style slippers on his/her feet at the time of the fall. Review of the Routine Care Plan, indicated that on 3/5/16 the care plan was updated to include the following intervention: - Resident to wear secure, non-slip footwear at all times when out of bed. Review of the nurse's note, dated 3/15/16, indicated that at 9:25 A.M., the resident screamed, I fell . There was no apparent injury. Further investigation indicated that the resident was found on the floor and the wheeled walker was not in reach of the resident. Review of the nurse's note, dated 3/16/16, indicated that the resident sustained [REDACTED]. The resident did not sustain an injury. Review of the nurse's note, dated 4/8/16, indicated that at 5:30 A.M., the CNA heard the resident yelling and found the resident on the floor in his/her bathroom. The resident did not sustain an injury. Further investigation indicated that the resident was found on the floor in the bathroom. There was no apparent injury. The fall was unwitnessed. Review of the Routine Care Plan, indicated that on 4/8/16 the care plan was updated to include the following intervention: - Reinforce and encourage resident to wear secure non slip footwear and to use walker when in his/her room. The surveyor observed Resident #19 on 4/20/16 at 10:45 A.M. in his/her room. The resident was sitting in a chair, with glasses on, walker in front of him/her and had full shoes on his/her feet. During a discussion with UM #3 on 4/20/16 at 2:10 P.M., he said that the resident required the use of the walker and tended to look around while walking and lose his/her balance. During a discussion with UM #1 on 4/20/16 at 2:30 P.M. She said that Resident #19 sustained several falls that were unwitnessed and the resident usually closed his/her door. UM #1 also said that the resident's sandals had a chunky heel and were not immediately removed from the resident's room. 3. For Resident #6, the facility failed to provide effective interventions and adequate supervision to prevent continued falls. the facility failed to follow the resident's falls care plan relative to the following: wheelchair alarm not utilized/did not activate, 15 minute checks were not consistently conducted, resident not in supervised area when in his/her wheelchair, call bell was not within reach and the motion sensor alarm did not activate, as planned. Findings include: Resident #6, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment of 10/8/15 identified the resident as utilizing eyeglasses; exhibiting moderate cognitive impairment; requiring assistance during transfers and ambulation and being unsteady when moving from a seated to a standing position, when walking and during surface to surface transfers (between bed and chair or wheelchair). Review of the falls care plan of 10/19/15 identified the resident as exhibiting decreased safety awareness related to cognitive deficits. The falls care plan indicated the following interventions: call bell within reach, assistance during transfers and bed and chair alarms. Review of the 10/28/15 Interdisciplinary Note indicated the resident experienced an unwitnessed fall (in room), with no injury. During interview with Unit Manager (UM) #1 (on 4/13/16 at 11:00 A.M.), UM #1 said the chair alarm was not on/did not activate, as planned. Review of the 11/14/15 Interdisciplinary Note indicated the resident experienced an unwitnessed fall (in room), with no injury. Review of the Staff In Service Sheet of 11/14/15 indicated that the resident would be placed on 15 minute checks for a 48 hour period. During interview with UM #1 (on 4/13/16 at 11:00 A.M.), she said the facility had no evidence that the 15 minute checks were conducted on 11/14/15 between 9:00 P.M. and 12:00 A.M. and the checks were also not conducted on 11/15/16, as planned. Review of the 12/9/15 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. During interview with UM #1 (on 4/13/16 at 11:00 A.M.), she said the resident's wheelchair alarm did not sound, as planned. Review of the investigation indicated that the resident would be placed on close supervision/15 minute checks. Further investigation indicated that the 15 minute checks were not conducted between 9:00 A.M. and 10:30 A.M., as planned. The falls care plan was updated to include: wheelchair cushion provided. Review of the quarterly MDS Assessment of 1/14/16 remained essentially unchanged except to indicate that the resident now exhibited severe cognitive impairment. Review of the 1/16/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The falls care plan was updated to include: place phone within resident's reach. Review of the 1/27/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall (in room), sustaining bilateral knee abrasions and a hip contusion. The falls care plan was updated to include: motion sensor. Review of the 1/29/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall (in room), with no injury. During interview with UM #1 (on 4/13/16 at 11:00 A.M.), a discussion was held regarding the investigation details being contradictory (i.e.: whether the motion sensor or chair alarm were either on or off), therefore, the facility was unable to determine the specific facts surrounding the falls. The falls care plan was updated to include: keep resident in supervised area when up in wheelchair. Review of the 4/6/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall (in room), with no injury. During interview with UM #1 (on 4/13/16 at 11:00 A.M.), she said that at the time of the fall, the resident was not in a supervised area when she was in the wheelchair, as planned. The care plan was updated to include: offer toileting between 2:00 P.M. and 3:00 P.M On 4/12/16 at 8:25 A.M., the surveyor and UM #1 observed the resident in bed and the call light was on the floor, not within the resident's reach, as planned. As the surveyor entered the room and passed by the motion sensor alarm, the alarm did not activate, as planned. During an interview with CNA (Certified Nursing Assistant) #1 on 4/12/16 at 9:45 A.M., she said the resident had an unsteady gait, required 2 assists while transferring and ambulating and needed to be supervised at all times. On 4/12/16 at 3:50 P.M., the surveyor observed the resident, in her/his wheelchair, in the hallway, however, no staff were in the area to provide the resident with supervision, as planned. During interview with UM #1 on 4/13/16 at 11:00 A.M., it was discussed that the facility failed to provide effective interventions and adequate supervision to prevent continued falls. On 4/14/16 between 3:25 P.M. and 3:40 P.M., the surveyor observed the resident, in her/his wheelchair, in the hallway, however, no staff were in the area to provide the resident with supervision, as planned. On 4/19/16 at 7:35 A.M., the surveyor observed the resident, in her/his wheelchair, in the hallway, however, no staff were in the area to provide the resident with supervision, as planned. 4. For Resident #22, the facility failed to provide effective interventions and adequate supervision to prevent falls. The Facility failed to follow the resident's falls care plan relative to the following: motion alarm was not on, bed alarm did not activate, 15 minute checks were not completed, chair alarm was observed not on and the resident was observed not to be in a supervised area, as planned. Findings include: Resident #22, with [DIAGNOSES REDACTED]. Review of the falls care plan of 12/28/15 identified the resident as exhibiting poor judgement and poor safety awareness related to cognitive deficits. The falls care plan indicated the following interventions: call bell within reach, clutter free environment and bed in locked position. Review of the 12/30/15 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. The falls care plan was updated to include: TABS alarm in wheelchair and in bed, bed alarm, motion sensor alarm in room and resident to be placed in a supervised area while awake. Review of the Admission Minimum Data Set (MDS) Assessment of 1/4/16 identified the resident as utilizing eyeglasses; exhibiting severe cognitive impairment, exhibiting inattention and disorganized thinking; requiring assistance during transfers, being unsteady when moving from a seated to a standing position, when walking and during surface to surface transfers (between bed and chair or wheelchair) and a history of falls. Review of the 2/16/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. The falls care plan was updated to include: medication evaluation. Review of the 3/15/16 Interdisciplinary Note indicated the resident experienced a fall, with no injury. The falls care plan was updated to include a chair alarm. Review of the quarterly MDS Assessment of 3/23/16 remained essentially unchanged. Review of the 3/26/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury. During interview with UM #1 (on 4/20/16 at 8:35 A.M.), she said the resident's motion alarm was not on and the bed alarm wire was disconnected from the alarm box and did not activate, as planned. The falls care plan was updated to include 15 minute checks for 24 hours. During further interview with UM #1, she said the facility had no evidence that the 15 minute checks were completed after the fall, as planned. Review of the 3/27/16 Interdisciplinary Note indicated the resident experienced an unwitnessed fall, with no injury During interview with UM #1(on 4/20/16 at 8:35 A.M.), she said that although the falls care plan was updated to include a motion sensor, the motion sensor had already been utilized and had been part of the resident's falls care plan, prior to this fall. On 4/19/16 at 1:25 P.M., the surveyor observed the resident, in the unit day room, sitting in a wheelchair and the chair alarm was not on, as planned. At 1:50 P.M., the surveyor observed the resident self propelling his/her wheelchair down the hall, no staff were in the area, therefore, the resident was not in a supervised area, as planned. During an interview with CNA (Certified Nursing Assistant) #2 on 4/19/16 at 4:00 P.M., she said the resident is unsteady on his/her feet, is forgetful and we need to constantly watch (him/her), (he/she) needs to be in a supervised area at all times. On 4/20/16 at 7:55 A.M., the surveyor observed the resident, in her/his wheelchair, in the hallway, however, no staff were in the area to provide the resident with supervision, as planned. During interview with UM #1 on 4/20/16 at 8:35 A.M., it was discussed that the facility failed to provide effective interventions and adequate supervision to prevent continued falls. 5. For Resident #2, who had a history of [REDACTED]. The facility also failed to follow the resident's plan of care relative to chair alarms, bed alarms, the motion detector alarm, and keeping the call bell within the resident's reach. Resident #2 was admitted to the facility in 10/2014 with a personal history of falls with closed rib fractures. Other [DIAGNOSES REDACTED]. Review of a 12/7/15 Quarterly MDS Assessment identified the resident as scoring 11 of 15 on the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition; mood indicators of feeling down and depressed, tired, little energy, feeling bad about self, trouble concentrating, and restlessness; having verbal behavioral symptoms towards others; required extensive assistance of one for all care with the exception of requiring two assists for bed mobility and toilet use; was frequently incontinent of urine; had a [DIAGNOSES REDACTED]. The fall care plan (dated 12/22/15) indicated the following: Resident has risk factors for falls/injury: limited mobility, impaired balance, (History right hip fracture increased pain), traumatic closed displaced fractures of multiple ribs, History of multiple falls . - Assist with transfers with 1 staff. - Wheelchair for mobility through facility. - Keep call light within reach. - Toileting needs and schedule every 2 - 3 hours and as needed/Uses toilet/bed pan and wears adult brief. - Motion sensor alarm in place to help ensure residents safety. - Observe for behaviors that place resident at risk for fall/injury. - Resident not to be left alone in bathroom. - Bed/Chair alarms. Review of a nursing note, dated 1/4/16, indicated that the nurse was at the medication cart at 7:45 P.M., heard a loud noise, and found Resident #2 on the floor in his/her room. The resident told the nurse that he/she stood up from the chair to try to shut the door. Review of the investigation indicated that there was no chair alarm, in the wheelchair (despite the 12/22/15 care plan for the chair alarm). The motion detector was also not in use as indicated in the (12/22/15) care plan. During interview on 4/20/16 with Unit Manager #1 (UM #1) at 11:30 A.M., she said that the motion detector and the chair alarm were not on, as planned. Further review of the investigation indicated the new intervention put into place after the fall was a motion detector, however, it was discontinued on 1/5/16 when an anti-rollback device was added to the resident's wheelchair. Review of a nursing note dated 2/27/16 indicated that the nurse was at her medication cart at 7:30 P.M. and witnessed the resident crawling out of his/her room on his/her hands and knees. The nurse immediately assessed the resident and found no injuries. A half hour prior to this fall the resident had been observed trying to get out of the bed by his/her self. The resident was told that she needed to ring the call bell for assistance when getting out of bed. The call bell was placed in her hand, and the wheelchair was removed from the room. Review of the investigation indicated the resident slid out of the bed onto the floor and crawled out of the room. The resident did not have the bed alarm on, as care planned. A new intervention for a motion detector was added to the care plan. During interview on 4/20/16 at 11:30 AM. with U.M. #1 she said the bed alarm was not on as planned. Review of a Significant Change in Status Assessment completed for an overall decline in condition, and the resident being placed on Hospice Services, dated 3/4/16, indicated the resident's BIMS score was 10, lower and indicative of moderately impaired cognition; continued with the same mood indicators and behavioral symptoms directed towards others; did not ambulate; was totally dependent for locomotion off the unit in the wheelchair; was frequently incontinent of bowel; had one fall with no injury; and had weight loss. Review of the nursing note of 3/5/16 indicated that the resident had 2 falls. The first fall occurred at 4:45 P.M The resident got up from the wheelchair in his/her room and fell to the floor in between his/her bed and the roommate's bed. After the fall, the resident was assessed and no injuries were found. The resident requested to go to bed. The resident was found sitting on the floor on the right side of the bed at 5:05 P.M Review of the Investigation indicated that for both falls the chair alarm and bed alarm were in place and sounded, however, the motion detector was not on, as planned. This intervention was put into place after the fall of 2/27/16. On 4/11/16 at 10:20 A.M. the surveyor was touring the Unit with UM #1. Resident #2 was described to the surveyor as being at high risk for falling. The resident was lying in the bed, with the over the bed table, across the bed, over her lap and the head of the bed slightly elevated. The bed was in an elevated position from the floor. The surveyor asked UM #1 why the bed was in an elevated position and UM #1 stated that it shouldn't be, and immediately took the bed control and placed the bed in the lowest position. On 4/11/16 at 3:50 P.M., the surveyor observed the resident in the wheelchair with a pad alarm sitting beside the nursing station. On 4/12/16, between 1:55 and 2:05 P.M. the surveyor observed a treatment to the resident's Left Buttock with Nurse #2. When the treatment was completed, Resident #2 indicated to the nurse that he/she wanted to stay in the bed and take a nap. Nurse #2 left the room, the resident closed his/her eyes, and the surveyor observed the resident's call bell on the floor, on the left side of the bed, out of the resident's reach. The motion detector was also not on, as care planned. At 3:05 P.M. the surveyor observed the call bell cord wrapped around the top left side rail of the bed. The motion detector was not on. During interview on 4/20/16 at 11:20 A.M., with CNA #4, she said that the resident was at risk for falls, and had a bed and chair alarm, and a motion detector alarm for safety. During interview on 4/20/16 at 11:30 A.M. with UM #1 she said that the plan of care was not followed regarding the bed and chair alarms, the motion detector, and the call light not being within the resident's reach. During interview with CNA #3 on 4/20/16 at 3:50 P.M., she said that the resident was at risk for falling and that the staff had to make sure that the resident was not left alone in the room. She said that the resident Sometimes (resident) wheels (self) and puts (self) in bed. Sometimes (resident) wheels (self) and puts (self) on the toilet.

Based on record review and interview, for one of four sampled Residents (Resident #1), the Facility failed to provide adequate supervision and assistance to Resident #1, who was assessed and care planned to require assistance with meals, and as a result Resident #1 spilled a cup of hot soup on his/her lap and sustained burns. Findings include: The Facility admitted Resident #1 in November, 2014 with [DIAGNOSES REDACTED]. An Individual Care Card and an ADL (Activities of Daily Living) Care Plan, both dated 11/17/14, indicated that Resident #1 required assistance with meals. A quarterly Minimum Data Set (MDS) assessment, dated 2/26/15, indicated Resident #1 had clear speech, but only sometimes understood others and was only sometimes understood by others. The MDS indicated that Resident #1 scored 0 out of 15 possible points on a Brief Interview for Mental Status, which represented severely impaired cognition. The MDS indicated that Resident #1 required extensive staff assistance with eating meals. The March, 2015 physician's orders [REDACTED].#1 received a regular consistency, no added salt diet. A nurse's note, dated 3/18/15, indicated that during dinner on the 3:00 P.M. to 11:00 P.M. shift Resident #1 dropped a cup of hot soup onto his/her lap, which resulted in burns to Resident #1's thighs. The nurse's note indicated that Resident #1 had an 11 inch x 5 inch burn to the top left thigh, a 12 inch x 4 inch burn to the left outer hip and a 6 inch x 4 inch burn to the right top thigh. The nurse's note indicated that the Physician and Nurse Practitioner were notified and assessed Resident #1. The Facility's Department of Food Service Quality Assessment and Temperature Log, dated 3/18/15, indicated that the soup served during the supper meal was cream of broccoli and the temperature of the soup was 200.6 degrees Fahrenheit when the soup left the kitchen. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 3:00 P.M. on 4/29/15. CNA #1 said she was a new CNA at the time of the incident, so she did not know the residents very well and was provided with a list of all residents that should be served soup. CNA #1 said soup was served to the residents prior to the rest of the meal. CNA #1 said she served Resident #1's soup and placed the soup on the table away from Resident #1, although Resident #1 was able to reach the soup if Resident #1 stretched. CNA #1 said she could not recall if any other staff were in the activity/dining room. CNA #1 said about 8 to 10 minutes after she served the soup to Resident #1, she entered the activity/dining room and a visitor alerted her that something was wrong with Resident #1. CNA #1 said she went over to Resident #1 and Resident #1 was in pain and Resident #1's lap was wet. CNA #1 said she pulled Resident #1's pants away from Resident #1's legs to try and stop the hot soup from touching Resident #1's skin. The Surveyor interviewed Nurse #1 at 3:18 P.M. on 4/29/15. Nurse #1 said she was told that a resident spilled their soup and she responded to the activity/dining room. Nurse #1 said Resident #1's lap was wet and Resident #1 was distressed. Nurse #1 said she notified Resident #1's nurse (Nurse #2) and Resident #1 was moved to his/her room to be assessed. Nurse #1 said that after Resident #1 was attended to, she went and checked the temperature on the soup left in the pot and the soup temperature was 185 degrees Fahrenheit. The Surveyor interviewed Nurse #2 at 3:35 P.M. on 4/29/15. Nurse #2 said he responded to the activity/dining room and they brought Resident #1 to his/her room. Nurse #2 said Resident #1's lap was wet and Resident #1 was visibly upset and crying. Nurse #2 said Resident #1's legs were red and there was one small area with loose skin. Nurse #2 said the Physician and Nurse Practitioner were notified and both were in the Facility. A progress note, completed by the Physician on 3/18/15, indicated Resident #1 was crying and in obvious discomfort. The progress note indicated Resident #1 had superficial [DIAGNOSES REDACTED] (redness) on the bilateral superior anterior thighs and along the lateral aspect of the left thigh covering to mid thigh. The progress note indicated the left lateral thigh had a superficial partial thickness excoriation of the epidermis approximately 4 centimeters in diameter. Resident #1 was unable to participate in an interview due to severely impaired cognition.

Based on observation, staff interview, and record review, the facility failed to implement interventions on the plan of care and/or follow physician's orders [REDACTED].#3, #7, #10, #13, #19 and #20). Findings include: 1. For Resident #3, the facility failed follow the plan of care for falls relative to alarm use. Resident #3 was admitted to the facility in 6/2011 with [DIAGNOSES REDACTED]. Review of the resident care plan for fall/injuries, dated 8/22/13, included the following intervention; -Bed and Chair alarm on at all times (11/4/14). Review of the resident's Individual Care Card, dated 10/28/13, included the following: -Bed and chair alarm. Review of the Annual MDS assessment dated [DATE], indicated the resident had severe cognitive impairment, required limited assistance with transfers and had one fall. Review of the facility's Fall Investigation, dated 9/5/14, indicated the resident had an unwitnessed fall in the bedroom at 7:45 A.M. The report indicated the resident may have tripped over bed linen while ambulating in the bedroom. The resident sustained [REDACTED]. New interventions included bed and chair alarms. Review of the Significant Change in Status MDS Assessment, dated 9/15/14, indicated the resident had severe cognitive impairment, was an extensive assist for bed mobility, transfers, ambulation, and had one fall with a major injury. Review of the facility's Fall Investigation, dated 11/4/14, indicated the resident had a witnessed fall in the hallway at 11:10 P.M. The report indicated the resident attempted to get out of the Geri-chair and fell over the side before a staff member could reach him/her. The resident sustained [REDACTED]. During an interview on 1/13/15 at 4:20 A.M., MDS Nurse #1 said the bed and chair alarms were indicated on the resident's daily Individual Care Card (used by Certified Nurses Aides). During an interview on 1/14/15 at 9:45 P.M., the DON said the alarms should have been in place when the resident fell on [DATE]. Refer to tag F323. 2. For Resident #13, the facility failed to follow the plan of care for pressure ulcer prevention relative to the use of a pressure relieving cushion. Resident #13 was admitted to the facility in 6/2013 with [DIAGNOSES REDACTED]. Review of the Rehabilitation Screen, dated 5/16/14, indicated the resident received a Roho Cushion (a specialized cushion to aid in the prevention of pressure ulcers). Review of the Annual Minimum Data Set (MDS) assessment, dated 6/4/14, indicated the resident had a stage II pressure ulcer. Review of the Care Area Assessment for Pressure Ulcers, dated 6/11/14, indicated the resident had a resolved pressure ulcer to his/her buttock but the tissue remained fragile. A Roho cushion was used in the wheelchair as an intervention. Review of the resident's care plan for Risk of Skin Breakdown indicated an intervention, dated 6/11/14, for a pressure relieving cushion in chair, monitor cushion for integrity and inflation. Review of the 12/2014 physician's orders [REDACTED]. Review of the 12/2014 Pressure Ulcer Treatment Sheet indicated the resident had acquired a stage II pressure ulcer, measuring 0.8 centimeters (cm.) X 0.4 cm. on 12/5/14. The results of the Rehabilitation Screen requested on 12/5/14 due to a new stage II pressure area, not dated until 12/19/14, indicated the resident was given a Roho cushion in May 2014. The resident's wheelchair was changed but the Roho cushion didn't transfer because the chair was a larger size. During an interview on 1/9/15 at 12:00 P.M., Physical Therapist #1 said the resident was, at some point, placed in a different wheelchair without the input of the rehabilitation staff. The Roho cushion was not used with the different wheelchair and she could not say why. She said the Roho cushion was put back into use on 12/9/14, when the rehabilitation staff became aware that the resident was no longer using the Roho cushion. At that time, the resident already had a new stage II pressure area. She said failure to use the Roho cushion could have contributed to the new stage II pressure area. During interview on 1/9/15 at 12:15 P.M., Certified Nurse's Assistant (CNA) #9 said she knew the resident and worked on the resident's unit. She said the resident was put into a larger chair, she thought, sometime in the middle of last November but couldn't say exactly when. She said the Roho cushion was not used with that chair. Please refer to F314. 3. For Resident #19, the facility failed to follow the Occupational Therapy recommended care plan for hand splints and hand rolls. Resident #19 was admitted to the facility in 3/2006 with [DIAGNOSES REDACTED]. Review of the 11/2014 physician's orders [REDACTED]. Apply after evening care and remove before morning care. There was no order for towel hand rolls. Review of the Annual MDS Assessment, dated 11/25/14, indicated the resident was cognitively impaired, had impaired ROM (Range of Motion) to the bilateral upper extremities and was totally dependent for all Activities of Daily Living (ADLs). Review of a Rehabilitation Services Inservice Attendance Sheet, dated 12/19/14 and signed by 5 members of the nursing staff, indicated the following: - Resident is to wear bilateral hand splints after P.M. care until after breakfast. - Resident is to wear towel rolls in hands after breakfast until P.M. care. Review of the care plan for ADL Management indicated an intervention, dated 1/12/15, for bilateral hand rolls in A.M. and off at bedtime and bilateral hand splints on at bedtime and off in the A.M. During an observation on 1/13/15 at 2:30 P.M., the resident was observed in bed covered with a blanket. The resident had bilateral hand contractures. No hand rolls were observed. On 1/13/15 at 4:00 P.M., the resident was observed by the surveyor and Nurse #10 in bed with no hand rolls. Nurse #10 said the resident should have hand rolls in place. On 1/14/15 at 8:15 A.M., the surveyor observed the resident in bed, accompanied by Occupational Therapist #1. The resident had no hand rolls or hand splints in place. The Occupational Therapist said the resident should have some type of device in his/her hands 24 hours a day. During an interview on 1/14/15 at 9:00 A.M., Unit Manager #1 said the resident should have bilateral hand splints in place because the resident had not received A.M. care yet. Please refer to 318. 4. For Resident #10, the facility failed to follow the plan of care for falls and Foley catheter care. Resident #10 was admitted to the facility in 12/2013 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 12/9/14, indicated the resident had moderately impaired cognition, had a Foley catheter and had not experienced a fall since the last MDS Assessment. Review of the plan of care for falls, dated 12/12/14, included; - Bed alarm on bed. Review of the plan of care for continence, dated 12/12/14, indicated; - The resident had a Foley catheter, and - Secure catheter to leg to avoid tension. On 1/7/15 at 3:05 P.M., the surveyor observed the resident lying in bed. The Foley catheter was attached to bedside drainage. The bed pressure alarm box was attached to the bed with the rear of the alarm box showing. The back of the alarm box was missing. There was no battery in the alarm box therefore, the alarm was not functioning. On 1/8/15 at 9:20 A.M. the surveyor, accompanied by the Assistant Director of Nurses (ADON), entered Resident #10's bedroom. The resident was observed in bed. The bed pressure alarm was still attached to the side of the bed without a battery. The surveyor showed the ADON the non functioning alarm with the missing battery. She said that was unacceptable. On 1/8/15 at 1:00 P.M. the surveyor, accompanied by Nurse #12, entered Resident #10's bedroom. Nurse #12 lifted up the resident's johnny to observe the Foley catheter. The Foley catheter was not secured to the resident's leg as planned. Nurse #12 said the catheter should have been attached to the resident's leg so it would not pull and cause tension. 5. For Resident #20, the facility failed to follow a physician's orders [REDACTED]. Resident #20 was admitted to the facility in 10/2014 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].) two times a day. Review of the Medication Administration Record [REDACTED]. two times a day, but to administer the medication at 12:00 P.M. Therefore, the resident received the [MEDICATION NAME] 100 mg. one time a day, not the prescribed two times a day. On 1/13/15 at 3:40 P.M. during an interview, Nurse #12 said that it was an error and the resident should have been receiving [MEDICATION NAME] two times a day. 6. For Resident #7, the facility failed to follow a physician's orders [REDACTED]. Resident #7 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the 1/2015 physician's orders [REDACTED]." Review of the Quarterly MDS Assessment of 11/18/14 indicated the resident had moderate cognitive impairment, and required extensive assistance with Activities of Daily Living. Observation of the resident on 1/7/14 at 3:40 P.M. indicated the resident asleep in bed with no evidence that the resident's heels were off loaded. During interview with the resident on 1/7/15 at 4:00 P.M., who was described by staff as interviewable on the initial tour, Resident #7 proceeded to pull off his/her non-skid socks on both feet to show the surveyor long toenails on both feet. A deflated pillow was observed stuck between the lower end of the resident's mattress and the footboard. The resident's heels were not on the pillow, but on the bed mattress. Observation of the resident asleep in bed on 1/8/15 at 7:50 A.M. indicated the resident did not have his/her heels off loaded as ordered. On 1/8/15 at 8:00 A.M. the surveyor observed with the resident's assigned daytime Certified Nursing Assistant (CNA) #8 the resident's heels were not off loaded when in bed, as planned. A pillow lay on the resident's straight back chair. During interview on 1/8/15 at 8:10 A.M., Nurse #4 said that the resident's heels were not off loaded and she would put a pillow under the resident's heels. Nurse #4 said that clearly physician's orders [REDACTED]. 7. For Resident #9, the facility failed to follow the resident's falls care plan regarding functioning alarms and the use of slipper socks. Resident #9 was admitted to the facility in 2/2011 with a [DIAGNOSES REDACTED]. Review of the falls care plan, in effect 5/5/14, included the following interventions: - Non skid shoes or slippers for all transfers and ambulation, - Bring to bathroom upon request. Check and change at night every 2-3 hours, - Motion sensor when in bed, - Floor mat on bathroom side of bed, and - Slipper socks on at all times when in bed. - Bed alarm. Review of the nurse's note, dated 5/5/14, indicated that, at 1:10 A.M., a loud thump was heard. The resident was found on the floor on the left side and the bed was soaked with urine. The resident's alarm did not sound. The resident sustained [REDACTED].) by 1.0 cm. skin tear to the left posterior forearm. The nurse's note further indicated that the staff were re-educated on alarm checks at the start of the shift and to report any devices not working to the nurse. Staff were also re-educated on toileting the resident so he/she stayed dry. Review of the facility's internal investigation, dated, 5/5/14, indicated that the resident was wearing socks, not slipper socks. Review of the nurse's note, dated 1/9/15, indicated that, at 10:30 A.M., the resident was found on the floor in the room. The resident said that he/she was going to the bathroom. The resident sustained [REDACTED]. Review of the facility's internal investigation, dated 1/9/15, indicated that at 10:30 A.M. the resident attempted to independently ambulate to the bathroom and was wearing socks (not slipper socks) on his/her feet. The surveyor observed Resident #9 on 1/13/15 at 7:50 A.M. Resident #9 was sitting in a recliner in front of the nurse's station in an upright position with his/her knees bent, leaning to the left side. During an interview on 1/13/15 at 4:10 P.M., the Quality Assurance Nurse said that the alarm should have consistently sounded, and the resident should have worn slipper socks.

Based on observation, record review and interview the facility failed to ensure that 2 of 12 applicable sampled residents (#3 and #9) with falls received adequate supervision and assistive devices to prevent accidents in a total sample of 30 residents. Additionally, the resident environment was not free of accident hazards related to 3 of 5 shower rooms and 1 medication cart. Findings include: 1. For Resident #3, the facility failed to maintain the use of alarms, as planned, to prevent falls with injuries. On 9/5/14 Resident #3 fell and sustained a fracture to his/her (L) acetabular (hip joint) and inferior pubic rami (pelvis). On 11/1/14 Resident #3 fell and sustained a fracture to his/her (R) humerus (bone running from shoulder to elbow). Resident #3 was admitted to the facility in 6/2011 with [DIAGNOSES REDACTED]. Review of the facility's Fall Protocol Policy, dated 6/1996 (reviewed 2/2014), indicated the following: -A resident who triggers a score above 10 will be considered a "High Risk" for falls. A care plan will be developed for this resident with appropriate interventions for prevention. Review of the resident care plan for fall/injuries, originally dated 8/22/13 to present, indicated the following interventions; -Keep floors clean, dry and free of clutter, -Insure appropriate, clean eyewear is on, -Assess and provide adequate lighting, -Encourage wearing of non-skid shoes or slippers for all transfers/ambulation, and -Two 1/4 siderails in bed. Review of the Annual Minimum Data Set (MDS) Assessment, dated 4/17/14, indicated the resident had severe cognitive impairment, required limited assistance with transfers, bed mobility, required extensive assistance with bathing and hygiene and had one fall with minor injury. Review of the Fall Risk Assessment, dated 5/1/14, indicated the resident was at high risk for falls with a score of 16. Review of an Interdisciplinary Note (ID), dated 9/5/14, indicated the resident was found on the floor in his/her bedroom and complained of pain. Review of the facility's Fall Investigation, dated 9/5/14, indicated the resident had an unwitnessed fall in the bedroom at 7:45 A.M. The report indicated the resident may have tripped over bed linen when ambulating in the bedroom. The resident was sent to the hospital and returned to the facility the same day with [DIAGNOSES REDACTED]. The Investigation recommended interventions that included bed and chair alarms. Review of the resident's Certified Nurses' Aide (CNA) Daily Care List, in effect 9/2014, included the following: -Sit in recliner for comfort, transfer with 1-2 assist, -Ambulate with gait belt and one assist, -Bed and chair alarm, -Reposition every 2 hours with 2 assist, -Sling to right arm at all times, and -Elevate right arm on pillow. Review of the Fall Risk Assessment, dated 9/5/14, indicated a score of 9 (risk assessment completed inaccurately should have been a score of 11). Review of the Significant Change in Status MDS Assessment, dated 9/15/14, indicated the resident had a severe cognitive deficit, was an extensive assist for bed mobility, transfers, ambulation, was dependent for hygiene and bathing and had one fall with major injury. Review of the Fall Risk Assessment, dated 9/28/14, indicated the resident was at high risk for falls with a score of 14. Review of an ID Note, dated 10/16/14, indicated the resident continued to get out of bed alone, all alarms were in place and sounding. Review of an ID Note, dated 11/4/14, indicated the resident had a fall from a Geri-chair while attempting to get up alone. Review of the facility's Fall Investigation, dated 11/4/14, indicated the resident had a witnessed fall in the hallway at 11:10 P.M. The report indicated the resident attempted to get out of the Geri-chair and fell over the side before a staff member could reach him/her. The resident was guarding his/her right arm. The resident was sent to the hospital and returned to the facility early the next morning with a [DIAGNOSES REDACTED]. Further review of the investigation indicated the the chair alarm was not in place, as planned. The care plan was updated 12/10/14 to include the following interventions: -Provide assist with transfers and ambulation, -Assist with position changes every two hours to maintain comfort, and -Observe for restless behavior, if present rule out physical need. On 1/10/15 at 12:15 P.M., the resident was observed sitting in the dining room area, in a chair with an alarm attached to it. The resident had his/her right arm in a sling and was using the left hand to eat. During an interview on 1/13/15 at 1:00 A.M., the Director of Nurses (DON) said it appeared that someone had discontinued the bed and chair alarms on 10/21/14 per the fall report, however she was unsure who had decided on that. She said the therapy notes did not indicate that they had recommended to discontinue the resident's alarms. During an interview on 1/13/15 at 4:20 P.M., MDS Nurse #1 said the bed and chair alarms were not discontinued off the care plan on 10/21/14 as the fall report of 11/4/14 indicated, nor were they discontinued from the Certified Nurses' Aide (CNA) Daily Care List. She said the bed and chair alarms remained part of the resident's care. During an interview on 1/14/15 at 9:45 P.M., the DON said she could not determine why the fall report of 11/4/14 indicated the alarms were not in use and had been discontinued. She said the alarms should have been in place at the time of the fall on 11/4/14. 2. For Resident #9 the facility failed to adequately supervise the resident. The resident sustained [REDACTED]. Resident #9 was admitted to the facility in 2/2011 with a [DIAGNOSES REDACTED]. Review of the falls care plan, in effect on 5/5/14, included the following interventions: - 1 to 2 assist with wheeled walker and gait belt for transfers. - Non skid shoes or slippers for all transfers and ambulation. - Bring to bathroom upon request. Check and change at night every 2-3 hours. - Motion sensor when in bed. - Floor mat on bathroom side of bed. - Slipper socks on at all times when in bed. - Bed alarm. - Chair alarm. Review of the nurse's note, dated 5/5/14, indicated that at 1:10 A.M. a loud thump was heard. The resident was found on the floor on the left side and the bed was soaked with urine. The resident's alarm did not sound. The resident sustained [REDACTED].) by 1.0 cm. skin tear to the left posterior forearm. The nurse's note further indicated that the staff were reeducated on alarm checks at the start of the shift and to report any devices not working to the nurse. Staff were also reeducated on toileting the resident so he/she stays dry. Review of the facility's internal investigation, dated, 5/5/14, indicated that the resident was wearing socks, not slipper socks. Review of the Falls Risk Assessment, dated 5/5/14, indicated that the resident was at high risk for falls. Review of the falls care plan indicated that on 5/5/14, the care plan was updated to include: - Check and offer toileting on first 11-7 rounds. Review of the annual Minimum Data Set (MDS) assessment, dated 5/7/14, indicated that the resident was severely cognitively impaired, as evidenced by a score of 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS); required extensive assistance for transfers and ambulation; and sustained 1 fall with a minor injury (no sutures or fractures) since the most recent MDS assessment. Review of the nurse's note, dated 7/13/14, indicated that at 4:30 P.M. the resident's bed and motion alarms sounded. The resident was found on the floor next to the bed. There was no apparent injury. Review of the facility's internal investigation, dated 7/13/14, indicated no new information. Review of the falls care plan indicated that on 10/9/14, the care plan was updated to include the following: - Check and offer toileting at the start of each shift. Review of the nurse's note, dated 7/19/14, indicated that the alarms sounded and resident was found on the floor, seated in the bathroom. The resident appeared agitated and was calling out, "get me up." The resident sustained [REDACTED]. Review of the facility's internal investigation, dated 7/19/14, indicated that the resident was wearing slipper socks at the time of the fall. Further review of the facility's internal investigation indicated that the staff were inserviced to check on the resident every 15 minutes while in bed. Review of the quarterly MDS assessment, dated 8/1/14, indicated that the resident was moderately cognitively impaired, as evidenced by a score of 9 out of a possible 15 on the BIMS; required extensive assistance for transfers and ambulation; and sustained 2 or more falls with no injury since the most recent MDS assessment. Review of the nurse's note, dated 9/16/14, indicated that at 6:30 A.M. the resident was found on the floor next to the bed. The resident sustained [REDACTED]. Review of the facility's internal investigation, dated 9/16/14, indicated that the fall was unwitnessed and the resident's call bell was sounding. Review of the nurse's note, dated 10/8/14, indicated that at 8:00 P.M. the resident slid out of the recliner in the dayroom while being repositioned. The resident did not sustain an injury. Review of the facility's internal investigation, dated 10/8/14, indicated that the staff lowered the foot rest on the recliner and the resident started to slide and was lowered to the floor. Review of the falls care plan indicated that on 10/8/14, the care plan was updated to include the following: - Keep in supervised area when out of bed. Review of the falls care plan indicated that on 10/9/14, the care plan was updated to include the following: - Reposition with 2 assist to boost up in recliner and/or reposition. Review of the quarterly MDS assessment, dated 10/24/14, indicated that the resident was moderately cognitively impaired, as evidenced by a score of 9 out of a possible 15 on the BIMS; required extensive assistance for transfers and ambulation; and sustained 1 fall with no injury since the most recent MDS assessment. Review of the nurse's note, dated 12/2/14, indicated that at 7:45 P.M. the resident sustained [REDACTED]. The resident was observed sitting on the floor, yelling, with blood dripping from his/her forehead. The resident was transferred to the emergency room and returned with sutures. Review of the facility's internal investigation, dated 12/2/14, indicated that the resident said that he/she was asleep in the recliner, woke up, attempted to stand, fell and bumped his/her head on the wheelchair. The facility's internal investigation further indicated that as the resident stood, the alarm sounded and a Certified Nurse Aide (CNA) was unable to reach the resident in time to prevent the fall. Review of the Falls Risk Assessment, dated 12/2/14, indicated that the resident was at high risk for falls. Review of the falls care plan indicated that on 12/4/14, the care plan was updated to include the following: - When in dayroom, CNA to sit next to resident. Review of the nurse's note, dated 1/9/15, indicated that at 10:30 A.M. the resident was found on the floor in the his/her bedroom. The resident stated that he/she was going to the bathroom. The resident sustained [REDACTED]. Review of the facility's internal investigation, dated 1/9/15, indicated that at 10:30 A.M. the resident attempted to independently ambulate to the bathroom and was wearing socks, not slipper socks, on his/her feet. Review of the falls care plan indicated that on 1/9/15, the care plan was updated to include the following interventions: - 15 minute checks while in bed. - While awake, must remain in a highly supervised area as tolerated. The surveyor observed Resident #9 on 1/13/15 at 7:50 A.M. Resident #9 was sitting in a recliner in front of the nurse's station in an upright position with his/her knees bent, leaning to the left side. During an interview with the Quality Assurance Nurse on 1/13/15 at 4:10 P.M., she said that the bed alarm, did not sound on the fall of 5/5/14. The bed alarm should have consistently sounded. She also said that the resident was getting up to go to the bathroom for 5 of the falls, 5/5/14, 7/13/14, 7/19/14, 9/16/14 and 1/9/15. 3. During observation of the medication pass, Nurse #6 failed to lock the medication cart on two different occasions. On 1/8/15 at 8:30 A.M., the surveyor observed a medication cart located at the end of a hall in front of the closed door of room 186. The medication cart was unlocked, no nurse was observed in the area. On 1/8/15 at 8:35 A.M., Nurse #6 exited room 186. The surveyor approached the nurse at the medication cart and explained that the medication cart had been unlocked and out of sight for 5 minutes. Nurse #6 said she was aware the medication cart was suppose to be locked. The surveyor continued to watch Nurse #6 dispense medications. On 1/8/15 at 8:50 A.M. Nurse #6 entered room 185 to administer medications to a resident. Again, she left the medication cart in the hallway, unlocked. The medication cart was out of sight for approximately 2 minutes. When Nurse #6 exited room 185, the surveyor showed the nurse that the medication cart had been unlocked and out of sight. Nurse #6 apologized and said the medication cart was left unlocked. 4. The facility failed to maintain 3 of 5 unlocked shower rooms free from potential accident hazards. During a tour of the environment on 1/9/15 between 1:00 P.M. and 2:30 P.M. with the Director of Maintenance, the following were observed: -Unit A1-unlocked shower area: used razor and a bottle of cream. -New York-unlocked shower area: 3 razors, 2 bottles of skin cream, 1 bottle of shaving cream, 1 bar of soap and 1 bottle of shampoo. -Unit C2-two unlocked shower areas and an unlocked resident bathroom: 5 bottles of shampoo, 2 bottles of conditioners, 1 bottle of body wash, and 1 bottle of prescription Tera-Gel (anti-dandruff) shampoo and a bottle of mouth wash. During an interview on 1/9/15 at 2:45 P.M., the Director of Maintenance said that the items left in the unsecured areas were potential hazards and they would be removed.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that a staff member remained in the dining room with Resident #1, per the plan of care, when on 12/16/13, Certified Nurse Aide (CNA) #1 left the dining room unattended and Resident #1 fell from his/her wheelchair and sustained a cervical spine fracture. The Findings include: Resident #1 was admitted to the Facility in December, 2012 with [DIAGNOSES REDACTED]. The Fall Risk assessment, dated 10/1/13, indicated Resident #1 was at risk for falls as evidenced by a score of 13. According to the scale used, a score of 10 or greater indicated a risk for falls. The significant change Minimum Data Set (MDS) assessment, dated 10/3/13, indicated Resident #1 was severely cognitively impaired as evidenced by a score of 3 out of 15 on the Brief Interview for Mental Status. Resident #1's Care Card indicated that he/she required assistance with meals and took his/her meals in the small, supervised dining room. A notice posted on Resident #1's nursing unit indicated that assignment A included staying in the dining room during all meals. The Certified Nurse Aide (CNA) assignment, dated 12/16/13, for the 3:00 P.M. to 11:00 P.M. shift indicated that CNA #5 was assigned to assignment A. The Incident Report, dated 12/16/13, indicated Resident #1 was in the dining room, in a wheelchair, and was reaching for the door frame. The report indicated Nurse #1 repositioned Resident #1 in the wheelchair and moved him/her away from the door frame. The report indicated a few minutes later Resident #1 fell , face down, out of the wheelchair. The Nurse's Note, dated 12/16/13, indicated Resident #1 was in the dining room, was sliding out of the wheelchair, was repositioned by Nurse #1 and moved away from the door frame that he/she was trying to grab. The note indicated that as Nurse #1 turned and walked away, she heard a loud bang, turned around and saw Resident #1 on the floor, face down. The note indicated the Physician and Family were notified and Resident #1 was transferred to the Hospital. The Surveyor interviewed the Unit Manager on 1/14/14 at 10:45 A.M. The Unit Manager said that staff has been instructed, and it is posted on the unit that the person who has assignment A is responsible for being in the small dining room and supervising residents for the entire meal time. She said that person is not supposed to leave the room for any reason. She said that the dining room is also supervised before and after meals, due to residents fall risk and cognitive status. She said at no time are residents in these areas unsupervised. The Surveyor interviewed Nurse #1 on 1/10/14 at 2:25 P.M. Nurse #1 said Resident #1 was agitated, trying to slide out of his/her chair, and grabbing at the door frame. She said this was normal behavior for Resident #1. She said she repositioned him/her and moved him/her away from the door. She said a minute later, Resident #1 fell out of the wheelchair. She said she did not see any other staff in the dining room when Resident #1 fell . The Surveyor interviewed Nurse #2 on 1/10/14 at 2:45 P.M. Nurse #2 said she was the Evening Supervisor. She said she was called to the unit when Resident #1 fell . She said Nurse #1 told her that Resident #1 had been reaching and agitated and pitched forward out of the wheelchair. Nurse #2 said that a staff member is always assigned to be in that room, and that staff member left the room unsupervised. The Surveyor interviewed Certified Nurse Aide (CNA) #1 on 1/10/14 at 3:05 P.M. She said Resident #1's baseline behavior included agitation, rocking in the wheelchair and trying to scoot down in the chair. She said CNA #5 had assignment A on 12/16/13 and was not supposed to leave the small dining room. She said CNA #5 was not in the small dining room when Resident #1 fell from the wheelchair. She said she saw CNA #5 passing out soup at the time of the fall. Multiple attempts were made to reach CNA #5, by telephone on 1/10/14, and 1/14/14, with no success. The written statement, dated 12/16/13, written by CNA #5 indicated that she was assigned to assignment A on 12/16/13 and was supposed to supervise the dining area where Resident #1 was having supper. The statement indicated that CNA #5 said she was not supposed to leave the room, but left the room and was in another area passing out soup when she heard a thump and saw Resident #1 on the floor. The Hospital Discharge Note, dated 12/17/13, indicated Resident #1was examined after falling at the Facility. The note indicated Resident #1 had a minimally displaced cervical spine fracture and a scalp hematoma. The note indicated Resident #1 would be required to use a hard cervical collar and no operative intervention was necessary.

Based on record review and interview, the facility failed to ensure that one of seven sampled Residents (Resident #1) received the necessary supervision to prevent burns from a hot cup of coffee; Resident #1 sustained second and third degree burns on the right thigh when Resident #1, who had severely impaired cognition and required extensive assistance with eating, grabbed a cup of hot coffee from Resident #1's meal tray, which was left within Resident #1's reach while Certified Nurse Aide (CNA) #1 was steps away getting a clothing protector for Resident #1, and Resident #1 spilled the hot coffee on Resident #1's right thigh. Findings include: Resident #1 was admitted to the Facility in March 2011, with [DIAGNOSES REDACTED]. A review of a CNA assignment sheet, revised on 9/8/11, indicated that Resident #1 required assistance with eating. A quarterly Minimum Data Set (MDS) assessment, dated 9/28/11, indicated that Resident #1 had unclear speech, rarely understood others, and was rarely understood by others. The MDS indicated that Resident #1 had impaired short term memory, impaired long term memory, and Resident #1 had severely impaired decision making ability. The MDS indicated that Resident #1 displayed inattention and disorganized thinking. The MDS indicated that Resident #1 required extensive staff assistance with eating. A review of an ADL (activities of daily living) care management care plan, updated on 10/4/11, indicated that Resident #1 required assistance with eating related to a [DIAGNOSES REDACTED]. A nurse's note, dated 10/5/11, indicated that Resident #1 sustained a scald / burn during dinner this evening when Resident #1 handled a hot beverage cup from Resident #1's tray and spilled the hot beverage on the right thigh. The nurse's note indicated that Resident #1 yelled and was observed holding an empty beverage cup and the right thigh of Resident #1's pants was observed to be wet. The nurse's note indicated that Resident #1 was removed from the dining room, transferred into bed, and Resident #1's clothing was removed. The nurse's note indicated an 18 centimeter x 30 centimeter red scald burn with swelling and fluid filled blisters was observed on Resident #1's right anterior, lateral, and posterior thigh. The nurse's note indicated that Resident #1 had facial grimacing and guarding of the right thigh. The nurse's note indicated that cool compresses were applied to the area and an order was obtained for Silvadene (topical cream). Nurse #1 was interviewed at 3:40 P.M. on 10/21/11. Nurse #1 said Nurse #1 was called to the dining room and informed that Resident #1 had spilled a hot beverage on Resident #1's right thigh. Nurse #1 said Resident #1 had facial grimacing, and guarded the right thigh, but Resident #1 was not screaming or crying. Nurse #1 said Resident #1 was removed from the dining room, taken back to Resident #1's room, and placed into bed using a mechanical lift with two staff members. Nurse #1 said the staff members then took the clothing off Resident #1 and Nurse #1 observed a 30 centimeter x 18 centimeter burn on Resident #1's right thigh that had started to blister. Nurse #1 said Nurse #1 applied cool compresses, administered Tylenol to Resident #1, positioned Resident #1 off the right side, and then notified the physician. Nurse #1 said the physician ordered Silvadene cream. CNA #1 was interviewed at 12:45 P.M. on 10/27/11. CNA #1 said CNA #1 worked on a different unit in the Facility and did not know Resident #1 at all. CNA #1 said CNA #1 was told that Resident #1 was a "feeder", but was not told that Resident #1 would try to grab items off the meal tray. CNA #1 said CNA #2 was seated at the same table as Resident #1, but was feeding another resident. CNA #1 said CNA #1 brought Resident #1's supper tray to the table and placed the tray to Resident #1's left (there was no resident seated to Resident #1's left) where CNA #1 believed the tray was out of Resident #1's reach. CNA #1 said CNA #1 then took a couple steps away to get a bib for Resident #1 and Resident #1 made a weird noise, not a yell or scream, but just a weird noise. CNA #1 said CNA #1 then observed that Resident #1's thumb was through the handle of the coffee cup and Resident #1's pants were wet. CNA #1 said this all happened in about two minutes. CNA #1 said Resident #1 then said something like ouch and CNA #1 notified Nurse #1 of the incident. CNA #2 was interviewed at 2:32 p.m. on 10/21/11. CNA #2 said CNA #2 was on a different unit when the trays were passed out in the dining room and when CNA #2 arrived in the dining room all the trays had been passed out. CNA #2 said CNA #2 then started feeding another resident at Resident #1's table. CNA #2 said CNA #2 and CNA #1 were in the dining room. CNA #2 said CNA #2 could not recall where Resident #1's meal tray was on the table in relationship to Resident #1. CNA #2 said the resident that CNA #2 was feeding, sneezed, and food went everywhere. CNA #2 said CNA #2 then quickly stood up and CNA #1 was standing as well. CNA #2 said CNA #1 went over to Resident #1 and the coffee cup was somewhere in Resident #1's lap. CNA #2 said CNA #1 picked up the coffee cup and then notified the nurse. CNA #2 said this all happened in a time span of about two minutes. CNA #2 said CNA #2 did not observe Resident #1 spill the coffee. CNA #2 said Resident #1 may have made a noise, but did not scream. CNA #2 said CNA #2 worked on a different unit and was not familiar with Resident #1. CNA #3 was interviewed at 3:00 P.M. on 10/21/11. CNA #3 said CNA #3 was passing meal trays in the hall and did not observe the incident. CNA #3 said Resident #1 required assistance with meals and sometimes grabbed at items on the meal tray. CNA #3 said it was not appropriate to place a meal tray with hot liquids where Resident #1 could have reached it if there was not a staff member with Resident #1. CNA #4 was interviewed at 3:10 P.M. on 10/21/11. CNA #4 said CNA #4 was also in the hallway passing meal trays when the incident happened. CNA #4 said at times Resident #1 tried to take items off the meal tray. CNA #4 said CNA #4 never placed a meal tray in front of Resident #1 without being there to assist and monitor Resident #1. A review of the Department of Food Service Quality Assessment Log indicated that on 10/5/11 during the evening meal, the temperature of the coffee when the coffee left the kitchen was 195 degrees Fahrenheit. A review of a Hospital Wound Clinic Consultation, dated 10/18/11, indicated that Resident #1 had second and third degree burns on the right thigh. Resident #1 was unable to participate in an interview due to severely impaired cognition.

Based on observation, record review, and staff interview, the facility failed to ensure that 2 of 11 applicable residents with pressure sores (#1 and #13), in a total sample of 30 residents, received the necessary treatment and services to prevent pressure sores from developing, and to promote healing. Findings included: 1. For Resident #1, the facility failed to monitor the resident's pressure reducing cushion for the wheelchair, to ensure the cushion was properly inflated, despite the resident's risk factors of a history of pressure sores, [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility in August of 1999. [DIAGNOSES REDACTED]. Review of the Behavior Monitoring Sheets and nurses' notes of January 2010 indicated that staff was monitoring the resident for yelling at staff and demanding behavior. There was no indication the resident was monitored for resisting care, or that the resident had resisted care. Review of the clinical record indicated that facility staff found an unstageable pressure sore on the resident's coccyx on 2/2/10. A Physician's Progress Note dated 2/2/10 indicated the Physician was asked to evaluate a new ulcer on the resident's coccyx. The note indicated the resident was "(usually on wc {wheelchair} with cushion - that ? (question) gets filled with air by therapy) did not have it checked weekly, noted to have --- open area last night. Resident has been managing own cushion." The note indicated the resident's new wound was an unable to stage area on the coccyx that measured 1.0 x 1.8 x 0.3 cm. (centimeters) with yellow slough and surrounding redness. There was also a firm macerated area measuring 2 x 5 cm. on the inferior lateral edge of the wound. Recommendations included: - Iodosorb gel (used on exuding wounds when infection is suspected) and Coversite Dressing (absorbent, non-adhering gauze-like dressing); - off loading (pressure relief); - add Zinc and Vitamin C; - check [MEDICATION NAME] level; - diet evaluation; - wheelchair cushion to be checked by Rehab on a scheduled basis. A Physical Therapy note dated 2/3/10 indicated the resident had been "self managing" the inflation of the pressure reducing cushion, and when the resident felt the cushion to be a bit low, would go to the Rehab Department for re-inflation. Rehab suggested that nursing should check the cushion and document when performing the treatment to the coccyx. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated the resident had: no memory deficits, and was able to make sound decisions; required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and bathing; was independent for personal hygiene; did not ambulate; was frequently incontinent of bowel; had an indwelling catheter (suprapubic), and had a Stage IV pressure sore. This MDS indicated no episodes of resisting care. The plan of care addressing skin breakdown was updated in 2/10. Interventions included: - Pressure reducing mattress; - Monitor skin daily during care and report abnormal areas; - Dietary to assess diet, weights, and labs as needed; - Assist with repositioning every 2 hours and as needed. A Nutrition Progress Note dated 2/9/10 indicated the resident's [MEDICATION NAME] level was mildly depleted at 18.9 (normal ranges 20-40). Protein powder was recommended twice daily to promote healing. Review of the 2/10 Wound Treatment Sheet indicated that on 2/9/10 the wound was larger at 2.5 x 0.2 cm. The Wound Sheet no longer was indicating the amount of drainage (only the type-yellow) per instructions. A nurse's note of 2/12/10 indicated the resident initially resisted the use of slipper socks (due to open areas on the toes), but with staff education was agreeable. There was no documentation that the resident refused care (i.e. dressing changes, repositioning). Review of the 2/10 Wound Treatment Sheet indicated that on 2/16/10 the wound was larger at 3.0 x 1.0 x .3 cm. deep. The Wound Sheet indicated the wound had an odor (did not specify foul or slight per instructions). The Physician was notified who changed the treatment to the chemical [MEDICATION NAME] agent Santyl daily after cleansing and then cover with a Coversite Dressing. Review of the 2/10 TAR (Treatment Record) indicated the resident's cushion was now checked daily by staff, and that on 2/17/10 the resident received a new cushion due to the old one being flat. (Interview with the Director of Nurses and the Consultant Nurse on 11/1/10 at 10:05 A.M. indicated the resident's cushion had a leak, which is why the cushion was replaced on 2/17/10.) Review of the Behavior Monitoring Sheets and nurses' notes of February 2010 indicated that staff was monitoring the resident for yelling at staff and demanding behavior. There was no indication the resident was monitored for resisting care. A Physician's Progress Note of 3/3/10 indicated the resident's pressure area had worsened, and that the resident was now "...resistant to intervention to off load the area. Likes independence of wheelchair - + (and) refuses to go to bed during day...." The Physician ordered a wound consultation for the resident at the Wound Clinic. A physician's orders [REDACTED]. (milligrams) twice daily for 10 days for a wound infection. A nurse's note of 3/5/10 indicated the resident was educated on the importance of bedrest to relieve pressure on the coccyx, and agreed with a bed schedule to go back to bed on the odd hours to off-load the buttocks. Review of the clinical record indicated the resident went out to the Wound Clinic on 3/9/10. The report from the clinic indicated the pressure sore measured 3.5 x 4.5 x 1.5 cm. deep with a necrotic base. The surrounding area was bright red and slightly warm. There was a foul, brown, discolored drainage. Recommendations were as follows: "*Patient should be on a minimum group II low air loss bed if not already. May need upgrade. Continue with Roho cushion on w/c (wheelchair). Reposition q (every) 2 hours in bed - HOB (head of bed) 30 degrees or lower. Clean incontinence as needed + change dressings with incontinence. Barrier cream to the perimeter of the wound, and to change the dressing to 1/4 strength Dakin's Solution (anti-infective agent), gauze packing twice daily and as needed with incontinence. Return in 1 week. Review of the clinical record indicated that in April of 2010, the resident was mostly compliant with the out of bed and repositioning schedules, and that the wound was improving. Review of the Significant Change in Status MDS Assessment (conducted for a decline in activities of daily living), dated 5/7/10 indicated the following changes from the previous assessment of 2/10: required cueing for decision-making; required total assistance from staff for transfers and toilet use; required extensive assistance from staff for personal hygiene; had 4 Stage IV pressure sores (coccyx and feet), and 4 Stage IV stasis ulcers (scabs on the toes), as well as an overall decline in care needs. Review of the clinical record from 5/10 to 8/10 indicated the resident was mostly compliant with the out of bed and repositioning schedules, and that the wound was improving with the use of a wound vac (negative pressure treatment) and different treatment modalities. The Quarterly MDS assessment dated [DATE] indicated the resident had one Stage IV pressure sore (coccyx). This MDS also indicated no episodes of resisting care. On 10/25/10 at approximately 8:30 A.M., the surveyor observed the resident sitting in the wheelchair self propelling in the hallway. The resident was sitting on a folded bath blanket that was folded several times to fit the wheelchair. The folded blanket was then placed on top of a pressure reducing cushion (making the cushion an ineffective intervention) with a Hoyer lift pad was on top of that. On 10/25/10 at approximately 2:45 P.M., the surveyor observed the resident lying in bed in the supine (back) position. On 10/26/10 at approximately 7:30 A.M. and 10:10 A.M., the resident was observed by the surveyor lying in bed flat on the back, despite the repositioning schedule to position off the affected area at all times when in bed. On 10/26/10, the surveyor observed the treatment to the coccyx area with permission from the resident. The present treatment (recommended by the Wound Clinic on 9/30/10) was to clean the wound with Normal Saline, apply [MEDICATION NAME] AG ([MEDICATION NAME] Wound Dressing with Ionic Silver) to the wound bed, the apply Zinc Barrier cream to the periwound and cover with a dry dressing every other day and as needed. The Wound Consult included, "Position off area @ (at) all times." During the treatment on 10/26/10 at 10:45 A.M., Nurse #3 was observed by the surveyor. The nurse incorrectly irrigated the wound instead of cleansing per order. On 10/26/10 at 3:15 P.M., the resident was observed in the wheelchair in the bedroom. The resident was again sitting on a multiple folded bath blanket which was on top of the pressure relief cushion (making the cushion ineffective). On 10/28/10 at 1:55 P.M., the resident was observed in the wheelchair in the bedroom. The resident was again sitting on a multiple folded bath blanket which was on top of the pressure relief cushion (making the cushion ineffective). On 11/1/10 at 7:45 A.M., the resident was observed by the surveyor lying in bed in the supine position. Interview with Unit Manager #3, on 11/1/10 at 7:50 A.M., indicated that as far as she knew the resident was repositioned every two hours off the back, but was also on an air mattress which would help relieve pressure regardless. Please refer to F281, Example #1 and F282, Example #1. 2. For Resident #13, the facility failed to: - appropriately monitor the excoriated areas on the resident's buttocks, and provide the ordered treatments to prevent further skin breakdown. Resident #13 was admitted to the facility in 5/06 and readmitted in 10/08. [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set)assessment dated [DATE] indicated the resident: had short and long term memory loss, and was unable to make decisions; required extensive assistance from staff for bed mobility, was dependent for transfers, required total assistance from staff for dressing, personal hygiene, and bathing; was non-ambulatory, and was incontinent of bowel and bladder. Review of the clinical record indicated the resident had a history of [REDACTED]. Review of the Treatment/Procedure Sheet dated 9/7/10 a nurse's observations of the left and right buttocks indicated the areas had "worsened". The physician's orders [REDACTED]. There was no stop date. Review of the 9/10 treatment records indicated that bilateral buttocks remained red and excoriated. The plan of care dated 9/28/10 for the risk of skin breakdown related to: [MEDICAL CONDITION], decreased mobility, diabetes, [DEVICE] (gastrostomy) fed, [MEDICAL CONDITION], incontinence, excoriated right and left buttocks. Interventions included: - Use of a pressure reducing mattress to bed and wheelchair; - Monitor skin daily during care; -Check and change schedule; -Incontinent care with use of barrier cream; -Dietary to assess diet, labs, weights as needed; -Assist with repositioning every two hours and as needed with two staff; -Weekly skin checks by nurse and document on the TAR (treatment record), -Heel protectors while in bed. A physician's orders [REDACTED]. The new order was to cleanse the buttocks with Wound Cleanser and apply [MEDICATION NAME] (silver based bactericidal cream) to bilateral buttocks twice daily and prn for one week. A physician's orders [REDACTED]. Review of the 10/10 Treatment/Procedure Sheet revealed no documentation on 10/7/10 on the 3:00-11:00 P.M. shift that the [MEDICATION NAME] had been applied per order on the right buttock. A nurse's note of 10/11/10 included, "...Mineral Oil and [MEDICATION NAME] to excoriated buttocks...." (The physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the 10/10 Treatment/Procedure Sheet indicated the areas on the buttocks were pink, fragile and intact from 10/14 - 10/21/10. Review of the Weekly Skin Check sheet indicated that on 10/25/10 the buttocks were "resolved." On 10/25/10 at 2:45 P.M., the surveyor observed the resident lying supine (on the back) in bed with the head of bed elevated at 45 degrees. During a discussion with Unit Manager #5 and the Physician on 10/26/10 at approximately 11:00 A.M., the Unit Manager told the surveyor and the Physician that the resident's buttocks were healed. On 10/26/10 12:50 P.M., Unit Manager #5 was requested by two surveyors to position the resident on the left side in order to observe the resident's buttocks. With the resident's buttocks exposed, the surveyors observed that the left buttock had an area of pink scar tissue, and was fragile and intact. The right buttock had pink scar tissue, but also had an area that measured approximately 2.0 x 1.0 cm. (centimeter). The area was white, raised, and macerated. Lateral to the macerated area were two pinpoint open areas surrounded by redness. Unit Manager #5 also observed the area with the two surveyors, and confirmed that the resident's right buttock was not healed as indicated earlier. Unit Manager #5 confirmed the resident had 2 Stage II open areas. Unit Manager #5 indicated there was no treatment at this time, and that the resident's skin "is fragile" and nursing should have been assessing the resident's buttocks on an ongoing basis. A physician's orders [REDACTED].R.N. Review of the 10/10 Treatment/Procedure Sheet indicated the resident's buttocks were assessed and documented once daily (and not twice as ordered) on 10/27, 10/28, 10/29 and 10/30. Documentation on 10/30/10 on the 3:00 - 11:00 P.M. shift revealed excoriated buttocks. Discussion with Unit Manager #5 on 11/1/10 at approximately 3:45 P.M. acknowledged the treatments ordered by the Physician were not consistently implemented per order.

3. For Resident #20, the facility failed to provide effective interventions and adequate supervision to prevent falls in order to provide an effective falls intervention program for the resident. Resident #20, with [DIAGNOSES REDACTED]. The plan of care for falls of 9/10/09 included the following interventions: call bell within reach, Physical Therapy/Occupational Therapy screen, evaluation and treatment as needed, encourage resident to move from one position to another slowly and grip socks at hour of sleep. Review of the 11/15/09 (7:30 A.M.) Nurse's Note revealed that the resident experienced an unwitnessed fall with no injuries. The care plan was updated to include a one quarter grab bar on the bed to enable repositioning. Review of the quarterly MDS (Minimum Data Set) assessment of 12/4/09 identified the resident as exhibiting short-term and long-term memory deficits, moderately impaired decision-making ability; independent (help/oversight provided only 1 or 2 times during the last 7 days or no help/oversight provided) during transfers and ambulation; had fallen within the past 30 days, and within the past 31 to 180 days. Review of the plan of care for falls of 12/8/09 remained unchanged. Review of the Rehabilitation (Rehab.) Screen of 12/10/09 revealed that the resident exhibited impaired decision making ability with the staff seeing increased confusion, forgetting the rolling walker when moving about. The screen also indicated that the resident was independent/ required supervision during transfers and ambulation. Review of the 1/12/10 (8:00 A.M.) Nurse's Note revealed that the resident experienced an unwitnessed fall with no injuries. During an interview with Unit Manager #2 (11/1/10 at 1:35 P.M.), Unit Manager #2 acknowledged the facility practice was to have at least one CNA (certified nursing assistant) stationed in the unit TV room at all times, to oversee the residents for safety, and that at the time of the resident's fall, staff were not in the TV room providing the necessary supervision for the resident, as planned. The care plan was updated to include a Physical Therapy referral. Review of the Rehab Screen of 1/12/10 revealed that the resident continued to exhibit increased confusion, and that the resident now required supervision/assistance (as needed) during transfers and supervision while ambulating. Review of the quarterly MDS assessment of 3/4/10 remained unchanged except to note that the resident had not fallen within the past 30 days. The plan of care for falls was updated on 3/5/10 to include: monitor closely at activities to be sure resident doesn't try to walk without using walker. Review of the Rehab. Screen of 3/11/10 revealed that the resident continued to require supervision/ assistance during transfers and supervision while ambulating. Review of the 6/01/10 (7:30 A.M.) Nurse's Note revealed that the resident experienced an unwitnessed fall, sustaining a hematoma on the top of the head, and 2 scrapes near each elbow which required steri-strips. During an interview with Unit Manager #2 (11/1/10 at 1:35 P.M.), Unit Manager #2 acknowledged that the resident was not being supervised while ambulating, prior to the fall, as planned. The care plan was updated to include: when sitting resident down for meals, ensure resident has everything set up where the resident wants it before leaving the resident. Review of the Change of Status MDS assessment of 6/2/10, now identified the resident as being easily distracted, impaired vision (requiring eye glasses), and had fallen within the past 30 days. The plan of care for falls was rewritten on 6/4/10 to include the following interventions: call bell within reach, Physical Therapy/Occupational Therapy screen, evaluation and treatment as needed, monitor closely for not leaving walker behind; and when sitting resident down for meals, ensure resident has everything set up where the resident wants it before leaving the resident. Review of the 6/22/10 Nurse's Note revealed that the resident experienced an unwitnessed fall, sustaining an abrasion on the back of the left forearm measuring 8 cm. (centimeters) by 2 cm, a bruise at the base of the left thumb measuring 3 cm. by 3 cm., a bruise on the top of the left hand/third finger, and a red area on the back of the head approximately 0.5 cm. by 0.5 cm.. During an interview with Unit Manager #2 (11/1/10 at 1:35 P.M.), Unit Manager #2 acknowledged that the resident was not being supervised while ambulating, as the fall was unwitnessed. The care plan was updated to include: Physical Therapy evaluation. Review of the Rehab. Screen of 6/23/10 indicated that the resident was independent/required supervision during transfers and required a rolling walker while ambulating. During an interview with the Director of Rehab. (11/1/10 at 10:15 A.M.), the following was acknowledged: a. the resident had a history of [REDACTED]. b. that although the resident was physically able to ambulate independently, the resident had continued to require staff supervision for safety while transferring and ambulating since after the first fall (on 11/15/09). Review of the 8/16/10 (8:35 A.M.) Nurse's Note revealed that the resident experienced an unwitnessed fall, sustaining a small reddened area on the top of the head and a small bruise on both hands. During an interview with Unit Manager #2 (11/1/10 at 1:35 P.M.), Unit Manager #2 acknowledged that the resident was not being supervised while ambulating, prior to the fall, and that the resident was not utilizing the rolling walker at the time of the fall. The care plan was updated to include: Physical Therapy evaluation and to utilize a motion detector by the bathroom door. During an interview, on 11/1/10 at 10:15 A.M. with the Director of Rehab. it was acknowledged that a Rehab Screen had been completed on 8/17/10, however, the therapist had mistakenly noted that the resident was independent with transfers and ambulation. She stated that the resident had continued to require staff supervision for safety during transfers and ambulation. Review of the quarterly MDS assessment of 8/28/10 remained unchanged. Review of the Rehab. Screen of 9/2/10 revealed that the resident continued to require supervision during transfers, however, the resident now required supervision/limited assistance while ambulating. Review of the 9/19/10 (8:20 A.M.) Nurse's Note revealed that the resident experienced an unwitnessed fall, with no injuries. During an interview with Unit Manager #2 (11/1/10 at 1:35 P.M.), Unit Manager #2 acknowledged that the resident was not being supervised, nor assisted while ambulating, prior to the fall, as planned. The care plan was updated to include: chair alarm, bed alarm and assist with ambulation, as tolerated. On 10/28/10 at 3:20 P.M., the surveyor observed the resident in the unit TV room, sitting in a straight back chair, with the chair alarm on. The surveyor observed one CNA sitting in the TV room, facing the hallway. The CNAs back was to the residents, and she could not oversee/supervise the residents for safety, per the facility practice, as planned, because the residents were not within her eyesight. On 11/1/10 at 8:15 A.M., the surveyor observed the resident in the unit TV room, sitting in a straight back chair. There were no CNAs in the TV room to provide the oversight/supervision for the resident's safety, as planned. During an interview with CNA #2 on 11/1/10 at 10:30 A.M., CNA #2 stated that ..."one CNA needs to remain in the TV room at all times to supervise the residents in the room...." During an interview with Unit Manager #2 on 11/1/10 at 1:35 P.M., Unit Manager #2 acknowledged the following: a. that 5 out of the 6 falls occurred between 7:30 A.M. and 8:35 A.M.; b. after the first two falls, the facility should have implemented additional interventions; c. she was unaware as to whether the resident had the eye glasses on, or not prior to the falls, as planned, and d. whether the call bell was within the resident's reach prior to the falls, as planned. Unit Manager #2 further acknowledged that the facility failed to provide effective interventions and adequate supervision to prevent falls. 4. On 10/26/10 at 11:30 A.M. and also on 11/1/10 from 1:20-2:05 P.M., during the environmental tour with the Director of Safety and Security, the surveyor observed the testing of water temperatures. It was confirmed at that time through interview, that the facility failed to maintain hot water temperatures within a safe range (no greater 110 degrees Fahrenheit). Findings were as follows: - 10/26/10 at 11:30 A.M. bathroom sink of Room 166 registered 113 degrees Fahrenheit. Nurse #2 indicated the water was very hot by saying "ouch! That's hot!" when washing hands prior to Resident #2's treatment. Water temperatures on 11/1/10 from 1:20-2:05 P.M. during the environmental tour with the Director of Safety and Security registered as follows: - Bathroom sink of Room 213 (shared by 2 residents) registered 116.7 degrees Fahrenheit. - Bathroom sink of Room 118 (private room) registered 115.3 degrees Fahrenheit. - Bathroom sink of Room 109 (private room) registered 114.2 degrees Fahrenheit. - Bathroom sink of Room 170 (private room) registered 112.6 degrees Fahrenheit. - Bathroom sink of Room 140 (shared by 2 residents) registered 113.1 degrees Fahrenheit. - Bathroom sink of Room 143 (private room) registered 113.1 degrees Fahrenheit. - Bathroom sink of Room 153 (private room) registered 111.3 degrees Fahrenheit. At the end of the tour on 11/1/10 at approximately 2:05 P.M., the surveyor asked for the recorded hot temperatures for the past 90 days. Interview with the Director of Safety and Security as well as the Support Services Coordinator on 11/1/10 at 3:50 P.M., indicated that the mixing valve in the boiler room was adjusted to lower the hot water temperatures. During the interview, it was also revealed that hot water temperatures in resident areas had not been conducted in over a year. The Security and Support Services Coordinator assured the surveyor that hot water temperatures would be conducted and recorded in resident areas Monday through Friday from this point forward. Based on record review, observation and interview, the facility failed to ensure that 3 of 14 applicable residents with falls (#3, #7 and #20) received adequate supervision and assistive devices to prevent falls, in a total sample of 30 residents and the facility failed to ensure that the resident environment remained free of accident hazards relative to maintaining safe water temperatures. Findings included: 1. For Resident #3 the facility failed to provide adequate supervision to a cognitively impaired resident, to prevent a fall with a fracture. The facility also failed to ensure the resident did not have access to a chair with wheels and did not ensure the motion detector in the resident's room sounded. Resident #3 was admitted to the facility in 3/05 with a [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment of 2/23/10 revealed that the resident was at high risk for falls. Review of the falls care plan revealed the following interventions: - Fall risk assessment per protocol. - Bed in locked position. - Hi-Lo Bed Review of the quarterly Minimum Data Set (MDS) Assessment of 2/27/10 revealed that the resident's short and long term memory were impaired; the resident exhibited moderately impaired decision making ability; was independent with ambulation/transfers and had fallen within the last 31 to 180 days. Review of the nurse's note of 5/14/10 revealed that the resident was ambulating with a walker outside the facility, lost balance, and fell to the pavement. The resident sustained [REDACTED]. Further review of the nurse's note revealed that a moderate amount of blood was noted from the right eyebrow laceration. Review of the facility investigation of 5/14/10 revealed that the resident was able to independently ambulate, however, required supervision while ambulating outside on the patio for gardening. During a discussion with the Director of Support Services (10/28/10 at 11:08 A.M.) she revealed that the hallway from the door of the unit where the resident lived to the front door was 128 feet in length. During a discussion with Unit Manager #3 (10/28/10 at 10:30 A.M.) she acknowledged that the resident was cognitively impaired, walked down the hallway, and left the building unsupervised. Review of the hospital discharge summary of 5/21/10 revealed that the resident sustained [REDACTED]. Multiple small hemorrhagic foci within the brain likely to represent hemorrhagic contusions/ petechial hemorrhages. 2. Left orbital blowout fracture with fracture of the inferior and medial wall without entrapment. There is associated opacification of the left maxillary sinus without entrapment which in this setting is likely to represent blood." Review of the Fall Risk Assessment of 5/24/10 revealed that the resident remained at high risk for falls. Review of the significant change of status MDS Assessment of 5/30/10 revealed that the resident's short and long term memory were impaired, the resident exhibited moderately impaired decision making ability; required extensive assistance with ambulation and transfers; had fallen within the last 30 days and had sustained a fracture within the last 180 days. Review of the nurse's note of 7/22/10 revealed that the resident was found on the floor with their pants next to them, legs outstretched and shoes on. The nurse's note further revealed that the resident had no apparent injury. On 7/22/10, the care plan was updated to include soft flat shoes when out of bed. Review of the nurse's note of 7/26/10 revealed that the resident was found on the floor in their room with slippers on feet. The note further revealed that the resident did not sustain an apparent injury. On 7/26/10, the care plan was updated to include motion alarm at all times in bed. Review of the Neurology report of 7/29/10 stated, "Unfortunately the patient fell this past spring and suffered traumatic brain injury with multifocal intracranial hemorrhage and contusion. Areas involved included right temporal lobe, scattered petechial hemorrhage in the bilateral hemispheres. Repeat imaging performed in June revealed resolution of hemorrhages without evidence of [DIAGNOSES REDACTED]." The report further indicated that the resident had white matter disease and was not themselves since the fall. The resident's speech was much worse, characterized by difficulty expressing self, and repeating the same word, sometimes focusing on the "s" sound. The resident's gait was worse and the resident required more assistance ambulating. Review of the nurse's note of 8/13/10, revealed that the resident lost balance while attempting to sit on a chair with wheels, fell to the floor, landing on buttocks, and no apparent injuries were noted. Review of the facility investigation revealed the fall was witnessed. On 8/16/10, the care plan was updated to include redirect resident to stationary chair as needed. Review of the Fall Risk Assessment of 8/22/10 revealed that the resident remained at high risk for falls. Review of the significant change MDS Assessment of 8/22/10 revealed that the resident's short and long term memory were impaired, the resident exhibited moderately impaired decision making ability; required supervision with ambulation/transfers; fell within the last 30 days and the last 31 to 180 days, and sustained a fracture within the last 180 days. Review of the nurse's note of 8/24/10 revealed that the resident was transferred to the secured dementia unit. Review of the nurse's note of 9/1/10 revealed that for a second time the resident lost their balance while attempting to sit on a chair with wheels, and fell to the floor, landing on their buttocks. No apparent injuries were noted. During a discussion with Unit Manager #2 (10/28/10 at 10:00 A.M.), she revealed that when the resident transferred to her unit, the information concerning the resident attempting to sit in chairs with wheels was received. Review of the nurse's note of 10/23/10, revealed that the resident got up from the bed, lost balance and fell to the floor. Review of the facility investigation revealed that the resident's bed sensor alarm sounded but the motion detector did not sound. Observation of the resident on 10/25/10 at 11:40 A.M. revealed that the resident was sitting in a stationary chair in the dayroom. A Certified Nurse Aide (CNA) was sitting within arms length of the resident. Observation of the resident on 10/26/10 at 8:50 A.M., revealed that the resident was sitting in the dining room at a round table in a stationary chair. A CNA was sitting next to the resident. During a discussion with CNA #2 on 10/28/10 at 8:45 A.M., she revealed that the resident walks with assistance, and the resident walks utilizing a wheeled walker with a gait belt around the waist. The above was reviewed with Unit Manager #2 on 10/28/10 at 10:00 A.M. 2. For Resident #7, the facility failed to provide adequate supervision to prevent falls. Resident #7 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) Assessment (of 10/1/09) revealed that the resident's short and long term memory was impaired, the resident exhibited severely impaired decision making; required extensive assistance with transfers, limited assistance with ambulation, and had fallen within the past 31 to 180 days. Review of the Fall Risk Assessment (10/1/09) revealed that the resident was at high risk for falls. Review of the falls care plan revealed the following interventions: - Fall Risk Assessment per protocol. - Bed alarm - Low bed with mattress on floor on both sides. - If awake on last rounds 11:00 P.M. to 7:00 A.M. assist the resident out of bed. - If the resident is not awake on last rounds 11:00 P.M. to 7:00 A.M. assist the resident out of bed first on assignment. - Ambulate with assistance. - Motion detector. Review of the nurse's note of 12/20/09 revealed that the resident was found on the floor next to the floor mats in a sitting position. Review of the facility investigation revealed that a Certified Nurse Aide (CNA) was sitting in the hallway charting while the resident's alarm was sounding. A second CNA called for assistance and the resident was found on the floor. On 12/21/09, the falls care plan was updated to include nurse to check if the resident is awake at 7:00 A.M. Review of the Fall Risk Assessment of 12/28/09 revealed that the resident remained at high risk for falls. Review of the quarterly MDS Assessment of 12/31/09 revealed that the resident's short and long term memory was impaired, the resident exhibited severely impaired decision making ability; required extensive assistance with transfers and ambulation, and had fallen within the past 30 days and 31 to 180 days. Review of the Fall Risk Assessment of 3/21/10 revealed that the resident remained at high risk for falls. Review of the quarterly MDS Assessment of 3/31/10 revealed that the resident's short and long term memory was impaired, the resident exhibited severely impaired decision making ability, extensive assistance with transfers and ambulation, and had fallen within the past 31 to 180 days. Review of the nurse's note of 4/5/10 revealed that the resident fell out of the chair to the bathroom floor sustaining a laceration to the forehead. Review of the facility investigation of 4/5/10 revealed that the resident fell out of the wheelchair in the bathroom while the CNA turned to obtain the resident's clothing. During a discussion with Unit Manager #2 (10/28/10 at 9:45 A.M.) she revealed that the CNA was disciplined for leaving the resident unattended. The resident's falls care plan was updated on 4/6/10 to include gathering all supplies prior to initiating care. Review of the nurse's note of 4/20/10 revealed that the resident was being transported in a wheelchair and fell forward out of the wheelchair. Review of the facility investigation of 4/20/10 revealed that the resident was being transported in a wheelchair without footrests. The resident's falls care plan was updated on 4/20/10 to include using footrests when transporting in a wheelchair. Review of the Fall Risk Assessment of 6/24/10 revealed that the resident remained at high risk for falls. Review of the quarterly MDS Assessment of 6/25/10 revealed that the resident's short and long term memory was impaired, the resident exhibited severely impaired decision making ability; required extensive assistance with transfers and ambulation, and had fallen within the past 31 to 180 days. Review of the nurse's note of 6/26/10 revealed that the resident stood up from the chair and walked inside the nurses' station. The resident was found on the floor laying on the left side with the resident's head leaning against the trash can next to the sink. Review of the facility investigation of 6/26/10 revealed that the resident was sitting in a wheelchair in front of the nurses' station, stood up, walked to the back of the nurses' station, unassisted, and was found on the floor with their head against a trash can. Review of the nurse's note 8/27/10 revealed that the resident was found on the floor. Review of the facility investigation of 8/27/10 revealed that the alarm and motion detector were sounding, and the resident was found on the floor in their room. Observation of the resident on 10/25/10 at 4:40 P.M., revealed the resident sitting in the wheelchair facing a counter in the dining room. A CNA sat next to the resident assisting the resident with the meal. The above was reviewed with Unit Manager #2 on 10/28/10 at 9:45 A.M.