Every finding on record at Katzman Family Center for Living

Based on record review, policy review and interviews, the facility failed to meet professional standards of quality for three Residents (#19, #32, and #27) out of a total sample of 26 residents. 1.) For Resident #19, the facility failed to implement physician's orders to notify the physician of a weight change. 2.) For Resident #32 and #27, the facility failed to ensure nursing implemented physician's orders for urinary catheter changes. Findings include: 1.) For Resident #19, the facility failed to implement physician's orders to notify the physician of a weight change. Review of the facility policy, Physician/ Family Notification, undated, indicated: 1. The Nurse Supervisor or Charge Nurse will notify a resident's Attending Physician or On-Call Physician when there has been: i. Instructions to notify the physician of changes in the resident's condition. Resident #19 was admitted to the facility in December 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 3/9/24, indicated Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. During an interview on 5/7/24 at 4:03 P.M., Resident #19 said his/her weights have been going up and he/she is weighed daily. Review of the plan of care related to congestive heart failure, indicated Resident #19 is at risk for complications due to congestive heart failure, dated 12/8/23, interventions included: -Weigh daily before breakfast. Notify provider (MD/NP) for gain (+) 3 pounds (lbs) in one day or +/-5 lbs in 1 week. Review of the physician's order, dated 1/27/24, indicated: - Weigh daily before breakfast. Notify provider (MD/NP) for gain (+) 3 pounds (lbs) in one day or +/-5 lbs in 1 week. Review of the physician progress note, dated 4/9/24, indicated: 2. NYHA class 3 heart failure with borderline preserved ejection fraction (HCC) -Continue daily weights as ordered. Review of the Weight Summary and Medication Administration Record (MAR), dated May 2024, indicated Resident #19 weighed the following: 5/1/24 250.8 lbs 5/2/24 251.0 lbs 5/3/24 253.4 lbs 5/4/24 253.0 lbs 5/5/24 255.0 lbs 5/6/24 no weight obtained. 5/7/24 258.0 lbs, a weight gain of 7.2 pounds in 6 days 5/8/24 259.4 lbs, a weight gain of 8.6 pounds in 7 days During an interview on 5/8/24 at 9:50 A.M., Nurse #2 said that Resident #19 requires daily weights. Nurse #2 said Resident #19 has a diagnosis of CHF and was hospitalized back in December for heart failure. Nurse #2 said Resident #19 became so sick, and he/she could gain 3 pounds over night. Nurse #2 said today's weight is 262 pounds (documented as 259.4, in the medical record). Nurse #2 said that she has not had to notify the physician about Resident #19's weights this week (record review indicated Nurse #2 was Resident #19's assigned Nurse on 5/1/24, 5/6/24, 5/7/24, and 5/8/24). Nurse #2 said the weights have been good this week and she would need to notify the provider for a weight gain of 3 pounds in 1 day or 5 pounds in one week. Nurse #2 said when she puts the weights in the electronic health record, she reviews the weights to ensure that she doesn't need to notify the provider. Nurse #2 reviewed the weights with the surveyor and said Resident #19's weights are good, and she did not need to notify the physician. Review of the nursing note, dated 5/8/24 at 9:05 A.M., indicated: - The resident complained of (C/O) shortness of breath when trying to wean him/her off oxygen. New orders from Nurse Practitioner (NP); Supplemental oxygen 0.5-2L/min via N/C as needed for shortness of breath (SOB). Further review of the note failed to indicate the NP was made aware of the weight gain. Review of the nursing note, dated, 5/8/24 at 1:51 P.M., indicated: - NP called with new orders for supplemental oxygen which override the previous orders; 1) Supplemental oxygen 0.5-2 L/min via N/C titrate to maintain 95% and above continuously to ensure Pt is not SOB. every shift Continue with plan of care. Further review of the note failed to indicate the NP was made aware of the weight gain. On 5/8/24 at 3:26 P.M., the surveyor called the Nurse Practitioner and requested a call back. During an interview on 5/8/24 at 3:45 P.M., Unit Manager #1 said that he notified the NP of Resident #19's shortness of breath and obtained new orders for oxygen continuous oxygen use. Unit Manager #1 said he would have the physician review the weights on Friday 5/10/24. During an interview on 5/8/24 at 3:54 P.M., the Triage Nurse, from the Nurse Practitioner's office, called the surveyor and reviewed the NP's note from 5/8/24. The Triage Nurse said that the weight gain was not reported to the NP, but she would notify the NP of the weight gain. During a follow up interview on 5/8/24 at 4:10 P.M., Unit Manager #1 reviewed weights with the surveyor and said nursing should have notified the provider of the 5-pound weight gain on 5/7/24 but they did not. Unit Manager #1 said when nursing notifies providers of weight gains, the notification would be documented in the nurses note. The surveyor and Unit Manager #1 reviewed the nursing notes and there was no documentation to support that nursing made the provider aware of the weight gain. Review of the nursing note dated 5/8/24 at 4:55 P.M., indicated: - NP called back regarding weight gain and elevated blood pressure. Lung sounds clear, denies SOB, no increased edema noted. New orders from NP; 1) STAT (immediately, without a delay) BMP (basic metabolic panel, laboratory test to check for electrolytes) 2) STAT NT-pro BNP (B-type Natriuretic Peptide, laboratory test used diagnose or rule out heart failure) Continue with plan of care. During a follow up interview on 5/9/24 at 10:00 A.M., Unit Manager #1 said that after he had spoken to the surveyor on 5/8/24 the NP called back after the NP became aware of Resident #19's weights and she ordered STAT labs to rule out congestive heart failure. During an interview on 5/9/24 at 1:24 P.M., the Director of Nursing said nursing should monitor Resident #19's daily weights per the physician's order and report changes as ordered. 2.) For Resident #32 and #27 the facility failed to ensure nursing implemented physician's orders for urinary catheter changes, as ordered by the physician. a.) For Resident #32 the facility failed to implement physician's orders for suprapubic catheter changes (an indwelling urinary catheter placed directly into the bladder through the abdomen) Specifically, the facility staff failed to ensure the correct size indwelling urinary catheter balloon was in place for Resident #32 as indicated in the plan of care (physician's order was not complete). b.) For Resident #27 the facility failed to implement physician's orders for indwelling urinary catheter/Foley (a flexible tube that passes through the urethra and into the bladder to drain urine) changes. Specifically, the facility staff failed to ensure the correct size indwelling urinary catheter was in place for Resident #27 as ordered by the physician. Review of the facility policy, Catheter Care, Urinary, indicated the purpose is prevent catheter associated infections. *Preparation 1. Review the resident's care plan to assess for any special needs of the resident. *General Guidelines -Changing Catheters 2. A physician's order is needed to insert and indwelling catheter including catheter care schedule and size of catheter. a.) Resident #32 was admitted to the facility in June 2013 with diagnoses including diabetes, neuromuscular dysfunction of the bladder, peripheral vascular disease, and benign prostate hyperplasia. Review of the Minimum Data Set (MDS) assessment, dated 4/20/24, indicated Resident #32 had an indwelling urinary catheter. Review of the physician's order, dated 3/5/23, indicated: -change suprapubic every 21 days and as needed. 14 french silicone coated only. Further review of the physician's order failed to include the size of the balloon. Review of the plan of care related to indwelling suprapubic catheter placement indicated: Resident #32 is at risk for complications related to insertion of indwelling suprapubic catheter due to urinary retention, dated as initiated 1/29/16, interventions included: - Change every 3 weeks or as needed - 14 French 10 cc balloon. Review of the Treatment Administration Record (TAR), dated April 2024, indicated on 4/8/24 and 4/29/24, nursing implemented the physician's order and changed the indwelling suprapubic catheter. Review of the nursing note, dated 4/8/24, indicated: - Change Suprapubic every 21 days and as needed. 14 fr silicone coated only. - Suprabic cath changed without any event. Review of the nursing note, by Nurse #1, dated 4/28/24, indicated: - Suprabic cath changed today without any issue. Review of the Urinary/ Straight Catheterization Competency, dated as 1/7/20, indicated Nurse #1 was trained and competent on catheterization including: 1. Verify or obtain the physician's order. 16. Document size of catheter inserted, amount of water in the balloon, patients' response to procedure and assessment of urine. On 5/8/24 at 10:29 A.M., the surveyor and the Assistant Director of Nursing (ADON) observed Resident #32 in bed, Resident had a suprapubic indwelling catheter size 14 French and a 30-cc balloon, not a 10-cc balloon as indicated by Resident #32's plan of care. On 5/9/24 at 7:47 A.M., two surveyors and the ADON reviewed the physician's order which did not include a balloon size. The ADON said nursing should have clarified the physician's order before inserting the indwelling catheter. The care plan was reviewed, and the care plan indicated a 14 french and 10-cc balloon. The two surveyors and the ADON observed Resident #32 with a 14 French and a 30-cc balloon. During an interview on 5/9/24 at 1:30 P.M., the Director of Nursing (DON) said nursing should have implemented suprapubic catheter size including the balloon. The DON said if the correct size balloon was unavailable nursing should have notified the provider and obtained a new order for the size available in stock. b.) Resident #27 was admitted to the facility in June 2022 with diagnoses including urinary retention and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 4/6/24, indicated Resident #27 had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 which indicated he/she was cognitively intact. The MDS indicated Resident #27 required an indwelling urinary catheter. During an interview on 5/7/24 at 8:07 A.M., Resident #37 was in his/her bed. Resident #37 said he/she did not like his/her indwelling urinary catheter. On 5/8/24 at 7:55 A.M., at the surveyor observed Certified Nurse Assistant (CNA) #1 providing care to Resident #27, there was a 14 french (fr) 10 cc indwelling urinary catheter. Review of the physician's order, dated 9/21/23, indicated: - Change catheter 12 Fr 10 cc as needed for blockage or leakage. - Foley catheter care every shift. Review of the plan of care related to indwelling foley catheter placement, indicated Resident #27 is at risk for complications related to insertion of an indwelling Foley catheter due to urinary retention, dated as reviewed 4/9/24, interventions included: -May change foley catheter with 12 french 10 cc secondary to blockage as needed. Review of the nursing progress note, dated 3/10/24, indicated: - Change catheter 12 Fr 10 cc as needed for blockage or leakage as needed. Resident complained of pain in his/her bladder. Bladder distended, Foley catheter changed due to blockage. Review of the Treatment Administration Record (TAR), dated March 2024, indicated nursing changed the catheter on 3/9/24. Review of the nursing progress note by Nurse #2, dated 3/27/24, indicated: - Foley catheter blocked. New catheter inserted without difficulty. Resident tolerated well. Catheter now patent. Review of the Treatment Administration Record (TAR), dated March 2024, failed to include nursing inserted a new catheter. Review of the Urinary/ Straight Catheterization Competency, dated as 8/11/20, indicated Nurse #2 was trained and competent on catheterization including: 1. Verify or obtain the physician's order. 16. Document size of catheter inserted, amount of water in the balloon, patients' response to procedure and assessment of urine. During an interview on 5/8/24 at 9:36 A.M., Nurse #2 said prior to changing an indwelling catheter, she would look to see what was currently inserted into Resident #27 and then she would verify the physician's order and care plan prior replacing the catheter. On 5/8/24 at 9:48 A.M., the surveyor and Nurse #2 observed Resident #27 indwelling urinary catheter together and Nurse #2 said the catheter that was inserted into Resident #27 was not the correct size according to the physician's order. During an interview on 5/8/24 at 3:38 P.M., Unit Manager #1 said there was at one point, a back order and the facility only had 14 french catheters. Unit Manager #1 said nursing should implement the correct catheter size based on the physician's order. Unit Manager #1 said that if nursing did not have the correct catheter size the physician should be made aware and a new order should be obtained for the insertion based on the catheter availability. During an interview on 5/9/24 at 1:29 P.M., the Director of Nursing said that nursing should verify the correct indwelling catheter size prior to implementing the physician's order. The DON said that if the correct size was unavailable nursing should reach out to the provider and obtain a new order with the size that is available.

Based on observation, record review, policy review, and interviews, for one Resident (#19), out of 26 sampled residents, the facility failed to maintain an accurate medical record in accordance with accepted professional standards and practice. Specifically, for Resident #19, the facility failed to ensure nursing documented oxygen administration on the treatment administration record. Findings include: Review of the facility policy, Oxygen Administration, undated, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify there is a physician's order for the procedure. 2. Review the resident's care plan to assess for any special needs of the resident. Steps in the Procedure 4. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Reporting 1. Report information in accordance with facility policy and professional standards of practice. Resident #19 was admitted to the facility in December 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 3/9/24, indicated Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. On 5/7/24 at 8:37 A.M., and on 5/7/24 at 12:01 P.M., the surveyor observed Resident #19 being administered continuous oxygen via nasal cannula at 1 liter per minute. During an interview on 5/7/24 at 4:03 P.M., Resident #19 was in his/her bedroom being administered oxygen at 3 liters per minute. Resident #19 said he/she needs nurses to help with oxygen administration and he/she cannot see the settings. Resident #19 said he/she has been wearing oxygen continuously for a few months. Review of the physician's order, dated 1/25/24, indicated: - Supplemental oxygen 0.5-2 liters/minute via nasal cannula (NC) as needed for oxygen saturation (O2 sat) greater than 92%, as needed. Review of the plan of care related to COPD: Resident #19 is at risk for complications due to COPD, dated 12/8/23, indicated: - Apply O2 via NC as needed. Review of the oxygen saturation summary indicated facility staff recorded Resident #19's oxygen saturations on the following dates and times: 5/1/24 12:57 P.M., 98.0% Oxygen via Nasal Cannula 5/2/24 9:08 A.M., 99.0% Oxygen via Nasal Cannula 5/3/24 8:36 A.M., 98.0% Oxygen via Nasal Cannula 5/4/24 1:09 P.M., 99.0% Oxygen via Nasal Cannula 5/5/24 9:33 A.M., 99.0% Oxygen via Nasal Cannula 5/7/24 1:09 P.M., 98.0% Oxygen via Nasal Cannula Review of the Treatment Administration Record, dated May 2024, failed to include documentation to support that nursing administered the as needed oxygen from 5/1/24 to 5/7/24. Further review of the nurses notes from 5/1/24 to 5/7/24, failed to include the flow rate of oxygen that nursing was administering to Resident #19. During an interview on 5/8/24 at 9:49 A.M., Nurse #2 said Resident #19 has been wearing continuous oxygen since his/her most recent hospitalization (December 2023). Nurse #2 said that oxygen administration is documented on the treatment administration record (TAR). Nurse #2 said she works the medication cart that Resident #19 is on 4 days a week and that she has not documented on the TAR as required but should have. Nurse #2 continued to say Resident #19 should have had an order for continuous oxygen but did not. Review of the nursing note, dated, 5/8/24 at 1:51 P.M., indicated: - new orders for supplemental oxygen which override the previous orders; During an interview on 5/8/24 at 3:45 P.M., Unit Manager #1 said Resident #19 has been on and off oxygen and since his/her most recent hospitalization he/she has been wearing the oxygen continuously. Unit Manager #1 and the surveyor reviewed the medical record, and he said that nursing should be documenting the oxygen administration on the TAR. Unit Manager #1 said that oxygen flow rate should be documented in the medical record. During an interview on 5/9/24 at 1:23 P.M., the Director of Nursing said that nursing should document the administration of oxygen on the treatment administration record.

Based on record review and interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for two Residents (#19 and #118) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that an MDS Assessment: 1.) For Resident #19, was accurately coded relative to a.) oxygen use and b.) use of a non-invasive mechanical ventilator (continuous positive airway pressure, CPAP). 2.) For Resident #118, was accurately coded for discharge location. Findings include: 1.) Resident #19 was admitted to the facility in December 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and diabetes. Review of Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2023, indicated the following: O0110: Special Treatments, Procedures, and Programs *Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column. *Coding Instructions for Column b. While a Resident -Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. If no treatments, procedures or programs were received by, performed on, or participated in by the resident within the last 14 days or since admission/entry or reentry, check Z, none of the above. a.) Review of the Minimum Data Set (MDS) assessment, dated 3/9/24, indicated: C1. Oxygen Therapy- not checked, left blank. Review of the physician's order, dated 1/25/24, indicated: - Supplemental oxygen 0.5-2 liters per minute (L/min) by nasal cannula (NC) as needed for oxygen saturation (O2 sat) greater than 92% as needed Review of the oxygen saturation summary indicated Resident #19 received oxygen via nasal cannula on the following dates: - 3/2/24, 3/4/24, 3/6/24, 3/7/24, 3/8/24, and 3/9/24 Review of the nursing notes dated, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/7/24, and 3/8/24, indicated Resident #19 received oxygen administration. During an interview on 5/8/24 at 9:49 A.M., Nurse #2 said Resident #19 has been wearing continuous oxygen since his/her most recent hospitalization (December 2023). During an interview on 5/8/24 at 3:45 P.M., Unit Manager #1 said Resident #19 has been utilizing oxygen. b.) Review of the Minimum Data Set (MDS) assessment, dated 3/9/24, indicated: G1. Non-invasive Mechanical Ventilator- not checked, left blank. Review of the physician's order, dated 12/8/23, indicated: -Provide CPAP at night at bedtime related to sleep apnea. Review of the Treatment Administration Record (TAR), dated March 2024, indicated from 3/1/24 to 3/9/24 nursing applied Resident #19's CPAP as ordered by the physician. During an interview on 5/8/24 at 3:52 P.M., Unit Manager #1 said Resident #19 uses a CPAP every night. During an interview on 5/9/24 at 10:33 A.M., the Regional Nurse said the MDS Nurse should code MDS assessments based on the RAI manual. 48671 2. Resident #118 was admitted in March 2024 with a diagnoses that included pneumonitis, multiple fractures of ribs, urinary tract infection, diabetes, and vascular dementia. Review of Resident #118's most recent Minimum Data Set (MDS), dated [DATE], indicated in section A of the MDS that the Resident discharged to a short-term general hospital. Review of Resident #118's social services note, dated 4/1/24, indicated the Resident was discharged home with services. Review of Resident #118's nursing progress note, dated 4/1/24, indicated, Resident was assessed by Dr. (doctor) and ordered to be discharged home with meds (medications) and services. He/she was picked up today about 11am. Review of Resident #118's nurse practitioner note, dated 4/1/24, indicated, May discharge patient home with meds and services. During an interview on 5/9/24 at 10:34 A.M., the Regional Nurse said Resident #118 was discharged home, he said the MDS should have been coded correctly, following the Resident Assessment Instrument (RAI) manual.

Based on observation record review and interview the facility failed to 1.) provide a dignified dining experience on 1 of 3 units and 2.) provide 1 Resident (#19) with (a) his/her meal timely and (b) identify Resident #19 in a dignified manner out of a total of 25 sampled Residents. Findings include: Review of the facility policy titled 'Quality of life-Dignity' with no revision date indicated the following: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. *Staff shall speak respectfully to residents at all times including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 1. On 3/7/23 the surveyor observed the breakfast meal service in the Dementia Unit dining room: At 8:20 A.M. there were 9 Residents seated at tables with their meals in front of them. 2 Residents were in their reclining chairs watching the others waiting for their meals and waiting for assistance. At approximately 8:40 A.M., the last Resident in the reclining chair was assisted with his/her meal, after watching all others in the room be served. * On 3/7/23, the surveyor observed the lunch meal service in the Dementia Unit dining room: At 12:04 P.M., there were 13 Residents seated at tables with eating their lunch. There were 2 tables of 3 Residents with staff who were providing assistance with their meals. There were 6 Residents seated in their wheelchairs or Reclining chairs with lap tables in front of them waiting for their meals. At 12:06 P.M., a staff person brought a Resident his/her meal and placed it in front of him/her. The Resident's eyes were closed and he/she was not alerted that his/her meal had been delivered. At 12:08 P.M. a staff person delivered another Resident who requires assistance his/her meal and placed it in front of him/her and walked away. The Resident looked at his/her plate and did not initiate eating. At 12:12 P.M. a nurse arrived and began assisting the Resident. At 12:13 P.M. a staff person served and started to assist a Resident in his/her recliner his/her meal. The Resident seated next to him/her attempted to ask about his/her meal but was not heard. At 12:18 P.M., the surveyor inquired with the Assistant Director of Nursing (ADON) if the last Resident had eaten his/her meal yet as he/she had attempted to get the attention of staff 5 minutes earlier. The ADON said she would check with the kitchen staff. At 12:21 P.M., the last Resident was served his/her meal. * On 3/8/23 the surveyor observed the breakfast meal on Dementia Unit: At 8:05 A.M., a Certified Nurses Aide (CNA) was wheeling a Resident backwards down the hallway in his/her reclining chair to the dining room. The CNA stopped and asked another staff person to continue bringing the Resident to the dining room. The staff person told the Resident she would continue to bring him/her to the dining room and continued to pull the Resident backwards down the hallway. At 8:07 A.M., there were 11 Residents seated at tables in the dining room. 1 Resident was asleep with his/her head on the table, his face was positioned close to his/her uncovered hot cereal. At 8:09 A.M., a staff person observed the sleeping Resident and put her hand in the Resident's face and pushed the Resident's head up saying wake up! At 8:15 A.M., staff began to assist the Resident who had been pulled backwards down the hallway into the dining room with his/her breakfast. During an interview with the ADON on 3/9/23 at 8:28 A.M., the surveyor shared the above observations. The ADON said that staff do their best to serve and assist all Residents at the same time. 43807 2.) (a) For Resident #19, the facility failed to provide a meal in a timely manner. Resident #19 was admitted to the facility in June 2015 with diagnoses including dementia and dysphagia. Review of the most recent minimum data set (MDS) completed on 1/21/23 indicated no brief interview for mental status because the resident is rarely/never understood. During an observation on 3/8/23 at 9:44 A.M., Resident #19 was observed in bed sleeping, all other residents on the unit had been served breakfast in the dining room, finished eating, all the other residents were observed moving on to the next activity of the day. During an interview with Nurse #4 on 3/8/23 at 9:46 A.M., the surveyor asked her if Resident #19 had eaten breakfast, she said she was not sure but will find the certified nurse's assistant (CNA) working with the Resident to find out. Nurse #4 said it should not take this long to assist the Resident with his/her meal. During an interview with CNA #1 on 3/8/23 at 9:50 A.M., the CNA was observed rushing into the Resident's room with his/her breakfast tray from the dining area, she told the surveyor that the Resident should not be eating this late, especially after all the other Residents had finished eating their breakfast. Nurse #1 came rushing into the room to assist CNA #1. During an interview with Nurse #1 on 3/8/23 at 9:57 A.M., he said he will be taking over from CNA #1 to assist Resident #19 with his/her meal. He said the Resident should not have waited this long to eat breakfast. During an interview with the Unit Manager (UM #1) on 3/8/23 at 10:19 A.M., she said the Residents who need assistance with eating should not wait this long to eat. UM #1 said that CNAs should not have to be prompted to assist the Residents with meals in a timely manner. During an interview with the Director of Nurses on 3/9/23 at 8:19 A.M., she said she expects Residents who need assistance with eating on the unit to be served in a timely manner. (b) The facility failed to identify Resident #19 in a dignified manner. During an interview with Nurse #4 on 3/8/23 at 9:48 A.M., she told the surveyor that the Resident #19 is a feed now, the nurses do assist residents eat when the certified nurse assistants (CNAs) on the unit are busy. During an interview with the Unit Manager #1 (UM #1) on 3/8/23 at 10:19 A.M., she said nurses and certified nurse assistants should not be referring to Residents as feeds , they are Residents who need assistance during meals. During an interview with the Director of Nurses (DON) on 3/8/23 at 12:17 P.M., she said she expects Residents who need assistance with meals on the unit to be referred to by their names and not a feed.

Based on observations, interviews and record review, the facility failed to complete an assessment for a possible restraint for 1 Resident (#55) out of a sample of 25 Residents. Findings include: Review of the facility policy titled 'Use of Restraints' with no revision date indicated the following: *Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. *The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e. side rails are put back down, rather that climbed over), and this restricts his/her ability to change position or place, that device is considered a restraint. *By definition, devices such as special mattress, chairs, pillows and recliners used for comfort and not to prevent movement are not considered restraint. Continued use an assessment will be done when there's a significant change in functioning and as needed. *Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need of restraints. Resident #55 was admitted to the facility in October 2015 with diagnoses including Dementia and a history of falling. Review of the most recent Minimum Data Set (MDS) completed in 1/28/23 did not indicate a brief interview for mental status (BIMS) score because Resident #55 is rarely/never understood. Further review of the MDS indicated no restraints were being used for Resident #55. During observations on 3/7/23 at 8:53 A.M., and 10:47 A.M., Resident #55 was observed sleeping on a scoop air mattress with two long pillows tucked under the fitted sheet on each side of Resident #55 restricting his/her movements in bed. During observations on 3/8/23 at 6:50 A.M., and 7:50 A.M., Resident #55 was observed sleeping on a scoop air mattress with two pillows tucked under the fitted sheet on each side of Resident #55 restricting his/her movements in bed. A review of the activities of daily living (ADL) care plan initiated 11/4/2015 indicated the following: *Turn and reposition in bed with 2 assist every 2 hours and as needed *Requires assist with toileting and transfers A review of the fall care plan initiated 10/29/15 indicated the following: *Supervise resident during transfers During an interview with Certified Nurse's Assistant (CNA) #1 on 3/8/23 at 9:05 A.M., she told the surveyor the pillows tucked in under the sheet on either side of Resident #55's bed are in place to prevent the Resident from falling and he/she is a high fall risk. CNA #1 pointed at the floor mat placed next to the Resident's bed and said look there is a fall mat, he/she falls a lot. During an interview with Unit Manager (UM) #1 on 3/8/23 at 9:11 A.M., UM #1 went to Resident #55's room with the surveyor, she said that Resident #55's movements in bed appeared to be restricted. UM #1 said she had no idea why there were pillows tucked in on either side of Resident #55's bed and she started removing the pillows. During an interview with the Director of Nursing (DON) on 3/9/23 at 8:23 A.M., she said she was not aware that staff were placing items under Resident #55's bed to restrict movement and now that she has this information, a restraint assessment will be completed because one wasn't done prior. The DON provided a physical restraint assessment completed in 8/12/22, the only devices assessed for possible restraints were the scoop mattress and a geri chair.

Based on observation, interviews and record review, the facility failed to develop and implement a personalized behavior care plan related to dining for 1 resident (#37) out of a sample of 25 residents. Findings include: Resident #37 was admitted to the facility in August 2021 with diagnoses including major depressive disorder and anxiety. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated a brief interview for mental status (BIMS) score of 5 out of a possible 15 indicating severe impairment. On 3/7/23 at 9:34 A.M., Resident #37 was observed sitting in his/her room visibly upset. He/she told the surveyor he/she had to leave the dining room before eating his/her toast because the staff were taking too long to serve him/her. Resident #37 said this happens every morning at breakfast and she/he ends up eating his/her toast after leaving the dining room. Resident #37 said he/she wants to be served breakfast quickly so she/he does not have to wait long periods of time. During an interview with Unit Manager (UM#1) on 3/7/23 at 9:44 A.M., she said she was aware that Resident #37 was upset at breakfast, and she said that Resident #37 can be very impulsive. During a follow up interview with UM #1 on 3/8/23 at 8:48 A.M., she said she looked into the concern further, she found out Resident #37 was upset because he/she was not getting his/her breakfast fast enough. Resident #37 ends up leaving the dining room very upset and the staff make sure she/he gets his/her breakfast in his/her room. During an interview with the Dietary Aide (DA#1) on 3/8/23 at 8:53 A.M., she said on several occasions in the dining room during breakfast, Resident #37 gets very upset when staff do not attend to him/her only. DA#1 said she serves Resident #37 orange juice and coffee, puts his/her toast in the oven, and while DA #1 waits for the toast, she attends to other Residents in the dining room. DA #1 said Resident #37 ends up getting very upset, leaves the dining room so staff make sure she/he eats his/her breakfast in his/her room. Review of Resident #37's behavior care plan did not indicate documentation to support that the facility developed and implemented an individualized plan of care and interventions addressing this specific behavior during breakfast meals. During an interview with the Social Worker on 3/8/23 at 9:19 A.M., she said a personalized behavior care plan and interventions should be added to address Resident #37's behavior during breakfast.

Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent falls for 1 Resident (#21) out of a total of 28 sampled residents. Subsequently, Resident #21 fell and sustained a nasal fracture and required 4 sutures. Findings include: Resident #21 was admitted to the facility in March 2021 with diagnoses including Alzheimer's disease, muscle weakness and [CONDITION(S)]. Review of Resident #21's most recent Minimum Data Set Assessment indicated that he/she severely cognitively impaired and requires assistance bathing, dressing and toileting. On each day of the survey, (12/14/21, 12/15/21, and 12/16/21) the surveyor made multiple observations of Resident #21 standing from a seated position and ambulating with staff providing stand by supervision or hands on assistance. Review of Resident #21's care plans indicated: Activities of Daily Living (ADL): Resident unable to perform ADL's independently due to weakness and confusion from dementia; 3/24/21 *Interventions: Assist Resident #21 with mobility/ambulation and wheelchair (initiated 3/24/21; revised 5/27/21) Resident is at risk for falls due to decreased safety awareness, history of falls, [CONDITION(S)] drug use, unsteady gait, 3/12/21. *Interventions: Administer medications as ordered. Assess resident for risk for falls on admission and quarterly as needed. Call light within reach. Check resident if unable to use call light. Assist resident during transfer, place bed in lowest and locked position. Review of Resident #21's Kardex (a form utilized to describe care needs for Residents) failed to indicate that Resident #21 was a fall risk or indicate that Resident #21 required assistance with mobility and ambulation per his/her ADL care plan. Review of Resident #21's most recent discharge summary from physical therapy and occupation therapy dated 4/20/21 indicated Resident #21 required supervision with all mobility during activities of daily living and required contact guard (stabilizing support)/stand by assistance with ambulation. Review of Resident #21's Fall Investigation Report indicated the following: 8/21/21 Around 9:30 P.M. Resident #21 was walking with his/her rolling walker in the hallway. This writer was in the nurses station supervising distantly. All of a sudden, Resident #21 fell face down. Resident #21 was sent to the hospital and was diagnosed with a fractured nose and required 4 sutures. During an interview with the Director of Nursing on 12/15/21 at 2:05 P.M. he said that Resident #21 was admitted to the facility and assessed to be a huge fall risk. The DON said that Resident #21 was supervised at all times on the unit and acknowledged that his/her ADL care plan indicated Resident #21 required assistance with ambulation at the time of his/her fall.

Based on observation, record review and interview the facility failed to assess 2 Residents (#51 and #93) for the use of pillows beneath a fitted sheet, and 2 Residents (#52 and #21) for the use of a reclining (Geri) chair as potential restraints out of a total sample of 28 residents. Findings include: Review of the facility policy titled Use Of Restraints and not dated, failed to indicate that a device that has the potential to restrain a person will be assessed to determine if the device actually acts as a restraint, for that person, prior to the application of the device. 1. For Resident #51 the facility failed to assess the use of pillows beneath the fitted sheet as a potential restraint. Resident #51 was admitted to the facility in April 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record failed to indicate an assessment for the use of pillows beneath a fitted sheet as a potential restraint. Further review failed to indicate a doctor's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #51's careplan failed to indicate a careplan for the use of restraints. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #51 was an extensive assist for transfers and mobility. Further review indicated that Resident #51 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS), indicating sever cognitive impairment. Review of the facility document titled ADL (activities of daily living) Flow Sheet, dated December 2021, indicated that Resident #51 required an extensive assist with ambulation. Review of the medical record indicated that Resident #51 has a history of wandering at night. Review of the nurse's notes dated 12/3/21, indicated that resident #51 fell , lowering her/himself to the floor. On 12/14/21, at 9:01 A.M., the surveyor observed Resident #51 lying in bed with pillows under the fitted bed sheet below the hand rail. On 12/14/21, at 11:16 A.M., the surveyor observed Resident #51 lying in bed with pillows under the fitted bed sheet below the hand rail. The surveyor then observed Resident #51's legs hanging over side of bed. On 12/15/21, at 7:15 A.M., the surveyor observed Resident #51 lying in bed with pillows under the fitted bed sheet on both sides of the bed. During an interview on 12/15/21, at 7:16 A.M., CNA #3 said that she was assigned to Resident #51 and she keeps the pillows in place under the fitted sheet to prevent Resident #51 from getting out of bed because she/he falls. 2. For Resident #52 the facility failed to assess the use of a reclining chair (geri chair) as a potential restraint. Resident #52 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record indicated a facility document titled, Physical Restrain Assessment, dated 10/14/21. Further review indicated that the decision making process the document uses to come to a conclusion as to whether the use of the device is a restraint or not, is blank. Review of the doctor's orders failed to indicate a doctor's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #52's careplan failed to indicate a careplan for the use of restraints. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #52 was an extensive assist for transfers and mobility. Further review indicated that Resident #52 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS), indicating sever cognitive impairment. Review of the facility document titled ADL (activities of daily living) Flow Sheet, dated December 2021, indicated that Resident #52 required an extensive assist with ambulation. Review of the nurse's notes indicated that on 11/24/21, Resident #52 was found on the floor by nursing. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/14/21, at 9:24 A.M., the surveyor observed Resident #52 in the dining room lying in a geri chair, tilted all the way back in a full reclining position. On 12/14/21, at 11:20 A.M., the surveyor observed Resident #52 in the dining room lying in a geri chair, tilted all the way back in a full reclining position. During an interview on 12/14/21, at 11:20 A.M., Certified Nurse's aide (CNA) # 4 said that Resident #52 tries to get up but isn't able to walk anymore so they use the reclining chair to prevent falls 3. For Resident #93 the facility failed to assess the use of pillows beneath the fitted sheet as a potential restraint. Resident #93 was admitted to the facility in September 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record failed to indicate an assessment for the use of pillows beneath a fitted sheet as a potential restraint. Further review failed to indicate a doctor's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #93's careplan failed to indicate a careplan for the use of restraints. Further review indicated a risk for falls due to a history of falls. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #93 was totally dependant for transfers and mobility. Further review indicated that Resident #93 was unable to complete the Brief Interview for Mental Status (BIMS) with the staff concluding that Resident #93 had moderate cognitive impairment. Review of the facility document titled ADL (activities of daily living) Flow Sheet, dated December 2021, indicated that Resident #93 required an extensive assist with ambulation. On 12/14/21, at 9:03 A.M., the surveyor observed Resident #93 lying in bed with pillows under the fitted sheet on both sides of the mattress. During an interview on 12/14/21, at 9:04 A.M., Certified Nurse's Aide (CNA) #5 said the pillows are there because Resident # 93 moves and tries to get out of bed. On 12/14/21, at 11:13 A.M., the surveyor observed Resident #93 lying in bed with pillows under the fitted sheet on both sides of the mattress. On 12/15/21, at 7:15 A.M. the surveyor observed Resident # 93 in bed while CNA #3 was providing A.M., care. CNA #3 then proceeded to place pillows under the fitted sheet on each side of the Resident's bed. During an interview on 12/15/21, at 7:15 A.M., CNA #3 said that she puts the pillows under the fitted sheet on each side of Resident #93 to prevent her/him from exiting the bed. 4. Resident #21 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's most recent Minimum Data Set Assessment indicated that he/she severely cognitively impaired and requires assistance bathing, dressing and toileting. On each day of the survey, (12/14/21, 12/15/21, and 12/16/21) the surveyor made multiple observations of Resident #21 standing from a seated position and ambulating with staff providing stand by supervision or hands on assistance. On 12/15/21, at 6:50 A.M., the surveyor observed Resident #21 seated in a Geri chair (a large reclining chair on wheels) in a fully reclined position. Resident #21 was tense and holding on to the arms of the chair tightly while holding his/her torso upward instead of laying back in the chair. On 12/15/21, at 7:10 A.M., the surveyor interviewed Nurse #4 and Nurse #5. Nurse #5 said that Resident #21 is seated in the Geri chair at night to discourage him/her from getting out of bed. Nurse #5 said that the Geri chair was used for Resident #21's safety and to help elevate Resident #21's legs. When asked if Resident #21 could get out of the reclining chair without assistance, Nurse #5 said it's possible and Nurse #4 shook her head and said no. During an interview with CNA #8 on 12/15/21, at 7:22 A.M., she said that Resident #21 is in the recliner for safety. CNA #8 said that Resident #21 does not sleep well at night and if he/she is left alone in bed, he/she will try to get up unassisted and fall. CNA #8 said that Resident #21 cannot get out of the recliner chair without assistance but can get up from a regular chair. On 12/16/21, at 7:09 A.M., the surveyor observed Resident #21 seated in a regular chair next to CNA #9. CNA #9 said that she had worked overnight and Resident #21 was in his/her Geri chair for safety earlier. CNA #9 said that Resident #21 cannot get out of the Geri chair without assistance and because Resident #21 is now in the regular chair, she is sitting with him/her in case he/she wants to get up and walk. Review of Resident #21's clinical record indicated 3 physical restraint assessments dated 4/1/21, 6/11/21, and 9/2/21 indicating the use of Resident 21's Geri chair was necessary for better positioning of Resident #21 while out of bed. Each assessment indicated that the Geri chair did not restrict Resident #21's freedom of movement, contradicting the statements from the facility staff. During an interview with the Director of Rehab Services (DOR) on 12/15/21, at 9:40 A.M he said that the use of the Geri chair for Resident #21 was not assessed by the rehab department for positioning or for potential restraint purposes.

Based on observation, interview and record review, the facilit failed to implement the plan of care for 3 Residents (#16, #56 and #81) out of a total sample of 28 residents. Findings include: 1. For Resident #16, the facility failed to implement his/her fall care plan and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #16 was admitted to the facility in June 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #16's most recent Minimum Data Set (MDS) dated [DATE] revealed that Resident #16 had a Brief Interview of Mental Status (BIMS) score of 11 out of a possible 15 which indicated that he/she had moderate cognitive impairment. The MDS also indicated Resident #16 was dependent on staff for all daily tasks. During an observation on 12/14/21 at 8:09 A.M., Resident #16 was lying in bed with both heels on the bed. Resident #16's bed was not in the lowest position. During an observation on 12/15/21 at 9:42 A.M., Resident #16 was lying in bed with both heels on the bed. Resident #16's bed was not in the lowest position. During an observation on 12/16/21 at 7:20 A.M., Resident #16 was lying in bed with both heels on the bed. Resident #16's bed was not in the lowest position. Review of Resident #16's fall care plan dated 6/6/21, indicated the following intervention: *Place bed in lowest and locked position Review of Resident #16's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Heel boot to right heel when in bed. *Apply multipodus (skin protection) boot to right lower extremity. multipodus boot to remain on at all times. Review of Resident #16's behavior sheets and nursing notes failed to indicate he/she refused care. During an interview on 12/16/21 07:29 A.M., Unit Manager (UM) #1 entered Resident #16's room with the surveyor. UM #1 adjusted Resident #16's bed and said that it was not in the lowest position. UM #1 also said that Resident #16 often refuses the foot boot and that staff do not apply it due to numerous refusals. UM #1 said that if a resident refuses a care plan intervention or order, nursing would document that refusal. Review of Resident #16's medical record failed to indicate he/she refused care and interventions put in place. 2. For Resident #56 the facility failed to ensure the medical plan of care was implemented for the use of a left upper extremity splint. Resident #56 was admitted to the facility in June of 2013 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that he/she had a brief interview of mental status exam score of 3, indicating severe cognitive impairment and is dependent on staff for all aspects of daily care. On 12/14/21 at 11:18 A.M., Resident #56 was observed resting in bed. His/her left hand was folded into a fist and arm was observed as flaccid. There was no device observed in the residents environment. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] * Splint to left upper extremity at all times during hours of sleep. May remove for care as needed. Monitor skin integrity every shift dated 2/20/21. Review of Resident #56's care plans indicated a potential for skin breakdown dated 7/10/14 with an intervention of left upper extremity splint (resting hand splint) as ordered. Review of the document Resident ADL Guide/Kardex dated 11/18 indicated under adaptive equipment splint to left hand. On 12/14/21at 4:43 P.M., Resident #56 was observed in bed. A geri-recliiner was next to his/her bed with a lift pad. No other devices observed in the room. On 12/15/21 at 6:50 A.M., Resident #56 was observed sleeping in bed. His/ her left hand was on the bed without any splint on. No splint was present in the areas around the Resident. During an interview on 12/15/21 at 4:41 P.M., CNA #6 said Resident #56 used to wear a left-hand brace. CNA #6 said he has not seen it since before the pandemic and that he was not told that it was discontinued. He said he recalled that the Resident would wear it when he was up in the recliner, (which is in conflict with the order). CNA #6 took a look on top of the closet and did not locate the splint. 3. For Resident #81 the facility failed to complete weekly skin assessments per the medical plan of care. Resident #81 was admitted in May of 2020 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that Resident #81 had severe cognitive impairment, was dependent on staff for most activities of daily living and is at risk for developing pressure ulcers. On 12/14/21 at 10:31 A.M., Resident #81 was observed resting in his/her bed. He/she said he/she had pain in his/her bottom area. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Right buttock skin tear, 1. Wash with simple saline, 2. Pat down dry, 3. Apply [MEDICATION(S)] directly onto open area, 4. Apply allevyn dressing, 5. To be done daily or change dressing if dressing becomes soiled or compromised, dated 11/10/21. *Weekly skin assessment by a licensed nurse, document under assessments in PCC (electronic medical record). Every night shift, every Sunday, dated 7/10/20. Review of weekly skin checks on 12/15/21 indicated the following: *No weekly skin checks were documented for the month of December 2021. *Weekly skin checks for November 2021 included 11/22/21, 11/15/21 and 11/9/21. *No weekly skin checks were documented for the month of October 2021. *One weekly skin check was documented as completed for the month of September 2021. *Two weekly skin checks were documented as completed for the month of August 2021. *One weekly skin check was documented for the month of July 2021. *Two weekly skin checks were documented as completed for the month of June 2021. From the period of June 2021 through December 15 2021, 19 weekly skin checks were not completed per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 12/16/21 at 10:10 A.M., Unit Manager #2 said the weekly skin assessments are to be documented on the assessment form in PCC.

Based on observation, record review and interview the facility failed to ensure practices to prevent the potential spread of infection by failing to perform hand hygience and failing to wear personal protection equipment. Findings include: Review of the facility's policy, entitled COVID-19 Infection Control Protocol, dated as revised November 30, 2021 indicated the facility is commiteed to preventind the spread of COVID-19 infections and adheres to the standards set by the state and federal government as well as Centers of Disease Control and Massachusetts Department of Public Health. All employess regardless of vaccination status must wear facemasks while in the facility at all times. Review of the facility policy entitled Influenza, Prevention and Control , not dated indicated under b. (1) hand hygiene staff will perform hand hygiene frequently, including before and after all resident contact, contact with potentially infectious material, and before putting on and upon remvoval of personal protections equipment including gloves. (2) Hand hygiene is healthcare settings will be performed by washing hands with soap and water or using alcohol-based hand rubs. If hands are visibly soiled, soap and [NAME], not alcohol hand rubs will be used. 1. On 12/14/21 at 4:15 P.M., the Activities Director was observed on the first floor unit, pulling his mask below his nose, announcing the music selection for residents in the area, then touched the speaker on the wall and replaced his mask without performing hand hygiene. He then proceeded to push a resident in a wheelchair to the elevator. 2 On 12/15/21, at 2:10 P.M., the surveyor observed the Activity Director in the hallway on the 3rd floor with his mask under his chin, speaking loudly to 2 Certified Nurse's Aids regarding the application of masks on residents in the main dining room during an activity. The surveyor observed 6 out of 15 residents in the main dining room on the 3rd floor without masks available for them to put on. During an interview on 12/15/21, at 2:12 P.M., CNA #4 said that she did not know why the Activity Director had his mask below his chin while speaking to her. She also said that some of the residents take their masks off all the time and that is why they were not given masks to wear during the activity, however not all the residents without masks available remove them. 3. During the medication pass observation on 12/16/21, at 8:10 A.M., the surveyor observed Nurse #2 enter a resident's bathroom, wash her hands and then turn off the faucet with her bare hands, contaminating them. Nurse #2 then passed medications to the resident. She then washed her hands in the resident's bathroom, turned off the faucet with her bare hands, contaminating them. She then dried her hands, exited the room and accessed the medication cart with her contaminated hands, contaminating the medication cart. During the medication pass observation on 12/16/21, at 8:42 A.M., the surveyor observed Nurse #2 as she washed her hands in the resident's bathroom. She then turned off the faucet with her bare hands, contaminating them. She then dried her hands, exited the room and accessed the medication cart with her contaminated hands, contaminating the medication cart. 4. On 12/16/21 at 7:05 A.M., the surveyor observed CNA #11 exit a resident room on the 3rd floor wearing gloves after giving care. CNA #11 removed the gloves in the hallway, entered another resident room across the hall and disposed of the gloves in the bathroom and did not perform hand hygiene. CNA #11 then walked down the hallway, entered the code to the clean utility room and entered the room, therefore contaminating the door handle, code box and the contents in the room. 5 On 12/14/21, at 1:37 P.M., the surveyor observed a homemaker eating food in the dining room, without her mask on, with residents in the room. During an interview on 12/16/21 at 1:51 P.M., the Director of Nursing was informed of the observations.

Based on observation and interviews, the facility failed to ensure privacy during care for 2 Residents (#375 and #104) out of a total sample of 28 residents. Findings include: Review of the policy titled, Quality of Life - Dignity, undated, indicated the following: *Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Resident #375 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #375's most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #375 had a Brief Interview for Mental Status score of 8 out of a possible 15 which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #375 was dependent on staff for his/her daily care. On 12/15/21 at 9:28 A.M., a Certified Nursing Assistant (CNA) was providing morning care for Resident #375. The bedroom door was open and from the hallway the surveyor observed Resident #375's johhny (gown) pulled up above his/her waist as the CNA washed his/her genital area. The Surveyor entered the room and told the CNA that care was visible from the hallway. The CNA pulled the curtain partially closed and continued care, with the care still visible from hallway. A second CNA then walked into the room and closed the door. During an interview on 12/15/21 at 9:29 A.M., CNA #1 said the curtain needs to be pulled or doors need to be closed during all care to ensure a resident's privacy. 2. Resident #104 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #104's Minimum Data Set (MDS) dated [DATE], revealed Resident #104 had a Brief Interview for Mental Status (BIM) score of 13 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated that Resident #104 required extensive with activities of daily living. On 12/14/21 at 9:33 A.M., the Surveyor walked by Resident #104's room. Resident #104 was seen sitting on the toilet going to the bathroom. A Certified Nursing Assistant (CNA) was observed walking by the room, looked into the bathroom and then left without closing the door. A minute later the same CNA then entered the room again to collect a breakfast tray, again walked by Resident #104's bathroom without closing the door. The Director of Nursing then walked by Resident #104's bathroom, observed the Resident and then asked the CNA to close the bathroom door. During an interview on 12/15/21 at 9:29 A.M., CNA #1 said the curtain needs to be pulled or doors need to be closed during all care to ensure a resident's privacy.

Based on record review and interview, the facility failed to completely resolve 2 grievances. Findings include: Review of the facility policy, titled Grievance Policy, undated, indicated the following: * Resident has the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents. *Unresolved complaints will be documented in the grievance form and will be discussed in the interdisciplinary meeting within 3 business days of the complaint or knowledge of the complaint. * The facility will notify the resident and/or responsible party about the result of the investigation or search within 7 days after the initial interdisciplinary meeting. * Resolution can mean: - The item was found or the resident agreed not to pursue the item further - The item was replaced by the facility - The resident and/or responsible party is satisfied with the actions of the facility * Unresolved grievances will be reported to the facility's ombudsman for resolution. * All grievances should be addressed with the resident and/or responsible party for resolution within 30 days of the initial interdisciplinary meeting. If not resolved within 30 days, the facility will make a diligent effort to come up with a resolution as soon as possible. Review of the grievance log indicated that a grievance was filed on 12/10/20 and indicated the following: - A Resident had placed his/her dentures in a napkin and the dentures were thrown out. The Resident was seen on 12/29/20 by the dentist for a replacement. There was not further resolution indicated on the grievance. On 12/15/2021, the facility Social Worker provided the surveyor with a written resolution indicating that the Resident's daughter was told that the Resident's insurance would not cover dentures on 5/11/2021, but the facility was not notified. The Resident will now be seen by the dentist on 1/12/2022, over one year from the initial grievance, for new dentures that will be paid by the facility. Review of the grievance log indicated that a grievance was filed on 8/31/2021 and indicated the following: - A Resident's spouse told the facility that he/she could not find two hats and a hearing aide. The facility was unable to locate the hats or the right hearing aide. The grievance indicated that Health drive informed for earliest appointment for new hearing aides and all staff in the unit to look for the missing hats in other resident's rooms as some wandering resident might take hats and place them in someone else's room. There was no further resolution for the missing hats. On 12/15/2021, the facility Social Worker provided the surveyor with a written resolution indicating that the Resident's spouse was called on 12/15/21, over 3 months after the initial grievance, and offered to reimburse the spouse for the hats and the Resident will be seen by the audiologist in 03/2022.

Based on record review and interviews the facility failed to report an allegation of verbal abuse for one resident (Resident # 48) out of a total sample of 28 residents. Findings include: Resident #48 was admitted to the facility in July of 2021 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that Resident #48 has a brief interview of mental status exam (BIMS) score of 3 out of 15 indicating severe cognitive impairment and that he/she is dependent on staff for all daily care. Review of the facility policy titled Abuse Prevention Program: Reporting, not dated indicated that Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Reporting: if there is a suspicion of serious bodily injury that occurred as a result of abuse or suspected abuse a report to DPH (Department of Public Health) will be made immediately, and no later than two hours, after knowledge of the abuse or possible abuse. During an interview with Resident #48 on 12/14/21 at 8:03 A.M., he/she said to the surveyor that staff yells at me and tells me that I don't do things right. On 12/14/21 at 8:10 A.M., the surveyor told Nurse #7 what Resident #48 said. Nurse #7 said she would speak to the Resident, inform the Unit Manager of the allegation, and said an investigation would be done. During an interview on 12/16/21 at 2:44 P.M., the Director of Nursing said that an investigation had been made and it was determined that the allegation was a communication concern and was a customer services issue and not abuse and that is why it was not reported.

Based on observation, interview and policy review, the facility failed to investigate an allegation of abuse. Findings include: Review of the facility policy titled, Abuse Prevention Program: Reporting, undated, indicated the following: *It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. *Employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. *The Administrator and Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. Resident #104 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #104's Minimum Data Set (MDS) dated [DATE], revealed Resident #104 had a Brief Interview for Mental Status (BIM) score of 13 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated that Resident #104 required extensive with activities of daily living. During an interview on 12/14/21 at 8:35 A.M., Resident #104 told the surveyor that a Certified Nursing Assistant (CNA) was rough and mean while providing morning care. Resident #104 said that this CNA often yells at him/her. The surveyor immediately left the room and reported this to Nurse #3. During an interview on 12/14/21 at 8:38 A.M., Nurse #3 said that she would report this incident to the Director of Nursing (DON). The surveyor reapproached Nurse #3 on 12/14/21 at 9:37 A.M. Nurse #3 said that she left a message for the DON and Unit Manager on their voicemail but did not directly speak with them to inform them of Resident #104's allegation. From 8:38 A.M., to 9:37 A.M., the surveyor observed the CNA in question providing assistance to residents in the dining room as well as personal care to 2 other residents in their rooms. During an interview on 12/14/21 at 9:48 A.M. Unit Manager (UM) #1 said Nurse #3 left a message about the allegation of abuse on her phone and she did not receive the message until she got into work, approximately 1 hour after the allegation was told to nurse #3. UM #1 said that it was okay to leave a message, but expectation is that staff should find a supervisor immediately if they are told of an allegation of abuse. UM #1 said an investigation of the allegation of abuse would need to begin immediately. During an interview on 12/14/21 at 12:05 P.M., both the Administrator and Director of Nursing said that an allegation of abuse needs to be investigated immediately. The Administrator said the staff accused are to immediately be taken off the floor and are not allowed to provide care to any other residents until the investigation is complete. The Administrator said that staff must directly contact a supervisor to inform them of an accusation of abuse and leaving a message is not acceptable.

Based on observation, record review and interviews, the facility failed to revise a care plan with person centered interventions after two Minimum Data set Assessments (MDS) for 1 resident (Resident #80) out of a total sample of 28 residents. Findings include: Resident #80 admitted to the facility in September of 2014 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #80's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview of Mental Status Exam score of 11 out of 15 indicating a moderate impairment in cognition. Further review of the MDS indicated that the Resident expressed depression for the past ,d+[DATE] days in the look back period. On [DATE] at 11:53 A.M., during an interview with Resident #80, he/she said that I am miserable and do not want to be here. Review of progress notes in Resident #80's medical record indicated that Resident #80's spouse passed away in May of 2021. Review of Resident #80's care plan for behaviors dated as last revised [DATE], indicated the following interventions: -Assist resident with calling their spouse -When possible, let resident know when their spouse will be visiting next and what they will be doing. Review of the MDS assessments in the medical record indicated quarterly MDS were completed [DATE] and [DATE]. During an interview on [DATE] at approximately 11:00 A.M, Social Worker #1 said care plans are reviewed at the quarterly care plan meetings. Social Worker #1 said that Resident #80's spouse had died and that the interventions of calling Resident #80's spouse should have been revised and that it was an oversight.

Based on observation, record review and interview, the facility failed to provide assistance for activities of daily living for 2 Residents (#92 and #56) out of a total sample of 28 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, undated, indicated the following: *ADL (activities of daily living) assistance will be provided according to the needs of the resident. *ADL include: bathing, grooming, dressing, mobility, incontinence care, positioning, transfer, eating and others. 1. For Resident #92, the facility failed to provide showers and grooming care. Resident #92 was admitted to the facility in June 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #92's Minimum Data Set (MDS) dated [DATE] revealed that he/she was unable to complete the Brief Interview of Mental Status (BIMS) and staff had assessed him/her to have severe cognitive impairment. The MDS also indicated that Resident #92 was dependent on staff for personal hygiene. During observations on 12/14/21 at 8:45 A.M., and 12/15/21 at 9:25 A.M., Resident #92 was observed lying in bed. His/her hair was greasy and he/she had significant chin and above lip hair. When asked, Resident #92 said that he/she would like his/her chin hair removed. Review of Resident #92's behavior monitoring reports, medical chart and nursing assistance documentation for the months of November 2021 and December 2021 failed to indicate that Resident #92 refused care. During an interview on 12/15/21 at 9:41 A.M., Certified Nursing Assistant (CNA) #2 said that each resident has a care card which explains the level of care that resident requires. CNA #2 also said that the care card lists the day(s) the resident is scheduled for a shower. Review of Resident #92's care card indicated that it was not filled out under the section listing days of showers. A shower schedule provided to the surveyor indicated Resident #87 is scheduled for showers on the 3 A.M. - 11 P.M., shift on Tuesdays and Fridays. During an interview on 12/15/21 at 11:31 A.M., CNA #1 said that Resident #87 requires two staff for completion of activities of daily living. CNA #1 said that CNA's do not remove facial hair from residents, only the facility aesthetician does. During an interview on 12/15/21 at 4:59 P.M., CNA #10 said Resident #87 can be combative with care so requires two staff for care. CNA #10 said that she regularly provides care for Resident #87 on the 3 A.M. - 11 P.M., shift and does not give her showers, she provides bed baths only. During an interview on 12/16/21 at 9:26 A.M., the aesthetician said that she completes waxing of chin hair for residents who desire chin hair removed. The aesthetician said that she attempted to wax Resident #87 in July 2021 and that he/she refused. The aesthetician said that she told the nursing staff they would be responsible for removing Resident #87's unwanted chin hair and she would no longer offer Resident #87 her services 2. For Resident #56 the facility failed to provide grooming specifically for nail are. Resident #56 was admitted to the facility in June of 2013 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that he/she had a brief interview of mental status exam score of 3, indicating severe cognitive impairment and is dependent on staff for all aspects of daily care. On 12/14/21 at 11:18 A.M., Resident #56 was observed resting in bed. His/her fingernails on his/her right hand were long, jagged and had dark colored debris under the nails. His/her left hand was folded in, and his/her fingernails were not visible. 12/14/21 at 4:40 P.M., Resident #56 was observed resting in bed. His/her fingernails on his/her right hand were long and jagged. The middle, ring and pinky fingers had dark colored debris under the nails. Resident #56's left hand was folded in a fist and his/her fingernails were not visible. Review of Resident #56's medical record indicated a care plan dated 7/10/14 with the focus of Activities of Daily Living (ADL.) Resident is dependent on staff with all ADLs due to left side [CONDITION(S)] due to prior cerebral vascular accident. The care plan had the goal that the Resident will accept care as evidenced by being out of bed, well groomed, and complying with ADLs. Resident #56 was not care planned for refusing care or for behaviors. During an interview on 12/15/21 at 4:41 P.M., CNA #6 said Resident #56 had long fingernails and that CNAs are not able to trim them. He said there is someone in the facility that trims fingernails for residents. During an interview on 12/15/21 at 4:50 P.M., Nurse #1 said the Resident was in need of fingernail trimming but had refused the person who does the trimming. Nurse #1 and the surveyor observed Resident #56's left hand which revealed long jagged fingernails. Both of Resident #56's hands had long, jagged, unkempt fingernails.

Based on observation, record review and interview, the facility failed to develop and implement a treatment plan to prevent the worsening of buttock pressure ulcer from a Stage II to an unstagable ulcer for 1 Resident (#78) out of a total of 28 sampled Residents. Findings include: Review of the facility's Pressure Ulcer Treatment policy undated, indicated the following: Purpose: The propose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. *Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. *Stage III Pressure Ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. *Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. *Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and or eschar (tan, brown or black) in the wound bed. *Stage II Protocol: Clean, shallow, minimal drainage. Determine wound treatment per wound status, exudate, bio-burden, location and resident's underlying support system. Choose primary dressing from the following: hydrogel, hydrogel sheet, alginate, [MEDICATION(S)], barrier cream/past, foam. Cleanse with normal saline or wound cleaner. Change dressing per order and manufacturer indications. *Stage III Protocol: Protect, fill dead space including tunnels and undermining. Manage drainage and promote moist wound healing. No drainage: treatment; irrigate wound with normal saline or other designated wound cleanser. Change per order and manufacturers directions. *Stage IV Protocol: Protect, fill dead space including tunnels and undermining. Manage drainage and promote moist wound healing. Debride slough/eschar. Select the method of debridement most appropriate to the resident's condition and goals (note: this is a physician task). Irrigate wound with normal saline or other designated wound cleanser. Determine wound treatment per wound status, exudate, bio-burden, location and resident's underlying support system. Apply an alginate dressing, foam dressing or hydrogel dressing to wound cavity. Cover with secondary dressing and determine change rate per exudate and change per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. Wound appearance, including wound bed, edges, presence of drainage. 3. The name and title of the individual changing the dressing or initials. 4. The type of dressing used and wound care given. 5. All assessment data. (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound. Resident #78 was initially admitted to the facility in September 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that Resident #78 is dependent on staff for activities of daily living and is severely cognitively impaired. On 12/14/21 at 7:58 A.M. on on 12/16/21 at 7:27 A.M. the surveyor observed Resident #78 resting in bed on an air mattress. Review of Resident #78's care plans indicated: Potential for skin breakdown: Resident has potential for skin breakdown due to decreased mobility, 9/15/21 Goal: Resident will not have any new skin breakdown x 90 days. Interventions: Assess resident's skin condition on admission. Barrier cream per house protocol. Dietary consult as needed. Incontinent absorbent products as needed. Reposition patient every 2 hours with assist of 2 staff members. Weekly skin assessment by a licensed nurse. Review of Resident #78's skin assessment dated [DATE] and progress note dated 10/27/21 indicated that he/she had returned from a brief hospitalization with a stage II pressure ulcer on his/her left buttock. The skin assessment and progress notes failed to indicate a measurement or description of Resident #78's pressure ulcer. Review of Resident #78's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #78's skin assessments indicated: 10/30/21: Left Buttock - Pressure Ulcer; There was no indication on the stage, measurements, assessment, or treatments indicated for Resident #78. 11/3/21: Left buttock - Pressure Ulcer Stage II .5 X. 5; Note: Resident came back from Hospital with left buttock stage II. Left buttock is dry and healing well. Treatments: Left buttocks - [MEDICATION(S)] Cream. During an interview with Nurse #4 on 12/15/21 at approximately 10:30 A.M., she said that Resident #78 had developed a stage II pressure ulcer in the hospital and the use of [MEDICATION(S)] was an intervention to prevent pressure ulcers and was not considered a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Additional review of Resident #78's skin and wound assessments indicated: 11/6/21: Left buttock - Pressure. There was no indication on the stage, current measurement, or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 11/10/21: Left buttock .6 X .5 Stage II; Note: small slough to left buttock. (Slough from a pressure ulcer is indicative of a Stage III, not Stage II) Treatment: Left buttock - apply Santyl to slough area and cover with dressing daily. Review of Resident #78's initial wound physician note dated 11/16/21 indicated: Unstageable (due to necrosis) of the left buttock Etiology: Pressure Wound size: 1.2 X 1.3 X not measurable Surface area: 1.56 cm Exudate: light serious Necrotic tissue (dead tissue): 90% Slough: 10% Recommend debridement (a surgical technique of removing dead tissue to clean a wound) of left buttock wound to decrease the risk of infection and allow medication to better penetrate into wound. Review of the Treatment Administration Record indicated the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Nurse Practitioner on 12/16/21 at 12:58 P.M. he said that he was aware that Resident #78 had developed a pressure ulcer. The Nurse Practitioner said that he will usually put in a temporary order for Santyl (an ointment used to promote the healing of ulcers) until the wound physician comes in and then will take over the care of the Resident's wounds. The Nurse Practitioner said that he was not aware that Resident #78 had no treatment in place for his/her buttock wound until 11/12/21. The Nurse Practitioner said he was not aware that the wound physician had not seen Resident #78 until 11/16/21.

Based on observation, record review and interview the facility failed to ensure services necessary to maintain foot care was provided for two residents (#7 and #56) out of a total sample of 28 residents. Findings include: Review of the facility's policy, entitled Foot Care, not dated, indicated the purpose, serves as a guideline for provision of foot care for residents in the facility. Under the heading general guidelines, the policy indicated that 1. foot care includes the whole foot including nails, 2. proper footcare can aid in the prevention of skin problems around the foot, 3. If trimming is done in-house, it will be done according to the schedule of the podiatrist's building visit, 5. The facility will assist the resident with scheduling podiatry appointment. Under the heading of Resident Rights, the policy indicated that 1. residents' rights include receiving proper foot care, 2. Residents have the right to pick their own podiatrist contracted by the facility and to seek outside services as requested, 3. Residents right also include the right to decline services. 1. For Resident #7 the facility failed to provide foot care, specifically for trimming elongated, thick nails. Resident #7 was admitted to the facility in March of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview of Mental Status (BIMS) exam score of 8 out of 15 indicating moderate impairment in cognition. The MDS also indicated in Section G that Resident # 7 is totally dependent for care and has been so since his/her admission to the facility. On 12/14/21 at 12:22 P.M., Resident #7 said that her/his toenails are long and would like them to be cut. Review of Resident #7's record did not indicate that she/he has been seen by podiatry since admission. Review of Resident #7's care plan indicated that Resident is dependent on staff with all ADL's due to weakness related to metastatic cancer. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission documents in Resident #7's record dated 3/3/21 and signed by Resident #7 authorizes the facility to secure me services of its various designated health care providers such as lab, x-ray, dental, podiatry, consulting physicians, and other professional services I may requires during my residency at the facility. During an interview on 12/14/21 at 4:34 P.M. Resident #7 said she/he wanted to see the foot doctor because her/his feet need attention. Resident #7 said her/his toenails are long. Resident #7 proceeded to remove her/his sock on his/her left foot. Resident #7's toenails were observed to be thick, yellowed, elongated beyond toe, with flaky dry skin around the toes. During an interview on12/15/21 at 10:58 A.M., Nurse #6 and the surveyor observed Resident #7's toenails. Nurse #6 removed Resident #7's socks revealing her/his toenails to be elongated, thick, jagged and yellow with some scaly skin debris falling onto the sheet. Resident #7 said that I can't wear shoes because it will hurt, and I would need bigger shoes. Nurse #6 said she would look into Resident #7's request to be seen by the foot doctor. 2. For Resident #56 the facility failed to ensure foot care was provided. Resident #56 was admitted to the facility in June of 2013 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that he/she had a brief interview of mental status exam score of 3, indicating severe cognitive impairment and is dependent on staff for all aspects of daily care. On 12/14/21 at 11:18 A.M., Resident #56 was observed resting in bed. His/her fingernails on his/her right hand were long, jagged and had buildup of dark colored debris under the nails. His/her left hand and feet were not visible. Review of the Resident #56's care plans indicated a care plan for risk for complication due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no care plan indicating Resident #56 refused care. Review of Resident #56's medical record failed to indicate any documentation of services administered by a podiatrist. Review of the Resident #56's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Daily foot care dated 4/14/19. *May have podiatry consult as needed dated 2/20/14. During an interview on 12/15/21 at 4:41 P.M., about Resident #56's activities of daily care, CNA #6 said many residents need their toenails trimmed including resident #56. CNA #6 and the surveyor observed Resident #56's toenails. His/her left great toenail was elongated, curled, jagged, and extended beyond toe. The third toenail, and pinky toenail were also elongated and jagged. Resident #56's right great toe was amputated, and the remaining toenails were observed to be elongated and jagged. Both feet were observed with dry, flaky scaley skin surrounding the nails and all over his/her feet. On 12/15/21 at 4:46 P.M. Nurse #1 was made aware of the observation made by CNA #6 and the surveyor. The surveyor requested documentation of the last podiatry care visit provided to Resident #56 from the Director of Nursing. Review of the document provided by the facility indicated the contacted podiatrist last provided service to Resident #56's toenails on 11/4/20.

Based on record review and interview the facility staff, failed to ensure that PRN (as needed) [CONDITION(S)] medication was limited to 14 days, and that the physician evaluated the appropriateness to extend the use and document the rationale and the duration for the PRN medication, for 2 residents (#104 and #48) out of a total sample of 28 residents. Findings include: 1. Resident #104 was admitted to the facility in November 2021 with diagnoses that included [CONDITION(S)]. Review of Resident #104's Minimum Data Set (MDS) dated [DATE], revealed Resident #104 had a Brief Interview for Mental Status (BIM) score of 13 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated that Resident #104 required extensive with activities of daily living. Review of Resident 104's physician orders indicated the following order dated 11/11/21: *Lorazepam (anti-anxiety medication) - give 1 tablet by mouth every 24 hours as needed for anxiousness related to major depressive disorder, recurrent, in partial remission. The physician order failed to indicate and end date of the medication. Review of the Medication Administration Record (MAR) for November and December 2021, indicated that Resident #20 was administered the as needed Lorazepam 22 times since the order was written. During an interview on 12/16/21 at 8:12 A.M., Unit Manager #1 said that all as PRN (as needed) [CONDITION(S)] medications required as assessment from the physician as to reason for use, as well as an end date at which time the physician would re-assess the use of the medication. UM #1 said the rationale for use and duration of the medication order should be documented. 2. For Resident #48 the facility failed to determine the duration for the use of an as needed [CONDITION(S)] medication. Resident #48 was admitted to the facility in July of 2021 and had diagnoses include dementia with behavioral disturbance, hypertension, afrial fibrillation, major depressive disorder, chronic pain of right lower extremity and anticoagulant use. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that Resident #48 has a brief interview of mental status exam score (BIMS) of 3 out of 15 indicating severe cognitive impairment and that he/she is dependent on staff for all care. Review of the resident's physician's orders indicated the following order dated 7/9/21: [MEDICATION(S)] Solution 2mg/ml-give 0.25 sublingually every 4 hours as needed for anxiety/nausea. The physician order failed to indicate the duration of the as needed [MEDICATION(S)]. Review of the Medication Administration Record (MAR) for the past three months in 2021, indicated that Resident #48 was administered the as needed [MEDICATION(S)] five times in October, five times in November and six times in December as of 12/15/21.

Based on observation, record review and interview, the facility failed to provide dental services to 2 Residents (#87 and #13) out of a total sample of 28 residents. Review of the policy titled, Dental Services, undated, indicated the following: *Oral health services are available to meet the resident's needs. *Routine and emergency dental services are provided to our residents through: - A contract agreement with a local dentist or consultant dental company - Referral to resident's personal dentist - Referral to community dentist - Referral to other health care organizations that provide dental services 1. Resident #87 was admitted to the facility in August 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #87's most recent Minimum Data Set (MDS) dated [DATE] revealed he/she had a Brief Interview for Mental Status score of 13 out of a possible 15 which indicated Resident #87 is cognitively intact. The MDS also indicated that Resident #87 requires assistance from staff for all activities of daily living. During an interview on 12/14/21 at approximately 9:00 A.M., Resident #87 said that he/she had asked to see the dentist a year ago and was told that it would cost a lot of money and he/she could not be seen. Resident #87 said he/she would like a full dental cleaning and examination. Observation of Resident #87's mouth showed he/she had several missing teeth and his/her front lower gums were black. Review of Resident #87's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *May have dentist, optometrist, and podiatrist consults as needed for dental. optometry, and podiatry needs. Review of Resident #87's medical record failed to indicate Resident #87 was ever seen by the dentist. During an interview on 12/15/21 at 11:17 A.M., Nurse #1 said that she remembered Resident #87 complain about tooth pain about one year ago. Nurse #1 said that Resident #87 was never seen by the dentist because of the cost. During interviews on 12/15/21 at 11:22 A.M., and 2:45 P.M., the Medical Record Director said that she remembered Resident #87 requesting dental services a year ago secondary to complaints of tooth pain. The Medical Record Director said that the old Unit Manager was supposed to call Resident #87's spouse to sign the Resident up for dental services because his/her insurance would have covered all costs. The Medical Record Director said that the old unit manager must have not followed through with this as Resident #87 was never seen by the dentist. 2. Resident #13 was readmitted to the facility in March 202 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had a Brief Interview of Mental Status score of 13 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated Resident #13 required extensive assistance for functional daily tasks. During an interview on 12/14/21 at 2:05 P.M., Resident #13 said that he/she has both upper and lower dentures but has not seen his/her lower set of dentures in a couple of weeks. Review of Resident #13's oral assessments dated 3/7/21, 9/6/21 and 11/26/21 all indicated that Resident #13 had both upper and lower dentures. Review of the last year of dental visits to the facility failed to indicate Resident #13 was seen by a dentist. During an interview on 12/15/21 at 11:30 A.M., Nurse #1 said that Resident #13 has both upper and lower dentures. Nurse #1 said she was unaware that Resident #13 was missing dentures. Nurse #1 said she would look for the dentures. During a follow-up interview on 12/16/21 at 7:24 A.M., Nurse #1 said that she had looked for Resident #13's dentures and was unable to find them. Nurse #1 said she had not yet notified administration or looked further in laundry or the kitchen for them. Nurse #1 said she was unaware of how long Resident #13 had been missing his/her dentures.

Based on records reviewed and interviews for 1 of 3 sampled resident (Resident #1) the Facility failed to provide Resident #1 with prompt, appropriate medical treatment after Resident #1 began complaining of numbness, tingling and inability to move his/her lower extremities following a fall. The Hospital Physician said he was not notified by the Facility of Resident #1's complaints of lower extremity numbness, tingling or inability to move his/her legs until approximately 10 days after Resident #1's fall on 7/1/2015. Physician #2 said Resident #1 had complete paralysis of his/her lower extremities, was diagnosed with [REDACTED].#1's spine and had bled into his/her surgical site. Findings include: Resident #1's [DIAGNOSES REDACTED]. A Fall Risk Assessment, dated 6/18/2016, indicated Resident #1 was at risk for falls. An Admission Minimum Data Set Assessment, dated 6/25/2016, indicated Resident #1 was cognitively impaired and required extensive assistance of 2 people for transfers and toileting. A Facility Incident Report, dated 7/1/2016, indicated Resident #1 was being assisted with a transfer from the bed to commode by Certified Nurse's Aide (CNA) #1 and CNA #2 when Resident #1's legs became weak and he/she was lowered to the floor. The Incident Report indicated a nursing assessment was conducted and their were no injuries noted at the time of the incident. A Nurse's Progress Note, dated 7/1/2016, indicated that on 7/1/2016 Resident #1's legs gave out while being assisted by the CNA's and Resident #1 was lowered to the floor. The Nurse's Progress Note indicated Resident #1 had no injuries and the Nurse Practitioner (NP) was informed. A Nurse's Progress Note, dated 7/4/2016, indicated Resident #1 complained of inability to move his/her foot and inability to tolerate Physical Therapy. A Nurse Practitioner's (NP) Progress Note, dated 7/5/2016, indicated Resident #1 complained of lower extremity numbness, inability to stand, had very limited function, unable to work with rehab services, was worried and anxious about everything. The NP's Note indicated Resident #1's complaints were related to psychiatric issues and a message was left for the psychiatrist. There was no indication Resident #1's spinal surgeon was notified and no indication of any further medical diagnostic testing or treatment. A Physician's Progress Note, dated 7/6/2016, indicated Resident #1 was unable to stand and bear weight on his/her legs, deep tendon reflexes (DTR's, a brisk contraction of a muscle in response to a sudden stretch) were sluggish and daughter was requesting an urgent psyche admission. The Physician's Note indicated the Facility was awaiting bed availability at two psychiatric hospitals. There was no indication of any further medical diagnostic testing or treatment. A Physician's Progress Note, dated 7/11/2016, indicated Resident #1 said he/she was unable to move both lower extremities. A Physician's Progress Note indicated Resident #1 had sensory intact with motor loss of both lower extremities and an appointment was made for Resident #1 to be seen by his/her spinal surgeon on 7/12/2016. The Surveyor interviewed CNA #1 at 10:54 A.M. on 10/05/2016. CNA #1 said that on 7/1/2016 she and CNA #2 assisted Resident #1 out of bed to transfer to the commode. CNA #1 said Resident #1 complained of pain, legs became weak and CNA #1 and CNA #2 lowered Resident #1 to the floor. CNA #1 said Resident #1 was not injured and the nurse did an assessment of Resident #1. The Surveyor interviewed CNA #2 at 1:41 P.M. on 10/05/2016. CNA #2 said that on 7/1/2016 she and CNA #1 assisted Resident #1 out of bed to transfer to the commode. CNA #2 said Resident #1 wasn't able to stand and CNA #2 and CNA #1 lowered Resident #1 to the floor. CNA #2 said Resident #1 was not injured and the nurse did an assessment on Resident #1. The Surveyor interviewed the Hospital Physician at 10:10 A.M. on 10/11/2016. The Hospital Physician said Resident #1 was recovering from spinal surgery and the Facility should have called him immediately when Resident #1 complained of numbness, tingling and inability to move his/her legs. The Hospital Physician said he was not notified by the Facility of Resident #1's complaints of lower extremity numbness, tingling or inability to move his/her legs until approximately 10 days after Resident #1's fall on 7/1/2015. The Hospital Physician said Resident #1 was sent to the hospital and presented with paralysis of both lower extremities and diagnosed with [REDACTED]. The Hospital Physician said the Facility delayed notifying him and delayed seeking medical treatment, or words to that effect, when Resident #1 complained of symptoms. The Hospital Physician said Resident #1 had complete paralysis of his/her lower extremities, was diagnosed with [REDACTED].#1's spine and had bled into his/her surgical site. The Surveyor interviewed the Facility Physician at 11:27 A.M. on 10/13/2016 and at 1:11 P.M. on 10/17/2016. The Facility Physician said Resident #1 was lowered to the floor on 7/1/2016, had not sustained a fall and did not sustain any trauma from the incident. The Facility Physician said Resident #1 had a history of [REDACTED].#1's spinal surgeon was not called because Resident #1's complaints were thought to be related to psychiatric issues, not medical issues. The Facility Physician said he assessed Resident #1 on 7/11/2016 and referred Resident #1 back to his/her spinal surgeon because Resident #1 was not getting better. The Facility Physician said in hindsight or words to that effect, he knew Resident #1's spinal surgeon wanted to be called for any issues and Resident #1's spinal surgeon should have been called sooner. The Surveyor interviewed Physical Therapist #2 at 4:24 P.M. on 10/17/2016. PT #2 said Resident #1 regressed with therapy from the day he/she was admitted to the Facility. PT #2 said Resident #1 was often anxious, was a maximum assist of 2 for transfers from the day of admission and a mechanical lift transfer was recommended for Resident #1's safety on 7/5/2016. The Surveyor interviewed the Nurse Practitioner (NP) at 11:01 A.M. on 10/18/2016. The NP said she assessed Resident #1 on 7/5/2016 and Resident #1 had complaints of lower extremity numbness, inability to stand and had limited function. The NP said she did not order further diagnostic testing because Resident #1's circulation was intact and there were no neurological changes. The NP said Resident #1 had an extensive history of psychiatric issues and anxiety which contributed to fluctuations in Resident #1's functional ability and Resident #1's complaints were nothing new, or words to that effect. The NP said Resident #1's family member was present and requested immediate psychiatric follow up. The NP said she left a message for the psychiatrist. The Surveyor interviewed Nurse #2 at 11:42 A.M. on 10/18/2016. Nurse #2 said she assessed Resident #1 on 7/4/2016 for complaints of inability to move his/her foot and inability to participate with physical therapy. Nurse #2 said Resident #1 was able to move his/her foot on assessment. Nurse #2 said Resident #1 had a history of [REDACTED].#1's complaints were nothing new, or words to that effect. Nurse #2 said a family member was present and requested Resident #1 be seen by psychiatric services because Resident #1 was not at his/her baseline. Nurse #2 said she notified Resident #1's physician, the nursing supervisor and placed a call to the Facility's psychiatric services. Resident #1 was sent to the hospital on [DATE] with paralysis of both lower extremities, had surgery and was hospitalized .

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure that the medical staff provided prompt and appropriate treatment when Resident #1, who was recovering from spinal surgery, began to complain of symptoms of numbness, tingling and inability to move his/her lower extremities after a fall. The Facility Physician was aware Resident #1's symptoms continued to worsen over 10 days and no diagnostic testing or follow up with the Hospital Surgeon was ordered until Resident #1 presented with complete paralysis of both lower extremities and sent back to the hospital 10 days after a fall at the Facility. Findings include: Resident #1's [DIAGNOSES REDACTED]. A Fall Risk Assessment, dated 6/18/2016, indicated Resident #1 was at risk for falls. An Admission Minimum Data Set Assessment, dated 6/25/2016, indicated Resident #1 was cognitively impaired and required extensive assistance of 2 people for transfers and toileting. A Facility Incident Report, dated 7/1/2016, indicated Resident #1 was being assisted with a transfer from the bed to commode by Certified Nurse's Aide (CNA) #1 and CNA #2 when Resident #1's legs became weak and he/she was lowered to the floor. The Incident Report indicated a nursing assessment was conducted and their were no injuries noted at the time of the incident. A Nurse's Progress Note, dated 7/1/2016, indicated that on 7/1/2016 Resident #1's legs gave out while being assisted by the CNA's and Resident #1 was lowered to the floor. The Nurse's Progress Note indicated Resident #1 had no injuries and the Nurse Practitioner (NP) was notified and no new orders were given. A Nurse's Progress Note, dated 7/4/2016 and written by Nurse #2, indicated Resident #1 complained of inability to move his/her foot and inability to tolerate Physical Therapy. There was no documentation to indicate the Physician or Nurse Practitioner (NP) were notified. A Nurse Practitioner's (NP) Progress Note, dated 7/5/2016, indicated Resident #1 complained of lower extremity numbness, inability to stand, had very limited function, unable to work with rehab services, was worried and anxious about everything. The NP's Progress Note indicated Resident #1's complaints were related to psychiatric issues and a message was left for the psychiatrist. There was no indication Resident #1's spinal surgeon was notified and no indication of any further medical diagnostic testing or treatment. A Physician's Progress Note, dated 7/6/2016, and documented as signed by the Facility Physician, indicated Resident #1 was unable to stand and bear weight on his/her legs, deep tendon reflexes (DTR's, a brisk contraction of a muscle in response to a sudden stretch) were sluggish and daughter was requesting an urgent psychiatric admission. The Physician's Progress Note indicated the Facility was awaiting bed availability at two psychiatric hospitals. There was no indication of any further medical diagnostic testing or treatment. A Physician's Progress Note, dated 7/11/2016, and documented as signed by the Facility Physician, indicated Resident #1 said he/she was unable to move both lower extremities. A Physician's Progress Note indicated Resident #1 had sensory intact with motor loss of both lower extremities and an appointment was made for Resident #1 to be seen by his/her spinal surgeon on 7/12/2016. The Surveyor interviewed the Facility Physician at 11:27 A.M. on 10/13/2016 and at 1:11 P.M. on 10/17/2016. The Facility Physician said Resident #1 was lowered to the floor on 7/1/2016, had not sustained a fall and did not sustain any trauma from the incident. The Facility Physician said Resident #1 had a history of [REDACTED].#1's spinal surgeon was not called because Resident #1's complaints were thought to be related to psychiatric issues, not medical issues. The Facility Physician said he assessed Resident #1 on 7/11/2016 and referred Resident #1 to his/her spinal surgeon because Resident #1 was not getting better. The Facility Physician said in hindsight or words to that effect, he knew Resident #1's spinal surgeon wanted to be called for any issues and Resident #1's spinal surgeon should have been called sooner. The Surveyor interviewed the Nurse Practitioner (NP) at 11:01 A.M. on 10/18/2016. The NP said she assessed Resident #1 on 7/5/2016 and Resident #1 had complaints of lower extremity numbness, inability to stand and had limited function. The NP said she did not order further diagnostic testing because Resident #1's circulation was intact and there were no neurological changes. The NP said Resident #1 had an extensive history of psychiatric issues and anxiety which contributed to fluctuations in Resident #1's functional ability and Resident #1's complaints were nothing new, or words to that effect. The NP said Resident #1's family member was present and requested immediate psychiatric follow up. The NP said she left a message for the psychiatrist. The Surveyor interviewed Nurse #2 at 11:42 A.M. on 10/18/2016. Nurse #2 said she assessed Resident #1 on 7/4/2016 for complaints of inability to move his/her foot and inability to participate with physical therapy. Nurse #2 said she notified Resident #1's physician, the nursing supervisor and placed a call to the Facility's psychiatric services. The Surveyor interviewed the Hospital Physician at 10:10 A.M. on 10/11/2016. The Hospital Physician said Resident #1 was recovering from spinal surgery and the Facility should have called immediately when Resident #1 complained of numbness, tingling and inability to move his/her legs. The Hospital Physician said he was not notified by the Facility of Resident #1's complaints of lower extremity numbness, tingling or inability to move his/her legs until approximately 10 days after Resident #1's fall on 7/1/2015. The Hospital Physician said Resident #1 was sent to the hospital on [DATE] and presented with paralysis of both lower extremities and was diagnosed with [REDACTED]. The Hospital Physician said Resident #1 required surgery and was hospitalized .

4. For resident #20, the facility failed to provide effective interventions and supervision in order to prevent 10 falls from 10/9/10 to 5/18/11, of which one fall resulted in a skin tear and one fall which resulted in a hematoma that required an emergency room visit. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The falls care plan dated 9/6/10 included the following: * Re-orient to call for assistance by using call light * Proper foot wear at all times, example sneakers and slipper socks * Keep clutter free environment * Keep glasses within reach * Monitor for increased confusion and report to MD as necessary * Assist in toileting * Incontinent care as needed * Offer toilet at 5:00AM * Toilet upon wakening, before and after meal and at hour of sleep and as needed * Staff to assist resident around 7:00PM to wash his/her face and apply cream * Continue bed alarm Review of the medical record and the Resident Incident/Accident Report on 7/19/11 at 9:00AM, revealed that between the dates of 10/9/10 and 5/18/11, the resident sustained [REDACTED]. Fall #1- On 10/9/10 at 1:20PM, the resident "apparently sat on the trash bucket" while looking for papers in the drawer. The resident slipped off of the bucket onto the floor. The resident did not sustain any injury as a result of the fall. On 10/9/10 the care plan was changed to keep the bed in the low position when the resident is in bed. The Falls Meeting Review was held on 10/11/10 and the care plan was again changed to discontinue the low bed and continue physical therapy. Fall #2 - On 11/6/10 at 8:00AM, the resident lost his/her balance and fell in the bathroom. The resident did not sustain any injury as a result of the fall. As an immediate intervention after the fall was "patient instructed to use call light at all times - take patient to the bathroom." (No new interventions were developed as these approaches were included in the plan of care on 9/6/10.) On 11/8/10, the Falls Meeting Review was held. The care plan was changed to assist the resident with grooming before breakfast and per resident request, to discontinued the use of the alarm. Fall #3 - On 11/18/10 at 11:40PM, the resident was speaking to the nurse in the bathroom. The resident let go of the walker and fell to the floor. The resident did not sustain any injury as a result of the fall. The plan of care was altered to re-educated the resident on the correct use of the assistive device (walker). Additionally, the resident and staff were educated to minimize distractions while the resident is using the bathroom by keeping conversation minimal. Fall #4 - On 12/15/10 at 2:10PM, the resident was cold, stood up from his/her bed, and walked over to the heater to turn it on when the resident stepped backwards and fell . The resident hit his/her head, but was not injured. The plan plan of care was updated on 12/15/10, to include a bed alarm every shift and re-educate resident to call for help by using the call light. (No new interventions were developed as re-orienting the resident to the use call bell was included in the 9/6/10 plan of care and the resident had been re-instructed on the use of the bell on 11/6/10. In addition, the use of the bed alarm was included on the 9/6/10 care plan, and was discontinued on 11/8/10 per resident request.) Fall #5 - On 12/19/10 at 11:00AM, the alarm beeped and the resident was found on the floor and claimed to have been "fixing my stuff." The resident did not sustain any injury as a result of the fall. The immediate intervention was to re-educate to use the call bell at all times for help. (No new interventions were developed as this approach was included in the care plan on 9/6/10 and the resident was re-educated on 11/6/10 and 12/15/10.) The plan of care was altered to include hourly checks by staff, while the resident is awake. There was no written documentation to indicate that staff performed hourly checks as per plan of care. Fall #6 - On 12/31/10 at 4:45PM, the resident was in the bathroom and attempted to pick up a hat that had fallen on the floor. The resident did not sustain any injury as a result of the fall. As a result of the fall on 12/31/10, the Falls Meeting Review was held. The plan of care was changed to educate the resident not to pick up objects from the floor. An annual Minimum Data Set ((MDS) dated [DATE], revealed that the resident had moderately impaired cognitive skills. The resident required extensive assist of one for transfer and ambulation. Fall #7 - On 2/21/11 at 9:00AM, the resident was in his/her room with the CNA (Certified Nursing Aide). The resident was told by the CNA to wait. The resident stepped backwards to turn around and fell hitting his/her head against the wall. The resident did not sustain any injury as a result of the fall. As a result of the fall the care plan was changed to re-educate the resident not to walk backwards. A physical therapy screen was also obtained. Fall #8 - On 3/11/11 at 3:15AM, the resident was attempting to reach for tissues from the bedside table and slipped from the bed. The resident did not sustain any injury as a result of the fall. As a result of the fall, the care plan was changed to provide the resident with a "reacher ". The resident was also re-educated to use the call light. (No new interventions were developed as this approach was included in the care plan on 9/6/10 and the resident was re-educated on 11/6/10, 12/15/10 and 12/19/11.) Fall #9 - On 3/19/11 at 4:20PM, the resident was in the room with the CNA. The CNA was attempting to get the resident up to go to the bathroom when the resident slipped off the side of the bed to the floor. As a result of the incident, the resident sustained [REDACTED]. An x-ray, taken on 3/22/11 revealed a dislocated left shoulder, however another x-ray taken on 3/25/11 revealed that the shoulder was not dislocated. The care plan was changed to place non-skid strips by the residents bedside on the floor. A quarterly assessment dated [DATE], revealed that the resident is cognitively intact. The resident required extensive assist of 1 for transfer and ambulation. Fall #10 - On 5/18/11 at 3:00PM, the resident stood up without calling for help and fell . The resident sustain an "egg size lump on the back of the head." As a result of the fall, the physician ordered that the resident be sent to the emergency room for further evaluation. A CT scan (computed tomography) was negative for hematoma or fracture. The plan of care was changed to include the use of a low bed and alarms. (No new intervention were developed as this approach was included as the use of a low bed had been implemented on 10/9/10, but discontinued on 10/11/10. The use of alarms was on the 9/6/10 care plan and was re-instated on 12/15/10.) Observation of the resident on 4 of 5 days (7/13 at 11:30AM and 12:22PM, 7/14 at 8:15AM and 11:45AM, 7/18 at 11:35AM and on 7/19/11 at 8:00AM) of survey revealed that the resident communicated easily and appeared alert and oriented. Further record review failed to indicate that the facility had worked/discussed with the resident (who the facility had identified as being cognitively intact) to develop new interventions/approaches to prevent falls. Interview on 7/19/11 at 10:45AM, with Unit Manager #1, revealed that the resident is "head strong and does what s/he wants." The Unit Manager also indicated that the resident is very smart and that the resident has been educated. Interview with the Director of Nurses on 7/19/11 at 4:00PM, revealed that the resident is very alert and requests independence with mobility. 5. For resident #7 the facility failed to provide effective interventions and supervision in order to prevent the 5 falls (from 10/3/10 to 5/25/11). Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed that the resident had impaired long term memory and modified independence with decision making. The resident required extensive assistance with transfer and independence with locomotion. Review of the 7/2010 plan of care falls revealed the following; * Call light within reach. Check patient if unable to use call light. * Monitor patient for toileting needs * PT/OT evaluation and treatment as needed * Assist patient during mobility in wheelchair * Assist patient during transfer * Maintain a clutter free environment Record review on 7/14/11 at 1:50PM, revealed the following falls; Fall #1 - On 10/3/10 at 12:30AM, the resident was found on the floor in front of the bed. The resident was attempting to self-transfer to the wheelchair in order to go to the bathroom. The facility failed to follow the plan of care which indicated that the resident required assistance during mobility in wheelchair and assistance during transfer. The resident did not sustain any injury as a result of the fall. As a result of the fall, the plan of care was altered to include the use of a bed alarm. In addition, the facility's interventions included resident education to lock the wheelchair prior to transfer and if in pain call for help, a rehabilitation screen, to check wheelchair brakes was ordered. Fall #2 - On 10/30/10 at 11:00AM, the resident fell while transferring from the wheelchair to the toilet. The facility failed to follow the plan of care which indicated that the resident required assistance during mobility in wheelchair and assistance during transfer. The resident did not sustain any injury as a result of the fall. As a result of the fall, the plan of care was altered to include toilet before and after meals and at hour of sleep. The use of alarms was discontinued as they had been refused by the resident. The resident was also educated to ask for help. Fall #3 - On 1/7/11 at 3:45AM, the resident fell while trying to get out of bed to go to the bathroom. The resident stated "I was trying to get out of bed to the bathroom and the bed moved." The facility failed to follow the plan of care which indicated that the resident required assistance during transfer. The resident did not sustain any injury as a result of the fall. As a result of the fall, the plan of care was altered to include continue toileting at hour of sleep and to re-educate resident to use call light when s/he wants to use the toilet. (No new interventions to the plan of care were developed as toileting at hour of sleep and asking for help were already implemented on 10/30/10.) The annual minimum data set ((MDS) dated [DATE] revealed that the resident had moderately impaired cognitive skills, transferred with assist of one and limited assistance and was mobile in a wheelchair with supervision. Fall #4 - On 5/25/11 at 4:15AM, the resident fell while in the bathroom and transferring from the wheelchair to the toilet. The facility failed to follow the plan of care which indicated that the resident required assistance during mobility in wheelchair and assistance during transfer. The resident did not sustain any injury as a result of the fall. As a result of the fall, the plan of care was altered to include toilet at hour of sleep. (No new interventions to the plan of care were developed as toileting at hour of sleep was already implemented on 10/30/10 and 1/7/11.) Fall #5- On 5/25/11 at 2:45PM, the resident fell while attempting to transfer from the wheelchair to the toilet. The facility failed to follow the plan of care which indicated that the resident required assistance during mobility in wheelchair and assistance during transfer. The resident did not sustain any injury as a result of the fall. As a result of the fall, the plan of care was altered to include obtaining a urinalysis and other laboratory findings, obtain a physical therapy screen and implement the use of a bed and chair alarm. The use of alarms had been previously attempted on 10/3/10, but were discontinued on 10/10/10 due to resident request. The quarterly assessment 6/26/11 revealed that the resident had moderately impaired cognitive skills, transferred with extensive assist of one and was independently mobile in a wheelchair. Observation of the resident on 4 of 5 days of survey, (7/13 at 11:30AM, 12:22PM and 2:30PM, 7/14 at 8:15AM, 11:45AM and 2:15PM, 7/18 at 11:35AM and 3:15PM and on 7/19/11 at 8:00AM) revealed that the resident communicated easily and appeared very alert and oriented. The resident was observed being mobile in his/her wheelchair. Interview with Unit Manager #1 on 7/19/11 at 10:50AM, revealed that the resident has opinions about his/her care and enjoys being independent and mobile. The facility failed to intervene and implement plans of care in order to prevent further falls and maintain the resident's safety. 6. For resident #13 the facility failed to provide effective interventions and supervision in order to prevent the 5 falls (from 10/2810 to 6/11/11). Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual minimum data set ((MDS) dated [DATE] revealed that the resident had impaired long and short term memory and severely impaired decision making skills. The resident transferred with extensive assistance of two and was mobile via wheelchair with extensive assistance of one. The plan of care for falls was originally dated 5/2010 and as of 9/11/10 the plan of care contained the following approaches: * Call light within reach. Check patient if unable to use call light. * Monitor patient for toileting needs * PT/OT evaluation and treatment as needed * 2 Assist patient during transfer * Bed/chair alarm at all times. * Bed in lowest position. * Attend activities during the day * Patient will be toileted upon rising, after meals and as needed. The plan of care for incontinence was dated 5/2010 and contained the following: * Incontinent care per house protocol * Incontinent absorbent products daily * Monitor for increased confusion, not patient's base line, to MD/RNP * Collect urine for UA/C+S as ordered * Totally dependent in toileting * Patient will be toileted upon rising, after meals and as needed. Record review on 7/18/11 at 10:50AM, revealed the following falls; Fall #1 - On 10/28/10 at 3:45PM, the resident was found on the floor by the bed having fallen while attempting to self transfer from the wheelchair to the bed. The resident did not sustain any injury as a result of the fall. As a result of the fall, the plan of care was altered to include a bed and chair alarm. (No new interventions to the plan of care were developed as the use of alarms was already on the plan of care as of 9/11/10.) Fall #2 - On 11/30/10 at 4:30PM, the resident was found sitting on the floor by the bedside, after having attempted to transfer from bed to the wheelchair. As a result of the fall, the resident complained of pain to the left shoulder/clavicle and was noted to have a bruise to the left clavicle. An x-ray taken at the time of the fall and ruled out a fracture. As a result of the fall, the plan of care was altered to include bed and chair alarms in place at all times, patient to attend activities during the day, bed in lowest position at all times. (No new interventions to the plan of care were developed as the use of alarms was already on the plan of care as of 9/11/10 and 10/28/10. The resident attending activities and bed in lowest position were already on the plan of care as of 9/11/10.) Review on 7/18/11 at 11:00AM, of the Rehabilitation Department Review dated 12/1/10 revealed that the resident was to have an alarmed clip belt. However, this was never documented or implemented on the plan of care. Fall #3- On 12/4/10 at 10:00AM, the alarm sounded and the resident was found in the bathroom after self transferring. The resident went to the bathroom alone even though, the care plan states that the resident is totally dependent for toileting. The resident did not sustain any injury as a result of the fall. As a result of the fall, the plan of care was altered to include toilet every 2 hours. (No new interventions to the plan of care were developed as care plan for incontinence dated 5/1010 already indicated that the resident was totally dependent in toileting and was to be toileted upon rising, after meals and as needed.) Fall #4 - On 1/25/11 at 11:30AM, the resident fell while attempting to self-transfer from the wheelchair to the toilet. The wheelchair cushion slipped out of the wheelchair. The staff were not assisting this resident as per plan of care. The resident did not sustain any injury as a result of the fall. As a result of the fall, a Dycem (a non skid material) was added to the wheelchair to prevent slipping. The quarterly assessment dated [DATE] revealed that the resident had severely impaired cognitive skills. The resident was totally dependent for transfer with assistance of two and was mobile via wheelchair with extensive assistance of one. Fall #5 - 6/11/11 at 6:40PM, the resident slipped to the floor while attempting to self transfer to the toilet. Again, the resident was self transferring and the resident is totally dependent for toileting. The resident did not sustain any injury as a result of the fall. As a result of the fall, the plan of care was altered to include toilet every night before bed. (No new interventions to the plan of care were developed as care plan for incontinence dated 5/10/10 and again on 12/4/10 indicated that the resident was totally dependent in toileting and was to be toileted upon rising, after meals and as needed.) Observation on 4 of the 5 days of survey, (7/13/11 at 11:45AM, 7/14/ at 11:55AM , 7/18/11 at 12:10PM and 7/19/11 at 7:55AM and 1:30PM) revealed that the resident sat in a wheelchair and was confused. Interview with Unit Manager #3 on 7/18/11 at 11:15AM, revealed that the resident had dementia and was confused. The Unit Manager also indicated that the resident had a history of [REDACTED]. The facility failed to intervene and implement plans of care in order to prevent further falls. Based on record review, interview, and observations, the facility failed for 6 sampled residents (#6, 7, 11, 13, 18 and 20) of 11 residents with falls out of a total sample of 24 residents to provide effective interventions and adequate supervision to prevent injury. Findings include: 1. For Resident # 6, the facility failed to provide effective interventions and adequate supervision to prevent 4 falls (from 9/2/10 to 6/25/11) of which one fall resulted in a fractured hip. Resident #6 was admitted to the nursing facility in February 2010 with [DIAGNOSES REDACTED]. A care plan was developed on 5/16/10 for "patient at risk for falls due to decreased muscle strength related to CVA (Cerebral Vascular Accident), psych med use, status [REDACTED]. Interventions included: - Assess patient for risk of falls on admission, quarterly and as needed. - Call light within reach. Check patient if unable to use call light. - Monitor patient for toileting needs. - PT (physical therapy)/OT (occupational therapy) evaluation and treatment as needed. - Medications as ordered. Monitor for side effects as needed. - Labs as ordered. - Psych consult as ordered. - ______(line has 1-2A(assist) but is crossed out) patient during mobility with rolling walker and assist. - ______(line has 1-2A(assist) but is crossed out) patient during transfer Assist. - Toilet at 6AM and bedtime. A Quarterly MDS (Minimum Data Set) Assessment, dated 8/13/10 and reviewed on 7/14/11 documents the resident as having short and long term memory losses with moderate impairment in daily decision making. The resident is easily distracted and mental function varies over the course of the day. The resident requires extensive assist with transfers, walking and toilet use. The resident has partial range of motion limitations on one side affecting a leg and foot. The resident is documented as incontinent of bowel and bladder with no scheduled toileting plan. A nurse's note dated 9/2/10 documents that the resident fell in the bathroom on 9/2/10 at 6:30AM. The Resident Incident/Accident Report documents that the Certified Nursing Assistant (CNA) assisted the resident to the bathroom and the CNA turned her back, and the resident lost his/her balance and fell backwards against the wall falling onto his/her bottom. The resident sustained [REDACTED]. However, the written statement of the registered nurse (RN) on duty at the time, documents that the CNA was observed in the hallway and was noted to run into the bathroom of Resident #6's room. "CNA was walking patient into bathroom and left her/him. RN instructed CNA never to leave a fall risk/unsteady patient by him/herself in the bathroom." A care plan review note, dated 9/2/10 (and reviewed on 7/14/11) documents "patient fell in AM in bathroom when aide was toileting. Patient screened by rehab, ortho Q (every) 72 hours (?orthostatic blood pressure) every shift, re-educate patient take his/her time getting up in AM." (The review note does not address being left alone in the bathroom and the fall did not involve getting up too quickly). The immediate intervention documented on the Incident/Accident form of never leaving a fall risk resident alone in the bathroom was not documented as discussed and was not added to the plan of care. The resident fell again on 12/25/10 while being assisted by a CNA to get out of a chair and lost his/her balance. The resident did not sustain an injury. The care plan review documents to continue the care plan. The Annual Minimum Data Set, dated dated [DATE] continues to document cognitive deficit, with a BIMS (screening tool that aids in detecting cognitive impairment) score of 6 out of a possible score of 15 (the score indicates severe impairment in recall and orientation). The resident is documented as needing extensive assistance of 2 people for transfers, extensive assistance of one person for mobility and as being unsteady when standing or walking. The care plan was not updated for the increased need of assistance (specifically the need for the assistance of 2 people) with transfers and mobility. The care plan continued to document 'assist' with both mobility and transfers. On 3/1/11, the resident fell again when the resident attempted to sit in a chair in the dining room (no injury sustained). The care plan review documents that the resident was educated to wait for assistance to be seated (the resident is severely impaired in cognition and may not remember the education given). No changes were made to the actual care plan for falls. A nurse's note, dated 6/25/11, and reviewed on 7/14/11, documents that the "resident found on floor inside the bathroom lying on right side, fall unwitnessed, unable to move right leg and complained of severe pain when trying to move, also had lump/bruise on right side of forehead." The resident was sent to the hospital and diagnosed with [REDACTED]." The history and physical section of the discharge summary from the hospital documents "patient notes that he/she brought to the bathroom by assistants at the facility, but they didn't return to help him/her back to bed. He/she therefore attempted ambulating on his/her own and was unable to maintain balance." Review of the Incident/Accident Report, dated 6/25/11 and reviewed on 7/18/11 documents that the "resident was trying to wipe him/herself, stood up and fell ." A CNA written statement documents that the resident was "left on toilet for a few minutes and instructed to use the call light which was in reach and he/she did not call because he/she thought that he/she could get up and go by him/herself." The Incident/Accident Meeting Review, dated 6/27/11 documents that the resident is not to be left alone in the bathroom when he/she returns (from hospital). This intervention was added to the care plan on 6/30/11. A Quarterly MDS Assessment, dated 7/14/11, and reviewed on 7/18/11 documents the resident as dependent in transfers with the assistance of 2 people. The resident requires the same level of assistance for bed mobility and toileting. The BIMS score documents a score of 10 out of 15 (moderately impaired cognition). The Administrator and Director of Nurses, when told of the concerns regarding this resident's falls on 7/19/11 at 4PM, stated that the resident was alert and oriented (even though the BIMS documented the resident as being moderately to severely impaired in cognition) and that the resident was not dependent in transfers, toileting and bed mobility on a regular basis. The Director of Nurses stated that the resident was scored as dependent because the resident had required that level of assistance only 1-2 days during the assessment period for the MDS and Quarterly Assessments. The Director of Nurses stated that the resident requested to be left alone in the bathroom and that the resident could be in the bathroom for up to 30 minutes at a time. The Director of Nurses stated "I cannot leave a nurses aide outside the resident's bathroom door for that long a time and the resident will not allow staff to stay in the bathroom." The Director of Nurses could not explain why a care plan had not been developed with interventions, to address how to safely allow privacy in the bathroom for a resident identified as being at high risk for falls. The facility could not provide any documentation that the resident would not allow staff to stay in the bathroom or that the resident had requested to be left alone in the bathroom. 2. For Resident #11, the facility failed to provide effective interventions and adequate supervision to prevent 5 falls (from 9/5/10 through 6/5/11) after the resident fell and sustained a fractured hip in August 2010. Resident #11 was admitted to the nursing facility in May 2010 with [DIAGNOSES REDACTED]. A care plan for falls was implemented on 6/1/10 and remains current. Interventions included: - Assess patient for risk for falls on admission and quarterly and as needed. - Call light within reach. Check patient if unable to use call light. - Monitor patient for toileting needs. - PT/OT evaluation and treatment as needed. - Medications as ordered. Monitor for side effects as needed. - Labs as ordered. - Psych consult as ordered. - Extensive assistance of 1 during mobility. - Extensive assistance of 1 during transfer. On 7/25/10 interventions added to the care plan included: - Bed alarm Q (every ) shift; check placement and function. - Re-educate patient to use call light when assistance is needed, as needed. A Quarterly MDS Assessment, dated 9/10/10, documents the resident as having no long or short term memory losses. The resident is documented as moderately impaired in daily decision making and having periods of restlessness. The resident requires extensive assistance with transfers, is totally dependent for mobility and requires limited assistance with toileting. Resident #11 is documented as having had falls within the past 30 days, 31 to 180 days and a hip fracture in the last 180 days. Nurses' notes, dated 9/15/10, document that the resident was lowered to the ground by a CNA after the resident's legs scissored (crossed over one another) and were unable to be safely uncrossed. The resident was then assessed (no injury) and assisted into a wheelchair due to an unsteady gait with a chair alarm on and functioning. On 10/21/10, an intervention added to the falls care plan was for seat belt in wheelchair-teach patient to release and fasten seatbelt as needed. The 12/3/10 Quarterly MDS Assessment documents the resident as cognitively intact (BIMS score of 13 out of 15). The resident requires the extensive assistance of 1 person for transfers and toileting and is incontinent of both bowel and bladder. Resident #11 fell on [DATE]. Nurses' notes document that at 11:20PM on 12/23/10, two CNAs called out that resident had fallen out of bed. The nurse's note documents that the resident was on the floor on his/her buttocks without injury. The Incident/Accident Report of 12/23/10 documents that the bed alarm was on and functioning. The report documents that the resident was reaching for a blanket at the end of the bed and slipped off the bed. The report documents that the resident was re-educated on the use of a reacher and use of the reacher was demonstrated. This intervention was added to the care plan on 12/25/10. The resident had another fall on 3/26/11. The nurse's note, dated 3/26/11 indicated that the Resident was found on the floor holding onto the siderail of the bed. "Resident states trying to pick up a piece of paper off the floor and slid out of bed." The nurse's note further documents "N.O. (new order) bed alarm at all times when in bed." The Incident/Accident Report, dated 3/26/11, documents the supervisor/unit manager's intervention as 'bed alarm, check placement Q shift.' (This has been an intervention since 7/25/10). The resident did not sustain an injury. An intervention, dated 3/26/11, was added to the care plan for a bed alarm, check placement and function Q shift (the bed alarm has been and still is listed as an intervention implemented on 7/25/10). The resident fell again on 3/28/11. A nurse's note of 3/28/11 at 12:40AM documents that Resident #11's roommate came to the nurses desk to report that Resident #11 had fallen. The nurse's note documents that the resident was found on the floor near his/her roommates bed. A bump was noted on the right side of the resident's head. The Incident/Accident Report, dated 3/28/11 documents that the alarm was on the wheelchair when checked and was not working (not on the bed per the care plan). The immediate intervention was to place the alarm on the bed (indicative of the alarm not being on the bed per the plan of care). The supervisor/unit manager's final intervention was to implement a low bed and to utilize bed and chair alarms (the alarms have been on the resident's care plan since 7/25/10. A CNA written statement attached to the Incident/Accident Report documents that the resident was placed back in bed. After the fall of 9/15 /10, nurses notes document use of a chair alarm, but this was not added to the falls care plan as an intervention.). The care plan review, dated 3/28/11 documents to continue with use of bed and chair alarms, however, the chair alarm was not listed as an intervention on the falls care plan. An intervention was added for a low bed at all times. Again on 3/30/11, the resident fell . On 3/30/11, at 12:30AM, nurses' notes document that Resident #11's roommate came to the nurses station to report that the resident was on the floor next to the door of the room. The note documents that the bed alarm was not connected. The resident did not sustain any injury. (This is a second fall within 2 days, both in which the bed alarm was not connected.) On 6/6/11, a nurses note documents that at 9:30PM, an alarm was sounding and Resident #11 was found on the floor. The note documents that the resident stated he/she fell out of bed. The Incident/Accident Report states that the alarm was sounding (as filled out by the nurse on duty) and that the bed was placed in lowest position (however, this is an intervention as of 3/28/11 and should have already been in place at the time of the fall.) Additionally, the CNA written statement documents that the CNA "was walking by patient's room and his/her roommate stopped me and said (resident's name) was on the floor. I got the nurse and we took vital signs and got him/her back into bed." (This written statement conflicts with both the nurses note of 6/6/11 and the Incident/Accident Report initial report which states the alarm was on and sounding). The Administrator and Director of Nurses, whe