Every finding on record at Leominster Rehabilitation and Nursing Center

Based on observations and interviews the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically,1. The facility failed to ensure that medications were dated once opened, according to manufacturer's guidelines in two of two medication carts observed.2. The facility failed to ensure medication and treatment carts were locked while a nurse was not present on all units.Findings include:Review of the facility policy Medication Labeling and Storage, dated February 2023, indicated The facility stores all medications and biologicals in locked compartments. Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 1. During a medication storage task on [DATE] the surveyor identified the following on the East Unit Medication cart: -two Ventolin HFA inhalers, open and in use, not dated. During a medication storage task on [DATE] the surveyor identified the following on the [NAME] Unit Medication cart: -two Ventolin HFA inhalers, open and in use, not dated. -one Spiriva inhaler, open and in use, not dated. -one Trelegy inhaler, open and in use, not dated. During an interview and observation on [DATE] at 10:43 A.M., Nurse #3 said that each nurse is responsible for labeling the inhalers when they are opened but they did not as these inhalers are not dated when opened. During an interview on [DATE] at 10:44 A.M., the Assistant Director of Nurses (ADON) said the nurses are responsible to date the inhalers when they are opened so each nurse is aware of when they will expire. During an interview on [DATE] at 11:21 A.M., the Director of Nurses (DON) said she expects the nurse who opens a new inhaler to date it so any other nurse that administers the inhaler to a resident knows when it is expired. 2. On [DATE] at 6:54 A.M., the surveyors entered the facility and observed unlocked and unattended medication and treatment carts on all three units of the facility. The surveyor was able to gain access to both medication and treatment carts where medications are stored. The surveyors observed multiple residents awake and in the hallways in the vicinities of the unlocked and unattended medication and treatment carts. On [DATE] at 8:01 A.M., on the South Unit the surveyor observed an unlocked and unattended treatment cart in the hallway. The surveyor was able to gain access to the treatment cart which contained medicated ointments and other supplies. During an interview on [DATE] at 8:04 A.M., the Director of Nurses observed the unlocked treatment cart and said that her expectation is that medication and treatment cart are locked when they are unattended. The Director of Nurses was made aware of unlocked and unattended medication and treatment carts during the surveyor's entrance into the facility and she said the expectation is that at all times, the carts are locked when unattended.

Based on observation and interview the facility failed to maintain a clean and comfortable home like environment for one Resident (#40) out of a total sample of 21 residents. Specifically, Resident #40's privacy curtain was soiled with a blood-like substance. Findings include:Review of facility policy titled Homelike Environment, dated February 2021, indicated the following:-Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.-The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect personalized, homelike setting. These characteristics include: a clean, sanitary and orderly environment. Resident #40 was admitted to the facility in September 2021 with diagnoses that included schizophrenia, bipolar disorder and chronic kidney disease. Review of Resident #40's Minimum Data Set (MDS) Assessment, dated 9/3/25, indicated a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. On 11/18/25 at 7:49 A.M., the surveyor observed Resident #40 sleeping in bed. The privacy curtain around Resident #40's bed was observed to be soiled with a dried blood-like substance throughout the curtain. On 11/19/25 at 8:07 A.M., and 9:50 A.M., the surveyor observed the privacy curtain around Resident #40's bed to be soiled with a dried blood-like substance throughout the curtain. Resident #40 declined to participate in an interview. During an interview on 11/19/25 at 9:23 A.M., Certified Nurse Aide (CNA) #3 said that she noticed the privacy curtain was stained last night when she worked on the 3:00 P.M. to 11:00 P.M. shift but that there was no one in the facility to notify for it to be changed. She said it is blood from a bloody nose that is dried onto the curtain. She said staff should have asked housekeeping to change the curtain immediately when it was observed. During an interview on 11/19/25 at 9:43 A.M., The Director of Social Services said that she is the ambassador for Resident #40's room and checks in daily. She said that she saw the curtain was stained with a dried substance yesterday and asked someone to change it, but they did not. She said it was not home-like to have a stained privacy curtain. During an interview on 11/19/25 at 12:48 P.M., the Director of Nurses observed the stains on the privacy curtain and said that staff should have immediately reported the staining and had the curtain replaced.

Based on observation, record review and interview the facility failed to develop a plan of care for one Resident (#29) and failed to implement a plan of care for two Residents (#4 and #51) out of a total sample of 21 residents. Specifically:1. For Resident #29 the facility failed to develop a plan of care for a pacemaker.2. For Resident #4 the facility failed to implement a physician's order for the use of a low air loss mattress.3. For Resident #51 the facility failed to implement a physician's order for a soft blue boot to the left foot. Findings include: Review of the facility policy titled Pacemaker, Care of a Resident with dated revised September 2023 indicated the following: For each resident with a pacemaker, document the following in the medical record and on pacemaker identification card on admission: a. The name address and telephone number of the cardiologist. b. Type of pacemaker. c. Type of leads. d. Manufacturer and model. e. Serial number. f. Date of implant. g. Paced rate. Further review indicated that the pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this. Make sure the medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. 1. Resident #29 was admitted to the facility in June 2022 with diagnoses including cognitive impairment, angina pectoris, and presence of a pacemaker. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 scored a 1 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the clinical record indicated Resident # 29 has a cardiac pacemaker. Further review failed to indicate the type of pacemaker. Review of the physician orders failed to indicate orders for the care of the pacemaker. Review of the care plan dated revised 5/6/25 failed to indicate directives for the care of the pacemaker. During an interview on 11/19/25 at 7:55 A.M. Nurse #1 said she has been Resident #29's full time nurse since she started a year and a half ago. Nurse #1 then said that since she has worked here Resident #29 has not had a pacemaker check. Nurse #1 said that she would expect there to be a physician's order for the care of the pacemaker. During an interview on 11/19/25 at 8:17 A.M. the Director of Nursing said that she would expect a physician's order to be present directing the nursing staff on how to care for the pacemaker. 2. Resident #4 was admitted to the facility with diagnoses that included kyphosis, dysphagia, hypotension, and altered mental status. Review of Resident #4's most recent Minimum Data Set (MDS) assessment, dated 9/10/25, indicated he/she scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairments. The MDS also indicated the Resident is at risk for developing pressure ulcers and has one unhealed stage 3 pressure ulcer. Review of Resident #4's most recent Norton Scale (Scale for predicting risk of pressure ulcers), dated 4/10/25, indicated he/she scored a 14 indicating the Resident is at moderate risk for developing pressure ulcers. Review of Resident #4's physician order, dated 4/2/25, indicated Low Air Loss Mattress weight 114 every shift for preventive skin care check proper functioning. Review of Resident #4's November 2025 Treatment Administration Record (TAR), indicated from November 1st through November 18th every shift the order of the Low Air Loss Mattress was signed off as administered by nursing staff. Review of Resident #4's actual skin integrity care plan, dated 9/9/25, indicated low air loss mattress, settings according to weight. Review of Resident #4's active Certified Nurse Aide (CNA) Kardex (form that explains the needs of the Resident), indicated low air loss mattress, settings according to weight. During observations made throughout survey the Resident was in bed and not on an air mattress. During an interview on 11/19/25 at 9:08 A.M., Certified Nurse Aide (CNA) #1 said she takes care of Resident #4 often and the Resident stays in bed. CNA #1 said the Resident has not been on an air mattress. During an observation and interview on 11/19/25 at 9:08 A.M., Nurse #2 said if a Resident has an order for an air mattress, then an air mattress should be in place. Nurse #2 said Resident #4 is not on an air mattress, and the Resident is in bed. During an interview on 11/19/25 at 11:41 A.M., the Director of Nurses (DON) said Resident #4 is at risk for skin breakdown and the air mattress should be in place as ordered as it is an intervention for their skin. 3. Resident #51 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis, dysphagia, muscle wasting and atrophy, and major depressive disorder. Review of Resident #51's most recent Minimum Data Set (MDS) assessment, dated 9/3/25, indicated he/she scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. The MDS also indicated the Resident is at risk for developing pressure ulcers. Review of Resident #51's most recent Norton Scale (Scale for predicting risk of pressure ulcers), dated 6/13/25, indicated he/she scored an eight indicating he/she is at high risk for developing pressure ulcers. Review of Resident #51's physician order, dated 5/30/25, indicated Please make sure that his/her left toes have support at all times. Review of Resident #51's physician order, dated 10/27/25, indicated Soft blue boot to left foot to assist with foot drop prevention. Monitor skin integrity with donning and doffing every shift remove for care. Review of Resident #51's progress notes for November 2025 failed to indicate that the Resident refused his/her soft blue boot. Review of Resident #51's limited physical mobility care plan, dated 6/24/25, indicated Soft blue boot to left foot to assist with foot drop prevention. Monitor skin integrity with donning and doffing. Review of Resident #51's active Kardex, indicated Soft blue boot to left foot to assist with foot drop prevention. Monitor skin integrity with donning and doffing. On 11/18/25 at 7:53 A.M., 8:54 A.M., and 11/19/25 at 9:09 A.M., Resident #51 was in bed without a boot on his/her left foot. The soft blue boot was observed on his/her chair throughout survey. During an interview and observation at 9:09 A.M., Nurse #1 said the Resident is in bed and does not have a boot on his/her left foot. Nurse #1 said if the Resident has an order for the boot, then it should be on but is not. Nurse #1 said his/her left foot is just resting on the mattress. During an interview on 11/19/25 at 11:21 A.M., the Assistant Director of Nurses (ADON) said the Resident should have a blue boot on at all times and remove for care. The ADON said the boot is in place to prevent foot drop. During an interview on 11/19/25 at 11:40 A.M., the Director of Nurses (DON) said she expects that Resident #51 would have the blue boot on at all times and remove for care to prevent skin breakdown and foot drop.

Based on observation, record review and interview, the facility failed to implement Occupational Therapy (OT) recommendations for one Resident (#47) for the treatment of a contracture to the left hand. Specifically, the facility failed to implement the use of an orthotic device for the maintenance and treatment of a contracture. Findings include:Review of facility policy titled Resident Mobility and Range of Motion, dated as revised July 2017, indicated the following:-Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM (range of motion).-Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Resident #47 was admitted to the facility in April 2024 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other reduced mobility, Review of the Minimum Data Set (MDS) Assessment, dated 8/27/25, indicated that Resident #47 is rarely or never understood and was assessed by staff to have severe cognitive impairment. Review of the MDS Section GG indicated: Functional Limitation in Range of Motion of the Upper extremity: impairment on one side. On 11/18/25 at 8:01 A.M., the surveyor observed Resident #47 sleeping in bed. The surveyor observed his/her left hand to be in a tight fist with no orthotic device in place. On 11/19/25 at 9:20 A.M., the surveyor observed Resident #47 up out of bed and in his/her wheelchair. On Resident #47's left hand, his/her third, fourth and fifth finger were tight, in a fist. No orthotic device or brace was in place to the left hand. On 11/19/25 at 10:39 A.M., and 12:34 P.M., the surveyor observed Resident #47 in the dining room. His/her left hand was in a fist without any orthotic device or brace in place. Review of the OT Discharge summary dated [DATE] indicated the following:-LT (long term) goal met on 7/13/25: 100% carryover of carrot splint wearing tolerance.Skilled interventions: skilled interventions provided: skilled treatment interventions focused on education and training patient and care givers in environmental modifications, positioning maneuvers and splinting/ orthotic schedule in order to improve overal QOL (quality of life) and prevent further contractures.-D/C Recs (Discharge recommendations): DC (discontinue) skilled OT. Tolerates LUE (left upper extremity) carrot splint 5+ hours with no signs of pain redness or discomfort Review of Resident #47's active plan of care failed to indicate interventions for the limited range of motion in the left hand. Review of physician's orders indicated the following:-Adaptive equipment: left hand splint, remove for care, dated 4/2/25. Review of active and discontinued physician's orders failed to indicate use of the carrot splint as recommended by Occupational Therapy. During an interview on 11/19/25 at 10:59 A.M. Rehab Staff #1 said that the carrot splint was an active ongoing recommendation that was being implemented overnight for the Resident. During a phone interview on 11/19/25 at 12:13 P.M., Nurse #5 said that she works overnight at the facility, most recently working last night. She said she takes care of Resident #47 regularly. She said that there is no treatment in place for the left hand overnight. She said there are no braces or orthotic devices ordered and she said, I don't even think you could get anything in there. During an interview on 11/19/25 at 12:34 P.M., Certified Nurse Aide # 4 said that she is assigned to care for Resident #47 regularly and that the Resident does not utilize any type of orthotic device or brace for the left hand. During an interview on 11/19/25 at 12:36 P.M., the Assistant Director of Nurses said that when recommendations are received from therapy, it is therapies responsibility to enter the orders into the Electronic Medical Record, then nursing review them with the providers and approves the orders. During an interview on 11/19/25 at 12:51 P.M., the Director of Nurses said that she would expect that all therapy recommendations are reviewed with the physician and implemented as ordered or recommended, but that the carrot splint was not implemented as recommended. She said the process in the facility is to review all recommendations provided at the facilities morning meeting with the interdisciplinary team to ensure all recommendations are followed up on and implemented. During a follow up interview on 11/19/25 at 1:19 P.M., Rehab Staff #1 said that when therapy has recommendations for orthotic devices or braces, they report the recommendations to nursing to have approved with the physician but said that therapy does not enter these orders or recommendations into the electronic medical record.

Based on record review and interview, the facility failed to complete a trauma screen and develop a comprehensive trauma care plan related to Post Traumatic Stress Disorder (PTSD) that identified triggers and interventions for one Resident (#40) out of a total of 21 sampled Residents. Findings include:Review of facility policy, titled Trauma Informed Care and Culturally Competent Care, dated as revised August 2022, indicated the following:-Purpose: to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization.-Trauma- informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma- informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.-Resident Screening: Perform universal screening of residents, which includes a brief, non- specialized identification of possible exposure to traumatic events.-Resident Assessment: Assessment involved an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers.-Resident Care Planning: Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate.-Identify and decrease exposure to triggers that may re-traumatize the resident. Resident #40 was admitted to the facility in September 2021 with diagnoses that included schizophrenia, bipolar disorder and chronic kidney disease. Review of Resident #40's Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. The MDS failed to indicate a diagnosis of PTSD. Review of a Nurse Practitioner note, dated 9/19/25, indicated the following:4. Anxiety, insomnia, schizophrenia, PTSD, bipolar disorder, paranoia, restless legs, unstable: continue psych services. Review of Resident #40's medical record failed to indicate a trauma assessment was completed. Review of the medical record indicated a social services note, dated 10/16/25, which indicated the following:This writer attempted to complete the Trauma questionnaire and resident refused at this time. Will continue to support and follow. Review of Resident #40's active care plans indicated the following focuses:-[Resident] carries a diagnosis of schizophrenia and bipolar disorder and PTSD (Post Traumatic Stress Disorder).-The resident uses psychotropic medications r/t (related to) bipolar schizophrenia DO (disorder) and PTSD.-PTSD [Resident] may experience feelings of sadness, emptiness, anxiety, uneasiness, bodily complaints, characterized by ineffective coping, low self-esteem, tearfulness, motor agitation, withdrawal from care/ activities related to Clinical Cond. causing mood problem with as PTSD following fire in his/her home. Resident #40's active plan of care failed to indicate specific triggers placing the Resident at risk for re-traumatization. During an interview on 11/19/25 at 9:35 A.M., The Director of Social Services said that the trauma assessment form used in the facility is about a year old and should be completed on all residents in the facility. She said that Resident #40 has a diagnosis of PTSD related to a house fire. She further said that October of 2025 was the first and only attempt that she had made to complete a trauma assessment on Resident #40. The Director of Social Services said that the Resident's PTSD care plan should include specific triggers to prevent re-traumatization, and if unable to identify triggers, then that should be included as well in the care plan. During an interview on 11/19/25 at 10:56 A.M., Nurse #4 said that as far as she knows, Resident #40 does not have PTSD based on looking in her medical record and she is not aware of any concerns or triggers for the Resident that staff should be aware of. During an interview on 11/19/25 at 12:42 P.M., the Director of Nurses said that residents with PTSD need to have timely trauma assessments completed and personalized care plans created with triggers for potential traumatization and staff should be made aware of those triggers. She said that Resident #40 has PTSD and staff need to know his/her triggers.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who had an indwelling catheter and whose Physician's orders included daily irrigation of the indwelling catheter, the Facility failed to ensure Resident #1 was provided with catheter care including but not limited to catheter irrigation, in accordance with his/her Physician's orders. Findings include:Review of the Facility policy titled Catheter Irrigation, Open System, revised October 2010, indicated the following: The purpose of this procedure is to maintain patency of the catheter.Unless specifically ordered by the Physician, do not apply a clamp to any catheter. Resident #1 was admitted to the Facility in February 2012, diagnoses included but not limited to Multiple Sclerosis (nerve damage that disrupts communication between the brain and the body that can result in numbness, weakness, and trouble walking), Dementia, and neuromuscular dysfunction of the bladder. Review of Resident #1's July 2025 Physician's orders related to indwelling catheter care indicated the following:Acetic Acid Irrigation solution 0.25%-instill 30 milliliters (ml) of acetic acid solution through the catheter and clamp off. Let the solution sit in the bladder for 30 minutes. After 30 minutes, unclamp the foley and flush with 30 ml of sterile water and reattach the BSD (bedside drainage bag), start date 3/14/25.Review of the Medication Administration Record for July 2025 indicated Resident #1 was administered Acetic Acid solution 0.25%, 30 ml catheter irrigation daily, on the day shift.During an interview on 07/29/25 at 2:20 P.M., Nurse #2 said that she worked the day shift, full time, on the [NAME] unit and had regularly performed Resident #1's bladder irrigation treatment. Nurse #2 said that when she performs the catheter irrigation she cleans around the tubing, and using a piston syringe, she inserts 30 ml of Acetic Acid into the catheter then reattaches the catheter tubing to let the liquid drain back into the bag. Nurse #2 said she had not been clamping off the catheter and waiting 30 minutes then unclamping before flushing out the solution, Nurse #2 and the surveyor reviewed the Physician's order and Nurse #2 said she had not performed Resident #1's catheter irrigation as ordered by the Physician. During an interview on 7/29/25 at 2:40 P.M., the Assistant Director of Nurses said Nurse #2 was responsible for following the Physician's order for Resident #1's catheter irrigation and she had not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who had a gastrostomy tube (G-tube, placed through the abdomen into the stomach, for feedings, liquids and medications) in place to meet his/her nutritional and fluid intake needs, and whose physician's orders included specific administration rates and volumes for formula feeds and water flushes, the Facility failed to ensure that Resident #1 was provided with appropriate treatment and services when Resident #1 was administered formula feeds and flushes at an incorrect rate and volume.Findings include:Review of the Facility policy titled Enteral Feeding-Safety Precautions, date revised November 2018, indicated the following:All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities.The facility will remain current in and follow accepted best practices in enteral nutrition. Preventing errors in administration: Check the following information: rate of administration (ml/hour- [milliliter per hour]).Review of a Facility Grievance/Concern Form dated, 02/21/25, indicated a visitor had observed Resident #1's tube feeding formula and water flushes to be placed in the incorrect enteral pump bags resulting in Resident #1 getting incorrect volumes of formula and water. Review of the Facility Investigation, dated 02/26/25, indicated the Nursing Supervisor had been notified on 02/21/25, by Resident #1's visitor, that Resident #1's formula feeding bag and water flush bag had been reversed resulting in Resident #1 not receiving the prescribed amount of formula and water. Resident #1 was admitted to the Facility in February 2012, diagnoses included but not limited to Multiple Sclerosis (nerve damage that disrupts communication between the brain and the body that can result in numbness, weakness, and trouble walking), Dementia, and Gastrostomy (G-tube, placed through the abdomen into the stomach, for feedings, liquids and medications) status. Review of Resident #1's Care Plan indicated the following:Tube feeding as ordered, date initiated 11/01/23. Flush feeding tube as ordered, date initiated 11/01/23. Review of Resident #1's Physician's orders for the Month of February 2025, related to G tube feed and water flushes indicated his/her orders included the following:Change tube feeding set every 24 hours, every night shift, date initiated 09/22/24.Enteral feed order, Jevity 1.5, per feeding tube, 45 milliliters (ml) per hour continuous, every shift, date initiated 09/23/24.Flush G-tube with 200 cc (cubic centimeter) every four hours, date initiated 09/23/24. During a telephone interview on 07/30/25 at 8:30 A.M., Nurse #1 said that Resident #1's formula and water flush was administered through a feeding pump using a two-bag system. Nurse #1 said that she could not recall the exact Physician's orders for Resident #1 back in February but said that the formula feeding was set at a certain rate of milliliters per hour and the water flush was set to give a certain amount of water every four hours. Nurse #1 said that she had been assigned Resident #1 on 02/21/25 on the night shift and that sometime between 5:00 A.M. and 6:00 A.M., she had removed and replaced the feeding pump tubing, formula and water flush. Nurse #1 said that she became aware of the mistake (that the Jevity formula and water were in the wrong bag) when she was called by the Nursing Supervisor and informed that the tubing and pump had not been set up correctly. During a telephone interview on 7/30/25 at 4:30 P.M., the Nursing Supervisor said that she had worked the evening shift on 02/21/25 when she was approached by Resident #1's visitor and informed that the tube feeding formula was in the water flush bag and water was in the tube feeding bag. The Nursing Supervisor said that switching the bags resulted in Resident #1 not receiving his/her tube feeding and water flushes as ordered by the Physician.During an interview on 7/29/25 at 2:40 P.M., the Assistant Director of Nursing said that Resident #1's formula feeding and water flush system had been set up incorrectly resulting in Resident #1 not being administered his/her tube feeding as prescribed by the Physician.

Based on interview, record review, and review of the Facility Assessment Tool, the facility failed to ensure that Licensed Nurses (#6, #1, #5, and #4) had the specific competencies and skill sets to care for the needs of one Resident (#372) relative to nephrostomy tube (a thin flexible tube that is surgically inserted through the skin, into the kidney and drains urine into a bag outside the body) care. Specifically, facility staff failed to ensure Licensed Nurses were assessed for competency to care for nephrostomy tubes when: -Resident #372 was admitted to the facility with bilateral (right and left side) nephrostomy tubes. -The Facility Assessment indicated staff at the facility could provide care for residents with diseases of the genitourinary (genital and urinary organs or functions) system and that special treatments provided included ostomy (surgically created opening between an internal organ and the body's surface) care. Findings include: Review of the Facility Assessment, dated 8/7/24, indicated the following: -Diseases and conditions typical for a resident in the facility included diseases of the genitourinary system. -Special treatments provided by facility staff included treatment for ostomy care. -The number/average number of residents who required ostomy care was zero to five. - . education was completed monthly and as needed, based on regulatory requirements and facility identified needs . Review of Nurse #6's Competency Evaluation dated 5/6/24, indicated Nurse #6 had been assessed for competency in the following areas: -Medication -Admission Assessment -Cracking (technique used to remove the protective tape and slowly open the cylinder valve to the tank, blowing excess dust away from the opening) Oxygen Tank -Sterile (free from living germs or microorganisms) Wound Care -Tube Feeding (device used to send nutrition from a bag directly into one's body) -Foley Catheter (device that drains urine from one's bladder into a collection bag outside the body) Care/Change -PEG (percutaneous endoscopic gastrostomy: a surgery to place a feeding tube which allows one to receive nutrition through the stomach) -Colostomy (surgical opening in one's abdomen that enters the colon and allows stool to exit the body) -IV (intravenous: administration of fluids or medication into a vein) Further review of Nurse #6's Competency Evaluation included no evidence that Nurse #6 had been assessed for competency to provide care for nephrostomy tubes. Review of Nurse #1's Competency Evaluation dated 6/10/24, indicated Nurse #1 had been assessed for competency in the following areas: -Medication -Admission Assessment -Cracking Oxygen Tank -Sterile Wound Care -Tube Feeding -Foley Catheter Care/Change -PEG -Colostomy -IV Further review of Nurse #1's Competency Evaluation included no evidence that Nurse #1 had been assessed for competency to provide care for nephrostomy tubes. Review of Nurse #5's Competency Evaluation dated 7/22/24, indicated Nurse #5's competency was assessed for the following areas: -Medication -Admission Assessment -Cracking Oxygen Tank -Sterile Wound Care -Tube Feeding -Foley Catheter Care/Change -PEG -Colostomy -IV Further review of Nurse #5's Competency Evaluation included no evidence that Nurse #5 had been assessed for competency to provide care for nephrostomy tubes. Review of Nurse #4's Competency Evaluation dated 8/19/24, indicated Nurse #4 had completed a self-assessment for competency in the following areas: - Medication - Admission Agreement - Cracking Oxygen Tank - Sterile Wound Care - Tube Feeding - Foley Catheter Care/Change - PEG - Colostomy - IV Further review of Nurse #4's Competency Evaluation included no evidence that Nurse #4 was assessed for competency by the Staff Development Coordinator (SDC) to provide care in the above self-assessed areas and that Nurse #4 was also assessed for competency to provide care for nephrostomy tubes. Resident #372 was admitted to the facility in September 2024, with a diagnosis of Malignant (condition that is dangerous to one's health) Neoplasm (abnormal growth of tissue that can be cancerous or non-cancerous) of the Bladder. Review of the Patient Care Referral provided to the facility from the hospital dated 9/5/24, indicated that Resident was being transferred to the facility with bilateral nephrostomy tubes in place. Review of Resident #372's Nursing Note dated 9/5/24, indicated the Resident was admitted to the facility with bilateral nephrostomy tubes. Review of the facility's Daily Nursing Attendance Records indicated the following: -Nurse #3 and Nurse #4 were assigned to care for Resident #372 on 9/5/24. -Nurse #1 and Nurse #5 were assigned to care for Resident #372 on 9/6/24. -Nurse #1 and Nurse #6 were assigned to care for Resident #372 on 9/7/24. During an interview on 9/11/24 at 11:45 A.M., the Assistant Director of Nursing (ADON) said that she also worked as the Staff Development Coordinator (SDC) at the facility. The ADON said she was on vacation when Resident #372 was admitted to the facility, but if she had been there, she would have started education with licensed staff right away relative to the care of nephrostomy tubes to ensure the Licensed Nurses were able to provide the necessary care for Resident #372. The ADON further said the Licensed Nurse competency evaluations did not include nephrostomy tube care. During an interview on 9/12/24 at 8:15 A.M. the Director of Nursing (DON) said that the special treatments indicated as ostomies in the Facility Assessment included nephrostomy tubes. At the time, the surveyor and the DON reviewed the competency evaluations completed for Nurse #1, Nurse #3, Nurse #4, Nurse #5, and Nurse #6. The DON said the competency evaluations did not include assessment of Licensed Nurse competencies relative to nephrostomy tubes. The DON said competency assessment for nephrostomy tubes needed to be added to the Licensed Nurses' competency evaluations. The DON also said she began to provide education relative to providing care for Resident #372's nephrostomy tubes to the Licensed Nurses on 9/7/24 (after the Resident's admission to the facility). The DON said she had not kept record of which staff had been educated.

Based on record reviewed and interview, the facility failed to ensure that the Director of Nursing (DON) did not serve as the Charge Nurse when the facility had an average daily occupancy of greater than 60 residents. Specifically, the facility failed to ensure the DON did not serve as Charge Nurse, providing direct resident care, when the facility's daily occupancy was greater than 60 residents: -on four dates during the Quarter Three (April 1, 2024 through June 30, 2024) Payroll Based Journal (PBJ) Staffing Data Report period where the facility reported excessively low weekend staffing. -on three dates over the four week time frame prior to the survey start date of 9/6/24. Findings include: Review of the facility's Quarter Three PBJ Staffing Data Report indicated the facility reported excessively low weekend staffing. Review of the facility's Daily Nursing Attendance Reports for the Quarter Three reporting period indicated the DON served as Charge Nurse on the following four dates: -5/15/24 (Wednesday) on the Back Unit, on the Night (11:00 P.M. through 7:00 A.M.) Shift. -5/18/24 (Saturday) on the Back Unit, on the Night Shift. -5/19/24 (Sunday) on the Back Unit, on the Day (7:00 A.M. through 3:00 P.M.) Shift. -6/16/24 (Sunday) on the Back Unit, on the Evening (3:00 P.M. through 11:00 P.M.) Shift. Review of the DON's Missed Punch Form, dated 5/15/24, indicated the DON worked from 11:00 P.M. through 7:30 A.M. on Wednesday 5/15/24. Review of the DON's Time Card, date range 5/12/24 through 5/25/24, indicated the DON worked: -from 12:45 P.M. through 7:00 A.M. on 5/18/24 (Saturday). -from 7:00 A.M. through 3:00 P.M. on 5/19/24 (Sunday). Review of the DON's Missed Time Punch Form, dated 6/16/24, indicated the DON worked from 3:00 P.M. through 11:30 P.M. on Sunday 6/16/24. Review of the facility's Daily Census Reports indicated the facility's in-house resident occupancy was: -67 on 5/15/24. -68 on 5/18/24 and 5/19/24. -63 on 6/16/24. Review of the facility's Daily Nursing Attendance Reports for 8/11/24 through 9/10/24 indicated the DON was scheduled to work as Charge Nurse on the following dates: -8/24/24 (Saturday) on the Back Unit, on the Day Shift. -8/27/24 (Tuesday) on the Back Unit, on the Night Shift. -9/3/24 (Tuesday) on the Front Unit, on the Day Shift. Further review of the Daily Nursing Attendance Report indicated the DON was also scheduled to work in the DON role on Tuesday, 9/3/24 from 7:00 A.M. through 3:00 P.M. Review of the DON's Time Card, date range 8/18/24 through 8/31/24 indicated the DON worked: -from 9:26 A.M. through 1:55 P.M. on 8/24/24 (Saturday) -from 12:50 A.M. through 7:00 A.M. on 8/27/24 (Tuesday) Review of the DON's Time Card for 9/1/24 through 9/12/24 indicated the DON worked as Charge Nurse: -from 7:00 A.M. through 3:00 P.M. on 9/3/24 (Tuesday). Review of the facility's Daily Census Reports indicated the facility's in-house resident occupancy was: -69 on 8/24/24. -67 on 8/27/24. -69 on 9/3/24. During an interview on 9/11/24 at 4:37 P.M., the DON said that staff at the facility would call her to come in and work on a Unit when a scheduled Nurse did not show up or called out of work and a replacement could not be found. The DON further said working as Charge Nurse interfered with her ability to perform her responsibilities as DON. During a follow-up interview on 9/12/24 at 8:15 A.M., the DON said she has had to work on the Units as Charge Nurse several times since she was hired in May 2024. The DON further said she worked as the Charge Nurse the same dates that were reflected on the facility's Daily Nursing Attendance Reports: 5/15/24, 5/18/24, 5/19/24, 6/16/24, 8/24/24, 8/27/24, and 9/3/24.

Based on interview, policy and record review, the facility failed to provide one Resident (#59), out of a total sample of 17 residents, the right to participate in their plan of care. Specifically, the facility failed to inform Resident #59 in advance of a medication treatment and the risks and benefits of the medication when the Resident was prescribed a new anti-psychotic (type of medication used to treat symptoms of psychosis including hallucinations [sights, sounds, smells, tastes, or touches that a person believes to be real but are not real] and delusions [false beliefs]) medication. Findings include: Review of the facility policy titled Psychotropic Medication Use, revised July 2022, indicated: -Residents, families, and/or the Representative are involved in the medication management process. -When determining whether to initiate, modify, or discontinue medication therapy, the Interdisciplinary Team (IDT) conducts an evaluation of the resident. The evaluation will attempt to clarify whether .the actual and intended benefit of the medication is understood by the resident/representative. -Residents (and/or representative) have the right to decline treatment with psychotropic medications. -The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. Resident #59 was admitted to the facility in August 2023, with diagnoses including Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations). Review of the Minimum Data Set (MDS) Assessment, dated 7/10/24, indicated that Resident #59: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15. -received an antipsychotic (psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought) and the antipsychotic medication was administered on a routine basis. During an interview on 9/12/24 at 8:56 A.M., Resident #59 said that when he/she was hospitalized in August 2024 and returned to the facility, no one reviewed his/her medications with him/her. Resident #59 further said he/she was not aware that he/she had taken Olanzapine (antipsychotic) medication or that his/her psychotropic medications were different from before he/she was hospitalized . Resident #59 said the Olanzapine had not been discussed with him/her upon return from the hospital. Review of Resident #59's August 2024 Physician's Orders indicated: -Olanzapine (antipsychotic) 5 mg (milligrams), give 1 tablet by mouth one time a day, initiated 8/6/24, discontinued 8/28/24 Review of Resident #59's August 2024 Medication Administration Record (MAR) indicated the Resident received the following medications: -Olanzapine, administered daily from 8/7/24 - 8/28/24 (22 total doses) Review of the medical record failed to provide evidence that the initiation of treatment with Olanzapine medication, and risks and benefits of Olanzapine, were reviewed with Resident #59 prior to the administration of the medication. Further review of the medical record indicated an Informed Consent for Psychotropic Medication for Olanzapine was signed by the Resident on 8/28/24. During an interview on 9/11/24 at 2:31 P.M., the surveyor and the Physician reviewed Resident #59's medical record. The Physician said Resident #59 was readmitted from a recent hospitalization on Olanzapine and Aripiprazole (atypical antipsychotic). The Physician said that she reviews if psychotropic medications are needed to make sure medications are given in the right dose and are effective. The Physician said that she made the decision to discontinue the Olanzapine on 8/28/24 on her own and the recommendation did not come from nursing or psychiatric services. The Physican was unable to provide additional information that treatment with Olanzapine was discussed with Resident #59 prior to administration of the medication. During an interview on 9/12/24 at 10:12 A.M., the surveyor and the Director of Nursing (DON) reviewed Resident #59's medical record. The DON said that after a hospitalization , if a resident had new psychotropic medications, the admitting Nurse would obtain a consent at the time of readmission. The DON said that consents should be obtained before psychotropic medication is provided. The DON said that Resident #59 received the Olanzapine from 8/6/24 - 8/28/24 and consent should have been obtained before administration of the medication and it had not been.

Based on record review and interview, the facility failed to notify the Physician of a significant change in condition for one Resident (#16), out of a total sample of 17 Residents. Specifically, the facility staff failed to notify the Physician/Nurse Practitioner (NP) so treatment could be altered when Resident #16 was identified with significant weight loss by the Registered Dietician. Findings include: Review of the facility policy titled Weight Management, undated, indicated: -Newly admitted residents are weighed weekly for four weeks. -Residents are weighed a minimum of monthly by the 7th of each month, with more frequent weights obtained as ordered or deemed necessary. -Check the previous monthly weight(s) for any significant weight change. If there is a significant weight change of plus/minus 5 percent (%) in 30 days (1 month), 7.5% in 90 days (3 months) or 10% in 180 days (6 months), schedule the resident to be reweighed within 24 hours. -Weights are verified and documented in the medical record as they are obtained. -The entire interdisciplinary team (IDT) must be involved in the resident's care needs to manage unplanned weight change. Each member performs tasks consistent with their area of expertise. Review of the facility policy titled Change in a Resident's Condition or Status, revised February 2021, indicated: -The facility promptly notified the resident, his or her attending Physician, and the resident representative of changes in the resident's medical/mental condition and or status. -The Nurse will notify the resident's attending Physician when there has been a significant change in the resident's physical/emotional/mental condition. Resident #16 was admitted to the facility in May 2024, with diagnoses including Muscle Wasting and Atrophy (also known as muscle atrophy - the loss of muscle tissue or muscle mass that cause muscles to weaken, shrink or shorten and can lead to a decrease in strength and mobility), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]) and Developmental Delay (a delay in reaching language, thinking, social or motor skills milestone). Review of the May 2024 Physician's orders indicated: -Weight every evening shift every Thursday for 4 weeks, initiated 5/9/24. -Weight every evening shift starting on the 1st and ending on the 1st every month, initiated 5/9/24. Review of the Physician Progress Note, dated 5/15/24, indicated: -Weight 223.8 pounds (lbs.) -Nutrition - continues regular diet with thin liquids, will continue with weekly weights monitoring once every Thursday in the evening for 4 weeks and will be followed by a Dietitian. Review of Resident #16's Weights and Vitals report provided by the facility on 9/10/24 indicated: -5/9/24: 223.8 lbs. -5/30/24: 224 lbs. -7/24/24: 220.3 lbs. -8/13/24: 199 lbs. -8/14/24: 198 lbs. -8/15/24: 198.8 lbs. -9/1/24: 197.4 lbs. (11.8% change indicating significant weight loss in less than 180 days) Review of the Nutritional Risk Evaluation Quarterly Assessment, dated 8/14/24 indicated: -Significant weight loss of 9.9% in less than 30 days and 11.2% weight loss in 90 days. -Weight on admission was 224 lbs, with a follow-up weight on 5/30/24: 224 lbs. -No June weight to assess. -Weight on 8/13/24: 199 lbs. per nursing. -Resident triggered for significant weight loss. Review of the medical record indicated no documented evidence that the Physician or the NP were notified of Resident #16's significant weight loss when identified by the Dietitian on 8/14/24. During an interview on 9/10/24 at 1:54 P.M., the NP said typically the Director of Nursing (DON), or nursing staff communicate any resident weight loss to her. The surveyor and the NP reviewed Resident #16's medical record and the NP said Resident #16's weights had not been communicated to her. The NP further said had the weights been reported to her, she would have reviewed the Resident's clinical record to see if any follow-up would have been warranted.

Based on observation, interview, record and policy review, the facility failed to ensure the plan of care was assessed and revised for two Residents (#6, #21) and that a care plan meeting was held for one Resident (#59), out of a total sample of 17 residents. Specifically, the facility staff failed to: 1. For Resident #6, assess and revise the Resident's Care Plan to include measurable goals for falls prevention after the Resident sustained a fall. 2. For Resident #21, obtain a Physician order and revise the Resident's Care Plan to include the use of mattress bolsters and floor mats after the Resident sustained a fall. 3. For Resident #59, provide evidence that an interdisciplinary care plan meeting was held, or that the Resident had participated in the care planning process following an MDS assessment completed on 4/18/24. Findings include: Review of the facility policy titled Care Planning - Interdisciplinary Team, revised March 2022, indicated: -Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). -The IDT includes but is not limited to: <Resident's attending physician <Registered Nurse with responsibility for the resident <Nursing assistant with the responsibility for the resident <Member of food and nutrition services staff <the Resident and/or Resident's Representative <Other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. -The resident, the resident's family and or/the residents legal representative .are encouraged to participate in the development of and revisions to the resident's care plan. -Care plan meetings are scheduled at the best time of day for the resident and the family when possible. 1. Resident #6 was admitted to the facility in August 2023, with diagnoses including Encephalopathy (a disease of the brain that can be caused by disease, injury, drugs or chemicals and alters brain function, which can cause confusion), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]), Schizoaffective Disorder (a mental health condition that is a combination of schizophrenia and mood disorder symptoms such as depressive episodes, hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) and delusions (false beliefs), and manic episodes), and Muscle Weakness (decreased strength in the muscles). Review of the Minimum Data Set (MDS) Assessment, dated 7/3/24, indicated Resident #6 was cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 99 (indicating unable to assess) and had visual hallucinations. Review of Activities of Daily Living (ADL) Care Plan, revised 9/5/23, indicated Resident #6 required assistance with ADL related to impaired mobility and included the following interventions: -Provide assist with mobility/positioning as needed when fatigued. -Provide assist with transfers as needed when fatigued. -Allow for periods of rest if resident becomes fatigued. Review of the Incontinence Care Plan, revised 7/17/24, indicated Resident #6 had mixed bladder [sic] incontinence related to impaired mobility and included the following interventions: -Ensure the Resident has unobstructed path to the bathroom. -Establish voiding (urinating) patterns. -Observe for/document/report to MD (medical doctor) as needed for possible medical causes of incontinence. Review of the Nursing Progress Note, dated 8/9/24, indicated Resident #6 was found standing between the bathroom door and the room with his/her brief soaked. The Nurse informed the Resident that she was getting a clean brief and while the Nurse was looking in the closet, the Nurse heard a big noise and found the Resident on the floor lying on his/her back. The Nurse indicated the Resident hit his/her head but was able to move his/her legs. The Resident reported a headache, and was transferred to the emergency room for further evaluation. Review of Resident #6's Care Plan did not indicate assessment of what led to the fall on 8/9/24, and any interventions implemented to prevent further falls by the Resident. On 9/11/24 at 2:06 P.M., the Director of Nursing (DON) said all falls are reviewed and assessed by the IDT, and interventions would be implemented to prevent further falls, but this was not completed for Resident #6. 2. Resident #21 was admitted to the facility in June 2022, with diagnoses including Cognitive Impairment (trouble remembering, learning new things, concentrating or making decisions that affect everyday life), Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Insomnia (sleep disorder with trouble falling and/or staying asleep), and Muscle Weakness. Review of the MDS assessment dated [DATE], indicated Resident #21 was severely cognitive impaired as evidenced by a BIMS score of 3 out of 15. On 9/6/24 at 9:04 A.M., the surveyor observed Resident #21 lying in bed with his/her eyes closed. The surveyor observed that the Resident was lying on a mattress with bolsters (a foam device used to prevent slipping or sliding out of the mattress) and had mats on the floor. Review of Resident #21's medical record including the Resident's Care Plan, did not indicate the use of mattress bolsters and floor mats. On 9/10/24 at 10:18 A.M., the surveyor and Nurse #6 reviewed the Medication Administration Record (MAR) and the Treatment Administration Record (TAR). Nurse #6 said residents with bolsters on the bed and mats on the floor would have Physician's orders and would be assessed every shift. Nurse #6 said Resident #21 did not have orders to the assess the need for and the use of placement of mattress bolsters on the bed and mats on the floor. During an interview on 9/10/24 a at 11:13 A.M., the DON said Resident #21 had utilized the mattress with bolsters and used the mats on the floor long before the DON started working in the facility. The DON said there should have been a Physician's order in place for the use of the bolsters on the mattress and mats on the floor and the Care Plan should have been revised to include the use of the bolsters and mats on the floor. 48206 3. Resident #59 was admitted to the facility in August 2023, with diagnoses including Depression and Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations). Review of the Resident's clinical record showed evidence that a MDS (Minimum Data Set) Assessment was completed on 4/18/24, and indicated that Resident #59 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Resident's clinical record did not provide evidence of involvement of the Resident and/or their Representative in the care planning process or that a care plan meeting had been held following the MDS Assessment completed on 4/18/24. During an interview on 9/11/24 at 7:50 A.M., the Director of Social Services (DSS) said that care plan meetings will include the Resident and/or their Representative and the IDT consisting of the Director of Social Services, the Activity Director, Rehabilitation services if involved with the Resident, and the MDS Nurse or Assistant Director of Nursing (ADON). If the Resident does not attend, the IDT will still hold the care plan meeting which is typically documented as a care plan meeting note. The DSS said that she was out sick in April when Resident #59's care plan meeting would have been held. The surveyor requested documentation that a care plan meeting was held relative to the 4/18/24 MDS assessment. During a follow-up interview on 9/11/24 at 11:51 A.M., the DSS said that there was no evidence that a care plan meeting was held relative to the 4/18/24 MDS assessment.

Based on record review and interview, the facility failed to provide services that met professional standards of quality for one Resident (#25), out of a total sample of 17 residents. Specifically, the facility staff failed to transcribe (to put into written word or print) a verbal order (a Physician order that is received in person via spoken word or over the telephone) for a medication change into the medical record, resulting in the verbal order not being implemented and Resident #25 not receiving an updated medication as ordered by the Physician. Findings include: Review of facility policy titled Telephone Orders, revised February 2014, indicated: -Verbal telephone orders may be accepted from each resident's attending Physician. -Verbal telephone orders may only be received by licensed personnel (Registered Nurse (RN), Licensed Professional Nurse (LPN), Pharmacist, Physician, etc.). -Orders must be reduced to writing (transcribed), by the person receiving the order, and recorded in the resident's medical record. Resident #25 was admitted to the facility in March 2024, with diagnoses including Gastro Esophageal Reflux Disease (GERD - a condition that causes heartburn or acid indigestion) and Irritable Bowel Syndrome (IBS - condition that affects the large intestine and can cause abdominal pain, bloating, and changes in bowel habits). Review of the Consultant Pharmacist Recommendations to Prescriber, dated July 2024, indicated: -Resident #25 currently receiving Protonix (Pantoprazole [a medication prescribed to treat GERD]) 40 milligrams (mg) twice daily. -Please consider switch to Prilosec OTC (Prilosec over the counter- a medication prescribed to treat GERD) .please specify Prilosec OTC consider starting dose of 20 mg daily and monitor. The Physician/Prescriber Response on the Consultant Pharmacist Recommendations to Prescriber form indicated: -Agreement with the recommendation. -Signed by the Director of Nursing (DON) not the ordering Physician, on 7/30/24. Review of the Physician's Order Summary Report, provided 9/12/24, indicated: -Protonix 40 mg, give1 tablet once time a day, initiated 3/31/24, active During an interview on 9/12/24 at 12:06 P.M., the DON said she received the Pharmacist recommendations for Resident #25 and called the Resident's Physician to obtain a verbal order for a change of Protonix 40 mg by mouth twice daily to Prilosec OTC 20 mg by mouth daily. The DON said she then signed and dated the pharmacy recommendation on 7/30/24. The DON said the new order had been entered into the Resident's electronic medical record. Further review of the active Physician's orders, as of 9/12/24, did not indicate evidence the Physician's verbal order to change Resident #25's medication from Protonix 40 mg by mouth twice daily to Prilosec OTC 20 mg by mouth daily had been transcribed and implemented. During a follow-up interview on 9/12/24 at 12:27 P.M., the DON said she had spoken with Resident #25's Physician on 7/30/24 and received a verbal order to change Protonix 40 mg by mouth twice daily to Prilosec OTC 20 mg by mouth daily. The DON said there was no evidence that the verbal order she obtained had been entered into Resident #25's medical record. The DON further said she had given the verbal order to another Nurse on 7/30/24 to transcribe but was unable to recall which Nurse. The DON said Resident #25 was not getting the correct medication as ordered by the Physician. The DON said all Residents should receive medications as ordered by the Physician to treat his/her medical conditions correctly.

Based on observation, interview, policy and record review, the facility failed to provide activities to meet the needs of one Resident (#28), out of a total sample of 17 residents. Specifically, the facility failed to provide activities of interest for Resident #28 based on their plan of care, comprehensive assessment, and preferences. Findings include: Review of the facility policy titled Activity Evaluation, revised June 2018, indicated: -The activity evaluation is used to develop an individual activities care plan .that will allow the resident to participate in activities of his/her choice and interest. -The activity evaluation and activities care plan identifies if a resident is capable of pursuing activities independently or if supervision and assistance are needed. Resident #28 was admitted to the facility in December 2023 with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #28 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of zero out of a possible 15. Review of the Activity Assessment, dated 2/26/24, indicated the following preferences for Resident #28: -Preference for afternoon participation in activities. -Somewhat important to have books/magazines to read. -Very important to listen to music. -Very important to keep up with the news. -Somewhat important to do things with people. -Very important to do favorite activities. Review of the Activities Note, dated 6/19/24, indicated: -Resident #28 is alert and able to make his/her needs known. -He/she had attended parties, television, and pet visits. -Staff continue to invite/encourage the Resident to join group programs, offer supplies and 1:1 (individual) visits as tolerated. Review of the Activity Care Plan, last revised 7/17/24, indicated: -Resident #28 is dependent on staff for activities, cognitive stimulation, and social interaction due to physical limitations, cognitive deficits. -Resident #28 had a plastic tool box to use to keep his/her hands busy. -Resident liked fishing, music, sports, to keep up with the news, and to read. -Staff to provide informal 1:1 visits for socialization to include facility happenings, upcoming events, and scheduled programs. During an observation on 9/6/24 at 9:17 A.M., the surveyor observed Resident #28 lying in bed, sleeping after the breakfast meal was completed. The surveyor did not observe any television or radio in the Resident's room. During a telephone interview on 9/6/24 at 1:00 P.M., Resident #28's Representative said the Resident was bored and staff don't know how to keep him/her busy. During an observation on 9/10/24 at 10:07 A.M., the surveyor observed Resident #28 sleeping in bed. The surveyor did not observe any television or radio in the Resident's room. During an observation on 9/10/24 at 12:07 P.M., the surveyor observed Resident #28 seated alone at a table in the South Dining Room. At 12:21 P.M.,the staff was observed moving Resident #28 to another table with a resident and their visiting family member. The surveyor did not observe Resident #28 engaging with the other resident or visitor at the table. During an observation on 9/10/24 at 3:59 P.M. the surveyor observed Resident #28 seated alone at an empty table in the South Dining Room in the same location where he/she was observed at 12:21 P.M. The surveyor did not observe any activity or reading materials in front of the Resident, and there were no staff, other Residents, or visitors in the South Dining Room at the time. The surveyor did not observe any music to be playing and the television in the room was off. Review of the September 2024 Recreation Participation Record indicated Resident #28 was greeted by Recreation staff on 9/6/24, 9/7/24, 9/8/24, 9/9/24, and 9/10/24 and was provided with 1:1 cognition game on 9/10/24. Further review of the Recreation Participation Record did not indicate that Resident #28 participated in any additional activities from 9/6/24 through 9/9/24. Review of the CNA (Certified Nurses Assistant) Flow Sheet for September 2024 did not indicate that any individual or group activity was provided to Resident #28 from 9/6/24 - 9/9/24. During an interview on 9/12/24 at 9:04 A.M., CNA #1 said that Resident #28 is not very social but he/she will color or read and that staff will give him/her a fidget board from the Activities department. CNA #1 said staff try to keep Resident #28 occupied and Activities staff will do 1:1 activities with him/her. CNA #1 said she would ask about activity preferences from the nursing or activity staff, and resident participation in any activities would be documented. During an interview on 9/12/24 at 9:15 A.M., the Activities Director (AD) said the Activity Department includes herself and two other staff. The AD said activities staff provide 1:1 visits to residents which are documented on the Recreation Participation forms. The AD said that Resident #28 did better with 1:1 activities, the staff have a toolbox setup for him/her, and that a busy board was available in the South Dining Room. The AD further said Resident #28 mostly preferred chit-chatting, coloring, and distractions with his/her hands. The surveyor and the AD reviewed the September 2024 Recreation Participation Record for Resident #28, and the AD said that there was no documentation of additional activities provided to the Resident on 9/6/24, 9/7/24, or 9/8/24. The AD said that on 9/10/24, a cognitive game was provided to the Resident by an activity staff member, but she was unsure of what the staff did as a cognitive interaction or what time that activity was provided. During a follow-up interview on 9/12/24 at 9:52 A.M., the AD said that she was unable to provide specifics of the cognitive game activity provided on 9/10/24 or if that activity occurred between 12:21 P.M. and 3:59 P.M.

Based on observation, interview, record and policy review, the facility failed to provide an environment was free of accidental hazards, relative to swallowing safety during one meal for one Resident (#10) out of a total sample of 17 residents. Specifically, facility staff failed to provide Resident #10 with necessary interventions, in accordance with the Resident's plan of care, to ensure the Resident's safety while eating his/her breakfast meal when the Resident had a diagnosis of Dysphagia (difficulty swallowing), required staff assistance for securing his/her dentures in place, and required verbal cues for safety while eating, which increased the Resident's risk for choking. Findings include: Review of the facility's policy titled Assistance with Meals, revised March 2022, indicated the following: -Residents should receive assistance with meals in a manner that meets the individual needs of each resident. -Facility staff will serve resident trays and will help residents who require assistance with eating. Resident #10 was admitted to the facility in February 2016 with diagnoses including Parkinson's Disease (progressive degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination) and Dysphagia (difficulty swallowing foods or liquids). Review of Resident #10's Activity of Daily Living (ADL) Care Plan, initiated 12/30/20 and revised 12/6/23, indicated the following: -Needs to be continually supervised -may need cues to slow down -and may require assist with meal at meal times Review of Resident #10's Dysphagia Care Plan, initiated 2/3/21 and revised 12/6/23, indicated the following: -Continual supervision when eating, provide assistance as needed. -Encourage Resident to chew and swallow each bite. -Encourage small sips/bites and cue as needed. -If coughing occurs, no food/liquids until coughing resolves. Review of Resident #10's active Physician's orders, initiated 8/15/23, indicated the Resident required a puree (food texture that is changed from a solid texture to smooth, with no lumps and pudding-like) diet texture with thin liquids due to signs/symptoms of Dysphagia. Review of Resident #10's Dental Exam Report, dated 11/16/23, indicated the following: -Complaint of loose dentures. -Use adhesive to improve retention. -Use denture adhesive as needed. Review of Resident #10's Speech Therapy (ST) Evaluation, dated 7/13/24, indicated the following: -The Resident was referred for a ST evaluation due to complaints of increased swallowing difficulty at meals including increased cough. -The Resident's diet was puree solids and thin liquids. -The Resident's oral motor structure (parts of the mouth that work together to help with eating) and function was impaired. -The Resident's cognitive-communicative skills were impaired. -The Resident's lower dentures were loose. Further review of the ST Evaluation indicated the Resident demonstrated clinical signs of Dysphagia with puree texture foods as evidenced by: >oral residue (food/liquid remaining in the mouth after swallow), >poor attention to task, >suspected premature (early) spillage into the pharynx (muscular tube that connects one's nose and mouth to the lungs and stomach), >coughing after swallow, >decreased self monitoring, >wet vocal quality prior to and after swallowing. General swallow techniques/precautions were recommended and no changes to the Resident's plan of care were recommended. Review of Resident #10's Minimum Data Set (MDS) Assessment, dated 7/17/24, indicated the following: -The Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of total possible 15. -The Resident required substantial/maximal assistance (helper does more than half the effort) for oral hygiene. On 9/11/24 between 8:15 A.M. and 8:32 A.M., the surveyor observed the following in the South Unit Dining Room: -Resident #10 sat with a plate of scrambled eggs on the table in front of him/her. -The Assistant Director of Nursing (ADON) was present in the Dining Room. -The Resident put a spoonful of scrambled eggs into his/her mouth, began to chew, then started to cough. -The Resident began to cough repetitively, then stopped coughing and the ADON immediately approached the Resident, using the palm of her hand forcefully on the Resident's back multiple times. -The Resident began to cough repetitively again, for a short time, then intermittently, and continued to eat his/her scrambled eggs. -The surveyor observed staff provide Resident #10 with a cup of apple juice at 8:23 A.M. -The surveyor observed Resident #10 take a bite of eggs, chew, cough, then gag, and take a drink of juice from his/her cup. -The surveyor observed some of the juice exit from the front of the Resident's mouth and run down his/her chin. -Resident #10 then cleared his/her throat and took a heaping spoonful of scrambled eggs. -The surveyor observed Resident #10's bottom dentures protrude over his/her bottom lip and partially out of his/her mouth multiple times while he/she was eating. -The surveyor observed Resident #10 fully load the bowl of his/her spoon with a heaping amount of scrambled eggs and place the eggs into his/her mouth under his/her bottom dentures that were not secured in place. -The Resident began to chew the eggs, with the bottom dentures continuing to move forward out of his/her mouth, and he/she began to gag. -The surveyor observed the Resident repeat placing a heaping spoonful of scrambled eggs under his/her bottom teeth and gag one more time, and the ADON instructed Certified Nurses Aide (CNA) #1 to remove the Resident's dentures at 8:27 A.M. -The surveyor observed CNA #1 remove Resident #10's dentures as instructed, and the Resident completed eating his/her meal. -At no time during the observation, through the time the Resident's dentures were removed, did the surveyor observe that the Resident's dentures were secured in his/her mouth. -At no time during the observation, did the surveyor observe staff encourage the Resident to chew and swallow each bite, encourage small bites of food, or ensure the Resident did not continue to eat until coughing was resolved. During an interview on 9/11/24 at 9:00 A.M., CNA #1 said that Resident #10 was always assisted out of bed and with personal care on the night (11:00 P.M. through 7:00 A.M.) shift, so she was not sure what assistance was provided for Resident #10's oral care in the morning. CNA #1 said that Resident #10's teeth (dentures) were consistently loose and she thought the Resident would benefit from the use of denture adhesive. CNA #1 said she was not sure if the Resident had any denture adhesive, but if he/she did, the denture adhesive would most likely be in the Resident's top night stand drawer. At that time, the surveyor, CNA #1 and Resident #10 entered the Resident's room. Resident #10 said he/she had denture adhesive in the top night stand drawer. CNA #1 opened the night stand drawer and the surveyor observed a tube of denture adhesive cream in the drawer. The Resident removed the denture adhesive cream and said that when the denture adhesive cream was put on his/her dentures, the dentures would stick forever. Resident #10 said he/she had adhesive cream on his/her dentures the previous day, but he/she did not think anybody put any adhesive cream on his/her dentures that morning. CNA #1 offered to apply the denture adhesive cream to the Resident's dentures, the Resident accepted, then said he/she would apply the adhesive cream themselves. The surveyor observed the Resident make several attempts to put the adhesive cream on his/her dentures, but the Resident was unable to squeeze the tube with enough force to expel any adhesive cream. CNA #1 then assisted Resident #10 with applying the adhesive cream to the Resident's dentures. During an interview on 9/11/24 at 9:38 A.M., the Speech Language Pathologist (SLP) said that he evaluated Resident #10 within the last month or two due to the Resident having increased coughing episodes when he/she ate. The SLP said that Resident #10 had difficulty swallowing, difficulty managing his/her own secretions at times, and experienced coughing episodes when eating. The SLP said that no changes were recommended to Resident #10's diet when he evaluated the Resident as the Resident was already on a puree diet. The SLP said that for safety, the Resident required continual supervision while eating. The SLP said staff should provide the interventions indicated in the Resident's care plan for encouraging small bites, chewing and swallowing each bite, and ensuring that the Resident's dentures were secured in place. During an interview on 9/11/24 at 11:00 A.M., the ADON said she supervised Resident #10 at the breakfast meal that same morning. The ADON said she recognized that the Resident was having difficulty managing his/her breakfast meal, that the Resident was coughing while eating and that she had provided assistance using her hand on the Resident's back when the Resident was coughing during the meal. The ADON said she knew the Resident was not choking and had positive air exchange, but was having difficulty. The ADON said she did not know that the Resident's care plan indicated required interventions for encouraging small bites and encouraging the Resident to chew and swallow each bite. The ADON further said once she recognized the Resident's bottom dentures were not secured in place, she instructed CNA #1 to remove them from the Resident's mouth. The ADON said there was no way the Resident had been provided with adhesive cream for his/her dentures that morning with the way the Resident's bottom dentures were moving around his/her mouth.

Based on interview, record and policy review, the facility failed to provide appropriate care and services for a nephrostomy tube (a thin flexible tube that drains urine from the kidney into a bag outside the body) according to professional standards of practice for one Resident (#372), out of a total sample of 17 residents. Specifically, the facility staff failed to flush Resident #372's nephrostomy tubes as ordered by the Physician to prevent blockage and increased risk of infection. Findings include: Review of the facility policy titled Nephrostomy Tube Care, revised October 2010, indicated: -The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous (through the skin) nephrostomy tube. -Verify that there is a Physician's Order. -Review the resident's care plan to assess for any special needs of the resident. Review of the facility policy titled Catheter Care, Urinary, revised 9/2014 indicated: to maintain an unobstructed urine flow. Review of the Management of Patients with Nephrostomy Tubes: Nursing toolkit, revised November 2022,(retrieved from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0011/807095/ACI-Management-patients-nephrostomy-tubes-nursing-toolkit.pdf) indicated: -A Medical Officer must order flushing (frequency and amount of fluid to be instilled) or removal of a nephrostomy tube. -A Medical Officer or a Registered Nurse experienced in the procedure must perform flushing of the nephrostomy tube. -A Medical Officer prescribes flushing of the nephrostomy tube with 2 -10 milliliters (ml) of sterile normal saline as a single procedure. Following a medical officer's review, the frequency of flushing will be adjusted according to treatment needs and outcome. -The flushing of the nephrostomy tube is done using a 10 ml syringe. It should be a gentle, slow flush. It is not necessary to draw back or retrieve the small amount of normal saline that may remain, as this will drain out naturally. Resident #372 was admitted to the facility in September 2024, with diagnoses including Malignant Neoplasm of the Bladder (cancer of the bladder), Muscle Weakness (decreased strength in the muscles), Intestinal Obstruction (a gastrointestinal condition in which digested material is prevented from passing normally through the bowels), and palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). Review of Resident# 372's Discharge Summary information (Patient Care Referral Facility and Home Care Page 2) indicated: -Bilateral Nephrostomy tubes draining clear yellow urine, every 8-hour flushes. Review of the Minimum Data Set (MDS) Assessment, dated 9/12/24, indicated Resident #372 was cognitively intact as indicated by a Brief Interview of Mental Status (BIMS) score of 14 out of total possible 15. During an interview on 9/6/24 at 10:45 A.M., Resident #372 said his/her only concern was the need to have his/or nephrostomy tubes flushed twice a day as he/she did at home, which was not occurring at the facility. Review of the September 2024 Physician's orders indicated: -9/7/24: Flush nephrostomies daily with 10 ml (milliliters) of normal saline every day shift. During an observation and interview on 9/10/24 at 10:11 A.M., Resident #372 said that he/she had repeatedly asked the facility staff to flush his/her nephrostomy tubes, and the facility staff informed him/her that there was no Physician's order to do this. The Resident further said that he/she was afraid of a potential obstruction and had requested the facility staff to provide him/her with supplies so that he/she could flush the nephrostomy tubes as he/she had been doing twice daily when previously at home. On 9/10/24 at 10:46 A.M., the surveyor and Nurse #6 reviewed the Medication Administration Record (MAR) and the Treatment Administration Record (TAR). Nurse #6 said there were no orders in the Administration Records to flush Resident #372's nephrostomy tubes. On 9/10/24 at 10:58 A.M., the Director of Nursing (DON) said the facility reviews resident orders with the Physician when the residents are admitted to the facility. The DON said she reviewed the discharge paperwork for Resident #372 on 9/7/24, after he/she had been admitted to the facility, and noted the order to flush the nephrostomy tubes had not been entered into the Electronic Medical Record (EMR). The DON said she entered the orders incorrectly and there were no orders on the Administration Records (MAR or TAR) to flush the Resident's nephrostomy tubes. Please Refer To F726

Based on interview, policy and record review, the facility failed to provide appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for one Resident (#59), out of a total sample of 19 residents. Specifically, the facility failed: -to develop an individualized care plan to address the emotional and psychosocial needs of Resident #59, -to monitor and provide ongoing assessment as to whether the care approaches were meeting the emotional and psychosocial needs of the Resident after he/she experienced Suicidal Ideation (SI- verbal expressions of thoughts of harming oneself that may or may not lack specific intent), and -to review and revise the Resident's care plan after expression of SI, hospitalization , and re-admission to the facility. Findings include: Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, revised March 2019, indicated: -Nursing staff will identify, document, and inform the Physician about specific details regarding changes in an individual's mental status including: <onset, duration, intensity, and frequency of behavioral symptoms; <any recent precipitating or relevant factors of environment triggers (e.g. medication changes, infection, recent transfer from the hospital); and <appearance and alertness of the resident and related observations -New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others -The care plan will incorporate findings from the comprehensive assessment .and be consistent with current standards of practice -Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: <A description of the behavioral symptoms including frequency, intensity, duration, outcomes, location, environment and precipitating factors or situation <Targeted and individualized interventions for the behavioral and psychosocial symptoms, the rational for the interventions and approaches, specific and measurable goals for targeted behaviors, and how the staff will monitor for effectiveness of the interventions. -If the resident is being treated for altered behavior or mood, the interdisciplinary team (IDT) will seek and document any improvements or worsening in the individual's behavior, mood, and function. Resident #59 was admitted to the facility in August 2023, with diagnoses including Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), and Alcohol Abuse. Review of the Nursing Progress Note, dated 6/7/24, indicated: -Resident was crying uncontrollably -Resident was unable to be redirected -Resident stated I want to kill myself. If I had the means I would have done it already. -Resident requested to go to the hospital -Resident was transferred to the emergency room Review of the Hospital Emergency Department (ED) Provider Note dated 6/7/24, indicated Resident #59: -Had a history of Anxiety -Had two prior suicide attempts last year -Anxiety had been worsening -Increased Depression that morning -Stated if he/she had a means to kill him/herself, he/she would have done it Review of the Nurse Practioner (NP) Note dated 6/11/24 indicated: -Resident was sent to the ED for SI on 6/7/24 and returned the next day -Resident stated he/she became suicidal as a result of domestic and family problems -Resident said he/she felt this way before -Resident reported breakthrough Anxiety -Resident stated that he/she might start talk sessions with psych [sic] Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #59: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15. -reported symptoms of Depression including loss of interest, Depression, and fatigue in the past several days prior to the assessment. Review of the Plan of Care initiated 8/9/23, indicated Resident #59 had diagnoses of Anxiety and Depression and the goal was that the Resident will have improved mood state: happier, calmer, no [signs or symptoms] of Depression, Anxiety, or sadness through the review date. Review of the care plan interventions indicated: -Behavioral Health Consults as needed (psycho-geriatric team, Psychiatrist etc), initiated 8/9/23 -Resident needs time to talk, encourage Resident to express feelings, initiated 8/9/23 Further review of the Plan of Care failed to indicate person-centered or targeted individualized interventions to attain the highest practicable mental and social well-being for Resident #59 or that the care plan interventions were revised after 8/9/23. During an interview on 9/12/24 at 8:56 A.M., the Resident said that he/she had been having negative thoughts about him/herself in June and was transferred to the Emergency Department. Resident #59 said that when he/she returned from the hospitalization , he/she did not recall meeting with the facility Social Worker (SW). The Resident further said that he/she was supposed to get weekly therapy visits but the visits only started recently. Review of the Psychiatric Evaluation and Consultation, dated 6/10/24, indicated: -Requested evaluation by nursing upon return from hospitalization related to making SI statements. -Plan to coordinate with staff to monitor changes. -Interventions: validation, active listening, emotional support, and psycho-education when confronting current stressors. -Patient will avoid trigger situations, practice grounding skills daily, and focus on things that he/she can change. -Patient will find a day structure and reach out to the nursing staff if he/she has concerns. -Continue psychotherapy to provide patient with emotional support. Review of the Psychological Services Progress Note, dated 6/13/24, indicated: -Met with Resident .to assess for worsening Depression and Anxiety symptoms -[Resident] was hospitalized after reporting SI ideation -Interventions included: active listening, empathy, safety planning -[Resident] asked Therapist to come back again -Plan: Therapist will follow up with [Resident] next week for mood rating and emotional support Review of the Psychosocial Services Progress note, dated 7/4/24, indicated: -Resident had not met for therapy since 6/13/24 -Resident agreed to meet again for emotional support next week Review of the Medical Record failed to indicate that any supportive visits or assessments were made by the facility's Social Services team following the Resident's hospitalization for SI or that the evaluations and recommended interventions by Psychological Support Services from visits conducted on 6/10/24, 6/13/24, and 7/4/24 had been reviewed. During an interview on 9/11/24 at 2:13 P.M., the Director of Social Services (DSS) said that she was notified about Resident #59's SI statements and hospital transfer on 6/10/24. The DSS said that she recalled meeting with the Resident on 6/10/24. The DSS said they discussed the Resident's trigger for SI on 6/7/24 related to family issues and the DSS has since provided additional supportive visits to Resident #59. The DSS said that her supportive visits should have been documented and had not been. The surveyor and the DSS reviewed Resident #59's Plan of Care relative to Depression and Anxiety. The DSS said that she reviews care plans as needed and quarterly, and that Resident #59's mood care plan was not revised after 6/7/24, and should have been. During an interview on 9/12/24 at 10:12 A.M., the Director of Nursing (DON) said that Resident #59's care plan should have been reviewed and revised when he/she returned from the hospital after expression of SI and the care plan had not been revised.

Based on policy and record review, and interview, the facility failed to review and address the Pharmacist Medication Review recommendations for two Residents (#6 and #56), out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #6, verify and/or confirm that the Pharmacist recommendations were reviewed or addressed. 2. For Resident #56, verify and/or confirm that the Pharmacist recommendations were reviewed or addressed. Findings include: Review of the facility's policy, titled Documentation and Communication of Consultant Pharmacist Recommendations, undated, indicated: -A record of the Consultant Pharmacist's observations and recommendations is made available in an easily retrievable form to Nurses, Physicians, and the care planning team. -Comments and recommendations concerning drug therapy are communicated in a timely fashion. -The Consultant Pharmacist and the facility follows up on his/her recommendations to verify action has been taken. 1. Resident #6 was admitted to the facility in August 2023, with diagnoses of Encephalopathy (a brain disease that alters brain function, which can cause confusion), Bipolar Disorder (episodes of mood swings ranging from depressive lows to manic highs), Schizoaffective Disorder (a mental health condition that is a combination of Schizophrenia and mood disorder symptoms such as depressive episodes, hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) and delusions (false beliefs), and manic episodes), and Muscle Weakness (decreased strength in the muscles). Review of the Minimum Data Set (MDS) Assessment, dated 7/3/24, indicated Resident #6 was cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 99 (indicating unable to access), and had visual hallucinations. Review of Resident #6's Pharmacy Progress Notes, indicated: -10/3/23: Recommendations made, review Clinical Pharmacy Report -12/6/23: Recommendations made, review Clinical Pharmacy Report Review of the clinical record did not indicate the specific pharmacy recommendations for the listed dates of 10/3/23 and 12/6/23. During an interview on 9/11/24 at 1:34 P.M., the Director of Nursing (DON) said that they were unable to find the pharmacy recommendations during the time of October 2023 and December 2023. The DON said that she would have to contact the pharmacy to have the recommendations faxed over, since it was not located in the Resident's record, and have the Physician address the recommendation. The facility was unable to provide evidence of the pharmacy recommendations being reviewed at the time of survey exit. 48206 2. Resident #59 was admitted to the facility August 2023, with diagnoses including Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #59 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15. The MDS Assessment further indicated Resident #59 received Antipsychotic (Antipsychotic-psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), Antianxiety (psychotropic medication used to manage anxiety), Antidepressant (psychotropic medication used to manage Depression), Hypnotic (psychotropic medication used to induce sleep), and Opioid (class of drugs to treat pain that derive from, or mimic, natural substances found in the opium poppy plant) medications. Review of Resident #59's Pharmacy Review Notes indicated: -9/13/23: Recommendations made, review Clinical Pharmacy Report -10/3/23: Recommendations made, review Clinical Pharmacy Report -11/3/23: Recommendations made, review Clinical Pharmacy Report -4/2/24: Recommendations made, review Clinical Pharmacy Report -5/6/24: Recommendations made, review Clinical Pharmacy Report Review of the clinical record did not indicate the specific pharmacy recommendations for the listed dates of 9/13/23, 10/3/23, 11/3/24, 4/2/24, and 5/6/24. During an interview on 9/11/24 at 3:45 P.M., the Director of Nursing (DON) said that she was unable to provide evidence of the Pharmacy reviews on 9/13/23, 10/3/23, 11/3/24, 4/2/24 and 5/6/24. The facility was unable to provide evidence of the pharmacy recommendations being reviewed at the time of survey exit.

Based on interview, policy and record review, the facility failed to ensure that one Resident (#59), out of a total sample of 17 residents, was free from the risks of side effects resulting from the unnecessary use of psychotropic medications. Specifically, the facility failed to ensure that appropriate monitoring for adverse consequences and side effects via an Abnormal Involuntary Movement Scale (AIMS) assessment (a clinical outcome checklist completed by a healthcare Provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body) was completed timely in accordance with standards of practice. Findings include: Review of the facility policy titled Psychotropic Medication Use, revised July 2022, indicated: -Psychotropic medication management includes: <adequate monitoring for efficacy and adverse consequences; and <preventing, identifying, and responding to adverse consequences. -Residents receiving psychotropic medications are monitored for adverse consequences . Review of the National Library of Medicine (NLM), dated 5/15/23 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10292174/ indicated but was not limited to: -The Abnormal Involuntary Movement Scale (AIMS) is administered every three to six months to monitor the patient for the development of TD (tardive dyskinesia - a syndrome characterized by abnormal involuntary movements of the patient's face, mouth, trunk, or limbs). Resident #59 was admitted to the facility in August 2023, with diagnoses including Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations) and Alcohol Abuse. Review of the Minimum Data Set (MDS) Assessment, dated 7/10/24, indicated Resident #59: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15. -received an antipsychotic (psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought) and the antipsychotic was administered on a routine basis. Review of the August 2024 Physician's orders indicated: -Olanzapine (antipsychotic) 5 mg, give 1 tablet by mouth one time a day, initiated 8/6/24, discontinued 8/28/24 -Aripiprazole (antipsychotic) 5 mg, give 1 tablet by mouth one time a day, initiated 8/6/24, active Review of the August 2024 Medication Administration Record (MAR) indicated Resident #59 received the following medications as ordered: -Olanzapine, administered from 8/7/24 - 8/28/24 -Aripiprazole, administered from 8/7/24 - 8/31/24 Review of the September 2024 Physician's orders indicated: -Aripiprazole 5 mg, give 1 tablet by mouth one time a day, initiated 8/6/24, active Review of the September 2024 MAR indicated Resident #59 received the following medications as ordered: -Aripiprazole, administered from 9/1/24 - 9/11/24 Review of Resident #59's Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE], indicated the Resident was assessed for abnormal movements and none were present. Review of the medical record failed to indicate that an updated AIMS had been completed every three to six months as required, since August 2023. Further Review of the medical record failed to provide evidence that a plan of care was developed to monitor for adverse consequences and side effects related to antipsychotic medication use. During an interview on 9/12/24 at 10:12 A.M., the surveyor and the Director of Nursing (DON) reviewed Resident #59's medical record. The DON said that an AIMS assessment is typically done every six months to assess for adverse consequences or side effects related to antipsychotic medication use. The DON said that an updated AIMS should have been completed for Resident #59 and had not been.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for one Resident (#14), out of a total sample of 17 residents. Specifically, the facility staff failed to document medicated lotion treatments administered to Resident #14's lower extremities as ordered by the Physician. Findings include: Review of the facility policy titled Charting and Documentation, revised July 2017, indicated: -All services provided to the resident .shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident condition and response to care. -The following information is to be documented in the resident medical record: <Treatments or services performed <Medications administered Resident #14 was admitted to the facility in August 2024 with diagnoses including Need for Assistance With Personal Care, Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment, weight loss, decreased appetite or poor nutrition and inactivity), and Cellulitis (potentially serious bacterial infection of the skin) of left and right lower extremities. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #14 was moderately cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of the September 2024 Physician's orders for Resident #14 indicated: -Lac-Hydrin Twelve External Lotion 12% (medicated cream to treat dry scaly skin) apply to LEs (lower extremities) topically (on the surface) two times a day for dry skin, initiated 9/4/24, active During an observation and interview on 9/6/24 at 10:26 A.M., the surveyor observed Resident #14 lying in bed, and dressed in a gown. The surveyor observed the skin on the Resident's right leg to be scaly, dry, flaky, red and scabbed. Resident #14 said the staff were supposed to put medicated lotion on his/her legs and feet twice a day, but this did not happen. During observation and interview on 9/6/24 at 11:39 A.M., the surveyor observed Resident #14 sitting up in a wheelchair. Resident #14 said that staff provided care and had put medicated lotion on his/her legs. Review of the September 2024 Treatment Administration Record (TAR) for Resident #14 failed to indicate that administration of Lac-Hydrin Twelve External Lotion 12% had occurred on: -9/5/24 at 8:00 A.M. -9/7/24 at 8:00 A.M. -9/8/24 at 8:00 A.M. -9/10/24 at 8:00 A.M. During an observation and interview on 9/10/24 at 4:13 P.M, the Director of Nursing (DON) said the Nurses should be signing off on the TAR when treatments are provided. The DON said there should not be blank spaces for signatures on the TAR because lack of a signature on the TAR indicated that the treatment was not provided. The DON confirmed the missing signatures on the TAR for the following dates and times: -9/5/24 at 8:00 A.M., -9/7/24 at 8:00 A.M., -9/8/2024 at 8:00 A.M. -9/10/2024 at 8:00 A.M. The DON said she would look for evidence that the treatments were provided to Resident #14. During a follow-up interview on 9/11/24 at 1:47 P.M., the Assistant Director of Nurses (ADON) said she contacted the Nurses who failed to sign off the TAR for: -9/5/24 at 8:00 A.M., -9/7/24 at 8:00 A.M., -9//8/2024 at 8:00 A.M. -9/10/2024 at 8:00 A.M. The ADON said care had been confirmed to have been provided but the Nurses had forgotten to sign off on the TAR. The ADON said that the TAR should be signed off in accordance with facility policy and standards of care to indicate that care was delivered as ordered by the Physician.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff for care, the Facility failed to ensure he/she was free from physical abuse and mental anguish, when on 06/11/24 during the evening shift (3:00 P.M. to 11:00 P.M), Resident #1 refused to transfer to bed, he/she became combative with staff and in response, Certified Nurse Aide (CNA) #1 physically restrained Resident #1, to which Resident #1 said stop, you're hurting me! CNA #1 yelled at Resident #1 telling him/her he was the captain, and forced Resident #1 to transfer into bed against his/her will. Findings include: Review of the Facility's Policy titled Abuse Prevention Program, dated as revised April 2021, indicated that the Facility's residents have the right to be free from abuse, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat a person's symptoms. Review of the Facility's Policy Titled and Neglect, Clinical Protocol, dated as revised September 2022, indicated that abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the Facility's Policy titled, Use of Restraints, dated as revised April 2017, indicated the following: -physical restraints are defined as any manual method of physical or mechanical device, material or equipments 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, and -restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or prevention of falls. Review of the Facility's Policy titled Behavioral Assessment, Intervention, and Monitoring, dated as revised March 2019, indicated the following: -Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated, and -the Resident and or resident surrogate will have the right to refuse treatment. Resident #1 was readmitted to the Facility in February 2024, diagnoses included right femur (long leg bone) fracture, Alzheimer's Disease, depression, and paranoid personality disorder. Review of Resident #1's Minimum Set Data (MDS) Quarterly Assessment, dated 04/24/24, indicated he/she had severe cognitive impairment and required maximal assistance from staff for all mobility. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 06/11/24, indicated that CNA #2 and CNA #3 reported to the Nursing Supervisor that during care, it appeared that CNA #1 was kneeling on Resident #1. Review of a Nursing Progress Note, dated 06/11/24, indicated that two Certified Nurse Aides (CNA #2 and CNA #3) heard CNA #1 talking loudly out of frustration due to Resident #1 being combative. The Note indicated that CNA #2 and CNA #3 reported that CNA #1 used excessive force by putting his (CNA#1) knee on Resident #1's lap to prevent him/her (Resident #1) from getting up. The Note also indicated that CNA #1 was observed (by CNA #2 and CNA #3) to be very loud and aggressive toward Resident #1. Review of the Facility's Investigation Summary Report, undated, indicated that the reporting CNAs (identified as CNA #2 and CNA #3) said that on 6/11/24, CNA #1 kneeled on Resident #1 when he/she attempted to stand up. The Report indicated that CNA #2 and CNA #3 also reported that CNA #1 spoke very loudly and told Resident #1 to listen to him because he (CNA #1) was the captain. Review of Resident #1's CNA Care Kardex, dated 06/11/24, indicated the following: -be careful not to invade Resident #1's personal space, -if Resident #1 refuses care, leave him/her and return in five to ten minutes, and -talk with Resident in a low pitch, calm voice to decrease or eliminate undesired behavior. The Report indicated that CNA #1 said that Resident #1 was being combative when he was trying to put him/her to bed, so he (CNA #1) put one of his (CNA #1) legs on top of Resident #1's legs. The Report indicated that CNA #1 was immediately suspended and then terminated. Review of a Police Report, dated 06/11/24, indicated that an Officer was dispatched to the facility on [DATE] at 10:31 P.M. The Report indicated that the Nursing Supervisor told the Officer that one of their employees (identified as CNA #1), had been aggressive with one of their residents (later identified as Resident #1). The Report indicated that CNA #1 had been suspended and had already left the Facility. The Report indicated that the Nursing Supervisor told the Officer that two employees (identified as CNA #2 and CNA #3) had witnessed CNA #1 place his knee on Resident #1's lap/hip area to hold him/her down. The Report indicated that CNA #2 and CNA #3 told the Officer that CNA #1 grabbed Resident #1's right hand, placed it on his/her lap/hip area and then CNA #1 put his left knee on top of Resident #1's lap/hip area while he/she was sitting down. The Report indicated that CNA # 2 and CNA #3 had also said that CNA #1 was yelling at Resident #1 in frustration. The Report indicated that CNA #2 and CNA #3 said Resident #1 became combative while CNA #1 was trying to set Resident #1 up to transfer him/her back to bed, and that they told CNA #1 to leave him/her alone. The Report indicated that the Officer was requesting a show-cause hearing for CNA #1 for a charge of assault and battery on a 60+/disabled person. During a telephone interview on 07/11/24 at 10:28 A.M., which included review of her Written Witness Statement, dated 06/11/24, CNA #2 said Resident #1 was confused and could be combative during care, but said if staff were patient with him/her, Resident #1 could typically be redirected. CNA #2 said if Resident #1 continued to be combative or refuse care, staff should tell the nurse and reapproach him/her later. CNA #2 said that on 06/11/24 at approximately 10:00 P.M., CNA #1 was trying to get Resident #1 to transfer to bed from his/her wheelchair, and Resident #1 said leave me alone. CNA #2 said CNA #1 was angry and yelled at Resident #1. CNA #2 said that Resident #1 was trying to free him/herself from CNA #1 and then CNA #1 grabbed Resident #1's hand, put it on his/her (Resident #1) lap and then CNA #1 put his knee on Resident #1's hand and lap to hold him down. CNA #2 said Resident #1 yelled, get away from me and ouch, you're hurting me! CNA #2 said that even though Resident #1 did not want to go to bed, CNA #1 forced Resident #1 to transfer into bed. CNA #2 said she and CNA #3 told CNA #1 to stop, but he would not. CNA #2 said she immediately went and told the Nursing Supervisor that CNA #1 was brutal and very aggressive, both verbally and physically, with Resident #1. During a telephone interview on 07/09/24 at 1:26 P.M. (which included a review of her Written Witness Statement, dated 06/11/24), CNA #3 said CNA #1 asked her for help with Resident #1, and that CNA #2 also came in to help. CNA #3 said CNA #1 was talking loudly to Resident #1 and she told him to lower his voice, but he refused. CNA #3 said Resident #1 told CNA #1 to get out! and CNA #1 responded to Resident #1 by telling him/her that he (CNA #1) was the captain and he/she (Resident #1) had to go to bed. CNA #3 said that Resident #1 tried to stand, and CNA #1 put his knee on Resident #1's lap to stop him/her. CNA #3 said CNA #1 should have left Resident #1 alone because he/she was being combative and did not want to go to bed. During a telephone interview on 07/11/24 at 12:03 P.M., (which included review of her Written Witness Statement, undated), the Nursing Supervisor said that on 06/11/24 at approximately 10:00 P.M., CNA #2 told her that she (CNA #2) and CNA #3 had been trying to help CNA #1 with Resident #1 and that CNA #1 had been excessively rough with him/her (Resident #1). The Nursing Supervisor said CNA #2 told her that CNA #1 had put his knee on Resident #1's lap and hand (which was on his/her lap) to hold him/her down. The Nursing Supervisor said she also interviewed CNA #3 that night, and said CNA #3 told her that CNA #1 had held Resident #1 down, was talking loudly, and told Resident #1 that he (CNA #1) was the captain. The Nursing Supervisor said she interviewed CNA #1 before she removed him from the Facility, and said he told her that Resident #1 was hitting him (CNA #1), so he put Resident #1's hand on his/her (Resident #1's) lap and then used his (CNA #1) knee to hold Resident #1's arm down. The Nursing Supervisor said she told CNA #1 that what he admitted to was abuse, and said she suspended CNA #1 and called the Police. During a telephone interview on 07/09/24 at 1:42 P.M., (which included a review of his Written Witness Statement, undated), CNA #1 said he was trying to get Resident #1 into bed, but Resident #1 was being combative, so he held both of Resident #1's hands down with his leg when he/she (Resident #1) was sitting in his/her wheelchair. CNA #1 said Resident #1 was yelling at him, hitting and kicking him, and said Resident #1 told him he/she did not want to go to bed. CNA #1 said he held Resident #1's hands and feet so he/she could not move and put Resident #1 to bed even though he/she had refused. During an interview on 07/02/24 at 2:17 P.M., Social Worker (SW) #1 said when she spoke to Resident #1 about the incident on 6/11/24 with CNA #1, that Resident #1 had been unable to answer any questions about the alleged abuse incident because of his/her severe cognitive impairment. SW #1 said Resident #1 is typically only aggressive when staff does not back off when he/she refuses something, and said Resident #1 gets angry when he/she is not heard. Although Resident#1's impaired cognition minimized his/her understanding of the incident, an unimpaired individual would have experienced mental anguish after being treated by a caregiver in this manner. The Surveyor was unable to interview Resident #1 as he/she was on a medical leave of absence at the time of the survey. During an in-person interview on 07/02/24 at 11:34 A.M., and a follow-up telephone interview on 07/11/24 at 1:04 P.M., the Director of Nurses (DON) said that on 06/11/24 during the evening shift, the Nursing Supervisor called her and said she had removed CNA #1 from the building and called the Police because CNA #2 and CNA #3 reported to her that CNA #1 had used his leg to restrain Resident #1. The DON said that if Resident #1 refused care or became combative, then CNA #1 should walked away, let the nurse know, and attempt care again later. The DON said CNA #1 was immediately suspended and then terminated. The DON said the Facility substantiated an allegation of abuse because CNA #1 had restrained Resident #1. During an in-person interview on 07/02/24 at 2:05 P.M., and a follow-up telephone interview on 07/11/24 at 12:41 P.M., the Administrator said the Nursing Supervisor notified her on 06/11/24 that CNA #1 had been rough and inappropriate with Resident #1. The Administrator said she interviewed CNA #1 in person and said that CNA #1 told her that Resident #1 was being aggressive during care, so he (CNA #1) put his/her (Resident #1) hand down and then he (CNA #1) put his leg on top of Resident #1's leg, so he/she would not kick. The Administrator said CNA #2 and CNA #3 told her that CNA #1 was also yelling at Resident #1. The Administrator said that the outcome of the Facility investigation was that CNA #1 restrained Resident #1, that staff are not allowed to restrain residents and that restraining a resident is considered abuse. The Administrator said CNA #1 had been terminated from the Facility.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Activity of Daily Living Care Plan indicated he/she required the assistance of one to two staff members for ambulation, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in his/her plan of care related to mobility and care needs. On 04/09/23, Certified Nurse Aide (CNA) #3, left Resident #1 standing alone on a wet floor in his/her room while she went to get supplies to clean his/her floor. Resident #1 slipped, fell , and complained of left wrist pain and was later transferred to the Hospital Emergency Department for further evaluation where he/she was diagnosed with a non-displaced left wrist fracture. Findings Include: Review of the Facility Policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated the Comprehensive Care Plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #1 was admitted to the Facility in September 2021, diagnoses included bipolar disorder, schizophrenia, generalized muscle weakness, unsteadiness on feet, and lack of coordination. Review or Resident #1's Activity of Daily (ADL) Living Care Plan, dated as revised on 01/13/23, indicated Resident #1 required assistance with ADLs related to decreased functional ability, easily fatigued, and physical limitations. The Care Plan indicated he/she required the assistance of one to two staff members with ambulation. The Care Plan indicated he/she required the assistance of two staff members for toileting, incontinence care, bathing, dressing, grooming, and hygiene. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required limited physical assistance of one staff member for transfers and ambulation. The MDS indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 (scores of 13-15 indicates cognitively intact), and was alert and oriented. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/08/23, indicated that on 04/09/23 at approximately 9:00 P.M., when CNA #3 went into Resident #1's room to assist him/her with P.M. care, she noticed that his/her bed was soiled and asked him/her to stand bedside the bed so she could remove the linens and clean the bed. The Report indicated that when Resident #1 stood beside the bed, he/she was incontinent of urine and CNA #3 asked him/her to stay there and she went out of the room to get supplies to clean the floor. The Report indicated that when CNA #3 returned, she found Resident #1 on the floor laying on his/her right side. The Report further indicated that Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed with a non-displaced left wrist fracture and returned with a soft case on his/her left wrist. Review of the Facility Incident Report, dated 04/09/23, indicated Resident #1 was observed on the floor laying on his/her right side. The Report indicated that CNA #3 stated that, after Resident #1 stood up from his/her bed, she noticed the floor was wet and told the resident to wait while she turned around to grab a towel and Resident #1 fell to the floor. The Report indicated there were no witnesses to his/her fall. The Note indicated that Resident #1 complained of left hip pain, elbow, and wrist pain and that he/she had an abrasion and slight bruising on his/her left elbow. The Incident Report indicated that a predisposing situational factor at the time of the incident included Resident #1 ambulated without assistance. Review of Resident #1's Nurse Progress Note, dated 04/09/23, indicated he/she was observed on the floor laying on his/her right side. The Note indicated that CNA #3 stated she noticed the floor was wet and told the resident to wait while she turned around to grab a towel and Resident #1 fell to the floor. The Note indicated that Resident #1 complained of left hip pain, elbow, and wrist pain and that he/she had an abrasion and slight bruising on his/her left elbow. However, documentation in the Facility Incident Report and the Nurse Progress Notes conflicted with the report the Facility submitted to the Department of Public Health and subsequent staff interviews which indicated CNA #3 left Resident #1 standing alone beside the bed in his/her room while she left the room to get supplies, versus just turning around to grab a towel. Review of Resident #1's Nurse Progress Note, dated 04/10/23, indicated Resident #1 returned from the Hospital Emergency Department at 4:30 A.M. and was diagnosed with a nondisplaced fracture of his/her left wrist and required a follow-up with an orthopedic specialist. Review of Resident #1's Hospital After Visit Summary, dated 04/10/23, indicated that Resident #1 sustained a non-displaced fracture of his/her left wrist as a result of a fall with a recommendation to follow-up with an orthopedic specialist. Review of the typed Telephone Statement from the CNA #3, dated 04/10/23, transcribed and signed by the Director of Nursing (DON) and a Human Resource (HR) staff member, indicated that CNA #3 stated (to the DON and HR staff member) that on 4/09/23, she provided incontinence care for Resident #1 at 8:30 P.M. and at 9:00 P.M., that she went into Resident #1's room with incontinence products and linens to assist him/her with evening care. The Statement indicated that CNA #3 said she noticed Resident #1's bed was wet and asked him/her to stand up (from the bed) so she could strip the bed and wipe it down. The Statement indicated that as Resident #1 was standing beside the bed, he/she (was incontinent) urinated on the floor and that CNA #3 asked him/her to stay where he/she was and that CNA #3 ran to get linen to clean the floor. The Statement indicated that when CNA #3 returned to Resident #1's room, she found him/her on the floor and went to notify the nurse. During an interview on 05/23/23 at 9:02 A.M., Resident #1 said, although he/she could not remember the date, said he/she recently fell and broke his/her wrist. Resident #1 said at the time of the fall, a CNA left him/her standing alone next to his/her bed, and he/she slipped and fell . During an interview on 05/24/23 at 12:24 P.M., Nurse #1 said she was assigned to Resident #1 when he/she fell on [DATE]. Nurse #1 said she could not recall the exact time, but that sometime between 8:00 P.M. and 9:00 P.M., CNA #3 came to her and told her that Resident #1 was on the floor. Nurse #1 said she went directly to Resident #1's room and observed him/her laying on the floor at the foot of his/her bed with his/her feet towards the door and his/her head towards the window. Nurse #1 said Resident #1 was mad that he/she fell and he/she said CNA #3 was useless and how dare she leave him/her in his/her room alone like that (or words to that effect) and that he/she had urinated on the floor and slipped in it. During an interview on 05/25/23 at 12:27 P.M., Nurse #2 said that on 04/09/23 she was the acting Nursing Supervisor during the 3:00 P.M. to 11:00 P.M. shift. Nurse #2 said she was on the unit and CNA #3 told her Resident #1 fell . Nurse #2 said CNA #3 told her that the fall occurred because Resident #1 urinated on the floor, told her (CNA #3) to go get some towels, so CNA #3 left him/her alone to go to the linen cart to get towels to wipe urine off the floor and for linens for his/her bed. Nurse #2 said at the time of Resident #2's fall, there were no other staff members in the room with him/her. Nurse #2 said she was unsure what Resident #1's functional status was, but said CNA #3 should have followed his/her Care Plan. During an interview on 05/30/23 at 8:22 A.M., CNA #3 said on 04/09/23 she worked the 3:00 P.M.-11:00 P.M. shift and said Resident #1 was on her assignment. CNA #3 said she went into Resident #1's room to assist him/her with evening care and said his/her bed was wet so she asked him/her to stand up so she could change the bed linens. CNA #3 said Resident #1 got up out of bed and stood at the foot of his/her bed and said she left him/her standing there while she left his/her room to go get supplies but said she was not sure what supplies she went out to get. CNA #3 said she left Resident #1 standing because she thought it was safe. CNA #3 said she could not recall if Resident #1's floor was wet. CNA #3 said she was unsure but thought Resident #1 required the assistance of one staff member for care and ambulation. CNA #3 said the way to determine the level of assistance a resident needs is by looking at the Care Plans. CNA #3 said she did not recall if she checked Resident #1's Care Plan before she provided care to him/her that shift. During an interview on 05/23/23 at 1:04 P.M. and on 05/25/23 at 1:11 P.M., the Director of Nursing (DON) said that the day after Resident #1 fell , she spoke to CNA #3 on the phone and said the HR Director was also present during the phone call. The DON said CNA #3 told her that she went into Resident #1's room to provide evening care and noticed that his/her bed was wet with urine so she asked him/her to stand up from the bed and when he/she stood up, he/she became incontinent of urine on the floor. The DON said CNA #3 told her that she then asked Resident #1 to stay where he/she was and not to move. The DON said CNA #3 told her that she then ran out of the room to get linens and when she returned, Resident #1 was on the floor. The Director of Nursing (DON) said resident Care Plans provide nursing staff with information about how to care for a resident and said when interventions are put into a resident's Care Plan, nursing staff, including CNA's, were able to view those interventions on the computer. The DON said when CNA #3 went into Resident #1's room to provide care for Resident #1, she did not have another staff member with her and said Resident #1's level of assistance varied depending on his/her level of fatigue. The DON said CNA #3 should not have left Resident #1 standing alone on a wet floor. The DON said CNA #3 should have followed what his/her Care Plan indicated.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of one to two staff members for ambulation and whose Care Plan indicated he/she had a potential for falls related to impulsiveness, poor safety awareness, and weakness, the Facility failed to ensure he/she was provided with the appropriate level of assistance required to maintain his/her safety, while in the presence of an environmental risk factor (wet floor), in an effort to prevent incident/accidents resulting in injury. On 04/09/23, Certified Nurse Aide (CNA) #3 left Resident #1 standing alone on a wet floor in his/her room while she went to get supplies to clean his/her floor. Resident #1 slipped, fell , and complained of left wrist pain and was later transferred to the Hospital Emergency Department for further evaluation where he/she was diagnosed with a non-displaced left wrist fracture. Findings Include: The Facility Policy titled Falls-Clinical Protocol, dated as revised March 2018, indicated that examples of risk factors for falling included weakness and environmental hazards. The Facility Policy titled Falls and Fall Risk, Managing, dated as revised March 2018, indicated that environmental risk factors that contributed to risk of falls included wet floors. Resident #1 was admitted to the Facility in September 2021, diagnoses included bipolar disorder, schizophrenia, generalized muscle weakness, unsteadiness on feet, and lack of coordination. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required limited physical assistance of one staff member for transfers and ambulation. The MDS indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 (scores of 13-15 indicates cognitively intact), and was alert and oriented. Review of Resident #1's Potential for Falls Care Plan, reviewed and renewed during his/her Care Plan Meeting in March 2023, indicated he/she had a potential for falls related to risk factors that included impulsiveness, poor safety awareness, and weakness. Review of Resident #1's Nurse Progress Note, dated 03/08/23, indicated that his/her Care Plan meeting was held and his/her Care Plans were reviewed. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, reviewed and renewed during his/her Care Plan Meeting in March 2023, indicated he/she required assistance with ADLs related to decrease in functional ability, easily fatigued, and physical limitations. The Care Plan indicated Resident #1 required the assistance of one to two staff members with ambulation. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/14/23, indicated that on 04/09/23 at approximately 9:00 P.M., CNA #3 entered Resident #1's room to assist him/her with P.M. care, noticed his/her bed was soiled, and asked him/her to stand bedside the bed so she could remove the linens and clean the bed. The Report indicated that when Resident #1 stood beside the bed, he/she was incontinent of urine and CNA #3 asked him/her to stay there and went out of the room to get supplies to clean the floor. The Report indicated that when CNA #3 returned, she found Resident #1 on the floor laying on his/her right side. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed with a non-displaced left wrist fracture and returned with a soft case on his/her left wrist. Review of the Facility Incident Report, dated 04/09/23, indicated Resident #1 was observed on the floor laying on his/her right side. The Report indicated that CNA #3 stated she noticed the floor was wet and told the resident to wait while she turned around to grab a towel and Resident #1 fell to the floor. The Report indicated there were no witnesses to his/her fall. The Note indicated that Resident #1 complained of left hip pain, elbow, and wrist pain and that he/she had an abrasion and slight bruising on his/her left elbow. The Incident Report indicated that Resident #1 stated, in his/her description of the incident, that he/she was incontinent of urine on the floor, stepped in it, lost his/her balance, and fell . The Incident Report indicated that a predisposing physiological factor at the time of the incident was Resident #1 was incontinent. The Incident Report indicated that predisposing environmental factors at the time of the incident included a floor surface spill, wet floor, and poor lighting, The Incident Report indicated that a predisposing situational factor at the time of the incident included Resident #1 ambulated without assistance. Review of Resident #1's Nurse Progress Note, dated 04/09/23, indicated he/she was observed on the floor laying on his/her right side. The Note indicated that CNA #3 stated she noticed the floor was wet and told the resident to wait while she turned around to grab a towel and Resident #1 fell to the floor. The Note indicated that Resident #1 complained of left hip pain, elbow, and wrist pain and that he/she had an abrasion and slight bruising on his/her left elbow. However, documentation in the Facility Incident Report and the Nurse Progress Notes conflicted with the report the Facility submitted to the Department of Public Health and subsequent staff interviews which indicated CNA #3 left Resident #1 standing alone beside the bed in his/her room while she left the room to get supplies, versus just turning around to grab a towel. A subsequent Nurse Progress Note, dated 04/09/23, indicated Resident #1 continued to complain of left elbow and wrist pain but refused to be transferred to the Hospital Emergency Department. Review of Resident #1's Nurse Progress Note, dated 04/10/23, indicated he/she approached the nurse at 10:45 P.M. (on 04/09/23), demanding to be transferred to the Hospital for evaluation related to his/her left upper extremity feeling immobile. The Note indicated Resident #1 was transferred to the Hospital Emergency Department. A subsequent Nurse Progress Note, dated 04/10/23, indicated Resident #1 returned from the Hospital Emergency Department at 4:30 A.M. with a diagnosis of a nondisplaced fracture of his/her left wrist that required a follow-up with an orthopedic specialist. Review of Resident #1's Hospital After Visit Summary, dated 04/10/23, indicated that Resident #1 sustained a non-displaced fracture of his/her left wrist as a result of a fall with a recommendation to follow-up with an orthopedic specialist. Review of the typed Telephone Statement from the CNA #3, dated 04/10/23, transcribed and signed by the Director of Nursing (DON) and a Human Resource (HR) staff member, indicated CNA #3 stated (to the DON and the HR staff member) that on 4/09/23, she provided incontinence care for Resident #1 at 8:30 P.M. and at 9:00 P.M., that she went into Resident #1's room with incontinence products and linens to assist him/her with evening care. The Statement indicated that CNA #3 said she noticed Resident #1's bed was wet and asked him/her to stand up (from the bed) so she could strip the bed and wipe it down. The Statement indicated that as Resident #1 was standing beside the bed, he/she (was incontinent) urinated on the floor and that CNA #3 asked him/her to stay where he/she was and that she (CNA #3) ran to get linens to clean the floor. The Statement indicated that when CNA #3 returned to Resident #1's room, she found him/her on the floor and went to notify the nurse. During an interview on 05/23/23 at 9:02 A.M., Resident #1 said, although he/she could not remember the date, said he/she recently fell and broke his/her wrist. Resident #1 said at the time of the fall, a CNA left him/her standing alone next to his/her bed and he/she slipped and fell . During an interview on 05/24/23 at 12:24 P.M., Nurse #1 said she was assigned to Resident #1 when he/she fell on [DATE]. Nurse #1 said although she could not recall the exact time, said that sometime between 8:00 P.M. and 9:00 P.M., CNA #3 came to her and told her that Resident #1 was on the floor. Nurse #1 said she went directly to Resident #1's room and observed him/her laying on the floor at the foot of his/her bed with his/her feet towards the door and his/her head towards the window. Nurse #1 said Resident #1 was mad that he/she fell and he/she said CNA #3 was useless and how dare she leave him/her in his/her room alone like that (or words to that effect) and that he/she had urinated on the floor and slipped in it. Nurse #1 said she observed the floor was wet next to where Resident #1 was observed laying. Nurse #1 said CNA #3 told her that she left Resident #1's room to get linens and when she returned he/she was on the floor. During an interview on 05/25/23 at 12:27 P.M., Nurse #2 said that on 04/09/23 she was the acting Nursing Supervisor during the 3:00 P.M. to 11:00 P.M. shift. Nurse #2 said she was on the unit and CNA #3 told her Resident #1 fell . Nurse #2 said CNA #3 told her that the fall occurred because Resident #1 urinated on the floor, that he/she told her (CNA #3) to go get some towels, and she (CNA #3) left him/her alone to go to the linen cart to get towels to wipe urine off the floor and for linens for his/her bed. Nurse #2 said Resident #1 frequently refused to wear incontinence briefs and frequently urinated when he/she stood up. Nurse #2 said at the time of Resident #2's fall, there were no other staff members in the room with him/her. Nurse #2 said she was unsure what Resident #1's functional status was, but said CNA #3 should have followed his/her Care Plan. During an interview on 05/30/23 at 8:22 A.M., CNA #3 said on 04/09/23 she worked the 3:00 P.M.-11:00 P.M. shift and said Resident #1 was on her assignment. CNA #3 said she went into Resident #1's room to assist him/her with evening care and said his/her bed was wet so she asked him/her to stand up so she could change the bed linens. CNA #3 said Resident #1 got up out of bed and stood at the foot of his/her bed and said she left him/her standing while she left his/her room to go get supplies but said she was not sure what supplies she went out to get. CNA #3 said she left Resident #1 standing because she thought it was safe. CNA #3 said she could not recall if Resident #1's floor was wet. During an interview on 05/30/23 at 12:19 P.M., the Assistant Director of Nursing (ADON) said that Care Plans were reviewed quarterly and said the last time Resident #1's Care Plans were reviewed prior to his/her fall on 04/09/23 was at his/her Care Plan meeting on 03/08/23. During an interview on 05/23/23 at 1:07 P.M., the Director of Nursing (DON) said that the day after Resident #1 fell , she spoke to CNA #3 on the phone and said the HR Director was also present during the phone call. The DON said CNA #3 told her that she went into Resident #1's room to provide evening care and noticed that his/her bed was wet with urine so she asked him/her to stand up from the bed and when he/she stood up, he/she became incontinent of urine on the floor. The DON said CNA #3 told her that she then asked Resident #1 to stay where he/she was and not to move. The DON said CNA #3 told her that she then ran out of the room to get linens and when she returned, Resident #1 was on the floor. The DON said CNA #3 should have sat Resident #1 back down on his/her bed or used a wheelchair to bring him/her to the bathroom when she saw his/her had urinated on the floor and said CNA #3 should not have left him/her standing alone on a wet floor because she put him/her at risk for falling like he/she did.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 received medications as ordered by the Physician, resulting Resident #1 being hospitalized . -On 4/1/15 and 4/5/15, the nursing staff documented they did not administer Resident #1 the prescribed dose of rapid-acting insulin. -On 4/6/15, at 7:30 A.M., Resident #1's finger stick blood sugar level (FSBS) was 144, which indicated Resident #1 did not require insulin, but Nurse #1 administered Resident #1 100 units of a rapid-acting insulin in error. Resident #1 was hospitalized as a result of the 4/6/15 error. Findings include: The Hospital Transition of Care, dated 4/1/15, indicated Resident #1's plan of care included the use of [MEDICATION NAME](rapid-acting insulin). The dose of insulin was based on Resident #1's FSBS, which was ordered to be obtained four times a day. The Admission Record indicated the staff admitted Resident #1 to the Facility in April 2014 and Resident #1's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment, completed on 12/30/14, indicated Resident #1 had cognitive impairment. The April 2014 Physician order [REDACTED]." The Surveyor interviewed the Director of Nurses (DON) at 7:30 P.M. on 4/27/15. The DON reviewed Resident #1's insulin order with the Surveyor and said the order was confusing and was not clarified with the Physician. The DON said the nurse, who transcribed the order onto the Medication Administration Record [REDACTED]. The DON said this made the documentation of the sliding scale insulin administered to Resident #1 confusing. 1. The MAR, dated 4/1/15 at 4:30 P.M., indicated Resident #1's FSBS level was 181. The MAR indicated [REDACTED]. 2. The MAR, dated 4/5/15 at 4:30 P.M., indicated Resident #1's FSBS level was 191. The MAR indicated [REDACTED]. The DON said prior to the Survey visit, she was not aware of the 4/1/15 and 4/5/15 medication errors regarding Resident #1. 3. The MAR, dated 4/6/15, indicated Resident #1's 7:30 A.M. FSBS was 144, which indicated Resident #1 did not require sliding scale insulin. The MAR indicated [REDACTED]. The Surveyor interviewed Nurse #1 at 12:45 P.M. on 4/27/15. Nurse #1 said when she reviewed the medication order for Resident #1's insulin, the order did not make sense to her. Nurse #1 said she noted the [MEDICATION NAME]at 100 mg and did not see the "ml". Nurse #1 said although she was a new RN, she had never given a resident 100 units of insulin. Nurse #1 said she brought the MAR, which noted the [MEDICATION NAME] order, to Unit Manager #2. Nurse #1 said she told Unit Manager #2 she was confused by the [MEDICATION NAME] order. Nurse #1 said Unit Manager #2 told her she was not familiar with Resident #1's care, and instructed her to review the physician's orders [REDACTED]. The Surveyor interviewed Unit Manager #2 at 1:35 P.M. on 4/27/15. Unit Manager #2 said on 4/6/15, Nurse #1 told her she had questions regarding Resident #1's insulin order. Unit Manager #2 said she told Nurse #1 to review the Physician order [REDACTED]. Nurse #1 said she reviewed the physician's orders [REDACTED].#1 was to receive [MEDICATION NAME] 100 units of insulin based on the FSBS level of 144. Nurse #1 said that on 4/6/15 at 7:30 A.M., she administered [MEDICATION NAME]100 units to Resident #1. Nurse #1 said prior to the lunch meal on 4/6/15, the Certified Nurse Aide (CNA) told her Resident #1 did not feel well and when checked, Resident #1's FSBS level was in the 80's (normal 70 to 110). Nurse #1 said Resident #1's FSBS level continued to drop, despite being given food and fluids, and when she and Unit Manager #2 reviewed Resident #1's MAR, realized the administration of 100 units of rapid-acting insulin to Resident #1 at 7:30 A.M. was an error. Nurse #1 said she reported the incident to the Physician and the staff transferred Resident #1 to the Emergency Department (ED) for an evaluation. The Hospital Discharge summary, dated 4/15/15, indicated the staff treated Resident #1 with oral and intravenous glucose and monitored Resident #1 in the intensive care unit.

Based on record review, observation, and staff interview, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 2 of 5 applicable residents (#4 and #10) out of a total sample of 15 residents. Findings include: 1. For Resident #10, the facility failed to provide effective interventions and adequate supervision to prevent falls in order to provide an effective falls intervention program for this Resident with short and long term memory impairment and poor safety awareness. The Resident had 10 falls (8 unwitnessed), and the facility failed to follow the Resident's falls care plan relative to the following: assistance with transfers/ambulation was not provided; wheelchair alarm did not activate; and alarming seat belt to wheelchair was not on. Resident #10, with [DIAGNOSES REDACTED]. Review of the "Nursing Assessment (Expanded)," dated 6/16/11, indicated that the Resident had a Fall Risk Score of 7. (Discussion with the Director of Nursing on 7/3/12 indicated there were no parameters to measure the actual risk for falls. He said that the higher the number, the greater the risk for falls.) Review of a Quarterly Minimum Data Set (MDS) assessment of 6/16/11 identified the resident as scoring 3 of 15 on the BIMS (Brief Interview for Mental Status), indicating the resident was severely impaired and had short and long term memory deficits; the resident felt bad about him/her self; required limited assistance/one person physical assist during transfers and ambulation and had not fallen since admission or prior assessment. The plan of care for falls, related to the resident's impaired mobility, cognitive loss, lack of safety awareness, and history of falls (initiated on 9/9/10) was updated on 6/24/11, and indicated the following interventions: - Assess for changes in medical status, pain status, mental status and report to MD (Medical Doctor) as indicated - Utilize low bed - Skid tape next to bed - Staff education regarding resident toileting status - Medication evaluation as needed - Assist the resident getting in and out of bed - Provide verbal cues for safety and sequencing when needed - Provide verbal cues for proper pacing and energy conservation techniques - Provide resident/caregiver education for safe techniques - Place call light within reach at all times - Remind resident to use call light when attempting to ambulate or transfer - Maintain a clutter-free environment in the resident's room and consistent furniture arrangement - When resident is in bed, place all necessary personal items within reach - Monitor for and assist toileting needs - Encourage resident to attend all activities that maximize their full potential while meeting their need to socialize - Fall risk assessment per protocol - Top 1/2 siderails to bed to assist with bed mobility Review of a 6/25/11 nursing note indicated the resident had an unwitnessed fall. Review of the investigation indicated the fall occurred at 5:00 P.M., when the resident was found on the floor at the bedside. The resident stated, "My feet got stuck on the floor." The investigation did not clearly identify if the resident was in the bed prior to the fall, or in the wheelchair, which made it difficult to conclude the circumstances leading to the fall. New interventions listed on the investigation included, "Resident to be in supervised setting and to be brought to appropriate activities." The resident had no apparent injuries from the fall. Review of a nursing note of 6/26/11 indicated the resident attended group activities with supervision and was observed making a few attempts to self transfer. Safety was maintained. The plan of care for falls was updated on 6/26/11 to include: place Dycem (non slip material) on seat of chair as prevention of sliding off w/c (wheelchair), on 6/27/11 to include: not to be left unattended in room during waking hours, and on 6/28/11 to include: hip protectors to be worn at all times. Review of a nursing note of 7/21/11 indicated that the resident had an unwitnessed fall at 8:45 P.M. across from the nursing station. The resident was left unsupervised while the Nurse went into another resident's room to perform a treatment, although the intervention on the fall investigation for the 6/25/11 fall indicated that the resident was to be in a supervised setting. When the nurse returned to the nursing station, the resident was found sitting on the floor in front of a storage closet door, with his/her back against the door, legs outstretched stating, "I think I broke my wrist." The resident's wrist looked abnormal in appearance and the resident was crying. "Just knock me out it hurts so terrible." The Physician was notified and the resident was sent to the hospital for evaluation. According to the clinical record, the resident returned to the facility on [DATE] at 4:45 A.M. with a [DIAGNOSES REDACTED]. The resident also had an order for [REDACTED]. Bed and chair pad alarms were added to the care plan. After being assisted to bed, the resident attempted to climb out of bed three times. The resident was complaining of severe pain in the wrist on 7/28/11 and 7/29/11. Percocet was given with positive effect. The resident continued to attempt to self ambulate on 7/31/11 x 2, and was re-directed. Review of a nursing note of 8/16/11 indicated that the resident was found sitting on the floor in the hallway in front of the wheelchair with no injury. The fall was unwitnessed. Review of the investigation indicated that the resident told the nurse she just slid out of the wheelchair. The wheelchair alarm did not sound as planned. New interventions included to add Dycem to the top of the alarm pad in the wheelchair. The intervention for the Dycem to the seat of the w/c was discontinued on (9/27/11). Review of a nursing note of 9/4/11 indicated that the resident had an unwitnessed fall outside of the bathroom while looking for his/her shoes. The resident sustained [REDACTED]. Areas were washed and Optifoam dressings applied. Review of the investigation indicated that staff attempted to educate the resident to call for assist (despite the resident's memory impairments). The care plan was updated on 9/6/11 to include: Obtain family consent to move room close to nursing station for closer supervision; and Geri-legs to be worn at all times, may be removed for care. On 9/6/11 at 11:29 P.M., the resident had a room change closer to the nursing station. Review of the "Nursing Assessment (Expanded)," dated 9/16/11 indicated that the resident had a Fall Risk Score of 15, indicating the resident's risk for falls had increased. A Significant Change in Status Assessment was completed on 9/16/11 due to a decline in ADL (Activities of Daily Living), falls, and fractured wrist. This assessment identified the resident had short and long term memory problems, moderately impaired decision making ability, had inattention, and disorganized thinking, and required extensive assistance/one person physical assist for all ADLs. The resident could eat independently, had functional limitation in range of motion (one side) upper extremity (wrist), and 1 fall with no injury, 1 fall with injury except major, and 1 fall with major injury. The resident utilized a walker and a wheelchair. Review of a Nursing Note/Care Plan Evaluation Note dated 9/27/11 indicated, "...resident sustained [REDACTED]. (His/Her) therapy has been discontinued as of 9/23/11. (He/She) utilizes (his/her) wheelchair as primary means of locomotion and ambulates with staff utilizing a rolling walker and gait belt." "...He/She has had falls x 2 since his/her fall with Fx and has sustained abrasions and skin tears." "...(He/She) continues on bed and chair alarms to alert the staff for frequent episodes of self transfers." Review of a Nursing Note of 9/29/11 indicated that the resident was seen by the Orthopedic Surgeon and the wrist fracture "healed." Review of a Nursing Note of 10/26/11 indicated that the resident was sitting across from the nursing station at 9:15 P.M. The Nurse was conversing with the resident when the resident was observed standing up from the chair, and taking a step forward. Review of the investigation revealed that the alarm sounded, the Nurse could not reach the resident in time, and the resident fell forward landing on the right side on his/her face. The resident had a 1 cm laceration on the right side of nose with nasal oozing, pain and swelling; a skin tear to the forehead an abrasion to the right knee and a bruise to the right elbow. The physician was notified and the resident was sent to the hospital for an evaluation. The resident returned to the facility on [DATE] at 5:10 A.M. with a [DIAGNOSES REDACTED]. The resident was assessed to have facial swelling and bruising periorbital bilaterally. The plan of care was updated to include: 15 minute checks x (times) 48 hours; keep head of bed elevated for 72 hours when in bed; ice to nose x 10 minutes q (every) 4 hours prn (as needed) for discomfort/swelling; Acetaminophen 650 mg po (by mouth) q (every) 12 hours scheduled and q 4 hours prn pain/increased temperature; Skilled PT/OT screen; Check CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) P.M. on 10/28/11. Review of a nursing note of 10/28/11 indicated that the resident had an unwitnessed fall while sitting near the nurses desk eating supper (6:00 P.M.). The resident stated he/she bumped head when he/she fell resulting in a raised area on head and the resident also sustained a skin tear on the left ring finger. The chair alarm malfunctioned, and did not sound. The care plan was updated to include: alarming self release seat belt to the wheelchair, check every half hour, release every 2 hours in supervised setting; 15 minute checks x 24 hours; ice to back of head x 10 minutes q 4 hours prn. The Nursing note of 10/28/11 (6:20 A.M.) indicated that the resident attempted to climb out of bed and had an unsteady gait. Continue monitoring every 15 minutes. The Nursing note of 11/4/11 indicated that the resident remained with yellowing bruises on the face, and the area to the bridge of the resident's nose was intact and scabbed (from the fall and acute fracture of the nose which occurred on 10/26/11). The Nursing note of 11/7/11 at 12:56 P.M., indicated that the resident's forehead, bridge of nose, and left ring finger skin tears were resolved (from falls of 10/26/11 and 10/28/11). The Nursing note of 11/7/11 (at 2:23 P.M.), indicated that the resident had an unwitnessed fall when he/she attempted to transfer from the wheelchair to the bed, and fell at 1:45 P.M. Review of the investigation revealed that the resident's seat belt alarm was off, despite the plan of care which indicated the alarming seat belt was to be on the wheelchair. The corrective action plan also included in-service education to be completed regarding not to leave the resident alone in the room while in the wheelchair. Review of the "Nursing Assessment (Expanded)," dated 12/14/11 indicated that the resident had a Fall Risk Score of 16, indicating the resident's risk for falls had increased. Review of a Quarterly MDS Assessment, dated 12/17/11 indicated that the resident's cognition remained the same, had signs and symptoms of delirium which included inattention and disorganized thinking, delusions, rejection of care (4-6 days), and wandered (1-3 days). The resident experienced 1 fall with no injury, 1 fall with injury (except major), and 1 fall with major injury. Review of a current plan of care for falls, (originally dated 9/9/10), printed by Unit Manager #2 on (6/28/12), which included resolved and discontinued interventions revealed the following: - Bed and chair alarms in place - D/C (discontinued)1/2/12 - Alarming self release seat belt to wheelchair - D/C 1/2/12 - Dycem to top of alarm pad in wheelchair - D/C 1/2/12 - Skid tape next to bed - D/C 3/12/12 Review of the "Nursing Assessment (Expanded)," dated 3/18/12 indicated that the resident had a Fall Risk Score of 8, and indicated now, that the resident's risk for falls had decreased. Review of a Quarterly MDS Assessment, dated 3/18/12 indicated that the resident's cognition remained the same, the resident continued with signs and symptoms of delirium which included inattention and disorganized thinking. The resident had no falls since the last Assessment. Review of a nursing note of 4/28/12 indicated that the resident had an unwitnessed fall while trying to transfer from the wheelchair. No apparent injuries were noted. Review of the investigation revealed that at 2:10 P.M., staff found the resident sitting on the floor between his/her wheelchair and the bench across from the nursing station. The resident explained he/she was trying to transfer from the wheelchair to the bench. The resident was put on 15 minute checks, and staff education was provided to redirect and assist the resident if seen self transferring, and staff education to redirect resident when he/she is observed leaving unit. The Nursing note of 5/6/12 indicated that the resident had a fall while attending the Fall Risk Group when he/she stood up unnoticed and fell . Review of the Investigation revealed that the fall occurred at 11:55 A.M. while the resident was attempting to transfer from the wheelchair to a straight back chair. No injuries were noted. The resident was placed on 15 minute checks. Review of a nursing note of 5/8/12 indicated that the resident was in the dining room and was observed to stand up from the chair and as he/she sat back down, he/she sat on the edge of the chair and slid onto the floor onto his/her buttocks. The plan of care was updated to include Dycem to chair. Review of the, "Nursing Assessment (Expanded)" dated 6/18/12 indicated that the resident had a Fall Risk Score of 15, indicating the resident's risk for falls had increased. Review of a Quarterly MDS Assessment, dated 6/18/12 indicated that the resident's cognition remained the same, the resident continued with signs and symptoms of delirium which included inattention and disorganized thinking, and other behavioral symptoms not directed towards others which occurred 1-3 days. The resident also rejected care daily. The resident had 2 or more falls without injury since the prior assessment. The Nursing note of 6/20/12 indicated the resident attempted to climb out of bed and was redirected. On 6/28/12 at 1:00 P.M., the surveyor observed the resident in the south dining area sitting in a straight back dining chair at the table. The resident stated to the surveyor that he/she was tired. The surveyor observed that the resident was sitting on the Dycem as care planned. On 6/28/12 from 1:20 to 3:25 P.M., the resident was observed sitting in a straight back chair in front of the nursing station. During an interview with the Director of Nursing on 6/28/12 at 4:15 P.M., he said he understood the concerns for this Resident who had 10 falls resulting in 2 fractures, abrasions, hematoma's, and numerous skin tears and bruises and that the plan of care was not effective. During further discussion, the Director of Nursing said the care plan was not followed as the alarms did not sound as planned. 2. For Resident #4, the facility failed to ensure the Resident received adequate supervision and assistive devices to prevent accidents. Resident #4 was admitted to the facility in 2/12. [DIAGNOSES REDACTED]. Review of Resident #4's fall care plan, initiated 2/8/12, indicated the Resident was at risk for falls related to MS, impaired mobility, cognitive loss, impulsive with poor safety awareness and had a history of [REDACTED]. Review of the Admission MDS Assessment, dated 2/15/12, indicated the resident had cognitive loss, was an assist with transfer, did not ambulate and had two or more falls. Review of the Resident Incident Report, dated 2/16/12 at 4:00 P.M., indicated the resident fell transferring self from bed to chair. Review of the Resident Incident Report, dated 3/19/12 at 12:00 P.M., indicated the resident was being assisted by a CNA. The CNA left the room to get a gait belt, to assist the resident with a transfer. Upon returning the resident was found lying on the floor. Review of the Resident Incident Report, dated 3/30/12 at 5:05 P.M., indicated the resident had a fall transferring self from chair to bed. Review of the Resident Incident Report, dated 4/30/12 at 12:30 P.M., indicated the resident fell transferring self from chair to bed. Review of the Resident Incident Report, dated 4/30/12 at 4:30 P.M., indicated the resident fell transferring self from bed to chair. The resident stated that he/she sat self on the floor. Review of the Quarterly MDS Assessment, dated 5/16/12, indicated the Resident was cognitively intact, was an assist for transfer, did not ambulate and had two or more falls in the past quarter. Review of the Resident Incident Report, dated 5/28/12 at 9:45 A.M., indicated the Resident fell from the wheelchair. The Resident stated he/she was packing clothes. On 6/26/12, during the initial tour, the surveyor observed the Resident lying in bed. There was a red mat to the right side of the bed and an alarm attached to the head of the bed. On 6/26/12 at 11:50 A.M., the surveyor observed the Resident in the dining room sitting in a wheelchair with an chair alarm attached. On 6/27/12 at 11:20 A.M., the surveyor entered the Resident's room for an interview and observed the Resident seated in a wheelchair with an alarm attached. The Resident said that when he/she wants to get up or go to bed he/she just does it. The surveyor asked Resident #4 if he/she knows how to call for help using the call light and the Resident said, "no". During an interview with the Director of Nurses (DON) on 6/28/12 at 10:00 A.M., he said that the Resident was a high risk for falls and numerous interventions had been put into place to keep the Resident from falling. The DON said the interventions did not work 100% of the time to prevent accidents.