Every finding on record at Linda Manor Extended Care Facility

Based on observation and interview, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in three out of three applicable facility unit kitchenettes. Specifically, the facility failed to implement safe food practices in three out of three facility unit kitchenettes relative to labeling, dating and guidelines for food storage. Findings include: Review of the facility policy titled Dietary Department Guidelines, last updated 5/2018, indicated: >Food Preparation and Handling-Food items should be labeled and use by dated to allow for rotation of supplies.-All items stored in the refrigerator will be covered and use by date labeled.-Refrigerated foods and cold foods will be stored and held at refrigerator temperatures 40 degrees Fahrenheit or below. -Refrigeration temperatures and will be monitored and documented on approved temperature monitoring logs, twice daily.-Frozen foods will be stored between zero and negative ten degrees Fahrenheit. >Foods not prepared in the facility-Personal foods brought into the facility by family members will be kept in appropriate storage containers, refrigerated if indicated and discarded as appropriate. -Prepared foods will be labeled with the Resident's name and use by date.-Prepared foods will be discarded after three days or sooner if there is any indication of spoilage.-Food brought in by visitors must be stored in such a way as to clearly distinguish it from food used or prepared by the facility. On 9/25/25 at 8:51 A.M., the surveyor and the Food Service Director (FSD) observed the following in the Sunrise Unit kitchenette:-two open containers of peanut butter in the cabinet unlabeled and undated-one open jar of honey unlabeled and undated.>in the unit refrigerator: -one package of cotton candy grapes with no resident name, dated 9/20/25-one plastic container of soup, unlabeled and dated 9/19/25-one plastic container of macaroni, unlabeled and dated 9/21/25During an interview at the same time, the FSD said that the peanut butter containers were not the facility's and should have had the resident's names and dates opened located on them. She also said that the kitchen staff is responsible for making sure that the food is labeled, dated, has the resident's name and is thrown away after three days to prevent contamination. On 9/25/25 at 9:03 A.M., the surveyor and the FSD observed the following in the Forestview kitchenette:-the refrigerator had an out of order sign on it-a 48-ounce container of opened prune juice on the counter, undated and warm to touch-a 64-ounce container of opened cranberry juice on the counter, undated and warm to touch-a 64-ounce container of opened apple juice on the counter, undated and warm to touch>a cooler with the following items inside: -two milkshakes, melted and not firm to touch, unlabeled and undated-small ice cream container, melted and not firm to touch, unlabeled and undated-bag of frozen berries, melted and not firm to touch, unlabeled and undated-melted ice and water inside the cooler During an interview at the same time the FSD said that the refrigerator had been broken since Monday 9/22/25. She also said that all the food items in the kitchenette had not been stored at the appropriate temperatures, the items were melted or not cold enough to prevent food born illness. On 9/25/25 at 9:14 A.M. the surveyor and the FSD observed the following in the Meadowview Unit kitchenette refrigerator: -three opened packages of deli meat, unlabeled and undated -one opened package of pre-sliced cheddar cheese, unlabeled and undated -one plastic container of pasta, dated 9/19/25-one plastic container of pasta, undated -one 64-ounce container of opened cranberry juice, undated -one opened container of grape jelly, undated During an interview at the same time, the FSD said that all the items in the refrigerator should have been discarded because they were older than three days, undated or unlabeled.

Based on observation, record review, and interview, the facility failed to ensure its staff provided care and services according to Physician orders for an indwelling urinary catheter (a thin, soft flexible tube that drains urine from the bladder) for one Resident (#88) out of four applicable residents, in a total sample size of 24 residents. Specifically, the facility staff failed to insert the correct indwelling urinary catheter size in accordance with Resident #88's Physician order, placing the Resident at risk for obstruction and pain. Findings include: Review of the facility policy titled Indwelling Urinary Catheters, dated 6/24/25, included but was not limited to:-Urinary catheters should only be placed under the direction of a Physician's order, including catheter size and care. Resident #88 was admitted to the facility in January 2024 with diagnoses including Obstructive (blockage in the urinary tract preventing normal urination) and Reflux (a backward flow of urine from the bladder into the ureters and kidneys) Uropathy. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident: -was cognitively intact as evident by a Brief Interview of Mental Status (BIMS) score of 15 out a total possible score of 15. -had an indwelling catheter. Review Resident #88's Physician orders included but was not limited to: -Foley (a specific type of indwelling urinary catheter) Catheter Size: 16 French, Retention bulb (a fluid filled [NAME] that anchors the indwelling catheter into the bladder): 10 milliliters (ml), every shift, effective 5/27/24. -May flush Foley Catheter with 60ml normal saline for occlusion or leaking as needed, effective 7/7/25. -May change Foley Catheter PRN (pro re nata [as needed]) for occlusion or leakage, effective 4/10/24. Review of Resident #88's person-centered care plan for catheter care, revised 4/10/25, indicated: -Resident had an indwelling urinary catheter due to Obstructive Uropathy -Catheter size:16 French/10cc (cubic centimeter [one cubic centimeter = one ml]) retention bulb. -Change catheter.and as needed to maintain patency Review of Resident #88's Treatment Administration record from September 2025 indicated but was not limited to: -The Resident's indwelling catheter was changed on 9/23/25 at 1:24 P.M. by Nurse #2 due to occlusion (blockage). During an interview and observation on 9/25/25 at 11:03 A.M., Nurse # 1 said that he was the nurse assigned to Resident #88. At that same time the surveyor and Nurse #1 observed Resident #88's indwelling urinary catheter together. Nurse #1 said that the indwelling catheter size currently in place for Resident #88 was a size 18 French with a 30 ml retention bulb. During a follow up interview on 9/25/25 at 12:04 P.M., Nurse #1 said Resident #88 did not have the correct indwelling catheter size in place as ordered by the Residents' Physician. Nurse #1 said Resident #88 should have had a French 16 with a 10 ml retention blub in place as ordered by the Resident's Physician. Nurse #1 said that the French 18 with the 30 ml retention bulb that was in the Resident was too big and could cause Resident #88 an obstruction or pain. Nurse #1 said Nurse #2 should have obtained a physician's order if a different indwelling catheter size was inserted but had not. During an interview on 9/25/25 at 1:00 P.M., the Director of Nursing (DON) said the facility routinely stocked indwelling catheters in size French 16 with 10 ml retention bulb. The DON said that French 16 with 10 ml retention bulb catheters were available in the facility on 9/23/25. The DON said she was unsure why Nurse #2 would have inserted the incorrect catheter size on 9/23/25. During an interview on 9/29/25 at 12:43 P.M., Nurse #2 said she was the nurse that inserted Resident #88's indwelling catheter on 9/23/25. Nurse #2 said that she had attempted to irrigate the Resident's indwelling catheter due to occlusion without success and therefore the catheter needed to be changed. Nurse #2 said that Resident #88 was ordered for French 16 with 10 ml retention blub. Nurse #2 said that she thought she had inserted the correct size of French 16 with 10ml retention bulb but did not. Nurse #2 said that if Resident #88 had an indwelling catheter that was too large the large catheter could cause Resident #88 to have pain or obstruction.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), whose care plan interventions included the need for two staff members to provide assistance during care, which included incontinence care, bed mobility and repositioning, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions. On 05/04/25, Certified Nurse Aide (CNA #1) provided incontinence care to Resident #3 without another staff member present for assistance, CNA #1 positioned Resident #3 on his/her side, then turned away from the resident, he/she rolled off the bed and fell onto the floor. Resident #3 was transferred to the Hospital Emergency Department (ED) and diagnosed with a closed displaced fracture (broken pieces of bone that moved away from each other) of the right femoral neck (part of the thigh bone just below the hip joint). Findings include: Review of the Facility's policy titled, Care Planning, last revised 10/18/22, indicated the Facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/09/25, indicated that on 05/04/25 around 7:45 P.M., CNA #1 was providing care to Resident #3 when he/she rolled out of the bed, was assessed to have a one centimeter (cm) laceration to the back of his/her head, pain in his/her leg, was transferred to the Hospital ED for evaluation and subsequently admitted to the Hospital with a right hip fracture. Review of Resident #3's Hospital History and Physical, dated 05/05/25, indicated he/she sustained a closed displaced fracture of the right femoral neck. Resident #3 was admitted to the Facility in April 2017, diagnoses included Dementia and Parkinson's Disease (a movement disorder of the nervous system that worsens over time). Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 02/05/25, indicated he/she was severely cognitively impaired as evidenced by a score of 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) Assessment (score of 0-7 suggest severe cognitive impairment, 8-12 suggest moderate cognitive impairment, and 13-15 suggest that cognition is intact). Further review of the MDS indicated Resident #3 had impaired range of motion to both sides of his/her upper and lower extremities, was dependent on staff for transfers, required substantial to maximum assistance rolling left to right, and with all ADLs. Review of Resident #3's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her Quarterly MDS Assessment, dated 02/05/25, indicated he/she was dependent on two staff members for dressing, toileting, bed mobility, and positioning. Review of Resident #3's Fall Prevention Care Plan, reviewed and renewed with his/her Quarterly MDS Assessment, dated 02/05/25, indicated he/she was at risk for falls and his/her bed should be low to the floor. During a telephone interview on 06/03/25 at 2:45 P.M., Family Member #1 said during the evening of 05/04/25, she received a telephone call from a Facility Nurse to notify her that Resident #3 had fallen. Family Member #1 said she immediately went to the Facility, saw Resident #3 lying on the floor in the area between his/her bed and window, and saw CNA #1 holding a towel to the back of Resident #3's head because he/she was bleeding. Family Member #1 said Resident #3 cried out in pain (which was unlike him/her) whenever staff tried to move his/her right leg. During a telephone interview on 06/10/25 at 11:55 A.M., (which included a review of her written witness statement, dated 05/04/25 and an additional witness statement, dated 05/09/25, both of which were obtained by the facility), CNA #1 said she works for a staffing agency, has been working at the Facility for several months, and was very familiar with Resident #3. CNA #1 said she routinely checks the CNA Assignment Sheet, obtains report at shift change from another CNA, and checks the resident Care Kardex (a centralized quick-reference document used by CNAs and other staff to track patient information and care plans) in the computer if she has any questions about care. CNA #1 said that on the evening of 05/04/25 around 7:30 P.M., she, along with another CNA transferred Resident #3 into bed via a mechanical lift. CNA #1 said they positioned Resident #3 on his/her back in the center of the bed and then the other CNA left the room. CNA #1 said after the other CNA left the room, she proceeded to get Resident #3 ready for bed. CNA #1 said another CNA (later identified as CNA #3) was in the room, but she was across the room assisting Resident #3's roommate. CNA #1 said she proceeded to get Resident #3 undressed, washed up, and covered his/her upper body with a hospital gown. CNA #1 said she then positioned Resident #3 onto his/her left side with his/her right leg crossed over his/her left leg so she provide incontinent care. CNA #1 said the bed had been raised to a higher position during care. CNA #1 said after she performed incontinent care for Resident #3, she placed a brief underneath him/her while he/she was lying on his/her side, and realized she did not have barrier cream (a cream used to protect a person's skin from moisture associated with incontinence) nearby. CNA #1 said she turned away from Resident #3 to look for the barrier cream, saw that it was on his/her dresser against the wall across from the foot of his/her bed, and that it was out of her reach. CNA #1 said she never completely walked away from Resident #3's bedside, but had maybe taken a step away from Resident #3 to obtain the cream. CNA #1 said the next thing she heard was somebody screaming Resident #3's name (later identified as CNA #2), observed CNA #2 run into the room and heard a loud noise. CNA #1 said it was then that she realized Resident #3 had fallen to the floor. CNA #1 said she was aware that Resident #3's Kardex said that he/she required two staff members to assist with bed mobility, for transfers in and out of bed, but said she thought Resident #3's Kardex said he/she was a one assist for all other ADL care. CNA #1 said she thought that bed mobility only meant when staff had to boost a resident up in bed or assist them to make small movements. CNA #1 said she did not think that when she provided personal care to a resident while they were in bed, that positioning them for care was bed mobility. CNA #1 said she had cared for Resident #3 many times without having assistance of another staff member. During an interview on 06/04/25 at 10:25 A.M., (which included a review of her written witness statement, dated 05/04/25, and an additional witness statement, dated 05/09/25, both of which were obtained by the facility), CNA #2 said on 05/04/25 around 7:45 P.M., as she was walking down the hall, she looked into Resident #3's room, saw him/her lying on his/her left side, he/she was actively rolling towards his/her right side and fell off of the bed. CNA #2 said when she saw Resident #3 falling, she screamed out his/her name and ran into his/her room, but she could not get to him/her in time to prevent the fall. CNA #2 said she had an unobstructed view of Resident #3 from the hallway and did not see a CNA or any other staff member in the room. CNA #2 said when she ran into the room, CNA #1 appeared from somewhere near the middle of the room and ran around the foot of Resident #3's bed to try to get to him/her before he/she fell, but she (CNA #1) was also unable to get to him/her in time. CNA #2 said information related to residents' care needs, and the amount of staff assistance required is located on their resident Kardex in the computer. CNA #2 said there is also some care information on the CNA Assignment Sheets, but CNAs should always check the Kardex before providing care to a resident. CNA #2 said Resident #3 is totally dependent on staff to provide all care, including ADLs. During a telephone interview on 06/04/25 at 1:45 P.M. (which included a review of her written witness statement, dated 05/09/25, and an additional witness statement on 05/09/25, both of which were obtained by the facility), CNA #3 said that during the evening of 05/04/25 around 7:45 P.M., she was providing care to Resident #3's roommate (Bed A, near the door), CNA #1 was providing care to Resident #3 in the bed by the window, and there were no other CNAs in the room. CNA #3 said her back was turned away from Resident #3, but that she saw CNA #2 run into the room yelling that Resident #3 was falling and heard a loud sound. CNA #3 said she did not know where, in the room, CNA #1 was prior to Resident #3's fall. During an interview on 06/04/25 at 10:03 A.M., CNA #4 said Resident #3 is dependent on staff members for all care, including meals, dressing, transfers, bed mobility, and personal hygiene. CNA #4 said each resident has a Kardex in the computer that includes the type of care and assistance each resident requires, and CNAs know that they should consult the Kardex prior to providing care to a resident. During an interview on 06/04/25 at 10:45 A.M., Nurse #1 said Resident #3 is total care, meaning he/she requires physical assistance from staff for feeding, dressing, bathing, bed mobility, positioning, transfers, and incontinence care. Nurse #1 said any information related to the level of staff assistance, including the number of staff member a resident requires during care is located in their Care Plan and the Kardex. Nurse #1 reviewed Resident #3's Care Plan and said, based on the information in his/her Care Plan, there should always be two caregivers present when providing care. Nurse #1 said if two caregivers were assisting Resident #3 on the evening of 05/04/25, one caregiver could have remained with him/her to maintain his/her safety, while the other caregiver could have obtained the barrier cream. During an interview on 06/04/24 at 11:07 A.M., Unit Manager #1 said Resident #3 is totally dependent on staff to provide care, and staff (CNAs) access the level of care a resident requires by looking at the Care Plan, the Kardex, and to some extent the CNA Assignment Sheets. Unit Manager #1 said the Kardex should have the most up to date information and is the preferred source to obtain resident care information. After reviewing Resident #3's Care Plan, Unit Manager #1 said that based on the Care Plan, there should always be two staff members present while providing care to him/her, and when CNA #1 provided care by herself, she was not following Resident #3's plan of care. During an interview on 06/04/25 at 4:10 P.M., the Director of Nursing (DON) said CNA #1 works for a staffing agency but has worked at the facility for several months and often took care of Resident #3. The DON said Resident #3's Care Plan clearly indicated Resident #3 required two staff members be present to assist with dressing, transfers, toileting, bed mobility and positioning. The DON said they were unable to provide a copy of Resident #3's care Kardex that was in effect at the time of the incident, because their Electronic Medical Record (EMR) does not have the capability to retrieve previous versions after an update. The DON did say however, that Resident #3's Kardex would have indicated the same level of care and staff assistance he/she required, per his/her plan of care at that time. The DON said CNA #1 did not follow Resident #3's plan of care and should have had another staff member assist with care. On 06/06/25 the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) On 05/07/25, CNA #1 was re-educated, topics included but were not limited to the following: - facility policy related to provision of care to residents, - the need to review and follow each residents plan of care/ resident care Kardex, - ensuring the required level of staff assistance is present and used during the provision of care, - facility protocol related to residents who are care planned for two person assist, - having all necessary supplies ready and available before providing care to a resident. B) On 05/09/25, Resident #3's Care Plan and CNA Care Kardex were immediately reviewed to ensure accuracy with the need for the specific number of staff member assistance clearly indicated for each ADL. C) From 05/09/25 through 05/13/25 (and ongoing) - Facility Unit Managers and/or Designees conducted facility wide audits to ensure the following: - All residents are receiving the necessary level of staff assistance needed for bed mobility (including when turning and repositioning a resident in bed to provide care), - Level of care and staff assistance is recorded accurately on both the Care Plan and Care Kardex, - Observations and record reviews for all residents with scoop mattresses to ensure they are receiving appropriate and necessary level of staff assistance required for bed mobility, including turning/repositioning while in bed to provide care while taking into consideration the width of the mattress and ability of each resident to participate in care. D) From 05/09/25 through 05/13/25 (and ongoing) - Interdisciplinary Team audited all residents to determine the need for additional fall interventions for safety and appropriateness of interventions that were in place. E) From 05/12/25 through 05/16/25 (and ongoing), the Staff Development Coordinator and/or their Designee completed nursing/CNA education, which included but was not limited to the following topics: - CNA's must check the Care Kardex prior to providing care as changes may occur daily, - Review of all current residents requiring two person assist for bed mobility, positioning and what two person assist for positioning and bed mobility means, - Clarifications of ADL tasks - bed mobility, turning and repositioning -as to what constitutes a two-person assist, - Careful positioning of residents when close to the edge of the bed, especially when they utilize scoop mattresses, - CNA's (nursing staff) to ensure second staff person is in place, and that necessary supplies needed are obtained and within reach prior to starting personal care to the resident. F) Ongoing, random audits conducted by the Staff Development Coordinator and/or their Designee to ensure accuracy of Care Plans, resident's Kardex, and staff are providing the appropriate level of assistance to residents. G) Deficient practice was presented at an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting, and the will continue to be discussed at monthly QAPI meetings as needed to ensure substantial compliance is achieved and maintained. H) The Director of Nursing and/or their Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who required the assistance of two staff members for dressing, toileting care needs, bed mobility, and positioning, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety to prevent an incident/accident resulting in a serious injury. On 05/04/25, Certified Nurse Aide (CNA) #1 provided care to Resident #3 without having another staff member present for assistance, CNA #1 repositioned Resident #3 onto his/her side in bed, then turned away from Resident #3 to grab something, leaving him/her unattended and he/she rolled off the bed onto the floor. Resident #3 was transferred to the Hospital Emergency Department (ED) and diagnosed with a closed displaced fracture (broken pieces of bone that moved away from each other) of the right femoral neck (part of the thigh bone just below the hip joint). Findings include: Review of the Facility's Policy titled, Fall Risk Reduction, dated as revised 11/2/23, indicated but was not limited to the following: - All residents will be assessed for falls risk factors. - Those determined to have risk factors will receive individualized interventions based on the risk factors in order to reduce risk for falls and minimize occurrence of falls. - Include fall interventions on Kardex and Care Plan. - Review and revise Care Plan and Kardex regularly to ensure individualized interventions are effective. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/09/25, indicated that on 05/04/25, around 7:45 P.M., CNA #1 was providing care to Resident #3 when he/she rolled out of the bed, was assessed to have a one centimeter (cm) laceration to the back of his/her head, pain in his/her leg, was transferred to the hospital and subsequently admitted with a right hip fracture. Review of Resident #3's Hospital History and Physical, dated 05/05/25 indicated he/she sustained a closed displaced fracture of the right femoral neck. Resident #3 was admitted to the Facility in April 2017, diagnoses included Dementia and Parkinson's Disease (a movement disorder of the nervous system that worsens over time). Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 02/05/25, indicated he/she was severely cognitively impaired as evidenced by a score of 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) Assessment (score of 0-7 suggest severe cognitive impairment, 8-12 suggest moderate cognitive impairment, and 13-15 suggest that cognition is intact). Further review of the MDS indicated Resident #3 had impaired range of motion to both sides of his/her upper and lower extremities, was dependent on staff for transfers, required substantial to maximum assistance rolling left to right, and with all ADLs. Review of Resident #3's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her Quarterly MDS Assessment, dated 02/05/25, indicated he/she was dependent on two staff members for dressing, toileting, bed mobility and positioning. Review of Resident #3's Fall Prevention Care Plan, reviewed and renewed with his/her Quarterly MDS Assessment, dated 02/05/25, indicated he/she was at increased risk for falls and interventions for his/her safety included two staff members to assist with dressing, toileting, transfers bed mobility and positioning. Review of a Nursing Progress Note, dated 05/04/25 at 9:54 P.M., indicated the following: - This Nurse was called into Resident #3's room by a CNA around 7:45 P.M. - The CNA reported Resident #3 rolled out of bed during care. - Small laceration was observed on back of his/her head, of approximately 1 centimeter (cm). - Applied pressure to the head injury to stop the bleeding. - Called Resident #3's daughter, who came in and wanted him/her to be sent out to the ED for evaluation. - Telephone call placed to on-call provider and Assistant Director of Nursing. - Resident #3 transferred to the hospital around 8:35 P.M., accompanied by two emergency medical technicians. During a telephone interview on 06/03/25 at 2:45 P.M., Family Member #1 said during the evening of 05/04/25, she received a telephone call from a Facility Nurse notifying her that Resident #3 had fallen. Family Member #1 said she immediately went to the Facility and saw Resident #3 lying on the floor in the area between his/her bed and the window, and that CNA #1 holding a towel to the back of Resident #3's head because he/she was bleeding. Family Member #1 said Resident #3 was crying out in pain (which was unlike him/her) whenever staff tried to move his/her right leg. Family Member #1 said prior to Resident #3's fall on 5/04/25, he/she would be out of bed in a specialized chair every day and was often in the Facility's common area where he/she could be around other people. Family Member #1 said since the fall, Resident #3 is no longer able to get out of bed and remains in his/her room because the mechanical lift required to transfer him/her out of bed into his/her specialized chair causes him/her too much pain. During a telephone interview on 06/10/25 at 11:55 A.M., (which included a review of her written witness statement, dated 05/04/25 and an additional witness statement, dated 05/09/25, both of which were obtained by the facility), CNA #1 said she works for a staffing agency, has been working at the Facility for several months, and was very familiar with Resident #3. CNA #1 said she routinely checks the CNA Assignment Sheet, obtains report at shift change from another CNA, and checks the care Kardex (a centralized quick-reference document used by CNAs and other staff to track patient information and care plans) in the computer if she has any questions about care. CNA #1 said that on the evening of 05/04/25 around 7:30 P.M., she, along with another CNA transferred Resident #3 into bed via a mechanical lift. CNA #1 said they positioned Resident #3 on his/her back in the center of the bed and the other CNA left the room. CNA #1 said after the other CNA left the room, she proceeded to get Resident #3 ready for bed, which included changing his/her clothes. CNA #1 said another CNA (later identified as CNA #3) was in the room, but she was across the room assisting Resident #3's roommate. CNA #1 said while the bed was in a high position, she proceeded to get Resident #3 undressed, washed up, and covered his/her upper body with a hospital gown. CNA #1 said she then positioned Resident #3 on his/her left side with his/her right leg crossed over his/her left leg so to provide incontinent care. CNA #1 said after she performed incontinent care for Resident #3, she placed a brief underneath him/her while he/she was still lying on his/her side, and realized she did not have his/her barrier cream (a cream used to protect a person's skin from moisture associated with incontinence) nearby. CNA #1 said she turned away from Resident #3 to look for the barrier cream, and saw that it was on his/her dresser which was against the wall across from the foot of his/her bed, which was out of her reach. CNA #1 said she may have taken a step away from Resident #3 to obtain the cream, then turned towards CNA #3 who was behind her after hearing her say something. CNA #1 said the next thing she heard was somebody screaming Resident #3's name (later identified as CNA #2), observed CNA #2 run into the room and heard a loud noise. CNA #1 said it was then that she realized Resident#3 had fallen on the floor. CNA #1 said she was aware that Resident #3's Kardex said that he/she required two staff members to assist with bed mobility, for transfers in and out of bed, but said she thought Resident #3's Kardex said he/she was a one person assist for all other ADL care. CNA #1 said she thought that bed mobility only meant when staff had to boost a resident up in bed or assist them to make small movements. CNA #1 said she did not think that when she provided personal care to a resident while they were in bed, that positioning them for care was bed mobility. During an interview on 06/04/25 at 10:25 A.M., (which included a review of her written witness statement, dated 05/04/25, and an additional witness statement, dated 05/09/25, both of which were obtained by the facility), CNA #2 said on 05/04/25 around 7:45 P.M., as she was walking down the hall, she looked into Resident #3's room, saw him/her lying on his/her left side actively rolling towards his/her right side off of the bed, and then he/she fell. CNA #2 said when she saw Resident #3 falling, she screamed his/her name and ran into his/her room, but she could not get to him/her in time to prevent the fall. CNA #2 said she had an unobstructed view of Resident #3 from the hallway and did not see any other CNA or staff member in the room. CNA #2 said when she ran into the room, CNA #1 appeared from somewhere near the middle of the room. During a telephone interview on 06/04/25 at 1:45 P.M. (which included a review of her written witness statement, dated 05/09/25, and an additional witness statement on 05/09/25, both of which were obtained by the facility), CNA #3 said that during the evening of 05/04/25 around 7:45 P.M., she was providing care to Resident #3's roommate (Bed A, near the door), CNA #1 was providing care to Resident #3 in the bed by the window, and there were no other CNAs in the room. CNA #3 said her back was turned away from Resident #3, but she saw CNA #2 run into the room yelling that Resident #3 was falling and heard a loud sound. CNA #3 said she did not know where CNA #1 was in the room prior to Resident #3's fall. CNA #3 said Resident #3 cannot do anything for him/herself and said he/she requires two people for transfers because he/she requires a mechanical lift. During an interview on 06/04/25 at 10:45 A.M., Nurse #1 said Resident #3 is total care, meaning he/she requires staff assistance with feeding, dressing, bathing, and incontinence care. During the interview, Nurse #1 reviewed Resident #3's Care Plan and said, based on the information in his/her Care Plan, there should have been two caregivers present when CNA #1 was providing care to Resident #3. Nurse #1 said if two caregivers were assisting Resident #3 on the evening of 05/04/25, one caregiver would have remained with him/her while the other caregiver could have obtained the barrier cream. Nurse #1 said if CNA #1 stepped away from Resident #3, she should not have left his/her bed in a high position and should not have left him/her positioned on his/her side. Nurse #1 further said prior to his/her fall, Resident #3 used to spend much of the day in the common area outside of his/her room so he/she could be around other people, but since the fall, he/she is no longer able to get out of bed and relies on both Morphine and Fentanyl (opioid pain medications) to remain comfortable. During an interview on 06/04/24 at 11:07 A.M., Unit Manager #1 said Resident #3 is totally dependent on staff to provide care and there should always be two staff members present while providing care to him/her. Unit Manager #1 said on 05/04/25, when Resident #3 fell out of bed, CNA #1 should not have been alone, and when CNA #1 stepped away from his/her bed, Resident #3 should not have been left lying on his/her side with the bed in a high position because that was unsafe. Unit Manger #1 further said if CNA #1 could not get to the barrier cream, after she saw that it was out of her reach, she could have asked CNA #3, who was in the room caring for Resident #3's roommate to get it for her. During an interview on 06/04/25 at 4:10 P.M., with the Director of Nursing (DON) and the Quality Improvement (QI) Manager, the DON said Resident #3 was care planned to have two staff members present to assist with dressing, transfers, toileting, bed mobility and positioning, and CNA #1 did not adhere to Resident #1's plan of care. In addition, the DON said if CNA #1 either looked away or stepped away from Resident #3 to find a needed supply, she should not have left him/her lying on his/her side as that was unsafe, and said when providing care, all necessary supplies should be within reach. The QI Manager said during her investigation after the incident, she noted Resident #3 utilized a scoop mattress that had bolsters (raised edges) on both sides with the exception of a 24 inch opening at the center of both sides of the mattress. The QI Manager said she noted that scoop mattress measured 29 inches wide, which is 7 inches narrower than a standard facility mattress. The QI Manager said when she interviewed CNA #1, she said she was confident Resident #3 was placed in the center of the bed on his/her left side but was positioned so that his/her right leg was crossed over his/her left leg. The QI Manager said that position likely caused a gravitational pull that propelled Resident #3's her body weight over the side of the bed causing him/her to roll quickly, and fall out of bed. The QI Manager said according to Resident #3's Care Plan, he/she should have had two caregivers present during care. On 06/06/25 the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) On 05/07/25, CNA #1 was re-educated, topics included but were not limited to the following: - facility policy related to provision of care to residents, - the need to review and follow each residents plan of care/ resident care Kardex, - ensuring the required level of staff assistance is present and used during the provision of care, - facility protocol related to residents who are care planned for two person assist, - having all necessary supplies ready and available before providing care to a resident. B) On 05/09/25, Resident #3's Care Plan and CNA Care Kardex were immediately reviewed to ensure accuracy with the need for the specific number of staff member assistance clearly indicated for each ADL. C) From 05/09/25 through 05/13/25 (and ongoing) - Facility Unit Managers and/or Designees conducted facility wide audits to ensure the following: - All residents are receiving the necessary level of staff assistance needed for bed mobility (including when turning and repositioning a resident in bed to provide care), - Level of care and staff assistance is recorded accurately on both the Care Plan and Care Kardex, - Observations and record reviews for all residents with scoop mattresses to ensure they are receiving appropriate and necessary level of staff assistance required for bed mobility, including turning/repositioning while in bed to provide care while taking into consideration the width of the mattress and ability of each resident to participate in care. D) From 05/09/25 through 05/13/25 (and ongoing) - Interdisciplinary Team audited all residents to determine the need for additional fall interventions for safety and appropriateness of interventions that were in place. E) From 05/12/25 through 05/16/25 (and ongoing), the Staff Development Coordinator and/or their Designee completed nursing/CNA education, which included but was not limited to the following topics: - CNA's must check the Care Kardex prior to providing care as changes may occur daily, - Review of all current residents requiring two person assist for bed mobility, positioning and what two person assist for positioning and bed mobility means, - Clarifications of ADL tasks - bed mobility, turning and repositioning -as to what constitutes a two-person assist, - Careful positioning of residents when close to the edge of the bed, especially when they utilize scoop mattresses, - CNA's (nursing staff) to ensure second staff person is in place, and that necessary supplies needed are obtained and within reach prior to starting personal care to the resident. F) Ongoing, random audits conducted by the Staff Development Coordinator and/or their Designee to ensure accuracy of Care Plans, resident's Kardex, and staff are providing the appropriate level of assistance to residents. G) Deficient practice was presented at an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting, and the will continue to be discussed at monthly QAPI meetings as needed to ensure substantial compliance is achieved and maintained. H) The Director of Nursing and/or their Designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had multiple wounds and required an appointment with an outside wound specialist, the Facility failed to ensure nursing staff clarified and/or followed up on his/her wound consult recommendations related to the need for an X-ray, in a timely manner, which resulted in a delay in treatment. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in March 2025, diagnoses included Type 2 Diabetes Mellitus, Multiple Myeloma (a type of cancer that affects a type of white blood cell in the body that produces antibodies to fight infection), Chronic Thrombocytopenia (a decreased amount of blood clotting cells in the body), Anemia (lower than normal red blood cells in the body), chronic foot wounds with recent right toe amputation. Review of a Wound Clinic Consultation Note, dated 03/12/25, indicated it included the following recommendation: - X-ray to right great toe placed and included an order requisition to obtain an X-ray of 3rd toe, right foot to rule out Osteomyelitis (an infection of the bone often caused by bacteria, that can lead to inflammation and potentially permanent bone damage if left untreated). Review of a Wound Clinic Consultation Note, dated 03/19/25, indicated in included the following recommendation: - Right foot X-ray to rule out Osteomyelitis in right third toe, ordered in CIS (the wound clinic computer system), and can be completed at [Name of Hospital]. Further review of Resident #1's medical record indicated there was no documentation to support that after his/her Wound Clinic appointment on 3/12/25 or 3/19/25, since the wound clinic had not provided results of an X-ray to the facility, that nursing followed up with the Clinic to clarify the X-ray order, and who was responsible for completing it. During a telephone interview on 06/05/25 at 1:25 P.M., the Wound Clinic Nurse Practitioner (NP) said their clinic does not have X-ray capabilities and that she put an order in for him/her to have an X-ray done at their outpatient Radiology office, and said if it was a problem for the Facility to get Resident #1 there, the Facility should have obtained an order from their Provider to have a portable X-ray done at the Facility. Review of a Wound Clinic Consultation Note, dated 04/15/25, indicated it included the following recommendation: - Patient needs an X-ray of right foot. Review of Resident #1's Medical Record indicated there was an X-ray report, dated 04/16/25 (obtained a month after the Facility was notified of the recommendation for the X-ray), with results that indicated he/she had Osteomyelitis in his/her right third toe. During an interview on 06/05/25 at 2:00 P.M., Unit Manager #2 said when a resident goes outside the Facility for a specialist visit, the Facility sends a Report of Consultation form with the resident or responsible person to give to the specialist so they can provide a summary of the visit as well as any recommendations they may have for the resident's ongoing care. Unit Manager #2 said the resident will come back from the appointment with the Report of Consultation form and the specialist will then fax a more detailed visit note to the facility shortly after the visit. Unit Manager #2 said it was the responsibility of the unit nurse who receives the Consultation form or the detailed visit note, to review the notes and discuss them with the Facility Provider, and obtain orders as needed. Unit Manager #2 said she reviewed the Wound Clinic Consultation Notes and corresponding visit notes on 03/12/25, 03/19/25 and 04/15/25 after each appointment and saw an X-ray to Resident #1's right foot was warranted to rule out Osteomyelitis. Unit Manager #2 said the way the Report of Consultation Notes were written were ambiguous and confusing, and seemed as though the Wound Clinic was planning to obtain the X-ray because the notes referred to ordering the imaging and entering the order into their own (Wound Clinic) computer system. Unit Manager #2 said it wasn't until she reviewed the Wound Consultation Note, dated 04/15/25, that she called the Wound Clinic to clarify and ask who was responsible to obtain Resident #1's X-ray. Unit Manager #2 said she was told by the Wound Clinic that they expected the Facility obtain Resident #1's right foot X-ray, (which was completed on 04/16/25 at the Facility). Unit Manager #2 said the results indicated Resident #3 had developed Osteomyelitis in his/her right third toe. During an interview on 06/05/25 at 2:30 P.M., the Director of Nursing said she reviewed the Wound Clinic Notes and Reports of Consultation and said the recommendations made by the clinic were unclear and understood why Unit Manager #2 thought the Wound Clinic was obtaining the X-ray for Resident #1. The DON said a call could have been made to the Wound Clinic by facility nursing staff to clarify the recommendation after his/her visit on 03/19/25.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who sustained two unwitnessed falls and whose Comprehensive Care Plan indicated he/she was at risk for dehydration with the potential for slow wound healing due to low albumin (may indicate malnutrition, kidney/liver disease) the Facility failed to ensure they maintained a complete and accurate medical record when 1) nursing did not complete the 72 hour neurological checks following each of his/her unwitnessed falls, and 2) Certified Nurse Aides (CNAs) daily documentation related to Resident #1's fluid and food intake were not consistently recorded on his/her flow sheets. Findings include: Review of the Facility's policy titled Falls Management: Post Fall, with a revision date of 11/02/23, indicated an Incident and Accident Report would be completed after each resident fall. Review of the Facility's Incident and Accident Report Form indicated to initiate neurological checks (assessment used to determine head injury) when a resident sustained an unwitnessed fall or head strike. Review of the Facility's Neurological Check Flowsheet indicated to assess the following with each check: -Level of consciousness -Pupil Response -Motor Response (hand grasps) -Pain Response -Vital Signs (record blood pressure, temperature, pulse and respiration) Further review of the Flowsheet indicated the neurological checks were to be completed every 15 minutes for the first hour, then every 30 minutes for the next four hours, then every hour for two hours, then every shift for 72 hours. Review of the Facility's policy titled Nutrition Management, with a revision date of 06/06/22, indicated to document residents' percentage of food intake. Resident #1 was admitted to the Facility in April 2024, diagnoses included atrial fibrillation, muscle weakness and unspecified protein-calorie malnutrition. 1) Review of Resident #1's Incident and Accident Report, dated 04/28/24 at 3:45 P.M., indicated Resident #1 sustained an unwitnessed fall in his/her room. Review of Resident #1's Neurological Check Flowsheet, dated 04/28/24, indicated Resident #1's neurological checks were initiated on 04/28/24 at 3:45 P.M., and checked again at 4:30 P.M. and 5:00 P.M. However, per facility policy his/her neurological checks were to be obtained every 15 minutes for one hour and were not obtained at 4:00 P.M., 4:15 P.M. and 4:30 P.M., as required Further review of the Flowsheet indicated Resident #1's neurological checks were not documented as being obtained on 4/30/24 for the 7:00 A.M. through 3:00 P.M. (day shift) or 3:00 P.M. through 11:00 P.M. (evening shift) or on 05/01/24 day or evening shifts to complete the 72-hour neurological checks. Review of Resident #1's Accident Report, dated 05/10/24 at 1:35 P.M., indicated Resident #1 sustained an unwitnessed fall in his/her room. Review of Resident #1's Neurological Check Flowsheet, dated 05/10/24, indicated neurological checks were done through 05/12/24 11:00 P.M. through 7:00 A.M. (night shift), but were not documented on 05/12/24 day or evening shifts, or on 05/13/24 day or evening shifts, to complete the 72-hour neurological checks. During an interview on 08/29/24 at 11:47 A.M., the Assistant Director of Nurses (ADON) said that neurological checks should be initiated when a resident sustains an unwitnessed fall or a head strike. The ADON said the neurological checks should be done at the intervals specified on the Flowsheet. During the interview, the ADON reviewed Resident #1's Neurological Check Flow Sheets, dated 04/28/24 and 05/10/24, and said they were not completed accurately. During a telephone interview on 08/30/24 at 11:52 A.M., the Director of Nurses (DON) said that Resident #1's neurological checks should have been completed accurately by nursing and according to facility protocol. 2.) Review of Resident #1's Nutrition Care Plan, dated 04/29/24 , indicated he/she was at risk for dehydration and slow wound healing due to low albumin, interventions included to monitor intakes. Review of Resident #1's Meal Intake by Day report, indicated from 05/01/24 through 05/19/24, that CNAs had not consistently completed his/her flow sheets related to the percentage of the meal consumed or the amount of fluids consumed, and that the following dates and times were left blank; 05/03/24- breakfast, lunch 05/05/24- breakfast, lunch, dinner 05/06/24- dinner 05/07/24- breakfast, lunch 05/08/24- breakfast, lunch 05/11/24- breakfast, lunch, dinner 05/12/24- dinner 05/13/24- dinner 05/17/24- breakfast, lunch, dinner During an interview on 08/28/24 at 3:40 P.M. Certified Nurse Aide (CNA) #2 said the CNAs were supposed to document resident meal intake percentages and fluids consumed for every meal. During an interview on 08/29/24 at 9:19 A.M., Unit Manager #1 said the CNAs were supposed document meal percentages and fluid intakes for every resident at every meal. During a telephone interview on 08/30/24 at 11:52 A.M., the Director of Nurses (DON) said the CNAs were expected to document fluid intake and meal intake percentage for each resident, at every meal.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was assessed by nursing to be at risk for skin breakdown with actual pressure injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence which can present as intact skin or an open ulcer and may be painful) the Facility failed to ensure nursing adequately assessed, measured and obtained Physician's orders related to wound care to his/her bilateral heels that included specifics related to treatments for offloading, in accordance with professional standards of practice in an effort to promote wound healing. Findings include: Review of the Facility's Policy titled Skin Integrity Management, dated 12/03/23, indicated the following: -Stage 1 Pressure Injury: A persistent area of redness that does not disappear when pressure is removed. Skin is not broken, the site may be tender, painful, firm, or soft, warm, or cool compared to surrounding skin. -Stage 2 Pressure Injury: Partial-thickness skin loss involving the outer layer of the skin and the inner layer, which are either damaged or lost. The wound may look like an abrasion, fluid filled blister, or shallow crater. -It is the policy of the facility, consistent with Centers for Medicare and Medicaid Services (CMS) regulations that any resident with pressure ulcer or injury receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. -Preventative measures to consider as part of resident care planning include (but not limited to) off loading devices such as heel cushions, pillows and pressure relieving device on chair and in bed. -All devices, dressings, nutritional supplements, and preventative skin care will be prescribed by the Medical Practitioner and will be entered in the resident's electronic health record: Physician's orders, electronic medication administration record (eMAR) and electronic treatment administration record (eTAR). -Conduct weekly wound rounds- complete measurements of each wound length x width x depth, description of wound bed, description of wound edges and surrounding skin, type and amount of exudates, type of wound drainage, signs of infection and presence or absence of pain. -Document findings of the weekly wound assessment in the resident's EMR. Review of the National Pressure Injury Advisory Panel (NPIAP) website defined a Deep Tissue Injury (DTI) as a persistent non-blanchable (redness that does not fade when pressure is applied) deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. Resident #1 was readmitted to the Facility in April 2024, diagnoses included Congestive Heart Failure and unspecified protein-calorie malnutrition. Review of Resident #1's Hospital Discharge (DC) Summary, which included the Hospital's Wound Nurse Initial Consult, dated 04/15/24, indicated Resident #1 had the following pressure injuries: -Right heel Stage 1- measured 1.2 centimeters (cm.) x 1.0 cm., non-blanchable erythema (redness). Recommend foam dressing and offloading boots. -Left heel Stage 2- beginning to form a blister, measured 1.3 cm. x 1.1 cm., non-blanchable, central area boggy tissue with slight purple discoloration. Also suspicious for deep tissue injury component. Recommend foam dressing and offloading boots. Review of Resident #1's Re-Admission Nursing Assessment, dated 04/18/24 and completed by Nurse #1, indicated his/her Norton Pressure Ulcer Risk Assessment score was 12, (indicating moderate risk for skin breakdown). The Assessment also indicated there was a Stage 2 pressure injury on his/her coccyx that measured 0.8 cm. x 1.2 cm. However, the Assessment did not include any reference to skin breakdown on his/her bilateral heels, despite having been clearly identified on his/her Hospital DC Summary. Review of Resident #1's Nurse Progress Note, dated 04/19/24 and written by Nurse #1, indicated Resident #1 was readmitted to the Facility following a short hospital stay and had a Stage 2 pressure injury to the coccyx and his/her bilateral heels were boggy, non-blanchable, tender to pressure and palpation. The Note indicated a foam dressing was applied to each heel and heels were offloaded on pillows. During a telephone interview on 09/03/24 at 10:06 A.M., Nurse #1 said she did not specifically remember Resident #1. Nurse #1 said when she admits a resident who has a wound(s), she obtains Physician's orders for a treatment and then passes it along to the Unit Manager that the resident has wound(s) and may need other interventions. Nurse #1 said that if there was no Unit Manager in place at the time, she would have passed the information along to the next shift's nurse. Nurse #1 said it was up to the Unit Manager to notify the Facility's Wound Nurse when a resident has a new wound. Review of Resident #1's Treatment Administration Record (TAR) for the month of April 2024 indicated the following: -04/19/24- new Physician's Order to apply a foam dressing to his/her bilateral boggy heels for protection every day, on 7:00 A.M. through 3:00 P.M. (day shift) and offload heels while in bed. -04/27/24- above referenced Physician's Order was discontinued -04/28/24- new Physician's Order to apply skin prep (used to create a barrier to reduce friction) to bilateral boggy heels every day on 3:00 P.M. through 11:00 P.M. shift (evening). However, the Physician's Order and therefore the TAR did not include to off-load pressure to Resident #1's bilateral heels. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 04/25/24, indicated he/she was dependent for bathing, dressing, hygiene and ambulation was not attempted at the time of the assessment due to medical or safety concerns. Review of Resident #1's Care Plan related to skin integrity and potential for skin breakdown, dated 04/23/24, indicated Resident #1 had Stage 1 pressure injuries to bilateral heels and interventions included to follow (the Facility's) skin and wound care protocols. Review of Resident #1's Nurse Progress Note, dated 05/11/24 and written by Nurse #2, indicated Resident #1's bilateral heels each had a small dark scab. Review of Resident #1's Nurse Practitioner (NP) Progress Note, dated 05/13/24, indicated Resident #1 had a Deep Tissue Injury (DTI) on the right heel and a Stage 2 pressure injury on the left heel, foam dressings were to be done daily and heels were to be elevated off of the bed. Review of Resident #1's Nurse Progress Note, dated 05/16/24 and written by Nurse #2, indicated Resident #1's right heel had a scabbed area and the surrounding tissue appeared necrotic. The Note indicated the wound measured 1 cm. x 0.5 cm, was unstageable (depth of the wound undetermined due to dead tissue) and a bootie was applied to his/her right foot and leg. During a telephone interview on 08/29/24 at 9:39 A.M., Nurse #2 said she was very familiar with Resident #1. Nurse #2 said the weekly wound measurements were supposed to be done by the Facility's Wound Care Nurse. Nurse #2 said she did not remember specifically when she noticed the scabs on Resident #1's bilateral heels but said she did notify the Nurse Practitioner at one point and a boot was applied to his/her right foot. Nurse #2 said she did not remember if any additional preventative measure were put in place at the time for Resident #1's left foot. Nurse #2 said that all devices, including boots for offloading should be on the Treatment Administration Record. Review of Resident #1's NP Progress Note, dated 05/16/24, indicated Resident #1's Stage 2 pressure injury on his/her left heel was worsening and to float bilateral heels with boots. The Progress Note indicated Resident #1 was now Comfort Measures Only (CMO). Review of Resident #1's TAR for the month of May 2024 indicated the following Physician's orders: - 05/01/24 through 05/14/24, Apply skin prep to bilateral boggy heels every evening shift. - 05/15/24 through 05/21/24, Cleanse left heel with normal saline, apply Santyl (chemical agent to remove dead tissue), cover with foam dressing every day shift. - 05/16/24 through 05/20/24, Cleanse right heel with normal saline, apply Santyl, cover with a dry clean dressing and wrap with Kling every day shift. However, there was still no Physician's Order or treatment on the TAR to indicate nursing to ensure to float heels or to apply boots. There was also no documentation on the TAR to support weekly measurements of Resident #1's wounds were completed by nursing, per facility policy. Review of Resident #1's medical record indicated there was no documentation to support that the wounds on his/her bilateral heels were: -measured weekly since his/her re-admission per facility policy -that his/her heels were off loaded every shift when in bed and how (boots, pillows etc.) -that he/she was assessed during weekly wound rounds per facility policy. During an interview on 08/29/24 at 10:31 A.M., the Wound Care Nurse said all pressure injuries, no matter the stage, should be measured on admission to the Facility, weekly, and with any change or upon re-admission. The Wound Care Nurse said that the nurses were supposed to measure Resident #1's wounds weekly. The Wound Care Nurse said that she was responsible to track all wounds in the Facility. The Wound Care Nurse said that she was not notified when Resident #1 was admitted to the Facility with wounds. The Wound Care Nurse said by the time she was notified of his/her wounds it was late in the game. The Wound Care Nurse said that all interventions, including off loading with pillows or boots, should be an order and documented on the Treatment Administration Record. During a telephone interview on 08/30/24 at 11:52 A.M., the Director of Nurses said she expected all wounds to be measured weekly and that any interventions or pressure relieving devices should be on the resident's care plan and on the Treatment Administration Record.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be at risk for nutritional decline, dehydration, and with the potential slow wound healing due to low albumin (may indicate malnutrition, kidney/liver disease), the Facility failed to ensure Resident #1's nutritional status including body weight, meal percentage and fluid intakes, were accurately assessed and monitored appropriately by nursing and per facility policy. Findings include: Review of the Facility Policy titled Weighing and Measuring Resident, with a revision date of 05/03/11, indicated the following: -Residents will be weighed using consistent scale on admission and at least monthly thereafter. -Reweigh will be obtained if weight is +/- three pounds (lbs.) from previous weight. Review of the Facility Policy titled Nutrition Management, with a revision date of 06/06/22, indicated the following: -Identify residents who have functional limitations which may affect ability to eat or drink independently: confusion, easily distracted, fine and gross motor tremors. -Unplanned weight loss or gain considered (greater than three pounds (lbs.) from last recorded weight and/or 5 % in one month, 7.5 % in three months and 10% in six months). -Document residents' percentage of food intake. Resident #1 was readmitted to the Facility in April 2024, diagnoses included Congestive Heart Failure and unspecified protein-calorie malnutrition. Review of Resident #1's Hospital Discharge Summary, which included a Clinical Nutrition assessment dated [DATE], indicated he/she had an estimated weight of 190 lbs. on 04/13/24. The Assessment also indicated that Ensure Plus (high protein/high calorie) supplement was ordered and provided with each meal. Review of Resident #1's Admission Nursing Assessment, dated 04/18/24, indicated that Nurse #1 entered Resident #1's re-admission weight on 04/19/24 at 10:46 A.M. as 190 lbs. The Assessment indicated Resident #1 was admitted with alterations in skin integrity which included a Stage 2 pressure injury on his/her coccyx and his/her bilateral heels were boggy and non-blanchable. Review of Resident #1's weight record, provided by the Facility, indicated the following: 04/04/24 - 215 lbs. 04/05/24 - 142 lbs. (later determined by the Facility to be an error) 04/19/24- 190 lbs. Further review of Resident #1's medical record indicated there was no documentation to support a re-weight was obtained, per the Facility policy, despite there being a 25 lb. difference in weight readings in approximately two weeks. During a telephone interview on 09/03/24 at 10:06 A.M., Nurse #1 said she did not specifically remember Resident #1 but that she likely helped to complete his/her re-admission to the Facility. Nurse #1 said that when a resident is readmitted to the Facility, his/her weight is obtained by nursing. Nurse #1 said that if for some reason they were unable to obtain his/her weight, they enter the weight from the Hospital Discharge Summary into the Admission Nursing Assessment. Nurse #1 said nursing did not always have access to a resident's previous weight but if they did and noticed a discrepancy, a re-weight would be done. Nurse #1 said she considered anything greater or less than 10 lbs. from the resident's previous weight to be a big difference that would require nursing to obtain a re-weight, but did not remember if she requested one for Resident #1. Review of Resident #1's Nutrition History and Assessment, dated 04/29/24 and signed by the Registered Dietician (RD), indicated Resident #1 weighed 190 lbs., had a Stage 2 pressure injury on his/her coccyx, and had a low albumin level. The Assessment also indicated that Resident #1 was at risk for nutritional decline due to unplanned weight loss, was at risk for dehydration and delayed wound healing. Review of Resident #1's Nutrition Care Plan, dated 04/29/24, indicated he/she was at risk for dehydration and potential for slow wound healing due to low albumin. Further review of the Care Plan indicated the following: -interventions included to monitor intakes and weights. -goals included that Resident #1 would maintain stable weights. Review of Resident #1's Medication Administration Record (MAR) for the month of April 2024, indicated his/her weekly weight was not obtained on 04/12/24 due to his/her hospitalization , and the order for weekly weights was discontinued on 04/18/24 (prior to his/her re-admission). Review of Resident #1's Physician's Orders for the months of April 2024 and May 2024 indicated nursing did not obtain another Physician's order to monitor Resident #1's weights, despite it being an intervention on his/her Care Plan. During a telephone interview on 08/29/24 at 3:24 P.M., the Registered Dietician (RD) said that she completed Resident #1's initial Nutrition Assessment on 04/29/24 (after he/she was readmitted to the facility). The RD said she absolutely would have expected a re-weight to be done for Resident #1 due to the documented 25 lb. weight loss from 04/04/24 through 04/19/24. The RD said that if Resident #1's weight was recorded from the hospital records, that was not enough, and nursing should have obtained another weight. The RD said she was sure a re-weight was requested and if it was not done immediately it should have been done as soon as possible. The RD said there was no Unit Manager on the Unit Resident #1 resided at that time and that follow through was very difficult without one. The RD said that her expectation was for residents to be weighed upon admission (and/or re-admission) to the facility, then weekly, and if stable at that time could go to monthly. The RD said that it was facility protocol and industry standard, and due to Resident #1's low albumin, wounds and potential weight loss, she would have expected Resident #1 to have been weighed weekly. The RD said that weekly she reviewed an electronic report from the Facility's Electronic Medical Record System (EMRS) that allowed her to view any changes in resident's weights. The RD said the problem in this case, was because the re-weight order for Resident #1 was never entered into the EMRS, so Resident #1 did not appear on her weekly report during his/her stay at the Facility. Therefore, she did not re-assess his/her weight for accuracy or weight loss. The RD said Resident #1 was at high risk for nutritional decline due to his/her low albumin level and wounds, therefore obtaining his/her weights was important. The RD said that Resident #1 was not started on any type of a nutritional supplement until she evaluated him/her on 04/29/24. The RD said if Resident #1 had been on Ensure Plus at the hospital, the order should have been implemented when he/she was readmitted to the Facility, and not ten days later when she (RD) did her initial assessment. During a telephone interview on 08/30/24 at 9:05 A.M., the Nurse Practitioner (NP) said that she was not made aware by nursing that there had been any weight discrepancies for Resident #1. The NP said nursing did weekly weights and if a resident sustained a weight loss, they would notify her. The NP said she found out this week (during survey) that Resident #1's Physician's order for weekly weights had been discontinued when he/she had a brief hospitalization and were not restarted when he/she was readmitted to the Facility. The NP said that if she had been aware that Resident #1 may have had a significant weight loss she could have discussed options with his/her family, such as an appetite stimulant. During an interview on 08/29/24 at 12:59 P.M., the Assistant Director of Nurses (ADON) said that she reviewed Resident #1's Physician's Orders and the order to weigh him/her weekly was discontinued when he/she was hospitalized . The ADON said the order was dropped and should not have been. During a telephone interview on 08/30/24 at 11:52 A.M., the Director of Nurses said that staff should obtain a resident's weight on their own, upon admission (re-admission) to the Facility. The DON said if a resident had a weight discrepancy of 25 lbs. in a two week period, she expected staff to obtain a re-weight as soon as possible. The DON said the CNAs should document resident meal and fluid intakes at each meal.

Based on observation, interview and record review, the facility failed to provide dental care and services as required for one Resident (#16) out of a total sample of 24 residents. Specifically, the facility staff failed to provide assistance with scheduling and maintaining dental services for Resident #16, when the Resident had consents for dental care and services. Findings include: Review of the facility policy titled, Consulting Services, Podiatry/Dental/Optometry/Audiology, dated 11/22/16, indicated the following: -The facility has a contract with credentialed providers for in house services of dental. -Services are offered to all residents as a means of providing the highest practicable level of functioning and care. -Residents/representatives are provided information about consulting services on admission and at any time the need arrives. -Residents/representatives provide written consent to treatment prior to initiation of services. -Appointments are arranged by facility staff. -Transportation is arranged by facility staff for outside appointments. -Credentialed Consultant documents, care and services provided, are in the medical record. Resident #16 was admitted to the facility in March 2015, with diagnoses including Aphasia (a language disorder that affects how one communicates) and Hemiplegia (paralysis of one side of the body). Review of Resident #16's most recent Minimum Data Set assessment (MDS), dated [DATE], indicated that Resident #16: -was unable to complete the Brief Interview for Mental Status (BIMS) exam because they were rarely or never understood. -was dependent on staff assistance with oral hygiene. On 7/2/24 at 9:59 A.M., the surveyor observed Resident #16 on the Sunrise Unit. The surveyor observed that the Resident's teeth were stained brown and coated with debris. During an interview on 7/2/24 at 2:38 P.M., Resident #16's daughter said that she did not feel the facility staff were taking good care of the Resident's teeth. The Resident's daughter also said that she was unsure if the Resident had seen the Dentist and wanted Resident #16 to be seen for dental services. Review of Resident #16's medical record indicated Consent Forms dated 11/30/15, 9/5/18, and 12/15/20, requesting dental services for Resident #16. Review of Resident #16's medical record failed to indicate whether Resident #16 was seen by the Dentist. During an interview on 7/8/24 at 9:49 A.M., Unit Manager (UM) #1 said that Resident #16 had not been seen by the Dentist since 2020. During an interview on 7/8/24 at 12:10 P.M., the Corporate Quality Improvement Nurse said that Resident #16 had not been seen by the Dentist and should have been.

Based on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded for four Residents (#88, #12, #89, and #110) out of a total sample of 24 residents. Specifically, the facility failed to: 1. Accurately code that Resident #88 was receiving Hemodialysis (also known as dialysis: a procedure where a machine with a special filter called a dialyzer is used to remove waste products and fluids from the blood). 2. Accurately code an indwelling urinary catheter (a tube inserted into the bladder used to drain urine outside the body) usage for Resident #12 and Resident #89. 3. Accurately code the discharge disposition for Resident #110. Findings include: 1. Resident #88 was admitted to the facility in May 2023, with a diagnosis of End Stage Renal Disease (ESRD - a medical condition where the kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and was dependent on Hemodialysis treatments. Review of the MDS assessment dated [DATE], indicated Resident #88 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15 points. Review of the quarterly MDS assessment dated [DATE], did not indicate that Resident #88 received Hemodialysis treatments. Review of the annual MDS assessment dated [DATE], did not indicate that Resident #88 received Hemodialysis treatments. During an interview on 7/2/24 at 4:41 P.M., Resident #88 said he/she has been going to dialysis every Tuesday, Thursday and Saturday for a year and a half. During an interview on 7/3/24 at 8:25 A.M., the surveyor and the Clinical Reimbursement Coordinator (CRC) reviewed the MDS Assessments dated 3/8/24 and 5/30/24. The CRC said the MDS assessments were not coded to reflect that the Resident had been receiving dialysis treatments. The CRC further said she needed to review Resident #88's medical record to determine the accuracy of the MDS assessments dated 3/8/24 and 5/30/24. During a follow-up interview on 7/3/24 at 2:40 P.M., the CRC said the MDS Assessments dated 3/8/24 and 5/30/24 were inaccurate and that Resident #88 was receiving dialysis treatments during the assessment periods in question. 45429 2a) Resident #12 was admitted to the facility in February 2022, with a diagnosis of urinary retention (condition that occurs when an individual is unable to empty their bladder completely or partially of urine) Review of Resident #12's care plans indicated that the Resident had a care plan for urinary catheter, last revised 3/28/24. Review of Resident #12's MDS assessment dated [DATE], indicated that the Resident did not have a catheter. Review of Resident #12's Physician's orders for July 2024 indicated the following: -Foley Catheter (a sterile tube that in inserted into your bladder to remove urine) care every shift -May change Foley catheter as needed for occlusion, leakage or accidental removal -Foley- site care every shift During an interview on 7/8/24 at 1:39 P.M., the MDS Nurse said that the MDS was inaccurately coded and that Resident #12's MDS should have been coded as the Resident having a urinary catheter. 44337 2b) Resident #89 was admitted to the facility in May 2023 with a diagnosis of acute on chronic respiratory failure (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, that can trigger serious complications for the individual). Review of Resident #89's MDS assessment dated [DATE], indicated that the Resident had an indwelling urinary catheter. Review of the Physician's orders dated 7/1/24 through 7/31/24 did not indicate an order for the placement of an indwelling urinary catheter. During an interview on 7/8/24 at 9:11 A.M., Unit Manager (UM) #1 said that Resident #89's indwelling urinary catheter had been discontinued in July 2023. During an interview on 7/8/24 at 2:37 P.M., the MDS Nurse said that Resident #89's indwelling urinary catheter had been discontinued in July 2023 and the MDS dated [DATE] had been coded inaccurately. The MDS Nurse said Resident #89 should not have been coded as having an indwelling urinary catheter. 42690 3. For Resident #110 the facility failed to accurately code Resident #110's discharge status. Resident #110 was admitted to the facility in March 2024. Review of the Nurse's Note dated 4/5/24, indicated the Resident was discharged home with discharge instructions, medication and belongings. Review of the MDS assessment dated [DATE], indicated the discharge status for Resident #110 was for a short-term general hospital discharge. During an interview on 7/9/24 at 1:38 P.M., the MDS Nurse said that Resident #110 had a planned discharge home to the community and that the discharge status should be coded to reflect a discharge to home to the community. The surveyor and the MDS Nurse reviewed the MDS assessment dated [DATE] and the MDS Nurse said that the MDS Assessment was coded as though the Resident had been sent out to the hospital for a short-term general hospital stay, which was not correct.

Based on record review, and interview, the facility failed to notify the Physician of the unavailability of an ordered medication for one Resident (#1) out of a total sample of 24 residents. Specifically, the facility staff failed to notify the Physician when Resident #1's Fluoxetine (a psychotropic medication used to treat Depression) medication was unavailable to be administered in accordance with his/her Physician orders, resulting in the Resident not receiving five scheduled doses of Fluoxetine medication. Findings include: Resident #1 was admitted to the facility in June 2024, with a diagnosis of Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #1 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of a total score of 15. Review of the current Physician's orders dated 7/8/24, indicated: -Fluoxetine 40 mg (milligram) capsule orally in the morning 7 A.M.-11 A.M., and at bedtime 7 P.M.-11 P. M., initiated on 6/11/24. Review of the July 2024 Medication Administration Record (MAR) indicated the letter H (held, not administered) documented in the spaces corresponding to the administration times for the Fluoxetine on: -7/1/24 at bedtime -7/2/24 at bedtime -7/3/24 for morning -7/5/24 for both morning and bedtime scheduled doses Further Review of the July 2024 MAR indicated that the Fluoxetine medication was administered to the Resident on 7/4/24. During an interview on 7/3/24 at 1:59 P.M., Nurse #1 said that the H documented on the MAR next to the Fluoxetine medication indicated that the medication was held and not administered. Nurse #1 said that she did not administer the Fluoxetine to Resident #1 this morning (7/3/24) as ordered because the medication was not available from the pharmacy. Nurse #1 said that she notified the pharmacy of the missing medication for Resident #1. Review of the clinical record progress notes did not indicate that Resident #1's Physician had been notified that the ordered Fluoxetine medication had not been administered as scheduled on 7/1/24, 7/2/24, 7/3/24 and 7/5/24. During an interview on 7/8/24 at 12:31 P.M., the surveyor and Unit Manager (UM) #1 reviewed Resident #1's MAR and UM #1 said that the H documented on the Resident #1's MAR next to the Fluoxetine indicated that the medication had been held and not administered. UM #1 said when the medication was held and not administered to Resident #1 as ordered, the Nurse should have notified the Physician and documented the Physician notification in the nursing progress notes. UM #1 said that she could not provide any evidence that Resident #1's Physician had been notified when the Fluoxetine medication was held and not administered as ordered to Resident #1 on 7/1/24, 7/2/24, 7/3/24 and 7/5/24.

Based on policy review, observation and interview, the facility failed to maintain sanitary conditions for two (Meadowview and Forestview) applicable unit kitchenettes out of a total of three unit kitchenettes. Specifically, the facility failed to maintain sanitary conditions for two of the two applicable unit kitchenette microwaves located on Meadowview and Forestview to prevent contamination and the spread of food-borne infections. Findings include: Review of the facility policy titled Dietary: Sanitary Conditions, revised on 9/21/22, indicated that when cleaning fixed equipment ( .equipment that cannot readily be immersed in water), the removable parts are washed and sanitized and non-removable parts are cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution. Review of the Housekeeping responsibilities for Forestview and Meadowview units, indicated that housekeeping staff are to ensure that all areas on the units are clean and kept up: this includes .kitchenettes. On 7/9/24 at 9:45 A.M., the surveyor observed splattered food and built up debris on the interior top and sides of the microwave in the kitchenette located on Meadowview. On 7/9/24 at 9:50 A.M., the surveyor observed splattered food and built up debris on the interior top and sides of the microwave in the kitchenette located on Forestview. During an interview on 7/9/24 at 10:17 A.M., Housekeeper #1 said that the microwaves in the two kitchenettes that have microwaves should be checked daily and cleaned if needed. The surveyor and Housekeeper #1 observed the splattered food particles and built up debris covering the top and sides of the interior of both microwaves on the Meadowview and Forestview units. Housekeeper #1 said that the two microwaves did not appear to have been cleaned for quite some time judging by the amount of built up debris and food splatter. Housekeeper #1 said the microwaves on the Forestview and Meadowview units should have been cleaned as they are supposed to be checked daily, and deep cleaned monthly.

Based on observation, interview, record and policy review, the facility failed to provide nutrition care and services for one Resident (#264) out of a total sample of 24 residents, when the Resident was determined to be at risk for malnutrition. Specifically, the facility staff failed to perform monthly weight measurements for Resident #264 as ordered for June 2024, resulting in a significant weight loss being missed and a delay of nutritional interventions. Findings include: Review of the facility policy titled Nutrition Management last revised June 2022 indicated the following: -staff will consistently observe and monitor residents for changes and implement revisions to care plan as needed. -to recognize, evaluate and address the nutritional needs of every resident, including but not limited to, the resident at risk or currently experiencing impaired nutrition. -address any immediate concern with the dietician and physician. -use the Dietician Consult Request to initiate a consult with Dietician when indicated for unplanned weight loss or gain of 5% in one month, 7.5% in three months and 10% in six months. -monitor resident's weight as ordered at a minimum monthly unless contraindicated by advanced directives. Resident #264 was admitted to the facility in April 2024 with diagnoses including displaced fracture of the left humerus (when the bones in the upper arm separated after they were broken and formed a gap), left maxillary fracture (broken facial bone) and Diabetes Mellitus (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #264 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15 and at risk for malnutrition (lack of proper nutrition caused by not eating enough food). On 7/2/24 at 10:16 A.M., the surveyor observed Resident #264 sitting on the edge of the bed with a breakfast meal on the bedside table. Resident #264 said that the food is terrible, and he/she has lost about twenty pounds since he/she was admitted to the facility. Review of the Physician's orders dated July 2024 indicated: -an order for a House Diet with controlled carbohydrates regular consistency, initiated on 4/29/24. -an order to obtain weights monthly on the first Saturday of every month, initiated on 5/28/24. Review of the Initial Nutritional History/assessment dated [DATE], indicated the following Dietician recommendations: -encourage adequate oral intake -monitor intake, weight and labs Review of the Weight Report provided by the facility indicated the following weights for Resident #264: -4/30/24: 130.0 pounds (lbs) -5/4/24: 130.0 lbs -5/18/24: 130.0 lbs -7/6/24: 112.0 pounds (weight loss of 18 lbs from 5/18/24, verified with a re-weigh) Further review of the Weight Report provided no evidence that Resident #264 had been weighed monthly as ordered in June 2024. During an interview on 7/9/24 at 7:18 A.M., The Director of Nursing (DON) #2 said Resident #264 had a Physician's order to be weighed monthly and should have been weighed for the month of June but was not weighed as ordered. DON #2 said that the facility was not aware of Resident 264's weight loss until it was identified on 7/8/24. DON #2 also said that the Dietician was notified of the weight loss on 7/8/24 and interventions were put into place. During a telephone interview on 7/9/24 at 10:50 A.M., the facility Dietician said she attends weekly risk meetings at the facility and reviews the facility weight report for all residents in the facility. The Dietician said the weekly report she uses to monitor resident weights does not indicate if a weight measurement was not performed as ordered. The Dietician said that Resident #264 should have been weighed in June 2024 but could not provide any evidence in the clinical record that Resident #264 had been weighed in June 2024 as ordered. The Dietician also said she was notified of Resident #264's significant weight loss on 7/8/24, and had put interventions into place at that time.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy, was transferred to the Hospital Emergency Department (ED) for an evaluation when he/she became unresponsive, the Facility failed to ensure that nursing notified his/her Health Care Agent (HCA) of the transfer. Findings include: Review of the Facility's policy, titled Health and Medical Condition, Informing Residents of, with an approval date of 01/10/17, indicated the following: -Each resident or resident representative admitted to our facility will be informed of his/her health status and medical condition on an ongoing basis. -The resident's family/resident representative will be notified when there is a medical change in the resident's condition. Review of the Facility's policy, titled Physician Notification, with a revision date of 09/2011, indicated the following: -If clinical findings are life threatening or an emergency, a nurse should notify the physician and family. -Document family notification. Resident #1 was admitted to the Facility in December 2022 with diagnoses including atrial fibrillation (irregular heart rate) and bilateral pulmonary embolisms (blood clots to both lungs). Review of Resident #1's medical record indicated Resident #1's Health Care Proxy was permanently invoked on December 3, 2022. Review of Resident #1's Nursing Progress Note, dated 01/26/24, indicated that Resident #1 became unresponsive in the bathroom, was assessed by Nurse Practitioner (NP) #1 who was in the Facility, and was sent to the Hospital (ED) via 911 for an evaluation. Further review of the Progress Note indicated there was no documentation to support that Resident #1's HCA was notified of the transfer. During a telephone interview on 02/28/24 at 11:26 A.M., Resident #1's HCA said she was not notified by the Facility of Resident #1's transfer to the hospital on 01/26/24. The HCA said that she was called by the Hospital ED staff, when consent for additional testing for Resident #1 was required, and that was how she learned that Resident #1 had been transferred to the hospital. During a telephone interview on 02/29/24 at 1:22 P.M., Nurse #1 said that she was on duty on 01/26/24 and was the one who sent Resident #1 to the ED via 911. Nurse #1 said she did not notify Resident #1's HCA of the transfer to the hospital because she thought the Assistant Director of Nurses had notified Resident #1's HCA. Nurse #1 said there was a breakdown in communication and that one of them should have notified Resident #1's HCA of his/her transfer to the ED. During a telephone interview on 03/01/24 at 1:00 P.M., the Director of Nurses (DON) said that Nurse #1 should have notified Resident #1's HCA of his/her transfer to the ED.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included the administration of Xarelto (anticoagulant medication) for treatment of atrial fibrillation (irregular heart rate) and history of bilateral pulmonary embolisms (blood clots in both lungs), the Facility failed to ensure they maintained a complete and accurate medical record when the Physician and Nurse Practitioner progress notes reference to Resident #1's anticoagulant dosage conflicted with the daily dosage being administered by nursing. Findings include: Review of the Facility's policy, titled Medical Records Policy, dated 05/19/23, indicated the following: Purpose: To ensure a system that abides by regulatory, state and federal requirements for medical records. -Each resident will have an active medical record. This record shall be kept current, complete and available at all times to authorized personnel. Resident #1 was admitted to the Facility in December 2022 with diagnoses including atrial fibrillation and bilateral pulmonary embolism. Review of Resident #1 Physician's Orders for the month of October 2023 indicated the order to administer Xarelto 20 milligrams (mg) by mouth daily at 5:00 P.M., was changed on 10/23/23 to Xarelto 20 mg give 1/2 tablet (10 mg) by mouth daily at 5:00 P.M. Further review of the Physician's Orders indicated Resident #1 was started on Paxlovid 150 mg/100 mg tablet one dose by mouth daily for suspected lower respiratory infection for five days (start date 10/23/23, end date 10/28/23). Review of Resident #1's Medication Administration Record (MAR) for the months of October 2023, November 2023, December 2023, and January 2024, indicated the following: -Resident #1 was administered Xarelto 20 mg 1/2 tablet (10 mg) by mouth daily from 10/23/23 through 10/31/23. -Resident #1 was administered Xarelto 20 mg 1/2 half tablet (10 mg) by mouth daily from 11/01/23 through 11/30/23. -Resident #1 was administered Xarelto 20 mg 1/2 half tablet (10 mg) by mouth daily from 12/01/23 through 12/31/23. -Resident #1 was administered Xarelto 20 mg 1/2 half tablet (10 mg) by mouth daily from 01/01/24 through 01/18/24. Review of Resident #1's Physician Progress Note, dated 11/27/23, indicated Resident #1's medication list included Xarelto 20 mg with dinner. Review of Resident #1's Nurse Practitioner (NP) Progress notes, dated 11/15/23, 11/20/23 and 12/01/23, all indicated that Resident #1's medication list included Xarelto 20 mg with dinner. During a telephone interview on 02/29/24 at 3:27 P.M., Physician #1 said that he had access to Resident #1's medical record and could see that he saw Resident #1 in the facility on 11/27/23. Physician #1 said that all of the progress notes he could see indicated that Resident #1 was on Xarelto 20 mg daily. Physician #1 said that anticoagulants were often decreased when they are prescribed at the same time as Paxlovid. Physician #1 went on to say that he did not know why the order for Xarelto did not include to resume the Xarelto 20 mg daily upon Resident #1's completion of the Paxlovid. During a telephone interview on 03/01/24 at 8:26 A.M., Nurse Practitioner #1 said that she had access to Resident #1's medical record and could see that she saw Resident #1 in the facility on 11/15/23, 11/20/23 and 12/01/23. NP #1 said that she reviewed Resident #1's medication list at each of those visits and had documented Xarelto 20 mg at dinner under the medication list section on her progress notes for each of those visits. NP #1 said that typically when the Xarelto dose was decreased due to Paxlovid being prescribed at the same time, that the original dose of Xarelto is resumed upon the completion of Paxlovid. NP #1 said that when the medications were reviewed, she referred to the medication list in Resident #1's electronic medical record which indicated that Resident #1 was on Xarelto 20 mg daily. NP #1 went on to say that the medication list did not always include the directions for the medication's administration. NP #1 said she likely did not see the directions to give the Xarelto 20 mg one half tablet (10 mg) daily. NP #1 said she was under the impression that Resident #1 had been administered Xarelto 20 mg daily since his/her completion of the Paxlovid in October 2023. During a telephone interview on 03/01/24 at 1:00 P.M., the Director of Nurses said that the residents' medication lists should be accurate in their medical records, which include progress notes.

Based on record review and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Immunizations per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#4) out of a total sample of five residents. Findings include: Review of the facility policy titled Resident Pneumococcal Immunization, revised 9/1/23, indicated the following: -Residents will be offered immunization to protect them from pneumococcal disease . Pneumococcal immunizations will be provided as recommended by the Centers for Disease Control and Prevention (CDC) Advisory Committee for Immunization Practices (ACIP) recommendations. Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (cdc.gov), dated 3/15/23 indicated the following: For adults 65 and over who have had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last pneumococcal vaccination then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20) . Resident #4 was admitted to the facility in July 2022 and was over the age of 65. Review of the Resident's Massachusetts Immunization Information System (MIIS) sheet provided by the facility indicated the Resident had previously been administered following vaccinations: -PPSV23 on 1/17/02 and 10/31/06 -PCV13 on 4/23/15 During an interview on 11/11/23 at 12:23 P.M., the surveyor met with the facility Infection Preventionist (IP), Regional Quality Improvement Nurse, and the Regional Director of Infection Control. The Regional Quality Improvement Nurse said there was no documentation that the Resident and/or Resident's Representative had been offered or educated on the PCV20 vaccination. The Regional Director of Infection Control said the Resident and/or Resident's Representative should have been offered the PCV20 vaccination. He further said if the vaccination was not pertinent for the Resident, it should have been documented in the Resident's record that the Resident's Primary Care Provider (PCP) had been consulted and assessed the Resident and this was not done. The facility IP said there currently was not a process to ensure the facility's long term care residents were offered or educated on the recommended PCV20 Vaccination.

Based on interview and record review the facility failed to implement a COVID-19 monitoring plan to prevent the spread of infection for two Residents (#1 and #2) out of a total sample of three residents. Specifically, the facility's staff failed to screen for signs and symptoms of COVID-19 every shift (Q-shift) while outbreak testing was being conducted within the facility. Findings include: Review of the facility policy titled Infection Prevention and Control Program, revised 12/22/16, indicated the following: -Ensure compliance with local, state, and federal regulations related to infection control and prevention . Review of the Massachusetts DPH Memorandum titled, Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, Including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 10, 2023 included, but was not limited to: -Residents included in outbreak testing or who are being tested following an exposure, should be assessed for symptoms of Covid-19 during each shift. Review of the facility policy titled COVID-19 Prevention and Outbreak Management, revised 6/8/23, indicated the following: -If resident is included in outbreak testing or who are being tested following an exposure, they should be assessed for symptoms of COVID-19 during each shift. During an interview on 11/1/23 at 8:44 A.M., Nurse #1 said residents should be screened for signs and symptoms of COVID-19 every shift and that Nurses documented this information in the Medication Administration Record (MAR). During an interview on 11/1/23 at 10:00 A.M., the facility Infection Preventionist (IP) said the facility began outbreak testing on the Sunrise Unit on 10/12/23 and outbreak testing on the Forestview Unit on 10/10/23. a. Resident #1 was admitted to the facility in June 2021 and resided on the Sunrise Unit. Review of Resident #1's October 2023 Physician's orders indicated: -COVID-19 Screening every shift .with a start date of 10/20/23 Review of Resident #1's October 2023 MAR indicated that the facility did not begin screening the Resident for signs and symptoms of COVID-19 until 10/20/23. b. Resident #2 was admitted to the facility in March 2021 and resided on the Forestview Unit. Review of Resident #2's October 2023 Physician's orders indicated: -COVID-19 Screening every shift .with a start date of 10/20/23 Review of Resident #2's October 2023 MAR indicated that the facility did not begin screening the Resident for signs and symptoms of COVID-19 until 10/20/23. During an interview on 11/1/23 at 10:32 A.M., the IP said when outbreak testing started on each unit the residents on those units should have been screened for signs and symptoms of COVID-19 on each shift and documentation should have been completed on the MAR. During a follow-up interview on 11/1/23 at 10:56 P.M., the IP said both Resident #1 and Resident #2 had been included in outbreak testing and had not been screened for signs and symptoms of COVID-19 according to the facility policy. She further said that both Residents should have been screened every shift, as soon as outbreak testing on their units started, for Resident #1 screening should have begun on 10/12/23, and for Resident #2 screening should have begun on 10/10/23, and this was not done as required.

Based on observations, interview, record and policy reviews, the facility failed to ensure its staff developed and implemented the plan of care for seven Residents (#40, #55, #61, #22, #16, #35 and #104), out of total sample of 22 residents. Specifically, the facility staff failed to: 1. ensure the plan of care relative to falls/activities of daily living (ADLs) was implemented for two Residents (#40 and #55), 2. implement the Physician's Orders for three Residents (#61, #22 and #16) relative to utilization of bed rails, and 3. obtain weights as ordered by the Physician for two Residents (#35 and #104). Findings include: Review of the facility policy titled Side Rails- Assessment and Use of, revised 10/17/17, included the following: -use of side rails will be addressed in the resident's plan of care and will also be documented in the resident's profile. Review of the facility policy titled Falls Risk Reduction, revised 11/28/18, included the following: -Residents determined to have risk factors will receive individualized interventions based on the risk factors in order to reduce the risk of falls and minimize the actual occurrence of falls -include fall interventions on the Resident Profile (Communication Tool utilized by the Certified Nurse Aides (CNAs) to guide/assist with the Resident's specific care needs), and Care plan 1a. For Resident #40, facility staff failed to A) implement the Falls and ADL Plan of Care relative to the accessibility of the call light, personal items (phone) and handheld grabber device, and B) failed to implement the Physician's orders relative to the use of side rails. Resident #40 was admitted to the facility in May 2022 with diagnoses including Dementia. A) Review of the Falls Care Plan, initiated 5/4/22, indicated Resident #40 was at risk for falls and included the following interventions: -place items the Resident uses frequently in reach to prevent bending or reaching, especially his/her phone -bed/chair alarm -provide and educate on using the handheld grabber device to retrieve items that are out of reach -re-educate on use of the call light Review of the Activities of Daily Living (ADLs) Care Plan, initiated on 7/31/22, included the following intervention: call light within reach and encourage use. B) Review of the March 2023 Physician's orders included the following: quarter (1/4) side rails on bilateral (both) sides of the bed, initiated 5/3/22. Review of the Resident Profile, initiated 5/23/22 included the following under safety devices: -Resident is confused, ensure his/her phone is within reach at all times to prevent reaching and educate the Resident to use the handheld grabber device to retrieve items that are out of reach. On 3/22/23 at 7:32 A.M. and at 9:39 A.M., the surveyor observed Resident #40 lying in bed with a 1/4 side rail on the left side and a half (1/2) side rail on the right side. There was no handheld grabber device observed within the Resident's reach. On 3/22/23 at 2:38 P.M., the surveyor observed Resident #40 lying in bed with a 1/4 side rail on the left side of the bed and a 1/2 side rail on the right side. The Resident's right leg was resting on the floor and the call light was looped around the lower section of the 1/2 side rail with the call button hanging towards the floor and not accessible to the Resident. There was no handheld grabber observed within reach of Resident #40 nor was there one observed within the room. On 3/24/23 at 9:02 A.M., the surveyor observed the Resident lying in bed with a 1/4 side rail in place on the left side and a 1/2 side rail in place on the right side of the bed. The call light was observed looped around the lower section of the right side rail and was hanging towards the floor and not accessible. An overbed table was on the left side of the Resident's bed and was positioned away from him/her. There was no handheld grabber device within the Resident's reach nor was the phone (which was on the overbed table) accessible to the Resident. When the surveyor asked Resident #40 if he/she could reach the phone, the Resident stated no and further said that he/she would like to use it to contact family. During an interview at this time, CNA #3 said the Resident's bed had a 1/4 side rail on the left side and a 1/2 side rail on the right side. He said he was did not know what side rails should be in place for Resident #40 and was unsure where he would find that information. When the surveyor inquired about the accessibility of the Resident's telephone and call light, CNA #3 said that they both should have been within reach and were not. CNA #3 said he was not aware of any handheld grabber device for Resident #40 and did not see one within the Resident's room. During an interview on 3/24/23 at 9:47 A.M., Unit Manager (UM) #1 said the type of side rails to be utilized for residents are ordered by the Physician, and should be implemented and not changed unless they are needed to be adjusted in order to provide resident care. She further said that if the side rails were adjusted to provide care, they should be put back into place after resident care was provided. UM #1 said the CNAs would not know what type of side rails, if any, a resident would have ordered by the Physician unless it was relayed to them from the nurse. During an interview on 3/24/23 at 10:24 A.M., the surveyor discussed with UM #1 the previous observations of the type of side rails utilized, and the lack of accessibility of the Resident's phone and call light. UM #1 said that she understood the concerns. She said that she would check into the Resident's side rails and handheld grabber device. During an interview on 3/24/23 at 2:20 P.M., UM #1 said that she was unable to find a handheld grabber device in Resident #40's room and that the Resident should have his/her call light, personal items like the telephone and the handheld grabber accessible. UM #1 said the type of side rails ordered (1/4) for Resident #40 should have been in place. 1b. For Resident #55, facility staff failed to implement the Falls Plan of Care relative to the implementation of the chair alarm and accessibility of the call light. Resident #55 was admitted to the facility in December 2022 with diagnoses including Dementia and Orthostatic Hypotension (low blood pressure that occurs when standing from lying down or sitting position which could cause dizziness/lightheadedness). Review of the Falls Care Plan, initiated 12/9/22, included the following interventions: -chair alarm -place items the Resident uses within reach to prevent bending or reaching -keep call bell within reach and remind/encourage the Resident to use prior to all transfers On 3/22/23 at 8:43 A.M., the surveyor observed Resident #55 seated in a wheelchair next to the left side of his/her bed eating breakfast. There was no chair alarm observed on the wheelchair and the Resident's call light was observed to be on the right side of the bed under the blankets and was not accessible to him/her. On 3/23/23 at 8:51 A.M., the surveyor observed Resident #55 seated in the wheelchair next to the left side of his/her bed eating breakfast. There was no chair alarm observed on the wheelchair, and the call light was on the right side of the bed and was not accessible. During an interview on 3/23/23 at 8:53 A.M., CNA #3 said Resident #55 required assistance with care and had transferred him/herself at times. CNA #3 said the Resident was able to and did use the call light to request assistance, that he/she had fallen while in the facility but did not have any interventions like alarms or other safety measures in place. When observing the Resident's room with the surveyor, CNA #3 said that the call light was not accessible to Resident #55 and observed CNA #3 move it from the right side of the Resident's bed to the left side where the Resident was positioned. During interview on 3/23/23 at 12:09 P.M., the surveyor discussed the previous observations with UM #1, who said that the Resident's call light should have been positioned next to him/her and that a chair alarm should have been in place. UM #1 accompanied the surveyor to Resident #55's room at this time. Resident #55 was observed lying in bed with the wheelchair positioned on the left side of the bed. UM#1 was observed to look around and behind the Resident's wheelchair and under the wheelchair cushion and said there was no alarm on the Resident's chair. During a follow-up interview on 3/24/23 at 10:18 A.M., UM#1 said Resident #55 should have a chair alarm on his/her wheelchair as indicated on the Falls Care Plan, but it had not been in place. She said the Resident had transferred from the first floor and the chair alarm was added as a falls intervention prior to his/her transfer. She said residents who have alarms or other special needs are listed on a check sheet which was supposed to be checked every shift by the CNAs. During a review of the check sheet with UM #1, the surveyor observed Resident #55 was not listed as requiring any alarms or other safety measures. Refer to F689 2a. For Resident #61, facility staff failed to implement the Physician's orders relative to the use of side rails. Resident #61 was admitted to the facility in October 2021 with diagnoses of Dementia, unsteadiness, and muscle weakness. Review of the March 2023 Physician's orders included the following order initiated on 3/2/22: 1/4 side rails on bilateral sides of the bed. On 3/24/23 at 8:21 A.M., the surveyor observed Resident #61 sitting upright in bed during breakfast with a 1/2 side rail on the left side of the bed and 1/4 side rail on the right. During an interview on 3/24/23 at 9:47 A.M., the surveyor discussed the observations about Resident #61's side rail with UM #1. UM #1 said the type of side rails to be used, if any, were ordered by the Physician. She said the side rails should be implemented by the staff as per the Physician's orders and should not be changed unless they needed to be adjusted to provide resident care, but after care they should be put back into place. 2b. For Resident #22, facility staff failed to implement the Physician's orders relative to the use of side rails. Resident #22 was admitted to the facility in December 2014 with a diagnosis of Dementia. Review of the March 2023 Physician's orders included the following order initiated on 5/21/19: 1/2 side rails on bilateral sides of the bed to assist with bed mobility and positioning. On 3/22/23 at 11:09 A.M., the surveyor observed Resident #22 lying in bed with eyes closed with a 1/4 side rail on the left side of the bed and a 1/2 side rail on the right side. On 3/22/23 at 3:09 P.M., the surveyor observed Resident #22 awake and lying in bed with a 1/2 side rail on the left side of the bed and a 1/4 side rail on the right side of the bed. On 3/24/23 at 8:23 A.M., the surveyor observed the Resident lying in bed with eyes closed with a 1/2 side rail on the left side of the bed and a 1/4 side rail on the right side. During an interview on 3/24/23 at 9:47 A.M., the surveyor discussed the observations about Resident #22's side rail with UM #1. UM #1 said the type of side rails to be used, if any, were ordered by the Physician. She said the side rails should be implemented by the staff per the Physician's orders and should not be changed unless the rails needed to be adjusted to provide resident care, but after care they should be put back into place. 2c. For Resident #16, facility staff failed to implement the Physician's orders relative to the use of side rails. Resident #16 was admitted to the facility in February 2022 with diagnoses including Cerebral Vascular Accident (CVA-stroke) and mild cognitive impairment. Review of the March 2023 Physician's orders included the following order initiated on 3/4/22: 1/4 side rails on bilateral sides of the bed. On 3/21/23 at 9:37 A.M. and 10:59 A.M., the surveyor observed Resident #16 lying in bed with a 1/4 side rail on the left side of the bed and a 1/2 side rail on the right. On 3/24/23 at 8:20 A.M., the surveyor observed the Resident lying in bed with a 1/4 side rail on the left side of the bed and a 1/2 side rail on the right. During an interview on 3/24/23 at 9:47 A.M., the surveyor discussed the observations about Resident #22's side rail with UM #1. UM #1 said the type of side rails to be used, if any, were ordered by the Physician. She said the side rails should be implemented by the staff as per the Physician's orders and should not be changed unless they needed to be adjusted to provide resident care, but after care they should be put back into place. 42690 3a. For Resident #35, facility staff failed to ensure a monthly weight was obtained per the Physician orders and the facility policy. Review of the Weighing and Measuring Resident policy, revised on 3/3/21, indicated that residents will be weighed using a consistent scale on admission and at least monthly thereafter. Resident #35 was admitted to the facility in June 2022. Review of the Active Orders Report indicated to obtain a monthly weight starting 10/26/22. Review of Nutritional History/Assessment for a significant change completed by the Registered Dietitian on 3/15/23 and 3/17/23 indicated the following: -Weight not obtained for this review period, last weight was obtained on 2/5/23. -Poor intake of 0-24% -At nutrition risk due to unplanned weight loss During an interview on 3/22/23 at 2:58 P.M., CNA #3 said that they typically obtain monthly weights for all residents, unless otherwise indicated, between the first and fifth of every month. He continued to explain that they document the weights on a clip board kept at the nurse's station. The Surveyor and CNA #3 reviewed the March monthly weight list and noted that Resident #35 had no information documented next to his/her name. CNA #3 said that it appeared that the weight had not yet been obtained for this month and they were still working on obtaining the weights. 3b. For Resident #104 the facility failed to ensure its staff obtained a weekly weight per the Physician orders. Resident #104 was admitted to the facility in December 2022. Review of the Active Orders Report indicated to obtain a weekly weight during the day shift on Saturdays starting 12/30/22. Review of the Administration History from 1/2023 through 3/2023 for the weekly weight order indicated that weights were not obtained on the following dates: 1/22/23 -weight held 2/18/23 -weight held due to short staff 2/25/23 -weight held, not documented on previous shift 3/4/23 - weight held - Resident refused to get out of bed There was no further documentation indicating the reason weights were not obtained on 3/11/23 and 3/18/23. Review of the clinical record indicated on 3/16/23 the Dietitian wrote the following: -Resident reviewed on 3/13/23, pending re-weigh for weight loss from 106 pounds on 1/28/23 to 102 pounds on 2/11/23. -Will monitor for March monthly weight. During an interview on 3/22/23 at 4:24 P.M., Unit Manager (UM) #1 said that she was unable to locate any additional weights. She said that Resident #104 should have been weighed weekly per the Physician's orders and was not, as required.

Based on record reviews and interview, the facility failed to ensure its staff provided a copy of the transfer and/or discharge notices to a Representative of the Office of the State Long-Term Care Ombudsman for four Residents (#113, #35, #55 and #61), out of a sample of 22 residents. Findings include: 1. Resident #113 was admitted to the facility in August 2019. A clinical record review indicated Resident #113 was sent to the hospital on 2/26/23. Further review of the clinical record indicated no documented evidence that the Ombudsman was notified of the hospital transfer on 2/26/23, as required. During an interview on 3/23/23 at 3:10 P.M., the Administrator said that the staff were unable to locate evidence that the Ombudsman was notified of Resident #113's transfer to the hospital on 2/26/23. 2. Resident #35 was admitted to the facility in June 2022. A clinical record review indicated that Resident #35 was sent to the hospital on 2/22/23. Further review of the clinical record indicated no documented evidence that the Ombudsman had been notified of the hospital transfer on 2/22/23 as required. 37400 3. Resident #55 was admitted to the facility in December 2022. Review of a Nurse's Note, dated 1/3/23, indicated that Resident #55 had a change in condition and was transferred to the hospital for evaluation at 11:00 P.M. Review of a Nurse's Note, dated 1/4/23, indicated the Resident returned to the facility at 5:30 A.M. Review of the clinical record indicated no documented evidence that the Office of the State Long-Term Care Ombudsman was notified of the Resident's transfer to the hospital, as required. 4. Resident #61 was admitted to the facility in October 2021. Review of a Nurse's Note, dated 12/25/22, indicated Resident #61 was transferred to the hospital for evaluation after sustaining a fall at 9:00 P.M. Review of a Nurse's Note, dated 12/26/22, indicated Resident #61 returned to the facility at 2:45 P.M. Review of the clinical record indicated no documented evidence that the Office of the State Long-Term Care Ombudsman was notified of the Resident's transfer to the hospital, as required. During an interview on 3/23/23 at 12:39 P.M., the Administrator said that the facility staff have not communicated hospitalization s to the Office of the State Long-Term Ombudsman for residents who have been transferred out of the facility to the hospital and have returned to the facility within 24 hours. He further said that it was his understanding that this information did not need to be relayed.

Based on observation and interview, the facility failed to ensure its staff treated each resident with respect and dignity, impacting one Resident (#35), out of a sample of 22 residents. Specifically, staff repeatedly did not address Resident #35 by his/her preferred name. Findings include: On 3/21/23 at 9:22 A.M., while standing in the hallway outside of Resident #35's room, the surveyor overheard Certified Nurse's Aide (CNA) #2 calling the Resident names such as dear, sweetie, honey, love, and sweetheart repeatedly while she provided care for the Resident. During an interview on 3/21/23 at 10:28 A.M., CNA #2 said that she was aware that she often refers to residents by names such as honey, dear, and sweetie. She further said that she was aware of the rules and had been educated to call residents by their preferred names, not pet names, and that it was a habit that was hard to break.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing upon admission to have no open areas (pressure injuries), had limited mobility due to a right distal femur (thigh bone) fracture and left distal humerus (long bone in the arm that runs from the shoulder to elbow) fracture, and was also assessed by nursing to be at high risk for skin breakdown, the Facility failed to ensure Resident #1 received adequate care to prevent the development of pressure injury, when nursing failed to consistently implement preventative skin care measure interventions including turning and repositioning, and application of foam boots. - Approximately 23 days after his/her admission, Resident #1 was assessed and noted to have an unstageable pressure injury (tissue damage that is full-thickness skin and tissue loss, obscured by dead tissue, but if the dead tissue is removed it would be a stage 4 pressure injury) to his/her left Achilles (back of the ankle). Approximately 64 days after admission, Resident #1 also developed deep tissue injuries (DTI - purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear) to his/her sacrum (lower back) and right and left heels. Findings include: Review of the Facility's Policy titled Pressure Injury Prevention Protocol, dated 12/2015, indicated that: - Prevention interventions are for residents at risk for skin breakdown, as defined by the Norton skin risk assessment tool. - All residents will be turned and positioned in bed and chair at least every two hours. - Provide clean, dry bedding. - For the short-term usage, place pillows under the calf to raise heels off the bed and use devices that float the heels. Review of the Facility's Policy titled Skin Integrity Management, dated 12/2016, indicated that: - A comprehensive nursing assessment of the resident is initiated upon admission and completed up to 72 hours. - This assessment includes the Norton to determine the risk of pressure injury. - Resident's skin integrity status and need for preventive interventions or treatment is identified through review and assessment information. - Care plan for residents at high risk for skin breakdown. Review of Resident #1's Medical Record indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Nursing Assessment, dated 1/11/22, indicated Resident #1 was admitted from an acute care hospital for rehabilitation. The Assessment indicated Resident #1 had no pressure injuries at the time of his/her admission, and that skin issues noted included a surgical wound to his/her right leg related to the surgical repair of his/her fractured femur, and bruises on his/her abdomen and right arm. The Assessment indicated the skin under Resident #1's right leg immobilizer was assessed and there were no pressure injuries noted. The Norton Score (Skin ) Assessment, dated 1/11/22, indicated Resident #1 triggered as being at high risk for the development of a pressure injury, and risk factors included baseline confusion, bed bound status, immobility, and urinary incontinence. Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated the following: - he/she was severely cognitively impaired, and was compliant with care, - he/she required an extensive assist of two persons with bed mobility and transfers, and was non-ambulatory, - he/she was incontinent of bladder and occasionally incontinent of bowel, - he/she had a surgical wound, with no other skin problems, - he/she had no pressure injuries, but was at increased risk for developing pressure injuries. Review of the MDS, Care Area Assessment, dated 1/17/22, indicated pressure injury triggered as an area of concern for Resident #1 and to address the pressure injury risk with a care plan. Resident #1's Activities of Daily Living (ADL) Care Plan, dated 1/17/22, indicated to maintain Resident #1's non-weight bearing status to his/her the right lower extremity and left upper extremity when re-positioning, he/she required an assist of two staff members during care, and was dependent on staff for positioning and/or re-positioning. Resident #1's Skin Prevention Care Plan, dated 1/17/22, indicated he/she was at high risk for pressure injury development. Interventions included a pressure redistribution mattress (standard issue pressure reducing mattress for all admissions) in bed, reposition resident every 2 hours while in bed, every hour when out of bed to a chair, and the use of devices that eliminate pressure on the heels, foam boots. a. The Nursing Progress Note, dated 1/26/22, indicated that the skin under Resident #1's immobilizer was intact and there was no redness. Review of the Nursing Progress Note, dated 2/03/22 at 3:01 P.M., indicated Resident #1 had a new pressure injury on the back of his/her right ankle, underneath his/her leg immobilizer. The Note indicated the wound bed was brown necrotic (dead) tissue with a small amount of brown drainage, area was cleaned with normal saline (NS), a foam dressing was applied and the Physician was notified. During an interview on 5/3/22 at 2:05 P.M., Nurse #1 said, Resident #1's treatments included that the nurses were required to check the skin underneath his/her immobilizer every shift. Nurse #1 said on 2/03/22 while performing the skin check on Resident #1, she found a pressure injury underneath his/her immobilizer. Nurse #1 said this was new issue, because prior to this, the skin underneath Resident #1's immobilizer was without any pressure injuries. Nurse #1 said Resident #1 could not reposition him/herself at all, said that two staff members were needed to reposition and turn Resident #1 every two hours to prevent pressure injuries from developing on his/her bony prominence's, and underneath the immobilizer. The Wound Sheet, dated 2/03/22, indicated Resident #1 had a unstageable pressure injury on the back of the right heel and Achilles area, measuring 2.5 centimeter (cm) in length and 1 cm in width and 0.1 cm in depth, with black to brown surrounding tissue. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Skin Prevention Care Plan, dated 2/05/22, indicated an updated intervention, to use devices (i.e., foam boots) that eliminate pressure on the heels. However, this intervention was already in place as of 1/17/22, per his/her Skin Prevention Care Plan, and nursing should have been implementing this measure. Review of Resident #1's Orthopedic Follow Up Consultation Note, dated 2/10/22, indicated resident was six weeks status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Repositioning Flow Sheet (completed by Certified Nurse Aide's- CNA's) indicated he/she required repositioning in bed every two hours, or four times per shift, however further review of the Flow Sheets indicated there was insufficient documentation to support Resident #1 was consistently repositioned, as required. Resident #1's Repositioning Flow Sheet, dated February 2022 indicated the following: - 7:00 A.M. to 3:00 P.M., 27 (out of 28 ) days, entire shift documentation was left blank - 3:00 P.M. to 11:00 P.M., 17 (out of 28) days, entire shift documentation was left blank - 11:00 P.M. to 7:00 A.M., 7 (out of 28) days, entire shift documentation was left blank The facility was unable to provide any other documentation to support that nursing staff consistently provided assistance to Resident #1 with turning and repositioning during February of 2022. b. Review of Resident #1's Admission Nursing Assessment, dated 1/11/22, indicated Resident #1 had no pressure injuries on his/her sacrum. The Nursing Progress Note, dated 3/15/22, indicated that Resident #1 had a new pressure injury on the sacrum, a purple area 4 cm in length and 2 cm in width, indicative of deep tissue injury. Review of Resident #1's Physician Order, dated 3/16/22, indicated he/she had new orders related to deep tissue trauma noted to lower back area, for nursing to apply skin prep (liquid film-forming dressing that upon application, forms a protective film to help reduce friction) and cover with a foam dressing. Review of Resident #1's Repositioning Flow Sheet for March 2022 indicated: - 7:00 A.M. to 3:00 P.M., 26 (out of 31) days, entire shift documentation was left blank - 3:00 P.M. to 11:00 P.M., 27 (out of 31) days, entire shift documentation was left blank - 11:00 P.M. to 7:00 A.M., 19 (out of 31) days, entire shift documentation was left blank The facility was unable to provide any other documentation to support that nursing staff consistently provided assistance to Resident #1 with turning and repositioning during March of 2022. c. Review of Resident #1's Admission Nursing Assessment, dated 1/11/22, indicated Resident #1 had no pressure injuries on his/her heels. The Nursing Progress Note, dated 3/16/22, indicated that Resident #1 had new bilateral pressure injuries on the right and left heels. Review of Resident #1's Repositioning Flow Sheet for March 2022 indicated: - 7:00 A.M. to 3:00 P.M., 26 (out of 31) days, entire shift documentation was left blank - 3:00 P.M. to 11:00 P.M., 27 (out of 31) days, entire shift documentation was left blank - 11:00 P.M. to 7:00 A.M., 19 (out of 31) days, entire shift documentation was left blank The facility was unable to provide any other documentation to support that nursing staff consistently provided assistance to Resident #1 with turning and repositioning during March of 2022, as required. During an interview on 5/03/22 at 2:35 P.M., CNA #2 said that Resident #1 required to be turned and repositioned every two hours to prevent pressure injury. Review of the Repositioning Sheets dated February 2022 and March 2022 with CNA #2, she said the staff had not turned and repositioned Resident #1 as required, that it was a hectic time at the Facility with nursing staff who did not know the resident's care needs. CNA #2 said prior to Resident #1 developing pressure injuries on both of his/her heels, CNA's were using a pillow, not foam boots, to offload his/her heels, but said the pillow did not always stay in place to keep his/her heels offloaded. During an interview on 5/04/22 at 4:45 P.M. and on 5/19/22 at 9:14 A.M., Family Member #1 said that multiple family members visited Resident #1 consistently from 11:00 A.M. to 6:00 P.M. daily, and said the foam boots were not put on him/her by staff, and said the foam boots were kept in a corner of his/her room. Family Member #1 said that while Resident #1 was wearing the knee immobilizer, the staff were not offloading the pressure on his/her bony prominence's or the knee immobilizer by turning and positioning him/her. Family Member #1 said Resident #1 was frequently found by family members positioned on his/her back and remained that way for more than four hours, while they visited with him/her. Family Member #1 said that often, despite their request for staff assistance, and Resident #1 was left lying in soiled briefs for an average of 45 minutes on multiple occasions. Review of Resident #1's wound sheets, dated 3/16/22, indicated that Resident #1 had deep tissue injury to the right and left heels, from pressure injuries as follows: - The right heel measured 3 cm in length by 2 cm in width and with no depth with a black purple wound bed. - The left heel measured 2.1 cm in length by 2.5 cm in width and with no depth with a black purple wound bed. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Wound Nurses Weekly Skin Log, dated 3/29/22, indicated that all four pressure injuries, on the right Achilles, the heels and the sacrum, had a decline in their condition. The measurements for the pressure injuries were: - The right Achilles, a stage 4 unstageable pressure injury, measuring 5 cm in length and 1.5 cm in width and 0.2 cm in depth. - The right heel measured 4 cm in length by 3.5 cm in width and with no depth. - The left heel measured 3 cm in length by 3.5 cm in width and with no depth. - The sacrum 5.5 cm in length by 4 cm in width and 0.1 in depth During the interview on 5/03/22 at 2:05 P.M., the Director of Nurse said that Resident #1's pressure injuries were acquired at the Facility, had not improved, had definitely become worse, and had progressed in size.

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 12 applicable residents (#8), in a total sample of 24 residents. Findings include: For Resident #8, the facility failed to provide adequate supervision and effective interventions to prevent a fall, resulting in a fractured shoulder, a 4 centimeter (cm.) laceration on the forehead above the eye and a 10 cm. flap skin tear on the hand. Resident #8, with [DIAGNOSES REDACTED]. Review of the 8/15/17 falls care plan indicated the resident required a bed and chair alarm. Review of the Interdisciplinary Progress Note of 8/16/17 indicated the resident made multiple attempts to self transfer. Review of the Admission Minimum Data Set (MDS) Assessment of 8/22/17 indicated that the resident required eye glasses; was severely cognitively impaired; required extensive assistance with transfers and ambulation and exhibited an unsteady balance. Review of the 8/23/17 falls care plan indicated the resident was at risk for falls due to a change in mobility/gait, confusion/ forgetfulness, exhibiting unsafe behavior and experiencing a fall within the past year, sustaining a fracture. The care plan indicated the following interventions were required: well lit and uncluttered environment, frequently used items within reach, gait belt for all transfers and call bell within reach. Review of the Interdisciplinary Progress Note of 8/27/17 indicated the resident experienced an unwitnessed fall, sustaining a fractured shoulder, a laceration on the forehead above the eye area and a 10 cm. flap skin tear on the hand. The Progress Note indicated that the resident transferred him/herself out of bed and was found laying on the bathroom floor, in the shower stall area. During review of the falls investigation with Unit Manager (UM) #1 (on 10/5/17 at 3:30 P.M.), UM #1 said that although the bed alarm had been functioning earlier in the shift, the resident's bed alarm did not activate, at the time of the fall (as planned). The Progress Note further indicated the CNA's (Certified Nursing Assistants) reported that the resident has been known to turn off the alarm. Review of UM #1's written fall investigation statement of 8/27/17 indicated the resident's roommate had reported that he/she had seen the resident pulling at his/her alarm cord in the past and had witnessed him/her pulling on the alarm cord earlier in the day and had probably unplugged it. During review of the falls investigation statements with UM #1 (on 10/5/17 at 3:30 P.M.), she said that (4) staff statements indicated that the resident was known to shut off/reset the alarm. UM #1 said the immediate action to prevent further falls, per the investigation, was to keep the bed alarm box out of the resident's reach. Review of the 8/31/17 DPH (Department of Public Health) report indicated the facility would continue to check alarms for placement and functionality every shift. Review of the Alarm Function/Safety Device Check Sheets (which require 2 staff members to check the placement/ functioning of the alarm, at the beginning of each shift) with UM #1 (10/5/17 at 9:45 A.M.) indicated the following bed alarm checks had not been conducted on the following shifts, as planned: 9/4/17 - 3:00 P.M. to 11:00 P.M.; 9/10/17 - 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.; 9/18/17, 9/19/17, 9/21/17, 9/22/17, 9/25/17, 9/26/17, 9/27/17 and 9/28/17 - 7:00 A.M. to 3:00 P.M.; 9/29/17 - 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M., and ; 10/1/17 and 10/3/17 - 7:00 A.M. to 3:00 P.M. On 10/4/17 at 3:50 P.M., the surveyor observed the resident lying in bed and the resident's wheelchair was placed in the bedroom entrance hallway. During an interview with CNA #1 on 10/5/17 at 3:18 P.M., he said that the resident was known to have shut off his/her bed alarm, had an unsteady gait, needed assistance with transferring and walking and that alarm checks were to be done at the change of every shift, by 2 CNAs. During an interview with UM #1, on 10/5/17 at 3:30 P.M., she said that prior to the resident's fall (8/27/17) she had no knowledge that the resident had been shutting off his/her alarm. She further said that at the time of the fall, the resident must have disengaged the alarm, by pulling at the alarm cord, even though the alarm clip was partially in the alarm box. During an interview with the Director of Nursing (DON) on 10/5/17 at 3:50 P.M., she said that she was unaware of the resident's history of shutting off/resetting the alarm and that the staff were inserviced relative to staff communication.

Based on record review, observation and staff interviews, the facility failed to follow the resident's plan of care relative to fall interventions, physician's orders [REDACTED].#7, #8, #12 and #13), in a total sample of 24 residents. Findings include: 1. For Resident #8, the facility failed to follow the resident's falls care plan relative to the following: bed alarm did not activate and alarm checks were not conducted, as planned. Resident # 8 was admitted /readmitted to the facility in 8/2017. Review of the 8/15/17 falls care plan indicated the resident required a bed and chair alarm. Review of the Interdisciplinary Progress Note of 8/16/17 indicated the Resident made multiple attempts to self ambulate. Review of the Interdisciplinary Progress Note of 8/27/17 indicated the resident experienced an unwitnessed fall, sustaining a fractured shoulder, a laceration on the forehead above the eye area and a 10 centimeter (cm.) flap skin tear on the hand. During review of the falls investigation with Unit Manager (UM) #1 (on 10/5/17 at 3:30 P.M.), UM #1 said that although the bed alarm had been functioning earlier in the shift, the resident's bed alarm did not activate, at the time of the fall (as planned). UM #1 said the immediate action to prevent further falls, per the investigation, was to keep the bed alarm box out of the resident's reach. Review of the Interdisciplinary Progress Note of 8/27/17 indicated the CNAs (Certified Nursing Assistants) reported that the Resident was known to turn off the alarm. Review of the 8/31/17 DPH (Department of Public Health) report indicated the facility would continue to check alarms for placement and functionality every shift. Review of the Alarm Function/Safety Device Check Sheets (which require 2 staff members to check the placement/ functioning of the alarm, at the beginning of each shift) with UM #1 (10/5/17 at 9:45 A.M.) indicated the following bed alarm checks had not been conducted on the following shifts, as planned: 9/4/17 - 3:00 P.M. to 11:00 P.M.; 9/10/17 - 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.; 9/18/17, 9/19/17, 9/21/17, 9/22/17, 9/25-28/17 - 7:00 A.M. to 3:00 P.M.; 9/29/17 - 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M., and, 10/1/17 and 10/3/17 - 7:00 A.M. to 3:00 P.M. On 10/4/17 at 3:50 P.M., the surveyor observed the resident lying in bed and the resident's wheelchair was placed in the bedroom entrance hallway. During an interview with Certified Nursing Assistant (CNA) #1 on 10/5/17 at 3:18 P.M., he said that the resident was known to have shut off his/her bed alarm and that alarm checks were to be done at the change of every shift, by 2 CNAs. During an interview with UM #1, on 10/5/17 at 3:30 P.M., she said that the facility had no evidence that the resident's falls care plan had been followed relative to the alarm checks and said that the bed alarm had not activated, at the time of the fall, as planned. 2. For Resident #12, the facility failed to secure a psychiatric consultation, per the physician's orders [REDACTED]. Resident # 12 was admitted to the facility in 12/2016. Review of the physician's orders [REDACTED]. Review of the 6/12/17 Telephone Orders, with Unit Manager (UM) # 3 (on 10/10/17 at 3:25 P.M.), indicated an order for [REDACTED].#3 said that the order was written incorrectly and that the resident was not on [MEDICATION NAME], but the resident was on [MEDICATION NAME]. During further discussion with UM #3, she said after surveyor query, that she spoke with the facility Social Worker (SW) #1 (who she said would be responsible to make the referral for the psychiatric consultation) and was informed by the social worker that the psychiatric consultation had not been conducted, as planned, because when SW #1 contacted the psychiatric provider (on 10/10/17) she was informed that they had not received the referral for the consultation, as planned. During an interview with the SW #1 on 10/10/17 at 3:40 P.M., she said she had not been made aware of the physician's orders [REDACTED]. The facility failed to follow the physician's orders [REDACTED]. 3. For Resident #13, the facility failed to follow the care plan for falls, ensuring that safety alarms were on and working as planned. Resident # 13 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of a Plan of Care for falls dated 8/2016, included the following interventions: - Educate resident/family on fall prevention strategies. - Provide well lit, uncluttered environment. - Place items resident uses frequently within reach. - Gait belt for all transfers. Review of a Progress Note indicated that on 9/2/16 at 8:45 P.M., the Resident had a fall when getting out of bed and attempting to transfer into the wheelchair. Both the bed alarm and the chair alarm sounded, as they were part of the Resident's Plan of Care. The Plan of Care was also updated to include auto lock brakes to the wheelchair. The Progress Note of 10/6/16 indicated that at 8:15 A.M., the Resident stood up from the wheelchair and the wheelchair alarm was present, but did not sound as planned. The resident was attempting to dress him/her self, and slipped to the floor. The Plan of Care was updated to include a Self Releasing Velcro Seat Belt Alarm to the wheelchair. The investigation also stated the Resident had regular socks on at the time of the fall. The Progress Note of 12/29/16 indicated that at 10:20 A.M., the Resident called out to the staff from his/her room and was found sitting on the floor in the room. The Resident attempted to self transfer from the bed and fell between the bed and the wheelchair. The bed alarm was present, but did not sound as planned. The bed alarm was not attached to unit. The plan of care was updated to include, encourage slipper socks when in bed. On 3/2/17, the Fall Care Plan was also updated to include a Tabs Alarm to the bathroom door in the Resident's room. On 10/5/17 at 3:50 P.M., the Surveyor observed Resident #13 alone in his/her room sitting by the window. The Resident's alarmed Velcro Seat Belt was released, and not sounding, as planned . The bathroom door in the Resident's room was open, and the alarm was not sounding, as planned. The Resident's pants were partly down to his/her hips. The surveyor alerted Unit Manager #3 (UM #3) who immediately went into the Resident's room with a Certified Nursing Assistant (CNA). UM #3 approached the surveyor shortly thereafter and indicated the Resident's son had been visiting earlier that day but was unsure of the time. Further review of the Plan of Care indicated to educate the Resident/Family on fall prevention strategies. On 10/10/17 at 3:00 P.M. UM #3 and the Surveyor approached Resident #13 in his/her room. UM #3 asked the Resident if he/she could remove the Velcro Alarmed Seat Belt and the Resident was able to remove it. During interview with the Director of Nursing on 10/11/17 at 4:20 P.M., she said that the care plan was not followed regarding ensuring the alarms were on and working for the safety of the Resident. 4. For Resident #7, the facility failed to administer Tamsulosin HCL (a medication to increase urination), 0.4 milligrams (mg) as ordered by the Physician. Resident #7 was admitted to the facility in 9/2013 with [DIAGNOSES REDACTED]. Review of the September physician's orders [REDACTED].#2 (UM#2). Review of the October Medication Administration Record [REDACTED].M., indicated that none of the Tamsulosin had been administered for the month of October. The 9:00 P.M. dose had not been administered on 10/1/17, 10/2/17, 10/3/17, or 10/4/17. During interview with UM #2 on 10/5/17 at 12:20 P.M., she said that medication had not been administered in October for the first 4 days of the month, and it was a medication error.

Based on record review and interview, the Facility failed to ensure that Nursing Assistant #1, who had completed the Facility's State approved Nurses Aide Training program, completed the competency evaluation requirements and became registered. The findings included: A review of Nursing Assistant #1's personnel file indicated that the Facility completed a State CNA Registry check on Nursing Assistant #1 on 4/19/10 and Nursing Assistant #1 was not on the Registry. The personnel file contained no indication that Nursing Assistant #1 was certified by the State Nurse Aide Registry. The Surveyor was provided with a certificate that indicated Nursing Assistant #1 completed a State approved Nurses Aide Training Program at the Facility on May 24, 2010. A review of a daily staffing schedule, dated 10/11/10, indicated that Nursing Assistant #1 was scheduled to work the 3:00 P.M. to 11:00 P.M. shift on Resident #1's unit. The Director of Nursing was interviewed at 12:05 P.M. on 11/24/10. The Director of Nursing said Nursing Assistant #1 was on the Facility's schedule at the time of Resident #1's fall, but had since been removed from the schedule related to having no CNA certification. The Director of Nursing said an audit of personnel files was completed and Nursing Assistant #1 was the only nursing assistant found to not have completed the competency evaluation and become registered. Refer to F 323.

Based on record review, interview, and observation, for one of nine sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was provided care by a properly certified nursing assistant when on 10/11/10, Nursing Assistant #1 assisted Resident #1 to the toilet; Resident #1 complained of feeling "not right", feeling weak and dizzy; and Nursing Assistant #1 left Resident #1 unattended on the toilet to go get help. Resident #1 fell and sustained a laceration requiring stitches. The findings included: A Hospice Certification and Plan of Care indicated Resident #1 was placed on Hospice care on 8/13/10 due to a terminal [DIAGNOSES REDACTED]. The Hospice Certification and Plan of Care indicated Resident #1 also had [DIAGNOSES REDACTED]. According to the Hospice Certification and Plan of Care, Resident #1 had decreased range of motion and decreased muscle strength of the upper and lower extremities. Resident #1 was admitted to the Facility in October 2010, for a respite stay. An admission nursing assessment, dated 10/8/10, indicated Resident #1 was admitted to the Facility at 6:15 P.M. by ambulance stretcher. The admission nursing assessment indicated Resident #1 was de-conditioned due to acute illness and Resident #1's mobility was impaired. The admission nursing assessment indicated Resident #1's functional mobility fluctuated during the day and there had been a change in Resident #1's mobility, gait, and balance. The admission nursing assessment indicated Resident #1 used a wheelchair and walker for mobility. The admission nursing assessment indicated Resident #1 had moderately impaired cognition. A fall risk assessment, dated 10/8/10, indicated Resident #1 was assessed to be at risk for falls and a fall risk care plan was developed on 10/8/10. Fall risk care plan interventions included providing a well lighted, uncluttered environment, placing frequently used items within reach of Resident #1 to prevent bending or reaching, and using a gait belt for all transfers. A nurse's note, dated 10/11/10 at 10:00 P.M., indicated Resident #1 was on the toilet at 8:15 P.M. and fell off, "lost my balance". The nurse's note indicated the fall was unwitnessed. The nurse's note indicated Resident #1 hit Resident #1's head and Resident #1 was sent out to the emergency department for evaluation and treatment. Nursing Assistant #1 was interviewed at 11:23 A.M. on 11/24/10. Nursing Assistant #1 said Resident #1 used the call light to summon assistance to go to the bathroom, so Nursing Assistant #1 assisted Resident #1 into the bathroom and onto the toilet. Nursing Assistant #1 said Resident #1 told Nursing Assistant #1 that Resident #1 did not feel right, felt weak and dizzy. Nursing Assistant #1 said Resident #1 was fine transferring onto the toilet, it was after Resident #1 was on the toilet that Resident #1 felt dizzy. Nursing Assistant #1 said Nursing Assistant #1 did not feel comfortable transferring Resident #1 alone if Resident #1 felt weak and dizzy, so Nursing Assistant #1 left the bathroom to go get help with the transfer. When asked why Nursing Assistant #1 did not stay with Resident #1 and use the call light to summon assistance, Nursing Assistant #1 said Nursing Assistant #1 knew that there was another nursing assistant at the nurses' station and believed it was quicker to go get help than to use the call light. Nursing Assistant #1 said that Resident #1 seemed secure on the toilet when Nursing Assistant #1 left the bathroom to get help. Nursing Assistant #1 said when Nursing Assistant #1 returned to the bathroom, Resident #1 was on the floor on Resident #1's side. The Surveyor toured Resident #1's former unit with the Director of Nursing at 10:45 A.M. on 11/24/10. The Surveyor observed that Resident #1's former room was approximately 40 feet from the nurses' station. Nurse #3 was interviewed at 1:55 P.M. on 11/24/10. Nurse #3 said Nursing Assistant #1 notified Nurse #3 that Resident #1 fell in the bathroom. Nurse #3 said when Nurse #3 entered the bathroom, Resident #1 was on the floor, maybe on the left side, but not sure. Nurse #3 said Resident #1 had no loss of consciousness and no headache, but had a scalp laceration. Nurse #3 said the physician and Resident #1's family were notified and both were in agreement with sending Resident #1 to the emergency department for evaluation and treatment. A nurse's note, dated 10/11/10, indicated Resident #1 left the Facility at 9:10 by ambulance. Hospital Emergency Department Records, dated 10/11/10, indicated Resident #1 arrived at the emergency department by ambulance with a chief complaint of a fall; and Resident #1 denied pain, denied a headache, denied nausea, but had a slightly sluggish pupillary response on the right (although the pupil became reactive ten minutes later) and a fixed pupil on the left initially. The Hospital Emergency Department Records indicated Resident #1 had a scalp laceration and a right forearm skin tear. The Hospital Emergency Department Records indicated the right forearm skin tear was cleansed and Dermabond was used for wound closure; and the scalp laceration was anesthetized, then irrigated with sterile saline, then the wound edges were approximated with 5-0 Vicryl Rapide (synthetic suture material). The Hospital Discharge Instruction Sheet indicated that Resident #1 had three stitches. A nurse's note, dated 10/12/10, indicated Resident #1 returned to the Facility by ambulance at 2:00 A.M. A review of Nursing Assistant #1's personnel file indicated that the Facility completed a CNA Registry check on Nursing Assistant #1 on 4/19/10 and Nursing Assistant #1 was not on the Registry. The personnel file contained no indication that Nursing Assistant #1 was certified by the State Nurse Aide Registry. The Surveyor was provided with a certificate that indicated Nursing Assistant #1 completed a State approved Nurses Aide Training Program on May 24, 2010. The Director of Nursing was interviewed at 12:05 P.M. on 11/24/10. The Director of Nursing said Nursing Assistant #1 was on the Facility's schedule at the time of Resident #1's fall, but had since been removed from the schedule related to having no CNA certification. Refer to F 496.