Every finding on record at Marlborough Hills Rehabilitation & Health Care Cen

Based on interviews and records reviewed, for one of three sampled employee files (Director of Nurses #1), the Facility failed to ensure they implemented and followed their abuse policy related to pre-employment requirements and annual training when a Massachusetts Criminal Offender Record Information (CORI) check was not conducted on Director of Nurses #1, as required, prior to working at the Facility, and the facility was unable to provide documentation to support that DON #1 had received annual abuse prohibition training as required. Findings include: Review of the Facility Abuse, Neglect and Exploitation Policy, implemented February 2023, indicated that potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. The Policy further indicated that background reference and credential checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. The Policy indicated the facility will maintain documentation of proof that the screening occurred.Further review of the Policy indicated that new employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. The Policy indicated existing staff will receive annual education through planned in-services and as needed. Review of Director of Nurses (DON) #1's Employee File, who served as the Acting Director of Nurses at the Facility beginning on 03/01/26 and who had been employed by the Corporation as a Regional Clinical Specialist since 01/17/19, there was no documentation to support that a CORI had been conducted prior to her employment, as required. Further review of the File indicated there was no documentation to support that DON #1 received training on abuse prohibition and reporting obligations at least annually. During an interview on 06/16/26 at 3:45 P.M., the Administrator said the Facility had no documentation to support that a CORI check had been conducted on DON #1 prior to hire. The Administrator said that CORI checks should be run on all employees prior to them working at the Facility. The Administrator further said there was no documentation to support that DON #1 had received annual training on abuse prohibition since her orientation as a new hire in January 2019.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who on 6/06/26 alleged he/she had been physically abused by a staff member, the Facility failed to ensure that a summary of the results of the findings from their investigation into the 6/06/26 allegation was submitted to the Massachusetts Department of Public Health (DPH) within five working days, as required.Findings include:Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/06/26, indicated that Resident #3 alleged that he/she was kicked, punched and thrown to the ground by a staff member. Further review of HCFRS indicated that, as of the survey date (06/16/26), the Facility had not submitted a final summary of their findings from its investigation into the allegation of physical abuse involving Resident #3 that had been initially reported to DPH on 06/06/26, within five working days (was due by 6/12/26). During an interview on 06/16/26 at 3:45 P.M., the Administrator said they were unable to provide any documentation to support a summary of the Facility's investigative findings (into the 6/06/26 allegation) had been completed and submitted to the DPH within five working days (by 6/12/26) of the incident.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) whose comprehensive plan of care interventions indicated that he/she required the assistance of two staff members with the mechanical lift for all transfers, the Facility failed to ensure that staff consistently implemented and followed interventions related to transfers, when on 09/17/25, Nurse #1 observed Certified Nurse Aide (CNA)#1 and CNA #2 transfer Resident #1 without the use of a mechanical lift, as required. Findings include:Review of the Facility policy titled, Resident Assessment and Care Plan, dated April 2025, indicated the Facility developed and implemented a resident-centered care plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs. Review of the Facility policy, titled Activities of Daily Living (ADL-activities related to personal care including eating, bathing, dressing, transfer, and mobility), dated April 2015, indicated that the Facility developed and implemented a program of assistance and instruction in ADL skills based on individual resident evaluation. Resident #1 was admitted to the Facility in October 2024, diagnoses included Alzheimer's disease, Major Depressive Disorder and Anxiety Disorder.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 07/11/25, indicated that he/she had moderate cognitive impairment, was dependent on staff for his/her care needs, did not walk, and was dependent on staff for positioning, transfers and mobility.Review of Resident #1's Activities of Daily Living Care Plan, reviewed and renewed with his/her 07/11/25 MDS, indicated he/she required a Hoyer (mechanical) lift for transfers. Review of Resident #1's Care Card (used by the CNA's to determine individual resident care needs), dated as last revised 01/28/25, indicated he/she required assistance of two staff members with a Hoyer (mechanical) lift for transfers.Review of CNA #1's written witness statement, dated 09/17/25, indicated that CNA #1 and CNA #2 lifted and transferred Resident #1 from his/her bed to the wheelchair and that a Hoyer (mechanical) lift had not been utilized.During an interview on 10/24/25 at 1:20 P.M., CNA #1 said that she was familiar with Resident #1's care and that he/she had been on her assignment. CNA #1 said that Resident #1 had been care planned for a Hoyer lift transfer but that on the morning on 09/17/25 she had bathed and dressed Resident #1 without difficulty, had placed the Hoyer lift pad onto his/her chair, and with the assistance of CNA #2, had transferred Resident #1 from his/her bed to the wheelchair without the use of the Hoyer lift. CNA #1 said that she did not use the Hoyer lift for Resident #1 because he/she could stand. Review of CNA #2's written witness statement, dated 09/17/25, indicated that CNA #2 assisted CNA #1 to transfer Resident #1 in the morning on 09/17/25. The statement indicated that the Nurse had walked in the room and observed CNA #1 and CNA #2 transferring Resident #1 without the Hoyer lift. During an interview on 10/14/25 at 2:15 P.M., CNA #2 said that although he was aware that Resident #1 required a Hoyer lift for transfer, he had assisted CNA #1 to transfer Resident #1 without one. During an interview on 10/15/25 at 8:40 A.M., Nurse #1 said that she had walked into Resident #1's room as CNA #1 and CNA #2 were transferring him/her without the Hoyer lift. Nurse #1 said she immediately reported the incident to the Director of Nursing. During an interview of 09/17/25 at 3:15 P.M., the Director of Nursing (DON) said Facility staff had not transferred Resident #1 utilizing a Hoyer lift in accordance with his/her plan of care, as required. On 10/14/25, the Facility was found to be in Past Non-Compliance effective 09/24/25, and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) The Facility discussed the area of concern at Quality Assurance Performance Improvement Committee meeting in September 2025 and initiated a Quality Improvement Plan. B) 09/17/25, the Facility implemented disciplinary actions for CNA#1 and CNA #2. C) 09/17/25, the Assistant Director of Nursing (ADON) conducted audits of all residents utilizing mechanical lift for compliance with transfer status, and skin condition to identify inconsistencies against observed head to toe assessments. D) 09/17/25, the Staff Development Coordinator (SDC) initiated education to facility CNAs on providing safe transfers. E) 09/18/25, the SDC initiated education to facility CNAs on the importance of adherence to information on the individual resident Care Cards and upholding safe transfers. F) 09/23/25, the SDC conducted clinical competency assessments on transferring Residents using a mechanical lift for CNA #1 and CNA #2. G) The SDC will conduct follow up audits consisting of random visual observations of mechanical lift transfers three times a week for three months. H) The Facility will continue to monitor compliance at monthly and quarterly Quality Assurance Meetings. I) The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was admitted to the Facility with a history of suicidal ideations and self-injurious behavior, the Facility failed to ensure Resident #1's Comprehensive Care Plan (CPs), which although they included some interventions related to self injurious behaviors, that they were reviewed and/or revised for effectiveness when he/she continued to gain access to objects that he/she used to threaten self harm with. Findings included: Review of the facility's policy, titled Comprehensive Care Plans, date revised 11/2017, indicated the following: -The facility is committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life. -Recognizing each resident as an individual, we identify those needs in a resident-centered environment. -The Interdisciplinary Team (IDT) develops a comprehensive Care Plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing, and psychosocial needs identified. -The care plan is evaluated and revised as needed, but at least quarterly. Resident #1 was admitted to the Facility in March 2025, diagnoses included suicidal ideations, major depressive disorder, unspecified dementia, and delusional disorders. Review of Resident #1's Dietary Care Plan, included an intervention initiated on 03/10/25 to provide plastic utensils with all meals. Review of Resident #1's Nursing Progress Note, dated 03/28/25, indicated staff found Resident #1 with a [metal] fork, trying to stab him/herself and Resident #1 was transferred to the Hospital Emergency Department (ED) for an evaluation. Review of Resident #1's medical record indicated he/she returned to the facility on [DATE]. Review of Resident #1's Comprehensive Care Plan, indicated there was a new focus area, dated 04/03/25 which included that Resident #1 had a history of suicidal attempts; most recently on 03/28/25. -The Care Plan interventions included: *Monitor the need for psychosocial, psychiatric support, *Psychotherapy weekly for one month and then as needed, * Staff to provide frequent rounding on the resident. Review of Resident #1's Nursing Progress Note, dated 04/05/25, indicated Resident #1 was observed with a plastic knife in his/her right hand and a [superficial] cut to his/her left forearm; Resident #1 made continual suicidal ideation statements and was transferred to the Hospital ED for an evaluation. Review of Resident #1's Nursing Progress Note, dated 04/10/25, indicated Resident #1 returned from the hospital. Review of Resident #1's Dementia Care Plan, indicated Resident #1 had suicidal ideations and suicide attempts, a new intervention was added for 1:1 monitoring by staff during meal times, was initiated on 04/11/25. Review of Resident #1's Nursing Progress Note, dated 05/08/25, indicated Resident #1 had taken a metal fork and broke off three of the four prongs and attempted to stab him/herself. The Note indicated Resident #1 was transferred to the Hospital ED for an evaluation and returned to the facility later that evening. Review of Resident #1's Care Plan for history of suicidal attempts, indicated a new intervention was added on 05/08/25 for every 15-minute head checks [per staff, 15 head checks were for 72 hours only]. Despite Resident #1's Care Plan interventions that he/she was only to have plastic utensils, and for staff supervision during meal times, on two separate occasions he/she was able gain access to and physically alter a metal fork then use it to threaten self harm. There were no additional care plan interventions developed or implemented that focused on how to prevent Resident #1 from gaining access to items he/she could use to inflect self harm. During an interview on 05/21/25 at 1:33 P.M., the Director of Nurses (DON) said that Resident #1 was placed on every 15-minute head checks for 72 hours following each incident and Resident #1 was no longer on them. The DON said that despite the interventions in Resident #1's care plan, he/she was able to obtain silverware on multiple occasions.

Based on records reviewed, interviews and observation, for one of three sampled residents (Resident #1), who had a history of suicidal ideation with threats of self harm with metal and plastic utensils, the facility failed to ensure they provided an adequate level of staff supervision in an effort to maintain a safe environment for Resident #1, when he/she was able to gain access to a metal fork on two separate occasions to threaten self harm, and although he/she required supervision with meals, the facility had no idea how or when he/she obtained them. Findings include: Review of the facility's policy, titled Accidents/Incidents, dated April 2015, indicated the following: -It is the responsibility of the staff to report all accidents and incidents which occur at the facility. -The charge nurse and/or the department director or supervisor must document the incident and conduct an investigation of the occurrence. -Every attempt will be made to ascertain the cause of the occurrence. Resident #1 was admitted to the Facility in March 2025, diagnoses included suicidal ideation, major depressive disorder, unspecified dementia, and delusional disorders. Review of Resident #1's Admission Minimum Data Set (MDS) assessment, dated 03/13/25, indicated the following: -He/she scored an 11 out of 15 on his/her Brief Interview for Mental Status (BIMS) assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderate cognitive impairment, and 13-15 suggests a resident is cognitively intact). -Had physical, verbal, and other behaviors for one to three days during the assessment period. -Had episodes of wandering for one to three days during the assessment period. -Could propel his/her wheelchair 150 feet in a corridor with supervision. Review of Resident #1's Dietary Care Plan, reviewed with the Admission MDS Assessment, included an intervention, dated as initiated 3/10/25, to provide plastic utensils with all meals. Review of Resident #1's Nursing Progress Note, dated 03/28/25, indicated he/she was found by staff to be in possession of a [metal] fork and was attempting to stab him/herself. The Note indicated Resident #1 was transferred to the Hospital Emergency Department (ED) for an evaluation. During an interview on 05/21/25 at 1:51 P.M., Nurse #1 said she was on duty on 03/28/25 during the 7:00 A.M. - 3:00 P.M. (day shift) and Resident #1 was on her assignment. Nurse #1 said Resident #1 was weepy, and he/she pulled a metal fork, which had only one prong left, out from the side of his/her wheelchair and made the gesture of stabbing him/herself with it. Nurse #1 said Resident #1 was transferred to the Hospital ED for an evaluation. Review of Resident #1's medical record indicated he/she was readmitted to the facility on [DATE]. Review of Resident #1's Dementia Care Plan, initiated on 04/03/25, indicated Resident #1 had suicidal ideation's and suicide attempts, a new intervention for 1:1 monitoring by staff during meals was initiated on 04/11/25. Review of Resident #1's Nursing Progress Note, dated 05/08/25, indicated Resident #1 had taken a metal fork and broke off three of the four prongs and attempted to stab him/herself. The Note indicated Resident #1 was transferred to the Hospital ED for an evaluation and returned to the facility later that evening. During an interview on 05/21/25 at 1:51 P.M., Nurse #1 said she worked the day shift on 05/08/25. Nurse #1 said Resident #1 was found in his/her room with a metal fork, which had only one prong left, and made the gesture of stabbing him/herself in the chest. Nurse #1 said Resident #1 refused to tell her where he/she got the fork from. Nurse #1 said Resident #1 did not sustain any injury. Nurse #1 said Resident #1 was supposed to have only plastic ware and 1:1 staff supervision for all meals. On 05/21/25 at 8:02 A.M., the surveyor observed Resident #1 coming out of his/her room, propelling his/her wheelchair into the hallway. Resident #1 was able to independently self propel his/her wheelchair down the hallway to the unit dining room. During an interview on 05/21/25 at 9:00 A.M., Resident #1 said he/she did not want to be at the facility but added that he/she was not going to escape or anything like that. Although Resident #1's Care Plan interventions included that he/she was to be provided with plastic ware only for meals, that staff were to provide 1:1 supervision during meals, both of which were to prevent him/her from having access to metal utensils, Resident #1 was still able on two separate occasions, undetected by staff, to gain possession of and physically manipulate a metal fork, which he/she then in the presence of staff, used to threatened self harm. During an interview on 05/21/25 at 1:33 P.M., the Director of Nurses (DON) said she spoke with staff following the incident on 05/08/25 and a room search of Resident #1's room was conducted and nothing was found. The DON said she should have completed a full, written investigation following the incident on 05/08/25 and did not. The DON said that despite the interventions in Resident #1's care plan, he/she was able to obtain and manipulate silverware on two occasions.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted to the facility with a history of suicidal ideation, self-injurious behavior, paranoia, and agitation, the facility failed to ensure behavioral psychiatric services evaluated him/her in a timely manner, following episodes of suicidal behaviors. Findings include: Review of the Facility's policy, titled Consultant Services, dated April 2015, indicated the Facility will identify and facilitate consultant services to meet the residents' needs, to ensure optimum care for each resident/patient through consultant services. Resident #1 was admitted to the Facility in March 2025, diagnoses included suicidal ideation, major depressive disorder, unspecified dementia, and delusional disorders. Review of Resident #1's Admission Minimum Data Set (MDS) assessment, dated 03/13/25, indicated he/she scored an 11 out of 15 on his/her Brief Interview for Mental Status (BIMS) assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderate cognitive impairment, and 13-15 suggests a resident is cognitively intact). The MDS also indicated Resident #1 had physical, verbal, and other behaviors for one to three days during the assessment period. Review of Resident #1's Behavioral Health Group Notes, dated 03/10/25 and 03/24/25, signed by Nurse Practitioner (NP) #1, indicated he/she had a history of suicidal ideation but was not a current risk to harm self or others. Review of Resident #1's Nursing Progress Note, dated 3/28/25, indicated staff found Resident #1 with a [metal] fork, trying to stab him/herself. Resident #1 was transferred to the Hospital Emergency Department (ED) for an evaluation. Review of Resident #1's Nursing Progress Note, dated 04/03/25, indicated Resident #1 was readmitted to the facility. Review of Resident #1's Nursing Progress Note, dated 04/05/25, indicated Resident #1 was observed with a plastic knife in his/her right hand and a [superficial] cut to his/her left forearm. The Note also indicated Resident #1 made continual suicidal ideation statements and was transferred to the Hospital ED for an evaluation. Review of Resident #1's Nursing Progress Note, dated 04/10/25, indicated Resident #1 was readmitted to the facility. Review of Resident #1's Nursing Progress Note, dated 04/11/25, indicated Resident #1 stated he/she wanted to kill him/herself. Resident #1 was transferred to the Hospital ED for an evaluation and returned to the facility later that day. Review of the Behavioral Services Referral Log, used for facility staff to communicate to the Behavioral Services Group when a resident needs to be seen, indicated the following entries: -04/04/25- [Resident #1] presenting with SI [suicidal ideation]. -04/11/25- [Resident #1] transferred to the hospital ED for SI/depression. Further review of the Log indicated NP#1 initialed the entries (indicating she reviewed and was aware). Review of Resident #1's Behavioral Health Group Note, dated 04/24/25 and signed by NP #1, included the following: -Per nursing staff, the resident [has] decreased anxiety/depression, reports positive sleep/appetite, no SI. There is no current risk to harm self or others. -Plan/recommendations: continue to monitor and support as needed. No medication recommendations at this time. Review of Resident #1's medical record indicated that although behavioral psychiatric services were involved with his/her care, there was no documentation to support that their services were provided to Resident #1 until 04/24/25 (13 days after his/her most recent incident of suicidal behavior). Furthermore, there was no documentation to support that NP #1 identified or adjusted Resident #1's plan, despite his/her episodes of suicide ideation/behavior. Review of Resident #1's Nursing Progress Note, dated 05/08/25, indicated Resident #1 had taken a metal fork and broke off three of the four prongs and attempted to stab him/herself. The Note indicated Resident #1 was transferred to the Hospital ED for an evaluation and returned to the facility later that evening. During an interview on 05/21/25 at 12:59 P.M. and a telephone interview on 05/22/25 at 4:20 P.M., Nurse Practitioner (NP) #1 said that although she initialed the Behavioral Log entries on 04/04/25 and 04/11/25, she was unaware that Resident #1 had episodes of suicidal behaviors involving various utensils. NP #1 said the Behavioral Log had indicated suicidal ideation, but had not specified that Resident #1 had threatened to kill him/herself with a metal fork or that Resident #1 cut him/herself with a plastic knife. NP #1 said she was usually in the facility three days per week and that she may not have seen Resident #1 from 04/11/25 through 04/24/25 due to her case load. NP #1 said that the first time she was informed by nursing of a suicide attempt for Resident #1 was in relation to the incident that occurred on 05/08/25. NP #1 said once she was informed of Resident #1's suicidal behavior, she ordered for him/her to start Lithium (a mood stabilizer) daily. NP #1 said had she known of the previous suicidal behaviors she would have adjusted Resident #1's plan of care and/or medications earlier. During an interview on 05/21/25 at 1:33 P.M., the Director of Nurses (DON) said she was not aware that Nurse Practitioner #1 was unaware of Resident #1's suicidal behaviors on 03/28/25 and 04/05/25. The DON said it was her understanding that NP #1 had been involved in Resident #1's plan of care since his/her admission to the facility.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), whose Health Care Proxy was invoked with his/her Health Care Agent (HCA) responsible for health care decision making, the Facility failed to ensure his/her HCA participated in the development and implementation of their person-centered care plans, which included conducting and inviting residents and/or their Representatives (HCA) to an interdisciplinary care plan meeting following the completion of their Quarterly Minimum Data Set (MDS) assessment. Findings include: Review of the Facility's Policy, titled Comprehensive Care Plans, revision date of 11/2017, indicated the following: -Care Plans are oriented toward preventing avoidable decline in clinical and functional levels, maintaining a specific level of functioning, and reflect resident preferences and the right to refuse certain services and treatment. -Care Plans are a combination of the resident and/or family goals for treatment. -The Care Plan is evaluated and revised as needed but at least quarterly. During a telephone interview on 03/18/25 at 11:29 A.M., Family Member #1 said she was Resident #2's Health Care Agent, that she had not been invited, and therefore unable to participate in, Resident #2's December 2024 care plan meeting. Resident #2 was admitted to the facility in June 2024, diagnoses included schizoaffective disorder, anxiety disorder and bipolar disorder. Review of Resident #2's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy (HCP) Act, dated 10/20/24, indicated Resident #2's Physician determined Resident #2 lacked the capacity to make or communicate health care decisions due to his/her moderate dementia, his/her HCP was activated. Review of the facility's Care Plan Meeting Invitation, dated 12/31/24, indicated the following boxes were left blank for Resident #2: -Invitation sent to the patient/guardian/responsible party? -Was the patient/guardian/responsible party reminded prior to the meeting? -Was [Did] the patient/guardian/responsible party decline the invitation? Review of Resident #2's Interdisciplinary Care Plan Meeting Form, dated 12/31/24, indicated that where Family Member #1 (HCA) would have signed as being in attendance, was blank. Further review of the Form indicated the box next to Resident Representative Participated in the Care Plan Process, was also left blank. Review of Resident #2's medical record indicated there was no documentation to support who (which included facility staff members) attended Resident #2's care plan meeting on 12/31/24. During an interview on 03/19/25 at 2:09 P.M., Social Worker #1 said the invitations to the care plan meetings were given to the residents, and if Resident #2's Health Care Proxy was invoked, an invitation should also have been sent to the residents' Health Care Agent. Social Worker #1 said the attendance sign-in sheet for Resident #2's care plan meeting on 12/31/24 should not have been left blank and there also should have been a progress note written in Resident #2's medical record to reflect who attended his/her care plan meeting. Social Worker #1 said she did not realize Resident #2's Health Care Proxy had been invoked until today (the day of survey). During a telephone interview on 03/20/25 at 12:01 P.M., the Administrator said it was his expectation that Social Services would have included Resident #2's Health Care Agent in the care planning process.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), whose Health Care Proxy was invoked and his/her Health Care Agent (HCA) was very involved in his/her care, the Facility failed to ensure that at the time of his/her discharge from the facility, his/her HCA/Family Member #1 was provided with a Notice of Intent to Discharge which included the necessary information to file an appeal. Findings include: Review of the Facility Policy, titled Discharge Planning Policy and Procedure, undated, indicated the following: -Residents who are admitted for short term rehabilitation and request/indicated their desire to return home will work with social service staff, as a member of the interdisciplinary team, to formulate a viable discharge plan. -Social Service will verify the request to be discharged with the resident and/or responsible party. -Social Service will ensure systems are implemented to provide written notification to the resident and/or responsible party to transfer/discharge in accordance with Massachusetts Department of Public Health. -The Intent to Discharge Notice will be provided and include: *The reason and effective date of discharge/transfer. *The location to which the resident is to be transferred/discharged *An explanation of the right to appeal *The name, address and telephone number of the ombudsman and other parties/agencies required by the state. *The name, address and telephone number of protection and advocacy agencies for individuals with developmental disabilities or mental illness *A statement as to how the resident will be prepared/oriented to move. During a telephone interview on 03/18/25 at 11:29 A.M., Family Member #1 said she was Resident #2's Health Care Agent, that she was not included in Resident #2's discharge planning to return to the community and did not receive notice prior to Resident #2's discharge. Resident #2 was admitted to the facility in June 2024, diagnoses included schizoaffective disorder, anxiety disorder and bipolar disorder. Review of Resident #2's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy (HCP) Act, dated 10/20/24, indicated Resident #2's Physician determined Resident #2 lacked the capacity to make or communicate health care decisions due to his/her moderate dementia, his/her HCP was activated. Review of Resident #2's Nursing Progress Note, dated 02/14/25, indicated Resident #2 was discharged to his/her home with services. Review of Resident #2's Notice of Intent to Discharge/Transfer Resident with Expedited Appeal, dated 02/14/25, indicated the name of the Resident Representative to receive a copy of the Notice, was entered as self [indicating Resident #2 was his/her own person]. During an interview on 03/19/25 at 2:09 P.M., Social Worker #1 said she issued the Notice of Intent to Discharge to Resident #2 on 02/14/25. Social Worker #1 said she did not realize at the time of his/her discharge, that Resident #2's Health Care Proxy was activated, and said if she had known, she would have provided a copy of the Discharge Notice to Resident #2's Health Care Agent (HCA, Family Member #1). During a telephone interview on 03/27/25 at 12:01 P.M., the Administrator said it was his expectation that Social Services would have notified Resident #2's HCA/Family Member #1 of his/her discharge to the community and provide his/her HCA with the Notice of Intent to Discharge.

Based on record review, observations and interview, the facility failed to provide a safe smoking environment for one Resident (#14), of 5 applicable residents, out of a total sample of 34 residents. Specifically, for Resident #14, the facility failed to: -ensure that oxygen was not in use by the Resident when a cigarette placed in the Resident's mouth was lit by staff during a supervised smoking session in the designated smoking area where eight other residents were also present. -ensure that the Resident's oxygen tank and oxygen equipment was prohibited from the designated smoking area. Findings include: Review of the facility's policy titled Smoking, revised November 2020, indicated the following: -It is the policy of the facility to provide a healthy and safe environment for residents, staff, and visitors by limiting the use of tobacco smoke materials on its campus. -To afford residents the privilege of smoking while maintaining a safe and clean environment within the policy of this facility. -Residents will not be allowed to take their portable oxygen tanks, e-tanks (type of gas cylinder used for providing portable oxygen), or oxygen tubing to the supervised smoking areas during their scheduled smoking times. Review of the facility's policy titled Oxygen Administration Nasal Cannula, revised November 2020, indicated the following: -Residents will not be allowed to take their portable oxygen tanks, E-tanks, or oxygen tubing to the supervised smoking areas during scheduled smoking times. Resident #14 was admitted to the facility in January 2025 with diagnoses including Respiratory Failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Nicotine Dependence. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #14: -Was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of total possible 15. -Utilized a walker to aid with ambulation. -Received oxygen therapy. Review of Resident #14's comprehensive person-centered care plan for Chronic Obstructive Pulmonary Disease (COPD), initiated on 1/23/25, indicated the Resident required oxygen therapy. Review of Resident #14's March 2025 Physician orders indicated: -Oxygen at 3 liters per minute (LPM) continuously every shift, initiated 1/22/25. Review of Resident #14's Medication Administration Record (MAR) for March 2025, indicated the Resident received oxygen therapy continuously via nasal cannula (rubber tubing with prongs that delivers oxygen directly into the nostrils) at 3 LPM and oxygen was administered as ordered from 3/1/25 - 3/6/25. Review of Resident #14's comprehensive person-centered care plan for Substance Use, initiated on 1/27/25, indicated: -The Resident used nicotine. -Interventions included a Tobacco Evaluation. Review of Resident #14's Smoking (Tobacco) Evaluation and Safety Screen, dated 1/22/25, indicated: -The Resident was a current smoker. -The Resident required routine supervision during scheduled smoking sessions to ensure safety during smoking. On 3/6/25 at 1:13 P.M., Surveyor #1 and Surveyor #2 observed through the facility conference room window that Resident #14 was ambulating with a rolling walker towards the facility's designated smoking area, where eight additional residents were also present. Resident #14 was further observed carrying a portable oxygen tank on the rolling walker and wearing a nasal cannula in his/her nostrils that was connected to the portable oxygen tank. Surveyor #1 and Surveyor #2 quickly approached the designated smoking area and observed Certified Nurses Aide (CNA) #5 light a cigarette that was in Resident #14's mouth. Surveyor #1 and Surveyor #2 observed that Resident #14's nasal cannula tubing remained in his/her nostrils and attached to the portable oxygen tank. At that same time, Resident #14 looked at the surveyors, removed the lit cigarette from his/her mouth and dropped the lit cigarette to the ground. Resident #14 then said aloud save my cigarette and walked back inside the facility. Resident #14 returned to the designated smoking area a few minutes later without the portable oxygen tank and nasal cannula tubing. During an interview on 3/6/25 at 1:16 P.M., Resident #14 said that CNA #5 had lit the cigarette in his/her mouth while his/her oxygen was being used via nasal cannula. During an interview and observation on 3/6/25 at 1:18 P.M., CNA #5 said that he did not see Resident #14 wearing oxygen when he lit the cigarette in the Resident's mouth. CNA #5 said he knew that residents were not allowed to smoke while wearing oxygen. CNA #5 said that the residents are responsible to leave the oxygen tanks and tubing inside the facility prior to coming outside to the designated smoking area. During an interview on 3/6/25 at 2:17 P.M., Resident #14 said that not all staff members reminded him/her to remove the oxygen equipment before going outside to the smoking area. Resident #14 said that he/she was receiving oxygen when CNA #5 lit the cigarette in his/her mouth. During an interview on 3/6/25 at 3:16 P.M., the Regional Nurse said that CNA #5 should have reminded and assisted Resident #14 to remove his/her portable oxygen and tubing before the Resident went outside to the designated smoking area. The Regional Nurse said oxygen equipment was not allowed in the designated smoking area. Please Refer to F726 and F838

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent and treat a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for one Resident (#43) out of a total sample of 34 residents. Specifically, for Resident #43, the facility staff failed to: -obtain a Physician's order for the appropriate application, removal, and monitoring of a Controlled Ankle Motion (CAM: orthopedic medical device used for the treatment of severe sprains, fractures in the ankle or foot) boot when the Resident was identified as being at risk for developing pressure ulcers. -assess the Resident's skin integrity during the CAM boot use and identify pressure ulcer development timely on the Resident's right lower extremity. Findings include: Review of the facility policy titled Splints/Orthotics/Prosthetics, dated April 2015, indicated: -Residents will receive splint/orthotic/prosthetic devices as deemed appropriate by the physician and rehabilitation services. Staff will monitor the circulation and skin integrity of residents using these devices at least every shift as part of routine care, or more as prescribed by the physician. -Upon admission/readmission, and at least every shift, all residents with a splint, orthotic or prosthetic device will have the affected extremity monitored for circulation, motion, and sensation (CSMs) as well as any signs of edema, redness, irritation, or pressure areas potentially caused by the device. -Nursing staff will apply/remove the designated splint/orthotic/prosthetic device during scheduled wear times. Review of the facility policy titled Prevention & Management of Pressure Injuries, revised January 2025, indicated: -The facility is dedicated to preventing pressure injuries and to developing a preventative plan of care based on individual needs. Residents receive the care and services they need according to established practice guidelines, so that residents who enter the facility without a pressure injury do not develop one unless the individual's clinical condition demonstrates that they were unavoidable. The necessary treatment and services will be provided to promote healing, prevent infection, and prevent new pressure injuries from developing. -Assessment: Ulcer/Risk factors: >The resident is assessed for pressure injury risk factors. >The resident's skin is observed daily with care. -Avoidable/Unavoidable Pressure Injuries: > Avoidable means the resident developed a pressure injury and that the facility did not do one or more of the following: *evaluate the resident's clinical condition and pressure injury risk factors *define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice *monitor and evaluate the impact of the interventions; or revise the interventions as appropriate Resident #43 was admitted to the facility in June 2018, with diagnoses including Quadriplegia C1- C4, Diabetes Mellitus with Diabetic Neuropathy, Right ankle contracture, and Left ankle contracture. Review of Resident #43's Comprehensive Care Plan for Potential Alteration in Skin Integrity, initiated 7/16/18, indicated: -The Resident was at risk for alteration in skin due to comorbidities of Incomplete Quadriplegia, decreased impaired mobility or function, Diabetes, incontinence, and risk assessment. -Intervention to assess skin under footwear, initiated 7/6/18. -Intervention to follow MD orders for skin care and treatments, initiated 1/7/19. Review of Emergency Department Discharge paperwork, dated 11/8/24, indicated: -The Resident sustained a right distal tibial (inner and larger of the two bones of the leg connecting the knee and the ankle) fracture. Review of the Minimum Data Set (MDS) Assessment, dated 11/15/24, indicated Resident #43: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total of 15. -had range of motion impairments affecting both lower extremities. -was dependent on staff for lower body dressing. -was dependent on staff for putting on and taking off footwear. -was dependent on staff for repositioning. -was at risk for developing a pressure injury. -had no pressure ulcers. Review of Resident #43's Orthopedic Consultation, dated 11/20/24, indicated: -The Resident's skin did not have any wounds or redness. -The Resident's diagnosis was a closed displaced oblique fracture of shaft of the right tibia. -Order placed for CAM walker boot. Review of Resident #43's Physician orders, dated 11/20/24, indicated: -Skin checks to RLE (Right Lower Extremity) due to CAM boot, was entered into the electronic medical record (EMR). Review of Resident #43's November 2024 Medication Administration Record (MAR) and November 2024 Treatment Administration Record (TAR) did not include: -Physician order for skin checks to RLE due to the CAM boot use, which were initiated on 11/20/24. -documentation of the application and removal of the CAM Boot. Review of Resident #43's December 2024 MAR and December 2024 TAR did not include: -Physician order initiated on 11/20/24, for skin checks to RLE related to the CAM boot use. -documentation of the CAM Boot use. Review of Nurse Practitioner (NP) Progress note, dated 12/20/24, indicated: -Resident #43 was seen by NP due to his/her CAM boot being removed and found to have an unstageable (full thickness tissue damage with depth that cannot be confirmed because is covered by damaged tissue) pressure ulcer on the right lateral leg. -Right lateral leg pressure ulcer appeared to have been caused by pressure from the hard plastic edge of the (CAM) boot. -Measurement of right lateral leg wound was 7.3 centimeter (cm) x (by) 3.2 cm x non-measurable depth, with the wound bed described as 100% dark/black necrotic (death of bodily tissue) tissue. -There was a small open area to right anterior shin, measuring 1.8 cm x 2 cm x 0.1 cm, described as superficial and 100% beefy red granulation (new connective tissue that develops on a wound in the process of healing) tissue. -Staff educated to apply abdominal gauze pad in the plastic area of boot, to avoid friction and further skin breakdown. Review of Resident #43's Physician's orders, dated 12/20/24, indicated: -Wound Consult - right leg ulceration with the house wound team. -Re-schedule orthopedics appointment as soon as possible. -Right lateral leg ulceration: please cleanse with wound cleanser, gently pat dry, apply thin layer of Santyl (medicated ointment used to remove damaged tissue from skin ulcers) only to necrotic area. Cover with Alginate (type of highly absorbent wound dressing) then cover with foam dressing. Change daily and as needed (PRN) for soilage. -Right anterior shin ulceration: please cleanse with wound cleanser, pat dry, apply Adaptic Alginate and cover with dry sterile dressing. Change daily and as needed (PRN) for soilage. Review of Resident #43's Wound Consultation Visit Note, dated 1/3/25, indicated: -New Unstageable Necrosis [sic] Pressure Ulcer (d/t [due to] orthopedic (CAM) boot; full thickness wound) is located on the right lateral lower leg. -Wound size 6.0 cm x 2.4 cm x 0.1 cm depth. Review of the most recent MDS Assessment, dated 2/27/25, indicated Resident #43: -was cognitively intact as evidenced by a BIMS score of 14 out of a total of 15. -had active pressure ulcers including: >one Stage 3 pressure injury >two Unstageable Pressure Injuries - one Venous ulcer Further review of the medical record did not provide evidence of the Stage 3 pressure injury identification in the Provider or Wound Consult notes. During an interview on 3/10/25 at 4:14 P.M., the Assistant Director of Nursing (ADON) said Resident #43 was issued a CAM boot from Orthopedics on 11/20/24, but an order with directions for how to use the CAM boot was not initiated from nursing. The ADON said the Nurse on duty should have clarified the CAM boot recommendations with the Orthopedic office, then should have confirmed the order with the facility Provider, but did not. The ADON said failure to properly enter the order to the Resident's medical record resulted in nursing staff not knowing when to apply or remove the CAM boot. The ADON said the unstageable pressure ulcer on the Resident's right lateral leg was caused by the CAM boot. During an interview on 3/11/25 at 7:30 A.M., CNA #4 said Resident #43 returned from the emergency room visit after fracturing his/her right leg in November 2024, with the right leg wrapped in an ace bandage that was left in place until the Resident went for his/her follow-up visit with Orthopedics. CNA #4 said that Resident #43 returned from the follow-up appointment a few weeks later wearing a boot on the right leg. CNA #4 said that Resident #43 wore the boot continuously day and night, and the boot was never removed for care. CNA #4 said a few weeks later, staff were instructed to remove the boot at night because a problem was identified with Resident #43's skin under the boot. CNA #4 said that after a few weeks, the staff were told the Resident did not need the boot any longer. During an interview on 3/11/25 at 7:35 A.M., Nurse #3 said Resident #43 returned from an Orthopedic appointment on 11/20/24 wearing the CAM boot which went from below the knee to above the toes and had Velcro straps holding it in place. Nurse #3 said she was under the impression that the CAM boot needed to be worn at all times, but after a wound developed on Resident #43's leg in December 2024, the Resident started wearing the boot only during the day. Nurse #3 said that when any Resident returns from a consultation appointment, the recommendations should be confirmed by the facility Practitioner, and a Physician's order should be written, but that did not happen. Nurse #3 said when a resident requires a specialty boot, Physician orders are transcribed by the Nurse on duty with specific instructions for removal and application of the CAM boot but the transcription was not done. The surveyor and Nurse #3 reviewed the November 2024 and December 2024 MARs and TARs, and Nurse #3 was unable to locate the order written on 11/20/24 that indicated Nurses should complete skin checks to RLE every shift related to the CAM boot use. Nurse #3 further said the order was incorrectly entered to the Resident's medical record, so the facility Nurses would not be prompted to apply/remove the CAM boot nor be prompted to complete a skin check to the Resident's right lower extremity every shift. During an interview on 3/11/25 at 7:53 A.M., Nurse #4 said she was the Nurse caring for Resident #43 upon the Resident's return from the Orthopedic follow-up appointment on 11/20/24. Nurse #4 said Resident #43 was wearing a CAM boot to the right lower extremity, and there was a recommendation for a CAM boot in the consultation paperwork. Nurse #4 said Resident #43 wore the CAM boot continuously. Nurse #4 said that when a resident wears a boot, there should be orders written about how and when to remove and apply the boot, but there was not. During an interview on 3/11/25 at 8:51 A.M., Resident #43 said that the CAM boot was applied at the Orthopedic appointment on 11/20/24. Resident #43 said that the boot remained in place for about 4 weeks, and during those 4 weeks he/she did not recall anyone checking the skin or removing the boot from the right lower extremity. Resident #43 said when staff identified the wound, the Resident was surprised because he/she was unable to feel the wound due to decreased sensation in both legs. Resident #43 said after staff identified the wound, the nursing staff only applied the CAM boot during the day but not at night. Resident #43 said the CAM boot caused the wounds to the right lower extremity because the CAM boot was worn too much. During an interview on 3/11/25 at 10:45 A.M., Nurse #4 said she had entered an order on 11/20/24 for skin checks every shift due to the CAM boot but did not put the order on the MAR/TAR, and therefore the facility Nurses were not aware to check the skin integrity under the CAM boot. Nurse #4 said that she should have called Orthopedics on 11/20/24 to clarify the recommendation for the CAM boot but did not. During an interview on 3/11/25 at 11:20 A.M., with the Director of Nursing (DON) and Corporate Nurse, the DON said there was never a Physician's order obtained for how and when to use the CAM boot, but there should have been. The Corporate Nurse said that the order obtained on 11/20/24, for skin checks to RLE due to CAM boot was entered incorrectly into PCC (Point Click Care- electronic medical record), and therefore the facility nursing staff did not complete the skin checks as ordered by the Provider. The Corporate Nurse said any specialty boot used in the facility should have clear orders for application and removal as well as skin checks conducted every shift to prevent Pressure Ulcers, but this did not happen.

Based on observation, interview, and document review, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day-to-day care of the population the facility currently serves. Specifically, the facility assessment failed to address the education and competencies for staff to provide a safe smoking environment for 51 residents identified as active smokers, out of a total census of 173. Findings include: On 3/6/25 at 1:13 P.M., two surveyors observed Resident #14 enter the designated smoking area for an assigned smoking session while wearing a nasal cannula and carrying a portable oxygen tank. The surveyors further observed Certified Nurses Aide (CNA) #5 light a cigarette in Resident #14's mouth while the nasal cannula remained present in his/her nostrils. Resident #14 saw the surveyors, removed the lit cigarette from his/her mouth and dropped the lit cigarette to the ground. Resident #14 was observed to walk back inside the facility, leave his/her oxygen equipment in the building and return to the designated smoking area. Review of Resident Smoker - Oxygen Initial Audit, dated 3/6/25, indicated that 51 residents out of a facility census of 173 were identified as smokers. Further review of the Initial Audit indicated that Resident #14's name was included on the audit and was listed as a smoker who utilized oxygen therapy. Resident #14 was admitted to the facility in January 2025 with diagnoses including Respiratory Failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Nicotine Dependence. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #14: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of total possible 15 -utilized a walker to aid with ambulation -received oxygen therapy. Review of Facility Assessment, dated 8/14/24, failed to indicate that the facility: -thoroughly evaluated and documented the needs of its resident population who were smokers. -identified the required resources to provide safe care and services for the resident population that smoked. -identified and implemented staff competencies necessary to provide safety and the skill sets needed for the resident population who smoke. During an interview on 3/6/25 at 1:16 P.M., Resident #14 said that CNA #5 had lit the cigarette in his/her mouth while his/her oxygen was being used via nasal cannula. During an interview on 3/6/25 at 2:17 P.M., Resident #14 said that not all staff members reminded him/her to remove the oxygen equipment before going outside to the smoking area. Resident #14 said his/her oxygen was being used when CNA #5 lit the cigarette in his/her mouth. Review of CNA #5's educational file failed to indicate that the CNA demonstrated competency with smoking and oxygen safety. During an interview on 3/6/25 at 1:16 P.M., CNA #5 said that he did not see Resident #14 wearing oxygen when he lit the cigarette in the Resident's mouth. CNA #5 said he knew that residents were not allowed to smoke while wearing oxygen. During an interview on 3/10/24 at 3:30 P.M., the Regional Nurse said the Facility assessment dated [DATE] was the most recent version. The surveyor and the Regional Nurse reviewed the Facility Assessment and the Regional Nurse said the Facility Assessment did not address residents who smoke and it should have. The Regional Nurse further said there was no evidence that safe smoking and oxygen competency was demonstrated by CNA #5 prior to the incident on 3/6/25.

Based on record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure completion of annual water sampling for Legionella placing residents at risk for exposure to Legionella bacterium (a bacteria which lives in fresh water and can cause pneumonia like or flu like illnesses). Findings include: Review of the facility policy titled Legionella Policy, revised 10/24/22, included but was not limited to the following: -It is the policy of this facility to have a water management program to reduce Legionella bacteria growth and spread in the facility, and staff to be educated annually on Legionella symptoms (Refer to the separate Water Management Program Policy). -People can get sick when they breathe in mist or accidentally swallow water into the lungs containing Legionella bacteria. -However, people [AGE] years or older .and people with a weakened immune system or chronic disease are at increased risk. -Facility will conduct an annual water program assessment with a qualified contractor. During an interview on 3/5/25 at 12:10 P.M., the Director of Physical Plant said that the facility water system was last tested for Legionella bacterium on 8/29/23, by an independent water management company. The surveyor and the Director of Physical Plant reviewed the laboratory results for Legionella testing that had been completed on 8/29/23. The Director of Physical Plant said he thought that testing should be done every year. During an interview on 3/5/25 at 12:35 P.M., the Director of Clinical Operations said that although the facility's Legionella policy indicated that there should have been a separate water management program policy to review, in-fact there was not a separate water management program policy for the facility. The Director of Clinical Operations said that the facility followed the qualified contractors (FCS-Facility Compliance Services LLC) process for Legionella monitoring and mitigation, dated 4/3/18. Review of the FCS Legionella sampling process for the facility dated 4/3/18, indicated but was not limited to the following: -As part of the assessment process itself, environmental sampling of Legionella will be performed annually to determine any possibility of colonization (establishment of a bacterial population on a surface), including the possibility of extensive biofilm (a community of bacteria that adheres to a surface in a slimy matrix of substances) involvement in the area of concern. -Four samples should be taken from the facility. Sampling locations should change from year to year based off the assessment of this plan or risk areas identified. -Sampling should be conducted by a water management consultant or may be taken by internal staff. During a follow-up interview on 3/5/25 at 12:47 P.M., the Director of Clinical Operations said that facility testing for Legionella should have been done in 2024 but had not been done. The Director of Clinical Operations said that Legionella testing was important so that the facility could identify if Legionella exposure to residents was occurring or not.

Based on interview, and record review, the facility failed to ensure that two Residents (#379 and #42) out of a total sample of 34 residents, were free from significant medication errors. Specifically, the facility failed to: 1. For Resident #379, ensure the appropriate medication administration syringe was available to administer Physician ordered medications through the Resident's Percutaneous Gastronomy (PEG) tube (a tube that provides a direct route to the stomach for delivering nutrition, fluids and medication to a person who is unable to eat or drink through their mouth) resulting in missed doses of the ordered medications. 2. For Resident #42, the facility failed to ensure that Permethrin (medication used to treat scabies [a contagious skin infestation caused by tiny mites]) cream was accurately transcribed on the Medication Administration Record (MAR), resulting in the Resident receiving five doses instead of one prescribed dose, and increasing the risk for adverse reaction to the medication. Findings include: Review of the facility policy, Medication Error Reporting, dated April 2015, indicated: -A medication error is any preventable event that may cause or lead to inappropriate medication use, which the medication is in control of the health care professional. -A licensed nurse makes an immediate evaluation of the resident in relation to the nature of the error. -The person finding the error is responsible for completing the medication error report and forwarding it to the Director of Nursing immediately. Resident #379 was admitted to the facility in February 2025 with diagnoses including, Dysphagia Oropharyngeal Phase, Personal History of Pulmonary Embolism, Mood Disorder due to known physiological condition with depressive features, and Essential (primary) Hypertension. Review of the Resident's clinical record indicated that no Minimum Data Set (MDS) Assessment had not been submitted due to Resident #379's recent admission to the facility. Review of the Resident's Speech Therapy comprehensive care plan initiated on 2/21/25, and revised on 3/3/25, indicated: >The Resident had swallowing difficulty related to an abnormal swallow study with interventions including: -Provide Resident with nothing by mouth (NPO) consistency diet. -Provide Resident with NPO consistency liquid. Review of Resident #379's Physician's orders for March 2025 indicated: -NPO diets, NPO texture, NPO consistency, effective 3/7/25 -Amlodipine Besylate (antihypertensive) oral tablet 2.5 milligrams (mg), give 1 tablet via PEG - tube in the morning, effective 2/20/25 -Apixaban (anticoagulant) oral tablet 5 mg, give one table via PEG-tube two times a day, effective 2/20/25 -Folic Acid (used to treat folate deficient anemia) oral tablet 1 mg, give one tablet via PEG-tube in morning, effective 2/20/25 -Levetiracetam (antiseizure) oral solution 100 MG/ML, give 7.5 ml two times a day via PEG - tube, effective 2/20/25 -Melatonin (supplement) oral tablet 3 mg, give one tablet via PEG - tube at bedtime, effective 2/20/25 -Quetiapine Fumerate (antipsychotics) oral table 25 mg, give one tablet via PEG - tube in the morning, effective 2/20/25 -Quetiapine Fumerate oral tablet 25 mg, give two tablets via PEG - tube at bedtime, effective 2/20/25 -Thiamine HCL (Vitamin) oral tablet 100 mg, give 1 tablet via PEG - tube in the morning, effective 2/20/25 -Trazadone HCL (antidepressant) oral tablet 100 mg, give one tablet via PEG tube at bedtime, effective 2/20/25 Review of the Resident #379' Medical Record indicated the following: -An orders administration note dated 3/5/25 at 23:42: syringe for administration not available, NP (Nurse Practitioner)/Supervisor notified. -An orders administration note dated 3/6/25 at 06:00: hold medications and follow-up with DON (Director of Nursing) for proper syringes. -An orders administration note dated 3/7/25 at 05:36: awaiting syringe delivery. -An orders administration note dated 3/8/25 at 06:11: awaiting delivery of special syringe. Review of the Resident's March 2025 Medication Administration Record (MAR) indicated the following: -Amlodipine Besylate was not administered as ordered on: 3/6, 3/7, and 3/8. -Folic Acid was not administered as ordered on: 3/6, 3/7, 3/8. -Melatonin was not administered as ordered on: 3/5 and 3/6. -Quetiapine Fumerate was not administered as ordered the morning of: 3/6, 3/7, 3/8 and the evening of: 3/5 and 3/6. -Thiamine HCL was not administered as ordered on: 3/6, 3/7 and 3/8. -Trazadone HCL was not administered as ordered on: 3/5 and 3/6. -Apixaban was not administered as ordered the morning of: 3/6, 3/7, 3/8 and the evening of: 3/5 and 3/6. -Levetiracetam was not administered as ordered the morning of 3/6, 3/7, 3/8 and the evening of 3/5 and 3/6. During an interview on 3/11/25 at 8:31 A.M., the DON said she did not find out until 3/10/25 that the medication administration syringe was not available, and that Resident #379 had not received the correct doses of his/her medications as prescribed by the Provider from 3/5/25 through 3/8/25. The DON said the procedure for missed doses of medication is the Nurse on duty should call the Physician or NP immediately for further instructions and contact the DON immediately. The DON said the Nurse should fill out the Report on Medication Incidents and forward it to the DON immediately. The DON said that she should have been contacted immediately so that a medication administration syringe could have been obtained. The DON said the facility should have had the syringes available prior to the Resident's admission to ensure that he/she received the medications as ordered by the Prescriber. During an interview on 3/11/25 at 10:48 A.M., Nurse #1 said she alerted the Assistant Director of Nurses (ADON) during her shift on 3/6/25, that the syringe to administer medications (via PEG tube) was unavailable. Nurse #1 said the Resident did not need to receive any medications during her shift on 3/6/25. Nurse #1 said if medications or equipment to administer medications is not available, the procedure is they should call the Physician and see how the Physician wants to proceed, and inform the DON right away. During an interview on 3/11/25 at 10:56 A.M., the ADON said she was unaware Resident #379 did not receive his/her medications as prescribed by the Provider until 3/10/25. During an interview on 3/11/25 at 12:49 P.M., Nurse #5 said she was the evening supervisor on 3/5/25, 3/6/25 and 3/7/25. Nurse #5 said the NP had been contacted but Nurse #5 could not recall what day or time. Nurse #5 said the NP said to call the DON so a syringe could be obtained. Nurse #5 said she did not call the DON. Nurse #5 said she ordered a syringe from Amazon on the evening of 3/7/25. Nurse #5 said the NP came in on Saturday 3/8/25 and showed the Nurses how to administer the medication without a syringe and how to assess the Resident. During an interview on 3/11/25 at 1:15 P.M., the Regional Nurse said someone from nursing should have called the Physician and the DON to notify them that Resident #379 was not receiving his/her medications. The Regional Nurse said the Nurse on duty should have entered the incident into the medical record in an 'at risk note' for the facility to be alerted of the problem. The Regional Nurse said the Resident should have gotten his/her medications as prescribed by the Provider or a hold order for the medications should have been obtained from the Physician. 51466 2. Review of the Mayo Clinic document, titled Drugs and Supplements - Permethrin, dated 2/1/25, indicated the following: -dosing for treatment of scabies is Permethrin 5% cream to be applied to the skin one time. -Side effects from Permethrin recommended dosage can include itching, numbness, rash, redness, swelling of the skin, stinging or burning, and tingling sensation. Resident #42 was admitted to the facility in September 2024 with diagnoses including an Open Wound of Abdominal Wall. Review of Resident #42's Minimum Data Set (MDS) assessment dated [DATE], indicated: -The Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview of Mental Status (BIMS). -The Resident was able to make him/herself understood. Review of the Resident's Physician order, dated 12/1/24 at 11:00 A.M., indicated: -Permethrin 5% cream - Apply to whole body from the neck down and wash off after eight to 14 hours. -Dermatology Consult. Review of the December 2024 Treatment Administration Record (TAR), indicated Resident #42 received Permethrin Cream 5% daily on: 12/2/24, 12/3/24, 12/4/24, 12/5/24 and 12/6/24. During an interview on 3/10/25 at 3:39 P.M., the DON said that Resident #42 received one dose of Permethrin cream every day for 5 days but should have received one dose only. The DON said the order for Permethrin cream written on 12/1/24 was transcribed incorrectly into the Resident #42's electronic medical record (EMR) which caused the medication administration error to occur.

Based on record review, and interview, the facility failed to ensure that residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications prior to their use for one Resident (#108) out of a total sample of 34 residents. Specifically, for Resident #108, the facility failed to obtain informed consent from the Resident's invoked (made active) Health Care Proxy (HCP - a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so) with notification of the risks and benefits for the use of Abilify ( antipsychotic medication) prior to administering the medication to the Resident. Findings include: Review of the facility policy titled Psychotropic Medication Management, dated April 2015, included but was not limited to: -Notify resident or responsible party of initiation of psychoactive medications, and with any changes of dose, and document in record. -Obtain and document informed consent for initiation of Antipsychotic medications. Resident #108 was admitted to the facility in February 2020 with diagnoses including other Frontotemporal Neurocognitive Disorder and Major Depressive Disorder, recurrent, unspecified. Review of Resident #108's clinical record included: -a completed HCP -a HCP invocation form signed by the Physician and dated 2/22/23, making the HCP active due to decision making incapacity caused by Frontotemporal Dementia. Further review of Resident #108's clinical record did not indicate any evidence that the following were discussed with the Resident's HCP: -the risks and/or benefits of psychotropic medications. -the informed consent to administer psychotropic medication related to the administration of Abilify medication. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #108: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points. Further review of the Resident's clinical record included a Physician's order dated 8/8/24, that indicated: -Abilify (Aripiprazole) Oral Tablet 2 MG (mg - milligrams). Give 1 tablet by mouth at bedtime related to Major Depressive Disorder, recurrent, severe with Psychotic Symptoms. Review of Resident #108's Medication Administration Record (MAR) for August 2024 indicated that the Abilify medication was administered to the Resident at bedtime from 8/9/24 through 8/31/24 as ordered by the Physician. During an interview on 3/11/25 at 8:53 A.M., the Director of Nursing (DON) said that she was unable to find evidence that the new order for Abilify initiated on 8/8/24, was reviewed with the HCP for risks, benefits, and consent. The DON said that the Nurses should be reviewing all psychotropic medications with the residents and/or their representatives before the initiation of a new psychotropic medication, and also annually or with any medication dose adjustment beyond the range of the medication noted on the Informed Consent Form. The DON said that the Nurses should have reviewed the risks and benefits of Abilify with Resident #108's HCP before the medication administration was initiated, but she could not provide any evidence that this had been done.

Based on interview and record review, the facility failed to report an allegation of misappropriation to the State Agency timely, for one Resident (#14) out of a total sample of 34 Residents. Specifically, the facility failed to ensure that an incident report form was submitted to the State Agency within two hours as required, of the Director of Nursing (DON) being notified of an allegation of misappropriation of Resident #14's personal property on 2/27/25. Findings include: Review of the facility's Policy titled Abuse, Neglect and Exploitation, dated 2/2023, indicated: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. -Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without resident consent. -The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. -An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. -Reporting/Response >The facility will have a written procedures that include: >>Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: >>>Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #14 was admitted to the facility in January 2025, with diagnoses including Respiratory Failure. Review of Resident #14's Minimum Data Set (MDS) assessment, dated 1/29/25, indicated: -the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. -was able to make his/her needs known. During an interview on 3/4/25 at 10:26 A.M., Resident #14 said that his/her personal cell phone was missing, and he/she had reported the phone missing to the DON on 2/27/25. Resident #14 said he/she had told the DON that he/she thought another resident was in possession of the phone. During an interview on 3/5/25 at 3:50 P.M., the DON said that on 2/28/25 Resident #14 reported a personal cell phone was missing. The DON said she had not filled out a grievance, had not notified the Social Worker, did not search the other resident's room, did not check the security cameras, and did not have an outcome for an investigation of the Resident's missing cell phone. The DON said she should have informed the Social Worker but did not. During an interview on 3/6/25 at 7:55 A.M., Resident #14 said that on 3/3/25, he/she had not heard anything about the investigation for the missing cell phone, that he/she requested an update and was told by the DON it was being looked into. During an interview on 3/6/25 at 10:14 A.M., the DON said that she should have submitted an incident report to the Department of Public Health (DPH) within two hours of being notified of the missing cell phone on 2/27/25, but she did not submit a report. During an interview on 3/7/25 at 2:17 P.M., Social Worker #2 said that she was notified of Resident #14's missing cell phone on 3/5/25, but should have been notified on 2/27/25.

Based on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) Assessments for three Residents (#132, #64, and #81) out of a total sample of 34 Residents. Specifically, the facility failed to: 1. For Resident #132, accurately code that the Resident was taking a diuretic medication during the observation period for the MDS assessment, while the Resident was in the facility. 2. For Resident #132, accurately code that the Resident was receiving oxygen therapy during the observation period for the MDS assessment, while the Resident was in the facility. 3. For Resident #64, accurately code that the Resident was taking an anticoagulant medication during the observation period for the MDS assessment, while the Resident was in the facility. 4. For Resident #81, accurately code that the Resident was taking an anticoagulant medication, not an antiplatelet medication during the observation period for the MDS assessment, while the Resident was in the facility. Finding include: 1. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual version 1.19.1 dated October 2024, indicated the following: -high risk drug classes use an indication: check if the resident is taking any medications by pharmacological classification. -Review the residents medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look back period. -check if a diuretic medication was taken by the resident at any time during the 7-day look back period. Resident #132 was admitted to the facility in November 2024 with diagnoses including Essential (primary) Hypertension, Obesity and Acute and Chronic Respiratory Failure with Hypoxia. Review of the Resident's MDS assessment dated [DATE], did not indicate that the Resident was taking a diuretic medication. Review of Resident #132's Physician's orders indicated the Resident had an order for Torsemide (diuretic medication) oral tablet 20 milligrams (MG), give three tablets by mouth in the morning (Daily) for edema, start date 1/22/25. Review of Resident #132's January 2025 Medication Administration Record (MAR) indicated the Resident was administered the Torsemide medication as prescribed by the Physician from 1/22/25 to 1/31/25. During an interview on 3/6/25 at 10:54 A.M., MDS Nurse #3 said the Resident was on a diuretic medication during the look back period for the 1/31/25 MDS Assessment and it should have been coded as yes. MDS Nurse #3 said she would modify the MDS and correct the error. 2. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual version 1.19.1 dated October 2024 indicated the following: Code continuous or intermittent oxygen administered via mask, cannula, etc delivered to a resident to relieve hypoxia. Resident #132 was admitted to the facility in November 2024. Review of the Resident's MDS dated [DATE], did not indicate that the Resident was receiving oxygen therapy. Review of Resident #132's Physician's orders indicated that the Resident had an order for oxygen continuously via nasal cannula at 5 liters per minute (LPM) every shift. Effective 1/28/25 Review of the Resident's January 2025 MAR indicated Resident #132 received oxygen therapy as prescribed by the Physician from 1/28/25 to 1/31/25. During an interview on 3/10/25 at 12:06 P.M., MDS Coordinator #5 said the Resident should have been coded as receiving oxygen therapy for the MDS assessment dated [DATE] but it was not coded. MDS Coordinator #5 said she would modify the MDS Assessment and correct the error. 44222 3. Resident #64 was admitted to the facility in November 2022 with diagnoses of Atherosclerotic Heart Disease of native coronary artery without Angina Pectoris and Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity. Review of Resident #64's clinical record included a Physician's order dated 1/11/25 for Eliquis (Apixaban - an anticoagulant medication that inhibits blood from clotting) Oral Tablet 5 MG (mg -milligrams). Give 1 tablet by mouth two times a day related to encounter for Orthopedic Aftercare following Surgical Amputation. Review of Resident #64's February 2025 MAR indicated that the Eliquis medication had been administered as ordered, twice each day from 2/1/25 through 2/28/25. Review of Resident #64's Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Score of 15 out 15 points. -no evidence that the Resident was administered anticoagulant medication during the MDS observation period. During an interview on 3/11/25 at 9:43 A.M., MDS Nurse #1 said after reviewing the February 2025 MAR and the MDS dated [DATE], the Resident was receiving an anticoagulant medication, Eliquis, but there was no anticoagulant identified on the MDS Assessment. MDS Nurse #1 said that the Eliquis medication administered to the Resident during the MDS observation period should have been coded as an anticoagulant medication on the MDS but it had not been coded. 48206 4. Resident #81 was admitted to the facility in March 2016 with diagnoses including history of Venous Thrombosis and Embolism. Review of Resident #81's March 2025 Physician's orders indicated: -Xarelto (anticoagulant medication) Tab 15 mg (milligrams), give 1 tablet orally one time a day, initiated 5/2/24. Review of Resident #81's Quarterly Minimum Data Set assessment dated [DATE], did not indicate that the Resident was administered an anticoagulant medication during the review period. Review of Resident #81's December 2024 MAR indicated that Resident #81 was administered Xarelto 15 mg daily as ordered by the Physician, from 12/1/24 to 12/31/24. During an interview on 3/7/25, MDS Nurse #2 said that the 12/20/24 MDS Assessment coding for the Xarelto was incorrect. MDS Nurse #2 said that the Xarelto medication was coded as an antiplatelet and should have been coded as an anticoagulant.

Based on record review, and interview, the facility failed to provide the resident and/or their representative with a summary of the baseline care plan for one Resident (#279), out of a total sample of 34 residents. Specifically, the facility failed to provide the Resident's Representative and invoked Health Care Proxy (HCP) with a written summary of the baseline care plan, medications, and dietary instructions when the Resident was determined to lack capacity for medical decision making. Findings include: Review of the facility policy titled Care Plan-Baseline, revised November 2017, indicated: -A baseline plan of care is developed within 48-hours of admission to the facility based on information obtained during the admission process as a guide for care until the comprehensive care plan is developed. - Process: >Obtain Physician's Orders on admission. >Complete Nursing Admission Assessment. Begin interdisciplinary assessment process. >Review inquiry and transfer information. >Interview resident and family accompanying resident/patient for additional information (if appropriate). >Develop baseline plan of care. >Initiate care plan. Resident #279 was admitted to the facility in February 2025 with diagnoses including Frontotemporal Neurocognitive Disorder and Abnormalities of Gait and Mobility. Review of the Hospital Consult Note, dated 1/30/25, indicated: -Resident lived with [Resident Representative (RR) #1]. -Resident had Dementia which has been worsening at home and Resident had left the house multiple times. -Resident had become increasingly confused and had reportedly been hallucinating, carrying knives with him/her, and reporting hallucinations that people might kidnap him/her. -RR #1 stated that he/she can no longer care for the Resident at home and had been trying to get the Resident into a facility. Review of Resident #279's Power of Attorney (POA) document, dated 5/21/19, indicated: -Resident had executed a General Durable Power of Attorney. -POA included a clause for Health Care Proxy (HCP) decision making. -Resident named Resident Representative #1 as their POA/HCP. Review of the Documentation of Resident Incapacity signed by the Physician, and dated 2/11/25, indicated: -Resident #279 lacked the capacity to make, or to communicate, health care decisions due to Neurocognitive Disorder. -the probable duration of Resident #279's incapacity was indefinite. Review of Resident #279's March 2025 Physician's orders indicated: -Invoke Health Care Proxy, initiated 2/11/25. Review of the Initial Meet and Greet Form, dated 2/13/25, indicated: -Rehabilitation: Strength/Range of Motion, Activities of Daily Living/Self-Care, Cognitive Abilities, Physical and Occupational Therapy Evaluation Only. -Nursing Services: Unstable Medical Condition, Altered Mental status, Nutrition/Weight Changes, Pain Management, Fall Risk. -Social Services: Prior living arrangements lived with family, Social supports: family, Mood/behavioral symptoms present, Probable Long-Term Care. -Resident/Family Signature: Telephone Call to Resident's DPOA/HCP. Further review of the Initial Meet and Greet Form did not indicate that the Resident lacked decision making capacity or that a written summary of the baseline care plan, medications, or dietary instructions were provided to the Resident or the Resident's Representative. Review of the Brief Interview for Mental Status (BIMS) assessment, dated 2/17/25, indicated the Resident was severely cognitively impaired as evidenced by score of 3 out of a total possible 15 points. Review of the Interdisciplinary Care Plan Meeting form, dated 2/18/25, indicated: -Admission Assessment. -Resident was evaluated by Behavioral Health on 2/17/25. -Resident had a POA and invoked HCP naming RR #1. -Section listing Resident or Representative participated in care plan process was blank. -If no Resident or Representative participation, give reason, section was blank. -Telephone conference if unable to attend meeting, section was blank. -RR #1 was called and message left. Further review of Resident #279's medical record did not indicate that RR #1 was provided with a written summary of the baseline care plan including dietary instructions and medications. During an interview on 3/4/25 at 3:11 P.M., RR #1 said that he/she had been caring for Resident #279 at home but was unable to continue due to the Resident's hallucinations and behaviors, and the plan was for long term care placement for the Resident. RR#1 said that he/she had received a voicemail from MDS Nurse #1 on 2/18/25 regarding a care plan meeting after the Resident was admitted to the facility, but RR #1 had tried to call back that same day to participate in the meeting, but was unable to connect with staff. RR #1 said that he/she connected with MDS Nurse #1 several days later and requested a copy of the care plan but he/she had not received it. RR #1 said that he/she wanted to discuss the Resident's plan of care as he/she had concerns about accessing Psychiatric and Behavioral Health Services but he/she had not received any further information from the facility. During an interview on 3/5/25 at 3:47 P.M., Social Worker (SW) #1 said that MDS Nurse #1 facilitated the baseline care plan meeting process for Resident #279 and SW #1 participated in and completed the Admission Meeting form on 2/13/25. During an interview on 3/7/25 at 10:31 A.M., SW #1 said that she was unable to locate any evidence that RR #1 had been provided with a copy of the baseline care plan. During an interview on 3/11/25 at 10:03 A.M., MDS Nurse #1 said that she had called and left a voicemail for RR #1 on 2/18/25. MDS Nurse #1 further said that she spoke with RR #1 on 2/21/25 and reviewed the care plan information from the 2/18/25 meeting. MDS Nurse #1 said that she did not provide a copy of Resident #279's care plan to RR #1.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#176), of two applicable residents, out of a total sample of 34 residents. Specifically, for Resident #176, the facility failed to: -measure and document the external catheter length to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm). -measure and document arm circumference. -document ordered Normal Saline (NS) flushes. Findings include: Review of facility policy titled Central Venous Access Device (VAD) Catheter Dressing Change, dated January 2022, indicated but was not limited to the following: - .The intravenous (IV) therapy order for care and maintenance is required. - .With each assessment of the VAD, presence of the following, at a minimum, should include: External Catheter Length. Review of facility policy titled Central Venous Access Device flushing, dated January 2022, indicated but was not limited to the following: - .A prescriber order is required for VAD flushing. The order will be specific with regards to flush solution, volume and frequency. - Document procedure in resident's medical records, including but not limited to: date and time, site assessment, flushing agent and volume flushed, any complication, resident's response to procedure, and any resident/caregiver education. Resident #176 was admitted to the facility in February 2025 with diagnoses including Endocarditis, valve unspecified (infection of the heart's inner lining usually involving the heart valve). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/14/25, indicated that Resident #176: -was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of a possible 15. -required IV medications. Review of Resident #176's Physician's orders in the electronic health record, dated 3/7/25, indicated but was not limited to: -Enhanced Barrier Precautions related to PICC, start date 2/11/25 -Cephazolin Sodium (antibiotic) Intravenous (IV) Solution Reconstituted 2 GM (gram) every 8 hours for 6 weeks, 2/11/25 - 3/25/25 for Endocarditis, valve unspecified, start date 2/11/25. Review of Resident #176's Infusion Therapy Order (paper Physician orders) dated 2/10/25, indicated but was not limited to: -PICC, single lumen - Document total catheter length and external catheter length. -Document baseline arm circumference and PRN (as needed). -Document external length weekly with dressing change and PRN. -Pre-flush (Prior to IV medication infusion) 10 ml (milliliter) NS (Normal Saline). -Post-flush (after IV medication infusion) 10 ml NS. During an interview on 3/7/25 at 12:15 P.M., the Assistant Director of Nursing (ADON) said that Resident #176 had a PICC line used to administer the IV Cephazolin and orders for PICC line care that were not in the electronic health record. The ADON said the PICC line orders were on paper Infusion Therapy Flowsheets. The ADON further said that's how she would know what orders were in place and PICC line care provided should be documented on the paper Infusion Therapy Flowsheet. On 3/7/25 at 1:00 P.M., the surveyor observed the following during a medication administration by the ADON: -an ordered dose of Cephazolin 2 GM administered to Resident #176 via the PICC line. -The ADON scrubbed the connector with an alcohol pad, and flushed the line with 10 ml (milliliter) of NS. -The ADON scrubbed the connector again with an alcohol swab, then connected the IV tubing to the connector and started the infusion with the pump. -The PICC line dressing was labeled with the date 3/7/25. -The ADON did not complete measurements of the external catheter length and arm circumference at this time. During an interview on 3/7/25 at 1:50 P.M., the surveyor and the ADON reviewed Resident #176's Infusion Therapy Flowsheets for February 2025 and March 2025. The ADON said that the Nurse should measure the external length of the catheter and the left arm circumference on admission and document it in the designated areas on the flowsheet. The ADON said the two measurements should be done at least weekly when the dressing was changed. The ADON said she changed the dressing today, and has never done any measurements. The ADON said that NS flushes should be done before and after the administration of the IV medication and documented on the flowsheet as well. Review of Resident 176's Infusion Therapy Flowsheet, dated February 2025, failed to indicate: -the measurement of the external length of the catheter and the left arm circumference were done or documented on admission -the measurements were done weekly with dressing changes or PRN as ordered. -NS IV flushes were documented with the administration of the IV Cephazolin 36 times. Review of Resident 176's Infusion Therapy Flowsheet, dated March 2025, failed to indicate: -the measurements were done weekly with dressing changes or PRN as ordered. -NS IV flushes were documented with the administration of the IV Cephazolin 9 times. During an interview on 3/7/25 1:58 P.M., the Director of Clinical Operations said IV orders were not in the electronic health record, the Nurses use the Infusion Therapy flow sheets as orders. The Director of Clinical Operations said the orders on the flowsheets were from the Physician and should be documented and signed off by the Nurse. The Director of Clinical Operations said that the expectation was that the measurements of the external catheter length and arm circumference for Resident #176 should have been done and documented as ordered. The surveyor and the Director of Clinical Operations reviewed the Infusion Therapy Flowsheets for external catheter and arm circumference measurements and found no evidence that the external catheter and arm circumference measurements were done or documented, and the ordered flushes were not signed off consistently. The Director of Clinical Operations said that the measurements and flushes should have been documented but had not been.

Based on record review, and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#109), of one applicable resident, out of a total sample of 34 residents, who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop functioning properly). Specifically, the facility failed to communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and the facility received the most current information pertaining to Resident #109. Findings include: Review of the facility policy titled Hemodialysis, dated April 2015, included but was not limited to: -Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consists of: >vital signs, >Copy of MAR (Medication Administration Record) >any change of condition from last hemodialysis treatment -Documentation will be completed prior to dialysis treatment -The communication book/sheet will be reviewed upon return from dialysis. Resident #109 was admitted to the facility in April 2021 with diagnoses including End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, and Major Depressive Disorder, recurrent, unspecified. Review of Resident #109's comprehensive person-centered care plan for hemodialysis, initiated 4/16/21, indicated: -goal to tolerate dialysis without complications, revised 2/10/25, -an intervention of: Dialysis Communication book in use, initiated 5/10/21. Review of Resident #109's most recent Minimum Data Set (MDS) Assessment, dated 2/14/25, indicated: -the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. -Resident #109 received Dialysis treatment. During an interview on 3/4/25 at 11:31 A.M., Resident #109 said that he/she went to the dialysis center three times a week on Monday, Wednesday, and Friday, and has been doing so for many years. Resident #109 said that the dialysis treatments were going well. Review of Resident #109's March 2025 Physician's orders included an order for: -Dialysis Days: Monday, Wednesday, and Fridays, Times: p/u (pick up) at 10 am (Dialysis Center) Review of Resident #109's Dialysis Communication Book did not provide evidence of any communication sent to, or received back from the Dialysis Center for any dialysis days in January 2025, February 2025, or March 2025. Review of the Resident #109's clinical record did not provide any evidence of ongoing communication between the facility and the dialysis center. During an interview on 3/11/25 at 12:07 P.M., Nurse #2 said he was providing care for Resident #109 today and has cared for the Resident many times in the past. Nurse #2 said that the Resident has gone to dialysis treatments regularly on Mondays, Wednesdays, and Fridays. Nurse #2 said he never sent the Resident out to dialysis because the Resident goes to dialysis during the early morning when the night shift staff was still on duty. Nurse #2 said he had never seen any communication sheet return with the Resident when the Resident returned from dialysis. During an interview on 3/11/25 at 2:07 P.M., the Director of Nursing (DON) said that the Resident went to dialysis treatment every Monday, Wednesday, and Friday. The surveyor and the DON reviewed the dialysis communication book and were unable to find any evidence of ongoing communication between the facility and the dialysis center for any days in January 2025, February 2025, or March 2025. The DON said that facility staff were expected to complete a communication form before sending the Resident to dialysis and then send the form with the Resident in the dialysis book that accompanies the Resident to the dialysis center. The DON further said that the expectation was that the dialysis center would communicate on the bottom half of the form, and the facility staff would review the communication from the dialysis center upon the Resident's return back to the facility. The DON said the staff should have been communicating with the dialysis center every time the Resident went for dialysis treatment but she could not provide any evidence that the staff had done so.

Based on observation, interview, and document review, the facility failed to ensure that nursing staff possessed the appropriate competencies and skills to assure resident safety when providing nursing and related services for one Resident (#14), out of a total of 51 residents who smoke as identified through smoking assessments. Specifically, for Resident #14, Certified Nurses Aide (CNA) #5 failed to demonstrate competency in skills and techniques necessary to provide safe smoking care and services during assigned smoking sessions when CNA #5 lit a cigarette in the Resident's mouth while he/she was using oxygen. Findings include: Resident #14 was admitted to the facility in January 2025 with diagnoses including Respiratory Failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Nicotine Dependence. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #14: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of total possible 15 -utilized a walker to aid with ambulation -received oxygen therapy Review of the Facility Assessment, dated 8/14/24, failed to indicate that the facility thoroughly evaluated and documented the needs of the resident population who smoke and identified the required resources needed to provide safe care and services. Further review of the Facility Assessment failed to identify staff competencies necessary to provide the skill sets and safety training needed for the resident population who smoke. On 3/6/25 at 1:13 P.M., during an assigned smoking session, two surveyors observed Resident #14 enter the designated smoking area wearing a nasal cannula and carrying a portable oxygen tank. The surveyors observed that there were 8 residents in addition to Resident #14 in the smoking area. The surveyors further observed CNA #5 light a cigarette in Resident #14's mouth while the nasal cannula remained present in his/her nostrils. Resident #14 removed the lit cigarette from his/her mouth when he/she saw the surveyors, dropped the lit cigarette to the ground, went back into the facility and returned to resume smoking without the oxygen equipment. During an interview on 3/6/25 at 1:16 P.M., Resident #14 said that CNA #5 lighted the cigarette in his/her mouth while his/her oxygen was being used via nasal cannula. During an interview on 3/6/25 at 2:17 P.M., Resident #14 said that not all staff members reminded him/her to remove the oxygen equipment before going outside to the smoking area. Resident #14 said his/her oxygen was being used when CNA #5 lit the cigarette in his/her mouth. Review of CNA #5's educational file failed to indicate that the CNA demonstrated competency with smoking and oxygen safety. Review of the Facility Orientation Packet for new staff failed to indicate any training or competencies to demonstrate smoking safety for residents who smoke. During an interview on 3/6/25 at 1:16 P.M., CNA #5 said that he did not see Resident #14 wearing oxygen when he lit the cigarette in the Resident's mouth. CNA #5 said he knew that residents were not allowed to smoke while wearing oxygen. During an interview on 3/10/24 at 3:30 P.M., the Regional Nurse said that the Facility Orientation Packet contained all of the training materials and competencies used to orient new employees. The Regional Nurse said there was no content in staff orientation regarding safe smoking for residents. The Regional Nurse further said there was no evidence that safe smoking and oxygen competency was demonstrated by CNA #5 prior to the incident on 3/6/25.

Based on records reviewed and interviews for one of four sampled residents (Resident #4), who had a surgical wound to his/her her right lower extremity, the Facility failed to ensure that nursing provided care in accordance with professional standards of practice, when dressings to his/her wound were not completed as ordered, physicians orders for the pressure settings for the wound vac (vacuum assisted closure) machine were not obtained, weekly wound care assessments were not completed, as a result Resident #4 was transferred and admitted to the Hospital, due to a surgical wound infection. Findings include: Review of Facility's Policy titled, Weekly Body Audit, dated 07/2017, indicated that staff are required to complete a skin check evaluation weekly. Review of Resident #4's Treatment Administration Record (TAR), dated September 2021 and October 2021, indicated that Resident #4 required a Weekly Skin Check on Thursdays during the Day Shift (7:00 A.M. to 3:00 P.M.). However, there was no documentation to support the Weekly Skin Checks were completed on 09/30/21 or 10/07/21. Resident #4 was admitted to the Facility in September 2021, medical history included, a right lower extremity surgical wound requiring a negative pressure wound vac (vacuum assisted closure), [CONDITION(S)], and chronic obstructed pulmonary disease. Review of Resident #4's Admission Minimum Data Set (MDS) indicated that he/she was cognitively intact, able to make needs known, and was his/her own decision maker. Review of the Facility's Policy titled, Skin Care Non-Pressure Wound Assessment, dated 07/2017, indicated that surgical incisions are evaluated and documented on weekly and the documentation would include: -Location -Measurement -Type of Wound -Drainage Amount -Drainage Color -Odor -Appearance of wound bed -Appearance of wound edges -Appearance of peri wound -Pain -Effectiveness of treatment Review of Facility's Policy titled, Wound VAC, dated 07/2017, indicated that staff are required to document: -Date and Time of the Procedure -Wound Assessment -VAC Settings -Date of Next Dressing Change -Residents tolerance of the procedure. Review of the Negative Pressure Wound Therapy (NPWT) Manual, undated, indicated that all orders for NPWT required: -Vacuum settings. Review of Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 3:00 P.M.). Review of Resident #4's Treatment Administration Record (TAR), dated October 2021, indicated that Resident #4's wound dressing was scheduled to be changed on 10/04/21, 10/06/21, and 10/08/21. Further review of the TAR, indicated, there was no documentation to support that Resident #4's right lower extremity surgical wound dressing was changed as ordered. During an interview on 03/23/22 at 1:44 P.M., Resident #4 said that staff were not changing his/her dressing to his/her right lower extremity. Resident #4 said that there was an odor to his/her leg for days and that he/she reported this to nursing. Resident #4 said he/she would ask nursing about his/her wound dressing changes, and said Nurse #5 told him/her that she didn't have time. Resident #4 said that his/her right leg was painful and he/she was not able to participate with therapy. During an interview on 03/25/22 at 3:55 P.M., Nurse #1, who was assigned to care for Resident #4 on 10/04/21 during the Day Shift (7:00 A.M. to 1:45 P.M.), said she did not complete Resident #4's wound treatment. During an interview on 03/23/22 at 12:02 P.M., Nurse #5, who was assigned to care for Resident #4 on 10/06/21 and 10/08/21 during the Day Shift (7:00 A.M. to 3:00 P.M.), said she did not complete Resident #4's wound treatment. During an interview of 03/23/22 at 11:45 A.M., Nurse #3, who was assigned to care for Resident #4 during the Evening Shift (3:00 P.M. to 11:00 P.M.) on 10/04/21 and 10/06/21, said he did not complete Resident #4's wound treatment. During an interview on 03/24/22 at 2:23 P.M., Nurse #12, who was assigned to care for Resident #4 during the Evening Shift (3:00 P.M. to 11:00 P.M.) on 10/08/21, said he did not complete Resident #4's wound treatment. Review of the Nursing Progress Note, dated 10/11/21, indicated that Resident #4's right lower leg surgical wound dressing was removed and there was a severe odor. The Note indicated that Resident #4's right lower leg was red, swollen, warm to touch, that there were copious amounts of thick pus and blood clots. During an interview on 03/29/22 at 11:20 A.M., the Staff Development Coordinator (SDC) said that on 10/11/21 she changed Resident #4's right lower leg surgical wound dressing. The SDC said that there was an odor and pus present in Resident #4's wound. The SDC said that the wound needed a further evaluation. The SDC said she transferred Resident #4 to the Hospital for an evaluation. Review of the Hospital Emergency Department Summary, dated 10/11/21, indicated that Resident #4 arrived to the Emergency Department for an evaluation of his/her right lower extremity wound. The Summary indicated that there was purulent drainage (a sign of an infection) and the surrounding tissue was red and indurated (swollen). Resident #4 received antibiotics and he/she was transferred to another hospital for further evaluation. Review of the Hospital Discharge Summary, dated 10/26/21, indicated that Resident #4 was admitted to the Hospital from 10/11/21 through 10/26/21 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 was treated with 10 days of intravenous and oral antibiotics. During an interview on 03/31/22 at 2:04 P.M., the Physician said that staff should have obtained settings for Resident #1's wound vac. The Physician said that he did not observe staff change Resident #4's wound dressing and said he did not evaluate his/her wound. During an interview on 03/23/22 at 4:15 P.M., Director of Nursing (DON) #1 said that nursing should have completed the skin checks. DON #1 said nursing should have obtained settings for the wound vac and nursing should have completed the dressing as ordered. DON #1 said nursing should have documented the status of Resident #4's surgical wound. The Facility was unable to provide the Surveyor any documentation for wound rounds relating to Resident #4's surgical wound.

Based on observation, record review, and interview the facility failed to provide pressure relief to prevent a pressure ulcer from worsening for one Resident (#98) out of four applicable sampled residents, in a total sample of 34 residents. Findings include: Review of the facility's policy for Prevention and Management of Pressure Injuries, dated July 2017, indicated the following: -Policy: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. -Avoidable means that the resident developed a pressure injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure injury risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions: or revise the interventions as appropriate. Resident #98 was admitted to the facility in April 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Norton Plus assessment, dated 9/21/21, indicated the Resident was at high risk for skin breakdown as evidenced by a score of 9 (scores below 10 indicate high risk). Review of the Pressure Injury Evaluation, dated 10/1/21, indicated an initial evaluation for newly facility acquired deep tissue injury (DTI- defined by the National Pressure Injury Advisory Panel (NPIAP) as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful,firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). The DTI was on the right plantar foot and measured 4.7 centimeters (cm) x 3.7 cm with 100% eschar (dry, dead tissue). Review of the wound consult, dated 10/8/21, indicated an unstageable DTI on the right plantar foot that measured 5.1 cm x 4.3 cm x non-measurable depth. The plan included to continue using soft heel boots for off-loading. Review of the wound consult, dated 10/29/21, indicated a not improved cluster of unstageable DTI pressure ulcers of the right plantar foot. The cluster size measured 9.2 cm x 6.1 cm x non-measurable depth. The plan included to continue using soft heel boots for heel off-loading and suggested a bed extender in setting of patient's plantar feet touching the footboard. Review of the wound consult, dated 11/5/21, indicated an improved cluster of unstageable DTI pressure ulcers of the right plantar foot that measured 9.0 cm x 5.8 cm x non-measurable depth. The plan included to continue using soft heel boots for heel offloading and suggested a bed extender in setting of patient's feet touching the footboard. Review of the wound consult, dated 11/12/21, indicated an improved cluster of unstageable DTI pressure ulcers of the right plantar foot that measured 7.3 cm x 4.8 cm x non-measurable depth. The plan included to continue using soft heel boots for heel offloading and suggested a bed extender in setting of patient's feet touching the footboard. Review of the wound consult, dated 11/18/21, indicated an improved cluster of unstageable DTI pressure ulcers of the right plantar foot that measured 7.0 cm x 3.4 cm x non-measurable depth. The plan included to continue using soft heel boots for heel offloading and suggested a bed extender in setting of patient's feet touching the footboard. Review of the wound consult, dated 11/23/21, indicated a not improved cluster of DTI pressure ulcers of the right plantar foot that measured 7.2 cm x 3.8 cm x non-measurable depth. The plan included to continue using soft heel boots for heel offloading and suggested a bed extender in setting of patient's feet touching the footboard. Review of the wound consult, dated 12/3/21, indicated an improved unstageable DTI pressure ulcer of the right plantar foot that measured 5.1 cm x 3.4 cm x non-measurable depth. The plan included to continue using soft heel boots for heel offloading and suggested a bed extender in setting of patient's feet touching the footboard. Review of the wound consult, dated 12/10/21, indicated a not improved unstageable necrosis pressure ulcer of the right plantar foot that measured 4.0 cm x 5.1 cm x non-measurable depth. The wound was debrided (removal of infected or dead tissue from a wound) at the bedside during this visit. The wound measured 4.0 cm x 5.1 cm x 0.2 cm depth post debridement and was then listed on the consult as a Stage 3 pressure ulcer of the right plantar foot. The plan included to continue using soft heel boots for heel offloading and suggested a bed extender in setting of patient's feet touching the footboard. Review of the wound consult, dated 12/22/21, indicated the Stage 3 (defined by NPIAP as: full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) pressure ulcer on the right plantar foot measured 3.0 cm x 3.8 cm x 0.1 cm. The plan included to continue using soft heel boots for heel offloading and suggested a bed extender in setting of patient's feet touching the footboard. Review of the wound consult, date 12/29/21, indicated the Stage 3 pressure ulcer on the right plantar foot measure 3.1 cm x 3.4 cm x 0.1 cm. The plan included to continue using soft heel boots for heel offloading and suggested a bed extender in setting of patient's feet touching the footboard. Review of a Minimum Data Set (MDS) assessment, dated 11/10/21, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status. On 12/30/21 at 9:58 A.M., the surveyor observed the Resident lying in bed, he/she told the surveyor he/she had the boots on. The Resident's feet were up against the footboard and covered with a sheet. On 12/31/21 at 10:19 A.M., the surveyor observed the Resident lying in bed with bilateral soft heel boots on, resting straight up against to footboard. The Resident said he/she wore the boots everyday. When the surveyor asked if the Resident had ever been offered a longer or different bed, the Resident said no. On 12/31/21 at 1:06 P.M., the surveyor observed the Resident lying in bed with bilateral soft heel boots on, resting straight up against the foot board. On 12/31/21 at 2:38 P.M., the surveyor observed the Resident lying in bed with bilateral soft heel boots on, resting straight up against the foot board. On 1/04/22 at 8:11 A.M., the surveyor observed the Resident lying in bed, with bilateral soft heel boots, resting straight up against the foot board. Review of the December 2021 physician's orders did not indicate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 1/04/22 at 9:52 A.M., the surveyor observed nurse #1 do the dressing change to the right plantar pressure ulcer. Upon completion of the treatment, nurse #1 put the bilateral soft boots back on the Resident. During an interview on 1/04/22 at 10:32 A.M., nurse #1 reviewed the current physician orders and the December 2021 and November 2021 TARs and said there was no order for the bilateral soft boots and no place to sign them off. He said there should be both because the Resident wore the boots every day. Nurse #1 said there was no evidence of a bed extender being trialed but he could see how that would be useful to relieve the pressure because the resident's feet were right up against the foot board. On 1/04/22 at 1:30 P.M., the wound nurse said that she went on weekly wound rounds and that she was in charge of implementing new recommendations. She said the Resident had worn boots in bed for months and the boots were made for bed use, and they had a fixator (bar) in them to keep the feet in an upright position (causing feet to be in an upright position against the foot board). She reviewed the clinical record and said she couldn't find a physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said there should have been an order and they probably should have been signing it off but that the Resident had used them all along. She said the order must have dropped off. The wound nurse then reviewed the wound consults listed above. She said that the wound team had never talked to her directly about extending the bed. She said they had not tried a bed extender or longer bed. She said when she reviewed the wound consults she only focused on the first part of the plan and failed to read the entire plan, which is where it was recommended multiple times to try a bed extender. The wound nurse said that it had become obvious that we were now talking about pressure ulcer caused by the Resident's foot being pressed up against the foot board.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status and track the resident's weight leading to a significant weight loss for one resident (#95), in a total sample of 34 residents. Findings include: Resident #95 was admitted to the facility in 10/2021. Review of the facility policy for weights indicated the following: -The following residents are weighed weekly X4 Newly admitted residents Newly readmitted residents Residents with an unplanned weight loss of >5% in a month All weight loss/gain of 5 pounds or more on a resident weighing over 100 pounds requires a reweigh for verification, on the same scale with a nurse present. If a significant weight loss (greater than 5% in 30 days, or greater than 10% in 6 months), the Interdisciplinary Team, dietician, physician and family are notified. Review of the Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive impairment as evidenced by a Brief Interview of Mental Status Score of 2 out of 15, required extensive assistance for eating and weighed 120 pounds. Review of the physician's orders from 10/6/21 to 10/31/81 indicated an order to weigh the resident weekly for four weeks on admission. In addition the nutritional supplement Glucerna was ordered, one can three times a day. Review of the Medical Nutritional Therapy Assessment signed by the dietician on 10/8/21, indicated that per hospital records, the resident weighed 120 pounds. The resident had a body mass index (BMI) of 18.3 which indicated the resident was underweight. The resident's skin was intact. It was suggested that the resident be weighed. Review of the resident's care plan, initiated on 10/8/21, indicated the resident was at risk for nutritional decline. Interventions included: -Monitor and evaluate weight/weight changes -Notify dietician of significant weight changes -Weekly weights -Provide nutritional supplement as ordered. Review of a nursing progress note, dated 10/26/21, indicated the was admitted to the hospital due to a fracture of their hip. The resident was readmitted to the facility on [DATE]. Review of the Medical Nutrition Therapy Assessment signed on 11/5/21 by the dietician indicated the resident weighed 120 pounds from the hospital records prior to the resident's initial admission, had a BMI of 18.3 still indicating the resident was underweight and was receiving the nutritional supplement Glucerna, one can three times a day. She suggested the resident be weighed and that nursing was aware. Review of the Weights and Vitals summary indicated the resident was not initially weighed by the facility until 11/8/21 and weighed 132.8 pounds. Review of the MDS, dated [DATE], indicated the resident had severe cognitive impairment as evidenced by a BIMS of 1 out of 15, required extensive assistance for eating and weighed 133 pounds. Review of a physician's order, dated 11/19/21, indicated to add Glucerna, 8 ounces, three times a day. Review of the Mediation Administration Record (MAR) from 11/1/21 to 11/30/21 indicated the resident did not start receiving Glucerna until 11/20/21, although it was documented on the Nutritional Assessment, dated 11/1/21, that the resident was receiving Glucerna three times a day. Review of a Pressure Injury Evaluation, dated 12/10/21 indicated the resident had an unstageable pressure area on the left heel. Review of the Weights and Vitals Summary indicated the resident was not weighed again until 12/17/21, and was not weighed weekly X4 after his/her readmission. The resident weighed 102.5. There was no documentation of a reweigh. Review of the Weights and Vitals Summary indicated the resident weighed 103.6 on 12/23/21. Review of a the dietician's progress note, dated 12/23/21, indicated the resident had a significant weight loss in one month (21.99%). The resident's BMI dropped to 15.8. The dietician suggested Glucerna, 8 ounces, three times a day. Review of a physician's order, dated 12/23/21, indicated an order to add Glucerna, 8 ounces, three times a day. Review of the 12/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented as being administered twice at 8:00 P.M. on 12/29/21 and 12/30/21. Review of the 1/1/22 physician's orders indicated the resident's diet had been changed from regular to mechanical soft. During an interview on 1/4/22 at 10:55 with Nurse #8, she said she was not aware of any resident recorded weights other than what was in the Weights and Vitals Summary in the electronic healthcare record. During an interview with the dietician on 1/4/22 at 10:56 A.M., she said she was unaware of any of resident #95's weights taken prior to 11/8/21. During an interview with Nurse #8 at 11:31 A.M., she said it looked like the Glucerna was not transcribed from the 11/2021 physician's orders to the 12/2021 physician's orders, and the resident did not receive the Glucerna until 12/23/21. Nurse #8 said she thought the the supplements were given to the resident from 12/23/21 to 12/31/21 but just weren't documented as administered. During an interview on 1/4/22 at 11:37 with the dietician, she said no weights were recorded prior to 11/8/21. She also said she was not aware of the resident's weight loss until 12/23/21 and was unaware the resident was not receiving Glucerna at anytime, and her evaluations indicated the resident was receiving Glucerna three times a day. She was not aware of the Glucerna being discontinued at any time.

Based on record reviews and interviews the facility failed to ensure obtained a urine specimen when ordered, resulting in the Resident being in pain and needed to be sent to the Emergency Department. For Resident #99 the facility failed to obtain a laboratory (urine) specimen in a timely manner. Resident #99 was admitted to the facility in November 2019. Review of a Progress Note, dated 7/24/21, indicated the Resident complained of urinary frequency and dark colored urine, the Resident did not have a fever. The Nurse Practitioner (NP) was notified and ordered to obtain a urine specimen for urinalysis with culture and sensitivity. Review of a Progress Note, dated 7/25/21, indicated the Resident was alert and oriented x 4 and complained of generalized body weakness. Review of a Progress Note, dated 7/26/21 (2 days after the order was placed to obtain a urine specimen), indicated the urine was obtained and was noted to be very dark red with thick sludge. The Resident complained of increased pain and frequency when urinating and pain in his/her back and abdomen. The NP was updated and a new order was obtained to send the Resident to the emergency room for evaluation. Review of a Progress Note, dated 7/28/21, indicated the Resident returned to the facility from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/05/22 at 10:33 A.M., nurse #1 said he was not working at the time of this incident, but they typically try to get a urine specimen immediately after the order is obtained. He said that this resident was alert and oriented and it would be easy for him/her to assist in getting the specimen. Nurse #1 said he was surprised that it took as long as it did to get the urine specimen. During an interview on 1/05/22 at 11:23 A.M., the Director of Nurses said that the urine sample should have been obtained sooner than it was and she didn't know why it took that long to get one.

Based on observation, record review and interview the facility staff failed to meet professional standards of quality for 7 Residents (#46, #93, #95, #163, #178, #181, and #381) out of a total sample of 35 residents. Findings include: 1. Based on record review and interviews the failed to ensure quality nursing services for Resident #181, when nursing staff were aware that his/her right leg cast was soiled, and did not communicate it to the orthopedic surgeon, as ordered in the discharge summary, and failed to arrange for assessment of Resident #181's skin and incision under the cast when it was suspected to be soiled. Findings include: The facility's policy titled, Cast Care of Resident with Rigid Cast, dated 4/2015, indicated staff would monitor the casted extremity and notify the Physician of any abnormalities. The facility's policy titled, Significant Change, dated 4/2015, indicated staff would communicate with the Physician regarding changes in condition to provide timely communication of resident status change. Resident #181 was admitted to the facility in April 2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Incident Report, dated 4/12/19, indicated Resident #181 was found on the floor, had an open injury to his/her right ankle, and was transferred to the Hospital Emergency Department. The Hospital Discharge Summary, dated 4/16/19, indicated Resident #181 was diagnosed with a fractured right ankle and underwent surgical correction and a cast was applied. The Discharge Summary indicated to keep the cast clean and dry, and to call the Surgeon if the cast became wet. The Care Plan, dated 4/16/19, indicated staff were to check the skin around Resident #181's cast every shift. The emergency room Report, dated 4/18/19, indicated Resident #181 was assessed for the cast being too tight, and the cast was bivalved (cut in half from each side, to allow the cast to open to reduce pressure and allow assessment of the limb). Resident #181 was transferred back the facility that night. The Treatment Administration Record Notes, dated 4/24/19 and 4/26/19, indicated Resident #181's cast was dirty. The Nurse Progress Note, dated 4/24/19, indicated Resident #181's cast was dirty and had food and drink spilled on it. The Nurse Progress Note, dated 4/25/19, indicated Resident #181 was incontinent of feces and feces got on his/her cast. The Hospital Emergency Department Record, dated 4/27/19, indicated Resident #181 was transferred to the emergency roiagnom on [DATE] for vaginal bleeding. The Record indicated there was a significant odor arising from Resident #181's right leg cast, and it was evident the cast had been bivalved. The Record indicated the cast had large areas of dark wet cast matting and web roll visible through the bivalved portions, and there was a significant odor coming from the foot. The Record indicated much of the cotton batting lining the cast was saturated with a brown foul smelling liquid. The Record indicated Resident #181's chief complaint was pain in his/her ankle and foot. The Hospital Emergency Department Record indicated once the cast was removed, Resident #181's ankle was significantly swollen, red, and puffy at the suture (stitches) line with purulent drainage (thick consistency fluid that oozes from a wound. Can be green, yellow, brown, or white) noted on the incision located on the outside of the ankle. The Report indicated there was an area of ulceration, an area on the skin that becomes red and results in a break in the skin, (from pressure) just above the suture line which had a large amount of fibrinous exudate (commonly referred to as pus, consistent with severe infections) and some purulent exudate, and indicated the plantar (bottom) surface of Resident #181's heel up to about mid-foot was white and boggy soft tissue, with significant redness and swelling consistent with [CONDITION(S)] (a potentially serious bacterial infection). The Hospital Emergency Department Record indicated Resident #181 had a significant infection to his/her right lower extremity which was limb threatening, and required immediate intervention, antibiotics, and transfer to another acute care Hospital. Facility Unit Manager #3 said Resident #181's cast was increasingly soiled over time, and said there was no instruction from the orthopedic surgeon for what staff should do if the cast were to become soiled. Unit Manager #3 said she notified Resident #181's Physician that the cast was dirty, and said there were no orders or instruction to call the orthopedic surgeon. Unit Manager #3 said she didn't know if there was an incision under the cast. Unit Manager #3 said staff were waiting to see if the cast developed an odor. The surveyor interviewed the Assistant Director of Nurses (ADON) at 2:55 P.M. on 5/23/19. The ADON said Resident #181's right lower leg cast was bivalved on 4/18/19, and said it was cut along the sides from the foot to just a few inches from the top of the cast. The ADON said the cast was not wrapped in any way on the outside. The ADON said he would expect Resident #181 to be sent for evaluation by the surgeon with any nursing observation of the cast being soiled. The surveyor interviewed the Director of Nurses at 8:45 A.M. on 5/23/19. The Director of Nurses said she was aware that Resident #181's cast had gotten dirty, and that staff had tried to clean it, and said staff were not able to clean all the way under the cast. The Director of Nurses said she did not assess Resident #181's cast herself after it became soiled. The Director of Nurses said she thought Physician #2 and Nurse Practitioner #2 were aware that the cast was dirty, and said there were no instructions from the orthopedic surgeon as to what to do if the cast became soiled, just a follow up appointment for 5/6/19. The Director of Nurses said when the cast was bivalved, it was cut from the top of the cast toward the foot, and the foot of the cast was not cut. The Director of Nurses said she could not recall if there was any wrapping around the outside of the cast. The surveyor interviewed Physician #2 at 2:08 P.M. on 5/23/19. Physician #2 said Unit Manager #3 did notify him that Resident #181's cast was dirty, and said he instructed Unit Manager #3 to arrange for Resident #181 to be reassessed by the orthopedic surgeon as soon as possible. Physician #2 said he did not assess the cast himself, and said he was not aware that it was as dirty as described in the Hospital Emergency Department Record, dated 4/27/19. 2. For Resident #95, the facility staff failed to obtain a treatment order for an mucous fistula, a connection between bypassed colon and the skin surface. Resident #95 was admitted to the facility in 8/2009. On 5/22/19 at 6:30 A.M. during an observation of a dressing change, Nurse #9 pulled up the resident's pajama top to change the [MEDICATION(S)] dressing which was located on the right side of the abdomen. The surveyor observed that the resident's left upper side of his/her abdomen had two [MEDICATION(S)] island (large bandaids) bandages that measures 2 inches x 3 inches in size. The surveyor asked the resident why he/she had the bandages on his/her abdomen. The resident said he/she had an opened mucous fistula. The nurse then removed the [MEDICATION(S)] island bandages and revealed a mucous fistula. The bandages had a small amount of serous drainage. The resident said the bandages were changed by the certified nurse aide (CNA) on his/her shower days. On 5/22/19 at 6:50 A.M. directly after the dressing change, the surveyor asked Nurse #9 if she had ever seen or changed the bandages to the resident's mucous fistula before today. She said that she had seen the bandages because she was usually the nurse who performed the resident's dressing change. Nurse #9 said she assumed the bandages must have been changed by another nurse because it was not done on her shift. On 5/22/19 at 9:15 A.M. during an interview with the Director of Nurses (DON) she said that the CNAs should not change any bandages and there needed to be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. For Resident #46, the facility staff failed to rotate the insulin injection sites. Resident #46 was admitted to the facility in 3/2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's policy for subcutaneous injections, dated 3/2017, indicated to document and rotate sites. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the administration instructions for [MEDICATION(S)] insulin indicated; rotate injection sites to decrease risk of [CONDITION(S)] (a disorder of the fatty tissue that increases the risk to develop insulin resistance). Review of the 4/2019 and 5/2019 Medication Administration Records (MARs), indicated the injection sites were not documented 38 out of 50 times. On 5/21/19 at 11:11 A.M. during an interview with Unit Manager (UM) #1 he said that the injection sites were supposed to be rotated. He then looked at the MARs and said there was no way to tell if the sites were rotated because the sites were not documented. 4. For Resident #93 the facility staff failed to ensure the manufacturers' guidelines were maintained for the use of an air mattress. Resident #93 was admitted to the facility in 4/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [NAME] Relief Alternating Pressure System with Low Air Loss Operation Manual indicated the following; -The alternating pressure system with low air loss is designed to treat and prevent wounds by facilitating blood circulation and decreasing pressure of each tissue's contact area. -Place the patient in the center of the mattress. Adjust the mattress's internal pressure according to the patient weight by using the weight button on the control panel. Review of the nutritional note, dated 3/27/19, indicated the resident refused weight checks. Review of the clinical record indicated there was no weight recorded for the resident. During an observation on 5/14/19 at 1:58 P.M., the resident was lying in bed on an air mattress with side rails up on both sides of the bed. The air mattress was set at 250 with alternating pressure. The resident was lying on his/her left side and appeared to be very thin. On 5/21/19 at 10:00 A.M., Nurse #11 and the surveyor observed the resident was lying on his/her left side in bed, on an air mattress. Nurse #11 said the air mattress was set at 250 with alternating pressure. On 5/21/19 at 10:46 A.M., the Director of Nurses (DON) and the surveyor observed the resident lying in bed, positioned on his/her left side. The DON said the air mattress was set at 250. She said the setting was supposed to be based on the resident's weight but was unsure about the manufacturer guidelines. When reviewing the 5/2019 TAR with the surveyor, she said the TAR did not indicate the air mattress setting. During an interview on 5/21/19 at 11:32 A.M., the Corporate Staff Development Nurse said the air mattress was set at 250 because the resident refused to have it changed to a setting based on her weight. She said she was unaware if another air mattress system was trialed or if the resident was aware of the air mattress benefits of having it set her current weight. See F686. 5. For Resident #163 the facility staff failed to document the rotation of insulin injection sites. Resident #163 was admitted to the facility in 11/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the 4/2019 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 9:00 P.M. Further review indicated the insulin injection sites were not documented for rotation for 12 out of 12 scheduled 9:00 P.M. doses. During an interview on 5/22/19 at 1:47 P.M. the said the insulin injections sites should have been documented to ensure rotation of sites. 6. For Resident #178 the facility staff failed to document the rotation of [MEDICATION(S)] (antibiotic) intramuscular (IM) injection sites. Review of the 5/2019 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review indicated no documentation of the (IM) injection sites. During an interview on 5/24/19 at 11:42 A.M., the DON said the injection sites should have been documented to ensure rotation. 7. For Resident #381 the facility staff failed to document the rotation of [MEDICATION(S)] (blood thinner) injection sites. Resident #381 was admitted to the facility in 5/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5/2019 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review indicated no documentation of the SC injection sites. During an interview on 5/21/19 at 9:23 A.M., UM #2 said the injection sites should have been documented and rotated and they hadn't been.

Based on staff interviews and record review, facility staff failed to provide treatment and care in accordance with professional standards of practice and a comprehensive person-centered care plan for 5 residents ( #70, #95, #139, #177, and #181). Findings include: 1. Specifically for Resident #181, the facility staff failed to ensure that Resident #181's right leg cast was clean, and failed to act when the cast became soiled, resulting in dark, foul smelling liquid which collected against Resident #181's skin and incision, resulting in a significant limb threatening infection, and hospitalization . Resident #181 was admitted to the facility in April 2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Policy titled, Cast Care of Resident with Rigid Cast, dated 4/2015, indicated staff would monitor the casted extremity and notify the Physician of any abnormalities. The facility's Incident Report, dated 4/12/19, indicated Resident #181 was found on the floor, had an open injury to his/her right ankle, and was transferred to the hospital Emergency Department. The Hospital Discharge Summary, dated 4/16/19, indicated Resident #181 was diagnosed with a fractured right ankle and underwent surgical correction and a cast was applied. The Discharge Summary indicated to keep the cast clean and dry, and to call the Surgeon if the cast became wet. The Care Plan, dated 4/16/19, indicated staff were to check the skin under Resident #181's cast every shift. The emergency room Report, dated 4/18/19, indicated Resident #181 was assessed for the cast being too tight, and the cast was bivalved (cut in half from each side, to allow the cast to open to reduce pressure and allow assessment of the limb). Resident #181 was transferred back the facility that night. The Treatment Administration Record Notes, dated 4/24/19 and 4/26/19, indicated Resident #181's cast was dirty. The Nurse Progress Note, dated 4/24/19, indicated Resident #181's cast was dirty and had food and drink spilled on it. The Nurse Progress Note, dated 4/25/19, indicated Resident #181 was incontinent of feces and feces got on his/her cast. The Hospital Emergency Department record, dated 4/27/19, indicated Resident #181 was transferred to the emergency roiagnom on [DATE] for vaginal bleeding. The record indicated there was a significant odor arising from Resident #181's right leg cast, and it was evident the cast had been bivalved. The record indicated the cast had large areas of dark wet cast matting and web roll visible through the bivalved portions, and there was a significant odor coming from the foot. The record indicated much of the cotton batting lining the cast was saturated with a brown foul smelling liquid. The record indicated Resident #181's chief complaint was pain in his/her ankle and foot. The Hospital Emergency Department record indicated once the cast was removed, Resident #181's ankle was significantly swollen, red, and puffy at the suture (stitches) line with purulent drainage noted on the incision located on the outside of the ankle. The Report indicated there was an area of ulceration (from pressure) just above the suture line which had a large amount of fibrinous exudate and some purulent exudate, and indicated the plantar (bottom) surface of Resident #181's heel up to about mid-foot was white and boggy soft tissue, with significant redness and swelling consistent with [CONDITION(S)], a potentially serious bacterial infection. The Hospital Emergency Department record indicated Resident #181 had a significant infection to his/her right lower extremity which was limb threatening, and required immediate intervention, antibiotics, and transfer to another acute care Hospital. The surveyor interviewed Certified Nurse Aide (CNA) #6 at 3:25 P.M. on 5/23/19. CNA #6 said Resident #181 would spill food on his/her cast, and said she could not tell if food or drinks had gotten into the cast. CNA #6 said that several times, Resident #181 would pull off his/her incontinence brief and sit on the side of the bed and urinate down his/her legs. CNA #6 said she was not sure if urine went into Resident #181's cast, but said it was possible. CNA #6 said she did not check to see if the inside of the cast was wet and said she did not notify the nurses that the cast might have gotten wet with urine. The surveyor interviewed Unit Manager #3 at 11:02 A.M. on 5/23/19. Unit Manager #3 said Resident #181 was known to be incontinent and to pull of his/her incontinence brief. Unit Manager #3 said on at least one occasion, she was assisting Resident #181 in the bathroom and Resident #181 stood up, pulled off the brief, and was incontinent of feces down his/her leg. Unit Manager #3 said feces got on the outside of Resident #181's cast, and said she was not certain if feces got into Resident #181's cast. Unit Manager #3 said she cleaned off the outside of Resident #181's cast, and said she could not clean under the cast or assess if Resident #181's incision was soiled. Unit Manager #3 said on at least one occasion, she witnessed Resident #181 pour coffee down the top of his/her cast, and said she did not know if the coffee had gotten into the cast. Unit Manager #3 said Resident #1's cast was increasingly soiled over time, and said there was no instruction from the orthopedic surgeon for what staff should do if the cast were to become soiled. Unit Manager #3 said she notified Resident #181's Physician that the cast was dirty, and said there were no orders or instruction to call the orthopedic surgeon. Unit Manager #3 said she didn't know if there was an incision under the cast. Unit Manager #3 said staff were waiting to see if the cast developed an odor. The surveyor interviewed the Assistant Director of Nurses (ADON) at 2:55 P.M. on 5/23/19. The ADON said Resident #181's right lower leg cast bivalved on 4/18/19, and said it was cut along the sides from the foot to just a few inches from the top of the cast. The ADON said the cast was not wrapped in any way on the outside. The ADON said he would expect Resident #181 to be sent for evaluation by the surgeon with any nursing observation of the cast being soiled. The surveyor interviewed the Director of Nurses at 8:45 A.M. on 5/23/19. The Director of Nurses said she was aware that Resident #181's cast had gotten dirty, and that staff had tried to clean it, and said staff were not able to clean all the way under the cast. The Director of Nurses said she did not assess Resident #181's cast herself after it became soiled. the Director of Nurses said she thought Physician #2 and Nurse Practitioner #2 were aware that the cast was dirty, and said there were no instructions from the orthopedic surgeon as to what to do if the cast became soiled, just a follow up appointment for 5/6/19. The Director of Nurses said when the cast was bivalved, it was cut from the top of the cast toward the foot, and the foot of the cast was not cut. The Director of Nurses said she could not recall if there was any wrapping around the outside of the cast. The surveyor interviewed Physician #2 at 2:08 P.M. on 5/23/19. Physician #2 said Unit Manager #3 did notify him that Resident #181's cast was dirty, and said he instructed Unit Manager #3 to arrange for Resident #181 to be reassessed by the orthopedic surgeon as soon as possible. Physician #2 said he did not assess the cast himself, and said he was not aware that it was as dirty as described in the Hospital Emergency Department Record, dated 4/27/19. 2. For Resident #139, the facility staff failed to provide proper care and treatments for a nephrostomy tube (a drainage tube placed into the kidney to drain urine). Resident #139 was admitted to the facility in 4/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also was admitted with a Percutaneous nephrostomy (PCN) tube. Review of the admission nurse's note, dated 4/16/19, indicated Nephrostomy tube patent, draining clear yellow urine. Review of the Physicians admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Treatment Administration Record (TAR), dated 4/2019, indicated there was no documentation related to the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Admission Minimum Data Set (MDS) Assessment, dated 4/23/19, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview of Mental Status (BIMS), was an assist for activities of daily living, did not ambulate, and had a nephrostomy tube. Review of the nurse's note, dated 4/23/19, indicated the resident displayed verbally aggressive behaviors and was not satisfied with the level of care offered to him/her. Review of the nurse's note, dated 4/24/19, indicated the nephrostomy tube was patent, drained well with 1000 milliliters (ml) of yellow urine output. This was the first time since admission (8 days) that there was documentation regarding the PCN tube. Review of the comprehensive care plan for PCN tube, dated 4/29/19, indicated the resident was at risk for infection. The goal was for the resident to show no signs and symptoms of infection. The interventions were: - Fever, changes in mental status, blood in urine, lower abdominal or pelvic pain or strong smell in urine may indicate infection, and - Monitor output for odor, color, consistency, amount, blood and sediment. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Keep stop cock (a valve) in place. Review of the TAR, dated 5/2019, indicated the following transcriptions: - Flush nephrostomy tube two times a day with 10 ml normal saline (this transcription was incomplete based upon the above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Document nephrostomy tube output every shift. Continued review of the TAR, dated 5/1/19 thru 5/14/19 indicated the following: - 14 out of the 28 shifts the PCN tube was not flushed, and - 31 out of the 42 shifts the output for the PCN tube was not initialed as done. In addition although the other 11 shifts were initialed as done the output was not documented anywhere with the exception of 1 shift. Review of the nurse's note, dated 5/15/19, indicated, bright red blood noted draining from the nephrostomy tube and around the insertion site. Tube flushed with normal saline and bloody drainage persists. The physician was notified and gave an order to send the resident to the emergency room for an evaluation. Review of the hospital discharge summary, dated 5/21/19, indicated the resident was admitted to the hospital with bloody output from the PCN tube and a low grade temperature. A CAT scan was done and found the PCN tube was displaced (repositioning needed) which caused an increase in right hydronephrosis (excess fluid in a kidney due to back up of urine). The PCN tube needed to be replaced while the resident was in the hospital on 5/16/19. On 5/22/19 at 10:00 A.M. during an interview with the Director of Nurses (DON) she said that she cannot find any admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that the treatment orders for the PCN tube in May were not transcribed correctly so she was not sure how the nurses cared for the PCN tube. The DON said that the outputs for the PCN tube were not documented. On 5/23/19 at 8:00 A.M. during an interview with the Regional Clinical Nurse she said that the facility did not provide any education or competencies for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/23/19 8:53 A.M. during an interview with Physician #1 he said that he was the physician who cared for Resident #139. The physician said that the order to flush the PCN tube 10 ml up to the resident and 10 ml down to the resident was the correct order. He said that the 5/2019 transcription to flush the PCN tube two times a day was an incomplete order. The surveyor asked if the flushes were not done correctly and not done two times a day as ordered could that have been the reason why the resident ended back in the hospital with hematuria (blood in urine) and increased hydronephrosis and Physician #1 said absolutely. In addition Physician #1 said that he was not aware that there were no orders in place for the care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/24/19 at 9:01 A.M. during an interview with the ADON, he said that he was the one who transcribed the order onto the TAR, dated 5/2019. He said that the order was not transcribed with all of the instructions needed for the care. He said the order was incomplete. On 5/24/19 at 10:03 A.M. during a telephone interview with Nurse #10 she said that she had done the treatments for the resident's PCN tube. She said that she followed the directions of the TAR, dated 5/2019. Nurse #10 said that she opened the stop cock so it flushed towards the kidneys. She used a 10 cubic centimeter (cc) syringe filled with normal saline and flushed the PCN tube. When she was done she opened the stop cock back up so it drained freely. The surveyor asked if she ever flushed the PCN tube so the normal saline would flow away from the resident. Nurse #10 said, no, she did not know that she was supposed to. On 5/24/19 at 10:30 A.M. the surveyor, Unit Manager (UM) #1, and the ADON entered the resident's room. The surveyor observed the resident in bed. The surveyor asked if it would be okay if the care to the PCN tube was observed. He/she said that would be fine and told the surveyor that for the first few weeks that he/she was at the facility no one took care of the PCN tube. The resident said that he/she would ask the nurses for a syringe to flush the tube him/herself because he/she knew that it needed to be done because he/she took care of it him/herself when living alone. The surveyor asked how many times he/she asked for the flushes the resident said that it was a couple of times but could not remember the exact number of times. The surveyor then observed the ADON donn gloves, use an alcohol wipe to clean the stop cock and opened it towards the kidneys, using a 10 cc syringe filled with normal saline, he flushed towards the kidneys and opened the stop cock up to allow drainage. When completed he disconnected the tubing (one end of the tubing was connected to the drainage bag and the other end was connected to the stop cock) that was connected to the stop cock. The surveyor asked why he would remove the tubing from the stop cock because it was a closed system and now it was an opened system which put the resident at greater risk of infection. The ADON said he was going to flush towards the bag through the tubing. The surveyor asked why he would not use the stop cock to flush towards the drainage bag. He was unsure. After thinking the ADON completed the flush the correct way. 3. For Resident #95, the facility failed to assess and provide care and treatment to two arterial ulcers. Resident #95 was admitted to the facility in 8/2009. Review of the Significant Change in Status MDS Assessment, dated 3/29/19, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS, needed assist for activities of daily living, did not ambulate, had functional limitations to range of motion to both sides of the lower extremities and did not have any arterial ulcers. Review of the TAR, dated 5/2019, indicated no treatments in place for arterial ulcers. On 5/22/19 at 6:40 A.M. the surveyor and Nurse #9 entered the resident's room to observe a treatment. The surveyor asked Nurse #9 if she could remove the resident's non skid socks to observe the resident's right heel. When the nurse removed the resident's socks the surveyor observed 2 scabbed areas on both the resident's right and left large toe. The resident said they were caused by his/her shoes. Nurse #9 measured the areas which measured approximately 1 centimeter (cm) round on the right toe and 0.7 cm round on the left toe. The surveyor asked the nurse how she would describe the areas. Nurse #9 said they were pressure ulcers but was not very good at staging so she was not sure what stage they were. Nurse #9 said that she had seen the areas on his/her toes before but said the resident told her that the wound nurse was aware of the areas so she didn't look any further into it. The resident said that he/she or a Certified Nurse Aide (CNA) applied skin prep to them. Record review indicated there was no documentation related to the wounds. There was no indication of arterial wounds on the consultant's wound reports, there was no assessments, no treatment orders in place for the care of the arterial wounds. On 5/22/19 at 8:54 A.M. during an interview with the Regional Staff Development Coordinator (SDC), she said she was unable to find any documentation related to the wounds on the resident's toes. Review of the consultant wound report, dated 5/23/19, indicated the resident had two new arterial wounds. The first arterial wound was located on the resident's left great toe and measured 0.3 cm x 0.6 cm x 0.2 cm with a small amount of serous drainage. The second arterial wound was located on the resident's right great toe and measured 0.3 cm x 0.6 cm x 0.1 cm with a small amount of serous drainage. On 5/23/19 at 3:44 P.M. during a telephone interview with the wound specialist, he said he was not aware of any wounds on the resident's toes until today. On 5/24/19 at 7:52 A.M. during an interview with CNA #5, she said that she worked full time and usually is the CNA that cared for Resident #95. She said that she applied the skin prep to the resident's toes for about the last 3 months. CNA #5 said the resident told her the nurses knew about the wounds on the resident's toes so she did not report anything. 4. For Resident #70, the facility failed to follow the recommended discharge instructions after surgery. Resident #70 was admitted to the facility in 7/2018 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge summary, dated 4/12/19, indicated the resident was admitted to the hospital on 4/11/19 for severe right ulnar [CONDITION(S)] (nerve damage). The resident had surgery to release the ulnar nerve in the resident's right elbow. Continued review of the discharge summary indicated the following instructions: - Use an ice pack to prevent pain and swelling. Use the ice pack for 20 minutes at a time, three times a day. - Keep the hand higher than the heart at all times, until told otherwise. When sleeping place forearm on pillows. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was 5 days after the resident returned from the hospital. Further review of the orders indicated the discharge instructions to keep the resident's hand elevated was never obtained. Review of the TAR, dated 4/2019, indicated a transcription to apply ice to right elbow three times a day, one time each shift. Further review indicated the ice was not applied 47 out of 54 shifts. There was no documentation that indicated if the hand was elevated at all times. Review of a follow up Consultation Form from the resident's surgeon, dated 4/24/19, indicated the wound to the resident's elbow was clean dry and intact. Instructions included to change the dressing daily. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR, dated 4/2019, indicated a transcription on 4/25/19 to change dressing daily. The transcription did not indicated the site of the dressing. Further review indicated the dressing was never initialed by a nurse as done for the remainder of the month. Review of the TAR, dated 5/2019, indicated a transcription to change dressing to the right hand daily (surgical site right elbow). The dressing was not initialed as done until 5/12/19. On 5/17/19 at 1:10 P.M. during observation of a dressing change to the resident's coccyx, when Nurse #10 removed the blankets the surveyor observed an old [MEDICATION(S)], wrapped around the resident's right elbow. There was no date when it was changed. The surveyor asked the resident if he/she knew when the dressing was changed and the resident said, I couldn't tell you the last time it was changed. On 5/17/19 at 2:00 P.M. during an interview with the Regional SDC, she looked at the treatment sheets and said it did not look like the dressing to the resident's elbow was done or the ice was applied. She could not answer why the orders were not followed. On 5/17/19 at 3:00 P.M. during an interview with UM #1, the surveyor asked if he could look to check if the discharge instructions from the hospital were ever reviewed with the physician. UM #1 said that he could not find any proof that they were ever reviewed. The surveyor asked UM #1 if when the resident returned from the hospital was his/her elbow elevated and iced as recommended. UM #1 said he could not say for sure but probably not because it was not documented as done. The surveyor further asked why the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . UM #1 was unable to answer the question. 5. For Resident #177, facility staff failed to conduct weekly skin checks and treatments as ordered by the physician when a blister was found on the resident's heel. Resident #177 was admitted to the facility in 7/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Significant Change Minimum Data Set (MDS) assessment, dated 2/8/19, indicated the resident had short and long term memory deficits and was unable to make decisions; received extensive assistance from staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene; required supervision for ambulation on the unit and was admitted to hospice services as of 2/4/19. Review of the plan of care addressing skin issues (initiated 11/2/17 and revised 3/19/18) indicated the resident had a Potential Alteration in Skin Integrity related to comorbidities, diabetes, incontinence and failure to thrive. The goal was that the resident's skin would remain intact. Interventions included: - Diabetic Foot Care - Follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Heels offloaded when in bed - House barrier cream to hips, coccyx, buttocks and/or heels every shift - Weekly skin check - Wound team as needed Review of the 3/2019 Treatment Administration Record (TAR) indicated that weekly Skin Checks were conducted on 3/5/19 and not on 3/12/19, 3/19/19 and 3/26/19 as ordered. A progress note, dated 4/1/19, indicated that staff found an open area on the resident's left heel. A new order was obtained to clean the ulcer with Normal Saline and apply a wet to dry dressing daily and to get a wound consult; Elevate foot/heel off bedding with boot or pillow. Review of the 04/2019 TAR indicated that between 4/1/19 and 4/8/19, the dressing was done 4 of 8 days. A progress note, dated 4/2/19, indicated there was a new ulceration to the left heel and that nursing reported the resident was wearing shoes that were compressing against the left heel. The note also indicated the left heel had a Stage 2 ulceration with mild serosanguinous drainage. Review of a Wound Consult, dated 4/4/19, indicated the resident had an arterial wound on the left heel.Patient is receiving hospice care and this consultation is for separate medical condition not related to hospice diagnosis. The consult also indicated the wound measured 1.0 x 1.0 centimeters (cm) with a non-measurable depth and that the wound bed was 100% eschar. The wound specialist recommended to use the medicated absorbent dressing Iodosorb and cover with a dry protective dressing (DPD). Change daily and as needed. Review of the clinical record indicated that the above wound dressing was not reported to the attending or covering physician until 4/8/19. The treatment was started on 4/8/19, but not conducted as ordered on 4/14, 4/16, and 4/17/2019. Review of the Wound Consultation, dated 4/18/19, indicated there was no improvement to the heel wound, and that an excisional debridement of subcutaneous tissue was done. The operative findings was a significant buildup of subcutaneous tissue necrosis posing risk for infection and slowing down the wound healing. Post debridement measurements were 1.0 cm length x 1.2 cm wide x 0.3 cm depth. The order was to continue with the Iodosorb dressing that was supposed to be initiated daily on 4/4/19, but was not verified until 4/8/19. A Wound Consult, dated 4/25/19, indicated the wound had improved and to continue with the same dressing orders. Review of the 4/2019 TAR indicated the treatment was not conducted as ordered on 4/26, 4/27, 4/28 and 4/29/19. Review of the 5/2019 TAR indicated the dressing was not done as ordered on 5/1/19. A Wound Consult, dated 5/9/19, indicated the wound had not improved since the last visit and to continue with daily and as needed dressing changes. The measurements were 0.6 cm length x 0.8 cm width and 0.1 cm depth. Treatment notes of 5/4/19 and 5/6/19 indicated the wound was dark red with a small amount of drainage. There were no further notes until 5/14/19. On 5/14/19 at 2:45 P.M., the surveyor observed the dressing change with Nurse #7. When the old dressing was removed, there was a large amount of thick yellow drainage. The wound bed was filled with a thick yellow slough and necrotic tissue. The wound had deteriorated and now measured 3.5 cm length, x 3.0 wide. The depth was unable to be determined due to the necrosis and slough. There was no evidence in the clinical record that the physician had been notified of the deterioration of the wound. On 5/14, 5/15 and 5/16/19, the surveyor observed the resident ambulating independently on the unit. He/she was walking in and out of the dining/activity room and in the hallways and sitting in a chair before getting up and walking again. During interview on 5/21/19 at 1:30 P.M., Nurse #7 said that in March 2019, the resident's daughter brought in some new shoes for the resident that did not fit properly. Nurse #7 said that the resident insisted on wearing thick socks with the shoes causing friction on that area of the left foot. During interview on 5/21/19 at 4:00 P.M., the Director of Nurses said she would review skin checks and treatment notes and that they should have been documented.

Based on observation, interview and record review, the facility staff failed to ensure 5 Residents (#52, #70, #93, #95 and #139) in a total sample of 35 residents, received the necessary treatment and services, consistent with professional standards of practice, based on a comprehensive assessment of the resident, to promote healing, prevent infection and prevent new ulcers from developing. Findings include: Specifically, for Resident #93 the facility staff failed develop appropriate interventions for personal care when the Resident refused care, resulting in the Resident sitting in feces for four days, which resulted in a Stage Four Pressure Injury to the left hip. For Resident #52, the facility staff failed to implement position changes while Resident #52 was in the wheelchair which resulted in an unstageable pressure injury to the posterior left thigh. Findings include: Review of the facility's policy for Prevention and Management of Pressure Injuries, dated 7/2017, indicated the following: Standard: The facility is dedicated to preventing pressure injuries and to developing a preventative plan of care based on individual needs. Residents receive care and services they need according to established practice guidelines, so that residents who enter the facility without a pressure injury do not develop one unless the individual's clinical condition demonstrates that they were unavoidable. The necessary treatment and services will be provided to promote healing, prevent infection and prevent new pressure injuries from developing. Policy: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed and provided appropriate treatment to encourage healing and or maintenance of skin integrity. Care plans are developed based on individual resident's goals and decisions for treatment. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. The facility follows National Pressure Ulcer Advisory Panel (NPUAP) guidelines when staging wounds. Protocol: The resident is assessed for pressure injury risk factors on admission then weekly for 3 weeks, quarterly, annually, and with any significant change in condition. -The resident's skin is observed daily with care. -Residents will have a weekly body audit completed by the licensed staff. -Pressure injuries are assessed and documented on at least weekly and with a significant change in the wound until it is resolved. -Pressure injury assessment includes: location, measurement in centimeters, stage, presence of tunneling or undermining, drainage amount, drainage color, odor if present, appearance of wound bed and edges, pain, effectiveness of treatment. -Facility staff and the resident (or the resident's legal representative) must discuss the resident's condition, treatment options, expected outcomes, and consequences of accepting or refusing treatment. -Facility staff are expected to address the resident's concerns and offer relevant alternatives if the resident has refused specific treatments. Review of the facility's policy for Pressure Injury, dated 7/2017, indicated the following: Policy: Those residents who score at risk on the Braden or Norton scale, or those identified to be at risk through comprehensive assessment or who have actual skin impairment are provided with care to address their individual risk factors and goals of treatment. Procedure: Determine cause of pressure and remove the causative agent if possible. Interventions may include: - Teach resident the importance of changing position to prevent pressure injuries. - Provide appropriate pressure redistributing devices to bed and wheelchairs. - Chair bound residents should have position changed every hour consistent with overall goals of care. Review of the facility's policy for Refusal of Treatment/Services, dated 4/2015, indicated the following: Policy: The facility will ensure that a resident's right to refuse treatment is honored and the resident will not be treated against their wishes .When treatment is refused, the facility continues to provide care and services to the resident that allows him or her to attain or maintain their highest practicable physical, mental and psychosocial well being within the context of the refusal. Procedure: When a resident refuses care, or .services directed by the physician, the involved professional staff determines and documents the following in the medical record: - The resident's statement of refusal and nature of the treatment refused. - Reason(s) for the refusal. - Initial clarification and resident education provided regarding possible consequences of refusal. A meeting will be scheduled with the resident/surrogate and appropriate Interdisciplinary Team (IDT) members as soon as possible. The content will include: - What treatment or services are being refused and the reason for the refusal - Education about the risk and benefit of such refusals - The availability of any pertinent alternatives that may exist - Whether the resident would like to consider any discussed treatment alternatives The IDT members will communicate the treatment refusal to other relevant staff members and develop a care plan with pertinent approaches for minimizing the risks of future complications. If refusal of treatment results in a significant change of condition for the resident, the facility will reassess the resident and institute care plan changes as appropriate. 1. Resident #93 was admitted to the facility in 4/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Potential Alteration in Skin Integrity, date initiated 1/23/18, indicated the following; -Discuss non-compliance issues with resident/responsible party and educate about primary risk factors and prevention. -Follow medical doctor (MD) orders for skin care and treatments. -House barrier cream to hips, coccyx, buttocks and/or heels every shift. -Pressure ulcer risk assessment upon admission and quarterly. -Protective skin care with incontinence care. -Provide positioning intervention as indicated on impaired functional mobility care plan. -Resident/Family education as needed. -Specialty air mattress, type H&R [NAME], setting 250. -Weekly skin checks. Review of a quarterly MDS assessment, dated 7/6/18, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS, was totally dependent for bed mobility and bathing, did not transfer or walk, required extensive assistance with hygiene, had impaired range of motion (ROM) for both right and left upper and lower extremities and had no pressure ulcers. Review of a Nurse Practitioner note, dated 7/31/18, indicated the resident was seen per request of the nursing staff to evaluate the resident's wounds. The note indicated the resident had been in his/her own feces for 4 days and would not let staff come near him/her for care. The note indicated the resident had 2 new open areas on the left hip and left lower extremity, and the existing wounds were thick with bloody drainage, exudate (thick fluid oozing from the wound. Can be green, brown,white or yellow) and had a very foul odor. The note indicated the resident would be sent out to the hospital via a Section 12 order (a transportation order to send the resident to the hospital to be evaluated by a psychiatrist for involuntary commitment to the hospital) and the guardian would be made aware. Review of the hospital discharge paperwork, dated 7/31/18, indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weekly Skin Audit, dated 8/1/18, indicated the following; Left back calf-new area 3 x 2.5 cm., beefy tissue exposed/open. Left hip-new wound, 1.5 x 1.0 cm center white, surrounded by red, excoriated skin. Right inner ankle-large opening present unable to measure due to patient's inability to separate his/her legs to view his/her inner ankles, thick green drainage noted with a strong odor. Patient out to the emergency roiagnom on [DATE] and started on IV (intravenous) antibiotics for [CONDITION(S)]. Review of a Physician's interim order, dated 8/1/18, indicated the following; [MEDICATION(S)] 1.0 grams (gm) intravenous (IV), in place of [MEDICATION(S)]. An order, dated 8/6/18, indicated to discontinue the [MEDICATION(S)] 1 gm IV and start [MEDICATION(S)] 1 gm intramuscular twice daily for 7 days, give daily if patient refuses twice daily. Review of the 8/2018 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M.-3:00 P.M. shift. Review of the clinical record indicated a Motion to Substitute Guardian dated 10/1/18. Further review indicated a Decree and Order of Appointment of Guardian for An Incapacitated Person was dated 11/7/18. During an interview on 5/14/19 at 2:00 P.M., Resident # 93 was weepy and upset. He/she indicated he/she was not happy being at the facility and felt the care was not good. He/she expressed a desire to go home. At this time, the resident was observed to be lying in bed on his/her left side, on an air mattress that was set at 250. The resident's bilateral lower legs were exposed, and the skin appeared impaired. Some areas on the legs were covered with dressings. His/her toes nails were very thick and long. His/her hair appeared long and matted, and long facial hair was visible. The resident was observed to be very thin, cachectic, and had overall poor personal hygiene. Review of the facility's Pressure Injury Evaluation Form, dated 5/17/19, indicated the date of origin was 7/31/18, it was facility acquired pressure, the original stage was 4, the current stage was 4, the wound site was the left trochanter (hip) and the current size was 5.0 x 3.0 x 0.0 cm. During an interview on 5/17/19 at 7:45 A.M., Nurse #4 said the resident refuses care and services most of the time. She said the resident is most receptive to UM #3 and will let her provide care most times. During an interview on 5/17/19 at 8:20 A.M., UM #3 said the resident would allow her to do treatments on some days and other days he/she refused. UM #3 said that when she was not working, the resident would not allow anyone else to care for him/her, including skin and hygiene care. During an interview on 5/17/19 at 11:28 A.M., the Regional Staff Development Nurse #2 said there were no documented wound measurements and assessments done for this resident's stage 4 pressure ulcer. During an interview on 5/22/19 at 3:05 P.M., the Director of Nurses said there were no measurements or pressure evaluations done for the wounds on hip and thigh until this week. During an interview on 5/23/19 at 8:24 A.M., UM #3 said she had never done any wound measurements of the resident's pressure wounds. During an interview on 5/24/19 at 7:57 A.M , Doctor #2 said the resident was a difficult patient due to his/her behavior of refusing care. He said he last saw the wounds in April 2019 and that there were no signs/symptoms of infection. He said he was unsure when the last wound treatment orders were changed, and they only were changed if the resident allowed a new treatment. During an interview on 5/24/19 A.M., the resident's Guardian said she spoke with the resident frequently and encouraged the resident to allow care, so his/her physical status won't decline. The Guardian said the resident had unrealistic goals and needed 24-hour care. 2. Resident #52 was admitted to the facility in 3/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. Review of the Occupational Evaluation and Plan of Treatment, dated 8/3/18, indicated Resident #52 was referred to therapy for seating as the resident's chair broke and he/she was in need of a new one. Limitations for the resident included decreased ability to shift weight and attain pressure relief in the chair due to posture issues and decreased skin integrity as the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the In-Service Program, dated 8/22/18, indicated the section for brief summary of lecture included the following: Resident to be tilted at various angles throughout the day for pressure relief to buttocks and thighs, upright for meals only, encourage back to bed between smoke breaks and insist on resident going back to bed at night. Further review indicated the in-service was attended by one nurse and one Certified Nurse Aid (CNA). Review of the Norton assessment, dated 3/4/19, indicated a score of 10. Further review indicated a score of 10 or below is high risk for skin breakdown. Review of the annual Minimum Data Set (MDS) assessment, dated 3/8/19, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), required extensive assist of 2 for bed mobility, and was not on a repositioning schedule. Review of the care plan for potential alteration in skin integrity related to decreased/impaired mobility or function, initiated 3/27/18 with target date of 6/6/19, did not indicate interventions to tilt the chair at various angles throughout the day or to be upright for meals only. Review of the Weekly Skin Audits, dated 4/29/19, 5/6/19, and 5/13/19, indicated the resident refused to have the skin assessments done. Review of the Norton assessment, dated 5/16/19, indicated the resident was at high risk for skin breakdown as evidenced by a score of 6. Review of the current Resident Care Card indicated the resident slept in the chair per choice and there was no direction to tilt the chair at various angles throughout the day or to be upright for meals only. (as recommended by occupational therapy) During an observation on 5/15/19 at 4:36 P.M., the resident was seated in his/her room in a specialized wheelchair (with ability to tilt/recline), the chair was in the upright position. The resident told the surveyor that he/she didn't refuse treatments and didn't mind going back to bed as long as the facility staff got him/her back up to attend the smoking sessions. During an interview on 5/16/19 at 2:41 P.M., the resident was seated upright in the specialized wheelchair and told the surveyor that the facility staff was getting him/her a new cushion for the chair. During an interview on 5/16/19 at 2:42 P.M., Unit Manager (UM) #2 said the resident was found with a new pressure ulcer to the back of the left leg the day before during wound rounds. She said the resident often refused care and refused skin assessments. When the surveyor asked why the skin assessments weren't done when the resident went back to bed for care, and how did the facility staff manage the resident's refusals, UM #2 did not have a response. Review of the Wound Care consult, dated 5/16/19, indicated a new cluster of unstageable necrotic (death of cells or tissue) pressure ulcers on the left posterior thigh, 3.6 centimeters (cm) x 11.0 cm x non-measurable depth. Moderate amount of serous drainage, wound bed had 80% yellow necrosis and 20% epithelialization. The area was debrided at the bedside. During an observation on 5/17/19 at 7:52 A.M., the resident was asleep and seated upright in the specialized wheelchair. During an interview on 5/17/19 at 8:59 A.M., CNA #2 said she often took care of this resident. She said she never tilted the wheelchair and sometimes the resident refused to get changed and they left him/her alone because that was the resident's right. During an interview on 5/17/19 at 9:12 A.M., UM #2 said that more than 2 staff members should have been educated about the chair needing to be tilted to offer pressure relief. During an observation of the dressing change, on 5/17/19 at 11:21 A.M., with UM #2 and the Regional Clinical Nurse, the pressure ulcer just above the back of the left knee was approximately 4 cm x 11 cm, wound bed had 80% slough (dead tissue). The resident told the surveyor that he/she was happy to have had the treatments done that day. During an interview on 5/23/19 at 3:55 P.M., Doctor #3 said he was aware that the resident preferred to stay in the wheelchair and did not go back to bed for any length of time. He said that he considered the wound above the back of the left knee to be a pressure ulcer related to the chair. b. Review of the wound care consult, dated 4/25/19, indicated Resident #52 had a cluster of open wounds (repeated brief trauma) located on the right posterior thigh. Cluster size was 2 cm x 4 cm x 0.1 cm depth with moderate amount of serous drainage. Part of the plan was to leave the brief off at night. Review of the wound care consult, dated 5/2/19, indicated the resident had a cluster of open wounds (repeated brief trauma) located on the right posterior thigh. Cluster size was 2 cm x 5 cm x 0.1 cm depth with moderate amount of serous drainage. Further review indicated the resident had a cluster of open wound (repeated brief trauma) located on the inferior right buttock 1.0 cm x 12 cm x 0.1 cm depth with small amount serous drainage. Part of the plan continued to be leave the brief off at night. Review of the wound care consult, dated 5/9/19, indicated the resident's cluster of open wounds (repeated brief trauma) on the right posterior thigh had improved with measurements of 0.6 cm x 3 cm x 0.1 cm depth. Further review indicated the cluster of open wounds (repeated brief trauma) located on the right inner thigh improved with measurements of 0.7 cm x 7 cm x 0.1 cm. Review of the wound care consult, dated 5/16/19, indicated the resident's cluster of open wounds on the right posterior thigh improved with measurements of 1 cm x 1.5 cm x 0.1 cm. Further review indicated the cluster of open wounds located on the right inner thigh improved with measurements of 0.5 cm x 7 cm x 0.1 cm. Review of the care plan for actual alteration in skin integrity, initiated 3/2018 with goal date of 6/6/19, indicated no intervention to leave the brief off at night and did not specify what size brief the resident wore. Review of the current Resident Care Card did not indicate the what size brief the resident was to wear nor did it indicate to leave the brief off at night. During an interview on 5/16/19 at 3:45 P.M. Certified Nurse Aide (CNA) #1 said that he took care of the resident regularly and the resident used an extra large brief. When asked how he knew what size to use he said he just guessed based on the size of the person. During an interview on 5/17/19 at 8:59 A.M., CNA #2 said she often took care of the resident. She said the resident was incontinent of both bladder and bowel and wore an extra large brief. She said she knew that because someone once told her. She said sometimes the resident refused to get changed and they left him/her alone because that was the resident's right. During an interview on 5/17/19 at 9:12 A.M., UM #2 said there used to be a list of what size briefs everyone wore but they don't have the list anymore. When asked how a CNA would know what size brief to use she said they wouldn't know. When asked if the briefs had been assessed due to them being identified as a cause of pressure, she did not have a response. 3. For Resident #70, the facility staff failed to assess and provide care to a chronic coccygeal ulcer. Resident #70 was admitted to the facility in 7/2018 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the wound care plan, dated 7/30/18, indicated the resident had an unstageable wound to his/her coccyx, the goal was for the resident to be free from infection. Interventions included: - Complete skin condition report weekly, - Pressure ulcer risk assessment quarterly, and - Follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the clinical record indicated the skin condition reports were not done weekly. The last report was dated 3/11/19. The report indicated the resident had an unstageable ulcer to his/her sacrum. It measured 2 cm x 2.5 cm x 3.25 cm in depth. Review of the Quarterly MDS Assessment, dated 3/15/19, indicated the resident was cognitively intact as evidenced by a score of 13 out of 15 on the BIMS, needed extensive assist for activities of daily living, did not ambulate and had one unstageable ulcer. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR, dated 4/2019 indicated the treatment was not done 24 out of 56 shift. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR dated, 5/1/19 - 5/14/19, indicated the treatment was not done 17 out of 28 shift. On 5/14/19 at 2:37 P.M. during a resident interview, the resident said that his/her dressing was supposed to be done two times a day. He/she said half the time I'm lucky if it gets done once a day. On 5/17/19 at 8:43 A.M. during an interview with the Assistant Director of Nurses (ADON) the surveyor asked where the weekly wound assessments were located. The ADON said there was not a system in place for weekly wound assessments that included measurements and a description of the wounds. He said the wounds were looked at weekly but were not documented on. The surveyor asked if wounds were not documented on how did the facility assess the wounds. The ADON was unable to answer. The ADON said if a resident was seen by the wound doctor then the clinical record would have included weekly assessments. The surveyor asked if Resident #70 was seen by the wound doctor and the ADON said, no. A few minutes later the ADON showed the surveyor a spread sheet that was not part of the clinical record that included measurements of the wound but no other information. The surveyor asked the ADON if this was a full assessment of the wound and the ADON said no, it was just the measurements. On 05/17/19 at 10:11 A.M. during an interview with the Regional Staff Developmental Coordinator (SDC) she said that looking at the TARs it looked like the treatments were not being done. Please refer to F841. 4. For Resident #95, the facility staff failed to assess and provide care for one pressure ulcer on the Resident's perineum. Resident #95 was admitted to the facility in 8/2009 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for actual alteration in skin integrity, dated 4/3/18, indicated the resident had a pressure ulcer, the goal included that the wound would show signs and symptoms of healing and the Resident would not develop an infection. The interventions included: - Consult Certified Wound physician, - Follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Monitor for signs and symptoms of infection, - Skin check (wound) assessments weekly, and - Weekly document skin checks. Review of Pressure Injury Evaluation, dated 2/8/19, indicated the resident had an unstageable pressure area on his/her sacrum (not clear to what wound this was because the resident had a wound to the left buttocks and the perineum). The ulcer measured 4 cm x 2 cm x 2.25 cm in depth. This was the last time the facility did an evaluation, description or documentation of either of the areas. Review of the Significant Change in Status MDS Assessment, dated 3/29/19, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS, was an assist for activities of daily living, and did not ambulate. In addition the resident was coded to have one stage 3 pressure ulcer and two unstageable pressure ulcers. Review of the Certified Wound Physician's Consultation Report, dated 4/18/19, indicated the resident had a wound to the left buttocks. The physician recommended to pack the wound with [MEDICATION(S)] ag rope (a treatment to help clean out a wound and promote healing) and cover with a 3 inch x 3 inch [MEDICATION(S)] border (a foam dressing). Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR, dated 5/1/19 - 5/14/19, indicated the treatment was not done three out of twenty eight shifts. On 5/15/19 at 7:02 A.M. during an interview, the resident said he/she had two wounds on his/her left buttock. He/she said that when Nurse #9 works he/she always gets the treatment done. But when she is not working the treatment is usually not done. On 5/17/19 at 8:23 A.M. during an interview, the ADON said that there was no system in place for assessment, description and documentation of wounds. He said that wounds are looked at weekly, but were not documented on. The surveyor asked if the assessment of the wounds are not documented on, how were they evaluated. He was unable to answer that question. On 5/22/19 at 6:40 A.M. the surveyor observed the resident in bed. The surveyor and Nurse #9 entered the resident's room. The surveyor observed Nurse #9 perform treatments to the resident's perineum and left buttocks. Directly after observation of the treatments the surveyor asked if there were any assessments or documentation of the wounds. Nurse #9 said the facility use to put sheets in the treatment book so the nurses could document their weekly assessments and their daily observation but the facility no longer does. Nurse #9 said she does not document her assessments of the pressure ulcers. On 5/22/19 at 1:58 P.M. during an interview with the Regional SDC she said the last time the facility staff assessed and documented on the pressure ulcers was 1/4/19. She said the facility protocol was for all wounds to be assessed and documented on weekly. Please refer to F841 and F880. 5. For Resident #139, the facility staff failed to assess and provide care to the resident's pressure ulcers. Resident #139 was admitted to the facility in 4/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses admission assessment, dated 4/16/19, did not indicate the resident had pressure ulcers. Review of the Physicians Orders, dated 4/16/19, indicated that there were no admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were also no orders for the use of the wound vac. Review of the Wound Consultant Report, dated 4/18/19, indicated the resident had pressure ulcers to his/her sacrum, and both lower extremities. The report indicated the following: - Stage 4 pressure ulcer located on the sacrum. Wound size 10 cm x 10 cm x 3 cm in depth, - Right lateral ankle unstageable deep tissue pressure injury, wound size 1 cm x 1.5 cm with no depth, - Left medial heel unstageable deep tissue pressure injury, wound size 2 cm x 2.5 cm with no depth, - Right medial heel unstageable deep tissue pressure injury, wound size 2.5 cm x 2.5 cm with no depth, - Right medial ankle unstageable deep tissue pressure injury, wound size 1.5 cm x 1.5 cm, no measurable depth, - Left lateral ankle unstageable deep tissue pressure injury, wound size 1.2 cm x 2 cm no depth, and - Left lateral foot unstageable deep tissue pressure injury, wound size 1 cm x 1 cm no depth. Review of the admission MDS Assessment, dated 4/23/19, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS, needed assist for activities of daily living, did not ambulate and had one stage 4 pressure ulcer and six unstageable pressure ulcers. The recommendations from the Wound Consultant Report, dated 4/18/19, indicated to cleanse sacral wound with an antibacterial wound cleanser and utilize the wound vac set to 125 millimeter (mm) of pressure and change three times a week. For the right lateral ankle, right medial ankle and left lateral ankle the consultant recommended to utilize Iodosorb (an antimicrobial ointment that cleans the wound bed and facilitates healing) followed by a dry clean dressing every day and apply skin prep to the left medial heel, right medial heel and left lateral foot wounds daily. Review of the clinical record and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Wound Consultant Report, dated 4/25/19, indicated the sacral pressure ulcer and the left lateral foot pressure ulcers had not improved, but the other pressure ulcers had improved. The above recommendations remained the same with the exception to discontinue the skin prep to the right medial heel and apply Iodosorb followed by a dry clean dressing daily. Review of the clinical record and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR, dated 4/16/19 - 4/30/19, indicated the following transcriptions: - Wound vac to sacral wound. Cleanse with normal saline (not the antibacterial wound cleanser as recommended), pat dry, apply black foam and cover with a clear film. Set machine to 125 mm of pressure. Change 3 times a week on Monday, Wednesday and Friday. Continued review of the TAR indicated that the wound vac was not changed five out of the six scheduled times. There was no transcribed treatment orders, as recommended by the Wound Consultant, for the care and treatment to the pressure ulcers to the resident's lower extremities. Review of the actual alteration in skin integrity care plan, dated 5/6/19, indicated the resident had a pressure ulcer to his/her sacrum, right ankle, right heel, left heel, left ankle and left lateral foot. The goal was for the ulcers to show evidence of healing. The interventions included: - Complete skin condition check weekly, - Follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Monitor for signs and symptoms of infection. Review of the TAR, dated 5/1/2019 - 5/14/19, indicated the following: - Left medial heel; normal saline wash, apply Iodosorb followed by a dry clean dressing was not done 6 out of 14 days, - Left lateral ankle; normal saline wash, apply Iodosorb followed by a dry clean dressing was not done 6 out of 14 days, - Right medial ankle; normal saline wash, apply Iodosorb followed by a dry clean dressing was not done 6 out of 14 days, and - Left later foot; normal saline wash, apply skin prep was not done 6 out of 14 days. Review of the nurses notes, dated 4/16/19 through 5/15/19, indicated that there was no assessment, description or documentation related to any of the resident's pressure ulcers. On 5/15/19 at 7:57 A.M. during a resident interview he/she said they are not doing my treatment. I think the wound vac is supposed to be changed every two to three days but that has not happened. On 5/22/19 at 2:00 P.M. during an interview with the DON she said that she had no idea why the admission assessment did not have anything written about his/her wounds but it definitely should. The DON said the resident never had orders in place for the wound vac or any of the other wounds. She said after the Wound Consultant came in to assess the resident on 4/18/19, the nurses should have contacted the physician with the recommendations, obtained treatment orders and transcribed them onto the TAR. The DON said none of that was done and she did not

Based on observation, interview and record review, the facility staff failed to revise the wound care plan when care was refused for 2 residents (#93 and #152) from a total sample of 35 residents. Findings include: 1. Resident #93 was admitted to the facility in 4/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Potential Alteration in Skin Integrity, date initiated 1/23/18, indicated the following; -Discuss non-compliance issues with resident/responsible party and educate about primary risk factors and prevention. -Follow medical doctor (MD) orders for skin care and treatments. -House barrier cream to hips, coccyx, buttocks and/or heels every shift. -Pressure ulcer risk assessment upon admission and quarterly. -Protective skin care with incontinence care. -Provide positioning intervention as indicated on impaired functional mobility care plan. -Resident/Family education as needed. -Specialty air mattress, type H&R [NAME], setting 250. -Weekly skin audits. Review of the quarterly Minimum Data Set (MDS) assessment, dated 7/6/18, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), displayed physical, verbal and other behaviors between 1 and 6 days during the look back period, and did not reject care. Review of a Nurse Practitioner note, dated 7/31/18, indicated the resident was seen per request of the nursing staff to evaluate the resident's wounds. The note indicated the resident had been in his/her own feces for 4 days and would not let staff come near him/her for care. The note indicated the resident had 2 new open areas on the left hip and left lower extremity, and the existing wounds were thick with bloody drainage, exudate and had a very foul odor. The note indicated the resident would be sent out to the hospital via a Section 12 order and the guardian would be made aware. Review of the Weekly Skin Audit, dated 8/1/18, indicated the following; a. Left back calf-new area 3 x 2.5 cm., beefy tissue exposed/open. b. Left hip-new wound, 1.5 x 1.0 cm center white, surrounded by red, excoriated skin. c. Right inner ankle-large opening present unable to measure due to patient's inability to open ankles, thick green drainage noted with strong odor. Patient out to the emergency roiagnom on [DATE] and started on IV (intravenous) antibiotics for [CONDITION(S)]. Review of the 8/2018 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M.-3:00 P.M. shift. Review of the current 5/2019 TAR indicated the above wound treatment (ordered 9/4/18), remained in place to treat the left hip wound. During an interview on 5/14/19 at 2:00 P.M., Resident # 93 was weepy and upset. He/she indicated he/she was not happy being at the facility and felt the care was not good. The resident expressed a desire to go home. At this time, the resident was observed to be lying in bed on his/her left side, on an air mattress that was set at 250. The resident's bilateral lower legs were exposed, and the skin appeared impaired. Some areas on the legs were covered with dressings. His/her toes nails were very thick and long. This resident's hair was long and matted, and long facial hair was visible. The resident was observed to be very thin and had overall poor personal hygiene. During an interview on 5/17/19 at 7:45 A.M., Nurse #4 said the resident refuses care and services most of the time. She said the resident is most receptive to Unit Manager (UM) #3 and will let her provide care most times. During an interview on 5/17/19 at 8:20 A.M., UM #3 said the resident would allow her to do treatments on some days and other days he/she refused. UM #3 said that when she did not work, the resident would not allow anyone else to care for him/her, including skin and hygiene care. She said she would do what wound treatments the resident accepted. During an interview on 5/17/19 at 11:28 A.M., the Director of Nurses (DON) was unsure if wound treatments had changed for this resident as she had refused care so often. She said staff would educate the resident on the risks of refusal of care During an interview on 5/22/19 at 9:31 A.M. Social Worker (SW) #1 said the resident refused all care and medications most of the time. She said she and other staff had educated the resident on risks of rejecting care. During an interview on 5/22/19 at 10:34 A.M., SW #1 she said there was no documentation about whether or not alternative treatments were discussed with the resident and/or his/her guardian. During an interview on 5/24/19 at 7:57 A.M., Physician #2 said the resident was a difficult patient due his/her behavior of refusing care. He said he was unsure when the last wound treatment orders were changed, and they only were changed if the resident allowed a new treatment. See F686. 2. Resident #52 was admitted to the facility in 3/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. Review of the Quarterly MDS assessment, dated 6/8/18, indicated the resident was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), required extensive assistance of 2 for bed mobility and transfers, and was at risk for pressure ulcers. Review of the In-Service Program (given by occupational therapy), dated 8/22/18, indicated the section for brief summary of lecture included the following: Resident to be tilted at various angles throughout the day for pressure relief to buttocks and thighs, upright for meals only, encourage back to bed between smoke breaks and insist on resident going back to bed at night. Further review indicated the in-service was attended by one nurse and one Certified Nurse Aid (CNA). Review of the care plan for potential alteration in skin integrity related to decreased/impaired mobility or function, initiated 3/27/18 with target date of 6/6/19, did not indicate interventions to tilt the chair at various angles throughout the day or to be upright for meals only (as recommended by occupational therapy). Review of the current Resident Care Card indicated the resident slept in the chair per choice and there was no direction to tilt the chair at various angles throughout the day or to be upright for meals only. Review of the weekly skin audits, dated 4/19/19, 5/6/19, and 5/13/19 indicated the resident refused to have the skin assessments done. During an observation on 5/15/19 at 4:36 P.M., the resident was seated in his/her room in a specialized wheelchair (with ability to tilt/recline). The chair was in the upright position. Review of the Wound Care Consult, dated 5/16/19, indicated a new cluster of unstageable necrotic (dead tissue) pressure ulcers on the left posterior thigh, 3.6 centimeters (cm) x 11 cm x non-measurable depth. Moderate amount of serous drainage, wound bed had 80% yellow necrosis and 20 % epithelialization. The area was debrided (dead tissue removed) at the bedside. During an interview on 5/16/19 at 2:42 P.M.,UM #2 said the resident was found with a new pressure ulcer to the back of the left leg the day before, during wound rounds. She said the resident often refused care and refused skin assessments. When the surveyor asked why the skin assessments weren't done when the resident went back to bed for care, and how did the facility staff manage the resident's refusals, UM #2 did not have a response. During an observation on 5/17/19 at 7:52 A.M., the resident was asleep and seated upright in the specialized wheelchair. During an interview on 5/17/19 at 8:59 A.M., CNA #2 said she often took care of this resident. She said she never tilted the wheelchair and sometimes the resident refused to get changed and they left him/her alone because that was the resident's right. b. Review of the Annual MDS, dated [DATE], indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS, required extensive assist of 2 for bed mobility, was dependent for transfers, and was frequently incontinent of bowel and bladder. Review of the wound care consult, dated 4/25/19, indicated the resident had a cluster of open wounds (repeated brief trauma) located on the right posterior thigh. Cluster size was 2 cm x 4 cm x 0.1 cm depth with moderate amount of serous drainage. Part of the plan was to leave the incontinent brief off at night. Review of the 4/2019 TAR indicated the resident refused the treatment to the right posterior thigh from 4/11-4/30/19. Review of the wound care consult, dated 5/2/19, indicated the resident had a cluster of open wounds (repeated brief trauma) located on the right posterior thigh. Cluster size was 2 cm x 5 cm x 0.1 cm depth with moderate amount of serous drainage. Further review indicated the resident had a cluster of open wound (repeated brief trauma) located on the inferior right buttock 1 cm x 12 cm x 0.1 cm depth with small amount serous drainage. Part of the plan continued to leave the brief off at night. Review of the wound care consult, dated 5/9/19, indicated the resident's cluster of open wounds (repeated brief trauma) on the right posterior thigh had improved with measurements of 0.6 cm x 3 cm x 0.1 cm depth. Further review indicated the cluster of open wounds (repeated brief trauma) located on the right inner thigh improved with measurements of 0.7 cm x 7 cm x 0.1 cm. Review of the wound care consult, dated 5/16/19, indicated the resident's cluster of open wounds on the right posterior thigh improved with measurements of 1 cm x 1.5 cm x 0.1 cm. Further review indicated the cluster of open wounds located on the right inner thigh improved with measurements of 0.5 cm x 7 cm x 0.1 cm. Review of the 5/2019 TAR indicated the resident refused treatments to the above stated areas from 5/3-5/15/19. Review of the care plan for actual alteration in skin integrity, initiated 3/2018 with goal date of 6/6/19, indicated no intervention to leave the brief off at night and did not specify what size brief the resident wore. Review of the current Resident Care Card did not indicate what size brief the resident was to wear nor did it indicate to leave the brief off at night. During an interview on 5/16/19 at 3:45 P.M., CNA #1 said that he took care of the resident regularly and the resident used an extra large brief. When asked how he knew what size to use he said he just guessed based on the size of the person. During an interview on 5/17/19 at 8:59 A.M., CNA #2 said she often took care of the resident. She said the resident was incontinent of both bladder and bowel and wore an extra large brief. She said she knew that because someone once told her. She said sometimes the resident refused to get changed and they left him/her alone because that was the resident's right. During an interview on 5/17/19 at 9:12 A.M., UM #2 said there used to be a list of what size briefs everyone wore but they don't have the list anymore. When asked how a CNA would know what size brief to use she said they wouldn't know. When asked if the briefs had been assessed due to them being identified as a cause of pressure, she did not have a response. Please refer to F686.

Based on observation, interview and record review the facility staff failed to ensure 1 resident (#93) received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being, from a total sample of 35 residents. Findings include: Review of the facility's Refusal of Treatment Services Policy, dated 4/2015, indicated the following: -When treatment is refused, the facility continues to provide care and services to the resident that allows him/her to attain or maintain their highest practicable physical, mental and psychosocial well being within the content of making the refusal. -When a resident refuses care, dietary recommendations and/or any other services directed by the physician, the involved professional staff determines and documents the following; the resident's statement of refusal and nature of the treatment refused, the reason for the refusal and initial clarification and resident education provided regarding possible consequences of the refusal. -A meeting/discussion will be scheduled with the resident and interdisciplinary team members as soon as possible. The content will include the availability of any pertinent alternates that may exist, and whether the resident would like to consider any discussed treatment alternatives. Resident #93 was admitted to the facility in 4/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Behavior Care Plan, revision date 4/21/18, indicated the following interventions: -Acknowledge concerns in the moment, provide reassurance. -Anticipate and meet the resident's needs. -Assess behavior episodes and attempt to determine underlying causes. Consider location, time of day, persons involved and situations. Document behaviors and potential causes. -Psychiatry services as needed. -Assist resident to develop more appropriate methods of coping and interacting. Encourage him/her to express feeling appropriately. -Educate on importance of accepting care from the staff and allow his/her care needs to be met. -Redirect/reapproach as needed upon verbal outbursts. Review of a social service note, dated 2/5/19, indicated a referral for a psychiatry consult was placed. Review of the Annual Minimum Data Set (MDS) Assessment, dated 3/29/19, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview of Mental Status (BIMS), had behaviors not directed towards others for 1 to 3 days during the look back period, the behaviors significantly interfered with the resident's care and participation in activities or social interactions, and the behaviors significantly intruded on the privacy or activity of others. The MDS indicated the behavior symptoms care area was triggered and was addressed in the care plan. Review of the facility's 4/2019 and 5/2019 Behavior/Intervention Monthly Flow Records indicated the resident was monitored for the refusal of care daily, on each shift. Further review of the records indicated the outcome was most often documented as unchanged. Review of the following psychiatry consults dated 4/4/19, 4/25/19 and 5/21/19, indicated the following; the resident is not on any [CONDITION(S)] medications due to refusal. Additionally, all the consult reports indicated the recommendations/plans were to continue current medications, continue to monitor mood changes and/or behaviors disturbances. Review of the 5/2019 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/14/19 at 2:00 P.M., Resident # 93 was weepy and upset. He/she indicated he/she was not happy being at the facility and felt the care was not good. He/she expressed a desire to go home. The resident was observed to be very thin and had overall poor personal hygiene. During an interview on 5/17/19 at 8:20 A.M., Unit Manager (UM) #3 said the resident would allow her to do treatments on some days and other days he/she refused. UM #3 said that when she was not working, the resident would not allow anyone else to care for him/her, including skin and hygiene care. During an interview on 5/17/19 at 9:56 A.M., UM #3 and Nurse #4 said Resident #93 refused care most of the time. They attempted care as he/she allowed, but the Resident was very resistant to care. They said his/her refusal of care was documented on every shift. UM #3 said they had psychiatric services attempt to see the resident but Resident #93 often refused, and will not take any medications. UM #3 said she had attempted to reapproach the resident after refusal of care but most often the resident would continue to refuse staff help. During an interview on 5/22/19 at 9:31 A.M. Social Worker (SW) #1 said the resident refused all care and medications most of the time. She said she had educated the resident on risks of rejecting care. She said psychiatry services had attempted to see him/her but he/she refused at times. SW #1 said that psychiatric services attempted an agreement with resident to allow more frequent care, however the Resident continued to refuse care the majority of the time. During an interview on 5/22/19 at 10:34 A.M., SW #1 she said there was no documentation about whether or not alternative treatments, therapies or placements were discussed with the resident and/or his/her guardian. During an interview on 5/23/19 at 8:39 A.M., Certified Nurse Aide (CNA) #4 said she would provide care only as the resident allowed. During an interview on 5/24/19 at 7:57 A.M., Physician #2 said the resident was a difficult patient due to his/her behavior of refusing care and the resident would only allow care and services when he/she chose to.

Based on records reviewed and interviews for three of 19 sampled residents (Resident #2, Resident #5 and Resident #7), the Facility failed to protect Resident #7 from being sexually abused by Resident #1, who was known to have sexually inappropriate behaviors; failed to protect Resident #2 from potential sexual abuse by Resident #1, and failed to protect Resident #5 from being verbally abused by Certified Nurse Aide (CNA) #9. - On 08/03/18, Resident #1 was found by staff members in Resident #7's bedroom performing oral sex on Resident #7. - On 08/05/18, Resident #2 reported to staff that sometime during the previous week, Resident #1 had touched him/her on the leg and then Resident #1, with a lubricant in his/her palm, attempted to undo Resident #2's brief. - On 08/18/18, Resident #5 was verbally abused by CNA #9 when he said to Resident #5 You're a pain in the ass or words to that effect. Findings include: The Facility Policy, titled Abuse Prohibition Policy, dated 12/2016, indicated that each resident has the right to be free from abuse, mistreatment, neglect, exploitation and misappropriation of his or her personal property. The Policy indicated sexual abuse includes, but not limited to, sexual harassment, sexual coercion or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. 1. Resident #1 was admitted to the Facility with [DIAGNOSES REDACTED]. A Resident Incapacity Pursuant to Massachusetts Health Care Proxy M.G.L. C201D Form, dated and signed by the Physician on 12/09 illegible year, indicated Resident #1 lacked the capacity to make, or communicate health care decisions due [MEDICAL CONDITION] dementia. A Behavior Care Plan for Resident #1, that included history of sexually inappropriate comments and behaviors towards others, dated as initiated on 03/21/18, indicated for staff to intervene as needed to protect the rights and safety of others; approach in a calm manner, divert attention, remove from situation and take to another location as needed. A Psychiatric Note, dated 04/30/18, indicated per staff, Resident #1 had no recent reports of sexual inappropriate behaviors. A Facility Investigation, dated 05/02/18, indicated Resident #1 was found in Resident #11's bathroom performing oral sex on Resident #11. The Investigation indicated Resident #1 and Resident #11 were immediately separated and Resident #1 was placed on one to one supervision. The Investigation indicated both Resident #1 and Resident #11 were incompetent and had Guardians. A Psychiatric Note, dated 05/08/18, indicated staff requested Resident #1 be seen due to recent inappropriate behaviors. The Note indicated Resident #1 acknowledged his/her behavior was inappropriate, was exhibiting more frustration and less ability to control his/her behaviors. The Note indicated that Resident #1 did not seem to need one to one supervision since he/she stated he/she would not engage in the behavior again and recommended 15 minute checks to assess stability of behaviors. A Nurse Progress Note, dated 05/23/18, indicated Resident #1's 15 minute checks were discontinued due to no further sexual behaviors, he/she would be followed in weekly behavior rounds and continue psychiatric service and social service visits for psychosocial well being. The Behavior Care Plan, indicated Resident #1's 15 minute checks were discontinued on 08/05/18, however, there was no documentation to support that 15 minute checks were conducted after 05/23/18. Review of the Behavior Rounds Documentation indicated Resident #1 was not reviewed weekly after 05/23/18. There was no documentation in Resident #1's clinical record that he/she was seen by social services from 05/23/18 through 08/03/18. The Surveyor interviewed Director of Nurses (DON) #1 at 2:27 P.M. and at 3:59 P.M. on 12/10/18. DON #1 said there was no documentation to indicate 15 minute checks were continued after 05/23/18 or that Resident #1 was reviewed in weekly behavior rounds, or that social services continued to follow Resident #1 after 05/23/18. A Psychiatric Note, dated 06/22/18, indicated Resident #1's [MEDICATION NAME] (an anticonvulsant medication also used to treat [MEDICAL CONDITION] disorder) medication was increased due to a recent incident of sexually inappropriate behavior. The Quarterly MDS, dated [DATE], indicated Resident #1 was independent on the unit in his/her wheelchair and exhibited behaviors towards others. The Facility Investigation, dated 08/03/18, indicated an incident occurred between Resident #1 and Resident #7 of unwelcomed sexual contact/advance. The Investigation indicated Resident #1 was witnessed by staff touching Resident #7's exposed genitalia. A Nurse Practitioner Note, dated 08/03/18, indicated Resident #1 was seen for a follow up status [REDACTED].#7). The Note indicated Resident #1 had a history of [REDACTED]. A Psychiatric Note, dated 08/06/18, indicated per staff, Resident #1 was recently sexually inappropriate towards another resident (Resident #7). The Note indicated Resident #1 acknowledged this but stated he/she wanted the other resident to be his/her boy/girlfriend and thought it was consensual. The Note indicated Resident #1 had poor insight into situation and that his/her behaviors weren't impulsive but rather thought out and rationalized in his/her head. Resident #7 was admitted to the Facility with [DIAGNOSES REDACTED]. A Resident Incapacity Pursuant to Massachusetts Health Care Proxy Massachusetts General Law (M.G.L.) C201D Form, dated and signed by the Nurse Practitioner on 01/31/17, indicated Resident #7 lacked the capacity to make, or communicate health care decisions due to dementia and impaired cognition. Review of Resident #7's clinical record indicated there was no documentation to support that he/she was evaluated and determined to have the capacity to consent to sexual activity. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #7 required extensive assist of two staff persons for transfers and dressing, was non ambulatory, and had limited range of motion of his/her bilateral upper and lower extremities. A Social Service Progress Note, dated 08/03/18, indicated Resident #7 was found to be engaging in a mild sexual encounter with another resident. A Psychiatric Note, dated 08/06/18, indicated Resident #7 had slow and sparse speech, poor judgement, fair insight, impaired fund of knowledge (information that a person has stored in memory about people, places, and things), and impaired immediate and recent recall. The Note indicated Resident #7 was the victim of a sexually inappropriate behavior by another resident. The Note indicated Resident #7 did not feel safe on the floor of the aggressor. The Surveyor interviewed CNA #2 at 11:20 A.M. on 12/04/18 and again at 11:20 A.M. and 1:35 P.M. on 12/10/18. CNA #2 said she was walking by Resident #7's room when she witnessed Resident #1 leaning over and touching Resident #7's genital area with his/her hands. CNA #2 said she called out to Resident #1 and asked what he/she was doing (which is inconsistent with what CNA #3 and Nurse #1 said to the Surveyor) and then called CNA #3 and Nurse #1 over to the room. CNA #2 said she could not recall if she provided the Facility with a written statement. Review of the Facility's Investigation File for Resident #1 and Resident #7, dated 08/03/18, indicated there was no documentation to support that a written statement was obtained from CNA #2. An Investigation Statement, dated 08/03/18, written and signed by CNA #3, indicated CNA #2 called CNA #3 to witness the incident between Resident #1 and Resident #7. The Statement indicated CNA #3 witnessed Resident #1 sucking Resident #7. The Statement did not indicate what Resident #1 was sucking on Resident #7's body. The Surveyor interviewed CNA #3 at 3:55 P.M. on 12/03/18 and again at 10:57 A.M. and 1:42 P.M. on 12/10/18. CNA #3 said CNA #2 called her over to Resident #7's room to witness Resident #1 with his/her mouth on and sucking Resident #7's genitalia. CNA #3 said she and CNA #2 just stood in the doorway, did not say anything, did not intervene, and watched for approximately two to three minutes before calling Nurse #1 over. CNA #3 said Resident #7 did not have the ability to pull his/her pants down, unzip them, and would not have the ability to push Resident #1 away from him/herself. An Investigation Statement, dated 08/03/18, written and signed by Nurse #1, indicated she and Administrator #2 were called to Resident #7's room by two CNAs. The Statement indicated Nurse #1 witnessed Resident #1 with his/her hands pulling on Resident #7's exposed genitalia. The Surveyor interviewed Nurse #1 at 4:10 P.M. on 12/03/18 and again at 11:41 A.M. on 12/10/18. Nurse #1 said she was walking onto the unit with Administrator #2 and saw CNA #2 and CNA #3 standing in Resident #7's doorway. Nurse #1 said CNA #2 and CNA #3 waved her over to the room. Nurse #1 said when she walked into Resident #7's room she witnessed Resident #1 playing, pulling, and tugging on Resident #7's genitalia. Nurse #1 said she separated Resident #1 and Resident #7 immediately. Nurse #1 said she said to Resident #7 It's not like you to engage in things like this or words to that effect. Nurse #1 said Resident #7 was awake, however, she did not think Resident #7 knew what was going on. Nurse #1 said Resident #7 did not speak that much, was not agile, and did not have the ability to push someone away from him/herself. The Surveyor interviewed Administrator #2 at 2:16 P.M. and 2:28 P.M. on 12/11/18. Administrator #2 said he and Nurse #1 were brought over to Resident #7's room by two CNA's, whom he could not recall, and the CNAs reported that Resident #1 and Resident #7 were engaged in a behavior. Administrator #2 said he could not recall the specific behavior the CNAs reported. Administrator #2 said he witnessed Resident #1 adjusting Resident #7's pants. Administrator #2 said he did not see any part of Resident #7's body exposed. Administrator #2 said he could not recall if he wrote a statement. Review of the Facility's Investigation File for Resident #1 and Resident #7, dated 08/03/18, indicated there was no documentation to support that a written statement was obtained from Administrator #2. The Surveyor interviewed Director of Nurses (DON) #1 at 3:59 P.M. on 12/10/18. DON #1 said that the Facility had provided the Surveyor with the complete Investigation File for the incident on 08/03/18 that involved Resident #1 and Resident #7. The Surveyor interviewed Resident #7 at 4:28 P.M. on 12/03/18. Resident #7 said Resident #1 touched his/her breasts and squeezed them. Resident #7 said he/she told Resident #1 to stop and he/she eventually did. Resident #7 could not recall anything else about the incident. The Surveyor interviewed Resident #1 at 4:58 P.M. on 12/03/18. Resident #1 said that he/she and Resident #7 were talking about sexuality and that he/she touched Resident #1 a little bit or words to that effect. Resident #1 said he/she touched Resident #7 and Resident #7 touched him/her, but could not recall where they touched each other on the body. 2. Resident #2 was admitted to the Facility in 06/2018. A Facility Investigation, dated 08/05/18, indicated Resident #2 reported to a CNA that Resident #1 had touched him/her inappropriately last week. The Investigation indicated Resident #1 started to touch Resident #2 on his/her leg. The Facility Investigation indicated Resident #2 told Resident #1 to stop when he/she noticed Resident #1 had Vaseline (a type of petroleum jelly used as an ointment or lubricant) on his/her hand and attempted to undo Resident #2's brief. Review of the Health Care Facility Reporting System (HCFRS) indicated the Facility reported the alleged resident to resident sexual abuse that occurred on 08/05/18, involving Resident #1 and Resident #2, on 08/07/18, 2 days after the alleged incident. The HCFRS Report indicated Resident #2 was alert and oriented x3 (to person, place and time), the Facility contacted the police and the Facility was unable to substantiate the allegation. The Surveyor interviewed Resident #2 at 9:25 A.M. on 12/14/18. Resident #2 said that one day Resident #1 had rubbed Resident #2's leg then grabbed a jar of Vaseline and Resident #1 tried to go up Resident #2's shorts and grab his/her genitalia, or words to that effect. Resident #2 said he/she told Resident #1 to stop and he/she did. Resident #2 said he/she informed a nurse about the incident a few days later. 3. Resident #5 was admitted to the Facility in (MONTH) (YEAR). The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #5 was cognitively intact. The Facility's Investigation, dated 09/23/18, indicated that on 09/22/18 at approximately 10:30 P.M. Resident #5 reported to Nurse #5 that CNA #9 called him/her a pain in the ass or words to that effect. The Investigation indicated CNA #8 heard CNA #9 say to Resident #5 Hi, pain in the ass or words to that effect. The Investigation indicated CNA #9 jokingly told Resident #5, in front of CNA #8, that Resident #5 could sometimes be a pain or words to that effect and that Resident #5 became upset from the remark. The Surveyor interviewed Resident #5 at 11:54 A.M. on 12/03/18. Resident #5 said CNA #9 entered his/her room with CNA #8 to set Resident #5 up for supper and upon entering his/her room called Resident #5 a pain in the ass or words to that effect. Resident #5 said he/she was upset by this remark and felt disrespected by CNA #9. The Surveyor interviewed CNA #9 at 3:13 P.M. on 12/10/18. CNA #9 said that he entered Resident #5's room at approximately 4:30 P.M. on 09/22/18 with CNA #8 and jokingly remarked that Resident #5 could be a pain or words to that effect. CNA #9 said that Resident #5 became upset after the remark. The Surveyor interviewed CNA #8 at 2:13 P.M. on 12/03/18. CNA #8 said that at approximately 4:30 P.M. on 09/22/18 when he and CNA #9 entered Resident #5's room, CNA #9 said the Resident #5 you pain in the ass or words to that effect. CNA #8 said Resident #5 seemed upset and responded to CNA #9 I don't like that or words to that effect. The Surveyor interviewed Nurse #5 at 3:35 P.M. on 12/03/18. Nurse #5 said she entered Resident #5's room and he/she looked distressed and upset. Nurse #5 said she asked Resident #5 what was wrong and Resident #5 said that when CNA #9 brought in his/her supper, CNA #9 had called him/her a pain in the ass or words to that effect. The Surveyor interviewed Director of Nurses (DON) #1 at 2:18 P.M. on 12/04/18. The DON said that she would consider calling a resident a pain in the ass or words to that effect verbal abuse.

Based on records reviewed and interviews for five of 19 residents (Resident #1, #2, #4, #5, and #7), the Facility failed to implement their abuse prohibition policy. - On 08/03/18, the Facility failed to protect Resident #7 from a sexual assault by Resident #1, who had a known history of sexual inappropriate behaviors. - On 08/03/18, the Facility staff failed to immediately intervene when a staff member witnessed Resident #7 being sexually assaulted by Resident #1. - The Facility failed to complete a thorough investigation of a sexual assault that occurred on 08/03/18, when staff witnessed Resident #1 sexually assaulting Resident #7. The Facility failed to obtain written statements from all potential witnesses, failed to clarify inconsistencies of the incident with the staff and failed to interview other potential victims on the unit. - The Facility failed to accurately and timely report to the Department of Public Health the sexual assault that occurred on 08/03/18, when staff witnessed Resident #1 sexually assaulting Resident #7. - On 08/18/18, the Facility failed to follow their policy and remove an accused staff member from the staffing schedule pending an investigation of an allegation of physical abuse. - On 09/22/18, the Facility failed to remove an accused staff member from the staffing schedule pending an investigation of an allegation of verbal abuse. Findings include: The Facility Policy titled, Abuse Prohibition Policy, dated 12/2016, indicated the Facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation and misappropriation of his or her property. The Policy indicated: - Identify events, occurrences, patterns and trends of potential abuse for residents. - It is the Facility's responsibility to identify, correct and intervene in situations where abuse, mistreatment, neglect, exploitation and/or misappropriation of residents property occur. - Any incident of actual or suspected abuse must have an incident report completed. - The Supervisory personnel are responsible to ensure that the initial investigation regarding the incident occurs timely and appropriate interventions are put into place to ensure residents safety or protect residents from additional harm. - Interventions will include the obtaining of statements from witnesses of the incident, the outcome of the supervisory investigation, and the timely notification of administrative personnel regarding the incident to ensure that a comprehensive internal facility investigation is completed in a timely fashion and appropriate staff interventions are included in the resident's comprehensive plan of care. - The Administrator shall assume the overall responsibility to ensure that incident reports are accurately completed, and personnel statements are obtained timely, to ensure completion of the internal investigation. - Protection of Residents from Harm, Immediate Action, is to remove the resident from the alleged abuser or remove the abuser from the resident. - Place the employee on administrative leave pending the completion of the investigation. - Report to the Department of Public Health (DPH): all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. A Facility Investigation, dated 05/02/18, indicated Resident #1 was found in Resident #11's bathroom performing oral sex on Resident #11. The Investigation indicated Resident #1 and Resident #11 were immediately separated and Resident #1 was placed on one to one supervision. The Investigation indicated both Resident #1 and Resident #11 were incompetent and had Guardians. A Nurse Practitioner Note, dated 08/03/18, indicated Resident #1 was seen for a follow up status [REDACTED]. The Note indicated Resident #1 had a history of [REDACTED]. Resident #7 was admitted to the Facility with [DIAGNOSES REDACTED]. A Social Service Progress Note, dated 08/03/18, indicated Resident #7 was found to be engaging in a mild sexual encounter with another resident. A Psychiatric Note, dated 08/06/18, indicated Resident #7 had slow and sparse speech, poor judgement, fair insight, impaired fund of knowledge (information that a person has stored in memory about people, places, and things), and impaired immediate and recent recall. The Note indicated Resident #7 was the victim of a sexually inappropriate behavior by another resident. The Note indicated Resident #7 did not feel safe on the floor of the aggressor. The Facility Investigation, dated 08/03/18, indicated an incident occurred between Resident #1 and Resident #7 of unwelcomed sexual contact/advance. The Investigation indicated Resident #1 was witnessed by staff touching Resident #7's exposed genitalia. The Surveyor interviewed Certified Nurse Aide (CNA) #2 at 11:20 A.M. on 12/04/18 and again at 11:20 A.M. and 1:35 P.M. on 12/10/18. CNA #2 said she was walking by Resident #7's room when she witnessed Resident #1 leaning over and touching Resident #7's genital area with his/her hands. CNA #2 said she could not recall if she provided the Facility with a written statement. Review of the Facility's Investigation File for Resident #1 and Resident #7, dated 08/03/18, indicated there was no documentation to support that a written statement was obtained from CNA #2. This is not consistent with the Facility policy. An Investigation Statement, dated 08/03/18, written and signed by CNA #3, indicated CNA #2 called CNA #3 to witness the incident between Resident #1 and Resident #7. The Statement indicated CNA #3 witnessed Resident #1 sucking Resident #7. The Statement did not indicate what Resident #1 was sucking on Resident #7's body. The Surveyor interviewed CNA #3 at 3:55 P.M. on 12/03/18 and again at 10:57 A.M. and 1:42 P.M. on 12/10/18. CNA #3 said CNA #2 called her over to Resident #7's room to witness Resident #1 with his/her mouth on and sucking Resident #7's genitalia. CNA #3 said she and CNA #2 just stood in the doorway, did not say anything, did not intervene, and watched for approximately two to three minutes before calling Nurse #1 over. An Investigation Statement, dated 08/03/18, written and signed by Nurse #1, indicated she and Administrator #2 were called to Resident #7's room by two CNAs. The Statement indicated Nurse #1 witnessed Resident #1 with his/her hands pulling on Resident #7's exposed genitalia. The Surveyor interviewed Nurse #1 at 4:10 P.M. on 12/03/18 and again at 11:41 A.M. on 12/10/18. Nurse #1 said when she walked into Resident #7's room she witnessed Resident #1 playing, pulling, and tugging on Resident #7's genitalia. The Surveyor interviewed Administrator #2 at 2:16 P.M. and 2:28 P.M. on 12/11/18. Administrator #2 said he and Nurse #1 were brought over to Resident #7's room by two CNA's, whom he could not recall, and the CNAs reported that Resident #1 and Resident #7 were engaged in a behavior. Administrator #2 said he could not recall the specific behavior the CNAs reported. Administrator #2 said he could not recall if he wrote a statement. Review of the Facility's Investigation File for Resident #1 and Resident #7, dated 08/03/18, indicated there was no documentation to support that a written statement was obtained from Administrator #2. The Surveyor interviewed Director of Nurses (DON) #1 at 3:59 P.M. on 12/10/18. DON #1 said that the Facility had provided the Surveyor with the complete Investigation File for the incident on 08/03/18 that involved Resident #1 and Resident #7. Review of the Health Care Facility Reporting System (HCFRS) indicated the alleged resident to resident sexual abuse that occurred on 08/03/18 that involved Resident #1 and Resident #7, was reported to the DPH as: Resident #1 was found to be reaching for Resident #7's private area. The Conclusion of the Report indicated Resident #1 had his/her hand on Resident #7's genitalia. The Report did not indicate that Resident #1 was witnessed by a staff member to have his/her mouth on and sucking on Resident #7's genitalia. The Report indicated this incident was not reported to Department of Public Health (DPH) immediately until 08/07/18, 4 days after the alleged incident. 2. Resident #2 was admitted to the Facility in (MONTH) (YEAR). The Admission MDS, dated [DATE], indicated Resident #2 is cognitively intact. A Facility Investigation Report, dated 08/05/18, indicated Resident #2 reported to a CNA that Resident #1 had touched him/her inappropriately last week. The Report indicated Resident #1 started to touch Resident #2 on his/her leg and Resident #2 told Resident #1 to stop when he/she noticed Resident #1 had Vaseline (a type of petroleum jelly used as an ointment or lubricant) on his/her hand and attempted to undo Resident #2's brief. Although the Facility Investigation Report indicated the Facility was informed of the alleged sexual abuse and began their investigation on 8/5/18, review of the Health Care Facility Reporting System (HCFRS) indicated the alleged resident to resident sexual abuse that occurred on 08/05/18, involving Resident #1 and Resident #2, was not reported to Department of Public Health (DPH) until 08/07/18, 2 days after the alleged incident was reported to the Facility. 3. Resident #4 was admitted to the Facility in (MONTH) (YEAR). The Admission MDS, dated [DATE], indicated Resident #4 was cognitively intact. The Facility Investigation, dated as initiated on 08/18/18, indicated Resident #4 reported on 08/20/18 to the Business Office Manager that CNA #5 grabbed, scratched, and pushed him/her onto the bed and broke his/her phone to prevent Resident #4 from making a phone call. The Investigation indicated the alleged physical abuse that occurred on 08/18/18 was reported to DON #2 by Nurse #4 after the incident happened, however, it was reported to DON #2 that Resident #4 hit CNA #5. The Surveyor interviewed Nurse #4 at 8:55 A.M. on 12/10/18. Nurse #4 said at about 5:00 A.M. on 08/18/18, he heard screaming from Resident #4's room. Nurse #4 said when he went to the room CNA #5 reported to him that Resident #4 threw his/her phone at her and scratched her on the arm. Nurse #4 said Resident #4 reported to him that CNA #5 had hit him/her. Nurse #4 said he asked CNA #5 to leave the room. Nurse #4 said he called DON #2 on 08/18/18 immediately after the incident and reported that Resident #4 alleged CNA #5 hit him/her. The Surveyor interviewed Director of Nurses #2 at 11:10 A.M. on 12/12/18. DON #2 said that Nurse #4 did call her on 08/18/18 regarding the incident between Resident #4 and CNA #5. DON #2 said Nurse #4 reported to her that Resident #4 hit CNA #5. DON #2 said she did not learn that Resident #4 alleged that CNA #5 grabbed, scratched, threw him/her onto the bed and broke his/her phone until 08/20/18. Review of the Time Detail Report, dated 01/01/18 through 11/21/18, indicated CNA #5 worked the following shifts: - On 08/17/18 from 2:46 P.M. until 7:34 A.M. on 08/18/18 - On 08/18/18 from 2:25 P.M. until 11:07 P.M. The Surveyor interviewed the Human Resources Coordinator at 3:50 P.M. on 12/10/18. The Human Resource Coordinator confirmed with Surveyor that CNA #5 worked her scheduled shifts on 08/18/18. The Surveyor interviewed Administrator #1 at 3:05 P.M. Administrator #1 said Nurse #4 should have sent the accused CNA #5 home pending the facility investigation. 4. Resident #5 was admitted to the Facility in (MONTH) (YEAR). The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #5 was cognitively intact. The Facility's Investigation, dated 09/23/18, indicated that on 09/22/18 at approximately 10:30 P.M. Resident #5 reported to Nurse #5 that CNA #9 called him/her a pain in the ass or words to that effect. The Investigation indicated DON #2 asked the Staffing Scheduler to remove the accused CNA #9 off the schedule pending the facility investigation, however, the Staff Scheduler removed the wrong staff member from the schedule. The Surveyor interviewed Director of Nurses #2 at 11:10 A.M. on 12/12/18. DON #2 said Nursing Supervisor #1 did not call her to inform her of the verbal abuse allegation on 09/22/18 and that she should have called her. DON #2 said she did not learn of the allegation until Nurse #5 called her on the morning of 09/23/18. DON #2 said she then notified the staffing scheduler to remove CNA #9 off the schedule pending the investigation, however the staffing scheduler removed the wrong staff member off the schedule and not the accused CNA #9. The Surveyor interviewed the Staffing Scheduler at 12:20 P.M. on 12/04/18. The Staffing Scheduler said when DON #2 called her and asked her to remove CNA #9 off the schedule, she removed the wrong staff member off the schedule. Review of the Time Detail Report, dated 01/18/18 through 11/21/18, indicated CNA #9 worked the following shifts: - On 09/22/18 from 3:21 P.M. until 7:48 P.M. and 8:16 P.M. until 11:19 P.M. - On 09/24/18 from 10:59 P.M. to 09/25/18 at 2:17 A.M. and from 2:34 A.M. until 7:10 A.M. - On 9/25/18 from 11:01 P.M. until 7:18 A.M. The Surveyor interviewed the Human Resources Coordinator at 3:50 P.M. on 12/10/18. The Human Resource Coordinator confirmed with Surveyor that CNA #9 worked his scheduled shifts on 09/22/18, 09/24/18, and 09/25/18. The Surveyor interviewed Administrator #1 at 3:05 P.M. on 12/04/18. Administrator #1 said she would have expected for CNA #8 to intervene when he heard CNA #9 tell Resident #5 he/she was a pain in the ass or words to that effect and then report it to a supervisor immediately. Administrator #1 said she would have expected Nursing Supervisor #1 to remove the accused CNA #9 off the unit and send home CNA #9 pending the facility investigation.

Based on records reviewed and interviews for three of 19 sampled residents (Resident #1, #2, and #7), the Facility failed to ensure that alleged incidents of resident to resident sexual abuse were reported to the Department of Public Health (DPH) within two hours as required. Findings include: The Facility Policy titled, Abuse Prohibition Policy, dated 12/2016, indicated that reporting requirements to the Department of Public Health (DPH): all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 1. The Facility Investigation, dated 08/03/18, indicated Resident #1 was witnessed by staff touching and sucking on Resident #7's genitalia. Review of the Health Care Facility Reporting System (HCFRS) indicated the alleged resident to resident sexual abuse that occurred on 08/03/18, involving Resident #1 and Resident #7, was not reported to Department of Public Health (DPH) until 08/07/18, 4 days after the alleged incident. 2. The Facility Investigation, dated 08/05/18, indicated Resident #2 reported to a Certified Nurse Aide (CNA) that Resident #1 had touched him/her inappropriately last week. The Investigation indicated Resident #1 started to touch Resident #2 on his/her leg and Resident #2 told Resident #1 to stop when he/she noticed Resident #1 had Vaseline (a type of petroleum jelly used as an ointment or lubricant) on his/her hand and attempted to undo Resident #2's brief. Review of the Health Care Facility Reporting System (HCFRS) indicated the alleged resident to resident sexual abuse that occurred on 08/05/18, involving Resident #1 and Resident #2, was not reported to Department of Public Health (DPH) until 08/07/18, 2 days after the alleged incident. The Surveyor interviewed Director of Nurses (DON) #2 at 11:10 A.M. on 12/12/18. DON #2 said allegations of sexual abuse should be reported to the DPH within two hours of the allegation.

Based on records reviewed and interviews for two of 19 residents (Resident #1 and Resident #7), the Facility failed to thoroughly investigate an alleged sexual assault that occurred between Resident #1 and Resident #7. Findings include: The Facility Policy titled, Abuse Prohibition Policy, dated 12/2016, indicated the Facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation and misappropriation of his or her property. The Policy indicated: - The Supervisory personnel are responsible to ensure that the initial investigation regarding the incident occurs timely and appropriate interventions are put into place to ensure residents safety or protect residents from additional harm. - Interventions will include the obtaining of statements from witnesses of the incident, the outcome of the supervisory investigation, and the timely notification of administrative personnel regarding the incident to ensure that a comprehensive internal facility investigation is completed in a timely fashion and appropriate staff interventions are included in the resident's comprehensive plan of care. - The Administrator shall assume the overall responsibility to ensure that incident reports are accurately completed, and personnel statements are obtained timely, to ensure completion of the internal investigation. 1. The Facility Investigation, dated 08/03/18, indicated an incident occurred between Resident #1 and Resident #7 of unwelcomed sexual contact/advance. The Investigation indicated Resident #1 was witnessed by staff touching Resident #7's exposed genitalia. The Surveyor interviewed Certified Nurse Aide (CNA) #2 at 11:20 A.M. on 12/04/18 and again at 11:20 A.M. and 1:35 P.M. on 12/10/18. CNA #2 said she was walking by Resident #7's room when she witnessed Resident #1 leaning over and touching Resident #7's genital area with his/her hands. CNA #2 said she called out to Resident #1 and asked what he/she was doing (which is inconsistent with what CNA #3 and Nurse #1 said to the Surveyor) and then called CNA #3 and Nurse #1 over to the room. CNA #2 said she could not recall if she provided the Facility with a written statement. Review of the Facility's Investigation File for Resident #1 and Resident #7, dated 08/03/18, indicated there was no documentation to support that a written statement was obtained from CNA #2. An Investigation Statement, dated 08/03/18, written and signed by CNA #3, indicated CNA #2 called CNA #3 to witness the incident between Resident #1 and Resident #7. The Statement indicated CNA #3 witnessed Resident #1 sucking Resident #7. The Statement did not indicate what Resident #1 was sucking on Resident #7's body. The Surveyor interviewed CNA #3 at 3:55 P.M. on 12/03/18 and again at 10:57 A.M. and 1:42 P.M. on 12/10/18. CNA #3 said CNA #2 called her over to Resident #7's room to witness Resident #1 with his/her mouth on and sucking Resident #7's genitalia. An Investigation Statement, dated 08/03/18, written and signed by Nurse #1, witnessed Resident #1 with his/her hands pulling on Resident #7's exposed genitalia. The Surveyor interviewed Nurse #1 at 4:10 P.M. on 12/03/18 and again at 11:41 A.M. on 12/10/18. Nurse #1 said when she walked into Resident #7's room she witnessed Resident #1 playing, pulling, and tugging on Resident #7's genitalia. Nurse #1 said she separated Resident #1 and Resident #7 immediately. The Surveyor interviewed Administrator #2 at 2:16 P.M. and 2:28 P.M. on 12/11/18. Administrator #2 said he and Nurse #1 were brought over to Resident #7's room by two CNA's, whom he could not recall, and the CNAs reported that Resident #1 and Resident #7 were engaged in a behavior. Administrator #2 said he could not recall the specific behavior the CNAs reported. Administrator #2 said he witnessed Resident #1 adjusting Resident #7's pants. Administrator #2 said he did not see any part of Resident #7's body exposed. Administrator #2 could not recall if he wrote a statement. Review of the Facility's Investigation File for Resident #1 and Resident #7, dated 08/03/18, indicated there was no documentation to support that a written statement was obtained from Administrator #2. The Surveyor interviewed Director of Nurses (DON) #1 at 3:59 P.M. on 12/10/18. DON #1 said that the Facility had provided the Surveyor with the complete Investigation File for the incident on 08/03/18 that involved Resident #1 and Resident #7. Review of the Health Care Facility Reporting System (HCFRS) indicated the alleged resident to resident sexual abuse that occurred on 08/03/18 that involved Resident #1 and Resident #7, was reported to the DPH as: Resident #1 was found to be reaching for Resident #7's private area. The Conclusion of the Report indicated Resident #1 had his/her hand on Resident #7's genitalia. The Report did not indicate that Resident #1 was witnessed by a staff member to have his/her mouth on and sucking on Resident #7's genitalia. The Surveyor interviewed Director of Nurses (DON) #2 at 11:10 A.M. on 12/12/18. DON #2 said she did not know why the statement from CNA #3 of her witnessing Resident #1 with his/her mouth on and sucking on Resident #7's genitalia was not reported to the DPH. DON #2 said she would expect staff to intervene immediately. DON #2 said statements should have been obtained from all staff that may have witnessed the incident. DON #2 said that the facility did not interview other residents on the unit.

Based on records reviews, interviews and observations, for 11 sampled residents of 20 residents who smoked (#6, #27, #29, #83, #86, #94, #123, #124, #281, #331, and #482), the facility failed to ensure that residents did not smoke in proximity to a liquid portable oxygen unit, as the unit can allow objects to ignite more easily, and to burn more quickly and at a higher temperature. - Resident #86 was observed at multiple times on multiple dates of survey, smoking with a portable liquid oxygen tank on or near his/her person. - On 03/21/18 at 4:45 P.M., Surveyors observed 7 residents in the Facility's designated smoking area during a designated smoking time. Resident #29 was in possession of a lighter, and was lighting the other residents' cigarettes. Certified Nurse Aide (CNA) #19, who was assigned to supervise the designated smoking group, was observed standing inside the Facility, without a key to open the locked exterior door in the event of an emergency. Findings include: The Facility Policy, titled Smoking, revised (MONTH) (YEAR), indicated that: - Residents who smoke would be evaluated for their ability to smoke safely upon admission, quarterly, and as dictated by any significant change in condition, to ensure that they continued to be capable of smoking and use smoking materials without presenting a danger to themselves or others; - All cigarettes, igniting and smoking materials will be kept in a secure location designated at the facility; - Smoking or the use of smoking materials by residents will not be permitted on the grounds of the facility with the exception of the designated smoking area; - Smoking would take place under the supervision of a staff member, and that the staff member would have the responsibility of lighting all cigarettes; and, - Staff members were not allowed to smoke when residents were smoking. Review of the Facility's Smoking Safety Screen (the paper assessment) and the Smoking Evaluation and Safety Screen (the electronic assessment) indicated that at minimum, a resident required supervision when smoking. Neither assessment tool allowed for a resident to be designated as independent with smoking. 1. On 03/15/18 at approximately 6:30 A.M., the Surveyor observed an individual walking independently with a rolling walker through the visitors parking area. The individual had a portable oxygen tank with him/her and had nasal cannula tubing (tubing with prongs to allow the oxygen to flow into the nose) around his/her neck. The Surveyor observed the individual stop between two parked cars, sit down on the seat of the rolling walker, then light and smoke a cigarette. The Surveyor observed the individual walk back towards the Facility's front entrance when he/she was done smoking. The Surveyors interviewed the ADON at 7:12 A.M. on 03/15/18. The ADON identified the individual observed by the Surveyor to be smoking in the Facility's parking lot as Resident #86. The ADON said Resident #86 required oxygen at all times, was cognitively intact, and was able to ambulate with a rolling walker without any additional assistance. The ADON said Resident #86 was not allowed to smoke on Facility property, unless during scheduled smoking times, and was not supposed to be in possession of smoking materials. The ADON said Resident #86 was supposed to sign himself/herself out of the Facility and leave the property to smoke, if not during scheduled smoking times. Resident #86 was admitted Facility to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #86's clinical record indicated that he/she signed a copy of the Facility's Smoking policy in (MONTH) (YEAR), indicating that he/she agreed to the terms and conditions of the smoking policy. Resident #86's Smoking Safety Screen, dated 09/16/17 through 09/18/17, indicated that supervision was provided to all residents who smoke for the duration of the scheduled smoking activity. The Smoking Care Plan, dated 01/04/18, indicated that oxygen must not be near smoking materials. The Resident Care Card, dated 01/17/18, indicated that Resident #86 used continuously flowing oxygen, and was a smoker. The Physician History and Physical, dated 02/13/17, indicated that Resident #86 continued to use oxygen, and had a nicotine addiction and still smoked. The physician's orders [REDACTED]. The ADON said the staff were aware Resident #86 smoked while in proximity to his/her oxygen tank. The ADON said Resident #86 was educated regarding the risks of smoking while in proximity to oxygen, but said that Resident #86 continued to do so anyway. As of 03/23/18, the DON and ADON were unable to provide the Surveyors with any documentation that Resident #86 was educated regarding any risks associated with smoking near his/her oxygen tank. The Surveyor interviewed Resident #86 at 8:09 A.M. on 03/15/18. Resident # 86 said there was a sign on the Facility's front door that indicated you must smoke 50 feet from building. Resident #86 said Facility staff told him/her that he/she had to smoke across the street, off of Facility property. Resident #86 said he/she had to sign out at the desk whenever he/she went out to smoke. Resident #86 said smoking material was supposed to be kept at desk but that he/she has his/her lighter and cigarettes in his/her pocket. Resident #86 pulled his/her lighter and cigarettes out of his/her pocket and showed the Surveyor. Resident #86 said that because the Surveyors were at the Facility, he/she had to turn in the lighter and cigarettes. On 3/16/18 at 7:00 A.M., the Surveyor observed Resident #86 outside of the Facility near the corner of the building closest to the entrance of the parking lot. The Surveyor observed Resident #86 seated on a rolling walker seat, facing the Surveyor. Resident #86 had on oxygen via nasal cannula, and was observed to be smoking a cigarette. The Surveyor was unable to visualize any Facility staff in the vicinity. The Surveyors interviewed the DON and ADON at 2:11 P.M. on 03/16/18 and at multiple times throughout the dates of survey. The DON and ADON said they were aware that Resident #86 signed himself/herself out of the Facility to smoke. The DON and ADON said Resident #86 used oxygen, and sometimes took the oxygen tank outside with him/her when he smoked. The DON and ADON said Resident #86 shut the oxygen off before smoking, and the DON said she had personally checked the oxygen tank a couple of times to make sure that it was off. The Facility Policy, titled Pro2Caire, revised 05/10/17, indicated the liquid portable oxygen units should not be operated near flames or in close proximity to someone smoking. On 3/20/18 at 10:08 A.M., the Surveyors observed Resident #86, five other residents, and a staff member in the Facility's designated smoking area. The Surveyors observed Resident #86 turn off his/her portable liquid oxygen tank, and the staff member begin to light the residents' cigarettes. The Surveyors asked the DON to observe the smoking group to determine if there were any safety concerns. The DON asked the Surveyors if there was a concern with Resident #86's portable liquid oxygen tank, and said it was not a problem because Resident #86 shuts the oxygen tank off. The Surveyors asked the DON about concerns with the oxygen tank being in the presence of residents smoking. The DON said that Resident #86 shut the oxygen off and would usually leave the tank in the hallway. The Surveyor interviewed CNA #12 at 10:16 A.M. on 03/20/18. CNA #12 said Resident #86 was already outside in the designated smoking area with his/her portable liquid oxygen before he arrived to supervise the smoking area. CNA #12 said he did not see the portable liquid oxygen tank with Resident #86, and removed the oxygen tank from the smoking area when the DON told him to. There was no documentation at the time of survey of a smoking safety evaluation completed for Resident #86 between 09/18/17 and 03/18/18, in accordance with Facility policy. There was no documentation at the time of survey of any education conducted with Resident #86 regarding the risks of smoking in proximity of his/her portable liquid oxygen tank. There was no indication at the time of survey of any concern for the health and safety of Resident #86, or any residents in his/her vicinity when he/she was smoking, by Facility staff of Resident #86 smoking in proximity to his/her portable liquid oxygen tank. 2. On 3/21/18 at 4:45 P.M., the Surveyors observed 7 residents outside in the Facility's designated smoking area for supervised smoking. The residents were observed to be in the possession of two cigarette lighters and were lighting their own, as well as each others', cigarettes. At this time, a Surveyor left the area to investigate and observed a CNA (identified as CNA #19 by the ADON) standing in the hall across from the exit door to the smoking area. The exit door was observed to be composed of metal with a narrow vertical window in the upper left quarter of the door, and was locked from the inside. The door was observed to exit to a small foyer, where there was a glass door to exit the Facility to the designated smoking area. The Surveyor looked outside and did not see any other staff member supervising the residents. The Surveyor attempted to exit the Facility to the designated smoking area where the 7 residents were actively smoking, but could not open the door because it was locked. When the Surveyor asked CNA #19 for assistance with opening the locked door, he said he needed to get the key. The Surveyor observed Nurse #5 in the hallway, and asked her who was supervising the residents smoking. The Surveyor said Nurse #5 looked outside, and then said she could not tell. The Surveyor observed Nurse #5 knock on the locked metal door, which was opened by one of the residents. Nurse #5 observed the seven residents with the cigarette lighters and/or lit cigarettes, and said they were not supposed to have the lighters, or be smoking without a staff member present. At that time, CNA #19 returned with the key to unlock the door and told Nurse #5 and the Surveyor that he was supervising the residents. When CNA #19 was asked why he was not outside with the residents, he said he did not like smoke and had forgotten his jacket up on the unit. CNA #19 was unable to explain what he would do if there was an accident involving a cigarette lighter or a lit cigarette given that he really couldn't observe the residents fully through the metal door, or unlock the door quickly because the key was not in his possession. On 3/21/18 at 5:00 P.M., the DON and ADON said CNA #19 did not follow the smoking policy. The 7 residents were identified by the ADON as Resident #6, Resident #29, Resident #83, Resident #94, Resident #123, Resident #124, and Resident #331. When interviewed on 03/16/18, the DON and the ADON said smoking was permitted at the Facility. The DON and ADON said smoking assessments should be completed at the time of a resident's admission and quarterly. The DON and ADON said that if a resident was assessed as being independent with smoking, the resident had to sign themselves out of the Facility and leave Facility property to smoke. The DON said the residents who were independent with smoking could not smoke in the Facility's designated smoking area because that area could only be utilized when a staff member was present to supervise the area, such as at designated smoking times. The DON and ADON said no resident was permitted to retain smoking materials, including cigarettes and lighters. The DON and ADON said all smoking materials were kept secured at the nurses' stations, and were only distributed when residents asked for them. The DON and ADON said residents were responsible to return the items when done smoking, and if they did not, a room search would be conducted. The Surveyor interviewed Unit Secretary #1 at 9:36 A.M. on 03/16/18. Unit Secretary #1 said the independent smokers have to sign themselves out in the leave of absence book, and were then given their cigarettes and lighter that were keep in an unlocked box at the nursing desk. Unit Secretary #1 said there was no system in place to monitor what residents were given cigarettes and lighters, or if the cigarettes and lighters were returned for storage. On 3/21/18 at 5:00 P.M., the Surveyor observed 8 residents in the designated supervised smoking area. The Surveyor observed one resident seated in a wheelchair, holding a lit cigarette with a long ash at the end of it, and his/her hand was shaking. The Surveyor observed another resident approached this resident, take the cigarette and disposed of it in a receptacle. A. Resident #6 was admitted to the Facility 2/2017. The Smoking Evaluation and Safety Screen, dated 02/19/18, indicated that Resident #6 required routine supervision during scheduled smoking activity. There was no documentation at the time of survey that Resident #6 was assessed to be safe to light his/her or any other resident's cigarette, or to be unsupervised while smoking. B. Resident #29 was admitted to the Facility in 8/2017. The Smoking Evaluation and Safety Screen, dated 03/09/18, indicated that Resident #29 required routing supervision during scheduled smoking activity. There was no documentation at the time of survey that Resident #29 was assessed to be safe to light his/her or any other resident's cigarette, or to be unsupervised while smoking. C. Resident #83 was admitted to the Facility in 10/2015. The Smoking Evaluation and Safety Screen, dated 01/09/18, indicated that Resident #83 required routine supervision during scheduled smoking activity. There was no documentation at the time of survey that Resident #83 was assessed to be safe to light his/her or any other resident's cigarette, or to be unsupervised while smoking. D. Resident #94 was admitted to the Facility in 7/2017. The Smoking Evaluation and Safety Screen, dated 01/22/18, indicated that Resident #94 required routine supervision during scheduled smoking activity. There was no documentation at the time of survey that Resident #94 was assessed to be safe to light his/her or any other resident's cigarette, or to be unsupervised while smoking. E. On 03/15/18 at 3:47 P.M., the Surveyor observed Resident #123 smoking in the front of the Facility. Resident #123 was admitted to the Facility in 2/2018. The Nursing Admission/Re-Admission Form, dated 02/01/18, indicated that Resident #123 smoked tobacco products. The Nurse Progress Notes, dated 03/18/18, indicated that Resident #123 continued to leave the Facility for independent smoking. Resident #123's care plans included that he/she wished to smoke. The care plan, initiated on 03/19/18, indicated that Resident #123 was independent with smoking. There was no documentation at the time of survey of a baseline care plan regarding Resident #123's wish to smoke, or of the completion of any evaluation to determine the level of supervision required for Resident #123 to smoke safely. There was no documentation to indicate that Resident #123 was assessed to be safe to light his/her or any other resident's cigarette. F. Resident #124 was admitted to the Facility in 9/2017. The Nurse Practitioner Progress Note, dated 11/24/17, indicated that Resident #124 continued to smoke. Resident #124's care plans included that he/she wished to smoke. The care plan, initiated on 02/05/18, indicated that he/she required supervision with smoking. There was no documentation at the time of survey of any evaluation of Resident #124's safety needs while smoking, or that Resident #124 was assessed to be safe to light his/her or any other resident's cigarette. G. Resident #331 was admitted to the Facility in 2/2018. The Smoking Safety Screen, dated 03/01/18, indicated that supervision was provided to all residents who smoke for the duration of the scheduled smoking activity. The Baseline Care Plan, undated, did not indicate that Resident #331 smoked. The Social Services Progress Note, dated 03/06/18, indicated that Resident #331 scored 3 out of 30 possible points on a Mini Mental Status Exam (a series of questions designed to test a range of everyday mental skills; a score of less than 12 indicates severe dementia). Resident #331's care plans included that he/she wished to smoke and was assessed for supervised smoking. The smoking care plan indicated that it was initiated on 03/19/18, after the start of survey. There was no documentation at the time of survey that a care plan was in place to address Resident #331's wish to smoke until 03/19/18, after the start of survey. There was no documentation to indicate that Resident #331 was assessed to be safe to light his/her or any other resident's cigarette, or to be unsupervised while smoking. 3. Resident #27 was admitted to the Facility in 9/2017. The Nursing Admission/Re-Admission Form, dated 11/08/17, did not include completed information regarding Resident #27's use of tobacco products. The Telephone Order, dated 01/03/18, indicated an order for [REDACTED]. The Progress Note, dated 01/10/18, indicated that Resident #27 was reported to be smoking in the bathroom. The Note indicated that the DON, Administrator, Social Services, and the writer of the note locked a lighter in the medication room. The Note indicated that Resident #27 could only attend supervised smoking time with staff. The Food and Drug Administration has warned that the use of nicotine replacement therapy, such as a nicotine patch, can cause serious short-term and long-term side effects such as: severe headaches and dizziness, weakness and [MEDICAL CONDITION], blurred vision, [MEDICAL CONDITION], or stroke. There was no documentation at the time of survey in Resident #27's paper or electronic clinical record, that the physician was notified of Resident #27's use of tobacco products while using nicotine replacement therapy, that Resident #27 was educated as to the risks of using tobacco products while receiving nicotine replacement therapy, that Resident #27 was evaluated or care planned regarding his/her ability to smoke safely, without a risk of injury to himself/herself and others. 4. The Surveyor interviewed Resident #58 at 8:47 A.M. on 03/15/18. Resident #58 said he/she does sign out and smoke outside independently and that he/she keeps his/her cigarettes and lighter in his/her room and that he/she does not always give them over to staff. Resident #58 showed Surveyor his/her cigarettes and lighter that were in his/her possession. On 03/22/18 at 6:50 A.M., the Surveyor observed a female smoking in the Facility parking lot. The female was identified by another Surveyor as Resident #58. Resident #58 was admitted to the Facility in 12/2017. Resident #58's Smoking Safety Screen, dated 12/11/17, indicated that supervision was provided to all residents who smoke for the duration of the scheduled smoking activity. The Smoking Evaluation and Safety Screen, dated 12/11/17, indicated that Resident #58 required routine supervision during scheduled smoking activity. Resident #58's care plans included that he/she wished to smoke. The care plan, initiated on 03/19/18, indicated that Resident #58 was independent with smoking. There was no documentation at the time of survey that a new assessment of Resident #58's safety while smoking had been reassessed, or of the reasons for the decreased level of supervision required while smoking. 5. On 03/16/18 at approximately 6:45 A.M., the Surveyor observed a resident, identified by another Surveyor as Resident #281, smoking in the Facility's front parking lot. On 03/22/18 at 10:14 A.M., the Surveyor observed three residents in the Facility's designated smoking area. There was no observable staff member present. As the Surveyor approached the designated area, a Certified Nurse Aide (CNA) was observed sitting inside the exterior door of the Facility, which led to the designated smoking area, using her cell phone. At 10:20 A.M., the ADON observed the CNA sitting in the same location as was observed 6 minutes prior, and observed that the CNA was using her cell phone. The ADON said the CNA should have been outside with the residents while they were smoking, and said the CNA should not have been using her cell phone. The ADON identified the three residents as Resident #86, Resident #281 and Resident #482. A. Resident #482 was admitted to the Facility in 3/2018. The Smoking Evaluation and Safety Screen, dated 03/15/18, indicated that Resident #482 required routine supervision during scheduled smoking activity. The Screen also included typed documentation that Resident #482 could sign out of the Facility to smoke off of the property. B. Resident #281 was admitted to the Facility in 2/2018. The Smoking Evaluation and Safety Screen, dated 02/21/18, indicated that Resident #281 required routine supervision during scheduled smoking activity. Resident #281's care plans included that he/she wished to smoke. The care plan, dated 03/05/18, indicated that he/she was independent with smoking, which conflicted with the assessment completed 12 days prior. 6. On 03/23/18 at 9:54 A.M., the Surveyor observed Nurse #5 smoking outside in the Facility's designated smoking area with residents during a designated smoking time, which was not in accordance with the Facility's smoking policy. 7. The facility staff failed to clean the lint traps of the dryers in the laundry area every two hours. Review of the Laundry Cleaning Schedule, revised 6/2009, indicated the lint traps of the dryers were to be cleaned every two hours. During inspection of the laundry area on 3/21/18 at 11:40 A.M. with the Administrator, the surveyor reviewed the log for cleaning the lint traps of the dryers. Review of the lint trap cleaning logs for 3/2018 indicated lint traps were primarily only cleaned from 8:00 A.M. to 2:00 P.M., or, 4:00 P.M. There were five days during the month where the cleaning was done after 4:00 P.M. There were no logs indicating cleaning for 11:00 P.M. to 7:00 A.M. At this time, the Administrator said that, as of approximately two weeks ago, laundry runs 24 hours a day. He said previously it had run until around 7:00 P.M. He said he felt the laundry staff were not logging the sheets correctly. He could show no monitoring on the 11:00 P.M. to 7:00 A.M. shift, and he would fix the situation immediately.

Based on interviews, observations, and record reviews, the facility staff failed to ensure that 2 sampled Residents (#92 and #115) were free from sexual abuse, in a total of 47 sampled residents. - The facility failed to ensure they took immediate corrective action and provided supervision following a resident to resident incident of sexual abuse, resulting in the aggressor (#49) being found in a third resident's room attempting to remove their clothing minutes after the first incident. - The facility staff also failed to assess residents for behaviors, which posed a threat to others and provide appropriate supervision for those behaviors for 2 sampled Residents (#92 and #49). - The facility staff failed to train staff regarding supervision and assessment of residents' behavior including how to respond to resident to resident incidents and abuse. - For Resident #92, who was known to lift his/her shirt and expose his/her breasts, the facility staff failed to assess or develop a care plan for this behavior. This behavior was observed while Resident #92 was in common areas prompting other residents to make inappropriate comments directed at Resident #92. Although staff were present, they took no corrective action in response. Findings include: The facility policy entitled Abuse Prohibition Policy, dated 12/2016, indicated the following: the facility staff- -have the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect and misappropriation of his/her personal property. -identify events, occurrences, patterns and trends of potential abuse for residents, -perform internal facility investigation of alleged violations and identification of staff members responsible for investigating incidents and the reporting of same to proper authorities, -protect residents from harm during an investigation of alleged abuse, which includes under immediate action: 1. Remove the resident from the alleged abuser or remove the abuser from the resident. Separate residents if it is a resident to resident altercation. 2. Notify the nursing supervisor. 3. Perform a physical assessment of the resident if physical abuse is suspected. 4. Provide any necessary interventions to insure the resident's safety and well being. 5. Provide emotional support and reassurance to the resident 1. Resident #92 was admitted to the facility in 1/2014 with a [DIAGNOSES REDACTED]. Review of the Significant Change of Status Minimum Data Set (MDS) Assessment, dated 1/17/18, indicated Resident #92 had severe cognitive impairment as evidenced by staff assessment, required total assistance from staff with transfers, did not ambulate, and exhibited physical, verbal and other behaviors not directed towards others during the assessment period. Review of the Behavior care plan, initiated 1/26/18 (and reviewed on 3/6/18), indicated Resident #92 had a behavior problem including being physically and verbally abusive relative to his/her [DIAGNOSES REDACTED]. The following interventions were included at this time: intervene as needed to protect the rights and safety of others; approach the resident in a calm manner; divert attention; remove from the situation and take him/her to another location as needed. Review of the current care card, indicated the resident has verbal, socially inappropriate behaviors and exhibits intrusive wandering. The care card does not indicate what the socially inappropriate behaviors were that were identified/nor interventions for the inappropriate behavior (later determined to be the behavior of lifting his/her shirt and exposing his/her breast (s)). Review of the 3/2018 Behavior Sheet, indicated Resident #92 was monitored for his/her wandering behavior. There were no other behaviors identified on the tracking sheet to be monitored. On 3/16/18 at 1:31 P.M., Resident #92 was observed seated in a wheel chair, in the dayroom with multiple other residents, during lunch. The surveyor observed Resident #92 intermittently lifting up his/her shirt, exposing his/her bare breasts. The surveyor observed a Certified Nurse Aide (CNA) #17 seated in front of Resident #92, and was observed not to intervene. On 3/16/18 from 2:04 P.M. - 2:13 P.M., Resident #92 was observed seated in a wheelchair, in the dayroom, with 12 other residents, while music played. He/she continuously lifted up his/her shirt, exposing his/her bare breasts with multiple other residents seated next to him/her. One facility staff member was observed in the day room at this time, and did not intervene. On 3/16/18 at 2:44 P.M., Resident #92 was observed seated in a wheelchair, in the dayroom during an activity, with other residents. He/she continuously pulled up his/her shirt to wipe his/her face, and exposed his/her bare breasts. A male resident seated at the same table was heard saying tits coming out. The surveyor observed there was no intervention by the two activity staff members in the dayroom at this time. During an interview on 3/16/18 at 2:55 P.M., Activities Assistant #4 said Resident #92 always lifts up his/her shirt to expose his/her bare breasts and that this is the resident's behavior. When the surveyor asked what the staff do when this occurs, Activities Assistant #4 said the facility staff try to cover him/her. During the interview/observation at this time, Resident #92 was observed to expose his/her bare breasts in front of the surveyor and Activities Assistant #4, and the facility staff did not intervene. On 3/20/18 at 12:36 P.M., Resident #92 was observed to be seated in a wheelchair in the day room, with multiple residents. The surveyor observed there were no facility staff members in the day room at this time. Resident #92 was observed to raise up his/her shirt towards his/her mouth, exposing his/her bare breasts, while 2 other residents who were seated at the same table made verbal comments, not audible to surveyor, and were pointing at Resident #92. During an interview on 3/20/18 at 1:39 P.M., Nurse #12 said Resident #92 has a behavior of lifting up his/her shirt, and needs frequent re-direction because of his/her cognition. Review of the progress notes from 1/2018 - 3/20/18, did not indicate the resident exhibited any socially inappropriate behavior, including lifting his/her shirt and exposing his/her breasts. During an interview on 3/27/18 at 8:06 A.M., CNA #10 said Resident #92 exposes his/her breasts about every 15-20 minutes when he/she is in the day room. She said this has been occurring for the last 2-3 months, and the intervention is to cover him/her, offer him/her snacks/drinks or bring him/her to his/her room. CNA #10 said when Resident #92 exposes his/her bare breasts, it does make other residents upset, but she does not think the resident is aware of what he/she is doing. She said when the resident does this, unusually Resident #92 is rubbing his/her face with his/her shirt, and is exposing his/her bare breasts. During an interview on 3/23/18 at 2:40 P.M., the Director of Nurses said she was unaware that Resident #92 had the behaviors of lifting his/her shirt and exposing his/her breast. She further said the purpose of the day room is for facility staff to monitor and supervise the residents until 8:00 P.M. During a follow up interview on 3/27/18 at 8:40 A.M., Unit Manager #1 said that when Resident #92 was observed by staff to lift up his/her shirt, and exposing his/her bare breasts in front of other residents, it should have been reported to nursing/administration because it is a dignity issue. 2. Resident #115 was admitted to the facility in 10/2017 with a [DIAGNOSES REDACTED]. The Quarterly MDS Assessment, dated 2/2/18, indicated the resident had moderate cognitive impairment as evidenced by staff assessment, required assistance of two staff for bed mobility, assistance of one staff for transfers and ambulation, and exhibited physical, verbal and other behaviors not directed towards others during the assessment period. 3. Resident #49 was admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. The Admission MDS Assessment, dated 12/27/17, indicated the resident had moderate cognitive impairment as evidenced by a score of 9/15 on the Brief Interview of Mental Status, required assistance of one staff for bed mobility, transfers and ambulation, and had no behaviors during the assessment period. Resident #49's current care plan, initiated 12/20/17 (and has a target date of 3/20/18), indicated the resident had a behavior problem related to a [DIAGNOSES REDACTED]. The interventions listed on the plan of care at this time included: intervene as needed to protect the rights and safety of others; approach in a calm manner; divert attention, remove from the situation and take to another location as needed. The current care plan, dated 12/20/17, indicated Resident #49 had impaired functional mobility related to cognition and required assist of 1 staff with ambulation, bed mobility and transfers. The nurse's note, dated 2/6/18, indicated Resident #49 had increased sexual behaviors with a female staff member and Nurse #13 during a shower. The note indicated the resident was re-directed with some success. The nurse's note, dated 2/7/18, indicated Nurse #13 notified the resident's family of the inappropriate sexual behaviors exhibited on the previous night, and was planned for male staff only assist with shower. Resident #49's current care card, undated, indicated he/she needed an assistance of 1 staff for transfers, bed mobility and ambulation. In addition, the care card indicated the resident was to have male staff only for showers. Resident #49's clinical record did not indicate the resident was monitored for behaviors. During an interview on 3/27/18 at 9:14 A.M., CNA #10 said Resident #49 was sexually inappropriate with her twice during showers. She said she told the nurse and called for help. CNA #10 said Resident #49 hits her on her bottom whenever she works, and she tells the nurse, and the resident is verbally re-directed. CNA #10 said that Nurse #13 is aware of this behavior. She further said she has seen Resident #49 put his/her hands in his/her pants inappropriately in front of other residents and this occurs all the time for weeks. She said that when this occurs, the facility staff take Resident #49 to his/her room, where he/she is put to bed and checked every 30 minutes. CNA #10 said then Resident #49 has the ability to get out of bed and move around the facility independently. The Incident Report Form, submitted to the Department of Public Health (DPH) on 3/22/18, indicated at 6:00 P.M., while a nurse and the certified nurses aides (CNAs) were assisting residents in the dining room, Resident #49 ambulated over to Resident #92 (who was sleeping in the chair), and put his/her hand under Resident #92's shirt to touch his/her breast, and was trying to rub his/her penis on him/her. The report indicated the nurse immediately separated the two residents and instructed Resident #49 to go to his/her room. The report indicated that nurse then heard yelling and found Resident #49 in Resident #115's room attempting to pull his/her shirt off. The nurse separated the two residents and the nurse escorted Resident #49 to his/her room and told another facility staff member to stay with him/her. The physician was updated and the resident was sent to the hospital for an evaluation. The report indicated the family and the police were notified of the incident. The investigation statement, dated 3/22/18, indicated Nurse #15 was passing medications during dinner and saw a resident stand up from the dining room table and was trying to move away from the table. Nurse #15 indicated she heard a staff member say don't do that. Nurse #15 indicated in the statement, that she was in the doorway of the dining room and Resident #49 had been exposing his/her penis during dinner. Resident #49 was re-directed at this time and was standing up and looking to the left where Resident #92 was seated. Resident #49 then reached up and under the shirt of Resident #92 and grabbed his/her breasts. Nurse #15 indicated in the statement that Resident #49 was re-directed out of the dining room and towards his/her room. She said she reported the incident to the 3:00 P.M. to 11:00 P.M. supervisor. The investigation statement, dated 3/22/18, indicated at about 5:20 P.M. during supper, Nurse #14 noted Resident #49 to be sexually inappropriate towards other female residents, exposing his/her penis and grabbing a resident by the breast. The statement indicated the resident was re-directed and escorted back to his/her room. At 5:30 P.M., Nurse #14 indicated she was still in the day room helping other residents when two other residents came and told her Resident #115 was yelling for help. Nurse #14 went to Resident #115's room and found Resident #49 forcefully pulling off Resident #115's sweatshirt while he/she was yelling Help me. Nurse #14 indicated in the statement that Resident #49 was difficult to re-direct and was combative. Nurse #14 indicated that Resident #115 was assessed, had no bruises or injury, and was described as terrified and shaking. Resident #115 was escorted to the nursing station with the nurse. The Physicians and the families were notified of the events, and one-to-one supervision was provided to Resident #49 while awaiting for transfer out of the facility for evaluation. During an interview on 3/27/18 at 9:06 A.M., CNA #17 said he was unaware of any sexual behaviors that Resident #49 had. CNA #17 said Resident #49 can be very mobile with his/her walker. During an interview on 3/27/18 at 9:24 A.M., Nurse #14 said that she was aware of a sexual situation with a female CNA in the shower and the resident was changed to a male CNA caregiver only. Nurse #14 said she witnessed the incident with Resident #49 on 3/22/18. She said Resident #49 stood up next to Resident #92 and was re-directed by staff to sit down. Another resident in the day room alerted Nurse #14 that Resident #49 was exposing his/her penis. Nurse #14 went to redirect him/her, and it was at this time Resident #49 touched Resident #92's breast. Nurse #14 said she removed Resident #49 from the day room and he/she was told to go back to his/her room. Nurse #14 said she went to the day room to check on Resident #92. About five to ten minutes later, a resident came to the day room to alert the staff what Resident #115 was calling for help, and she went to Resident #115's room and found Resident #49 trying to undress him/her. Review of the Physician's Telephone Orders, dated 3/22/18, indicated an order to provide one to one (supervision) for Resident #49, and to transfer him/her to the hospital for evaluation secondary to inappropriate and combative behaviors towards other residents. Review of the social services note, dated 3/23/18 at 10:28 A.M., indicated Resident #49 was sent to the hospital for sexually abusing another resident.

Based on observations, interviews and record review, the facility staff failed to maintain dignity for 1 sampled Resident (#92), who was known to lift his/her shirt up and expose his/her breast in the common area, in a total of 47 sampled residents. The facility staff also failed to provide an environment that maintained each residents' dignity and respect in 2 of the 4 dining rooms. Findings include. 1. Resident #92 was admitted to the facility in 1/2014 with [DIAGNOSES REDACTED]. Review of the Significant Change of Status Minimum Data Set (MDS) Assessment, dated 1/17/18, indicated Resident #92 had severe cognitive impairment as evidenced by staff assessment, exhibited physical, verbal and other behaviors not directed towards others during the assessment period. Review of the Behavior care plan, initiated 1/26/18 (and reviewed on 3/6/18), indicated Resident #92 had a behavior problem including being physically and verbally abusive relative to his/her [DIAGNOSES REDACTED]. The following interventions were included at this time: intervene as needed to protect the rights and safety of others; approach the resident in a calm manner; divert attention; remove from the situation and take him/her to another location as needed. Review of the current care card, no date, indicated the resident has verbal, socially inappropriate behaviors and exhibits intrusive wandering. The care card does not indicate what the socially inappropriate behaviors were that were identified/nor interventions for the socially inappropriate behavior. Review of the 3/2018 Behavior Sheet, indicated Resident #92 was monitored for his/her wandering behavior. There were no other behaviors identified on the tracking sheet to be monitored. On 3/16/18 at 1:31 P.M., Resident #92 was observed seated in a wheel chair, in the dayroom with multiple other residents, during lunch. The surveyor observed Resident #92 intermittently lift up his/her shirt, to expose his/her bare breast. The surveyor observed a Certified Nurse Aide (CNA) #17 seated in front of Resident #92, and was observed not to intervene. On 3/16/18 from 2:04 P.M. - 2:13 P.M., Resident #92 was observed seated in a wheelchair, in the dayroom, with 12 other residents, while music played. He/she continuously lifted up his/her shirt, exposing his/her bare breast with multiple other residents seated next to him/her. One facility staff member was observed in the day room at this time, and did not intervene. On 3/16/18 at 2:44 P.M., Resident #92 was observed seated in a wheelchair, in the dayroom during an activity, with other residents. He/she continuously pulled up his/her shirt to wipe his/her face, and exposed his/her bare chest. A male resident seated at the same table was heard saying tits coming out . The surveyor observed there was no intervention by the two activity staff members in the dayroom at this time. During an interview on 3/16/18 at 2:55 P.M., Activities Assistant #4 said Resident #92 always lifts up his/her shirt to expose his/her bare breast and that this is the resident's behavior. When the surveyor asked what the staff do when this occurs, Activities Assistant #4 said the facility staff try to cover him/her. During the interview/observation at this time, Resident #92 was observed to expose his/her bare breast in front of the surveyor and Activities Assistant #4, and the facility staff did not intervene. On 3/20/18 at 12:36 P.M., Resident #92 was observed to be seated in a wheelchair in the day room, with multiple residents. The surveyor observed there were no facility staff members in the day room at this time. Resident #92 was observed to raise up his/her shirt towards his/her mouth and expose his/her bare breast, while 2 other residents who were seated at the same table made verbal comments, not audible to surveyor, and pointed at Resident #92. During an interview on 3/20/18 at 1:39 P.M., Nurse #12 said Resident #92 has a behavior of lifting up his/her shirt, and needs frequent re-direction because of his/her cognition. Review of the progress notes from 1/2018- 3/20/18, did not indicate the resident exhibited any socially inappropriate behavior. During an interview on 3/21/18 at 10:22 A.M., Unit Manager #1 said she was updated about the surveyors observations of Resident #92 exposing his/her bare breast in the day room. She further said she was unaware of the resident's behaviors, of him/her lifiting his/her shirt and exposing his/her breast before the surveyor brought it to her attention. During an interview on 3/23/18 at 2:40 P.M., the Director of Nurses said she was unaware that Resident #92 lifted up his/her shirt and exposed his/her breast. She further said the purpose of the day room is for facility staff to monitor and supervise the residents until 8:00 P.M. During an interview on 3/27/18 at 8:06 A.M., CNA #10 said Resident #92 exposes his/her breast about every 15-20 minutes when he/she is in the day room. She said this has been occurring for the last 2-3 months, and the intervention is to cover him/her, offer him/her snacks/drinks or bring him/her to his/her room. CNA #10 said when Resident #92 exposes his/her bare breast, it does make other residents upset, but she does not think the resident is aware of what he/she is doing. She said when the resident does this- he/she is rubbing his/her face with his/her shirt, and is exposing his/her bare breast. 2. During a meal observation on 3/14/18 at 1:23 P.M., the surveyor observed lunch being served in the day room on the second floor. There were 24 residents present in the day room. The lunch meals were served to the residents on meal trays. There were no table linens or music playing. The surveyor observed one facility staff member standing next to a resident who was seated in a geriatric chair, while assisting him/her with the lunch meal. During a meal observation on 3/20/18 at 1:21 P.M., the surveyor observed 1 resident positioned in the day room in a geriatric chair with no meal in front of him/her, and 21 other residents who had their lunch meals were eating/being assisted by staff. The surveyor observed another resident in the hallway with no meal in front of him/her. During an interview on 3/20/18 at 1:21 P.M., Nurse #12 said there are 12 residents on the second floor that are feeds. When the surveyor asked why some residents did not have their meals yet who where present in the day room or in the hallway, Nurse #12 said their lunch meal is still on the meal truck. She further said they have three CNAs to assist with feeding residents. When surveyor asked if there was enough staff to feed residents, Nurse #12 would not answer. During a breakfast meal observation on 3/21/18 at 9:36 A.M., the surveyor observed CNA #1 in a resident room with residents in both the A and B beds. Both residents were observed to be in bed. The surveyor observed another resident from another room seated between the A and B beds in a geriatric chair. CNA #1 was seated next to the resident in the B bed and had an over-bed table with two breakfast trays present. CNA #1 was observed to be assisting both the resident in the geriatric chair and the resident in the B bed with their meal. During an interview on 3/21/18 at 9:36 A.M., CNA #1 said the resident from another room who was seated in the geriatric chair always eats there because there are too many feeds and not enough room in the day room. During a meal observation on 3/21/18 at 1:27 P.M., the surveyor observed 24 residents in the day room during lunch. The surveyor observed there was limited space to move about the room. In the corner of the day room was a bin that had heaping laundry that was halfway up the wall. During an interview on 3/21/18 at 1:27 P.M., CNA #10 said the laundry in the day room was from yesterday's meals and breakfast from today. She further said it should be emptied after every meal by facility staff. During an interview 3/21/18 on 1:35 P.M., Unit Manager #1 said the second floor has too many residents that are feeders. She further said that the facility has had to cut the staff down to four CNAs and with the numerous residents that are feeders, it makes meals difficult. Unit Manager #1 said the environment was not homelike because the residents are served from meal trays, there are too many residents in the day room, and because of the linen that was piled in the dining room during the meal period. During an interview on 3/21/18 at 3:04 P.M., the Food Service Director said there is overcrowding of residents in the day room during meals. He also said there were numerous feeds. When the surveyor asked if it was appropriate to refer to residents as feeds or feeders, he said no. 3. Review of the policy for Food and Dining Service, dated 4/2015, indicated that all residents requiring help with eating are assisted promptly upon the receipt of meals. On 3/15/18 from 8:30 A.M. to 9:00 A.M. during observation of the dining room on the 3rd floor the surveyor observed the following: -One Certified Nurses' Assistant (CNA) #13 was standing over a resident feeding him/her with gloves on. After about 15 minutes, CNA #13 left and got a chair to sit at eye level with the resident. -One resident was observed to be asleep in a wheelchair at 8:40 A.M. with a tray, not set up, in front of him/her. He/she was not assisted with the meal until 9:15 A.M. after the residents seated at the same table had finished eating. -One table had 3 residents seated, two were eating and had finished about half of their meal, and one had not been served. -A second table had 2 residents who were nearly finished eating, and a third resident had not been served. -All meals were served on trays. On 3/20/18 at 8:40 A.M. to 9:15 A.M. during an observation of the 3rd floor dining area the surveyor observed the following: -One table with 2 residents eating at 8:40 A.M. Another resident was not served until 8:57 A.M. -One table observed with 4 residents. One resident was eating at 8:40 A.M. At 8:50 an additional resident was served. At 9:07, the remaining two residents were served their breakfast, the first two had left the dining area. One of the remaining 2 residents required assistance. -One resident observed at 8:40 A.M. at a table where two other residents had been served. At 8:58 A.M., the two residents had finished their breakfast and left. The third resident was served his/her breakfast and assisted. -All residents were served on trays. On 3/20/18 at 9:11 A.M. CNA #14 said this was a typical breakfast. Residents who eat independently are served first, and those who require assistance are served last. On 3/21/18 at 8:17 A.M. during a dining observation on the second floor the following was observed: -18 residents were in the dining area -A large pile of dirty linen consisting of sheets, blankets and towels was in the corner of the dining room, unbagged, and remained there for the entire meal. CNA #10 said it had been there since yesterday. -Five square tables, intended to seat 4 residents. -CNA #15 was standing over a resident while feeding. -CNA #9 was standing over a resident while feeding. -Five residents were seated at 3 of the square tables intended for 4 residents. -Six residents were seated at one table intended for 4 residents. -Two totally dependent residents were not assisted until 9:30 A.M., even though they had been in the dining area for the entire observation. -All residents served on trays. Many tables were overcrowded with the trays hanging over the edge of the tables. Residents observed seated at the corner of tables. During an interview on 3/21/18 at 9:35 A.M., CNA #9 said there wasn't enough staff to feed all the residents. The nurse was too busy to help. On 3/21/18 at 9:37 A.M. the Food Service Director said the square tables were meant to seat 4 residents. He said the dining room was too crowded. On 3/21/18 at 9:45 A.M., Rehabilitation Staff #4 said the dining room was too crowded and felt more staff was needed. See F584

Based on observation, record review and interview, the facility staff failed to follow the Physician's orders/plan of care relative to fall interventions, TED stockings (to manage leg [MEDICAL CONDITION]), and medication administration for 6 residents (#2, #4, #9, #10, #21 and #23) in a total sample of 25 residents. Findings include: 1. For Resident #23, the facility staff failed to follow the resident's plan of care for fall prevention for 3 of 4 falls. Resident #23 was readmitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. Review of an Investigation of a Bruise/Skin Tear/Abrasion Report, dated 10/16/15, indicated the resident sustained [REDACTED]. Review of the facility New Intervention Communication form, dated 10/16/15, indicated the resident was to be in a supervised area at all times when not in bed to ensure optimal safety and to avoid accidents in the future. Review of the Behavior Care Plan, date started 12/31/15, indicated the following: -Staff will ensure resident is closely supervised. -Provide 1:1 interaction, especially when resident appears anxious or restless - late afternoon. Review of an Accident/Incident Report, dated 1/18/16, indicated the resident sustained [REDACTED].M. The report indicated the staff responded to the call bell. When entering the room, the resident told the staff member to leave and slammed the door. The staff member left, leaving the resident unsupervised while agitated. Staff responded later when the resident was heard yelling for help. The resident was found on the floor with a laceration above the right eye. He/she was transferred to the hospital. Review of the Accident/Incident Report, dated 3/1/16, indicated the resident sustained [REDACTED].M. The report indicated the resident was attempting to reach for the light and fell out of the wheelchair. Review of an Accident/Incident Report, dated 6/16/16, indicated the resident sustained [REDACTED].M. The report indicated the resident was attempting to self transfer from the toilet and fell . The resident sustained [REDACTED]. He/she was transferred to the hospital for evaluation and later returned. During an interview on 12/14/16 at 1:45 P.M., the Director of Nursing (DON) and Nurse #1 said the resident should not have been alone in his/her room and were unsure why he/she was allowed to be alone. Both said the intervention of being in a supervised area should have been implemented as indicated in the Resident's Behavior care plan. It had been implemented after a previous incident in 10/2015 as a way to help keep the him/her safe. See F323. 2. For Resident #9, the facility staff failed to apply TED stockings as ordered by the Physician. Resident #9 was admitted to the facility in 10/2013 with [DIAGNOSES REDACTED]. Review of the 11/2016 Physician's orders indicated an order for [REDACTED].M. and remove at bedtime. Review of the 12/2016 Treatment Administration Record (TAR) indicated TED stockings were applied daily. During an observation on 12/13/16 at 11:45 A.M., the resident was seated in a wheelchair, dressed and wearing socks and sneakers. The resident was not wearing TED stockings. During an observation on 12/14/16 at 7:45 A.M., the resident was lying in bed. The resident was dressed and wearing sneakers and socks but was not wearing TED stockings. During an observation on 12/14/16 at 8:45 A.M., the resident was wearing sneakers and socks. Certified Nurses Aide (CNA) #4 said the resident was not wearing TEDS stockings as ordered. 3. For Resident #10, the facility staff failed to administer an iron supplement as ordered by the Physician. Resident #10 was admitted to the facility in 1/2014 with [DIAGNOSES REDACTED]. Review of laboratory results, dated 11/11/16, indicated a below normal range for both Iron and Transferrin % Saturation (labs used to measure iron and iron binding capacity in the blood). Review of a Physician's order, dated 11/11/16, indicated an order for [REDACTED].) daily. Review of the 12/2016 Medication Administration Record (MAR) indicated the Iron had not been administered from 12/1/16 through 12/13/16. During an interview on 12/14/16 at 10:40 A.M., Nurse #1 said the Iron had not been transcribed onto the 12/2016 MAR. She said the Iron had not been administered to the resident as ordered and the Physician would be notified. 4. For Resident #2, the facility staff failed to follow the Falls care plan relative to providing adequate supervision and ensuring the use of an assistive device (walker) while ambulating. Resident #2 was admitted to the facility in 7/2014 with [DIAGNOSES REDACTED]. Review of the Falls care plan, dated 6/12/15, indicated that Resident #2 was independent with ambulation using an assistive device, and required periods of supervision for redirection due to cognition, functional ability and increased fatigue. Review of the Quarterly Minimum Data Set (MDS) Assessment, Assessment Reference Date (ARD) 8/28/15, indicated that Resident #2 had severe cognitive impairment, difficulty with focusing attention, wandered daily, required supervision when ambulating in his/her room or the corridor, and required the use of a walker. Review of Progress Notes, dated 9/30/15, indicated that Resident #2 experienced an unwitnessed fall, with no injury, in the day room at 12:15 P.M. Further review of the investigation indicated the resident was not supervised or using his/her walker as care planned. Review of the Accident/Incident Report and Investigation form, dated 1/22/16, indicated that Resident #2 experienced a witnessed fall, with no injury, in the day room at 6:20 P.M. Further review of the investigation indicated that the resident did not have his/her walker when ambulating as care planned. Review of the Quarterly MDS Assessment, ARD 3/11/16, indicated that Resident #2 required extensive assistance of 1 staff for transfers, required limited assistance of 1 staff for ambulation in his/her room and in the corridor, and indicated that he/she was not steady and required staff assistance to stabilize when walking, when turning around, and when moving from a seated to a standing position. Review of the Accident/Incident Report and Investigation form, dated 4/15/16, indicated that Resident #2 experienced an unwitnessed fall, with no injury, in the hallway at 2:45 P.M. Further review of the report indicated that the resident was not supervised while ambulating as care planned. Review of the Accident/Incident Report and Investigation form, dated 5/16/16, indicated that Resident #2 experienced a fall, with no injury, in the dining/activity room at 2:15 P.M. Further review of the report indicated that the resident did not have his/her walker as care planned. During an interview on 12/14/16 at 2:30 P.M., Nurse #1 said Resident #2 was not supervised on 4/15/16 as care planned. The rolling walker was not used by the resident during the falls on 9/30/15, 1/22/16, and 5/16/16 as care planned. 5. For Resident #4, the facility staff failed to follow the Physician's orders for [MEDICATION NAME] (an antipsychotic medication). Resident #4 was admitted to the facility in 1/2014 with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 10/25/16, indicated a medication review was conducted with the Physician. A new Physician's order indicated to hold scheduled [MEDICATION NAME] 0.125 mg. at bedtime for tonight, and instead, give [MEDICATION NAME] 0.25 mg. one time. Review of the Physician's Interim/Telephone Orders, dated 10/25/16, indicated an order to give [MEDICATION NAME] 0.25 mg. 1 time tonight at bedtime, and to hold the scheduled 0.125 mg. dose 1 time for tonight. Review of the 10/2016 MAR, indicated an order for [REDACTED].) by mouth at bedtime. Further review indicated that [MEDICATION NAME] 0.125 mg. was administered on 10/25/16. Review of the MAR for 10/2016 did not indicate the Physician's ordered dose of [MEDICATION NAME] 0.25 mg was given at bedtime on 10/25/16, as ordered. During an interview on 12/9/16 at 12:15 P.M., Nurse #4 said the order for [MEDICATION NAME], 0.125 mg. at bedtime on 10/25/16, should have been put on hold in the MAR. The new order for [MEDICATION NAME], 0.25 mg. at bedtime for 1 dose should have been written into the MAR for that date, as the Physician ordered. Nurse #4 said there was no indication the ordered dose for [MEDICATION NAME] 0.25 mg. at bedtime was given on 10/25/16, as ordered. 6. For Resident #21 the facility staff failed to administer [MEDICATION NAME] (antidepressant) as ordered by the Physician. Resident #21 was admitted to the facility in 7/2016 with multiple [DIAGNOSES REDACTED]. Review of the 11/2016 Physician's orders indicated an order for [REDACTED]. Review of the 11/2016 MAR indicated the Physician's order for [MEDICATION NAME] 50 mg., 1/2 tablet every six hours as needed for agitation, was transcribed onto the MAR. The [MEDICATION NAME] entries on the MAR indicated the resident received [MEDICATION NAME] from 11/1/16 through 11/23/16. There was no indication of what time the medication had been administered. The back of the MAR indicated the resident received [MEDICATION NAME] 50 mg. for agitation with positive effect on the following dates: -11/8/16 -11/9/16 -11/10/16 -11/11/16 -11/14/16 -11/15/16 -11/17/16 -11/18/16 -11/22/16 -11/23/16. During an interview on 12/14/16 at 3:10 P.M. the Assistant Director of Nurses said, according to the Physician's order, the resident should have been administered 1/2 of a 50 mg. tablet (25 mg.) and not 50 mg. as documented on the MAR. She said the nurse was not giving the resident the correct dose as ordered by the Physician.

Based on observation, interview and record review, the facility staff failed to ensure 2 residents (#2 and #23), of 8 applicable residents with falls, received adequate supervision and assistive devices to prevent accidents, in a total sample of 25 residents. Findings include: 1. For Resident #23, the facility staff failed to provide adequate supervision for 2 of 4 falls with injuries. Resident #23 was readmitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. Review of the Potential for Falls Care Plan, start date of 3/20/15, indicated the following interventions; -Dependent with ambulation/transfers providing 1 assistance using wheel chair or rolling walker. -Monitor for toileting needs. Review of a Fall Risk Evaluation, dated 9/22/15, indicated the resident was a high risk for fall as evidenced by of score of 19 (a total score of 10 or more indicates a high risk). Review of an Investigation of a Bruise/Skin Tear/Abrasion Report, dated 10/16/15, indicated the resident sustained [REDACTED]. Review of the facility New Intervention Communication Form, dated 10/16/15, indicated the resident was to be in supervised area at all times when not in bed to ensure optimal safety and avoid accidents in the future. Review of the Fall Care Plan and Resident Care Card did not indicated the above intervention was implemented. Further review of the same Communication Form indicated only one staff member had been educated about the new intervention. Review of the Behavior Care Plan, started 12/31/15, indicated the following; -Staff will ensure resident is closely supervised. -Provide 1:1 interaction, especially when resident appears anxious or restless - late afternoon. Review of a Fall Risk Evaluation, dated 12/22/15, indicated the resident remained at a high risk of falls as evidenced by a score of 19. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/25/15, indicated the resident was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), required extensive assistance with mobility, transfers, ambulation and toilet use, was totally dependent for hygiene and bathing and had no falls. Review of an Accident/Incident Report, dated 1/18/16, indicated the resident sustained [REDACTED].M. The report indicated that staff responded to a call bell. When entering the room, the resident told the staff member to leave, and slammed the door. The staff member left, leaving the resident alone while agitated. The staff responded later when the resident was heard yelling for help. The resident was found on the floor with a laceration above the right eye. The resident was transferred to the hospital. The report indicated no further interventions were implemented to prevent further occurrences. Review of Nurse's note, dated 1/20/16, indicated the resident returned to the facility with sutures above his/her right eye. Review of the Accident/Incident Report, dated 3/1/16, indicated the resident sustained [REDACTED].M. The report indicated the resident was attempting to reach for the light and fell out of the wheelchair. The resident was uninjured. The new intervention added was a Physical Therapy referral. Review of the Annual MDS Assessment, dated 3/18/16, indicated the resident had moderate cognitive impairment as evidence by a score of 11 out of 15 on the BIMS, required extensive assistance for bed mobility, transfers, ambulation and toilet use, was totally dependent for hygiene and bathing, and had no falls. Review of the Quarterly MDS Assessment, dated 6/10/16, indicated the resident had moderate cognitive impairment as evidence by a score of 10 out of 15 on the BIMS, required extensive assistance for bed mobility, transfers, dressing and toilet use, was totally dependent for hygiene and bathing, and had no falls. Review of a Fall Risk Evaluation, dated 6/6/16, indicated the resident remained at a high risk of falls as evidenced by a score of 21. Review of an Accident/Incident Report, dated 6/16/16, indicated the resident sustained [REDACTED].M. The report indicated the resident was attempting to self transfer from the toilet and fell . The resident sustained [REDACTED]. The resident was transferred to the hospital for evaluation and later returned. Additional interventions added included to toilet the resident every 2 hours, do not leave him/her alone in the room and remind him/her to call for help with toileting. Review of a Nurse's Note and Therapy Referral Form, dated 6/25/16, indicated the resident had a witnessed fall at 3:30 P.M. The resident was not injured. During an interview on 12/14/16 at 1:45 P.M., the Director of Nursing (DON) and Nurse #1 said the resident should not have been alone in his/her room and were unsure why he/she was allowed to be alone. They both said they were unsure why that intervention was not added to the Resident's fall care plan or care card. Both said said there were no effective interventions implemented after the fall of 1/18/16. The DON said it was an unobtainable goal to keep him/her in a supervised area when out of bed, because he/she was so mobile. 2. For Resident #2, the facility staff failed to provide adequate supervision and an assistive device (walker) to prevent falls. Resident #2 was admitted to the facility in 7/2014 with [DIAGNOSES REDACTED]. Review of the Falls care plan, dated 6/12/15, indicated that Resident #2 was independent with ambulation using an assistive device, and required periods of supervision for redirection due to cognition, functional ability and increased fatigue. Review of the Physical Therapy Discharge Summary, dated 8/10/15, indicated that Resident #2 required a rolling walker for ambulation and transfers and needed occasional verbal cues from facility staff for safety. Review of the Quarterly Minimum Data Set (MDS) Assessment, Assessment Reference Date (ARD) of 8/28/15, indicated that Resident #2 had severe cognitive impairment, difficulty with focusing attention, wandered daily, required supervision when ambulating in his/her room or corridor, and required the use of a walker. Review of Progress Notes, dated 9/30/15, indicated that Resident #2 had an unwitnessed fall, with no injury, in the day room at 12:15 P.M. Further review of the investigation indicated the resident was not supervised or using his/her walker. The Falls care plan was updated on the date of the fall to continue to remind the resident to use the walker for ambulation. Review of the Significant Change in Status MDS Assessment, with an ARD of 12/18/15, remained essentially unchanged from the previous assessment. Review of the Accident/Incident Report and Investigation form, dated 1/22/16, indicated that Resident #2 experienced a witnessed fall, with no injury, in the day room at 6:20 P.M. Further review of the investigation indicated the resident did not have his/her walker when ambulating. The Falls care plan was updated on the date of the fall to include re-education to facility staff on providing Resident #2 with the walker immediately and to monitor the use of the walker while ambulating. Review of the Quarterly MDS Assessment, with an ARD of 3/11/16, indicated that Resident #2 required extensive assistance of 1 staff for transfers, required limited assistance of 1 staff for ambulation in his/her room and in the corridor, and indicated that he/she was not steady and required staff assistance to stabilize when walking, when turning around, and when moving from a seated to a standing position. Review of the Accident/Incident Report and Investigation form, dated 4/15/16, indicated that Resident #2 experienced an unwitnessed fall, with no injury, in the hallway at 2:45 P.M. Further review of the report indicated that the resident was not supervised while ambulating. The intervention implemented to prevent reoccurrence was for the resident is to be supervised while ambulating. Review of the Accident/Incident Report and Investigation report, dated 5/16/16, indicated that Resident #2 had a fall, with no injury, in the dining/activity room at 2:15 P.M. Further review of the report indicated that the resident, again, did not have his/her walker. The intervention added to the Falls care plan was, again, to continue to remind the resident to use his/her walker for ambulation. The surveyor observed Resident #2 on 12/8/16 at 2:30 P.M. During the observation, Resident #2 was seated in a wheelchair at the end of the hallway near his/her room. During an interview on 12/14/16 at 2:30 P.M., Nurse #1 said that Resident #2 was not supervised on 4/15/16, as care planned, and that the rolling walker was not used by the resident during the falls on 9/30/15, 1/22/16 and 5/16/16. Nurse #1 further said the interventions implemented for prevention of falls were not appropriate or effective because of the resident's dementia.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure the staff followed Resident #1's 2/3/15 plan of care related to fall prevention. Resident #1, who was at risk for falls, ambulated on the nursing unit independently with a cane or walker, which was not consistent with the plan of care. Although Resident #1's ability to ambulate was re-evaluated by Physical Therapist #2 on 2/28/15, which included only the use of a walker and contact guard (defined as hands on assistance to stabilize) supervision with ambulation, this information was not communicated to direct care nursing staff. On 4/5/15, at 10:45 P.M., the staff observed Resident #1 sitting on the floor at the bottom of the steps between the second floor and third floor with the cane at his/her side. Resident #1 sustained a cervical neck fracture as a result of the fall. Findings include: The Admission Record indicated the staff admitted Resident #1 to the Facility in January 2015. The Admission Record indicated Resident #1's [DIAGNOSES REDACTED]. The Plan of Care for Fall Prevention, dated 2/3/15, included one staff to assist Resident #1 with ambulation and transfer activities using rolling walker/cane, provide Resident #1 with verbal cues for safety and sequencing when needed, and provide Resident #1 with verbal cues for proper pacing. The Physical Therapy Evaluation, dated 2/28/15, indicated Resident #1 required contact guard and supervision with a rolling walker. The Surveyor interviewed Physical Therapist #2 at 11:10 A.M. on 5/19/15. Physical Therapist #2 said on 2/28/15, she evaluated Resident #1. Physical Therapist #2 said Resident #1 had dementia, was forgetful, and had weakness, and therefore required contact guard when ambulating. Physical Therapist #2 said the plan was for Resident #1 to use the walker and not the cane. Physical Therapist #2 said on 2/28/15, she placed Resident #1's cane in his/her closet. Physical Therapist #2 said the rehabilitation staff were not allowed to revise a resident's Plan of Care when not on rehabilitative services, therefore, she notified the nurse that Resident #1 was only to use the rolling walker and not the cane. There was no documentation contained within Resident #1's record to indicate the nurses revised Resident #1's Plan of Care to include the use of a rolling walker only and to discontinue use of a cane. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 7:15 A.M. on 5/19/15. The Surveyor interviewed Nurse #1 at on 5/19/15. The Surveyor interviewed Nurse #3 at 10:00 A.M. on 5/27/15. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 9:25 A.M. on 5/19/15. The Surveyor interviewed CNA #2 at 9:40 A.M. on 5/19/15. The Surveyor interviewed CNA #3 at 9:50 A.M. on 5/19/15. The Surveyor interviewed CNA #4 at 8:15 A.M. on 5/20/15. The Surveyor interviewed CNA #5 at 8:30 A.M. on 5/20/15. The Surveyor interviewed CNA #6 at 1:05 P.M. on 5/19/15. The ADON, Nurse #1, Nurse #3, CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, and CNA #6 said they were not aware Resident #1 was to only use a walker and not a cane or that Resident #1 required contact guard level of assistance. Nurse #1, Nurse #3, CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, and CNA #6 said Resident #1 ambulated independently in the hallway and occasionally needed one staff person to redirect away from other residents' rooms. This was not consistent with the 2/3/15 fall prevention plan of care or the 2/28/15 assessment by Physical Therapist #2. Nurse #3's written statement that was not dated, indicated that on 4/5/15, at 7:00 P.M., Resident #1 returned to the Facility with his/her family. Nurse #3's statement indicated that at 9:00 P.M., the staff provided personal care to Resident #1 and assisted Resident #1 to bed. Nurse #3's statement indicated that at 9:45 P.M. and 10:30 P.M., Resident #1 rested in bed with his/her eyes closed. Nurse #3's statement indicated that at 10:45 P.M., the door alarm beeped and Nurse #3 ran to the door. Nurse #3's statement indicated that when Nurse #3 opened the door, he observed Resident #1 sitting cross legged, at the bottom of the steps, with the cane at his/her side. The Nurse's Note, dated 4/5/15, indicated that the door alarm sounded and the staff observed Resident #1 sitting at the bottom of the stairs. The Nurse's Note indicated Resident #1 had a small, pink bump on the right side of his/her head and denied pain. The Nurse's Note indicated the emergency medical technicians transferred Resident #1 to the Hospital. Nurse #3 said the staff were not aware Resident #1 required contact guard when ambulating, therefore, on 4/5/15, prior to Resident #1's fall, the staff were not ambulating Resident #1. The Hospital documentation, dated 4/6/15, indicated Resident #1 had a cervical spine fracture and required a soft cervical neck collar.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure the staff followed Resident #1's 2/3/15 plan of care related to fall prevention. Resident #1, who was at risk for falls ambulated on the nursing unit independently with a cane or walker, which was not consistent with the plan of care. Although Resident #1's ability to ambulate was re-evaluated by Physical Therapist #2 on 2/28/15, and the evaluation indicated Resident #1 was to use a walker when ambulating, this information was not communicated to direct care nursing staff. On 4/5/15, Resident #1 ambulated independently, using a cane in the hallway between 9:30 P.M. and 10:45 P.M., and at 10:45 P.M., when a door alarm sounded, staff responded and observed Resident #1 sitting at the bottom of the steps with his/her cane at his/her side. Resident #1 sustained a cervical fracture as a result of the fall. Findings include: The Admission Record indicated the staff admitted Resident #1 to the Facility in January 2015. The Admission Record indicated Resident #1's [DIAGNOSES REDACTED]. The Plan of Care for Falls, dated 2/3/15, related to decreased safety awareness, dementia, weakness, and difficulty walking included assist Resident #1 with ambulation and transfer activities using rolling walker/cane, and provide Resident #1 with verbal cues for safety and sequencing when needed, and provide Resident #1 with verbal cues for proper pacing. The Surveyor interviewed Physical Therapist #1 at 10:15 A.M. on 5/19/15. Physical Therapist #1 said she evaluated Resident #1 on 1/25/15. Physical Therapist #1 said the initial plan for Resident #1 was for a potential discharge home after rehabilitation therapy. Physical Therapist #1 said the rehabilitation staff trialled Resident #1 with a rolling walker and a cane. Physical Therapist #1 said Resident #1 was steadier with the rolling walker, but at that time, was able to safely use a cane. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 7:15 A.M. on 5/19/15. The ADON said Resident #1 was hosptalized on [DATE] related to vomiting. The ADON said when Resident #1 returned to the Facility, the family decided Resident #1 would require long term placement. The Physical Therapy Evaluation, dated 2/28/15, indicated Resident #1 required contact guard (hands on assistance) and supervision while using a rolling walker. The Surveyor interviewed Physical Therapist #2 at 11:10 A.M. on 5/19/15. Physical Therapist #2 said when Resident #1 returned from the Hospital, she evaluated Resident #1. Physical Therapist #2 said Resident #1 had dementia, was forgetful, and had weakness, and therefore required contact guard when ambulating. Physical Therapist #2 said the plan was for Resident #1 to use the walker and not the cane. Physical Therapist #2 said on 2/28/15, she placed Resident #1's cane in his/her closet. Physical Therapist #2 said the rehabilitation staff were not allowed to revise a resident's plan of care therefore, she notified the nurse that Resident #1 was only to use the rolling walker and not the cane. There was no documentation to indicate in Resident #1's record that the nurses revised Resident #1's Plan of Care to include the use of a rolling walker only and not a cane. The Surveyor interviewed Nurse #1 at on 5/19/15. The Surveyor interviewed Nurse #3 at 10:00 A.M. on 5/27/15. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 9:25 A.M. on 5/19/15. The Surveyor interviewed CNA #2 at 9:40 A.M. on 5/19/15. The Surveyor interviewed CNA #3 at 9:50 A.M. on 5/19/15. The Surveyor interviewed CNA #4 at 8:15 A.M. on 5/20/15. The Surveyor interviewed CNA #5 at 8:30 A.M. on 5/20/15. The Surveyor interviewed CNA #6 at 1:05 P.M. on 5/19/15. The ADON, Nurse #1, Nurse #3, CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, and CNA #6 said they were not aware Resident #1 was to only use a walker and not a cane. Nurse #1, Nurse #3, CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, and CNA #6 said Resident #1 ambulated independently in the hallway, occasionally needed redirection and they were not aware Resident #1 was to have contact guard during ambulation. This was not consistent with the 2/3/15 plan of care or the 2/28/15 re-evaluation by Physical Therapist #2. CNA #2, CNA #3, CNA #5, and CNA #6 said prior to 4/5/15, Resident #1 occasionally went near the door at the end of the corridor, never tried to open the door, and they directed Resident #1 away from the door. CNA #6's written Statement, dated 4/5/15, indicated that on 4/5/15, during the evening shift, Resident #1 wandered from room to room and CNA #6 last observed Resident #1 at 10:30 P.M. CNA #4 said at 10:00 P.M., Resident #1 had increased confusion and wandered in the hallway. CNA #4 said she directed Resident #1 to his/her room. CNA #4 said she did not observe Resident #1 after 10:00 P.M. CNA #5 and CNA #6 said on 4/5/15, at 10:30 P.M., Resident #1 was lying in bed with his/her eyes closed. Nurse #3's written statement, which was not dated, indicated that on 4/5/15, at 7:00 P.M., Resident #1 returned to the Facility with his/her family. Nurse #3's statement indicated that at 9:00 P.M., the staff provided personal care to Resident #1 and assisted Resident #1 to bed. Nurse #3's statement indicated that at 10:30 P.M., Resident #1 rested in bed with his/her eyes closed. Nurse #3's statement indicated that at 10:45 P.M., the door alarm beeped and Nurse #3 ran to the door. Nurse #3's statement indicated that when Nurse #3 opened the door, he observed Resident #1 sitting cross legged, at the bottom of the steps, with the cane at his/her side. The Nurse's Note, dated 4/5/15, indicated that the door alarm sounded and the staff observed Resident #1 sitting at the bottom of the stairs. The Nurse's Note indicated Resident #1 had a small, pink bump on the right side of his/her head and denied pain. The Nurse's Note indicated the emergency medical technicians transferred Resident #1 to the Hospital. The Hospital documentation, dated 4/6/15, indicated Resident #1 had a cervical spine fracture and required a soft cervical neck collar.

Based on record review and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure that Resident #1's bed safety alarms were in working condition and functioning per plan of care, when on 6/4/13 Resident #1 got out of bed, his/her bed alarms failed to sound, he/she fell and sustained a 2.5 centimeter (cm) left eyebrow laceration that required closure at the Hospital. The Director of Nurses (DON) said on 6/10/13 Resident #1 was in the dayroom in the wheelchair alone and did not have visual supervision, per plan of care, he/she fell and sustained a 1.5 cm laceration that required steri-strips. Findings include: The history and physical examination [REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 7:30 A.M. and 4:20 P.M. on 7/8/13 and at 4:30 P.M. on 7/10/13. The DON said Resident #1 was at high risk for falls and between admission and 5/11/13, had three previous falls at the Facility without an injury. The care plan, updated 5/11/13, indicated that Resident #1 required: slipper socks to be worn while in bed, safety alarms at all times, physical assistance with wheelchair mobility, physical assistance during ambulation while using a rolling walker, and visual supervision when out of bed. The certified nurse aide (CNA) flow sheet, dated 6/1/13 to 6/4/13, indicated that Resident #1 required physical assistance during ambulation and transfers. The Surveyor interviewed Nurse #1 on 7/8/13 at 1:15 P.M and at 3:20 P.M. on 7/10/13. Nurse #1 said Resident #1's plan of care for falls included safety alarms at all times and once awake was placed in the dayroom within view of staff. The DON said Resident #1's usual routine included visual supervision while awake, he/she was observed by staff as he/she was seated in a wheelchair in the dayroom or was physically assisted when he/she ambulated on the unit with a rolling walker, and was provided two safety alarms (clip alarm and pressure alarm) at all times. The DON said on 6/4/13 Resident #1 was sleeping in bed with two bed alarms that did not sound when he/she got out of bed without assistance and fell in his/her bedroom. The DON said there was no protocol or policy to ensure that safety alarms were in working condition. The DON said Resident #1 was transferred to the Hospital where it was determined he/she required closure of a 2.5 centimeter laceration of the left eyebrow and during hospitalization was diagnosed with [REDACTED]. The nurse's note, dated 6/4/13 for the 11:00 P.M. to 7:00 A.M. shift, indicated that Resident #1 was sleeping in bed when at approximately 6:30 A.M., Nurse #1 heard a loud bang from his/her bedroom, and Resident #1 was observed on his/her bedroom floor. The nurse's note indicated that Resident #1 was assessed, he/she was crying loud, was bleeding from a left eyebrow laceration, had no other sign of injury, and first aid was given. The nurse's note indicated that the Physician was notified and Resident #1 was transferred to the Hospital, per physician's orders [REDACTED]. The Hospital Discharge Summary, dated 6/8/13, indicated that Resident #1 sustained a laceration above the left eyebrow that required closure, and during hospitalization Resident #1 was diagnosed with [REDACTED]. The Hospital Discharge Summary included recommendations to review Resident #1's fall precautions at the Facility. The nurse's note, dated 6/8/13 at 2:30 P.M., indicated that Resident #1 returned to the Facility after treatment for [REDACTED]. The DON said on 6/10/13 Resident #1 was left seated in the wheelchair in the dayroom alone (not within view of staff) when Nurse #2 walked out of the dayroom, had her back facing Resident #1 when Resident #1got out of his/her wheelchair and fell to the floor. The CNA flow sheet, dated 6/1/13 to 6/10/13, indicated that Resident #1 required physical assistance and continual supervision (within view of staff) while seated in his/her wheelchair. The Surveyor interviewed Nurse #2 at 8:20 A.M. and 2:40 P.M. on 7/8/13. Nurse #2 said she exited the dayroom to work at her medication cart located across the hall from the dayroom. Nurse #2 said while at the medication cart her back was facing Resident #1 thus she was unaware that Resident #1 stood up from his/her wheelchair until the alarm sounded and she turned around, but was unable to reach Resident #1 before he/she fell to the floor. The nurse's note, dated 6/10/13 at 9:30 A.M., for the 7:00 A.M. to 3:00 P.M. shift, indicated that Resident #1 was seated in his/her wheelchair in the dayroom when at approximately 9:30 A.M., Resident #1 stood up from his/her wheelchair, and fell to the floor. The nurse's note indicated that Resident #1 was assessed and sustained a laceration over the right eyebrow that required the use of pressure to stop the bleeding and steri-strips were applied. The nurse's notes indicated that Resident #1 had no other sign of injury, was evaluated by the Physician, who was in the Facility, and 1:1 supervision was added after Resident #1's fall. The DON said on 6/10/13 Resident #1 sustained a 1.5 cm laceration above the right eye that required steri-strips and 1:1 supervision was provided after the fall. The Surveyor interviewed Physician #1 at 10:15 A.M. on 7/8/13. Physician #1 said Resident #1 sustained a 2.5 cm laceration after the fourth fall that required closure at the hospital. Physician #1 said Resident #1 sustained a 1.5 cm laceration after the fifth fall that required steri-strips and did not require sutures. .