Every finding on record at Mary Ann Morse Nursing & Rehabilitation

Based on records reviewed, interviews and observations for one of three sampled residents (Resident #1), who had been assessed as having moderately impaired cognition, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to prevent an incident of elopement, when on 04/30/26 at 3:00 A.M., Resident #1 was able to exit his/her unit and the Facility, undetected by staff and was found on a loading dock of a neighboring Facility about 150 yards away. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation.Findings include:Review of the Facility Policy titled Missing Persons Policy (Absent Without Leave), dated as last revised 08/23/24, indicated the following;-Unit Clinical Staff are required to know the location of each resident at all times of day; and-Unit Charge Nurse is responsible for assuring that each unit resident's location is known and accounted for in a manner that relies upon formal communications and data systems.Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 05/05/26, indicated Resident #1 had been last seen by the Nurse Supervisor at 3:00 A.M. in his/her bed. The Report indicated that at around 3:30 A.M., staff received a call from the local Police Department (PD) informing them a resident (later identified as Resident #1) had been located on the loading dock of a nearby Facility and was being transported to the Hospital Emergency Department (ED) for evaluation.Resident #1 was admitted to the Facility in April 2026, diagnoses include diabetes mellitus, new onset of atrial fibrillation, pancreatic head lesion, and dementia.Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated he/she scored an 11 out of 15 on his/her Brief Interview for Mental Status (BIMS, 0-7 suggests severe cognitive impairment, 8-12 suggest moderately impaired cognition, and 12-15 suggests a resident in cognitively intact).Review of Resident #1's Physician's Orders, dated 04/27/26, indicated his/her Health Care Proxy had been invoked.During an interview on 05/20/26 at 8:51 A.M., the Nursing Supervisor said she was Resident #1's nurse on 4/29/26 into 04/30/26, for the night shift (11:00 P.M.-7:00 A.M).The Supervisor said around 12:30 A.M. she observed Resident #1 walking in the hallway, and he/she asked her what time it was. The Supervisor said she told him/her the time, asked if he/she knew where he/she was (in a facility), escorted Resident #1 to the bathroom and then assisted him/her back to bed.The Supervisor said she checked on Resident #1 each time she passed his/her room, said he/she was last seen (by her) in bed between 2:50 A.M. and 3:00 A.M. and he/she appeared to be asleep (observed with eyes closed).The Supervisor said she was in another resident's room when Nurse #1 said a Police Officer called asking if one of their resident's was missing and said that he/she may be at the Facility next door.The Supervisor said the Police Officer had located Resident #1 on the loading dock on the adjacent property, outside knocking on their back door. The Supervisor said that the Police Officer told her Resident #1 had abrasions on his/her knees and they were calling for Emergency Medical Services (EMS) to transport his/her to the ED.The Supervisor said that she had no idea how Resident #1 could have eloped [exited the facility] and said she never heard any alarms to indicate someone had left the building.During an interview on 05/20/26 at 11:33 A.M., with the Environmental Service Director (ESD, which included a Facility tour and Surveyor observations) the ESD said the Facility has a security surveillance camera system that covers the exit doors to the Facility. The ESD said that they reviewed the security footage from 04/30/26 and identified which door Resident #1 was seen exiting the building through.The ESD said that no one saved the security surveillance footage and said they were unable to retrieve the footage from their Corporate Information Technology (IT) Department. The ESD said although there was no surveillance camera footage to show how Resident #1 exited the Facility and no witnesses that had determined where and how Resident #1 got out of the building. The ESD said that Resident #1's room was adjacent to a hallway which led to an employee service door (about 100 feet from Resident #1's room), that employee service door led to a stairwell and egress door that led outside, which is how he/she got out that night.The ESD said and the Surveyor observed a door in the service corridor that had a keypad for staff to enter a numerical code that would disengage a locking mechanism and the alarm making it clear to exit.The ESD said some doors have a keypad for the staff to enter a code to open the door and disengage the alarm so staff can pass through the door without issue while maintaining resident safety.During the observation the Surveyor opened the service door via lever (handle), without putting the code into the keypad, the door opened as an alarm sounded. The alarm was loud, however, the ESD said and the Surveyor observed the door was not hard-wired to a system that would allow the alarm to be heard in other parts of the building, such as on the nursing units.The Surveyor observed that once the door closed behind them, the alarm automatically shut off.During the observation the Surveyor noted that crossing the threshold of the door entering the stairwell, led to a flight of stairs down to a second door that exited to the outside.At the second door there was a keypad requiring a code to exit, when the Surveyor pushed down on the door lever to exit, the door opened and the alarm sounded, and again the alarm shut off (no longer sounding) once the door was the closed.The ESD said that doors with the keypad should continue to sound through to a central point where other staff are able to hear the sounding alarm. The ESD said the alarm should sound until a responding staff member arrives at the door, looks into why it sounded and enters the security code which disengages the alarm.The ESD said Resident #1 was seen via security surveillance camera footage (unsaved, not recorder) at that exit door, that Resident #1 was seen walking up the back lot/driveway and likely went through the woods to the neighboring Facility onto their loading dock.The ESD said the alarmed doors should have had a maglock (secures doors using a low-voltage electromagnet and a metal armature plate (crossbar) and because of a fail-safe, cutting the power or pressing the crossbar for 15 seconds releases the door and one is able to exit while alarm is still sounding).During an interview on 05/20/26 at 3:40 P.M., the Administrator said the doors that Resident #1 exited through were not properly secured and the alarms could only be heard if someone had been nearby at the time the doors were opened.On 05/20/26, the Facility staff presented the Surveyor with a plan of correction with an effective date of 05/16/26 that addressed the area of concern identified in this survey, as follows:A) Resident #1 was transported to the ED for evaluation, upon assessment was not found to have any serious physical injuries and was not readmitted to the Facility.B) On 04/30/26, the Administrator and Unit Managers completed new Elopement Risk Assessments for all Residents and updated care plans as needed.C) On 04/30/26 through 05/03/26, the Director of Nurses (DON) and Administrator began Facility wide Staff education regarding elopement, alarmed and locked doors, night shift responsibilities, and missing resident protocols.D) On 04/30/26 the ESD and Regional Support inspected all doors requiring a keypad and code to exit, identifying three (3) doors requiring changes and/or updates.E) On 05/01/26, the Administrator contacted a Security Door company to evaluate and fix all doors identified as not being properly secured.F) On 05/01/26, a third Certified Nurse Aide (CNA) was added to the 11:00 P.M.-7:00 A.M. shift for additional monitoring. One CNA (of the three scheduled) on the overnight shift will not have a resident assignment, that CNA will be responsible for monitoring the hallway(s) on unit, making observations of residents, redirecting as needed, until the new doors and alarms are installed.G) On 5/01/26 all door alarm codes were changed by the ESD and Administrator and will continue to be changed quarterly and on an as needed basis.H) On 5/15/26, the Door Company provided the Facility with quotes and contracts to fix/upgrade identified doors, parts have been ordered and will be fixed as soon as the company is able.I) Audits will be conducted on all alarmed doors nightly on the 11:00 P.M.-7:00 A.M. shift by Nursing and weekly by the ESD.J) Results of all audits will be reviewed at QAPI meeting by the management team.K) The Administrator is responsible for overall compliance.

Based on interview, record and policy review, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for two Residents (#33 and #37) out of a total sample of 22 residents. Specifically, the facility failed to: 1. for Resident #33, ensure that the MOLST (Medical Orders for Life Sustaining Treatment: a form completed by the Resident to indicate their wishes for treatment to sustain their life in emergency situations in case they are not able to make their wishes known) was maintained as part of the Resident's active medical record and was accessible to facility staff in the event the Resident had a change in condition. 2. for Resident #37, ensure that the Physician's orders matched the Resident's current MOLST. Findings include: Review of the facility policy titled MOLST (Massachusetts Medical Orders for Life Sustaining Treatment), dated January 2014, indicated: -Completed MOLST forms will be accepted as valid medical orders . -When the Physician or Nurse Practitioner visits in person (within 72 hours after admission) or at the time of signing a MOLST anytime after admission, the actual order saying Full Code, DNR (Do Not Resuscitate), Do Not Hospitalize etc. should be handwritten as a Physician's Order. -Once reviewed the MOLST should be copied and the current original form placed in a page protector in the advanced directives section of the chart along with any other advanced directives completed . 1. Resident #33 was admitted to the facility in February 2023, with diagnoses of Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs) and Cerebral Infarct (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area). Review of Resident #33'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 of a total 15. Review of Resident #33's clinical record indicated: -A blank MOLST form in the front of the chart. -No evidence of a completed MOLST on file. Review of Resident #33's September 2024 Physician's orders indicated: -Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive), No Dialysis, initiated 7/25/24, active During an interview on 9/19/24 at 12:58 P.M., Resident #33 said he/she believed that someone had completed a MOLST with him/her a long time ago but he/she could not recall when. During an interview on 9/19/24 at 1:20 P.M., the surveyor and Social Worker (SW) #1 reviewed the Resident's chart and Physician's orders. SW #1 said she would review her records and the Resident's clinical record and follow-up with the surveyor. During a follow-up interview on 9/19/24 at 1:28 P.M., SW #1 said her records indicated Resident #33 had declined to fill out a MOLST but that this would be addressed again at his/her upcoming care plan meeting. During an interview on 9/19/24 at 3:04 P.M., the Director of Nursing (DON) presented the surveyor with a completed MOLST form dated 2/15/23, that indicated the following: -Attempt Resuscitation -Intubate and Ventilate -Use Non-Invasive Ventilation (e.g. CPAP [sic] - a device that provides Continuous Positive Airway Pressure) -Transfer to the Hospital -No dialysis -No artificial nutrition -Use artificial hydration During a follow-up interview on 9/20/24 at 9:26 A.M., the DON said the MOLST form dated 2/15/23, had been located in Resident #33's old chart in medical records. The surveyor and the DON reviewed the portion of the MOLST where the Resident had indicated no dialysis and no artificial nutrition. The DON said that there would be concern because if Resident #33 became incapacitated, staff would not have been able to follow his/her wishes if they cannot access the MOLST form. 2. Resident #37 was admitted to the facility in November 2019, with diagnoses including Cerebral Infarction and Chronic Obstructive Pulmonary Disease (COPD: a lung disease that causes restricted air flow in the lungs and difficulty breathing). Review of Resident #37's MDS assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a BIMS score of 13 out of total 15. Review of Resident #37's MOLST, dated 11/13/23, indicated: -MOLST had been signed by Resident #37 -Do Not Resuscitate (DNR) -Do Not Intubate and Ventilate (DNI/DNV) -Option to use or not use Non-Invasive Ventilation left blank -Do Not Transfer to Hospital (unless needed for comfort) (DNH) -Page 2 of the MOLST form addressing treatment decisions for dialysis, artificial nutrition, and artificial hydration was left blank Review of Resident #37's September 2024 Physician's orders, initiated 7/25/24, active indicated the following: -DNR -DNI -may transport to hospital -use non- invasive ventilation -use artificial hydration short term only During an interview on 9/19/24 at 1:25 P.M., the surveyor and SW #1 reviewed the MOLST and Physician's orders. SW #1 said Resident #37 had declined to fill out the back of the MOLST form. SW #1 further said that the Physician's orders should match the MOLST form, but that the Physician's orders and MOLST did not match.

Based on observation, interview, record and policy review, the facility failed to provide treatment and services, consistent with professional standards of practice to prevent the development of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device)/skin injuries for one Resident (#357) out of a total sample of 22 residents. Specifically, for Resident #357, the facility failed to ensure: 1. that a Licensed Nurse completed an assessment after a Certified Nurses Aide's (CNA) observation of an alteration to the Resident's skin which resulted in the development of pressure ulcers for the Resident. 2. that the Community Physician recommendation for a therapeutic air mattress/alternating pump pad mattress was reviewed with the facility Physician. Findings include: Review of the facility policy titled Skin Conditions (Assessment of), revised January 2023, indicated the following: -It is the policy of the facility to routinely assess and report resident skin condition, implement preventative measures as warranted . -A weekly skin assessment will be completed on shower days by [a] nurse, noting any abnormalities on the treatment record. Complete necessary documentation for any condition noted (e.g.nurse's note, etc.) -Any area(s) of skin breakdown or potential breakdown (i.e. unstageable reddened/purplish areas) will be sized on assessment and have the appropriate treatment plan and care plan put into place. Resident #357 was admitted to the facility in September 2024, with diagnoses including, Chronic Obstructive Pulmonary Disease (COPD: a lung disease that causes restricted air flow in the lungs and difficulty breathing), Chronic Kidney Disease Stage 3a (mild to moderate loss of function of the kidneys causing them to be less able to filter waste and fluid from the blood) and Type 2 Diabetes Mellitus (DM II - long-term condition where the pancreas is unable to produce enough insulin hormone to regulate blood glucose [sugar] levels resulting in higher than normal blood sugar levels). Review of the Minimum Data Set (MDS) assessment, dated 9/12/24, for Resident #357 indicated: -moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. -was admitted to the facility with no pressure ulcers. -was dependent on staff for bed mobility (ability to position self and roll left to right or right to left). -was at risk for developing pressure ulcers. -had an indwelling urinary catheter. Review of Resident #357's care plans indicated an at risk for pressure ulcer care plan that was initiated on 9/6/24 with the following interventions: -follow facility policies/protocols for the prevention/treatment of skin breakdown. -skin check every shift with care [sic]. 1. Review of Resident #357's skin assessment titled Skin Only Evaluation, dated 9/5/24, indicated: -the only alteration to the Resident's skin was a biopsy site to the forehead. Review of the Skin Monitoring: Comprehensive CNA Shower Review Form, dated 9/9/24, indicated: -the CNA had documented the Resident's buttocks as red on 9/9/24. -the Charge Nurse signed the Comprehensive CNA Shower Review Form as received. -The assessment and intervention portion of the form was left blank. Review of Resident #357's Treatment Administration Record (TAR) indicated: -skin assessment was refused on 9/9/24. -skin assessment was rescheduled for 9/13/24, with blanks in the staff initial box of the TAR. -no evidence in the clinical record that skin assessment had been attempted on 9/13/24 by a Licensed Nurse. Review of Resident #357's Nursing Progress Notes indicated the following: -9/5/24: Skin Evaluation note indicated lower body and buttocks are free from any abnormalities -9/6/24: History and Physical indicated: >skin: dry protective dressing on scalp >cranial nerves: Oriented to person, city, month, year and POTUS (President of the United States), alert, calm, on exam, answers questions appropriately -no other documentation of skin assessment or skin alterations -9/16/24: a note written by Unit Manager (UM) #2 that a new area of Moisture Associated Skin Damage (MASD - a condition where the skin becomes inflamed and eroded from prolonged exposure to moisture) to the Resident's buttocks (7 days after the CNA first identified red areas on the Resident's buttocks on 9/9/24). Review of Resident #357's Physician's orders indicated: -order for Silver Sulfadiazine (a cream used to treat wounds and burns) to buttocks twice a day for incontinent (having no or insufficient voluntary control over urination or defecation) dermatitis (inflammation of the skin), initiated 9/16/24. On 9/19/24 at 10:31 A.M., the surveyor and UM #2 observed the Resident's buttocks. The surveyor observed that Resident #357 had multiple open areas on the buttocks including two small areas on the right buttock and coccyx (tailbone: tiny bones joined with the sacrum [large flat bone in the lower part of the spine]) and one larger area on the left buttocks. During an interview immediately following the observation, UM #2 said she believed the open areas to be MASD but was unsure of the cause as the Resident's bowel pattern had not identified a pattern of frequent incontinence and an indwelling urinary catheter (a device inserted into the bladder that drains urine into a collection bag) was already in place. UM #2 further said that the areas appeared worse, and the Resident would be seen by the Wound Doctor/Physician #2 that day (9/19/24). Review of the Wound Doctor/Physician #2's Initial Wound Evaluation and Management Summary Note, dated 9/19/24, indicated the following: -intermittent fecal incontinence -Stage 2 Pressure Wound (an open wound or blister that occurs when the skin breaks and some of the outer upper layers of skin are damaged) of the Left Buttock with etiology (cause) of pressure, documentation of exposed dermis (second layering of skin) and recommendation to offload (minimizing or removing weight placed on the wound to help prevent and heal ulcers) wound. -Stage 2 Pressure Wound of the Right Buttock with etiology of pressure, documentation of exposed dermis and recommendation to offload wound. -Stage 2 Pressure Wound of the Coccyx (tailbone) with etiology of pressure, documentation of exposed dermis and recommendation to offload wound. During an interview on 9/19/24 at 1:44 P.M., the Wound Doctor/Physician #2 said he had seen Resident #357 for the first time on 9/19/24. The Wound Doctor/Physician #2 further said that he did not feel the wounds were MASD or had a moisture component. The Wound Doctor/Physician #2 said that based on his assessment all three (wound) areas were Stage 2 Pressure Ulcers. During an interview on 9/19/24 at 2:47 P.M., the surveyor and UM #2 reviewed the skin assessment documentation in the Electronic Medical Record (EMR). UM #2 said a skin assessment should have been completed on 9/9/24, and that had not occurred. UM #2 further said the purpose of weekly skin assessment is to catch areas of skin breakdown before they develop or early in development to prevent development or worsening. On 9/20/24 at 8:38 A.M., the surveyor and UM #2 reviewed the newly provided form titled Skin Monitoring: Comprehensive CNA Shower Review dated 9/9/24, and the TAR for Resident #357. UM #2 said that if the skin assessment was refused (by the Resident) it should have been re-attempted. UM #2 further said this was especially important because the CNA had identified a potential new area of skin breakdown. During an interview on 9/20/24 at 9:14 A.M., the surveyor and the Director of Nursing (DON) reviewed the Skin Monitoring: Comprehensive CNA Shower Review Form dated 9/9/24, and the TAR for Resident #357. The DON said that the 9/9/24 skin assessment should have been re-attempted if the Resident refused but it was not. 2. Review of Resident #357's admission paperwork included a Physician Progress Note from the Community Physician, dated 9/4/24, that indicated: -would benefit from an alternating pump pad mattress (an air mattress that regulates the inflation and deflation of its air cells in a cyclical pattern, alternating pressure between different areas of the body) due to history of pressure ulcers and the inability to frequently change position. Review of Resident #357's History and Physical, dated 9/6/24, did not indicate that the facility Provider (Physician/ Nurse Practitioner [NP]/ Physician Assistan [PA]) reviewed the admission paperwork from the Community Physician. Review of Resident #357's clinical record indicated no evidence of an order for, or discussion of the Community Physician recommendations for an air mattress/alternating pump pad mattress. The surveyor observed Resident #357 lying in bed with a standard mattress in use at the following times: -9/18/24 at 8:12 A.M. -9/18/24 at 9:53 A.M. -9/19/24 at 8:00 A.M. -9/20/24 at 7:15 A.M. -9/20/24 at 9:50 A.M. During an interview on 9/20/24 at 10:55 A.M., the surveyor and UM #2 reviewed Resident #357's admission Physician's Progress Note dated 9/4/24. UM #2 said the Resident had not been put on an air mattress. UM #2 further said the (Community Physician) recommendation should have been reviewed with the (facility) Provider and the Provider should determine if the recommendation is or is not implemented. During an interview on 9/20/24 at 11:10 A.M., the surveyor and Physician #1 reviewed Resident #357's admission Community Physician's Progress Note, dated 9/4/24. Physician #1 said he did not specifically recall the conversation when the facility Nurse reviewed admission medications and recommendations with him. Physician #1 said that he would have given an order for the air mattress had the recommendation been relayed to him.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and interventions for three Residents (#72, #63, and #94) out of a total of 22 sampled residents, who were diagnosed with Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), to attain their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility staff failed to: 1a. provide individualized interventions when Resident #72 and Resident #63 were engaged in verbal interactions and Resident #72 directed undignified statements toward Resident #63. 1b. respond timely to Resident #63's requests to disengage in an activity when the Resident voiced that he/she did not want to participate, and the Resident's escalating symptoms and behaviors were not immediately addressed by the Activities staff. 1c. respond promptly to Resident #63 when the Resident initiated a request to use the bathroom. 2. provide appropriate individualized interventions for Resident #94, when the Resident stood up from his/her wheelchair multiple times, and staff identified that standing from the wheelchair indicated the Resident wanted to use the bathroom or move, but neither intervention was offered timely to the Resident by facility staff. Findings include: 1. Resident #72 was admitted to the facility in December 2023 with diagnoses including Dementia with Behavioral Disturbance and Alzheimer's Disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, that is severe enough to interfere with daily life). Review of Resident #72's Physical Mobility Care Plan, initiated 3/22/24, indicated the following: -The Resident could propel his/her wheelchair, but preferred to have staff assist him/her. -The Resident required assistance from staff to walk. Review of Resident #72's Alzheimer's Care Plan, initiated 12/6/23 and revised 1/9/24, indicated the following: -The Resident had the potential to be . verbally aggressive. -Staff were required to modify the Resident's environment by taking the Resident to a quieter place and attempt to redirect. -When the Resident became agitated, staff were required to intervene before the Resident's agitation escalated by guiding the Resident away from the source of distress, . engaging the Resident calmly in conversation or activity. Review of Resident #72's MDS Assessment, dated 8/19/24, indicated the following: -The Resident was unable to complete the Brief Interview for Mental Status (BIMS) Assessment. -The Resident's cognitive skills for daily decision making were severely impaired as evidenced by staff interview. -The Resident had short and long-term memory problems. -The Resident demonstrated physical and verbal behaviors directed at others. Resident #63 was admitted to the facility in June 2024, with diagnoses including Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances), Dementia with Agitation, and Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #63's Dementia Care Plan, initiated 6/13/24 and revised 7/2/24, indicated the following: -The Resident had impaired cognitive function or impaired thought process related to Dementia. -The Resident's goal was to be able to communicate basic needs on a daily basis. Review of Resident #63's Communication Care Plan, initiated 6/21/24 and revised 7/2/24, indicated the following: -The Resident had a communication problem related to Dementia, Anxiety, and Depression. -Staff were required to anticipate and meet the Resident's needs. Review of Resident #63's MDS Assessment, dated 9/9/24, indicated the Resident's cognitive skills were severely impaired as evidenced by a score of zero out of 15 total possible points. a. On 9/17/24, between 8:58 A.M. and 9:17 A.M., the surveyor observed the following in the Birch Unit Multi-Purpose Room: -Resident #63 sat in a wheelchair with his/her back to the windows in the room and faced the other residents in the room. -Resident #72 sat in a wheelchair, at a table, diagonally to the left side and in front of Resident #63. -Resident #63 yelled loudly, One two three four five! Put it on a can! . One two three four five six seven eight nine ten! You do not have one now! -The surveyor observed Resident #72 look at Resident #63 and say shut up -Resident #63 then said, no!, and Resident #72 immediately responded, while looking at Resident #63, by saying, shut up! -The surveyor observed Resident #63 shake his/her hands repeatedly in the air while saying, No more food! Bring it back! One two three five four three two one stop! -At 9:03 A.M., the surveyor observed Resident #63 call out loudly, Shacka shacka shacka eeka eeka eeka! . We did not get kicked off because we were working with the people involved! . No! . -At the same time, the surveyor observed the Activities Director (AD) approach Resident #63. The Resident said, Go to [expletive] and the AD walked away from the Resident. -The surveyor observed Resident #72 look at Resident #63 and say, You're are a mess! -At 9:17 A.M., the surveyor observed Resident #63 call out loudly, Ahhh and Resident #72 said, shut up! At no time during the surveyor's observation did any staff modify Resident #72's environment, intervene to guide Resident #72 away from Resident #63, or attempt to engage Resident #72 calmly in conversation or activity. b. On 9/17/24 between 9:33 A.M. and 10:09 A.M., the surveyor observed the following in the Birch Unit Multi-Purpose Room: -Resident #63 participated in large group exercise activity until the activity was completed at 9:52 A.M. -The AD immediately transitioned the activity from exercise group to a large group activity using a large ball. -The surveyor observed Resident #63 wave his/her hands in the air repetitively and say, Where are you! Where are you! Stop doing so much stuff! -At 9:59 A.M., Resident #63 called out loudly while in the group activity, I can't do this .! I've got to get out of here! I can't play this! I will be dead! I'm sick, I've got to go! -No staff were observed to offer to remove Resident #63 from the activity at this time. -The surveyor observed the AD move the ball toward Resident #63 and the Resident used his/her hands to push the ball, then yelled, No! Stop it! I'll shot you! Get out of here! I'm going home! It's too much for me! I can't do this! Ahhh! . -The surveyor further observed the ball come back to Resident #63 and the Resident shook his/her hands in the air and called out, Don't bring it back around to me! Ahhh! I don't want it! I can't play this! It's too much for me! I'm going home! . -At the time, the surveyor observed the AD approach Resident #63 and say, You are good at this game and the Resident responded, Stop, don't anymore! At no time during the surveyor's observation did any staff offer to assist Resident #63 away from the activity or offer to provide an alternate activity for the Resident. On 9/17/24 at 10:10 A.M., the surveyor observed the Administrator enter the Birch Unit Multi-Purpose Room while Resident #63 continued to call out loudly during the activity. The surveyor observed the Administrator approach the Resident, then the AD and request that the AD assist the Resident away from the activity. The surveyor observed the AD offer to assist Resident #63 away from the activity, the Resident agreed, and the AD assisted to the Resident to a table in the room. The AD provided the Resident with a book to look at and the Resident's calling out and yelling stopped at that time. c. On 9/18/24, between 3:13 P.M. and 3:20 P.M., the surveyor observed the following in the Birch Unit Multi-Purpose Room: -Resident #63 was seated in his/her wheelchair, waving and pointing his/her finger in the air saying, I need to go to the bathroom . I've been waiting a long time -The surveyor observed Resident #63 count loudly and repetitively and said, Now! . No! No! . while the Resident slapped the armrest of his/her wheelchair and used his/her hands on the armrests to push up and move forward in the wheelchair seat repeatedly. -At the time, the surveyor observed three staff members (Nurse #2, Nurse #3, and Certified Nurses Aide[CNA] #3) in area of the Multi-Purpose Room, but no staff were observed to respond to the Resident's request. -The Resident continued to move him/herself up and forward in the wheelchair repeatedly. -At 3:20 P.M., Resident #63 stopped moving up and forward in the wheelchair and no longer requested the use of the bathroom. During an interview on 9/18/24 at 3:25 P.M., the AD said Resident #63 had difficulty with transitions between activities and transitions within different rooms in the facility. The AD also said that she thought large activities in the Birch Unit's Multi-Purpose Room was too much, . over-stimulating for Resident #63. During an interview on 9/18/24 at 3:30 P.M., the surveyor shared the observation of Resident #63 requesting to use the bathroom, waving his/her arm in the air, and moving up and forward in the wheelchair with Nurse #2 and Nurse #3. At the time, Nurse #2 said she had worked the day (7:00 A.M. through 3:00 P.M.) shift and did not stay through the conclusion of the interview. Nurse #3 said she was working the current (3:00 P.M. through 11:00 P.M.) shift, then asked the surveyor if any of the staff in the room responded to Resident #63's request to use the bathroom. During an interview on 9/19/24 at 8:55 A.M., Unit Manager (UM) #1 said all staff at the facility were required to undergo training to care for residents with Dementia. UM #1 said if residents raised their voices or made undignified comments to each other, staff were required to intervene immediately by offering a calm approach, separating the residents, and offering diversional activity. UM #1 said staff should have intervened, as required, when Resident #72 raised his/her voice and made undignified comments toward Resident #63. UM #1 also said someone should have responded to Resident #63 when he/she demonstrated signs for needing, and requested use of the bathroom. During an interview on 9/19/24 at 10:00 A.M., the Administrator said if residents became upset with or raised their voices at each other, staff were required to intervene by separating the residents and offering diversional activity. The Administrator said that staff should have intervened when Resident #63 repetitively called out by offering a change in the environment and diversional activity, and that staff should also have intervened when Resident #72 raised his/her voice and made undignified comments toward Resident #63. The Administrator said she observed Resident #63 clearly state that he/she did not want to participate in the large group activity with the ball on 9/17/24 and that the staff should have responded to the Resident's request to leave the activity. The Administrator also said staff should have assisted Resident #63 away from the ball activity when the Resident requested to leave and that staff should have offered the Resident something else to do. The Administrator said that staff should have been aware of Resident #63's movement in his/her wheelchair when he/she requested to use the bathroom and should have responded to the Resident's request to use the bathroom. 2. Resident #94 was admitted to the facility in March 2024, with diagnoses including Dementia, Parkinson's Disease (PD - a progressive degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), and Abnormalities of Gait (pattern one uses to walk) and Mobility. Review of Resident #94's Cognitive Function Care Plan, initiated 3/21/24 and revised 4/4/24 indicated the following: -The Resident had impaired cognitive function. -One of the Resident's goals was to be able to communicate basic needs on a daily basis. -Staff were required to face the Resident when speaking and make eye contact. -The Resident understood consistent, simple, directive sentences. -Staff were required to ask yes/no questions in order to determine the Resident's needs. Review of Resident #94's Activities of Daily Living (ADL) Care Plan, initiated 3/22/24 and revised 7/11/24, indicated the following: -The Resident had ADL self-care performance deficit related to PD. -The Resident required assistance of two staff for transfers. -The Resident required assistance of two staff to ambulate (walk). Review of Resident #94's Physical Therapy Evaluation, dated 9/16/24, indicated the following: -The Resident had been referred for a PT evaluation due to reduced ability to transfer and ambulate. -The Resident required maximal assistance of two staff members to transition from sitting to standing, with step by step cues. -The Resident was able to ambulate 50 feet with assist of two staff, use of a rolling walker with cues, and use of a wheelchair to follow behind the Resident. On 9/19/24, between 8:55 A.M. and 9:25 A.M., the surveyor observed the following in the Birch Unit Multi-Purpose Room: -Resident #94 was seated in a wheelchair with a table in front of him/her. -CNAs #1 and #2 were in the Multi-Purpose Room. -The Resident used his/her hands to push up on the armrests of the wheelchair and stood. -After approximately 20 seconds, the surveyor observed CNA #2 approach Resident #94 at the Resident's left side, instruct the Resident to sit down, and the Resident complied. The surveyor observed that CNA #2 did not make eye contact with the Resident or ask any yes/no questions in attempt to determine the Resident's need at that time. -At 9:10 A.M., the surveyor observed CNA #1 standing next to Resident #94's right side. -The Resident placed his/her hands on the wheelchair armrests and began to stand when CNA #1 touched the Resident's right upper back and instructed the Resident to sit down. The Resident complied. -The surveyor observed that CNA #1 did not make eye contact with the Resident or ask any yes/no questions in attempt to determine the Resident's needs at that time. During an interview at the time, CNA #2 said Resident #94 had difficulty making his/her needs known and that the Resident was always trying to stand up. CNA #2 also said he did not ask Resident #94 what he/she needed when he/she stood up because the Resident couldn't say what he/she needed. CNA #2 said that Resident #94 was able to transfer and walk with staff assistance and that when the Resident stood up, it usually meant that he/she wanted to move. CNA #2 said the Resident usually sat in one of the recliner chairs in the Multi-Purpose room following breakfast and that that was where the Resident probably wanted to go at that time. -At 9:16 A.M., Resident #94 placed his/her hands on the wheelchair armrests again and began to stand. CNA #1 was still standing next to the Resident, instructed the Resident to sit down, and the Resident complied. No staff were observed to make eye contact with Resident #94 or ask any yes/no questions to determine what the Resident needed until 9:25 A.M. when the Resident was assisted away from the table. During an interview on 9/19/24 at 9:26 A.M., CNA #1 said staff were required to watch Resident #94 all of the time because the Resident always tried to stand. CNA #1 said she did not ask the Resident what he/she needed when he/she attempted standing during the surveyor's observation because when staff asked the Resident what he/she needed, he/she would answer with a statement that did not align with the question asked. CNA #1 said Resident #94 was able to transfer with assistance of two staff and that changing the Resident's position had not been offered to the Resident until another CNA came to assist him/her away from the table at 9:25 A.M. to provide the Resident with daily personal care. During an interview on 9/19/24 at 10:08 A.M., UM #1 said Resident #94 had difficulty communicating his/her needs verbally to staff and that staff had identified when the Resident attempted standing, he/she usually wanted to get up, walk, or use the bathroom. UM #1 said that the Resident had experienced a decline in transfers and walking recently and required assistance of two staff for transfers. UM #1 further said there were enough staff working on the Unit to provide the required assistance for Resident #94 and that staff should have offered to assist the Resident to move away from the table and use the bathroom.

Based on observation, interview, record and policy review, the facility failed to ensure that residents were free of significant medication errors during the medication pass process for one Resident (#207) out of five residents observed, out of a total sample of 22 residents. Specifically, for Resident #207, the facility staff failed to administer the Sevelamer medication (phosphate binder -used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis [the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood]) timely and with meals as required. Findings include: Review of the facility policy titled Medication Administration; Information Needed, revised 5/2012 indicated: -To ensure resident/patient safety, the facility will define what information will be available to the licensed nursing staff who administer medications. -Other resources are available if the licensed staff has questions relating to medication administration, for example: Current Nursing Drug Handbook. Facility follows Nursing 2024 Drug Handbook relative to Sevelamer medication, which indicated: -Assess patient for GI (gastrointestinal) side effects periodically during therapy. -Administer with meals. -Advise patient to notify health care professional if GI effects (worsening of existing constipation, bloody stools) occur. -Instruct patient to take Sevelamer medication with meals as directed and to adhere to prescribed diet. Resident #207 was admitted to the facility in September 2024, with diagnoses including End Stage Renal Disease (ESRD - a medical condition where the kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and Dependence on Renal Dialysis. Review of Resident #207's September 2024 Physician's orders indicated: -Sevelamer 800 mg, give one tablet with meals related to End Stage Renal Disease, ordered 9/16/24 Review of Resident #207's September 2024 Medication Administration Record (MAR) indicated: -Sevelamer 800 mg tablet, give one tablet with meals scheduled for 8:00 A.M., 12:00 P.M., 5:00 P.M. On 9/18/24 at 1:52 P.M., the surveyor observed Nurse #4 prepare and administer the Sevelamer medication (the 12:00 P.M. dose) for Resident #207. Nurse #4 was observed bringing the medication to Resident #207, and the Resident told Nurse #4 that he/she took the Sevelamer medication with food. Nurse #4 told the Resident that he/she could take the Sevelamer medication at any time. Resident #207 was observed to swallow the Sevelamer medication with a cup of water. During an interview on 9/18/24 at 2:24 P.M., Nurse #4 said was she was not aware the Sevelamer medication needed to be taken with food and that she did not read the medication instructions. During an interview on 9/18/24 at 2:45 P.M., Unit Manager (UM) #3 said Nurse #4 should have reviewed the medication instructions and listened to the Resident but she did not.

Based on interview, policy and record review, the facility failed to maintain complete and accurate medical records for one Resident (#81), out of a total sample of 22 residents. Specifically, For Resident #81, the facility failed to: -maintain accurate documentation of advanced directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) when the MOLST (Massachusetts Medical Orders for Life-Sustaining Treatment) form was not signed by the Resident. -maintain accurate documentation of the Resident's code status (advanced directives) on the dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) communication sheet sent from the facility to the dialysis center which would inform the dialysis staff on the appropriate response for the Resident in the event of a cardiac emergency. Findings include: Review of the facility policy titled, Physician's orders: Receiving and Noting Of, revised March 2016, indicated: -Document all changes and orders in the nurses' progress notes adding reasons for the orders or changes in the orders. -Document the notification of the resident/patient and/or the responsible party. -Document in the care plan as needed. -Document in the logbook and communicate the changes to the on-coming nurse. Resident #81 was admitted to the facility in May 2024, with diagnoses including Altered Mental Status (change in awareness, cognition, attention, or consciousness), Malignant Neoplasm of Prostate (cancer in the tissues of the prostate gland), and Hypertensive Chronic Kidney Disease of the Kidney (high blood pressure caused by the narrowing of the arteries that carry blood to the kidneys). Review of Resident #81's September 2024 Physician's orders indicated: -Dialysis scheduled in the morning on Monday, Tuesday, Thursday, and Friday, by the facility Kidney Care Center, ordered 7/19/24. -Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) Invoked (put into effect by a Physician indicating that a resident is unable to make medical decisions), ordered 7/2/24. -Do Not Resuscitate (DNR), ordered 8/27/24. Review of the facility's Health Care Proxy (HCP) invocation form titled Documentation of Patient Incapacity, signed on 7/1/24, indicated: -Resident #81 had moderate incapacity for medical decision making. -Health Care Proxy (HCP) has been invoked. -Invocation was temporary. -Duration was questionable of two weeks from 7/1/24. Review of Resident #81's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) dated 8/26/24, indicated the Resident's HCP signed the MOLST form with decision for Do Not Resuscitate (DNR) code status. Review of the facility's Dialysis Transition of Care Form indicated Resident #81's code status as follows: -8/27/24: Code Status is blank. -8/29/24: Code Status is DNR. -8/30/24: Code Status is Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). -9/2/24: Code Status is Full Code. -9/3/24: Code Status is Full Code. -9/5/24: Code Status is DNR. -9/9/24: Code Status is DNR. -9/10/24: Code Status is blank. -9/12/24: Code Status is blank. -9/13/24: Code Status is Full Code. During an interview on 9/19/24 at 10:24 A.M., Unit Manager (UM) #3 said Resident #81's HCP was invoked temporarily for two weeks from 7/1/24. UM #3 said there had been no follow-up to the invocation by the facility. UM #3 said the Dialysis Transition of Care Form was a communication tool between the facility and the dialysis department. UM #3 further said the Transition of Care Form had not been filled out correctly to reflect Resident #81's advanced directives and that the facility should not have had the HCP sign the MOLST form.

Based on observation, interview, record and policy review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections within the facility on two Units (Birch and Cedar) out of three total Units. Specially, the facility failed to ensure: 1. On the Cedar Unit, that staff utilized the indicated Personal Protective Equipment (PPE-items such as gowns, gloves, etc. worn to protect the wearer for exposure to potential infection or from exposing the care recipient to potential infection) while caring for a Resident (#357) on Enhanced Barrier Precautions (EBP - protective barrier gowns and gloves used as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDROs] during high contact resident care). 2. On the Birch Unit, that staff cleaned and disinfected glucometers (multiuse device used to check blood sugar levels) between use on multiple residents. Findings include: 1. Review of the undated facility policy titled Enhanced Barrier Precautions indicated the following: -Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. -EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. -Examples of high-contact care activities requiring the use of gown and gloves for EBPs include: .changing briefs .wound care. Resident #357 was admitted to the facility in September 2024, with diagnoses including Neuromuscular Dysfunction of the Bladder (a condition where the nerves and muscles of the bladder do not work together well and can cause problems with the emptying of the bladder) and Chronic Indwelling Urinary Catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body). Review of Resident #357's Enhanced Barrier Precautions care plan, initiated 9/6/24, indicated: -Staff will wear appropriate PPE when providing close contact care. During a wound observation on 9/19/24 at 10:31 A.M., the surveyor observed an EBP sign posted at the door of Resident #357's room indicating the Resident was on EBP. The surveyor observed Unit Manager (UM #1) perform hand hygiene prior to entering Resident #357's room. The surveyor further observed that UM #1 did not don (put on) gloves, or a gown as indicated, before proceeding to position Resident #357 on his/her right side. The surveyor observed UM #1 then hold the Resident's left hip and lateral (near the side) buttocks near open wounds with her bare hands and no gown, while she observed the buttocks wounds with the surveyor. During an interview immediately following the observation, UM #1 said she did not wear a gown or gloves while assessing the wound with the surveyor but should have. During an interview on 9/19/24 at 1:48 P.M. the Infection Preventionist (IP) said when doing care and assessing a wound of a Resident on EBP, the expectation was that the Nurse should wear a gown and gloves. 47901 2. Review of the facility policy titled Blood Glucose Testing Policy, revised March 2013, indicated: -The glucometer will be used according to the manufacturer's guidelines (refer to the following pages and/or manual in the nursing policy and procedure book). -Disinfect glucometer with bleach wipes or approved facility disinfectant. The facility references the glucometer brand (Assure Prism) instructions manual, page 38 on cleaning and disinfecting which indicated: -The meter should be cleaned and disinfected after use on each patient. -The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. -The disinfection procedure is needed to prevent transmission of blood-borne pathogens. -Clorox healthcare bleach germicidal wipes and dispatch hospital cleaner disinfectant towels with bleach have been validated as cleaning agents for the blood glucose meter. -All parts of the Assure Prism multi blood glucose system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. During the medication administration observation on the Birch Unit on 9/19/24 at 7:44 A.M., the surveyor observed Nurse #1 perform blood glucose testing on a Resident. The surveyor observed that Nurse #1 wore gloves during the blood glucose testing, returned to her medication cart after testing with gloves still in place, placed the glucometer machine back in the device carrying case and then placed the device carrying case in the medication cart. Nurse #1 then removed her gloves and sanitized her hands. During an interview immediately following the observation, Nurse #1 said she forgot to sanitize the glucometer machine. Nurse #1 then removed the glucometer machine from the device carrying case, wiped the machine with an alcohol wipe, and placed the machine back in the carrying case. Nurse #1 said the facility used alcohol wipes to clean the glucometer machine. During an interview on 9/19/24 at 11:32 A.M., the Director of Nursing (DON) said the facility used disinfecting with bleach wipes and not alcohol wipes to disinfect the glucometer machine. The DON said Nurse #1 should have cleaned the glucometer machine with the facility approved disinfecting bleach wipes. The DON further said Nurse #1 could have contaminated the carrying case and should not have placed the glucometer machine back in the carrying case and into the medication cart.

Based on interview, record and policy review, the facility failed to ensure that Pneumococcal (any infection caused by bacteria called Streptococcus Pneumoniae, or Pneumococcus that can range from ear and sinus infections to Pneumonia and blood stream infections) Vaccinations were offered to three Residents (#72, #33, #2) out of five applicable residents, out of a total sample of 22 residents, increasing the residents risk for developing facility acquired Pneumococcal infections. Specifically, the facility failed to: 1. Offer Resident #72 an updated Pneumococcal Vaccine when the Resident was not up to date and was eligible to receive an updated vaccine. 2. Offer Resident #33 an updated Pneumococcal Vaccine when the Resident was not up to date and was eligible to receive an updated vaccine. 3. Offer Resident #2 an updated Pneumococcal Vaccine when the Resident was not up to date and was eligible to receive an updated vaccine. Findings include: Review of the facility policy titled Pneumococcal Vaccine, revised August 2016, indicated: -Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Assessments of pneumococcal vaccination status will be conducted within seven working days of the resident's admission . -Pneumococcal vaccines with be administered to residents (unless medically contraindicated, already given, or refused) . -Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Preventions (CDC) recommendations at the time of vaccination. Review of CDC (Center for Disease Control and Prevention) guidelines titled Pneumococcal Vaccination Timeline for Adults, dated 9/14/24, indicated the following for adults aged [AGE] years and older: -Make sure your patients are up to date with Pneumococcal Vaccination. -If the following vaccines series has been completed: PCV (Pneumococcal Conjugate Vaccine) 13 at any age & PPSV (Pneumococcal Polysaccharide Vaccine ) 23 at [AGE] years of age or older, -then together with the patient, vaccine Providers may choose to administer PCV20 and PCV21 (Pneumococcal Conjugate Vaccine/ Prevnar 20/21: vaccine used to protect against 20 and 21 types of Pneumococcal bacteria that commonly cause serious infections) to adults [AGE] years of age or older, who already received PCV13 (but not PCV15 [Pneumococcal Conjugate Vaccine 15-valent: vaccine used to protect against 15 types of pneumococcal bacteria that commonly cause serious infections in adults] or PCV20) at any age, and PPSV23 at or after the age of [AGE] years old. -PCV20, PCV21, and PPSV23 may be administered after a minimum interval of greater than one year after the last dose of PPSV23 or PCV13. 1. Resident #72 was admitted to the facility in December 2023 with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), and was over the age of 65. Review of Resident #72's MIIS (Massachusetts Immunization Information System) record indicated he/she was administered the PPSV23 on 1/1/05. Review of the CDC PneumoRecs VaxAdvisor recommendation indicated: -Give one dose of PCV15, PCV20, or PCV21 at least 1 year after the last dose of PPSV23. Review of Resident #72's Medical Record did not indicate that the Resident and/or Representative was offered an updated Pneumococcal Vaccination or that the Pneumococcal Vaccination was medically contraindicated. During an interview on 9/19/24 at 2:03 P.M., the Infection Preventionist (IP) said the facility process was to review and offer vaccination to residents on admission and as needed (PRN). The IP said the facility would review a resident's MIIS and contact the Community Primary Care Provider to verify or obtain vaccination records if needed. The surveyor and the IP reviewed Resident #72's MIIS vaccination record. The IP said that the Resident's Pneumococcal Vaccination was not up to date and it had been [AGE] years since his/her last vaccination. The IP said that she will review if there was documentation in the Resident record indicating an updated Pneumococcal Vaccination had been offered or refused. During a follow-up interview on 9/20/24 at 7:35 A.M., the IP said that Resident #72's Pneumococcal Vaccination was not up-to-date and she was unable to provide evidence any vaccination had been offered. 2. Resident #33 was admitted to the facility in April 2023, with diagnoses including Cerebrovascular Accident (CVA- also known as stroke, when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel), and was over the age of 65. Review of Resident #33's MIIS record indicated he/she was administered the PCV13 on 11/27/19. Review of the CDC PneumoRecs Vax Advisor indicated: -Give one dose of PCV20, PCV21, or PPSV23 at least 1 year after PCV13. Review of the Medical Record did not indicate that Resident #33 and/or their Representative was offered an updated Pneumococcal Vaccination or that the Pneumococcal Vaccine was medically contraindicated. During an interview on 9/20/24 at 7:35 A.M., the IP said that she was not aware that Resident #33's Pneumococcal Vaccination was not up-to-date. 3. Resident #2 was admitted to the facility in June 2023, with diagnoses including Dementia, and was over the age of 65. Review of Resident #2's MIIS record indicated he/she was administered the PCV13 on 11/5/14. Review of the CDC PneumoRecs Vax Advisor indicated: -Give one dose of PCV20, PCV21, or PPSV23 at least 1 year after PCV13. Review of the Medical Record did not indicate evidence that Resident #2 and/or their Representative was offered an updated Pneumococcal Vaccination or that a Pneumococcal Vaccine was medically contraindicated. During an interview on 9/20/24 at 7:35 A.M., the IP said that Resident #2's Pneumococcal Vaccination was not up- to-date and she was unable to provide evidence an that updated vaccination was offered. The facility did not provide any additional evidence to the survey team relative to Resident's #72, #33, and #2 Pneumococcal Vaccinations at the time of survey exit.

Based on interview, record and policy review, the facility failed to provide education regarding the benefits and potential risks associated with COVID-19 vaccines for three Residents (#33, #2, and #81), out of five residents reviewed for immunizations, out of a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #33, to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine prior to administration of the vaccine. 2. For Resident #2, to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine prior to administration of the vaccine. 3. For Resident #81, to provide education regarding changes in the benefits and risks of additional COVID-19 vaccination doses. Findings include: Review of the facility policy titled Vaccination of Residents, revised August 2016, indicated: -Prior to receiving vaccinations, the resident or legal representative will be provided with information regarding the benefits and potential side effects of the vaccinations. -Provision of such education shall be documented in the resident's medical record. -If vaccines are refused, the refusal shall be documented in the resident's medical record. 1. Resident #33 was admitted to the facility in April 2023, with diagnoses including Cerebrovascular Accident (CVA- cerebrovascular accident, also known as stroke, when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel). Review of Resident #33 MIIS (Massachusetts Immunization Information System) record indicated he/she was administered COVID-19 Vaccinations on 10/18/23 and 4/5/24. Further review of the medical record did not indicate that education on the risks and benefits or potential side effects associated with the COVID-19 vaccinations was provided to the Resident prior to administration of the vaccine. During an interview on 9/19/24 at 1:52 P.M., the Infection Preventionist (IP) said that the process is to ask Residents or their Responsible Parties if appropriate, about their vaccination status. The IP said if the Resident requests vaccination, the facility will obtain a Physician's order for the vaccine and order it from the Pharmacy. The IP said that the facility does not have a process for using consent forms. The IP said that she or other nursing staff will obtain consent verbally and will provide a VIS (Vaccine Information Sheet) form to the Resident or Responsible Party. The IP said if the Resident or their Responsible Party refuses a vaccine, the refusal will be documented in the Resident's electronic record immunizations information. During a follow-up interview on 9/20/24 at 7:35 A.M., the IP said that she did not have evidence that Resident #33 consented to the COVID vaccinations or that education on the risks and benefits or potential side effects were provided prior to the COVID vaccines being administered. 2. Resident #2 was admitted to the facility in June 2023, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of Resident #2 MIIS record indicated he/she was administered a COVID-19 Vaccination on 10/19/23. Further review of the medical record did not indicate that education on the risks and benefits or potential side effects associated with the COVID-19 vaccinations was provided to the Resident prior to administration. During an interview on 9/20/24 at 7:35 A.M., the IP said that she did not have evidence that Resident #2 or their Responsible party was provided education on the risks and benefits or potential side effects were provided prior to the COVID vaccine being administered. 3. Resident #81 was admitted to the facility in May 2024, with diagnoses of fracture (break) of lower leg. Review of Resident #81's MIIS record indicated he/she was last administered a COVID vaccine on 10/12/23. Further review of the medical record did not indicate education was provided to Resident #81 or their Representative on the risks and benefits or potential side effects associated with the COVID-19 vaccinations or that an updated vaccine had been offered and declined. During an interview on 9/20/24 at 7:35 A.M., the surveyor and the IP reviewed Resident #81's medical record. The IP said that an updated COVID booster was offered to Resident #81 on 5/29/24, but the Resident refused, and this was documented in the electronic medical record immunizations tab, which was shown to the surveyor. The IP said she was unable to provide evidence that education on the risks and benefits of the vaccine were provided to the Resident or their Representative. The facility did not provide any additional evidence to the survey team relative to Resident's #33, #2, or #81 COVID vaccinations at the time of survey exit.

Based on record and policy review, and interview, the facility failed to ensure that one Resident (#307) out of a total sample of 22 residents, was afforded the ability to review/sign documents pertaining to his/her medical care. Specifically, the facility failed to ensure that Resident #307, who was identified as his/her own person and was able to make his/her own decisions, was able to review and sign documentation relative to Advanced Directives (life sustaining measures), side rail consent, self-administration of medication consent and consent for the use of psychotropic medications. Findings include: Review of the facility policy titled MOLST (Massachusetts Medical Orders for Life Sustaining Treatment), dated 1/2014, indicated the following: -The admitting nurse will note the existence of the MOLST form in the nursing notes and on the Physician's Orders. -Confirm with the patient/resident or their legally recognized healthcare agent that the MOLST form in hand has not been revoked or changed by a subsequent MOLST form. -A qualified health care provider, a licensed nurse or social worker, may conduct an initial review of the MOLST with the resident or if the resident lacks decision making capacity, the legally recognized health care agent. -The initial review and discussion about continuing, revising, or revoking the MOLST should be documented in the medical record. This documentation should include the time and date of the discussion, the parties involved and plans for follow-up action if needed. Resident #307 was admitted to the facility in September 2024, with diagnoses including Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment, weight loss, decreased appetite or poor nutrition and inactivity), Thoracic Aortic Aneurysm (ballooning of the upper aspect of the aorta, above the diaphragm) without Rupture, Status Post Kidney Transplant (surgery to replace a diseased or damaged kidney with a healthy one from a donor) and Severe Protein Malnutrition (an imbalance between the nutrients the body needs to function and the nutrients the body gets, that causes fluid retention, swollen abdomen and muscle wasting). Review of Resident #307's clinical record included the following: -Nursing Facility Authorization to Treat signed by the Resident's Representative on 9/11/24. -Medication Reconciliation Worksheet signed by the Resident's Representative on 9/11/24. -Side Rail Utilization Informed Consent signed by the Resident's Representative on 9/11/24. -Self-Administration Medications signed by the Resident Representative on 9/11/24. -Informed Consent Form for Remeron (medication used to trat major depressive disorder) signed by Resident Representative on 9/11/24. -MOLST form completed and signed by Resident Representative on 9/11/24, as Do Not Resuscitate, Do Not Intubate. Further review of Resident #307's clinical record indicated that the Resident's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) was not invoked (put into effect, was not dependent on a designated person to make medical and health care decisions) by the Physician/Medical Provider since his/her admission. On 9/20/24 at 7:45 A.M., the surveyor and Unit Manager (UM) #3 reviewed the Resident's clinical record. During an interview at the time, UM #3 said Resident #307's HCP was not invoked relative to decision making for health care treatment. During an observation and interview on 9/20/24 at 8:00 A.M., Resident #307 declined speaking to the surveyor. Resident #305 was lying in bed and when the surveyor attempted to talk to him/her, the Resident pulled up the blanket and covered his/her head. During an interview on 9/20/24 at 8:22 A.M., Social Worker (SW) #2 said the facility had not addressed Resident #307's medical decision capabilities. SW #2 said initial review and discussion about continuing, revising, or revoking the MOLST should have been completed and documented in the medical record, but it was not.

Based on record review and interview, the facility failed to ensure that a Minimum Data Set (MDS) Assessment was accurately coded for four Residents (#72, #33, #2, #357) out of a total sample of 22 residents. Specifically, the facility failed to accurately code: 1) For Resident #72, that Pneumonia Vaccination was not up to date. 2) For Resident #33, that Pneumonia Vaccination was not up to date. 3) For Resident #2, that Pneumonia Vaccination was not up to date. 4) For Resident #357, identify the type of urinary catheter in use. Findings include: 1. Resident #72 was admitted to the facility in December 2023, with diagnoses including Dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking). Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated that Resident #72's Pneumococcal Vaccination was up to date. Review of Resident #72's Massachusetts Immunization Information System (MIIS) record indicated his/her last Pneumococcal Vaccination was administered 1/1/05. During an interview on 9/20/24 at 7:35 A.M., the Infection Preventionist (IP) said that Resident #72's Pneumococcal Vaccination was not up to date. During an interview on 9/20/24 at 10:35 A.M., the MDS Coordinator said that the Pneumococcal Vaccination information was auto populated from the immunization documentation in a resident's record. The surveyor and the MDS Coordinator reviewed Resident #72's Pneumococcal Vaccination record and the MDS Coordinator said the 8/12/24 MDS Assessment was inaccurately coded and a modification would be submitted. 2. Resident #33 was admitted to the facility in April 2023, with diagnoses including Cerebrovascular Accident (CVA- cerebrovascular accident, also known as stroke, when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel). Review of the MDS assessment dated [DATE], indicated Resident #33's Pneumococcal Vaccination was up to date. Review of Resident #33's MIIS record indicated his/her last Pneumococcal Vaccination was administered 11/27/19. During an interview on 9/20/24 at 7:35 A.M., the IP said that Resident #33's Pneumococcal Vaccination was not up to date. During an interview on 9/20/24 at 10:35 A.M., the MDS Coordinator said the 7/28/24 MDS Assessment was inaccurately coded and a modification would be submitted. 3. Resident #2 was admitted to the facility in June 2023, with diagnoses including Dementia. Review of the MDS assessment dated [DATE], indicated Resident #2's Pneumococcal Vaccination was up to date. Review of Resident #2's MIIS record indicated his/her last Pneumococcal Vaccination was administered 11/5/14. During an interview on 9/20/24 at 10:35 A.M., the MDS Coordinator said the 8/12/24 MDS Assessment was inaccurately coded and a modification would be submitted. 50563 4. Resident #357 was admitted to the facility in September 2024, with diagnoses including Neuromuscular Dysfunction of the Bladder (a condition where the nerves and muscles of the bladder do not work together well and can cause problems with the emptying of the bladder) and Chronic Indwelling Catheter (device inserted into the bladder that drains urine into a collection bag). Review of Review of Resident #357's Minimum Data Set (MDS) Assessment, dated 9/12/24, indicated the presence of an indwelling catheter and an external catheter (a device placed over the external genitalia to collect urine that has exited the body and contain it in a collection bag). During an interview on 9/19/24 at 3:12 P.M., the surveyor and the MDS Coordinator reviewed the MDS assessment dated [DATE]. The MDS Coordinator said she would have to review her records and get back to the surveyor. During a follow-up interview on 9/19/24 at 3:23 P.M., the MDS Coordinator said that the external catheter was marked because a CNA had errantly marked external catheter instead of indwelling catheter during the look-back period and this transferred over to the MDS. The MDS Coordinator further said that the documentation that transferred over to the MDS should have been reviewed and corrected before the MDS was completed and submitted. Please Refer To F883

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was moderately cognitively impaired, with hearing, vision and communication deficits, the Facility failed to ensure he/she was free from the use of physical restraints, when on 02/10/24 during the overnight shift, the Nursing Supervisor held Resident #1 by his/her wrists as he/she displayed combative behavior with staff while they tried to meet his/her care needs. Findings include: Review of the Facility's Physical Restraint Policy, dated 11/30/10 indicated the use of a physical restraint affects the dignity, physical and emotional well-being of an individual. The Policy indicated a resident has the right to be free from any physical restraints for the purposes of discipline or convenience. Review of Resident #1's medical record indicated his/her diagnoses included Parkinson's Disease without dyskinesia (involuntary muscle movements), aftercare following joint replacement surgery, atrial fibrillation, asthma, dementia with behavioral disturbances, psychosis (mental disorder characterized by disconnection from reality), repeated falls, unsteadiness on feet, cognitive communication deficits, Dysphagia (difficulty swallowing) and displaced fracture of left femur. Resident #1's Quarterly Minimum Data Set assessment, dated 12/18/23 indicated he/she had moderate difficulty hearing, sometimes understood others, sometimes made him/herself understood, had highly impaired vision and moderate cognitive impairment. Resident #1's Care Plan related to communication, reviewed and renewed with his/her December 2023 MDS, indicated to allow sufficient time for speech/communication, provide emotional support and encouragement to vent feelings related to Parkinson's disease. Resident #1's Care Plan related to safety, dated as revised on 01/25/24, indicated he/she was deconditioned, had gait/balance problems, psychoactive drug use, had vision/hearing problems, was impulsive, had no safety awareness related to Parkinson's Dementia, and that he/she was combative with staff. The Care Plan interventions for safety included the following: floor mats on both side of the bed, review information on past falls and attempt to determine cause, alter any potential causes if possible, scoop mattress, and medication review. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 02/10/24, indicated that on 02/10/24 at 10:20 A.M., Resident #1 reported experiencing rib pain, and alleged he/she was struck in the chest/ribs during care. The Report indicated a full skin check was conducted on Resident #1 and there was no evidence of trauma. Review of Nurse #1's Written Witness Statement, undated, indicated on 02/10/24, she performed a head to toe skin assessment on Resident #1. The Statement indicated his/her skin was clear, however an area of purpura (purple, red or brown patches on skin) was observed to his/her right wrist. Resident #1's Radiology Interpretation, dated 02/11/24, indicated there was no dislocation or fractures to the ribs. During an interview on 03/06/24 at 11:45 A.M., Resident #1 said there was an incident that occurred at night (exact date unknown) while he/she laying in bed, and that two people (later identified as CNAs) came into his/her room first and then a woman (later identified as Nursing Supervisor) entered after them. Resident #1 initially said the Nursing Supervisor pressed on his/her throat with her hands and later clarified that the Nursing Supervisor held both his/her wrists up against his/her neck. Resident #1 said he/she was unable to breathe for a second. Resident #1 said he/she did not like how the Nursing Supervisor treated him/he that night. Resident #1 said he/she shouted don't do this and was kicking and hitting at them (the CNA's and Nursing Supervisor). Resident #1 said he/she had no concerns with the CNAs in the room. During a telephone interview on 03/13/24 at 2:00 P.M., CNA #2 said Resident #1 was at risk of falling, believe he/she could walk independently, but could not. CNA #2 said Resident #1 can become violent when he/she wants to do something independently, like get out of bed without the mechanical lift, which was an unsafe request. CNA #2 said on 2/10/24 during the overnight shift, the Nursing Supervisor alerted her that Resident #1 was sitting on the edge of the bed. CNA #2 said she immediately entered Resident #1's room, and Resident #1 pointed to the bathroom. CNA #2 said she and CNA #1 tried to use the Sara lift to safely transfer him/her to the bathroom. CNA #2 said Resident #1 was unable to stand properly, his/her knee was bending making the process unsafe. CNA #2 said Resident #1 was placed back onto the bed. CNA #2 said Resident #1 did not want to be in bed despite the offer to use a bedpan. CNA #2 said Resident #1 began kicking at them, and tried to get out of bed by him/herself. CNA #2 said the Nursing Supervisor was called into the room. CNA #2 said the Nursing Supervisor tried to calm down Resident #1, and told him/her it was not okay to hit the staff. CNA #2 said Resident #1, while seated on the edge of the bed, threatened to urinate on the Nursing Supervisor, then he/she kicked her and attempted to slap her. CNA #2 said the Nursing Supervisor held Resident #1's knees against his/her chest to stop him/her from kicking. CNA #2 said at one point the Nursing Supervisor also held Resident #1 arm. CNA #2 said Resident #1 was screaming spitting, violent and repeatedly trying to get out of bed. CNA #2 said Resident #1 was out of control, and a danger to him/herself and others. CNA #2 said at one point the Nursing Supervisor told Resident #1 that she was stronger than him/her. CNA #2 said she saw a bruise on Resident #1's right wrist. CNA #2 said she left the room and the Nursing Supervisor left the room when Nurse #2 came in to help with Resident #1. CNA #2 said Resident #1 calmed down with Nurse #2. During a telephone interview on 03/15/24 at 11:20 A.M., Certified Nurse Aide (CNA) #1 said on 2/10/24, (during the overnight shift) she entered Resident #1's room, and he/she was pointing at the bathroom. CNA #1 said although Resident #1 was told they needed to use the [NAME] (mechanical) lift for a safe transfer, Resident #1 made a gesture waving no. CNA #1 said when Resident #1 saw the mechanical lift he/she became agitated, but agreed for it to be used. CNA #1 said Resident #1's legs were wobbly and it appeared unsafe to use the mechanical lift at that time. CNA #1 said when Resident #1 was placed back onto the bed, he/she became frustrated, was cursing, combative, was sitting on the edge of the bed and refused to lay down. CNA #1 said when the Nursing Supervisor entered the room, Resident #1's agitation increased and he/she pushed her (the Nursing Supervisor). CNA #1 said the Nursing Supervisor told Resident #1 not to put his/her hands on her and said I'll punch you into next week to Resident #1. CNA #1 said Resident #1 grabbed the Nursing Supervisor's arm with both hands, was biting at her arm and kicking her. CNA #1 said as she removed one of Resident #1's hands from the Nursing Supervisor's arm, Resident #1 fell backward onto the bed with the Nursing Supervisor falling on top of him/her. CNA #1 said Resident #1's knees were bent up with the Nursing Supervisor's body against them. CNA #1 said she released Resident #1's right hand and noticed the Nursing Supervisor was holding Resident #1's left wrist on his/her chest. CNA #1 said the Nursing Supervisor told Resident #1 I'm bigger than you and stronger. CNA #1 said Resident #1's body was squirming, and he/she was gasping for breath. CNA #1 said the Nursing Supervisor got up off of Resident #1 after a few minutes passed. CNA #1 said when the Nursing Supervisor got up, there was urine on her clothes from Resident #1 (who had been incontinent during the altercation). CNA #1 said she saw a bruise on Resident #1's right wrist. CNA #1 said the Nursing Supervisor then left the room and Nurse #2 entered. CNA #1 said Resident #1 was breathing heavily, touching his/her chest. During a telephone interview on 03/15/24 at 3:00 P.M., the Nursing Supervisor said Resident #1, at times, struck out at staff, refused to let staff use the Sara lift for transfers and was then offered the urinal, when they could not safely transfer him/her to the bathroom. The Nursing Supervisor on 02/10/24 at 4:15 A.M., Resident #1 was more intent on getting up alone, and was striking out at staff. The Nursing Supervisor said she entered Resident #1's room and CNA #1 said they needed help because Resident #1 was violent and not cooperating. The Nursing Supervisor said Resident #1 had refused to let staff use the mechanical lift to transfer him/her, and was asked to lay safely on the bed to use a urinal. The Nursing Supervisor said at one point Resident #1 was laying on his/her side in bed, pushing the bed with his/her legs on the floor and his/her arms were over the side of the bed grabbing the bedframe. The Nursing Supervisor said she did not want Resident #1 to get hurt against a bedrail or fall to the floor because he/she had been thrashing around. The Nursing Supervisor said at one point Resident #1 fell backwards onto the bed sideways. The Nursing Supervisor said she did not restrain Resident #1's legs. The Nursing Supervisor said she was protecting herself with her arm and was concentrating on Resident #1's hands and him/her trying to bite her. The Nursing Supervisor said she tried to emphasize to Resident #1 that they were trying to get him/her safely into bed. The Nursing Supervisor said Resident #1 swung at CNA #1. The Nursing Supervisor said she held Resident #1's wrists to stop his/her arms from swinging, and that his/her knees were bent up and she was leaning forward while he/she was sitting on edge of bed. The Nursing Supervisor said Resident #1's arm (did not specify left or right) pulled free, he/she pinched her arm, then he/she sat up and tried to bite her. The Nursing Supervisor said she held both of Resident #1's wrists after he/she tried to hit her again, asked that he/she calm down and stop hitting. The Nursing Supervisor said Resident #1's wrists were positioned in front of him/her by his/her upper chest. The Nursing Supervisor said although she held Resident #1's wrists, he/she was still able to move his/her arms from side to side, but he/she could no longer punch forward at them. The Nursing Supervisor said when she let go, she saw there was a bruise on his/her right wrist approximately 3 inches wide. The Nursing Supervisor said she stepped out of the room and got Nurse #2, who was more familiar to Resident #1, to try to calm him/her down. The Nursing Supervisor said she could not be sure if Resident #1's behaviors escalated because of her, and that perhaps she should have left the room sooner. The Nursing Supervisor said she felt frustrated during the incident. The Nursing Supervisor said she did not want Resident #1 to fall on the floor since they would need a hoyer lift (mechanical lift) to get him/her up off the floor and did not think Resident #1 would be cooperative to its use. During an interview on 03/22/24 at 1:20 P.M., the Director of Nurses (DON) said Resident #1 initially alleged the Nursing Supervisor struck his/her chest and at a later time Resident #1 said she held his/her wrists. The DON said the Nursing Supervisor said she held Resident #1's wrists to keep Resident #1 from hitting them and to keep him/her from falling to the floor.

Based on policy review, observation, record review and interview, the facility failed to ensure its staff provided treatments in accordance with professional standards of practice for three Residents (#203, #204 and #207) out of a total sample of 21 residents. Specifically, 1. For Resident #203, the facility failed to ensure that its staff removed a post operative dressing in a timely manner, as ordered by the Physician, which resulted in a deterioration of the surgical incision. 2. For Resident #204, the facility failed to ensure that its staff obtained Physician's orders for the application of an ace wrap bandage to the right lower extremity, and the frequency of which to change it. 3. For Resident #207, the facility failed to ensure that its staff obtained Physician's orders for the application of a foam adhesive dressing to the coccyx (tailbone), and the frequency of which to change it. Findings include: Review of the facility's Treatment Policy, dated 2/6/10, indicated the following: -Policy: It is the policy of the facility to provide treatments (e.g. changing dressing of surgical wounds, decubitus ulcers, applying ointments and creams, etc.) in accordance with current standard of care for which the staff has received education. -Procedure: *A Physician's order is required for all treatments. The order will be transcribed onto the treatment record. *The order for the treatment must contain the treatment, any specific prescription, the location of the treatment, the number of times to be administered . *The treatment outcome and all assessments related to the treatment will be documented in the treatment record or in the nurse's note. *The Physician will be notified of any adverse reaction to the treatment or of any treatment that appears ineffective. 1. Resident #203 was admitted to the facility in June 2023 with a diagnosis including status-post Open Reduction Internal Fixation (ORIF- a surgical procedure for repairing fractured bone using either plates, screws, or rods to stabilize the bone) of the right patella (knee cap). Review of the hospital discharge orders, dated 6/5/23, indicated the following: -Current Aquacel (antimicrobial) dressing should remain in place until 6/9/23. Apply dry sterile dressing if drainage is present. -May shower with Aquacel dressing on, keep incision site clean and dry. -Knee immobilizer to right lower extremity at all times. Review of a progress note, dated 6/5/23, indicated Resident #203 was cognitively intact. Review of the Nursing Admission assessment, dated 6/5/23, indicated under the skin section: right knee with Aquacel dressing and knee immobilizer at all times, remove only for care. On 6/21/23 at 9:53 A.M., the surveyor observed the Resident in bed with a sling to the left arm. The Resident said he/she had a fall that resulted in a broken right patella and left broken shoulder. Resident #203 told the surveyor that he/she went for an Orthopedic follow-up appointment the previous day (6/20) and the Surgeon was very upset because care to the surgical incision had not been provided at the facility. The Resident told the surveyor that the facility staff had peeked at the right knee incision but did not do any treatments to it. The Resident said that because of that, the sutures to the right knee could not be removed at the follow-up appointment. The Resident asked the surveyor to please read the notes from the Orthopedic follow-up appointment. Review of the Orthopedic Consultation, dated 6/20/23, under the section titled Physician findings, the following was entered: -Change dressing daily. Keep dry!!! -Keep brace on in extension, no bending. -Wound is macerated (process of skin softening and breaking down due to prolonged exposure to moisture) from not changing bandage? -Please keep an eye on this. Call if it worsens. -Can use wheelchair with leg rests straight. -Sponge bath. -Can clean around wound then dry bandage. -Follow up in one week. Review of the June 2023 Medication Administration Record (MAR) indicated a Physician's order for wound care to the right knee with Aquacel dressing, should remain in place until 6/9/23. Apply dry sterile dressing if drainage is present, every shift. Further review indicated the Physician's order was never signed off by the Nursing staff as being completed from 6/5/23 through 6/20/23. The order was discontinued on 6/20/23, following the Orthopedic follow-up appointment. Review of a progress note, dated 6/12/23, indicated the right knee surgical site Aquacel dressing was 30 % loose, two sutures visible, no redness, no bleeding, no drainage, slightly swollen. The note did not indicate that the dressing was removed or replaced. Review of a progress note, dated 6/19/23, indicated the right knee surgical site Aquacel dressing was 30 % loose, two sutures visible, no redness, no bleeding, slightly swollen, no signs or symptoms of infection. The note did not indicate the dressing was removed or replaced. On 6/23/23 at 9:02 A.M., the surveyor and Unit Manager (UM) #2 reviewed the hospital discharge instructions and the Orthopedic follow-up consult. UM #2 continued to review the clinical record and said the dressing to the right knee should have been removed on 6/9/23. She said there was no evidence in the clinical record that the surgical wound had been monitored by the Nursing staff. On 6/23/23 at 1:45 P.M., the surveyor observed the dressing change to the right knee, with the Wound Physician and Nurse #2. The Resident was in bed with right knee brace in place. Nurse #2 loosened the brace and removed the dressing to the right knee. The Wound Physician measured the incision and said it was 13 centimeters (cm) in length. The distal and proximal ends (each end) of the incision had several observable sutures, the middle of the incision had no observable sutures. The Wound Physician said he was unsure if the sutures were buried in the middle area of the incision. Review of the Wound Consult from 6/23/23 indicated the following: -surgical wound closed with sutures in place on the upper and lower 1/3rds. Central 1/3 is the open area. Measurements given for the entire wound- open area measures 4 cm x 1.5 cm - the entire wound measures 13 cm x 1.5 cm x 0.2 cm. During an interview on 6/23/23 at 12:15 P.M., the Director of Nurses (DON) said she understood the surveyor's concerns and that there had been a misunderstanding about the dressing change orders when the Resident was admitted . 2. Resident #204 was admitted to the facility in June 2023 with a diagnosis including status post right femur ORIF. Review of the clinical record indicated Resident #204 was able to make his/her own decisions. Review of a progress note, dated 6/14/23, indicated the Resident had an incision to the right leg which was covered by a dressing and ace wrap. Review of a progress note, dated 6/16/23, indicated the Resident had intact sutures to the right groin area and an ace wrap to the right lower leg was intact. On 6/21/23 at 10:40 A.M., the surveyor observed the Resident seated in a wheelchair in his/her room. The Resident had an ace wrap to the right lower leg which was loose. Review of the June 2023 Physician's orders indicated no order for the application of the ace wrap or the frequency in which to remove it. Minimum Data Set (MDS) assessment for Resident #204 was not available for review at the time of the survey. On 6/22/23 at 2:00 P.M., the surveyor observed the Resident seated in a wheelchair in his/her room with an ace wrap to the right lower leg. The Resident told the surveyor that he/she did not remember the last time the ace wrap was taken off. On 6/22/23 at 2:06 P.M., UM #2 said she did not know why the ace wrap was on but she would remove it to see what was going on. The surveyor and UM #2 went to Resident #204's room and UM #2 removed the ace wrap to the right lower leg. There were no open areas observed. UM #2 said she did not know who put the ace wrap on, or how often it was changed but she would look into it. During an interview on 6/22/23 at 2:33 P.M., UM #2 said she spoke with the Nurse Practitioner (NP) and there was no order for the ace wrap. UM #2 said she understood the concern of there possibly being something under the ace wrap that staff were unaware of since there was no order to remove it. 3. Resident #207 was admitted to the facility in June 2023. Review of the Nursing Admission assessment, dated 6/19/23, indicated that the Resident had an intact, reddened coccyx and there was a Mepilex (absorbent) dressing on it from the hospital. Review of a progress note, dated 6/19/23, indicated the Resident was admitted from the hospital and had an intact, reddened coccyx. The Mepilex dressing was replaced. Review of the June 2023 Physician's orders indicated no order for the application of a dressing to the coccyx or the frequency in which to change the dressing. During an interview on 6/23/23 at 10:58 A.M., UM #2 said she did not know about the Resident having a dressing on admission. UM #2 reviewed the clinical record and said she did not see anything from the hospital about a wound. UM #2 then reviewed the admission note and said the Nurse did indicate that the Resident arrived with a dressing to the coccyx but that the skin was intact. UM #2 said maybe the Nurse put a dressing on for protection. The surveyor asked if a wound assessment had been done or if any follow up orders for wound care had been obtained. UM #2 said there were no wound assessments or follow up orders and there should have been. On 6/23/23 at 11:10 A.M., the surveyor observed the Resident's coccyx area with UM #2. UM #2 had removed the foam dressing prior to the surveyor's arrival. The dressing was undated. The coccyx was slightly reddened and intact. UM #2 said she could not determine when the dressing was applied but that the admitting Nurse probably put it on for protection. UM #2 said there should have been orders in place to apply a dressing and the frequency in which to change the dressing.

Based on observation, document review and interview, the facility failed to ensure that staff: 1. Maintained appropriate sanitation of dishware as evidenced by the dish machine not having the required final rinse temperatures. 2. Stored food in accordance with professional standards for food service safety. Findings include: 1. Review of the facility's Cleaning Dishes/ Dish Machine policy, dated 2021, indicated the following: -Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. -High Temperature Dishwasher: Wash temperature 150 to 165 degrees Fahrenheit (F), final rinse temperature or sanitization 180 degrees F. During a tour of the kitchen on 6/22/23 at 1:30 P.M., the surveyor observed the following: -The dish machine temperature gauge indicated the required wash temperature to be 150 degrees F, and the required final rinse temperature to be 180 degrees F. -Three consecutive cycles were completed. The wash temperatures were noted to be between 154 and 157 degrees F. A final rinse temperature was not displayed. At this time, the Food Service Director (FSD) said that there had been an issue with the dish machine for a few weeks. He said that the final rinse temperature had not been reaching the required 180 degrees F. He said he notified the Maintenance Director about it, and they were waiting for someone to service the dish machine. During a second observation of the dish machine on 6/22/23 at 2:28 P.M., the surveyor observed Dietary Staff #2 loading dirty dishes into the dish machine. He said the final rinse temperature had not been reaching the required 180 degrees F, but they were still using the machine. Review of the facility's June 2023 Hot Temperature Dishwasher Temperature Sheet indicated that from 6/1/23 through 6/21/23, all final (sanitizing) rinse temperatures were documented as being between 163 and 166 degrees F. The form indicated the acceptable temperature was 180 degrees F, or greater. During an interview on 6/22/23 at 3:29 P.M., the FSD said the dish machine had been in use even though the final rinse temperature was not reaching the temperature required to sanitize the dishware. He said he had not put an alternate plan in place to sanitize dishware in the facility. During an interview on 6/22/23 at 3:39 P.M., the Administrator said the FSD should have implemented a plan to ensure dishware was being sanitized as soon as the dish machine started experiencing temperatures below required values. 2. Review of the facility's Food Storage policy, dated 2021, indicated the following: -Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be accurately labeled and dated. -Scoops must be provided for bulk food and should be kept covered in a protected area near the containers rather than in the container of food. During a tour of the kitchen on 6/22/23 at 1:30 P.M., the surveyor observed the following: -A 25 pound (lb) bag of flour, a 25 lb bag of bread crumbs, and a 25 lb bag of sugar were opened and stored in bins. None of the items were labeled and dated as to when they were opened. In addition, the bag of sugar had a small metal scoop stored directly in the sugar. -A five lb box of biscuit mix was stored on a shelf, and it was observed to be open to air and not labeled and dated when opened. -In the dry storage room, a 25 lb bag rice was open to air and was not labeled and dated when opened. During an interview on 6/22/23 at 2:10 P.M., the FSD said all food items should be labeled and dated when opened. He also said that staff should not have left the scoop stored directly in the sugar.

Based on observation, policy review, record review and interview, the facility failed to maintain infection surveillance for three out of three applicable Residents (#14, #22 and #85) for signs and symptoms of COVID-19 during a facility outbreak. Findings include: Review of the Massachusetts Department of Public Health's Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Resident, including Visitation Conditions, and Communal Dining and Congregate Activities, dated 5/10/23, indicated the following: -Residents included in outbreak testing or who are being tested following an exposure, should be assessed for symptoms of COVID-19 during each shift. Review of the facility's Infection Control-Mitigating Respiratory Illness policy, undated, indicated the following: -Residents included in outbreak testing or who are being tested following an exposure, should be assessed for signs and symptoms of COVID-19 during each shift. During an interview on 6/22/23 at 2:18 P.M., the Director of Nurses (DON) said that a COVID-19 outbreak began in the facility on 5/23/23, with one Resident testing positive for the virus. 1. Resident #14 was admitted to the facility in January 2023 with diagnoses including Acute Pulmonary Edema (excess fluid in the lungs), Dyspnea (trouble breathing), and Heart Failure. Review of the May 2023 Treatment Administration Record (TAR) indicated no evidence of monitoring for signs and symptoms of COVID-19 during each shift. Review of a Physician's order, dated 6/11/23, indicated Antigen Testing (used to detect for the presence of a specific viral infection) for suspected COVID-19 every 24 hours as needed. Review of the June 2023 TAR indicated no evidence of monitoring for signs and symptoms of COVID-19 during each shift. 2. Resident #22 was admitted to the facility in November 2022 with diagnoses including Heart Failure and Dementia. Review of the May 2023 TAR indicated no evidence of monitoring for signs and symptoms of COVID-19 during each shift. Review of a Physician's order, dated 6/20/23, indicated Antigen Testing every day shift, one day on and one day off, for seven days. Review of the June 2023 TAR indicated no evidence of monitoring for signs and symptoms of COVID-19 during each shift. 3. Resident #85 was admitted to the facility in February 2023 with diagnoses including Ischemic Cardiomyopathy (when the heart muscle cannot pump well because of damage due to lack of blood supply to the heart) and Vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain). Review of the May 2023 TAR indicated no evidence of monitoring for signs and symptoms of COVID-19 during each shift. Review of a Physician's order, dated 6/21/23, indicated Antigen Testing every day shift, one day on and one day off, for seven days. Review of the June 2023 TAR indicated no evidence of monitoring for signs and symptoms of COVID-19 during each shift. During an interview on 6/23/23 at 1:39 P.M., after reviewing the clinical records of Resident #14, #22 and #85, the Infection Preventionist said that the Nursing staff should have obtained orders for monitoring signs and symptoms of COVID-19 once the COVID-19 outbreak began in May. She said that there was no evidence that indicated staff had been monitoring for signs and symptoms of COVID-19, during each shift, for any of the three Residents.

Based on policy review, record review and interview, the facility failed to provide care and services for an ileostomy (a surgically made opening that connects the lower end of the small intestine [ileum] to the abdominal wall. Through the abdominal wall opening, or stoma, the lower intestine is stitched into place. A wafer (dressing that surrounds the stoma) is then applied to the surrounding skin and allows for a bag to be attached to collect stool) appliance, for one Resident (#205), out of two applicable residents, in a total sample of 21 residents. Findings include: Review of the facility's policy for Colostomy, Ileostomy Care, dated January 2014, indicated the following: -Policy: Ostomy care is provided to monitor bowel patterns, to protect peri-stomal skin from irritation, infection and breakdown, eliminate odors and provide ongoing education for self care of the ostomy. -Procedure: *Inspect the stoma and peri-stomal skin with each pouch (bag) change. *Note any swelling of the stoma, any irritation, bruising, rashes or skin breakdown of stoma or surrounding skin. *Document in the nurse's notes and/or treatment record, include patient/resident's tolerance to the procedure. *Residents who have demonstrated competency may perform under the supervision of a licensed Nurse. 1. Resident #205 was admitted to the facility in June 2023 with a diagnosis including Ileostomy. During an interview on 6/22/23 at 2:12 P.M., the Resident said he/she has had the ileostomy for many years. The Resident said he/she changed the appliance (wafer) him/herself, once since admission to the facility. The Resident said the staff only assisted him/her to empty the bag. Review of the clinical record indicated no evidence that an assessment or competency was done to determine if the Resident was capable of providing his/her own ostomy care. Review of the June 2023 Physician's orders indicated the following: Assist with ileostomy .report any abnormalities to area when changing the bag to the Physician, every shift. Further review of the Physician's orders indicated no orders that specified the frequency of the wafer change or to assess the stoma and the surrounding skin. Review of the progress notes from 6/3/23 through 6/23/23 did not indicate any evidence that the Nursing staff changed the ileostomy wafer or assessed the stoma and the surrounding skin. During an interview on 6/22/23 at 2:34 P.M., Unit Manager (UM) #2 said it was her understanding that the Resident was taking care of the ileostomy. UM #2 said that's what she was told by other staff members. The surveyor asked if the Resident had been assessed to determine if he/she was competent to take care of the ileostomy. UM #2 said they usually did an assessment to determine that, but she would need to look into it. During an interview on 6/22/23 at 2:41 P.M., UM #2 said that there was no evidence the Resident was assessed for competency to change the ileostomy appliance. UM #2 reviewed the clinical record and said there was no evidence that the wafer had been changed since admission because the order did not specifically address changing the wafer. UM #2 said that the wafer should be changed maybe daily, but then said she would need to check with the Nurse Practitioner (NP) for how often she wanted the wafer changed. UM #2 said she understood the current Physician orders were not reflective of all the care and services an ileostomy required.

Based on interview and record review, the facility failed to provide the required notification to the Office of the State Long-Term Care Ombudsman for two Residents (#33 and #45), when they were transferred to the hospital. Specifically, the facility staff failed to provide evidence that the required Ombudsman notification was completed as required for Resident's #33 and #45. Findings include: 1. Resident #33 was admitted to the facility in May 2020. Review of the Nursing Progress Notes indicated that Resident #33 was transferred and admitted to the hospital on 6/1/23. Review of the Resident's medical record showed no documented evidence that the Office of the State Long-Term Care Ombudsman was notified of the Resident's transfer to the hospital, as required. 44337 2. Resident #45 was admitted to the facility in August 2021. Review of the Resident's clinical record indicated that he/she was transferred to the hospital on 4/28/23 and returned to the facility on [DATE]. Further review of the Resident's clinical record indicated no documentation evidence that a copy of the transfer notice for Resident #45, had been provided to a Representative of the Office of State Long-Term Care Ombudsman. During an interview on 6/22/23 at 10:39 A.M., the Social Worker (SW) said she could not provide any evidence that the Ombudsman had been notified of Resident #45's transfer out of the facility on 4/28/23. She said she stopped notifying the Ombudsman of any facility transfers because she thought the requirement had changed and that she no longer had to notify the Ombudsman of transfers out of the facility. During an interview on 6/22/23 at 1:26 P.M., the Administrator said that the facility had not notified the Ombudsman of any resident transfers since last July (2022).

Based on observation, record review and interview, the facility failed to provide Activities of Daily Living (ADL- basic care tasks that an individual does on a day to day basis such as eating, bathing, dressing, grooming and mobility) for one Resident (#91) out of a total sample of 21 residents. Specifically, the facility staff failed to provide grooming services for a resident who was dependent for ADLs. Findings include: Resident #91 was admitted to the facility in July 2022 with a diagnosis of Macular Degeneration (an eye disease which can result in blurred or no vision in the center of the visual field). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely, cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of six out of a total possible score of 15. Further review of the MDS assessment indicated Resident #91 required extensive assistance for ADLs. During an observation and interview on 6/21/23 at 11:06 A.M., the Resident was observed to have many long white hairs on his/her chin. The Resident said that he/she asks the staff to shave the chin hair whenever he/she notices the hair growing. On 6/22/23 at 11:22 A.M., Resident #91 was observed talking to Unit Manager (UM) #1 in the hallway near a medication cart. Resident #91 was again observed to have many long white hairs on his/her chin. During an interview on 6/22/23 at 11:40 A.M., UM#1 said that she noticed the white chin hair on Resident #91. UM#1 also said that the Resident shouldn't have any chin hair and staff should have assisted the Resident to remove the chin hair as soon as it was noticed.

Based on record review and interview, the facility failed to provide 7 Residents (#67, #96, #203, #6, #89, #18, and #21) and/or their representatives a summary of the Baseline Care Plan within 48 hours of admission, out of a total sample of 21 residents. Findings include: 1. Resident #67 was admitted to the facility in August 2021. Review of the clinical record indicated a Baseline Care Plan was developed within 48 hours of admission, but neither the Resident nor the Resident's representative had received a copy of the Baseline Care Plan. 2. Resident #96 was admitted to the facility in August 2021. Review of the clinical record indicated a Baseline Care Plan was developed within 48 hours of admission, but neither the Resident nor the Resident's representative had received a copy of the Baseline Care Plan. 3. Resident #203 was admitted to the facility in September 2021. Review of the clinical record indicated a Baseline Care Plan was developed within 48 hours of admission but neither the Resident nor the Resident's representative had received a copy of the Baseline Care Plan. 4. Resident #6 was admitted to the facility in March 2021. Review of the clinical record indicated a Baseline Care Plan was developed, but there was no evidence that the Resident or Resident Representative was given a copy of the Baseline Care Plan summary, as required. 5. Resident #89 was admitted to the facility in May 2021. Review of the clinical record indicated a Baseline Care Plan was developed, but there was no evidence that the Resident or Resident Representative was given a copy of the Baseline Care Plan summary, as required. 6. Resident #18 was admitted to the facility in June 2021. Review of the clinical record indicated a baseline care plan was developed. Further review of the clinical record indicated no documented evidence that the Baseline Care Plan was provided to, and reviewed with, the resident and/or their representative within 48 hours of their admission as required. 7. Resident #21 was admitted to the facility in March 2021. Review of the clinical record indicated a baseline care plan was developed. Further review of the clinical record indicated no documented evidence that the Baseline Care Plan was provided to, and reviewed with, the resident and/or their representative within 48 hours of their admission as required. During an interview on 9/17/21 at 10:59 A.M., the survey team and Social Worker #2 reviewed the concerns for the above seven resident records relative to no documented evidence that interdisciplinary care plan meetings were held within 48 hours of admission. She said the initial Baseline Care Plan were not reviewed and were not provided to the Residents and/or their representatives within 48 hours of admission as required.

Based on observation, document review, and interview, the facility failed to ensure appropriate kitchen sanitation, and safe food storage and food handling, to help minimize the risk of food borne illnesses. Findings include: Review of the facility's Food Safety Requirement policy, updated 3/12/16, indicated the following: -All food brought in by family member will be stored on the unit the resident is living on. -All food items must be properly labeled, dated, include the resident's name and room number. -Food items stored for more than three days will be discarded. Review of the facility's Dry Food Storage Guidelines, undated, indicated the following: -All boxes and cans should be labeled properly with a description of the contents within, date of delivery, and expiration dates. Older items should always be located in the front of newer products. -Food from open packages should be stored in airtight containers with clear labels that indicate what the food is, when it was transferred from its original container and any relevant dates. Review of the facility's Safe Food Handling; Handling Ready To Eat Food Fact Sheet, undated, indicated the following: -Cross-contamination from hands to food is one of the leading causes of the spread of pathogenic organisms that lead to human illnesses. -Acceptable means of handling ready-to-eat foods include using: deli tissue, tongs, spatulas, dispensing equipment and non-latex single use gloves. Review of the facility's Daily Refrigeration Monitoring Record form indicated the following: Refrigerator/ Freezer temperatures must be checked and logged daily. During an initial tour of the kitchen on 9/15/21 at 7:20 A.M., the surveyor observed the following: -The sanitizing solution in a bucket with a rag, that the staff indicated was for cleaning and sanitizing the counter tops, did not register any level of sanitizing concentration when tested using a sanitizer test strip. -Three separate storage bins, one with flour, one with bread crumbs and one with sugar, did not have dates when each product was placed in the bin. Additionally, a large scoop was stored directly in the flour bin. -18 plastic jars of spices were open to air and not being used for the breakfast meal preparation. -A small bin of salt was stored on a shelf with a spoon inside of it. The container was unlabeled and undated. -A 4 pound (lb.) box of salt was open to air and was undated. -A 48 ounce (oz.) container of uncooked oatmeal, approximately two thirds full, was undated. -Two Styrofoam cups were stored on a shelf with food items in them. They both were undated and unlabeled with what was stored in the cups. -Two 8 oz. containers of thickener, both approximately one half full, were undated. -A 16 oz. box of cornstarch and a 2 lb. box of baking soda were stored on a shelf and were open to the air and undated. -A 20 oz. bottle of hand lotion was lying on top of a bin of napkins and condiments. -An 18 oz. jar of peanut butter, approximately half full, was undated. -A 32 oz. jar of grape jelly stored on a shelf was approximately three fourths full and was undated. Also, the label indicated to refrigerate when opened. -The larger mixer was dirty with dried food splashes. -The meat slicer was dirty with food particles. -In a walk-in refrigerator was a large bin of tomato sauce, approximately 14 quarts, that did not have a label when the sauce was put in the bin. -On a shelf in the walk-in freezer was a 13.75 lbs. of frozen pancakes that were open to the air and undated. -In the dry storeroom, there were two opened 10 lb. bags of small pasta, one opened 10 lb. bag of elbow pasta, and one opened 10 lb. bag of wheat spaghetti, all were undated. Also, a 25 lb. box of rice on a shelf was open to the air and undated. On 9/16/21 at 8:10 A.M., the surveyor observed breakfast meal service on the Cedar Unit. The surveyor observed Certified Nursing Assistants (CNAs) #5 and #6, using their bare hands to take slices of toast off residents' plates to butter them and then return the toast to the plates for residents to eat. On 9/16/21 at 8:30 A.M., the surveyor observed the refrigerator in the unit dining area on the Cedar unit. The temperature log on the door indicated no documented temperatures for the refrigerator and freezer in the A.M. and P.M., on 9/2/21, 9/3/21, and 9/11/21 through 9/15/21. Additionally, there were no documented P.M. temperatures for the refrigerator and freezer from 9/4/21 through 9/10/21. On 9/17/21 at 8:36 A.M., the surveyor observed the refrigerator in the Cedar Unit nourishment kitchen. The temperature log indicated no documented temperatures for either the refrigerator or freezer from 9/1/21 through 9/16/21. The surveyor observed a 32 oz. bottle of Gatorade in the refrigerator that had no name or date. On 9/17/21 at 8:40 A.M., the surveyor observed the refrigerator in the nourishment kitchen on the Birch Unit. The temperature log indicated no documented P.M. temperatures for either the refrigerator or freezer from 9/13/21 through 9/16/21. The surveyor observed a 16 oz. bottle of Snapple Iced tea and a one pint container of ice cream stored in the freezer, neither had a resident name or date on them. The surveyor observed a 12 oz. bottle of Habaneros Sauce (half full), an 8 oz. brick of cheddar cheese and a plastic grocery bag containing a one liter bottle of [MEDICATION(S)] and a 5 oz. container of cottage cheese stored in the refrigerator. None of the items were labeled with a resident name or date. At 8:50 A.M., the surveyor observed the refrigerator in the Birch Unit dining room. The temperature log indicated no P.M. documented temperatures for either the refrigerator or freezer from 9/13/21 through 9/16/21. The surveyor observed an uncovered 2.5 quart of ice cream stored in the freezer that had no resident name or date on it. The surveyor observed a 20 oz. bottle of orange soda stored in the refrigerator that had no resident name or date on it. On 9/17/21 at 9:00 A.M., the surveyor and Unit Manger #2 observed both refrigerator/ freezers on the Birch unit. Unit Manager #2 said the items noted above, should not have been stored in either the refrigerator or freezer without a resident's name and date when brought in, as required. On 9/17/21 at 11:00 A.M., the surveyor observed the temperature log for the refrigerator/ freezer on the [NAME] Unit. The log indicated no P.M. temperatures documented for the refrigerator or freezer, from 9/12/21 through 9/15/21. During a second tour of the kitchen on 9/17/21 at 11:25 A.M., the surveyor and the Food Service Director (FSD) reviewed the concerns from 9/15/21, and noted that the concerns remained During an interview on 9/17/21 at 11:30 A.M., the FSD said all the food items should have been labeled when opened and nothing should be left open to the air. He said food storage, kitchen sanitation, and equipment cleaning were not maintained properly as required to help prevent the potential spread of food borne illnesses. Additionally, he said the temperature logs for the refrigerator and freezers on each unit were not properly maintained by the dietary staff, as required. He said all food and drink stored in those refrigerator/ freezers should have been labeled with a resident's name and date when brought in. The FSD also said the CNAs should not have been touching food with their bare hands and giving it back to the residents to eat.

Based on record review, observation and staff interview, facility staff failed to identify fall risks and hazards and ensure that effective interventions were in place to prevent falls for 2 of 9 applicable residents (#1 and #15) in a total sample of 23 residents. Findings include: 1. For Resident #15, the facility staff failed to identify as having increased bladder incontinence and was at increased risk for falls due to trying to get up and go to the bathroom unassisted. Facility staff also failed to put effective interventions in place to prevent falls and a fracture. Resident #15 was admitted to the facility in 11/2015 with [DIAGNOSES REDACTED]. Review of the Falls Care Plan developed 11/27/15, included the following interventions: - Be sure call light is within reach. - Check medications to ensure they are not contributing to falls and discuss with MD. - Assist to bathroom as needed. - Keep room neat and clutter free. - Appropriate footwear - Monitor the need for devices that alert staff if resident attempts to transfer alone. - If in bed, place necessary items within reach. Review of the Initial Minimum Data Set (MDS) Assessment, dated 12/4/15, indicated the Resident was: alert, oriented and was able to make decisions independently; required extensive assistance from staff for bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene and bathing; balance was unsteady; had a fall prior to admission with a fracture (right shoulder). Review of the Quarterly MDS Assessment of 3/2/16 indicated the Resident was: alert, oriented and able to make decisions independently; occasionally incontinent of bladder and still required extensive assistance from staff for bathroom use. Review of the Quarterly MDS Assessment of 6/1/16 indicated the Resident scored 14/15 on the Brief Interview for Mental Status (BIMS) which indicated no cognitive impairment; required limited assistance from staff for bed mobility, transfers, ambulation, toilet use and personal hygiene; extensive assistance from staff for dressing and bathing. The Quarterly Bowel and Bladder Assessment of 6/6/16 indicated the Resident was always continent of bladder, and required pads/briefs. Further review indicated the Resident had no contributing factors despite a history of UTIs and Diabetes Mellitus (not checked in the section). The plan was to continue with the Current Plan of Care. A Nurse's Progress Note of 7/18/16 indicated the Resident was confused and disrobing. Resident thought he/she was going to the bathroom. A Nurse's Progress Note of 7/20/16 indicated the Resident attempted to self toilet. Safety reminders given with poor outcome. A Nurse's Progress Note of 7/21/16 indicated the Resident was seen by the Psychiatrist for changes in mood. The [DIAGNOSES REDACTED]. Nurses' Progress Notes of 7/22 -7/26/16 indicated the Resident was more confused. A Nurse's Progress Note of 7/26/16 indicated the Resident had a urinary tract infection (UTI) and was put on the anti-infective medication Macrobid. A UTI can cause a feeling of urgency and frequency. Nurses' Progress Notes of 7/27/16, 7/28/16, 7/29/16 and 7/31/16, indicated the Resident remained confused with episodes of disrobing. A Fall Risk Assessment of 8/1/16 indicated the Resident was at Moderate Fall Risk with a score of 8. The Fall Risk Assessment was inaccurate due to facility failing to indicate the Resident was receiving anti-hypertensive medications and a psychotropic medication (Remeron). Review of a Fall Report of 8/1/16 indicated the resident was found lying on the floor between the bedroom and the bathrooms at 1:15 A.M. The report indicated the Resident stated, I put the call light on and run away. The fall was unwitnessed and the Resident had no apparent injuries. The report also indicated the Resident was confused due to a UTI. There were no new interventions made to the Care Plan. The report indicated the Resident would be monitored for 72 hours for bruising, change in mental status/condition, pain or other injuries related to the fall. The Quarterly MDS Assessment of 8/31/16 identified the Resident as having a small decline in cognition, BIMS score 11/15, indicating moderate cognitive impairment and mood; required extensive assistance from staff for bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene and bathing (decline from previous assessment of 6/1/16). Review of the CNA Flowsheets indicated the Resident was occasionally incontinent of bladder from 9/9-9/27/16, mostly at night. Review of the clinical record indicated the Resident continued with occasional increased confusion through 9/27/16. Review of the clinical record and Fall Report of 9/27/16 indicated the Resident was found sitting on the floor in the bedroom at 1:18 A.M., (second fall in bathroom in early morning hours) and had last been toileted by staff at 9:00 P.M. The Resident said that he/she was trying to get to the bathroom at the time of the fall. The resident sustained [REDACTED].) skin tear requiring steri-strips., and an abrasion on the back. The report indicated the Resident was not using the wheelchair or walker at the time of the fall. Immediate measures taken were 15 minute checks and keep the wheelchair at the bedside (despite the Resident requiring extensive assistance from staff for transfers and toilet use). The Fall Risk Assessment was scored as a high risk for falls with a score of 19. Greater than 13 is High Risk. The Care Plan was revised on 9/27/16 to include the following new interventions: - Falling Star program (sticker placed on name at doorway to alert staff the resident is at high risk for falls) - Remind the resident to call for help to get out of bed, chair or bathroom. - Wear non-skid socks in bed. - Wheelchair to be placed by bedside. Further review of the CNA flow sheets indicated that Resident #15 declined further in continence, evidenced by documentation that the resident was occasionally to frequently incontinent of urine from 9/28/16-10/15/16 and that from 10/16/16-11/01/16 the Resident further declined and was frequently to always incontinent. There was no documentation that a Significant Change in Status Assessment was completed. Review of the clinical record indicated the Resident continued to exhibit increased confusion from 9/28/16 to 10/26/16. Review of a Progress Note and Fall Report of 10/26/16 indicated the Resident was found sitting on the floor in the bedroom next to the bed at 11:30 P.M. The Resident stated that he/she was trying to get into the wheelchair to go to the bathroom. There was no immediate apparent injury. A Nurse's Progress Note of 10/27/16 written at 7:46 A.M., indicated the Resident complained of left leg pain while transferring to go to the bathroom. The pain reliever Tylenol 650 milligrams (mg) was administered at 2:31 A.M. with good effect. Every 15 minute checks continued. New interventions to Falls Care Plan on 10/27/16 included: - 15 minute checks for 24 hours. - Initiate a voiding pattern assessment to establish a toileting schedule due to frequency. is continent at this time. - Offer a bed or room change closer to the bathroom. A Nurse's Progress Note of 10/28/16 indicated the Resident was complaining of increased pelvic pain. An X-ray was done which was questionable for a fracture. The Physician ordered a CT Scan as soon as possible. Review of Progress Notes indicated the Resident was sent out for a scan on 10/28/16, and returned to the facility the same evening with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. During an interview on 11/1/16 at 2:00 P.M., Unit Manager (UM)#2 told the surveyor that the Resident was never totally continent of urine, and that he/she used to use the call light to ask for help. UM #2 said that the Resident was more confused and did not always call for help, especially at night when staffing was less. UM #2 said that the Resident had never been on a scheduled toileting plan, but it would have been a good idea. During interview on 11/1/16 at 2:30 P.M., the Director of Nurses (DON) said that she was unaware the Resident always had some incontinent episodes and that it was getting worse. She said that she always thought the Resident was totally continent and, had she been aware, the Resident would have been assessed for a toileting schedule. The facility failed to provide effective interventions to reduce the risk of Resident #15 self-toileting and falling resulting in a pelvic fracture. 2. For Resident #1, the facility staff failed to ensure adequate supervision, effective interventions and follow the care plan related to 7 falls (from 11/2/15 - 9/14/16), 3 falls resulted in minor injury, such as, hip and shoulder contusions, a left knee abrasion, and skin tears. Resident #1 was admitted to the Facility in 2/2012 with [DIAGNOSES REDACTED]. Review of the Resident's Care Plan (inaccurately dated 7/22/2010), indicated the resident was at risk for falling, related to having a history of falls with a hip fracture, used an assistive device, scored a 10 and was a high fall risk (score of 10 or greater indicates a high risk for falls). Interventions indicated: - ensure resident is wearing eyeglasses; - encourage the use of proper, well-maintained footwear; - give verbal reminders not to ambulate/transfer. Review of an 11/2/15 Progress Note, indicated Resident #1 was found on the floor. The Resident complained of (C/O) pain in the left leg, was unable to move and stated the pain level was a 10/10. Emergency Response was called immediately. Review of the 11/2/15 fall investigation report indicated the Resident with heart disease, balance problems, arthritis, chronic left shoulder pain and confusion, was found on the floor at 2:50 P.M., with left arm behind him/her. The report did not indicate the time Resident #1 was last seen by staff, only that staff had observed the Resident as being sleepy, prior to the fall. The report indicated N/A (not applicable) for wearing eyeglasses (care plan indicated to ensure resident is wearing eyeglasses). The report indicated there was no signs of acute illness, and that the Resident would not benefit from 1:1 visits, strengthening or diversional activities. Further review indicated Resident #1 attempted to climb into bed, from the wheelchair, slipped and fell . The fall was unwitnessed (adequate supervision had not been provided). According to the report, Resident #1 was crying and rubbing the left leg. The Resident was transferred to the emergency room (ER) for an evaluation, and returned with [DIAGNOSES REDACTED]. Interventions indicated the Resident would have every (Q) 15 minute checks for 72 hours, secondary to continuous attempts to self transfer, and a Rehabilitation (Rehab) Screen would be completed. Review of the Interdisciplinary Rehabilitation Screen, comment section from Nursing to Rehab, indicated that CNAs said Resident #1 had increased difficulty with transfers, had not ambulated in the past two days, and requested an evaluation for mobility. The Care Plan was updated 11/3/15, and indicated interventions to prevent further falls was to toilet the resident Q 2 hours. (This fall was not related to toileting, but self transferring from the chair to the bed due to being tired). The care plan did not indicate effective interventions to prevent further falls. Review of the Quarterly MDS assessment, dated 11/18/15, indicated Resident #1 had adequate vision with eyeglasses; was moderately impaired for cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 12 out of 15; had no behaviors; required extensive assist for bed mobility, transfers and toilet use, used a walker and had 1 fall with no injury. Review of a 2/13/16 fall investigation report indicated that Resident #1 was found on the floor, at the foot of the bed, and the fall was unwitnessed (adequate supervision had not been provided). Review of an attached statement, indicated, a staff member had walked past the Resident's Room (located quite a distance from the Nursing Desk), and observed Resident #1 on the floor at 5:30 P.M. The report indicated mobility devices were not being used (resident uses a walker). There was no change in gait or mobility. N/A was documented regarding the Resident's wearing of eyeglasses (despite the falls care plan included to ensure the resident wore eyeglasses). The report indicated the resident said he/she leaned over to pick something up off the floor. Another nursing staff statement indicated she last observed Resident #1 around 4:00 P.M., when she assisted Resident #1 to the bathroom. The new approach was for staff to provide Q 15 minute checks for 72 hours. Review of a Progress Note (dated 2/14/16) indicated the Resident had a recent fall and that Q 15 minute checks would be done. Review of an Annual MDS assessment, dated 2/17/16, indicated the Resident's vision was adequate with vision devices; scored a 12/15 on the BIMS; had no behaviors; was supervision for bed mobility, required limited assist for transfers, ambulation and toilet use; used a wheelchair (walker was not identified for the 7 day look back period); had balance problems (cannot correct balance without support of staff when going from one surface to another) and 1 fall with no injury. A Care Plan approach, dated 2/17/16, indicated: Resident is at risk for falling, related to (R/T) history (HX) of falls, with a hip fracture, use of an assistive device, and was a high risk for falls with a score of 10. The approach indicated the facility staff would speak with the Resident's family about moving the Resident closer to the Nursing Desk. A Care Plan approach, dated 2/18/16, indicated that there was a new order for a Video Monitor for increased safety to be used on the 3:00 P.M. - 11:00 P.M. and 11:00 P.M. - 7:00 A.M. shift, and that the Resident's invoked Health Care Proxy (HCP) consented. Review of a progress note, dated 5/1/16, indicated Resident #1 fell in the bathroom, trying to transfer him/herself from the toilet to the wheelchair at 8:00 A.M. The note indicated the Resident was re-educated on the importance of asking for help, and using the call light, due to decreased strength and previous falls. Review of the 5/1/16 fall investigation report indicated the assigned staff member went to get Resident #1 dressed for breakfast at 8:00 A.M., and found the resident on the floor. The fall was unwitnessed (adequate supervision was not provided). The report indicated that the last time Resident #1 was toileted was at 5:00 A.M., subsequently, the Resident had not been toileted Q 2 hours, as planned. A statement indicated the Resident went to the bathroom on his/her own, and fell while transferring (resident requires assist with transfers, and cannot correct balance without support of staff when going from one surface to another). Resident #1 remained in the same room, farthest from the Nursing Desk. The report did not identify why the Resident was not transferred to a room closest to the Nursing Desk, as care planned after the 2/13/16 fall. Review of the 5/1/16 updated care plan indicated Falling Star Program and blue bracelet applied to wrist; and Q 15 minute checks would be done for 48 hours, secondary to the fall on 5/1/16. Review of a 5/13/16 Progress Note indicated the Resident was found on the floor in the bathroom at 6:30 P.M. Review of the 5/13/16 fall investigation report indicated that Resident #1 went into the bathroom, unescorted, without a walker, was confused and disoriented, had a history of [REDACTED]. The fall was unwitnessed. There was no mention in the report of the Video Monitor used, as planned for the 3:00 P.M. - 11:00 P.M. shift, subsequently, adequate supervision had not been provided. The report indicated the Resident's mobility level was with assist and use of a device, and the device was not available. New interventions to the care plan to prevent further falls was to conduct Q 30 minute checks for 72 hours. Resident #1 remained in the same room, farthest from the Nursing Desk. The report did not identify why the Resident was not transferred to a room closest to the Nursing Desk. Review of the Quarterly MDS, dated [DATE], indicated it was relatively unchanged from the Annual MDS of 2/2016, with the exception of understanding, being understood and falls. The Quarterly MDS indicated the Resident sometimes understands, sometimes understood, and had 2 or more falls, with no injury. Review of a 5/19/16 Progress Note, indicated the facility staff spoke with the Resident's HCP regarding moving the Resident's room closer to the Nursing Desk, due to frequent falls. The HCP said that he/she wanted to discuss this with another family member first, and will let facility staff know in a day or two (a care planned intervention from 2/18/16). Review of the 6/2/16 Progress Note indicated the Resident was found on the floor in the bathroom, and had apparently, slid from the wheelchair trying to transfer self from the toilet to the wheelchair independently. Review of the 6/2/16 fall investigation report indicated the Resident was found on the floor in the bathroom at 12:00 P.M. The report did not identify when the Resident had been toileted or observed, prior to the fall. A witness statement indicated that staff were looking for the Resident for lunch, and upon arrival to the Resident's room, found the resident on the floor in the bathroom. The education record indicated that the Resident refuses teaching on a one to one basis, and is Non-Compliant (resident is moderately impaired for cognition, sometimes understands what is being said, and sometimes understood). The report also indicated that the Resident had no cognitive deficits, and did not use the call light. The Care Plan was updated 6/3/16 and indicated the following interventions: - Be sure my call light is where I can reach it. - Help me to use the bathroom as I need to. - Make sure my footwear is appropriate. - Monitor me for the need to use any devices that alert staff if I try to transfer alone. - Remind me that I need to call for help to get out of bed or use the bathroom. Review of a 6/3/16 Progress Note indicated at 1:31 P.M., the Facility staff received a call from Resident #1's HCP, and was in agreement with moving the Resident's room closer to the Nursing Desk, and that this would be done as soon as a room was available. Review of a 6/30/16 Progress Note indicated that the Resident was observed turning the Video Monitor away and toward the window. Review of the 8/10/16 Progress Note, indicated the Resident was found on the floor at 4:30 P.M., when the Nurse went to deliver 5:00 P.M. medications. The note indicated the Resident said he/she was coming back from using the bathroom, got tired and sat on the floor. The Resident c/o soreness to buttocks and sustained a skin tear to the left elbow measuring 0.5 centimeters (cm) x 0.1 cm, surrounded by redness and a bruise. First aid was provided. The note also revealed the Resident was not wearing appropriate footwear, as planned, and described the shoes Resident #12 had been wearing were without a sole or good grip. Review of the 8/10/16 fall investigation report indicated the resident's call light was not on. The Resident fell trying to self go from the bathroom to bed, was tired, and was not wearing adequate footwear, as planned. Resident #1 was found on the floor at 4:30 P.M., by a nurse delivering scheduled medication (in the same room that was still a distance from the Nursing Desk). The Video Monitor had not been mentioned as being used for safety on the 3:00 P.M. - 11:00 P.M. shift as a fall prevention intervention, subsequently, adequate supervision had not been provided, as planned. The facility staff indicated the family would be contacted to bring in shoes with good grips. Review of the Quarterly MDS assessment, dated 8/17/16 indicated the Resident had wandering behaviors, required extensive assist for bed mobility and transfers, limited assist for toilet use, was dependent for bathing, had one fall with no injury (inaccurate, as resident sustained [REDACTED]. Review of an 8/26/16 Social Worker progress note indicated the Resident had multiple falls, primarily attempting to toilet self. The Resident's room as a distance from the Nursing Desk, and responsible family members had been asked about a room change, but felt it would have added to the Resident's confusion and declined. Review of the 9/14/16 Progress Note, indicated the Resident was found on the floor, beside the bed. The note indicated that the Resident said he/she fell when he/she got out of bed, and attempted to pick something up from the floor. Review of the 9/14/16 investigation report indicated the resident fell , and the fall was unwitnessed. Interventions to prevent falls indicated that Q 15 minute checks would be completed for 24 hours. The report did not indicate whether the Video Monitor, as care planned as a fall prevention intervention had been utilized, subsequently, adequate supervision had not been provided. Review of the Care Plan, updated 9/15/17 (should be 9/15/16), indicated the following interventions: - For transfers and ambulation, I need assist. Review of a 9/28/16 Progress Note indicated that the Resident's room was changed (moved to a room closest to the Nursing Desk). On 10/31/16 from 8:55 A.M. to 9:05 A.M., the Surveyor observed Resident #1 in the wheelchair. The Resident was wearing eyeglasses and appropriate shoes, as he/she self-propelled around the unit, past the Nursing Desk and up a long hallway, and beyond the elevators. On 10/31/16 from 11:45 A.M. - 12:00 P.M., the Surveyor observed Resident #1, with eyeglasses on, sitting in a wheelchair, up to a table in the Dining Room, located just across from the Nursing Desk on the Resident's Unit. On 11/1/16 at 1:12 P.M., the Surveyor observed Resident #1 self-propelling in wheelchair, out of Resident's room, close to the Nursing Desk, into the hallway. The Resident continued to self-propel past the Nursing Desk, and up the hallway, beyond the elevators. The Resident then stopped and sat in the wheelchair. The Resident was wearing glasses and appropriate footwear. During interview on 11/1/16 at 2:30 P.M., the Director of Nursing (DON) said that falls meetings are held daily, and Unit Managers are instructed to go to their respective units and update care plans with effective interventions for fall preventions, as discussed. The DON said that she did not think the Unit Manager included all interventions, and updated the care plan accordingly. The DON said that adequate supervision and effective interventions had not been provided for Resident #1. She said that since the Resident moved to the room closest to the Nursing Desk, that Resident #1 has not had a fall since 9/14/16. During interview on 11/1/16 at 3:00 P.M., the Social Worker said that when the Resident's family agreed to changing the Resident's room, there was no longer a room close to the Nursing Desk available, and when asked again, the family declined, then agreed in 9/2016, when a room became available.

Based on record review and interview, the facility failed to ensure that 1 Resident (#3) in a total sample of 24 sampled residents and 7 Non-sampled Residents (NS#1, NS#2, NS#3, NS#4, NS#5, NS#6, NS#7) was free a from significant medication error resulting in 20 missed doses of [MEDICATION NAME] (an antipsychotic). Findings include: Resident #3 was admitted to the facility in May 2013 with [DIAGNOSES REDACTED]. Resident #3 had moderate dementia with a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (0 low and 15 high). Resident #3 was admitted to the facility on [MEDICATION NAME] ([MEDICATION NAME]). [MEDICATION NAME] is an antipsychotic drug that has caused agranulocytosis defined as an absolute [DIAGNOSES REDACTED] count (ANC) less than 500 cubic millimeters. Absolute [DIAGNOSES REDACTED] count (ANC) is a measure of the number of segmented [DIAGNOSES REDACTED]s (SEGs) present in the blood. (The medical record identified Resident #3 as allergic to 18 other antipsychotic medications). Pharmacy protocol for dispensing [MEDICATION NAME] is to issue a 7 day supply for the [MEDICATION NAME], after review of the weekly laboratory blood results, if the absolute [DIAGNOSES REDACTED] values are within normal limits. On 6/23/14 at 10:00 A.M. Surveyor review of the May, 2014 Physician Orders identified an order for [REDACTED]. On 5/2/14, the Pharmacy entered the physician's order for [MEDICATION NAME] onto the iMAR (electronic Medical Administration Record) as follows: [MEDICATION NAME] 25 mg tablet ([MEDICATION NAME]) One Half tab (2.5 mg.) by mouth at bedtime. WBC =7.3; ANC=3.7. Labs Weekly, Due 5/9/2014 DC Date: 5/8/14 Duration Days: 7 The Unit Nurse reconciling the pharmacy iMAR order entry for [MEDICATION NAME] on 5/2/14 with the original physician's order did not question the "stop date" and accepted the pharmacy order on the iMAR This removed the [MEDICATION NAME] order from the iMAR from which a Medication Nurse administers active medication orders resulting in 20 missed doses for Resident #3. Previous [MEDICATION NAME] iMAR orders for the category Duration were entered as "maintenance" with no amount of days specified (meaning on going). The Pharmacy had been dispensing a 7 day supply after reviewing the weekly neutophil lab report since Resident #3's admission in May, 2013. The Pharmacy continued to receive weekly lab reports of labs within normal limits and continued to dispense a 7 day supply of [MEDICATION NAME] on 5/9/14, 5/16/14, and 5/23/14. On 5/28/14 the day shift Nurse noted that there were more cards of [MEDICATION NAME] for Resident #3 than usual in the medication cart. The day shift Nurse's review of the iMAR identified Resident #3 had not received [MEDICATION NAME] for 20 days or 20 missed doses.. The facility monitored Resident #3 for effects which may be due to the omission of [MEDICATION NAME], such as weight loss and behaviors. Weight Loss: The resident's weights were stable around 180 pounds from January through April, 2014 as follows: January 14 = 180 pounds, February 23 = 181.8 pounds, March 29 = 178.6 pounds, April 5 = 180 pounds. Following the last bedtime dose of [MEDICATION NAME] on 5/8/14, the resident's weights reflected a 5% weight loss of 9.2 pounds in 20 days from 180 to 170.8 pounds. These were: 5/10 =180 pounds, 5/12 =178 pounds, 5/19 =176.8 pounds, 5/26 =176.8 pounds, 5/28 =174.2 pounds, 5/29 =172.8 pounds, 5/30 =170.8 pounds. Resident #3 was on a house regular diet and eating 70% to 100% of meals. On 5/13/14 the dietician recommended (and a physician order was written for) a snack at bed time and on 5/30/14 Med Plus 2.0 (nutritional supplement) at 60 ml 3 times a day and ice cream 4 ounces 3 times a days were ordered. Following the restart of the [MEDICATION NAME], June weights reflect an increase in weight on 6/9/14 to 178 and 177.2 pounds on 6/16/14. Behaviors: The 2/12/14 Quarterly MDS coded the resident at a "0" for Behavior. The 5/15/14 Annual MDS Assessment (after the [MEDICATION NAME] was stopped), coded Resident #3 as having behavioral symptoms not directed toward others that occurred from 1 to 3 days. On 5/11/14 (2 days after [MEDICATION NAME] stopped), Resident #3 was in the dining room and became agitated and threw a plate at a Certified Nursing Assistant (CNA). He/she was resistant to being redirected. Behavior resolved and the CNA was able to walk the Resident to his/her room. On 5/22/14, the resident was found disrobed in another resident's room. Resident #3 was then placed on, and continues on, 2 hourly checks. On 5/27/14 nurses notes indicate that Resident #3 was found to be confused, gait unsteady and was assisted with ambulation. On 6/24/14 at 10:45 A.M, interview with the Director of Nursing (DON) regarding the medication error identified that the facility investigated the event, in serviced the staff regarding iMAR orders and flagged any discontinued [MEDICATION NAME] orders for further DON review. The DON is following up with Pharmacy about the pharmacy order entry error.

Based on record review, document review, and interview with staff, the facility failed to provide pharmaceutical services that ensured the accuracy of pharmacy order entry and the reconciliation of pharmacy orders with physicians orders resulting in 20 missed doses of Clozaril for 1 Resident (#3) in a total sample of 24 Residents and 7 Non-sampled Residents (NS#1, NS#2, NS#3, NS#4, NS#5, NS#6, and NS#7). Findings include: Resident #3 was admitted to the facility in May 2013 with [DIAGNOSES REDACTED]. Resident #3 had moderate dementia with a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (0 low and 15 high). On 6/22/14, review of the Physicians medication orders identified that Resident #3 was admitted to the facility on Clozaril (An antipsychotic). The June, 2014 electronic Medical Administration Record (iMAR) included an order for [REDACTED]. Absolute [DIAGNOSES REDACTED] count (ANC) is a measure of the number of segmented [DIAGNOSES REDACTED]s (SEGs) present in the blood. [DIAGNOSES REDACTED]s are a type of white blood cell that fights against infection. (The medical record identified Resident #3 as allergic to 18 other antipsychotic medications). Pharmacy protocol for dispensing Clozaril is to issue a 7 day supply for the Clozaril, after review of the weekly laboratory blood results, if the absolute [DIAGNOSES REDACTED] values are within normal limits. The Pharmacy had been dispensing Clozaril for Resident #3 as a maintenance medication weekly since admission after review of ANC lab results which have been within normal limits. On 5/2/14, the Pharmacy failed to enter the weekly Clozaril order as a "maintenance" medication (ongoing). The Pharmacy added a 7 day stop date of 5/9/14. The Unit Nurse checking the pharmacy iMAR entry orders with the original physician orders did not question the "stop date" and accepted the pharmacy iMAR order as reconciled even though Resident #3 was receiving a maintenance dose since admission in May, 2013. This "stop date" removed the Clozaril order from the iMAR resulting in Resident #3 not receiving Clozaril for 20 days from May 9th to May 29th or 20 missed doses. The facility monitored Resident #3 for effects which could be due to the omission of Clozaril, such as weight loss and behaviors. Weight Loss: The resident's weights were stable around 180 pounds from January through April, 2014 as follows: January 14 = 180 pounds, February 23 = 181.8 pounds, March 29 = 178.6 pounds, April 5 = 180 pounds. Following the last bedtime dose of Clozaril on 5/8/14, the resident's weights reflected a 5% weight loss of 9.2 pounds in 20 days from 180 to 170.8 pounds. These were: 5/10 =180 pounds, 5/12 =178 pounds, 5/19 =176.8 pounds, 5/26 =176.8 pounds, 5/28 =174.2 pounds, 5/29 =172.8 pounds, 5/30 =170.8 pounds. Resident #3 was on a house regular diet and eating 70% to 100% of meals. On 5/13/14 the dietician recommended (and an order was written for) a snack at bed time and on 5/30/14 Med Plus 2.0 (nutritional supplement) at 60 milliliters (mls) 3 times a day and ice cream 4 ounces 3 times a days were ordered. Following the restart of the Clozaril, June weights reflect an increase in weight on 6/9/14 to 178 and 177.2 pounds on 6/16/14. Behaviors: The 2/12/14 the Quarterly Minimum Data Set (MDS) coded the resident at a "0" for Behavior. The 5/15/14 the Annual MDS Assessment (after the Clozaril was stopped), coded Resident #3 as having behavioral symptoms not directed toward others that occurred from 1 to 3 days. On 5/11/14 (2 days after Clozaril stopped), Resident #3 was in the dining room and became agitated and threw a plate at a Certified Nursing Assistant (CNA). He/she was resistant to being redirected. Behavior resolved and the CNA was able to walk the Resident to his/her room. On 5/22 14, the resident was found disrobed in another resident's room. Resident #3 was then placed on, and continues on, 2 hourly checks. On 5/27/14 nurses notes indicate that Resident #3 was found to be confused, gait unsteady and was assisted with ambulation. On 6/24/14 at 10:45 A.M, interview with the Director of Nursing (DON) regarding the medication error identified that the facility investigated the event, in serviced the staff regarding iMAR orders and flagged any discontinued Clozaril orders for further DON review. The DON is following up with Pharmacy about the pharmacy order entry error.

Based on record review and staff interview, the facility failed to provide adequate supervision to prevent a fall to 1 resident (#20), in a total sample of 23 residents. Findings include: For Resident #20, the facility failed to monitor the resident in a supervised area and the resident fell on [DATE] and sustained a nasal fracture and a fracture of the 5th finger on the left hand. Resident #20 was cognitively impaired with [DIAGNOSES REDACTED]. Record review on 5/6/13 revealed that the resident had a history of [REDACTED]. On 8/25/12, the resident fell in his/her room and sustained a laceration on the right occipital area on the scalp that required 3 staples. On 11/6/12 the resident fell but had no injury. On 12/4/12, the resident fell in his/her room and sustained a fracture of the 5th finger on the left hand. On 3/5/13 and 3/7/13 the resident had falls but no injuries. On 3/22/13 the resident fell in the living room and sustained a nasal fracture and fracture of the left 5th finger. The significant change MDS (minimum data set) completed 11/28/12 and the quarterly MDS completed 2/27/13 both coded the resident with having falls with injuries. Fall risk assessments completed 8/25/12, 11/7/12, 2/27/13 and 3/5/13 coded the resident as a high risk for falls. The resident had a care plan for fall prevention dated 3/1/13 that read: "I may fall because I am unsteady and weak. I also have hallucinations about family members." The resident had the following interventions on the care plan: a) remind me to call for help to get out of bed, chair and bathroom; b) two assist for transfers; c) non skid footwear; d) on the falling star program which includes checking the resident frequently; e) encourage/assist to participate in activities and f) seat with other residents in the living room. According to the facility incident report, the resident was found lying on the floor in the living room on 3/22/13 at 8:30 A.M. The facility reported that the resident stated he/she was looking for her/his mother and most likely stood up to walk and fell in front of the wheelchair. Just prior to the fall, the resident had been assisted to the living room from the dining room. According to documentation, the nurses aides were constantly back and forth into the living room transporting residents during this time. The staff statements in the facility's investigation revealed that at the time of the fall: 3 nurses aides were transporting residents to the living room from the dining room. Statements also indicate an activity assistant was in the activity closet off the living room getting supplies. There was no evidence that a staff member was constantly in the living room providing supervision. During interview on 5/6/2013 at 3:45 P.M., the DNS (Director of Nursing Services) stated that the facility practice is have a staff member in the living room/activity area at all times. On 5/7/13, the facility provided additional documentation indicating that there is not a policy and procedure that specifically states there must be a staff member in the living room at all times but it is the facility practice to provide supervision for residents in the memory care unit during meals and activities. After the Resident's fall in the living room, the facility developed a formal system where 2 staff members are assigned to the living room while residents are present including following meals and during activities.